The baseline pain assessment can be completed prior to a known painful event such as surgery or a diagnostic procedure to best help health care professionals manage the patient's pain in a proactive manner. The following activities comprise a baseline assessment.

1. While pain is the standard term used in the protocol, it is commonly recognized that many individuals use other terms (e.g., 'ache,' 'discomfort'). Use of preferred terminology will enhance understanding and participation by patients in their pain management program.
   • Investigate pain terminology typically used by the patient and use this term throughout the implementation of protocol.
2. Provide opportunity for individualized patient/family and nurse interaction. Involve family in all aspects of assessment and planning for pain management. Assess patient/family's current knowledge of pain management strategies that may be implemented during hospitalization.
3. Using a standard mental status tool, such as the Mini Mental State or the Short Portable Mental Status Questionnaire assess the patient's cognitive ability. Also assess functional status using the Katz ADL Scale or an institutional measure of functional abilities remembering to include sensory assessment. Obtain family assistance as needed.
4. Complete a thorough assessment of patient pain levels with the assistance of the patient and/or the family, which includes the following: (A pain Assessment Inventory is available in the full protocol):
   1. Assess patient and family attitudes and beliefs regarding: pain and analgesics, prior successes/failures with analgesics, expectations regarding pain and stress during hospitalization. Fear of addiction and analgesic side effects, beliefs related to ageism, passivity of patient role, and stoicism function as barriers to patient's report of pain.
   2. Assess sociocultural variables (e.g., ethnicity; acculturation) which may influence pain behavior and expression.
   3. Determine history of other chronic disorders which may also cause pain and interfere with accurate assessment of acute pain.
   4. Investigate medication use for chronic conditions that may interact or interfere with analgesic use.
   5. Assess patient for depression and/or anxiety which may alter pain perception and enhance intensity of pain.
   6. Investigate methods commonly used by the patient to relieve pain (e.g., folk/home remedies) and methods used to cope with pain (e.g., distraction, prayer).
   7. If the patient is noncommunicative, try to elicit from the family the patient's usual pain behaviors such as withdrawal, agitation, facial grimacing, guarding, moaning.
   8. Assess pain intensity by selecting a tool based on the patient's preferences and cognitive/functional abilities. The Verbal Descriptor Scale, pain Thermometer, Numeric Rating Scale and Faces Scale have an acceptable accuracy, are preferred by persons and can often be used by individuals with cognitive impairment.
      Examples of pain Scales that have been used with patients:
      • Verbal Descriptor Scale (VDS)
      • pain Thermometer (PT)
      • Numeric Rating Scales (NRS)
      • Faces pain Scale (ES)

      Please note: Mildly to moderately cognitively impaired individuals are often able to rate pain using these instruments, however individual patient ability to do so should be assessed.

Educate Patient and Family about pain Management

Research has demonstrated that implementing an educational program for pain management for the patient and family helps promote effective pain management. Although this program was developed for patients with cancer pain at home the overall structure of the program can also be adapted for patients with acute pain. The following activities can be included in this program.

1. General information about pain
   • Provide information regarding planned procedure and associated painful sensations to the patient and family prior to the upcoming procedure or surgery.Then offer opportunities for patient and family to discuss fears/concerns regarding the diagnostic procedure or surgery.
   • Provide patient and family with a brochure, such as the brochure offered through the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research [AHCPR]) publication titled "pain Control After Surgery: A Patient's Guide".
     This brochure (AHCPR Publication No. 92-0021) is available for sale from:

   AHRQ Publications Clearinghouse
   PO Box 8547
   Silver Spring, MD 20907-8547
   Call 800 358-9295 (in the US) or (410) 381-3150 (outside the US). Information is also available at the AHRQ Web site.
   

