ASSESSING PAIN (THE 5TH Vital sign)

Pain- unpleasant sensory and emotional experience

- Associated with tissue damage
- Subjective; pain is whatever the person say it is
Physiologic responses to Pain

- ❑ Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide.

- ❑ Focus on pain, reports of pain, cries and moans, frowns, and facial grimaces.
- ❑ Decrease in cognitive function, mental confusion, altered temperament, high somatization, and
dilated pupils.
- ❑ Increased heart rate; peripheral, systemic, and coronary vascular resistance; increased blood
pressure
- ❑ Increased respiratory rate and sputum retention, resulting in infection and atelectasis
- ❑ decreased gastric and intestinal motility
- ❑ decreased urine output, resulting in urinary retention, fluid overload, depression of all immune
responses
- ❑ increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagons; decreased
insulin, testosterone
- ❑ Hyperglycemia, glucose intolerance, insulin resistance, protein catabolism
- ❑ Muscle spasm, resulting in impaired muscle function and immobility, perspiration
Classification of Pain
1. Nociceptive » represents the normal response to noxious insult or injury of tissues such as skin, muscles,
visceral organs, joints, tendons, or bones.
o Somatic » musculoskeletal (joint pain, myofascial pain), cutaneous; often well localized
o Visceral » hollow organs and smooth muscle; usually referred
2. Neuropathic » pain initiated or caused by a primary lesion or disease in the somatosensory nervous system
o Examples include, but are not limited to, diabetic neuropathy, postherpetic neuralgia, spinal cord injury
pain, phantom limb (post amputation) pain, and poststroke central pain.
3. Inflammatory » a result of activation and sensitization of the nociceptive pain pathway by a variety of
mediators released at the site of tissue inflammation.
o Examples include appendicitis, rheumatoid arthritis, inflammatory bowel disease, and herpes zoster

Duration and Etiology

1. Acute Pain » usually associated with a recent injury
2. Chronic Nonmalignant Pain » usually associated with a specific cause or injury and described as a constant
pain that persists for more than 6 months
3. Cancer Pain » often due to the compression of peripheral nerves or meninges or from the damage to these
structures following surgery, chemotherapy, radiation, or tumor growth and infiltration.
4. Intractable Pain » defined by its high resistance to pain relief
Pain Location
1. Cutaneous Pain » skin or subcutaneous tissue
2. Visceral Pain » abdominal cavity, thorax, cranium
3. Deep Somatic Pain » ligaments, tendons, bones, blood vessels
4. Radiating » perceived both at the source and extending to other tissues
5. Referred » perceived in body areas away from the pain
6. Phantom pain » perceived in nerves left by a missing, amputated, or paralyzed body part 10

7 Dimensions of Pain
1. Physical dimension » includes the patient’s perception of the pain and the body’s reaction to the stimulus.
2. Sensory dimension » includes the patient’s perception of the pain’s location, intensity, and quality.
3. Behavioral dimension » refers to the verbal and nonverbal behaviors that the patient demonstrates in
response to the pain.
4. Sociocultural dimension » concerns the influences of the patient’s social context and cultural background on
the patient’s pain experience.
5. Cognitive dimension » concerns “beliefs, attitudes, intentions, and motivations related to the pain and its
management” which are affected by all of the dimensions mentioned but can be associated with the
management part of the pain experience, which is dependent on cognitive.
6. Affective dimension » concerns feelings, sentiments, and emotions related to the pain experience. The pain
can affect the emotions and the emotions can affect the perception of pain.
7. Spiritual dimension » refers to the meaning and purpose that the person “attributes to the pain, self, others,
and the divine.”

Physiologic factors affecting pain perception

❑ Estrogen » decreases tolerance to pain and to pain threshold

❑ Testosterone » increases pain tolerance

Psychosocial factors affecting pain perception

1. Developmental Level
2. Culture Nursing Considerations:

❑ Do not stereotype! Treat each client as a unique individual, assess each client, respect each client’s
response to pain, and treat each client with dignity and consideration.

❑ Recognize you own response to pain.

Psychosocial factors affecting pain perception
To be culturally competent nurse caring for clients in pain:
1. Be aware of your own cultural and family values.
2. Be aware of your personal biases and assumptions about people with different values than yours.
3. Be aware and accept cultural differences between yourself and individual clients.
4. Be capable of understanding the dynamics of the difference.
5. Be able to adapt to diversity.
Barriers to Pain Assessment
Barriers based on beliefs
1. Acknowledging pain is not manly; it is a sign of weakness.
2. Pain is a punishment (often thought to be from God) for past mistakes, sins, or behaviors, and must be
tolerated.
3. Pain indicates that my condition/disease is getting worse, and that I am going to die soon. If I don’t
acknowledge it, it won’t be so bad.
4. Pain medications are addictive; cause awful side effects; and make confused, and sleepy or
unconscious.
Barriers based on Physical Conditions
1. The disease/illness/injury for which the patient is being treated is not the source of the pain.
2. Both the current disease and another disease are causing pain.
3. The patient expresses few, if any, pain-related behaviors once accommodated to prolonged chronic pain
conditions.
Barriers based on health care providers’ beliefs
1. Patients who complain of pain frequently are just trying to get more pain medicine or are addicts wanting
more narcotics.
2. Patients who complain of pain but do not show physical and behavioral signs of pain do not need more
pain medication, whether they are chronic pain patients or acute pain patients.
3. Old people simply have more pain.
4. Pain medication causes addiction/respiratory depression or too many side effects.
Tips for Collecting Subjective Data
1. Quiet and calm environment
2. Privacy and confidentiality
3. Open-ended questions
4. Quote client’s verbal descriptions
5. Observe client’s facial expressions and grimaces
6. DO NOT put words in the client’s mouth.
7. Past experiences with pain
8. Believe the client’s expression of pain.

Hierarchy of Pain Assessment

1. Self-report
2. Search for potential causes of pain
3. Observe patient behaviors
4. Surrogate reporting (family members, parents, caregivers) of pain and behavior/activity changes.
5. Attempt an analgesic trial

Assessment Tools
Assessment Scales
1. Visual Analog Scale (VAS)
2. Numeric Rating Scale (NRS)
3. Numeric Pain Intensity Scale (NPI)
4. Verbal Descriptor Scale
5. Simple Descriptive Pain Intensity Scale
6. Graphic Rating Scale
7. Verbal Rating Scale
8. Faces Pain Scales

Assessment Scales:
For neonates and infants
1. N-PASS: Neonatal Pain, Agitation, and Sedation Scale
2. Wong-Baker FACES Pain Rating Scale
3. FLACC Scale (Face, Legs, Activity, Cry, and Consolability)