Pain Assessment
DSN
Kevin Dobi, MS, APRN
Copyright © 2013 by Mosby, an imprint
of Elsevier Inc.
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Pain relief is primary responsibility of all health care
providers.
Assessing patient’s pain is first step in achieving goal of
pain relief.
Pain assessment and management often referred to as
fifth vital sign.
Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage.
One person cannot judge perception or meaning of pain
of another person.
No correlation between amount of tissue damage and
degree or intensity of pain.
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Any cause of reduced perfusion interrupts oxygen
supplied to tissues and can lead to impaired integrity.
Pain:
 Reduces mobility.
 Impairs sleep.
 Contributes to loss of appetite.
Narcotics change elimination pattern.
Understanding of the interrelationship helps the nurse
recognize risk factors.
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Perception of pain is influenced by cognitive and
cultural factors:
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Patient’s previous experiences with pain and current
physical and mental status affect pain perception and
response.
Cognitive factors:
Attention people give to the pain.
 Expectation or anticipation of pain.
 Appraisal or expression of pain.
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Cultural factors:
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Cultural influences may affect how pain is
communicated.
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of Elsevier Inc.
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Pain is categorized in several ways, but clear
distinctions among types may not be possible.
Acute pain has recent onset and results from tissue
damage, is usually self-limiting, and ends when tissue
heals.
 May cause physiologic signs associated with pain.
Persistent (chronic) pain may be intermittent or
continuous pain lasting more than 6 months.
 Clinical manifestations of chronic pain are not those
of physiologic stress because patient adapts to pain,
but often reports symptoms of irritability,
depression, withdrawal, or insomnia.
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Nociceptive pain:
Arises from somatic structures such as bone, joint, or
muscle.
 Results from activation of normal neural systems.
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Neuropathic pain:
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Occurs because of abnormal processing of sensory input.
Referred pain:
Pain felt in a location away from the injury.
 Often visceral pain, as many abdominal organs have no
pain receptors.
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Phantom pain:
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Pain felt in an amputated extremity.
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The Joint Commission standards assert that patients
have a right to appropriate assessment and
management of pain, including the following:
 Pain is assessed in all patients.
 Initial assessment and regular reassessment of pain,
taking into account personal, cultural, spiritual, and
ethnic beliefs.
 Education of all relevant providers in pain
assessment and management.
 Education of patients and families regarding roles in
managing pain and potential limitations and side
effects of pain treatments.
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Physiology of pain involves journey:
 Transduction from site of stimulation of peripheral
receptors to spinal cord.
 Transmission up spinal cord.
 Perception at cerebral cortex.
 Modulation back down spinal cord.
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The pain process begins with response of nociceptors
to noxious stimuli.
 Nociceptors are primary sensory nerves located in:
 Tendons
 Muscles
 Subcutaneous tissue
 Epidermis
 Skeletal muscles
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Sensory peripheral nerves are stimulated.
 Sensory nerve fibers carry pain impulses:
• Large A-Delta fibers – associated with sharp, pricking,
acute, well localized pain of short duration.
• Small C fibers – associated with dull, aching, throbbing,
or burning sensations.
 Initiate an action potential that travels along peripheral
nerves to the dorsal horn of the spinal cord:
• Substantia Gelatinosa – “The gate” is opened.
• Pain impulses enter spinal cord and ascend through
spinothalamic tract to thalamus.
• Pain is perceived.
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Thalamus receives impulses from spinothalamic tract:
 Impulses travel to parietal lobe in cerebral cortex and
to limbic system.
 When impulses reach parietal lobe, patient feels
pain.
 Although journey takes a fraction of a second, no
pain is perceived until parietal lobe is stimulated.
 Stimulation of limbic system generates emotional
response to pain:
 Crying
 Anger
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Pain journey ends when body produces substances to reduce
pain perception:
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Release of substances that inhibit transmission of noxious stimuli
and produce analgesia:
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As sensory nerve fibers travel to brainstem, they stimulate nerves
that inhibit nociceptor stimuli.
Descending fibers start in brainstem and travel down the dorsal
horn of the spinal cord.
Endogenous opioids, e.g., endorphins and enkephalins
Serotonin (5HT)
Norepinephrine (NE)
Gamma-aminobutyric acid (GABA)
These substances occupy the receptors sites, which prevent A
and C nerve fibers from opening “the gate.”
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Concepts of pain threshold and pain tolerance affect
patient’s pain experience.
 Pain threshold is point at which a stimulus is perceived as
pain.
 This threshold does not vary significantly among
people or in same person over time.
 Pain tolerance is duration or intensity of pain a person
will endure before outwardly responding.
