Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. In their classic work, McCaffery and Pasero (1999) offered a more personal explanation of pain when they stated that pain is whatever the experiencing person says it is and exists whenever he or she says it does. This understanding of pain requires that the patient be seen as the authority on the pain and as the only one who can define the experience. In other words, self-report is always the most reliable indication of pain. Nurses who approach pain from this perspective can help the patient achieve effective pain management by advocating for proper control. Of course, if the patient cannot communicate, self-report is not possible. In this case, a variety of methods and observation of nonverbal indicators are used to assess the pain, as described later in this chapter.

Scope of the Problem

Pain is also a major economic problem and a leading cause of disability that hampers the lives of many people, especially older adults. Chronic pain is the most common cause of long-term disability, affecting millions of Americans and others throughout the world.

Pain is not adequately treated in all areas of health care. Populations at the highest risk are older adults, substance abusers, and those whose primary language differs from that of the health care professional. Older adults in nursing homes are especially at risk because of lack of professional staff and communication problems. In patients who are substance abusers, unrelieved pain can contribute to relapses or increased substance use.

Inadequate pain management can lead to many consequences affecting the patient and family members. These consequences often affect the patient’s and family’s quality of life (Table 5-1). Therefore, as a nurse, you have a legal and ethical responsibility to ensure that patients receive adequate pain control. In 2000, The Joint Commission (TJC) published pain standards approved by the American Pain Society. TJC states that patients in all health care settings, including home care, have a right to effective pain management.

TABLE 5-1 IMPACT OF UNRELIEVED PAIN

Patients rely on nurses and other health care professionals to adequately assess and manage their pain. As the coordinator of patient care, be sure to accurately document your assessments and actions, including patient and caregiver teaching.

Categorizing Pain

Pain can be categorized in two ways: by type related to the characteristics of the pain (Table 5-2) or by the physiologic source of the pain. The two major types of pain are acute and chronic. Acute pain often results from sudden, accidental trauma (e.g., fractures, burns, lacerations) or from surgery, ischemia, or acute inflammation. Chronic pain or persistent pain is further divided into two subtypes. Chronic cancer pain is pain associated with cancer or another progressive disease such as acquired immune deficiency syndrome (AIDS). The cause of pain is usually life threatening. Chronic non-cancer pain is associated with tissue injury that has healed or is not associated with cancer, such as arthritis or chronic back pain. This type of pain is the most common.

TABLE 5-2 CHARACTERISTICS OF ACUTE PAIN AND CHRONIC PAIN

ACUTE	CHRONIC* (OR PERSISTENT)
• Has short duration • Usually has a well-defined cause • Decreases with healing • Is reversible • Serves a biologic purpose (warning sign) • Ranges from mild to severe intensity • May be accompanied by anxiety and restlessness	• Lasts longer than 3 months • May or may not have well-defined cause • Begins gradually and persists • Is exhausting and serves no biologic purpose • Ranges from mild to severe intensity • May be accompanied by depression and fatigue, as well as decreased functional ability

^* Includes chronic cancer pain and chronic non-cancer pain.

Pain is also categorized as either nociceptive (normal processing of pain) or neuropathic (abnormal pain processing). Nociceptive pain is either visceral or somatic (Table 5-3). Somatic pain arises from the skin and musculoskeletal structures, and visceral pain arises from organs. Neuropathic pain is one of the most challenging types of chronic non-cancer pains; it results from some type of nerve injury. Neuropathic pain is still not completely understood. It is divided into centrally or peripherally generated pain. Regardless of the cause, neuropathic pain is described as burning (most common), shooting, stabbing, and feeling “pins and needles.”

TABLE 5-3 PHYSIOLOGIC SOURCES OF PAIN

Theoretical Bases for Pain

Pain Transmission

Painful stimuli often originate in the periphery (extremities) of the body. To be perceived, the stimuli must be transmitted first to the spinal cord and then to the central areas of the brain. If the pain impulse is not transmitted to the brain, the person feels no pain. In the periphery, two specific fibers can transmit stimuli: (1) A delta fibers, which are found primarily in the skin and muscle; and (2) C fibers, which are distributed in muscle, periosteum, and viscera. Both of these nerve fibers are capable of accepting nociceptive stimuli.

A delta fibers are myelinated fibers that carry rapid, sharp, pricking, or piercing sensations. A person feeling these sensations can generally localize them readily to a fairly well-defined area. Because these fibers respond mainly to mechanical rather than chemical or thermal stimuli, they are called mechanical nociceptors.

C fibers are unmyelinated or poorly myelinated fibers that conduct thermal, chemical, and strong mechanical impulses. Pain conduction from C fibers is slow, more diffuse (widespread) and dull, burning, or achy—quite different from the sensations of A delta fibers. In contrast to the intermittent nature of A delta sensations, C fibers usually produce persistent pain.

