Pain Assessment

Objectives

1.     Provide a definition of pain.

2.     Identify the physiology of pain.

3.     Describe the different types of pain.

4.     Discuss factors that influence pain.

5.     Describe techniques used for assessment of a client having pain.

Key Concepts

Overview

• Pain assessment is the fifth vital sign.

• Pain is a highly unpleasant and personal sensation.

• Pain must be assessed accurately for treatment to be successful.

Definition

• Pain comes from the Greek word meaning penalty.

• Pain is whatever the person says it is.

• Pain can be the primary problem or associated with a specific diagnosis, treatment, or procedure.

• No two people experience pain in the same way.

• Pain is subjective; however, it can produce objective changes in the individual.

Physiology of pain

• Pain is a subjective, complex, multidimensional phenomenon that is not clearly understood.

• Specificity theory demonstrates that paieurons are special.

• Pattern theory indicates clients will respond in a different manner to the same stimulus.

• Gate control theory says peripheral nerve fibers carrying pain to the spinal cord can have their input modified at the spinal cord level before transmission to the brain.

• Nociception is composed of four processes: transduction, transmission, perception, and modulation.

• Three types of pain stimuli are mechanical, thermal, and chemical.

Nature of pain

• Pain, a subjective and personal experience, can be described many ways.

• Acute pain, mild to severe, lasts through the expected recovery period and is considered to be of short duration.

• Chronic pain is prolonged, recurring or persisting over a 6-month or longer time frame.

• Cutaneous pain originates in the skin or subcutaneous tissue.

• Somatic pain arises from ligaments, tendons, bones, or blood vessels.

• Visceral pain results from stimulation of structures in the abdomen, cranium, or thorax.

• Radiating pain is perceived at the site of origin and surrounding structures.

• Referred pain is felt in a body part distant from the source of origin.

Factors influencing the pain experience

• Age and developmental stage must be considered when assessing a client’s pain.

• Family, culture, and gender will influence a client’s ability to express pain and seek treatment.

• External environmental factors such as heat and cold will influence pain.

Assessment

• Pain is considered the fifth vital sign.

• Accurate and timely assessment is mandatory for effective pain management.

• Taking a detailed history using many of the focused interview questions provides a detailed subjective database.

• Unidimensional and multidimensional tools are available for pain assessment.

Glossary

acute pain   Pain that lasts only through the expected recovery period from illness, injury, or surgery, whether it has a sudden or slow onset and regardless of the intensity.

chronic pain   Pain that is prolonged, usually recurring or persisting over 6 months or longer, and interferes with functioning.

cutaneous pain   Pain that originates in the skin or subcutaneous tissue.

deep somatic pain   Diffuse pain that arises from ligaments, tendons, bones, blood vessels, and nerves, tends to last longer than cutaneous pain.

fifth vital sign   Pain assessment.

intractable pain   Pain that is highly resistant to relief.

nociceptors   The receptors that transmit pain sensation.

pain   A highly unpleasant sensation that affects a person’s physical health, emotional health, and well-being.

pain threshold   The amount of pain stimulation the person requires to feel pain.

pain tolerance   The maximum amount and duration of pain that an individual is willing to endure.

radiating pain   Pain perceived at the source of the pain and extends to nearby tissues.

referred pain   Pain felt in a part of the body that is considerably removed from the tissues causing the pain.

visceral pain   Pain results from stimulation of pain receptors in the abdominal cavity, cranium, and thorax, appears diffuse and often has feeling of pressure, burning, or aching.

Caring for someone with a life threatening illness requires careful and thorough evaluation, or assessment, of their pain and other symptoms. You are the eyes and ears for the doctor and nurses caring for your loved one. You will be relaying important information about the patients pain and symptoms back to the health care team. Assessing pain and communicating it to the health care team will be one of the most important things you can do while caring for a loved one.

What is Pain?

It is important when assessing pain to understand what it is. The important thing to remember here is that pain is always what the person experiencing says it is, occurring when and where they describe it.

If a person can communicate their pain, it will be easy to record it and relay it back to their doctor. If they cannot communicate what they are feeling, it is can be more difficult to assess their pain but it is still possible. To do so, you must aware of physical signs and symptoms that convey what they are feeling, which we discuss more in detail below.

Assessing pain is something your healthcare provider will be doing at every visit or appointment but it will be up to you to assess their pain between professional visits. The following information will be helpful to you as you assess the pain yourself.

Severity of Pain

The first step in assessing pain is to find out how bad it is at the present moment. There are tools that can help someone who is able to communicate describe the severity of their pain. For adults, this is usually done with a numeric scale of 0-10. Zero would describe the absence of pain and ten would symbolize the worst pain imaginable. Ask the patient to rate their pain somewhere on that scale.

When asking young children or non-verbal adults to describe their pain, the tool most often used by healthcare providers is the Wong-Baker FACES Pain Rating Scale. It is recommended for persons age 3 years and older. With this scale, you would point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes their pain.

Acceptable Level of Pain

Everyone will have their own acceptable level of pain. For some it may be no pain and others will tolerate a pain level of 3 on a scale of 0-10. It is important to find out what the acceptable level is for the individual you are caring for. If your loved one is happy at a pain level of 3, you wouldn’t want to medicate them to the point of sedation to get them at a zero level of pain.

Location of Pain

The location of pain may be the same every time you ask. Someone with end stage liver disease may always have pain in the upper right side of their abdomen. It is important to ask, however, because new pain may develop. If the location differs or new pain emerges, be sure to record that information and pass it on to the patients healthcare provider.

Palliation and Provocation

Ask the patient what makes their pain better, or palliates it. This may only be pain medications. It may be changing positions or lying only on their left side. Finding this out will not only help you do things that aide in their comfort but may provide some clues to the physician on the cause of the pain if it isn’t already known.

Also ask what makes the pain worse, or provokes it. Again, it could be movement or lying on a particular side. It could also be eating or touch. This again will help you avoid things that cause discomfort and provide important clues to the physician.

Assessing Non-Verbal Signs of Pain

It was mentioned early that it can be difficult to assess someone’s pain if they are unable to verbalize it and/or unable to point to the FACES scale. There are some signs and symptoms that a patient may exhibit if they are in pain that can clue you in:

·         Facial grimacing

·         Writhing or constant shifting in bed

·         Moaning or groaning

·         Restlessness and agitation

·         Guarding the area of pain or withdrawing from touch to that area

The more symptoms a patient has and the more intense they are will give you a clue as to how much pain they may be in. You can then record their pain as “mild”, “moderate”, or “severe”.

Keep a Record

One of the most important things you can do for the person you are caring for is to keep an accurate record of their pain and their pain treatments. Once you assess their pain, record the severity and location and any medications or treatments that you gave them. Take note whether the medications or treatments worked effectively. Also write down anything new they may have told you about what makes it feel better or worse. This is a great way to team up with your healthcare professionals to provide the best palliative care possible.

Example of a Pain Log

 

Introduction to Assessing Pain

Although pain is referred to as the fifth vital sign,pain is a symptom. Subjective iature, pain is “whatever the person says it is, whenever she or he says it does” (McCaffery, 1999). Pain has also been defined as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage” (International Association for the Study of Pain, 2006). It is the most common reason patients seek healthcare.

Far too often, not only the public but also healthcare providers undertreat pain owing to misconceptions surrounding it and its effective management. This is a serious issue,as undertreated pain can have serious physical, psychological, and financial consequences that affect the patient’s quality of life.

