M.sc Nursing ANP TOPIC Bio psycho socio pathology of pain, sleep, sensory deprivation, unconsciousness TNMGR UNIVERSITY BY MANIMEGALAI.M

1. BIO PSYCHO SOCIO
PATHOLOGY
M.MANIMEGALAI
I YR M.SC NURSING

9. MANIMEGALAI.M
I YEAR M.SC., NURSING
ADVANVCED NURSING
PRACTICE
PAIN ASSESSMENT
AND PAIN SCALES

10. CONTENT
1. INTRODUCTION
2. DEFINITIONS
3. PAIN THEORIES
4. SIGNS AND SYMPTOMS
5. TYPES OF PAIN
6. ASSESSMENT OF PAIN
7. PHARMACOLOGICAL MANAGEMENT
8. NON PHARMACOLOGICAL MANAGEMENT

11. INTRODUCTION

12. DEFINITION OF PAIN
INTERNATIONALASSOCIATION FOR THE STUDY OF PAIN(1980)
• AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ARISING FROM
ACTUAL OR POTENTIAL TISSUE DAMAGE OR DESCRIBED IN TERMS OF SUCH
DAMAGE

13. • ANALGESIA : Absence of pain in response to stimulation
which would normally be painful.
• HYPERALGESIA : An increased response to stimulus
which is normally Painful
• NEURALGIA : Pain in the distribution of nerve or nerves
• NEUROPATHIC PAIN: Pain initiated or caused by a
primary lesion or dysfunction in the nervous system.
• NOCICEPTOR: A receptor preferentially sensitive to
noxious stimulus.

14. • NOXIOUS STIMULUS:
A Noxious stimulus is the one which is damaging to normal
tissues
• PAIN THRESHOLD: The least experience or level
of pain which a subject can recognize
• PAIN TOLERANCE LEVEL: The greatest level of
pain which a subjects prepared to tolerate
• PERIPHERAL NEPHROPATHY PAIN:
Pain initiated or caused by a primary lesion or
dysfunction in peripheral nervous system

15. PAIN THEORIES:
• GATE CONTROL THEORY: MELZACK WALLS CLASSIC 1965

16. 2.BIO PSYCHO SOCIO MODEL

17. SENSORY INTERACTION THEORY
• NOORDINBOS 1959

18. THE FOURTH THEORY OF PAIN
• HARDY WOLFF &GOODELL,1940S

19. INTENSIVE THEORY(ERB 1874)

20. SPECIFICITY THEORY VON FREY,1895

21. STRONG’S THEORY – STRONG 1893
• HE ISOLATED PAINFROM DISPLEASURE BY FOCUSING ON CUTANEOUS
PAIN,WHERE THE INFLICTION OF PAIN CARRIED NO IMMEDIATE THREAT

22. PATTERN THEORY

23. CENTRAL SUMMATION THEORY
(LIVINGSTONE,1943)

24. PAIN ASSESSMENT
• BY ITS VERY DEFINITION, PAIN IS AN INTERNAL, SUBJECTIVE EXPERIENCE THAT
CANNOT BE DIRECTLY OBSERVED BY OTHERS OR MEASURED BY THE USE OF
PHYSIOLOGIC MARKERS OR BIOASSAYS.
• THE ASSESSMENT OF PAIN, THEREFORE, RELIES LARGELY (AND IN MANY CASES
EXCLUSIVELY) UPON THE USE OF SELF-REPORT.

25. PAIN ASSESSMENT
• THOUGH THE SELF-REPORT OF PAIN OR ANY OTHER CONSTRUCT IS SUBJECT TO
A NUMBER OF BIASES, A GOOD DEAL OF EFFORT HAS BEEN INVESTED IN TESTING
AND REFINING SELF-REPORT METHODOLOGY WITHIN THE FIELD OF HUMAN PAIN
RESEARCH.

