Class 3-Pain Assessment: The 5th Vital Sign

Question 1

Pain is subjective…

Answer 1

-it is whatever the patient says it is, existing wherever the patient says it does
-grimacing, guarding, moaning, tachycardia, hypoventilation (hypoxia)–>alveoli can collapse

Question 2

Pain assessment

Answer 2

-it’s not just a number!
-it’s the interpretation of the number and critically thinking about a series of other factors that may be influencing pain
-requires attention to response to pain relief methods
-requires attention to the side effects of medication administration
-requires attention to “if the patient doesn’t have relief” what else can be done
-need accurate pain assessment-better able to develop non-pharmacologic and/or pharmacologic strategies to obtain improved clinical results
**ask about if it’s new, where, intensity, radiates anywhere, limitations of ADL, duration, relief, and aggravating

Question 3

Pain relief…it’s holistic in nature

Answer 3

-isn’t just about providing pain medication
-it is about looking at alternative methods alone or in conjunction with medication:
-music, relaxation, massage, biofeedback, acupuncture etc.
-tubes to decompress/relieve pressure
-anxiolytics
-improving breathing and oxygenation
-positioning
-heat and/or cold application (good for musculoskeletal)

Question 4

Pain relief..it’s holistic in nature (cont)

Answer 4

-psychological support, chaplain, social work etc
-hospice support
-palliative care team
-conflict resolution
-family support
-assisting with rituals

Question 5

Pain relief..it’s about understanding structure and function

Answer 5

-neuroanatomic pathway and nocioception
-nocioception is a term used to describe how noxious stimuli are perceived as pain
-pain originates from either the CNS or PNS or both
-where are nocioceptors located?
-how do they get stimulated?
-how does the pain stimulus travel to the CNS?

Question 6

Structure and function

Answer 6

-nociceptors: specialized nerve endings designed to detect painful sensations
-transmit sensations to central nervous system by two primary sensory (afferent) fibers: A delta & C fibers

Question 7

A delta fibers

Answer 7

-myelinated and larger in diameter, and they transmit pain signal rapidly to CNS: localized, short-term, and sharp sensations result from A delta fiber stimulation

Question 8

C fibers

Answer 8

-unmyelinated and smaller, and transmit signal more slowly: sensations are diffuse and aching, and they persist after initial injury

Question 9

Peripheral sensory A delta & C fibers

Answer 9

-enter spinal cord by posterior nerve roots within dorsal horn by tract of Lissauer

Question 10

Nociceptors and the 4 concepts of…

Answer 10

1. transduction, stimulus takes place in periphery
2. transmission, pain moves from spinal cord to brain
3. perception, conscious awareness of pain sensation
4. modulation, inhibition of pain sensation (endogenous pain relievers)

Question 11

Phase 1-transduction

Answer 11

-occurs in response to noxious stimuli
-release variety of chemical mediators
-substance p, histamine, prostaglandins, serotonin, and bradykinin
-neurotransmitters lead to pain propagation
- a long sensory afferent nerve fibers to spinal cord and terminate in dorsal horn
-second set of neurotransmitters carry pain signal-substance p, glutamate, and atp

Question 12

Phase 2- transmission

Answer 12

-pain impulse moves from level of spinal cord to brain
-if pain is not stopped it moves via various ascending fibers within the spinothalamic tract to the thalamus

Question 13

Phase 3-perception

Answer 13

-consciousness of awareness of pain signal
-cortical structures such as limbic system account for emotional response to pain
-only when “pain” has reached the cortical structures can it be perceived as pain

Question 14

Phase 4- Modulation

Answer 14

-body has built-in mechanism to slow down and stop the process of a painful stimulus that inhibits and blocks pain
-descending pathways release third set of neurotransmitters to produce analgesic effect
-neurotransmitters include:
-serotonin; norepinephrine; neurotensin; aminobutyric acid (GABA); and our own endogenous opioids; beta endorphins; enkephalins, and dynorphins

Question 15

Pain treatment approaches

Answer 15

-when we treat pain we take 4 basic approaches toward each of these 4 components within the neuroanatomic pathway:
1. we can modify the source of pain (moving away from source)
2. we can attempt to alter the central perception of pain
3. we can modulate the transmission of pain in the CNS (internal pain relievers)
4. we can block the transmission of pain to the CNS (nerve block)

Question 16

What is neuropathic pain?

Answer 16

-abnormal processing of pain message
-doesn’t follow the predictable phases of nociceptive pain
-most difficult type of pain to assess and treat
-pain is perceived long after injury heals
-neurochemical level
-conditions may lead to development
-diabetes mellitus, herpes zoster (shingles), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and/or chemotherapy

Question 17

What is the source of pain?

