Chapter 17. Improving the Quality of Care Through 

Pain Assessment and Management 

Nancy Wells, Chris Pasero, Margo McCaffery 

Background 

At some point in life, virtually everyone experiences some type of pain. Pain is often 

classified as acute or chronic. Acute pain, such as postoperative pain, subsides as healing takes 

place. Chronic pain is persistent and is subdivided into cancer-related pain and nonmalignant 

pain, such as arthritis, low-back pain, and peripheral neuropathy. These authors will draw from 

the body of knowledge related to chronic pain; however, this chapter will focus on the evidence 

supporting management of acute pain experienced by hospitalized adults. 

Scope of the Problem 

Almost 35 million patients were discharged from U.S. hospitals in 2004; of these patients, 46 

percent had a surgical procedure and 16 percent had one or more diagnostic procedures.1

 Pain is 

common, and expected, after surgery. Recent data suggest 80 percent of patients experience pain 

postoperatively2 with between 11 and 20 percent experiencing severe pain.2, 3 Despite the 

availability of analgesics—particularly opioids—and national guidelines to manage pain, the 

incidence of postoperative pain has remained stable over the past decade.4 Thus, acute pain 

associated with surgical and diagnostic procedures is a common occurrence in U.S. hospitals and 

remains inadequately managed for many patients. 

Importance of Controlling Pain 

Inadequately managed pain can lead to adverse physical and psychological patient outcomes 

for individual patients and their families. Continuous, unrelieved pain activates the pituitaryadrenal axis, which can suppress the immune system and result in postsurgical infection and poor 

wound healing. Sympathetic activation can have negative effects on the cardiovascular, 

gastrointestinal, and renal systems, predisposing patients to adverse events such as cardiac 

ischemia and ileus. Of particular importance to nursing care, unrelieved pain reduces patient 

mobility, resulting in complications such as deep vein thrombosis, pulmonary embolus, and 

pneumonia. Postsurgical complications related to inadequate pain management negatively affect 

the patient’s welfare and the hospital performance because of extended lengths of stay and 

readmissions, both of which increase the cost of care. 

Continuous, unrelieved pain also affects the psychological state of the patient and family 

members. Common psychological responses to pain include anxiety and depression. The 

inability to escape from pain may create a sense of helplessness and even hopelessness, which 

may predispose the patient to a more chronic depression. Patients who have experienced 

inadequate pain management may be reluctant to seek medical care for other health problems. 

(For more detail, go to the section, “Harmful Effects of Unrelieved Pain,” below.) 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Poorly managing pain may put clinicians at risk for legal action. Current standards for pain 

management, such as the national standards outlined by the Joint Commission (formerly known 

as the Joint Commission on Accreditation of Healthcare Organizations, JCAHO),5

 require that 

pain is promptly addressed and managed. Having standards of care in place increases the risk of 

legal action against clinicians and institutions for poor pain management,6 and there are instances 

of law suits filed for poor pain management by physicians.7 Nurses, as part of the collaborative 

team responsible for managing pain during hospitalization, also may be liable for legal action. 

Hospitals stand to lose reputation as well as profit if pain is poorly managed. Patient 

satisfaction with care is strongly tied to their experiences with pain during hospitalization. 

Evidence indicates that higher levels of pain and depression are linked to poor satisfaction with 

care in ambulatory settings.8 With the advent of transparent health care, report cards for hospitals 

are becoming more prevalent, and performance on pain management is likely to be one of the 

indicators reported. 

Undertreatment of Pain 

The undertreatment of pain was first documented in a landmark study by Marks and Sachar 

in 1973.9 These researchers found that 73 percent of hospitalized medical patients had moderate 

to severe pain. The undertreatment of pain continues. Thirty years later in 2003, Apfelbaum and 

others2 found that 80 percent of surgical patients experienced acute pain after surgery, and 86 

percent of those had moderate to extreme pain. Of 1,308 outpatients with metastatic cancer from 

54 cancer treatment centers, 67 percent reported pain.10 Of those who had pain, 62 percent had 

pain severe enough to impair their ability to function, and 42 percent were not given adequate 

analgesic therapy. It is estimated that 45 percent to 80 percent of elderly patients in nursing 

homes have substantial pain that is undertreated.11 These studies and others suggested that when 

patients had moderate to severe pain, they had only about a 50 percent chance of obtaining 

adequate pain relief.12

Harmful Effects of Unrelieved Pain 

Patients suffer from pain in many ways. Pain robs patients of their lives. Patients may 

become depressed or anxious and want to end their lives. Patients are sometimes unable to do 

many of the things they did without pain, and this state of living in pain affects their relationships 

with others and sometimes their ability to maintain employment. 

What is often overlooked is that pain has physically harmful effects. It is often actually 

physiologically unsafe to have pain.13 The effects of pain on the endocrine and metabolic system, 

cardiovascular system, gastrointestinal system, and immune system—and the potential for future 

pain—are but a few of examples of how unsafe unrelieved pain may be.13

Pain causes stress. The endocrine system reacts by releasing an excessive amount of 

hormones, ultimately resulting in carbohydrate, protein, and fat catabolism (destruction); poor 

glucose use; and other harmful effects. This reaction combined with inflammatory processes can 

produce weight loss, tachycardia, increased respiratory rate, fever, shock, and death.14

Unrelieved pain prolongs the stress response, adversely affecting the patient’s recovery.13

The cardiovascular system responds to stress of pain by activating the sympathetic nervous 

system, which produces a variety of unwanted effects. In the postoperative period, these include 

hypercoagulation and increased heart rate, blood pressure, cardiac work load, and oxygen 

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Symptom Management—Pain

demand. Aggressive pain control is required to reduce these effects and prevent thromboembolic 

complications. Cardiac morbidity is the primary cause of death after anesthesia and surgery.13, 15 

Since the stress response causes an increase in sympathetic nervous system activity, intestinal 

secretions and smooth muscle sphincter tone increase, and gastric emptying and intestinal 

motility decrease. This response can cause temporary impairment of gastrointestinal function and 

increase the risk of ileus.13, 15

Unrelieved pain may be especially harmful for patients with metastatic cancers. Stress and 

pain can suppress immune functions, including the natural killer (NK) cells that play a role in 

preventing tumor growth and controlling metastasis.13, 16 Further, management of perioperative 

pain is probably a critical factor in preventing surgery-induced decrease in resistance against 

metastasis.17

Unrelieved acute pain can result in chronic pain at a later date. Thus, pain now can cause 

pain later. If acute shingles pain is not treated aggressively, it is believed to increase the risk of 

postherpetic neuralgia.18, 19 A survey of patients having undergone surgery found a high 

prevalence of chronic postsurgical pain in patients whose acute postsurgical pain was 

inadequately managed.20 

Assessment of Pain 

Assessment of pain is a critical step to providing good pain management. In a sample of 

physicians and nurses, Anderson and colleagues21 found lack of pain assessment was one of the 

most problematic barriers to achieving good pain control. There are many recommendations and 

guidelines for what constitutes an adequate pain assessment; however, many recommendations 

seem impractical in acute care practice. Nurses working with hospitalized patients with acute 

pain must select the appropriate elements of assessment for the current clinical situation. The 

most critical aspect of pain assessment is that it is done on a regular basis (e.g., once a shift, 

every 2 hours) using a standard format.5 The assessment parameters should be explicitly directed 

by hospital or unit policies and procedures.5, 22, 23 To meet the patients’ needs, pain should be 

reassessed after each intervention to evaluate the effect and determine whether modification is 

needed. The time frame for reassessment also should be directed by hospital or unit policies and 

procedures.5

An early Clinical Practice Guideline on Acute Pain Management released by the Agency for 

Health Care Policy and Research addressed assessment and management of acute pain.22 This 

guideline outlines a comprehensive pain evaluation that would be most useful when obtained 

prior to the surgical procedure. In the pain history, the nurse identifies the patient’s attitudes, 

beliefs, level of knowledge, and previous experiences with pain. Expectations of patient and 

family members for pain control postsurgically will uncover unrealistic expectations that can be 

addressed before surgery. This comprehensive pain history lays the foundation for the plan for 

pain management following surgery, which is completed collaboratively by the clinicians 

(physician and nurse), the patient, and his or her family. 

