Pain Assessment in Health care

setting
Augustine Yaw Assah
 Critical Outcome
• Nurse assesses, identifies, and manages
acute and chronic pain within the
hospital and emergency setting
• Pain Definitions: Pain
– An unpleasant sensory and emotional experience
– Associated with actual or potential tissue damage
or described in terms of such damage
– Personal and subjective experience
• Can ONLY be described by person experiencing
pain
• Exists whenever the person says it does

• Pain is whatever the experiencing person says it is,

existing whenever he or she says it does!
 Definitions: Pain Management
• Pain Management
– Comprehensive approach to patient
needs experiencing problems
associated with acute or chronic pain
 Definitions: Pain Threshold
• Pain Threshold

–Least level of stimulus intensity

perceived as painful
 Definitions: Suffering
• Suffering

–Physical or emotional reaction to

pain

–Feeling of helplessness,
hopelessness, or uncontrollability
 Pain Physiology
• Nurses need an understanding of
basic physiology of pain to effectively
assess, intervene, and evaluate
patient outcomes.
Pain Receptors and stimuli
• Bare sensory nerve endings (nociceptors)
innervate all organs and tissues (except the
brain)

• Respond to all types of noxious stimuli

• Damaged cells release bradykinin (the most

potent pain producing chemical/enzyme
known), histamines, prostaglandins and acids
which bind to pain receptors

• This does not always lead to the perception of

pain
 Nociception
• The process of transmitting a pain signal from a
site of tissue damage to areas of the brain where
perception occurs

• Nociceptors are the primary afferent fibers that

initiate the pain experience when stimulated by
tissue damage

• Nociceptive process involves:

– Transduction
– Transmission
– Modulation
– Perception
 Transduction
• The process by which a chemical, thermal, or
mechanical noxious stimulus is changed into
an electrical stimulus by activating nociceptors
 Transmission
• Involves a series of events in which the electrical
impulse passes from the site of injury to the dorsal
horn of the spinal cord and then to the brain
– Once the signal enters the dorsal root of the spinal cord,
the nerve fibers separate into 2 groups of fibers:
a. Thinly myelinated faster conducting A-delta fibers
which transmit sharp or pricking, easily localized pain
and
b. Slower – conducting unmyelinated C fibers that
transmit burning, dull or aching, more diffused pain
 Modulation
• Involves changing or inhibiting transmission of
pain impulses in the spinal cord
– Descending modulatory pain pathway
• Can lead to either an increase in the transmission of
pain impulses (excitatory) or a decrease in
transmission (inhibition)
– Endogenous pain modulation (endorphins)
• Found throughout the CNS and suppress pain by
1. preventing the release of some excitatory
neurotransmitters (i.e., substance P) presynaptically
2. inhibiting the transmission of pain impulses
postsynaptically
 Perception
• The action potential reaches cortical
areas (the somatosensory projections
and limbic system) that allow recognition
of the pain sensation.
 Perception continued…..
• This thinking-feeling component of pain is
subjective, highly complex and individual.
• It is influenced by the following:
1. Stimulation of nociceptors
2. Alteration of transmission
3. Receptivity of cortex
4. Interpretation in cerebral cortex
 Neural Pathways
* Impulses travel to the central nervous system through two different fibers

1. Neospinothalamic (Lateral) Tract

- A- delta fibers transmit impulses quickly and end in the motor and sensory
areas of the cortex
- Believed to mediate localized, sharp, pricking, brief pain
- Mediates the sensory-discriminative dimension
- Via the cerebral cortex mediates the cognitive-evaluative dimension

2. Paleospinothalamic (Medial) Tract

- C – fibers transmit impulses more slowly and end in the lower regions of the
forebrain.
- Believed to mediate dull, burning, aching, prolonged pain
- Mediates emotional-motivational dimension

- Reticular Activating Formation

- Involved in aversive drive & similar pain related behavior
- Integrates pain experience with pain behavior
C fiber, A delta, & Dorsal horn
 Tolerance