Accurate assessment of your patient’s pain is the first step in developing an effective treatment plan to deal with pain. Because pain is subjective, no two patients experience pain the same way. Since pain has physiological, psychological, sociocultural, behavioral, and affective components, assessment must address each component as it relates to your patient.

 

Structure and Function of Pain

Understanding the process of pain will help you to accurately assess and develop a plan of care to manage your patient’s pain.The process by which a painful stimulus is transmitted to the central nervous system (CNS) and perceived as pain is referred to as nociception.

 

The process of pain includes transduction, transmission, perception, and modulation. However, the exact mechanism of pain is unknown, and this process does not explain all types of pain, such as phantom limb. Also, not all nociception results in the perception of pain.

Transduction. Transduction begins with a response to a noxious (painful) stimulus that results in tissue injury. The noxious stimuli can be mechanical, thermal,or chemical. The noxious stimuli are then converted into a nerve impulse by sensory receptors called nociceptors.

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. In response to tissue injury, cells break down and release byproducts and inflammation mediators (bradykinin, prostaglandins, substance P, histamine, serotonin,and cytokines).These substances activate or sensitize the nociceptors.Bradykinin also acts as a potent vasodilator, triggering the inflammatory response of redness, swelling, and pain. The inflammatory response is the greatest cause of pain.However,all pain that originates from the periphery is not nociceptive pain. Damaged peripheral nerves can result in peripheral neuropathic pain.

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. Primary afferent nerve fibers travel along C-fibers,unmyelinated, slow-conducting fibers that transmit dull,aching pain,or A-delta fibers,myelinated, fast-conducting fibers that transmit sharp, localized pain. C-fibers transmit slow, constant pain from mechanical, thermal,and chemical stimuli.A-delta fibers transmit fast, intermittent pain from mainly mechanical stimuli. Excitatory amino acids (e.g., glutamine, aspartate) and  neuropeptides (e.g., substance P) facilitate transmission of impulse to the dorsal horn at the synapses from the primary afferent neuron to a second-order neuron in the dorsal horn. Inhibitory aminoacids (e.g., γ-aminobutyric acid [GABA]) and  neuropeptides (e.g., endogenous opioids) inhibit transmission of impulse.Once in the dorsal horn, the impulse can be transmitted to the brain or inhibited.Neuroregulators, neurotransmitters, or neuromodulators either inhibit or facilitate nociception.

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, and (4) the spinohypothalamic tract to the hypothalamus. Most impulses are transmitted to the thalamus from which they are directed to three areas: the somatosensory cortex, which perceives and interprets physical sensation; the  limbic system, which allows for emotional response to stimuli; and the frontal cortex, which involves thought and reason and perception of pain.

Perception. Perception is an awareness of pain and involves both the cortical and the limbic system structures.Realize that pain threshold, the point at which a painful stimulus is perceived as painful, is consistent from one person to the next; however, pain tolerance, the amount of pain one is able to endure, varies greatly.Psychosocial and cultural factors and past experiences influence pain perception, thereby accounting for such individual differences in pain perception even with similar painful stimuli.

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 gate-control theory of pain modulation. Inhibitory substances (e.g., GABA and neuropeptides [endogenous opioids, serotonin, norepinephrine]) bind to primary afferent receptors and dorsal horeurons to inhibit transmission of impulse. Endogenous opioids include enkephalins, dynorphins, and beta endorphins.

Endogenous opioids can also be produced through exercise, meditation, visualization, and music therapy. The brain also sends descending inhibitory input that modulates the transmission of nociceptive transmission in the dorsal horn.

The gate-control theory of pain modulation (Fig. 4.2) proposes that impulses can be blocked by non-painful somatic stimuli. Impulses compete for transmission. Since two impulses cannot be transmitted at the same time, one goes through while the other is blocked.

For example, if you stub your toe, you automatically rub your toe.The rubbing sensation is transmitted by the fast, A-delta fibers, while the impulse from stubbing the toe travels along the slow C-fiber and is blocked.

 

Sensitization. Sensitization to pain can be peripheral or central. 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.

 

Classification of Pain

Pain can be categorized by duration, site of pain, cause,or other qualities.

 

Acute Pain. Pain is defined as acute when it lasts the expected recovery time. Acute pain serves as a protective mechanism in response to an actual or potential threat to injury, such as when you withdraw your hand from a hot surface. Injury also activates the “stress hormone response,” which, if left untreated, can produce negative physiological and psychological effects resulting in chronic pain. Acute pain is seen with injury and surgery and may last up to 6 months.

Chronic Pain. Chronic pain is defined as pain enduring for 6 months or 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.

Cancer/Malignant Pain. Pain associated with cancer may be categorized separately. Cancer or malignant pain may be acute pain or chronic pain that is associated with an underlying malignancy, diagnostic procedure, or disease treatment. The level of pain strongly correlates with the degree of pathology. Intractable pain, pain resistant to treatment, is often seen with advanced metastatic disease.

Chronic Noncancer Pain. Persistent paiot associated with malignancy may be categorized as chronic noncancer pain, a subtype of chronic pain. Pain levels and pathology have a weak link and may have no discernable cause.The pain becomes the disease. Any body system or region can be affected, with intensity ranging from mild to severe. Chronic noncancer pain has a major effect on every aspect of the patient’s 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.

 

Nociceptive/Neuropathic Pain

Pain can also be classified by underlying pathology.

Nociceptive Pain. Nociceptive pain results from exposure to noxious (painful) stimuli. The painful stimuli can occur in the viscera, resulting in  visceral pain, or tissue, resulting in somatic pain.

Visceral pain results from overdistension, spasms, ischemia, inflammation, or traction of organs such as colic, appendicitis, peptic ulcer disease, and bladder distension. The pain can be localized or diffuse or referred. Referred pain is felt at a site other than at the site of origin. Referred pain occurs when internal organs and structures share nerve pathways within the CNS (Fig. 4.3). Pain can also radiate. Radiating pain begins in one area and extends to others, such as chest pain associated with myocardial infarction may be in the chest and radiate to the jaw or arm. The quality of visceral pain is deep aching or sharp stabbing. Visceral pain is often accompanied by nausea, vomiting, malaise, sweating, tenderness, and muscle spasm.

 

Somatic pain can be superficial or deep. Superficial somatic pain originates in the skin or mucous membranes from external stimuli such as sunburn; chemical and thermal burns; or injury to the skin, such as lacerations or contusions.The pain is very localized and described as sharp, pricking, or burning. Cutaneous tenderness, hyperalgesia (increased sensitivity to pain), hyperesthesia (increased sensitivity to sensory stimuli), and allodynia (painful response to nonpainful stimulus) may be associated with superficial somatic pain.

Deep somatic pain originates in muscles, bones, and joints from overuse, injury ischemia, cramping, or inflammation such as arthritis, tendinitis, and sprains. The pain can be localized or diffuse and radiating and described as dull, achy, or cramping. Tenderness and muscle spasm with an autonomic response (increase pulse,blood pressure, and respiratory rate; sweating; pallor; dilated pupils; nausea; vomiting; dry mouth; and increased muscle tension) are often associated with deep somatic pain.

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, sympathetically maintained pain, and central pain (Clark, 2004).

Mono/Polyneuropathies. Mono/polyneuropathies 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. The pain associated with neuropathies may be described as continuous,deep,burning, aching or bruised, paroxsymal shocklike,or abnormal skin sensitivity.

