PAIN – ASSESSMENT & MANAGEMENT
PAIN
➢ Is an unpleasant sensory TYPES OF PAIN INTENSITY
and emotional experience
associated with actual or
potential tissue damage. 1.LOCATION
➢ The 5th vital sign 1.Mild Pain- Pain in the 1-3 range.
➢ “Whatever the experiencing 2.DURATION
2. Moderate Pain - A rating of 4-6
person says it is, existing 3.INTENSITY
whenever he says it 3. Severe Pain - Pain reaching 7-10
does”(McCaffery). 4.ETIOLOGY
LOCATION
ETIOLOGY
1.Referred
1.NOCICEPTIVE PAIN
➢ Appear to arise in different areas to other parts of
the body. ➢ Nociceptive pain is a type of pain caused by damage
❖ E.g.: cardiac pain maybe felt in the shoulder to body tissue.
or left arm ➢ Nociceptive pain feels sharp, aching, or throbbing.
It’s often caused by an external injury, like stubbing
2. Visceral your toe, having a sports injury, or a dental
procedure.
➢ Pain arising from organs or hollow viscera is often
perceived in the area remote from the organ 2. SOMATIC PAIN
causing the pain
➢ Originates in the skin, muscles, bone, or connective
tissue.
DURATION ❖ E.g: the sharp sensation of a paper cut
ACUTE PAIN 3.NEUROPATHIC PAIN
➢ When pain lasts only through the expected ➢ Is associated with damaged or malfunctioning
recovery period, whether it is sudden or slow nerves due to illness
onset, regardless of its intensity. ❖ (e.g., injury (e.g.: phantom limb pain)
CHRONIC PAIN
➢ Also known as persistent pain, is prolonged,
usually recurring or lasting 3 moths or longer, and
interferes with functioning
CANCER PAIN
➢ May result from the direct effects of the disease
and its treatment, or it may be unrelated maybe
acute or chronic
PAIN – ASSESSMENT & MANAGEMENT
CONCEPTS ASSOCIATED WITH PAIN
1. PAIN THRESHOLD 2. PAIN TOLERANCE
➢ Is the maximum amount of painful stimuli that a person is willing
➢ Is the least amount of stimuli that is needed for a
to withstand without seeking avoidance of the pain or relief.
person to label a sensation as pain.
➢ Pain tolerance varies considerably from person to person, even
within the same person at different times and in different
➢ May vary slightly from person to person, and may be
circumstances.
related to age, gender, or race, but it changes little in
the same individual over time.
❖ Example, a woman may tolerate a considerable amount
of labor
NOCICEPTION
The physiologic process related to pain perception
TRANSDUCTION
¨When a pain threshold has been reached and there is injured tissue, substances that
stimulate the pain receptors called nociceptors, are released.
¨These pain receptors can be stimulated by serotonin, histamine, prostaglandin,
bradykinin and substance P.
¨Ibuprofen and local anesthetic can decrease pain
BRADYKININ
PROSTAGLANDIN
➢ a powerful vasodilator is released at the site of an
➢ These compounds sensitize the pain receptors
injury increases capillary permeability causes the
and enhance the effects of bradykinin and
release of inflammatory chemicals such as
histamine.
histamine.
➢ These two chemicals (bradykinin and histamine) SUBSTANCE P
cause the area to redden, swell, and become
tender. ➢ act as a stimulant to the nociceptors involved
➢ Bradykinin also stimulates the release of in the inflammatory response of the tissues.
prostaglandins. ➢ known to be a neurotransmitter that enhances
the movement of impulses across the nerve
SEROTONIN synapse from the primary afferent neuron to
the second order neuron
➢ a major component of the inflammatory chemical
milieu and contributes to the pain of tissue injury.
PAIN – ASSESSMENT & MANAGEMENT
2.TRANSMISSION
¨The 2nd process of nociception, transmission of pain, includes three (3) segments:
Substance P
➢ serves as a neurotransmitter, enhancing the movement of the impulses across the nerve synapse
from the primary afferent neuron to the second-order-neuron in the dorsal horn of the SC.
1.TRANSMISSION OF IMPULSE FROM THE 2. FROM THE SC TO BRAIN STEM AND THALAMUS VIA
PERIPHERAL NERVE FIBERS TO THE SPINAL THE SPINOTHALAMIC TRACT.
CORD (SC).
