Pain Management

Definition of Pain

The International Association for the Study of Pain (IASP) defines pain as a "sensory
and emotional experience associated with tissue damage or described in terms of
such damage."

Mnemonic for Characteristics of Pain

• SOCRATES is a mnemonic used by emergency medical services, doctors, nurses

and other health professionals to evaluate the nature of pain that a patient is
experiencing.

(SOCRATES)

• Site - Where is the pain?

• Onset - When did the pain start, and was it sudden or gradual?

• Character - What is the pain like? An ache? Stabbing?

• Radiation - Does the pain radiate anywhere? (See also Radiation.)

• Associations - Any other signs or symptoms associated with the pain?

• Time course - Does the pain follow any pattern?

• Exacerbating/Relieving factors - Does anything change the pain?

Effects of pain

 Increased heart rate

 Diaphoresis
 increased blood glucose levels
 dilatation of pupils

 decreased GI motility

 increased muscle tension

 increased respiratory rate

Factors that influence pain

Numerous factors can affect a person’s perception and reaction to pain. These includes:

 Socio-cultural Factors: Ethnic and cultural background have been recognized as

factors that influence both a person’s reaction to pain and the expression of that pain.
Individuals in one culture may have learned to be expressive about pain, whereas
individuals from other culture may have learned to keep those feelings to themselves
and not bother others.
Also, gender has been recognized as factor affecting pain perception. Men and
women are thought to be socialized to respond differently and differ in their
expectations about pain. Some studies shows that women consistently reported higher
pain intensity, pain unpleasantness, frustration and fear compared to men.
 Past experience of pain: Previous pain experiences alters client’s sensitivity to pain.
It is tempting to expect that people who have had multiple or prolonged experiences
with pain will be less anxious and more tolerant of pain than those who have had little
experiences with pain.
 Anxiety and depression: Anxiety and depression alters perception and response to
acute pain. Anxiety that is relevant or related to the pain may increase the patient’s
perception of pain. For example, the patient who was treated 2 years ago for breast
cancer and now has hip pain may fear that the pain indicates metastasis. But, anxiety
that is unrelated to the pain may distract the patient and may actually decrease the
perception of pain. For example, a mother who is hospitalized with complications
from abdominal surgery and is anxious about her children may perceive less pain as
her anxiety about her children increases.
 Environment and support of people: A strange environment such as hospital , with
its noises, lights and activity can compound pain. In addition, a lonely person who is
without a support network may perceive pain as severe, whereas the person who has
supportive people around may perceive less pain.
 Developmental stage: The age and developmental stage of a client is an important
variable that will influence both the reaction to and the expression of pain. Children
may be less able than adults to articulate their experience or needs related to pain
which may result in their pain being under treated. The prevalence of pain in older
adults is gradually higher due to both acute and chronic illness.
Types of Pain

Classifications of pain based on where it is in the body may be useful in determining the
client’s underlying problems or needs.

a. Location
Complicating the categorization of pain by location is the fact that some pains
radiate(spread or extend) to other areas.

• -Localized pain: pain that do not radiate(spread or extend) to other areas

• -Radiating pain: pain radiate (spread or extend) to other areas.

b. Duration
 Acute pain- lasts only through the expected recovery period whether it has a
sudden or slow onset and regardless of intensity.
 Chronic pain- is prolonged, usually recurring or persisting over 6 months or
longer, and interferes with functioning.
Mild to severe, constant or recurring without an anticipated or predictable end
and a duration of greater than 6 months. (Ackley&Ladwig, 2006)
c. Intensity
Classified using a standard 0(no pain) to 10 (worst possible pain) scale.

-Mild pain- rating of 1-3

-Moderate pain- rating of 4-6
-Severe pain- reaching 7-10 and is associated with worst outcome.

d. Etiology

Physiological pain- experienced when an intact, properly functioning nervous system sends
signals that tissue are damaged, requiring attention and proper care.

• Somatic pain- originates in the skin, muscles, bones or connective tissue with sharp
sensation of a paper cut or aching of sprained ankle.

