πŸ•‹
Trisquel.ink/Nursing
/
πŸ•‹
Adult Health Assesment
/
πŸ“˜
Chapter 11: Pain Assessment
πŸ“˜

Chapter 11: Pain Assessment

β€£
Theoretical Information (You probably do not need this for the test)

πŸ”Ή Development of Pathologic Pain

There are two main pathways of pain: nociceptive and neuropathic processing. Because these pathways produce different types of symptoms, patients may respond differently to therapies. This makes an accurate pain assessment essential in order to select effective non-pharmacologic and/or pharmacologic strategies for improved outcomes.

πŸ”Ή Neuroanatomic Pathways

Nociceptors are specialized nerve endings that detect painful sensations. They transmit signals to the CNS through two primary sensory fibers:

  • AΞ΄ fibers β†’ myelinated, large, rapid conduction β†’ sharp, localized, short-term pain.
  • C fibers β†’ unmyelinated, small, slow conduction β†’ diffuse, aching, persistent pain.

Both types of fibers enter the spinal cord through the dorsal horn (tract of Lissauer) and synapse in the substantia gelatinosa (lamina II). Pain signals then cross to the opposite side of the spinal cord and ascend via the anterolateral spinothalamic tract to the brain.

πŸ”Ή Nociception Phases

Nociceptive pain occurs when intact nerve fibers in the periphery and CNS are stimulated, usually by actual or potential tissue damage. This process has four phases:

  1. Transduction – tissue injury β†’ release of chemical mediators (substance P, histamine, prostaglandins, serotonin, bradykinin). These neurotransmitters propagate the pain signal to the spinal cord.
  2. Transmission – the pain impulse travels from the spinal cord to the brain along the spinothalamic tract. Opioids act on this part.
  3. Perception – awareness of the pain; cortical structures such as the limbic system also generate the emotional response.
  4. Modulation – descending pathways release inhibitory neurotransmitters (serotonin, norepinephrine, GABA, endogenous opioids) to block or dampen the pain signal.
image

πŸ”Ή Neuropathic Pain

Unlike nociceptive pain, neuropathic pain does not follow the typical pathway. It is caused by a lesion or disease in the somatosensory system and involves abnormal processing of pain messages.

  • Often persists long after tissue healing.
  • Common causes: diabetes mellitus, shingles (herpes zoster), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, chemotherapy.
  • Difficult to diagnose β†’ imaging (X-ray, CT, MRI) is not helpful; instead, electromyography and nerve conduction studies are required.
  • Mechanisms include spontaneous firing of nerve fibers, central β€œwind-up” (excitability), and hypersensitivity to minor stimuli.

πŸ“Œ Quick Summary

  • Pathways: Nociceptive vs Neuropathic.
  • Nociceptors: AΞ΄ (fast, sharp) & C fibers (slow, aching).
  • Nociception Phases: Transduction β†’ Transmission β†’ Perception β†’ Modulation.
  • Neuropathic Pain: abnormal processing; diabetes, shingles, HIV, phantom limb, chemo.
  • Sources:
    • Visceral = organs, autonomic symptoms.
    • Deep somatic = joints, bones, muscles.
    • Cutaneous = skin, sharp/burning.
    • Referred = distant site, shared innervation.

πŸ”Ή Sources of Pain

Pain can be categorized based on its origin:

  • Visceral pain β†’ from larger internal organs (injury, distention, ischemia). Often accompanied by autonomic responses such as nausea, vomiting, pallor, diaphoresis. Poorly localized due to sparse innervation of visceral structures. Described as dull, crampy, or aching.
  • Deep somatic pain β†’ from blood vessels, joints, tendons, muscles, bones. Described as aching or throbbing; usually well localized; may include systemic signs (nausea, tachycardia, hypertension). Somatic = Structures for movement.
  • Cutaneous pain β†’ from skin and subcutaneous tissues. Superficial, sharp, burning sensation.
  • Referred pain β†’ felt at a site distant from the origin. Occurs because both sites are innervated by the same spinal nerve, making it difficult for the brain to localize the true source.

⚑ Types of Pain – Classification

Pain can be classified based on its duration. This distinction is important because it provides insight into underlying mechanisms and guides treatment decisions.

