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Chapter 11

Pain Assessment

Two main pathways:

Nociceptive and/or neuropathic processing

Patients present with different types of symptoms

Thereby differing in clinical response to therapy

Need for accurate pain assessment

Better able to develop non-pharmacologic and/or pharmacologic strategies to obtain improved clinical results

Development of Pathologic Pain

Neuroanatomic Pathways

Structure and Function

Nociceptors: specialized nerve endings designed to detect painful sensations

Transmit sensations to central nervous system by two primary sensory (afferent) fibers: Aδ and C fibers

Aδ fibers

Myelinated and larger in diameter, and they transmit pain signal rapidly to CNS; localized, short-term, and sharp sensations result from Aδ fiber stimulation

C fibers

Unmyelinated and smaller, and transmit signal more slowly; sensations are diffuse and aching, and they persist after initial injury

Peripheral sensory Aδ and C fibers

Enter spinal cord by posterior nerve roots within dorsal horn by tract of Lissauer

Nociceptors Fibers

Substantia gelatinosa: Specific area of cord in which fibers synapse with interneurons

A cross section shows that gray matter of the spinal cord is divided into a series of consecutively numbered laminae (layers of nerve cells).

Considered to be lamina II, which receives sensory input from various areas of body

Pain signals then cross over to other side of spinal cord and ascend to brain by anterolateral spinothalamic tract.

Nociception Phases

Nociception Process

Nociceptive pain

Develops when functioning and intact nerve fibers in the periphery and CNS are stimulated

Triggered by outside events from the nervous system as a result of actual or potential damage

Nociception can be divided into four phases:

Transduction

Transmission

Perception

Modulation

Phase 1—Transduction

Occurs in response to noxious stimuli

Release variety of chemical mediators

Substance P, histamine, prostaglandins, serotonin, and bradykinin

Neurotransmitters lead to pain propagation.

Along sensory afferent nerve fibers to spinal cord and terminate in dorsal horn

Second set of neurotransmitters carry pain signal—substance P, glutamate and adenosine triphosphate (ATP).

Phase 2—Transmission

Pain impulse moves from level of spinal cord to brain.

If pain is not stopped it moves via various ascending fibers within the spinothalamic tract to the thalamus.

Nociception Phase I and II

Phase 3—Perception

Consciousness of awareness of pain signal

Cortical structures such as limbic system account for emotional response to pain.

Only when “pain” has reached the cortical structures can it be perceived as pain.

Phase 4—Modulation

Body has built-in mechanism to slow down and stop the process of a painful stimulus that inhibits and blocks pain.

Descending pathways release third set of neurotransmitters to produce analgesic effect.

Neurotransmitters include

serotonin; norepinephrine; neurotensin; γ-aminobutyric acid (GABA); and our own endogenous opioids, β-endorphins, enkephalins, and dynorphins.

Nociception Phase III and IV

Neuropathic Pain (1 of 2)

Indicates type of pain that does not adhere to typical phases inherent in nociceptive pain

Pain due to a lesion or disease in the somatosensory system

Neuropathic pain implies an abnormal processing of pain message that is difficult to assess and treat.

Often perceived long after site of injury heals

Conditions that may lead to development

Diabetes mellitus, herpes zoster (shingles), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and/or chemotherapy

Neuropathic Pain (2 of 2)

Diagnosis

Sustained on a neurochemical level that cannot be identified by x-ray, computerized axial tomography (CAT) scan, or magnetic resonance imaging (MRI)

Electromyography and nerve-conduction studies are needed.

The abnormal processing of neuropathic pain impulse can be continued by peripheral or central nervous system.

Proposed mechanisms

Spontaneous and repetitive firing of nerve fibers, almost seizure like in activity

Central neuron excitability ( wind-up)

Minor stimuli can lead to significant pain.

Sources of Pain (1 of 2)

Pain sources based on their origin

Visceral pain originates from larger interior organs.

Stems from direct injury to organ or from stretching of organ from tumor, ischemia, distention, or severe contraction

Pain impulse transmitted by ascending nerve fibers along with nerve fibers of autonomic nervous system

Presents with autonomic responses such as vomiting, nausea, pallor, and diaphoresis

Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone.

