Exam 1/ Lecture 4: Assessment of Pain Flashcards
What is a complex condition that leads to frequent access to the US healthcare system?
Pain
Slide 5
What type of pain affects more Americans than diabetes, cancer, and heart disease combined
Chronic pain
Slide 5
Which population of patients pain usually goes unrecognized, leading to inadequate management with numerous patient safety concerns?
African American (Minorities) and females
Slide 5
Untreated acute pain may lead to
adverse sequelae
Slide 5
Due to the recent opioid epidemic, more emphasis has been placed on the Providers to provide the patient with …
- early multimodal pain management
- nonpharmacologic options
- ononopioid alternatives
Slide 5
What are general pain management challenges?
- Failure to recognize or differentiate pain from anxiety
- Lack of education for healthcare providers, especially regarding nonpharmcologic
modalities. - Safety concerns, fear of patient addiction or prescription legal repercussions
- Lack of pre-existing physician-patient relationships
- Inadequate discharge pain plans resulting in return visits or admissions
- Pressure to see patients rapidly, especially those perceived to be more critical
- Physiologically unstable patients are least likely to receive a standardized pain assessment and to receive pain medications
- Outpatient settings may have limited time to perform full pain assessments or to evaluate for psychosocial contributors to pain
- Stereotypes towards patients with chronic pain being drug- seekers
- Analgesic shortages leading to medication errors and changing protocols
- And many more!
Slide 6&7
What is the big concern for opioid safety across the continuum of care?
patient safety concern
Slide 8
What are the things to keep in mind to balance pain management?
- safe opioid/analgesic prescribing
- high-risk patient recognition with appropriate pain management strategies
- while being mindful of different types of pain, individual pain factors and comorbidities.
Slide 9
Pain is a (BLank) which affects people physically, psychologically, socially and spiritually.
Multidimensional
Slide 10
True or false: A patient’s response to prescribed pain treatment can be influenced by factors related to actual pharmacological therapies.
False
Slide 11
What three factors will affect a patient’s perception of how the healthcare team will manage their pain?
- Perceived effective communication with physicians and nurses by the patient
- Perceived responsiveness by the treating team
- Perceived empathy by the treating team
Slide 11
What factors affecting pain response to painful stimuli?
- Age, Gender, Ethnicity
- Socioeconomic (finance) and Psychological factors
- Catastrophizing
- Culture and Religion
- Genetics
- Previous experiences
- Patient perceptions
- Patient expectations
Slide 12 – Refer to Slide 13-19
Which population of patients display more sensitivity towards pain and express pain more frequently and effectively?
Females
Slide 13
What is associated with pain intensity and interference?
Ethnicity
Slide 14
How patient cope with pain can be influenced by what?
their existing social support system (Culture and Religion)
Slide 15
An exaggerative cognitive response to an anticipated or actual painful stimulus and affects how individuals experience and express pain is
Pain Catastrophizing
Slide 17
What are the 3 types of Catastrophizing and which one do you need to pay attention to?
- Magnification – “dramatizing”
- Rumination – individual focuses repeatedly on attributes of an event
- Helplessness – belief that nothing can be done to improve situation
pay attention to Rumination to make sure it is not a head injury
Slide 18
What genetic polymorphism to watch out for with patients?
“ultra rapid metabolizers” vs. “slow metabolizers” of medications
Slide 19
What are the 4 classifications of pain?
- underlying etiology
- anatomic location
- temporal nature
- intensity
Slide 22
What are the 3 underlying etiology of pain?
- Nociceptive pain – direct tissue injury from a noxious stimuli
- Inflammatory pain – result of released inflammatory mediators
- Neuropathic pain– injury to nerves leading to an alteration in sensory transmission
Slide 23
What are the 2 anatomical locations of pain?
- Somatic – musculoskeletal pain
- Visceral – pain from internal organs or tissues that supprt them
Slide 24
What are 3 temporal nature of pain?
1.** Acute pain**– lasting < 3 months
- Chronic pain – lasting > 3 months or beyond
- Acute on Chronic pain – acute exacerbations of a chronic painful syndrome or new pain in someone with chronic condition.
Slide 25
What are the types of pain intensity?
- mild
- moderate
- severe
(each pain scale has its’ own scoring range)
Slide 26
1/25/24
What are the Basics of pain history elements and questions?
