PAIN Assessment

After you have successfully completed this chapter, you should be able to:

Define the mechanisms of pain Describe different types of pain Dispel myths associated with pain Identify developmental influences on pain Identify cultural influences on pain Perform pain assessment Perform symptom analysis Identify components of a pain assessment

What is Pain?
is whatever the person says it is, whenever she or he says it does (McCaffery, 1999). unpleasant sensory and emotional experience associatedwith actual or potential tissue damage (International Association for the Study of Pain, 2006). Subjective in nature

PAIN
The fifth vital sign An unpleasant sensory and emotional experience associated with actual and potential tissue damage Most common reason for seeking healthcare Disables and distress more people than any single disease Highly subjective to person so when he says that it existit does exist!

Physiology of Pain

Figure 92 A, Touching the hot lid activates nociceptors in the skin, generating pain impulses that travel via fast A and slower C fibers to the spinal cord. B, Secondary neurons in the dorsal horn pass impulses across the spinal cord to the anterior spinothalamic tract. C, Pain impulses ascend to the thalamus and, from there, to the cerebral cortex and the reticular and limbic systems in the brainstem, which integrate the emotional, cognitive, and autonomic responses to pain.

Nociception
The process by which a painful stimulus is transmitted to the central nervous system (CNS) and perceived as pain

The process of Pain

Transduction transmission Perception modulation

Transduction
Transduction begins with a response to a noxious (painful) stimulus that results in tissue injury. Nociceptors are receptors found in the skin, subcutaneous tissue, joints, walls of arteries, and most internal organs (with the highest concentration found in the skin and the least in internal organs) that respond to painful stimuli.

TYPES OF NOXIUS STIMULI Mechanical Tissue trauma, such as surgery, laceration Alteration of tissue, such as edema Obstruction, such as biliary or bowel Abnormal tissue growth, such as tumor Abnormal contraction of muscle, such as spasm Thermal Extreme heat or cold Chemical Tissue ischemia, such as coronary artery disease ormuscle spasms

Transmission
Once the nociceptors are activated, the nerve impulse is transmitted to the spinal cord and brain. The sensory nerve impulses travel via afferent neurons to the dorsal horn of the spinal cord.

From the dorsal horn, the impulses are then transmitted from (1) the spinothalamic tract to the thalamus, (2) the spinoreticular tract to the reticular formation, (3)the spinomesencephalic tract to the mesencephalon, (4) the spinohypothalamic tract to the hypothalamus. .

Perception
is an awareness of pain and involves both the cortical and the limbic system structures. PAIN THRESHOLD- the point at which a painful stimulus is perceived as painful, is consistent from one person to the next PAIN TOLERANCE- the amount of pain one is able to endure

Modulation
Nerve transmission from the dorsal horn is modulated by descending inhibitory input. Inhibition can also occur at the peripheral, spinal, and supraspinal levels. Inhibition occurs by analgesia or the gatecontrol theory of pain modulation.

Pain Transmission When a person experiences an injury such as stubbed toe, specialized cells called nociceptor sense potential tissue damage Send an electric signal called an impulse, to the spinal cord via a sensory nerve A specialized region of the spinal cord known as the dorsal horn

 Processes the pain signal, immediately sending another impulse back down the leg via a motor nerve This cause the muscles in the leg to contract and pull the toe away from the source of injury At the same time, the dorsal horn sends another impulse up the spinal cord to the brain. During the trip the impulse travels between nerve cells.

 When the impulse reaches a nerve ending, the nerve releases chemical messengers called neurotransmitters, which carry the message to the adjacent nerve. When the impulse reaches the brain, it is analyzed and processed as an unpleasant physical and emotional sensation.

Pain Theories
Specificity and pattern theories Melzack and Walls gate control theory Neuromatrix theory

Sensitization to pain
Peripheral sensitization occurs with prolonged exposure to noxious stimuli. The result is a lower threshold of pain,leading to hyperalgesia (increased response to painful stimuli) and allodynia (painful response to nonpainful stimuli). Central sensitization also occurs with prolonged exposure to noxious stimuli with spinal neuron hyperexcitability and results in hyperalgesia and allodynia as well as persistent pain and referred pain. Sensitization can act as a protective mechanism during healing,but when it persists, chronic pain can develop.

