section name header

Purpose

Equipment

Assessment

Assessment should focus on the following:

Nursing Diagnoses

Nursing diagnoses may include the following:

Outcome Id

Outcome Identification and Planning

Desired Outcomes navigator

Sample desired outcomes include the following:

Special Considerations in Planning and Implementation

General navigator

Remember that the client is the expert regarding pain. The nurse's direct observations should not be used to dispute the client's perception. Pain is present if the client says it is. Perform pain assessment with vital signs and additional times as indicated.

Pediatric navigator

Use nonverbal cues to determine the presence of pain in newborns, infants, and toddlers. Although children as young as 8 years can use a 0-to-10 scale, a graphic rating scale, such as a faces chart, can be quite effective.

Geriatric navigator

Remember that elderly clients often have multiple sources of pain. Pain may be chronic, and the elderly client may demonstrate a stoic approach to pain. Observe for nonverbal cues of pain if cognitive impairment is present. Assess for altered pain sensation in some elderly clients, particularly if diabetes or neurovascular disease is present.

Image_Transcultural Transcultural navigator

Consider the impact of the individual's culture when assessing pain level. Open expression of pain is encouraged in some cultures, while other cultures value stoic responses to pain as something to be ignored or endured in silence.

Delegation navigator

Pain assessment should be performed by a nurse, particularly with ongoing pain management (e.g., PCA or epidural) and when interpretation of nonverbal cues is needed. In some facilities, unlicensed staff may be trained in basic pain assessment.


[Outline]

Implementation

ActionRationale
1Explain procedure to client, emphasizing the importance of the client’s pain report.Decreases anxiety; promotes cooperation; reassures client that all pain reports will be believed
2Perform hand hygiene and organize equipment.Reduces microorganism transfer; promotes efficiency
3Ask client if pain or discomfort is or has been present. Ask client about pain at rest and with movement.Provides an indication of pain status and pain history; encourages client to report discomfort
4Determine location of pain: Use a form with a body outline (Fig. 3.4) and ask client to indicate where the pain is.Provides a way for client to show areas of discomfort
5Assess intensity of pain:Quantifies pain; provides a way to determine effectiveness of pain management therapies
  • Using a pain scale: Ask client what number best represents his or her level of pain (0 indicates no pain, the highest number indicates the strongest pain). OR
  • Using a graphic scale: Ask client to point to the picture (e.g., faces [Fig. 3.5]), the number, or stack of chips, for example, that indicates the level of pain experienced.
6Ascertain quality of pain: Ask client to choose from a list of descriptive terms (Appendix A). Read the list to client if client has visual impairments or is illiterate.Helps client describe pain with frequently used terms
7Assess temporal pattern. Ask the following questions:Provides further information about pain; helps determine appropriate dosing schedule for pain medication
  • When did/does the pain start?
  • How long does the pain last?
  • Does the pain recur before it’s time for the next pain medication?
Indicates breakthrough pain
8Ask client if other symptoms accompany pain (Appendix A).Assists in determining causes of pain and additional treatments needed
9Inquire about alleviating or aggravating factors (e.g., movement, cough, repositioning).Indicates measures to be used in pain relief or pain prevention
10Initiate comfort measures:
  • Apply cool cloth to head for headache, and dim lights.
Reduces pain perception by decreasing noxious stimuli
  • Offer massage (see Appendix A for other measures).
Decreases tension, which may aggravate pain
  • Administer analgesic as ordered.
Relieves pain via various mechanisms
11Perform hand hygiene.Reduces microorganism transfer
12Reassess client; notify doctor if pain is not relieved.Initiates prompt medical intervention

Evaluation

Were desired outcomes achieved? Examples of evaluation include:

Documentation

The following should be noted on the client's record: