Chapter 9

Assessing Pain: The Fifth

Vital Sign
Definitions
 International Association for the Study of Pain (IASP):
Unpleasant sensory and emotional experience which we
primarily associate with tissue damage or describe in
terms of such damage, or both.
 McCaffery and Pasero: Pain is whatever the person says
it is.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #1
Is the following statement true or false?
An unpleasant sensory and emotional experience, which we
primarily associate with tissue damage, is termed pain.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer to Question #1
True.
An unpleasant sensory and emotional experience, which we
primarily associate with tissue damage, is termed pain.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Pathophysiology
 Transduction
 A-delta primary afferent fibers
 Transmission
 Perception
 Modulation

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Definition: Acute Pain
 Usually associated with a recent injury.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Definition: Chronic Nonmalignant
 Usually associated with a specific cause or injury and
described as a constant pain that persists for more than
6 months.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Definition: 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.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Pain Descriptors
 Cutaneous pain: skin or subcutaneous
 Visceral pain: abdominal cavity, thorax, cranium
 Deep somatic pain: ligaments, tendons, bones, blood vessels, nerves
 Radiating: perceived both at the source and extending to other tissues
 Referred: perceived in body areas away from the pain source
 Phantom pain: perceived in nerves left by a missing, amputated, or paralyzed
body part
 Neuropathic pain: causes an abnormal processing of pain messages and
results from past damage to peripheral or central nerves due to sustained
neurochemical levels
 Nociceptive: response to noxious insult or injury of tissues such as skin,
muscles, visceral organs, joints, tendons, or bones
 Inflammatory: a result of activation and sensitization of the nociceptive pain
pathway by a variety of mediators released at a site of tissue inflammation

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Physiologic Responses to Pain #1

 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; and blood pressure

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Physiologic Responses to Pain #2

 Increased respiratory rate and sputum retention,

resulting in infection and atelectasis
 Decreased gastric and intestinal motility
 Decreased urinary output, resulting in urinary retention,
fluid overload, depression of all immune responses

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Physiologic Responses to Pain #3

 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

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Seven Dimensions of Pain
 Physical
 Sensory
 Behavioral
 Sociocultural
 Cognitive
 Affective
 Spiritual

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Subjective Data
 Review past and family histories in terms of pain.
 Review lifestyle and health habits to determine how the
pain interferes with the client’s life.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Tips for Collecting Subjective Data #1

 Maintain a quiet and calm environment that is

comfortable for the client being interviewed.
 Maintain the client’s privacy and ensure confidentiality.
 Ask the questions in an open-ended format.
 Listen carefully to the client’s verbal descriptions and
quote the terms used.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Tips for Collecting Subjective Data #2

 Watch for the client’s facial expressions and grimaces

during the interview.
 DO NOT put words in the client’s mouth.
 Ask the client about past experiences with pain.
 Believe the client’s expression of pain.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Objective Data

 Visual Analog Scale (VAS)

 Numeric Rating Scale (NRS)
 Numeric Pain Intensity Scale (NPI)
 Verbal Descriptor Scale
 Simple Descriptive Pain Intensity Scale
 Graphic Rating Scale
 Verbal Rating Scale
 Faces Pain Scale

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Hierarchy of Pain Assessment Techniques
 Self-report
 Search for potential causes of pain
 Observe client behaviors
 Surrogate reporting
 Attempt an analgesic trial

Copyright © 2018 Wolters Kluwer · All Rights Reserved

QUESTT Principles for Pain in Children

 Question the child.

 Use pain-rating scales.
 Evaluate behavior and physiologic changes.
 Secure parents’ involvement.
 Take cause of pain into account.
 Take action and evaluate results.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question #2
Which is an appropriate pain assessment tool for pediatric
clients?
A. Verbal Descriptor Scale
B. Numeric Rating Scale
C. Visual Analog Scale
D. Faces Pain Scale

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Answer to Question #2
D. Faces Pain Scale.
An appropriate pain assessment tool for pediatric clients is
the Faces Pain Scale. The Verbal Descriptor Scale, Numeric
Rating Scale, and Visual Analog Scale are other pain
assessment tools for collecting objective data, more
appropriate for adult clients.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Validating and Documenting Findings
 Health promotion diagnoses
 Risk diagnoses
 Actual diagnoses
 Collaborative problems
 Medical problems

Copyright © 2018 Wolters Kluwer · All Rights Reserved