Pain is a distressing feeling often caused by intense or

damaging stimuli. The International Association for the

Study of Pain's widely used definition defines pain as "an
unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in
terms of such damage"; however, due to it being a
complex, subjective phenomenon, defining pain has
been a challenge. In medical diagnosis, pain is regarded
as a symptom of an underlying condition.
PAIN (best definition)
The most widely acceptable definition of pain is “an
unpleasant sensory and emotional experience associated
with actual or potential tissue damage or described in terms
of such damage” (adopted by the American Pain Society).
 This definition explains pain as a complex phenomenon
that impacts an individual’s psychosocial and physical
functioning. Because pain is a highly personal and
subjective experience, Margo McCaffery’s (1968) definition
is appropriate for clinical practice:
“Pain is whatever the experiencing person says it is,
existing whenever he/she says it does”.
Pain can be classified as;
 nociceptive pain, which is considered a warning signal that
results from actual or threatened damage to non-neural
tissue resulting in the activation of nociceptors in a normal
functioning nervous system; or
 neuropathic pain, which is a clinical description of pain
thought to be caused by damage from a lesion or disease of
the somatosensory nervous system that is confirmed by
diagnostic investigations.
Also, pain categories can be based on the location of lesion
(somatic, visceral), diagnosis (headache) or duration (acute,
persistent). A person may experience both nociceptive (such
as with surgery), and neuropathic pain (e.g., diabetic
neuropathy) at the same time
The RNAO expert panel on Assessment and
Management of Pain developed these guiding principles;
Any person has the right to expect:
 Their pain to be acknowledged and respected.
 The best possible personalized evidence-based pain
assessment and management including relevant bio-
psychosocial components.
 Ongoing information and education about the assessment
and management of pain.
 Involvement as an active participant in their own care in
collaboration with the interprofessional team.
 Communication and documentation among
interprofessional team members involved in their care to
monitor and manage their pain.
Pain Assessment
Nurses have an important role in screening for pain.
Randomized controlled trials report screening is essential for
effective pain management.
Screen for the presence, or risk of, any type of pain:
 On admission or visit with a health-care professional;
 After a change in medical status; and
 Prior to, during and after a procedure.
When conducting a screen for the presence, or risk, of any
type of pain, it is important for the nurse to ask directly about
pain rather than assuming the person or their family or
caregivers will voluntarily disclose it.
Assessment Tools
• Location of pain
• Effect of pain on function and activities of daily living
• Level of pain at rest and during activity
• Medication usage and adverse effects
• Provoking and precipitating factors
• Quality of pain (in the resident’s words – achy, hurting)
• Radiation of pain – does it extend beyond the site?
• Severity of the pain (intensity, 0-10 scale)
• Pain related symptoms
• Timing (constant, occasional)
Tools to Assess the Intensity of Pain (established validity)
• Visual Analogue Scale (VAS)
• Numeric Rating Scale (NRS)
• Verbal Scale
• Faces Scale
• Behavioural Scale
A Pain Assessment Tool must be;
 Reliable – consistent and trustworthy ratings, regardless of time, setting or who is
administering the measure.
 ■ Valid – degree to which the evidence and theory supports the interpretation of the
scores: the instrument truly measures the intended target (pain) it was created to
measure.
 ■ Responsive – able to detect change in pain due to the implemented pain management
interventions.
 ■ Feasible to use – simple and quick to use, requiring a short training time and are easy to
administer and score.
 ■ Practical – assessing different types of pain when possible; some tools (such as those
for neuropathic pain) are very specific.
 The tool should also be:
 ■ Developmentally and culturally appropriate for the population it is designed for;
 ■ Available in various languages or easily translatable;
 ■ Easily and quickly understood by the person;
 ■ Liked by persons, clinicians and researchers using it;
 ■ Easy to obtain, reproduce, and distribute; and
 ■ Able to be disinfected if touched by a person.
Let’s begin by reviewing the 12 principles for pain assessment
and management as presented in the Registered Nurses’
Association of Ontario’s best practice guideline, Assessment
and Management of Pain.
1. Patients have the right to the best pain relief possible.
2. Unrelieved acute pain has consequences and nurses should
prevent pain where possible.
3. Unrelieved pain requires a critical analysis of pain-related
factors and interventions.
4. Pain is a subjective, multidimensional and highly variable
experience for everyone regardless of age.
5. Nurses are legally and ethically obligated to advocate for
change in the treatment plan where pain relief is inadequate.
6. Collaboration with patients and families is required in
making pain management decisions.
7. Effective pain assessment and management is
multidimensional in scope and requires coordinated
interdisciplinary intervention.
8. Clinical competency in pain assessment and management
demands ongoing education.
9. Effective use of opioid analgesics should facilitate routine
activities such as ambulation, physiotherapy, and activities of
daily living.
10. Nurses are obligated to participate in formal evaluation of
the processes and outcomes of pain management at the
organizational level.
11. Nurses have the responsibility to negotiate along with