Characteristics

 Constant pain

 May be dull or sharp

 Well localized

 Often worse with movement

Eg.- Bone and soft tissue , chest wall

• Visceral pain- poorly located and may have cramping, throbbing, pressing, or aching
quality. Often associated with feeling sick.
 Characteristics

 Constant or crampy
 Poorly localized
 Usually with Nausea & Vomit

 Often referred

 Eg. Cancer of pancreas, liver capsule distension and bowel obstruction


Assessment of Pain

The relief and management of pain requires careful assessment of the causes, severity and
type of pain. Assessment of pain includes:

A. Subjective Assessment of Pain

B. Objective Assessment of Pain

A. Subjective Assessment: The subjective assessment of pain includes:

1. Pain History
While taking pain history, nurse must provide an opportunity for clients to
express in their own words, how they view it and their situation
This will help the nurse to understand means of pain to client and how the client
is coping with it.

2. Onset and Duration of Occurrence:

- When did pain begin?
- How long has it lasted?
- Does it occur at same time each day?
- How often does it occurs?

3. Location

- In which area it is felt? Do the area differ under different circumstances?

- If several parts of body are painful, do pain occur simultaneously?

- Is pain unilateral / bilateral?

- Ask the individual to point site of discomfort

4. Intensity

- Use of pain intensity scale is an easy and reliable method of determining the
clients pain intensity

- Most scales are either 0 to 5 or 0 to 10

- Currently used scales are:

• Numerical scale

• Descriptive scale

• Visual analog scale

• Wong Baker Faces Pain scale

 Numerical Rating Pain Scale

• This is most commonly used pain scales in health care, the numerical rating scale.

• If we use the numerical scale, we have the option to verbally rate pain from 0 to
10 or to place a mark on a line indicating one’s level of pain.

• This enables to assess how severe the pain is and whether it is improving over
time or getting worse.

• Zero indicates the absence of pain, while 10 represents the most intense pain
possible.

Fig: Numerical Rating pain Scale

 Descriptive scale: This scale use words to describe pain. Words such as no pain
and severe pain are used to describe pain levels. Patients are asked to select the
category that best describes their pain.
  Visual Analogue Scale: This scale uses a vertical or horizontal line with words
that convey “ no pain” at one end and worst pain at the opposite end. Patient is
asked to mark along the line that indicates her/his level of pain.

Fig: Visual Analogue Scale

 Wong-Baker FACES Pain Scale

• The Wong-Baker FACES Pain Scale combines pictures and numbers
for pain ratings. It can be used in children over the age of 3 and in adults. Six
faces depict different expressions, ranging from happy to extremely upset.

• Each is assigned a numerical rating between 0 (smiling) and 10 (crying). If you

have pain, you can point to the picture that best represents the degree and
intensity of your pain. 

B. Objective Assessment

Fig: Wong-Baker FACES Pain Scale

B. Objective Assessment: An objective assessment of pain includes:

Behavioral Effects:

 Assess verbalization, vocal response, facial and body movements & social
interaction

 Facial expression is often 1st indication of pain & may be only one manifestation
 Vocalization like moaning, groaning, crying, grunting, screaming are associated
with pain.

Physiological Responses:

 It vary with the origin and duration of pain

 Early in onset of acute pain, the symapthetic nervous system is stimulated

 Results in increased blood pressure, pulse rate, respiration, pallor, diaphoresis

and pupil dilation

 Heart rate may increase, respiratory rate and pattern may shift from normal ie:
increase, decrease or change pattern, blood pressure may increase and oxygen
saturation may decrease.

 Physiological indicators in isolation cannot be used as a measurement for pain.

 A tool that incorporates physical, behavioural and self report is preferred when
possible.

 However, in certain circumstance (for example, the ventilated and sedated child)
physiological indicators of pain can be helpful to determine a patient’s experience
of pain.

Key considerations

• Assess pain using a developmentally and cognitively appropriate pain tool

• Reassess pain after interventions given to reduce pain (eg. Analgesia) have had
time to work

• Assess pain at rest and on movement investigate higher pain scores from
expectation document pain scores.

• Use parent/guardian pain behaviour knowledge for children with cognitive

impairment.

FLACC Pain Scale

• FLACC stands for face, legs, activity, crying, and consolability. The FLACC pain scale
was developed to help medical observers assess the level of pain in children who are too
young to cooperate verbally.3 It can also be used in adults who are unable to
communicate.

