PAIN ASSESSMENT AND NURSING MANAGEMENT

Pain can be a common experience for patients in the hospital setting. It is integral to the role of
a nurse to effectively assess and manage the perception of pain for patients. Nurses require
both the knowledge and skills to appropriately plan and provide interventions for pain.

Definition

The International Association for the Study of Pain (IASP) defines pain as a "sensory and
emotional experience associated with tissue damage or described in terms of such damage."

Pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort
signals actual or potential injury to the body. However, pain is more than a sensation, or the
physical awareness of pain; it also includes perception, the subjective interpretation of the
discomfort. Perception gives information on the pain's location, intensity, and something about
its nature. The various conscious and unconscious responses to both sensation and perception,
including the emotional response, add further definition to the overall concept of pain.

Process of Pain

Nociception is the process where information about tissue damage is conveyed to the central
nervous system through sensory receptors (nociceptors). There can be pain without
nociception (such as phantom limb pain), or nociception without pain. Pain occurs through four
activities:

Transduction: Energy is converted from a noxious stimulus (thermal, mechanical, or chemical)

into electrical energy (nerve impulses) by nociceptors

Transmission: The transmission of the neural signals from the transduction site to the spinal
cord and brain

Perception: In higher structures, the arriving signals are appreciated as pain

Modulation: Occurs at the spinal cord level; descending input from the brain influences
(modulates) nociceptive transmission

Factors that Influence Pain

Many different factors influence the experience of pain, which is different for everyone. These
include:

 Age
 Gender
 Culture
 Ethnicity
 Spiritual beliefs
 Socio-economic status
 Emotional response
  Support systems
 Life before pain onset

Other factors can include a learned response that can be related to the response of your family.
Parents, for example, may respond to a child’s pain in a certain manner, setting a foundational
pain response for an individual that may influence future pain experiences. Also, societal and
medical care systems can impact the pain experience. For example, you may not have access to
the care of a physician who is an expert in managing pain.

Additionally, changes in functioning, role (societal, social, or family), daily routines, job status,
and sleep disturbance may contribute to chronic pain. These factors can cause distress which
may also increase pain.

Some common emotional responses to pain can include anxiety, depression, anger, feeling
misunderstood, and demoralization.

According to a 2004 study, individuals who are experiencing chronic pain in primary care
settings have a higher probability to experience anxiety and depressive disorders than those
who are not.

Impact of Pain on Family

As you experience pain symptoms, either acute or chronic, this can shift family patterns and
roles. For example, a parent might not be able to fulfill certain tasks anymore and
communication between family members may change based on not wanting to “bother” the
affected member.

Other family factors may include increased stress, financial burden, effect on sexuality and
other intimate relationships, and potential resentment in the relationship. For family members
of people in chronic pain, a goal is to strike a balance between validating patient’s pain and
experience while helping him/her stay involved in life.

Impact of Pain on the Medical System

According to another study in 2005, patients report not feeling heard by their doctors because
they may not agree with the medical interpretation of pain.(2) Patients may believe that the
pain is related to other ailments or medical history and disagree with the doctor’s opinion.

When patients’ pain does not respond to a certain treatments or interventions, they may feel
like symptom magnifiers and complainers. As a result, patients may feel demoralized or feel
they are not being heard or taken seriously, all increasing patient distress.

Maladaptive Pain Beliefs and Ways to Address Them

As we experience pain, we may have many different beliefs of how we should live our life with
the pain we are experiencing; these beliefs may be maladaptive and might hinder our
functioning level. In other words, some coping and adaptive mechanisms used by those with
chronic pain may not be the most physically or psychologically beneficial.

Examples of maladaptive beliefs as related to pain are:

1. Catastrophizing: Exaggerated, negative reaction towards actual or anticipated pain

experiences. In this case, patients report higher pain, poorer physical functioning, more
depression and stress, and more disability.(3,4,5)
2. Pain is sign of damage.
3. Pain means activity should be avoided.
4. Pain leads to disability.
5. Pain is uncontrollable.
6. Pain is permanent.

According to a 2007 study, these maladaptive beliefs can cause higher pain, poorer physical
functioning, depression, stress, and more disability.(3)

Maintaining a sense of control over your life and believing you can continue to function, despite
the pain, can decrease risk of depression. Gaining control can mean finding more resources to
understand the impact of pain, such as patient education about how to live with pain,
communicating to your doctor about your different concerns and challenges, discussing if pain
is a sign of damage or whether activity can be continued based on tolerance, and accepting
your situation.

