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Chapter 10- Pain Assessment: The Fifth Vital Sign

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by

E. Kohut

on 3 March 2015

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Transcript of Chapter 10- Pain Assessment: The Fifth Vital Sign

Chapter 10- Pain Assessment: The Fifth Vital Sign
Structure & Function
Structure and Function cont...
Structure and Function:Developmental Competence
Subjective Data
Objective Data
Nociceptors
Specialized nerve endings designed to detect painful sensations
Transmit sensations to central nervous system
Located within skin; connective tissue; muscle; and thoracic, abdominal, and pelvic viscera
These nociceptors can be stimulated directly by trauma or injury or secondarily by chemical mediators released from site of tissue damage
Nociceptors carry pain signal to central nervous system by two primary sensory (afferent) fibers: A delta and C fibers
Nociceptors cont...
A-delta fibers are myelinated and larger in diameter, and they transmit pain signal rapidly to CNS; localized, short-term, and sharp sensations result from A-delta fiber stimulation
In contrast, C fibers are unmyelinated and smaller, and transmit signal more slowly; sensations diffuse and aching, and they persist after initial injury
Sources of Pain
Pain sources based upon their origin

Visceral pain originates from larger interior organs, i.e., kidney, stomach, intestine, gallbladder, pancreas
Pain can stem from direct injury to organ or from stretching of organ from tumor, ischemia, distention, or severe contraction
Examples of visceral pain include ureteral colic, acute appendicitis, ulcer pain
Pain impulse transmitted by ascending nerve fibers along with nerve fibers of autonomic nervous system
That is why visceral pain often presents with autonomic responses such as vomiting, nausea, pallor, and diaphoresis
Sources of Pain cont...
Pain sources based upon their origin (cont.)

Deep somatic (aka musculoskeletal) pain comes from sources such as blood vessels, joints, tendons, muscles, and bone
Injury may result from pressure, trauma, or ischemia
Cutaneous pain derived from skin surface and subcutaneous tissues; injury is superficial, with a sharp, burning sensation
Linking pain to a mental disorder (psychogenic pain) negates person’s pain report
A clinician’s lack of awareness and understanding of neuropathic pain may contribute to this mislabeling
Sources of Pain cont...
Pain sources based upon their origin (cont.)

Pain that is felt at a particular site but originates from another location is termed referred pain
Both sites are innervated by same spinal nerve, and it is difficult for brain to differentiate point of origin
Referred pain may originate from visceral or somatic structures
Sources of Pain cont...
Pain sources based upon their origin (cont.)

It is useful to have knowledge of areas of referred pain for diagnostic purposes
For example, an inflamed appendix in right lower quadrant of abdomen may have referred pain in periumbilical area
Common Sites For Referred Pain
Types of Pain (by duration)
Pain can be classified by its duration

Duration can provide information on possible underlying mechanisms and treatment decisions
Pain is divided into acute or chronic categories
Acute pain is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals
Examples of acute pain include surgery, trauma, and kidney stones
Acute pain serves a self-protective purpose; acute pain warns individual of actual or potential tissue damage
Pain is divided into acute or chronic categories (cont.)

In contrast, chronic (or persistent) pain is diagnosed when pain continues for 6 months or longer
It can last 5, 15, or 20 years and beyond
Chronic pain can be further divided into malignant (cancer related) and nonmalignant
Malignant pain often parallels pathology created by tumor cells
Pain induced by tissue necrosis or stretching of an organ by growing tumor
Types of Pain (by duration)
Types of Pain (by duration)
Chronic pain can be further divided into malignant (cancer related) and nonmalignant (cont.)

The pain fluctuates within the course of the disease
Chronic nonmalignant pain is often associated with musculoskeletal conditions, such as arthritis, low back pain, or fibromyalgia
Chronic pain does not stop when the injury heals
It persists after the predicted trajectory
Chronic pain outlasts its protective purpose, and the level of pain intensity does not correspond with the physical findings
Types of Pain (by duration)
Chronic pain can be further divided into malignant (cancer related) and nonmalignant (cont.)

Unfortunately, many patients with chronic pain are not believed and often labeled as malingers, attention seekers, drug seekers, and so forth
Chronic pain originates from abnormal processing of pain fibers from peripheral or central sites
Because pain is transmitted on a cellular level, our current technology cannot reliably detect this process
Therefore most important and reliable indicator for pain is patient’s self-report
Infants
Infants have same capacity for pain as adults
By 20 weeks of gestation, ascending fibers, neurotransmitters, and cerebral cortex are developed and functioning to extent that fetus is capable of feeling pain
However, inhibitory neurotransmitters are in insufficient supply until birth at full term
Therefore preterm infant rendered more sensitive to painful stimuli
Preverbal infants are at high risk for undertreatment of pain because of persistent myths and beliefs that infants do not remember pain
Infants cont...
Infants have same capacity for pain as adults (cont.)

