pain assessment

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ways to assess a client's level of pain using different mnemonics (e.g., PQRST, COLDD SPA, OLD CARTS) and different visual analogs

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pain assessment

  1. 1. Maria Carmela L. Domocmat, RN, MSN
  2. 2. an unpleasant sensory and emotionalexperience, which we primarily associatewith tissue damage or describe in terms ofdamage, or both (IASP)the fifth vital sign Maria Carmela L. Domocmat, RN, MSN
  3. 3. http://static.howstuffworks.com/gif/pain-2.gif Maria Carmela L. Domocmat, RN, MSN
  4. 4. http://static.howstuffworks.com/gif/pain-2.gif Maria Carmela L. Domocmat, RN, MSN
  5. 5. Proposed by Melzack and Wall in 1965Has influenced pain research and treatmentPain is explained as a combination ofphysiologic phenomena in addition to apsychosocial aspect that influences theperception of pain Maria Carmela L. Domocmat, RN, MSN
  6. 6. Maria Carmela L. Domocmat, RN, MSN
  7. 7. Acute pain Usually associated with injury of recent onset (‹6 mos)and duration (‹1 mo)Chronic non-malignant pain Usually assoc with specific cause or injury Constant pain that persists more than 6 mosCancer pain Often due to compression of meninges or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration Maria Carmela L. Domocmat, RN, MSN
  8. 8. Maria Carmela L. Domocmat, RN, MSN
  9. 9. Nociceptive or somatic pain Pain r/t tissue damage Subtypes: acute and remitting or chronic and persistentNeuropathic pain Result from direct injury to the peripheral or CNSPsychogenic and idiopathic pain Relates to many factors that influence the patient’s report of pain –psychiatric conditions like anxiety or depression, personality and coping style, cultural norms, and social support systems Idiopathic pain – pain without an identifiable etiology Maria Carmela L. Domocmat, RN, MSN
  10. 10. Characteristic of Nociceptive Nociceptive deep somatic Nociceptive visceral Neuropathicpain superficialOrigin of stimulus Skin, subcutaneous Bone joints, muscles, Solid or hollow organs, Damage to nociceptive pathways tissue; mucosa- tendons, ligaments; deep tumor masses, deep mouth, nose, superficial lymph nodes; lymph nodes sinuses, urethra, organs and capsules, anus mesothelial membranesExamples Pressure ulcers, Arthritis, liver capsule Deep abdominal or chest Tumor related brachial, lumbosacral stomatitis distension or inflammation masses, intestinal, biliary plexus or chest wall invasion, spinal cord ureteric colic compression; nontumour related: postherpetic neuralgia, postthoracotomy syndrome, phantom painDescription Hot, burning, Dull, aching Dull, deep Dysesthesia (pins and needles, tingling, stinging burning, lancinating, shooting) Allodynia; phantom pain, pain in numb areaLocalization to Very well defined Well defined Poorly defined Nerve or dermatome distributionsite of stimulusMovement No effect Worsening pain May improve pain Nerve traction provokes pain, e.g. sciatic Resident prefers to be still stretch testReferral No Yes Yes YesLocal tenderness Yes Yes Maybe YesAutonomic effects No No Nausea, vomiting, Autonomic instability: warmth, sweating, sweating, BP and heart rate pallor, cold, cyanosis (localized to nerve changes pathway) Maria Carmela L. Domocmat, RN, MSN
  11. 11. Maria Carmela L. Domocmat, RN, MSN
  12. 12. raised heart rate, pulse, temperature,respiratory rate, blood pressure or sweatingabnormal color of skin, discharge from eyes,nose, vagina or rectumlesions to oral or rectal mucosa, skindistension of the abdomen, swelling of limbs,swelling of body jointsabnormal results on testing urine (e.g. presenceof blood, leucocytes, glucose)functional decrease in mobility, range ofmovement, activity, endurance, and increase infatiguechanges in posture-standing, sitting, reclining Maria Carmela L. Domocmat, RN, MSN
  13. 13. Maria Carmela L. Domocmat, RN, MSN
  14. 14. aggression, resistance, withdrawal,restlessnessfacial expression: grimacing, fear, sadness,disgustverbalizations: self reports of pain, requestsfor analgesia, requests for help, sighing,groaning, moaning, crying, and unusualsilence. Maria Carmela L. Domocmat, RN, MSN
  15. 15. http://www.hospicepatients.org/images/capqf2.gif Maria Carmela L. Domocmat, RN, MSN
  16. 16. Maria Carmela L. Domocmat, RN, MSN
  17. 17. Maria Carmela L. Domocmat, RN, MSN