Although many theories of pain have been discussed, the classic gate control theory by Melzack and Wall (1982) still forms the basis of what is believed by most pain researchers today. According to this theory, a gating mechanism occurs in the spinal cord. Nerve fibers (A delta and C fibers) transmit pain impulses from the periphery of the body. These impulses travel to the dorsal horn of the spinal cord, specifically to the substantia gelatinosa, where the gating mechanism occurs. When the gate is opened, pain impulses ascend to the brain; when the gate is closed, the impulses do not get through and pain is not perceived (Fig. 5-1).

FIG. 5-1 The gate control theory of pain.

Morphine-like substances called endorphins are released when the large-diameter nerve fibers are stimulated. These fibers close the gate and decrease pain transmission. This helps explain why many noninvasive pain management techniques work to relieve pain. Endorphins are thought to be a gene product, and producing them requires a stimulus to the brain.

The gate control theory has helped nurses and other health care professionals recognize the holistic nature of pain. As a result, many cognitive-behavioral therapies (e.g., imagery and distraction described on p. 60) are used to help relieve pain.

Attitudes and Practices Related to Pain

The attitudes of health care professionals toward pain influence the way they perceive and interact with patients in pain. Without adequate assessment skills or knowledge of pain and analgesic therapy, they may not be able to understand their patients’ pain.

Nurses who have little personal experience with pain may not appreciate the scope of painful conditions associated with diseases and medical or surgical interventions. They may expect patients with chronic pain to react similarly to those with acute pain. Nurses may assume that reactions to pain fall within a certain norm based on their own cultural values. The more that a patient’s response varies from these expected norms, the more likely that a nurse’s attitude toward the patient will be positively or negatively biased.

Not only do health care professionals need continued education about pain management, but the public needs education as well. Nurses can help patients and their families achieve and maintain successful pain management through education.

Many patients are reluctant to report pain. When they do, they may underreport its severity. Patients may not share their existence of pain because they want to be “good” patients or do not want to bother or distract their caregivers from other issues in their care. In patients with a history of cancer, pain can be an unwanted reminder of the disease and its progression.

Some patients are also reluctant to take pain medications, especially opioid analgesics, because they fear becoming addicted to or used to the drug, especially older adults. Educate patients and reassure them that these drugs are not likely to cause addiction in those having pain.

Pain Perception

Many variables affect the perception of and response to pain. Factors such as age, gender, sociocultural background, and genetics influence the patient’s ability to process and react to pain. These factors also put patients at risk for undertreatment.

Considerations for Older Adults

Age can influence how pain is perceived, assessed, and treated. It has been well documented that the incidence of pain in older adults is high, as is risk for undertreatment. Chart 5-1 addresses special considerations for assessing and managing pain in older adults.

Chart 5-1 Nursing Focus on the Older Adult

Pain

Prevalence of Pain

• Recognize that older adults are at great risk for undertreated pain.

• Consider the older adult at risk for the undertreatment of cancer pain because of inappropriate beliefs about pain sensitivity, tolerance, and ability to take opioids.

Beliefs About Pain

• In addition to receiving less analgesia, older adults tend to report pain less often than do younger adults. These findings may be related to beliefs and concerns about pain and the reporting of pain. Many older people hold these beliefs and concerns about pain:

• Pain is something that must be lived with.

• Expressing pain is unacceptable or is a sign of weakness.

• Reporting pain will result in being labeled as a “bad” patient.

• Nurses are too busy to listen to reports of pain.

• Pain signifies a serious illness or impending death.

• Nurses should be aware of the beliefs of older patients regarding pain management. Nurses and other caregivers often undermedicate these patients and are sometimes reluctant to administer the prescribed analgesics.

Assessment

• Ask about present pain only; ask the patient to assess his or her pain whenever possible.

• Ask the patient’s family or other caregiver whenever the patient cannot respond appropriately.

• Document using a standard behavioral pain assessment scale.

• Explain the scale each time it is used.

• Use verbal descriptions such as “ache,” “sore,” and “hurt,” rather than the word “pain.”

• Use visual representations of pain measures rather than mental images of pain rating scales. Be sure that the patient is wearing glasses and hearing aids if needed and available.

• Alter a written pain scale to include large lettering, adequate space between lines, non-glossy paper, and color for increased visualization.

• Provide adequate lighting and privacy to avoid distracting background noise.

Considerations for Cognitively Impaired Patients

• Assess for nonverbal indicators of pain (facial expressions, grimacing, vocalizations, body movements, behavioral changes).

• Remember to “assume pain is present” (APP) in cognitively impaired patients with diseases and conditions commonly associated with pain.

