Learning Objectives
By the end of this section, you will be able to:
- Classify types and levels of pain
- Describe nursing assessment related to pain
- Plan individualized pain management
Older adults are at increased risk for undertreatment of pain. Many older adults in the community or living in long-term care centers have significant pain due to chronic conditions (AgeWays, 2019). Pain is often underassessed in older adults because they are less likely to report it and also because it may not present with a clearly identifiable cause (AgeWays, 2019).
Types and Levels of Pain
What distinguishes administering pain management in mental health settings from other acute care settings? It is the complicated interaction between mental illness, analgesic drugs, and related addiction, along with the necessity of preserving the environment’s safety in order to establish and maintain the therapeutic relationship, which is client centered. The American Nurses Association (ANA Center for Ethics and Human Rights, 2018) presents a position statement that describes the nurse’s ethical responsibility to relieve pain and to customize the nursing interventions.
Onwumere et al. (2022) assert that the experience of those with mental illness who also experience pain is complex and requires understanding from caregivers. Accurate assessments are essential. Intervention must be individualized, such as physical activity as a therapy, and pain management must be considered within the overall care (Onwumere et al., 2022). Behavior may project anxiety, distress, or fear. Behavioral assessment tools for pain may be impacted by many other stressors. It can be difficult to separate emotional responses from sensory aspects.
Pain can be divided into visceral, deep somatic, superficial, and neuropathic pain. Visceral organs are midline in the body within the abdomen, highly sensitive to stretch, ischemia, and inflammation. Visceral pain is diffuse, and often referred outward to other locations in the body. It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull.
Deep somatic pain comes from stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fascia, and muscles and is a dull, aching, poorly localized pain. Examples include sprains and broken bones.
Superficial pain comes from the activation of nociceptors in the skin or other superficial tissue and is sharp, well-defined, and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first-degree) burns.
Neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory nervous system. It is typically described by clients as “burning” or “like pins and needles.” Neuropathic pain can be caused by several disease processes, such as diabetes mellitus, strokes, and HIV, and is generally undertreated because it typically does not respond to analgesics. Medications, such as tricyclic antidepressants and gabapentin, typically manage this type of pain.
Pain can radiate from one area to another. For example, back pain caused by a herniated disk can cause pain to radiate down an individual’s leg. Referred pain is different from radiating pain because it is perceived at a location other than the site of the painful stimulus. For example, pain from retained gas in the colon can cause pain to be perceived in the shoulder. See the following figure (Figure 24.5) for an illustration of common sites of referred pain.
Duration
Pain is also differentiated by duration, or acute pain and chronic pain. When the pain has limited duration and is associated with a specific cause, it is considered to be acute pain. It usually creates a physiological response resulting in increased pulse, respiration, and blood pressure. It may also cause diaphoresis (sweating, especially to an unusual degree). Examples of acute pain include postoperative pain; burns; acute musculoskeletal conditions like strains, sprains, and fractures; labor and delivery; and traumatic injury.
When pain is ongoing and persistent for three to six months or more, it is considered to be chronic pain. It typically does not cause a change in vital signs or diaphoresis. It may be diffuse and not confined to a specific area of the body. Chronic pain often affects an individual’s psychological, social, and behavioral responses and can influence daily functioning. Chronic medical problems, such as osteoarthritis, spinal conditions, fibromyalgia, and peripheral neuropathy, are common causes of chronic pain. Chronic pain can continue even after the original injury or illness that caused it has healed or resolved. Some people suffer chronic pain even when there is no past injury or apparent body damage.
People who have chronic pain often have physical effects that are stressful on the body. These effects include tense muscles, limited ability to move around, lack of energy, and appetite changes. Emotional effects of chronic pain include depression, anger, anxiety, and fear of reinjury. These effects can limit a person’s ability to return to work or participate in leisure activities. It is estimated that chronic pain affects 50 million U.S. adults, and 19.6 million of those adults experience high-impact chronic pain that interferes with daily life or work activities. For older adults, chronic pain may be a part of life due to arthritis in the joints and back or due to previous injuries. They can also have a higher risk of falls due to stiffness in the morning and when standing as well as knees that “give out.” Whereas some older adults consider this “just a part of getting old,” others struggle with the limitations and can become withdrawn, depressed, or lash out. This can cause frustration for both the client and the caregiver. Caregivers can need support as well and caregiver burden and burnout are also within the nurse’s scope of assessment.
