Pain Assessment And Management
TERMINAL LEARNING OBJECTIVE
Given the necessary medical equipment, identify procedures for pain assessment and management.
INTRODUCTION
Pain is present whenever a person says it is, even when no specific cause of the pain can be found. Pain is an individual, subjective symptom. Health care providers must rely on the patient’s description of his/her pain. As a soldier medic, you will play an integral role in the management of your patient’s pain. You must become proficient in the accurate assessment, treatment, and documentation of the pain experience
a. Pain is the body’s defense mechanism that indicates the person is experiencing a problem.
b. Classic definition of pain: Pain is an abstract concept which refers to a personal, private sensation of hurt, a harmful stimulus which signals current or impending tissue damage, and a pattern of responses which operate to protect the organism.
c. Leading nursing definition: Pain is whatever the experiencing person says it is, existing whenever he/she says it does.
a. Physical Origin
(1) Cutaneous pain
(a) Superficial, usually involves the skin or subcutaneous tissue
(b) Example - A paper cut that produces sharp pain with a burning sensation
(2) Somatic pain
(a) Diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves
(b) Example - Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain
(3) Visceral pain
(a) Poorly localized and originates in body organs (thorax, cranium, abdomen)
(b) Visceral pain usually presents as referred pain, which is perceived in an area distant from the point of origin
(c) Example - Pain associated with a myocardial infarction is frequently referred to the neck, shoulder, or left arm
b. Psychogenic pain
(1) Physical cause for the pain cannot be identified
(2) Pain can be just as intense as pain that results from a physical origin
a. Physiologic (involuntary)
(1) Sympathetic response- moderate and superficial
(a) Increased blood pressure, pulse, and respirations
(b) Pupil dilation
(c) Muscle tension and rigidity
(d) Pallor
(e) Increased glucose
(2) Parasympathetic response to severe and deep pain
(a) Nausea and vomiting
(b) Fainting and unconsciousness
(c) Decreased blood pressure
(d) Decreased pulse rate
(e) Rapid and irregular breathing
b. Behavioral
(1) Moving away from painful stimuli
(2) Grimacing, moaning, and crying
(3) Restlessness
(4) Protecting the painful area and refusing to move
c.
Affective
(1) Examples - exaggerated weeping and restlessness, withdrawal, anxiety, depression, and fear
(2) Person’s past experience with pain and sociocultural background play an important role in emotional responses to pain
(3) Emotions tend to intensify the reactions to pain
(4) Explains why similar circumstances causes a different pain responses in different groups of people
d. Acute Versus Chronic Pain
(1) Acute pain
(a) Generally rapid onset
(b) Varies in intensity from mild to severe
(c) May last for a brief period up to a period of 6 months
(d) Protective in nature, warns of tissue damage or organic disease
(e) Once underlying cause is resolved, pain disappears
(f) Examples - pricked finger, sore throat, post surgical pain
(2) Chronic pain
(a) Last 6 months or longer and interferes with normal functioning
(b) May be limited, intermittent or persistent
Factors Affecting the Pain Experience
a. Culture
(1) Cultures vary in what is an acceptable response to pain
(2) An assessment of the cultural influences of:
(a) The meaning of the pain event
(b) Ways in which patient choose to demonstrate and cope with the pain experience
(c) Responsibilities in pain relief
b. Religion
(1) Religion can effect patient’s views on their pain experience
(2) Some see pain as a purifying experience. This becomes a sense of strength for them. these patients might refuse pain medications.
(3) Pain might be viewed as a punishment from God. These patients might become angry and resentful.
c. Anxiety and other stressors
(1) Anxiety leads to muscle tension and fatigue which can also increase pain intensity
(2) Factors which may increase anxiety
(a) Strange environment in the hospital
(b) Support people not available
(c) Fear of the unknown
d. Past pain experience
(1) Whether the patient has experienced pain in the past and qualities of that experience profoundly affect new pain experiences
(2) Some patients have never known severe pain and have no fear of pain. Patients who have had severe pain without adequate pain relief may have an increase sensitivity to pain
Components of Pain Assessment
a. Characteristics of pain (PQRST)
(1) Palliative / Provocative factors of pain
(a) Aggravating factors
1) Question the patient on what makes the pain increase
2) Example - "Does your pain become worse upon exertion?"
(b) Alleviating factors
1) Ask patient to describe what makes pain go away or lessen.
2) Determine what pain relief methods have worked in the past. For how long these pain relief methods used?
(2) Quality of pain
(a) Encourage the patient to describe his/her pain
(b) Examples - sharp, stabbing, pressure, dull, aching
(3) Radiation (Location) of pain
(a) Instruct the patient to point the area of pain. Patients with chronic or visceral pain might have difficulty localizing specific area.