• The FLACC scale is based on observations, with zero to two points assigned for each of
the five areas.
 • The overall score is recorded as follows:

• 0 = Relaxed and comfortable

• 1 to 3 = Mild discomfort

• 4 to 6 = Moderate pain

• 7 to 10 = Severe discomfort/pain

• By recording the FLACC score periodically, healthcare providers can gain some
sense of whether someone's pain is increasing, decreasing, or stable.

Behaviour 0 1 2

Face No particular Occasional Frequent to

expression or grimace or constant
smile frown, quivering chin,
withdrawn, clenched jaw
disinterested

Legs Normal Uneasy, Kicking or legs

position or restless, tense drawn up
relaxed

Activity Lying quietly, Squirming, Arched, rigid or

normal shifting, back jerking
position, and forth, tense
moves easily

Cry No cry (awake Moans or Crying steadily,

or asleep) whimpers; screams, sobs,
occasional frequent
complaint complaints

Consolability Content, Reassured by Difficult to

relaxed touching, console or
hugging or comfort
being talked to,
distractible
Pain Reassessment after Treatment

• It is important to review a patient’s pain after analgesia to assess its effect:

– 30 minutes after parenteral analgesic

– 1 hour after oral analgesic

– With each report of new or changed pain

Pain Management Approaches

Pain management is considered such an important part of acre that the American Pain
society coined the phrase “Pain: The 5th Vital Sign” to emphasize its significance and to
increase the awareness among health care professionals of the importance of effective
pain management. It includes both pharmacological and non- pharmacological
approaches.

A. Pharmacological Approach

The WHO in 1986 established a stepwise pharmacological approach. The goal was to
provide treatment guidelines that health-care practitioners could easily follow. In the
WHO guidelines, morphine remains the cornerstone for the management of cancer pain.

Three Basic Principles of Pain Management (WHO)

• By Mouth: The oral route is preferred for all commonly used analgesics unless
there is a problem with swallowing or absorption.

• By the clock: most patients with pain from cancer or another chronic illness have
continuous pain and require regular medication. PRN medication leads to poor
pain control.

• By the ladder: The WHO analgesic ladder has three steps for the management of
increasingly severe pain.

The WHO declared cancer pain management a worldwide emergency adopted the
Canadian 3 steps ladder of analgesic agents for control of nociceptive pain, as part of
its efforts to improve public health worldwide. It includes:
Step I

• For patients with mild pain, the use of non- opioids is the treatment of choice.
These may or may not be combined with adjuvant drugs (drugs that are used to
hasten or add to the primary mode of treatment.
Step II

• For patients with mild to moderate pain, who did not feel relief after using only
non-opioids, a combination of opioids and non-opioids should be tried. Again
adjuvant may or may not be used.

Step III

• For patients with moderate to severe pain, strong opioids should be used, with or
without non-opioids, and with or without adjuvant.

Fig: Three Step Ladder WHO, 1986

Classification

1. Non- opioid analgesics

i. Acetaminophen (10-15 mg/kg/day): 500-1000mg upto every 6 hours. Upper

limit is 4gm/day. Preferred route of administration is oral but IV can be given
if needed for short duration. It should be taken in caution for patients with
liver disease.
 ii. Non-steroidal anti-inflammatory drugs (NSAIDs)
Drug Duration Dose Frequency Route Maximum
dose per
Of Action (Adult) day

Ibuprofen 8hrs 400- tds PO 2400m

800mg g

Diclofenac 8hrs 50mg tds PO/SC 150mg

/IM

Naproxen 8-12 hrs 250-500 bd PO 1000m

g
mg

Meloxicam 24 hrs 7.5-15mg od PO 15mg

Ketorolac 6 hrs 10- 30 tds PO/SC 90mg

/IV
mg

2. Opioid analgesics

• These are divided into weak opioids and strong opioids.

• All opioids have a similar spectrum of action and cause similar side effects,
particularly constipation and sometimes nausea and vomiting.