Severity and Assessment
Pain severity refers to a person’s individual concept of the level of discomfort that they are experiencing at a point in time. Generally, severity is measured in terms, such as none, mild, moderate, and severe, though more detailed assessments may come into play. Pain is a very subjective concept as is the severity of that pain. Each person is different, and their pain perceptions can vary by personality, experiences that they have had in their lives, and past experience with pain.
Asking a client to rate the severity of their pain on a scale from zero to ten, with zero being no pain and ten being the worst pain imaginable is a common question used to screen clients for pain. The Joint Commission, an accrediting body for health-care organizations, requires this quick question to be followed by a thorough pain assessment. Additionally, providers must assess the client’s comfort-function goal. The comfort-function goal provides the basis for the client’s individualized pain treatment plan and is used to evaluate the effectiveness of interventions. The same assessment tool utilized to plan care for pain management should also be used to evaluate relief and plan further care.
The mnemonics “OLDCARTES,” which stands for onset, location, duration, character, aggravating/relieving, time, and severity, or “COLDSPA,” which stands for character, onset, location, duration, severity, pattern, and associated factors, can be helpful in remembering a standardized set of questions used to gather additional data about a client’s pain. “PQRSTU” is another tool assessing these categories. Table 24.6 lists the questions utilized with a “PQRSTU” assessment framework. While interviewing a client about pain, use open-ended questions to allow the client to elaborate on information that further improves understanding of their concerns. Most older adults are fully able to participate in the pain interview, but for those who are unable, use alternative pain scales or more subjective pain assessment. If their answers do not seem to align, continue to ask focused questions to clarify information. For example, if a client states that “the pain is tolerable” but also rates the pain as a “seven” on a zero to ten pain scale, these answers do not align, and the nurse should continue to use follow-up questions using the PQRSTU framework.
Upon further questioning, perhaps this client will explain that they rate the pain as a “seven” in their knee when participating in physical therapy exercises, but currently feel the pain is tolerable while resting in bed. Another question that can be asked is what is a pain level that is acceptable to them. This additional information assists the nurse in customizing interventions for effective treatment with reduced potential for overmedication with associated side effects. Assessment of pain and ongoing assessment of pain is important as pain is not always stated as a complaint. Sometimes pain is an underlying cause of behavior or mood. In some cultures, pain is not to be expressed or complained about and pain is expressed by withdrawal, making assessment more important.
| PQRSTU | Questions Related to Pain |
|---|---|
| Provocation/palliation | What makes your pain worse? What makes your pain feel better? |
| Quality | What does the pain feel like? You can provide suggestions for pain characteristics, such as “aching,” “stabbing,” or “burning.” |
| Region | Where exactly do you feel the pain? Does it move around or radiate elsewhere? Instruct the client to point to the pain location. |
| Severity | How would you rate your pain on a scale of zero to ten, with zero being no pain and ten being the worst pain you’ve ever experienced? |
| Timing/treatment | When did the pain start? What were you doing when the pain started? Is the pain constant or does it come and go? If the pain is intermittent, when does it occur? How long does the pain last? Have you taken anything to help relieve the pain? |
| Understanding | What do you think is causing the pain? |
Pain Scales
Pain assessments should be specific to the client. A client with psychosis, severe cognitive impairment, or socially withdrawn may not be accurately assessed with questionnaires. Nursing observations are sometimes more effective, such as monitoring vital signs, facial expressions, or vocalizations. Other physical signs that could indicate pain are diaphoresis, muscle tension, agitation, or poor response to general comfort measures.
The FACES scale, for example, is a visual pain scale tool for assessing pain with children and others who cannot quantify the severity of their pain on a scale of zero to ten. Figure 24.6 shows a sample pain rating scale. To use this scale, explain to the client that each face represents a person who has no pain, some pain, or a lot of pain. “Face 0 doesn’t hurt at all. Face 2 hurts just a little. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to have this worst pain.” Ask the person to choose the face that best represents the pain they are feeling. This can be very helpful in the older adult with cognitive impairment, illiteracy, or a language barrier because they may not be able to understand the number scales.
Presentation and Tolerance
Some older adults may not complain of pain, particularly those with cognitive impairment, but will show signs in other ways. There may be subtle signs, such as a change in functional status or body posture and gait. They may socially isolate, even from family. Others may become agitated, or more agitated, or confused. Those who are nonverbal may moan or grimace. Naturally, very functional older adults will complain of pain or increased pain to loved ones or their medical providers. There also may be an association with depression or anxiety to pain.