Deafferentation. Deafferentation pain occurs with loss of afferent input from damage to a peripheral nerve, ganglion, or plexus, or the CNS. Phantom limb and postmastectomy pain are examples of deafferentation pain. The pain is often described as burning, cramping, crushing, aching, stabbing, or shooting. The patient may experience hyperalgesia (excessive sensitivity to pain),hyperpathia (hypersensitivity to sensory stimuli), dysesthesia (abnormal sensations of the skin such as numbness, tingling, burning, or cutting), or other abnormal sensations. Phantom limb pain, pain that is experienced in a missing limb or body part, is the result of sensory representations of the missing limb that are still present in the brain.

Sympathetically Maintained Pain. Sympathetically maintained pain is a pain mechanism that results from sympathetic nervous stimulation. Peripheral nerve damage, sympathetic efferent innervation, or circulating catecholamines can result in sympathetically maintained pain. Chronic pain syndrome, phantom limb pain, postherpetic neuralgia, and some metabolic neuropathies can trigger sympathetically maintained pain.

Central Pain. Central pain results from a primary lesion or dysfunction of the CNS. Ischemia (stroke), tumors, trauma, syrinx (a pathological cavity in the spinal cord or brain), or demyelination (multiple sclerosis) can cause central pain. The quality of the pain varies from a burning, numbing, tingling to a shooting sensation.Onset may be spontaneous, steady, or reactive with positive or negative sensory loss, allodynia, and hyperalgesia (Clark, 2004).

 

Developmental, Cultural, and Ethnic Variations

A common misconception is that infants, young children, and older adults or cognitively impaired adults do not experience pain. Just because the patient cannot verbally describe pain, that does not negate its presence. Although self-report is the most reliable indicator of pain, if this is not possible, physiological and behavioral indicators are used to assess pain.The challenge then is to accurately assess for pain in all patients at any age and to develop an effective treatment plan.

Infants. At one time, it was believed that infants did not experience pain, but research has refuted that idea. The process of pain is intact even though the emotional response is unclear. Since the infant cannot verbalize pain, physiological and behavioral indicators are used to assess for pain in the infant.

Infant physiological changes associated with pain include (Wong & Hockenberry-Eaton, 2001):

■ Integumentary system: Pallor or flushing,diaphoresis, palmar sweating.

■ Cardiovascular: Increased heart rate, increased blood pressure.

■ Respiratory: Rapid, shallow respirations, decreased arterial oxygen saturation, and transcutaneous oxygen saturation.

■ Musculoskeletal: Increased muscle tone.

■ Neurological: Increased intracranial pressure, dilated pupils, decreased vagal nerve tone.

■ Endocrine (hormonal release): Increased catecholamines, growth hormones, glucagon, cortisol, corticosteroids, and aldosterone.

■ Metabolism: Increased plasma lactate, pyruvate, ketone bodies, and fatty acids.

■ Laboratory values: Increased blood glucose (hyperglycemia) and corticosteroid levels and decreased pH.

Infant behavioral changes associated with pain include:

■ Vocalization: Intense, sustained crying, whimpering, and groaning.

■ Facial expression: Eye squeeze, brow bulge, open mouth, taut tongue, chin quivering, and grimaces.

■ Body movements: Limb withdraw, thrashing, rigidity or flaccidity, and fist clenching.

■ Sleep/wake cycle: Increased wakefulness and irritability.

■ Feeding: Loss of appetite, vomiting, loss of interest and/or energy in sucking.

■ Activity level: Decreased activity level; fussiness, irritability, and listlessness.

Children. Depending on the age of the child, assessing pain in children can be a challenge. The mnemonic QUESTT is helpful in assessing pain in children (Wong & Hockenberry-Eaton, 2001).QUESTT stands for:

■ Question the child.

■ Use a pain rating scale.

■ Evaluate behavioral and physiological changes.

■ Secure parents’ involvement.

■ Take the cause of pain into account.

■ Take action and evaluate results.

Question the Child. Self-report is the most accurate means for assessing pain, so ask the child to describe the pain. Self-report is more accurate than the child’s behavior.

 

Use a Pain Rating Scale. Various pain rating scales are available for assessing pain in children. Be sure to select one that is age appropriate for your patient.These scales are discussed later in this chapter.

Evaluate Behavioral and Physiological Changes. If the child is nonverbal and unable to describe pain, detecting behavioral and/or physiological changes is essential. Physiological changes that may be seen with acute pain include increase in blood pressure, increased or decreased heart rate, increased respirations, flushing, sweating, dilated pupils. Behavioral changes can vary depending on the child’s developmental level. Behavioral changes for a young child include crying, screaming, vocalizing hurt, thrashing of arms and legs, pushing away, clinging to parents, and increasing restlessness and irritability. Behavioral changes for a school-age child include crying, muscle rigidity, clenched fists, white knuckles, clenched teeth, closed eyes, and stalling techniques when anticipating a painful procedure. Behavioral changes for an adolescent include verbalization of pain and muscle tension.

Secure Parents’ Involvement. Parents know their child, so rely on their assessment. Parents are more attuned to subtle changes in their child’s behavior. Parents also usually know what will best comfort their child.Ask the parent:

■ What is the child’s past experience with pain?

■ What is the child’s response to pain?

■ How do you know your child is having pain?

■ What relieves the child’s pain?

Take the Cause of Pain Into Account. Consider the pathophysiology of the underlying problem when you evaluate the child’s pain.

Take Action and Evaluate Results. After assessing the pain, develop a plan to treat the pain. After treating pain, you need to assess the child to evaluate the effectiveness of the treatment and revise the plan as needed.

Older Adults. Assessing pain in the older patient can be challenging because of the misconceptions both patients and healthcare providers have surrounding pain and the elderly.

It is important to realize that the elderly do experience pain both acute and chronic. Untreated pain increases the risk for complications such as pneumonia, constipation, deep vein thrombosis, impaired immune function, sleep disturbances, weight loss, social isolation, and depression. Often, the older patient experiences chronic pain and does not exhibit the typical signs of pain.Answers to questions about the patient’s functional level and quality of life are good indicators of the effects of pain.

If the patient is cognitively impaired, assessing for pain becomes a greater challenge.The degree of impairment will determine the use of pain scales. Keep questions simple, specific, and in the here and now. If the patient is unable to verbally communicate, rely on physiological signs associated with pain, such as increased blood pressure, heart rate, and respirations; diaphoresis; and behavioral changes, such as agitation, restlessness, facial expression of pain, and vocal sounds (moaning and groaning) of pain.

Family members or caregivers should be included in the assessment process.They can provide invaluable data of the patient’s pain-related behavior and effective methods for relieving pain.

 

People of Different Cultures and Ethnic Groups. Although the physiological response to pain is consistent across cultures, your patient’s cultural or ethnic background influences his or her psychological and behavioral responses to pain. (See Cultural and Ethnic Variations in Response to Pain.)

 

Performing the Pain Assessment

Pain assessment includes a history and physical examination. As with any assessment,always begin with a history. Since pain is subjective in nature, the history component of the pain assessment is the most important.

Health History. Self-report is the most accurate indicator of pain. Because pain is subjective, the patient’s health history provides the best assessment of pain. The history also allows you to assess past experiences with pain,effective pain treatments, and the effects pain has on every aspect of the patient’s life.

Biographical Data. Review your patient’s biographical data. As described previously, your patient’s age,ethnicity,and religion may affect her or his perception and behavioral response to pain. Even the patient’s gender may influence her or his perception of pain. Also, your patient’s occupation may be a direct cause of the pain, such as back pain related to heavy lifting; the presence of pain may prohibit a return to work.

