How nurses assess pain and relieve it with comfort measures beyond medication
NCLEX-RN topic: Nonpharmacological comfort / palliative
- Pain is whatever the client says it is.
- Use PAINAD for advanced dementia; FLACC for ages 2 months to 7 years.
- Chronic pain usually leaves vital signs unchanged.
- Heat 5 to 20 minutes, cold up to 20, massage about 3 to 5.
- Reassess within 1 hour after any pain intervention.
Key facts
- A client's report of pain is respected, and being unable to speak does not mean a client has no pain.
- With the FACES scale the client picks the face; FLACC is for ages 2 months to 7 years or people who cannot speak; PAINAD is for advanced dementia; each scores 0 to 10.
- Acute pain often raises pulse, respirations and blood pressure, while chronic pain (longer than 6 months) usually does not change vital signs.
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- When pain is above the client's comfort-function goal, the nurse intervenes and follows up within 1 hour.
- Heat is applied for 5 to 20 minutes and cold for no longer than 20 minutes, never over medication patches or implanted devices.
- Massage lasts about 3 to 5 minutes and is never given over red or swollen areas or pressure points.
- To protect sleep, bundle care so the client gets uninterrupted sleep cycles of at least 90 minutes.
Quick check1 question · 2 more at the end
The nurse needs to assess pain in a client with advanced dementia who can no longer communicate verbally. Which tool is most appropriate?
Correct answer: A.
The Pain Assessment in Advanced Dementia (PAINAD) scale scores breathing, negative vocalization, facial expression, body language and consolability from 0 to 2 each, for a total of 0 to 10. It is designed for noncommunicative clients with advanced dementia. Self-report tools such as the 0–10 numeric scale and the FACES scale need the client to choose a rating.
A Correct: PAINAD is a valid, reliable tool for noncommunicative clients with advanced dementia.
B The numeric scale depends on the client's self-report, which this client cannot give.
C With the FACES scale, the client chooses the face; the nurse does not pick one based on appearance.
D The COMFORT Behavioral Scale is validated for children receiving mechanical ventilation.
Full lesson
Each part starts with its main idea. Open a part when you want the details.
The short answer: Pain is whatever the client says it is. Screen with a 0–10 scale, assess fully with PQRSTU or OLDCARTS, and use a behavioral scale such as PAINAD or FLACC when the client cannot self-report. Combine medication with positioning, heat or cold, massage, relaxation and distraction, and reassess within 1 hour against the client's comfort-function goal.
1 How do you assess pain when the client can and cannot tell you?Start from the rule that pain is whatever the client says it is. 1 min
Start from the rule that pain is whatever the client says it is. A 0–10 rating is only a screen. A full assessment uses a structured tool such as PQRSTU (provocation/palliation, quality, region, severity, timing/treatment, understanding) or OLDCARTS.
Also watch for nonverbal signs such as grimacing, moaning, restlessness, and rubbing or guarding a body part. Some clients are at higher risk of undertreated pain:
- Older adults, whose pain may show up as confusion or agitation
- Clients who are nonverbal, cognitively impaired or unconscious
- Clients who stay stoic for cultural or religious reasons, or who do not speak English
Acute pain often raises pulse, respirations and blood pressure and can cause sweating. Chronic pain lasts longer than 6 months and usually leaves vital signs unchanged, so normal vital signs never disprove it.
2 Which pain scale fits which client?Choose the scale that matches the client's age and ability to communicate. 1 min
Choose the scale that matches the client's age and ability to communicate.
| Scale | Best for | How it works |
|---|---|---|
| 0–10 numeric | Adults who can rate pain | Client picks a number |
| FACES | Children and others who cannot use numbers | Client picks the face; the nurse does not choose for them |
| FLACC | Ages 2 months to 7 years, or people who cannot speak | Face, legs, activity, cry, consolability, each 0–2 |
| PAINAD | Advanced dementia | Breathing, vocalization, face, body language, consolability, each 0–2 |
| COMFORT Behavioral | Children on mechanical ventilation | Eight indicators scored 1–5 |
Set a comfort-function goal with the client, which is the pain level that lets them do recovery activities such as walking. If pain is above the goal, intervene and follow up within 1 hour.
3 Which comfort measures work, and what are their safety limits?Nonpharmacological measures can be used alone or with medication, and they are documented and evaluated like any other intervention. 1 min
Nonpharmacological measures can be used alone or with medication, and they are documented and evaluated like any other intervention.
| Measure | Examples | Safety limits |
|---|---|---|
| Relaxation and distraction | Rhythmic breathing, guided imagery, music, games, photos | Let the client choose |
| Positioning | Pillows between joints and bony areas; avoid sudden movement | Reposition immobile clients at least every 2 hours |
| Cold | Ice pack, cool compress | No longer than 20 minutes; thin barrier on the skin |
| Heat | Heating pad, warm compress | 5 to 20 minutes; thin barrier on the skin |
| Massage | Back rub | About 3 to 5 minutes; never over red or swollen areas or pressure points |
| Other | TENS unit, acupressure, aromatherapy | Per the plan of care |
Never put heat or cold over a medication patch or an implanted device. If the client cannot communicate, lift the pack and check the skin every 5 minutes.
4 How do comfort measures support palliative care and sleep?In palliative care, comfort measures follow the client's own goals for quality of life. 1 min
In palliative care, comfort measures follow the client's own goals for quality of life. For breathlessness, use a fan, raise the head of the bed, and teach pursed-lip breathing and relaxation. For nausea, serve food and fluids at room temperature, avoid strong odors and high-bulk meals, and consider peppermint aromatherapy.
Pain and sleep affect each other, because pain wakes clients and lack of sleep heightens pain sensitivity. Promote sleep by:
- Bundling care so the client gets sleep cycles of at least 90 minutes
- Keeping the client's usual bedtime routine and limiting screens before bed
- Reducing light and noise, and offering ear plugs or an eye mask
5 What the nurse doesThe nurse assesses with the right tool, offers measures the client prefers, and checks whether they worked. 1 min
The nurse assesses with the right tool, offers measures the client prefers, and checks whether they worked.
- Assess pain with a self-report tool or, if the client cannot report, a behavioral scale.
- Plan with the client: set a comfort-function goal and choose medication plus comfort measures.
- Act safely within time limits for heat, cold and massage, and give comfort measures before painful activities.
- Reassess within 1 hour, and notify the provider if pain stays above the goal.
- Teach clients to tell the provider about any supplements, because some interact with medications.
Common mistakes
The traps students fall into most. Read these before you practice.
Watch out: Use PAINAD for a client with advanced dementia, not the FACES scale, which needs the client to choose a face.
Watch out: Normal vital signs do not disprove chronic pain.
Watch out: Reassess within 1 hour of an intervention, not at the next routine vital signs.
Watch out: Put a thin towel between the skin and an ice or heat pack, not the pack directly on the skin.
Watch out: For nausea in palliative care, serve food at room temperature and avoid strong odors, not large, high-bulk meals.
How to remember it
Think "ask, scale, soothe, recheck in an hour" for every client in pain.
Self-check:
- Name the pain scale for a client with advanced dementia and one for a 3-year-old.
- State the time limits for heat, cold and massage.
- Explain why a client with chronic pain may have normal vital signs.