26. PAIN ASSESSMENT
• PAIN ASSESSMENT SHOULD BE ONGOING, INDIVIDUALIZED,
AND DOCUMENTED.
• PATIENTS SHOULD BE ASKED TO DESCRIBE THEIR PAIN IN
TERMS OF THE FOLLOWING CHARACTERISTICS: LOCATION,
RADIATION, MODE OF ONSET, CHARACTER, TEMPORAL
PATTERN, EXACERBATING AND RELIEVING FACTORS, AND
INTENSITY.

27. ASSESSING PAIN
• QUESTION THE PATIENT
• USE PAIN RATING SCALES
• EVALUATE BEHAVIOR & PHYSIOLOGIC
SIGNS
• SECURE FAMILY’S INVOLVEMENT
• TAKE ACTION AND ASSESS EFFECTIVENESS

28. SOCRATES
• Site - where is the pain?
• Onset - when did the pain start,
was it sudden or gradual?
• Character - what is the pain like?
• Radiation - does the pain radiate anywhere?
• Associations - any other signs or symptoms
associated with the pain?
• Time course - does the pain follow any pattern?
• Exacerbating/relieving factors - does anything
change the pain?
• Severity - how bad is the pain?

29. USE PAIN RATING SCALES
• SELECT A SCALE THAT IS SUITABLE FOR THE PATIENTS ABILITIES,
AGE, AND PREFERENCES
• TEACH PATIENT TO USE SCALE BEFORE PAIN IS EXPECTED, SUCH
AS PREOPERATIVELY
• USE SAME SCALE WITH THE PATIENT EACH TIME PAIN IS ASSESSED

30. TYPES OF PAIN RATING SCALES
• SIMPLE DESCRIPTIVE SCALE
• NUMERICAL RATING SCALE (NRS)
• LINEAR ANALOGUE SCALE
• RUPEE SCALE
• FLACC SCALE
• BRIEF PAIN INVENTRY
• NEUROPATHIC PAIN SCALE
• WONG BAKER FACES PAIN RATING SCALE
• VISUAL ANALOG SCALE (VAS)
• SPECIALIZED TEST

31. SIMPLE/VERBAL DESCRIPTIVE SCALE
• The verbal descriptor scale is a list of words,
ordered in terms of severity from least to most,
that describe the amount of pain that a patient
may be experiencing.
• Patients are asked to either circle or state the word
that best describes their pain intensity at that
moment in time.
• The benefits of this scale is instruments are that
they have been validated and are simple for
patients to understand and quick to use.
• A disadvantage is that it is t forces patients to
select words that are not of their own choosing to
describe their pain.
• Changes in pain over time are difficult to interpret and probably
have different meanings to each individual.
• This may especially be a problem with the vds when only a
limited number of possible choices are offered to the patient

32. SIMPLE DESCRIPTIVE SCALE

33. VISUAL ANALOG SCALE
• The VAS is most commonly a straight 100-mm
line without demarcations that has the words
“no pain” at the left-most end and “worst pain
imaginable”(or something similar) at the right-
most end.
• Benefits of the vas is that it has been validated
and shown to be sensitive to changes in a
patient's pain experience.
• It is quick to use and relatively easy to
understand for most patients.
• It avoids the imprecise use of descriptive
words to describe pain and allows a
meaningful comparison of measurements over
time.

34. VISUAL ANALOG SCALE
• Disadvantages of the VAS is that it
attempts to assign a single value to a
complex, multidimensional experience.
• Some patients have trouble deciding how
to represent their pain sensation. They
often have no real concept of what “worst
pain imaginable” actually means because
every experience of pain is different.
• It has a false ceiling at the upper-most
end. If a patient later time decides that the
pain has become worse, the patient has no
way to document this change if it was
already at maximum.

35. VISUAL ANALOG SCALE

36. VERBAL DESCRIPTIVE SCALE

37. NUMERICAL RATING PAIN SCALE

38. NUMERICAL RATING PAIN SCALE
• THE NUMERICAL RATING SCALE OFFERS THE
INDIVIDUAL IN PAIN TO RATE THEIR PAIN
SCORE.
• IT IS DESIGNED TO BE USED BY THOSE OVER
THE AGE OF 9.
• IN THE NUMERICAL SCALE, THE USER HAS THE
OPTION TO VERBALLY RATE THEIR SCALE
FROM 0 TO 10 OR TO PLACE A MARK ON A
LINE INDICATING THEIR LEVEL OF PAIN.
• 0 INDICATES THE ABSENCE OF PAIN, WHILE
10 REPRESENTS THE MOST INTENSE PAIN
POSSIBLE.

