Subjective

Pain is a subjective experience, and its presence cannot be proved or disproved (McCaffery, Herr, & Pasero, 2011). Self-report is the most reliable method of evaluating pain presence and intensity (APS, 2008). A client with cognitive ability who is able to speak or provide information about pain in other ways, such as pointing to numbers or words, should use a self-report pain tool (e.g., Numerical Rating Scale [NRS]) to identify the current pain intensity and establish a comfort-function goal (McCaffery, Herr, & Pasero, 2011; Puntillo et al, 2009).

Objective

Pain is a subjective experience, and objective measurement is impossible (APS, 2008; Breivik et al, 2008). If a client cannot provide a self-report, there is no pain intensity level (McCaffery, Herr, & Pasero, 2011). Behavioral responses should never serve as the basis for pain management decisions if self-report is possible (Erstad et al, 2009; Pasero, 2009a). However, observation of behavioral responses may be helpful in recognition of pain presence for clients who are unable to provide a self-report (Bjoro & Herr, 2008; Herr et al, 2006). Observable pain responses may include loss of appetite and inability to deep breathe, ambulate, sleep, and perform ADLs. Pain-related behaviors vary widely and are highly individual (McCaffery, Herr, & Pasero, 2011). They may include guarding, self-protective behavior, and self-focusing; and distraction behavior ranging from crying to laughing, as well as muscle tension or rigidity (Puntillo et al, 2009). Clients may be stoic and lie completely still despite having severe pain. Sudden acute pain may be associated with neurohumoral responses that can lead to increases in heart rate, blood pressure, and respiratory rate (McCaffery, Herr, & Pasero, 2011). However, physiological responses, such as elevated blood pressure or heart rate, are not sensitive indicators of pain presence and intensity as they do not discriminate pain from other sources of distress, pathological conditions, homeostatic changes, or medications (Arbour & Gelinas, 2010; Gelinas & Arbour, 2009; McCaffery, Herr, & Pasero, 2011). Behavioral or physiological indicators may be used to confirm other findings; however, the absence of these indicators does not mean that pain is absent (McCaffery, Herr, & Pasero, 2011).

Note: The defining characteristics are modified from the work of NANDA-I.

Client Will (Specify Time Frame)

• Determine if the client is experiencing pain at the time of the initial interview. If pain is present, conduct and document a comprehensive pain assessment and implement or request orders to implement pain management interventions to achieve a satisfactory level of comfort. Components of this initial assessment include location, quality, onset/duration, temporal profile, intensity, aggravating and alleviating factors, and effects of pain on function and quality of life. Determining location, temporal aspects, pain intensity, characteristics, and the impact of pain on function and quality of life are critical to determine the underlying cause of pain and effectiveness of treatment (Breivik et al, 2008; McCaffery, Herr, & Pasero, 2011; Ming Wah, 2008). This initial assessment includes all pain information that the client can provide and provides data for the development of the individualized pain management plan. Self-report is considered the single most reliable indicator of pain presence and intensity (APS, 2008; McCaffery, Herr, & Pasero, 2011). (Please refer to the Hierarchy of Pain Measures presented later for assessment approach in clients who are unable to provide self-report of pain.)

• Assess pain intensity level in a client using a valid and reliable self-report pain tool, such as the 0-10 numerical pain rating scale. The first step in pain assessment is to determine if the client can provide a self-report. Ask the client to rate pain intensity or select descriptors of pain intensity using a valid and reliable self-report pain tool (Breivik et al, 2008; McCaffery, Herr, & Pasero, 2011; Pasero, 2009a). EB: Single-dimension pain ratings are valid and reliable as measures of pain intensity level (Breivik et al, 2008; McCaffery, Herr, & Pasero, 2011). CEB & EBN: Investigation of nursing attitudes and beliefs about pain assessment revealed that effective use of pain rating scales is often determined by the nurse’s personal attitude about its effectiveness (Layman-Young, Horton, & Davidhizar, 2006; McCaffery, Herr, & Pasero, 2011).

• Assess the client for pain presence routinely; this is often done at the same time as when a full set of vital signs are obtained, and during activity and rest. Also assess for pain with interventions or procedures likely to cause pain. EB: Pain assessment is as important as physiological vital signs (APS, 2008). Acute pain should be reliably assessed both at rest (important for comfort) and during movement (important for function and decreased client risk of cardiopulmonary and thromboembolic events) (Breivik et al, 2008; McCaffery, Herr, & Pasero, 2011).

• Ask the client to describe prior experiences with pain, effectiveness of pain management interventions, responses to analgesic medications including occurrence of side effects, and concerns about pain and its treatment (e.g., fear about addiction, worries, or anxiety) and informational needs. EBN: Obtaining an individualized pain history helps to identify potential factors that may influence the client’s willingness to report pain, as well as factors that may influence pain intensity, the client’s response to pain, anxiety, and pharmacokinetics of analgesics (Deane & Smith, 2008; Pasero et al, 2011b). Pain management regimens must be individualized to the client and consider medical, psychological, and physical condition; age; level of fear or anxiety; surgical procedure; client goals and preference; and previous response to analgesics (Bhavani-Shankar & Oberol, 2009; Pasero et al, 2011b).

