Introduction

unpleasant sensory and emotional experience brought on by actual or potential tissue damage, or expressed in terms of such damage (International Association for the Study of Pain); abrupt or gradual onset of any intensity ranging from mild to severe, with a predictable or expected end, and lasting less than six months Pain is a very subjective state where a patient may experience a wide range of unpleasant sensations and disturbing circumstances.

The protective purpose of acute pain is to alert the patient to an injury or disease. The patient seeks respite when intense pain suddenly appears. The body reacts to pain as a stressor, which causes the physiological symptoms associated with acute pain. Acute pain may be exacerbated by the patient’s cultural background, feelings, and psychological or spiritual discomfort. Assessing pain can be difficult, particularly for elderly people who are more likely to have cognitive impairment and sensory-perceptual deficiencies. The evaluation and treatment of acute pain in hospital or home care settings are the main objectives of this care plan.

Specifying Qualities

The existence of subjective pain cannot be confirmed or refuted because it is a subjective experience (McCaffery,2011). The most accurate way to assess the existence and severity of pain is by self-report (APS, 2008). A self-report pain tool, such as the Numerical Rating Scale [NRS], should be used by a client with cognitive ability who can communicate about their pain in other ways, such as by pointing to words or numbers, in order to determine their current level of pain and set a comfort-function goal (Puntillo et al, 2009).

Goal

Since pain is a subjective feeling, it cannot be measured objectively (APS, 2008). There is no pain intensity level if a client is unable to self-report (McCaffery, Herr, & Pasero, 2011). If self-reporting is feasible, behavioral responses should never be the foundation for judgments about pain management (Erstad et al., 2009).

For clients who are unable to self-report, behavioral responses may be useful in identifying the presence of pain (Bjoro & Herr, 2008). Pain reactions that might be seen include decreased hunger and difficulties breathing deeply, walking, sleeping, and doing activities of daily living.

Pain-related behaviors are quite individualistic and vary widely (McCaffery, Herr, & Pasero, 2011). These could include self-defense, self-focusing, and guarding behaviors; they could also include diversion behaviors like laughing or sobbing, as well as stiffness or tension in the muscles (Puntillo et al., 2009).

Patients may experience excruciating pain but remain stoic and motionless. Increases in heart rate, blood pressure, and respiratory rate can result from neurohumoral reactions linked to sudden acute pain (McCaffery,2011).

Nevertheless, physiological reactions, like elevated heart rate or blood pressure, are not sensitive markers of the presence and severity of pain because they cannot distinguish pain from other causes of distress, pathological conditions, homeostatic changes, or medication (McCaffery,2011).

Although other conclusions may be supported by behavioral or physiological signs, pain does not necessarily disappear just because these symptoms are absent (McCaffery, Herr, & Pasero, 2011).

Related Factors Elements

• Agents of injury (chemical, biological, physical, and psychological).

Suggested Nursing Outcome Results

• Pain Control, Comfort Level, and Pain Level

Example of a NOC result.

Pain Level as demonstrated by a numerical pain rating system. The most accurate way to determine the presence and severity of pain is through self-report (Pasero, 2011).

Note: Pain Level is the NOC Outcome label; due to the volume of research substantiating its usage, this article suggests using the self-report numerical pain rating scale in lieu of the NOC indicator scales.

Results for Clients

The client will specify the time frame.
For the patients who can give a self-report: Establish a comfort-function target and use a self-report pain tool to determine your present level of pain intensity. Report that your pain management regimen has no negative effects.

Explain nonpharmacological techniques that can be applied to assist in reaching the comfort-function objective.  Perform activities of recovery or ADLs easily. Describe how unrelieved pain will be managed. State ability to obtain sufficient amounts of rest and sleep.

Notify a member of the medical staff right away if there are adverse effects or if the pain level is continuously higher than the comfort-function target.

For the clients who is incapable of submitting a self-report:

Reduced pain-related behaviors; easy performance of recovery or ADLs based on the client’s condition; absence of analgesic side effects; no pain-related behaviors will be noticeable in the client who is totally unresponsive; a reasonable result is to demonstrate the absence of side effects associated with the recommended pain treatment plan.

Nursing Interventions Classification

Suggested NIC Interventions

Patient-Controlled Analgesia (PCA) Support, Pain Management, and Analgesic Administration. For example NIC Activities: Handling Pain Assure attentive analgesic treatment for clients; Conduct a thorough evaluation of pain, taking into account its location, features, start and duration, frequency, quality, intensity or severity, and contributing variables.

