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PAIN ASSESSMENT
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l STRUCTURE AND FUNCTION
DEFINITION
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional expe- rience, which we primarily associate with tissue damage or describe in terms of such damage, or both.” Recent literature has emphasized the importance of pain and recommended it being the fifth vital sign. Some states in the United States have passed laws necessitating the adop- tion of an assessment tool and documenting pain assess- ment in patient charts along with temperature, pulse, heart rate and blood pressure (see Chapter 7).
PATHOPHYSIOLOGY
Several theories attempt to explain the concept of pain. Melzack and Wall in 1965 proposed the gate control model emphasizing the importance of the central nervous sys- tem mechanisms of pain; this model has influenced pain research and treatment. Pain is explained as a combination of physiologic phenomena in addition to a psychosocial aspect that influ- ences the perception of pain. The pathophysiologic phenomenon of pain is sum- marized by the processes of transduction, transmission, modulation, and perception. Transduction of pain begins when a mechanical, ther- mal or chemical stimulus results in tissue injury or damage stimulating the nociceptors, which are the primary affer- ent nerves for receiving painful stimuli. Nociceptors are distributed in the body in the skin, subcutaneous tissue, skeletal muscles, and joints. Pain receptors are also located in the peritoneal surfaces, pleural membranes, dura mater, and blood vessel walls rather than in the parenchyma of
visceral organs. Noxious stimuli initiate a painful stimulus resulting in an inflammatory process, which leads to the release of cytokines and neuropeptides from circulating leukocytes, platelets, vascular endothelial cells, immune cells, and cells from within the peripheral nervous sys- tem. This results in the activation of the primary afferent nociceptors (A-delta and C-fibers). Furthermore, the noci- ceptors themselves release a substance P that enhances nociception, causing vasodilatation, increased blood flow, and edema with further release of bradykinin, serotonin from platelets, and histamine from mast cells. A-delta primary afferent fibers (small-diameter, lightly myelinated fibers) and C-fibers (unmyelinated, primary afferent fibers) are classified as nociceptors because they are stimulated by noxious stimuli. A-delta primary afferent fibers transmit fast pain to the spinal cord within 0.1 sec- ond, which is felt as pricking, sharp, or electric quality sen- sation and usually caused by mechanical or thermal stimuli. C-fibers transmit slow pain within 1 second, which is felt as burning, throbbing or aching and is caused by mechanical, thermal or chemical stimuli usually result- ing in tissue damage. By the direct excitation of the pri- mary afferent fibers, the stimulus leads to the activation of the fiber terminals. The transmission process is initiated by this inflam- matory process, resulting in the conduction of an impulse in the primary afferent neurons to the dorsal horn of the spinal cord. There, neurotransmitters are released and con- centrated in the substantia gelatinosa (which is thought to host the gating mechanism described in the gate control theory) and bind to specific receptors. The output neurons from the dorsal horn cross the anterior white commissure and ascend the spinal cord in the anterolateral quadrant in two ascending pathways (Fig. 8-1):
- Spinothalamic tract (STT): ascends through the lat- eral edge of the medulla, lateral pons, and midbrain to the thalamus then to the somatosensory cortex. It
108 U N I T III • NURSING ASSESSMENT OF THE ADULT
transmits location, quality, and intensity of acute pain and threatening events.
- Spinoreticular tract (SRT): ascends to the reticular for- mation, the pontine, medullary areas, and medial tha- lamic nuclei. It transmits pain information from the brainstem to the limbic area through noradrenergic bundles. Modulation of pain is a difficult phenomenon. Mod- ulation inhibits the pain message and involves the body’s own endogenous neurotransmitters (endorphins, enkeph- alins, and serotonin) in the course of processing the pain stimuli. The process of pain perception is still poorly under- stood. Studies have shown that the emotional status (depression and anxiety) affects directly the level of pain perceived and thus reported by patients. The hypothal- amus and limbic system are responsible for the emotional aspect of the pain perception while the frontal cortex is responsible for the rational interpretation and response to pain.
CLASSIFICATION
Pain has many different classifications. Common cate- gories of pain include acute, chronic non-malignant, and cancer pain.
- Acute pain: usually associated with an injury with a recent onset and duration of less than 6 months and usually less than a month - Chronic non-malignant pain: usually associated with a specific cause or injury and is described as a constant pain that persists more than 6 months - Cancer pain: often due to the compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration Pain is also described as transient pain, tissue injury pain (surgical pain, trauma-related pain, burn pain, iatro- genic pain as a result of an intervention), and chronic neuropathic pain. Also pain is viewed in terms of its inten- sity and location.
