Nursing 102 Fundamentals of Nursing

Module D: Vital Signs-Pain Assessment

• Reading assignments: Potter & Perry, Chapter 43- Pain Management

• Bring NUR 102 syllabus pgs. 55, 56, & 57.

What is pain?

• According to the International Association for the Study of Pain, pain is an

unpleasant, subjective sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such damage.

• 2000-2010

1. Decade of Pain Control and Research declared by Congress.

2. Providing pain relief is a basic human right and is in the Pain Care Bill
of Rights ( American Pain Foundation, 2001)

3. http://www.painfoundation.org/Publications/BORenglish.pdf

4. Amaerican Bar Association declared pain relief a basic legal right.

Nurses are legally and ethically responsible for pain management.

5. Pain is whatever the experiencing person says it is, existing whenever

he says it does, McCaffery, 1979.

6. http://www.addiction-free.com/cost-of-pain-conditions.html

Nature of Pain, pg 1052

• Subjective

1. Individualized

2. Involves physical, cognitive, and emotional components

3. Is exhausting

4. Can interfere with personal relationships and influence the meaning of life

• Processes of pain

1. Transduction (depolarization)- Pain is usually caused by thermal, chemical,

or mechanical stimuli. The stimuli energy is converted to electrical energy.
Transduction is the energy conversion. Begins in the periphery when a pain-
producing stimulus sends an impulse across a nociceptor (peripheral pain nerve
fiber). This initiates an action potential.
 2. Transmission of the pain impulse begins once the transmission is
complete. Transmission is the process by which these stimuli proceed along
primary afferent (sensory) nociceptive axons to the spinal cord and then on to
higher centers.

Gate-Control Theory of Pain, pg 1053

• Wall and Malzack, 1965

1. Pain has obligatory emotional and cognitive components.

2. Pain impulses can be regulated or even blocked by gating mechanisms

located along the CNS.

3. Pain impulses pass through when a gate is open and impulses are
blocked when a gate is closed.

4. Closing the gate is from pain relief interventions. Nurses can gain a
useful conceptual framework for pain management by understanding
what can influence these gates.

Pain threshold

• The point at which a person feels pain.

1. Stress, exercise, and other factors increase the release of endorphins.

Physiological Responses pg 1054, Table 43-1

• Low-moderate intensity & superficial= (fight-or-flight ) sympathetic

• Continuous, severe, or deep= parasympathetic nervous system is activated

Behavioral Responses

• Clenching the teeth

• Holding the painful part

• Bent posture

• Grimaces

• Cry

• Moan

• Restless

•
Terminology

• 1.Acute pain- has identifiable cause, short duration (< 6 months), usually has
limited tissue damage and emotional response.

1. Usually resolves with/out treatment.

2. Usually treated aggressively but can turn into chronic pain.

Considered protective.

• 2. Chronic pain- may not have an identifiable source, last longer than
anticipated, and leads to personal suffering. Can/not be caused from cancer

Types of Pain, pg 1055

• Chronic Episodic Pain

• Cancer Pain

• Pain by Inferred Pathological Process

• Idiopathic

Non-cancer pain

• Non-life threatening

• May lead to psychological depression and suicide

• Major cause of psychological and physical disability

• Symptoms- fatigue, insomnia, anorexia, weight loss, apathy, hopelessness,

anger

• Pseudo addiction

• “doctor-shops”

• Often labeled as drug seekers

• Discourage patient from using multiple health care providers, refer him to a
pain expert

• Emphasize that the pain may not be cured but it can be managed

Cancer Pain

• 90% of cancer patients can have their pain managed with simple means

• Variety of ideologies
Pain by Inferred Pathology Process p. 1235

• Nociceptive (Normal pain )

1. Somatic-musculoskeletal

2. Visceral- internal organs

• Neuropathic- from abnormal pain receptors

1. Centrally generated

2. Peripherally generated

Idiopathic pain

• Unidentifiable source

• Pain perceived as excessive for the extent of organic pathological condition

Factors influencing pain

• Social factors

1. attention

2. previous experience

3. family and social support

• Psychological factors

1. Anxiety

2. Coping style

• Cultural factors

1. meaning of pain

2. Ethnicity

Characteristics of Pain

• Onset

1. When did the pain begin?

1. Time

2. Duration
 2. Does the pain come and go?

3. Does it hurt all the time?

4. Do you have both types of pain (acute and chronic)?

• Intensity (0-10)

1. Script: “On a scale of 0-10, with 0 being no pain at all and 10 being
the worst pain you can imagine”

2. What is your pain now?

3. What has the average been

• over the last 5 days (chronic pain)

• over the last 24 hours (acute)

• Location

1. Where is the pain?

2. Elderly, cancer and AIDS patients average three separate sites of pain

3. Document all pain sites

Classification of pain by location

• Superficial or cutaneous

• Deep or visceral

• Referred

• Radiating

Quality

Adjective to describe the pain

• Burning

• Aching

• Tender

• Shooting

• Tingling

• Cramping
 • Radiating

• Pressure

• Numbness

• Throbbing

Nonverbal Indicators

• Write down some nonverbal indicators of pain.

Aggravating and Alleviating Factors

• What makes the pain better?

• What makes the pain worse?

How does the pain affect?