• Ask the client to identify a comfort-function goal, a pain level, on a self-report pain tool, that will allow the client to perform necessary or desired activities easily. This goal will provide the basis to determine effectiveness of pain management interventions. If the client is unable to provide a self-report, it will not be possible to establish a comfort-function goal. The relationship between pain level and functional goals should be a major focus of the development of individualized pain management plans (McCaffery, Herr, & Pasero, 2011). EB: Effective pain relief with function such as mobilization, coughing, and deep breathing is critical for decreasing risk factors for cardiopulmonary and thromboembolic complications after surgery (Breivik et al, 2008). CEB & EBN: Immobilization and poorly managed acute pain also are risk factors for persistent (chronic) post-surgical and post-trauma pain syndromes (Pasero, 2011; Stubhaug & Breivik, 2007).

• Describe the adverse effects of unrelieved pain. CEB & EBN: Unrelieved acute pain can have physiological and psychological consequences that facilitate negative client outcomes. Ineffective management of acute pain has the potential for neurohumoral changes, neuronal remodeling, an impact on immune function, and long-lasting physiological, psychological, and emotional distress, and it may lead to persistent pain syndromes (Brennan, Carr, & Cousins, 2007; Evans et al, 2009; Pasero, 2011; Pasero & Portenoy, 2011).

• Use the Hierarchy of Pain Measures as a framework for pain assessment (McCaffery, Herr, & Pasero, 2011; Pasero, 2009a): (1) attempt to obtain the client’s self-report of pain; (2) consider the client’s condition and search for possible causes of pain (e.g., presence of tissue injury, pathological conditions, or exposure to procedures/interventions that are thought to result in pain); (3) observe for behaviors that may indicate pain presence (e.g., facial expressions, crying, restlessness, and changes in activity); (4) evaluate physiological indicators, with the understanding that these are the least sensitive indicators of pain and may be related to conditions other than pain (e.g., shock, hypovolemia, anxiety); and (5) conduct an analgesic trial. CEB & EBN: Pain assessment cannot be standardized and must take into account ability to provide self-report, underlying painful condition or procedure, and level of fear or anxiety (Herr et al, 2006; Pasero, 2009a). Certain behaviors have been shown to be indicative of pain and can be used to assess pain in clients who cannot use a self-report pain tool (e.g., the cognitively impaired client) (Herr et al, 2006; McCaffery, Herr, & Pasero, 2011; Puntillo et al, 2009). However, behaviors vary among individuals, and behavior that may indicate pain in one client may not indicate pain for another (McCaffery, Herr, & Pasero, 2011). A surrogate who knows the client well may be able to provide information about the underlying painful pathology and behaviors specific to the client that may signal pain (Pasero, 2009a). Behavioral or physiological indicators may be used to confirm other findings; however, the absence of these indicators does not indicate the absence of pain (McCaffery, Herr, & Pasero, 2011; Pasero, 2009a).

• Assume that pain is present if the client is unable to provide a self-report and has tissue injury, a pathological condition, or has undergone a procedure that is thought to produce pain. Pain is associated with actual or potential tissue damage such as pathological conditions (e.g., cancer) and procedures (e.g., surgery or trauma, fractures). In the absence of self-report (e.g., anesthetized, critically ill, or cognitively impaired client), the clinician should assume pain is present and implement pain management interventions accordingly (McCaffery, Herr, & Pasero, 2011; Pasero, 2009a).

• Conduct an analgesic trial for clients who are unable to provide self-report and have underlying pathology/condition that is thought to be painful, or who demonstrate behaviors that may indicate pain is present. Administer a nonopioid if pain is thought to be mild and an opioid if pain is thought to be moderate to severe. Reassess the client to evaluate intervention effectiveness within a specific period of time based on pharmacokinetics (intravenous [IV] 15 to 30 minutes, subcutaneous 30 minutes, oral 60 minutes). EBN: For clients who are able to demonstrate behaviors but are unable to provide self-report of pain, use a valid and reliable behavioral pain tool (e.g., Critical Care Observation Tool in critically ill or Checklist of Nonverbal Pain Indicators in cognitively impaired elders) to assess behaviors that may indicate pain (McCaffery, Herr, & Pasero, 2011). If client is unable to demonstrate the requisite behaviors in the selected behavioral tool (e.g., is receiving goal-directed sedation or a neuromuscular blocking agent, or is paralyzed or unresponsive), clinical judgment must be used to evaluate pain presence, behavioral observation tools should not be used, pain should be assumed to be present, and recommended analgesic doses should be administered (McCaffery, Herr, & Pasero, 2011; Pasero, 2009b). The purpose of the analgesic trial is to help confirm the presence of pain and provide a basis for the development of an individualized pain management plan (Pasero, 2009a).

• Determine the client’s current medication use. Obtain an accurate and complete list of medications the client is taking or has taken. Accurate medication reconciliation can prevent errors associated with incorrect medications, dosages, omission of components of the home medication regimen, drug-drug interactions, and toxicity that can occur when incompatible drugs are combined or when allergies are present. This history will provide the clinician with an understanding of what medications have been tried and were or were not effective in treating the client’s pain (APS, 2008; Pasero et al, 2011b).

• Explain to the client the pain management approach, including pharmacological and nonpharmacological interventions, the assessment and reassessment process, potential side effects, and the importance of prompt reporting of unrelieved pain. One of the most important steps toward improved control of pain is a better client understanding of the nature of pain, its treatment, and the role the client needs to play in pain control (APS, 2008).