• Opioids should therefore normally be prescribed with a laxative and with anti-
emetics if nausea occurs.

i. Weak opioids

a. Codeine: It is a pro-drug that requires an enzyme for breakdown to morphine for

pain relief. The recommended adult dose is 15 mg to 60mg every 4 to 6 hours as
required, not to exceed 240 mg in one day.

b. Tramadol: The recommended dose for adult is 50-100mg (immediate release

tablets) every 4-6hours for pain. The maximum dose is 400mg/day.

ii. Strong opioids

 a. Morphine: It is the drug of choice for management of pain in patients who have
moderate to severe pain. It is accepted as the ‘gold standard’ strong opioid in
palliative care.

• Starting dose for opioid- naïve patients (who are not chronically receiving opioid
analgesics on a daily basis) is oral morphine 2.5 to 5 mg immediate every 4 hours
and titrates according to pain relief and toxicity .

• Double dose can be given at bedtime, so that patient does not need to wake up in
middle of night to take the medicine. If the patient experiences pain between
doses, extra dose of morphine can be given. The extra dose (breakthrough dose) is
calculated as 1/6th of the total morphine taken in 24 hours.

• For eg: If Mr. R is taking 5mg morphine 4 hourly, breakthrough dose is calculated
as {1/6th dose of total dose in 24 hours; i.e. (5mgx6)/6 =30mg/6=5mg}. So,
breakthrough dose is 5mg.

• If more than 3-4 doses of breakthrough medication are used for chronic pain,
increase the dose of opioid by an amount equivalent to 50-100% of total amount
in 24 hours.

b. Fentanyl: It is indicated if a patient can’t take oral medication. It is also indicated in

patients with renal impairment. A fentanyl patch when applied lasts for 72 hours , after
that it should be removed and replaced. The patient should be stabilized on morphine first
and then the correct amount of fentanyl is calculated and the correct size of patch is used.

3. Adjuvant Analgesics: These are medications that are not typically used for pain relief
but they are effective for specific types of pain, notably bone and neuropathic pain. The
primary agents are:

• Steroids: Steroids are used when pain is caused by pressure. Eg: stetched liver
capsule, raise intracranial pressure etc.

• Antidepressants: These are used for neuropathic pain. Amitriptyline 10-75mg at

night.

• Anticonvulsants: These are used for neuropathic pain. Eg: Gabapentin

B. Non-pharmacological Approach
 Various non- pharmacological approaches can be used for pain management:

a. Palliative radiation

b. Surgery

c. Acupuncture

d. Hypnosis

e. Guided imagery

f. Relaxation

g. Massage

h. Skin stimulation

i. Psychotherapy

j. Emotional support and counseling

a. Palliative Radiation: Palliative radiation therapy is one form of palliative therapy,

treatment for the symptoms of a medical problem that doesn't treat the problem itself.
It's considered comfort care and is mainly intended to improve a patient's quality of life.
People who have cancer may receive palliative radiation therapy, not to cure or even treat
cancer but, instead, to relieve the symptoms, especially pain, that it's causing. Typically
the radiation is used to shrink a tumor or tumors that are causing the symptoms.

Some common reasons for considering palliative radiation for people with cancer
include:

-Pain Relief: Palliative radiation is especially helpful in treating pain caused by

tumors that have invaded bone. It can also relieve pain caused by tumors pressing
on nerves.

-Spinal Cord Compression: A serious and painful condition, spinal cord

compression is caused by tumors pressing on the spine and spinal cord. Palliative
radiation may bring welcome relief.

-Superior Vena Cava Obstruction: Tumor obstruction of the superior vena cava

(the second-largest vein in the body, carrying blood to the heart from the upper
body) causes swelling in the face, shortness of breath, and a feeling of fullness in
the head. Shrinking of the tumor using palliative radiation therapy may improve
the patient's blood flow.
 -Bleeding: Some tumors can cause troublesome bleeding. Hemoptysis, or
coughing up blood, can be caused by tumors in the airway. Bleeding due to
tumors in the rectum, vagina, or urinary tract may also be uncomfortable enough
to treat with palliative radiation.