Acute Pain
Injury or pathology Nociception and/or sensitized central neurons lasts the expected recoverytime. Acute pain serves as a protective mechanism in response to an actual or potential threat to injury seen with injury and surgery and may last up to 6 months Cutaneous and deep somatic pain Visceral pain Referred pain

Figure 94 Referred pain results of the convergence of sensory nerves from certain areas of the body within the spinal cord. For example, a toothache may be felt in the ear, pain from inflammation of the diaphragm may be felt in the shoulder, and pain from ischemia of the heart muscle (angina) may be felt in the left arm.

Chronic Pain
is defined as pain enduring for 6 monthsor longer. More specifically, chronic pain endures beyond expected recovery time. Chronic pain may be in response to a progressive illness or result from no apparent injury, as with neuropathic pain. Chronic pain often serves no adaptive purpose, and frequently results in depression. Chronic pain can be further classified as cancer/ malignant pain or chronic noncancer pain.

Breakthrough Pain
Pain which exceeds baseline chronic or persistent pain Described as a sudden flare, exceeds longacting pain medications The onset and intensity can vary Incident or episodic pain

Cancer/Malignant Pain
Cancer or malignant pain may be acute pain or chronic pain that is associated with an underlying malignancy, diagnostic procedure, or disease treatment Intractable pain,pain resistant to treatment, is often seen with advanced metastatic disease

Chronic noncancer pain

Persistent pain not associated with malignancy Pain levels and pathology have a weak link and may have no discernable cause. has a major effect on every aspect of the patients daily life and is referred to as chronic pain syndrome. In this syndrome,the patient can no longer function and her or his entire life is centered on finding pain relief.

Neuropathic Pain
Neuropathic pain results from injury to the peripheral or central nervous system. Neuropathic pain serves no adaptive purpose and therefore is pathological pain. Neuropathic pain can be classified as mono/polyneuropathies, deafferentation, and central pain

Mono/Polyneuropathies pain
involve pain along one or more damaged peripheral nerves. Neuropathies may be caused by metabolic disorders (diabetic neuropathy), toxins (alcoholic neuropathy or chemotherapy), infections (human immunodeficiency virus [HIV], postherpetic neuralgia), trauma, compression (compartment syndrome, carpal tunnel syndrome), and autoimmune and hereditary diseases.

Deafferentation pain
occurs with loss of afferent input from damage to a peripheral nerve, ganglion, or plexus, or the CNS. Example: Phantom Limb Sensation Syndrome that occurs following amputation of a body part Pain experienced in the missing body part

Central Pain
Caused by a lesion or damage in the brain or spinal cord Constant, of moderate to severe intensity Difficult to treat Depends on the area of the CNS affected Described as burning, pressing, lacerating, or aching

Pain Modulation
No one experiences pain from an identical stimulus in the same way or at the same intensity. Neural and chemical responses explain how pain can be modified.

Figure 93 A, Pain impulse causes presynaptic neuron to release burst of neurotransmitters across synapse. These bind to postsynaptic neuron and propagate impulse. B, Inhibitory neuron releases endorphins, which bind to presynaptic opiate receptors. Neurotransmitter release is inhibited, and pain impulse interrupted.

The Individualized Pain Response

Shaped by physiologic responses, age, gender, sociocultural influences, and psychological influences Pain threshold Pain tolerance
Amount of pain a person can endure before outwardly responding Varies significantly among individuals and over time

The Individualized Pain Response

Age
Influences a persons perception and expression of pain No evidence that nociception is altered by age Pain tolerance decreases with aging

The Individualized Pain Response

Gender
Women have lower pain threshold and experience higher intensity of pain

Sociocultural influences
Response is influenced by family, community, and culture Affects pain behavior Cultural standards

The Individualized Pain Response

Psychological Influences
Intensity of perceived pain is affected by attention, expectation, and suggestion

Collaborative Care for Pain

Necessary for effective pain relief Acute pain management can be straightforward Chronic pain requires a multidisciplinary approach

Collaborative Care for Pain

Medications
Most common approach to pain management Acute pain, straightforward Chronic pain, broader range of drug classes Nursing responsibilities

Figure 95 The WHO analgesic ladder illustrates the process for selection of analgesic medications for pain management. Source: The WHO Analgesic Ladder from Cancer Pain Relief and Palliative Care, Technical Report Series, No. 804, The World Health Organization, Geneva, Switzerland. Reprinted by permission.

Figure 96 The transdermal patch administers medication in predictable doses.

Figure 97 PCA units allow the patient to self-manage acute pain. The units may be portable or mounted on intravenous poles.

Surgery
Only used if all other methods have failed, and typically reserved for patients experiencing nerve pain Cordotomy Neuroectomy Sympathectomy Rhizotomy

Figure 98 Surgical procedures may be used to treat severe pain that does not respond to other types of management. They include cordotomy, neurectomy, sympathectomy, and rhizotomy.

