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Pain Assessment and Management in the Adult Patient

2.00 Contact Hours:
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Authors:    Arlene Davis (RN, MSN, AOCN) , Donna Thomas (RN, MSN, BSHEd)


This course updates the healthcare professional on current assessment and management of pain in the adult population. Special considerations necessary for pain assessment in nonverbal patients are addressed.


After studying the information presented on pain assessment and pain management of the adult patient, you will be able to:

  1. Describe appropriate pain assessment in the adult patient.
  2. Identify pharmacologic interventions to relieve pain.
  3. Identify common side effects of opioids.
  4. Identify non-pharmacologic interventions useful in pain management.
  5. Describe special considerations in assessing pain in nonverbal patients.

Definition and Scope of Pain

An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. The physical part of pain results from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it can be more diffuse, as in disorders like fibromyalgia. Pain is mediated by specific nerve fibers that carry the pain impulses to the brain where their conscious appreciation may be modified by many factors (www.Medicine.net.com, 2013).

Patients may experience acute, chronic, or cancer pain.

  1. 1. Acute pain follows injury to the body and generally disappears as healing takes place. There is identifiable pathology that accounts for the pain. It may arise from operative procedures or from tissue trauma associated with an inflammatory process, for examples. It may be associated with objective physical signs such as increased heart rate, hypertension, and pallor (autonomic nervous system activity), making patients "look" like they are in pain.
  2. 2. Chronic non-malignant pain is pain that lasts for an extended period of time. There may or may not be known active pathology to account for the suffering that the individual is experiencing. Chronic pain, in contrast to acute pain, is rarely accompanied by signs of autonomic nervous system activity.
  3. 3. Cancer pain may be acute, chronic, or intermittent. It usually has a definable cause, which is usually related to tumor recurrence or treatment.

The prevalence of pain is high. It is estimated that over 75 million Americans suffer with pain. Approximately 50 million Americans have chronic pain and 25 million have acute pain. These numbers make it easy to understand that pain is one of the most common reasons that people seek medical attention.

Pain causes suffering. Unrelieved, it can destroy the quality of life. Persistent pain can impair sleep and appetite, leading to fatigue and nutritional decline. It can delay healing, cause increased stress and anxiety, alter immune function, lead to depression and destroy the will to live. Additionally, current unrelieved acute pain can cause chronic pain at a later date.

The good news is that we have the knowledge and skills to effectively manage most pain. So what is the problem? Why is unrelieved pain still so prevalent?

Knowledge is important. Clinicians as well as patients need to be made knowledgeable about methods of relieving pain. But knowledge alone rarely changes practice. Efforts must go beyond education alone if pain treatment is to improve. Pain needs to be made visible so it will not go unnoticed by clinicians.

What is meant by the phrase “pain as the 5th vital sign?

Assessment of pain is a critical step in providing good pain management. The American Pain Society initially promoted the phrase "pain as the 5th vital sign" to increase the visibility of pain among healthcare professionals. Vital signs are taken seriously. Practitioners usually do not fail to recognize and take action on an elevated blood pressure, for example. Blood pressure is routinely measured and recorded in the patient´s chart and standard practice holds that elevated blood pressure requires assessment and action. If pain intensity is assessed routinely with the same zeal as the traditional four vital signs (temperature, heart rate, respiratory rate, and blood pressure) and documented with them, pain management would improve. As the "5th vital sign," pain intensity becomes visible and can be used to guide treatment.

When and how should pain intensity be assessed?

Basic pain assessment is simple and must be performed regularly. Action needs to be planned on the basis of patient reports of pain.

It makes no difference whether patients are in the hospital, a long-term care facility, a behavioral health facility, an outpatient clinic or being cared for by a home care agency. No matter where patients are, the intensity of pain should be assessed and documented (1) during the initial evaluation of the patient, (2) after any known pain-producing procedure, (3) with each new report of pain, (4) at regular intervals when vital signs are taken, and (5) at suitable intervals after pharmacologic (45-60 minutes after oral intervention; 15-30 minutes after parenteral intervention) or non-pharmacologic intervention to evaluate the current pain treatment plan.