Management of Pain

• Use around-the-clock dosing of analgesics.

• Consider an analgesic trial in a cognitively impaired patient.

• Beware of adverse effects of acetaminophen (hepatotoxicity, nephrotoxicity) and NSAIDs (GI bleeding, nephrotoxicity).

• Start low and go slow with drug dosing, especially opioids.

• Avoid the use of meperidine, codeine, and propoxyphene (available in combination with acetaminophen, as Darvocet).

• Do not give meperidine to older adults and those with renal disease because of the prolonged half-life of its drug metabolite normeperidine.

• Use non-drug pain relief measures or adjuvant drugs as appropriate.

• To promote drug adherence, suggest using a pillbox to organize each day’s medications.

• Teach the patient and family or other caregiver about the drug regimen and when to notify the primary care provider if adverse drug effects occur.

Certain painful conditions are more common in either men or women. Most chronic pain sufferers are women. Women have more migraine headaches, tension headaches, rheumatoid arthritis and osteoarthritis, fibromyalgia, and multiple sclerosis. Men have more cluster headaches, back pain, gout, peripheral vascular disease, and postherpetic neuralgia.

Addiction, Pseudoaddiction, Tolerance, and Physical Dependence

It is crucial that nurses and other health care professionals not label a patient as an “addict,” “clock-watcher,” or “drug seeker.” These labels have caused biases and have a negative impact on the patient-nurse relationship.

In their classic position statement, the American Society for Pain Management Nursing (ASPMN) states that addiction is (ASPMN, 2002):

… a primary, chronic neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. (p. 1)

Addiction occurs over a long time—not as a result of one hospital stay or treatment for one episode of acute pain.

The danger of addiction to pain medication is vastly overrated. Although available data on addiction consistently show that it is rarely a result of using opioids for pain relief, health care professionals still have exaggerated fears. Patients and families also have fears related to addiction. Carefully explain the difference between physical dependence and addiction whenever a patient starts on opioid therapy.

Pseudoaddiction is (ASPMN, 2002):

… an iatrogenic syndrome created by the undertreatment of pain. It is characterized by patient behaviors such as anger and escalating demands for more or different medications, and results in suspicion and avoidance by staff. (p. 1)

Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.

Tolerance is (ASPMN, 2002):

… a state of adaptation in which exposure to a drug induces changes that result in a decrease in one or more of the drug’s effects over time. (p. 1)

Some of these changes include increasing drug excretion and reducing the number of receptors to bind the drug. Many advanced cancer patients find that they need increasing doses of opioids to control their pain.

Physical dependence is the (ASPMN, 2002):

… adaptation manifested by a drug-class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. (p. 1)

A person who is drug tolerant, however, does not experience withdrawal, even when the drug is stopped suddenly.

Physical dependence occurs in everyone who takes opioids over a period of time. It is important to prevent physical withdrawal. So-called withdrawal or abstinence syndrome results when a patient who is physically dependent on opioids abruptly ceases using them. Abstinence syndrome may also occur if a patient on opioids receives a reversal agent, such as naloxone (Narcan). These symptoms result from autonomic nervous system responses and include nausea and vomiting, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions. When necessary to discontinue opioid analgesia for a patient who is opioid dependent, a slow tapering (weaning) of the drug dosage lessens or alleviates the physical withdrawal symptoms. Doses of opioids should be tapered by 10% to 20% daily for patients on chronic opioid therapy. Clonidine (Catapres, Dixarit ) may be used to help alleviate the distressing symptoms of withdrawal in younger adults. It should not be given to older adults because of its side effects.

Although tolerance, physical dependence, and addiction are different conditions, they may coexist. However, it is important to distinguish tolerance and physical dependence from addiction.

Patients who are substance abusers often have traumatic injuries and other health problems that cause pain. Keep in mind that substance abusers, typically those abusing opioids, are often tolerant to the pain-relieving effects of opioid analgesics and generally require increased doses. Abrupt physiologic withdrawal is always a danger when recreational users of opioid agonists are given mixed agonist-antagonists and partial agonists.

The clinical use of placebos in non–research-based therapies has not been shown to have a sustained effect on pain relief. A placebo is any medical treatment or nursing care that produces an effect in a patient because of its therapeutic intent and not because of its actual physical or chemical properties. When a patient responds favorably to a placebo, it is known as the placebo effect. Placebos do not indicate whether or not a patient has real pain.

Nursing Safety Priority

Drug Alert

Because of the deception involved and the need for informed consent, never administer a placebo to your patient.

As required by most health care accrediting or regulatory agencies, health care agencies have developed programs to educate professionals about pain management, including the inappropriate use of placebos. Because of The Joint Commission’s commitment to effective pain control, a policy against the use of placebos is recommended to be in place in all accredited institutions and agencies. The American Society for Pain Management Nursing (ASPMN) has a position statement available on the website against the use of placebos for the management of pain (ASPMN, 2010).