– Greatest level of discomfort a person is

prepared to endure

– Person requires increased amount of

substance to achieve desired effect
Factors that influence tolerance
Increased tolerance Decreased tolerance
• Alcohol • Fatigue
• Drugs • Anger
• Hypnosis • Boredom
• Warmth • Anxiety
• Rubbing • Persistent pain
• Distraction • stress
• Faith
• Strong beliefs
 The meaning of pain
• Pain has different meaning for each person
• It may also differ for the same person at
different times
• Generally, most people see pain as a negative
experience, although it may have some
positive aspects
 Meaning of pain
Some of the meaning of pain may include
Harm or damage
Complication., such as infection
A new illness
Recurrence of disease
Fatal disease
Loss of mobility
Punishment for sins
Necessary for cure
Release from unwanted responsibilities, etc…..
 Response to pain
• Our perception to pain, tolerance and the meaning
we attach to a painful stimulus can greatly affect how
we respond to pain.
• Some of the responses include: weeping, anxiety,
frightfulness, apprehension, moaning, screaming,
begging for relieve or help, thrashing about in bed,
walking about aimlessly
• Others may lie quietly in bed and close their eyes,
grit their teeth, bite their lips, clench their hands or
sweat profusely
 Response to pain
How individuals respond to pain may also be influenced by
1. Past experience
2. Cultural values
3. Social expectation
4. Parental attitudes towards pain
5. Setting
6. Usual way of responding to stressors
7. Age
8. Preparation for pain context
9. Health professionals’ response
 Types of Pain
By longevity
I. Acute pain
II. Chronic

By tissue involved
I. Nociceptive
II. Neuropathic
 Acute
• Elicited by injury to body tissues

• Typically seen with trauma, acute illness,

surgery, burns, or other conditions of
limited duration

• Generally relieved when healing takes

place (within 3 months).
Acute pain
Acute pain
 Acute pain ctd…..
• It is accompanied by increased
muscle tension and anxiety both of
which contribute to increased pain
perception.

• Signs include tachycardia, increased

BP, pupillary dilatation, diaphoresis.
 Chronic
• Elicited by tissue injury

• May be perpetuated by factors remote from

the original cause and extend beyond the
expected healing time

• Generally lasts longer than 3 months

Chronic pain
 Chronic pain
• The source is either unknown or
cannot be eliminated
• It could be persistent or
• Intermittent
• It is characterised by:
 c
irritability

Increased Hopelessne
Preoccupati Social ss
on with isolation helplessnes
pain s

withdrawal
 Nociceptive
• Elicited by noxious stimuli that damages tissues or
has the potential to do so if the stimuli are
prolonged.

– Somatic pain: arises from skin, muscle, joint,

connective tissue, or bone; generally well localized and
described as aching or throbbing.
– Visceral pain: arises from internal organs such as the
bladder or intestine; poorly localized and described as
cramping.
– Referred pain: pain experienced at a different site
distant from the injured tissue
Somatic pain
Visceral pain
 Neuropathic
• Caused by damage to peripheral or central nerve
cells
– Peripheral:
• Arises from injury to either single or multiple peripheral
nerves
• Felt along nerve distributions
• Burning, shooting, stabbing or like an electric shock
• Diabetic neuropathy, herpetic neuralgia, radiculopathy, or
trigeminal neuralgia
– Central:
• Associated with autonomic nervous system
dysregulation
• Phantom limb pain (peripheral) or complex regional
 Types of Neuropathic Pain
• Paresthesia: an abnormal sensation, whether spontaneous
or evoked
• Dysesthesia: an unpleasant abnormal sensation, whether
spontaneous or evoked
• Allodynia: pain from a stimulus that does not normally
provoke pain (e.g., touching skin with a wisp of cotton)
• Hypoalgesia: diminished pain in response to normally
painful stimulus
• Hyperalgesia: painful syndrome characterized by an
abnormally painful reaction to a stimulus
Peripheral Neuropathic Pain
 Central Neuropathic Pain

http://timesofindia.indiatimes.com/photo/3582425.cms
 General Strategy
• Assessment

• Analysis

• Planning and Implementation/Intervention

• Evaluation and Ongoing monitoring

• Documentation
 Assessment
• Primary and secondary assessment

• Focused assessment
– Subjective data collection
– Objective data collection
 Subjective Data