other health care professionals for organizational change to
facilitate improved pain management practices.
12. Nurses advocate for policy change and resource allocation
that will support effective pain management.
 Abbey Pain Scale
The Abbey Pain Scale is best used as part of an
overall pain management plan.
Objective:
The Pain Scale is an instrument
designed to assist in the assessment of pain in
patients who are unable to clearly articulate
their needs.
Pain In The Elderly
 The prevalence of pain in the elderly
who live in long-term care is
considered to be extremely high.
Ebersole & Hess (1999), suggest that it
might be as high as 85 percent due to
the presence of conditions that cause
chronic pain such as arthritis,
peripheral vascular disease, etc. The
aged are at high risk for pain. They
have lived longer and have a greater
chance of developing degenerative and
pathological conditions. Several
conditions may be present
simultaneously which makes
assessment and treatment more
challenging.
Symptoms of Pain in Dementia
MILD PAIN
 Abbey pain scale rating: 1-4
 Can express pain through verbalization.
 Pain is tolerable and stable.
 No such physiological changes, i.e. stable vitals signs.
MODERATE PAIN
 Abbey’s pain rating scale: 5-8
 Pain can be tolerated up to some extent.
 Behavioral changes such as crying loudly, agitation,
increased discomfort, poor concentration.
 Physiological changes may be observed like tachycardia.
Severe Pain
 Abbey’s pain rating scale- 10 or above
 Change in facial expressions such as grimacing,
restlessness, vocalization.
 Physiological changes such as tachycardia, tachypnea.
 Behavioral changes like aggression, irritation, refusal
to move or change position (rigidity), crying, agitation.
Screening for Pain
Self-report is the ‘gold standard’ and primary source of
assessment for the verbal, cognitively intact resident. This
may include caregiver and family reports for the non-verbal
or non-cognizant resident.
Additional Screening Markers (non-verbal, non-
cognizant)
• Any change in condition
• Diagnosis of a chronic, painful disease
• History of chronic, unexpressed pain
• Taking medication for > 72 hours
• Distress related behaviours or facial grimaces
• Family/others indicate pain is present
Factors Influencing a Residents Response to pain
• Past pain experience
• Cultural
• Gender
• Significance of pain
• Depression
• Fatigue
• Altered pain stimulus transmission
• Decrease in inflammatory response
Barriers that interfere with pain assessment
and treatment in the elderly.
• Under reporting of pain
• Choosing to suffer in silence
• Perception of pain by others
• Cognitive functioning
• Fear of losing self-control
• Fear of addiction
• Inability to swallow pills
Management of Pain in the Elderly
PHARMACOLOGICAL PAIN MANAGEMENT
Steps in the management of pain using pharmacological methods (Analgesic
Ladder)
STEP I
 Start with simple analgesics and medications that are effective in the treatment
of mild pain (1-3/10) on the
 Numeric Rating Scale. These include the non-opioids:
 Acetaminophen (Tylenol)
 Non- steroidal anti-inflammatory (NSAIDS) – e.g. ibuprofen
 COX-2 inhibitors – (Celecoxib)
 STEP II
 Weak opioids (as defined by the Analgesic Ladder) are the mainstay of
treatment for moderate to severe pain
 (4-6/10) on the Numeric Rating Scale.
 Common medications are:
 Codeine
 Oxycodone
STEP III
 Strong opioids (as defined by the Analgesic Ladder) are the
drugs used for severe pain (7-10/10) on the
 Numeric Rating Scale.
 Common medications are:
 Morphine
 Hydromorphone
 Methadone
 Fentanyl
 Other factors to consider in selecting opioids
 Pain pattern
 Presence of renal, gastrointestinal or cognitive dysfunction
 Lifestyle
 Existing medications
 Specific type of pain
Non-pharmacological Management of Pain
Although analgesics are the mainstay of pain management, a more
systematic use of non-pharmacological pain methods has been
found to be beneficial to the elderly. Heat and massage/vibration
were rated by the elderly as being the most effective methods
Other modalities to consider
 Heat/Cold
 Massage
 TENS(transcutaneous electrical nerve stimulation)
 Touch
 Acupuncture
 Biofeedback
 Distraction
 Relaxation, meditation, and imagery
 Hypnosis
Forms of Distraction
Visual
 Reading
 Watching TV
 Watching a sport
 Guided imagery
Auditory
 Humor
 Listening to music
Tactile
 Massage
 Stroking a pet
 Slow rhythmic breathing
Intellectual
 Crossword puzzles
 Card games
 Hobbies
Mnemonics (can be helpful to structure a baseline data of pain)
PQRST
 P– provoking or precipitating
 factors
 Q– quality of pain (resident’s description – sharp, achy
etc.)
 R– radiation of pain (does the pain extend from the
site?)
 S– severity of the pain (intensity 1-10)
 T– timing(occasional v.s. constant)
Mnemonics Contd
PAINED
 P– place – location(s) of the pain
 A– amount –refers to pain intensity
 I– intensifiers- what makes the pain worse
 N– nullifiers - what makes the pain better
 E– effects – effects of pain on quality of life
 D– descriptors – of the quality of pain (aching,
burning, throbbing etc.)
Mnemonics Contd
OLD CART
 O– onset – when did the pain start?
 L– location – where is your pain?
 D– duration – persistent, periodic?
 C– characteristics – what does it feel like?
 A– aggravating factors - what makes the pain worse?
 R– relieving factors – what makes the pain better?
 T– treatment - what medications work for you ?
- do you have adverse effects from your medications?
Reassessing Pain
 At each new report of pain
 After starting the treatment plan – at pre-determined
intervals after each pharmacological and non-
pharmacological intervention
 If pain is suddenly not relieved by previously effective
strategies
 If there is unexpected, intense pain associated with
altered vital signs; hypotension, tachycardia, or fever
 Myth Busting Facts