A "0 to 10" numerical scale is the most widely used measure to assess pain intensity. When using the Numerical Rating Scale (NRS), patients are asked to rate their pain from 0 to 10, with "0" equaling no pain and "10" equaling the worst possible pain they can imagine. Since we have no instrument to objectively measure pain intensity in the same way that blood pressure is measured by a sphygmomanometer, for example, the only valid measure of pain is the patient´s self-report (a subjective measure). Sometimes healthcare providers may believe that they are the best judges of a person´s pain; however, many studies demonstrate that healthcare providers either over or underestimate a patient´s pain.

For patients who are NOT cognitively impaired but who cannot respond verbally and/or rate their pain numerically, faces scales with happy faces representing no pain (0), and progressively sadder faces representing increasing pain intensity may be used. The patient is asked to choose the face that best depicts how they are feeling.

Once current pain intensity is assessed, then what?

Each institution should select a pain intensity rating that will elicit a full assessment to help formulate the plan of care. Since research suggests that pain at a level of 4 out of 10 is the point at which pain significantly interferes with function, most institutions choose that a full assessment be completed for pain levels of 4 or greater. Besides current pain intensity, the complete pain assessment includes the following:

  1. Location of pain
  2. Pain intensity for the worst pain, the best pain gets, and the acceptable level of pain. Satisfactory pain relief is a level of pain that may be noticeable, but not bothersome.
  3. Character or quality of pain. The words used by the patient to describe pain may enhance the understanding of the etiology of the pain and provide usefulness in selecting interventions to manage it. For example somatic (musculo-skeletal) pain is usually localized and described as dull, achy, and sore. Visceral pain is usually poorly localized and described as cramping or squeezing. Descriptors of burning, shooting or knife-like are indicative of neuropathic (nerve) pain. (Refer to Table 1).
  4. Onset, duration, variations, rhythms (is the pain better or worse at certain times, certain hours?)
  5. Alleviating factors – what makes the pain better?
  6. Aggravating factors – what makes the pain worse?
  7. Impact of pain on quality of life and daily functioning. How does the pain affect sleeping, relationships with others, mood, emotions, concentration, for examples?
Table 1
Pain Type Description Etiology Treatment
Neuropathic Burning,
Nerve involvement
  • Tumor
  • Postherpetic neuralgia
  • Diabetic neuropathy
  • Post stroke pain Coanalgesics
  • Anticonvulsants
  • Antidepressants
  • SSNRIs
  • Local anesthetics
  • Antidepressants
  • SSNRIs: Selective-Serotonin Norepinephrine Reuptake Inhibitor
Local anesthetics
(poorly localized)
Tumors occupying the liver, pancreas, spleen; abdominal or thoracic surgery; ascites Non-opioids
  • Acetaminophen
  • NSAIDs
  • Corticosteroids
  • Local anesthetics
  • Bisphosphonates
  • Radioisotopes
(well localized)
Dull, achy, throbbing, sore Bone metastases, musculoskeletal injury, mucositis, skin lesions

Pain Management Plan

Once pain is assessed, a pain management plan is formulated. The goal of pain management is to achieve optimal comfort and function with minimal side effects from analgesic therapy. The pain management plan may include treatment of the cause of the pain (if possible), optimal use of analgesic and adjuvant medication, use of non-pharmacologic interventions, and referral for invasive approaches when appropriate.

Pharmacologic Interventions

Opioid analgesics are the cornerstone of pharmacological management for acute pain, especially when the pain is moderate or severe. Other agents such as Non-steroidal anti-inflammatory drugs or NSAIDs may control mild to moderate pain or reduce opioid dose requirements for more severe pain. The intravenous route is the route of choice with acute pain only until oral intake is tolerated. Once oral intake is tolerated, the route should be changed to oral. Intramuscular (IM) administration of medications is never recommended for treatment of any type of pain. Absorption of medication is variable with the IM route and IM injections hurt!

Non -0pioid analgesics include ketamine, an N-methyl-D-aspartate receptor antagonist. Adjuvant analgesics include antiepileptic drugs and antidepressants which are used for the treatment of neuropathic pain.