• Manage acute pain using a multimodal approach. Multimodal analgesia combines two or more medications, or methods, from different pharmacological classes that target different mechanisms along the pain pathway, including opioid, nonopioid, and adjuvant analgesics (Pasero & Portenoy, 2011; Pasero et al, 2011b). Specifically, an acute pain multimodal regimen may include an opioid, acetaminophen, a nonsteroidal antiinflammatory drug (NSAID), an anticonvulsant, a local anesthetic, or combinations of some or all of these (Pasero et al, 2011b). The advantage of this approach is that the lowest effective dose of each drug can be administered, resulting in fewer or less severe side effects such as nausea, sedation, and respiratory depression (APS, 2008; Pasero et al, 2011b).

• Recognize that the oral route is preferred for pain management interventions. If the client is receiving parenteral analgesia, use an equianalgesic chart to convert to an oral analgesic as soon as possible. The least invasive route of administration capable of providing adequate pain control is recommended (Pasero et al, 2011b). The oral route is always the preferred route because of its convenience and the relatively steady blood levels that can result (AGS, 2009). The rectal route may be used in clients who are unable to use the oral route; almost anything that can be given orally can be given rectally (Pasero et al, 2011b). The IV route provides the most rapid time to peak serum concentration (6 to 10 minutes) and is preferred for rapid control of severe pain (AGS, 2009; Pasero et al, 2011b).

• Provide PCA, perineural infusions, and intraspinal analgesia as ordered, when appropriate and available. The least invasive route of administration capable of providing adequate pain control is recommended (Pasero et al, 2011b). EBN: The oral route is the preferred route of administration for all types of pain and should be used whenever possible; most of the analgesics given orally may be given rectally if necessary (Pasero, 2010a). EBN: Preoperative rectal administration of an NSAID reduced acute postoperative pain (Bahar et al, 2010); the IV route is preferred for rapid control of severe acute pain; perineural and intraspinal analgesic techniques are indicated for the control of postoperative pain associated with some major surgical procedures (Pasero et al, 2011b).

• Avoid giving pain medication by the intramuscular (IM) route of administration. IM injections are painful, result in unreliable absorption, and lead to variable blood levels of the administered medication (APS, 2008; Pasero et al, 2011b). Repeated IM injections can cause sterile abscesses and fibrosis of muscle and soft tissue. IM injection also may lead to nerve injury with subsequent chronic neuropathic pain (APS, 2008; Pasero et al, 2011b). CEB: PCA was more effective in controlling pain than on-demand IM injections (Bainbridge, Martin, & Cheng, 2006).

• Obtain a prescription to administer a nonopioid analgesic for mild to moderate pain and an opioid analgesic if indicated for moderate to severe acute pain. Nonopioids, such as acetaminophen and NSAIDs, are first-line analgesics for the treatment of mild and some moderate acute pain (Pasero, Portenoy, & McCaffery, 2011). Opioids are first-line analgesics for the treatment of moderate to severe acute pain (APS, 2008; DeSandre & Quest, 2009; Ming Wah, 2008; Pasero et al, 2011b). Local anesthetics are used for a wide variety of types of acute pain, and anticonvulsants may be added to treat or prevent neuropathic pain (Pasero et al, 2011a).

• Treat acute pain in a comprehensive manner. Analgesics are administered around-the-clock (ATC) for continuous pain (expected to be present approximately 50% of the day, such as postoperative pain) (DeSandre & Quest, 2009; Pasero, 2010b). PRN “as needed” dosing is appropriate for intermittent or breakthrough pain (APS, 2008; Pasero, 2010b).

• Prevent pain by administering analgesia before painful procedures whenever possible (e.g., endotracheal suctioning, wound care, heel puncture, venipunctures, and peripherally inserted IV catheters). Use a topical local anesthetic or IV opioid as determined by individualized client status and severity of associated pain. IV catheter placement is one of the most common painful procedures performed in all ages and health care settings, often without anesthetic, despite research demonstrating effectiveness (Valdovinos et al, 2009). Wound care and endotracheal suctioning are known to be painful procedures but are often performed without analgesia (Pasero et al, 2011b). EBN: Topical anesthetic creams can effectively decrease venipuncture and IV insertion pain significantly (Brown, 2009; Pasero et al, 2011a; Valdovinos et al, 2009). IV opioids can effectively decrease the severe pain associated with many common procedures (Pasero et al, 2011b).

• Administer supplemental analgesic doses as ordered to keep the client’s pain level at or below the comfort-function goal, or desired outcome based on clinical judgment or behaviors if client is unable to provide a self-report. An order for PRN supplemental analgesic doses between regular doses is essential in providing comprehensive pain management (APS, 2008; Pasero et al, 2011b).

• Perform nursing care when the client is comfortable. This is facilitated when the peak time (maximum serum concentration) of the analgesic is considered. The peak time is approximately 60 minutes for oral nonopioids and opioids, 30 minutes for subcutaneous opioids, and 15 to 30 minutes for IV nonopioids and opioids (Pasero et al, 2011b). Transdermal fentanyl patch becomes effective in 12 to 16 hours after application, with steady-state blood levels (as much drug is entering as is being eliminated from the body) in approximately 48 hours (APS, 2008; DeSandre & Quest, 2009). Knowing peak time helps guide the timing of reassessment to ensure that adequate pain relief has been obtained and that the analgesic and dose was tolerated without side effects (Pasero et al, 2011b). This approach facilitates planning nursing care activities because moderate to severe pain and unacceptable side effects significantly diminish the client’s ability to participate in recovery activities (McCaffery, Herr, & Pasero, 2011).

