Pain is a common experience, alerting us "something is wrong." Many patients expect pain related to illness, injury or treatment; this acute pain is expected to resolve as healing occurs.

About 45 million surgical, nonsurgical and treatment-related procedures were performed on hospitalized patients in 2005.¹ Many resulted in acute pain, sometimes continuous for the first few days. Thus, nurses are confronted daily by hospital patients in pain.

Best Practice Based on Guidelines

Despite acute pain being effectively treated with analgesics, particularly opioids, research has demonstrated a substantial number of patients are undertreated. This results from a number of factors, including lack of knowledge, negative attitudes and fear of addiction in patients, their family members and providers.²

Beginning in 1992 with the Acute Pain Clinical Practice Guideline (APCPG) by the Agency for Health Care Policy and Research (AHCPR), guidelines have been developed to assist nurses and physicians in the management of acute pain.³ The Joint Commission adopted many of the APCPG recommendations into its criteria for hospital accreditation.

Because guidelines are based on research and clinical experience, there is a high degree of consistency across guidelines for acute pain assessment and principles for analgesic management. To ensure good pain management, quality indicators have been identified so institutions can monitor and adjust practice to improve pain performance.

The First Step

Pain assessment is an essential step in providing good pain management. An initial assessment, in the form of a pain history, is ideally obtained from the patient and family prior to any procedure. Post-procedurally, assessment should be completed on a regular schedule using a standard format.⁴

The initial pain history provides information that allows the nurse to tailor the pain management plan for the individual patient. It also provides an opportunity to educate the patient and family about the importance of pain control and the expectations for pain, as well as to mutually develop a pain management plan. While patients and their family members may expect pain to be eliminated, this is an opportunity to discuss acceptable levels of pain and select the easiest format for pain assessment after the procedure.

The basic elements of a pain history include:

• previous and/or current pain and the effect on the patient;
• previous methods of pain control that worked or did not work;
• attitudes toward the use of opioids, anxiolytics and other medications for pain;
• typical coping responses to pain and other stressful events, including current or previous psychiatric disorders;
• family members' expectations and beliefs about pain and measures used to control it;
• typical ways the patient describes or shows pain; and
• patient expectations and preferences for pain control after surgery.

The goal for pain management is to prevent and control pain, not treat it once it becomes severe. Thus, the goal for the patients is a mild or acceptable level of pain allowing engagement in activities required for recovery, such as coughing, turning and walking.

Ongoing Assessment

The tool used to assess pain after a procedure should be quick and easy to use. In addition to intensity, a simple assessment should include location and quality of pain. There are a number of validated tools to measure pain intensity, with the numeric rating scale most commonly used with adults.

Patients may prefer one of the many alternate tools used to self-report pain. These include, but are not limited to, a numeric rating scale, where patients rate their pain from zero (no pain) to 10 (worst pain); a verbal description scale, with ratings from no pain to mild, moderate or severe pain; and the revised Baker-Wong Faces Scale, with pictures of facial expressions ranging from no pain to severe pain.

No matter which tool is selected, patient understanding and compliance are essential. For patients such as infants, toddlers and adults in critical care or with cognitive impairment and unable to verbally report pain, behavioral observation tools are available.^5,6

The Joint Commission requires pain assessment be completed on a regular schedule defined by institution or unit policies and procedures. While regular assessment is essential, reassessment after a pain intervention is critical to ensure the intervention provided the expected relief. Reassessment should occur based upon the onset of action of the analgesic administered, e.g., 15-30 minutes after IV administration and 45-60 minutes after oral administration.

The timing of reassessment should be set by institution or unit policies and procedures. Effectiveness is determined by the acceptable level of pain set by the patient and nurse. Ideally this would be mild pain, typically defined as 1-4 on the numeric rating scale. If reassessment reveals minimal effect, additional analgesics or other interventions should be pursued.