19. CCA Study Notes: Pain Types, Assessment, Reactions, and Comfort Measures

The Big Picture

Pain is personal. One person might describe a feeling as aching, while another describes a similar feeling as burning. You cannot see, hear, touch, or smell another person’s pain, so you must believe a client who reports pain or discomfort.

Some clients do not tell you that they hurt. Their body language or behaviour might show discomfort instead. Watching, listening, and reporting what you notice are important parts of supporting a client in pain.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

Jump to:

Course Notes: Key Ideas You Need to Know

Pain Is Personal

Pain and discomfort are subjective. This means the experience belongs to the person feeling it. Different clients experience different levels and descriptions of pain.

A client might describe pain as sore, aching, burning, or another feeling. If a client says they have pain or discomfort, believe the client.

Pain may signal tissue damage. Pain also has physical, emotional, social, and spiritual effects. A client in pain might appear sad, impatient, irritable, or angry.

Support workers must treat clients in pain with kindness and empathy.

Body language also matters. A client who does not speak about pain, or who cannot communicate it clearly, might show discomfort through behaviour or movement. Report the client’s complaints and your observations to your supervisor.

Five Types of Pain

Type	What It Means
acute pain	Starts suddenly because of injury, disease, trauma, surgery, or tissue damage. It usually lasts less than 6 months and decreases as healing occurs.
chronic pain	Lasts longer than 6 months. It might stay constant or occur off and on. It is also called persistent pain.
radiating pain	Starts at the site of tissue damage and spreads into nearby areas.
referred pain	Is felt in a body area separate from the actual source of the pain.
phantom limb pain	Is felt in a body part that is no longer present. It results from disruption of nerve endings in the stump.

Arthritis and cancer are common causes of chronic or persistent pain.

Examples help separate radiating pain from referred pain. Heart attack pain often occurs on the left side of the chest and extends to the left jaw, shoulder, and arm, although women sometimes experience a different pattern. Gallbladder disease might produce pain in the right upper abdomen, back, and right shoulder.

Referred pain appears away from its source. A kidney stone, for example, might produce pain in the groin.

A person who has had a leg amputated might still feel pain in that missing leg. This is phantom limb pain.

Factors That Affect a Person’s Response to Pain

Pain does not affect every client in the same way. Several factors influence the way a person experiences or responds to it.

Past experience

Previous pain experiences affect current reactions. Important details include:

• how severe the previous pain was
• what caused it
• how long it lasted
• whether the person received relief

Knowing what to expect sometimes helps a person cope. A client without previous pain experience might feel more fearful because the experience is unfamiliar.

Anxiety

Pain and anxiety affect each other. Pain increases anxiety, and anxiety makes pain feel worse.

Reducing anxiety helps reduce pain. Knowing what to expect, including expected pain and planned pain relief, helps lower anxiety.

Rest and sleep

Rest and sleep restore energy and support body repair. Ill and injured clients need more sleep than usual.

Pain often feels worse when a client feels tired or restless.

Attention

Focusing on pain makes it seem worse. Severe pain sometimes becomes the person’s main focus.

Even mild pain feels worse when a person keeps thinking about it. Pain often seems worse at night when fewer distractions are present.

The meaning of pain

People give different meanings to pain. Some people view pain as:

• weakness
• a sign of serious illness
• something to ignore or deny
• a way to avoid certain people or situations
• a way to receive attention

Support from others

Comfort and support from family and friends make pain easier to deal with. A friend or loved one’s presence provides comfort.

A person without supportive family or friends faces pain alone. This situation increases fear, anxiety, and suffering. Support workers should show extra sensitivity to clients who are suffering alone.

Culture

Culture affects pain responses. Some people show little outward reaction. Others show strong verbal or nonverbal responses.

A strong pain expression does not always mean greater pain. A quiet response does not always mean less pain.

Age

Age also affects pain reactions. Older persons have several specific concerns related to recognizing, reporting, and living with pain.

Signs and Symptoms of Pain

A client might tell you about pain. At other times, body responses or behaviour provide important clues.

Body responses

Pain often occurs with:

• increased pulse
• increased respirations
• increased blood pressure
• nausea
• pale skin, called pallor
• sweating, called diaphoresis
• vomiting

Behavioural signs

Watch for:

• speech becoming slow, rapid, loud, or quiet
• crying
• gasping
• grimacing
• groaning
• grunting
• holding the affected body part, called splinting
• irritability
• staying in one position or refusing to move
• moaning
• unusual quietness
• restlessness
• rubbing
• screaming
• rocking back and forth

A client’s behaviour matters even when the client denies pain. Report pain information and observations to your supervisor. Use the client’s exact words when reporting and recording what the client says.

Words Clients Use to Describe Pain

Clients use many different words for pain. Common descriptions include aching, burning, cramping, crushing, dull, gnawing, knifelike, piercing, pressing, sharp, sore, squeezing, stabbing, throbbing, and viselike.