• Discuss the client’s fears of undertreated pain, side effects, and addiction. Clients often have multiple fears and misconceptions regarding pain and its treatment; therefore, education about how pain and side effects can be controlled safely and effectively and correction of myths and misconceptions about the use of opioids should be included as part of the treatment plan (McCaffery, Herr, & Pasero, 2011; Pasero et al, 2011b). Addiction is unlikely when clients take opioids for pain management (APS, 2008; DeSandre & Quest, 2009; McCaffery, Herr, & Pasero, 2011; Pasero et al, 2011b). CEB & EBN: Clients often harbor unrealistic anxieties and misconceptions about the use of opioids, risk of addiction, and management of side effects (Brennan, Carr, & Cousins, 2007; McCaffery, Herr, & Pasero, 2011).

• Assess pain level, sedation level, and respiratory status at regular intervals during opioid administration (Jarzyna et al, 2011; Pasero, 2009a; Pasero et al, 2011b). Assess sedation and respiratory status every 1 to 2 hours during the first 24 hours of opioid therapy, then every 4 hours if respiratory status has been stable without episodes of hypoventilation, or more frequently as determined by individualized client status. Conduct the respiratory assessment before sedation assessment by evaluating the depth, regularity, and noisiness of respiration, and counting respiratory rate for 60 seconds (Pasero, 2009b). Awaken sleeping clients for assessment if the respiration is inadequate (e.g., if respirations are shallow, ineffective, irregular, or noisy [snoring], or periods of apnea occur). Snoring indicates respiratory obstruction and warrants prompt arousal, repositioning, and evaluation of respiratory risk factors (Pasero, 2009a). Discontinue titration or continuous opioid infusions immediately, and decrease subsequent opioid doses by 25% to 50% if the client develops excessive sedation (Pasero, 2009b, 2010c; Pasero et al, 2011b). EBN: Life-threatening respiratory depression is the most serious of opioid side effects and is preceded by excessive sedation (Pasero, 2009b). EBN: Although all clients receiving opioids for pain management are at risk for excessive sedation and respiratory depression, some are identified as particularly high risk (e.g. those with obstructive sleep apnea or preexisting pulmonary dysfunction or other comorbidities) (ASA, 2006; Jarzyna et al, 2011). CEB & EBN: Clients are also at the highest risk for opioid-induced respiratory depression during the first 24 hours of therapy, when the dose is increased, the opioid has been changed to a different opioid, or within the first 4 hours of arrival to the nursing care unit from PACU (ASA, 20006, 2009; Jarzyna et al, 2011 Lucas, Vlahos, & Ledgerwood, 2007; Pasero, 2009b). Opioid-induced respiratory depression can be prevented by performing systematic sedation assessment and reducing the opioid dose when excessive sedation is identified (Jarzyna et al, 2011; Pasero, 2009b; Pasero et al, 2011b). EBN: Use a valid and reliable sedation tool that identifies distinct changes in the client’s level of alertness and arousability and that provides guidance for nursing action at each level of sedation (Dempsey et al, 2009; Jarzyna et al, 2011; Nisbet & Mooney-Cotter, 2009). EBN: The goal of care is considered when selecting a sedation scale; sedation scales that are used to assess purposeful, goal-directed sedation include other parameters such as agitation and are not recommended when the desired client outcome is prevention of sedation (Dempsey et al, 2009; Jarzyna et al, 2011; Nisbet & Mooney-Cotter, 2008; Pasero, 2009b; Pasero et al, 2011b).

• Ask the client to report side effects, such as nausea and pruritus, and to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to prevent and improve these conditions and functions. Obtain a prescription for a combination stool softener plus peristaltic stimulant to prevent opioid-induced constipation. Opioids cause constipation by decreasing intestinal motility and reducing mucosal secretions (Panchal, Muller-Schwefe, & Wurzelmann, 2007). Constipation is one of the most common side effects of opioid therapy and can become significant problem in pain management, affecting whether or not a client adheres to the treatment plan. Prevention and early detection are much easier than management of opioid-induced constipation (Pasero et al, 2011b).

• Review the client’s pain flowsheet and medication administration record to evaluate effectiveness of pain relief, previous 24-hour opioid requirements, and occurrence of side effects. EBN: Systematic tracking of pain is an important factor in improving pain management and making adjustments to the pain management regimen (McCaffery, Herr, & Pasero, 2011). If pain is constant, analgesics should be administered ATC (Pasero, 2010b). If a previous dose was safe but ineffective, obtain an order to increase the dose by 25% to 50% for a moderate effect and by 50% to 100% for a greater effect (Pasero et al, 2011b).

• Obtain orders to increase or decrease opioid doses as needed; base analgesic and dose on the client’s report of pain severity (clinical judgment of effectiveness if the client is unable to provide a self-report), response to the previous dose in terms of pain relief, occurrence of side effects, and ability to perform the activities of recovery or ADLs. It is important that nurses knowledgeable in pain management have an “as needed” range of opioid doses available to provide appropriate pain relief (Pasero et al, 2011b). Policies or protocols that require clinicians to begin at a certain opioid dose or administer a specific dose based on pain intensity levels are inappropriate and unsafe (Pasero, 2010c; Pasero et al, 2011b). Safe and effective pain management requires opioid dose adjustment based on individualized, adequate pain and sedation assessment, opioid administration, and evaluation of the response to treatment (Pasero, 2009b). This ability to adjust the dose based on client assessment requires knowledge about opioid action, onset, time to peak serum concentration, duration of action, and potential side effects (Pasero et al, 2011b).

