1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 7Pain Assessment by LWW and Dr. Karen Hill

2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Pain One of the most common reasons patients seek help from health care professionals Does not respect gender, age, or ethnicity Can occur at any time, to anyone Can profoundly affect –Quality of life –Interactions with family and friends –Sense of well-being and self-esteem –Financial resources

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Neuroanatomy of Pain Peripheral nervous system –Two main types of nerve fibers A-delta C fibers Central nervous system –Opening or closing the "gate" –Lateral spinothalamic tracts –Limbic system

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5. Gate Control Theory Theory of pain with the widest acceptance Steps for pain transmission in the gate control theory Pain-facilitating and pain-inhibiting substances

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7. Definition of Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (American Pain Society, 2003) Pain is “whatever the experiencing person says it is, existing whenever he says it does (McAffrey & Pasero, 1999)

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Pain Box 7.2 1. Acute pain –Visceral pain –Somatic pain –Cutaneous pain –Referred pain 2. Chronic pain

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 3. Neuropathic pain (page 130) –Neuronal plasticity –Peripheral sensitization –Neuronal windup –Central sensitization Types of Pain (cont.)

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Health History Have you had this pain before? If so, how has it changed? When did it start and has it changed since first began? What have you used to help with pain? ALLERGIES are crucial here – may be side effects Has it affected your sleep or ADL?

11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Lifespan Considerations Newborns, infants, and children –Undertreatment –More hormonal, metabolic, and cardiovascular responses to pain –Inadequate pain treatment Older adults –Not a normal consequence of aging –Increased age on pain perception –Undertreatment –Impairments

12. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins For Children 2 months – 7 years

13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Could also use this for those who are mentally challenged or don’t communicate well Adults or children

14. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Racial and ethnic minority groups –Caucasians receive more pain medication than other cultures Gender differences in pain exist –Males can’t cry? –Be a man and quit complaining! –Some conditions are primarily female and some males Sociocultural variables- pt. values, resources, & expectations Cultural and Environmental Considerations

15. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Assessment and Health-Related Patient Teaching Pain is not a benign experience Usually a symptom and not a disease Acute pain that is undertreated or untreated can lead to more serious conditions or death Teaching patients- essential Patient refusal of pain medications- they have that right

16. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessing Pain Subjective data collection – page 132 –Location – DON’T ASSUME –Duration – how long, has it changed –Intensity – pain scale –Quality/description – sharp vs dull, constant or intermittent, radiating –Alleviating/aggravating factors –Pain management goal –Functional goal Accept the patient’s rating

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18. Objective Data Collection Pain has objective effects – Table 7.1 –Grimacing, fetal position, not using a body part Stress response Inadequately treated pain Observable behavioral responses – –Relax vs tense, crying, anxious

19. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Pain Assessment Tools One-dimensional pain scales Visual Analog Scale (VAS) Verbal Descriptor Scale (VDS) Numeric Pain Intensity Scale (NPI) Combined Thermometer Scale Multidimensional Pain Scales McGill Pain Questionnaire (MPQ) Brief Pain Inventory (BPI) Brief Pain Impact Questionnaire (BPIQ)

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21. No pain Worst pain

22. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Lifespan Considerations Newborns, infants, and children –Usually best seen in their posture, facial expression, crying, lip quivering, Older adults – –May not be able to explain their pain –May not want to “borther you”

23. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Situations Patients unable to report pain –Self-report is the most reliable indicator of pain –Try to identify any potential causes for pain –Obsere patient behaviors –Ask the family or other caregivers if they hae noticed any changed in behavior –Attempt an analgesic trial

24. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Patients with opioid tolerance –Altered physiologic response to the pain stimulus –More sensitive to pain as repeat use of opioids (opioid hypersensitivity) –High level of bias from health care personnel –Have a right to pain relief

25. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Diagnoses, Outcomes, and Interventions The nurse incorporates critical thinking to establish a nursing problem or diagnosis list Assessment data are the basis for the care provided to relieve acute or chronic pain YOUR job is to report, not judge

26. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Reassessing and Documenting Pain JCAHO requirements Reassessment necessary to see if interventions are working Institutions usually have policy for assessment and reassessment of pain

27. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Barriers to Pain Assessment Prejudices and bias related to educational, family, or cultural values can affect how nurses perceive the patient’s self-report of pain Inaccurate or poor pain assessment Can be grating on nerves if addicted or in constant pain with low pain tolerance

28. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Evidence-Based Critical Thinking The nurse is responsible for assessing pain and negotiating pain and functional goals Can be considered negligence is they c/o pain and you do nothing about it