Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a duration of less than 3 months

Altered physiological parameter

Appetite change

Diaphoresis

Distraction behavior

Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally

Expressive behavior

Facial expression of pain

Guarding behavior

Hopelessness

Narrow focus

Positioning to ease pain

Protective behavior

Proxy report of activity changes

Proxy report of pain behavior

Pupil dilation

Reports intensity using standardized pain scale

Reports pain characteristics using standardized pain instrument

Self-focused

Biological injury agent

Chemical injury agent

Physical injury agent

Refer also to Altered Comfort.

AUTHOR'S NOTE

Nursing management of pain presents specific challenges. Is acute pain a response that nurses treat as a nursing diagnosis? Despite that an individual receives a medication for acute pain, nurses are the primary professional who influence the pain experience. Acute pain can be the etiology of another response that also describes the condition that nurses treat. Does some cluster of nursing diagnoses represent a pain syndrome or chronic pain syndrome (e.g., Fear, Compromised Family Coping, Impaired Physical Mobility, Social Isolation, Ineffective Sexuality Patterns, Fatigue)? McCaffery and Beebe (*1989) cite 18 nursing diagnoses that can apply to people experiencing pain. Viewing pain as a syndrome diagnosis can provide nurses with a comprehensive nursing diagnosis for people in pain to whom many related nursing diagnoses could apply.

Pain

If the cause of the pain is known:

Ask the person to rate the pain: At its best, after pain-relief measures, and at its worst.

For adults, use an oral or visual analog scale of 0 to 10 (0 = no pain, 10 = excruciating). For someone who may not understand the 0 to 10 scale, try to elicit past painful experiences from the individual and assist him/her to attach a number to them. If the 0 to 10 pain scale was drawn as a thermometer (vertically), it may represent what a 10 means versus a horizontal picture.

For children, select a scale appropriate for their developmental age: a scale for assessed age or younger can be used; include the child in the selection:

• 3 years and older: Use drawings or photographs of faces (Oucher scale) ranging from smiling to frowning to crying with a numeric scale.
• 4 years and older: Use 4 white poker chips to ask the child how many pieces of hurt he or she feels (no hurt = no chips).
• 6 years and older: Use a numeric scale, 0 to 5 or 0 to 10 (verbally or visually); use blank drawing of body, front and back, asking the child to use 3 different crayons to color places with a little pain, medium pain, and a lot of pain (Eland Color Tool).

"Are any other symptoms associated with your discomfort (nausea, vomiting, numbness)?"

What helps the pain? What makes it worse?

Level 3 Advanced Focused Assessment (all settings)

Refer to the above basic assessment.

"Where is your discomfort located; does it radiate?" (Ask child to point the place.)

"When did it begin?"

"Can you relate the cause of this discomfort?" or "What do you think has caused your discomfort?"

"Describe the discomfort and its pattern."

Time of day

Frequency (constant, intermittent, transient)

Duration

Quality/intensity

Assess for Cultural Influences on Pain

Country of origin

Native language

Availability of interpreter

Food, beverage preferences

Time in United States

Ability to understand/speak English

Religious practices (blood transfusion,

specific clothing, male attendants)

Objective

Musculoskeletal Manifestations

Mobility of painful part

Muscle tone

Dermatological Manifestations

Color (redness)

Temperature

Moisture/diaphoresis

Edema

The individual will experience a satisfactory relief measure as evidenced by (specify):

• Increased participation in activities of recovery
• Reduction in pain behaviors (specify)
• Improvement in mood, coping

Level 2 Extended Focused Interventions

Assess for Factors That Decrease Pain Tolerance

• Disbelief from others; uncertainty of prognosis
• Fatigue
• Fear (e.g., of addiction or loss of control)
• Monotony
• Financial and social stressors
• Lack of knowledge

Reduce or Eliminate Factors That Increase Pain

CARP'S CUES

"While the undertreatment of pain is a recognized issue among pain researchers, we argue that the concept of ‘pseudoaddiction' is problematic because it ultimately relies on a clinical judgment that attempts to separate out ‘bad' drug-seeking addicts from ‘good' undertreated pain patients in the face of behaviors that are virtually indistinguishable" (*Bell & Salmon, 2009).