πŸ“Œ Quick Summary

  • Acute pain β†’ short-term, protective, predictable, resolves with healing.
  • Incident pain β†’ predictable acute pain with movement/activity.
  • Chronic pain β†’ lasts β‰₯6 months, persists beyond healing, malignant (tumor-related) or nonmalignant (arthritis, back pain, fibromyalgia).
  • Breakthrough pain β†’ spike acute pain in patients with β€œcontrolledβ€œ chronic pain.
β€£
πŸ”Ή Acute Pain

Acute pain is short-term and self-limiting. Its main purpose is self-protective β€” it serves as a warning signal of actual or potential tissue damage.

A specific subtype, incident pain, occurs predictably with certain movements or activities (for example, pain on standing after surgery).

β€£
πŸ”Ή Chronic Pain

Chronic pain is diagnosed when pain persists for 6 months or longer. The intensity of pain may not always correlate with physical findings, which can complicate diagnosis and treatment.

Chronic pain can be further classified as:

  • Malignant (cancer-related) β†’ parallels tumor growth, tissue necrosis, or organ stretching caused by tumor mass. Pain often fluctuates with the disease course.
  • Nonmalignant β†’ commonly associated with long-term conditions such as arthritis, low back pain, or fibromyalgia.

Unfortunately, patients with chronic pain are often misunderstood or mislabeled as exaggerating, malingering, or seeking drugs, which adds to their suffering.

β€£
πŸ”Ή Breakthrough Pain

A sudden increase in pain that may occur in patients who already have chronic pain from cancer, arthritis, fibromyalgia, or other conditions. Breakthrough pain usually lasts for a short time.

Is a transient spike of pain in a patient whose chronic pain is otherwise controlled.

  • It may occur due to end-of-dose medication failure or as a result of incident/episodic pain.
  • Treatment often requires adjusting therapy, such as shortening the dosing interval or increasing medication.

    • Because pain is a biopsychosocial phenomenon, patient self-report remains the most reliable indicator of breakthrough pain.

β€£
❓ Question 1 – Pain Management

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

  1. Verify that the patient has an order for pain medications and administer order as directed.
  2. 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.
  3. Assess the level of pain and give medications according to pain level, and then reassess pain.
  4. Reposition the patient, then reassess the pain after intervention.

βœ… Correct Answer: 2

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

πŸ“š Rationale

  • Pain is subjective β†’ always begin with a pain assessment.
  • Asking the patient what has worked before ensures individualized care.
  • After intervention (medication), the nurse must reassess pain level.
  • Option 1 skips assessment, option 3 lacks patient input, option 4 delays pain relief.

πŸ“Œ Key Rule: Assess β†’ Intervene β†’ Reassess

πŸ“– Developmental Competence in Pain Assessment

πŸ‘΅ The Aging Adult

There is no evidence that older adults perceive pain less intensely or have diminished sensitivity. Pain is a common experience in those over 65.

β†’ It should never be considered a normal part of aging. Pain in older adults always indicates pathology or injury and should not be tolerated or dismissed. Unfortunately, both clinicians and older patients often assume that pain is expected in later years, which leads to undertreatment.

Older adults also face unique fears related to pain management, including worries about becoming dependent, undergoing invasive procedures, needing long-term pain medication, and creating a financial burden.

Most common causes of pain in older adults: arthritis, osteoarthritis, osteoporosis, peripheral vascular disease, cancer, neuropathies, angina, and chronic constipation.

Dementia:

It is important to note that dementia does not reduce the ability to feel pain, but it does affect the ability to effectively use self-report tools, making assessment more challenging.

🚹🚺 Gender Differences

Gender influences pain perception through societal expectations, hormonal changes, and genetics. Traditionally, men have been encouraged to be stoic, while women’s emotional expressions of pain are more accepted.

Hormonal changes strongly affect women’s pain sensitivity. Women are:

  • 2–3 times more likely to experience migraines during childbearing years
  • More sensitive to pain during the premenstrual period
  • 6 times more likely to have fibromyalgia

🌍 Cultural Differences in Pain

Silent pain: refers toΒ the experience of physical or emotional suffering that is not openly expressed, leading to internalized struggles and often hidden from others

Culture greatly shapes the expression and reporting of pain. Patients from different backgrounds may under-express pain or show pain in ways unfamiliar to the provider.