➢ Pain signals are also sent upwards in the spinal
C FIBERS cord via the Spinothalamic tract (amongst
others) to an area in the brain stem (base of the
➢ larger, unmyelinated nerve fibers,
brain) called the thalamus.
dull aching pain
3. TRANSMISSION OF INFORMATION TO THE BRAIN
A DELTA
➢ Further processing occurs in the thalamus with
➢ smaller, myelinated fibers, sharp,
signals being sent to areas controlling blood
localized pain
pressure, heart rate, breathing, and emotions.
➢ OPIOIDS CAN DECREASE PAIN
❖ Messages come out of the spinal cord and
travel via motor nerves to the arm
muscles, causing the arm to withdraw
quickly.
❖ This is an automatic reflex that does not
involve the brain or conscious thought
PAIN – ASSESSMENT & MANAGEMENT
3. PERCEPTION 4. MODULATION
¨When the client becomes conscious of the pain. Pain Neurons send signal back to dorsal horn of SC.
perception is the sum of complex activities in the CNS
Causes release of endogenous opioids, serotonin
that may shape the character & intensity of pain
and norepinephrine (NE)
perceived and give meaning to the pain.
➢ can inhibit or reduce ascending painful
impulses in the dorsal horn.
COGNITIVE-BEHAVIORAL THERAPY & approaches such
¨Tricyclic antidepressant
as distraction & imagery have been developed based on
evidence that brain processes can influence pain ➢ can relieve pain by blocking the resorption
perception. of NE and serotonin making them more
available.
¨GATE CONTROL THEORY
➢ In 1965, Melzack and Wall proposed the gate control The pain gate in the spinal cord can be shut in several
theory. different ways:
➢ According to this theory, peripheral nerve fibers( A-
1.Stimulation of touch fibers
delta or C) carrying pain to the spinal cord can have
their input modified at the spinal cord level before 2.Release of endogenous opioids
transmission to the brain.
3.Electrical stimulation
I¨Synapses in the dorsal horns act as gates that close to keep
impulses from reaching the brain or open to permit impulses 4.Morphine and other opioid drugs
to ascend to the brain. 5.Normal and excessive sensory stimuli
¨According to the gate control theory: 6.Cerebral cortex and thalamic inhibition of pain
➢ Small-diameter nerve fibers (A-delta or C)carry pain
stimuli through a gate..
FACTORS AFFECTING THE PAIN EXPERIENCE
➢ Large diameter nerve fibers (A- beta) going through the
same gate can inhibit the transmission of those pain
impulses-that is, close the gate. 1.Ethnic and Cultural Values
2.Developmental Stage
3.Environment and Support people
4.Previous Pain Experiences
5.Meaning of Pain
PAIN – ASSESSMENT & MANAGEMENT
NURSING MANAGEMENT – ASSESSMENT
1.Pain History LOCATION PAIN INTENSITY
2.Observation of Behavioral and Specific Location The SINGLE MOST IMPORTANT indicator
Physiological Responses of the existence and intensity of pain -----
➢ ask the client to point the site of
“the client’s REPORT of pain.
3.Daily Pain diary the discomfort.
Multiple pain sites
1.LOCATION PAIN ASSESSMENT SCALES ADULT
➢ (symbol) with an X
2.PAIN INTENSITY OR RATING SCALES ❖ Numerical Rating Scale (NRS)
Child
❖ Visual Analog Scale (VAS)
3.PAIN QUALITY ❖ Pain Assessment in Advanced
➢ needs to understand their
4.PATTERN vocabulary (e.g.: “tummy”) Dementia Scale (PAINAD)
parents can help in interpreting
5.PRECIPITATING FACTORS PEDIATRICS
Documenting
6.ALLEVIATING FACTORS ❖ Faces, Legs, Activity, Cry and
➢ body landmarks Consolability (FLACC)
7.ASSOCIATED SYMPTOMS ▪ e.g.: proximal, distal, ❖ Wong-Baker Faces scale
medial, lateral, diffuse ❖ Numerical Rating Scale (NRS)
8.EFFECT ON ACTIVITIES OF DAILY
❖ Visual Analog Scale (VAS)
LIVING
9.COPING RESOURCES
PAIN QUALITY
10.AFFECTIVE RESPONSES
Descriptive adjectives help people
communicate the quality of pain.
➢ Each person’s pain
experience is unique
“it is important to record the
➢ The client is the best description of pain VERBATIM”
interpreter of the pain
experience
PAIN – ASSESSMENT & MANAGEMENT
PATTERN PRECIPITATING FACTORS ALLEVIATING FACTORS
Includes time of onset , duration and Certain activities precedes pain these Nurses must ask clients to describe
recurrence or intervals without pain. observations can help prevent pain and anything that they have done to
determine its cause. alleviate the pain (e.g.: home
remedies).
