pain assessment

Maria Carmela L. Domocmat, RN, MSN

an unpleasant sensory and emotional
experience, which we primarily associate
with tissue damage or describe in terms of
damage, or both (IASP)
the fifth vital sign


http://static.howstuffworks.com/gif/pain-2.gif


Proposed by Melzack and Wall in 1965
Has influenced pain research and treatment
Pain is explained as a combination of
physiologic phenomena in addition to a
psychosocial aspect that influences the
perception of pain


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 mos
Cancer pain
Often due to compression of meninges or from the
damage to these structures following surgery,
chemotherapy, radiation, or tumor growth and
infiltration


Nociceptive or somatic pain
Pain r/t tissue damage
Subtypes: acute and remitting or chronic and
persistent
Neuropathic pain
Result from direct injury to the peripheral or CNS
Psychogenic 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


Characteristic of Nociceptive Nociceptive deep somatic Nociceptive visceral Neuropathic
pain superficial
Origin 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 membranes

Examples 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 pain

Description Hot, burning, Dull, aching Dull, deep Dysesthesia (pins and needles, tingling,
stinging burning, lancinating, shooting)
Allodynia; phantom pain, pain in numb
area

Localization to Very well defined Well defined Poorly defined Nerve or dermatome distribution
site of stimulus
Movement No effect Worsening pain May improve pain Nerve traction provokes pain, e.g. sciatic
Resident prefers to be still stretch test

Referral No Yes Yes Yes
Local tenderness Yes Yes Maybe Yes
Autonomic effects No No Nausea, vomiting, Autonomic instability: warmth, sweating,
sweating, BP and heart rate pallor, cold, cyanosis (localized to nerve
changes pathway)

raised heart rate, pulse, temperature,
respiratory rate, blood pressure or sweating
abnormal color of skin, discharge from eyes,
nose, vagina or rectum
lesions to oral or rectal mucosa, skin
distension of the abdomen, swelling of limbs,
swelling of body joints
abnormal results on testing urine (e.g. presence
of blood, leucocytes, glucose)
functional decrease in mobility, range of
movement, activity, endurance, and increase in
fatigue
changes in posture-standing, sitting, reclining

aggression, resistance, withdrawal,
restlessness
facial expression: grimacing, fear, sadness,
disgust
verbalizations: self reports of pain, requests
for analgesia, requests for help, sighing,
groaning, moaning, crying, and unusual
silence.


http://www.hospicepatients.org/images/capqf2.gif

Location
Severity
Verbal descriptor Scale (VBS)
Visual Analog Scale (VAS)
Numeric Rating Scale (NRS)
Wong-Baker Faces Pain Scale (FACES)
Associated features
Attempted treatments, medications, related
illness, impact on daily activities


Ask patient to describe pain and how the
pain started
Is it related to a site of injury, movement, or
time of day?
What is the quality of pain –sharp, dull,
burning?
Ask if pain radiates (spread around) or follow
a specific pattern
What makes pain better or worse?


Attempted treatments, medications, related
illness, 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)

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 does
it last? How often does it come?
Setting in which it occurs: include environmental
factors, personal activities, emotional reactions,
or other circumstances that may have
contributed to the illness
Remitting or exacerbating factors: is there any
thing that makes it better or worse?
Associated manifestations: have you noticed
anything else that accompanies it?

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)


OLD CARTS
Onset
Location
Duration
Character
Aggravating/Alleviating Factors
Radiation
Timing
Severity


This is a simple descriptive pain intensity
scale that ranges pain intensity from no pain
to worst pain.


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)

Character
Onset
COLDSPA Location
Duration
Severity
Pattern
Associated Factors

Character: describe the sign or symptom;
how does it feel, look, sound, smell, and so
forth?
Onset: when did it begin?
Location: where is it?, does it radiate
Duration: how long does it last?
Severity: how bad is it?
Pattern: what makes it better? what makes it
worse?
Associated Factors: what other symptom
occur with it?


Simple descriptive pain intensity scale
Ranges pain on a scale between mild, moderate
and severe


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

a verbal tool where a scale of 0-10 pain
intensity is asked to the patient. The patient
then states pain from 0-10 where 0 is no pain
and 10 is worst pain


http://understandingpain.files.wordpress.com/2010/07/pain_scale1.png


Shows different facial expression where the
client is asked to choose the face that best
describes the intensity or level of pain
esp for pediatric client


http://pacificu.edu/optometry/ce/courses/22746/images/clip_image002.j
pg

The Abbey Pain Scale is suitable for residents
with dementia who cannot verbalise their
pain, and may also be useful for cognitively
intact residents who aren't willing or cannot
talk about their pain.

http://www.racgp.org.au/silverbookonline/images/tools_abbey_pain_scale
.gif

http://www.racgp.org.au/silverbookonline/images/tools_abbey_pain_scale
.gif

The Resident's Verbal Brief Pain Inventory is
suitable for residents able to verbalize their
pain. The same scale/s selected for the
individual resident should be for
reassessment.

http://www.racgp.org.au/silverbookonline/images/tools_pain_inventory.gif

http://www.racgp.org.au/silverbookonline/images/tools_pain_inventory.gif

http://img.medscape.com/fullsize/migrated/452/694/pn452694.tab3.gif

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


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


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


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


HR
Normal finding: 60-100 bpm
Abnormal finding: increased HR may indicate
discomfort or pain


RR
Normal finding: 12-20 breathes per min
Abnormal finding: RR may be increased;
breathing may be irregular and shallow


BP
Normal finding:100-130/60-80
Abnormal finding: increased BP often occurs in
severe pain


Other observations r/t specific part
Palpation of abdomen
ROM tests for joints


Validate your data
Document data
Possible conclusions


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)


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


Wellness diagnoses
Readiness for enhanced spiritual well-being r/t
coping with prolonged physical pain
Readiness for enhanced comfort level


pain assessment

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pain assessment