Pain tolerance or sensitivity to pain is a very individual experience, particularly for older adults. Life experience plays a very large role as previous exposures to pain and general discomfort impact how much acute pain a person can tolerate. For example, a person who has had a low level of arthritis pain for many years will likely not report as high of a level of acute pain as a person who has been largely without pain most of their lives. Pain tolerance or expression of pain can be cultural as well. In some cultures, pain is expressed freely, in others, expression of pain is discouraged. When the same dose of a drug has been given repeatedly, clients may demonstrate a reduced response to pain medication called tolerance, requiring a higher dose of the drug to achieve the same level of response. For example, when a client receives morphine for palliative care, the dosage often needs to be increased over time because the client develops a tolerance to the effects of the medication.
Quality of Life
Pain is a huge component of quality of life. A person cannot live their best life if they are uncomfortable. The medical team and the client’s family, as well as the client, have a responsibility to manage discomfort in ways that maximize that person’s function and day-to-day life. Ongoing evaluation of the older adult with acute or chronic pain should be part of every assessment in order to monitor management of the pain.
Person-Centered Care in Pain Management
Person-centered care is defined by the Centers for Medicare and Medicaid Services as integrated health-care services delivered in a setting and manner that is responsive to the individual and their goals, values, and preferences, in a system that empowers clients and providers to make effective care plans together (Centers for Medicare & Medicaid Services, n.d.). This includes:
- care that is influenced and informed by the objectives, tastes, and values of the person
- person-reported outcomes being used to gauge success
- integrated care across health systems, providers, and care settings, that is coordinated
- managing persistent and complicated disorders
- relationships that are anchored in mutual trust and dedication to long-term well-being
Person-centered care for pain, particularly chronic pain, is a holistic and therapeutic form of treatment allowing the client to take ownership of their pain management. The health-care provider’s role is to guide the client in finding the best way to manage their pain. This may include medications but will also include possible alternative methods, such as massage, exercise, acupuncture, Tai Chi, supplements, and possibly addressing the underlying social and behavioral components of their pain. By addressing the spiritual, emotional, and psychosocial components of the whole person, the team provides more holistic care. This model is about listening to the individual and working with them closely to understand them as a person and empathize with them.
Clinical Judgment Measurement Model
Taking Action/Evaluating Outcomes: Monitoring Effectiveness of Pain Management
As the nurse enters a client’s room, the client has just finished combing his hair. The client is smiling as he greets the nurse.
Nursing knowledge is required to recognize the effect of pain-relieving medication one hour after administration. The client had been unable to perform personal grooming due to arthritic shoulder pain rated 6/10 on pain scale. The client had displayed a sad facial expression. The client elected to use the pain-relieving medication ordered on an as-needed basis, every six hours offered by the nurse. The nurse administered the medication.
The nursing action is to apply the same assessment scale to the client’s pain now as was used prior to medication administration. The client rates current pain as 2/10 on the scale.
The nurse monitors for adverse effects of the medication, noting that the client has consumed 75 percent of his breakfast meal and denies nausea.
The nurse will reassess as needed.
Perspectives of Client and Family
As part of person-centered care, the family plays a large role in pain management. The family has a strong influence on an individual’s beliefs and behaviors surrounding pain as well as health and illness. The family can be an integral part of the pain management plan and treatment or can have a negative effect due to dysfunctional relationships and reactions. A positive family relationship can help a person cope with pain as well as work through strategies of pain relief. An individual with a dysfunctional family will frequently require more medication intervention, have more depressive symptoms, have lower activity levels, and will have more pain behaviors and more emotional distress (American Association of Colleges of Nursing, n.d.).
Treatment Modalities
Treatment modalities are an integral part of person-centered care as the client can work with the physical therapist to choose the modality that is best for them. The therapist and the client work as a team with the therapist providing instruction and support that respects the client’s experience. A pain treatment modality is a method of treatment utilizing electrical, thermal, mechanical energy, or medication that affects the body’s physiology. Examples of these are transcutaneous electrical nerve stimulation (TENS), heat or cold therapy, or vibration. These modalities are typically used in physical therapy to reduce swelling, enhance circulation, and relieve pain. Physical therapy is an integral part of both acute and chronic pain management. Incorporating these modalities in the pain management plan with traditional physical therapy, such as exercise and massage, reduces the need for as many pharmacological analgesics.