39. NUMERICAL RATING PAIN SCALE
• THE NUMERICAL RATING PAIN SCALE ALLOWS THE
HEALTHCARE PROVIDER TO RATE PAIN AS MILD, MODERATE
OR SEVERE, WHICH CAN INDICATE A POTENTIAL DISABILITY
LEVEL.
• ATTEMPTS HAVE BEEN MADE TO DEFINE WHAT IS
CONSIDERED A MEANINGFUL CHANGE IN THE NRS.
• AT LEAST A 30% REDUCTION OR AN ABSOLUTE REDUCTION IN
THE VALUE OF AT LEAST 2 HAS BEEN SUGGESTED AS
REPRESENTING MEANINGFUL PAIN RELIEF TO PATIENTS

40. NUMERICAL RATING PAIN SCALE
• DISADVANTAGES OF THE NRS AND VNS ARE
SIMILAR TO THOSE OF THE VAS IN THAT
THEY ATTEMPT TO ASSIGN A SINGLE
NUMBER TO THE PAIN EXPERIENCE.
• THEY ALSO HAVE THE SAME CEILING
EFFECT IN THAT IF A VALUE OF “10” IS
CHOSEN AND THE PAIN WORSENS, THE
PATIENT OFFICIALLY HAS NO WAY TO
EXPRESS THIS CHANGE.
• IN PRACTICE, AT LEAST WITH THE VNS,
PATIENTS OFTEN RATE THEIR PAIN AS SOME
NUMBER HIGHER THAN 10 (E.G., “15 OUT
OF 10”) IN AN ATTEMPT TO EXPRESS THEIR
EXTREME LEVEL OF PAIN INTENSITY.

41. • THE WONG BAKER FACES PAIN SCALE COMBINES
PICTURES AND NUMBERS TO ALLOW PAIN TO BE RATED
BY THE USER.
• IT CAN BE USED IN CHILDREN OVER THE AGE OF 3, AND
IN ADULTS.
• THE FACES RANGE FROM A SMILING FACE TO A SAD,
CRYING FACE.
• A NUMERICAL RATING IS ASSIGNED TO EACH FACE, OF
WHICH THERE ARE 6 TOTAL.
WONG BAKER FACES PAIN SCALE

43. 0 2 4 6 8 10
Wong Baker Faces Pain Scale

45. FLACC PAIN SCALE
• FLACC STANDS FOR FACE, LEGS, ACTIVITY, CRYING AND
CONSOLABILITY.
• IT IS AN OBSERVER RATED PAIN SCALE, PERFORMED BY A HEALTHCARE
PRACTITIONER SUCH AS A DOCTOR OR A NURSE.
• THE FLACC PAIN SCALE WAS DESIGNED FOR NEONATES AT 2 MONTHS,
MAY BE USEFUL UP TO 7 YEARS OF AGE.
• HOWEVER, SOME PRACTITIONERS IN ADULT SETTINGS MAY USE THE FLACC PAIN
SCALE FOR PEOPLE WHO ARE UNABLE TO COMMUNICATE THEIR PAIN.
• FLACC PROVIDES A PAIN ASSESSMENT SCALE BETWEEN 0 AND 10.