1. HPI (history of present illness/injury) or Chief Complaint

• History of pain (OPQRST)
– Onset
– Provoking factors
– Quality
– Region/Radiation
– Severity
– Timing
• Efforts to relieve symptoms
– Others OLD CARTS, SOCRATES
 Subjective Data
2. Past medical history
a) Current or preexisting diseases/illness
- Any history of chronic pain conditions
b) New or recurring problem
c) Substance and/or alcohol use/abuse
d) Last known menstrual period
e) Current medications
- Prescriptions and over-the-counter
f) Nonpharmacologic interventions
- Massage, ice, heat, splinting, rest
g) Food or drink
- Type, amount, last full meal
h) Coping mechanisms
i) Allergies
 Subjective Data
3. Psychological/social/environmental factors:
a) Anxiety, Depression
b) Aggravating or alleviating factors
c) Expressions of pain
- This may be influenced by age, gender, ethnicity, culture,
& religion
d) Pain behavior is learned, yet adaptive, and it related to
pain threshold and pain tolerance
e) Pain expressions can be verbal, behavioral, emotional,
and physical
 Objective Data
1. General appearance
a) Psychological
- Change in level of consciousness or emotional state
b) Observations of behavior and vital signs should not be used
solely in place of self-report
- Crying, moaning, grimacing, frowning
- Rubbing or splinting body part, limping
c) Positioning and movement
- Unable to sit still
d) Physiologic
- Elevated blood pressure, elevated pulse, and elevated respiratory
rate with an irregular pattern
e) Level of distress/discomfort
 Objective Data
2. Obtain pain rating

a) Adults
1. Visual analog scale
- Often used when a paper copy of the scale is
needed
2. Numeric rating scale
3. Graphic rating scale
4. Thermometer-like scale
Visual Analog Scale
Numeric Rating Scale
Graphic Rating Scale
Thermometer-like Scale
 Objective Data
2. Obtain pain rating

b) Pediatric
1. FACES scale (> 6 years old)
2. Poker chip (> 3 years old)
- Child is given between 1-4 poker chips to
indicate the “size” of the pain
3. Numeric rating scale
- Depending on child’s age – may use “big hurt” as
opposed to “little hurt”
FACES / Numeric combined
Faces/numeric combined
 Objective Data
2) Obtain a pain rating

c) Infant
1. Neonatal Infant Pain Scale (NIPS)
2. Face, Legs, Activity, Cry, and Consolability (FLACC)
- Very similar to the NIPS
3. Neonatal Pain, Agitation, and Sedation Scale (NPASS)
4. Pain Assessment Tool (PAT)
NIPS
 FLACC
Categories 0 1 2
Face Smile or no Occassional Quivering chin,
expression grimace or frown; clenched jaw
withdrawn

Legs Normal position or Uneasy, tense, Kicking, legs drawn

relaxed restless up
Activity Lying quietly, Squirming, tense Arched, rigid,
moves easily shifting back and jerking
forth

Cry No cry Moans or Crying, screaming,

whimpers; frequent
occasional complaints
complaints

Consolability Content, relaxed Reassured by Difficult to console

occasional touch, or comfort
hug, or talk;
distractable
NPASS
PAT
 Objective Data

3. Inspection

– Position
– Skin color
– External bleeding
– Skin integrity
– Obvious deformity
– Edema
 Objective Data
4. Auscultation

- Breath sounds
- Bowel sounds
 Objective Data
5. Palpation

- Areas of tenderness (light, deep)

**Save painful part until last

 Diagnostic Procedures
• Laboratory studies

• Imaging

– TO FIND THE CAUSE OF THE PAIN

Management of pain
 Planning & Implementation
1. Determine priorities of care
a) Maintain ABC
b) Provide supplemental oxygen
c) IV access
d) Obtain and set up equipment
e) Prepare/assist with medical interventions
- Treat underlying conditions
- Cardiac & pulse oximetry monitoring as needed
f) Provide measures for pain relief
- Consider non-pharmacological interventions like positioning
(splints, support with pillows, sling) & cutaneous stimulation (ice,
heat, massage)
g) Administer pharmacological therapy as ordered
 Planning & Implementation
2. Relieve anxiety and apprehension

3. Allow significant others to remain with

patient if supportive

4. Educate patient and significant others

• About the efficacy and safety of opioid analgesics
 Analgesia
• The loss of sensitivity to pain

• In the clinical setting this refers to the

reduction of pain through therapy

• Interventions can be: pharmacological,

psychological, and social support
 Oligoanalgesia
• Inadequately or poorly treated acute pain

• Can result in negative physiologic outcomes

and exacerbate the underlying
pathophysiology of many illnesses and injuries
 Intervention: Administer Pharmacological
Therapy as Ordered
The World Health Organization (WHO)
recommends the use of the analgesic ladder as a
systematic plan for the use of analgesic
medications.

