Pain – “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”- (International Association for the Study of Pain)

What is pain?

• A message to the brain, pain is a whole body experience involving the mind and the body
• A protective mechanism to warn us to be careful of our bodies
• Different for different people: “pain is whatever the experiencing person says it is and exists wherever he or she says it does” – Margo McCaffrey, MSN,RN, FAAN

Types of Pain:

• Acute pain is of short duration and can be important for the body to tell the brain that tissue damage has occurred or may occur, or to help prevent injury or disease. It gradually resolves as the injured tissues heal.
• Chronic pain is pain that extends beyond the expected period of healing. It needs regular assessment and a different approach to treatment.

Components of a Comprehensive Pain Assessment

General Treatment Goals

• Reduce pain
• Improve level of activity
• Improve strength, stability and flexibility
• Improve quality of life
• Promote self-care by educating patient to actively participate in their treatment
• The overall aims are to reduce an individual’s pain and increase their activity

Documentation Tips for Daily and Weekly Notes:

• Included updated scores for standardized tests & measures, including subjective pain ratings
• If new or worsening pain is identified, indicate the action taken and staff notified of the change
• When pain is noted, document the specifics (rating, location, type, frequency, features, etc.)
• Document skilled techniques utilized and patient response. If using physical agent modalities for pain reduction – record the subjective pain rating before and after treatment

Melissa Ward

Director of Clinical Services