PAIN ASSESSMENT
&
PAIN MANAGEMENT
Prepared by:
REMEROSE C. RAGASA, RN
Pain
- An unpleasant sensory and emotional experience associated
with actual or potential tissue damage.
- It is multidimensional, affecting people physically,
psychologically, socially and spiritually.
- Identified as fifth vital sign.
- It Individualized and subjective.
Common Myths about Pain Management
Myth: Medications will cure all pain.
Fact: Medications can help control pain, but they
rarely cure it
Myth: I shouldn’t take medications unless I’m in
severe pain.
Fact: Preventing pain from developing is much
easier than treating pain once it has begun.
For best results, take pain medication on
schedule.
Myth: Taking pain medication means I’m weak. Fact: Feeling
pain is a medical problem. Taking
medication can help you get more of out of
other treatments.
Myth: I’ll get addicted to pain medication.
Fact: For those with no history of addictive disease,
the risk is less than 1% (Joranson, Ryan, Gilson,
Dahl, 2000).
FACTORS AFFECTING PATIENT RESPONSE TO
PAINFUL STIMULI
- Age, Gender, Ethnicity
- Socioeconomic and Psychological factors
- Catastrophizing
- Culture and Religion
- Genetics
- Previous experiences
- Patient perceptions
- Patient expectations
CLASSIFICATION OF PAIN
PAIN
PAIN
UNDERLYIN ANATOMIC TEMPORA INTENSIT
G LOCATION L Y
ETIOLOGY
Nociceptive Acute Mild
Inflammatory Somatic
Chronic Moderate
Neurophatic Visceral
Acute on Chronic Severe
Idiopathic
• Nociceptive Pain is the result of direct tissue injury from a
noxious stimulus. Examples include bone fracture, new
surgical incision.
• Inflammatory Pain is the result of released inflammatory
mediators that control nociceptive input and are released at
sites of tissue inflammation. Examples include appendicitis,
rheumatoid arthritis, IBD.
• Neuropathic Pain is the result of injury to nerves leading to
an alteration in sensory transmission. Examples include
diabetic peripheral neuropathic pain, postherpetic neuralgia.
• Somatic Pain, also known as musculoskeletal pain, is pain
that occurs from injury to skin, muscle, bone, joint, connective
tissue and deep tissues. Examples include lacerations,
fractures, and pelvic pain
• Visceral Pain is internal pain and typically occurs from
internal organs or tissues that support them. Pain is usually
poorly localized and described as vague deep aches, colicky,
and/or cramping. Examples include appendicitis, peptic ulcer
disease, diverticulitis, endometriosis
• Acute pain is defined lasting less than 3 months and is a
neurophysiological response to noxious injury that should resolve
with normal healing. Examples include post-operative pain,
fractured bones, appendicitis
• Chronic pain is defined lasting more than 3 months or beyond the
expected course of an acute disease or after complete tissue healing.
Examples include low back pain, chronic pancreatitis
• Acute on Chronic pain refers to times of acute exacerbations of a
chronic painful syndrome or new acute pain in a person suffering
from a chronic condition. Examples include a sickle cell
exacerbation in a patient with sickle cell disease
• Pain Intensity is determined by pain assessment scores in
combination with history and physical exam. Pain intensity is
subjective and may vary from one patient to another. Pain
Scales are used to assess and quantify the intensity of a
patients pain.
Pain intensity can Scores typically range
range from: from:
Mild 1–3
Moderate 4–7
Severe 8 – 10
HOW TO PERFORM PAIN ASSESSMENT
A. Components of Pain History
B. Pain Focused Physical Exam
Patient Factors to Consider When Assessing Pain
• Age
• Level of development
• Communication skills/language
• Cognitive skills
• Prior pain experiences
• Associated beliefs
A. Components of Pain History
A.1 Basics
SOCRATES
OPQRTS Site
Onset of event Onset
Provocation and Character
palliation of symptoms Radiation
Quality Associations
Region and radiation Time course
Severity Exacerbating/Relieving
Timing Severity
A.2 Functionality
1. How is pain affecting current level of function?
2. Is patient working?
3. How is patient coping with pain?
A.3 Co-morbidities
4. Significant past medical / surgical history
2. Chronic diseases
3. Psychosocial / psychiatric comorbidities
4. Family history of substance abuse
B. Pain Focused Physical Exam
You should be examining
the patient’s:
Appearance obese, emaciated, histrionic
Posture splinting, scoliosis, kyphosis
Gait antalgic, hemiparetic, using assisting
devices
Facial Expression grimacing, tense, diaphoretic, anxious
Vital Signs sympathetic overactivity, temperature
asymmetries
You should be examining the
PAINFUL AREAS
Inspection Skin
Muscle
Edema
Palpation Changes in sensory or pain processing
Demarcation of the painful area
Musculoskeletal system Limit range of motion
Abnormal movements
Flaccidity
Neurological exam Cranial nerve exam
Spinal nerve function
Coordination
PAIN ASSESSMENT SCALE
Adult Pain Assessment Scales
Pediatric Pain Assessment Scales
PAIN ASSESSMENT SCALE
Pain scales are typically applied to all pain types.