46. FLACC SCALE

47. MCGILL PAIN QUESTIONNAIRE (MPQ)
• THE MPQ AND ITS BRIEF ANALOG, THE SHORT-
FORM MPQ, ARE AMONG THE MOST WIDELY
USED MEASURES OF PAIN.
• IN GENERAL, THE MPQ IS CONSIDERED TO BE A
MULTIDIMENSIONAL MEASURE OF PAIN QUALITY;
HOWEVER, IT ALSO YIELDS NUMERICAL INDICES
OF SEVERAL DIMENSIONS OF THE PAIN
EXPERIENCE.
• RESEARCHERS HAVE PROPOSED THREE
DIMENSIONS OF THE EXPERIENCE OF PAIN:
SENSORY-DISCRIMINATIVE,
AFFECTIVEMOTIVATIONAL, AND COGNITIVE-
EVALUATIVE.
• THE MPQ WAS CREATED TO ASSESS THESE MULTIPLE
ASPECTS OF PAIN.

48. MCGILL PAIN QUESTIONNAIRE
• THE MCGILL PAIN QUESTIONNAIRE
CONSISTS OF GROUPINGS OF WORDS
THAT DESCRIBE PAIN.
• THE PERSON RATING THEIR PAIN RANKS
THE WORDS IN EACH GROUPING. SOME
EXAMPLES OF THE WORDS USED ARE
TUGGING, SHARP AND WRETCHED.
• ONCE THE PERSON HAS RATED THEIR
PAIN WORDS, THE ADMINISTRATOR
ASSIGNS A NUMERICAL SCORE, CALLED
THE PAIN RATING INDEX.

49. NEUROPATHIC PAIN SCALE

50. Neuropathic Pain Scale

51. • GROUPS 1-10 = SOMATIC IN NATURE
• GROUPS 11-15 = AFFECTIVE
• GROUP 16 = EVALUATIVE
• GROUP 17-20 = MISCELLANEOUS WORDS THAT ARE USED
IN THE SCORING PROCESS.
McGill Pain Questionnaire

53. MCGILL PAIN QUESTIONNAIRE
• THE BENEFITS OF THE MPQ ARE THAT IT IS VALID,
RELIABLE, AND CONSISTENT IN ITS ABILITY TO
ASSIGN SEEMINGLY APPROPRIATE DESCRIPTIONS TO
A GIVEN PAIN EXPERIENCE.
• THE MPQ MAY BE ABLE TO DISCRIMINATE BETWEEN
DIFFERENT TYPES OF PAIN SYNDROMES. MOREOVER,
IT HAS BEEN SHOWN TO BE SENSITIVE TO CHANGES
IN THE AMOUNT OF PAIN EXPERIENCED BY PATIENTS
IN RESPONSE TO RECEIVING VARIOUS ANALGESIC
THERAPIES IN BOTH THE ACUTE AND CHRONIC
SETTING.
• ONE DISADVANTAGE OF THE MPQ IS ITS LENGTH.
THE MPQ SHOULD TAKE FROM 5 TO 15 MINUTES TO
COMPLETE, WHICH FOR SOME PATIENTS MAY BE
SEEN AS MORE TROUBLE THAN IT IS WORTH.
• IN ADDITION, THIS AMOUNT OF TIME IS
PROHIBITIVE FOR USE ON A REPEATED BASIS OVER A

54. SHORT-FORM MCGILL PAIN
QUESTIONNAIRE
• THE MORE FREQUENTLY USED SHORT FORM
OF THE MPQ CONSISTS OF 15
REPRESENTATIVE WORDS THAT FORM THE
SENSORY (11 ITEMS) AND AFFECTIVE (4
ITEMS) CATEGORIES OF THE ORIGINAL MPQ.
• EACH DESCRIPTOR IS RANKED ON A 0
(“NONE”) TO 3(“SEVERE”) INTENSITY SCALE.
THE PPI, ALONG WITH A VAS, ARE ALSO
INCLUDED. THE SHORT FORM CORRELATES
HIGHLY WITH THE ORIGINAL SCALE, CAN
DISCRIMINATE AMONG DIFFERENT PAIN
CONDITIONS, AND MAY BE EASIER THAN
THE ORIGINAL SCALE FOR GERIATRIC

