• Patients who may have difficulty communicating their pain require particular attention. This includes patients who are cognitively impaired, psychotic, or severely emotionally disturbed; children; the elderly; patients who do not speak English; and patients whose level of education or cultural background differs significantly from that of the health-care team.

• Unexpected intense pain, particularly if sudden and associated with altered vital signs, such as hypotension, tachycardia, or fever, should be evaluated immediately, and new diagnosis such as wound dehiscence, infection, or deep vein thrombosis, should be considered.

• Family members should be involved when appropriate.

The preoperative preparation of the patient cannot be overemphasized. This will enhance the recovery period and prepare the patient in understanding their role and the clinician's role in managing their pain. Inform patients that it is easier to prevent pain than to chase it and reduce it after it has become established, and that communication of unrelieved pain is essential to its relief. Emphasize the importance of factual report of pain.

The following things should be considered in the preoperative preparation of the patient. It is important to discuss the patient's previous experiences with pain and beliefs about the preferences for pain assessment and management. Provide the patient information about pain management therapies that are available and the rationale underlying their use. Develop with the patient a plan for pain assessment and management, select a pain assessment tool and teach the patient to use it, and provide the patient with education and information about pain control, distraction, imagery, and massage.

Management of pain can be so varied that various types of pain assessment tools have been developed. It should be remembered that the most reliable indicator of the existence and intensity of pain and any resultant distress is the patient's self-report. Self-report measurement scales include numeric or adjective ratings and visual analogue scales (see Chapter 5). The tools should be reliable, valid, and easy for the patient and the nurse and physician to use. One may use these tools by showing a diagram to the patient to indicate the appropriate rating. One may also use tools by simply asking the patient for a verbal response: "on a scale of 0-10 with 0 being as no pain and 10 being as the worst pain possible, how would you rate your pain?" Tools must be appropriate for the patient's developmental, physical, emotional, and cognitive status.

Postoperatively the patient's perception along with behavioral and psychological response should be carefully assessed. Observations of behavior and vital signs should not be used instead of self-reporting, unless the patient is unable to communicate.

Pain should be assessed and reassessed frequently during the immediate postoperative period. The frequency of assessment should be based on the operation performed and the severity of the pain. Pain should be assessed every 2 h during the first postoperative day of the major surgery. If necessary, increase the frequency of assessment and reassessment if the pain is poorly controlled or if interventions are changing. Pain intensity and response to intervention should be recorded in an easily visible and accessible place, such as a bedside flow sheet. Observations of behavior and vital signs should not be used instead of self-reporting, unless the patient is unable to communicate.

Review with the patient before discharge the interventions used and their effectiveness and provide specific discharge instructions regarding pain and its management (Rothrock 2011).

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