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PAIN Assessment

After you have successfully completed this chapter, you should be able to:

■ Define the mechanisms of pain ■ Describe different types of pain ■ Dispel myths associated with pain ■ Identify developmental influences on pain ■ Identify cultural influences on pain ■ Perform pain assessment ■ Perform symptom analysis ■ Identify components of a pain assessment

• Subjective in nature .What is Pain? • is “whatever the person says it is. • “unpleasant sensory and emotional experience associatedwith actual or potential tissue damage” (International Association for the Study of Pain. whenever she or he says it does” (McCaffery. 1999). 2006).

PAIN • The fifth vital sign • An unpleasant sensory and emotional experience associated with actual and potential tissue damage • Most common reason for seeking healthcare • Disables and distress more people than any single disease • Highly subjective to person so when he says that it exist…it does exist! .

Physiology of Pain .

Figure 9–2 A. C. to the cerebral cortex and the reticular and limbic systems in the brainstem. generating pain impulses that travel via fast Aδ and slower C fibers to the spinal cord. which integrate the emotional. Touching the hot lid activates nociceptors in the skin. B. and autonomic responses to pain. Secondary neurons in the dorsal horn pass impulses across the spinal cord to the anterior spinothalamic tract. Pain impulses ascend to the thalamus and. cognitive. . from there.

Nociception The process by which a painful stimulus is transmitted to the central nervous system (CNS) and perceived as pain .

The process of Pain • • • • Transduction transmission Perception modulation .

• Nociceptors are receptors found in the skin. and most internal organs (with the highest concentration found in the skin and the least in internal organs) that respond to painful stimuli. . joints.Transduction • Transduction begins with a response to a noxious (painful) stimulus that results in tissue injury. walls of arteries. subcutaneous tissue.

laceration •Alteration of tissue. such as tumor •Abnormal contraction of muscle. such as surgery. such as coronary artery disease ormuscle spasms .TYPES OF NOXIUS STIMULI Mechanical •Tissue trauma. such as biliary or bowel •Abnormal tissue growth. such as edema •Obstruction. such as spasm Thermal •Extreme heat or cold Chemical •Tissue ischemia.

The sensory nerve impulses travel via afferent neurons to the dorsal horn of the spinal cord. . the nerve impulse is transmitted to the spinal cord and brain.Transmission • Once the nociceptors are activated.

.From the dorsal horn. . (4) the spinohypothalamic tract to the hypothalamus. (2) the spinoreticular tract to the reticular formation. (3)the spinomesencephalic tract to the mesencephalon. the impulses are then transmitted from (1) the spinothalamic tract to the thalamus.

the point at which a painful stimulus is perceived as painful.the amount of pain one is able to endure . • PAIN THRESHOLD.Perception • is an awareness of pain and involves both the cortical and the limbic system structures. is consistent from one person to the next • PAIN TOLERANCE.

. and supraspinal levels. spinal.Modulation • Nerve transmission from the dorsal horn is modulated by descending inhibitory input. • Inhibition can also occur at the peripheral. • Inhibition occurs by analgesia or the gatecontrol theory of pain modulation.

Pain Transmission When a person experiences an injury such as stubbed toe. to the spinal cord via a sensory nerve ▼ A specialized region of the spinal cord known as the dorsal horn . specialized cells called nociceptor sense potential tissue damage ▼ Send an electric signal called an impulse.

immediately sending another impulse back down the leg via a motor nerve ▼ This cause the muscles in the leg to contract and pull the toe away from the source of injury ▼ At the same time. the dorsal horn sends another impulse up the spinal cord to the brain. . During the trip the impulse travels between nerve cells.▼ Processes the pain signal.

▼ When the impulse reaches a nerve ending. ▼ When the impulse reaches the brain. . it is analyzed and processed as an unpleasant physical and emotional sensation. the nerve releases chemical messengers called neurotransmitters. which carry the message to the adjacent nerve.

Pain Theories • Specificity and pattern theories • Melzack and Wall’s gate control theory • Neuromatrix theory .

The result is a lower threshold of pain.leading to hyperalgesia (increased response to painful stimuli) and allodynia (painful response to nonpainful stimuli). • Central sensitization also occurs with prolonged exposure to noxious stimuli with spinal neuron hyperexcitability and results in hyperalgesia and allodynia as well as persistent pain and referred pain. chronic pain can develop.but when it persists.Sensitization to pain • Peripheral sensitization occurs with prolonged exposure to noxious stimuli. Sensitization can act as a protective mechanism during healing. .

Acute pain serves as a protective mechanism in response to an actual or potential threat to injury • seen with injury and surgery and may last up to 6 months • Cutaneous and deep somatic pain • Visceral pain • Referred pain .Acute Pain • Injury or pathology Nociception and/or • sensitized central neurons • lasts the expected recoverytime.