- Onset of recent pain
- Aggravating and alleviating factors
- Quality of pain experience
- Location of pain
- Severity of pain
- Circumstances of original pain
Slide 30, Slide 32
1/25/24
Questions to assess Functionality of pain (Pain History)?
- How is pain affecting current level of function?
- Is patient working?
- How is patient coping with pain?
Slide 30
1/25/24
What to assess for Co-morbidities of pain (Pain History)?
- Significant past medical and/or surgical history
- Chronic diseases (obesity, hypertension, diabetes, etc.)
- Psychosocial and/or psychiatric co- morbidities
- Family history of substance abuse
Slide 31
1/25/24
What to assess for Pyschosocial and psychiatric of pain (Pain History)?
- Depression
- Suicidal ideation or past suicide attempts
- Past psychiatric admissions
- Physical, sexual and/or emotional abuse.
slide 31
1/25/24
What other **pain tool **to consider when assessing for pain?
Patient Pain Diagram
(especially with kids)
Slide 33
1/25/24
What is the OPQRST mnemonics for obtaining pain history?
Onset of event
Provocation and palliation of symptoms
Quality
Region and radiation
Severity
Timing
Slide 34, Refer to Slide 35-36
1/25/24
What is the SOCRATES mnemonics for obtaining pain history?
Site
Onset
Character
Radiation
Associations
Time course
Exacerbating/Reli eving factors
Severity
Slide 34, Slide 37
What is the **QISS TAPED
** mnemonics for obtaining pain history?
Quality
Impact
Site
Severity
Temporal
Aggravating and alleviating
Past response and
preferences
Expectations and goals
Diagnostics and physical exam
Slide 34, Refer to Slide 38-39
1/25/24
Pain history questions to ask related to Cancer
Different types of pain may be caused by multiple etiologies:
- Tumors: involvement of bone, vessels, nerves, body organs
- Diagnostic procedures: may be painful such as biopsies, lumbar punctures, or venipuncture
- Treatment: radiation, chemotherapy, or surgical excision
Slide 40
1/25/24
Pain history questions to ask related to Recent Surgery
- Incisional pain
- Complications such as anastomotic leak, bleeding, compartment syndrome, etc..
Slide 40
Pain history questions to ask related to Other Conditions
- Diabetes which can lead to neuropathic pain
- Herpes zoster which can lead to radicular pain
- Migraines which can lead to mixed etiology
Slide 40
1/25/24
What patient factors to consider when assessing pain for certain special populations?
- Age
- Level of development
- Communication skills/language
- Cognitive skills
- Prior pain experiences
- Associated beliefs
Slide 41
1/25/24
What are Communication Cards?
are used to assist healthcare providers in communicating with scared, nonverbal or non-English speaking patients and families
* History taking and
assessment
* Pain, mechanism of injury
* Explanation of treatments
* Procedures and testing
* Discharge instructions
Slide 42
What 5 things of physical examination should be examined during pain assessment?
- Appearance
- posture
- gait
- facial
- expression
- vital signs.
Slide 44
When examining the painful area, what would your inspection include?
Skin: color changes, hair loss, flushing, goose bumps, sweating
Muscle: atrophy or spasm
Edema
Slide 45
When palpating the painful area, what would you palpation include?
Demarcation of the painful area
Detection of changes in pain intensity within the area
Trigger points
Changes in sensory or pain processing
Slide 45
When assessing the musculoskeletal system of the painful are, what would it include?
Flaccidity: extreme weakness (may be from paralysis)
Abnormal movements: neurologic damage or impaired sense of proprioception, reduced sense of light touch
Limit range of motion: disc disease, arthritis, pain
Slide 45
when performing neurological exam on the painful area, what would it include?
Cranial nerve exam
Motor strength
Spinal nerve function: deep tendon reflexes, pinprick, proprioception
Coordination: Romberg’s test, toe-to-heal, finger-to-nose, rapid hand movement
Slide 45
What would BP and HR elevation indicate?
Inadequate control of PAIN
Slide 46
Normal vital signs should not negate a patient’s reported pain. True or false?
True
Slide 46
What would be the important cues from your patient who is in pain?
- Patients will often assume a position of comfort.
- Observe vocalizations, facial expressions, body posture, movements, and motor response (decreased movement).
- Observe physiological clues such as skin flushing, diaphoresis, and/or vital sign abnormalities.
