pain and comfort

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. 

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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

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

personal communication

, 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

“Why You Shouldn’t Wiki” blog post

. Though some .com sites are acceptable, most undergraduates have trouble identifying whether they can be trusted, so an easy guideline to follow is to avoid them. Websites ending in .gov, .net, .edu, .org, and so forth are typically more trustworthy than a .com source. See the Library’s

Evaluating Resources webpage

for more tips on finding reliable sources.

The body of your paper should have a couple of paragraphs or more. Your

conclusion paragraph

should briefly summarize the main points of your paper and place the paper in the context of social change. While your conclusion should not introduce new topics, you may suggest a direction for future research. Generally, you should not write anything in the conclusion that would require you to cite a source; instead, the conclusion should represent only your own thoughts and analysis.

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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