PHYSIOLOGIC RESPONSES
TO PAIN
Pain elicits a stress response in the human body triggering the sympathetic nervous system, resulting in physiologic responses such as the following:
- Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide
- Focus on pain, reports of pain, cries and moans, frowns and facial grimaces
- Decrease in cognitive function, mental confu- sion, altered temperament, high somatization, and dilated pupils
- Increased heart rate, peripheral, systemic, and coronary vascular resistance, blood pressure
- Increased respiratory rate and sputum retention resulting in infection and atelactasis
- Decreased gastric and intestinal motility
- Decreased urinary output resulting in urinary retention, fluid overload, depression of all immune responses
- Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagons, decreased insulin, testosterone
- Hyperglycemia, glucose intolerance, insulin resistance, protein catabolism
- Muscle spasm resulting in impaired muscle function and immobility, perspiration
l HEALTH ASSESSMENT
COLLECTING SUBJECTIVE DATA:
THE NURSING HEALTH HISTORY
There are few objective findings on which the assess- ment of pain can rely. Pain is a subjective phenomenon and thus the main assessment lies in the client’s report- ing. The client’s description of pain is quoted. The exact words used to describe the experienced of pain are used
Postcentral gyrus
A-delta C
Ascending pathways
Thalamus
Spinal cord
Figure 8-1 Pathways for transmitting pain.
To establish the presence or absence of perceived pain.
The location of pain helps to identify the underlying cause.
Radiating or spreading pain helps to identify the source. For example, chest pain radiating to the left arm is most probably of cardiac origin while the pain that is prick- ing and spreading in the chest muscle area is probably musculoskeletal in origin.
Accompanying symptoms also help to identify the possi- ble source. For example, right lower quadrant pain asso- ciated with nausea, vomiting, and the inability to stand up straight is possibly associated with appendicitis.
The onset of pain is an essential indicator for the sever- ity of the situation and suggests a source.
This helps to identify the precipitating factors and what might have exacerbated the pain.
This is also to help identify the nature of the pain.
Understanding the course of the pain provides a pattern that may help to determine the source.
Clients are quoted so that terms used to describe their pain may indicate the type and source. The most com- mon terms used are: throbbing, shooting, stabbing, sharp, cramping, gnawing, hot-burning, aching, heavy, tender, splitting, tiring-exhausting, sickening, fearful, punishing.
Relieving factors help to determine the source and the plan of care.
Identifying factors that increase pain helps to determine the source and helps in planning to avoid aggravating factors.
This question establishes any current treatment modal- ities and their effect on the pain. This helps in planning the future plan of care.
An open-ended question allows the client to mention anything that has been missed or the issues that were not fully addressed by the above questions.
Are you experiencing pain now or have you in the past 24 hours?
Where is the pain located?
Does it radiate or spread?
Are there any other concurrent symptoms accompany- ing the pain?
When did the pain start?
What were you doing when the pain first started?
Is the pain continuous or intermittent?
If intermittent pain, how often do the episodes occur and for how long do they last?
Describe the pain in your own words.
What factors relieve your pain?
What factors increase your pain?
Are you on any therapy to manage your pain?
Is there anything you would like to add?
QUESTION Continued RATIONALE Continued
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C H A P T E R 8 • PAIN ASSESSMENT 111
Past experiences of pain may shed light on the previous history of the client in addition to possible positive or negative expectations of pain therapies.
llä PAST HEALTH HISTORY
QUESTION RATIONALE
Have you had any previous experience with pain?
To assess possible family-related perceptions or any past experiences with persons in pain.
To assess how much the pain is interfering with the client’s family relations.
llä FAMILY HISTORY
QUESTION RATIONALE
Does any one in your family experience pain?
How does pain affect your family?
Identifying the client’s fears and worries helps in prior- itizing the plan of care and providing adequate psycho- logical support.
These are the main lifestyle factors that pain interferes with. The more that pain interferes with the client’s ability to function in his/her daily activities, the more it will reflect on the client’s psychological status and thus the quality of life.
llä LIFESTYLE AND HEALTH PRACTICES
QUESTION RATIONALE
What are your concerns about pain?
How does your pain interfere with the following?
- General activity
- Mood/Emotions
- Concentration
- Physical ability
- Work
- Relations with other people
- Sleep
- Appetite
- Enjoyment of life
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- Choose an assessment tool reliable and valid to your culture.
- Explain to the client the purpose of rating the intensity of pain.
- Ensure the client’s privacy and confidentiality.
- Respect the client’s behavior towards pain and the terms used to express it.
Understand that different cultures express pain differently and maintain different pain thresholds and expectations.
Client appears to be slumped with the shoulders not straight (indicates being disturbed/uncomfortable). Client is inattentive and agitated. Client might be guarding affected area and have breathing patterns reflecting distress.