Medications are the cornerstone of the management of cancer pain because they are effective, relatively low risk, inexpensive, and usually have rapid onset. The following three major classes of medications are used alone or, more commonly, in combination to manage cancer pain: (1) NSAIDs, ASA, and acetaminophen; (2) opioid analgesics and (3) adjuvant or co-analgesic medications. Adjuvant or co-analgesic medications are those medications that are not usually thought of as analgesics but which, when given with known analgesics, have synergistic effects or exhibit analgesic activity of their own. Anticonvulsants (gabapentin, for example) and antidepressants (amitriptyline, for example) are adjuvant medications used to treat neuropathic pain. (Refer to Table 1).

Most cancer pain can be managed using oral medications; however, such things as difficulty in swallowing, gastrointestinal disturbances that make absorption unreliable, and the amount of medication required may necessitate the use of an alternative route of administration.

Over twenty years ago the World Health Organization developed a three-step analgesic ladder which is a simple and effective method for assuring the proper titration of therapy with cancer pain. (Refer to figure 1, A Stepwise Approach to Pain Management.) The steps of the ladder illustrate the process of selecting medications based on pain intensity. Step 1 includes medications that are effective for mild pain, step 2 for moderate pain, and step 3 for severe pain. At each step of the ladder, adjuvant drugs may be combined with analgesics, if indicated. At steps 2 and 3 non-opioids may be combined with opioids for improvement in analgesia. All patients may not enter the ladder at step 1; they should enter at the step of the ladder that corresponds to the intensity of their pain. For example, patients having severe pain should enter the ladder at step 3. While the ladder focuses on a pharmacologic approach to pain management, non-drug modalities for pain control can be used at each step, depending on the patient’s need.

In the past, patients with chronic non-malignant pain had been excluded from long-term therapy with opioids for fear they would become addicted or psychologically dependent, using the opioid for effects other than pain relief. Although often confused with addiction, tolerance and physical dependence are not equivalent to addiction. Physical dependence is just that; if the opioid is suddenly stopped or an antagonist medication such as naloxone is given, symptoms of withdrawal will occur. Tolerance is a decrease in one or more effects of the opioid, whether it is decreased analgesia, sedation, or respiratory depression. When tolerance to analgesia occurs, patients may need increased doses of opioids to achieve the same pain relief. Although most patients who take opioids several times daily for more than one month develop some degree of tolerance and physical dependence, the risk of addiction is slight – less than one percent. Recent studies have shown that along with other modalities, opioids might be a reasonable treatment addition for chronic pain in many patients who are not terminally ill. The oral route of administration is the optimal route for administration of medications for chronic pain. The same Stepwise Approach to Pain Management (Figure 1) is appropriate for treatment of chronic non-malignant pain as it is for the treatment of cancer pain.

For treatment of any type of pain, the need to change opioid medication may arise if unacceptable side effects develop, if one drug is not providing adequate pain relief in spite of dose escalation, or if the route of administration is changed. Opioids vary in the dose each requires to produce the same amount of analgesia. Also the method of delivery can make a difference. The same amount of drug given by mouth may have a vastly enhanced effect if injected intravenously. Be aware of the differences in changing the route of administration or the opioid medication. Refer to the equianalgesic table (Table 2) to adjust for the differences in the medication or the route of administration to achieve the same results.

TABLE 2: Opioid Equianalgesic Table
Use this table as a guide only. The following equianalgesic doses are medication and route conversions approximately equal to a single morphine 10 mg parenteral dose. The equianalgesic dose is not the usual starting dose, but just an estimate. Doses and intervals between doses need to be individualized and titrated according to patient response and the clinical situation.
Medication Parenteral Route Oral Route Duration (hours)
Morphine Sulfate Immediate release 10 mg 30 mg 2-4
Morphine Controlled release N/A 60-90 mg 8 or 12
Hydromorphone 1.5 mg 7.5 mg 2-4
Oxycodone Immediate release (also in Percocet, Percodan, Tylox, Roxicet) N/A 20 mg 3-4
Oxycodone Controlled release N/A 60 mg 12
Hydrocodone (also in Vicodin, Lortab, Lorcet) N/A 30 mg 3-4
Codeine 120 mg 200 mg 3-4