Step 1: Use nonopioid analgesics for mild pain

Step 2: Adds a mild opioid for moderate pain
Step 3: Use of stronger opioids when pain is moderate to
severe
WHO Analgesic Ladder
 Other drugs for pain relief
• Adjuvant drugs may be given along with
analgesia to augment pain relief. They may also
be an option for pain relief when other analgesia
are not effective. Examples include
• Sedatives and antianxiety agents
• Tricyclic antidepressants such as amitriptyline
• Anticonvulsants such as phenytoin sodium and
carbamazepine
• Corticosteroids such as dexamethasone
 Non pharmacological pain
management
1. Altering pain transmission
• Nerve block:
• Acupuncture
• Electrical stimulator
• Neurosurgical procedures
 MODIFYING THE PAIN STIMULUS

1. Cutaneous stimulation
• Lightly rubbing the affected area
• Application of compresses, either cold or
warm to the area
• Massaging the affected area
• Back rubbing
• Vibration
2. Reducing additional physical stimuli
• Placing pillows under painful joints when
helping patient to change positions
• The use of fracture boards for patients with
arthritis
• Using special beds (foster beds, stryker frame)
for patients with severe general trunk pain
• Lifting bed sheets with cradles from
painful body parts and turning sheets for
patients with severe neck pains
• Avoid bumping the bed or moving it
suddenly
3. Reducing auditory and visual stimuli
• Nursing patient in a quieter environment or
room
• Providing dim lights, pulling shades if sunlight is
intense
• Keeping verbal interactions at a minimum when
pain is severe
• Controlling the number of persons entering
patient’s room or visiting the patient
• Encouraging patients to use headphones or
keeping television or radio at reasonable level
 4. Distraction and relaxation
exercises
a. Distractive measures interfere with the pain
stimulus, thereby modifying the awareness of
pain. Meaningful distractive measures include
• Playing games, watching television
• Talking with someone
• Listening to favourite music
• Rhythmic breathing
• Focusing on an object
 Relaxation measures/techniques
• Relaxation measures decrease muscle tension
and fatigue that accompanies pain. It also
helps to decrease anxiety.
• Relaxation techniques are mostly beneficial to
patients with chronic pain to help reduce
stress that exacerbates the pain and the
person achieves a sense of control
• Common relaxation techniques
employed in nursing include
progressive relaxation and Benson’s
relaxation response.
 5. Reducing social isolation
• In cases when external stimuli are decreased
too much, the patient may lack distraction
from the pain stimuli; thus pain perception is
increased.
• But inevitably, some conditions require patient
to be isolated (e.g ca)
• Others are hospitalised far from home, leading
to limited visitation
Interventions that could help solve these include
• Placing the patient with a compatible
roommate
• Planning frequent contacts with health team
members
• Facilitating visits by family and friends
• Helping patient to be as comfortable as
possible during visits by family or friends
 MODIFYING PAIN RESPONSE

• Pain is largely subjective.

• Factors such as cultural background, past
experience, social expectations, parental
attitudes towards pain, age, setting, health
professional’s response to pain, etc influence
how people respond to pain.
• In all situations, the nurse can tactfully reduce
the individual’s response to painful stimuli by
 Explaining the problem

• sometimes, patients’ response to pain is really

the manifestation of their lack of knowledge
about the cause of pain.
• In these cases, simple explanation about what
is causing the pain and how long it will last is
all that is needed.
• Understanding that pain or discomfort is to be
expected may relieve anxiety or help patient
to alter expectations and be better prepared
for what will happen.
 Decreasing anxiety
because anxiety increases pain, measures taken to
decrease anxiety may help decreases pain
response. Interventions may include
• Maintain a calm, quiet manner
• Help patient explore concerns related the pain
(from socio-cultural perspective)
• Respect the patient’s response to pain, even if it
differs considerably from what you expect
• Maintain affection and empathize with the patient
• Arrange for someone to be with the patient if the
person fears being alone
• Talk with family or close friends and help them to
allay their anxieties so that these are not
transmitted to the patient
• Talk with patient and friends ways in which they
can help the patient, such as massage, distraction,
and changing patient’s position. People often feel
helpless when observing a loved one in pain and
may need help themselves to cope.
 Review Question
Which statement indicates the
development of opioid tolerance?

a. Larger doses of opioids are needed to control

pain compared to several weeks earlier
b. Stimulants are needed to counteract the sedating
effects of opioids
c. The patient becomes anxious about knowing the
exact time of the next dose of opioid
d. The patient no longer experiences constipation
from the usual dose of opioid.
 Answer
a. Larger doses of opioids are needed to control
pain compared to several weeks earlier
 Review Question
The pain management nurse observes a male
patient with complex regional pain syndrome not
wearing his right jacket sleeve. The patient
reports intense, right arm pain on light touch.
The nurse recognizes this pain as:

a. Allodynia
b. Hypoalgesia
c. Neuritis
d. Paresthesia
 Answer

a. Allodynia