• Sleep

• Appetite

• Energy

• Activity

• Relationships

• Mood

Pain scales

• A. Visual analog p. 1243

• B. Oucher p. 1244

• C. Wong-Baker FACES p. 1244

• D. FLACC Pain Rating Scale p. 61 Nursing 102 Syllabus

• E. Use facilities pain scale

Principles of pain assessment in children

QUESTT

Question the child.

Use a pain rating scale.

Evaluate behavioral and physiologic changes

Secure parents’ involvement.

Take the cause of pain into account.

Take action and evaluate results.

Infant Pain Scale

• Universal Pain Assessment

• Pain Behavioral Scale

• Assessing the Demented Patient

Recognizing pain behaviors

• facial grimacing

• guarding any areas

• restless impatient motion

• isolation – increasing time in bed/alone

• negative vocalizations

• decreased appetite

• aggressive behavior

Pain scale for dementia

• Pain Assessment in the Elderly

1. Poor memory, depression and sensory impairment may make getting

pain information from the patient difficult

• Use of standard tools

1. Assess Patient on Routine Rounds

2. At minimum, when you make rounds at the beginning of your shift

• Other assessments during the shift as the patient’s condition warrants; or, as
ordered

• List nursing strategies to assist the patient cope with pain.

• Ask and assess about pain regularly, systematically

 • Believe the patients report and what helps

• Choose pain control appropriately

• Deliver interventions timely and logically

• Empower and enable patient and family to control their course

Nursing Diagnosis

• Acute pain

• Self-care deficit

• Chronic pain

• Plan/ Intervention

Special needs of the patient taken into consideration (i.e.. developmental level,
aphasia, etc.)

• Personal, cultural, spiritual &/or ethnic beliefs considered

Give pain meds as ordered

• If no orders, call physician

Implementation

• Drug therapy

• Relaxation techniques

• Cutaneous stimulation (massage, heat, cold)

• In your next lecture, you will be learning more about comfort measures.

Evaluation

• Reassess pt. w/in 30min-1hr

• Review & modify plan of care for pts who have unrelieved pain

• Goal is to relieve pain or reduce to a level acceptable to patient

• Documentation of Pain

• Admission assessment

• On the clinical path

• Charting by exception sheet

 • Narrative notes

• Meds follow-up pathway in MIS

• Discharge assessment form

DOCUMENTATION IS REQUIRED NOT OPTIONAL

• JCAHO Standard:
Patients have the right to appropriate assessment and management of pain.

Pain assessed on all patients

• Admission assessment

• Regular/routine assessment

• When the patient asks for med

• Follow-up within 2 hours

• Discharge pain assessment

• JCAHO Standard: Patient involved in all aspects of care

• Education

• Care Notes

• Documentation of patient education

• Existing patient education pathway

Documentation

• Nursing 102 syllabus, p55: Pain Management Flow Sheet

• NUR 102 syllabus pgs. 65-67

• Scenerio:

• 1100- A 53 y/o/w/f presented to the ER with C/C of lower back pain. The pain
started hurting this AM at 0500. She describes the pain as a sharp shooting
pain that originates over the spinal column area and radiated down to the left
leg. She noticed this pain upon arising for the day. She rates her pain a 4/5.
 Walking makes her pain worse but the heating pad made it better. PTA she
has Tylenol 500mg . Denies N/V. The doctor orders Demerol 25mg IM. 45
minutes after the shot, her pain is 1/5.

• Remember……….

Always, Evaluate, Re-evaluate!!

• Review

1. Which organization declared pain relief a basic legal right?

State Boards of Nursing

American Bar Association

American Nurses Association

National League for Nursing

2. Pain is viewed as a:

Separate disease

Symptom of an illness

Symptom of a condition

• Objective finding

• 3. This type of pain lasts longer than anticipated, may not have an
identifiable cause, and leads to great personal suffering:

• Cancer pain

• Chronic pain

• Acute pain

• Idiopathic pain

• 4. One of the reasons many nurses avoid acknowledging a client’s pain is:

• Inadequate pain management skills

• Insufficient time to respond to the client

• Fear that the intervention may cause addiction

• Inability to manage their increased client load

• 5. Cognitively this age-group is unable to recall explanations about pain or
associate pain with experiences that can occur in various situations.

• Preschoolers

• Adolescents

• Young adults

• Elderly

• 6. The client requested medication for her abdominal incision pain, which she
rates 5 on scale 0-10. One hour after administration of her pain medicine, she
was able to walk in the hall for 10 minutes and rated her pain as a 7. This
indicated that the dosage for pain was:

• Adequate

• Excessive

• Insufficient

• Unnecessary

• 7. Approx. 30 minutes after administering a complementary treatment such

as heat therapy or back massage, the nurse should:

• Turn and reposition the client

• Document the pain assessment data

• Evaluate the effectiveness of the treatment

• Administer the prescribed medication

• 8. A preventive approach for acute pain relief means that analgesic

medications are given:

• Before the pain is experienced

• With complimentary therapies

• Before the pain becomes severe

• When the pain tolerance level is exceeded

• 10. One of the reasons that PCAs are frequently used for postop. Pain
management is to :

• Increase client satisfaction

• Decrease the frequency of client complaints

• Control client use of narcotics and reduce the chance of addiction

• Encourage the use of pain medications before the client experiences severe
pain