Current Health Status. When your patient presents with pain, perform a symptom analysis. The mnemonic PQRST provides a thorough description of pain. Ask:

■ Precipitating/Palliative/Provocative Factors

■ What were you doing when the pain started?

■ Does anything make it better, such as medication ora certain position?

■ Does anything make it worse, such as movement or breathing?

■ 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?

■ 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.

■ 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 pain–related symptoms  include sickening feeling, nausea, vomiting, and autonomic symptoms.

■ Neuropathic pain–related symptoms  include hyperalgesia and allodynia.

■ Complex regional pain syndrome–related symptoms  include hyperalgesia, hyperesthesia, allodynia, autonomic changes, and shin, hair, and nail changes.

■ Severity

■ Use appropriate pain scale. (See Pain Scales, below.)

■ 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 intestinal colic.

■ Plateau pain: Pain that rises then plateaus such as angina.

■ Paroxysmal: Such as neuropathic pain.

■ How often does it occur?

■ Continuous fluctuating pain: As with musculoskeletal pain.

■ Do you have times when you are pain free?

 

When taking a patient’s current health status, pay attention to the words that the patient uses to describe her or his current pain level. They can provide important clues to her or his status.

 

Pain Scales. Various instruments are available to assess pain. Consider the patient’s age and developmental status along with his or her cultural background when selecting a pain scale. Select the one that will best meet your patient’s needs.

Pain Scales for Adults. Unidimensional and multidimensional pain scales are available.The unidimensional scale assesses one dimension, usually intensity of pain, and is often used to assess acute pain. Multidimensional scales provide additional information about pain, such as the pain’s characteristics and the effects on the patient’s daily life.A multidimensional scale is useful in assessing chronic pain.

Unidimensional Scales. These scales generally use numeric, verbal, or visual descriptors to quantify pain. Examples include the Numeric Rating Scale, Visual Analogue Scale, and categorical scales.

Numeric Rating Scale. The Numeric Rating Scale rates pain on a scale of 0 (no pain) to either 5 or 10 (worst pain) by asking the patient to rate her or his current pain level.

Visual Analogue Scale. The Visual Analogue Scale utilizes a vertical or horizontal 10-cm line with anchors. One end of the line is labeled “No pain” and the opposite end of the line is labeled “Worst pain.”The patient marks his or her current pain level on the line.

 

Categorical Scales. Categorical scales use verbal or visual descriptors to identify pain intensity. The patient selects the descriptor that she or he feels best represents the current pain level. Verbal descriptors include:

■ Mild, discomforting, distressing, horrible, excruciating.

■ No pain, mild pain, moderate pain, severe pain, very severe pain,worst possible pain.

Visual descriptors include the Faces Pain Scale for Adults and Children (FPS), which utilizes illustrated faces with facial expressions ranging from happy (no pain) to sad and crying (worst pain). The FPS has eight faces to select current pain level.The patient is asked to select the face that best represents his or her current pain level.

Multidimensional Pain Scales. These scales assess pain characteristics and its effects on patient’s activities of daily living and include such scales as the Initial Pain Assessment Inventory (IPAI), Brief Pain Inventory (BPI), McGill Pain Questionnaire (MPQ), and the Neuropathic Pain Scale.

Initial Pain Assessment Inventory. The IPAI is used for initial assessment of pain. It assesses characteristics of pain; effects of pain on the patient’s life, such as daily activities, sleep, appetite, relationships, and emotions; and the patient’s expression of pain. This assessment tool includes a diagram to note pain location, a scale to rate pain intensity,and space to document additional comments and the treatment plan.

Brief Pain Inventory. The BPI is used to quantify pain intensity and associated disability. It assesses pain intensity, location, effects on life, type, and effectiveness of treatment over the last 24 hours. Benefits of the BPI include that it is quick and easy to use and available in multiple languages.

McGill Pain Questionnaire. The MPQ uses descriptive words to assess pain on three levels: sensory, affective, and evaluative. It can be used with other tools and is available in short and long forms.

Neuropathic Pain Scale. The Neuropathic Pain Scale assesses the type and degree of sensations associated with neuropathic pain. The patient rates eight common qualities of neuropathic pain (sharp, dull, hot, cold, sensitive, itchy, deep, or surface pain) on a scale of 0 (no pain) to 10 (worst pain). This scale is still in the developmental stages,but early testing holds diagnostic and therapeutic promise.

Pain Scales for Children. Many pain scales are available to assess a child’s pain. Many of the pain scales are age specific. Instruments may also be specified by your institution since pain assessment forms are common use.

FACES Pain Rating Scale. The FACES Pain Rating Scale assesses pain for children ages 3 years and up.The Wong-Baker has five faces from which the child can select her or his current pain level (Fig. 4.4).

 

Oucher. The Oucher scale assesses pain for children ages 3 to 13 years with photos or a numeric scale.The photographic scale uses six photographs of children ranging from a child with “no hurt” to a child with “a lot of hurt.”The photographs are arranged vertically from 0 to 5, with 0 (no hurt) on the bottom and 5 (lot of hurt) on the top. This scale also has photographs of black and Hispanic children available.

Numeric Scale. The numeric scale ranges vertically from 0 to 100,with 0 being “no hurt” and 100 being “biggest hurt” (Beyer, Denyes,& Villaruel, 1992):

■ 0 = no hurt.

■ 1–29 = little hurt.

■ 30–69 = middle hurt.

■ 70–99 = big hurt.

■ 100 = biggest hurt.

Poker Chip Tool. The Poker Chip Tool assesses pain in children 4 years of age and up. The nurse places red poker chips horizontally in front of the child, with the poker chips denoting “pieces of hurt.” She then asks the child to select how many pieces of hurt he or she has (Hester et al., 1998).

Word-Graphic Rating Scale. The Word-Graphic Rating Scale assess pain in children ages 4 to 17 years. It uses words on a horizontal linear scale to assess pain. The child is asked to identify her or his current pain level on the scale (Tesler et al., 1991).

Numeric Scale. The Numeric Scale assesses pain for children ages 5 years and older. It uses a horizontal linear scale with numbers from 0 to 5 or 10, with 0 being “no pain” and 5 or 10 being “worst pain.”The child is asked to identify his or her current pain level on the scale. Although similar to a scale used for adults, this provides the child with a visual to help assess his or her pain.

 

Visual Analogue Scale. The Visual Analogue Scale, which assesses pain in children ages 4^1⁄2 and older, is similar to that used for adults. The child is asked to identify her or his pain level by marking the line in the area that represents her or his level of pain (Cline et al., 1992).

Color Tool. The Color Tool assesses pain for children as young as 4 years by having the child create a body outline using colored markers or crayons. The child selects four colors. The first color represents “most hurt,” the second represents “little hurt,” the third represents “least hurt,”and the last represents “no hurt.” Using all four colors, the child identifies areas and degree of hurt on the body outline (Eland & Banner,1999).

Past Health History. The past health history can identify factors that may affect the patient’s pain, response to pain, and treatment plan. When conducting the past health history, make sure to identify:

■ Cause of pain.

■ Past and present medical problems that may influence pain and its management.

■ Past psychiatric illnesses and chemical dependence.

■ Past and present pain management strategies.

■ Past experiences with pain.

■ Chronic vs. acute pain.