   • Explain to patient and family that pain can be managed and/or relieved and the importance of reporting pain and pain control in the recovery process (e.g., facilitation of post-op exercises to prevent complications). Coach the patient in accurately reporting pain.
   • Explain to the patient and family the importance of preventing rather than 'chasing' pain in effective pain management.
2. pain Assessment
   • Explain the pain assessment schedule and method of pain assessment utilizing selected assessment tool(s). Assess the patient's and family's understanding and accurate use of selected tool.
   • Communicate with the patient and set an acceptable level of pain control that is based on pain rating criteria.
   • Explain the need to differentiate pain related to procedure and pain related to other chronic disorders.
3. Pharmacologic Management
   • Allay common fears/misconceptions regarding opiate use, such as addiction and respiratory depression.
   • Negotiate pain rating criterion for analgesic administration (i.e., a rating on pain assessment tool.
   • Explain common side effects of analgesics (e.g., constipation) and planned interventions for any side effects experienced.
   • Describe as well as demonstrate typical analgesic regimen (e.g., PCA).
4. Nonpharmacologic Management
   • Describe cognitive/behavioral pain management options (e.g., relaxation strategies, imagery) and cutaneous stimulation options (heat/cold; Transcutaneous Electrical Nerve Stimulation (TENS)) and select options based on patient preference and cognitive/functional abilities.
   • Explain/demonstrate routine post-procedure exercises/activities (e.g., coughing) and methods to decrease discomfort from these (e.g., splinting).

1. Be aware that older individuals often suffer from chronic pain in addition to acute pain and implement strategies to relieve pain from chronic disorders as much as possible.
2. Assess and document characteristics, intensity, duration, and effects of pain: Use selected assessment tool.
   • Assess pain at least every two hours and during rest, during activity, and through the nighttime when pain is often heightened. Ability to sleep does not indicate absence of pain.
   • Observe for nonverbal cues of pain (e.g., grimacing, guarding) and behavioral changes (e.g., new onset of confusion, agitation and/or withdrawal; sleep disruption).
   • Elicit pain statements from communicative, cognitively impaired patients and use a selected assessment tool. Try several tools to evaluate which one is most easily used by the cognitively impaired individual. Many cognitively impaired subjects can complete at least one of the pain scales included in this protocol.
   • In noncommunicative, cognitively impaired patients, observe for change in usual behavior (e.g., withdrawal, increased confusion, agitation), facial expressions of pain (e.g., grimacing), bodily tension, fidgeting, and vocalization. Research indicates that failure to assess and treat pain in these individuals is often due to an unfounded belief by healthcare providers that pain sensations are diminished in individuals with cognitive impairments.
   • Assess for autonomic responses typically associated with acute pain (e.g., increased heart rate and blood pressure; increased or decreased respiratory rate; diaphoresis).
   • Assess pulmonary function (e.g., respiratory rate, lung sounds, signs of hypoxia) for pain-related complications every four to eight hours.
   • Differentiate procedural pain from pain due to chronic disorders or complications of procedure (e.g., new pain, increased intensity of pain, pain not relieved by previously effective strategies).
   • Assess the patient for atypical presentation of complications commonly seen in . For example:
     • Shortness of breath and confusion with MI and absence of or delayed chest pain.
     • Absence of pain during intra-abdominal emergencies.
     • pain of various conditions often referred from the site of origin.
   • Document pain assessment findings on a flowsheet that includes: date, time, pain rating, use of analgesics, other pain intervention, vital signs and side effects.