In this author's previous practice as a family nurse practitioner, I encountered weekly requests for controlled medications. After careful assessments, if I was still uncertain if the request was due to undertreated pain or abuse, I prescribed the medication at the visit for 14 days. On the next visit, with additional assessment, I could better differentiate the origins of the request; I could differentiate the legitimate request from those that were not. This practice has caused me to sometimes prescribe once for a drug-seeking addict or street entrepreneur. But, most importantly, I did not deprive a person with creditable pain the medication for relief of their pain. I can live with both outcomes.

Presently, I practice in residential facilities for older adults. Management of pain is a priority.

I have encountered some drug abuse, but for the most part, management of their pain is not complicated by suspicions of abuse or addiction.

Disbelief from Others

• Establish a supportive accepting relationship:
  • Acknowledge the pain.
  • Listen attentively to their discussion of pain.
  • Convey that you are assessing pain because you want to understand it better (not determine if it really exists).
• Assess the family for any misconceptions about pain or its treatment:
  • Explain the concept of pain as an individual experience.
  • Discuss factors related to increased pain and options to manage.
  • Encourage family members to share their concerns privately (e.g., fear that the individual will use pain for secondary gains if he or she receives too much attention).

Lack of Knowledge/Uncertainty

• Explain the cause of the pain, if known.
• Relate the severity of the pain and how long it will last, if known.
• Explain diagnostic tests and procedures in detail by relating the discomforts and sensations that the individual will feel; approximate the duration.
• Support the individual in addressing specific questions regarding diagnosis, risks, benefits of treatment, and prognosis. Consult with the specialist or primary care provider.

Fear

• Provide accurate information to reduce fear of addiction.

R:Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences (American Society of Addiction Medicine, 2019).

• Explore reasons for the fear. Assist in reducing fear of losing control.
• Provide privacy for the individual's pain experience.
• Allow the individual to share the intensity of pain; express to the individual how well he or she tolerated it.

Level 2 Extended Focused Interventions (all settings)

Provide Information to Reduce Fear That the Medication Will Gradually Lose Its Effectiveness

R:Drug tolerance occurs when the person no longer responds to the drug in the way that the person initially responded. Higher doses are required for an effective response. There is no compulsive use of the drug but withdrawal symptoms can occur (*National Institute of Drug Abuse, 2007).

• Discuss interventions for drug tolerance with the physician/NP/PA (e.g., changing the medication, increasing the dose, decreasing the interval, adding adjunct therapy).
• Discuss the effect of relaxation techniques on medication effects.
• Determine the cause of fatigue (pain, sedatives, analgesics, sleep deprivation).

Assess present sleep pattern and the influence of pain on sleep.

Refer to Disturbed Sleep Pattern

Provide Optimal Pain Relief with Prescribed Analgesics

R:Analgesics should be initiated at the lowest effective dose and titrated to achieve pain control with minimal adverse effects; this requires frequent reassessment of patients for pain relief and side effects as doses are adjusted. Localized use of medication (e.g., joint injections, trigger point injections) may be preferable to systemic medications (e.g., oral analgesics) when applicable (Galicia-Castillo & Weiner, 2014).

• Use oral route when feasible; intravenous or rectal routes if needed with permission.
• Avoid intramuscular routes due to erratic absorption and unnecessary pain.

R:Oral administration is preferred when possible. Liquid medications can be given to those who have difficulty swallowing.

R:If frequent injections are necessary, the IV route is preferred because it is not painful and absorption is guaranteed. Side effects (decreased respirations and blood pressure), however, may be more profound (Galicia-Castillo & Weiner, 2014).

• Assess vital signs, especially respiratory rate, before administration.
• Consult with pharmacist for possible adverse interactions with other medications (e.g., muscle relaxants, tranquilizers).
• Use the around-the-clock (ATC) approach: not PRN.

R:Paice, Noskin, and Vanagunas reported the results of comparing the use of ATC-scheduled opioid doses with PRN-opioid doses in medical inpatients and found that those who received ATC doses had lower pain intensity ratings (*2005). "As might be expected, a significantly greater percentage of the prescribed opioid was administered when it was given ATC (70.8%) compared with PRN (38%); however, there were no differences in adverse effects between the 2 groups" (*Pasero, 2010).

