Why is pain assessment important?
- What does it have a profound effect on?
- Who assesses pain most often?
A universal symptoms experienced by all at some point in their lives - Pain is primary reason clients access health care in Canada
- Can have a profound impact on a client’s function, quality of life, relationships, family structure, financial resources
- Nurses are the health professionals that most often assess and help manage clients’ pain
What is pain?
“An unpleasant sensory and emotional experience associated with actual and potential tissue damage, or described in terms of such”
- Honours that pain is subjective
- Sensory and affective dimensions
- Pain can exist in the absence of actual tissue pathology
In affirming the subjective, emotional, and sensory nature of pain and the fact that it may occur in the absence of an identifiable cause, the definition encourages…
clinicians to address all complaints of pain seriously
Myth or Fact:
- If they don’t complain, they don’t have pain.
- If they don’t look like they’re in pain, then they’re not
- Pain is expected with aging.
- If they’re asleep, they aren’t in pain.
- Infants do not feel pain
- Kids cannot tell you where they hurt
- Myth - people find a way to cope with their pain that allows them to continue with their lives the best that they can. Some people complain and some don’t, but never assume that the patient who doesn’t complain isn’t experiencing pain.
- Myth - what does a person in pain look like? There are some classic signs of pain, like grimacing, moaning, groaning, rocking back and forth, crying etc. But these are mandatory criteria for a person in pain. The patient sipping on the coffee his partner brought him and looking through some photos that him smile can still be in pain. Firstly, people act differently when they’re in pain. Secondly, sometimes patients just want to behave normally and have a nice visit with their family. Patients don’t want the family member to sit there and watch them be in pain, or hear them complain about pain, they just want to enjoy the time that they are together.
- Myth – pain is not expected with aging. As people age, and their bodies change, and illnesses accumulate, we know this. It might be expected with certain disease, but not simply because of age. As soon as we start thinking that way, we start dismissing patients’ experiences, and tolerating a system that supports pain and suffering as part of the norm.
- Myth - – no one can stay awake forever. Patients have to sleep sometime, even if it’s in spite of their experience of pain. It is unethical to withhold pain management/analgesia because the patient appears to you as resting comfortably.
- Myth – of course they do, the problem of course is, we can’t ask them about it. However, there are observations that can be made, and most often, babies are treated on the assumption that they do have pain. For example, babies who are experiencing signs of withdrawal after birth from a mother addicted to substances, are treated with pain management, usually morphine, on the assumption that they are in pain.
- Myth - yes they can! There are numerous tools and scales used to assess pain, many to do with specifically assessing pain in kids. There are visual analogue scales, other pictorial methods of identifying pain, and there is the nurse’s knowledge base about kids and knowledge about the health condition itself that can provide an excellent description of where the child feels pain.
How do you react to pain and why do you react that way?
- Think of a time when you experienced pain
- What did the pain tell you?
- Did you communicate it to anyone else?
- If so, what was the response?
- What did you want? How did you treat the pain?
Pain can tell us things:
- Make judgments based on where it is, what it feels like, how severe is it, how long have I had it, when did it start..etc.
- Nurses ask questions about all of those things, and the answers are very informative.
- Most of this assessment is subjective and can’t be corroborated by nurses at all.
Lots of different things influence how we feel about pain, how we interpret it, whether and how we treat it, how we understand it and how we communicate it to others
- Start with reflecting on your own beliefs and feelings around pain - How do you respond to others in pain? Why do you respond that way? How do you know to do that? What does the pain mean? How we tolerate pain can depend on what it means to and for us.
- For example, labour pain is some of the worst pain there is, but we tolerate it because of the human need to procreate, and also because there is a reward at the end.
Medications exist to make experiences more comfortable, other times the reward is enough for us to tolerate pain
Sometimes the meaning of the pain is frightening because we just somehow KNOW that something is wrong
Our prior experiences and family values/ways in which we are socialized to understand pain affect our experiences in the future.