Pain History 

The pain history should include the following: 

• Significant previous and/or ongoing instances of pain and its effect on the patient 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

• Previously used methods for pain control that the patient has found either helpful or 

unhelpful 

• The patient's attitude toward and use of opioids, anxiolytics, or other medications, 

including any history of substance abuse 

• The patient's typical coping response for stress or pain, including the presence or absence 

of psychiatric disorders such as depression, anxiety, or psychosis 

• Family expectations and beliefs concerning pain, stress, and postoperative course 

• Ways the patient describes or shows pain 

• The patient's knowledge of, expectations about, and preferences for pain management 

methods and for receiving information about pain management22 (p. 7–8) 

Pain Assessment Tools 

During the postsurgical period, pain assessment must be brief and simple to complete.22

Because choice of intervention, including type of analgesic and dosing, is made based upon 

intensity, every pain assessment should include this type of measure. Numerous pain intensity 

measures have been developed and validated. Several tools provide a numeric rating of pain 

intensity (e.g., visual analogue scale, numeric rating scale (NRS)). Simpler tools such as the 

verbal rating scale, which classifies pain as mild, moderate or severe, also are commonly used. 

For patients with limited cognitive ability, scales with drawings or pictures are available (e.g., 

the Wong-Baker FACES scale). Patients with advanced dementia require behavioral observation 

to determine the presence of pain; tools such as the PAIN-AD are available for this patient 

population. (For more detail, go to section “Tools to Assess Pain Intensity in Cognitively Intact 

and Impaired Adults,” below.) 

The Joint Commission developed pain standards for assessment and treatment based upon the 

recommendations in the Acute Pain Clinical Practice Guideline. The Joint Commission requires 

that hospitals select and use the same pain assessment tools across all departments. This standard 

suggests providing options among scales such as the NRS, the Wong-Baker FACES scale, and a 

verbal descriptor scale. 

Selecting the pain assessment tool should be a collaborative decision between patient and 

health care provider. When this is done during the preoperative period, it ensures the patient is 

familiar with the scale. If the nurse selects the tool, he or she should consider the age of the 

patient; his or her physical, emotional, and cognitive status; and preference.22 We tend to think of 

these intensity scales as verbal, but patients who are alert but unable to talk (e.g., intubated, 

aphasic) may be able to point to a number or a face to report their pain. The pain tool selected 

should be used on a regular basis to assess pain and the effect of interventions. It should not, 

however, be used as the sole measure of pain perception.24

Location and quality of pain are additional assessment elements useful in selecting 

interventions to manage pain. Since patients may experience pain in areas other than the surgical 

site, location of pain using a body drawing or verbal report provides useful information. The pain 

experienced may be chronic (e.g., headache, low-back pain) or it may be related to the 

positioning and padding used during the procedure. The quality of pain varies depending upon 

the underlying etiology. Instruments such as the McGill Pain Questionnaire25, 26 contain a variety 

of verbal descriptors that help to distinguish between musculoskeletal and nerve-related pain. 

Typically, patients describe deep tissue pain as dull, aching, and cramping, while nerve-related 

pain tends to be more sporadic, shooting, or burning.27, 28

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Symptom Management—Pain

Pain interferes with many daily activities, and one of the goals of acute pain management is 

to reduce the affect of pain on patient function and quality of life.24 The ability to resume 

activity, maintain a positive affect or mood, and sleep are relevant functions for patients 

following surgery. The Brief Pain Inventory10, 29 includes four items that may be useful in 

assessing this aspect of the pain experience. Using an NRS format, assessment of interference 

with ability to walk, general activity, mood, and sleep during the recovery period will assist in 

selecting interventions to enhance function and quality of life. 

The final elements of pain perceptions involve determining current aggravating and 

alleviating factors.22, 24 Aggravating factors may be as simple as patient position, a full bladder, 

or temperature of the room. Alleviating factors include the interventions used (e.g., analgesics) 

and cognitive strategies used to control pain. Examples of such strategies are distraction, positive 

self-talk, and pleasant imagery. The pain history will provide insight into the coping strategies 

previously used by the patient and their effectiveness with previous painful episodes. 

In addition to self-reported pain perceptions, a comprehensive assessment of pain following 

surgery includes both physiological responses and behavioral responses to pain22 (p. 11). 

Physiological responses of sympathetic activation (tachycardia, increased respiratory rate, and 

hypertension) may indicate pain is present. Behaviors that may indicate pain include splinting, 

grimacing, moaning or grunting, distorted posture, and reluctance to move. While these 

nonverbal methods of assessment provide useful information, self-report of pain is the most 

accurate. A lack of physiological responses or an absence of behaviors indicating pain may not 

mean the patient is not experiencing pain. (Go to section “Tools to Assess Pain Intensity in the 

Cognitively Impaired,” below, for more detail.)

Adequate pain management requires an interdisciplinary approach.22, 24 Documentation of 

pain assessment and the effect of interventions are essential to allow communication among 

clinicians about the current status of the patient’s pain and responses to the plan of care. The 

Joint Commission requires documentation of pain to facilitate reassessment and followup. The 

American Pain Society suggests that pain be the fifth vital sign as a means of prompting nurses 

to reassess and document pain whenever vital signs are obtained.30 Documentation also is 

important as a means of monitoring the quality of pain management within the institution. 

Monitoring the Quality of Pain Management 

Establishing and maintaining an institutional pain performance improvement plan is a Joint 

Commission requirement.5

 Institutions should develop interdisciplinary approaches to acute pain 

management with clear lines of responsibility for achieving good acute pain control.5, 22, 24 This 

interdisciplinary approach includes an individualized plan of care for pain control, developed in 

collaboration with the patient and family. Systems should be in place to monitor pain 

management that alerts the clinician when pain is poorly managed. For example, in an institution 

with a computerized documentation system, an alert may pop up when a patient’s pain exceeds a 

threshold. The threshold may be set individually by patient and clinician or institutionally. A 

reasonable threshold might be moderate to severe pain, which means a pain score of greater than 

4 on a 0–10 scale.31 The plan of care provides the basis for monitoring the quality of acute pain 

management provided. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

American Pain Society Current Guidelines

One of the first quality improvement programs was developed by the American Pain 

Society.23 The quality improvement guideline was refined and expanded in 200524 (p. 1576) 

based upon a systematic review of pain quality improvement studies conducted over the past 10 

years.32 The emphasis has shifted from processes to outcomes. 

• Recognize and treat pain promptly. 

• Involve patients and families in pain management plan. 

• Improve treatment patterns. 

• Reassess and adjust pain management plan as needed. 

• Monitor processes and outcomes of pain management. 

The goal of pain management after surgery is to prevent and control pain. Postsurgical pain, 

like cancer pain, is expected to be present continuously with spikes of increased pain with 

movement, deep breathing and coughing, and ambulation during the fist 24–48 hours after 

surgery. Around-the-clock dosing is recommended during this early postsurgical period to 

prevent severe pain and control continuous pain. 

Quality Indicators24 (p. 1578) 

Quality indicators for pain management focus on appropriate use of analgesics and outcomes. 

• Intensity of pain is documented using a numeric (0–10) or descriptive (mild, moderate, 

severe) rating scale. 

• Pain intensity is documented at frequent intervals. 