• Carefully monitor individuals who are taking sedating medications and opioid analgesics for respiratory failure every hour for the first 12 hours (with pulse oximetry, blood pressure, respiratory rate) (Myers-Glower, 2013).
• Explain the various noninvasive pain-relief methods and why they are effective. Ask the individual if they prefer heat or cold.
• Discuss the use of heat applications,* their therapeutic effects, indications, and related precautions.
  • Hot water bottle
  • Warm tub or wraps to painful body part
  • Hot summer sun
  • Electric heating pad
  • Moist heat pack
  • Thin plastic wrap over painful area to retain body heat (e.g., knee, elbow)
• Discuss the use of cold applications, their therapeutic effects, indications, and related precautions.
  • Cold towels (wrung out)
  • Cold water immersion for small body parts
  • Ice bag
  • Cold gel pack
  • Ice massage
• Explain the therapeutic uses of menthol preparations, massage, and vibration.
• Practice distraction (e.g., guided imagery, music).
• Practice relaxation techniques.

R:In addition to heat warming muscles, other modalities, such as menthol rubs and cold compresses interrupt the brain's perception of pain and substitute it with the sensation of menthol, cold compress, massage (Norris, 2019).

Reduce or Eliminate Common Side Effects of Opioids

AUTHOR'S NOTE

"No matter what the cause or pattern of the pain, its chronicity causes physiologic and psychological stress that wears on the patient (and their loved ones) physically and emotionally" (*D'Arcy & Johann, 2008).

The real tragedy of experiencing chronic pain is the failure of healthcare professionals to understand the lived experience or perhaps worse project disbelief or commendation toward those who suffer. "Thus pain and psychological illness should be viewed as having a reciprocal psychological and behavioral effects involving both processes of illness expression and adaption, as well as pain having specific effects on emotional state and behavioral function" (*Von Korff & Simon, 1996).

NANDA-I has approved 2 nursing diagnoses related to chronic pain, Chronic Pain and Chronic Pain Syndrome. These 2 diagnoses can be viewed as on a trajectory of Chronic Pain in the early months with a focus on pain management to Chronic Pain Syndrome with the focus management of pain and on the negative effects of living with chronic pain on relationships, activities of daily living, and ability to work.

Refer to Chronic Pain Syndrome for Interventions.

Minimize Procedural and Diagnostic Pain

• Anticipate pain and premedicate the individual prior to painful procedures (e.g., sedation).
• Encourage the use of relaxation or guided imagery during procedures.

Initiate Health Teaching, as Indicated

• Discuss with the individual and family noninvasive pain-relief measures (e.g., relaxation, distraction, massage, music).
• Teach the techniques of choice to the individual and family.
• Explain the expected course of the pain (resolution) if known (e.g., fractured arm, surgical incision).
• Provide the individual with written guidelines for weaning from pain medications when the acute event is relieved.

Level 2 Extended Focused Assessment (pediatrics any setting)

Assess the Child's Pain Experience (Hockenberry, Rodgers, & Wilson, 2018)

• Ask the child to point to the area that hurts.
• Determine the intensity of the pain at its worst and best. Use a pain scale appropriate for the child's developmental age. Use the same scale the same way each time and encourage its use by parents and other healthcare professionals. Indicate on the care plan which scale to use and how (introduction of scale, language specific for child); attach a copy if it is a visual scale.
• Ask the child what makes the pain better and what makes it worse.
• With infants, assess crying, facial expressions, body postures, and movements. Infants exhibit distress from environmental stimuli (light, sound) as well as from touch and treatments.
• Use tactile and vocal stimuli to comfort infants while assessing the effects of comfort measures and individualized intervention techniques and consequences of pain overall.

Assess for Developmental Manifestations

Infant

Irritability

Inconsolability

Changes in eating or sleeping

Generalized body movements

Toddler

Irritability

Aggression (kicking, biting)

Sucking

Changes in eating or sleeping

Rocking

Clenched teeth

Preschool

Irritability

Aggression

Changes in eating or sleeping

Verbal expressions of pain

School-Aged

Changes in eating or sleeping

Verbal expressions of pain

Change in play patterns

Denial of pain

Adolescent

Mood changes

Verbal expressions when asked

Behavior extremes ("acting out")

Changes in eating or sleeping

Level 3 Advanced Interventions (pediatrics all settings)

Explain the pain source to the child, as developmentally appropriate, using verbal and sensory (visual, tactile) explanations (e.g., perform treatment on doll, allow the child to handle equipment). Explicitly explain and reinforce to the child that he or she is not being punished.