Client’s facial expressions indicate dis- tress and discomfort, including frown- ing, moans, cries, and grimacing. Eye contact is not maintained, indicating discomfort.
Edema of a joint may indicate injury. Pain may result in muscle tension.
Bruising, wounds, or edema may be the result of injuries or infections, which may cause pain.
Increased heart rate may indicate dis- comfort or pain.
Respiratory rate may be increased, and breathing may be irregular and shallow.
Increased blood pressure often occurs in severe pain.
PHYSICAL ASSESSMENT
Assessment Procedure Normal Findings Abnormal Findings
General Observation
Inspection
Observe posture.
Observe facial expression.
Inspect joints and muscles.
Observe skin for scars, lesions, rashes, changes or discoloration.
Vital Signs
Inspection
Measure heart rate.
Measure respiratory rate.
Measure blood pressure.
Note: Refer to physical assessment chapter appropriate to affected body area. Body system assessment will include techniques for assessing for pain, e.g., palpating the abdomen for tenderness and performing range of motion test on the joints.
Posture is upright when the client appears to be comfortable, attentive, and without excessive changes in posi- tion and posture.
Client smiles with appropriate facial expressions and maintains adequate eye contact.
Joints appear normal (no edema); muscles appear relaxed.
No inconsistency, wounds, or bruis- ing is noted.
Heart rate ranges from 60 to 100 beats per minute.
Respiratory rate ranges from 12 to 20 breaths per minute.
Blood pressure ranges from: Systolic: 100 to 130 mmHg Diastolic: 60 to 80 mmHg.
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VALIDATING AND
DOCUMENTING FINDINGS
Validate the pain assessment data you have collected. This is necessary to verify that the data are reliable and accu- rate. Document the assessment data following the health care facility or agency policy.
Sample Documentation
of Subjective Data
Ms. S.B. is a 68-year-old female pa- tient known previously as having osteo- porosis. This visit she presents with low back pain, burning in nature, radiating to the left lower extremity associated with tin- gling and numbness sensation of the lower extremity. The pain is continuous and exac- erbates mostly in the morning and after any movement. Pain is moderately relieved by pain medications and rest. “Pain is inter- vening with my activities of daily life. I am not able to bathe, dress, and perform the daily household chores. Also, I am not able to concentrate on my work anymore. I can- not sleep at night and I seem not to enjoy anything lately.” Using the Visual Analog Scale (VAS), Ms. S.B. rates her pain to be 8/10.
Sample Documentation
of Objective Data
Client comes in leaning on her daughter and has difficulty sitting down on the chair. Her posture is not upright and she seems to be irritated. She is frowning and grimacing most of the time. Focusing on her pain, she is unable to concentrate and con- tinue an idea. Her HR = 108 beats/min, RR = 22 breaths/min, BP = 135/80 mmHg.
l ANALYSIS OF DATA
DIAGNOSTIC REASONING:
POSSIBLE CONCLUSIONS
After collecting subjective and objective data pertaining to the pain assessment, identify abnormal findings and client strengths. Then, cluster the data to reveal any sig- nificant patterns or abnormalities. These data may then be used to make clinical judgments about the status of the client’s pain.
Selected Nursing Diagnoses
Following is a listing of selected nursing diagnoses (well- ness, risk, or actual) that you may identify when analyzing the cue clusters.
Wellness Diagnoses
- Readiness for enhanced spiritual well-being related to coping with prolonged physical pain
- Readiness for enhanced comfort level
Risk Diagnoses
- Risk for activity intolerance related to chronic pain and immobility
- Risk for constipation related to nonsteroidal anti- inflammatory agents or opiates intake or poor eating habits
- Risk for spiritual distress related to anxiety, pain, life change, and chronic illness
- Risk for powerlessness related to chronic pain, healthcare environment, pain treatment-related regimen
Actual Diagnoses
- Acute pain related to injury agents (biological, chemical, physical, or psychological)
- Chronic pain related to chronic inflammatory process of rheumatoid arthritis
- Ineffective breathing pattern related to abdomi- nal pain and anxiety
- Disturbed energy field related to pain and anxiety
- Fatigue related to stress of handling chronic pain
- Impaired physical mobility related to chronic pain
- Bathing/hygiene self-care deficit related to severe pain (specify)
Selected Collaborative Problems
After grouping the data, certain collaborative problems may become apparent. Remember that collaborative prob- lems differ from nursing diagnoses in that they cannot be prevented by nursing intervention. However, these physi- ologic complications of medical conditions can be detected and monitored by the nurse. In addition, the nurse can use physician- and nurse-prescribed interventions to mini- mize the complications of these problems. The nurse may also have to refer the client in such situations for further treatment of the problem. Following is a list of collabora- tive problems that may be identified when obtaining a gen- eral impression. These problems are worded as Potential Complications (or PC), followed by the problem.
