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Pain Assessment Pain Types Pain Patternn
- 1. Pain Types andViscerogenic Pain Patterns
- 2. Pain • Primary symptomin many PT practices • Recognized as the 5th vital sign
- 3. Most common sitesof referred pain from a systemic disease process • Chest • Back • Shoulder • Scapula • Pelvis • Hip • Groin • SI joint
- 4. Mechanisms of ReferredVisceral Pain • Embryologic Development • Multisegmental Innvervation • Direct Pressure and shared pathways
- 5. Mechanisms of ReferredVisceral Pain • Embryologic Development • Pain refers to the organ location during fetal development • Pain refers to other body part/s coming from the same tissue in the utero • Chest is part of the gut • Pneumonia or pleuritis refer pain to the abdomen • Heart’s pericardium is formed from the gut • MI or pericarditis can also refer pain to the abdomen
- 7. Mechanisms of ReferredVisceral Pain • Multisegmental Innervation • Viscera have multisegmental innervation • Heart • Bronchi • Stomach • Kidneys • Intestines • Bladder • Pain may be referred to areas supplied by the corresponding spinal nerves • cardiac pain can occur in jaw, neck, upper trapezius, shoulder, and arm (innervated by C3 to T4) • Shoulder pain - cardiac and diaphragmatic origin • C5 spinal segment - supplies the heart, respiratory diaphragm, and shoulder
- 9. Mechanisms of ReferredVisceral Pain • Direct Pressure and Shared Pathways • Direct pressure from any inflamed , infected , or obstructed organ in contact with the respiratory diaphragm can refer pain to the ipsilateral shoulder • Spleen tucked up under the diaphragm on the left side • Tail of the pancreas in contact with the diaphragm on the left side • Head of pancreas in contact with the diaphragm on the right side • Gallbladder located under the liver on the right side • Central diaphragm impingement can refer pain to the shoulder • Peripheral diaphragm impingement can refer pain to the ipsilateral costal margins and/or lumbar region
- 10. Assessment of Painand Symptoms • Cultural rules • Differences in pain perception • Intensity and responses
- 11. Assessment of Painand Symptoms • Component of a comprehensive pain assessment • Health history • physical exam • medication history • including nonprescription drug use and complementary and alternative therapies • assessment of functional status • consideration of psychosocial-spiritual factors
- 12. Assessment of Painand Symptoms • To elicit a complete description of symptoms from the client, use a term other pain • Client’s symptoms • Hurt • Sore • Burning • Tightness • Heaviness • Discomfort • Aching
- 13. Pain Assessment inthe Older Adult • Pain is accepted as key feature of the aging process • Older adults use OTC analgesic medications for pain, aching & discomfort • Adults may avoid giving an accurate assessment of their pain • Some may expect pain with aging • Fear that talking about pain will lead to expensive tests or medications with unwanted side effects • Others underreport pain symptoms due to fear of losing one's independence
- 14. Pain Assessment inthe Older Adult • Factors affecting older adults’ reliability in reporting pain • Sensory impairment • Cognitive impairment • Ability to comprehend a scale and communicate a response • Frail adults • Dementia (pain report is reliable in the early stages using VAS) • Alzheimer’s type dementia • Loses short-term memory • Cannot always identify the source of recent painful stimuli
- 15. Pain Assessment inthe Older Adult • Symptoms of Pain in Clients with Cognitive Impairment • Verbal comments such as ouch or stop • Nonverbal vocalizations (e.g., moans, signs, gasps) • Facial grimacing or frowning • Audible breathing independent of vocalization (labored, short or long periods of hyperventilation) • Agitation or increased confusion • Unable to be consoled or distracted • Bracing or holding onto furniture • Decreased mobility • Lying very still; refusing to move • Clutching the painful area • Resisting care provided by others; striking out; pushing others away • Sleep disturbance • Weight loss • Depression
- 16. Pain Assessment inthe Older Adult • McGill Melzack Pain Questionnaire • Verbal Descriptor Scale (VDS) • Most sensitive and reliable among older adults • Indicated for those with mild to moderate cognitive impairment • Alzheimer’s Discomfort Rating Scale • Helpful for adult who are unable to communicate their pain • Pain Assessment in Advanced Dementia • a simple, valid, and reliable instrument for measurement of pain in noncommunicative clients
- 17. Pain Assessment inthe young group • Infants and children with substantial cognitive impairment may be able to use pain-rating scales when explained carefully • If using a rating scale is not possible: • may rely on the parent or caregiver’s report and/or other measures of pain in children with cognitive or communication impairments and physical disabilities • Terms to use • Hurt rather pain: understood by children as young as 3 years old • Owie or ouchie
- 18. Pain Assessment inthe young group • Look for telltale behavior: • Lack of cooperation • Withdrawal • Acting out • Distractibility • Seeking comfort • Altered sleep patterns • Vocalizations • Eating patterns
- 19. Pain Assessment inthe young group • Faces Pain Scale – Revised (FPS-R) • child looks at the faces, the therapist or parent uses the simple words to describe the expression • corresponding number is used to record the score • Child Facial Coding System (CFCS) and the Neonatal Facial Coding System (NFCS) • can be used as behavioral measures of pain intensity in very young children and infants
- 20. Characteristics of Pain •Location • Description of sensation • Intensity • Duration • Frequency and Duration • Pattern • Other additional components: • Factors that aggravate the pain • Factors that alleviate/relieve the pain
- 21. Location of Pain •Show me exactly where your pain is located • Do you have any other pain or symptoms anywhere else? • If yes, what causes the pain or symptoms to occur in this other area?
