Core Principles of Pain Assessment and Management • Patients have the right to appropriate assessment and management of pain (JCAHO Standard RI 1.2.8, 2000). Pain (should be) is assessed in all patients (JCAHO Standard PE1.4, 2000). • Pain is always subjective.1 Therefore, the patient’s selfreport of pain is the single most reliable indicator of pain.5 A clinician needs to accept and respect this self-report, absent clear reasons for doubt. • Physiological and behavioral (objective) signs of pain (e.g., tachycardia, grimacing) are neither sensitive nor specific for pain.5 Such observations should not replace patient self-report unless the patient is unable to communicate.5 • Assessment approaches, including tools, must be appropriate for the patient population. Special considerations are needed for patients with difficulty communicating. Family members should be included in the assessment process, when possible. • Pain can exist even when no physical cause can be found. Thus, pain without an identifiable cause should not be routinely attributed to psychological causes. • Different patients experience different levels of pain in response to comparable stimuli. That is, a uniform pain threshold does not exist. • Pain tolerance varies among and within individuals depending on factors including heredity, energy level, coping skills, and prior experiences with pain. • Patients with chronic pain may be more sensitive to pain and other stimuli. • Unrelieved pain has adverse physical and psychological consequences. Therefore, clinicians should encourage the reporting of pain by patients who are reluctant to discuss pain, deny pain when it is likely present, or fail to follow through on prescribed treatments (JCAHO standard PE1.4, 2000). • Pain is an unpleasant sensory and emotional experience, so assessment should address physical and psychological aspects of pain. Sources: Gallup survey conducted by the Gallup Organization from May 21 to June 9, 1999. Supported by the Arthritis Foundation and Merck & Company, Inc.. American Pain Foundation. Facts about pain. Available at: http://www.painfoundation.org/page_fastfacts.asp. Accessed September 2001. 5. Brookoff D. Chronic pain: 1. A new disease? Hospital Practice. Available at: www.hosppract.com/issues/2000/07/brook.htm. Accessed June 2001. 6. Teoh N, Stjernsward J. WHO cancer pain relief program: ten years on. IASP Newsletter, 1992. 7. Brookoff D. Chronic pain: 2. The case for opioids. Hospital Practice. Available at: www.hosppract.com/issues/2000/09/brook.htm. Accessed June 2001.   Endocrine/metabolic  Altered release of multiple hormones (e.g., Weight loss ACTH (adrenocorticotrophic hormone) (cortisol, catecholamines, insulin) with Fever associated metabolic disturbances, Increased respiratory and heart rate,Shock Cardiovascular  Increased heart rate, Unstable angina (chest pain) Increased vascular resistance, Myocardial infarction (heart attack) Increased blood pressure, Deep vein thrombosis (blood clot) Increased myocardial oxygen demand Hypercoagulation Respiratory  Decreased air flow due to involuntary Atelectasis (reflex muscle spasm) and voluntary Pneumonia (“splinting”) mechanisms that limit respiratory effort Gastrointestinal  Decreased rate of gastric emptying, Delayed gastric emptying, constipation, Decreased intestinal motility anorexia, ileus Musculoskeletal Muscle spasm, Immobility Impaired muscle mobility and function, Weakness Fatigue Immune Impaired immune function, Infection Genitourinary Abnormal release of hormones that affect urine output Decreased urine output, fluid volume, and electrolyte balance Hypertension (fluid retention) Electrolyte disturbances 2009 Pain Management Directory