1. Use the following guidelines for analgesic administration:
   • patients receive significantly less analgesic medication than younger adults experiencing similar painful conditions/procedures, therefore leading to inadequate pain relief in these older patients. This tendency may be due to a belief on the part of healthcare providers that, in general, pain sensation decreases with age. There is no research base to support this misguided belief.
   • Ethnic minorities receive significantly less narcotic analgesics for similar painful events secondary to ethnic influences on the part of the patient (e.g., reluctance to request medication) and/or the caregiver (e.g., misinterpretation of ethnic-based pain behavior). Formal caregivers must assess for ethnic influences in order to provide appropriate pharmacological interventions.
   • Cognitively impaired individuals receive significantly less analgesics then cognitively intact patients with similar painful events. There is no empirical evidence to support that cognitive impairment is associated with decreased pain sensation.
   • Safe analgesic administration in the is complicated by interactions with multiple chronic disorders, multiple drugs to treat these disorders, nutritional alterations (e.g., protein deficiency) and altered pharmacokinetics. The incidence of acute confusion and other adverse reactions increases with the number of prescription drugs administered.
   • individuals generally receive greater peak and longer duration of action from analgesics than younger individuals, thus dosing should be initiated at lower doses (1/4-1/2 adult dose) and titrated carefully.
   • Use patient-controlled analgesia for intravenous analgesics particularly during immediate post-procedure period (e.g., 48 hours), but monitor and titrate cautiously due to increased potential for toxicity.
   • Recognize that cognitively impaired patients may require nurse assisted use of PCA.
   • Administer oral analgesics on an around-the-clock (ATC) basis. Administer on PRN basis later in course as indicated by patient's pain status. If given on PRN basis, administer 30 minutes prior to activities (e.g., PT) and postoperative exercises. Assess for breakthrough pain and need for supplemental doses.
   • If acute confusion develops, assess for other contributing factors prior to altering the prescription or discontinuing analgesic use. Confusion in postoperative patients has been found to be associated with unrelieved pain rather than opiate use.
   • Assess bowel function daily and initiate patient's home protocol or the Constipation Management research-based protocol to prevent the constipating effects of analgesic use. Assess for signs of ileus related to narcotic analgesics.
   • Measure intake and output and assess for signs of urinary retention/suppression.
   • Slowed intramuscular absorption of analgesics in patients may result in delayed/prolonged effect of IM injections, altered analgesic serum levels and possible toxicity with repeated injections. This is more common with IM meperidine than IM morphine. Use IV or intraspinal analgesia for rapid control of severe pain.
   • Antiemetics for analgesic-induced nausea may result in problems in patients due to anticholinergic effects (bowel and bladder dysfunction, confusion, movement disorders).
2. The following analgesics and adjuvants may produce increased confusion levels in patients:
   • NSAIDS (greatest risk during initial use).
   • Meperidine.
   • Pentazocine (Talwin).
   • Anticholinergics (Antihistamines, e.g., hydroxyzine; Phenothiazines).
3. Drug interactions occur more frequently in the .
4. The analgesic effects of NSAIDS supplement the analgesic effects of prescribed opioids, therefore reducing the dose of opioid that is required for effective pain management. Thus, they may reduce the incidence of opioid-induced respiratory depression in patients. The following NSAID complications are common among patients and must be carefully monitored:
   • GI bleeding especially with initiation of drug or higher doses of a drug. Therefore, avoid use, if patient has a history of peptic ulcers. A meta-analysis of the variability and risk of GI complications of NSAIDS found that low dose ibuprofen (under 1,600 mg/day) was associated with the lowest relative risk. Initiate antacid regimen and administer with food. Monitor for signs of GI bleeding.
   • Nephrotoxicity. Avoid use if patient has a history of renal impairment, congestive heart failure, concurrent volume depletion or diuretic use.
   • Bleeding disorders. Avoid use if patient has a history of bleeding disorders or a concurrent use of anticoagulants, or use platelet-sparing agent (e.g., Salsalte, Diflunisal).
   • Confusion. Monitor patient for new onset or increased confusion in demented patients during initial use. Long-term use has been found to have a protective effect on cognitive decline.
   • Other (e.g., constipation, headaches, dizziness).
5. Age-associated physiologic changes (e.g., reduced renal and/or liver function) result in increased toxicity with aspirin use.
6. ACETAMINOPHEN is an effective analgesic in the and does not produce the gastric and bleeding complications seen with NSAIDS. Other complications that may be associated with acetaminophen usage include:
   • Increased risk of end-stage renal disease with long-term use.
   • Toxicity due to reduced hepatic metabolism.
   • Over coagulation with warfarin in the outpatient setting.
7. OPIATES produce greater analgesic effect and have a higher serum peak and duration in patients. Therefore:
   • Initiate opioid therapy with 25% to 50% lower dose than that recommended for adults and slowly increase dosage by 25% on an individual basis, balancing analgesic need with undesirable effects. Use intravenous, intraspinal or oral routes of administration, not intramuscular.
   • Monitor for respiratory depression (e.g., less than 10/min) and reduced arterial oxygen saturation (less than 85%) particularly in opioid-naive patients. Cheynestokes during sleep without other adverse signs does not necessitate opioid reduction.
   • Omit if respiratory complications develop or if patient experiences excess sedation. Administer naloxone (Narcan).
   • Monitor for other side effects of opioids including sedation, hypotension, urinary retention (especially if coexisting BPH), constipation/ileus, and exacerbation of Parkinson's disease.
   • MEPERIDINE should be avoided in patients due to the possibility of normeperidine toxicity, especially if the patient has coexisting CHF or renal impairment. Normeperidine produces CNS excitability with tremors, seizures, mood alterations and confusion. Symptoms are managed with anticonvulsants. Narcan should NOT be administered for normeperidine toxicity.