Patient-Centered Collaborative Care

Assessment

History

The American Pain Society refers to pain as the fifth vital sign. Like for vital signs, health care agencies require initial and ongoing pain assessments. Begin by asking the patient about the:

• Pain experience, including the sequence of events (precipitating and relieving factors)

• Nature of adjustments, if any, in life or in the family

• Beliefs about the cause of the pain and what should be done about it (patient’s expectations)

Remember that the patient’s personal preferences and values affect how he or she reports the pain history. When culturally appropriate, be sure to include families and significant others in this information-gathering process to be family-centered.

Patients may report pain in the absence of any observable or documented physiologic changes. To be patient-centered, respect the patient’s verbal and nonverbal expressions of pain without making judgments or inferences about the reality of the pain. If patients perceive that health care professionals doubt the existence of their pain, mistrust and other negative feelings can arise and interfere with a therapeutic nurse-patient relationship.

Assess the length of time the patient has experienced pain. Patients may welcome an opportunity to discuss acute pain with the nurse because it is a relatively short-term experience and is easily described. However, those with chronic pain can become frustrated when they are unable to adequately describe their often vague and diffuse pain experience. Structured interviews using assessment aids (e.g., pain scales, descriptors) often help patients express their pain.

Information about a person’s pain can be helpful in understanding the factors associated with the present pain or previous episodes of pain. If the patient is in pain when you are obtaining the history, keep the session reasonably short or continue later. Essential data include:

• Precipitating factors. Does the person associate any activities, food, or other environmental factors with the onset of pain? What does the patient think causes the present pain? Was the onset of pain sudden or slow? Has the patient done anything or taken anything to relieve the pain? What were the results of the intervention?

• Aggravating factors. What factors make the pain worse? What influence has this pain had on the patient’s activity? What lifestyle changes have been affected (e.g., diet, job, sleep)?

• Localization of pain. Can the person localize the pain or describe where it travels or radiates?

• Character and quality of pain. What words does the patient use to describe the pain and its character, quality, or intensity?

• Duration of pain. How long has the patient experienced this pain?

Physical Assessment/Clinical Manifestations

People with acute pain may have physiologic changes, such as tachycardia and blood pressure changes. Blood pressure is usually increased initially and then decreased. However, not all patients with acute pain have these signs, so his or her statement of pain is the only reliable indicator.

A person with chronic pain usually adapts to these physiologic changes as the body attempts to compensate for and adapt to noxious stimuli. The pain no longer serves as a necessary warning. Patients with chronic pain, then, often develop coping skills and may appear to look quite well.

Certain motor or body movements may be associated with either acute or chronic pain. Some may be more exaggerated or obvious than others. Patients in pain may support or shield (“splint”), holding painful body parts while moving, or they may lie listlessly because they are afraid to move. Assess the functional status and degree of impairment in the patient with pain.

The mnemonic PQRST may be helpful in organizing the pain assessment (Jarvis, 2012):

P: Precipitating or palliative. What brings it on? What makes it better? Worse? When did you first notice it?

Q: Quality or quantity. How does it look, feel, or sound? How intense/severe is it?

R: Region or radiation. Where is it? Does it spread anywhere?

S: Severity scale. How bad is it (on a scale of 1 to 10)? Is it getting better, worse, or staying the same?

T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last? Frequency—How often does it occur?

Location of Pain

Assess the level and location of pain. If oriented, most patients can usually describe the severity of acute pain or chronic pain. The actual area or location of the pain, however, may not be as easily identified. Ask the patient whether the pain is superficial or deep. In general, those with pain involving superficial or cutaneous (skin) structures describe their pain as superficial and can often localize the pain to a specific area.

Pain may be described as belonging to one of four categories related to its location:

• Localized pain is pain confined to the site of origin.

• Projected pain is pain along a specific nerve or nerves.

• Radiating pain is diffuse pain around the site of origin that is not well localized.

• Referred pain is pain perceived in an area distant from the site of painful stimuli.

Ask the patient who has difficulty specifying the exact location of pain to point to the painful areas on his or her own body or on another person. If the patient is able to communicate, have him or her point to or shade in the painful areas on a diagram of the front and back of the human body (Fig. 5-2). Encourage those who cannot identify the painful areas and state that they just “hurt all over” to focus on parts of the body that are not painful. Ask the patient to concentrate on different body parts, beginning with the hand and fingers of one extremity, and identify the presence or absence of pain. By focusing attention on selected areas of the body, the patient is assisted in localizing painful areas. People who state that they hurt everywhere often begin to realize that some parts of the body are not painful.