55. SHORT-FORM MCGILL PAIN
QUESTIONNAIRE

56. • FACIAL EXPRESSIONS (GRIMACING)
• LESS OBVIOUS: SLIGHT FROWN, RAPID BLINKING,
SAD/FRIGHTENED, ANY DISTORTION
• VOCALIZATIONS (CRYING, MOANING, GROANING)
• LESS OBVIOUS: GRUNTING, CHANTING, CALLING OUT,
NOISY BREATHING, ASKING FOR HELP
• BODY MOVEMENTS (GUARDING)
• LESS OBVIOUS: RIGID, TENSE POSTURE, FIDGETING,
PACING, ROCKING, LIMPING, RESISTANCE TO MOVING
Nonverbal Pain Indicators

57. PHYSIOLOGICAL INDICATIONS
OF
ACUTE PAIN
• DILATED PUPILS
• INCREASED PERSPIRATION
• INCREASED RATE/ FORCE OF HEART
RATE
• INCREASED RATE/DEPTH OF
RESPIRATIONS
• INCREASED BLOOD PRESSURE
• DECREASED URINE OUTPUT
• DECREASED PERISTALSIS OF GI TRACT
• INCREASED BASAL METABOLIC RATE

58. POSSIBLE PHYSIOLOGIC SIGNS OF
PAIN
•  PALLOR OR FLUSHING
• DIAPHORESIS, PALMAR SWEATING
•  O2 SATURATION
•  VAGAL TONE
• EEG CHANGES

59. POSSIBLE PHYSIOLOGIC SIGNS OF
PAIN

60. DOLORIMETERY
• DOLORIMETRY HAS BEEN DEFINED AS "THE
MEASUREMENT OF PAIN SENSITIVITY OR PAIN
INTENSITY.“
• A DOLORIMETER IS AN INSTRUMENT USED TO MEASURE
PAIN THRESHOLD AND PAIN TOLERANCE.
• INTRODUCED IN 1940 BY JAMES D. HARDY OF CORNELL
UNIVERSITY
• THERE ARE SEVERAL KINDS OF DOLORIMETERS THAT
HAVE BEEN DEVELOPED.
• DOLORIMETERS APPLY STEADY PRESSURE, HEAT, OR
ELECTRICAL STIMULATION TO SOME AREA, OR MOVE A
JOINT OR OTHER BODY PART AND DETERMINE WHAT
LEVEL OF HEAT OR PRESSURE OR ELECTRIC CURRENT
OR AMOUNT OF MOVEMENT PRODUCES A SENSATION
OF PAIN.

61. DOLORIMETERS

62. THE LEEDS ASSESSMENT OF NEUROPATHIC SYMPTOMS AND SIGNS
(LANSS) PAIN SCALE

63. REFERENCES
• INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN: PAIN DEFINITIONS
[CITED 10 SEP 2011]. "PAIN IS AN UNPLEASANT SENSORY AND EMOTIONAL
EXPERIENCE ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE DAMAGE, OR
DESCRIBED IN TERMS OF SUCH DAMAGE" DERIVED FROM BONICA JJ. THE NEED OF
A TAXONOMY. PAIN. 1979;6(3):247–8. DOI:10.1016/0304-3959(79)90046-0.
PMID 460931.
• TURK DC, DWORKIN RH. WHAT SHOULD BE THE CORE OUTCOMES IN CHRONIC
PAIN CLINICAL TRIALS?. ARTHRITIS RES. THER.. 2004;6(4):151–4.
DOI:10.1186/AR1196. PMID 15225358.
• HART RP, WADE JB, MARTELLI MF. COGNITIVE IMPAIRMENT IN PATIENTS WITH
CHRONIC PAIN: THE SIGNIFICANCE OF STRESS. CURR PAIN HEADACHE REP.
2003;7(2):116–26. DOI:10.1007/S11916-003-0021-5. PMID 12628053.
• BRUEHL S, BURNS JW, CHUNG OY, CHONT M. PAIN-RELATED EFFECTS OF TRAIT
ANGER EXPRESSION: NEURAL SUBSTRATES AND THE ROLE OF ENDOGENOUS
OPIOID MECHANISMS. NEUROSCI BIOBEHAV REV. 2009;33(3):475–91.
DOI:10.1016/J.NEUBIOREV.2008.12.003. PMID 19146872