Pain and comfort

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1.        Read chapter 27 in your text: “Pain and comfort,” provide a summary of what  has been written regarding pain in the older adult population.

2.       Identify factors that affect the pain experience in older adults. 

3.       Identify barriers that interfere with pain assessment treatment.

4.       Address the key components of a nursing assessment and data to include in a pain assessment.

5.       Discuss pharmacological and nonpharmacological pain management therapies.

6.       Discuss how the gerontological nurse can develop a care plain to care for an older adult with pain. 

How can the geriatric nurse help to advocate and improve the care of older adults as it relates to pain management including nursing interventions or 

teaching and education using evidence-based research.

F.       Minimum of 5-6 references are required for this assignment. Example of an article on this topic:

Chapter 27

Pain and Comfort

Copyright © 2020 by Elsevier, Inc. All rights reserved.


Pain and Comfort

Copyright © 2020 by Elsevier, Inc. All rights reserved.

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described as such”

Nociceptive pain

Neuropathic pain (Box 27-1)

All pain is multidimensional with sensory, psychosocial, emotional, personal, and spiritual components

Pain is categorized as either acute, or chronic and persistent


Nociceptive comes from actual injury to organs—arthritis, ulcers, heart attack, etc and is often described differently from

Neuropathic pain that arises from damage/changes to peripheral nerves and is often described as burning, itching


Pain and Comfort

As one ages, acute pain occurs most often superimposed on the persistent pain of preexisting chronic pain

The most common type of pain in late life is persistent

Persons with persistent pain are more likely to be depressed and to have sleep disorders, but not all who are depressed have physical pain

Inadequately treated persistent physical pain will almost always lead to impaired functional status and in some cases cognitive impairments (Box 27-3)

Copyright © 2020 by Elsevier, Inc. All rights reserved.


And this can lead to decreased quality of life and downhill trajectory!


Pain in the Older Adult

More men than women report pain

Barriers to pain management in the older adult (Box 27-4)

Potential impact of persistent pain (Box 27-5)

With aging there is a decrease in density of both myelinated and unmyelinated nerve fibers very slightly delaying sensation of pain from the periphery and there is slower resolution once triggered


Copyright © 2020 by Elsevier, Inc. All rights reserved.

We discussed these in Pharm—barriers can come from everyone involved in the interaction and we as nurses need to be aware of them and

Address them so patients have appropriate pain management!

Consider what it means to have chronic pain

Can’t sleep—exhausted during the day, further limiting my independence

Don’t enjoy activities because of the painlose healthy activities and interaction with others

Consider how the person will evaluate chronic pain management—it is best to look for goals that are important to the patient, instead of just a number

”I consider my pain managed when I can play with my grandchildren”

”It is important to me to be able to play a round of golf with my old squadron mates”

Etc—what does the pain mean to the patient?



Pain in Older Adults With Cognitive Impairments

Persons with cognitive impairments are consistently untreated or undertreated for pain

Older adults who are cognitively impaired receive less pain medication, even when they experience the same acutely painful events

Providing comfort requires careful observation of behavior and attention to caregiver reports and knowing when subtle changes have occurred

Pain cues in persons with communication difficulties (Box 27-6)

Copyright © 2020 by Elsevier, Inc. All rights reserved.


Look for

Changes in behavior

ADL’s—is there a change?


Physical changes


Promoting Healthy Aging: Implications for Gerontological Nursing


Copyright © 2020 by Elsevier, Inc. All rights reserved.


Pain management is that in which both pharmacological and nonpharmacological interventions work in harmony

The basic approach considers what has worked in the past and been effective without causing harm

Promoting Healthy Aging: Implications for Gerontological Nursing


A high-quality comprehensive instrument incorporates the most important aspects of assessment and includes person’s self-report, and both qualitative and quantitative measures of comfort

Pain diary


Assess for coexisting depression and anxiety

Copyright © 2020 by Elsevier, Inc. All rights reserved.


Pain Diary

Location of pain

What was happening/being done at time of pain

Medication taken

Any other treatment/intervention

Intensity of pain

Intensity of pain an hour after interventions









Iatrogenic pain—pain related to treatments or care—turning the cancer patient with mets to the bone—adapt and individualize the care of every patient


Promoting Healthy Aging: Implications for Gerontological Nursing


Rating the intensity of pain

A key element of assessment is the intensity of pain perceived by the person; it is always what the person says it is

Rating scales have become the standard of care

Scales that are currently available and tested may not be reliable for persons with delirium or more severe impairments

Tools for comprehensive review of pain (Box 27-9)

Copyright © 2020 by Elsevier, Inc. All rights reserved.

Box 27.8 lists additional factors they may impact pain assessment

How does the pain affect function?

Does the patient use alternative expressions of pain?