• Pain is treated by route other than intramuscular. 

• Pain is treated with regularly administered analgesics, and, when possible, multimodal 

approach is used. (Multimodal approach includes a combination of pain control 

strategies, such as opioids, nonsteroidal anti-inflammatory drugs, nonpharmacological 

interventions.) 

• Pain is prevented and controlled to a degree that facilitates function and quality of life. 

• Patients are adequately informed and knowledgeable about pain management. 

To efficiently monitor quality indicators, patient records should contain documentation of 

• Pain intensity (0–10 or mild, moderate, severe) 

• Analgesics prescribed and administered, including drug, route, and dosing 

• Impact of pain on function and quality of life (e.g., ability to walk, general activity, 

mood, sleep) 

• Pain education for patient and family member(s) 

Patient Satisfaction 

Although satisfaction with pain management currently is used as a measure of institutional 

quality, satisfaction with pain management is no longer recommended as a quality indicator for 

pain control.24, 32 This is because patient satisfaction findings are difficult to interpret. In their 

review of 20 quality improvement studies conducted between 1992 and 2001, Gordon and 

colleagues32 noted 15 studies reported high satisfaction with pain management despite many 

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Symptom Management—Pain

patients experiencing moderate to severe pain during hospitalization. Thus, patient satisfaction 

data should be cautiously interpreted and, if used, used in conjunction with other quality 

indicators. Because of the current focus on report cards for health care organizations, patient 

satisfaction data are routinely collected and easily obtained for review. 

Many institutions use commercial patient satisfaction surveys to monitor satisfaction with 

care. Most of these surveys have at least one item on satisfaction with pain management. 

Institutions also may use generic health status or quality of life surveys, such as the Medical 

Outcomes Study Short From-36, to monitor patient outcomes; most of these surveys include one 

or more questions on pain experienced. Regular review of these patient satisfaction data can be 

used as a quick measure of quality of pain care. If satisfaction scores on pain management dip, a 

more thorough investigation of pain management processes is warranted. 

Use of an interdisciplinary team to monitor current pain practice, identify areas for 

improvement, and oversee quality improvement plans is consistently recommended in the 

guidelines.5, 22, 24 To effectively monitor pain practice within a hospital, electronic systems are 

needed to capture and collate data on the indicators in a readily available form. One method of 

changing clinician behavior is through the use of feedback on performance; thus the reports 

generated for interdisciplinary committee review also may be used to assist clinicians to review 

and adjust their performance. 

Current Guidelines 

Many State and professional organizations have developed clinical practice guidelines to 

direct health care providers in adequate management of acute pain. The 1992 Acute Pain Clinical 

Practice Guideline22 lays the foundation for the more current guidelines. Listed below is a 

sample of current guidelines available from the National Guideline Clearing House. 

• Pain management guideline; developed by the Health Care Association of New Jersey; 

released July 2006. This guideline includes definitions of pain (acute and chronic); clear 

direction for assessment and treatment with pharmacological and nonpharmacological 

interventions (including physical and occupational therapy); policies for pain education 

for staff, patients, and families; and direction for quality monitoring. The guideline is 

applicable to pain management in acute care and long-term care nursing facilities. Web 

site: http://www.guidelines.gov/summary/summary.aspx?doc_id=5526&nbr=003757& 

string=pain+and+assessment+and+nursing 

• “Pain Management”; written for the 2nd edition of Geriatric Nursing Protocols for Best 

Practice; published in 2003. This guideline addresses pain in the elderly, assessment 

strategies, and nursing interventions to control pain. Pharmacological and 

nonpharmacological interventions are included in the guideline. Web site: 

http://www.guidelines.gov/summary/summary.aspx?doc_id=3514&nbr=002740&string=

pain+and+assessment+and+nursing 

• ASPAN Pain and Comfort Clinical Guideline; developed by American Society of 

Perianesthesia Nurses; released August 2003. This guideline provides direction for 

assessment, interventions, and expected outcomes for the preoperative and postoperative 

phases of treatment. Use of pharmacological and nonpharmacological interventions is 

endorsed. Web site: http://www.guidelines.gov/summary/summary.aspx?doc_id=5526& 

nbr=003757&string=pain+and+assessment+and+nursing 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

• Clinical Practice Guideline for the Management of Postoperative Pain; developed by the 

Veterans Health Administration; released May 2002. This guideline is organized into two 

main algorithms, one for the preoperative phase and the other for the postoperative phase. 

The pain management plan is set within the context of comprehensive pre- and 

postsurgical care and includes discharge planning. A patient-focused objective is 

provided for each step of the pain management plan. Emphasis is placed upon 

reassessment and modification of the treatment plan. Clear descriptions of common 

opioid side effects and interventions to reduce them are included in the guideline. Web 

site: http://www.guidelines.gov/summary/summary.aspx?doc_id=3284&nbr=002510& 

string=pain+and+assessment+and+nursing 

• The American Society of Pain Management Nursing has published two position 

statements on pain management issues that pose difficulty ethically and in practice. 

Practice recommendations based upon research and clinical expertise are included in both 

position statements. 

 Herr et al. Pain assessment in the nonverbal patient: Position statement with clinical 

practice recommendations. Pain Management Nursing 2006;7(2):44-52. 

 American Society for Pain Management Nursing. ASPMN position statement: pain 

management in patients with addictive disease. Journal of Vascular Nursing 

2004;17(3):99-101. 

• With the implementation of the Joint Commission standards for pain management, the 

requirements for “as needed” (PRN) orders were altered. The American Society of Pain 

Management Nursing and the American Pain Society developed a consensus statement 

on the use of PRN range orders to guide nursing practice. 

 Gordon et al. Use of “as needed” range orders for opioid analgesics in the 

management of acute pain. Home Healthcare Nurse, 2005;23(6):388-96. 

Research Evidence 

Analgesics, particularly opioids, are the primary treatment for acute pain. It is estimated that 

up to 90 percent of cancer pain can be adequately managed with analgesics using the World 

Health Organization (WHO) analgesic ladder.33, 34 Although no evidence exists to estimate the 

likelihood of adequately managing acute pain, it is reasonable to infer that the vast majority of 

postsurgical pain can be well managed with the appropriate use of analgesics. While there are 

many factors that contribute to poor pain management—lack of assessment and inadequate or 

inapposite use of analgesics are primary, and modifiable, factors.35 Thus, it is the responsibility 

of clinicians to be knowledgeable about the analgesics used to treat pain, including onset, peak 

action, and duration of the drug(s) administered; common side effects, and methods of managing 

those side effects.36 Easy access to an equianalgesic table assists in providing good pain control 

when switching from one opioid to another and from one route to another. This approach is 

particularly important when preparing the postsurgical patient for discharge with an oral 

analgesic. 

The objective for postsurgical and procedural pain is to prevent and control pain.22, 24 This 

does not mean that patients will be pain free, a misconception that some patients and families 

have when entering the hospital. This misconception is best addressed during the preoperative 

pain assessment by collaboratively setting goals for pain control and function. A multimodal 

approach (balanced analgesia), which includes opioids, nonopioids such as nonsteroidal anti8 
Symptom Management—Pain

inflammatory drugs (NSAIDs), and adjuvant medications such as anticonvulsants, is 

recommended. (For more detail go to the “Balanced Analgesia” section in this chapter.) 

Following the WHO’s analgesic ladder for control of cancer pain, the Clinical Practice Guideline 

Committee recommended the use of NSAIDs for mild to moderate pain with the addition of 

opioids for moderate to severe pain.22 

Principle of Analgesic Management of Pain 

Based upon evidence and clinical practice, there are several principles of analgesic 

management to meet the objective of preventing moderate to severe pain: 

• When continuous pain is anticipated, a fixed-dose schedule (around the clock) should be 

used. 