Transcutaneous Electrical Nerve Stimulation (TENS)

Application of electrical current through the skin to control acute or chronic pain Controls pain in several ways

Figure 99 The TENS unit is used to assist in acute and chronic in pain management. Electrodes deliver low-voltage electrical stimuli through the skin to block transmission of pain stimuli.

Complementary and Adjunctive Therapies (Complementary and Alternative Medicine)

Acupuncture Biofeedback Chiropractic Distraction Hypnotherapy and Guided Imagery Massage Therapy Natural Products Relaxation

Assessment
Varies by acuity of pain and circum-stances Acute pain Chronic pain

Assessment
Patient Perceptions
Most reliable indicator of pain PQRST mnemonic
P: What precipitated the pain? Q: What is the quality of the pain? R: What is the region of the pain? S: What is the severity of the pain? T: What is the timing of the pain?

McGill Pain Questionnaire Pain-Rating Scales

P- Precipitating/Palliative/Provocative Factors
What were you doing when the pain started? Does anything make it better, such as medication or a certain position? Does anything make it worse, such as movement or breathing?

Q- Quality/Quantity
What does it feel like? Superficial somatic pain is sharp, pricking, or burning. Deep somatic pain is dull or aching. Visceral pain is dull, aching, or cramping. Neuropathic pain is burning, shocklike, lancing, jabbing, squeezing, or aching. How often are you experiencing it? To what degree is the pain affecting your ability to perform your usual daily activities?

R- Region/Radiation/Related Symptoms
Can you point to where it hurts? Does the pain occur or spread anywhere else? Localized pain is confined to the site of origin, such as cutaneous pain. Referred pain is referred to a distant structure, such as shoulder pain with acute cholecystitis or jaw pain associated with angina. Projected (transmitted) pain is transmitted along a nerve, such as with herpes zoster or trigeminal neuralgia. Dermatomal pattern as with peripheral neuropathic pain.

R- Region/Radiation/Related Symptoms
Nondermatomal pattern as with central neuropathic pain, fibromyalgia. No recognizable pattern as with complex regional pain syndrome. Do you have any other symptoms? (e.g., nausea, dizziness, shortness of breath) Visceral painrelated symptoms include sickening feeling, nausea, vomiting, and autonomic symptoms. Neuropathic painrelated symptoms include hyperalgesia and allodynia. Complex regional pain syndromerelated symptoms include hyperalgesia, hyperesthesia, allodynia, autonomic changes, and shin, hair, and nailchanges.

S- Severity
Use appropriate pain scale.

Figure 910 The McGill Pain Questionnaire. The descriptors fall into four major groups: sensory (1 10), affective (1115), evaluative (16), and miscellaneous (1720). The rank value for each descriptor is based on its position in the word set; the sum of the rank values is the pain rating index (PRI). The present pain intensity (PPI) is based on a scale of 0 to 5.

Figure 911 Examples of commonly used pain scales. Commonly Used Pain Scale from FPS-R. This figure has been reproduced with permission of the International Association for the Study of Pain (IASP). The figure may not be reproduced for any other purpose without permission

T- Timing
When did the pain begin? How long did it last? Brief flash:Quick pain as with needle stick. Rhythmic pulsation: Pulsating pain as with migraine or toothache. Long-duration rhythmic: As with intestinalcolic. Plateau pain:Pain that rises then plateaus such asangina. Paroxysmal: Such as neuropathic pain. How often does it occur? Continuous fluctuating pain: As with musculoskeletalpain. Do you have times when you are pain free?

Another mnemonic used to assess pain is OLDCART.

Onset: When did the pain begin? Location: Where does it hurt? Can you point to where it hurts? Duration: How long does it last? Characteristics: What does it feel like? Aggravating factors: Does anything make it worse? Radiation: Does the pain go anywhere else? Treatment: Did anything make it better? (Pain medication, ice, heat?)

Physiologic Responses
Predictable physiologic changes Over time, these changes might not be visible in patients with chronic pain

Behavioral Responses
Pain behaviors
Bracing/guarding the painful part Crying, moaning, or grimacing Withdrawing from activity Breathing with increased effort Becoming immobile

Behavioral Responses
Might not coincide with the patients report of pain Not always reliable cues to the pain experience

Behavioral Responses
Self-Management of Pain
Useful information for the assessment database Individualized and patient-specific Get detailed descriptions of:
Actions taken When and how the measures were applied How well the measures worked