-Obstruction of the Airway or Esophagus (Food Tube): Tumors that are

obstructing the airway or esophagus, making breathing or eating difficult, are
often treated with palliative radiation.

b. Surgery
 Palliative Surgery: Cancer causes pain to most cancer patients as does the
treatment. It is estimated that 80% of cancer patients have two or more episodes
of pain. More patients experience pain with advanced disease. The quality of life
of those patients in great pain, resulting from either the disease or the treatment, is
greatly compromised. Under such circumstances, palliative surgery may be
performed. For example, the procedure may involve the removal of a painful
primary or metastatic tumor mass such as a solitary spinal metastasis.

The purpose of palliative surgery is mainly to reduce pain for the patient. The
surgery may not necessarily aim to eradicate cancer tissue in the patient. In fact,
palliative surgery is often deemed as worthwhile and feasible by cancer specialists
when the disease is not responsive to any type of curative treatment. A successful
palliative surgery may not only make the patient's life more comfortable, but it
may also prolong the cancer patient's life in some cases. Palliative surgery which
removes cancer tissue is recorded as cancer-directed surgery.

Palliative surgery such as a nerve block procedure to interrupt pain signals in the
nervous system, or a stent placement to alleviate obstruction, etc., which does not
remove cancer tissue is not recorded as cancer-directed surgery. Palliative
procedures are recorded as non-cancer directed surgery.

 Dorsal Rhizotomy: It involves cutting the dorsal nerve roots as it enters the spinal
cord. It is effective for relieving localized acute pain in the area supplied by the
nerve root and deep visceral pain.

 Spinal cordotomy: It is the division of anterolateral nerve pathways in the spinal

cord to give relief from the intense pain of advanced malignant disease.

c. Acupuncture: Traditional Chinese acupuncture involves the insertion of

extremely fine needles into the skin at specific "acupoints."
This may relieve pain by releasing endorphins, the body's natural pain- killing
chemicals, and by affecting the part of the brain that governs serotonin, a brain
 chemical involved with mood. Acupuncture is generally quite safe, and the
complication rate appears to be quite low.
In this therapy, each point is thought to control the feeling of pain in a different
part of the body. When the needle is put in, some people feel a slight ache, dull
pain, tingling, or electrical sensation for a few seconds. Once the needles are in
place, they shouldn’t hurt. The needles are usually left in for 15 to 30 minutes. It
doesn’t hurt when the needles are removed. Acupuncture is widely available, but
it should only be done by a licensed, certified acupuncturist.

d. Hypnosis: Hypnosis is a trance-like state of high concentration in which you are

awake but calm and still. In this relaxed state, people might become more relaxed
and open to suggestion. Hypnosis can be used along with other methods to blunt
the awareness of pain, to substitute another feeling for the pain, or to change the
feeling to one that’s less painful. The patients can be hypnotized by a person
trained in hypnosis, often a psychologist, psychiatrist, or other mental health
therapist. A trained hypnotherapist can teach people to put themselves in a
hypnotic state, make positive suggestions to themselves, and leave the hypnotic
state when they’re ready.

e. Guided Imagery: Imagery is using own imagination to create mental pictures or

situations. The way imagery relieves pain is not fully understood, although it may
be simply a combination of relaxation and distraction. The term guided imagery
refers to a wide variety of techniques, including simple visualization and direct
suggestion using imagery, metaphor and story telling, fantasy exploration and
game playing, dream interpretation, drawing , and active imagination where
elements of the unconscious are invited to appear as images that can communicate
with the conscious mind.
Imagery can be thought of as a deliberate daydream that uses all of your senses –
sight, touch, hearing, smell, and taste. Some people believe that imagery is a form
of self-hypnosis. Certain images may reduce your pain both during imagery and
for hours afterward.

If the patient must stay in bed or can’t leave the house, he/she may find that
imagery helps him/her feel less closed in – can imagine and revisit her/his
favorite spots in mind. Imagery can help relax, relieve boredom, decrease
anxiety, and helps to sleep. Imagery usually works best with eyes closed.

f. Relaxation: Relaxation helps relieve pain and/or keeps it from getting worse by reducing
muscle tension. It can help you fall asleep, give you more energy, make us less
tired, reduce anxiety, and help other pain-relief methods work better. Relaxation
may be done sitting up or lying down.
 In this technique:

• Choose a quiet place whenever possible. Close your eyes. Do not cross
your arms and legs because that may cut off circulation and cause
numbness or tingling.