Injury may result from pressure, trauma, or ischemia.

Described as aching or throbbing

Usually well localized and able to be identified

Like visceral pain it can be accompanied by nausea, sweating, tachycardia, and HTN.

Sources of Pain (2 of 2)

Pain sources based on their origin

Cutaneous pain derived from skin surface and subcutaneous tissues

injury is superficial, with a sharp, burning sensation.

Referred pain felt at a particular site but originates from another location

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.

Various structures maintain their same embryonic innervation.

It is useful to have knowledge of areas of referred pain for diagnostic purposes.

Types of Pain: Classification

Pain can be classified by its duration

Acute

Chronic (persistent)

Duration provides information r/t underlying mechanisms and treatment decisions.

Types of Pain: Acute

Acute pain

Short-term and self-limiting:

Often follows a predictable trajectory, and dissipates after an injury heals

Self-protective purpose:

Acute pain warns individual of actual or potential tissue damage.

Incident pain:

Type of acute pain that occurs predictably with certain movements

Types of Pain: Chronic (1 of 2)

Chronic pain can be further divided into malignant (cancer related) and nonmalignant.

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.

Malignant pain often parallels pathology created by tumor cells.

Pain induced by tissue necrosis or stretching of an organ by growing tumor.

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

Types of Pain: Chronic (2 of 2)

Chronic pain can be further divided into malignant (cancer related) and nonmalignant.

Does not stop when the injury heals

It persists after the predicted trajectory.

Outlasts its protective purpose

The level of pain intensity does not correspond with the physical findings.

Unfortunately, many patients with chronic pain are not believed.

Often labeled as malingers, attention seekers, drug seekers, and so forth

Types of Pain: Breakthrough

Breakthrough pain

Transient spike in pain level with moderate to severe intensity in an otherwise controlled pain syndrome

Can result from:

End of dose medication failure

Result of incident or episodic pain

Treatment:

Shorten interval dosing and/or increase medication

Experience of pain is a complex biopsychosocial mechanism.

More clinical research is needed.

Rely on patient report as best indicator of pain

Question 1

A patient is crying and says, “Please get me something to relieve this pain.” What should the nurse do next?

Verify that the patient has an order for pain medications and administer order as directed.

Assess the level of pain and ask patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level.

Assess the level of pain and give medications according to pain level, and then reassess pain.

Reposition the patient, then reassess the pain after intervention.

Answer to Question 1

The correct answer is 2.

Options 1, 3, and 4 are incorrect because pain management should be collaborative, and the patient is not part of the decision-making process in these answers.

Developmental Competence: Infants (1 of 2)

Infants have same capacity for pain as adults.

Fetal development:

By 20 weeks of gestation, ascending pathways are in place but perception of pain by fetus may not be seen until about 30 weeks due to immaturity of cortex and lack of conscious awareness.

Inhibitory neurotransmitters are in insufficient supply until birth at full term

Therefore, preterm infant rendered more sensitive to painful stimuli.

Developmental Competence: Infants (2 of 2)

Infants have same capacity for pain as adults.

Preverbal infants are at high risk for under treatment of pain

because of persistent myths and beliefs that infants do not remember pain.

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.

Developmental Competence: The Aging Adult (1 of 2)

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.

Many clinicians and older adults wrongfully assume pain should be expected in aging, which leads to less aggressive treatment.

Developmental Competence: The Aging Adult (2 of 2)

Older adults have additional fears about

becoming dependent, undergoing invasive procedures, taking pain medications, and having a financial burden.

Most common pain-producing conditions for aging adults include

pathologies such as arthritis, osteoarthritis, osteoporosis, peripheral vascular disease, cancer, peripheral neuropathies, angina, and chronic constipation.

Dementia does not impact ability to feel pain, but it does impact person’s ability to effectively use self-report tools.

Gender Differences

Gender differences are influenced by societal expectations, hormones, and genetic makeup.

Traditionally, men have been raised to be more stoic about pain, and more affective or emotional displays of pain are accepted for women.

Hormonal changes are found to have strong influences on pain sensitivity for women.

