Assessment of Pain - NURS 1090

Assessment of Pain NURS 1090 Concepts and Unit Outcomes COMFORT Identify principles of pain assessment. List basic pharmacological and non-pharmacological interventions for pain.  What is Pain? Pain is an unpleasant sensory and emotional experience associated with actual or potenti...

Assessment of Pain NURS 1090 Concepts and Unit Outcomes COMFORT Identify principles of pain assessment. List basic pharmacological and non-pharmacological interventions for pain.  What is Pain? Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. (International Association for the Study of Pain) Pain is whatever the experiencing person says it is and exists whenever the client says it exists (McCaffery.) Nature of Pain Involves physical, emotional, and cognitive components Results from physical and/or mental stimulus Reduces quality of life Not measurable objectively Subjective and highly individualized component  Pathophysiology of Pain Pain triggered by the Peripheral Nervous System (PNS) Two types of neurons in PNS Sensory receptors (nociceptors) – respond to pain Send a signal along the sensory neurons to the spinal cord Signal is transmitted to the brain for interpretation Motor - Signal then sent from the brain back to the site of pain via the motor neuron Now the body will respond to the painful stimulus This process happens very quickly Subjective experience is an important part Physiology of Pain Categories of pain stimuli from external factors that activate nociceptors: ◦ Biological: bacteria, viruses ◦ Mechanical: shearing forces, fractures ◦ Thermal: burns, frostbite ◦ Electrical: electrical burn, shock ◦ Chemical: cleaning solutions, tobacco smoke  Physiology of Pain Categories of pain stimuli from cellular injury: ◦ Triggers the release of biochemicals that stimulate nociceptors ◦ Prostaglandins, bradykinin, histamine ◦ These inflammatory biochemicals act to stimulate the pain neurons (nociceptors) Physiolog y of Pain Pain Transmission  Pain Classifications NOCIOCEPTIVE NEUROPATHIC Results from external stimuli on Caused by nerve malfunction or an uninjured, fully functioning injuries resulting from trauma, disease, chemicals, infections, and nervous system tumors Usually throbbing, aching, and This type of pain is usually intense, localized shooting, burning When injury is treated or healed, “pins and needles” the pain generally resolves Nociceptive pain can be magnified in the presence of neuropathic pain  Types of Pain ACUTE CHRONIC Usually, sudden onset Ongoing or recurs frequently Temporary, usually self-limiting and Physiological responses are not resolves with tissue healing usually altered Physiological responses: SNS signs and symptoms May not respond well to interventions May see grimacing, moaning, flinching, guarding Management aimed at symptomatic relief Interventions include treatment of the underlying cause  Categories of Acute Pain Somatic Originates from nociceptors in the skin and musculoskeletal tissue Sharp Responds well to mild analgesics Visceral Originates from internal organs and linings of body cavities (stomach, intestines) Dull, deep, aching Responds best to opioid treatment Referred Sensed in a region other than the site of origin  Pain Assessment The frequency of pain Pain management is best assessment is determined by achieved by a team the severity and stability of the Pain can be assessed when vital approach: patient, family, pain, the underlying condition signs are taken and healthcare providers (s), and the patient’s activities and treatments As part of client teaching when discomfort is anticipated as During emergency department Pain is whatever the part of a disease process or visits and at the time of experiencing person says it is procedure admission to a health care and exists whenever the client facility. Gather baseline data before says it exists (McCaffery.) the pain starts  At regular intervals after initiation of a treatment (Example: radiation therapy) Pain At each new report of pain or report of Assessment, a change in the pain cont. At a suitable interval after administration of pharmacological/non- pharmacological intervention  Pain assessment: Specific pain history Nursing history Physical exam Assess patient presentation Getting movement, posture, facial expressions, hygiene Started with Patient Profile and Chief Complaint Pain Assessment Past medical/surgical history: (obtained with the initial nursing history cont Allergies Past Pain Experiences Note past illnesses and conditions and discomfort associated with them How long did the pain last? What interventions helped?  Physiological: Age Fatigue Genetic sensitivity Neurological and cognitive function Psychosocial Factors Spirituality/Religion Influencing Attitudes toward pain and suffering Pain Language Home Environment Work environment and schedule Excessive fatigue? Ability to maintain employment?  