Pharmacological
When pharmacological pain agents are utilized in older adults, significant oversight and care is required. The current trend has been toward multimodal pain management with nonopioid drugs for acute pain. There are limits to this approach, however, depending on the chronic medical issues of the client and on drug interactions. There are also times when opioids, narcotics that are powerful pain-reducing medications that carry a high risk of dependency, must be used due to high levels of pain or limited options. The goal with opioid use is to use the lowest dose for the least amount of time possible, while appropriately managing pain. Opioids in older clients should not be avoided if needed, but they can cause delirium at higher doses, and all can increase risk of falls.
Nonopioid analgesics include acetaminophen and NSAIDs. Acetaminophen (Tylenol) is used to treat mild pain and fever but does not have anti-inflammatory properties. Acetaminophen is safe for all ages and can be administered using various routes, such as orally, rectally, and intravenously. Many over-the-counter (OTC) medications contain acetaminophen, along with other medications. Acetaminophen has a greater pain-relieving effect as a person ages and can be a very effective pain reliever in older adults, particularly in the very older adult.
Duloxetine is a SNRI, which can help with painful neuropathies, low back pain, fibromyalgia, and chronic musculoskeletal pain due to osteoarthritis. Titrate slowly to effect and to improve tolerability. Avoid in renal or hepatic impairment.
The class of drugs called nonsteroidal anti-inflammatories (NSAIDs) provides mild to moderate pain relief and also reduces fever and inflammation by inhibiting the production of prostaglandins. They can also be used as an adjuvant with opioids for severe pain. Examples of NSAIDs include ibuprofen, naproxen, and ketorolac. All NSAIDs, except aspirin, increase the risk of heart attack, heart failure, and stroke, with the risk being higher if the client takes more than is directed or takes it for longer than directed. Common side effects include dyspepsia, nausea, and vomiting, so it is helpful to administer this medication with food. Older adults and those taking NSAIDs concurrently with other drugs, such as warfarin or corticosteroids, are at elevated risk for gastrointestinal bleeding. Renal failure can also occur with NSAIDs. Generally, avoid giving NSAIDs to adults over seventy-five due to the risks for GI bleeding, hypertension, renal injury, and fluid retention or edema.
Topical agents range from active numbing to using heat or cooling sensation to reduce pain. Lidocaine comes in many forms and is applied as needed. It comes in prescription strength and there are many formulations of OTC topical pain lotions, patches, and roll-ons that can be heat-creating, menthol, or capsaicin-containing.
Link to Learning
Read this article about pain management for older adults from the University of Iowa.
Nonpharmacological
Nonpharmacological interventions can be used with or without pharmacologic interventions and often provide tremendous benefits to the client. Clients can select from a variety of techniques according to what best fits their needs and goals. Nonpharmacological interventions should be documented in the plan of care and their effectiveness evaluated in terms of their ability to meet the client’s goals for pain relief.
Link to Learning
Read this article for more about complementary approaches to treat pain from the National Center for Complementary and Integrative Health.
Table 24.7 provides examples of several types of nonpharmacological interventions.
| Intervention | Examples |
|---|---|
| Distraction | Describing photos, telling jokes, and playing games |
| Relaxation | Rhythmic breathing, meditation, prayer, imagery, and music therapy |
| Basic comfort measures | Proper positioning and therapeutic environment; avoiding sudden movement; reducing pain stimuli within the environment |
| Cutaneous stimulation | Acupuncture and acupressure massage: three to five minutes offers benefits Transcutaneous Electrical Nerve Stimulation (TENS) unit: a specialized stimulator placed over the area of pain |
| Application of heat or cold | Heat: vasodilation increases blood flow; duration should be five to twenty minutes based on client tolerance Cold: vasoconstriction reduces blood flow; cold numbs nerve sensations; duration should be no longer than twenty minutes Cool baths and moist, cool compresses |
| Mind-body therapies | Biofeedback Meditation and mindfulness |
| Aromatherapy | Lotions and moisturizing cream avoiding strong smells |
| Exercise | Physical activity, Tai Chi Yoga |
| Therapy | Physical therapy, occupational therapy |
Clients may also consider using complementary health approaches to manage chronic pain. Complementary approaches include acupuncture, massage therapy, meditation, relaxation techniques, spinal manipulation, Tai Chi, yoga, and dietary supplements.
Link to Learning
Read this Joint Commission document titled “Non-pharmacologic and non-opioid solutions for pain management” for more information on complementary techniques to manage pain.