• A PRN order of a rapid onset analgesic may be necessary to control activity-related 

(breakthrough) pain. 

• To ensure opioids are safely administered, begin with a low dose and titrate to comfort. 

• Modification in analgesic administration is based upon assessment of the effect of the 

previous dose, including change in pain intensity, relief, and side effects experienced. 

• Patients respond differently to various opioid and nonopioid analgesics; therefore if one 

drug is not providing adequate pain relief, another in the same class may result in better 

pain control. 

• Assessment of effect should be based upon the onset of action of the drug administered; 

for example, IV opioids are reassessed in 15–30 minutes, whereas oral opioids and 

nonopioids are reassessed 45–60 minutes after administration. 

Opioid Analgesics 

A series of three systematic reviews have been published in the past 5 years examining the 

efficacy, safety, and side effect profile of opioids used to manage postsurgical pain.2, 37, 38 The 

first review3 concluded that patient-controlled analgesia (PCA) and epidural routes of 

administration were superior to intramuscular (IM) injections when pain intensity and relief were 

considered. The safety of opioids used to control postsurgical pain was examined for 

hypotension and respiratory depression; observed rates were less than 5 percent for hypotension 

and less than 1 percent for respiratory depression.37 The most common opioid side effects 

included 25 percent nausea, 20 percent vomiting, 23.9 percent mild sedation, 2.6 percent 

excessive sedation, 14.7 percent pruritis, and 23 percent urinary retention. The use of intravenous 

PCA was associated with the highest levels of nausea and sedation, whereas epidural analgesia 

was associated with the highest rate of urinary retention.38 This series of systematic reviews 

suggests the IM route of administration produces the poorest outcomes. Approximately one in 

every four patients will experience common opioid side effects; however, the rate of excessive 

sedation, respiratory depression, and hypotension related to opioids are low in the postsurgical 

population. 

Patient and Family Education

Beginning with the Acute Pain Clinical Practice Guideline,

22 patient and family education 

has been a central recommendation for acute pain management. This education is best 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

implemented during the presurgical clinic visit or during admission pain assessment. The 

essential elements of pain education include telling the patient the following: 

• Preventing and controlling pain is important to your care. 

• There are many interventions available to manage pain; analgesics (opioid and 

nonopioid) are the most effective in managing acute pain. 

• Some people are afraid of using opioids because of the side effects and risk of addiction. 

Side effects can be managed effectively with medication. The risk of addiction when 

using opioids to control acute pain is extremely low. 

• Your responsibility in achieving good pain control is to tell us when you are experiencing 

pain or when the nature or level of pain changes. 

• Complete pain relief usually is not achievable; however, we will work with you to keep 

pain at a level that allows you to engage in activities necessary to recover and return 

home. 

This last comment flows directly into a discussion about goals for pain management during 

the hospitalization. This goal is set in light of the functional requirements (e.g., when ambulation 

will begin, need for deep breathing) to promote recovery. Thus, the patient, family member(s), 

and nurse collaboratively set a tolerable or satisfactory level of pain and function during the 

hospitalization, which is documented either in the patient’s room or record so that all clinicians 

are working toward the same goals for pain control. Shared goal setting is one dimension of 

relational coordination associated with adequate postsurgical pain management.39 Information 

obtained from the pain history (e.g., previous experience with pain and what helped or did not 

help, typical coping strategies used) will assist in developing a plan of care that incorporates the 

patient’s preferences into the plan. 

Patient-Nurse Interactions 

One of the earliest evidence-based protocols was developed as part of the Conduct and 

Utilization of Research in Nursing (CURN) project. Pain: Deliberative Nursing Interventions40

describes an approach to a patient’s complaint of pain that includes skilled communication to 

determine the patient’s needs. While administering analgesics may be the most appropriate way 

to meet the patient’s needs, the nurse may uncover other factors contributing to discomfort, such 

as uncomfortable position, thirst, or the need to urinate.40 Addressing these needs will improve 

patient comfort and communicate the nurse’s desire to promote comfort. McCaffery35 suggested 

that the time spent with the patient to communicate concern and caring may go a long way in 

providing patient comfort. The content of this 5-minute conversation may include the following: 

• Listening to patient concerns 

• Communicating the desire to help the patient become more comfortable 

• Determining strategies that might achieve more comfort35 (p. 78) 

Communication with patients is one of the core dimensions of relational coordination, an 

approach examined in the orthopedic surgical population.39 In a cross-sectional study of nine 

hospitals, Gittell and colleagues39 found that the better the relational coordination, the better the 

postsurgical pain relief. Of note, four dimensions (frequent communication, shared goals, shared 

knowledge, and mutual respect among clinicians) were associated with this improvement in pain 

control. Thus, this study suggested that communication, goal setting, and patient education 

contributed to better pain outcome. 

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Symptom Management—Pain

Nondrug Techniques To Manage Pain 

People naturally use many nondrug strategies, such as distraction, imagery, and massage, to 

alleviate pain. During episodes of acute pain, patients may rely on these previously used and 

“proven” methods. For example, Kwekkeboom41 found women recovering from breast and 

gynecological surgery used a variety of nondrug techniques in addition to analgesics to relieve 

pain at home. Although the techniques varied, methods to increase relaxation were common 

(e.g., breathing, meditation, imagery, and music). Hospitalized patients also may use techniques 

that have worked for them in the past; in a study of nondrug techniques to manage postsurgical 

pain, Pellino and colleagues42 reported that between 19 and 28 percent of patients in the usual 

care control group used nondrug techniques during the first 3 days after surgery. Thus, patients 

in pain may spontaneously (i.e., without instruction or help) use a wide variety of nondrug 

methods to control their pain. Before suggesting or instructing patients in the use of nondrug 

techniques, nurses need to be aware of the methods used effectively and preferred by the patient. 

For example, in a trial of five cognitive-behavioral techniques to manage cancer pain in 

ambulatory patients, Anderson and colleagues43 noted that a number of patients had difficulty 

using their assigned technique because it did not match their usual coping style. In addition to 

applying the wrong technique, instructing patients in the use of a specific technique, such as 

imagery, may undermine their confidence in the techniques they typically use to control pain. 

Nurses have used nondrug techniques for years to help patients manage pain. These 

techniques have been labeled differently over the years. Noninvasive, nonpharmacological, 

nondrug, and complementary therapies have been used interchangeably to reflect nonmedical 

therapies. McCaffery35 noted that there is no classification system for these nondrug techniques. 

For the purposes of this chapter, techniques will be grouped as cognitive and physical. Cognitive 

techniques focus primarily on mental functions that require some degree of attention. Distraction 

or focusing attention away from the pain may be one of the primary mechanisms resulting in 

pain relief. Relaxation and music are included in this cognitive category. Physical techniques 

focus on altering physiological processes that may reduce pain. Massage and the application of 

heat and cold are included in this category. One possible mechanism of action for massage and 

heat/cold therapy is the stimulation of the large diameter fibers, which are hypothesized to 

reduce central pain transmission. Reducing muscle tension, which may contribute to pain 

transmission, is another possible mechanism of action. 

Relaxation. There are many methods available to achieve a relaxation response. Some 

require initial training and practice to be used effectively; progressive muscle relaxation, 

systematic relaxation, and autogenic training are skills that require some practice. Each session 

using progressive, systematic, or autogenic training may take 15–30 minutes. Typically in 

research, the instructions are delivered via audiotape, a method that may be used for hospitalized 

patients as well. Simpler forms of relaxation, which may be more suitable to institute during an 

acute pain episode, include jaw dropping and rhythmic breathing. 

Reviews on the effectiveness of relaxation for pain relief have arrived at different and often 

opposite conclusions.44–46 This is not surprising because of the wide variety of techniques that 

were used as well as the small number of studies published (11 to 12 in the most recent reviews). 