Meperidine has purposefully been omitted from this table because its use should be limited. Accumulation of its metabolite, normeperidine, is associated with confusion and seizures. Its use should be considered only for management of acute episodes of pain if the patient has a history of unmanageable adverse reactions to other opioids, for conscious sedation of adults in some circumstances, or for prevention or treatment of rigors and treatment of post-anesthesia shivering. Meperidine should not be used for longer than 48 hours and should not be used for patients with renal insufficiency. Contrary to persistent belief, meperidine has not been shown to have any specific benefit in patients with biliary colic.

Effective pharmacologic management of all types of pain requires that the regimen be individualized. In addition to choosing a suitable medication or medications, optimal doses must be selected. As with acetaminophen and ASA, all NSAIDs have ceiling (maximum) doses that, if exceeded, may precipitate toxicity without improving analgesia. Opioids, however, have no maximum or ceiling dose. Generally, with opioids, the goal is to use the smallest dose that relieves the maximum amount of pain with the fewest side effects. Equally important for effective pharmacologic management of pain, the medication should be given:

  1. before pain occurs or increases (that is, before a painful event such as wound debridement) or
  2. “around the clock” (ATC) or at regularly scheduled times if pain is present most of the day.

A rule of thumb is if the pain is expected to be present 12 or more hours out of the next 24 hours, ATC dosing should be considered. The analgesics should be routinely scheduled to prevent the recurrence of pain. Along with ATC dosing, supplementary analgesia or rescue dose should be available for breakthrough pain (flares of pain or intermittent increases in pain).

Common Side Effects with Long-term Opioid Treatment

All opioid analgesics share common side effects, the most common being constipation, nausea and/or vomiting, sedation and mental clouding, and respiratory depression. Although side effects are usually a less serious problem than the under treatment of pain, they are common enough to warrant discussion. Tolerance to all the side effects, except constipation, develops with time.

Constipation will NOT diminish with time and can become a significant clinical problem if preventive measures are not instituted. Opioids reduce the motility of the intestines. Reduced activity and decreased appetite can make the problem even worse. Constipation can be alleviated by eating foods high in fiber and by drinking eight to ten glasses of water a day (if not contraindicated by other problems). Exercise can help too. When starting on routine opioids, patients need to start on a stool softener/laxative preparation, and they need to be continually re-assessed to make sure the current bowel regimen is working.

When patients complain of nausea and/or vomiting after opioid administration has begun, it is often helpful to administer an antiemetic on a fixed schedule for several days, until tolerance to this side effect develops. At that point, prn dosing is usually adequate. Depending on the antiemetic chosen, patients need to be monitored for the possibility of increased sedation.

Transitory sedation and mental clouding is common when opioid doses are increased, but tolerance usually develops rapidly. Persistent drug-induced sedation is usually best treated by reducing the amount of opioid for each dose and increasing the dosage frequency. This strategy will decrease the peak concentrations in the blood while maintaining the same total dose. CNS stimulants such as caffeine or methylphenidate may be added to increase alertness if the above approach is ineffective in reducing sedation.

Patients receiving long-term opioid therapy usually develop tolerance to the respiratory-depressant effects of these agents. Occasionally, respiratory depression occurs when pain is abruptly relieved and the sedative effects of opioids are no longer opposed by the stimulating effects of pain. In a symptomatic patient, physical stimulation may be enough to prevent significant hypoventilation. When needed, the opioid antagonist naloxone should be administered cautiously to patients who are receiving opioids on a long-term basis. Symptomatic respiratory depression should be treated using a dilute solution of naloxone (0.4 mg in 10 ml of saline), administered as 0.5 ml (0.02 mg) boluses every minute. Naloxone should be given in doses to improve respiratory function, but not to reverse analgesia, since a return to full alertness may be accompanied by a severe withdrawal syndrome as well as a return of pain.