 

Family History. The family history may identify genetically linked causes of pain, such as sickle cell anemia and cancer. The family history also identifies familial history of chronic pain or illness. Ask the patient about hereditary or familial health problems.

Review of Systems. If there is a problem in one system, eventually other systems will be affected.The underlying cause of the pain determines the effect the pain will have on other systems.

Psychosocial Profile. Assessing the psychosocial history identifies the effects that pain has on every aspect of the patient’s life and evaluates quality of life.

 

Physical Assessment. The initial purpose of the physical examination is to identify the underlying cause of pain. As you perform the examination, assess the effects of physical movements (e.g., deep breathing, position changes) on the patient’s pain level.The physical examination may also reveal complications associated with untreated pain. The history findings should direct the physical exam.Be alert for physical, behavioral, and psychological responses to pain.

The autonomic response of the sympathetic nervous system to painful stimuli accounts for many of the physiological changes that are seen. This response is acute and cannot be sustained for prolonged periods of time, as the body adapts and physical indicators are no longer apparent in patients with prolonged pain or chronic pain. Again, physical signs are not as reliable of an indicator as self-report, the most reliable indicator of pain. However, when patients are unable to verbally communicate or who are cognitively impaired, you must rely on physical and behavioral indicators obtained by a head-to-toe assessment to evaluate your patient’s pain. (See Performing a Head-to-Toe Physical Assessment.)

 

Behavioral Pain Assessment Scales. Although the patient’s self-report of pain is the most accurate means to assess pain, there are times when the patient’s age or condition does not permit self-report, such as when the patient is confused or very young. Pain scales have been developed to objectively assess pain by scoring behavioral and physiological responses to pain. A variety of objective pain scales are available. The scales are mainly geared for the infant and young child. You need to consider the age of your patient in selecting a scale that will best assess your patient’s pain.

Behavioral Pain Assessment Scales for Infants. Since an infant cannot verbalize feelings of pain, physiological and behavioral changes need to be used to assess pain. Many scales are available to help you assess your patient’s pain. Identify the scale that is most appropriate in assessing your patient.

CRIES. CRIES (crying, requiring increased oxygen, increased vital signs, expression, sleeplessness) assesses postoperative pain from 32 weeks’ gestation to 20 weeks’ post-term. Each of the five categories is scored from 0 to 2. A score of 10 equates to the worst pain, and any score greater than 4 identifies significant pain (Krechel & Blidner, 1995). (See CRIES.)

 

Postoperative Pain Score. The Postoperative Pain Scale (POPS) assesses postoperative pain in infants ages 1 to 7 months. It scores each of its 10 categories (sleep, facial expression, quality of cry, spontaneous motor activity, spontaneous excitability, flexion of fingers and toes, tone, consolability, and sociability) on a scale of 0 to 2. A total score of 0 indicates worst pain, a score of 20, no pain (Attia, 1987).

Neonatal Infant Pain Scale. The Neonatal Infant Pain Scale (NIPS) is used to assess infants at an average gestational age of 33.5 weeks. It grades six categories: facial expression (0 to 1), cry (0 to 2), breathing pattern (0 to 1), arms (0 to 1), legs (0 to 1), and state of arousal (0 to 1).A final score of 0 identifies no pain while a score of 7 identifies worst pain (Lawrence et al., 1993).

Pain Assessment Tool. The Pain Assessment Tool (PAT) assesses pain from a gestational age of 27 weeks to full term. It grades 10 different categories:posture/tone (1 to 2), sleep pattern (0 to 2), expression (1 to 2), color (0 to 2), cry (0 to 2), respirations (1 to 2),heart rate (1 to 2), saturations (0 to 2), blood pressure (0 to 2), and nurse’s perception (0 to 2). A final score of 4 identifies no pain,while a score of 20 identifies worst pain (Hodgkinson et al., 1994).

Pain Rating Scale. The Pain Rating Scale (PRS) assesses pain for infants ages 1 to 36 months.The infant is given a grade of 0 (no pain) through 5 (worst pain) based on the following guidelines. For a score of 0, the infant exhibits smiling, sleeping, and no change when moved or touched. Behaviors associated with a score of 1 include taking small amounts orally, restlessness, moving, and crying. A score of 2 includes behaviors of not eating or drinking and short periods of crying but distracted with rocking or use of pacifier. With a score of 3, a definite change in behavior is noted. The baby is irritable with facial grimacing and arms and/or legs shake or have jerking movements. With a score of 4, the baby is inconsolable, flailing with a high-pitched wailing cry.A score of 5 is characterized by prolonged sleep periods interrupted by jerking movements, continuous crying, and shallow respirations ( Joyce et al., 1994).

Premature Infant Pain Profile (PIPP). The Premature Infant Pain Profile (PIPP) assesses pain for gestational ages 28 to 40 weeks. It grades seven categories on a scale of 0 (no pain) to 3 (worst pain).The categories are gestational age, behavioral stage, heart rate, oxygen saturation, brow bulge, eye squeeze, and nasolabial furrow. A final score of 0 identifies no pain, while a score of 21 identifies worst pain (Stevens, 1996).

Modified Behavioral Pain Scale. The Modified Behavioral Pain Scale (MBPS) assesses pain for children ages 4 to 6 months. It assesses three categories: facial expression (0 to 3), cry (0 to 4), and movements (0 to 3). A final score of 0 identifies no pain, while a score of 10 identifies worst pain (Taddio et al., 1995).

Behavioral Pain Assessment Scales for Children. Several behavioral pain assessment scales have been developed to assist in assessing paiot only for the infant but also for the older child. Brief descriptions are provided below.Again, you need to select the instrument most appropriate to meet your patient’s needs.

Objective Pain Score. The Objective Pain Scale (OPS) assesses pain for infants and children from ages 4 months to 18 years. It assesses five categories, each on a scale of 0 (no pain) to 2 (worst pain). The categories are blood pressure, crying, moving, agitation, and verbal evaluation/body language. A final score of 0 identifies no pain, and a score of 10 identifies worst pain (Hannallah et al., 1987).

Children’s Hospital of Eastern Ontario Pain Scale. The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) assesses pain for children ages 1 to 5 years. It assesses six categories: crying (1 to 3), facial (0 to 2), child verbal (0 to 2), torso (1 to 2), touch (1 to 2), and legs (1 to 2).A final score of 4 identifies no pain,while a score of 13 identifies worst pain (McGrath et al., 1985).

Nurses Assessment of Pain Inventory. The Nurses Assessment of Pain Inventory (NAPI) assesses pain for infants and children from birth to age 16 years. It assesses three categories: body movement (0 to 2), facial (0 to 3),and touching (0 to 2). A final score of 0 identifies no pain,while the higher score identifies the worst pain (Stevens, 1990).

Behavioral Pain Score. The Behavioral Pain Score (BPS) assesses pain for children ages 3 to 36 months. It assesses three categories: facial expression (0 to 2), cry (0 to 3), and movements (0 to 3). A final score of 0 identifies no pain, while a score of 8 identifies worst pain (Robieux et al., 1991).

Riley Infant Pain Scale. The Riley Infant Pain Scale (RIPS) assesses pain in children younger than 36 months and children with cerebral palsy. It assesses five categories on a scale of 0 (no pain) to 3 (worst pain).

 

FLACC Postoperative Pain Tool. The FLACC Postoperative Pain Tool assesses pain for children ages 2 months to 7 years. It assesses five categories using a scale of 0 (no pain) to 2 (worst pain).A final score of 0 indicates no pain,while a score of 10 indicates worst pain.