  18. 18. LocationSeverity Verbal descriptor Scale (VBS) Visual Analog Scale (VAS) Numeric Rating Scale (NRS) Wong-Baker Faces Pain Scale (FACES)Associated featuresAttempted treatments, medications, relatedillness, impact on daily activities Maria Carmela L. Domocmat, RN, MSN
  19. 19. Ask patient to describe pain and how thepain startedIs it related to a site of injury, movement, ortime of day?What is the quality of pain –sharp, dull,burning?Ask if pain radiates (spread around) or followa specific patternWhat makes pain better or worse? Maria Carmela L. Domocmat, RN, MSN
  20. 20. Attempted treatments, medications, relatedillness, impact on daily activities Ask any treatments the patient has tried (meds, PT, alternative meds) Comprehensive med history (rationale: helps you identify drugs with analgesics and reduce their efficacy) Identify any morbid condition (e.g., arthritis, DM, HIV/AIDS, substance abuse, sickle cell disease, or psychiatric disorder) (rationale: these can have a significant effects on patient’s experience of pain) Inquire about effects of pain in ADL, mood, sleep, work, and sexual activity (rationale: chronic pain is the leading cause of disability and impaired performance at work) Maria Carmela L. Domocmat, RN, MSN
  21. 21. Location: where is it? Does it radiate?Quality: what is it like?Quantity or severity: how bad is it?Timing: When did (does) it start? How long doesit last? How often does it come?Setting in which it occurs: include environmentalfactors, personal activities, emotional reactions,or other circumstances that may havecontributed to the illnessRemitting or exacerbating factors: is there anything that makes it better or worse?Associated manifestations: have you noticedanything else that accompanies it? Maria Carmela L. Domocmat, RN, MSN
  22. 22. OPQRST P:palliating or provoking factors Q: quality of pain (what words does the person use to describe pain) R:radiation of pain (does the pain extend from the site) S:severity of pain (intensity, can be measured using pain scales) T: timing (occasional, intermittent, constant) Maria Carmela L. Domocmat, RN, MSN
  23. 23. OLD CARTS Onset Location Duration Character Aggravating/Alleviating Factors Radiation Timing Severity Maria Carmela L. Domocmat, RN, MSN
  24. 24. Maria Carmela L. Domocmat, RN, MSN
  25. 25. This is a simple descriptive pain intensityscale that ranges pain intensity from no painto worst pain. Maria Carmela L. Domocmat, RN, MSN
  26. 26. P: palliating or provoking factors Q: quality of pain (what words does the person use to describe pain) R: radiation of pain (does the pain extend from the site) S: severity of pain (intensity, can be measured using pain scales) T: timing (occasional, intermittent, constant)Registered Nurses Association of Ontario(RNAO) Recommended Verbal Assessment(RNAO, 2007) Maria Carmela L. Domocmat, RN, MSN
  27. 27. Character Onset COLDSPA Location Duration Severity Pattern Associated FactorsMaria Carmela L. Domocmat, RN, MSN
  28. 28. Character: describe the sign or symptom;how does it feel, look, sound, smell, and soforth?Onset: when did it begin?Location: where is it?, does it radiateDuration: how long does it last?Severity: how bad is it?Pattern: what makes it better? what makes itworse?Associated Factors: what other symptomoccur with it? Maria Carmela L. Domocmat, RN, MSN
  29. 29. Maria Carmela L. Domocmat, RN, MSN
  30. 30. Simple descriptive pain intensity scaleRanges pain on a scale between mild, moderateand severe Maria Carmela L. Domocmat, RN, MSN
  31. 31. Maria Carmela L. Domocmat, RN, MSN
  32. 32. Visual Analog Scale (VAS) Rates pain on a 10 cm continuum numbered from 0 to 10 where 0 reflects no pain and 10 reflects pain at its worst http://www.queri.research.va.gov/ptbri/HTM/HSRD08_Walker_files/slide0 033_image011.jpg Maria Carmela L. Domocmat, RN, MSN
  33. 33. Maria Carmela L. Domocmat, RN, MSN
  34. 34. a verbal tool where a scale of 0-10 painintensity is asked to the patient. The patientthen states pain from 0-10 where 0 is no painand 10 is worst pain Maria Carmela L. Domocmat, RN, MSN
  35. 35. http://understandingpain.files.wordpress.com/2010/07/pain_scale1.png Maria Carmela L. Domocmat, RN, MSN
  36. 36. Maria Carmela L. Domocmat, RN, MSN
  37. 37. Shows different facial expression where theclient is asked to choose the face that bestdescribes the intensity or level of painesp for pediatric client Maria Carmela L. Domocmat, RN, MSN