ASSOCIATED SYMPTOMS
EFFECT ON ACTIVITIES DAILY Explore
Also included in the clinical appraisal of
pain are associated symptoms such as The nurse should ask the client to • relief was obtained or not
nausea, vomiting, dizziness and describe how the pain has affected
diarrhea.
The following aspects of life: COPING RESOURCES
These symptoms may relate to the
❖ Sleep Appetite Everyone exhibits personal ways of
onset of pain or they may result from
❖ Concentration coping with pain.
the presence of pain.
❖ Work/school
❖ Interpersonal
AFFECTIVE RESPONSES ❖ Relationships Marital Strategies may include seeking quiet
relations/sex and solitude, learning about their
Affective responses vary according to
❖ Home activities condition, pursuing interesting or
the situation, the degree and duration
❖ Driving/walking exciting activities (for distraction),
of pain, the interpretation of it, and
❖ Leisure activities saying prayers (or engaging in other
many other factors.
❖ Emotional status (mood, meaningful rituals), or socializing (with
The nurse needs to explore the client’s irritability, depression, anxiety). family, friends, support groups, etc.).
feelings of anxiety, fear, exhaustion,
level of function, depression, or a sense
of failure. ASSESSMENT INTERVIEW PAIN HISTORY
Precipitating factors: Severity:
▪ On a scale of 0 to 10, with ‘0’ representing no pain
▪ What triggers the pain or makes it worse?
(substitute the term client uses e.g., ‘no burning’) and
▪ What measures or methods have you found helpful in ‘10’ representing the worst pain imaginable (e.g.,
reducing or relieving the pain? ‘burning sensation’), how would you rate the degree of
▪ What pain medications do you use? discomfort you are in right now?
Timing:
Quality: a. Time of onset: When did or does the pain start?
b. Duration: How long have you had it, or how long does it
▪ Tell me what your discomfort feels like.
usually last?
Region/Radiation: c. Constancy: Do you have pain-free periods? And for how
long?
▪ Where is your discomfort? Ask client to point to the Understanding:
location and document the exact location (e.g., left ▪ What does experiencing this pain mean to you?
▪ Does it signal something about the future or the past?
lower abdomen instead of abdominal pain).
▪ What worries or scares you the most about your pain?
▪ Do you feel the pain moving to other parts of the body?
If yes, Where?
PAIN – ASSESSMENT & MANAGEMENT
Associated symptoms:
▪ Do you have any other symptoms (e.g., nausea, dizziness, shortness of breath) before, during, or after your pain?
Coping resources:
▪ What do you usually do to deal with pain?
Affective response:
▪ How does the pain make you feel? Anxious? Depressed? Frightened? Tired? Burdensome?
Past pain experience:
▪ Tell me about past pain experiences you have had and what was done to relieve the pain.
Effects on ADLs:
▪ How does the pain affect your daily life? (e.g., eating, working, sleeping, & social and recreational activities)?
B. OBSERVATION OF BEHAVIORAL AND PHYSIOLOGICAL RESPONSES
A client’s self-report is an important! Physiologic responses vary with the origin and duration of the pain.
▪ Not all clients, however, are able Early in the onset of acute pain (v/s is Elevated).
to self-report.
• The body does not sustain the increased sympathetic function over a
This group, referred to as “nonverbal” prolonged period and, therefore, the sympathetic nervous system
clients, includes: adapts, causing the responses to be less evident or even absent.
1. The very young;
2. Individuals who are cognitively C. DAILY PAIN DIARY
impaired, critically ill, or
comatose; and some individuals ➢ For clients who experience chronic pain, a daily diary may help the client
at end of life. and healthcare provider identify pain patterns and factors that worsen or
resolve the pain experience.
➢ The recorded data in the diary provide the basis for developing or modifying
Nonverbal responses: the plan for care.
1.Facial expression The record could include the following:
2.Vocalizations • Time of onset of pain
3.Immobilization of the body or a part • Activity or situation
4.Purposeless body movements • Physical pain character (quality) and intensity level (0–10)
5.Behavioral changes • Emotions experienced and intensity level (0–10)
6.Rhythmic body movements or rubbing • Use of analgesics or other relief measures (intervention)
• Pain rating after intervention taken
• Comments.
PAIN – ASSESSMENT & MANAGEMENT
DIAGNOSIS BARRIERS TO PAIN MANAGEMENT
➢ Over the last 20 years, opioid misuse and abuse has
EXAMPLES OF SUCH NURSING DIAGNOSES FOLLOW:
become an increasing problem in our society (Assil,2016).