New research indicates that repetitive and poorly controlled pain in infants (daily heel sticks, venipunctures) can result in lifelong adverse consequences such as neurodevelopmental problems, poor weight gain, learning disabilities, psychiatric disorders, and alcoholism

Aging Adult
No evidence exists to suggest that older individuals perceive pain to a lesser degree or that sensitivity is diminished
Although pain is common experience among individuals 65 years of age and older, it is not normal process of aging; it indicates pathology or injury
Pain should never be considered something to tolerate or accept in one’s later years
Unfortunately, many clinicians and older adults wrongfully assume pain should be expected in aging, which leads to less aggressive treatment
Gender Differences
With recent findings from Human Genome Project, genetic differences between both sexes may account for differences in pain perception
A pain gene exists, which helps to explain why some people feel more/less pain even with same stimulus
Efforts are being made to tailor pharmacological agents to improve pain treatment based on genetic sequencing
Cultural Differences
Most research conducted on racial differences and pain has focused on disparity in management of pain for various races
Comparing pain treatment for individuals of color (e.g., African Americans, Hispanics) with standard treatment for individuals with similar injuries or diseases
Various studies describe how African American and Hispanic patients are often prescribed and administered less analgesic therapy than white patients, although majority of these differences is small
Pain
Defined as an unpleasant sensory and emotional experience

Associated with actual or potential tissue damage or described in terms of such damage
Pain is always subjective
Pain is whatever the experiencing person says it is, existing whenever he or she says it does
Subjective report is most reliable indicator of pain
Because pain occurs on a neurochemical level, clinician cannot base diagnosis of pain exclusively on physical examination findings, although these findings can lend support
Initial Pain Assessment
Where is your pain?
When did your pain start?
What does your pain feel like?
Burning, stabbing, aching
Throbbing, firelike, squeezing
Cramping, sharp, itching, tingling
Shooting, crushing, sharp, dull
How much pain do you have now?
Initial Pain Assessment cont...
What makes your pain better or worse? Include behavioral, pharmacologic, nonpharmacologic interventions
How does pain limit your function or activities?
How do you usually behave when you are in pain? How would others know you are in pain?
What does this pain mean to you? Why do you think you are having pain?
Pain Assessment Tools
Numeric rating scales ask patient to choose a number that rates level of pain, with 0 being no pain and highest anchor 10 indicating worst pain

It can be administered verbally or visually along a vertical or horizontal line
Pain Assessment Tools cont...
In general, older adults find numeric rating scale abstract and have difficulty responding, especially with a fluctuating chronic pain experience
An alternative is simple Descriptor Scale that lists words that describe different levels of pain intensity, such as no pain, mild pain, moderate pain, and severe pain
Older adults will often respond to scales in which words are selected
Infants and Children
Because infants are preverbal and incapable of self report, pain assessment is dependent upon behavioral and physiologic cues
It is important to underscore understanding that infants do feel pain
Children 2 years of age can report pain and point to its location
They cannot rate pain intensity at this developmental level
It is helpful to ask parent or caregiver what words their child uses to report pain
Infants and Children cont...
Rating scales can be introduced at 4 or 5 years
Wong-Baker Scale is one example; child asked to choose face that shows, “how much hurt you have now”
Oucher Scale has six photographs of young boys’ faces with different expressions of pain, ranked on a 0 to 5 scale of increasing intensity
Child asked to point at face that best matches their hurt or pain
Oucher Scale has variations for girls and ethnic groups
Preparation
Physical examination process can help you understand the nature of the pain
Consider whether this is an acute or chronic condition
Recall that physical findings may not always support patient’s pain complaints, particularly for chronic pain syndromes
Pain should not be discounted when objective, physical evidence is not found
Based on the patient’s pain report, make every effort to reduce or eliminate pain with appropriate analgesic and nonpharmacologic intervention
Preparation cont...
According to American Pain Society
In cases in which cause of acute pain is uncertain, establishing a diagnosis is a priority, but symptomatic treatment of pain should be given while investigation is proceeding
With occasional exceptions, (e.g., initial examination of patient with an acute condition of abdomen), it is rarely justified to defer analgesia until a diagnosis is made
In fact, a comfortable patient is better able to cooperate with diagnostic procedures
Preparation cont...
Equipment needed

Tape measure to measure circumference of swollen joints or extremities
Tongue blade

Joints
Note size and contour of joint
Measure circumference of involved joint for comparison with baseline
Check active or passive range of motion
Joint motion normally causes no tenderness, pain, or crepitation

Muscles and Skin
Inspect skin and tissues for color, swelling, and any masses or deformity
To assess for changes in sensation, ask person to close his or her eyes
Test person’s ability to perceive sensation by breaking a tongue blade in two lengthwise
Lightly press sharp and blunted ends on skin in a random fashion and ask to identify it as sharp or dull
This test will help you identify location and extent of altered sensation
Abdomen
Observe for contour and symmetry
Palpate for muscle guarding and organ size
Note any areas of referred pain

Nonverbal Behaviors of Pain
When individual cannot verbally communicate pain, you can (to a limited extent) identify pain using behavioral cues
Recall that individuals react to painful stimuli with a wide variety of behaviors
Behaviors are influenced by a wide variety of factors, including nature of pain (acute versus chronic), age, and cultural and gender expectations
Nonverbal Behaviors of Pain cont...
Acute pain behaviors
Because acute pain involves autonomic responses and has protective purpose, individuals experiencing moderate to intense levels of pain may exhibit the following behaviors:
Guarding, grimacing, vocalizations such as moaning, agitation, restlessness, stillness, or change in vital signs
This list of behaviors is not exhaustive because they should not be used exclusively to deny or confirm presence of pain
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