  38. 38. http://pacificu.edu/optometry/ce/courses/22746/images/clip_image002.jpg Maria Carmela L. Domocmat, RN, MSN
  39. 39. Maria Carmela L. Domocmat, RN, MSN
  40. 40. Maria Carmela L. Domocmat, RN, MSN
  41. 41. The Abbey Pain Scale is suitable for residentswith dementia who cannot verbalise theirpain, and may also be useful for cognitivelyintact residents who arent willing or cannottalk about their pain. http://www.racgp.org.au/silverbookonline/images/tools_abbey_pain_scale .gif Maria Carmela L. Domocmat, RN, MSN
  42. 42. http://www.racgp.org.au/silverbookonline/images/tools_abbey_pain_scale .gifMaria Carmela L. Domocmat, RN, MSN
  43. 43. Maria Carmela L. Domocmat, RN, MSN
  44. 44. Maria Carmela L. Domocmat, RN, MSN
  45. 45. The Residents Verbal Brief Pain Inventory issuitable for residents able to verbalize theirpain. The same scale/s selected for theindividual resident should be forreassessment. http://www.racgp.org.au/silverbookonline/images/tools_pain_inventory.gif Maria Carmela L. Domocmat, RN, MSN
  46. 46. http://www.racgp.org.au/silverbookonline/images/tools_pain_inventory.gifMaria Carmela L. Domocmat, RN, MSN
  47. 47. Maria Carmela L. Domocmat, RN, MSN
  48. 48. http://img.medscape.com/fullsize/migrated/452/694/pn452694.tab3.gif Maria Carmela L. Domocmat, RN, MSN
  49. 49. Maria Carmela L. Domocmat, RN, MSN
  50. 50. Observe posture Normal findings: Posture is upright when the client feels comfortable, attentive and without excessive changes in position and posture Abnormal findings: client appears to be slumped with the shoulders not straight (indicates being disturbed/uncomfortable) May be guarding affected area and have breathing patterns reflecting distress Maria Carmela L. Domocmat, RN, MSN
  51. 51. Observe facial expression Normal findings: Smiles with appropriate facial expressions Maintains adequate eye contact Abnormal findings: Facial expression may indicate distress and discomfort Frowning Moans Grimacing Cries Fear Sadness Disgust Eye contact is not maintained, indicating discomfort Maria Carmela L. Domocmat, RN, MSN
  52. 52. Inspect joints and muscles Normal findings: Joints appear normal – no edema Muscles appear relaxed Abnormal findings: Edema of joints may indicate injury Pain may result in muscle tension Maria Carmela L. Domocmat, RN, MSN
  53. 53. Observe skin for scars, lesions, rashes,changes or discolorations Normal findings: No inconsistency, wounds, or bruising is noted Abnormal findings: Bruising, wounds, or edema may be the result of injuries or infections, which may cause pain Maria Carmela L. Domocmat, RN, MSN
  54. 54. Maria Carmela L. Domocmat, RN, MSN
  55. 55. HR Normal finding: 60-100 bpm Abnormal finding: increased HR may indicate discomfort or pain Maria Carmela L. Domocmat, RN, MSN
  56. 56. RR Normal finding: 12-20 breathes per min Abnormal finding: RR may be increased; breathing may be irregular and shallow Maria Carmela L. Domocmat, RN, MSN
  57. 57. BP Normal finding:100-130/60-80 Abnormal finding: increased BP often occurs in severe pain Maria Carmela L. Domocmat, RN, MSN
  58. 58. Other observations r/t specific part Palpation of abdomen ROM tests for joints Maria Carmela L. Domocmat, RN, MSN
  59. 59. Maria Carmela L. Domocmat, RN, MSN
  60. 60. Validate your dataDocument dataPossible conclusions Maria Carmela L. Domocmat, RN, MSN
  61. 61. Actual diagnoses Acute pain r/t injury agents (biological, chemical, physical or psychological) Chronic pain r/t chronic inflammatory process of rheumatoid arthritis Ineffective breathing pattern r/t abdominal pain and anxiety Fatigue r/t stress of handling chronic pain Impaired physical mobility r/t chronic pain Bathing /hygiene self-care deficit r/t severe pain (specify) Maria Carmela L. Domocmat, RN, MSN
  62. 62. Risk diagnoses Risk for activity intolerance r/t chronic pain and immobility Risk for constipation r/t nonsteroidal anti- inflammatory agents or opiates intake or poor eating habits Risk for spiritual distress r/t anxiety, pain, life changes, and chronic illness Risk for powerlessness r/t chronic pain, healthcare environment, pain treatment-related regimen Maria Carmela L. Domocmat, RN, MSN
  63. 63. Wellness diagnoses Readiness for enhanced spiritual well-being r/t coping with prolonged physical pain Readiness for enhanced comfort level Maria Carmela L. Domocmat, RN, MSN

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