• When the client is able to tolerate oral intake, obtain a prescription to change analgesics to the oral route of administration; use an equianalgesic chart to determine the initial dose and adjust for incomplete cross tolerance. The oral route is preferred because it is the most convenient and cost effective (APS, 2008; Pasero et al, 2011b). Equianalgesic doses (doses of opioids that are approximately equal to one another in their ability to provide pain relief) should be used when changing from one opioid or route of administration to another to help prevent loss of pain control from underdosing and side effects from overdosing (Pasero et al, 2011b).

• In addition to administering analgesics, support the client’s use of nonpharmacological methods to help control pain, such as distraction, imagery, relaxation, and application of heat and cold. Cognitive-behavioral (mind-body) strategies can restore the client’s sense of self-control, personal efficacy, and active participation in his or her own care (APS, 2008; Bruckenthal, 2010).

• Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions. EBN: Pain causes cognitive impairment (Pasero et al, 2011b). Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions (APS, 2008).

Client Will (Specify Time Frame)

• Determine if the client is experiencing pain at the time of the initial interview. If pain is present, conduct and document a comprehensive pain assessment and implement or request orders to implement pain management interventions to achieve a satisfactory level of comfort. Components of this initial assessment include location, quality, onset/duration, temporal profile, intensity, aggravating and alleviating factors, and effects of pain on function and quality of life. Determining location, temporal aspects, pain intensity, characteristics, and the impact of pain on function and quality of life are critical to determine the underlying cause of pain and effectiveness of treatment (Breivik et al, 2008; McCaffery, Herr, & Pasero, 2011; Ming Wah, 2008). It is very important to ask clients with chronic pain to describe the quality of their pain to determine the presence of neuropathic pain, which is characterized by distinctive descriptors, such as “sharp,” “shooting,” or “burning” (McCaffery, Herr, & Pasero, 2011). The initial assessment includes all pain information that the client can provide and provides data for determining the type of pain and the development of the individualized pain management plan that addresses pain in a comprehensive manner. Self-report is considered the single most reliable indicator of pain presence and intensity (APS, 2008; McCaffery, Herr, & Pasero, 2011). Please refer to the Hierarchy of Pain Measures later for assessment approach in clients who are unable to provide self-report of pain.

• Assess pain intensity level in a client using a valid and reliable self-report pain tool, such as the 0-10 numerical pain rating scale. Ask the client to rate pain intensity or select descriptors of pain intensity using a valid and reliable self-report pain tool (Breivik et al, 2008; McCaffery, Herr, & Pasero, 2011; Pasero, 2009a). EB: Single-dimension pain ratings are valid and reliable as measures of pain intensity level (Breivik et al, 2008; McCaffery, Herr, & Pasero, 2011). CEB & EBN: Investigation of nursing attitudes and beliefs about pain assessment revealed that effective use of pain rating scales is often determined by the nurse’s personal attitude about its effectiveness (Layman-Young, Horton, & Davidhizar, 2006; McCaffery, Herr, & Pasero, 2011).

• Ask the client to describe prior experiences with pain, effectiveness of pain management interventions, responses to analgesic medications including occurrence of side effects, and concerns about pain and its treatment (e.g., fear about addiction, worries, or anxiety) and informational needs. EBN: Obtaining an individualized pain history helps to identify potential factors that may influence the client’s willingness to report pain, as well as factors that may influence pain intensity, the client’s response to pain, anxiety, and pharmacokinetics of analgesics (Deane & Smith, 2008; McCaffery, Herr, & Pasero, 2011). Pain management regimens must be individualized to the client and consider medical, psychological, and physical condition; age; level of fear or anxiety; client goals and preference; and previous response to analgesics (Pasero et al, 2011b).

• Describe the adverse effects of persistent unrelieved pain. CEB & EBN: Pain can have physiological and psychological consequences that facilitate negative client outcomes. Unrelieved pain can result in suppressed immune function, which can lead to infection, increased tumor growth, and other complications (Brennan, Carr, & Cousins, 2007; Evans et al, 2009; Herr & Titler, 2009; Pasero & Portenoy, 2011). Clients with persistent pain, or its inadequate treatment, often experience functional impairment, depression, anxiety, decreased socialization, sleep disturbances, disruption in relationships (work, family, social), and decreased quality of life (Closs et al, 2008; McDermott et al, 2006).

• Ask the client to identify the pain level, on a self-report pain tool, that will allow the client to perform desired activities and achieve an acceptable quality of life. This comfort-function goal will provide the basis to determine effectiveness of the individualized pain management plan. If the client is unable to provide a self-report, it will not be possible to establish a comfort-function goal. Comfort-function goals should be established for managing pain to a level that allows improved function (e.g., performance of desired activities), decreased psychosocial suffering, and achievement of an acceptable quality of life (AGS, 2009; McCaffery, Herr, & Pasero, 2011).

