PAIN ASSESSMENT willing to withstand without seeking

avoidance of the pain or relief

What is PAIN?
● Hyperalgesia and Hyperpathia -
● An unpleasant sensory and emotional
heightened responses to a painful stimuli
experience associated with actual or
● Allodynia - includes non painful stimuli
potential tissue damage, or described in
that produces pain
terms of such “damage”
● Dysesthesia – is an unpleasant
● Pain is whatever the person says it is,
abnormal sensation (tightening, burning,
and exists whenever he says it does
aching, pins-and-needles, tingling,
● Fifth vital signs; perceived through
pickling, and electric shock-like
nociception
sensation)
● Given highly subjective and individually
● Sensitization – an increased sensitivity of
unique nature of pain, a comprehensive
a receptor
assessment of the pain experience
● Windup – progressive increase in
(psychological, physiological,
excitability and sensitivity of spinal cord
behavioral, emotional, and
neurons, leading to persistent, increased
sociocultural) provides necessary
pain
foundation for optimal pain control
TYPES OF PAIN STIMULI
● This strategy of linking pain assessment
1. Mechanical
to routine vital signs assessment and
a. Trauma to body tissues (e.g.,
documentation represents a push to
surgery)
make pain assessment a routine aspect
i. Tissue damage; direct
of care for all clients
irritation of the pain
● Inadequate treatment of acute pain
receptors; inflammation
has been shown to result in physiologic,
b. Alterations in body tissues (e.g.,
psychological, and emotional distress
edema)
that can lead to chronic pain
i. Pressure on pain receptors
THREE ASPECTS OF THESE DEFINITIONS
c. Blockage of a body duct
Pain is…
i. Distention of the lumen of
1. A physical and emotional experience;
the duct
2. Exists in response to actual or potential
d. Tumor
tissue damage;
i. Pressure on pain receptors;
3. Described in terms of such damage
irritation of nerve endings
CONCEPTS ASSOCIATED WITH PAIN
e. Muscle spasm
● Pain Threshold – is the least amount of
i. Stimulation of pain
stimuli that is needed for a person to
receptors also see
label a sensation as pain
chemical stimuli
● Pain Tolerance – is the maximum
2. Thermal
amount of painful stimuli that a person is
a. Extreme heat or cold (e.g., burns)
 i. Tissue destruction; b. Moderate – scored as 4-6 in pain
stimulation of scale
thermosensitive pain c. Severe – scored as 7-10 in pain
receptors scale
3. Chemical 4. Etiology
a. Tissue ischemia (e.g., blocked a. Nociceptive Pain – an intact,
coronary artery) properly functioning nervous
i. Stimulation of pain system sends signals that tissues
receptors because of are damaged, requiring
accumulated lactic acid attention and proper care
and other chemicals, such i. Somatic – pain that
as bradykinin and enzymes originates in the skin,
in tissues muscles, bone, or
b. Muscle spasm connective tissue
i. Tissue ischemia secondary ii. Visceral – pain arising from
to mechanical stimulation organs or hollow viscera,
CLASSIFICATION tends to be characterized
1. Duration by cramping, throbbing,
a. Acute – sudden or low onset, pressing, or aching
regardless of pain intensity < 6 qualities
months b. Neuropathic – associated with
b. Chronic – persistent pain, damaged and malfunctioning
prolonged, > 6 months nerves due to illness, injury of
c. Cancer – compression of undetermined reasons
peripheral nerves or meninges i. Peripheral Neuropathic
from the damage to these Pain – follows damage or
structures following surgery, sensitization of peripheral
chemotherapy, radiation, or nerve (phantom limb)
tumor growth and infiltration ii. Central Neuropathic Pain –
2. Location results from malfunctioning
a. Referred – pain is perceived in nerves in the central
body areas away from the pain nervous system (stroke)
source iii. Sympathetically
b. Visceral – pain arising from Maintained Pain – pain
organs or hollow viscera, is often from spasms in the blood
perceived in an area remote vessel
from the organ causing the pain 5. Intractable Pain – defined by its high
3. Intensity resistance of pain relief
a. Mild – scored as 1-3 in pain scale
 3. Intensity – on a scale of 0 to 10, with 0
representing no pain and 10
representing the worst possible pain.
How would you rate the degree of