Nursing Interventions and Rationales

Ascertain whether the client is in pain during the first interview. Conduct and record a thorough pain assessment if there is pain, and then carry out or ask for permission to carry out pain management procedures in order to attain a suitable degree of comfort.

Location, quality, onset/duration, temporal profile, intensity, aggravating and mitigating factors, and the impact of pain on function and quality of life are all elements of this preliminary evaluation.

To identify the underlying cause of pain and the efficacy of treatment, it is essential to ascertain the location, temporal aspects, characteristics, intensity, and impact of pain on function and quality of life.

All of the client’s available pain information is included in this preliminary evaluation, which also supplies information for creating a customized pain treatment strategy. Self-report is thought to be the most accurate way to determine the existence and severity of pain. (Please consult the Hierarchy of Pain Measures, which will be discussed later, for an assessment method used with clients who are unable to self-report their pain.)

Determine the client’s level of pain intensity using a valid and trustworthy self-report pain instrument, like the numerical pain rating scale with a range of 0 to 10. Finding out whether the client is able to self-report is the first stage in the pain evaluation process. Ask the client to use a legitimate and trustworthy self-report pain tool to rate their level of discomfort or choose pain intensity descriptors.

The validity and reliability of single-dimension pain ratings as indicators of pain intensity level have been established by Breivik et al. (2008) and McCaffery, Herr, and Pasero (2011). The effective use of pain rating scales is frequently dictated by the nurse’s own attitude toward its usefulness, according to research on nursing attitudes and beliefs around pain assessment conducted by CEB & EBN.

Regularly check the client for the existence of pain; this is frequently done during activity and relaxation, as well as when a complete set of vital signs are gathered. Additionally, employ interventions or procedures that are likely to cause discomfort to gauge any pain.

EB: According to APS (2008), pain evaluation is just as significant as physiological vital signs. Both at rest (essential for comfort) and when moving (vital for function and lowering the client’s risk of cardiopulmonary and thromboembolic events), acute discomfort should be accurately measured.

Inquire about the client’s past experiences with pain, the efficacy of pain management techniques, reactions to analgesic drugs, including the occurrence of adverse effects, anxieties about addiction, anxiety, or pain and its treatment, and informational needs.

EBN: Getting a client’s unique pain history aids in determining possible variables that could affect the client’s willingness to report pain, as well as variables that could affect the client’s response to pain, anxiety, and the pharmacokinetics of analgesics.

Individualized pain management plans must take into account the client’s physical, mental, and physiological conditions; age; degree of anxiety or dread; surgical technique; client preferences and goals; and prior analgesic response.

Using a self-report pain instrument, ask the client to select a comfort-function goal, or pain level, that will enable them to carry out required or preferred tasks with ease. This objective will serve as the foundation for evaluating the efficacy of pain management strategies.

It will be impossible to set a comfort-function goal if the client is unable to submit a self-report. The creation of a customized pain management plan should primarily concentrate on the connection between functional objectives and pain level.

Reducing risk factors for post-operative cardiac and thromboembolic problems requires effective pain management with movements like coughing, deep breathing, and mobilization (Breivik et al., 2008). CEB & EBN: Poorly managed acute pain and immobilization are also risk factors for chronic post-trauma and post-surgical pain disorders.

Explain the negative consequences of unrelieved pain. CEB and EBN: Acute pain that is not eased may have psychological and physiological effects that contribute to unfavorable client outcomes. Inadequate treatment of acute pain can result in persistent pain syndrome, long-lasting physiological, psychological, and emotional suffering, immunological dysfunction, neurohumoral alterations, and neural remodeling.

For pain evaluation, use the Hierarchy of Pain Measures as a framework (McCaffery,2011): (1) seek the client’s self-report of pain; (2) assess the client’s condition and look for potential causes of pain (such as tissue damage, pathological conditions, or exposure to procedures/interventions that are believed to cause pain); (3) watch for behaviors that might suggest the presence of pain (such as facial expressions, crying, restlessness, and changes in activity); (4) assess physiological indicators, keeping in mind that these are the least sensitive indicators of pain and may be connected to conditions other than pain (such as shock, hypovolemia, and anxiety); and (5) perform an analgesic trial.

The ability to self-report, the underlying painful condition or procedure, and the degree of fear or anxiety must all be considered when assessing pain, which cannot be standardized. It has been demonstrated that some behaviors are suggestive of pain and can be used to gauge pain in clients who are unable to use a self-report pain instrument (such as the cognitively impaired client). But each person is different, and a behavior that can be a sign of suffering for one client might not be for another.