The recent randomized clinical trials also contribute to this inconsistency.43, 47, 48 Therefore, the 

current evidence does not support a consistent, predictable effect of relaxation on pain. 

Music. Sedating or soothing music is instrumental, rhythmic, and 60–80 beats per minute. In 

much of the research, musical pieces are selected from five types of music identified by Good 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

and colleagues:49 synthesizer, harp, piano, orchestral, or slow jazz. The intervention is delivered 

via audiotape and headphones. The duration is typically 20–30 minutes and may involve a single 

or multiple exposures. 

A recent meta-analysis of 51 studies examining the effect of music on pain concluded that 

although music produced a significant reduction in pain intensity (0.5 units), this result may not 

reflect a clinically important change.50 Gordon and colleagues24 suggest a 1.5 to 2.0 unit change 

in pain intensity on a 0–10 scale constitutes a clinically important difference. Despite the large 

number of studies included, approximately 50 percent were of low quality, leading to low 

confidence in the results of the analysis. Contrary to previous meta-analyses,51 Cepeda and 

colleagues50 did not find differences in pain reduction related to whether the music was patientor clinician-selected. Recently published studies, all conducted on patients undergoing 

cardiovascular procedures, found significant short-term reductions in pain, distress, or anxiety 

after exposure to music.52–54 In each of these studies, music was used during an episode of 

increased pain (e.g., getting up from a chair). While these studies hold promise, currently the 

evidence for the effectiveness of music in reducing acute pain is weak to moderate. 

Massage. Massage is defined as the systematic manipulation of soft tissues by manual or 

mechanical means.55 Nurses have used massage—a back rub—to improve circulation, promote 

comfort, and enhance sleep. More recently investigators have examined hand and foot massage 

as an alternative to back or body massage. The duration of massage varies from 5 to 20 minutes. 

Wong and Keck56 suggested that 20 minutes of massage was required to achieve the desired 

effect, but little evidence exists to substantiate this claim. 

Reviews of the massage literature conclude it has a beneficial effect on anxiety and tension, 

depression, and stress hormones (cortisol and catecholamines).57, 58 The evidence on the 

beneficial effects of massage on reducing pain is positive, but involves few studies, so that firm 

conclusions cannot be drawn. More recent studies produced inconsistent findings, particularly in 

terms of the effect of massage on pain control.56, 59–62 As with the relaxation and music literature, 

studies of the effect of massage suffer from methodological problems57 that produce unstable or 

biased results. 

Heat/cold therapy. The application of heat and ice to reduce pain or promote comfort has 

been a common nursing intervention, which may require a physician’s order to implement. 

Despite the use of heat and cold by nurses, there are few studies investigating the impact on 

pain or function. A meta-analysis of heat and cold for low-back pain concluded that continued 

use of heat (over a 5 day period) improved pain intensity and function.63 Only two studies on the 

use of heat for postsurgical pain were found, and the findings from these were inconclusive.64

The application of ice/cold for low-back pain has limited evidence to support it’s use.63 Cold 

therapy has been investigated in patients undergoing orthopedic surgeries (primarily total knee 

arthroplasty) and has been found to improve pain, range of motion, and function.65 However, a 

study by Smith and others66 found that pain was similar with the cryo pad (a new technology to 

deliver cold therapy) and the compression bandage applied by the surgeon at the end of surgery; 

in addition, the cold therapy increased the cost of care and took more nursing time. Thus, using 

cold therapy via the cyro pad provides no benefit over compression bandages after knee 

replacement and is less cost efficient. 

Use of multiple nondrug therapies for pain management. Introduction to a variety of 

nondrug techniques may be used to better meet patients’ needs. Two recent studies examined the 

effect of providing multiple nondrug techniques (e.g., a cafeteria style) on postsurgical pain. In 

both studies, the interventions were developed to allow the patient maximum control and require 

12 
Symptom Management—Pain

minimum nursing time. Common techniques used in both studies included relaxation, music, and 

massage.42, 67 While it is too early to determine if providing a pain “tool kit” will have benefit to 

postsurgical patients, Kshettry and colleagues67 demonstrated the feasibility of implementing 

such a program in a busy intensive care unit (ICU). 

Evidence-Based Practice Implications 

Lack of adequate assessment and inappropriate treatment remain the major factors of 

undertreatment of pain. There is ample evidence that the appropriate use of analgesics—the right 

drug(s) at the right intervals—can provide good pain relief for the majority of patients. Thus, 

institutions should place their money and effort on improving these provider behaviors 

(assessment, prescription and administration of analgesics).35 The use of nondrug therapies is 

recommended in most pain guidelines; however, the evidence for their consistent benefit in terms 

of pain intensity, relief, or improved function is weak at best. This result does not mean a 

nondrug technique, or several techniques provided cafeteria style, may not improve a patient 

outcome. The nurse who uses these techniques should be aware that the effect is not 

predictable.35 

Ensuring Patient Safety 

Following are some patient safety issues that relate to pain management: 

• When administering sedatives, consider the patient’s physical safety (e.g., using bed rails, 

fall precautions, assistance with ambulation). 

• Eliminate errors related to PCA infusions (improper dose/quantity, wrong drug, drug 

omission) by using systems to double-check drug and dose (e.g., bar coding, nurse-nurse 

checking).68

• Eliminate errors and complications related to catheter administration (initial dose testing, 

monitoring catheter and response to medication).69

• Nondrug techniques have minimal adverse events reported and do not pose safety issues. 

• Protect skin when applying heat or cold. 

Tools To Assess Pain Intensity in Cognitively Intact Adults 

The first step in relieving pain to prevent its harmful effects, and doing so safely, is to assure 

that patients are properly assessed for pain so that appropriate pain relief measures can be 

implemented. Otherwise, pain may be unnoticed by clinicians or may be undertreated. 

Self-report is the most reliable way to assess pain intensity. When the patient is able to report 

pain, the patient’s behavior or vital signs should never be used in lieu of self-report. For the 

cognitively intact adult, assessment of pain intensity in the clinical setting is most often done by 

using the zero to 10 numerical rating scale or the zero to 5 Wong-Baker FACES scale.70 The 

NRS consists of a straight horizontal line numbered at equal intervals from zero to 10 with 

anchor words of “no pain” for zero, “moderate pain” for 5, and “worst pain” for 10. The FACES 

scale consists of six faces showing progressive pain intensities, beginning with a smiling face 

and ending with a crying face. 

Once the patient knows how to use a pain intensity scale, the patient should be taught how to 

establish a comfort-function goal. This is the pain intensity at which the patient is easily able to 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

perform necessary activities, such as ambulating after surgery or being able to concentrate on 

job-related activities. Interventions are implemented to achieve and maintain this pain rating as 

much of the time as possible.70

Tools To Assess Pain Intensity in Cognitively Impaired Adults 

When the patient is unable to self-report pain, other less reliable measures must be used to 

identify the existence of pain and estimate the probable intensity. These assessment measures 

form a hierarchy, arranged in order of probable importance:70, 71

• Conditions, such as surgery, or procedures, such as wound care, that are likely to cause 

pain. 

• Patient behaviors that are likely to indicate pain. A behavioral assessment tool, discussed 

below, may be used. Whenever possible, a pain behavior scale should be chosen that has 

been researched for reliability and validity in the clinical setting. 

• Knowledge of others who know the patient, such as the family or caregivers. They should 

be asked if they see behaviors that may indicate pain or if they know of preexisting 

conditions, such as arthritis, that cause pain. 

