Hi class, this is Professor Williams and today we're going to be going over our pain assessment. So neuroanatomic pathway. So pain is originated from the central nervous system and or the peripheral nervous system.
It is a subjective experience and specialized in nerve endings called nociceptors. Nociceptors are located within the skin, joints, connective tissues, muscles, and thoracic, abdominal, and pelvic. visceral. These pain receptors develop when functioning and intact nerve fibers in the periphery and CNS are stimulated.
So we can see in this picture here, we have a patient who has an inflamed appendix. So there's visceral sensory nerve stimulation and somatic sensory nerve stimulation. Patient is feeling some kind of pain on that right lower quadrant area.
So those impulses are sent to the spinal cord and then they shoot up into the brain and that's where the pain is interpreted. at that time. Nociceptors.
They can be divided into four phases. First is the transduction phase. This phase occurs when there is a noxious stimulus in the form of a traumatic or chemical injury, burn, incision, or tumor that takes place in the periphery.
Neurotransmitters carry the pain impulse across the nerve fiber. Next is the transmission phase. The pain impulses move from the level of the spinal cord to the brain. Then we have the perception phase.
In this phase, we become consciously aware of the painful sensation. And lastly is the modulation phase. The pain message is then inhibited and neurotransmitters release serotonin, norepinephrine, GABA, and other endogenous opioids to help inhibit and block the impulse.
In this phase, we process the pain as a warning signal. that an injury is about to or has taken place. We quickly learn to move our hand away from the hot stove, for example.
Nociceptors are predictable and limited to the injury. Neuropathic pain. This type of pain does not adhere to the typical or rather predictable phase, such as a nociceptive pain. It is pain caused by a lesion or disease in the somatosensory nervous system.
Neuropathic pain and pulses are abnormal and process from the injury to the nerve fiber. This type of pain is the most difficult to assess. The pain usually evolves into a chronic condition. Conditions that can cause neuropathic pain include diabetes, shingles, HIV or AIDS, sciatica, phantom limb pain, and chemotherapy. There are several sources of pain.
We have four that we're going to discuss. So visceral pain is originated in the larger internal organs, such as the stomach, intestines, bladder, or pancreas. It is described as dull, deep, squeezing, or cramping.
The pain can be caused by direct injury to the organ or stretching of the organ from a tumor, ischemia, extension, or severe contraction. Somatic pain, on the other hand, originates from the muscles, skeletal system with the tissues and other body surfaces. Deep somatic pain comes from the sources below, such as the deep vessels, joints, tendons, muscles, and bones.
Pain may be caused by pressure, trauma, or ischemia, and is often described as aching or throbbing. Cutaneous pain is pain from the top of the surface, which is the skin, and subcutaneous tissue, which is below. This pain is described as superficial, sharp, or burning.
Referred pain is pain that is at a particular site but originates from another location. Both sides are innervated by the same spinal nerve, so it is difficult for the brain to differentiate the point of origin. Referred pain may originate from visceral or somatic structures.
For example, if you have an inflamed appendix in the right lower quadrant of the abdomen, a patient might have referred pain. either in the pre-umbilical area or even the left lower quadrant. Another example is if you're taking care of a patient who has chest pain, they might have referred pain to their left arm or even crawling up into the left side of the neck. There are two types of pain. There's acute and chronic.
Acute pain is short and self-limiting. It is often followed by a predictable trajectory and dissipates after the injury has healed. An example of acute pain includes surgery, trauma, or a kidney stone. So on the slide here, acute pain is a protective mechanism that alerts the individual to a condition or experience that is immediately harmful to the body.
So the onset is sudden. With chronic pain, on the other hand, this is diagnosed when a patient continues to have pain for six months or longer. There's two different types of chronic pain. There's malignant or non-malignant. For malignant pain, the pain is induced by a...
tissue that is necrotic and there can be stretching of the organ due to the growth of the tumor. It tends to fluctuate with the course of the disease. Chronic non-malignant pain is often associated with muscle skeletal issues, such as arthritis, low back pain, fibromyalgia, and chronic pain is difficult to treat.
Opium medications are often discouraged because this increases the risk for the dependency of long-term use. So with chronic pain here in this on the slide, it is persistent or intermittent, usually defined as lasting at least six months. So we have to be really careful when we're assessing our pain levels on these patients who have chronic pain. We have to differentiate if they're just at the hospital seeking for pain medications because they might be addicted or they're really having these chronic pains and they're gaining a tolerance. So it's important to do a really good interview when you're assessing the patient's pain.
in their history and what they have taken at home, what helps them, what doesn't, what non-pharmacological interventions they are taking at home. Example for ice, heat, exercise, physical therapy, and things like that. So the aging adult.