A surrogate with a thorough understanding of the client may be able to provide details regarding the underlying painful pathology and client-specific behaviors that could indicate discomfort. Although behavioral or physiological signs can be used to support other findings, their absence does not necessarily mean that pain is not there.

If the client is unable to self-report and has a pathological condition, tissue injury, or has had a procedure that is believed to cause pain, then assume that pain is present. Pain is linked to real or possible tissue damage, including diseases like cancer and medical procedures like surgery, trauma, and fractures. When a client does not self-report (such as when they are sedated, extremely ill, or cognitively challenged), the therapist should presume that pain is occurring and administer pain management techniques appropriately.

Conduct an analgesic trial for patients who exhibit behaviors that would suggest pain is present or who are unable to self-report and have underlying pathology or conditions that are deemed to be painful. If pain is deemed to be minor, provide a nonopioid; if pain is deemed to be moderate to severe, give an opioid. Reassess the client to determine the efficacy of the intervention within a given time frame based on pharmacokinetics (15 to 30 minutes for intravenous [IV], 30 minutes for subcutaneous, and 60 minutes for oral).

Use a valid and trustworthy behavioral pain tool (such as the Critical Care Observation Tool for critically ill patients or the Checklist of Nonverbal Pain Indicators for cognitively impaired elders) to evaluate behaviors that might indicate pain in clients who are able to exhibit behaviors but are unable to self-report their pain.

Clinical judgment must be used to assess the presence of pain if the client is unable to exhibit the necessary behaviors in the chosen behavioral tool (for example, is receiving goal-directed sedation or a neuromuscular blocking agent, or is paralyzed or unresponsive), behavioral observation tools should not be used, pain should be presumed to be present, and recommended analgesic dosages should be given.

The goal of the analgesic trial is to assist in confirming the existence of pain and serve as a foundation for creating a customized pain management strategy.  Find out what medications the client is currently taking. Obtain a comprehensive and accurate list of all the medications the client has taken or is currently taking.

Errors related to erroneous dosages, medications, missing elements of the home medication regimen, drug-drug interactions, and toxicity that may arise from combining incompatible medications or from allergies can all be avoided with accurate medication reconciliation. The physician will be able to determine from this history which medications have been used and whether they were successful in addressing the client’s pain.

Inform the client about the pain management strategy, which includes both pharmaceutical and nonpharmacological treatments, the evaluation and reevaluation procedure, possible adverse effects, and the significance of promptly reporting pain that has not been alleviated. A greater client awareness of the nature of pain, how it is treated, and the part the client must play in pain control is one of the most crucial first steps toward better pain management.

Treat acute pain with a multimodal strategy. Combining two or more drugs, or techniques, from various pharmacological groups that target various pathways of pain, such as opioid, nonopioid, and adjuvant analgesics, is known as multimodal analgesia . In particular, an opioid, acetaminophen, NSAID, anticonvulsant, local anesthetic, or combinations of some or all of these may be used in an acute pain multimodal regimen. This method has the benefit of allowing for the administration of each medicine at its lowest effective dose, which reduces or eliminates adverse effects such drowsiness, nausea, and respiratory depression.

Acknowledge that the best method for managing pain is the oral route. As soon as practical, switch to an oral analgesic if the client is receiving parenteral analgesia using an equianalgesic chart. It is advised to choose the least invasive delivery method that can effectively control pain. Due to its simplicity and the potential for comparatively stable blood levels, the oral route is always the recommended one . Almost anything that can be administered orally may also be administered via the rectal route, which can be used for clients who are unable to use the oral route.

The IV method is recommended for the quick management of severe pain since it offers the fastest time to peak serum concentration (6 to 10 minutes) . When accessible and appropriate, administer intraspinal analgesia, PCA, and perineural infusions as directed. It is advised to choose the least invasive delivery method that can effectively control pain. EBN: For all forms of pain, the oral route is the recommended method of administration and ought to be used whenever feasible; the majority of oral analgesics can be administered intrarectally if required. EBN: Lower initial postoperative pain with preoperative rectal NSAID administration.

For the quick management of severe acute pain, the intravenous route is recommended; for the management of postoperative pain related to some major surgical procedures, perineural and intraspinal analgesic approaches are recommended.  Refrain from administering painkillers via intramuscular (IM) injection. IM injections cause discomfort, inconsistent absorption, and fluctuating blood levels of the drug. Sterile abscesses and soft tissue and muscle fibrosis can result from repeated intramuscular injections. Additionally, an IM injection may cause nerve damage that results in chronic neuropathic pain.