- PC: Angina
- PC: Decreased cardiac output
- PC: Endocarditis
- PC: Peripheral vascular insufficiency
- PC: Paralytic ileus/small bowel obstruction
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Confirm the diagnosis because it meets the defining charact- eristics and is confirmed by the client
Confirm the diagnosis because it meets the defining charact- eristics and is confirmed by the client
Confirm the diagnosis because it meets the defining charact- eristics and is confirmed by the client
Confirm the diagnosis because it meets the defining charact- eristics and is confirmed by the client
Major: 7/10 continuous and increasing deep stabbing and dull pain for the past 8– months
Major: Restlessness, concern over effect of pain on lifestyle, anxious, increased respiration, increased pulse, sleep disturbance, increased blood pressure, awareness of physiologic symptoms
Major: Limited ROM limited ability to perform gross motor activities
Major: Daytime drowsiness, decreased ability to function, tiredness, anxious, inability to concentrate
- Diagnosed with prostate cancer treated with surgery/chemotherapy 1 year ago
- Pain is stabbing, deep and dull; increasing for the past 8–10 months
- Pain on average 7/10 on the VAS
- Continuous low back pain and leg pain that exacerbates at night and while walking
Client has an onset of pain which is worrying him. Refer for medical investigation and diagnosis
Client has difficulty in mobility affecting his work
Client is awakened by his pain and his inability to sleep is affecting his performance during the day time
Client is uncomfortable and shows facial expressions relating to being distressed and his posture is not straight; vital signs increased in line with discomfort or anxiety
Chronic pain increasing r/t unknown cause
Sleep Deprivation r/t prolonged physical discomfort
Anxiety r/t prolonged pain affecting daily activities
Impaired Physical Mobility r/t the pain
- Chronic Pain (increasing) r/t unknown cause
- Impaired Physical mobility r/t the pain
- Sleep Deprivation r/t prolonged physical discomfort
- Anxiety r/t prolonged pain affecting daily activities
PC: Prostate cancer metastasis
- “I sometimes feel that I will fall down while walking and at night I am awakened by stabbing deep dull pain in my legs”
- Limited ROM or legs w/pain
- Ability to lift knees in standing position for marching/walking decreased - Increased respirations and pulse - Frowns and grimaces as facial expressions - Sat on the chair with his shoulders slumped - Changes his position every 2 – 3 minutes - “I feel tired and unable to proceed with my work” - Unable to sleep because of pain
- “Not able to sleep at night”
- Pain exacerbates at night
- Diagnosed with prostate cancer; treated with surgery and chemotherapy 1 year ago
- Low back and leg pain while walking and at night
- Pain is stabbing, deep and dull
- “Not able to sleep at night”
- “I feel tired and unable to proceed with my work”
- Decreased appetite and weight loss
- Rates pain on the Visual Analog Scale (VAS) to be 7/ on average
- “I am awakened by stabbing pain”
- Entered the room limping
- Sat on the chair with his shoulders slumped
- Changes his position every 2 – 3 minutes
- Appears anxious and uncomfortable
- Frowns and grimaces
- Vital signs: HR = 110 beats/min, RR = 22 breaths/min, BP = 135 /8 5 mmHg
- ROM tests of legs: Standing: lifts knees only 20 degrees from straight position when asked to march in place. Lying: able to lift each leg with knee unbent 1 5 degrees before pain starts; lying prone, able to lift each leg only 10 degrees before pain.
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References and Selected Readings
Carrier-Kohlman V., Lindsey, A. M., & West, C. M. (2003). Pathophysiologic phenomena in nursing: Human response to illness (3rd ed., pp. 235–254). St. Louis: Saunders. NANDA International. (2005). Nursing diagnoses: Definition & classi- fication 2005–2006. Philadelphia: NANDA International. Price, S. A., & Wilson, L. M. (1997). Pathophysiology, clinical concepts of disease process (5th ed., pp. 819–848). St. Louis: Mosby-Year Book Inc.
Rankin, E. A., & Mitchel, M. L. (2000). Creating a pain management educational module for hospice nurses: Integrating the New JCAHO Standards and the AHCPR pain management guidelines. Journal of Hospice and Palliative Nursing, 2 (3), 91–100. Regan, J. M., & Peng, P. (2000). Neurophysiology of cancer pain. Cancer Control, 7 (2), 111–119. Wall, P. D., & Melzack R. (1994). Textbook of pain (3rd ed., pp. 523–540). London, England: Longman Group U.K. Limited.