• Assess the client for the presence of pain routinely; this is often done at the same time as when a full set of vital signs are obtained in the inpatient setting. Assess pain during both activity and rest. EB: Pain assessment is as important as physiological vital signs (APS, 2008). Pain should be assessed both at rest (important for comfort) and during movement (important for maximum function) (Breivik et al, 2008; McCaffery, Herr, & Pasero, 2011). Regular assessment of clients with chronic pain is critical because changes in the underlying pain condition, presence of comorbidities, and changes in psychosocial circumstances can affect pain intensity and characteristics and require revision of the pain management plan (Chou et al, 2009).

• Ask the client to maintain a diary (if able) of pain ratings, timing, precipitating events, medications, and effectiveness of pain management interventions. EBN: Systematic tracking of pain has been demonstrated to be an important factor in improving pain management (Hager & Brockopp, 2009; McCaffery, Herr, & Pasero, 2011).

• Use the Hierarchy of Pain Measures as a framework for pain assessment (McCaffery, Herr, & Pasero, 2011; Pasero, 2009a): (1) attempt to obtain the client’s self-report of pain; (2) consider the client’s condition and search for possible causes of pain (e.g., presence of tissue injury, pathological conditions, or exposure to procedures/interventions that are thought to result in pain); (3) observe for behaviors that may indicate pain presence (e.g., facial expressions, crying, restlessness, and changes in activity); (4) evaluate physiological indicators, with the understanding that these are the least sensitive indicators of pain and may be related to conditions other than pain (e.g., shock, hypovolemia, anxiety); and (5) conduct an analgesic trial. CEB & EBN: Pain assessment cannot be standardized and must take into account ability to provide self-report, underlying painful condition or procedure, and level of fear or anxiety (Herr et al, 2006; Pasero, 2009a). Certain behaviors have been shown to be indicative of pain and can be used to assess pain in clients who cannot use a self-report pain tool (e.g., the cognitively impaired client) (Herr et al, 2006; McCaffery, Herr, & Pasero, 2011; Puntillo et al, 2009). However, behaviors vary among individuals, and behavior that may indicate pain in one client may not indicate pain for another (McCaffery, Herr, & Pasero, 2011). A surrogate who knows the client well may be able to provide information about the underlying painful pathology and behaviors specific to the client that may signal pain (Pasero, 2009a). Behavioral or physiological indicators may be used to confirm other findings; however, the absence of these indicators does not mean that pain is absent (McCaffery, Herr, & Pasero, 2011; Pasero, 2009a).

• Assume that pain is present if the client is unable to provide a self-report and has tissue injury or a pathological condition or has undergone a procedure that is thought to produce pain. Pain is associated with actual or potential tissue damage such as pathological conditions (e.g., cancer) and procedures (e.g., surgery or trauma, fractures). In the absence of self-report (e.g., anesthetized, critically ill, or cognitively impaired client), the clinician should assume pain is present and implement pain management interventions accordingly (McCaffery, Herr, & Pasero, 2011; Pasero, 2009a).

• Conduct an analgesic trial for clients who are unable to provide self-report and have underlying pathology/condition that is thought to be painful, or who demonstrate behaviors that may indicate pain is present. Administer a nonopioid if pain is thought to be mild and an opioid if pain is thought to be moderate to severe. Reassess the client to evaluate intervention effectiveness within a specific period of time based on pharmacokinetics (intravenous [IV] 15 to 30 minutes; subcutaneous 30 minutes; oral 60 minutes). EBN: For clients who are able to demonstrate behaviors but are unable to provide self-report of pain, use a valid and reliable behavioral pain tool (e.g., Checklist of Nonverbal Pain Indicators in cognitively impaired elders) to assess behaviors that may indicate pain (McCaffery, Herr, & Pasero, 2011). If client is unable to demonstrate the requisite behaviors in the selected behavioral tool, clinical judgment must be used to evaluate pain presence, behavioral observation tools should not be used, pain should be assumed to be present, and recommended analgesic doses should be administered (McCaffery, Herr, & Pasero, 2011; Pasero, 2009a). The purpose of the analgesic trial is to help confirm the presence of pain and provide a basis for the development of an individualized pain management plan (Pasero, 2009a).

• Determine the client’s current medication use. Obtain an accurate and complete list of medications the client is taking or has taken. Accurate medication reconciliation can prevent withdrawal and errors associated with incorrect medications, dosages, omission of components of the home medication regimen, drug-drug interactions, and toxicity that can occur when incompatible drugs are combined or when allergies are present. A history will provide the clinician with an understanding of what medications have been tried and were, or were not, effective in treating the client’s pain (APS, 2008; Pasero et al, 2011b).

• Explain to the client the pain management approach that has been ordered, including therapies, medication administration, side effects, and complications. One of the most important steps toward improved control of pain is a better client understanding of the nature of pain, its treatment, and the role the client needs to play in pain control (Pasero et al, 2011b).

• Discuss the client’s fears of undertreated pain, addiction, and overdose. Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan (McCaffery, Herr, & Pasero, 2011). Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with addiction (APS, 2008; McCaffery, Herr, & Pasero, 2011). Addiction is unlikely when clients take opioids for pain relief (McCaffery, Herr, & Pasero, 2011; Pasero et al, 2011b).

• Manage chronic pain using a multimodal approach. Multimodal analgesia combines two or more medications, or methods, from different pharmacological classes that target different mechanisms along the pain pathway (Pasero & Portenoy, 2011; Pasero et al, 2011b). Specifically, a chronic pain multimodal regimen may include an anticonvulsant, antidepressant, local anesthetic, and opioid (Dworkin et al, 2010; Pasero et al, 2011a, 2011b; Turk, Wilson, & Cahana, 2011). The advantage of this approach is that the lowest effective dose of each drug can be administered, resulting in fewer or less severe side effects, such as sedation and nausea (APS, 2008; Pasero et al, 2011a, 2011b).

