3 Pain Management

Understanding and assessing pain

Pain is a personal sensory and emotional experience. It may occur with actual or potential tissue damage, but visible behavior, vital signs, or an apparent cause cannot establish how much pain a person feels. Take the patient's report seriously; difficulty describing pain does not mean pain is absent.

When a patient can communicate reliably, their self-report is the primary guide. If they cannot, use a validated observational tool suited to their age and condition, considering facial expression, guarding, movement, vocalization, and changes from their usual behavior. A patient's baseline and caregiver observations can add context, but do not replace assessment.

A structured pain assessment

Ask about pain regularly and when the patient reports a change. Use open, nonjudgmental questions, and do not assume that a quiet patient is comfortable or that a diagnosis produces the same pain in everyone.

The PQRSTU framework organizes a focused assessment:

• P — Provocation/palliation: What makes the pain worse or better?

• Q — Quality: Does it feel aching, burning, sharp, or pressure-like?

• R — Region/radiation: Where is it, and does it move or spread?

• S — Severity: How intense is it now? Choose a consistent scale suited to the person's age and ability, such as a rating from $0$ to $10$ or a faces scale.

• T — Timing/treatment: When did it begin? Is it constant or intermittent? What has helped so far?

• U — Understanding: What does the patient think may be causing it, and what concerns them?

Also ask how pain affects sleep, mood, mobility, breathing, and other activities. Agree on a comfort-function goal: a meaningful activity the patient hopes to manage with adequate relief. A pain rating alone may not capture what matters most to the patient.

Communication and shared goals

Listen, acknowledge the patient's experience, and clarify answers rather than challenging them. For example, a patient may report a higher pain rating while walking than at rest; ask whether that description is accurate and consider both situations when planning care.

Ask about prior treatments, preferences, concerns, and side effects. Document useful patient statements, assessment findings, agreed goals, interventions, and the patient's response. Communicate unmet needs to the care team.

Choosing safe, individualized interventions

Choose interventions with the patient, taking into account the likely cause of pain, health status, preferences, risks, and functional goals. A multimodal plan may combine medication and nonmedication methods. Administer medication only as prescribed and within the clinician's scope and facility policy.

Medication approaches

• Nonopioids: Acetaminophen and nonsteroidal anti-inflammatory drugs may be used for some mild-to-moderate pain. Check allergies, contraindications, and relevant precautions; for example, a nonsteroidal anti-inflammatory drug may be unsuitable for some patients with bleeding or kidney risks.

• Opioids: These may be prescribed for selected acute or severe pain when expected benefits outweigh risks. Follow the prescribed plan and facility procedures, and monitor alertness, breathing, pain relief, and other effects. Report concerning sedation or slowed breathing promptly.

• Adjuvant medications: Some medicines developed for other purposes may help particular pain types, including some nerve-related pain. Give them only when prescribed and monitor for relevant effects.

Before giving medication, verify the medication, dose, route, timing, allergies, and relevant assessment findings. Explain its intended effect and watch for adverse effects. Opioids carry risks that include sedation, respiratory depression, and overdose, so use and monitoring require attention to the prescribed plan and applicable safety procedures.

Nonmedication approaches

Offer Nonpharmacological interventions that are safe and acceptable to the patient. Options may include repositioning, supporting or splinting an incision during coughing, reducing environmental stress, paced breathing, relaxation, guided imagery, distraction, music, or massage. Heat or cold may help in some situations; check precautions and protect the skin. These methods can complement medication but should not dismiss pain or delay necessary assessment and treatment.

Evaluating relief and responding

After each intervention, perform Reassessment using the same scale when possible and allowing time for the intervention to take effect. The appropriate interval depends on the medication's route and expected onset, the type of intervention, and facility policy. Ask whether pain improved and whether the patient can better meet the agreed comfort-function goal. Check for adverse effects as well as relief.

If relief is inadequate, pain worsens unexpectedly, or an adverse effect occurs, reassess the patient, document findings, and notify the appropriate clinician. The plan may need adjustment or further evaluation. Continue checking at intervals appropriate to the patient's condition and care plan.

For example, a patient reports incision pain of $7/10$ when coughing and wants to cough deeply without stopping because of pain. The nurse assesses the pain, supports the incision, gives the prescribed analgesic, and returns at an appropriate interval. The nurse asks for a new rating, observes the patient's ability to cough, checks for side effects, and documents the response. If the goal is not met, the nurse follows up with the care team.

Takeaway: Effective pain care combines respectful assessment, a patient-centered goal, safe individualized interventions, and follow-up on both function and adverse effects.