1. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Pain Assessment DSN Kevin Dobi, MS, APRN

2.  Pain relief is primary responsibility of all health care providers.  Assessing patient’s pain is first step in achieving goal of pain relief.  Pain assessment and management often referred to as fifth vital sign.  Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.  One person cannot judge perception or meaning of pain of another person.  No correlation between amount of tissue damage and degree or intensity of pain. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.2

3.  Any cause of reduced perfusion interrupts oxygen supplied to tissues and can lead to impaired integrity.  Pain:  Reduces mobility.  Impairs sleep.  Contributes to loss of appetite.  Narcotics change elimination pattern.  Understanding of the interrelationship helps the nurse recognize risk factors. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.3

4.  Perception of pain is influenced by cognitive and cultural factors:  Patient’s previous experiences with pain and current physical and mental status affect pain perception and response.  Cognitive factors:  Attention people give to the pain.  Expectation or anticipation of pain.  Appraisal or expression of pain.  Cultural factors:  Cultural influences may affect how pain is communicated. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.4

5.  Pain is categorized in several ways, but clear distinctions among types may not be possible.  Acute pain has recent onset and results from tissue damage, is usually self-limiting, and ends when tissue heals.  May cause physiologic signs associated with pain.  Persistent (chronic) pain may be intermittent or continuous pain lasting more than 6 months.  Clinical manifestations of chronic pain are not those of physiologic stress because patient adapts to pain, but often reports symptoms of irritability, depression, withdrawal, or insomnia. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.5

6.  Nociceptive pain:  Arises from somatic structures such as bone, joint, or muscle.  Results from activation of normal neural systems.  Neuropathic pain:  Occurs because of abnormal processing of sensory input.  Referred pain:  Pain felt in a location away from the injury.  Often visceral pain, as many abdominal organs have no pain receptors.  Phantom pain:  Pain felt in an amputated extremity. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.6

7.  The Joint Commission standards assert that patients have a right to appropriate assessment and management of pain, including the following:  Pain is assessed in all patients.  Initial assessment and regular reassessment of pain, taking into account personal, cultural, spiritual, and ethnic beliefs.  Education of all relevant providers in pain assessment and management.  Education of patients and families regarding roles in managing pain and potential limitations and side effects of pain treatments. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.7

8.  Physiology of pain involves journey:  Transduction from site of stimulation of peripheral receptors to spinal cord.  Transmission up spinal cord.  Perception at cerebral cortex.  Modulation back down spinal cord. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.8

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10.  The pain process begins with response of nociceptors to noxious stimuli.  Nociceptors are primary sensory nerves located in:  Tendons  Muscles  Subcutaneous tissue  Epidermis  Skeletal muscles Copyright © 2013 by Mosby, an imprint of Elsevier Inc.10

11.  Sensory peripheral nerves are stimulated.  Sensory nerve fibers carry pain impulses: Large A-Delta fibers – associated with sharp, pricking, acute, well localized pain of short duration. Small C fibers – associated with dull, aching, throbbing, or burning sensations.  Initiate an action potential that travels along peripheral nerves to the dorsal horn of the spinal cord: Substantia Gelatinosa – “The gate” is opened. Pain impulses enter spinal cord and ascend through spinothalamic tract to thalamus. Pain is perceived. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.11

12.  Thalamus receives impulses from spinothalamic tract:  Impulses travel to parietal lobe in cerebral cortex and to limbic system.  When impulses reach parietal lobe, patient feels pain.  Although journey takes a fraction of a second, no pain is perceived until parietal lobe is stimulated.  Stimulation of limbic system generates emotional response to pain:  Crying  Anger Copyright © 2013 by Mosby, an imprint of Elsevier Inc.12

13.  Pain journey ends when body produces substances to reduce pain perception:  As sensory nerve fibers travel to brainstem, they stimulate nerves that inhibit nociceptor stimuli.  Descending fibers start in brainstem and travel down the dorsal horn of the spinal cord.  Release of substances that inhibit transmission of noxious stimuli and produce analgesia:  Endogenous opioids, e.g., endorphins and enkephalins  Serotonin (5HT)  Norepinephrine (NE)  Gamma-aminobutyric acid (GABA)  These substances occupy the receptors sites, which prevent A and C nerve fibers from opening “the gate.” Copyright © 2013 by Mosby, an imprint of Elsevier Inc.13

14.  Concepts of pain threshold and pain tolerance affect patient’s pain experience.  Pain threshold is point at which a stimulus is perceived as pain.  This threshold does not vary significantly among people or in same person over time.  Pain tolerance is duration or intensity of pain a person will endure before outwardly responding.  Pain tolerance decreases with repeated exposure to pain, fatigue, anger, boredom, and sleep deprivation.  Tolerance increases after alcohol consumption, medications, hypnosis, warmth, distracting activities, and strong faith-related beliefs. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.14