Social support

Pain history



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Numeric Rating Scale (NRS) and Faces Pain Scale—Revised (FPS-R)

Image of FACES pain scale with 5 faces: smiling, slightly smiling, neutral, slightly sad, very sad

Numeric pain scale of 0 (no pain) to 10 (worst pain) with 5 being (moderate pain)

For those who do not acknowledge or express pain for cultural reasons, these will not change that and will not work


Promoting Healthy Aging: Implications for Gerontological Nursing


Assessment of pain in cognitively impaired/nonverbal

Persons with impaired communication skills with noncommunicative patients (Box 27-10)

It is recommended that attempts are made to use standard assessment instruments first even when the person has advanced dementia

The Pain Assessment in Advanced Dementia (PAINAD) Scale developed for use for those who either cannot express or cannot reliably express pain (Table 27-1)

PACSLAC-2: behavioral assessment tool that may be helpful as an initial pain screen

Copyright © 2020 by Elsevier, Inc. All rights reserved.



Negative vocalization

Facial expression

Body language



Facial expression

Verbalizations and vocalizations

Body movement

Changes in interpersonal interactions

Changes in activity patterns or routines

Mental status changes


Promoting Healthy Aging: Implications for Gerontological Nursing

Copyright © 2020 by Elsevier, Inc. All rights reserved.

Interventions: Providing comfort

Clinical manifestations are complex with multiple potential sources and sites for pain and confounding variables such as chronic disease, frailty, and depression

Nonpharmacological measures


Transcutaneous electrical nerve stimulation

Acupuncture and acupressure

Relaxation, meditation, and guided imagery



Cognitive-behavioral therapy


These should be used in addition to pharmacological, especially for chronic pain

Generally take more time, but improve pain management


Promoting Healthy Aging: Implications for Gerontological Nursing

Pharmacological interventions

While treatment regimens vary, all are guided by the same underlying principles (Box 27-12)

To achieve the highest level of pain control, it is helpful to ease the “memory of pain,” especially when persistent pain is intense, meaning prevent pain, not simply relieve it

ATC dosing, at the appropriate dosage

PRN for break through pain

Current recommendations are to start with the lowest anticipated effective dose, monitor the response frequently, and increase the dose slowly to desired effect: “Start low, go slow, but go!”

Copyright © 2020 by Elsevier, Inc. All rights reserved.


ATC is around the clock instead of prn—this helps to maintain that therapeutic level of drug in the body to avoid loss of

Pain relief when doses are delayed by having to request them


Promoting Healthy Aging: Implications for Gerontological Nursing

Pharmacological interventions

Nonopioid analgesics


Nonsteroidal antiinflammatories

Opioid analgesics

Tramadol, morphine, fentanyl

Adjuvant drugs

Herbal preparations, antidepressants, and anticonvulsants

Copyright © 2020 by Elsevier, Inc. All rights reserved.


Acetaminophen—remember it can impact the liver, is metabolized by the liver, excessive doses can harm the liver

Max of 3,000 mg (3 g) per day in patients who are frail or have liver or kidney disease (max for all is 4g/24 hours)

Keep in mind the effect of alcohol on metabolism of acetaminophen, so that must be taken into consideration

Although it is considered safe when used with warfarin, as it does not increase the risk of bleeding, it can affect warfarin levels, so

Monitoring of the PT/INR is essential

NSAID’s are ideal for inflammatory disorders, BUT have a high adverse effect profile

Of course most people are aware of its effect on the GI tract (blocking the positive protective effects of prostaglandins in the stomach),

So the patient must be aware of the risk of GI bleeding with chronic use

These drugs also impact the creation of prostaglandins body wide and the concern is the effect on the vasculature in the kidney—

Prostaglandins cause vasodilation-blocking prostaglandins will cause vasoconstriction decreased blood flow to the kidney

Can result in acute kidney injury, increased blood pressure, as RAAS is stimulated with decreased perfusion of the kidney

Worsening of hypertension!!!

NSAID’s OTC are ibuprofen and naproxen


Celecoxib (COX-2 selective, so block pain causing prostaglandins, so less effect on stomach)

Give NSAID’s with misoprostol or PPI’s to decrease effect on stomach

Patches and creams are being produced in a variety of formulations that reduce systemic effects

Opioids—increase risk of falls and can produce increased adverse effects based on concurrent chronic diseases like COPD

Start low and slow, but treat pain

NO MEPERIDINE IN OLDER ADULTS (it is now used rarely in any patient, as there are safer opioids—chronic use increases risk of seizures)

Neuropathic pain often responds poorly to opioids, and better to antidepressants (SNRI’s, TCA’s) and antiseizure meds

Some use is limited to the anticholinergic side effects, especially with TCA’s, so make sure you know what is meant by anticholinergic side effects!

Cannabis has been shown to have a positive effect for some


Promoting Healthy Aging: Implications for Gerontological Nursing


Pain clinics

Provide a specialized, often comprehensive and multidisciplinary approach to the management of pain that has not responded to the usual, more standard approaches

Three types:




Copyright © 2020 by Elsevier, Inc. All rights reserved.