Far more common than acute respiratory depression is sub-acute overdose, in which sedation gradually builds and is followed by a slowing of respiratory rate and then by ventilatory failure. The degree of sedation, rather than the respiratory rate, is a better indicator of impending respiratory depression. This complication is best managed by withholding one or two doses and then reducing the standing dose by 25% of its current level.

Opioids may also occasionally cause other side effects such as urinary retention, pruritus, myoclonus (jerking), seizures, hallucinations, confusion, sexual dysfunction, and sleep disturbances.
In the United States the current climate of change related to opioid use is as follows:

  • 80 % of the global opioid use is consumed by Americans and 99 % of the hydrocodone supply (Manchikanti, L., et al. 2010).
  • From 2009 drug-induced deaths exceeded motor vehicle deaths in the U.S.
  • The number of U.S. drug poisoning deaths involving any opioid analgesic from 1990 to 2010 more than quintupled (CDC. July, 2010).
  • ER visits due to opioids doubled between 2004 and 2008 (CDC, MMWR, June, 2010).

The current climate of change related to prescription drug abuse as noted by the Department of Defense/Veterans Administration is the following:

  • Prescription drug abuse doubled from 2002 to 2005 and almost tripled between 2005 and 2008 (Newsletter of the Office of National Drug Control policy: Executive Office of the President Volume 1, Issue 2 (2010).
  • Rx’s for pain medications written for military and veterans is up more than 438% since 2001(National Council of Alcohol and Drug Dependence, Veterans and Drugs)
  • 11.5% of military personnel reported prescription drug misuse compared to 4.4 % in the civilian population (Newsletter of the Office of National Drug Control policy: Executive Office of the President Volume 1, Issue 2 (2010).
  • The prevalence of prescription drug misuse among women in the military was 13.1 %, more than four times the rate for civilian women (Newsletter of the Office of National Drug Control policy: Executive Office of the President Volume 1, Issue 2 (2010).
  • Between 2009 and 2011, 72 % of drug-related undetermined or accidental deaths involved prescription drugs ( Tan, M (2112).

Another medication used for pain relief is the Medical Marijuana Pill called Dronabinol. Dronabinol contains the active ingredient of marijuana and is being researched. The newest study at Columbia University’s Department of Psychiatry was with assistant professor of clinical neurology, Ziva Cooper. She said “the new findings suggest a marijuana pill can produce analgesic effects far longer without the health risks that come along with smoking. Information on this study was published in the journal Neuropsychopharmacology.

Experts in the current study found that the drug Dronabinol provided a longer-lasting effect in pain sensitivity and was less susceptible to abuse-associated outcomes, compared to marijuana. Dronabinol contains the active ingredient of marijuana - tetrahydrocannabinol (THC) - and has already been approved to treat chemotherapy and AIDS patients with nausea and vomiting.

Dr. John Roberts, an oncologist at the Yale School of Medicine who has studied the effects of marijuana's active ingredient on pain has stated “there might be a role for each form of the drug in pain relief, depending on the users' preferences. For instance, some people with a pain condition may say that they prefer smoking marijuana because it both reduces their pain and gives them a high. However, the issue of whether to allow patients to use potentially addictive drugs (ones they find pleasurable) is a question for public policy”. Medical marijuana is legal in 18 states, and studies have suggested that smoking the drug relieves pain. More research is needed.

Non-pharmacologic techniques of pain management are gaining in popularity. It is estimated that Americans spend $21 billion out of pocket annually on complimentary methods of pain control. Nurses need to know about these approaches to assist patients in making educated decisions. Analgesics are the mainstay of pain relief. However, even with the optimal use of analgesics, pain may be more effectively treated with a combination of analgesic and non-analgesic approaches. For some types of mild pain, non-analgesic approaches alone may provide sufficient relief. However, non-analgesic techniques are a supplement for, but do not replace, pharmacologic interventions for moderate to severe pain.

Cognitive-Behavioral Interventions

The basis for the use of these methods is that thought influences feelings, and if thought (and behaviors) can be changed, so can feelings and even sensations, such as pain. Cognitive-behavioral methods require the patient’s active participation.