If any of the above suggest pain is present, the clinician may assume pain is present and use 

the acronym APP to record assessment when a pain intensity rating cannot be obtained. Next, a 

conclusion is made about an appropriate intervention based on the probable intensity of pain. If 

appropriate, a trial dose of analgesic is given and the patient’s behavior is observed before and 

after this intervention. If the behavior subsides, this may indicate that indeed the patient has pain 

and that the analgesic should be continued. If there is no change in behavior, a stronger dose of 

analgesic may be indicated.71

Behavioral assessment tools are helpful in identifying the existence of pain and evaluating 

interventions. These scales are of two types: (1) pain behavior scales, and (2) pain behavior 

checklists. Some of these scales are scored by identifying the number or intensity of behaviors. 

However, this score is not a pain intensity score. No research as yet confirms that a pain behavior 

score is a pain intensity score.71 Therefore, it is unsafe to use pain behavior scores as pain 

intensity scores. A patient with only a few behaviors may have as much pain as a patient with 

many more behaviors. 

An example of a pain behavior scale is the Behavioral Pain Scale (BPS), developed for use in 

the critically ill patient in the ICU.72 It evaluates and scores three categories of behavior: 

1. Facial expression, scores range from 1 for relaxed to 4 for grimacing 

2. Upper-limb movement, scores range from 1 for no movement to 4 for permanently 

retracted 

3. Ventilator compliance, scores range from 1 for tolerating ventilator to 4 for unable to 

control ventilation 

Once again, a score above 3 may indicate 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 useful, the patient must be able to respond in all categories of behavior. For example, the 

BPS would be useless in a patient who is receiving a neuromuscular blocking agent. 

Behavior checklists differ from pain behavior scales in that they do not evaluate the degree of 

an observed behavior and do not require a patient to demonstrate all of the behaviors specified, 

although the patient must be responsive enough to demonstrate some of the behaviors. These 

14 
Symptom Management—Pain

checklists are useful in identifying the patient’s “pain signature,” that is, the pain behaviors 

unique to the individual.73 

An example of a pain behavior checklist is the Pain Assessment Checklist for Seniors with 

Limited Ability to Communicate (PACSLAC).74 The PACSLAC evaluates 60 behaviors such as 

facial expressions, activities, and mood. A check mark is made next to any behavior the patient 

exhibits. The total number of behaviors may be scored, but again, this cannot be equated with a 

pain intensity score. It is unknown if a high score represents more pain than a low score. In other 

words, a patient who scores 10 out of 60 behaviors does not necessarily have less pain than a 

patient who scores 20.71 However, in an individual patient, a change in the total pain score may 

suggest more or less pain. A more comprehensive description of pain assessment tools for the 

cognitively impaired are located at the following Web site in the education section of Pain in the 

Elderly: http://www.cityofhope.org/PRC/. 

Balanced Analgesia 

Analgesics are usually divided into three categories: (1) nonopioids, which include 

acetaminophen and NSAIDs; (2) opioids, which include morphine-like drugs; and (3) adjuvant 

analgesics, which include local anesthetics and anticonvulsants. Using an analgesic from each 

one of the three groups, referred to as balanced or multimodal analgesia, may improve the safety 

of analgesic therapy. When more than one analgesic is used, the same level of pain relief may be 

achieved with a lower dose of each analgesic. For example, use of a local anesthetic along with 

an opioid usually allows reduction of the opioid dose needed for adequate pain control. 

Safe Use of Opioids 

Of all the analgesics used in pain control, the most safety issues arise with the use of those 

referred to as mu opioids, or morphine-like drugs such as morphine, hydromorphone 

(DilaudidTM), and fentanyl. Clinicians fear causing harm with these analgesics by administering 

too much and causing life-threatening respiratory depression. Sometimes this fear results in 

undertreatment of pain. Clinicians need to be educated about the effective methods of preventing 

respiratory depression and appropriate use of naloxone if respiratory depression does occur. 

Opioid-induced respiratory depression is preceded by an increasing level of sedation. An 

alert patient will not suddenly succumb to respiratory depression. Consequently, respiratory 

depression can be prevented by observing sedation levels and decreasing the opioid before 

respiratory depression occurs. Box 1 presents a sedation scale that nurses can use at regular 

intervals to monitor patients receiving opioids. This scale should be used for all opioid naïve 

patients with moderate to severe pain when opioid dosing is initiated. These patients should be 

monitored at least every 2 hours during the first 24 hours of opioid therapy. Using this scale, the 

nurse knows when it is or is not safe to administer additional opioid and when the opioid dose 

should be decreased or stopped. 

When selecting a sedation scale for prevention of opioid-induced respiratory depression, care 

must be taken to be sure that the selected scale matches the intended purpose. For example, the 

Ramsey is appropriate for monitoring the patient’s tolerance for ventilation in the ICU, but is not 

intended for use in prevention of opioid-induced respiratory depression. It contains irrelevant 

items, such as agitation, which have nothing to do with opioid-induced respiratory depression. 

Nurse monitoring of sedation levels and respiratory status is more appropriate for preventing 

opioid-induced respiratory depression than relying on pulse oximetry or apnea monitory. These 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

can give a false sense of security.75–77 Further, decreased oxygen saturation is a later sign of 

impending respiratory depression. Capnography may more accurately detect respiratory 

depression and apnea;78 however, further research is required to recommend widespread use of 

the method outside of the operating room or post-anesthesia care unit. The use of mechanical 

monitoring is recommended if a patient has a preexisting condition that requires it, such as sleep 

apnea or chronic obstructive pulmonary disease.76

Instructions for the safe use of naloxone to reverse clinically significant opioid-induced 

respiratory depression are included in Box 1. Naloxone must be titrated carefully. Giving too 

much naloxone or giving it too fast can precipitate severe pain and increase sympathetic activity 

leading to hypertension, tachycardia, ventricular dysrhythmias, pulmonary edema, and cardiac 

arrest.79

The IM route of administration is not recommended for pain management.76 It is painful, and 

it has unreliable absorption with a 30–60 minute lag time to peak effect and a rapid drop in 

action. In addition to being ineffective, the IM route is dangerous because patients are often 

alone at the time of peak effect of the opioid administered, can become excessively sedated, 

vomit, and aspirate. A better alternative is the intravenous (IV) route of administration. Points to 

consider in the overall safe management of opioid naïve patients receiving IV or intraspinal 

analgesia are in Box 2. 

Box 1: Pasero - McCaffery Opioid-induced Sedation Scale 

S = Sleep, easy to arouse

Acceptable: No action necessary; supplemental opioid may be given if needed.

1 = Awake and alert

Acceptable: No action necessary; supplemental opioid may be given if needed. 

2 = Slightly drowsy, easily aroused 

Acceptable: No action necessary; supplemental opioid may be given if needed. 

3 = Frequently drowsy, arousable, drifts off to sleep during conversation 

Unacceptable: Decrease opioid dose by 25–50 percent . Administer acetaminophen or an 

NSAID, if not contraindicated, to control pain; monitor sedation and respiratory status closely 

until sedation level is less than 3. 

4 = Somnolent, minimal or no response to physical stimulation 

Unacceptable: Stop opioid. Notify anesthesia provider; very slowly administer dilute IV naloxone 

(0.4 mg naloxone in 10 mL saline; 0.5 mL over 2-minute period); administer acetaminophen or 

an NSAID, if not contraindicated, to control pain; monitor sedation and respiratory status closely 

until sedation level is less than 3. 

Source: Pasero C. Acute pain service: policy and procedure guideline manual. Los Angeles, CA: Academy Medical 

Systems, 1994; Pasero C, Portenoy RK, McCaffery M. Opioid analgesics, In: McCaffery M, Pasero C. Pain: clinical 

manual. 2nd ed. St. Louis, MO: Mosby; 1999. p. 161-299. Copyright Chris Pasero, 1994. Used with permission. 

