Laxmi thapaB.sc. Nursing 3rd year

Roll no:29

PAIN“Pain is complex multifactorial phenomenon which includes an emotional experience associated with actual as potential” -MERSKEY & BUGDULK, 1994

ASSESSMENT OF PAINAssessment of pain includes SUBJECTIVE OBJECTIVE

A. SUBJECTIVE ASSESSMENT1. PAIN HISTORYWhile taking pain history, nurse must provide an opportunity for clients to express in their own words, how they view it and their situation This will help the nurse to understand means of pain to client and how the client is coping with it.

2. ONSET AND DURATION OF OCCURRENCE:- When did pain begin?- How long has it lasted?- Does it occur at same time each day?- How often does it occurs?

3. LOCATION- In which area it is felt? Do the area differ

under different circumstances?- If several parts of body are painful, do pain

occur simultaneously?- Is pain unilateral / bilateral?- Ask the individual to point site of discomfort

4. INTENSITY- Use of pain intensity scale is an easy and

reliable method of determining the clients pain intensity

- Most scales are either 0 to 5 or 0 to 10 - Currently used scales are:• Numerical scale• Descriptive scale• Visual analog scale

PAIN ASSESSMENT SCALE1. NUMERICAL RATING SCALE A numerical rating scale with the range of 0 to

10 is another type of pain scale that is used The word “no pain” appear by “0” and “worst

pain possible” is found by “10” Patient are asked to choose a number from 0

to 10 that best reflects his/her level of pain

2. VERBAL RATING SCALESVerbal pain scales as name suggests, use words to describe pain. Word such as no pain, mild pain, moderate pain & severe pain are used to describe pain levels.

3. VISUAL ANALOGUE SCALES:- VSA use a vertical or horizontal line with

words that convey “no pain” at one end and “worst pain” at opposite end

- Patient is asked to place a mark along line that indicates his/her level of pain.

WONG-BAKER FACES PAIN RATING SCALE

With the wong-baker pain scale, six faces are used that are numbered 0 to 5 underneathFace 0 is a happy faceFace 2 is still smilingFace 4 is not smiling or frowningFace 6 is starting to frownFace 8 is definitely frowningFace 10 is crying

B. OBJECTIVE ASSESSMENT1. BEHAVIORAL EFFECTS:Assess verbalization, vocal response, facial

and body movements & social interactionFacial expression is often 1st indication of pain

& may be only one manifestationVocalization like moaning, groaning, crying,

grunting, screaming are associated with pain.

2. PHYSIOLOGICAL RESPONSES: It vary with the origin and duration of pain Early in onset of acute pain, the symapthetic

nervous system is stimulated Results in increased blood pressure, pulse

rate, respiration, pallor, diaphoresis and pupil dilation

P-Q-R-S-T FORMATPROVOCATION: how the injury occurred &

what activities increase or decrease the painQUALITY: characteristics of painREFERRAL/ RADIATION Referred: site distant to damaged tissue that

does not follow course of peripheral nerve Radiating: follows peripheral nerve, diffuse

pain

QUESTION TO ASK ABOUT PAINPATTERN: onset & durationAREA: locationINTENSITY: levelNATURE: description

WHO 3-STEP LADDER

NURSING DIAGNOSIS

1. Ineffective airway clearance r/t chest pain2. Anxiety r/t past experience of poor control of

pain3. Altered health maintenance r/t chronic pain4. Impaired physical mobility r/t asthmatic pain

perception5. Knowledge deficit r/t pain6. Self-care deficit r/t pain or disease condition

NURSING INTERVENTIONUse pain assessment scale to identify intensity

of painAssess and record pain & its characteristics,

condition, quality, frequency & durationAdminister analgesics as prescribed to

promote optimal painDocument severity of patient pain on chart

Identify & encourage patient to use strategies that have been successful with previous pain

Consider cultural influence on responseEliminate the factors that increase the pain

experiencedTeach the use of non pharmacological therapy

techniques