Mental pain, what is it? How do we explain this? Do we understand it in ourselves and other people the same way that we understand physical pain
Describe the brief physiology of pain:
NOCICEPTORS
- These PNS fibres carry painful stimuli to the CNS
- Located in various body tissues
- Activated by thermal, mechanical & chemical stimuli
- This is how the pathway starts
Impulse PNS to Spinal cord CNS to Pain may be blocked/allowed to continue to Thalamus to Limbic system (emotions to control pain produced here) to Cerebral cortex (pain recognized here)
What are analgesic researchers constantly looking for?
Ways to “close the gate”
What do nurses assess when administering medications for pain?
- What s key in pain management?
Nurses assess patients, administer medications, and assess the efficacy of the medications
Continual reassessment is key in pain management.
- The goal is for the patients to experience steady pain relief—meaning, the patient does not ride the pain roller coaster up and down of pain, take the medications, let the medications wear off, pain, take the medication etc etc etc.
What is the goal of pain management?
For the patient to have steady relief of pain
What are the 4 components of pain?
- Explain each
- Sensory / Physical*
- Action in pain nerves and effect on physiological status, severity
- Receives the most attention - Emotional/affective
- How the pain makes us feel, fears, knowledge - Cognitive
- The effect of pain on behaviour, coping strategies, what does it mean - Social
- Our behaviour, how we react and respond
What are 4 ways to classify pain?
DURATION
Acute vs. Chronic
a) Acute
- Acute pain results from tissue damage – ie injury or surgery , or heart attack
- Acute pain’s role is to alert and protect the body from further harm - It has purpose
- Shorter in duration
- Usually runs a finite course, then resolves or heals
- Limited emotional response.
- If acute pain is unrelieved or undertreated it can lead to chronic pain; This is because of the prolonged duration leading to central sensitization
- Central sensitization is that response produced by continuous pain that persists even after the pain stimulus is gone
b) Chronic
- Chronic pain is pain that persists beyond normal healing time
- Typically identified as pain lasting longer than 3-6 months (being cognizant of the actual time it can take to heal damaged tissues
- Chronic pain has no role and serves no purpose physiologically
- Often does not have any identifiable cause, which also contributes to its ‘invisible’ nature
- Physical suffering, mental health suffering
STIGMA - depression – suicide and problems at work, with self-care
- HCPs, including nurses, may impose objectivity–the tendancy to judge and label patients as “hard to work with,” “complainers,” and “drug seeking.”
- For patients, chronic pain is a HUGE energy consumer, but there is seemingly no visible indication of this burden and so patients’ burdens are undiscovered, unacknowledged, and dismissed
- Goal – reduce pain to an acceptable level if no reasonable expectation of resolution – Pain scale becomes “what level of pain do you think you could live with?
- Addition of supports to develop/develop new coping strategies and companion non-pharmacological treatments
FREQUENCY
Continuous vs. Intermittent
FORM
Nociceptive vs. neuroleptic
ASSOCIATED WITH CANCER
With cancer and/or with treatment for cancer
This actually gets its own class
Pain exists if…
if the patient says it does, it can’t be objectively characterized
Pain presents and is experienced…
differently depending on its type, and that’s aside from the says that individual people naturally experience pain differently from one another
Can be helpful to understand the nature of different types of pain as it allows nurses …
nurses some insight into how to gather information, how to explore the subjective experience, what treatments are typically offered for this or that type of pain, anticipation of challenges and mobilization of patient strengths to promote quality of life
What is nociceptive pain?
Where are nociceptors found?
Is the pain caused by actual or potential injury to tissues, and serves as a warning
Nociceptors are found outside and inside body
- Visceral
- Somatic
- Cutaneous
- Referred
- Parietal
What is neuropathic pain caused by?
- Does external stimuli provoke this type of pain?
- What is it associated with?