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Symptom Management—Pain

Box 2: Safe Care of the Opioid Naïve Patient Receiving Opioids by IV or Intraspinal Routes 

• Develop standardized, preprinted order sets that include 

o Opioid prescription 

o Administration of nonopioid analgesia, e.g., acetaminophen and an NSAID 

o Monitoring parameters 

o Activity, ambulation 

o IV access if indicated 

o Management of breakthrough pain 

o Treatment of adverse effects 

o When to notify anesthesia or primary care provider (e.g., unrelieved pain, excessive adverse 

effects) 

• Monitor sedation and respiratory status every 1 to 2 hours for the first 24 hours after opioid therapy is 

initiated, then every 4 hours until IV or intraspinal opioid therapy is discontinued, then routine in 

stable patients (see Sedation Scale, Box 1). 

• Monitor other vitals signs every 4 hours until IV or intraspinal opioid therapy is discontinued, then per 

routine in stable patients (evaluate need to monitor blood pressure more often in some patients). 

• When possible, avoid sedating drugs for treatment of opioid-induced adverse effects, such as 

antihistamines for pruritus and antiemetics for nausea. 

• Develop criteria for selecting appropriate patients to receive 

o Patient-controlled analgesia (PCA) 

o Family-controlled analgesia (parent or significant other) 

o Nurse-activated dosing (primary nurse) 

• Teach patients, family members, and visitors about the proper use of PCA and the dangers of 

anyone other than the patient or an authorized person pressing the button. 

Source: Pasero C, McCaffery M. Authorized and unauthorized use of PCA. Am. J. Nurs. 2005;105(7):30,31, 33; 

Pasero C, Portenoy RK, McCaffery M. Opioid analgesics, In: McCaffery M, Pasero C. Pain: clinical manual. 2nd ed. 

St. Louis, MO: Mosby; 1999 p. 161-299. Copyright Chris Pasero, 2005. Used with permission. 

Research Implications 

The evidence base supporting the use of analgesics to manage acute pain is strong and 

clear—to date, analgesics, particularly opioids, are effective in controlling acute pain. 

Undertreatment of acute pain, however, remains prevalent despite the availability of analgesics 

and guidelines. Undertreatment is attributed to clinician behaviors—lack of adequate pain 

assessment and inadequate prescription and administration of analgesics—that are modifiable. 

17 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Thus, the research in this area needs to be directed toward effective strategies for changing 

clinician attitudes and behaviors that will result in better pain management for patients. 

The evidence base for the use of nondrug therapies to manage acute pain requires further 

development; the current knowledge does not support achieving consistent outcomes from these 

therapies. Lack of standardization of nondrug therapies is one of the drawbacks of the current 

literature. Using standard relaxation or massage techniques with a determined duration (i.e., 

dose) and frequency (i.e., interval) would improve our ability to summarize the literature and 

determine the effectiveness of these therapies for pain control. 

Conclusion 

Education about safe pain management will help prevent undertreatment of pain and the 

resulting harmful effects. Safety includes the use of appropriate tools for assessing pain in 

cognitively intact adults and cognitively impaired adults. Otherwise pain may be unrecognized or 

underestimated. Use of analgesics, particularly opioids, is the foundation of treatment for most 

types of pain. Safe use of analgesics is promoted by utilizing a multimodal approach, that is, 

using more than one type of analgesic to treat the individual’s pain. Opioid use is often avoided 

or inadequate for fear of causing life-threatening respiratory depression. Nurse monitoring of 

sedation levels when opioids are initiated is one way to assure safety. While nondrug techniques 

pose minimal safety issues, the current evidence does not support that these techniques produce 

consistent, predictable pain management outcomes. 

Search Strategy 

The terms “pain assessment” and “pain management” were used in the literature search. The 

research was limited to the English language, published in the last 10 years, meta-analyses, 

practice guidelines, literature reviews, clinical trials, and randomized clinical trials (RCTs). The 

literature for nondrug techniques was searched using the key terms “relaxation,” “music,” 

“massage,” “heat and cold,” and “pain.” The nondrug literature was limited to the English 

language, meta-analysis, and literature reviews. 

Author Affiliations 

Nancy Wells, D.N.Sc., R.N., F.A.A.N., director of nursing research, Vanderbilt Medical 

Center, and research professor, Vanderbilt University School of Nursing; e-mail: 

Nancy.wells@vanderbilt.edu. 

Chris Pasero, R.N., pain management consultant; e-mail: cpasero@aol.com. 

Margo McCaffery, R.N., F.A.A.N., pain management consultant; e-mail: 

margopain@aol.com. 

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Symptom Management—Pain

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21 
Evidence Table for Pain Assessment and Pain Management 

Source Safety Issue Related to Clinical Practice Design Type Study Design & Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s) Anderson 200643 Relaxation Randomized controlled trial Pain intensity Quality of life, cancer specific Mood Symptom severity Symptom interference Self-efficacy Cancer clinic N = 57 chronic cancer pain requiring opioids Relaxation Distraction Positive mood delivered via audiotape at home 20 minute tape used 5x/week for 2 weeks Wait listed control Significant pre-po

intensity using reNo difference in oto intervention exNo difference for outcomes. In poststudy interimmediate relief wdistraction tape, bimmediately after Some mismatch bpreference and tyassigned. Pain reduction wa

Cashman 200437 Respiratory and hemodynamic adverse events related to opioid analgesia Systematic literature review Respiratory depression Hypotension Published literature 165 papers > 20,000 patients Analgesic techniques IM PCA Epidural Respiratory depre

across studies; inupon definition. Incidence of respmeasured by low percent. Incidence of hypoanalgesia < 5 per

22
23

Source 

Safety Issue Related to Clinical Practice Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Cepeda 200750

Music Meta-analysis Pain intensity 

Pain relief Opioid use 

51 RCTs reviewed > 2,600 patients All types of pain 

Music Studies of postsu

reduction in intenstudies). Patient- versus pshowed no benefPatients exposed greater likelihood pain relief than thstudies). Patients exposed less of morphine postsurgery than studies). No difference in muse of music (4 sClinical importancclear. 

Chandler 200264

Heat/cold Literature 

review 

2 studies 

Acute pain 

Limited evidence for pain control in 

Chang 200654 Music Randomized 

controlled trial 

Pain intensity Heart rate (HR) Resp rate (RR) Blood pressure (B/P) Oxygen saturation (SpO2) Collected 15, 30, and 45 minutes after clamp applied 

ICU in 2 acute care hospitals in Hong Kong N = 43 compression with C-clamp after percutaneous cardiac intervention 

Patient selected music from 15 selections of soft, slow, nonlyric music Control: usual care 

Significant differe45 minutes of comPatients exposed reduction in pain. Patients in controincrease in pain. HR, RR, and SpOmusic at 30 and 4control. Systolic B/P, HR, music over time. Analysis controllecomparisons. Music has benefit procedure in ICU
24

Source 

Safety Issue Related to Clinical Practice Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

De Jong 200645

Relaxation Systematic 

literature review 

Pain intensity Pain distress 

11 studies reviewed Postsurgical and procedural (burn care) pain 

Rhythmic breathing Simple relaxation 

Review sought to simple relaxation breathing) on paiNo research publacute phase. Most promising tebreathing with jaw 

Dolin 20023 Efficacy of analgesic 

administration techniques 

Systematic literature review 

Pain intensity Pain relief 

Published literature 165 papers > 20,000 patients 

Analgesic techniques IM PCA Epidural 

Incidence of: Moderate to seveSevere pain: 10.9 Poor pain relief: 3Fair-to-poor pain Highest incidence Significant decline (years of publicat

Dolin 200538 Adverse (side) effects 

to opioid analgesics via 3 modes of administration 

Systematic literature review 

Nausea Vomiting Sedation Pruritis Urinary retention 

Published literature 283 papers > 100,000 patients 

Analgesic techniques IM PCA Epidural 

Incidence of adveacross all 3 technNausea: 25 perceVomiting: 21 percMild sedation: 23Excessive sedatioPruritis: 14.7 percUrinary retention: 

Field 199857 Massage Literature 

review 

Multiple outcomes of a wide variety of diseases 

Massage therapy 

Consistent findingdecreases anxietcatecholamines. Massage and vibtypes of pain inclumoderate vibratioextended time maMethodological p(nonexperimentaassignment) and 
25

Source 

Safety Issue Related to Clinical Practice Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

French 200763 Heat/cold Systematic 

literature review 

Pain intensity Physical function Overall improvement Patient satisfaction Adverse effects 

9 papers 1,117 patients Acute, subacute, and chronic lowback pain 

Superficial heat/cold 

Heat wrap producin pain after 5 dayDisability reduced days (2 studies). Heat produced adskin) in 6/128 patLimited evidence effect on pain. 