. pain from inflammation of the diaphragm may be felt in the shoulder. For example.Figure 9–4 Referred pain results of the convergence of sensory nerves from certain areas of the body within the spinal cord. and pain from ischemia of the heart muscle (angina) may be felt in the left arm. a toothache may be felt in the ear.


• Chronic pain can be further classified as cancer/ malignant pain or chronic noncancer pain. Chronic pain often serves no adaptive purpose. and frequently results in depression. chronic pain endures beyond expected recovery time. as with neuropathic pain. Chronic pain may be in response to a progressive illness or result from no apparent injury. .Chronic Pain • is defined as pain enduring for 6 monthsor longer. • More specifically.

Breakthrough Pain • Pain which exceeds baseline chronic or persistent pain • Described as a sudden flare. exceeds longacting pain medications • The onset and intensity can vary • Incident or episodic pain .

is often seen with advanced metastatic disease . diagnostic procedure.pain resistant to treatment. or disease treatment • Intractable pain.Cancer/Malignant Pain Cancer or malignant pain may be acute pain or chronic pain that is associated with an underlying malignancy.

the patient can no longer function and her or his entire life is centered on finding pain relief. In this syndrome. .Chronic noncancer pain • Persistent pain not associated with malignancy • Pain levels and pathology have a weak link and may have no discernable cause. • has a major effect on every aspect of the patient’s daily life and is referred to as chronic pain syndrome.

Neuropathic Pain • Neuropathic pain results from injury to the peripheral or central nervous system. Neuropathic pain serves no adaptive purpose and therefore is “pathological” pain. • Neuropathic pain can be classified as mono/polyneuropathies. deafferentation. and central pain .

• Neuropathies may be caused by metabolic disorders (diabetic neuropathy). postherpetic neuralgia). toxins (alcoholic neuropathy or chemotherapy). compression (compartment syndrome. carpal tunnel syndrome).Mono/Polyneuropathies pain • involve pain along one or more damaged peripheral nerves. . and autoimmune and hereditary diseases. infections (human immunodeficiency virus [HIV]. trauma.

Deafferentation pain • occurs with loss of afferent input from damage to a peripheral nerve. or plexus. Example: Phantom Limb Sensation • Syndrome that occurs following amputation of a body part • Pain experienced in the missing body part . ganglion. or the CNS.

of moderate to severe intensity • Difficult to treat • Depends on the area of the CNS affected • Described as burning. lacerating. or aching .Central Pain • Caused by a lesion or damage in the brain or spinal cord • Constant. pressing.

.Pain Modulation • No one experiences pain from an identical stimulus in the same way or at the same intensity. • Neural and chemical responses explain how pain can be modified.

Neurotransmitter release is inhibited. These bind to postsynaptic neuron and propagate impulse. B. Pain impulse causes presynaptic neuron to release burst of neurotransmitters across synapse. and pain impulse interrupted. Inhibitory neuron releases endorphins.Figure 9–3 A. . which bind to presynaptic opiate receptors.

The Individualized Pain Response • Shaped by physiologic responses. age. and psychological influences • Pain threshold • Pain tolerance – Amount of pain a person can endure before outwardly responding – Varies significantly among individuals and over time . gender. sociocultural influences.

The Individualized Pain Response • Age – Influences a person’s perception and expression of pain – No evidence that nociception is altered by age – Pain tolerance decreases with aging .

The Individualized Pain Response • Gender – Women have lower pain threshold and experience higher intensity of pain • Sociocultural influences – Response is influenced by family. community. and culture – Affects pain behavior – Cultural standards .

expectation.The Individualized Pain Response • Psychological Influences – Intensity of perceived pain is affected by attention. and suggestion .

Collaborative Care for Pain • Necessary for effective pain relief • Acute pain management can be straightforward • Chronic pain requires a multidisciplinary approach .

broader range of drug classes – Nursing responsibilities . straightforward – Chronic pain.Collaborative Care for Pain • Medications – Most common approach to pain management – Acute pain.

Figure 9–5 The WHO analgesic ladder illustrates the process for selection of analgesic medications for pain management. 804. . Source: The WHO Analgesic Ladder from Cancer Pain Relief and Palliative Care. The World Health Organization. Switzerland. Technical Report Series. Reprinted by permission. Geneva. No.

Figure 9–6 The transdermal patch administers medication in predictable doses. .

Figure 9–7 PCA units allow the patient to self-manage acute pain. . The units may be portable or mounted on intravenous poles.

and typically reserved for patients experiencing nerve pain • Cordotomy • Neuroectomy • Sympathectomy • Rhizotomy .Surgery • Only used if all other methods have failed.

. neurectomy. sympathectomy. and rhizotomy.Figure 9–8 Surgical procedures may be used to treat severe pain that does not respond to other types of management. They include cordotomy.