(b) Clearly document areas of pain. Utilize a diagram of the body to be more specific if needed.
(4) Severity of pain
(a) Since pain is subjective, it is very important to have patients rate the pain they are experiencing. This becomes extremely important when assessing the effectiveness of pain medications.
(b) Various scales may be used. One example is a 0-10 scale
0 No Pain
1
2 Mild Pain
3
4
5 Moderate Pain
6
7 Severe Pain
8
9
10 As bad as it can be Pain
(c) Ask patient to rate pain at various stages
1) At its worse
2) At its least
3) After pain medication
(5) Time of pain
(a) Duration
1) Ask how long the patient has been experiencing the pain
2) If pain is intermittent, ask how long the pain lasts and how often does pain occur
(b) Chronology
1) Have the patient describe how the pain first began
2) Question if the pain has change since the onset
3) Identify if the pain is worsening or improving
4) Is the pain intermittent or constant?
(6) Associated phenomena
(a) Identify if there were any factors that seem to relate consistently to the pain
(b) Examples - Increased anxiety before pain begins
b. Physiological responses
(1) Sympathetic stimulation – occur with acute pain
(2) Parasympathetic stimulation - with prolonged severe pain
(3) Responses to watch - Vital signs, skin color, perspiration, pupil size, nausea, muscle tension, anxiety
c. Behavioral Responses
(1) Posture, gross motor activities
(a) Assess if the patient guards an area
(b) Does the patient make frequent position changes?
(c) Posture and gross motor activities increased in acute pain, might be absent with chronic pain
(2) Facial features - Does the patient have a pinched look? Are there facial grimaces? Look of fatigue?
(3) Verbal expression - Does patient sigh, moan, scream, cry, repeat same words?
Methods Used in the Relief of Pain
a. Non-pharmacologic relief measures
(1) Distraction
(a) Techniques for distraction
1) Visual - Staring at an object or spot and describing it in detail, reading or watching television
2) Auditory - listening to music
3) Tactile/Kinesthetic – Holding or stroking a loved one, pet, or toy, rocking back and forth, slow breathing
4) Project Distraction – Playing a games, creative work, writing in a journal
(b) Requires the patient to focus on something other than the pain
(c) Best used before the pain starts or becomes moderate to severe. Is not to be used as the only intervention for severe pain. Can be used as adjuvant treatment.
(2) Imagery – example of mind-body interaction-concentrates on an image that involves one or all of the senses , gradually becomes less aware of the pain. Does not work as the only intervention for severe pain.
(3) Relaxation - techniques to relieve anxiety and reduce stress. Includes listening to music while taking slow deep breaths and consciously relaxing each muscle group. Should be utilized early in the pain experience. Patient should practice technique.
b. Pharmacologic
(1) Non-narcotic analgesics (aspirin, Tylenol, NSAIDS)
(a) Used for mild to moderate pain
(b) Works best on muscle and joint pain.
(c) Produces analgesia at the peripheral nervous system.
(d) Major Side-effects - Nausea, vomiting, increased bleeding tendencies.
(2) Narcotic analgesic (morphine, codiene, demerol)
(a) Used for severe pain.
(b) In sufficient dose, considered capable of relieving pain, in most cases
(c) Analgesia produced at the central nervous system
(d) Major side-effect - Respiratory depression, sedation and addiction
(3) Other medications (antidepressants, anticonvulsants)
(a) Used usually in combination with opioids especially when there is a neurologic component as one of the causes of the pain.
(b) Mechanism of action not clearly understood, may block pain transmission or may suppress abnormal nerve endings from injury to nerve tissue (anticonvulsant).
a. Obtain a thorough baseline pain assessment
b. Assess pt’s beliefs and misconceptions regarding pain management
c. Provide patient education regarding pain management regime
(1) Assure the patient that every step will be taken to treat their pain effectively. Do not let the patient think he/she is being left alone to DEAL with the pain.
(2) Correct any misconceptions regarding pain medication that the patient might have. Reinforce information regarding newly prescribed medication.
d. In the hospitalized patient, document the patient’s response to the pain medication. This is very important for the ongoing accurate assessment of the patient’s pain.
e. When administering narcotic analgesia, monitor for signs and symptoms of overdose, especially respiratory depression and severe sedation. Obtain baseline respirations before administering medication.
f. Inform health care team if pain management regime is not effective
SUMMARY
The role of the 91W soldier medic in the management of pain is crucial. The bedside care provider is the eyes and ears of the health care team. As a soldier medic, you will provide care for patients in pain daily. These patients will look to you for relief. You must learn the importance of an accurate initial and ongoing assessment of pain. You must recognize the signs of inadequate pain therapy. Remember, although not all pain can be completely, all pain can be reduced to an acceptable level for the patient.