 Pain tolerance decreases with repeated exposure to
pain, fatigue, anger, boredom, and sleep deprivation.
 Tolerance increases after alcohol consumption,
medications, hypnosis, warmth, distracting activities,
and strong faith-related beliefs.
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Do you have any chronic illnesses? If so, do they cause
you pain?
 Describe
Do you take any medications?
 What, and how often?
 Do they relieve your pain?
 Are you allergic to any medications?
 What kind of allergic reaction occurs from these
medications?
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Pain is a complex, multidimensional, subjective
experience
Collect data from patients using a symptom analysis
applying the mnemonic OLD CARTS
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O = Onset
L = Location
D = Duration
C = Characteristics
A = Aggravating factors
R = Related symptoms
T = Treatment by the patient
S = Severity
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Do you communicate your pain verbally or
nonverbally?
 Be aware of cultural influences of pain:
 Overt pain expression
 Stoicism
 Silence
 Smiling
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Location:
 Where is your pain? Point to location(s).
Quality:
 Describe what the pain feels like.
Quantity:
 How would you describe intensity, strength, or
severity of the pain on a scale of 0 to 10, with 0 being
no pain and 10 being most intense pain possible?
 At what point on this scale of 0 to 10 do you usually
take medication for your pain?
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Onset:
 When does the pain occur?
 During activity?
 Before or after eating?
Does the pain occur suddenly or gradually?
What do you think is causing your pain?
 Why do you think the pain started when it did?
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Location:
 Where do you feel pain?
 Can you point to the location(s)?
Duration:
 How long do you feel the pain?
 Is it constant or intermittent?
 How often does it occur?
 How long does it last?
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Can you describe what the pain feels like?
Aggravating factors:
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What makes the pain worse?
Related symptoms:
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What other symptoms do you have during pain?
 Palpitations
 Shortness of breath
 Sweating
 Rapid or irregular heartbeat
 Nausea or vomiting
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Have you tried to relieve the pain?
 How effective have these measures been?
 What medications did you take, and in what
amounts?
 Have you considered alternative methods?
 Massage
 Mind-body medicine
 Lifestyle changes
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How much pain are you expecting?
 Cultural beliefs may affect expectations.
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How would you describe your pain?
 On a scale of 0 to 10, with 0 being no pain and 10
being the worst pain possible, describe:
 Intensity
 Strength
 Severity
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At which point on this 0 to 10 scale do you usually
want to take your pain medicine?
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How do you react to pain?
 How do you express your pain?
 What do you fear most about the pain?
 What problems does your pain cause you?
Does your pain have any particular meaning to you?
 Spiritual
 Psychological
Do you have any concerns about taking pain relief?
Has the pain affected your quality of life?
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After taking the medication, how would rate your
pain now?
 30 minutes after parenteral administration.
 60 minutes after oral administration.
Assessing those who cannot communicate:
 Attempt self-report.
 Search for potential causes of pain.
 Observe for behavioral changes.
 Question caregivers about patient’s usual response
to pain.
 Attempt analgesic trial and observe behavior.
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Observe patient for posture and behavior that helps
relieve pain.
Observe facial expressions.
Listen for sounds made by patient.
Inspect skin for color, temperature, moisture.
Measure blood pressure and pulse.
Assess respiratory rate and pattern.
Observe pupillary size and reaction to light.
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Nurses find different responses to pain depending on
age of patient.
Neonate responses to pain are global, evidenced by
increased heart rate, hypertension, pallor, sweating,
and decreased oxygenation saturation.
Young children have difficulty understanding pain but
have a basic ability to describe pain and location.
School-age children better understand pain and are
able to describe pain location.
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Although transmission and perception of pain may
have slowed down in older person, pain is felt no
differently than by any other adult.
Many older adults have a lifetime of experience in
coping with pain, but pain is not an expected part of
aging.
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Initiation of intravenous access can be a painful experience
for the patient. As the needle is inserted into skin, the
patient is calm. However, when the needle pierces the vein,
the patient pulls the hand away. The time that the person
endured the pain before outwardly responding is known
as:
A.
B.
C.
D.
Pain tolerance.
Pain intolerance.
Pain perception.
Pain threshold.
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Assessment of circulation, motion, and sensation is done
every 8 hours in a patient recovering from a laminectomy 3
days after surgery. The patient had the surgery for
consistent low back pain. Now on day 3, the patient has a
burning sensation on the lateral edge of the right foot. This
is best described as:
A.
B.
C.
D.
Cellulitis.
Nociceptive pain.
Fasciitis.
Neuropathic pain.
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