PAIN

ASSESSMENT
 PAIN
 It is a phenomenon that defies
precise definition
 is an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage
Components:
 Stimulus
 Bodily sensation
 Reaction of the person
experiencing the pain
Cardinal Rule:
“ALL PAIN IS REAL”-
regardless of its cause
 PAIN SENSATION
 Needed for survival
 Serves as a protective
measures by signaling the
presence of noxious stimuli or
tissue damaging condition
 Considered as the 5th vital
signs
THE PAIN SYSTEM
 NOCICEPTORS
- These are free nerve endings found
in every tissue of the body except
in the brain
- It can be activated by:
 Thermal stimuli
 Mechanical stimuli
 Chemical stimuli
Conditions that may elicit pain:
Excessive
distention/compression
Prolonged muscular contraction
Ischemia
 TYPES OF PAIN
Fast Pain:
Onset:
 0.1 sec after
the stimulus
Tract:
 A-delta fibers
in the lateral
spinothalamic
tract
Quality:
 acute, sharp/pricking pain
Occurrence:
 superficial but not felt in the
deeper tissue
Slow Pain:
Onset:
 1 sec or more
after the
stimulus but
gradually
increase its
intensity
Tract:
 C-delta fibers
of the lateral
spinothalamic
tract
Quality:
 excruciating pain; chronic;
burning; aching; throbbing pain
Occurrence:
 skin; deep tissues; internal
organs
Slow and Fast Pain
Superficial Somatic Pain
- Pain that arises from the
stimulation of the receptors in the
skin
Deep Somatic Pain
- Due to stimulation of the receptors
in the skeletal muscles, joints,
tendons, & fascia
Visceral Pain
- Pain perceived from internal organs
 SPINOTHALAMIC TRACT
DIVISION
Neospinothala
mic Tract
- It ascends to
thalamus &
project to
somatosensory
cortex
• It transmit information about the
quality, intensity, & location of
painful stimulus
Paleospinothala
mic Tract
- Transmit
impulses through
the reticular
system &
terminate in the
thalamus with
the projection to
the limbic
subcortical areas
• Pain sensation are more diffuse
SPINOTHALAMIC TRACT
 PAIN THEORIES
Specificity Theory (Rene
Descartes):
- Proposes that there are separate
& specific receptors for pain and
these transmit information to
pain center in the brain
Premise:
• that pain is the direct product of
a noxious stimulus activating a
dedicated pain pathway, from a
receptor in the skin, along a
thread or chain of nerve fibers
to the pain center in the brain,
to a mechanical behavioral
response
Pattern Theory :
Erbs:
• a pain signal can be generated
by stimulation of any sensory
receptor, provided the
stimulation is intense enough
• the pattern of stimulation
(intensity over time and area),
not the receptor type,
determines whether
nociception occurs
Goldscheider:
• over time, activity from many
sensory fibers might accumulate
in the dorsal horns of the spinal
cord and begin to signal pain
once a certain threshold of
accumulated stimulation has
been crossed
Noordenbos:
• observed that a signal carried from
the area of injury along large
diameter "touch, pressure or
vibration" fibers may inhibit the
signal carried by the thinner "pain"
fibers –
• the ratio of large fiber signal to
thin fiber signal determining pain
intensity
Gate Control Theory (Melzack &
Walls):
- Proposes that there is interaction
between pain and other sensory
modalities and that stimulation of
fibers that transmit nonpainful
stimuli are able to block the
transmission of painful impulses
through an inhibitory gating circuit
(neural circuit)
Gate Control Theory: Schema
Therefore:
 FACTORS INFLUENCING PAIN
PERCEPTION
Endorphins & Enkephalins:
- The endogenous morphine
(morphine within)
- Found in heavy concentration in
CNS & relieve pain by blocking
their transmission in the brain &
spinal cord
Implications:
 People feel different amount of
pain from similar stimuli
 Certain nonpharma techniques
may relieve pain
 Mental stimulation helps release
endorphins
Other Factors include:
- Cultural influences
- Past experience with pain
 PAIN ASSESSMENT
ACUTE PAIN
- Recent in onset & is most
commonly associated with a
specific injury
- Usually without residual damage or
systemic disease
- Subsides with healing
- Occurs ordinarily in less than 6
months
CHRONIC PAIN
- Constant/intermittent pain lasting
for longer period (> 6 months)
- May or may not be associated with
structural damage
- May persist after healing takes
place
- Does not have well-defined onset
- Does not respond to treatment
- Serves no useful purpose
 TYPES OF CHRONIC PAIN
Recurrent Acute Pain
- Has fairly-defined episodes of pain
interspersed with pain-free
intervals and may occur over a
period of time
Pain with On-going Peripheral Pathology
- Can be limited or with unlimited
duration
Ex: pain in cancer; degenerative
arthritis
Chronic Benign Pain (CBP)
- May be due to peripheral or
central pathology
- Pathology is often unclear but is
not life-threatening
- Patient can still function well in
daily life in spite of the pain
Chronic Intractible Pain (CIBPs)
- Has the same characteristic of
CBP, but the patient copes poorly
with the pain
 REFERRED PAIN
 Pain perceived in area distant
from stimuli
 Intense although there is little or
no pain at the point of noxious
stimuli.