Types Of Pain

 ACUTE PAIN: is short-term pain that comes on suddenly and has a specific cause, usually
tissue injury. Generally, it lasts for fewer than six months and goes away once the
underlying cause is treated. Acute pain tends to start out sharp or intense before
gradually improving. Common causes of acute pain include: broken bones, surgery,
dental work, labor and childbirth, cuts and burns.
 CHRONIC PAIN: Pain that lasts for more than six months, even after the original injury
has healed, is considered chronic. Chronic pain can last for years and range from mild to
severe on any given day. While past injuries or damage can cause chronic pain,
sometimes there’s no apparent cause. Without proper management, chronic pain can
start to impact your quality of life. As a result, people living with chronic pain may
develop symptoms of anxiety or depression. Other symptoms that can accompany
chronic pain include: frequent headaches, nerve damage pain, low back pain, arthritis
pain and fibromyalgia pain
 NOCICEPTIVE PAIN: is the most common type of pain. It’s caused by stimulation of
nociceptors, which are pain receptors for tissue injury. You have nociceptors throughout
your body, especially in your skin and internal organs. When they’re stimulated by
potential harm, such as a cut or other injury, they send electrical signals to your brain,
causing you to feel the pain. This type of pain you usually feel when you have any type
of injury or inflammation. Nociceptive pain can be either acute or chronic. It can also be
further classified as being either visceral or somatic.
 SOMATIC PAIN: results from stimulation of the pain receptors in your tissues,
rather than your internal organs. This includes your skin, muscles, joints,
connective tissues, and bones. It’s often easier to pinpoint the location of
somatic pain rather than visceral pain. Somatic pain usually feels like a constant
aching or gnawing sensation. It can be further classified as either deep or
 superficial. For example, a tear in a tendon will cause deep somatic pain, while a
canker sore on your inner check causes superficial somatic pain. Examples of
somatic pain include:
o bone fractures
o strained muscles
o connective tissue diseases, such as osteoporosis
o cancer that affects the skin or bones
o skin cuts, scrapes, and burns
o joint pain, including arthritis pain
 VISCERAL PAIN: Visceral pain results from injuries or damage to your internal
organs. You can feel it in the trunk area of your body, which includes your chest,
abdomen, and pelvis. It’s often hard to pinpoint the exact location of visceral
pain.
Visceral pain is often described as:
o pressure
o aching
o squeezing
o cramping

You may also notice other symptoms such as nausea or vomiting, as well as
changes in body temperature, heart rate, or blood pressure.

Examples of things that cause visceral pain include:

o gallstones
o appendicitis
o irritable bowel syndrome
 NEUROPATHIC PAIN: results from damage to or dysfunction of your nervous system.
This results in damaged or dysfunctional nerves misfiring pain signals. This pain seems to
come out of nowhere, rather than in response to any specific injury. You may also feel
pain in response to things that aren’t usually painful, such as cold air or clothing against
your skin.
Neuropathic pain is described as:
o burning
o freezing
o numbness
o tingling
o shooting
o stabbing
o electric shocks

Diabetes is a common cause of neuropathic pain. Other sources of nerve injury or

dysfunction that can lead to neuropathic pain include:

o chronic alcohol consumption

o accidents
o infections
o facial nerve problems, such as Bell’s palsy
o spinal nerve inflammation or compression
o shingles
o carpal tunnel syndrome
o HIV
o central nervous system disorders, such as multiple sclerosisor Parkinson’s
disease
o radiation
o chemotherapy drugs
Pain Assessment

Pain assessment is a multidimensional observational assessment of a patients’ experience of

pain. It is crucial if pain management is to be effective. Nurses are in a unique position to assess
pain as they have the most contact with the patient in hospital. Pain is multidimensional
therefore assessment must include the intensity, location, duration and description, the impact
on activity and the factors that may influence the patient’s perception of pain (bio psychosocial
phenomenon) The influences that may alter pain perception and coping strategies include
social history/issues, cultural and religious beliefs, past pain experiences and the first pain
experience.

Pain is often referred to as the “fifth vital sign,” and should be assessed regularly and
frequently. Pain is individualized and subjective; therefore, the patient’s self-report of pain is
the most reliable gauge of the experience. If a patient is unable to communicate, the family or
caregiver can provide input. Use of interpreter services may be necessary. Components of pain
assessment include: a) history and physical assessment; b) functional assessment; c)
psychosocial assessment; and d) multidimensional assessment.