     Avoid intramuscular use of meperidine because of tissue irritation and muscle fibrosis, compounding reduced tissue mass in patients. Intramuscular meperidine is poorly absorbed and leads to variable analgesic response and may result in increased dosage requirements and associated side effects.

   • MORPHINE SULFATE is a safer choice than meperidine in the for the following reasons:
     • Longer duration of action, therefore less overall dosage is required and less possibility of toxicity.
     • Reduced hemodynamic alterations.
     • Effects are most understood and predictable.
   • TRANSDERM FENTANYL is NOT indicated in management of acute pain. It has been used in patients with chronic pain but should be used with caution in opioid-naive due to extreme potency and potential for delirium and respiratory depression.
   • COMBINED AGONISTS/ANTAGONISTS have properties that may be pronounced in patients:
     • Butorphanol (Stadol) and pentazocine (Talwin) produce psychotomimetic effects and may lead to confusion.
     • Buprenorphine (Buprenex) is less likely to produce respiratory depression, but this complication cannot be completely reversed with naloxone (Narcan).
   • OPIOIDS WITH LONG HALF-LIFE (i.e. methadone, levorphanol) may result in toxicity in patients.
   • Identify other medications prescribed for chronic conditions that may potentiate opioid side effects (sedation with sedatives, tranquilizers, antiemetics; postural hypotension with antihypertensives, tricyclics; confusion with phenothiazines, tricyclics, antihistamines and other anticholinergics).

Nonpharmacological Management

• Assist patient to enhance his/her sense of personal control over pain (e.g., allow movement at preferred pace).
• Demonstrate interest in patient's comfort level and willingness to implement/alter strategies as needed to facilitate pain relief; frequently reinforce availability of pain relief measures; encourage verbalization regarding pain concerns.
• Support usual pain coping methods. (e.g., prayer, meditation).
• Facilitate use of home/folk pain remedies, unless contraindicated.
• Use relaxation strategies and distraction (e.g., breathing, massage, touch, music, imagery) to complement analgesics. Avoid imagery in-patients with severe cognitive impairment or psychoses.
• TENS has been used successfully in for postoperative pain.
• The can benefit from multimodal pain treatment that includes pharmacologic and non pharmacologic interventions.

1. Assess pain relief from interventions (30 minutes after parenteral, 60 minutes after oral) using patient-based feedback through one of the pain intensity scales described herein.
2. Document all pharmacologic and nonpharmacologic pain interventions on a pain flowsheet (Document pain assessment findings on a flowsheet that includes: date, time, pain rating, use of analgesics, other pain intervention, vital signs and side effects. A pain flowsheet is included in the full protocol).
3. Monitor each patient's pain flowsheet for patterns, in order to identify the efficacy of the pain intervention activities chosen and to determine any need for revision in the pain plan.

   The pain Level Outcome from the Nursing Outcomes Classification (NOC) can also be used to assess the effectiveness of pain management for each individual patient

4. If pain management is not adequate, revise the plan based on consultation among the patient's physician, nursing staff, and the pharmacy department.
5. In collaboration with the patient and his/her family, develop a discharge plan for pain management and provide written instructions, which include drug dosage, interval, drug interactions, and prevention of common side effects (e.g., constipation). Review routine medications for possible interactions. Assess patient and family member's ability to obtain analgesics and intervene accordingly.

For quality improvement of nursing care:

Acute pain management for patients should be evaluated at the organizational level (unit, hospital, nursing home, etc.) to evaluate whether the staff is using the pain management guidelines in a consistent and effective manner. Therefore it is important to monitor the use of the pain management guidelines in a structured manner.

This guideline was excerpted from the National Guideline Clearinghouse Brief Summary of the original University of Iowa Guideline.