Not all pain scales are equal and one should be chosen
based on the patient.
Pain scales DO NOT take into account patient genetics,
past experiences or comorbidities.
In patients with preexisting pain it is important to
determine their baseline pain level.
Surrogate reporting of a non-verbal patient’s pain and
behavior can aid in pain assessment.
ADULT PAIN SCALES: Verbal, Alert, Oriented
Numeric Rating Scale Verbal Rating Scale
ADULT PAIN SCALES: Non Verbal, GCS <15, Cognitive
Impairment
Critical Care Observation Adult Non Verbal Pain
Tool Scale
ADULT PAIN SCALES: Non Verbal, GCS <15, Cognitive
Impairment
Pain Assessment in Advanced Dementia
PEDIATRIC PAIN SCALES: Birth to 6 months
CRIES Neonatal Infant Pain Scale
PEDIATRIC PAIN SCALES: Infant and older (nonverbal
children)
Faces, Legs, Activity, Cry, and Consolability (FLACC)
PEDIATRIC PAIN SCALES: 3 years and older
Wong Baker Faces
Management of Pain
a. General principles of pain management
b. Re-assessment of pain
c. Consequences of Unrelieved Pain
a. General principles of pain management
WHO Analgesic Ladder
The WHO analgesic ladder is a 3 step algorithm
for the management of acute and chronic pain
Pain Non Opioid Mild Strong Adjuvant
Severity Analgesics Opioid Opioid Drugs
Step I Mild - - If Required
Step II Moderate - If Required
Step III Severe - If Required
Pharmacological Agents
Analgesic Mechanism of action Examples
Medication
Non Opioid Inhibit activity of COX-1 Aspirin, Ibuprofen,
and/or COX-2 thus decreasing Naproxen, Etodolac,
the production of Meloxicam, Piroxicam,
prostaglandins. and Acetaminophen
Opioids Act by binding to μ- opioid Morphine, Codeine,
receptors in the brain Hydrocodone
Analgesic Mechanism of action Examples
Medication
Adjuvants
Antidepressants Block reuptake of serotonin Amitriptyline,
and Norepinephrine Nortriptyline,
Anticonvulsants Modulation of Ion channels Topiramate, Valproic
acid Carbamazepine,
Pregabalin
Muscle Relaxants Direct action on CNS Baclofen, Tizanidine
CNS and other unknown Methocarbamol,
mechanism Cyclobenzaprine,
Analgesic Mechanism of action Examples
Medication
Adjuvants
Topical Agents Block generation and Capsaicin (substance P),
transmission of nerve signals to Lidocaine (Na+ channel),
the brain through peripheral Diclofenac (NSAID),
actions
Non Pharmacologic Interventions
Non pharmacologic interventions should always be considered
in the treatment of pain. They may be used solely or in
combination with pharmacologic intervention.
Cognitive-behavioral interventions
Physical (Sensory) intervention
Cognitive-Behavioral Physical (Sensory) Interventions
Interventions Positioning
Psychologic preparation, education, Cutaneous stimulation
information Nonnutritive sucking, sucrose
Distraction (passive or active): Pressure
Video games, TV, movies,
Hot or cold treatments
Relaxation techniques
Music
Guided imagery
Training and coaching
Coping statements: “I can do this”
b. Re-assessment of Pain
Timely reassessment of pain is essential. One of the most
common mistakes made in pain management is failure of
reassessment after an intervention.
Pain level should be reassessed after an intervention, such
as medication administration, and once the intervention has
had time to exert its effect.
The same scale or scoring system used previously should
be used on reassessment for consistency.
Appropriate monitoring for respiratory depression should
be used especially when using pain relievers with sedating
effects (opioids).
The timeframe and frequency for re-assessment will
depend on the setting.
- consider reassessing pain level 15 - 30 minutes
after parenteral administration and 60 minutes after
PO administration of a medication.
c. Consequences of Unrelieved Pain
Psychological Impacts - The psychological impact of
untreated pain can include post-traumatic stress disorder,
anxiety, catastrophizing, and depression.
Chronic pain syndromes - Chronic pain syndromes can
develop as a consequence of untreated acute pain
mechanisms including spinal cord hyper-excitability.
Mortality and Morbidity - Increased mortality and
morbidity can result from unrelieved acute pain. This can
occur through increased oxygen demand, increased
metabolic rate, cardiovascular and pulmonary
complications, and impaired immune function.
Thank You