 All doctors are qualified to treat pain.

 MYTH – When it comes to treating pain not all doctors are equal. It takes years of
specialized training to be able to effectively analyze, diagnose, and treat a patient
experiencing chronic pain. In some cases it even requires further specialization to treat
pain. When the pain is caused by a rheumatic diseases, like arthritis, or autoimmune
diseases, like lupus, a rheumatologist is needed to treat both the pain and the
underlying condition.

 You’ll probably get addicted to pain medication.

 MYTH – The well publicized stories of celebrities, like Rush Limbaugh and Michael
Jackson, becoming addicted to their pain drugs makes it seem like everyone gets
addicted to their prescription pain medication. While it is true that some people get
addicted to certain types of painkillers, the actual occurrence of addiction to pain
medication is very low. If you are worried about becoming addicted, or have a family
history of addiction, let you rheumatologist know so that they can take your concerns
into account when deciding on how to treat your pain.
 Getting pain treatments means you’re weak.
 MYTH – Admitting you are in pain and getting treated can
be scary. It means you don’t know what is causing the pain
and that you are turning over your pain relief treatment to
someone else. It actually takes a great deal of courage to
seek out medical treatment for your pain.
 Pain is affected by the weather
 TRUE – Not everyone’s pain is affected by changes in the
weather, but it does happen. Though physicians are not
positive as to the reasons, there does appear to be pattern
associated with the barometric pressure. Low pressure
systems found during cold weather seems to make the pain
worse. Warmer weather associated with high pressure
systems usually brings a reduction in the pain.
 There is a “silver bullet” for every type of pain.
 MYTH – There is almost never one treatment that cures
chronic pain. Usually a complete pain management
regimen involves many different treatments. Your
physician may prescribe things like medication, physical
therapy, immobilization, and ice.

 Rest is best for pain

 MYTH – In some cases a physician may prescribe a short
period of rest, like after surgery. Almost always though,
physical therapy or even exercise will be included in a pain
treatment plan. For example, exercise benefits arthritis
patients in many ways and is an option that rheumatology
specialist’s often include for pain management.
Myth/Fact about Pain in the elderly
Myth: Pain is expected with aging.
Fact:
Pain is not normal with aging. The presence of pain in the elderly necessitates aggressive
assessment, diagnosis and management similar to younger individuals.
Myth: Pain sensitivity and perception decrease with aging.
Fact:
Research is conflicting regarding age-associated changes in pain perception, sensitivity, and
tolerance. Con-sequences of belief in this myth may mean needless suffering and under
treatment of pain and underlying cause.
Myth: If an elderly person does not complain of much pain, they must not be in pain.
Fact:
Older individuals may not report pain for a variety of reasons. They may fear the meaning of
pain, diagnostic workups, or pain treatments. They may think pain is normal.
Myth: A person who appears to have no functional impairment and is occupied in activities
of daily
living must not have significant pain.
Fact:
People have a variety of reactions to pain. Many individuals are stoic and refuse to “give in”
to their pain.
Over extended periods of time, the elderly may mask any outward signs of pain.
Myth: Narcotic medications are inappropriate for the elderly with
chronic non-malignant pain.
Fact:
Opioid analgesics are often indicated in non-malignant pain.
Myth: Potential side effects of narcotic medication make them too
dangerous to use in the elderly.
Fact:
Narcotics may be used safely in the elderly. Although the elderly
may be more sensitive to narcotics, this
does not justify withholding narcotics and failing to relieve pain.
 References
• Accreditation Canada. (2011). Pain Management Standards from Canadian Council on
Health Service Accreditation. Retrieved from
http://www.canadianpainsociety.ca/pdf/Standards-Statement-CCHSA.pdf
• American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in
Older Persons (AGS). (2009). Pharmacological management of persistent pain in older
persons. The Journal of the American Geriatrics Society, 57(8), 1331-1346.
• Bell, L., & Duffy, A. (2009). Pain assessment and management in surgical nursing: A
literature review. British Journal of Nursing, 18(3), 153-156.
• Canadian Nurses Association (CNA). (2012). Competencies 2012-2015. Retrieved from
http://www.cna-aiic.ca/en/ becoming-an-rn/rn-exam/competencies/