Assessment of Pain May have to get Location descriptions from others if Intensity client is non-verbal or in too ◦ Pain intensity scales much pain to talk Quality ◦ Is this a new pain or a change in an existing pain? Onset, duration and recurrence Visual assessment of pain: facial ◦ Familiar vs unfamiliar expressions/mood and affect ◦ Grimacing, crying, posture changes, movement  Other Descriptions ◦ Movement and Non-Verbal Body Language ◦ Restlessness or thrashing around ◦ Inability to assume a position for any length of time or at all (example: sitting) ◦ Frozen – unable or unwilling to move ◦ Guarding or favoring a body part ◦ Gait or posture changes ◦ Limited ROM of an extremity ◦ Facial grimacing ◦ Crying, moaning Assessment of Pain, cont ◦ Precipitating factors ◦ Alleviating factors ◦ Associated symptoms ◦ Effects of pain Vital signs: fluctuations may indicate pain increase or decrease ◦ What changes would you expect for a patient in pain?  Causes for Error in Pain Assessment Nurse-related attitudes, misconceptions, and preconceptions: ◦ Ideas about how a patient should be feeling ◦ Concerns about over-medication ◦ Cultural or age-related variations in pain expression may be misinterpreted ◦ Concern with addiction  Concerns with Addiction Addiction: An overwhelming preoccupation with obtaining and using a substance for non-therapeutic purposes ◦ Not common with short term use of pain medications Tolerance: over time, larger amounts of a medication are needed to achieve the same effect ◦ This is not addiction Not all concerns about overmedication with opioids are unfounded ◦ Highest rate of unintentional overdose deaths is in the 35 – 44 age range ◦ Ohio has one of the higher overdose rates in the country—5397 deaths in 2022 ◦ Us total 2022: 109,000  Many older adults have conditions associated with chronic pain Physiological changes of aging affect perception of pain Pain and the Older Evidence shows: Adult Pain is under detected and poorly managed Cognitive impairment contributes to the patient’s inability to report pain There are no absolute physical assessments or lab tests to detect the presence of pain  Barriers to Pain Management: Older Adult Inadequate knowledge of healthcare providers ◦ Pain is a natural outcome of aging ◦ Pain perception or sensitivity decreases with age ◦ Patients will report more pain as they age. ◦ If pain is not reported, it must mean he/she does not have pain ◦ If patient appears to be occupied, sleeping, or distracted, he/she must not have pain. ◦ Potential side effects of opioids make them too dangerous to use. ◦ Fear of opioid dependence ◦ Patients with cognitive impairments do not feel pain and/or their reports of pain are not reliable. **Undertreated pain is serious ◦ May lead to increased anxiety with acute pain and depression with chronic pain  Pain Management: Older Adult Pain can potentially cause serious impairment in functional status ◦ How can it impact mobility, ADLs, social activities, activity tolerance? Main goal is to maximize function and quality of life by minimizing pain whenever possible REMEMBER: Absence of a particular facial expression or behavior does not necessarily indicate that the individual does not have pain There is no such thing as “normal” pain – it is individual to each patient ASKING about pain at regular and frequent intervals is an important assessment strategy  Nonpharmacological Interventions for Pain Management Distraction ◦ Ambulation, visitors, deep breathing, TV, music Cutaneous stimulation ◦ Heat, Cold Relaxation ◦ Repositioning, meditation, yoga Imagery ◦ Focusing on pleasant thoughts Reduce stimulation in the environment Physical therapies to reduce physical pain: ex: TENS, PT, Heat/Cold Psychological therapies to help change patient’s perception of pain and improve coping: ex: relaxation, guided imagery, distraction  Pharmacological Interventions Analgesics Co-analgesics: provide analgesia and/or enhance the effects of the Non-opioids: mild to moderate other medications intermittent pain ◦ Anticonvulsants ◦ Acetaminophen, NSAIDs ◦ Antianxiety Opioids: moderate to severe pain ◦ Antidepressants ◦ morphine, fentanyl, hydromorphone ◦ Antiemetics (Dilaudid), oxycontin, oxycodone 4. Medications can be administered: PRN (as needed), scheduled, patient-controlled  Pharmacological Interventions: Older Adult Many factors need to be taken into consideration ◦ Co-morbities ◦ Use of multiple medications ◦ Drug to drug interactions ◦ May have variability in drug absorption, metabolism, and excretion ◦ Reduced effect of pain medication ◦ Amplified effect (increased side effects) Medications to avoid or use cautiously in the older adult due to ineffectiveness or high risk for side effects ◦ meperidine (Demerol) ◦ ketorolac (Toradol) ◦ pentazocine (Talwin) ◦ All can cause confusion, hallucinations, ineffective