15.  Do you have any chronic illnesses? If so, do they cause you pain?  Describe  Do you take any medications?  What, and how often?  Do they relieve your pain?  Are you allergic to any medications?  What kind of allergic reaction occurs from these medications? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.15

16.  Pain is a complex, multidimensional, subjective experience  Collect data from patients using a symptom analysis applying the mnemonic OLD CARTS  O = Onset  L = Location  D = Duration  C = Characteristics  A = Aggravating factors  R = Related symptoms  T = Treatment by the patient  S = Severity Copyright © 2013 by Mosby, an imprint of Elsevier Inc.16

17.  Do you communicate your pain verbally or nonverbally?  Be aware of cultural influences of pain:  Overt pain expression  Stoicism  Silence  Smiling Copyright © 2013 by Mosby, an imprint of Elsevier Inc.17

18.  Location:  Where is your pain? Point to location(s).  Quality:  Describe what the pain feels like.  Quantity:  How would you describe intensity, strength, or severity of the pain on a scale of 0 to 10, with 0 being no pain and 10 being most intense pain possible?  At what point on this scale of 0 to 10 do you usually take medication for your pain? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.18

19.  Onset:  When does the pain occur?  During activity?  Before or after eating?  Does the pain occur suddenly or gradually?  What do you think is causing your pain?  Why do you think the pain started when it did? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.19

20.  Location:  Where do you feel pain?  Can you point to the location(s)?  Duration:  How long do you feel the pain?  Is it constant or intermittent?  How often does it occur?  How long does it last? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.20

21.  Can you describe what the pain feels like?  Aggravating factors:  What makes the pain worse?  Related symptoms:  What other symptoms do you have during pain?  Palpitations  Shortness of breath  Sweating  Rapid or irregular heartbeat  Nausea or vomiting Copyright © 2013 by Mosby, an imprint of Elsevier Inc.21

22.  Have you tried to relieve the pain?  How effective have these measures been?  What medications did you take, and in what amounts?  Have you considered alternative methods?  Massage  Mind-body medicine  Lifestyle changes  How much pain are you expecting?  Cultural beliefs may affect expectations. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.22

23.  How would you describe your pain?  On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain possible, describe:  Intensity  Strength  Severity  At which point on this 0 to 10 scale do you usually want to take your pain medicine? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.23

24.  How do you react to pain?  How do you express your pain?  What do you fear most about the pain?  What problems does your pain cause you?  Does your pain have any particular meaning to you?  Spiritual  Psychological  Do you have any concerns about taking pain relief?  Has the pain affected your quality of life? Copyright © 2013 by Mosby, an imprint of Elsevier Inc.24

25.  After taking the medication, how would rate your pain now?  30 minutes after parenteral administration.  60 minutes after oral administration.  Assessing those who cannot communicate:  Attempt self-report.  Search for potential causes of pain.  Observe for behavioral changes.  Question caregivers about patient’s usual response to pain.  Attempt analgesic trial and observe behavior. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.25

26.  Observe patient for posture and behavior that helps relieve pain.  Observe facial expressions.  Listen for sounds made by patient.  Inspect skin for color, temperature, moisture.  Measure blood pressure and pulse.  Assess respiratory rate and pattern.  Observe pupillary size and reaction to light. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.26

27.  Nurses find different responses to pain depending on age of patient.  Neonate responses to pain are global, evidenced by increased heart rate, hypertension, pallor, sweating, and decreased oxygenation saturation.  Young children have difficulty understanding pain but have a basic ability to describe pain and location.  School-age children better understand pain and are able to describe pain location. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.27

28.  Although transmission and perception of pain may have slowed down in older person, pain is felt no differently than by any other adult.  Many older adults have a lifetime of experience in coping with pain, but pain is not an expected part of aging. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.28

29. Initiation of intravenous access can be a painful experience for the patient. As the needle is inserted into skin, the patient is calm. However, when the needle pierces the vein, the patient pulls the hand away. The time that the person endured the pain before outwardly responding is known as: A. Pain tolerance. B. Pain intolerance. C. Pain perception. D. Pain threshold. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.29

30. Assessment of circulation, motion, and sensation is done every 8 hours in a patient recovering from a laminectomy 3 days after surgery. The patient had the surgery for consistent low back pain. Now on day 3, the patient has a burning sensation on the lateral edge of the right foot. This is best described as: A. Cellulitis. B. Nociceptive pain. C. Fasciitis. D. Neuropathic pain. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.30

31. Copyright © 2013 by Mosby, an imprint of Elsevier Inc.31