Pain Assessment: The Fifth Vital Sign Health Assessment Across the Lifespan NRS 102

Structure and Function Neuroanatomic pathway Nociception Neuropathic pain Sources of pain Types of pain

Neuroanatomic Pathway Nociceptors Interneurons Anterolateral spinothalamic tract

Neuroanatomic Pathway (cont.)

Nociception Transduction Transmission Perception Modulation

Nociception (cont.)

Neuropathic Pain Abnormal processing of pain message Most difficult type of pain to assess and treat Neurochemical level

Sources of Pain Visceral pain Deep somatic pain Cutaneous pain Referred pain Visceral pain originates from larger interior organs. The pain can stem from direct injury or stretching. Examples include ureteral colic, acute appendicitis, ulcer pain, and cholecystitis. It is transmitted by ascending nerve fibers along with nerve fibers of the autonomic nervous system, hence presentation is with autonomic responses (vomiting, nausea, pallor, and diaphoresis). Deep somatic pain comes from blood vessels, joints, tendons, muscles, and bone. Injury may result from pressure, trauma, or ischemia. Cutaneous pain is derived from skin surface and subcutaneous tissues. The injury is superficial, with a sharp, burning sensation. Referred pain is felt at a particular site but originates from another location. Both sites are innervated by the same spinal nerve, and it is difficult for the brain to differentiate the point of origin.

Common Sites for Referred Pain © Pat Thomas, 2006.

Types of Pain Acute pain Chronic pain Short term Self-limiting Follows a predictable trajectory Dissipates after injury heals Chronic pain Continues for 6 months or longer Types are malignant (cancer related) and nonmalignant Does not stop when injury heals

Subjective Data—Health History Pain assessment questions Pain assessment tools

Pain Assessment Questions Questions to ask: Where is your pain? When did your pain start? What does your pain feel like? How much pain do you have now? What makes the pain better or worse? How does pain limit your function/activities? How do you behave when you are in pain? How would others know you are in pain? What does pain mean to you? Why do you think you are having pain? Note to faculty: Because of the amount of text used on this screen, each bullet point is set to appear on a mouse click. This will prevent your students from reading ahead and being distracted.

Pain Assessment Tools Initial pain assessment Brief pain inventory Pain rating scales Numeric rating scales Descriptor scale

Initial Pain Assessment From McCaffery M, Pasero C: Pain: Clinical manual, ed 2, St. Louis, 1999, Mosby.

Brief Pain Inventory From McCaffery M, Pasero C: Pain: Clinical manual, ed 2, St. Louis, 1999, Mosby.

Objective Data—Physical Exam Joints—note Size/contour/circumference AROM/PROM Muscles/skin—inspect Color/swelling Masses/deformity Sensation changes

Objective Data—Physical Exam (cont.) Abdomen—inspect and palpate Contour/symmetry Guarding/organ size Pain behavior—inspect Nonverbal cues Acute pain behavior Chronic pain behavior

Acute Pain Behaviors Guarding Grimacing Vocalizations such as moaning Agitation, restlessness Stillness Diaphoresis Change in vital signs Note to faculty: Because of the amount of text used on this screen, each bullet point is set to appear on a mouse click. This will prevent your students from reading ahead and being distracted.

Chronic Pain Behaviors Bracing Rubbing Diminished activity Sighing Change in appetite Being with other people Movement Exercise Prayer Sleeping Note to faculty: Because of the amount of text used on this screen, each bullet point is set to appear on a mouse click. This will prevent your students from reading ahead and being distracted.

Sample Charting

Abnormal Findings Reflexive sympathetic dystrophy Follows trauma to the nerve Most commonly appears in 40- to 60-year-old men and women

Which type of pain would cholecystitis (gallbladder disease) cause? Somatic Visceral Cutaneous Chronic Correct Answer: B. Visceral.

What anticipated finding regarding patients with chronic pain should guide a nurse’s care planning? Patients with chronic pain have trouble sleeping. Patients with chronic pain show elevated blood pressures. Patients with chronic pain need less medication. Patients with chronic pain may show few or no outward signs of pain. Correct Answer: D. Patients with chronic pain may show few or no outward signs of pain.