After completing the chapter, you will be able to accomplish the following:

1. Promote patient comfort.
2. Give a back massage.
3. Apply and care for a patient using a transcutaneous electrical nerve stimulation (TENS) unit.
4. Care for a patient receiving PCA.
5. Care for a patient receiving epidural analgesia.
6. Care for a patient receiving continuous wound perfusion pain management.

• Assessment
• Clinical decision making/clinical judgment
• Comfort
• Safety
• Teaching and learning/patient education

• acute pain
• adjuvant
• continuous wound perfusion pain management systems
• epidural
• nonpharmacologic
• pain tolerance
• perineural routes

Comfort is an important need and ensuring a patient's comfort is a major nursing responsibility. Providing comfort can be as simple as straightening the patient's bed linens, offering to hold the patient's hand, or assisting with hygiene needs. Often, providing comfort includes providing pain relief. The classic definition of pain that is probably of greatest benefit to nurses and patients is that offered by McCaffery (1968): “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (p. 95). This definition rests on the belief that the only one who can be a real authority on whether, and how, a person is experiencing pain is that person; pain is the individual experience and description of a sensation or feeling (Sonneborn & Williams, 2020). The International Association for the Study of Pain (IASP) further defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (IASP, 2020, para. 3). Additional key factors that define pain include (IASP, 2020):

• Pain is always a personal experience, influenced by biological, psychological, and social factors.
• Individuals learn the concept of pain through life experiences.
• A person's report of an experience as pain should be respected.
• Pain may have adverse effects on function and social and psychological well-being.
• Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a person experiences pain.

Differences in individual pain perception and response to pain, as well as the multiple and diverse causes of pain, require the use of accurate knowledge and appropriate interventions to promote comfort and relieve pain. The most important of these are the nurse's belief that the patient's pain is real, a willingness to become involved in the patient's pain experience, and competence in collaborating to develop effective pain management regimens. It is important for nurses to understand the pathophysiology of pain and of the crucial role pain assessment plays in pain management (IASP, 2020; Sonneborn & Williams, 2020).

Assessment of pain is an integral part of providing nursing care, including individualized pain assessment, treatment, and management. Fundamentals Review 10-1 outlines factors to include in a pain assessment. Because pain is subjective, self-report is generally considered the most reliable way to assess pain and the nurse should use this method whenever possible; however as noted above, a verbal description is only one of several behaviors to express pain (IASP, 2020; Sonneborn & Williams, 2020). Pasero and McCaffery (2011) identified, additional methods to assess a person's pain that are still relevant today and include the following: identification of pathologic conditions or procedures that may be causing pain; take into account the report of a family member/caregiver, another person close to the patient, or caregiver who is familiar with the patient; the nonverbal behaviors that may indicate the presence of pain (restlessness, grimacing, crying, clenching fists, protecting the painful area); and physiologic measures (increased blood pressure and pulse), although most research verifies that reliance on vital signs to indicate the presence of pain should be minimized (Herr et al., 2019). The absence of an increase in vital signs does not mean that pain is not present. Infants, young children, patients who are nonverbal or have difficulty communicating verbally, and cognitively impaired adults, such as those with dementia, are at high risk for underassessment and undertreatment/overtreatment of pain (Herr et al., 2019).

Use of a pain guide and a pain scale should be part of the initial and continued assessment of pain and evaluation of pain control measures. Choosing an appropriate tool for patient assessment is necessary to obtain an accurate assessment and valid pain ratings. Fundamentals Review 10-2 is one example of a pain assessment tool. Pain assessment guides and pain scales eliminate guesswork and biases when dealing with the patient's pain; help the nurse appreciate what the person is experiencing; analyze findings that will help prepare an appropriate nursing response to the patient's pain; and facilitate improved outcomes (Taylor et al., 2023). Alternative approaches to pain assessment for special populations ensure that unacceptable levels of pain are addressed and treated. For example, a nurse caring for a patient in an intensive care unit would use a valid and reliable pain assessment tool that considers the unresponsive and/or noncommunicative nature of the patient. Fundamentals Review 10-3 provides a listing of pain assessment scales that can be used in adults and children who can self-report, as well as scales that can be used to assess pain in adults and children who cannot self-report discomfort and pain. Fundamentals Review 10-4 is an example of a scale that can be used to assess discomfort and pain in patients who are unable to self-report. A comprehensive pain assessment must also include discussion of the patient's expectations for pain relief. The patient and health care team need to set mutually agreed upon goals that are acceptable and satisfactory, and that facilitate recovery. For example, it may not be possible to have a pain rating of zero after a surgical procedure when the movement required to prevent complications naturally causes some pain or discomfort. Having this conversation and setting a realistic, mutually agreed upon goal facilitates the patient's recognition and report of pain that is unacceptable. Setting pain management goals also provides the nurse the opportunity to establish rapport, discuss individualized pain management interventions, and evaluate the plan with the patient and caregivers (Taylor et al., 2023).

This chapter covers skills to assist the nurse in providing for patient comfort, including pain relief. Refer to Fundamentals of Nursing (Taylor et al., 2023) textbook for further, in-depth discussions of the physiology, assessment, and treatment of pain.

You can find suggested answers after the Bibliography at the end of this chapter.

1. Review the patient's health record and care plan for information about the patient's status and contraindications to back massage, and review the prescribed intervention for the patient's activity level. Because of the surgery, it will probably be difficult for Mrs. Simpson to lie in a prone position; assess their ability to turn to their side for the massage. It will be necessary to maintain the position of the abductor pillow, to prevent adduction of her hip. Assess the patient's level of pain. Check the patient's medication administration record for the time an analgesic was last administered. If appropriate, administer an analgesic sufficiently early so it has time to take effect before beginning the massage. Assess for the need to obtain assistance of another caregiver to assist the patient to their side and maintain that position for the massage. Include an assessment of the patient's skin integrity, because of the increased risk for impaired skin integrity.
2. Review the patient's health record and care plan for specific instructions related to TENS therapy, including the order and conditions indicating the need for therapy, and prescribed settings. Review the patient's history for conditions that might contraindicate therapy, such as pacemaker insertion, cardiac monitoring, or electrocardiography. Determine the location of electrode placement in consultation with the ordering health care provider and based on the patient's report of pain. Assess the patient's understanding of TENS therapy and the rationale for its use. Explain the rationale for the use of TENS therapy and patient instructions.Before initiating therapy, inspect the skin of the area designated for electrode placement for irritation, redness, or breakdown. Assess the patient's pain and level of discomfort using an appropriate assessment tool. Check the unit to ensure proper functioning and review the manufacturer's instructions for use.
3. Provide teaching for Mr. Batiste and their wife concerning the rationale for the use of a PCA and how a PCA works. Show the equipment as part of the explanation and provide a written copy of the information. Include information regarding safety mechanisms built into the device, as well as guidelines for adverse effects. Instruct the patient and their wife regarding symptoms that should be reported to the health care provider. They should be aware that community-based care provider/nurse will be consulted to continue support at home. The patient and/or their wife should be able to verbalize and demonstrate an understanding of information.