• If lying down, be sure the position is comfortable.

• Put a small pillow under your neck and under the patient’s knees or use a
low stool to support his/her lower legs.

Visual concentration and rhythmic massage relaxation methods:

• Open the eyes and stare at an object, or close your eyes and think of a peaceful,
calm scene.

• With the palm of your hand, firmly massage near the area of pain in a circular
movement. Avoid red, raw, or swollen areas. A family member or friend can do
this for the patient.

• Inhale/tense, exhale/relax.

• Breathe in deeply. At the same time, tense your muscles or a group of muscles.
For example, you can squeeze your eyes shut, frown, clench your teeth, make a
fist, stiffen your arms and legs, or draw up your arms and legs as tightly as you
can.

• Hold your breath and keep your muscles tense for a second or two.

• Let go. Breathe out and let your body go limp.

g. Massage: This technique includes using a slow, steady, circular motion, massage
over or near the area of pain with just bare hand or with any substance that feels
good, such as powder, warm oil, or hand lotion. Depending on where the pain is,
it may be done by oneself or get help from a family member, friend, or a massage
therapist. Some people find brushing or stroking lightly feels better than deep
massage.
Precautions: If the patients is getting radiation therapy, avoid massage in the
treatment area as well as in any red, raw, tender, or swollen areas.

h. Skin stimulation: This technique requires the advice of the doctor or help from
the cancer care team to know if skin stimulation is a safe option for the patient.
The patients getting radiation therapy, shouldn’t put ointments, menthol, on the
treatment area, and shouldn’t use heat or extreme cold on treated areas.
 If the patient is getting chemotherapy, some techniques for the skin may worsen
skin-related or neuropathy side effects.

In this series of techniques, pressure, warmth, or cold is used on the skin, while
the feeling of pain is lessened or blocked. Massage, pressure, vibration, heat, cold,
and menthol preparations can also be used to stimulate the skin. These techniques
also change the flow of blood to the area that’s stimulated. Sometimes skin
stimulation will get rid of pain or lessen pain during the stimulation and for hours
after it’s finished. It is done either on or near the area of pain. It can also be used
on the side of the body opposite the pain. For example, patient might stimulate the
left knee to decrease pain in the right knee.

i. Psychotherapy: The most common type of psychotherapy used in pain

management is cognitive behavioral therapy( CBT) , the goal of which is to
motivate patients to become aware of how they think about pain and to
consciously and consistently replace negative thoughts with positive thoughts.
It begins with changing attitudes by addressing the harmful thinking that is
common among patients with chronic pain. Harmful thinking focuses on what the
person does not like or desire. It includes judgment using negative words,
visualization, self talk and metaphors as well as replaying of negative memories.

j. Emotional support and counseling: If the patient feel anxious or depressed,

pain may feel worse. Pain also can make us feel worried, depressed, or easily
discouraged. Some people feel hopeless or helpless. Others may feel embarrassed,
inadequate, angry, frightened, lonely, or frantic. These are all normal feelings.
The patients should try to talk about their feelings with someone you feel
comfortable with – doctors, nurses, social workers, family or friends, a member of
the clergy, or other people with cancer. They can also talk to a counselor or a
mental health professional. Their cancer care team can help them find a counselor
who is specially trained to help people with chronic illnesses.

Nursing Management

Assessment

 Assess the nature of pain: “SOCRATES”

 Assess the physiological indicators and behavioural changes.

 Assess the site of treatment: chemotherapy/radiotherapy to rule out the cause of

pain.

 Identifying the root of the problem

Nursing Diagnoses

 Acute pain
 Self-care deficit

 Anxiety

 Ineffective coping

 Fatigue

 Impaired physical mobility

 Imbalanced nutrition less than body requirements Ineffective role performance

 Disturbed sleep pattern Sexual dysfunction Impaired social interaction

Planning

Goals and outcomes

 Eg: goal- “the client will achieve a satisfactory level of pain relief within 24 hours”;
possible outcomes-“ reporting that the pain is a 3 or less on scale, using pain relief
measures safely”

Setting priorities

 Eg: pain related to incisional pain and cancer pain can be reduced by analgesics.

