1. Nursing care plan/implementation:
      1. Goal: provide relief of pain.
        1. Assess level of pain; ask patient to rate on scale of 0 to 10 (0 = no pain; 10 = worst pain) or smile/sad faces. Use age-, condition-, and language-appropriate scale.

          2. Format for Assessing Pain

          FIRST, assess the pain:

          Frequency Is it intermittent or constant?

          Intensity

          What is the quality of the pain? Sharp or dull? Throbbing? Squeezing?
          Radiation Does the pain move to other parts of the body?
          Severity On a scale of 1 to 10, how bad is the pain?

          Timing

          When did the pain begin? How long does it last?Does anything make it worse or take the pain away? What precedes the pain?


        2. Determine cause and try nursing comfort measures before giving drugs:
          1. Environmental factors: noise, light, odors, motion.
          2. Physiological needs: elimination, hunger, thirst, fatigue, circulatory impairment, muscle tension, ventilation, pressure on nerves.
          3. Emotional: fear of unknown, helplessness, loneliness (especially at night).
        3. Relieve: anger, anxiety, boredom, loneliness.
        4. Report sudden, severe, new pain; pain not relieved by medications or comfort measures; pain associated with casts or traction.
        5. Remove pain stimulus:
          1. Administer pain medication - nonopioids: NSAIDs - ketorolac (Toradol); opioids: first-line analgesics include morphine, hydromorphone, fentanyl, oxycodone, hydrocodone; adjuvants: local anesthetics, sedatives, muscle relaxants; give at appropriate time intervals; do not withhold due to overestimated danger of addiction.
          2. Avoid cold (to reduce immediate tissue reaction to trauma).
          3. Apply heat (to relieve ischemia).
          4. Change activity ( e.g., restrict activity in cardiac pain).
          5. Change, loosen dressing.
          6. Comfort ( e.g., smooth wrinkled sheets, change wet dressing).
          7. Give food (e.g., for ulcer).
        6. Reduce pain-receptor reaction.
          1. Ointment (use as coating).
          2. Local anesthetics.
          3. Padding (of bony prominences).
        7. Assist with medical/surgical interventions to block pain-impulse transmission:
          1. Injection of local anesthetic into nerve ( e.g., dental).
          2. Cordotomy - sever anterolateral spinal cord nerve tracts.
          3. Electrical stimulation - transcutaneous (skin surface), percutaneous (peripheral nerve).
          4. Peripheral nerve implant - electrode to major sensory nerve.
          5. Dorsal column stimulator - electrode to dorsal column.
        8. Minimize barriers to effective pain management:
          1. Achieve “balanced analgesia”; aroundthe-clock administration of NSAIDs or acetaminophen if possible, continuous infusion, patient-controlled analgesia (PCA); combination therapy (opioids, nonopioids, adjuvants).
          2. Accept patient and family report of pain.
          3. Discuss fear of addiction with patient/ family (incidence <1% when opioids taken for pain relief).
          4. Discuss fear of respiratory depression with staff; preventable; related to sedation.
        9. Document response to pain-relief measures.
      2. Goal: use nonpharmacological methods to reduce pain.
        1. Distraction, e.g., TV (cerebral cortical activity blocks impulses from thalamus).
        2. Aromatherapy - assists in relaxation.
        3. Hypnosis - assess appropriateness for use for psychogenic pain and for anesthesia; needs to be open to suggestion.
        4. Acupuncture - assess emotional readiness and belief in it.
      3. Goal: alter interpretation and response to pain.
        1. Administer narcotics - result: no longer sees pain as disturbing.
        2. Administer hypnotics - result: changes perception and decreases reaction.
        3. Help patient obtain interpersonal satisfaction from ways other than attention received when in pain.
      4. Goal: promote patient control of pain and analgesia: patient-controlled analgesia (PCA), an analgesia administration system designed to maintain optimal serum analgesia levels; safely delivers intermittent bolus. doses of a narcotic analgesic; preset to maximum hourly dose.
        1. Advantages: decreased patient anxiety; improved pulmonary function; fewer side effects.
        2. Limitations: requires an indwelling intravenous line; analgesia targets central pain, may not relieve peripheral discomfort; cost of PCA unit.
        3. Goal: health teaching.
          1. Explain causes of pain and how to describe pain.
          2. Explain that it is acceptable to admit existence of pain.
          3. Relaxation exercises.
          4. Biofeedback methods of pain perception and control.
          5. Proper medication administration (PGA, continuous around-the-clock dosing), when necessary, for self-care.
    2. Evaluation/outcome criteria:
      1. Verbalizes comfort; awareness of pain decrease.
      2. Knows source of pain; how to reduce stimulus and perception.
      3. Uses alternative measures for pain relief.
      4. Able to cope with pain, remains active, relaxed appearance; verbal and nonverbal clues of pain absent.