Answer 17

-visceral pain
-deep somatic
-cutaneous pain
-referred pain

Question 18

Visceral pain

Answer 18

-originates from larger interior organs
-stems from direct injury to organ or from stretching of organ from tumor, ischemia, distention, or severe contraction
-presents with autonomic responses such as vomiting, nausea, pallor, and diaphoresis

Question 19

Deep somatic

Answer 19

-pain comes from sources such as blood vessels, joints, tendons, muscles, and bone
-injury may result from pressure, trauma, or ischemia
-described as aching or throbbing; usually well localized
-like visceral pain it can be accompanied by nausea, sweating, tachycardia, and HTN

Question 20

Cutaneous pain

Answer 20

-derived from skin surface and subcutaneous tissue
-injury is superficial, with a sharp, burning sensation

Question 21

Referred pain

Answer 21

-is felt at a particular site, but originates in another location
-important concept for performing an accurate, comprehensive pain assessment
-particularly useful for diagnostic purposes
**see slide 17

Question 22

Types of pain

Answer 22

-acute
-chronic

Question 23

Acute pain

Answer 23

-short term
-self-limiting
-follows a predictable trajectory
-dissipates after injury heals
-has a protective quality
-malignant pain can also have an acute component
-activates autonomic nervous system (ANS) vital sign indications (VS can change)

Question 24

Chronic pain

Answer 24

-continues beyond expected time
-types are malignant (cancer related) and nonmalignant
-in cancer pain an increase is often a sign of increasing disease
-does not stop when injury heals
-has no protective qualities (can be good)
-the level of pain may not correspond with your physical findings

Question 25

Types of pain symptomology (acute)

Answer 25

-protective responses
-diaphoresis
-anxiety
-restless or stillness
-moaning

Question 26

Types of pain symptomology (chronic)

Answer 26

-normal vital signs
-skin warm and dry
-depressed, withdrawn
-anxiety
-anger, instability
-substance abuse
-no protective behaviors
-bracing, rubbing
-sighing
-appetite change
-reduced activity
-may not be as visible, just adapted

Question 27

Aging adult with pain…

Answer 27

-not a normal process of aging
-common occurrence in people > 65 years
-indicates pathology or injury
-should not be considered something that must be tolerated

Question 28

Aging and pain…

Answer 28

-what are some of the common conditions that cause pain in this population?
-how do you determine if the presence of pain in a person with dementia? PAINAD–>objective
**subjective is best indicator

Question 29

Pain is subjective data

Answer 29

-pain assessment using subjective data: taking a health history
-using effective pain assessment questions
-using valid and reliable pain assessment tools

Question 30

Pain assessment questions (use your PQRST)

Answer 30

-Questions to ask:
-where is your pain?
-when did your pain start?
-what does your pain feel like?
-how much pain do you have now?
-what makes the pain better or worse?
-how does pain limit your function/activities?
-how do you behave when you are in pain? how would others know you are in pain?
-what does pain mean to you?
-why do you think you are having pain?

PQRST= provocation, quality, region/radiation, severity, and time: these are the 5 aspects of pain that this tool measures

Question 31

Pain assessment tools

Answer 31

-initial pain assessment
-brief pain inventory
-short-form McGill pain questionnaire
-PQRST
-pain rating scales:
-numeric rating scales
-descriptor scale

Question 32

Types of pain assessment-tools

Answer 32

-pain rating scales are unidimensional and are intended to reflect pain intensity
-pain rating scales can indicate a baseline intensity, track changes, and give some degree of evaluation to a treatment modality
-there are different subtypes that use numbers, verbal description, visual analog, or descriptor scale
-selection of pain rating scale is based on patient understanding and age of development

Question 33

Numeric rating scales

Answer 33

patient to choose a number that rates level of pain, with 0 being no pain and highest anchor 10 indicating worst pain

Question 34

Verbal descriptor scales

Answer 34

have the patient use words to describe pain

Question 35

Visual analog scales

Answer 35

have the patient mark the intensity of the pain on a horizontal line from “no pain” to “worst pain”

Question 36

Descriptor scales

Answer 36

in which patients are asked to indicate their pain by using selected pain term words

Question 37

Cultural considerations…

Answer 37

-according to the American pain society “there is a need to develop and evaluate pain assessment instruments that reflect cultural, linguistic, and ethnic diversity”
-there is disparity in pain management for minority patients as a result of difficultly in assessing pain because of culture and language barriers

Question 38

Examples of cultural beliefs related to pain

Answer 38

African American
Mexican American

Question 39

African American

Answer 39

-pain sign of disease/illness
-if no pain may affect compliance with treatment
-pain is inevitable and endured
-high tolerance
-spiritual and religious beliefs related to pain
-praying and laying of hands to treat pain

Question 40

Mexican American

Answer 40

-pain accepted as a necessary part of life
-pain as a consequence of immoral behavior
-seek to restore balance between person and environment with pain relief methods
-pain perception may delay seeking treatment
-type and amount of pain divinely predetermined

Question 41

Objective assessment of pain

Answer 41

-although pain is subjective what are some objective data you may use to support pain

Question 42

What type of objective data could we use as part of a pain assessment?

Answer 42

-joints
-muscle and skin
-abdomen

Question 43

Joints

Answer 43

note size, contour, and circumference of joints. check active or passive range of motion. joint motion normally causes no tenderness, pain, or crepitation

Question 44

Muscle and skin

Answer 44

inspect skin and tissues for color, swelling, and any masses or deformity

Question 45

Abdomen

Answer 45

observe for contour and symmetry. palpate for muscle guarding and organ size. note any areas of referred pain

Question 46

Nonverbal behaviors of pain

Answer 46

-when individual cannot verbally communicate pain, you can (to a limited extent) identify pain using behavioral cues
-recall that individuals react to painful stimuli with a wide variety of behaviors

-behaviors are influenced by:
-nature of pain (acute vs chronic)
-age
-cultural and gender expectations