Good 200548 Relaxation Randomized 

controlled trial 

Pain intensity Pain distress Opioid use Days 1 & 2 Secondary analysis of larger study included in lit review on music and relaxation 

4 hospitals in United States N = 167 Intestinal surgery 

Jaw relaxation Patient selected music (5 types) Combined relaxation + music Control: 15 minutes quiet rest 

3 intervention groless pain than cobefore and after r(16–40 percent leNo difference ampain intensity immRelaxation or mureducing acute panot improve effec

Hattan 200260 Massage Randomized 

controlled trial 

Psychological well-being (e.g., pain, anxiety, calm) Heart rate (HR) Resp rate (RR) Blood pressure (B/P) 

Teaching hospital in United Kingdom N = 25 postCABG patients 

20 minute foot massage 20 minute guided relaxation Delivered on day 2 postsurgery Control: usual care 

No difference in ppost treatment. Significant differeperception of calmhigher than controbetween relaxatioNo difference in canxiety, relaxatio

Hulme 199959 Massage Randomized 

controlled trial 

Pain intensity Analgesic use Quality of care (satisfaction) 

Day surgery unit in United Kingdom N = 59 women day surgery for sterilization 

5 minute foot massage postsurgery Control: usual care 

Significant decreapostsurgical perioNo difference in pgroup. Pattern over time received massagcontrols. No difference in aearly and postdis
26

Source 

Safety Issue Related to Clinical Practice Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Hutchison 20074 IV PCA analgesia Literature review Published literature None MEDMARX data 

most common errerrors. Recommendationprescription, admmodification of PC

Kwekkeboom 200646

Relaxation Systematic 

literature review 

Pain intensity Pain distress Pain relief 

15 RCTs published 1996–2005 Acute and chronic noncancer pain 

Relaxation, 5 types PMR Autogenic Systematic Jaw relaxation Rhythmic breathing 

8/15 studies had intensity. 8/13 had positive Pain relief improvrelaxation used mstudies showed nRelaxation reduceInsufficient evidenapplication of rela

McRee 200361 Massage Randomized 

controlled trial 

Anxiety Heart rate (HR) Blood pressure (B/P) Cortisol Prolactin Analgesic use 

Hospital in United States N = 52 surgical patients 

Swedish massage Music (1 selection) Massage + music 30 minutes for each group delivered presurgery Control: usual care 

No difference amanxiety, prolactinvariables, or analSignificant decline post surgery for aNone of the intervbeneficial effect oafter surgery. 

Pellino 200542 Nondrug tool kits Randomized 

controlled trial 

Pain intensity Interference Anxiety Control over pain Opioid use 

Hospital in United States N = 65 Elective orthopedic patients (total hip or knee) 

Tool kit included Tape player Soothing music Relaxation tape 9 PMR) Massager (hand held, nonelectric) Stress ball Control: usual care 

Patients receiving nondrug therapiepatients also repotechniques spontNo difference betintensity, interferePatients with tool opioid on day 2 b
27

Source 

Safety Issue Related to Clinical Practice Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Richards 200058 Massage Systematic literature 

review 

Relaxation Comfort Sleep 

22 studies Published 1980–1999 

Massage Consistent finding 

anxiety and/or tenMassage produce(7/10 studies). Massage has imm(3/3 studies; cancInconclusive findion sleep related tproblems. 

Roykulcharoen 200447

Relaxation Randomized 

controlled trial 

Pain intensity Pain distress Anxiety Opioid use 

Hospital in Thailand N = 102 adults; abdominal surgery 

Systematic relaxation for 15 minutes after 1st

ambulation via audiotape Control: 15 minutes quiet rest 

Relaxation signifiintensity and distrNo difference in a

Kshettry 200667 Nondrug tool kits Randomized controlled trial Pain intensity Tension 

Heart rate (HR) Blood pressure (B/P) Complications 

Hospital in United States N = 104 CV surgery in ICU 

Combination of preop Guided imagery relaxation + gentle touch or light massage and postop music + gentle touch or light massage Control: usual care 

Pain intensity and for tool kit patientpostsurgery. No differences novariables betweeNo difference in cThese nondrug teeasy to use in an 
28

Source 

Safety Issue Related to Clinical Practice Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Seers 199844 Relaxation Systematic 

literature review 

Pain intensity Pain distress Anxiety Analgesic consumption 

7 RCTs 352 patients, 150 received relaxation training 33 studies did not meet inclusion criteria Surgical and procedural pain 

Relaxation 3/7 studies showe

intensity and/or d4/7 showed no sigNo adverse effecWeak support for control. 

Sendelbach 200653

Music Randomized 

controlled trial 

Pain intensity Anxiety Heart rate (HR) Blood pressure (B/P) Opioid use 

3 hospitals in United States N = 86 undergoing CV surgery 

20 minutes of music twice/day for 3 days postsurgery Patient selected 1/3 choices Control: 20 minutes of rest twice/day 

Significant reductanxiety pre-post texposed to musicNo difference in pbetween groups. No difference in oBecause of missifor PO day 1 AM only. 

Smith 200266 Heat/cold Randomized 

controlled trial 

Pain Swelling Flexion Opioid use Blood loss Transfusion Length of stay 

N = 84 Total knee replacement 

Cold therapy via cryo-pad technology vs Compression bandage applied by surgeon 

No difference in otreatment. Cost analysis indbandage less costerms of nursing t

Taylor 200362 Massage Randomized 

controlled trial 

Pain intensity Pain affect Anxiety Distress Analgesic use Systolic B/P Cortisol (24 hr urine) Complications Length of stay (LOS) 

Teaching hospital in the United States  N = 105 abdominal surgery for suspected gynecological cancer 

45 minutes Swedish massage for 3 days postsurgery 20 minutes vibration for 3 days+ PRN postsurgery Control: usual care 

Multivariate analydifferences amonaffect, anxiety, or No differences fooutcomes (analgecomplications, LOSome benefit for over usual care wanalyses, but diffemay not be clinica
29

Source 

Safety Issue Related to Clinical Practice Design Type 

Study Design & Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Voss 200452 Music Randomized 

controlled trial 

Pain intensity Pain distress Anxiety 

Hospital in United States N = 61 CV surgery patients 

Patient selected music (6 types) Scheduled rest Control: usual care 30 minutes during chair rest 

Significant reductdistress, and anxmusic and rest grPost hoc test indimusic reported siintensity, distressor control patientsMusic reduced oupercent after 30 mcompared to cont

Wong 200456 Massage Pretest, posttest Pain intensity Distress 

Heart rate (HR) Resp rate (RR) Blood pressure (B/P) 

Teaching hospital in United States Postsurgical patients 

20 minute foot and hand massage No control 

Significant decreadistress pre-post Significant decreadifferences small important. No difference in B