  • Always use interpreters when language barriers exist to avoid misunderstanding.
  • Lack of outward signs does not mean absence of pain.
  • Research shows disparities in pain management among racial and ethnic groups, with minority patients often receiving less effective treatment.
  • Poorly treated pain increases physiological and psychological costs.
  • Pain expression is influenced by social, cultural, emotional, and spiritual concerns.

πŸ’Š The Opioid Epidemic

In 2017, the U.S. declared the opioid crisis a Public Health Emergency. Opioids are highly effective for severe pain but carry serious risks, including euphoria, dependence, and addiction.

Opioids produce: analgesia, respiratory depression.

Effective pain management requires weighing risks versus benefits, along with strong emphasis on:

  • Evidence-based pain management principles
  • Ongoing patient and provider education

πŸ“Œ Quick Summary

  • Aging Adult β†’ pain is common but not normal; undertreatment is common; major causes = arthritis, PVD, cancer, neuropathies.
  • Gender β†’ women more sensitive due to hormones; higher risk for migraines & fibromyalgia.
  • Cultural β†’ expression varies; use interpreters; disparities in treatment exist.
  • Opioids β†’ effective but risky; linked to U.S. epidemic; dependence and addiction possible.

πŸ“– Pain Assessment

πŸ₯‡ Subjective Report = Gold Standard

Pain is always assessed based on the patient’s self-report. Since pain occurs at a neurochemical level, it cannot be diagnosed solely from physical findings, though exam findings may support the report.

β€£
πŸ“ Initial Pain Assessment – Key Questions

All information should be gathered in the patient’s own words.

  1. Do you have pain? (or discomfort, soreness, β€œouch”)
  2. Where is your pain? (all affected locations)
  3. When did your pain start? (onset, activity at the time, constant vs intermittent)
  4. What does your pain feel like?
    • Burning, stabbing, aching
    • Throbbing, squeezing, cramping
    • Sharp, dull, itching, tingling
    • Shooting, crushing, fire-like
  5. How much pain do you have now? (current intensity)
  6. What makes your pain better or worse? (behavioral, pharmacologic, nonpharmacologic factors; medication use and adequacy)
  7. How does pain affect your function or activities? (limitations, impact on daily life)
  8. How do you usually react to pain? (symptoms, behavior, how others can tell)
  9. What does pain mean to you? (personal beliefs or fears about cause)

πŸ“Š Pain Assessment Tools

  • 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 forchronic pain conditions or particularly problematic acute painproblems.Copyright Β© 2020 by Elsevier Inc. All rights reserved.

Pain is multidimensional β€” affecting physical, emotional, and functional domains. Assessment tools vary:

  • Initial Pain Assessment β†’ 8 open-ended questions covering location, duration, quality, severity, aggravating/relieving factors, expression, and impact on life.
  • Brief Pain Inventory β†’ (Last 24 hours) The Brief Pain Inventory (BPI) isΒ a self-report questionnaire used to assess chronic pain.Β It measures both the severity and impact of pain on daily life.Β  Rates pain over last 24 hours (0–10 scale) and evaluates impact on mood, sleep, and activity.
β€£
Short-Form McGill Pain Questionnaire β†’ patient ranks descriptors and gives overall pain intensity.
image

πŸ“ Pain Rating Scales (One-Dimensional)

Designed to reflect pain intensity only. Best for tracking progress over time.

  • Numeric Rating Scale (NRS) β†’ 0 to 10 / (no pain) to (worst pain).
  • Verbal Descriptor Scale (VDS) β†’ patient selects descriptive words.
β€£
Visual Analog Scale (VAS) β†’ patient marks pain on a horizontal line from β€œno pain” to β€œworst pain.”
image
  • Descriptor Scales β†’ patient chooses from a list of descriptive terms.

Choice of scale depends on patient’s age, understanding, and ability.