Women are two to three times more likely to experience migraines during childbearing years, are more sensitive to pain during premenstrual period, and are six times more likely to have fibromyalgia.

Cultural Differences in Pain

Make sure to review methods of working with an interpreter if assessing patients from a different culture and/or who speak a different language to avoid misunderstanding.

Perform a thorough pain assessment examination on all patients.

Lack of outward pain “symptom” or expression does not indicate an absence of pain.

Most research conducted on racial differences and pain has focused on disparity in management of pain for various races.

Poorly treated pain leads to increased physiologic and psychological costs.

Pain and expression of pain are influenced by social, cultural, emotional and spiritual concerns

Identified as a Public Health Emergency in 2017

Strategy to combat rising epidemic

Effective against severe pain but can cause serious side effects

Consider risks versus benefits.

Opioid receptors connect with mu-opioid receptors throughout the body.

Effects range from pain relief to euphoria.

Use can lead to physical dependence.

Practice management concerns

Pain management principles

Patient and provider education

The Opioid Epidemic

The Opioid Receptor Response

Subjective Data: 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 gold standard of pain assessment.

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 Questions (1 of 2)

Qualify all information in the patient’s own words.

Do you have pain?

Discomfort, soreness or “ouch”

Where is your pain?

Tell me about all of the places that have pain.

When did you pain start?

What were you doing when the pain started?

Is it constant or does it come and go?

What does your pain feel like?

Burning, stabbing, aching

Throbbing, fire like, squeezing

Cramping, sharp, itching, tingling

Shooting, crushing, sharp, dull

How much pain do you have now?

Initial Pain Assessment Questions (2 of 2)

Qualify all information in the patient’s own words.

What makes your pain better or worse?

Include behavioral, pharmacologic, and non-pharmacologic interventions.

What medications control your pain? Are doses adequate?

How often do you take pain medication?

How does pain limit your function or activities?

What does pain prevent you from doing?

How do you usually react when you are in pain?

Any other symptoms along with the pain?

How would others know you are in pain?

Is it constant or does it come and go?

What does pain mean to you?

Why do you think you are having pain?

Pain Assessment Tools

Pain is multidimensional in scope, encompassing physical, affective, and functional domains.

Various tools have been developed to capture one-dimensional aspects or multidimensional components.

Select pain assessment tool based on its purpose, time involved in administration, and patient’s ability to comprehend and complete tool.

Rate and evaluate all pain sites.

Use assessment tool consistently.

Reassessment of pain following intervention is critical in determining clinical response to therapy.

Standardized overall pain assessment tools are more useful for chronic pain conditions or particularly problematic acute pain problems.

Types of Pain Assessment Tools (1 of 3)

Initial pain assessment

Clinician asks patients eight questions concerning location, duration, quality, intensity, and aggravating/relieving factors.

Furthermore, clinician adds questions about manner of expressing pain and effects of pain that impairs one’s quality of life.

Brief pain inventory

Clinician asks patient to rate pain within past 24 hours on graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep.

Short-form McGill Pain Questionnaire

Clinician asks patient to rank list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain.

Types of Pain Assessment Tools (2 of 3)

Pain rating scales are one-dimensional and are intended to reflect pain intensity.

Pain rating scales can indicate a baseline intensity, track changes, and give some degree of evaluation to a treatment modality.

There are different subtypes that use numbers, verbal description, visual analog, or descriptor scale.

Selection of pain rating scale is based on patient understanding and age of development.

Numeric rating scales patient to choose a number that rates level of pain, with 0 being no pain and highest anchor 10 indicating worst pain.

Verbal descriptor scales have the patient use words to describe pain.

Visual analog scales have the patient mark the intensity of the pain on a horizontal line from “no pain” to “worst pain.”

Descriptor scales in which patients are asked to indicate their pain by using selected pain term words

Types of Pain Assessment Tools (3 of 3)

PQRST Method of Pain Assessment

For each of the initials a series of questions are asked to help qualify patient’s self-report of clinical symptoms

P = Provocation/palliation

Q = Quality/quantity

R = Region/radiation

S = Severity scale

T = Timing

Pain Assessment: Infants and Children

Because infants are preverbal and incapable of self-report, pain assessment is dependent on 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 but cannot rate pain intensity.