Myocardial ischemia is not felt as
pain in the heart.
Rather it is felt as left arm,
shoulder or jaw pain.
Referred Pain
 CAUSES OF PAIN
Nociceptive
- pain is initiated by stimulation of
nociceptors, and may be classified
according to the mode of noxious
stimulation:
 Thermoreceptive nociceptors:
- are stimulated by temperatures
that are potentially tissue
damaging
 Mechanoreceptive nociceptors:
- respond to a pressure stimulus
that may cause tissue damage
 The Mechanoreceptors
PACINIAN
CORPUSCLE
 nerve
endings of
capillaries
 for pain &
pressure
RUFFINI
ENDINGS
- Nerve
endings
sensitive to
skin stretch
MEISSNER’S
CORPUSCLE
- Nerve
endings
sensitive to
light touch.
MERKEL’S DISK
- nerve
endings
that provide
touch
information
to the brain.
 Neuropathic
- caused by damage to or
malfunction of the nervous
system, and is divided into
"peripheral“ and “central”
• Neuropathic pain is usually
associated with an identifiable
disorder such as stroke,
diabetes, or spinal cord injury,
and is frequently described as
having a "hot" or burning
quality.
Neuropathic Pains:
 Psychogenic
- also called psychalgia or
somatoform pain, is a sensation
of pain caused, increased, or
prolonged by mental, emotional,
or behavioral factors
signals
 Phantom pain
- is the sensation of pain from a
part of the body that has been
lost or from which the brain no
longer receives physical
FACTORS IN PAIN ASSESSMENT
Intensity
- Patient is asked to scale his own
pain
- This aids in identifying the
pattern of pain and evaluating
its interventions
Thresholds
Perception Threshold:
- is the point at which the stimulus
begins to hurt
Tolerance Threshold:
- is reached when the subject acts
to stop the pain
Tolerance
- The maximum intensity/duration
of pain the person is willing to
endure
Characteristics
Location: area of pain
Duration: period of waxing/waning
the intensity/existence of pain
Quality: ex: pricking, burning,
throbbing, stabbing
Effects of pain in ADLs
Alleviating/Exacerbating Factors
Patient’s concern about his pain
 Wong-Baker Faces Pain Scale
• This scale can be used with young
children (sometimes as young as 3
years of age)
• It also works well for many older
children and adults as well as for
those who speak a different
language.
• Explain that each face represents
a person who may have no pain,
some pain, or as much pain as
imaginable.
WBFPS vs FPS-S
 Numeric Rating Scale
• Ask the patient to rate their pain
intensity on a scale of 0 (no pain)
to 10 (the worst pain imaginable).
• Some patients are unable to do
this with only verbal instructions,
but may be able to look at a
number scale and point to the
number that describes the
intensity of their pain.
Word Graphic Rating Scale
OUCHER SCALE
 FLACC Rating Scale
• Stands for Face, Legs, Activity,
Crying and Consolability
• Designed for children between the
ages of 2 and 7
• Can be used in adult settings may
use the FLACC pain scale for
people who are unable to
communicate their pain.
• Provides a pain assessment scale
between 0 and 10.