Obtain a prescription to give an opioid analgesic if necessary for moderate to severe acute pain, and a nonopioid analgesic for mild to moderate pain. First-line analgesics for mild to moderate acute pain include nonopioids like NSAIDs and acetaminophen. When it comes to treating moderate to severe acute pain, opioids are the first-choice analgesics. Anticonvulsants may be administered to treat or prevent neuropathic pain, while local anesthetics are utilized for a wide range of acute pain types.

Handle intense discomfort in a thorough approach. For persistent pain that is anticipated to last for around 50% of the day, such as postoperative pain, analgesics are given continuously (ATC). For intermittent or breakthrough pain, PRN “as needed” dosage is suitable. Whenever feasible, give analgesics prior to painful operations (such as endotracheal suctioning, wound care, heel punctures, venipunctures, and peripherally implanted IV catheters) to avoid pain. Depending on the specific client’s condition and the intensity of the related pain, administer an IV opioid or topical local anesthetic. Despite studies showing its efficacy, IV catheter installation is one of the most common unpleasant procedures carried out in healthcare settings and at all ages, frequently without anesthesia.

Although endotracheal suctioning and wound care are recognized to be painful procedures, they are frequently carried out without analgesics. EBN: According to Brown (2009), topical anesthetic creams can efficiently and considerably reduce the discomfort associated with venipuncture and IV insertion. The severe discomfort connected to several routine procedures can be effectively reduced by intravenous opioids (Pasero et al., 2011b).

If the client is unable to self-report, administer additional analgesic dosages as directed to maintain the client’s pain level at or below the comfort-function target, or the intended outcome based on clinical judgment or behaviors. To provide comprehensive pain management, a PRN supplemental analgesic dose order is necessary in between regular doses (APS, 2008; Pasero et al, 2011b). Provide nursing attention only when the patient is at ease.

This is made easier when the analgesic’s peak time (highest serum concentration) is taken into account. Oral nonopioids and opioids peak at around 60 minutes, subcutaneous opioids peak at 30 minutes, and intravenous opioids and nonopioids peak at 15 to 30 minutes (Pasero et al., 2011b). The transdermal fentanyl patch takes effect 12 to 16 hours after application, and within 48 hours, blood levels stabilize (as much drug enters the body as is removed) (APS, 2008; DeSandre & Quest, 2009). Understanding peak time aids in determining when to conduct a review to make sure that sufficient pain relief has been achieved and that the analgesic and dosage were well tolerated (Pasero et al., 2011b).

Because moderate to severe pain and undesirable side effects severely reduce the client’s ability to participate in rehabilitation activities, this technique makes it easier to organize nursing care activities. Talk to the client about their concerns about addiction, side effects, and undertreated pain. Since clients frequently have a variety of concerns and misconceptions about pain and how to treat it, part of the treatment plan should include education about safe and effective ways to manage pain and its side effects as well as dispelling myths and misconceptions regarding the use of opioids.

During the administration of opioids, periodically check the patient’s respiratory condition, level of pain, and level of sedation. During the first 24 hours of opioid therapy, check on sedation and respiratory status every 1 to 2 hours. If respiratory status has remained stable without bouts of hypoventilation, check on it every 4 hours; otherwise, check on it more frequently as needed based on the client’s particular condition. Prior to the sedation assessment, do the respiratory examination by measuring the depth, regularity, and noiseness of breathing and recording the respiratory rate for 60 seconds.

Pediatrics

Determine whether pain is present using a valid and reliable pain scale that takes into account the child’s age, cognitive development, and capacity for self-reporting. CEB: Children may effectively measure pain at the age of eight by using self-report methods that correlate pain levels with numerical values, such as the Numerical Rating Scale. EBN: It has been demonstrated that scales that represent faces at different intensities of pain are valid and dependable in young children as young as three years old. The Oucher, FPS-R, and Wong-Baker FACES scales are a few examples. With these scales, the kid must choose the face on the scale that most accurately represents the pain they are feeling.

There are numerous behavioral observation strategies that can be used to identify pain in newborns, babies, and kids under four years old. As directed, administer analgesics. Pharmacological therapies are the first-line methods for managing pain in children, babies, and neonates, just like in adults. For the management of acute pain, a multimodal strategy involving both opioid and nonopioid analgesics is advised.  Pediatric patients take local anesthetics well, and there are several ways to deliver them. EB: Intraspinal and perineural analgesic treatments may be employed for major surgical procedures, and children as young as 4 years old may receive PCA.