➢ Mild acute pain/moderate acute pain/severe The Centers for disease Control and Prevention(CDC, 2018)
➢ Acute pain, or chronic pain related to provided data that showed the rise in opioid overdose
➢ Impaired coping related to prolonged continuous deaths occurred in three distinct waves (1990, 2010 and
back pain, ineffective pain management, and 2013).
inadequate support systems ➢ The CDC’s Guideline for Prescribing Opioids for Chronic
➢ Altered physical mobility related to pain and Pain (2017;CDC, n.d.) provides 12 recommendations
inflammation Secondary to arthritic pain in knee grouped into 3 areas:
and ankle joints (1) Determining when to initiate or continue opioids for
➢ Impaired sleep related to increased pain chronic pain;
perception at night. (2) Opioid selection, dosage,duration, follow-up, &
discontinuation;
PLANNING (3) assessing risk and addressing harms of opioid use.
The National Academies of Sciences, Engineering, and Medicine
When planning, nurses need to choose pain relief (2017) reports four strategies, each with a variety of approaches,
measures appropriate for the client, based on the To address the opioid epidemic while meeting the needs of
assessment data and input from the client or support clients.
people.
These strategies include the following
1.Restricting the supply of opioids.
Nursing interventions may include a variety of
pharmacologic and non- pharmacologic strategies. 2.Influencing prescribing practices.
3.Reducing demand.
IMPLEMENTING 4.Reducing harm. (One of the approaches for this
strategy is to expand access to naloxone, an opioid
Nursing management of pain consists of antagonist, to reverse overdose.
both independent and Collaborative nursing Another barrier to effective pain management is the fear of
actions. becoming addicted. Both nurses and clients often hold this fear
1.Tolerance occurs when the client’s opioid dose, over
time, leads to a decreased sensitivity to the drug’s
Independent nursing actions analgesic effect.
Example: ______________ 2.Physical dependence is an expected physical
response when a client who is on long-term opioid
Collaborative nursing actions? therapy has the opioid significantly reduced or
withdrawn.
Example: ______________
3.Addiction is a chronic, relapsing, treatable disease
influenced by genetic, developmental, and
environmental factors. Research
PAIN – ASSESSMENT & MANAGEMENT
IMPLEMENTING
KEY STRATEGIES IN PAIN MANAGEMENT ➢ The most concerning adverse effect of
Another barrier to effective pain management is the fear opioids is RESPIRATORY DEPRESSION (e.g.,
of becoming addicted. Both nurses and clients often hold 8 breaths per minute or less)
this fear ➢ Assessing for sedation and respiratory status
1.Acknowledging and Accepting Clients’ Pain. is critical during the first 12 to 24 hours after
starting opioid therapy.
2.Assisting Support People.
➢ The most critical period is during the peak
3.Reducing Misconceptions About Pain. effect of the first dose(15 minutes if
4.Reducing Fear and Anxiety. administered IV; first hour after IM, oral,
route).
5.Preventing Pain
Preemptive analgesia
NON PHARMACOLOGIC
➢ Is the administration of analgesics before surgery
to decrease or relieve pain after surgery and Nonpharmacologic pain management
reduce the need for opioid pain control. consists of a variety of physical, cognitive–
Multimodal analgesia behavioral, and lifestyle pain management
strategies that target the body, mind,
➢ Combines analgesics from two or more drug
classes and a variety of delivery approaches for
spirit,and social interactions (Table 30.6).
the analgesics that result in reducing, and often
eliminating, the need for opioids. his is also
referred to as opioid-sparing therapy.
EVALUATING
PHARMACOLOGIC
OPIOID SIDE EFFECTS ➢ The goals established in the planning phase
When administering any analgesic, the nurse must review
are evaluated according to specific desired
adverse effects. Adverse effects of the opioids typically outcomes, also established in that phase.
include: ➢ If outcomes are not achieved, the nurse
and client need to explore the reasons
before modifying the care plan.
1. Sedation
➢ Evaluation of the client’s pain therapy
2. Respiratory depression
3. Nausea includes the response of the client, the
4. Vomiting changes in the pain, and the client’s
5. Constipation perceptions of the effectiveness of the
6. Urinary retention therapy.Ongoing verbal or written feedback
7. Blurred vision
from the client and family is integral to this
8. Sexual dysfunction.
process.
PAIN – ASSESSMENT & MANAGEMENT
PAIN – ASSESSMENT & MANAGEMENT
PAIN – ASSESSMENT & MANAGEMENT