discomfort you are having right now?
4. Pattern
a. Time of onset – when did or does
the pain start?
b. Duration – how long have you
had it? Or how long does it
usually last?
c. Constancy – do you have
pain-free periods? When? And
PAIN ASSESSMENT for how long?
PAIN HISTORY 5. Precipitating Factors – what triggers the
● While taking a pain history, the nurse pain or makes it worse?
must provide an opportunity for clients 6. Alleviating Factors – what methods
to express in their own words how they have you found helpful in reducing or
view the pain and the situation relieving the pain? What pain
● Initial Pain Assessment For Severe Acute medications do you use?
○ Previous pain treatment and 7. Associated Symptoms – do you have
effectiveness any other symptoms before, during, or
○ When and what analgesics were after your pain? (nausea, dizziness,
last taken blurred vision, shortness of breath)
○ Other medications being taken 8. Effects on ADLs – how does the pain
○ Allergies to medications affect your daily life? (eating, working,
● Initial Pain Assessment For Chronic Pain sleeping, and social and recreational
○ For the person with chronic pain, activities)
the nurse may focus on the 9. Past Pain Experiences – tell me about
client’s coping mechanisms, past pain experiences you had and
effectiveness of current pain what was done to relieve the pain
management, and ways in which 10. Meaning of Pain – what does having this
the pain has affected the client’s pain mean to you?
body, thoughts and feelings, 11. Coping Resources – what do you usually
activities, and relationships do to help you deal with the pain?
ASSESSMENT INTERVIEW: PAIN HISTORY 12. Affective Response - how does the pain
1. Location – where is your discomfort? make you feel? Anxious? Depressed?
2. Quality – tell me what your discomfort Frightened? Tired? Burdensome?
feels like
PAIN ASSESSMENT TOOLS: COLLECTING ● Numeric Rating Scale
SUBJECTIVE DATA
● The client’s description of pain is
quoted, use exact words used to
describe the experienced pain
● Pain assessment includes questions ● Verbal Descriptor Scale
about location, intensity, quality,
pattern, precipitating factors, and pain
relief, as well as the effect of the pain on
daily activities, what coping strategies
● Graphic Rating Scale
have been used, and emotional
responses to the pain
● May use COLDSPA, PQRST, or LIQORAAA
as guide for assessment of pain history
PAIN ASSESSMENT TOOLS: COLLECTING CLINICAL ALERT!
SUBJECTIVE DATA GUIDELINES ● Perception is reality. The client’s
1. Maintain a quiet and calm environment self-report of pain is what must be used
that is comfortable for the patient being to determine pain intensity. The nurse is
interviews obligated to record the pain intensity as
2. Maintain the client’s privacy and ensure reported by the client. By challenging
confidentiality the believability of the client’s report.
3. Ask the questions in an open-ended The nurse is undermining the therapeutic
format relationship and preventing the
4. Listen carefully to the client’s verbal fulfillment of advocacy and helping
descriptions and quote the terms used people with pain, which is called for in
5. Watch for the client’s facial expressions the ANA’s Standards of Professional
and grimaces during the interview Performance for Pain Management
6. DO NOT put words in the client’s mouth Nursing
7. Ask the client about past experiences
with the pain
8. Believe the client’s expression of pain
9. NRS has been shown to be best for older
adults with no cognitive impairment,
and the Faces Pain Scale for cognitive
impaired adults
PAIN INTENSITY SCALES
● Visual Analog Scale
PAIN ASSESSMENT OF INFANTS AND NEONATES, 5. Understand that different cultures
USE: express pain differently and maintain
● N-PASS: Neonatal Pain, Agitation, and different pain thresholds and
Sedation Scale expectations

● FLACC Scale (Face, Legs, Activity, Cry,

and Consolability)

PAIN ASSESSMENT TOOLS: COLLECTING

OBJECTIVE DATA GUIDELINES
1. Choose an assessment tool reliable and
valid to the client’s culture
2. Explain to the client the purpose of
rating the intensity of pain
3. Ensure the client’s privacy and
confidentiality
4. Respect the client’s behavior towards
pain and the terms used to express it