This document discusses pain assessment, diagnosis, and treatment. It emphasizes that pain is subjective and should be assessed regularly as the 5th vital sign. Pain can be nociceptive from tissue damage, neuropathic from nerve pathway issues, or psychogenic from cognitive factors. Chronic pain lasting over 6 months is difficult to treat and often requires a multidisciplinary approach using medications, physical therapy, or alternative treatments in addition to addressing psychological factors. Practitioners must carefully treat pain to provide relief while avoiding risks of addiction, doctor shopping, or enabling drug seeking behavior.

1. Pain: Diagnosing, Assessing and
Treating
GM Unit 6

2. Learning Goals
• Identify the correct method for assessing pain
and labeling it.
• Discuss how pain is used in diagnostics.
• Establish knowledge of common treatments
for pain relief.

3. The Physiological Purpose of Pain
• Pain is an important sensory input that gives
us protection from and awareness of injury.
– Pain is an important diagnostic tool.
– Pain is considered the 5th vital sign, and should be
assessed regularly.

4. Sources or Causes of Pain
• Nociceptive Pain
– This is pain that occurs due to
actual stimulation of the pain
receptors.
– It is an indication of damage,
injury, or potential injury
• Neuropathic Pain
– This is pain that is NOT a result
of a stimulated pain receptor.
– It is due to damage in the pain
pathway. This may be in the
peripheral fibers, the spinal
cord, or the thalamus.
– Causes may be previous injury,
current injury, invasion by
cancer, or chronic disease.
• Psychogenic
– This is pain that is caused by
misperceptions in the cognitive
channels (higher brain
function).
– This often occurs in people
with mental illness or severe
emotional trauma.
– This is not a popular diagnosis,
as it may seem dismissive to
the patient, and relies on a
perfect medical diagnosis that
actual pain is not occurring.

5. Sensing Pain
• Nerves that send pain signals to the CNS are
called nociceptors, and are located
throughout the body in skin, joints and
organs.
– There are no nociceptors in the brain.
– There are several types of nociceptors that
respond to different type of stimuli.

7. In Review…
• Pain can be experienced for many reasons:
– Damage to body tissues
– Problems with nervous system pathways
– Emotional or physical issues in the brain
• Pain is SUBJECTIVE
• Pain is a physical, emotional, and social
experience

8. Pain as the Fifth Vital Sign
• We record and assess pain as the fifth vital
sign for several reasons:
– Doing so ensures that we assess it regularly.
– It can effect the other vital signs and patient
emotional status.
– It is an important diagnostic tool.

9. Assessing Pain
• Step 1: Remove your judgment.
• A major barrier in accurately assess and treating pain
is the caregiver not “believing” or “trusting” the
patient regarding their pain.
• Remember: Pain is what they say it is.
• Women and elderly people are much more likely to be
judged or not believed in regards to pain treatment.
• Step 2: Obtain a quantified report of pain.
– Record on a 0 to 10 scale in verbal patients

10. Assessing Pain
• Evaluate the Pain:
– Ask the patient to describe the pain: Location,
quality, amount of time it has been happening,
any related symptoms, injuries or factors.
• Assess the Patient as a Whole:
– Does the patient’s demeanor match their report
of pain? Are there social or emotional factors that
might effect this patient’s report? Does the
patient’s physical state match their report of pain?
What other sings or symptoms are present?

11. Assessing Pain in the Nonverbal
Patient
• People with altered mental status, varying
degrees of sedation, and children may not be
able to report pain on a verbal scale.
– In this case we use the faces scale and the
following factors: a noted reason that pain would
exist (injury, surgery), patient behavior (crying,
grimacing, irritability), vital sign changes.

12. Reporting Pain in the Medical Record
• ALWAYS record that pain was assessed, even if
the patient said they have no pain.
• ALWAYS record the patient’s report of pain,
along with your observations.
• NEVER omit a report of pain because you
believe the patient is lying or dishonest.

13. Diagnostics: Types of Pain
• Assessments of pain amount, location, quality
and duration can give hints as to the cause of the
pain:
– The easy and obvious: Pain related to acute injury is
localized to the site of the injury, is sharp and varies by
degree of injury.
– The more difficult:
• Nerve pain (pathway damage) may be poorly localized, may
vary in degree and quality (burning, tingling, etc.)
• Visceral pain may be vague or dull, may refer to other body
locations, and often comes with other symptoms (nausea,
hot flashes, etc.)