 

Behavioral Pain Assessment Scales for Older Adults. Since a confused patient may not be able to verbalize feelings of pain, physiological and behavioral changes need to be used to assess pan.

Pain Assessment in Advanced Dementia Scale. The Pain Assessment in Advanced Dementia Scale (PAINAD) can be used to assess pain levels in patients with advanced dementia. It assesses five categories on a scale of 0 to 2.The higher the score, the greater the pain.

 

Reassessment of pain

Reassessment of pain is imperative to determine the effectiveness of treatment. Self-report and physical findings will help you evaluate the effectiveness of treatment. Compare the patient’s responses to the expected outcomes.Have the patient grade his or her current pain level and compare the grade with the previous rating. If relief has not been obtained, revise your plan and implement alternative interventions. Current recommendations for pain reassessment include:

■ Within 30 minutes after parenteral administration of pain medication.

■ Within 1 hour after oral administration of pain medication.

■ After each and every report of new or changes in pain.

The frequency of reassessment depends on the patient, type of pain, and setting. In acute care settings, reassessment of pain frequently occurs when vital signs are obtained. Outpatients or long-term healthcare residents should be instructed to report any changes in pain or ineffective pain control. Patients with chronic pain should have periodic pain reassessments to ensure effective pain control.

 

Pain Management

Pain and the control of pain are very big problems. There are over one millioew cancer cases each year in the United States alone. Add that to the chronic diseases that cause intractable pain and you can see the magnitude of the problem. Unfortunately much of this pain is not being adequately controlled.

I had the opportunity to discuss this issue with Linda Schickedanz R.N. a Clinical Nurse Specialist who has extensive experience in the field of pain control. We discussed the inadequacies in pain control in this country and how it is affecting the lives of those in pain. The information she gave me should be of prime importance to seniors who at high risk for inadequate pain control.

The Problem

Pain is a major symptom for 70% of cancer patients, but 50 – 80% of cancer patients receive inadequate pain control. Advances in pharmacology have made many new drugs and technologies available that makes more than 90% of cancer pain controllable. The problem then is under treatment. Undertreatment of pain can lead to depression, non-compliance, anger, fear, and loss of control and suicide.

Risk Factors for Undertreatment

Who is more likely to be under treated for pain?

·         Minorities are three times as likely to be under treated.

·         Patients receiving a poor pain assessment from an inexperienced health care provider.

·         People with non-cancer pain.

·         People with “Good” performance status, such as someone who appears to be coping well and performing activities adequately.

·         People over the age of 70.

·         Females.

There Is Failure To Treat Pain Adequately In The Elderly
Seniors are among the biggest group that suffers from inadequate pain control. The elderly tend to minimize the expression of pain. They may also have underlying depression or dementia, which may affect their ability to communicate pain effectively. They may have impaired kidney or liver function that affect the absorption and metabolism of pain medications. Because of physical limitations such as poor eyesight the elderly may have difficulty managing high-tech pumps and infusion devises. One study found a lower pain medication use among non-communicative patients iursing home than for patients who were able to communicate their needs. Did they really have less pain or were they just less able to communicate the pain.

Other Factors in Undertreatment

·         There is inadequate education for medical professionals on pain assessment and pain management.

·         Healthcare providers fear regulatory scrutiny, and legal consequences.

·         Patients and family fear addiction to pain medications.

·         Pain management is poorly reimbursed by payers.

·         Government regulations can be confusing and cumbersome. Regulations vary widely state by state.

When is Pain Controlled Adequately?

Pain evokes numerous physical and emotional responses such as a racing pulse, a rise in blood pressure, rapid respiration, sweating and dilation of the pupils. You might become frightened, anxious, or annoyed. Chronic pain can take over your life and dominates your every thought. It will interfere with sleep, work and relationships. Pain is controlled when the pulse and blood pressure are in normal ranges for the person affected, breathing is calm and eyes normal. It is controlled when functioning and sleep patterns become more normal and pain does not dominate thought.

Current Pain Treatment

·         Non-Steroidal Anti-inflammatory

·         These drugs which include ibuprofen and aspirin, have been very effective in treating pain that is caused by inflammation such as rheumatoid arthritis. The main side effects are stomach irritation and interference with the clotting mechanisms of the blood. The risk of problems with these medications increases with age.

·         Acetaminophen (Tylenol®)

·         This drug, which is gentle on the stomach but does little or nothing for inflammation. It is recommended for osteoarthritis. It can cause liver and kidney damage with high doses or long term use.

·         Narcotics
These are the most effective pain relievers, and work by blocking the pain signal that travels to the brain. Side effects can include drowsiness, constipation, slowed breathing, and mood changes. While used cautiously due to fears about addiction and abuse, research has found those fears unfounded in patients with chronic pain and no history of addiction.

·         Antidepressant and Antianxiety Drugs

·         These drugs can be used along with analgesics and often enhance the effects of those drugs. They are used cautiously as they can be addictive.

·         Disease Specific Drugs

·         Several new drugs have been introduced in the last few years that were designed to treat one specific disorder. These drugs include Imitrex® for migraines, Synvisc® for osteoarthritis of the knee, DMARDS such as methotrexate or Enbrel® for rheumatoid arthritis, oral or injected steroids for arthritis and lupus and the topical (skin cream) capsaicin used for arthritis or shingles pain.

·         Non – Drug Treatments

·         There are numerous other treatments that have all proven effective for some people. These include acupuncture, massage, meditation, and relaxation therapy.

Steps for Ensuring Adequate Pain Treatment

·         Establish open and honest communication with your physician. Describe your pain and ask for treatment. If your physician brushes you off or dismisses your pain it may be time to find a new physician.

·         Discuss any medications prescribed with your physician and pharmacist. Understand the side effects and signs of problems.

·         Set aside your fears of addiction or dependence. Most people once they have achieved pain control will actually be able to cut back some on their medications due to greater peace of mind.

·         Look at the legislation on pain control drugs that have been enacted in your state. If it restricts physicians in adequately treating their patients you can contact your representative and ask for a change in the law.

 

Importance of Controlling Pain

Inadequately managed pain can lead to adverse physical and psychological patient outcomes for individual patients and their families. Continuous, unrelieved pain activates the pituitary-adrenal axis, which can suppress the immune system and result in postsurgical infection and poor wound healing. Sympathetic activation can have negative effects on the cardiovascular, gastrointestinal, and renal systems, predisposing patients to adverse events such as cardiac ischemia and ileus. Of particular importance to nursing care, unrelieved pain reduces patient mobility, resulting in complications such as deep vein thrombosis, pulmonary embolus, and pneumonia. Postsurgical complications related to inadequate pain management negatively affect the patient’s welfare and the hospital performance because of extended lengths of stay and readmissions, both of which increase the cost of care.

Continuous, unrelieved pain also affects the psychological state of the patient and family members. Common psychological responses to pain include anxiety and depression. The inability to escape from pain may create a sense of helplessness and even hopelessness, which may predispose the patient to a more chronic depression. Patients who have experienced inadequate pain management may be reluctant to seek medical care for other health problems. (For more detail, go to the section, “Harmful Effects of Unrelieved Pain,” below.)

Poorly managing pain may put clinicians at risk for legal action. Current standards for pain management, such as the national standards outlined by the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations, JCAHO), require that pain is promptly addressed and managed. Having standards of care in place increases the risk of legal action against clinicians and institutions for poor pain management, and there are instances of law suits filed for poor pain management by physicians. Nurses, as part of the collaborative team responsible for managing pain during hospitalization, also may be liable for legal action.