R:Nurses, physicians, and the parents should identify and use consistent pain assessment criteria (e.g., assessment scale, specific behaviors) to assess pain in a child (Hockenberry, Rodgers, & Wilson, 2018).

Assess the Child and Family for Misconceptions About Pain or Its Treatment

• Explain to the parents the necessity of good explanations to promote trust.
• Do not lie to parents or especially the child that something will not hurt if there is a possibility that it likely will for the sake of easing the child's anxiety about the pain. Doing this breeds mistrust between the family/patient and the medical team.
• Explain to the parents that the child may cry more openly when they are present, but that their presence is important for promoting trust.

R:Assessment of pain in children consists of 3 parts: The nature of the pain-producing pathology, the anatomic responses of acute pain, and the child's behaviors. It never should be based on only behavior.

Promote Security with Honest Explanations and Opportunities for Choice

Promote Open, Honest Communication

• Tell the truth; explain:
  • How much it will hurt
  • How long it will last
  • What will help with the pain
• Do not threaten (e.g., do not tell the child, "If you don't hold still, you won't go home.")
• Explain to the child that the procedure is necessary so he or she can get better and that holding still is important so it can be done quickly and possibly with less pain.
• Discuss with parents the importance of truth-telling. Instruct them to:
  • Tell the child when they are leaving and when they will return.
  • Relate to the child that they cannot take away pain, but that they will be with him or her (except in circumstances when the parents are not permitted to remain).
• Allow parents opportunities to share their feelings about witnessing their child's pain and their helplessness.

R:Anxiety, fear, and separation can increase pain.

Prepare the Child for a Painful Procedure

• Discuss the procedure with the parents; determine what they have told the child.
• Explain the procedure in words suited to the child's age and developmental level.
• Relate the likely discomforts (e.g., what the child will feel, taste, see, or smell). "You will get an injection that will hurt for a little while and then it will stop."
• Be sure to explain when an injection will cause 2 discomforts: The prick of the needle and the injection of the drug.
• Encourage the child to ask questions before and during the procedure; ask the child to share what he or she thinks will happen and why.
• Share with the older child that:
  • You expect them to hold still and that it will please you if he or she can.
  • It is all right to cry or squeeze someone's hand if it hurts.
• Find something to praise after the procedure, even if the child could not hold still.
• Arrange to have the parents present for procedures (especially for young children), and explain to them what to expect before the procedure. Give them a role during the procedure, such as holding a child's hand or talking to them.

R:Verbal communication usually is not sufficient or reliable to explain pain or painful procedures with younger children. The nurse can explain by demonstrating with pictures, dolls, or actual equipment as case appropriate. The more senses that are stimulated in explanations to children, the greater the communication. When possible, parents should be included in preparation.

Reduce the Pain during Treatments When Possible

• If restraints must be used, have sufficient clientele available so the procedure is not delayed and so restraints are applied smoothly as not to increase anxiety/discomfort.
• If injections are ordered, try to obtain an order for oral or IV analgesics instead. If injections must be used:
  • Expect the older child to hold still, however, have extra staff available to assist with holding the younger child still to minimize increased pain or possible injury to staff or child.
  • Consider the use of topical analgesics prior to injections (e.g., LET/L-M-X4/EMLA gels and creams or Vapocoolant sprays).
  • Have the child participate by holding the Band-Aid for you.
  • Tell the child how pleased you are that he or she helped.
  • Comfort the child after the procedure, or leave the room so that parents can comfort the child in the event that staff's presence continues to upset the child.
• Offer the child, as age appropriate, the option of learning distraction techniques for use during the procedure. (The use of distraction without the child's knowledge of the impending discomfort is not advocated because the child will learn to mistrust.):
  • Tell a story with a puppet.
  • Allow the child to use a cell phone, hand-held gaming device, and/or electronic tablet.
  • Blow a party noisemaker, pinwheels, or bubbles.
  • Ask the child to name or count objects in a picture.
  • Ask the child to look at the picture and to locate certain objects (e.g., "Where is the dog?").
  • Ask the child to tell you a story or about something from their lives.
  • Ask the child to count your blinks.
• Avoid rectal thermometers in preschoolers; if possible, use other methods, such as tympanic, temporal, or oral (if tolerated) as allowed by the medical institution's guidelines and protocols.
• Provide the child with privacy during the painful procedure; use a treatment room rather than the child's bed.