So pain is not a normal process of aging. Unfortunately, many healthcare providers and older adults wrongfully assume that pain should be expected in aging. which leads to under-reporting of pain and less aggressive treatment. Older adults may have additional fears about becoming dependent on pain meds, undergoing invasive procedures, and have financial burdens with doctor visits and costs of taking all these medications and getting refills.
The most common pain-producing conditions for aging adults include osteoarthritis, osteoporosis, peripheral vascular disease, cancer, peripheral neuropathies, angina, and chronic illnesses such as diabetes because it can lead to diabetic neuropathy. It could be difficult to assess the pain level of a patient who has dementia. You can assess the body language, of course, instead of using their verbal communication.
With dementia, they're going to have a lot of scattered thoughts. So really hone into the nonverbal communication on what they're exhibiting. For example, You might see that the patient might have their fist clenched or extremely agitated.
There are a lot of pain assessment tools that we can use on patients who have dementia. So we have to make sure that we're looking through those tools that the hospital or clinic has in their protocols and utilizing them so that we're making accurate pain assessments and monitoring them when we do provide an intervention if their pain has decreased. or increase based off of their nonverbal cues.
When you look for behavioral cues, look at changes in functional status. Observe for changes in dressing, walking, toileting, or involvement in activities. A slowness and rigidity may develop and fatigue may occur. Look for a sudden onset of acute confusion, which may indicate poorly controlled pain.
So our subjective versus objective data. Remember that subjective data is what the patient is telling you. So we want to make sure that we're doing a really good interview on the patient's pain level so that we can understand where their pain level is and initiate a treatment modality to help reduce the pain level that is tolerable for them. We want to make sure that we use the PQRST method of pain assessment. So on the slide here, we see P is indicated.
for provocation or palliation. Q is quality. R is region or radiation. S is severity, signs, and symptoms. And T is time of onset, duration, and intensity.
Please make sure that you are looking at page 169 on your Jarvis textbooks. It's table 11.1. You can see a better breakdown of how to use that and what kind of questions. that you can ask the patients based off the PQRST pain assessment tool. For example, when we ask a patient about their pain, we can say, do you have pain?
Where is your pain located? When did your pain start? What does your pain feel like? How much pain do you have right now?
What makes your pain better? What makes your pain worse? How does your pain limit your function or activities? How do you usually react when you have pain? And what does this pain mean to you?
Objective data. So objective data is what you see. And this is really helpful for patients who are in a state you're taking care of someone in the ICU who's sedated.
We can look at their vital signs. Usually they're hypertensive, they're tachycardic, their respiratory rate might be elevated. So these are all cues that we can see that is objective data to help assess whether or not that patient might need some more pain medication. Also, when you're taking care of a patient who might have brain bleed, and you can look at other cues on the monitors, like their ICP level might increase. So making sure that you're not only looking at the patient, but you can also look at the monitors too, to get the objective data and also what you're seeing as well.
A patient could be diaphoretic or they can be pale. They could be nauseous, even vomiting, shaking, clenched fists. So these are all really good information for us as nurses to use and how we can intervene to help bring down their pain levels.
Pain assessment tool. The most common pain assessment tool that we use in the hospital is an American pain intensity scale. And we can see that on the picture here. This is where we have the patient rate their pain from zero to 10, 10 being the worst pain that you can ever think of and zero being no pain.
We can also use the faces for patients to help determine what their pain level is as well. So the numeric is really good because, you know, it's Basic, same with the faces as well. Faces is used typically for pediatric patients, but can also be used for any age. And remember when you're asking the patient, zero is no pain. 10 is the worst imaginable pain you can ever think of.
Cutting limbs, like in labor, severe pain. Where do you fall? Because you want to get a baseline.
And then when you provide... um, an intervention you want to reassess, right? So say if their pain is at a seven and you give, um, Tylenol and it drops down to five, you're documenting that and keeping an eye on, um, how you can keep it within the patient's comfort level.
Say for example, they're at a level seven and then you ask the patient, well, what are you taller about? What's your pain level that you can be tall? Oh, maybe like a three to five and you get there to five.
So, um, it's a good baseline time. And also is well documented so that we can make sure that we're staying on top of their patients'pain levels and bringing them down. One quick thing I do want to mention are nonverbal behaviors of pain. So acute pain behaviors, the patients with acute pain, they might have guarding, grimacing, vocalizing. Oh, I'm in so much pain.
They're moaning. They're agitated, restless, even some stillness. They'll be really quiet. They will be sweating and also have changes in their vital signs like what we talked about.
Chronic pain behaviors. So patients with chronic pain typically have little indication that they are in any pain and therefore are at higher risk for under detection. Behaviors associated with chronic pain include bracing, rubbing, diminished activity, changes in appetite.
So this concludes our pain assessment. I do want you all to make sure you're looking at page 178, table 11.3. It's a great chart on the summary of the different types of pains.
And we'll talk more about our assessment in regards to pain in class and in lab.