6.3 Pain

Pain is traditionally defined in health care as, “Whatever the patient says it is, experienced whenever they say they are experiencing it.”^[1] In 2020 the International Association for the Study of Pain released a revised definition of pain as, “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” along with these additional notes:

• Pain is always a personal experience that is influenced to varying degrees by the body’s ability to function, how the brain perceives pain, and even how pain has been reacted to or cared for by others in the past.
• Individuals learn the concept of pain throughout all stages of their life.
• A person’s report of an experience of pain should be respected.
• Although pain usually serves an adaptive role to protect oneself, it can have adverse effects on function, socialization, and psychological well-being.
• Verbal description is only one of several behaviors that express pain. The inability to communicate does not negate the possibility that a person is experiencing pain.^[2]
• Be aware that cultural beliefs and generational norms affect how an individual expresses their pain.

Pain motivates the individual to withdraw from dangerous stimuli, like touching a hot stove. It reminds the body to protect an injured part while it heals, such as not walking on a sprained ankle. Most pain resolves after the painful stimulus is removed and the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body. Pain can also occur in the absence of any detectable stimulus, damage, or disease.^[3],[4]

Factors Affecting Pain

There are many factors that affect how a person perceives pain, how they will act while they are in pain, and how they communicate their pain to others. See Table 6.3a for common factors that influence pain.^[5]

Table 6.3a Factors Affecting Pain^[6]

There are endless sources of pain. For example, as people age, osteoarthritis is a common cause of pain. Osteoarthritis is a type of arthritis causing inflammation or swelling of the joints due to daily wear and tear on the body. The extent of a person’s arthritis can be affected by repeatedly performing physically demanding tasks such as those found in jobs such as health care, construction, and manufacturing. Topical medications and treatments such as arthritis cream, ice, or heat can be very effective in managing arthritis pain.

Acute Versus Chronic Pain

The duration of a person’s pain can be classified as either acute or chronic. Acute pain has limited duration and is associated with a specific cause. It is often attributed to a specific event, such as a fracture, childbirth, or surgery, and should lessen as the body heals. Acute pain usually causes observable physiological responses such as increased pulse, respirations, and blood pressure. The person may also have excessive sweating called diaphoresis.^[7]

Chronic pain is ongoing and persistent for longer than six months. It typically does not cause a change in vital signs or diaphoresis. Chronic pain can affect an individual’s psychological, social, and behavioral responses and impact 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, and it may not be located in a specific area of the body.^[8]

People experiencing chronic pain often have other physical effects that are stressful on the body such as tense muscles, limited ability to move around, lack of energy, and appetite or sleep 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 their regular work or leisure activities.^[9],[10]

Objective and Subjective Signs of Pain

The concepts of objective and subjective data were previously discussed in the Chapter 1, “Guidelines for Reporting” subsection. Subjective signs of pain are what the person reports to you, such as “My stomach hurts” or “My knees ache when I walk.” Objective data is observable, such as the change in vital signs that can occur when an individual is experiencing acute pain. Signs of pain can also include nonverbal responses such as grimacing, guarding the injured body part, rocking, rubbing the area, or moaning. See Figure 6.8^[11] for an image of observable signs of pain.

When an individual is unable to communicate pain due to cognitive deficits, recognizing objective signs of pain is vital for providing comfort measures and improving their quality of life. The Pain Assessment in Advanced Dementia (PAINAD) is an example of a tool that nurses and NAs use to identify the presence of pain in individuals who are unable to verbally report it.^[12] See the PAINAD scale in Table 6.3b. A number is identified for each row and the total number is their pain rating.

Table 6.3b PAINAD Scale^[13]