Hospitals stand to lose reputation as well as profit if pain is poorly managed. Patient satisfaction with care is strongly tied to their experiences with pain during hospitalization. Evidence indicates that higher levels of pain and depression are linked to poor satisfaction with care in ambulatory settings. With the advent of transparent health care, report cards for hospitals are becoming more prevalent, and performance on pain management is likely to be one of the indicators reported.

Undertreatment of Pain

The undertreatment of pain was first documented in a landmark study by Marks and Sachar in 1973. These researchers found that 73 percent of hospitalized medical patients had moderate to severe pain. The undertreatment of pain continues. Thirty years later in 2003, Apfelbaum and others found that 80 percent of surgical patients experienced acute pain after surgery, and 86 percent of those had moderate to extreme pain. Of 1,308 outpatients with metastatic cancer from 54 cancer treatment centers, 67 percent reported pain. Of those who had pain, 62 percent had pain severe enough to impair their ability to function, and 42 percent were not given adequate analgesic therapy. It is estimated that 45 percent to 80 percent of elderly patients iursing homes have substantial pain that is undertreated. These studies and others suggested that when patients had moderate to severe pain, they had only about a 50 percent chance of obtaining adequate pain relief.

Harmful Effects of Unrelieved Pain

Patients suffer from pain in many ways. Pain robs patients of their lives. Patients may become depressed or anxious and want to end their lives. Patients are sometimes unable to do many of the things they did without pain, and this state of living in pain affects their relationships with others and sometimes their ability to maintain employment.

What is often overlooked is that pain has physically harmful effects. It is often actually physiologically unsafe to have pain. The effects of pain on the endocrine and metabolic system, cardiovascular system, gastrointestinal system, and immune system—and the potential for future pain—are but a few of examples of how unsafe unrelieved pain may be.

Pain causes stress. The endocrine system reacts by releasing an excessive amount of hormones, ultimately resulting in carbohydrate, protein, and fat catabolism (destruction); poor glucose use; and other harmful effects. This reaction combined with inflammatory processes can produce weight loss, tachycardia, increased respiratory rate, fever, shock, and death. Unrelieved pain prolongs the stress response, adversely affecting the patient’s recovery.

The cardiovascular system responds to stress of pain by activating the sympathetic nervous system, which produces a variety of unwanted effects. In the postoperative period, these include hypercoagulation and increased heart rate, blood pressure, cardiac work load, and oxygen demand. Aggressive pain control is required to reduce these effects and prevent thromboembolic complications. Cardiac morbidity is the primary cause of death after anesthesia and surgery.

Since the stress response causes an increase in sympathetic nervous system activity, intestinal secretions and smooth muscle sphincter tone increase, and gastric emptying and intestinal motility decrease. This response can cause temporary impairment of gastrointestinal function and increase the risk of ileus.

Unrelieved pain may be especially harmful for patients with metastatic cancers. Stress and pain can suppress immune functions, including the natural killer (NK) cells that play a role in preventing tumor growth and controlling metastasis. Further, management of perioperative pain is probably a critical factor in preventing surgery-induced decrease in resistance against metastasis.

Unrelieved acute pain can result in chronic pain at a later date. Thus, paiow can cause pain later. If acute shingles pain is not treated aggressively, it is believed to increase the risk of postherpetic neuralgia. A survey of patients having undergone surgery found a high prevalence of chronic postsurgical pain in patients whose acute postsurgical pain was inadequately managed.

Assessment of pain is a critical step to providing good pain management. In a sample of physicians and nurses, Anderson and colleagues found lack of pain assessment was one of the most problematic barriers to achieving good pain control. There are many recommendations and guidelines for what constitutes an adequate pain assessment; however, many recommendations seem impractical in acute care practice. Nurses working with hospitalized patients with acute pain must select the appropriate elements of assessment for the current clinical situation. The most critical aspect of pain assessment is that it is done on a regular basis (e.g., once a shift, every 2 hours) using a standard format.⁵ The assessment parameters should be explicitly directed by hospital or unit policies and procedures. To meet the patients’ needs, pain should be reassessed after each intervention to evaluate the effect and determine whether modification is needed. The time frame for reassessment also should be directed by hospital or unit policies and procedures.⁵

An early Clinical Practice Guideline on Acute Pain Management released by the Agency for Health Care Policy and Research addressed assessment and management of acute pain. This guideline outlines a comprehensive pain evaluation that would be most useful when obtained prior to the surgical procedure. In the pain history, the nurse identifies the patient’s attitudes, beliefs, level of knowledge, and previous experiences with pain. Expectations of patient and family members for pain control postsurgically will uncover unrealistic expectations that can be addressed before surgery. This comprehensive pain history lays the foundation for the plan for pain management following surgery, which is completed collaboratively by the clinicians (physician and nurse), the patient, and his or her family.

Pain History

The pain history should include the following:

• Significant previous and/or ongoing instances of pain and its effect on the patient

• Previously used methods for pain control that the patient has found either helpful or unhelpful

• The patient’s attitude toward and use of opioids, anxiolytics, or other medications, including any history of substance abuse

• The patient’s typical coping response for stress or pain, including the presence or absence of psychiatric disorders such as depression, anxiety, or psychosis

• Family expectations and beliefs concerning pain, stress, and postoperative course

• Ways the patient describes or shows pain

• The patient’s knowledge of, expectations about, and preferences for pain management methods and for receiving information about pain management (p. 7–8)

Pain Assessment Tools

During the postsurgical period, pain assessment must be brief and simple to complete. Because choice of intervention, including type of analgesic and dosing, is made based upon intensity, every pain assessment should include this type of measure. Numerous pain intensity measures have been developed and validated. Several tools provide a numeric rating of pain intensity (e.g., visual analogue scale, numeric rating scale (NRS)). Simpler tools such as the verbal rating scale, which classifies pain as mild, moderate or severe, also are commonly used. For patients with limited cognitive ability, scales with drawings or pictures are available (e.g., the Wong-Baker FACES scale). Patients with advanced dementia require behavioral observation to determine the presence of pain; tools such as the PAIN-AD are available for this patient population. (For more detail, go to section “Tools to Assess Pain Intensity in Cognitively Intact and Impaired Adults,” below.)

The Joint Commission developed pain standards for assessment and treatment based upon the recommendations in the Acute Pain Clinical Practice Guideline. The Joint Commission requires that hospitals select and use the same pain assessment tools across all departments. This standard suggests providing options among scales such as the NRS, the Wong-Baker FACES scale, and a verbal descriptor scale.

Selecting the pain assessment tool should be a collaborative decision between patient and health care provider. When this is done during the preoperative period, it ensures the patient is familiar with the scale. If the nurse selects the tool, he or she should consider the age of the patient; his or her physical, emotional, and cognitive status; and preference. We tend to think of these intensity scales as verbal, but patients who are alert but unable to talk (e.g., intubated, aphasic) may be able to point to a number or a face to report their pain. The pain tool selected should be used on a regular basis to assess pain and the effect of interventions. It should not, however, be used as the sole measure of pain perception.