14. Chronic vs. Acute Pain
Acute
• Typically related to an
injury, change or disease.
• Last less than six months
(not coming and going)
• Relieved when the cause of
pain is removed or healed.
• Usually is reflected in vital
sign changes.
• Can be successfully treated
with narcotics, etc.
Chronic
• Any pain that last for longer
than sic months or is recurrent
beyond six months.
• Often causes are scarring,
disease, cancer, degeneration.
• May have profound emotional
consequences. Not typically
seen in vital sign changes.
• Difficult to treat, as narcotics
and analgesics are limited in
effectiveness.

15. Treating Pain: Medications
Anesthetics
• Removes the sensation of
pain entirely (via reducing
consciousness or numbing
an area)
• May be general (putting the
patient “Under”) or regional
(epidurals)
Analgesics
• Reduce the sensation of
pain (usually by blocking
pain receptors or limiting
the bodies ability to
respond)
• Two types: Narcotic
(morphine, hydrocodone,
etc.) and Non Narcotic
(Tylenol, NSAIDS)

16. Drug Types
Narcotics
• Act on the central nervous system
to reduce the brain’s reception of
pain.
• Do not reduce the inflammatory
response.
• Can depress respirations, cause
constipation, sedation.
• Risks of addiction and overdose
with unregulated use.
• Commonly abused.
• Tolerance Issues: long term use
associated with reduced
effectiveness (permanent).
Non Narcotics
• Act in the peripheral system to
block pain sensors or reduce
inflammation.
• No risk of abuse or
dependence.
• Side effect with over use
include toxicity, damage to
stomach, liver, etc.
• Ceiling Effect: doses above a
certain point do not increase
effects, only adverse reactions.

17. Other Medications to Reduce Pain
• Steroids:
– Reduce inflammatory
response, but can
weaken immune system,
cause other side effects.
• Antidepressants,
Anticonvulsants:
– Alter brain chemistry to
change the reception of
pain. Usually used in
chronic and verve pain.

18. Alternate Treatments for Pain
• Physical Therapy:
– Can correct issues with
musculoskeletal pain.
– May include hot/cold,
water therapy, massage,
etc. to treat pain and
reduce inflammation.
• Surgery:
– Can remove pain causing
structures.
– May cause scarring = more
pain.
• Psychological/Behavioral
Approach:
– Focus on thoughts,
emotions, biofeedback.
• Alternative/Complementa
ry Treatments:
– Acupuncture
– Massage
– Medication and Relaxation
– Energy Work (Reiki)

19. Developing a Pain Treatment Plan
• Things to address:
– Label it as chronic or acute.
– Can the cause be removed or reduced?
– What is the severity, and how much is this pain
effecting the patient’s life?
– Avoid long term prescriptions of narcotics.
– Encourage a MULTIDISCIPLINARY approach.
• Ex: Medications, physical therapy, massage for chronic
pain.

20. Legal Issues with Pain Treatment
• Practitioners feel a lot of pressure from
patients to prescribe certain types of pain
medications, even when they are not the best
and safe choice.
• Safety issues also arise when patients “Doctor
Shop” and practitioners do not check all of the
medications a person is on, leading to
redundant prescriptions.

21. Nursing Dilemma: The “Drug Seeker”
• This is a common term for a patient who
comes into the ER or Hospital frequently for
treatment of issues related to pain.
• They may be diagnosed with chronic pain
issues, and take several types of pain
medication, be demanding with dosing, and
show little evidence of pain in assessment.
• What can you do?

22. Solutions to the “Drug Seeker”
• Give doses as ordered, so long as you feel it is
safe.
• Do not judge your patient. Judging is easy,
empathizing is hard.
• Look for underlying psychological issues, signs of
addiction.
• Educate to alternative treatments, dangers of
abuse honestly.
• Discuss concerns with other HCPs and develop a
plan when real problems are identified.

23. Ethical Resolutions
• Remember, believe your patient and be their
advocate.
• Offer narcotics only when they are a legitimately
sound medical option.
• Offer alternatives and encourage treating the
cause of pain.
Patients will make their own choices, but ethical
and legal responsibility says that medical
professionals are responsible for patient safety and
education.