Nurses’ perceptions of pain affect the nurse/patient relationship

Nurses’ opinion of how pain should be dealt with affect how they treat clients with pain
complaints. It is important that they should be aware of this to prevent throwing judgments
and imposing preferences to clients. Simply acknowledging pain can go a long way in easing
clients with pain, seeing as how it is real to them. On the other hand, nurses should be vigilant
about pain that is being faked by some individuals so appropriate referrals can be taken into
consideration.

History and Physical Assessment

The assessment should include physical examination and the systems in relation to pain
evaluation. Areas of focus should include site of the pain, musculoskeletal system, and
neurological system. Other components of history and physical assessment include:
  Patient’s self-report of pain
 Patient’s behaviors and gestures that indicate pain (e.g. crying, guarding, etc.)
 Specific aspects of pain: onset and duration, location, quality of pain (as described by
patient), intensity, aggravating and alleviating factors
 Medication history
 Disease or injury history
 History of pain relief measures, including medications, supplements, exercise, massage,
complementary and alternative therapies

Functional and Psychosocial Assessment

Components of the functional and psychosocial assessment include:

 Reports of patient’s prior level of function

 Observation of patient’s behaviors while performing functional tasks
 Patient or family’s report of impact of pain on activities of daily living, including work,
self-care, exercise, and leisure
 Patient’s goal for pain management and level of function
 Patient or family’s report of impact of pain on quality of life
 Cultural and developmental considerations
 History of pain in relation to depression, abuse, psychopathology, chemical or alcohol
use
 Impact of pain on patient’s cognitive abilities

Assessment of Pain

SUBJECTIVE ASSESSMENT

1. PAIN HISTORY: While taking pain history, nurse must provide an opportunity for clients to
express in their own words, how they view it and their situation. This will help the nurse to
understand means of pain to client and how the client is coping with it.
2. ONSET AND DURATION OF OCCURRENCE: When did pain begin? How long has it lasted?
Does it occur at same time each day? How often does it occur?
3. LOCATION: In which area it is felt? Do the areas differ under different circumstances? If
several parts of body are painful, does the pain occur simultaneously? Is pain unilateral /
bilateral? Ask the individual to point site of discomfort
4. INTENSITY: Use of pain intensity scale is an easy and reliable method of determining the
clients pain intensity

Assessment Tools Used for Subjective Assessment

1. NUMERICAL RATING SCALE: The numeric scale is the most commonly used pain scale with
adult patients, rating pain on a scale of 0-10. Many nurses ask for a verbal response to the
question. Use of this scale with the visual analog can provide a more accurate response.
This scale is appropriate with patients aged nine and older that are able to use numbers to
rate their pain intensity (Health Care Association of New Jersey, 2011).

2. VERBAL RATING SCALES: Verbal pain scales as name suggests, use words to describe pain.
Word such as no pain, mild pain, moderate pain & severe pain are used to describe pain
levels.
3. VISUAL ANALOGUE SCALES: VAS use a vertical or horizontal line with words that convey “no
pain” at one end and “worst pain” at opposite end. Patient is asked to place a mark along
line that indicates his/her level of pain.
4. WONG-BAKER FACES PAIN SCALE: This scale, which goes from Level 0-10, asks the person in
pain to choose from a series of faces that best indicate the level of pain he or she is
experiencing. Level 0 is a happy face, indicated as “No Hurt”, and the scale goes up to Level
10, which is a sad/pained face with tears, indicated as “Hurts Worst.”
OBJECTIVE ASSESSMENT

1. BEHAVIORAL EFFECTS:
 Assess verbalization, vocal response, facial and body movements & social interaction
 Facial expression is often 1st indication of pain & may be only one manifestation
 Vocalization like moaning, groaning, crying, grunting, screaming are associated with
pain.
2. PHYSIOLOGICAL RESPONSES:
 It varies with the origin and duration of pain
 Early in onset of acute pain, the sympathetic nervous system is stimulated
 Results in increased blood pressure, pulse rate, respiration, pallor, diaphoresis and
pupil dilation
 PQRST Pain Assessment
 Question to ask about pain:
 Pattern: onset & duration
 Area: location
 Intensity: level
 Nature: description
Other Pain Assessment Tools Used in Hospitals