Transcutaneous Electrical Nerve Stimulation (TENS) • Application of electrical current through the skin to control acute or chronic pain • Controls pain in several ways .

. Electrodes deliver low-voltage electrical stimuli through the skin to block transmission of pain stimuli.Figure 9–9 The TENS unit is used to assist in acute and chronic in pain management.

Complementary and Adjunctive Therapies (Complementary and Alternative Medicine) • • • • • • • • Acupuncture Biofeedback Chiropractic Distraction Hypnotherapy and Guided Imagery Massage Therapy Natural Products Relaxation .

• Varies by acuity of pain and circum-stances • Acute pain • Chronic pain

• Patient Perceptions
– Most reliable indicator of pain – PQRST mnemonic
• • • • • P: What precipitated the pain? Q: What is the quality of the pain? R: What is the region of the pain? S: What is the severity of the pain? T: What is the timing of the pain?

– McGill Pain Questionnaire – Pain-Rating Scales

P- Precipitating/Palliative/Provocative Factors
• ■ What were you doing when the pain started? • ■ Does anything make it better, such as medication or • a certain position? • ■ Does anything make it worse, such as movement or • breathing?

■ Neuropathic pain is burning. pricking. or burning. shocklike. ■ How often are you experiencing it? ■ To what degree is the pain affecting your ability to perform your usual daily activities? . or cramping.Q. ■ Deep somatic pain is dull or aching. jabbing. ■ Visceral pain is dull. aching.Quality/Quantity ■ What does it feel like? ■ Superficial somatic pain is sharp. squeezing. lancing. or aching.

such as shoulder pain with acute cholecystitis or jaw pain associated with angina. ■ Projected (transmitted) pain is transmitted along a nerve. .R. ■ Dermatomal pattern as with peripheral neuropathic pain. ■ Referred pain is referred to a distant structure.Region/Radiation/Related Symptoms ■ Can you point to where it hurts? ■ Does the pain occur or spread anywhere else? ■ Localized pain is confined to the site of origin. such as cutaneous pain. such as with herpes zoster or trigeminal neuralgia.

fibromyalgia. nausea.. hair. ■ Neuropathic pain–related symptoms include hyperalgesia and allodynia.Region/Radiation/Related Symptoms ■ Nondermatomal pattern as with central neuropathic pain. .R. nausea.g. ■ No recognizable pattern as with complex regional pain syndrome. dizziness. shortness of breath) ■ Visceral pain–related symptoms include sickening feeling. Do you have any other symptoms? (e. ■ Complex regional pain syndrome–related symptoms include hyperalgesia. allodynia. and nailchanges. hyperesthesia. and shin. and autonomic symptoms. vomiting. autonomic changes.

Severity ■ Use appropriate pain scale. .S.

and miscellaneous (17–20). evaluative (16).Figure 9–10 The McGill Pain Questionnaire. the sum of the rank values is the pain rating index (PRI). The rank value for each descriptor is based on its position in the word set. The present pain intensity (PPI) is based on a scale of 0 to 5. . The descriptors fall into four major groups: sensory (1 –10). affective (11–15).

Figure 9–11 Examples of commonly used pain scales. This figure has been reproduced with permission of the International Association for the Study of Pain® (IASP®). Commonly Used Pain Scale from FPS-R. The figure may not be reproduced for any other purpose without permission .


■ Do you have times when you are pain free? .T. ■ How often does it occur? ■ Continuous fluctuating pain: As with musculoskeletalpain.Timing ■ When did the pain begin? ■ How long did it last? ■ Brief flash:Quick pain as with needle stick. ■ Paroxysmal: Such as neuropathic pain. ■ Rhythmic pulsation: Pulsating pain as with migraine or toothache. ■ Plateau pain:Pain that rises then plateaus such asangina. ■ Long-duration rhythmic: As with intestinalcolic.

Another mnemonic used to assess pain is OLDCART. heat?) . ice. • Onset: When did the pain begin? • Location: Where does it hurt? Can you point to where it hurts? • Duration: How long does it last? • Characteristics: What does it feel like? • Aggravating factors: Does anything make it worse? • Radiation: Does the pain go anywhere else? • Treatment: Did anything make it better? (Pain medication.

these changes might not be visible in patients with chronic pain .Physiologic Responses • Predictable physiologic changes • Over time.

Behavioral Responses • Pain behaviors – Bracing/guarding the painful part – Crying. moaning. or grimacing – Withdrawing from activity – Breathing with increased effort – Becoming immobile .

Behavioral Responses • Might not coincide with the patient’s report of pain • Not always reliable cues to the pain experience .

Behavioral Responses • Self-Management of Pain – Useful information for the assessment database – Individualized and patient-specific – Get detailed descriptions of: • Actions taken • When and how the measures were applied • How well the measures worked .