 CRIES Pain Assessment
 is often used in the neonatal
healthcare setting
 is an observer-rated pain
assessment tool which is
performed by a healthcare
practitioner such as a nurse or
physician
 CRIES assesses:
- Crying
- Oxygenation
- Vital signs
- facial expression
- Sleeplessness
 CRIES Pain Scale is generally
used for infants 6 months old
and younger
CRIES Pain Assessment
 COMFORT Scale
 a pain scale that may be used by a
healthcare provider when a person
cannot describe or rate their pain
 Applicable to:
• children
• cognitively impaired adults
• adults whose cognition is
temporarily impaired, by
medication or illness
• the learning disabled
• sedated patients in an ICU or
operating room setting
 McGILL Pain Questionnaire
• Consists of groupings of words
that describe pain
• Person rating their pain ranks the
words in each grouping
• Once the person has rated their
pain words, the administrator
assigns a numerical score, called
the Pain Rating Index
Comparison of Different Pain
Assessment Tools
 PQRST
P- provokes/point
Q- quality
R- radiation/relief
S- severity
T- time/onset
 COLDERRA
C- haracteristics
O-nset
L-ocation
D-uration
E-xacerbation
R-adiation
R-elief
A-ssociated s/s
 OLD CART
O-nset
L-ocation
D-uration
C-haracteristics
A-ggravating factors
R-elief measures
(alleviating factors)
T- reatment
Should also assess for the following
behavioral responses:
 Physiologic manifestation
 Verbal statement
 Verbal responses
 Facial expression
 Body movements
 Alteration in responses to
environment
 Physical contact with others
 Adaptation of physiologic or
behavioral responses
 Effects of pain in communication
and ADLs
 Assess factors that influences
responses to pain:

A. Ethnic and cultural factors

B. Previous pain experience
C. Meaning of pain experience
D.Patient’s response to pain
relief strategies
 Gerontologic Consideration:
Older persons may have reduced
sensory perception resulting to
increase pain threshold
Therefore, pain in elderly is more
significant as compared to that in
younger persons
 Basic Care Plan for Pain
FIRST PHASE
- Plans to alter factors that influence
the nature of pain
- Factors that influence the intensity
of the patient’s behavioral
response to pain experience
SECOND PHASE
- Identify appropriate ways to
respond to the patient’s behavior
& attitude about the pain
THIRD PHASE
- Identify appropriate goals for
nursing interventions & validate it
with the patient because:
For some patients:
- The goal is total elimination of
pain, but to some patient it is
unrealistic
For some:
- The goal is to decrease the
intensity, duration, frequency,
limit detrimental effects of pain
During Acute Phase:
- Patient participates less in pain
relief measures
During Recovery Phase:
- The goal is to decrease pt’s
reliance to pain medications
- Increase pt’s self-management
of non-invasive pain relief
measures
Managing Anxiety Related to Pain

Anticipation of Pain:
- Provide health teaching about
pain & pain relief measures
Effects:
 Intense anxiety
 Complete absence of anxiety
- Nurse must explore whether the
patient needs information or not
- Health teaching must focus on
pain relief measures & must be
brief, essential & general
 Failure to forewarn pain is a mistake
UNLESS:
1.In previous experience,
forewarning produced high level of
anxiety;
2.Patient specifically requests not to
be forewarned after thorough
exploration of the patient;
3.If in previous experience, it
hampers his coping mechanism.
Sensation of Pain:
- If pain is felt, it is desirable to
decrease anxiety as low as
possible
- Pain relief measures should be
used before pain becomes
severe
Aftermath of Painful Experience:
- When the pain sensation
subsides, it is hoped that anxiety
also subsides
- For many patients, the
experience continues after the
pain sensation subsides
- The nurse must help the patient
to integrate the pain experience
 MANAGEMENT
Non-Pharmacologic Approach:
- Is not considered as substitute for
analgesics
- Appropriate for brief episodes of
pain lasting only for seconds or
minutes
- Most effective when used with
analgesics
 Non-Pharmacologic/Non-invasive
Approaches:
1.Nurse-Patient relationship and
teaching
- Establish trust
- Focus on pain and pain relief
measures
- Use the patient-group situation
- Manage people who comes in
contact with the patient
2. Cutaneous Stimulation
- Stimulation of the large diameter
nerve fibers to decrease the
intensity of pain
- Consideration in choosing forms to
be used:
• Location
• Duration
• Intensity of stimulation (pain)
• Usually chosen from trial and
error technique but common
sense is often an effective guide
Forms of Cutaneous Stimulation
• Shiatzu
Vibration:
Hot and cold application:
Bathing:
Lotion/Menthol Cream:
Transcutaneous Electronic Nerve
Stimulation (TENS):
3. Distraction
- Focusing the patient’s attention
away from the painful sensation
- It decreases the pain intensity
and increases pain tolerance
- Deficiency in environmental
stimulation increases the pain
theshold
Examples: (Mild Forms)
• Minimizing strange noises
• Brief but frequent visit to the
patient
• Bringing him some snacks
• Teaching appropriate exercises
 Effectiveness of distraction
depends on the degree of patient
to create sensory increased in
direct relation to:
• Patient’s direct participation
• # of sensory modalities used
• Patient’s interest to stimuli
introduced
- Pt in severe pain, may not be
able to concentrate well
- Many patient devise their own
distraction technique
4. Relaxation technique
- Skeletal muscle relaxation may decrease
pain intensity or increase pain tolerance
- Can be combined with other pain relief
measures
Example:
Yoga:
Alexander Technique:
Breathing Control
Aroma Therapy:
Music Therapy:
5. Guided Imagery
- the use of one’s imagination in
an especially designed manner
to achieved a specific positive
effect (relaxation & pain relief)
- Needs considerable period of
time to teach & explain the
technique
Requirements:
• Pt must be able to concentrate
• Use his imagination
• Follow directions
- practice: 5 mins 3X a day