  1. Relaxation is a state of relative freedom from both anxiety and skeletal muscle tension, a quieting or calming of the mind and muscles. Although relaxation is a learned technique, it can be achieved quickly in a motivated patient.
  2. Distraction from pain is the focusing of attention on stimuli other than the pain sensation. The stimuli focused upon can be auditory, visual, or tactile-kinesthetic (hearing, seeing, touching, and moving). By focusing attention and concentration on stimuli other than pain, pain is placed on the periphery of awareness. Distraction does not make the pain go away, nor does the effectiveness of the use of distraction indicate the absence of pain. Music and humor are extremely effective means of distraction.

    Sari went to the dentist and had to have a deep cleaning of all her gums. This was very painful and the dentist had to administer an analgesic to relieve the potential pain. The injection of the analgesic would also be painful. To distract Sari the hygienist kept tapping her upper arm on the side that the dentist was not on. This distraction decreased the sensation of pain and discomfort.
  3. Imagery/visualization involves mentally creating a picture by using one’s imagination. This may be a focus on a close person, a place of enjoyment, a past event, or anything that is thought to bring pleasure. Since the mind is occupied, the pain is reduced in focus.

Non-invasive Mechanical Interventions

  1. Massage is soothing and relaxing, both physically and mentally. Massage may decrease pain by relaxing muscle tension and increasing capillary circulation, thereby improving general circulation.   
  2. Vibration is a form of electric massage. When vibration is applied lightly, it may have a soothing effect similar to massage. Vibration applied with moderate pressure may relieve pain by causing numbness, paresthesia, and/or anesthesia of the area stimulated.   
  3. Heat/Cold – Heat reduces inflammation and promotes relaxation. It can be in the form of hot tub baths, heating pads, or heat packs. Cold is often more effective in relieving pain than heat. Applications of cold reduce muscle spasms secondary to underlying skeletal muscle spasm, joint pathology, or nerve root irritation. Methods of cold application include ice massage, ice bags, and gel packs. Alternating heat and cold may be more effective than the use of either one alone.   
  4. Transcutaneous Electrical Nerve Stimulation (TENS) provides low voltage electricity to the body via electrodes placed on the skin. TENS may help with acute or chronic pain. Electrical stimulation of sensory nerves helps block pain signals going to the brain.

Acupuncture is a neurostimulatory technique that treats pain by the insertion of small, solid needles into the skin at varying depths. Various theories exist to offer explanation of how acupuncture works.

Music Therapy to treat pain

Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional. This individual has to complete an approved music therapy program. Research in music therapy supports its effectiveness in a wide variety of healthcare and educational settings. Music Therapists use music to facilitate changes that are non-musical in in nature. Music therapy currently is considered an established health service similar to occupational or physical therapy. Studies done with those patients who have arthritis demonstrated that music helps to relieve pain and anxiety, induce relaxation, promote healing, enhance mental function, improve communication, promote physical rehabilitation, and reduce stress providing positive changes in both mood and emotional state. Individuals doing music therapy listen to music created under the guidance of an individual specially educated and certified in music therapy.

Jackie, a seventy two year old woman complained of unrelieved chest pain and in the ambulance the EKG showed an elevated ST segment. She was having a myocardial infarction. She was taken to a hospital which did cardiac catherizations (PCI/percutaneous coronary intervention). Three of her coronary vessels were blocked and her vessels were tiny. It was decided she needed open heart surgery. She was to undergo Coronary Artery Bypass Surgery (CABG). Jackie had no tolerance for pain and agreed to listen to music created by the music therapist prior to, during and after surgery.

The surgery was successful and Jackie complained of very little pain. Since she was an actress, the music therapist helped her to choose music she could relate to, dance to and sing to. When she did need pain medication it did not take much. Jackie had always had reactions to medications and was hypersensitive. It did not take a high dose of pain medication to relieve her discomfort.