Promoting Healthy Aging: Implications for Gerontological Nursing

Evaluation of effectiveness

Effectiveness of any intervention designed to relieve pain is quantitatively measured with repeated use of the intensity scale; qualitative observations are supplements to this

The nurse advocates for the person so that adjustments of treatment regimens and interventions are based on reassessment findings

“Start low, go slow, but go!”


Copyright © 2020 by Elsevier, Inc. All rights reserved.

Question 1

Which is an effective pain assessment tool?

Pain diary

FACES Pain Scale

Numeric Pain Scale

All of the above

Copyright © 2020 by Elsevier, Inc. All rights reserved.




Question 2

Pain is:

whatever the client says it is

what the family says it is

what the nurse observes

what the health care provider observes

Copyright © 2020 by Elsevier, Inc. All rights reserved.




Running Head Title of the Paper

Title of the Paper in Full

Student Name

Program Name or Degree Name (e.g., Bachelor of Science in Psychology), Stratford University

COURSE XXX: Title of Course

Instructor: Dr. Keshia Thompson

Month XX, 202X

Title of the Paper in Full

APA format and college-level writing can be difficult for many students returning to school after several years away from academia. The references page shows some sample references for sources such as webpages, books, journal articles, and course videos. Below follows some advice for writing your paper and adhering to APA standards.

Each Section should have a heading. Your
introductory paragraph
and every paragraph that follows should have a minimum of 5-6 sentences, and no more than seven sentences. The last sentence of your opening paragraph should be the

thesis statement

, which summarizes the purpose of the assignment and how you intend to address it. The sentences preceding your thesis statement should simply provide background that contextualizes your thesis for readers. This can include statistics on the issue and how the issue impacts patients, nursing, and healthcare.

Each paragraph should begin with a
topic sentence
, which summarizes the paragraph’s main argument or idea. Also, the last sentence (or lead-out) of each paragraph should be a transition statement that connects what you discussed in that paragraph and what is to come in the next one. In the middle of each paragraph, you should cover something with your own thoughts, and in a separate sentence, provide a sentence paraphrased from a source with an in-text citation at the end. The source may back up your opinion, or give an alternative viewpoint, or even simply provide some background. See the Writing Center’s
webpage on paragraphs
for further advice.

Try to use
instead of
direct quotations
when possible, only quoting when the meaning of the idea or excerpt would be lost if you paraphrase it. All information from sources, whether paraphrased or quoted, need to be cited.
should be in parenthetical or narrative citation format and include the last name(s) of the author(s) or name of the organization that published the material, year of publication, and a page or paragraph number for quoted material. Each source cited in your paper, unless it is a
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, should include a corresponding
reference list
entry. If no date is given for a source, write “n.d.” in place of the year (it stands for “no date”). This sentence does not come from a source, but I will end it with an in-text citation so you can see an example (Author, n.d.). If you have more than two sentences of information from one source, ensure that it is clear to the reader where the information in each sentence is from, using citations or other cue phrases (e.g. The authors also stated…). For more information and examples, see APA 7, Section 8.

Many websites that information comes from are suspect in terms of factual and unbiased information. In a nutshell, avoid using Wikipedia,,, or similar websites, as the Writing Center explains in the
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The body of your paper should have a couple of paragraphs or more. Your
conclusion paragraph
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Make sure you follow directions, and we recommend you download the grading rubric from Doc Sharing that breaks down how an assignment is graded. A one-page essay means a full one page of writing and does not include elements such as references, tables or figures, or the title page. The requirement of using 5 sources in your assignment directions does not mean simply providing two in-text citations for the same source; the sources themselves must be different. Lastly, if you have any questions about writing a paper or properly citing sources, feel free to contact the Writing Center.


(Note that the following references are intended as examples only. These entries illustrate different types of references but are not cited in the text of this template. In your paper, be sure every reference entry matches a citation, and every citation refers to an item in the reference list.)

American Counseling Association. (n.d.). About us.

Anderson, M. (2018). Getting consistent with consequences. Educational Leadership, 76(1), 26-33.

Bach, D., & Blake, D. J. (2016). Frame or get framed: The critical role of issue framing in nonmarket management. California Management Review, 58(3), 66-87.

Burgess, R. (2019). Rethinking global health: Frameworks of Power. Routledge.​

Herbst-Damm, K. L., & Kulik, J. A. (2005). Volunteer support, marital status, and the survival times of terminally ill patients. Health Psychology, 24(2), 225–229.

Johnson, P. (2003). Art: A new history. HarperCollins.

Lindley, L. C., & Slayter, E. M. (2018). Prior trauma exposure and serious illness at end of life: A national study of children in the U.S. foster care system from 2005 to 2015. Journal of Pain and Symptom Management, 56(3), 309–317.

Osman, M. A. (2016, December 15). 5 do’s and don’ts for staying motivated. Mayo Clinic.

Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: Theory and practice (7th ed.). Wiley.

Walden University Library. (n.d.). Anatomy of a research article [Video].

Walden University Writing Center. (n.d.). Writing literature reviews in your graduate coursework [Webinar].

World Health Organization. (2018, March). Questions and answers on immunization and vaccine safety.

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