It is helpful to ask parent or caregiver what words the child uses to report pain.

Rating scales can be introduced at 4 or 5 years.

Faces Pain Scale-Revised (FPS-R) is an example.

6 drawings of pain intensity from “no pain” on right (0) to “very much pain” on left (10)

Realistic facial expressions used

Objective Data Preparation

Physical examination process can help you understand the nature of the pain.

Is it an acute or chronic condition?

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.

American Pain Society

Important to establish a diagnosis for the cause of acute pain is a priority but symptomatic treatment should be started during the investigation process.

Patient comfort will better lead to cooperating with diagnostic procedures.

The nurse is reassessing a patient’s pain level after pain medication administration following a pain level of 9/10. The patient states that his pain level is now a 3/10. What should the nurse do next?

Verify orders for medications and offer more pain medication, if appropriate.

Continue to assess patient’s pain level.

Document the pain level in the chart.

There is no need for action, because the patient’s pain is manageable.

Chapter Question 1

The correct answer is 1. Patients have the right to be pain free, and a level of 3/10 would indicate that the patient is still in pain.

Option 2 is incorrect because this patient needs intervention.

Option 3 is incorrect because although the patient’s pain level should be documented, this is not the main priority and offers no resolution for the patient’s pain.

Option 4 is incorrect because a pain level of 3/10 indicates that the pain is not manageable.

Answer to Chapter Question 1

Objective Data

Joints

Note size, contour, and circumference of joint.

Check active or passive range of motion.

Joint motion normally causes no tenderness, pain, or crepitation.

Muscle and skin

Inspect skin and tissues for color, swelling, and any masses or deformity.

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

nature of pain (acute versus chronic).

age.

cultural and gender expectations.

Acute Pain Behaviors

Acute pain behaviors

Involve autonomic responses

Protective purpose

Individuals experiencing moderate to intense levels of pain may exhibit the following behaviors:

Guarding, grimacing

Vocalizations such as moaning, agitation, restlessness, stillness

Diaphoresis,

Change in vital signs

Chronic Pain Behaviors

Persistent (Chronic) pain behaviors

Often live with experience for months and years

Adaptation occurs over time.

Clinicians cannot look for or anticipate the same acute pain behaviors to exist in order to confirm a pain diagnosis.

Shows more variability than acute pain behaviors

Higher risk for under detection

Associated behaviors:

Bracing, rubbing

Diminished activity

Sighing

Change in appetite

Developmental Competence: Infants

Most pain research on infants has focused on acute, procedural pain.

Limited understanding of how to assess chronic pain in infants:

There is no one assessment tool that adequately identifies pain in infants.

Using a multidimensional approach for whole infant is encouraged.

Changes in facial activity and body movements may help assess pain.

Tools used to assess pain in infants:

CRIES

Measures postoperative pain in preterm and term neonates

Examines physiologic and behavioral indicators on 3 point scale

FLACC

Nonverbal tool used for infants and young children up to age 3

Assesses 5 behaviors of pain (facial expression, leg movement, activity level, cry, and consolability)

Developmental Competence: Infants Tool

Tool: CRIES

Tool: FLACC

Developmental Competence: The Aging Adult

Although pain should not be considered a “normal” part of aging, it is prevalent.

Older adults with history of comorbidities—should anticipate pain.

Older adults often deny having pain

for fear of dependency, further testing or invasive procedures, cost, and fear of taking painkillers or becoming a drug addict.

Observe for changes in functional behavior and/or behavioral cues.

Comorbidity of dementia may prevent patient from identifying and describing pain—observe behaviors—use PAINAD scale.

PAINAD Scale

Evaluates 5 common behaviors

Breathing, vocalization, facial expression, body language, and consolability

Quantified behaviors in category 0 to 2

Total score metric 0 to 10

Score of 4 or more requires treatment.

Developmental Competence: PAINAD Scale

Tool: PAINAD Scale

Also known as reflexive sympathetic dystrophy (RSD)

Chronic progressive nerve condition

Complex interaction of sensory, motor, autonomic nervous system, and immune system

Equally seen in gender, usually around ages 40 to 60

Key feature is an innocuous stimulus.

