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5-10: Principles of Pain Management

Michael W. Rabow; Steven Z. Pantilat; Ann Cai Shah; Lawrence Poree; Scott Steiger

The experience of pain is unique to each person and influenced by many factors, including the patient’s prior experiences with pain, meaning given to the pain, emotional stresses, and family and cultural influences. Pain is a subjective and multi-faceted phenomenon, and clinicians cannot reliably detect its existence or quantify its severity without asking the patient directly. A brief means of assessing pain and evaluating the effectiveness of analgesia is to ask the patient to rate the degree of pain along a numeric or visual pain scale (Table 5–4), assessing trends over time. Clinicians should ask about the nature, severity, timing, location, quality, and aggravating and relieving factors of the pain.

Table 5–4.Pain assessment scales.
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Table 5–4. Pain assessment scales.
A. Numeric Rating Scale

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 None, mild, moderate, severe
B. Numeric Rating Scale Translated into Word and Behavior Scales
Pain Intensity Word Scale Nonverbal Behaviors
0 No pain Relaxed, calm expression
1–2 Least pain Stressed, tense expression
3–4 Mild pain Guarded movement, grimacing
5–6 Moderate pain Moaning, restlessness
7–8 Severe pain Crying out
9–10 Excruciating pain Increased intensity of above
C. Wong-Baker FACES Pain Rating Scale1

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1Especially useful for patients who cannot read English (and for pediatric patients).

© 1983 Wong-Baker FACES Foundation. www.WongBakerFACES.org. Used with permission. Originally published in Whaley & Wong’s Nursing Care of Infants and Children (Mosby Elsevier).

General guidelines for diagnosis and management of pain are recommended for the treatment of all patients with pain but clinicians must comprehend that such guidelines may not be suited for every individual. Because of pain’s complexity, it is important to understand benefits and risks of treatment with growing evidence for each patient (eTable 5–1). Distinguishing between nociceptive (somatic or visceral) and neuropathic pain is essential to proper management.

eTable 5–1.Recommended clinical approach to pain management.
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eTable 5–1. Recommended clinical approach to pain management.

Ask about pain regularly. Assess pain systematically (quality, description, location, intensity or severity, aggravating and ameliorating factors, cognitive responses). Ask about goals for pain control, management preferences.

Believe the patient and family in their reports of pain and what relieves it.

Choose pain control options appropriate for the patient, family, and setting. Consider drug type, dosage, route, contraindications, side effects. Consider nonpharmacologic adjunctive measures.

Deliver interventions in a timely, logical, coordinated manner.

Empower patients and their families. Enable patients to control their course to the greatest extent possible.

Follow up to reassess persistence of pain, changes in pain pattern, development of new pain.

Adapted from Jacox AK et al. Management of Cancer Pain: Quick Reference Guide No. 9. AHCPR Publication No. 94–0593. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. March 1994

In addition, while clinicians should seek to diagnose the underlying cause of ...

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