Location and quality of pain are additional assessment elements useful in selecting interventions to manage pain. Since patients may experience pain in areas other than the surgical site, location of pain using a body drawing or verbal report provides useful information. The pain experienced may be chronic (e.g., headache, low-back pain) or it may be related to the positioning and padding used during the procedure. The quality of pain varies depending upon the underlying etiology. Instruments such as the McGill Pain Questionnaire contain a variety of verbal descriptors that help to distinguish between musculoskeletal and nerve-related pain. Typically, patients describe deep tissue pain as dull, aching, and cramping, while nerve-related pain tends to be more sporadic, shooting, or burning.

Pain interferes with many daily activities, and one of the goals of acute pain management is to reduce the affect of pain on patient function and quality of life. The ability to resume activity, maintain a positive affect or mood, and sleep are relevant functions for patients following surgery. The Brief Pain Inventory includes four items that may be useful in assessing this aspect of the pain experience. Using an NRS format, assessment of interference with ability to walk, general activity, mood, and sleep during the recovery period will assist in selecting interventions to enhance function and quality of life.

The final elements of pain perceptions involve determining current aggravating and alleviating factors. Aggravating factors may be as simple as patient position, a full bladder, or temperature of the room. Alleviating factors include the interventions used (e.g., analgesics) and cognitive strategies used to control pain. Examples of such strategies are distraction, positive self-talk, and pleasant imagery. The pain history will provide insight into the coping strategies previously used by the patient and their effectiveness with previous painful episodes.

In addition to self-reported pain perceptions, a comprehensive assessment of pain following surgery includes both physiological responses and behavioral responses to pain (p. 11). Physiological responses of sympathetic activation (tachycardia, increased respiratory rate, and hypertension) may indicate pain is present. Behaviors that may indicate pain include splinting, grimacing, moaning or grunting, distorted posture, and reluctance to move. While these nonverbal methods of assessment provide useful information, self-report of pain is the most accurate. A lack of physiological responses or an absence of behaviors indicating pain may not mean the patient is not experiencing pain. (Go to section “Tools to Assess Pain Intensity in the Cognitively Impaired,” below, for more detail.)

Adequate pain management requires an interdisciplinary approach. Documentation of pain assessment and the effect of interventions are essential to allow communication among clinicians about the current status of the patient’s pain and responses to the plan of care. The Joint Commission requires documentation of pain to facilitate reassessment and followup. The American Pain Society suggests that pain be the fifth vital sign as a means of prompting nurses to reassess and document pain whenever vital signs are obtained. Documentation also is important as a means of monitoring the quality of pain management within the institution.

Establishing and maintaining an institutional pain performance improvement plan is a Joint Commission requirement. Institutions should develop interdisciplinary approaches to acute pain management with clear lines of responsibility for achieving good acute pain control. This interdisciplinary approach includes an individualized plan of care for pain control, developed in collaboration with the patient and family. Systems should be in place to monitor pain management that alerts the clinician when pain is poorly managed. For example, in an institution with a computerized documentation system, an alert may pop up when a patient’s pain exceeds a threshold. The threshold may be set individually by patient and clinician or institutionally. A reasonable threshold might be moderate to severe pain, which means a pain score of greater than 4 on a 0–10 scale. The plan of care provides the basis for monitoring the quality of acute pain management provided.

American Pain Society Current Guidelines

One of the first quality improvement programs was developed by the American Pain Society. The quality improvement guideline was refined and expanded in 2005 (p. 1576) based upon a systematic review of pain quality improvement studies conducted over the past 10 years. The emphasis has shifted from processes to outcomes.

• Recognize and treat pain promptly.

• Involve patients and families in pain management plan.

• Improve treatment patterns.

• Reassess and adjust pain management plan as needed.

• Monitor processes and outcomes of pain management.

The goal of pain management after surgery is to prevent and control pain. Postsurgical pain, like cancer pain, is expected to be present continuously with spikes of increased pain with movement, deep breathing and coughing, and ambulation during the fist 24–48 hours after surgery. Around-the-clock dosing is recommended during this early postsurgical period to prevent severe pain and control continuous pain.

Quality Indicators (p. 1578)

Quality indicators for pain management focus on appropriate use of analgesics and outcomes.

• Intensity of pain is documented using a numeric (0–10) or descriptive (mild, moderate, severe) rating scale.

• Pain intensity is documented at frequent intervals.

• Pain is treated by route other than intramuscular.

• Pain is treated with regularly administered analgesics, and, when possible, multimodal approach is used. (Multimodal approach includes a combination of pain control strategies, such as opioids, nonsteroidal anti-inflammatory drugs, nonpharmacological interventions.)

• Pain is prevented and controlled to a degree that facilitates function and quality of life.

• Patients are adequately informed and knowledgeable about pain management.

To efficiently monitor quality indicators, patient records should contain documentation of

• Pain intensity (0–10 or mild, moderate, severe)

• Analgesics prescribed and administered, including drug, route, and dosing

• Impact of pain on function and quality of life (e.g., ability to walk, general activity, mood, sleep)

• Pain education for patient and family member(s)

Patient Satisfaction

Although satisfaction with pain management currently is used as a measure of institutional quality, satisfaction with pain management is no longer recommended as a quality indicator for pain control. This is because patient satisfaction findings are difficult to interpret. In their review of 20 quality improvement studies conducted between 1992 and 2001, Gordon and colleagues noted 15 studies reported high satisfaction with pain management despite many patients experiencing moderate to severe pain during hospitalization. Thus, patient satisfaction data should be cautiously interpreted and, if used, used in conjunction with other quality indicators. Because of the current focus on report cards for health care organizations, patient satisfaction data are routinely collected and easily obtained for review.

Many institutions use commercial patient satisfaction surveys to monitor satisfaction with care. Most of these surveys have at least one item on satisfaction with pain management. Institutions also may use generic health status or quality of life surveys, such as the Medical Outcomes Study Short From-36, to monitor patient outcomes; most of these surveys include one or more questions on pain experienced. Regular review of these patient satisfaction data can be used as a quick measure of quality of pain care. If satisfaction scores on pain management dip, a more thorough investigation of pain management processes is warranted.

Use of an interdisciplinary team to monitor current pain practice, identify areas for improvement, and oversee quality improvement plans is consistently recommended in the guidelines. To effectively monitor pain practice within a hospital, electronic systems are needed to capture and collate data on the indicators in a readily available form. One method of changing clinician behavior is through the use of feedback on performance; thus the reports generated for interdisciplinary committee review also may be used to assist clinicians to review and adjust their performance.

 

SUMMARY

■ Pain is referred to as the fifth vital sign. Subjective iature, self-report is the most accurate assessment indicator of pain.

■ Pain assessment includes a detailed history and symptom analysis and physical examination. The history is the most important piece of the assessment.

■ Realize that pain threshold, the point at which a painful stimulus is perceived as painful, is consistent from one person to the next; however, pain tolerance, the amount of pain one is able to endure, varies greatly.

■ Developmental, psychosocial, and cultural factors and past experiences influence pain perception, thereby accounting for such individual differences in pain perception even with similar painful stimuli.

■ The initial purpose of the physical examination is to identify the underlying cause of pain. The physical examination also identifies physical, behavioral, and psychological nonverbal responses to pain.

■ Although self-report is the most accurate assessment tool of pain, the age and mental status of the patient may prevent self-report. Assessment then becomes dependent on assessing physical, behavioral, and psychological nonverbal responses to pain.

■ Various pain scales are available to assess pain. Select the one best suited to meet your patient’s needs.

■ Be sure to document your findings,evaluate the effects of treatment, and revise the plan of care as needed to ensure pain relief for your patient.

 

 

 

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