πŸ”Ž PQRST Method of Pain Assessment

A simple structured tool to qualify the patient’s pain experience:

  • P β†’ Provocation/Palliation (What makes it better/worse?)
  • Q β†’ Quality/Quantity (What does it feel like?)
  • R β†’ Region/Radiation (Where is it? Does it spread?)
  • S β†’ Severity (Rate the pain, e.g., 0–10)
  • T β†’ Timing (When did it start? How long? Pattern?)

πŸ“Œ Quick Summary

  • Subjective report = gold standard.
  • Initial assessment asks about location, onset, quality, intensity, factors, impact, reaction, and meaning.
  • Tools: Initial assessment, Brief Pain Inventory, McGill Questionnaire.
  • Scales: Numeric, verbal, visual analog, descriptor.
  • PQRST: Provocation, Quality, Region, Severity, Timing.

🩺 Pain Complaints and Objective Evidence

  • Physical findings do not always support a patient’s pain report, especially in chronic pain syndromes.
  • Pain should never be discounted simply because no objective evidence is found.
  • The nurse must rely on the patient’s self-report and make every effort to reduce or eliminate pain through both analgesics and nonpharmacologic interventions.

πŸ‡ΊπŸ‡Έ American Pain Society Guidelines

  • For acute pain, establishing a diagnosis for the cause is important.
  • However, symptomatic treatment should begin immediately β€” even while the diagnostic process is ongoing.
  • Relieving pain improves patient comfort, which in turn increases cooperation with diagnostic procedures and overall care.

πŸ“Œ Professor’s Note:

βœ… Believe the patient’s pain report.

βœ… Start treatment early β€” don’t wait for all tests to confirm the cause.

β€£
❓ Question– Pain Reassessment

Scenario:

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?

  1. Verify orders for medications and offer more pain medication, if appropriate.
  2. Continue to assess patient’s pain level.
  3. Document the pain level in the chart.
  4. There is no need for action, because the patient’s pain is manageable.

βœ… Correct Answer: 1

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

πŸ“š Rationale

  • Patients have the right to adequate pain control, and a pain score of 3/10 still indicates pain.
  • Option 2 is incorrect β†’ continued assessment without intervention does not address the patient’s current discomfort.
  • Option 3 is incorrect β†’ documentation is necessary, but it does not resolve pain.
  • Option 4 is incorrect β†’ assuming a 3/10 pain score is β€œmanageable” dismisses the patient’s right to be pain-free.

πŸ“Œ Key Point: After reassessment, if pain is still present, the nurse must consider further intervention, including administering additional medication if ordered.

πŸ“š Pain Assessment – Objective Data

πŸ”Ž Objective Data Collection Check for pain.

  • Joints β†’ Check for pain. Inspect size, contour, and circumference. Assess active and passive range of motion. Normally, there is no tenderness, pain, or crepitation.
  • Muscle and Skin β†’ Check for pain. Inspect for color, swelling, masses, or deformity.
  • Abdomen β†’ Check for pain. Observe for contour and symmetry. Palpate for muscle guarding, organ size, and referred pain.

🀐 Nonverbal Behaviors of Pain

When a patient cannot verbally communicate pain, nurses can rely (to a limited extent) on behavioral cues. These vary widely depending on:

  • The nature of pain (acute vs. chronic)
  • Age
  • Cultural and gender expectations

⚑ Acute Pain Behaviors

Acute pain is often associated with autonomic responses and serves a protective purpose. Patients with moderate to severe acute pain may exhibit:

β€£
Guarding, grimacing
image
image
  • Vocalizations (moaning, restlessness, agitation, stillness)
  • Diaphoresis
  • Changes in vital signs (↑ HR, ↑ BP, ↑ RR)

⏳ Chronic Pain Behaviors

Persistent or chronic pain is lived with for months to years, and patients often adapt over time.

