Chapter 10: pain assessment the fifth vital sign

Question 1

Where does pain originate from?

Answer 1

central nervous system, peripheral nervous system or both

Question 2

What is nociception?

Answer 2

this is the term used to describe how noxious stimuli are perceived as pain

Question 3

What is visceral pain?

Answer 3

originates from larger interior organs (kidney, stomach, intestine, gallbladder, pancreas)
pain can stem from direct injury to organ or stretching of organ from tumor, ischemia, distention, or severe contraction
Pain impulse transmitted by ascending nerve fibers along with nerve fibers of autonomic nervous system
That is why visceral pain often presents with autonomic responses such as vomiting, nausea, pallor, and diaphoresis

Question 4

What are examples of visceral pain?

Answer 4

ureteral colic, acute appendicitis , ulcer pain, and cholecystitis

Question 5

What is deep somatic pain?

Answer 5

comes from sources such as blood vessels, joints, tendons, muscles, and bone
injury may result from pressure/trauma/ischemia

Question 6

What is cutaneous pain?

Answer 6

derived from skin surface and subcutaneous tissues; injury is superficial with a sharp burning sensation

Question 7

What is psychogenic pain?

Answer 7

linking pain to a mental disorder negates a person’s pain report
a clinician’s lack of awareness and understanding of neuropathic pain may contribute to this mislabeling

Question 8

What is referred pain?

Answer 8

pain that isfelt at a particular site but originates from another location
both sites are innervated by same spinal nerve and it is difficult for the brain to differentiate point of origin
referred pain may originate from visceral or somatic structures
Various structures maintain their same embryonic innervation
It is useful to have knowledge of areas of referred pain for diagnostic purposes

Question 9

What is acute pain?

Answer 9

Acute pain is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals
Examples of acute pain include surgery, trauma, and kidney stones
Acute pain serves a self-protective purpose; acute pain warns individual of actual or potential tissue damage

Question 10

What is chronic pain?

Answer 10

In contrast, chronic (or persistent) pain is diagnosed when pain continues for 6 months or longer
It can last 5, 15, or 20 years and beyond
Chronic pain does not stop when the injury heals
It persists after the predicted trajectory
Chronic pain outlasts its protective purpose, and the level of pain intensity does not correspond with the physical findings
Unfortunately, many patients with chronic pain are not believed and often labeled as malingers, attention seekers, drug seekers, and so forth

Question 11

Chronic pain can be further divided into malignant (cancer related) and nonmalignant pain. What are they?

Answer 11

Malignant pain: parallels pathology created by tumor cells. Pain induced by tissue necrosis or stretching of an organ by growing tumor. The pain fluctuates within the course the disease
Chronic nonmalignant: pain is often associated with musculoskeletal conditions, such as arthritis, low back pain, or fibromyalgia

Question 12

What are the most common pain producing conditions for aging adults?

Answer 12

as arthritis, osteoarthritis, osteoporosis, peripheral vascular disease, cancer, peripheral neuropathies, angina, and chronic constipation
Somatosensory cortex is generally unaffected by dementia of Alzheimer type

Question 13

What are the gender differences involving pain?

Answer 13

Gender differences are influenced by societal expectations, hormones, and genetic makeup
Traditionally, men have been raised to be more stoic about pain, and more affective or emotional displays of pain are accepted for women
Hormonal changes are found to have strong influences on pain sensitivity for women
Women are two to three times more likely to experience migraines during childbearing years, are more sensitive to pain during premenstrual period, and are six times more likely to have fibromyalgia

Question 14

What are some initial pain assessment questions?

Answer 14

Where is your pain?
When did your pain start?
What does your pain feel like?
Burning, stabbing, aching
Throbbing, fire like, squeezing
Cramping, sharp, itching, tingling
Shooting, crushing, sharp, dull
How much pain do you have now?
What makes your pain better or worse? Include behavioral, pharmacologic, nonpharmacologic interventions

Question 15

What is the initial pain assessment?

Answer 15

Clinician asks patient to answer eight questions concerning location, duration, quality, intensity, and aggravating/relieving factors
Furthermore, clinician adds questions about manner of expressing pain and effects of pain that impairs one’s quality of life

Question 16

What is a brief pain inventory?

Answer 16

Asks patient to rate pain within past 24 hours on graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep

Question 17

How do you understand the nature of the pain a patient is experiencing?

Answer 17

Consider whether this is an acute or chronic condition
Recall that physical findings may not always support patient’s pain complaints, particularly for chronic pain syndromes
Pain should not be discounted when objective, physical evidence is not found
Based on the patient’s pain report, make every effort to reduce or eliminate pain with appropriate analgesic and nonpharmacologic intervention

Question 18

What are acute pain behaviors?

Answer 18

Because acute pain involves autonomic responses and has protective purpose, individuals experiencing moderate to intense levels of pain may exhibit the following behaviors:
Guarding, grimacing, vocalizations such as moaning, agitation, restlessness, stillness, diaphoresis, or change in vital signs
This list of behaviors is not exhaustive because the behaviors should not be used exclusively to deny or confirm presence of pain

Question 19

What are chronic pain behaviors?

Answer 19

Persons with chronic pain often live with experience for months and years
One cannot function physiologically and go on with life in a repetitive state of grimacing, diaphoresis, guarding, and the like
Person adapts over time, and clinicians cannot look for or anticipate the same acute pain behaviors to exist in order to confirm a pain diagnosis
Chronic pain behaviors have even more variability than acute pain behaviors
Persons with chronic pain typically try to give little indication they are in pain and therefore are at higher risk for underdetection
Behaviors that have been associated with chronic pain include bracing, rubbing, diminished activity, sighing, and change in appetite
Chronic pain behaviors—such as being with other people, movement, exercise, prayer, sleeping, or inactivity—underscore more subtle, less anticipated ways in which persons behave when they are experiencing chronic pain
Sleeping is one way persons behave in response to chronic pain in order to self-distract
Unfortunately, clinical staff may inadvertently interpret this behavior as “comfort” and do not follow up with an appropriate pharmacologic intervention

Question 20

When do we anticipate a pain problem in the aging adult?

Answer 20

Although pain should not be considered a “normal” part of aging, it is prevalent
When older adult reports a history of conditions such as osteoarthritis, peripheral vascular disease, cancer, osteoporosis, angina, or chronic constipation, be alert and anticipate a pain problem
Older adults often deny having pain for fear of dependency, further testing or invasive procedures, cost, and fear of taking painkillers or becoming a drug addict
During interview, you must establish an empathic and caring rapport to gain trust

Question 21

When you look for behavioral cues what changes in functional status are noticed?

Answer 21

Observe for changes in dressing, walking, toileting, or involvement in activities
Slowness and rigidity may develop, and fatigue may occur
Look for sudden onset of acute confusion, which may indicate poorly controlled pain
However, you will need to rule out other competing explanations such as infection or adverse reaction from medications