R:The child's bed should be a "safe place."

Provide the Child Optimal Pain Relief with Prescribed Analgesics

• Medicate the child before the painful procedure or activity (e.g., dressing change, obtaining x-ray of fractured limb, ambulation, injection/PIV placement).
• Consult with the physician/NP/PA for a change of the IM route to the PO, topical, or IV route when appropriate.
• Along with using pain assessment scales, observe for behavioral signs of pain (because the child may deny pain); if possible, identify specific behaviors that indicate pain in an individual child.
• Assess the potential for use of patient-controlled analgesia (PCA), which provides intermittent controlled doses of IV analgesia (with or without continuous infusion) as determined by the child's need. Children as young as 5 years can use PCA. Parents of children physically unable can administer it to them. PCA has been found safe and to provide superior pain relief compared with conventional-demand analgesia (Ball, Bondler, & Cowen, 2016).

Reduce or Eliminate the Common Side Effects of Opioids

Sedation

• Assess whether the cause is the opioid, fatigue, sleep deprivation, or other drugs (sedatives, antiemetics).
• If drowsiness is excessive, consult with physician about reducing dose.

Constipation

• Explain to older children why pain medications cause constipation.
• Increase fiber-containing foods and water in diet.
• Instruct the child to keep a record of exercises (e.g., make a chart with a star sticker placed on it whenever the exercises are done).
• Refer to Constipation for additional interventions.

Dry Mouth

• Explain to older children that narcotics decrease saliva production.
• Instruct the child to rinse the mouth often, suck on sugarless sour candies, eat pineapple chunks and watermelon, and drink liquids often.
• Explain the necessity of brushing teeth after every meal.
• Discontinue medications/treatments that are causing symptoms as soon as appropriate.

R:Management of side effects will increase comfort and use of medications.

Assist Child with the Aftermath of Pain

• Tell the child when the painful procedure is over. Allow the child to have contact with a parent or person whom they find comforting.
• Encourage the child to discuss pain experience (draw or act out with dolls).
• Encourage the child to perform the painful procedure using the same equipment on a doll under supervision.
• Praise the child for his or her endurance and convey that he or she handled the pain well regardless of the actual behavior (unless the child was violent to others).
• Reward good behavior, such as with a sticker, ice pop, or other prize.
• Teach the child to keep a record of painful experiences and to plan a reward each time he or she achieves a behavioral goal, such as a sticker (reward) for each time the child holds still (goal) during an injection. Encourage achievable goals; holding still during an injection may not be possible for every child, but counting or taking deep breaths may be.
• Consult with child life specialists for assistance in teaching coping techniques, providing distraction, and modifying behavior in cases where the child is receiving repetitive, unpleasant treatments (e.g., child who has difficulty with frequent, routine blood draws).

R:Provides an opportunity to discuss experience.

Collaborate with Child to Initiate Appropriate Noninvasive Pain-Relief Modalities

• Encourage mobility as much as indicated, especially when pain is lowest.
• Discuss with the child and parents activities that they like and incorporate them in daily schedule (e.g., clay modeling, drawing/coloring).

R:Distraction measures can include listening to music, watching video, or blowing bubbles. Keep in mind that even if the child seems adequately distracted, the child could still be experiencing pain (Ball, Bondler, & Cowen, 2016).

Assist Family to Respond Optimally to Child's Pain Experience

• Assess family's knowledge of and response to pain (e.g., do parents support the child who has pain?).
• Assure parents that they can touch or hold their child, if feasible (e.g., demonstrate that touching is possible even with tubes and equipment).
• Give accurate information to correct misconceptions (e.g., the necessity of the treatment even though it causes pain).

Initiate Health Teaching and Referrals, if Indicated

• Provide child and family with ongoing explanations.
• Use available mental health professionals, if needed, for assistance with guided imagery, progressive relaxations, and hypnosis.
• Use available pain service (pain team) at pediatric healthcare centers for an interdisciplinary and comprehensive approach to pain management in children.