  • Clinicians cannot rely on typical acute pain behaviors to confirm diagnosis.
  • Behaviors are more subtle and variable, increasing the risk of under-detection.
  • Associated behaviors:
      • β€£
      Bracing, rubbing
      image
    1. Diminished activity
      2. β€£
      Sighing
      image
    2. Changes in appetite

πŸ“Œ Quick Summary

  • Objective Data: joints (ROM, contour), muscles/skin (swelling, deformity), abdomen (symmetry, guarding).
  • Nonverbal cues: vary by pain type, age, culture, and gender.
  • Acute pain β†’ guarding, grimacing, moaning, diaphoresis, VS changes.
  • Chronic pain β†’ bracing, rubbing, ↓ activity, sighing, appetite changes.

πŸ‘΅ Developmental Competence: The Aging Adult and Pain

πŸ”Ή Pain in Older Adults

  • Comorbidities increase the likelihood of pain (e.g., arthritis, osteoporosis, neuropathies).
  • Many older adults deny pain due to: fear of dependency, further testing or invasive procedures, financial concerns, fear of addiction or side effects of painkillers

Because of this, nurses must observe functional and behavioral changes that may signal pain rather than relying only on verbal reports.

🧠 Dementia and Pain

  • Dementia does not reduce the ability to feel pain, but it impairs the ability to communicate pain verbally.
β€£
πŸ“ŠThe PAINAD Scale is recommended for these patients.
  • Evaluates 5 behaviors:
    1. Breathing
    2. Vocalization
    3. Facial expression
    4. Body language
    5. Consolability
  • Each category scored 0 to 2.
  • Total score range: 0–10.
  • Score β‰₯ 4 β†’ requires intervention/treatment.

πŸ“Œ Quick Summary

  • Pain in older adults is common but not normal.
  • Watch for behavioral changes (function, mood, activity).
  • Dementia β†’ use PAINAD scale (score β‰₯ 4 = treat).
β€£
πŸ”₯ Complex Regional Pain Syndrome (CRPS)

(also known as Reflex Sympathetic Dystrophy, RSD)

  • Chronic, progressive nerve condition involving a complex interaction of the sensory, motor, autonomic, and immune systems.
  • Characterized by burning pain, swelling, stiffness, and discoloration of the affected extremity.
  • Epidemiology: occurs equally in men and women, usually between ages 40–60.

πŸ”‘ Key Feature

  • An innocuous stimulus (e.g., light touch from clothing or cotton ball) produces a severe, intense painful response β†’ allodynia.

πŸ—£ Subjective Data

  • Severe burning pain, often disproportionate to the degree of injury.
  • Joint pain during movement.

πŸ‘€ Objective Data

  • Swelling
  • Disappearance of skin wrinkles
  • Cool skin temperature
  • Discoloration of the extremity
  • Brittle nails
  • Atrophic changes in advanced stages:
    • Pale, dry, shiny skin
    • Muscle atrophy

πŸ’Š Treatment

  • Medications to manage symptoms (e.g., corticosteroids, neuropathic pain agents, antidepressants).
  • Physical therapy β†’ crucial for regaining function, preventing contractures, and maintaining mobility.

πŸ”Ή Clinical Features

  • Key feature: pain triggered by an innocuous stimulus (allodynia).
  • Symptoms:
    • Severe burning pain
    • Swelling
    • Stiffness
    • Discoloration of the affected extremity

πŸ”Ή Treatment

  • High-dose medications:
    • Prednisone (corticosteroid)
    • Amitriptyline (antidepressant)
    • Pregabalin (anticonvulsant/neuropathic pain agent)
    • Clonidine (alpha-agonist)
  • Physical therapy: essential to help regain function and prevent loss of mobility in the limb.

πŸ“Œ Quick Summary

  • CRPS/RSD β†’ chronic nerve disorder; burning pain + swelling + stiffness + discoloration; treat with medications + physical therapy.
β€£
πŸ“ŒQuestions

10. SATA – Barriers to Pain Management Which are common barriers to effective pain management in adults? (Select all that apply)

a) Fear of addiction or dependence

b) Belief that pain is a normal part of aging

c) Reluctance to β€œbother” staff

d) Overuse of the Numeric Rating Scale (NRS)

e) Cultural beliefs that discourage pain expression

  • βœ…Correct: A, B, C, E
  • Fear of addiction, belief pain is normal in aging, reluctance to bother staff, and cultural barriers are all real.
  • β€œOveruse of NRS” is not a recognized barrier.