Presents with burning pain, swelling, stiffness, and discoloration of the affected extremity

Treatment

High doses of medications (e.g., prednisone, amitriptyline, pregabalin, clonidine) to decrease symptoms

Physical therapy to regain limb function

Complex Regional Pain Syndrome (CRPS)

Case Study

A 52-year-old female presents with complaints of continuing pain across her lower back. Denies any injury or traumatic event but states that the pain is a 10 on a scale of 1 to 10 and that no one believes that she is really in “pain.” Pain has been present for several months.

Case Study Question 1

What information would you as the nurse obtain in order to validate the patient’s complaints?

Answer to Case Study Question 1

Review information relative to subjective and objective data.

From Textbook:

Subjective data:

Ask the patient about her pain using basic-level questions to determine an initial baseline:

Presence of pain, location of pain, onset of pain,

Quality of pain, pain perception on a scale metric (0 to 10)

Alleviating or worsening factors

Does pain prevent you from performing ADLs or limit other activities?

Reaction to pain—symptoms experienced

Can use PQRST to obtain data relevant to pain health history

Objective data:

Inspect the skin and tissues for color, swelling, and any masses or deformity.

Assess for changes in sensation.

Case Study Question 2

The patient is still complaining of pain after having been medicated with morphine 1 mg given via intravenous route as an IVP. When you attempt to reposition the patient, she complains even more than just a “mere touch” causes her severe discomfort. How would the nurse interpret this finding?

The detection of pain etiology is a difficult process, especially when the patient presents with what appears to be a chronic pain presentation.

Additional information relative to the patient’s complaint would focus on

past medical/surgical history, current status relative to medications, both prescription and over-the-counter remedies.

The nurse must be careful not to pass judgment at this time and continue to obtain relevant data necessary to determine the source of the patient’s pain.

Additional investigation must be performed in conjunction with the patient’s complaint in order for the nurse to make an accurate determination.

Severe pain upon touch indicates both an increased pain response (hyperalgesia) and allodynia (pain sensation evoked in response to a normal stimuli), which pose considerable concern about the patient’s health status.

Answer to Case Study Question 2

Case Study Question 3

In reviewing the patient’s health record, the nurse notes that there have been multiple admissions for the same “pain complaint” and that the patient had been treated with a variety of pain medications ranging from nonsteroidal anti-inflammatory drugs (NSAIDs) to narcotics with little success. What recommendations might the nurse consider for this patient in order to manage her pain more effectively?

Answer to Case Study Question 3

As the patient’s history provides evidence of multiple admissions for the same “pain complaint,” the nurse may want to consider

implementing an interdisciplinary health care team to help manage the patient’s pain.

Inclusion of a pain management specialist would be beneficial so as to look at alternative methods of pain control.

Pharmacologic as well as nonpharmacologic measures might prove to be effective. Additionally, collaborative care with physical therapy and occupational therapy might help the patient become more in “control of her pain.”

The nurse should also review the patient’s records for potential comorbidities such as

diabetes or shingles that might be a possible etiology to neuropathic pain.

As the pain pattern has persisted, the patient must be assessed for complex regional pain syndrome (CRPS) or reflexive sympathetic dystrophy (RSD).

Case Study Question 4

What clinical data, if observed in this patient, would lead the nurse to believe that the patient is experiencing complex regional pain syndrome (CRP)?

Answer to Case Study Question 4

RSD/CRPS is a chronic progressive nerve condition, characterized by burning pain, swelling, stiffness, and discoloration of the affected extremity.

A key feature is that a typically innocuous stimulus (e.g., a light brush of a cotton ball or clothing) can create a severe, intense painful response.

Other subjective data include

burning pain often disproportionate to the degree of injury and joint pain during movement.

Objective data include

swelling, disappearance of skin wrinkles, cool skin temperature, discoloration, brittle nails, and finally atrophic changes (pale, dry, shiny skin and muscle atrophy).

Treatment includes

medication to treat symptoms and physical therapy to regain limb function