It is believed that music, like relaxation and guided imagery, can  strengthen the right side of the brain, which controls the body's healing processes. The theory of music therapy's effect on chronic pain deals with how pain signals travel through the body. When the brain senses injury to the body, pain signals begin in the somatosensory cortex and the hypothalamus and work their way through the “pain pathway”, ultimately sending signals that provide pain relief. There are also signals that stimulate the release of neurotransmitters such as endorphins, dynorphins, and enkephalins. Music helps in pain reduction by activating these sensory pathways.

Invasive therapies

With rare exception, less invasive analgesic approaches should precede invasive approaches. However, if drug therapy, cognitive-behavioral interventions, and/or non-invasive mechanical interventions do not alleviate pain, invasive therapies such as nerve blocks and neurosurgery may be useful.

Nonverbal Patients – A Special Population

Since pain is a subjective experience, we measure the existence and intensity of it by the patient’s self-report. Unfortunately, adult patients who have cognitive/expressive deficits or who are intubated, sedated, and/or unconscious may not be able to provide a self-report. Individuals who cannot communicate their pain remain a challenge and are at even greater risk for inadequate pain control.

When patients cannot self-report, other measures need to be used to detect pain. Even if they cannot speak for themselves, these patients have the right for pain assessment and management. Valid and reliable methods to assess pain in nonverbal patients are clearly needed. The American Society for Pain Management recommends the following multifaceted approach for consideration in detecting pain in this population.

  1. Use the Hierarchy of Importance of Measures of Pain Intensity for Nonverbal Patients.
    1. Self-report of pain is the most reliable way to assess pain.
      1. Although self-report may be possible with mild to moderate cognitive impairment, as dementia progresses, the ability to self-report decreases and eventually becomes impossible. However, even if patients cannot communicate the experience of pain, they still experience pain sensation.
      2. Obtaining a report of pain from a critically ill patient may be hampered by such conditions as delirium, decreased level of consciousness, presence of an endotracheal tube, sedatives, and neuromuscular blocking agents, for example. In these situations, the patient’s ability to self-report may wax and wane; therefore, serial assessment for the ability to self-report should be conducted.
    2. Search for Potential Causes of Pain.
      1. Assume pain is present and intervene with common problems or procedures known to cause pain (e.g., surgery, wound care, positioning), even in the absence of behavioral indicators of pain.
      2. Rule out or treat other problems that may cause discomfort (e.g., infection, constipation, urinary retention).
      3. Consider chronic pain causes that may have been present before (e.g. history of arthritis or low back pain).
    3. Observe patient behaviors – a valid approach only when self-report is absent. The American Geriatrics Society identifies the following six main types of pain behaviors: (1) facial expressions (grimacing, e.g.), (2) verbalizations or vocalizations (moaning, e.g.), (3) body movements like tense body posture, (4) changes in interpersonal interactions (aggression or resisting care, e.g.), (5) changes in activity patterns (refusing food or increased wandering, e.g.), and (6) mental status changes like crying or increased confusion.
    4. Encourage proxy pain rating by family members or care-givers who know the patient when patients are unable to provide self-reports of pain. Inquire about behaviors that may indicate pain or whether preexisting conditions that may cause pain, such as arthritis, are present.
    5. Attempt an analgesic trial with procedures or conditions that are likely to cause pain or when pain behaviors continue after attention to basic needs and comfort measures. Make appropriate adjustments such as increases in dose or addition of other analgesics if behaviors indicative of pain persist, or additional potentially painful procedures occur.
  2. Establish a Procedure for Pain Assessment.

    When patients are unable to self-report pain, other less reliable measures must be used to identify its existence. These assessment measures (described above) form a hierarchy, arranged in order of probable importance. Healthcare facilities should institute a procedure for the use of this hierarchy of assessment techniques as a template for the initial assessment and treatment procedure.
  3. Use Behavioral Pain Assessment Tools, as Appropriate.

