Decoding Pain: Advocating for Your Patients

By Nadine Salmon, BSN, IBCLC, Clinical Content Specialist AMN Healthcare

Pain is a subjective experience, and there are no objective tests to accurately measure it (American Pain Society, 2009). Thus, the presence of pain is whatever the patient says it is. But what about patients who cannot articulate their perception of pain? As advocates, nurses can find creative ways to identify more subtle, non-verbal indicators of pain.

According to a Position Paper by Herr et al., (2001), there are five populations of patients who may be unable to self-report:  Older adults with advanced dementia, infants and preverbal toddlers, critically ill/unconscious patients, persons with intellectual disabilities and patients at the end of life. Each of these populations may be unable to self-report pain owing to cognitive, developmental or physiologic issues, including medically-induced conditions, creating a major barrier for adequate pain assessment and achieving optimal pain control (Herr et al., 2001).

The American Society for Pain Management Nursing maintains that all persons with pain deserve prompt recognition and treatment. Pain should be routinely assessed, reassessed and documented, in order to safely implement pain-relieving measures. No single objective assessment strategy, such as interpretation of behaviors, pathology or estimates of pain by others, is sufficient by itself (Herr et al., 2001).

The American Pain Society (2009) recommends the following guidelines for assessing and managing pain:

• Establish a procedure for assessing pain. An appropriate pain assessment scale should be used to assess pain intensity thoroughly, and on a regular basis. In addition, a behavioral assessment tool can be used in patients unable to articulate pain. This tool can identify non-verbal behavior consistent with discomfort or pain. Remember that physiological indicators such as blood pressure, respiratory rate and rhythm are not sufficient or accurate indicators of pain and should not be viewed independently of other presenting factors. A thorough assessment of each body system can also reveal possible causes of pain, and action should be initiated to resolve the possibility of pain, such as hidden infection or early development of pressure sores.

• Closely observe your patient for facial grimacing and other behavioral indicators of discomfort. Grimacing, frowning and wincing are often seen in critically ill patients experiencing pain (Puntillo et al, 2011). Yet, in comatose or brain injured patients, facial grimacing may be absent in the presence of pain.

• Regularly and thoroughly reassess pain to rapidly identify changes in pain status.

In advocating pain relief, nurses have an ethical and moral duty to remain knowledgeable about pain assessment. RN.com offers two pain management courses. Pain Control & Symptom Management is a one contact hour CE course for nurses. The course includes an introduction to pain control and symptom management, misconceptions about pain,  pharmacological and non-pharmacological strategies. Acute & Chronic Pain: Assessment and Measurement is a four contact hour CE course outlining current assessment and management techniques. It includes valuable information including addiction issues, types of pain and myths about pain management.  


American Pain Society. (2009). Principles of analgesic use in the treatment of acute pain and cancer pain. (6th ed.). Glenview, Il: American Pain Society.

Herr, K., Coyne, P., McCaffery, M., Manwarren, R. & Merkel, S. (2001). Pain Assessment in the patient unable to self-report: Position Statement. Pain Management Nursing, 12 (4), p. 230-250.

Puntillo, K., Morris, B. & Thompson, C., et al. (2011). Patients’ perceptions and responses to procedural pain: Results from Thunder Project II. American Journal of Critical Care, 10 (4), p. 238-251.

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