• Recognize that the oral route is preferred for pain management interventions. If the client is receiving parenteral analgesia, use an equianalgesic chart to convert to an oral analgesic as soon as possible. The least invasive route of administration capable of providing adequate pain control is recommended (Pasero et al, 2011b). The oral route is always the preferred route because of its convenience and the relatively steady blood levels that can result (AGS, 2009). The rectal route may be used in clients who are unable to use the oral route; almost anything that can be given orally can be given rectally (Pasero et al, 2011b). The IV route provides the most rapid time to peak serum concentration (6 to 10 minutes) and is preferred for rapid control of severe pain (AGS, 2009; Pasero et al, 2011b).

• Avoid giving pain medication intramuscularly (IM). Please refer to the care plan on Acute Pain for rationales on why not to utilize IM injections.

• Recognize that many clients with chronic pain have neuropathic pain. (Please refer to assessment earlier.) Treat neuropathic pain with adjuvant analgesics, such as anticonvulsants, antidepressants, and topical local anesthetics. EB: First-line analgesics for neuropathic pain belong to the adjuvant analgesic group and include anticonvulsants, antidepressants, and some topical local anesthetics (Dworkin et al, 2010).

• Administer a nonopioid analgesic for mild to moderate chronic pain, such as osteoarthritis or cancer pain. Nonopioids, such as acetaminophen and NSAIDs, are first-line analgesics for the treatment of mild and moderate pain conditions, such as cancer pain and osteoarthritis pain (AGS, 2009; APS, 2008; Pasero, Portenoy, & McCaffery, 2011).

• Recognize that opioid therapy may be indicated for some clients experiencing chronic pain. Although opioids are considered second-line options for chronic neuropathic pain (Dworkin et al, 2011), they are often administered for the treatment of other types of moderate to severe chronic pain, such as chronic cancer pain or osteoarthritis pain (AGS, 2009; Portenoy, 2011; Turk, Wilson, & Cahana, 2011). They are also used for treatment of acute pain in clients with underlying chronic pain (Pasero et al, 2011b). For clients who are opioid-naïve, initiate opioid therapy at a low dose and titrate slowly, to decrease the risk of opioid-induced side effects such as oversedation or opioid-induced respiratory depression (Pasero et al, 2011b). Some clients, such as frail older persons or those with comorbidities, require extremely cautious initiation and titration of opioid therapy. Initiation of opioid therapy with a short-acting opioid administered around-the-clock (ATC) followed by conversion to a long-acting opioid may be beneficial for more consistent pain control and increased adherence to the pain management plan (AGS, 2009; Chou et al, 2009).

• Treat chronic pain in a comprehensive manner. Analgesics are administered ATC for continuous pain (expected to be present approximately 50% of the day) (DeSandre & Quest, 2009; Pasero, 2010a). PRN “as needed” dosing is appropriate for intermittent or breakthrough pain (APS, 2008; Pasero, 2010a).

• Administer supplemental opioid doses for breakthrough pain as needed to keep pain ratings at or below the comfort-function goal (APS, 2008; Pasero et al, 2011b). Please refer to the care plan on Acute Pain for rationales on use of opioids for breakthrough pain.

• Assess pain level, sedation level, and respiratory status at regular intervals during opioid administration in the inpatient setting (Jarzyna et al, 2011; Pasero, 2009b; Pasero et al, 2011b). Assess sedation and respiratory status every 1 to 2 hours during the first 24 hours of opioid therapy, then every 4 hours if respiratory status has been stable without episodes of hypoventilation, or more frequently as determined by individualized client status. Conduct the respiratory assessment before sedation assessment by evaluating the depth, regularity, and noisiness of respiration and counting respiratory rate for 60 seconds (Pasero, 2009b). Awaken sleeping clients for assessment if the respiration is inadequate (e.g., if respirations are shallow, ineffective, irregular, or noisy [snoring], or periods of apnea occur). Snoring indicates respiratory obstruction and warrants prompt arousal, repositioning, and evaluation of respiratory risk factors (Pasero, 2009a). Discontinue titration or continuous opioid infusions immediately, and decrease subsequent opioid doses by 25% to 50% if the client develops excessive sedation (Pasero, 2009b, 2010b; Pasero et al, 2011b). EBN: Life-threatening respiratory depression is the most serious of opioid side effects and is preceded by excessive sedation (Pasero, 2009b). EB: Tolerance to opioid-induced respiratory depression develops within days of regular daily opioid dosing, making this side effect less likely to occur in clients who are taking opioids for underlying chronic pain and are opioid tolerant than in those who are not (APS, 2008; Pasero et al, 2011b). However, opioid-tolerant clients are at similar risk for this side effect when they are admitted to the hospital for surgery or experience any other acute pain condition and are given opioid doses in addition to their usual dose (Pasero et al, 2011b). EBN: Although all clients receiving opioids for pain management are at risk for excessive sedation and respiratory depression, some are identified as particularly high risk (e.g., those with obstructive sleep apnea, preexisting pulmonary dysfunction, or other comorbidities) (Jarzyna et al, 2011). EBN: Clients are also at the highest risk for opioid-induced respiratory depression during the first 24 hours of therapy, when the dose is increased, when the opioid has been changed to a different opioid, or within the first 4 hours of arrival to the nursing care unit from PACU (ASA, 2009; Jarzyna et al, 2011; Lucas, Vlahos, & Ledgerwood, 2007; Pasero, 2009b). Opioid-induced respiratory depression can be prevented by performing systematic sedation assessment and reducing the opioid dose when excessive sedation is identified (Jarzyna et al, 2011; Pasero, 2009b; Pasero et al, 2011b). EBN: Use a valid and reliable sedation tool that identifies distinct changes in the client’s level of alertness and arousability and that provides guidance for nursing action at each level of sedation (Dempsey et al, 2009; Jarzyna et al, 2011; Nisbet & Mooney-Cotter, 2009). EBN: The goal of care is considered when selecting a sedation scale; sedation scales that are used to assess purposeful, goal-directed sedation include other parameters such as agitation and are not recommended when the desired client outcome is prevention of sedation (Dempsey et al, 2009; Jarzyna et al, 2011; Nisbet & Mooney-Cotter, 2008; Pasero, 2009b; Pasero et al, 2011b).

