Post on 01-Jan-2016
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Assessing Pain
By InnaKorda, MD, By InnaKorda, MD,
Institute of Nursing, TSMUInstitute of Nursing, TSMU
The Fifth Vital Sign
Pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage (International Association for the Study of Pain).
Not only a sensory experience resulting from activation of pain receptors, but also the pt’s emotional and cognitive response.
Pain is personal and subjective
Physiology of Pain
Pain is the result of 2 opposing pathways
1. Pain impulses are carried to the brain, generating sensation of pain– Activation of pain receptors by mechanical (pressure), thermal, or chemical
(histamine, serotonin, bradykinin) stimuli.– Prostaglandins or substance P can enhance the sensitivity of pain
receptors to activation.– Periphery Spinal Cord Thalamus Cerebral Cortex
2. Pain impulses are suppressed by the brain, diminishing pain sensation– Done by endogenous opioids, especially endorphins and enkephalins.– Released at both spinal cord and cerebral cortex– The opioids we give activate the same receptors as these endogenous
opioids
2 Types of PainNociceptive
Results from injury to tissues Carried to CNS by 2 types of
fibers, Aδ and C fibers 2 types Somatic
Results from injury to somatic tissues (bones, joints, muscles)
Described as localized and sharp
Visceral Results from injury to visceral
organs (intestine). Described as vaguely localized
and achy Both forms of nociceptive pain
respond well to opioid analgesics (morphine) and may respond to nonopioids (ibuprofen)
Neuropathic Results from injury to peripheral
nerves Described as burning, shooting,
jabbing, tearing, numb, dead, cold.
Responds poorly to opioid analgesics
Responds well to adjuvant analgesics (antidepressants, anticonvulsants, local anesthetics such as lidocaine)
Phantom limb syndrome. Neuropathic pain which occurs when an arm or a leg has been removed because of illness or injury. But the brain still gets pain messages from the nerves that originally carried impulses from the missing limb. These nerves now misfire and cause pain.
May be caused by cancer or by therapeutic interventions
Direct invasion or metastatic invasion of other sites
Neuropathic pain may be caused through infiltration of nerves
Visceral pain may be caused through infiltration, obstruction, and compression of organs
What kind of pain iscaused by cancer?
Types of Pain (by duration) Acute pain
Short term Following injury, surgery, trauma Dissipates after injury heals
Chronic pain Pain longer than 6 months Malignant or nonmalignant Malignant pain due to invasion of surrounding tissues
(nerves, organs, bone) or interventions such as chemotherapy (causing neuropathy)
Nonmalignant pain often has no protective purpose and is due to abnormal processing of pain from peripheral and central sites
Assessing Pain Location – Where is your pain? Do you feel pain in more than
one place? Can you point to the location of pain? Onset and temporal pattern – When did it begin? How often
does it occur? Has the intensity increased, decreased or remained constant?
Quality – What does your pain feel like? Is it sharp or dull? Does it ache? Is it burning or tingling?
Intensity Modulating factors – What makes your pain better? What
makes it worse? Previous treatments – What have you previously tried to relieve
your pain? Was it effective? Function – Does your pain affect your ability to function and
how? Does it interfere with work, eating, sleeping, etc?
Assessing Pain
Numeric – “Can you rate your pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain you can imagine.”
Descriptive – for older adults. List words to describe intensity of pain.
Wong-Baker FACES Scale -
Assessing Pain – Nonverbal Cues
Acute Pain Grimacing, moaning, agitation,
diaphoresis Change in vital signs (tachycardia,
increased BP, hypoventilation) Other physiological changes (N&V,
decreased immunity, muscle spasms, depression)
Chronic Bracing, rubbing, diminished activity,
sighing, appetite change
Developmental Considerations
Infants Lack inhibitory neurotransmitters until 38 weeks
gestation more sensitive if preterm It’s now believed to be a myth that infants don’t
feel pain Aging adults
Don’t assume pain is normal
Question 1
During your physical exam, your patient is diaphoretic, pale, and complains of pain directly over the LUP of the abdomen. This would be categorized as:
1. Cutaneous pain
2. Somatic pain
3. Visceral pain
4. Psychogenic pain
Question 2
While caring for an infant, you are aware that:1. Inhibitory neurotransmitters are in sufficient
supply by 15 weeks’ gestation
2. The fetus has less capacity to feel pain
3. Repetitive blood draws have minimal long-term consequences
4. The preterm infant is more sensitive to painful stimuli
Question 3
The most reliable indicator of pain the in the adult is:
1. Degree of physical functioning
2. Nonverbal behaviors
3. MRI findings
4. The client’s self report
Question 4
While examining a broken arm of a 4-year old boy, select the appropriate assessment tool to evaluate his pain status
1. 0-10 numeric rating scale
2. Wong-Baker scale
3. Simple descriptor scale
4. 0-5 numeric rating scale
Question 5
The CRIES is an appropriate pain assessment tool for:
1. Cognitively impaired elderly
2. Children ages 2-8
3. Infants
4. Preterm and term neonates