- Perform a focused exam taking into account the information given by the patient.
Slide 47
What do majority of pain scales assess?
Pain intensity
Slide 49
What do pain scales not take into account?
- patient genetics
- past experiences
- comorbidities
Slide 50
What is important to determine in patients with preexisting pain?
Baseline pain level
Slide 50
What can aid in pain assessment of a non-verbal patient?
- Surrogate reporting pain
- change in behavior/activity
- vital signs.
Slide 51
What pain scales are appropriate for adult patient who is verbal, alert and oriented?
- Verbal Numeric Scale (VNS) / Numeric Rating Scale (NRS)
- Verbal rating scale (VRS)
- Visual Analogue Scale
- Defense and Veterans Pain Rating Scale 2.0 (DVPRS)
Slide 52/53, Refer to Slide 54
what pain scales are appropriate for adult patient who is non- verbal, GCS <15 or with cognitive impairment?
- Adult Non-Verbal Pain Scale (NVPS)
- Pain Assessment in Advanced Dementia (PAINAD) Scale
- Behavioral Pain Scale (BPS)
- Critical-Care Observation Tool (CPOT)
Slide 52, refer to Slide 59-60
Types of pain scales for pediatrics
Slide 52, Refer to Slide 57, 60
What 3 items does a Behavioral Pain Scale assess for?
- Facial expression
- upper limbs
- compliance with ventilation.
Slide 57
General principles of pain management
- No Perfect Recipe or “Cookbook”
- No Universal Recipe
Slide 62
Opioid Prescribing and Equinalgesic Chart
get to a steady state which is really what I’m trying to achieve to keep my patient comfortable
Types of Non-Opioid Analgesics
*remember the pediatric Tylenol:
15 mg/kg PO q 4-6H
max: 90 mg/kg/d
Slide 67
Intranasal and Nebulized Medications
- Use concentrated solution
- Use an atomizer
Slide 68 & 69
What is Ketamine MOA?
- Blocks NMDA receptors, peripheral Na+ channels and and μ-opioid receptors providing sedation, [retrograde]amnesia, and analgesia.
- Has high lipid solubility- cross BBB fast and has a peak concentration at 1 minute IV
Slide 70
What are the benefits of nonpharmocologic pain treatment along w/ pharmalogical techniques?
-improve assessment
-decrease or avoid the use of opioids or anxiolytics
-decrease time and recovery for procedures
-decrease adverse events
Hospitals are now required to incormorate these techniques in pain managment plans to improve quality & safety
Slide 72, Slide 74
What are Cognitive-Behavioral Interventions for pain?
Nonpharmacological Interventions
What are Physical (Sensory) Interventions for pain?
Nonpharmacological Interventions
What do we forget a lot of times on the healthcare side (as discussed in class)?
moving things around that are broken
make people comfortable before we do things to them and thinking about all their injuries
Slide 76
What is one of the most common mistakes made in pain management?
Failure of reassessment after an intervention (pharmacologic or nonpharmacologic)
Slide 78
Things to consider during re-assessment of pain
- The same scale or scoring system used previously should be used on re- assessment for consistency.
- All patients do not respond to identical management in the same manner due to genetic and other factors.
- Appropriate monitoring for respiratory depression should be used especially when using pain relievers with sedating effects (opioids).
- Pain should always be reassessed at time of discharge or within an appropriate time interval in the outpatient setting.
Slide 79
What are the consequences of unrelieved acute pain?
- Psychological impacts
- Chronic pain syndromes
- Mortality and morbidity
Slide 80
What is Chronic Pain Syndrome?
affect:
- sleep
- mood
- activity
- energy level
has both physical and psychological effects that can result in detrimental cycle
Slide 81
What to consider during discharge planning?
- what interventions the patient has received during the visit
- transportation home
- will the patient be able to safely take the prescribed medicaitons at home
- will the patient be able to obtain the prescribed medications
- prescribed medication education
Slide 83
Why is sound management of pain important?
- It reduces return visits
- Expedites return to normal activities and work
- Helps reduce risk of acute pain progressing to chronic pain
patient often take 4-6 weekns to experience pain reduction after an acute injury!
Slide 84
What are the legal implications for providers?
- Providers must be familiar with regulations regarding pain management at their institution and at the local, state, and federal levels.
- Most states now have PDMPs (prescription drug monitoring programs) and opioid legislation.
Slide 87