- 22. Location of Pain •Superficial lesion (probably not severe) • client points to a small, localized area and the pain does not spread • Viscera or deep somatic structure (diffuse, segmental, referred pain) • client points to a small, localized area but the pain does spread
- 23. Description of Pain •What does it feel like? • You may want to ask: Is your pain/Are your symptoms: • Knifelike • Dull • Boring • Burning • Throbbing • Prickly • Deep aching • Sharp
- 24. Description of Pain •Has the pain changed in quality since it first began? • Changed in intensity? • Changed in duration (how long it lasts)?
- 25. Description of Pain •Systemic origin of symptoms • client describes the pain as… • knifelike, boring, colicky, coming in waves, or a deep aching feeling • Aching pain of a muscular lesion • Pain increases by squeezing or by pressing the muscle overlying the area of pain • Resisting motion of the limb may also reproduce aching of muscular origin that has no connection to deep somatic aching
- 26. Intensity of Pain •Extremely important but difficult component to assess in the overall pain profile • Highly subjective • Careful assessment of the person's nonverbal behavior • Correlation of the person's personality with his or her perception of the pain • May be influenced by psychologic factors (emotions) • African Americans vs. Caucasians • Men vs. Women • Reported less among individuals with some means of social and emotional support
- 27. Intensity of Pain •Quantify symptoms other than pain such as: • Stiffness • Pressure • Soreness • Discomfort • Cramping • Aching • Numbness • Tingling
- 28. Intensity of Pain •Visual Analog Scale • Numerical Rating Scale • (+) plus is used for clients who indicate the pain is "off the scale" or "higher than a 10"
- 29. Frequency and Durationof Pain • Should be asked how often the symptoms occur • Is the pain constant or intermittent? • How long do the symptoms last? • Systemic disease – shown to be constant rather than an intermittent type of pain experience • Clients who indicate that the pain is constant should be asked: • Do you have this pain right now? • Did you notice these symptoms this morning immediately when you woke up?
- 30. Frequency and Durationof Pain • Pain of musculoskeletal origin • not actually present consistently • can be reduced with rest or change in position
- 31. Pattern of Pain •These questions may be helpful in further assessing the pattern of pain, especially how the symptoms may change with time • Tell me about the pattern of your pain/ symptoms. • Alternate question: When does your back/shoulder (name the involved body part) hurt? • Alternate question: Describe your pain/ symptoms from first waking up in the morning to going to bed at night
- 32. Pattern of Pain •Follow-up questions may include: • Have you ever experienced anything like this before? • If yes, do these episodes occur more or less often than at first? • How does your pain/symptom(s) change with time? • Are your symptoms worse in the morning or evening?
- 33. Pattern of Pain •Pattern of pain associated with systemic disease • often a progressive pattern with a cyclical onset • the client describes symptoms as being alternately worse, better, and worse over a period of months • If the client is unsure of the pattern of symptoms/ avoided paying any attention to this pain description • Advise patient to keep a record at home to take note of the symptoms for 24 hours
- 34. Pattern of Pain •Record the use of any medications (medications can alter pain pattern or characteristics) • Did the current medication reduce, control, or relieve pain? • Look for side effects or adverse reactions to any drugs or drug combinations • Possible peptic ulcer • Clients taking nonsteroidal anti-inflammatory drugs (NSAIDs) who experience an increase in shoulder, neck, or back pain several hours after taking the medication
- 35. Pattern of Pain •Constitutional symptoms affect the whole body and are characteristic of systemic disease or illness • Fever • Diaphoresis (unexplained perspiration) • Night sweats (can occur during the day) • Nausea • Vomiting • Diarrhea • Pallor • Dizziness/syncope (fainting) • Fatigue • Weight loss
- 36. Aggravating & RelievingFactors • Aggravating factors: • What brings your pain (symptoms) on? • What kinds of things make your pain (symptoms) worse? • Eating • Exercise • Rest • Specific positions • Excitement • Stress • Relieving factors: • What makes the pain better?
- 37. Aggravating & RelievingFactors • Follow-up questions: • How does rest affect the pain/symptoms? • Are your symptoms aggravated or relieved by any activities? • If yes, what? • How has this problem affected your daily life at work or at home? • How has this problem affected your ability to care for yourself without assistance (e.g., dress, bathe, cook, drive)?
- 38. Aggravating & RelievingFactors • Systemic pain • tends to be relieved minimally • relieved only temporarily, or • unrelieved by change in position or by rest. • Musculoskeletal pain • often relieved both by a change of position and by rest
- 40. Associated Symptoms • Whatother symptoms have you had that you can associate with this problem? • Use this follow-up question if the client denies any additional symptoms • Burning • Heart palpitations • Numbness/Tingling • Difficulty in breathing • Problems with vision • Hoarseness • Difficulty in swallowing • Nausea • Vomiting • Dizziness • Night sweats • Weakness
- 41. Associated Symptoms • Ifthe clients answers “yes” • Check for the presence of the bilateral symptoms • Red flag • Bilateral weakness (either proximal or distal) • Early symptoms of Multiple Sclerosis or warning signs of an impending CVA • Blurred vision • Double vision • Scotomas (black spots before the eyes) • Temporary blindness
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