Use anesthetics and opioid analgesics as prescribed in the right quantities to avoid procedural discomfort in newborns, babies, and kids. CEB & EB: Adequate preventive pain medication should be given to children clients undergoing endotracheal intubation, chest tube insertion, or other painful operations, just like it is for adults,

Apply a topical local anesthetic, such as LMX-4 or EMLA cream, before to venipuncturing infants, children, or newborns. Venipunctures are a painful and stressful treatment for young patients. EBN: Compared to heel punctures, topical anesthetics are more successful at reducing pain during venipuncture, circumcisions, arterial punctures, and percutaneous venous catheter placement.

Use human milk or oral sucrose and nonnutritional sucking (NNS) for the neonate’s short-term pain, such as venipuncture or heel stick. Compared to older kids, neonates especially preterm ones are more sensitive to pain. EB: In infants up to six months of age, oral sucrose temporarily induces analgesia . For venipuncture, oral sucrose and NNS work better than EMLA. Be aware that nursing has been demonstrated to lessen pain-related behavioral signs. CEB & EBN: However, oral sucrose is more beneficial than breastfeeding at reducing discomfort.

Home Care

Work with the client and caregivers to create the treatment plan. Incorporating clients into the care plan increases the chances of effective management. Create a comprehensive medication profile that includes all prescription drugs as well as over-the-counter drugs. Check for any medication interactions. Advise the patient not to combine drugs without a doctor’s permission. Painkillers can have serious adverse effects and have a substantial impact on other drugs. Certain pharmacological combinations are expressly forbidden.

Examine the client’s and family’s understanding of the risks and safety measures related to painkillers (such as using caution when operating machinery after taking opioids for the first time or after the dosage has been increased significantly). Opioids typically have cognitive adverse effects that go away a week after the first dosage or increase. Long-term opioid usage doesn’t seem to have an impact on cognitive function. EB: Pain alone may have a greater negative impact on cognitive test scores than oral opioid therapy.

Planning for Client/Family Education and Discharge: Note: When instructing clients, use the term “pain medicine” to avoid the bad connotations attached to the terms “drugs” and “narcotics.”

• Talk about the different discomforts that the term “pain” encompasses and invite the client to provide instances of pain they have previously experienced. Describe the pain rating scale’s objective and the pain evaluation procedure. Clients frequently find it challenging to define pain and explain their own experiences with it. Providing a thorough explanation of the evaluation procedure, including the use of scales, and using different language can guarantee that an accurate treatment plan is created.
• Instruct the client to rate the severity of their current or previous pain using the self-report pain tool. Ask the client to choose a pain level on the self-report questionnaire that will enable them to complete required or desired recovery tasks with a reasonable amount of ease (e.g., turn, cough, deep breathe, ambulate, participate in physical therapy) in order to set a comfort-function target.
• The client should take pain-relieving measures or alert a member of the healthcare team if the level of pain is continuously higher than the comfort-function target so that fast and efficient pain management treatments can be put in place. The treatment strategy is guided by the use of comfort-function goals. Adjustments are made based on the client’s reaction and the accomplishment of the rehabilitation or recovery objectives.
• Provide written resources on pain management that explain how to take analgesics and how to utilize a pain rating scale. Talk about the entire pharmacological and nonpharmacological treatment plan, including the prescription schedule for ATC administration and additional dosages, as well as the usage of tools and supplies.
• Assess the client’s capacity to press the right button if PCA is prescribed. Inform the staff and clients that the PCA button is exclusively for client usage. The precision and safety of administering medication are increased by appropriate teaching.
• Stress how crucial it is to use painkillers in order to preserve the comfort function objective. Helping clients manage their pain and keep it from becoming unmanageable will increase their capacity to meet their rehabilitation objectives.

References

1. American Geriatric Society (AGS). Panel on Persistent Pain in Older Persons: The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(S205):1–20.
2. American Pain Society (APS). Principles of analgesic use in acute and chronic pain, ed 6. Glenview, IL: Author; 2008.
3. American Society of Anesthesiologists (ASA). Practice guidelines for perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2006;104(5):1081–1093.
4. American Society of Anesthesiologists (ASA). Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology. 2009;110:218–230.
5. Anand, K.J. Pharmacological approaches to the management of pain in the neonatal intensive care unit. J Perinatol. 2007;27:S4–S11.
6. Arbour, C., Gelinas, C. Are vital signs valid indicators for the assessment of pain in postoperative cardiac surgery ICU adults? Intensive Crit Care Nurs. 2010;26(2):83–90.