• Ask the client to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Obtain a prescription for a combination stool softener plus peristaltic stimulant to prevent opioid-induced constipation. Constipation is one of the most common side effects of opioid therapy and can become a significant problem in pain management, affecting whether or not a client adheres to the treatment plan. Prevention and early detection are much easier than management of opioid-induced constipation (Pasero et al, 2011b). Opioids cause constipation by interrupting rhythmic contractions required for intestinal motility, reducing mucosal secretions, decreasing gastrointestinal (GI) transit by inhibiting gastric emptying, and slowing small and large bowel transit through activation of mu-opioid receptors located in the GI tract (Panchal, Muller-Schwefe, & Wurzelmann, 2007). Stool softeners alone are ineffective to prevent opioid-induced constipation (Pasero et al, 2011b). The client should be started on a combination of a stool softener plus stimulant laxative when the opioid is prescribed. Titrate doses to effect, and add osmotic laxatives and enemas when less aggressive approaches fail (Panchal, Muller-Schwefe, & Wurzelmann, 2007). A peripherally acting mu-opioid receptor antagonist may be used to reverse opioid-induced constipation without affecting analgesia in clients with advanced illness (Pasero et al, 2011b; Thomas et al, 2008).

• Question the client about any disruption in sleep. CEB: Clients with low back pain had significant loss of sleep (Marin, Cyhan, & Miklos, 2006).

• Watch for signs of depression in the clients with chronic pain, including sleeplessness, not eating, flat affect, statements of depression, or suicidal ideation. CEB: Chronic pain clients had twice the rate of suicide compared to people without pain (Tang & Crane, 2006). Clients over 60 who committed suicide had physical illness, especially pain, breathlessness, and disability (Harwood et al, 2006).

• Review the client’s pain diary, flow sheet, and medication records to determine the overall degree of pain relief, side effects, and analgesic requirements for an appropriate period (e.g., 1 week). CEB & EBN: Pain diaries are valid and reliable methods of documenting pain severity, activity including aggravating and alleviating factors (Hadjistavropoulos et al, 2007; Hager & Brockopp, 2009; McCaffery, Herr, & Pasero, 2011).

• Obtain orders to increase or decrease opioid doses as needed; base analgesic and dose on the client’s report of pain severity (clinical judgment of effectiveness if the client is unable to provide a self-report), response to the previous dose in terms of pain relief, occurrence of side effects, and ability to perform the activities of recovery or activities of daily living (ADLs). It is important that nurses knowledgeable in pain management have an “as needed” range of opioid doses available to provide appropriate pain relief (Pasero et al, 2011b). Policies or protocols that require clinicians to begin at a certain opioid dose or administer a specific dose based on pain intensity levels are inappropriate and unsafe (Pasero, 2010b; Pasero et al, 2011b). Safe and effective pain management requires opioid dose adjustment based on individualized, adequate pain and sedation assessment, opioid administration, and evaluation of the response to treatment (Pasero, 2009b). This ability to adjust the dose based on client assessment requires knowledge about opioid action, onset, time to peak serum concentration, duration of action, and potential side effects (Pasero et al, 2011b).

• In addition to administering analgesics, support the client’s use of nonpharmacological methods to help control pain, such as distraction, imagery, relaxation, and application of heat and cold. Cognitive-behavioral (mind-body) strategies can restore the client’s sense of self-control, personal efficacy, and active participation in his or her own care (APS, 2008; Bruckenthal, 2010).

• Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions. EBN: Pain causes cognitive impairment (Pasero et al, 2011b). Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions (APS, 2008).

• Encourage the client to plan activities around periods of greatest comfort whenever possible. Pain impairs function. Clients will find it easier to perform their ADLs and enjoy social activities when they are rested and pain is under control.

• Explore appropriate resources for management of pain on a long-term basis (e.g., hospice, pain care center). Most clients with cancer or chronic noncancer pain are treated for pain in outpatient and home care settings. Plans should be made to ensure ongoing assessment of the pain and the effectiveness of treatments in these settings (APS, 2008).

• If the client has progressive cancer pain, assist the client and family with handling issues related to death and dying. Peer support groups and pastoral counseling may increase the client’s and family’s coping skills and provide needed support (APS, 2008).