- Pain is subjective and an individual experience; therefore, the client's report of pain characteristics must be considered accurate and valid.
- Pain tolerance is subjective and varies among individuals.
- Acute pain, by definition, generally lasts less than 6 months.
- Chronic pain, by definition, lasts more than 6 months.
- Successful assessment and management of pain depends, in part, on a good nurse–client relationship.
- Anticipatory pain management is best; intervene when pain is anticipated and before it becomes significant.
- Self-report of the client's perceptions regarding pain must be considered valid.
- Assess factors/characteristics of client's pain:
- Location (Where is the pain? Can you point to it?)
- Intensity (On a scale of 1–10, how bad is the pain? [Or use visual pain analog scale.])
- Quality (Is it dull, sharp, nagging, burning?)
- Radiation (Does it radiate? Where does it radiate to?)
- Precipitating factors (What were you doing when it occurred?)
- Aggravating factors (What makes it worse?)
- Associating factors (Do you get nauseated or dizzy with the pain?)
- Alleviating factors (Do you know of anything that has made it better at times?)
- The following factors must be considered in assessing and managing the client's pain: medical diagnosis, age, weight, and sociocultural affiliation (e.g., religion, race, gender)
- Self-management devices (e.g., patient-controlled analgesia pumps). DO NOT exempt the nurse from performing frequent and careful client assessments.
- Assess clients receiving drug therapy for pain management every 1 to 2 hr (more often, if needed) to ensure adequate pain control and avoid complications of uncontrolled pain and complications of drug therapy.
General Pain Management Strategies 
- Always assess pain first.
- Client/family teaching should be included as part of nonpharmacologic management to include factors such as what causes the pain, what the client can expect, what needs to be reported, instructions for reducing activity and treatment-related pain, and relaxation techniques.
- Consider general comfort measures such as client repositioning, back rubs, pillows at lower back, bladder emptying, and applying a cool or warm washcloth to the affected area.
- Consider management of anxiety along with pain, using relaxation strategies.
- Escalating and repetitive pain may be difficult to control. Early intervention is best.
- Around-the-clock (ATC) pain-therapy drug protocols are used to treat persistent pain, using the analgesia ladder standard as set forth by the World Health Organization. The use of oral medications, when possible, is recommended. Nonopioid or nonsteroidal anti-inflammatory drugs (NSAIDS) are used in the initial treatment, with progression to an ATC opioid and steroids, antidepressants, or anticonvulsants, as needed to control pain. Treatment proceeds to steps 2 and 3 of the analgesia ladder with increased potency of opioids and use of parenteral routes.
- Unrelieved pain has negative physical and psychological consequences.
- Take into consideration what the client believes will help relieve the pain and the client's ability to participate in treatment.
- If pain cannot be realistically relieved completely, educate client as to what would be considered a tolerable level of pain in consideration of the condition.
- Nonsteroidal anti-inflammatory drugs and drugs that inhibit platelet aggregation should be used with caution in clients with bleeding tendencies and conditions such as thrombocytopenia or gastrointestinal ulceration.
- Always check the general surgical area for manifestations of postoperative complications when the client complains of pain. Watch for problems such as compromised circulation, excessive edema, bleeding, wound dehiscence and evisceration, and infection.
- Goals of postoperative pain management regimens include attaining a positive client outcome and reducing the length of stay.
- Administering nonsedative pain medications before ambulation should be considered to facilitate early and consistent ambulation postoperatively.
- The Agency for Healthcare Research and Quality (AHRQ) and the American Pain Society (APS) guidelines for management of acute pain indicate that surgical clients should receive nonsteroidal anti-inflammatory drugs or acetaminophen around the clock, unless contraindications prohibit use.
- Opioid analgesics are considered to be the cornerstone for management of moderate to severe acute pain. Effective use of opioid analgesics may facilitate postoperative cooperation in activities such as coughing and deep breathing exercises, physical therapy, and ambulation.
- Intravenous administration is the parenteral route of choice after major surgery.
- Oral drug administration is the primary choice of drug routes in the ambulatory surgical population.
- Oral administration of drugs should begin as soon as the client can tolerate oral intake.
- Acute or significant pain, not explained by surgical trauma, may warrant a surgical evaluation.
- Watch for signs of narcotic overdose carefully—decreased respiratory rate and/or depth, decreased mentation, decreased blood pressure.
- Administer naloxone as indicated by orders/agency policy immediately if signs of respiratory depression occur in clients receiving narcotics. Naloxone may increase rather than reverse the effects of meperidine.
- Major signs of drug dependence are client need for increased dosages of medication (after other methodologic and drug alternatives have been attempted).
- Check if narcotic administration produces consistent euphoria rather than just pain relief.
Pain Management in the Elderly
- Elderly clients often have complex pain because of multiple medical problems. Elderly clients are at a greater risk for drug–drug and drug–disease interactions.
- Elderly clients may experience a longer duration and higher peak effect of opioids. It is best to start with more conservative doses and increase as needed from that point. Meperidine (Demerol) should be given with caution, and the client should be monitored particularly for neurologic changes and seizures.
- Some elderly clients may experience more severe postsurgical pain than other age groups. In these cases, consider options such as oral morphine or hydromorphone, if ordered.
- As a routine, pain medications are not given to clients with acute neurologic conditions, since assessment of the true status of the neurologic status may be skewed with central or peripheral nervous system effects.
- The pain status of clients who have had recent vascular surgery should be monitored carefully. Excessive pain may result in increased blood pressure in response to stress, with subsequent rupture of newly grafted or anastomosed vessels.
- Note the following procedures in this book: Using Patient-Controlled Analgesia, Using a Transcutaneous Electrical Nerve Stimulation (TENS) Unit, Using Epidural Pump Therapy, and Procedures on Administering Heat/Cold Therapy (see Chapter 10).
- Note verbal statement of pain decrease or increase.
- Note accompanying clinical indicators of pain increase or decrease.
- Note appearance of area of pain.
- Note coping skills successfully used by client.
- Note anxiety-reducing techniques successfully used.