    The number of studies addressing assessment of pain in nonverbal adults who cannot provide a self-report has increased recently. Further study is required, though, to demonstrate their reliability, validity, and usefulness in the clinical setting. When utilizing behavioral pain assessment tools, one must keep in mind the following considerations:
    1. Scores obtained when utilizing behavioral pain assessment tools are NOT equivalent to self-reported intensity ratings and should never be documented as such. Only self-reported intensity ratings may be documented as the “5th Vital Sign”.
    2. Pain behaviors may not indicate pain, but another source of distress, such as emotional distress.
    3. It is best to observe a patient during care activities when pain behavior is more likely, rather than at rest.
    4. Behavioral assessment tools may be helpful to identify the presence of pain. They also can be used to evaluate attempts to relieve pain by observing for a decrease in pain behaviors following intervention.
      1. At least 14 behavioral assessment tools have been developed to assess for pain in nonverbal patients with dementia. These tools are in varying stages of development and validation. When selecting a tool, choose one that has been researched for reliability and validity in a similar clinical setting. Behavioral assessment tools for the cognitively impaired are of two types: pain behavior scales and pain behavior checklists.
        1. Pain behavior scales are scored by identifying the degree of an observed behavior. This score is not the same as a pain intensity score. An example of a pain behavior scale is the Pain Assessment in Advance Dementia Scale (PAINAD). It evaluates and scores five categories of behavior: breathing, negative vocalization, facial expression, body language, and consolability. Each category may receive a score ranging from 0 to 2. Any positive score may indicate that pain is present and the score can be used to evaluate intervention, but cannot be interpreted to mean pain intensity. For a pain behavior scale to be used, the patient needs to be able to respond in all categories of behavior. For example, the PAINAD should not be used with a patient who is a quadriplegic, since body language could not be scored.
        2. Behavior checklists differ from pain behavior scales. They do not evaluate the degree of an observed behavior, but just its presence or absence, and do not require a patient to demonstrate all of the behaviors specified. An example of a pain behavior checklist is the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). This checklist evaluates 60 behaviors such as restlessness, agitation, decreased activity, and appetite changes. The total number of behaviors that a pain exhibits cannot be equated with a pain intensity score. A patient who scores 5 out of 60 behaviors does not necessarily have less pain than a patient who scores 10 out of 60. In an individual patient, though, a change in the total number of behaviors may suggest more or less pain and can be used to evaluate response to interventions.
      2. Tools developed to assess pain with mechanically ventilated and/or unconscious patients are fewer in number. One such tool – the Adult Nonverbal Pain Scale (NVPS) – was patterned after the Faces, Legs, Activity, Cry, Consolability Observation Tool (FLACC) used to assess pain in infants and children. When tools are adapted and used in different settings, they need to be tested for reliability and validity in the new patient population. The NVPS was tested in the burn trauma unit at Strong Memorial Hospital, Rochester, New York. After initial testing, further revision was made to include a respiratory component with ventilator compliance. This revised scale, which scores the categories of facial expression, activity, guarding, physiology (vital signs), and compliance with ventilator, is currently being implemented in several health-care institutions while undergoing further testing.
  4. Minimize Emphasis on Physiologic Indicators

    Research does not support the use of vital sign changes for identifying pain. Absence of an increase in blood pressure, respiratory rate, or heart rate does not indicate absence of pain.   
  5. Reassess and Document

    Just as with patients who self-report pain, reassessment of pain with non-verbal patients’ needs to occur after intervention and regularly over time. Reassessment should occur utilizing the same initial behavioral pain assessment tool and observing for changes in those behaviors with effective treatment.


The updated 2013 Dublin Business Wire press report in May 2013 related to Pain Therapeutics-drugs, markets and companies stated that the latest concepts of pathomechanisms of pain is to be used as a basis for the management and development of new pharmacotherapies for pain. Tools described in this course are being used for pain management along with brain imaging. Advances in molecular and biological techniques are markedly advancing our understanding of pain and the development of rational and personal therapies for the management of pain.

We all need to strive to ensure that the patient’ rights are not infringed and that all of our patients receive what they have a right to receive – that is appropriate pain assessment and management. The resulting improvements in functional status and quality of life will prevent needless suffering. Nurses are in a key position to make a difference.


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This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)


Advance Practice Nurse Pharmacology Credit, CPD: Practice Effectively, Medical Surgical, Michigan Requirements, Pain Management

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