Neuropathic pain is caused by disease or lesion in the nervous system somewhere
- No
- Associated with chronic health challenges
What is break through pain?
Breakthrough pain has connections to acute and chronic pain a flare up of pain experienced by a person living with chronic pain brief, but severe enough to literally ‘break through’ the management of pain associated with the chronic condition (and patients often treat it with another medication prescribed for this purpose)
What is mental pain?
- Manifests?
Mental pain/psychic pain from intolerable feelings/emotions/distress of the psyche
- Manifests as physical pain for the individual
- It’s an “invisible” pain which affects the experience of the sufferer in many different ways
- Highly complex for some with multiple types competing at once
Acute Pain Assessment:
What are the red flags?
- Relieved by medication?
- What to do?
Sudden onset is a red flag
- Explosive headache
- Problems breathing
- Chest pain
- Abdominal pain, right lower quadrant
Severe pain unrelieved by appropriate medication
New onset, indiscernible cause
What to do
- Focused/emergent history
- Involve others, family/witnesses
- Observation of the patient & their behaviours
What is the most reliable indicator of the existence of pain and its intensity?
The clients description
The Patients Experience:
Influencing factors
- Examples
Influencing Factors:
- Age (e.x. babies cannot understand/verbalize their pain; be simple but specific with kids)
- Gender
- Culture
- Spiritual
- Family and social support
- Personal meaning of the pain
- Level of anxiety
- Coping style
- Fatigue
- Previous experiences
What is the role of the nurse in pain management?
- The nurse is with the patient the most (therapeutic relationship)
- Best position is to observe and notice changes
- Reassessment of pain is the most important
- Nurses document pain, responses to pain, outcomes of treatments, subjective data - other clinicians need this
- Nurse can make recommendations based on assessments - i.e. advocate for modifications to the treatment plan, communicate client wishes, advocate for consultation to other services
- Advocate for complimentary medicine therapies
What is a misconception of palliative care?
Sometimes palliative as only for end of life care
- Not the case
Palliative care is involved at any point when you have the type of patient with difficult pain to manage, other health problems, complications, etc.
Sometimes they see palliative as a “I give up” patient care
- This is not what it is
- It is used as a last resort but should have been involved earlier
More on palliative care:
- What is it?
- What is medicine resistant to?
Palliative care is a type of medicine specialty that supports patients at different states of illness by managing all aspects and types of their pain.
- They are philosophically oriented with patients right at the centre of their and in control of as much as they can be.
Sometimes, medicine is resistant to a consult to Palliative care.
- Usually it’s because of the way that they have interpreted Palliative care, which is often as surrender, let’s give up, it’s end of life care.
- It’s misguided though, and is a really good example of the clash of orientation to medicine that exists at times.
- Yes, palliative care very often means end of life care, stop looking for problems that you don’t intend to fix, keep them comfortable, and let them go.
- But palliative care can actually go on for quite some time, because patients can live with illnesses/terminal illnesses for a long time before they die from it.
Truly, the palliative service will tell you that if you’ve waiting until the client is actively dying to bring them in on the case, then you have done your patient a great disservice. They likely should have been involved long ago.
- The point here is, they are experts in managing pain of all different types. They can make informed, useful recommendations that can really help get on top of unmanaged pain.
- As a nurse, you can advocate for the involvement of such a service. Most of my patient advocacy was around pain management, and most of that was around involving palliative sooner than later.
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Week 1 - Class 2 (Introduction to Health Assessment)33
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Week 2 - Class 1 (SD & Health Determinants)33
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Week 2 - Class 2 (Culture as Context)21
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Week 3 - Class 1 (Vital Signs)37
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Week 3 - Class 2 (Health History & Documentation)41
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Week 4 (Class 2) - Interviewing, Privacy, and Confidentiality26
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Week 5 (Class 1) - Pain Assessment29
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Week 5 (Class 2) - Neurological Assessment43
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Week 6 (Class 2) - Musculoskeletal & Mobility Assessment27