Record the client’s description using the client’s exact words.

Using PQRSTU to Organize Pain Information

Nurses use pain-assessment tools to understand pain. For clients who communicate, nurses often organize pain assessment using PQRSTU.

Support workers should report and record pain using the same PQRSTU format. This helps communication with the nurse.

P: Provoking causes

This part looks at what was happening around the time the pain began.

Ask:

• What were you doing before the pain started?
• When did it start?

Provoking factors listed in the pain information include:

• moving or turning in bed
• coughing
• deep breathing
• exercise

Q: Quality of pain

This part helps describe the type and intensity of pain. Visual tools include pain scales, a colour visual analogue scale, and the Oucher pain scale.

Determine whether the client describes the pain as mild, moderate, or severe.

Pain often occurs with increases in:

• pulse
• respirations
• blood pressure

Other symptoms include dizziness, nausea, vomiting, weakness, numbness, and tingling.

R: Region and radiation

This part identifies where the pain begins and whether it spreads.

Ask the client to point to the painful area. Then ask whether pain occurs anywhere else and have the client point to those areas too.

S: Severity

This part looks at how uncomfortable the client feels.

Ask the client to describe the pain. Write the description using the client’s exact words.

T: Timing

This part identifies how long the pain has been present.

Ask:

• When did the pain start?
• How long has it lasted?

U: Understanding

This part looks at the client’s understanding of the pain.

Ask whether:

• the client has experienced this pain before
• the pain is increasing in intensity
• the client has an idea about what is causing it

When a Client Cannot Communicate Pain

Some clients have difficulty speaking or answering questions. Dementia is one example.

When a client cannot communicate pain directly, health care providers rely on careful observation and assessment to judge comfort. The Pain Assessment in Advanced Dementia Scale, or PAINAD, is one tool used by the health care team.

PAINAD: What the Tool Looks At

PAINAD uses five behaviour areas:

1. breathing
2. negative vocalization
3. facial expression
4. body language
5. consolability

Observe the patient for 5 minutes before scoring the behaviours.

Each behaviour receives a score of 0, 1, or 2.

Behaviour	0	1	2
Breathing	Normal	Occasional laboured breathing or a short period of hyperventilation	Noisy laboured breathing, a long period of hyperventilation, or Cheyne-Stokes respirations
Negative vocalization	None	Occasional moan or groan, or low-level negative speech	Repeated troubled calling out, loud moaning or groaning, or crying
Facial expression	Smiling or inexpressive	Sad, frightened, or frowning	Facial grimacing
Body language	Relaxed	Tense, distressed pacing, or fidgeting	Rigid, clenched fists, knees pulled up, pulling or pushing away, or striking out
Consolability	No need for consolation	Reassured or distracted by voice or touch	Unable to console, distract, or reassure

The total PAINAD score ranges from 0 to 10.

One possible interpretation is:

• 1 to 3: mild pain
• 4 to 6: moderate pain
• 7 to 10: severe pain

These ranges come from a standard 0-to-10 pain scale. The source information states that these ranges have not been substantiated in literature for PAINAD.

Breathing behaviours in PAINAD

Normal breathing is quiet, smooth, rhythmic, and effortless.

Occasional laboured breathing involves brief episodes of difficult or harsh breathing.

A short period of hyperventilation involves rapid, deep breathing for a short time.

Noisy, laboured breathing sounds difficult and takes effort. Sounds include loud, gurgling, or wheezing respirations.

A long period of hyperventilation involves an excessive rate and depth of breathing for a longer period.

Cheyne-Stokes respirations move between deep and shallow breathing and include periods when breathing stops.

Negative vocalizations in PAINAD

A score of zero reflects neutral or pleasant speech or vocalization.

Negative vocalizations include:

• occasional moaning or groaning
• muttering or mumbling
• whining
• grumbling
• swearing in a low, complaining tone
• repeated troubled calling out
• loud moaning or groaning
• crying

Facial expressions in PAINAD

The tool looks for:

• smiling or an inexpressive, relaxed face
• sadness
• fear
• frowning
• facial grimacing

Grimacing creates a distressed appearance, often with increased wrinkling around the brow and mouth.

Body language in PAINAD

Behaviour ranges from relaxed to increasingly distressed.

Possible observations include:

• tension
• distressed pacing
• fidgeting
• rigid posture
• clenched fists
• knees pulled toward the chest
• pulling or pushing away
• striking out

Consolability in PAINAD

The tool looks at whether the person needs comfort and how the person responds.

The person might:

• appear content and need no consolation
• become reassured or distracted through voice or touch
• remain unable to settle despite reassurance or comforting actions

Pain Reactions in Children

Some support workers work with children experiencing pain.

Children with little previous pain experience might struggle to understand:

• what pain means
• what to expect
• how to handle it
• how to explain it

Toddlers and preschool children might not know the words needed to describe pain. Crying or fussing in infants and toddlers also has causes other than pain, so caregivers watch for behaviours and situations associated with pain.

