11.5 Applying the Nursing Process

Assessment

Nurses play an essential role in performing comprehensive pain assessments. Assessments include asking questions about the presence of pain, as well as observing for nonverbal indicators of pain, such as grimacing, moaning, and touching the painful area. It is especially important to observe for nonverbal indicators of pain in clients unable to self-report their pain, such as infants, children, clients who have a cognitive disorder, client at end of life, non-English-speaking clients, or clients who tend to be stoic due to cultural beliefs. See Figure 11.14^[1] for an image of a simulated client who is expressing pain nonverbally.

Recall that pain is defined as whatever the person experiencing it says it is. Subjective assessment includes asking questions regarding the severity rating, as well as obtaining comprehensive information by using standard measures like PQRSTU or OLDCARTES for assessing a chief complaint. For some clients who are unable to quantify the severity of their pain, visual scales like the FACES scale are the best way to perform subjective assessment regarding the severity of pain. Review the PQRSTU, OLDCARTES, FACES, and other pain assessment scales in the “Pain Assessment Methods” section of this chapter.

Objective data includes observations of nonverbal indications of pain, such as restlessness, facial grimacing and wincing, moaning, and rubbing or guarding painful areas. For clients who cannot verbalize their pain, using a scale like the FLACC, COMFORT, or PAINAD is helpful to standardize observations across different staff members. Keep in mind that clients experiencing acute pain will also likely have vital signs changes, such as increased blood pressure, increased heart rate, and increased respiratory rate.

It is important to assess the impact of pain on a client’s daily functioning. This can be accomplished by asking what effect the pain has on their ability to bathe, dress, prepare food, eat, walk, and complete other daily activities. Assessing the impact of pain on daily functioning is a new standard of care that assists the interdisciplinary team in tailoring treatment goals and interventions that are customized to the client’s situation. For example, for some clients, chronic pain affects their ability to be employed, so effective pain management is vital so they can return to work. For other clients receiving palliative care, the ability to sit up and eat a meal with loved ones without pain is an important goal.^[2]

When performing a client assessment, any new complaints of pain or pain that is unresponsive to the current treatment plan should be reported to the health care provider. Instances of sudden, severe pain or chest pain/pressure require immediate notification or contact of emergency services.

Diagnoses

Commonly used NANDA-I nursing diagnoses for pain include Acute Pain (duration less than three months) and Chronic Pain. See Table 11.5 for more information regarding these diagnoses.^[3] For more information about defining characteristics and related factors for other NANDA-I nursing diagnoses, refer to a current nursing diagnosis resource.

Table 11.5 Pain NANDA-I Nursing Diagnoses^[4]

Outcome Identification

An overall goal when providing pain management is, “The client will report that the pain management treatment plan achieves their comfort-function goals.”^[5]

SMART outcomes are customized to the client’s unique situation. An example of a SMART goal is, “The client will notify the nurse promptly for pain intensity level that is greater than their comfort-function goal throughout shift.”^[6]

Planning Interventions

Several pharmacological and nonpharmacological interventions have been described throughout this chapter. See the following box for a summarized list of interventions for acute pain management.

See the following box for a summarized list of interventions for chronic pain management.

Implementing Pharmacological Interventions

Clients should be involved and engaged in their plan of care to treat pain. By demonstrating empathy and collaborating with clients and the interdisciplinary team, it is more likely the treatment plan will be effective based on the client’s goals.

When administering analgesic medication, holistic nursing care is important. Begin by considering the client’s goals for pain relief and ask if they have been met effectively by previously administered medications. If they have not been met, it may be necessary to advocate for additional or alternative medication with the health care provider. It is also important to consider if the client is experiencing any side effects that may impact the client’s desire to take additional pain medication.

When administering medications that have been ordered on an “as-needed” basis, it is vital for the nurse to verify the amount of medication the client received in the past 24 hours and if any dosage limits have been met to ensure client safety.

Prior to administration, consider the best route of administration for this client at this particular time. For example, if the client is nauseated and vomiting, then an oral route may not be effective. On the other hand, if a client’s pain has improved when receiving intravenous medications during the recovery process, it may be possible for the client to begin taking oral pain medications in preparation for discharge home. Keep the WHO ladder in mind when selecting medications to reach client goals while also avoiding potential adverse effects when possible.

When preparing opioid medications, it is important to remember that these medications are controlled substances with special regulations regarding storage, count auditing, and disposal/wasting of medication. This generally involves two registered nurses counting, auditing, and wasting medications. Follow agency policy regarding these issues. It is also important to assess the client’s level of sedation and respiratory status before administering additional doses of opioids and withhold the medication if the client is oversedated or their respiratory rate is less than 12/minute. However, when providing pain management during end-of-life care, these parameters no longer apply because the emphasis is on providing comfort according to the client’s preferences. Read more about end-of-life care in the “Grief and Loss” chapter.

Evaluation

It is vital for the nurse to regularly evaluate if the established interventions are effectively meeting the pain management and function goals established collaboratively with the client. Additionally, when administering analgesics, the client should be reassessed in an hour (or other time frame based on the route, onset and peak of the medication) to determine if the medication was effective. If interventions are not effective, then follow-up interventions are required, which may include contacting the health care provider.

For clients living with chronic pain, it can be helpful for them or their caregiver to maintain a pain journal. In the journal they can document activities that precipitated pain, medications taken to manage the pain, and whether these medications were effective in helping them to meet their functional goals. This journal is shared with the health care provider during follow-up visits to enhance the treatment plan.^[9]

The nurse must continually monitor for potential adverse effects of pain medications. For example, if a client is receiving acetaminophen daily for chronic osteoarthritis pain, signs of liver dysfunction, such as jaundice and elevated liver function bloodwork, should be monitored. For older adults receiving NSAIDs, it is important to watch for early signs of gastrointestinal bleeding, such as melena. Clients receiving opioids should be continually monitored for oversedation, respiratory depression, constipation, nausea and vomiting, urinary retention, and pruritus. Side effects should be reported to the health care provider and orders received for treatment.