Continuity of care

 A comprehensive plan includes a variety of resources for pain control which include
nurse specialists, doctors of pharmacology, physical therapist, occupational therapist.

Implementaion 

• Administer medication securing rights of the patient.

• Evaluate effectiveness, ensure good pain control and individualize treatment
• Include nursing interventions such as giving tender nursing care, preventing pain,
educating, advocating, communicating, comforting, supporting, and counseling
the patient.

• Use both pharmacological and non pharmacological treatments to individualize

treatment, know all the drugs that are used for the treatment of Cancer Pain, how
these drugs relieve pain and what their side effects are.
• Use the WHO guidelines to treat pain and must choose the right drug, right dose,
given at the right times, with the right intervals and to the right patient.

• Evaluate effectiveness of treatment, give PRN doses for breakthrough pain and
recommend for specific changes.

• Anticipate the patient's pain needs, advocate for the patient for what feels
appropriate for him within his cultural context and incorporate the patient's belief.

• Promote comfort, support painful area, gentleness in handling the patient and use
nursing treatments.

• Recommend physiotherapy, (TENS)/acupuncture, occupational therapy, spiritual

support, social worker, psychologist, and psychiatrist to address different types of
pain.

• Relieve both pain and other associated symptoms and ensure that the patient has
good sleep.

• Show kindness, compassion and empathize with him/her. Understand that each
patient is unique, the process of controlling cancer pain develops differently each
time.

• Manipulate factors affecting pain by removing or altering additional physical

stimuli or factors that affect pain tolerance:

– Provide a quiet, clean and uncluttered environment.

– Provide warmth or coolness as needed.

– Provide recreational activity as requested (tv, radio, reading material).

– Reposition frequently and maintain good body alignment for the patient.

– Keep linen clean, smooth and unwrinkled.

– Use comfort devices such as extra cushions, air mattress, etc.

– Support limbs at joints when handling an extremity.

– Assist with active or passive range of motion and encourage general

conditioning and strengthening exercises.

– Avoid bumping, jarring or moving the bed suddenly.

– Assist with hygiene and provide skin and oral care.

 – Assist with elimination needs.

– Maintain adequate hydration.

Patient and family education:

• Instruct patients/families to contact clinician if pain or side effects worsen.

• Encourage patients to report their pain.

• Inform patients they have the right to receive adequate pain management.
Reassure them their report of pain will be believed and acted upon.

• Explain how to use pain medication effectively

• Explain about what the medications are and why they have been prescribed.

• Explain how and when they should be taken, potential adverse effects and how
they can be managed if they occur.

• Instruct about medication safety processes.

• Teach about safe handling, storage, and pharmacy take-back, disposal of

analgesics, particularly opioids.

• If patient and family disagree about the use of pain medication, explore their
understanding and come to agreement, especially if family members are
administering analgesics.

• Accurate and reliable information should be given regarding opioid treatment;

detect and correct false beliefs or misunderstandings that may affect adherence to
the treatment, its effectiveness, and patient

• Give an explanation for the cause of each pain and reassurance that pain can
usually be very well controlled.

• Identify the three simple stepwise goals for pain management:

– A good night’s sleep.

– Pain control during the day while at rest.

– Pain control when active and ambulatory.

• Describe the 3 common side effects for opioid naïve patients: cognitive
(confusion or sedation), nausea and constipation.
 • Explain that cognitive and nausea side effects commonly improve and disappear
in 3 to 7 days.

• Elicit level of patient and family willingness to tolerate short term side effects
during the titration phase.

• Teach that constipation will need ongoing management.

• Teach patients and families how to use an appropriate pain assessment tool, and
encourage patients to keep a pain diary.

• Use creative assessment skills, clinical judgment, psychological support,

advocacy and good communication skills in such a way that the contribution of
drugs, nursing care, nursing and other non pharmacological treatments are
maximized to the patient's benefit.

• When evaluating the overall care, find out what is the total effect of all
approaches taken to relieve pain.

“Nurses can make a difference between a patient who suffers until the last breath of
his/her life and a patient who is comfortable and dies pain free and in dignity.”