The Northern Pain Scale uses six faces ranging from a smiling, happy face to a very sad face. Children point to the face that best shows how much pain they are experiencing.

Pain Reactions in Older Persons

Older persons sometimes live with pain for years. Long-term pain affects how some people think about and report new pain.

Some older people:

• become used to chronic pain and stop reporting it
• believe pain is a normal part of aging
• believe chronic pain is untreatable
• mistake new pain for an existing health problem
• ignore or deny pain because they fear serious or advanced illness

Existing chronic pain sometimes masks a new type of pain.

Without pain relief, an older person might experience:

• decreased appetite
• changes in thought or mentation
• decreased mobility

These changes lead to further health challenges.

Some conditions, including dementia, affect pain perception. Some older people also have difficulty recognizing or reporting pain.

Pain alerts a person to illness or injury. A person who does not feel pain might not recognize a problem or seek health care.

For some clients with impaired thinking or verbal communication, a change in behaviour is the only sign of pain. Report any change in the client’s behaviour to your supervisor.

Culture and Pain

Culture influences how people understand, describe, express, and cope with pain.

Pain expression differs among and within cultures. Some people show pain openly. Others remain stoic, meaning they bear it quietly.

The amount of pain a person expresses does not necessarily match the intensity of the pain.

Cultural factors include:

• beliefs about what causes pain, such as fate, lifestyle, punishment, or witchcraft
• emotional responses to pain
• words used to describe pain, including hurt, ache, and discomfort
• personal and social meanings attached to pain
• previous pain experiences
• beliefs about the meaning and intensity of pain
• preferences for pain-coping strategies
• beliefs and expectations about pain expression
• goals related to pain management

Language also affects how a person describes or reports pain. Support workers need awareness that different people express pain in different ways.

Pain Relief and the Care Plan

Nurses and case managers use the care-planning process to promote comfort and relieve pain.

A physician orders medications used for pain relief. Some pain medications can cause:

• drowsiness
• dizziness
• lack of coordination

Clients receiving these medications must be protected from injury. Follow the care plan for safety practices.

Non-medication pain-control measures include:

• distraction
• relaxation
• guided imagery

Nurses and therapists teach these techniques. As a support worker, you may be trained to assist with some of these techniques.

Distraction

Distraction shifts the client’s attention away from pain.

Examples include:

• conversation
• music
• television
• games
• needlepoint

Relaxation

Relaxation means an absence of mental or physical stress. A relaxed state reduces pain and anxiety.

A nurse or therapist teaches the client to:

• breathe deeply and slowly
• contract and relax muscle groups

A comfortable position and quiet room help create a relaxed state.

Guided Imagery

Guided imagery involves forming a pleasant mental image and focusing attention on it.

The client thinks about a pleasant scene. A nurse uses a calm, soft voice to help the client focus on the image and guides relaxation exercises.

Helpful surroundings include:

• soft music
• a blanket for warmth
• a darkened room

Comfort Measures in the Care Plan

Several measures promote comfort and relieve pain.

Timing care after pain medication

Wait at least 30 minutes after pain medication is given before providing care.

Oral pain medication may take at least 1 hour to take effect.

Positioning and physical comfort

• Position the client in good body alignment.
• Use pillows for support.
• Keep bed linens tight and wrinkle-free.
• Make sure the client is not lying on drainage tubes.
• Assist with elimination needs.
• Provide blankets for warmth and prevent chilling.
• Use correct lifting, moving, and turning procedures.
• Give extra support to painful areas during movement. Use your hands or a pillow when appropriate.
• Give a back massage.
• Avoid sudden or jarring movements.
• Handle the client gently.

Comfort through the environment and other people

• Provide soft music as a distraction.
• Use touch to provide comfort.
• Allow family and friends to visit when the client requests it and the facility allows it.
• Provide a calm, quiet, darkened environment.

Heat and cold

Provide heat or cold applications as directed.

Safety With Strong Pain Medication or Sedatives

When a client receives strong pain medication or sedatives:

• Keep a hospital bed in its lowest position.
• Follow the care plan for bed rail use.
• Check on the client every 10 to 15 minutes.
• Assist the client when the client is up.

Common Mix-Ups

Wrong Idea	Better Idea
Acute and chronic pain differ only in intensity.	Acute pain usually lasts less than 6 months. Chronic pain lasts longer than 6 months.
Chronic pain is always constant.	Chronic pain is constant or occurs off and on.
Radiating pain and referred pain mean the same thing.	Radiating pain spreads from its source into nearby areas. Referred pain is felt away from its source.
A person who shows little reaction has little pain.	Pain expression does not necessarily match pain intensity.
A client who does not verbally report pain has no pain.	Body language and behaviour also indicate discomfort or pain.
Long-term pain means a new pain is unimportant.	Existing chronic pain sometimes masks a new type of pain.