PAIN ASSESSMENT

The International Association for the Study of Pain (IASP) defines pain as an
unpleasant sensory and emotional experience, which we primarily associate with
tissue damage or describe in terms of such damage, or both.\
Pathophysiology of Pain
Pain is explained as a combination of physiologic phenomena in addition to a
psychosocial aspect that influences the perception of pain.
The pathophysiologic phenomenon of pain is summarized by the processes of
transduction, transmission, modulation, and perception.
1. Transduction
-Noxious stimuli(tissue injury) trigger the release of biochemical
mediators(e.g.,prostaglandins, bradykinin,serotonin, histamine, substance
P)that sensitize nociceptors.
-Noxious or painful stimulation also causes movement of ion across cel
membranes, which excites nociceptors.
-Pain medications can work during this phase by blocking the production of
prostaglandin(e.g.ibuprofen)or by decreasing the movement of ions across the
cell membrane(e.g.local anesthetic)
2. Transmission
-The second process of nociception, transmission of pain, includes three
segments.
-Pain control can take place during this second process of transmission. For
example,opioids(narcotics)block the release of neurotransmitters, particularly
substance P, which stops the pain at the spinal level.
First segment- Pain impulse travels from the peripheral nerve fibers to the
spinal cord. Substance P serves as the neurotransmitter, enhancing the
movement of impulses across the nerve synapse from the primary afferent
neuron to the second-order neuron in the dorsal horn of the spinal cord.Two
types of nociceptor fibers cause this transmission to the dorsal horn of the
spinal cord: C fibers which transmit dull, aching pain and A-delta fibers which
transmit sharp, localized pain.
Second Segment- Transmission from the spinal cord and ascension,via
spinothalamic tracts, to the brainstem and thalamus.
Third Segment- Involves transmission of signals between the thalamus to the
somatic sensory cortex where pain perception occurs.
3. Perception
-The third process is when the client become conscious of the pain.
-It is believed that pain perception occurs in the cortical structures, which
allows for different cognitive-behavioral strategies to be applied to reduce the
sensory and affective components of pain.
-For example, nonpharmacologic interventions such as distraction, guided
imagery, and music can help direct the clients attention away from the pain.
4.Modulation
-Often described as the descending system,this fourth process occurs when
neurons in the brainstem send signals back down to the dorsal horn of the spinal
cord. These descending fibers release substances such as endogenous opioids,
serotonin, and norepinephrine, which can inhibit the ascending noxious(painful
impulses in the dorsal horn.
Melzack and Wall in 1965 proposed the gate control model emphasizing the
importance of the central nervous system mechanisms of pain;this model has
influenced pain research and treatment.
CLASSIFICATION OF PAIN
1. Acute Pain
-usually associated with an injury with a recent onset and duration of less than 6
months and usually less than a month.

2. Chronic Non-malignant Pain

- usually associated with a specific cause or injury and is described as a constant
pain that persists more than 6 months.
3.Cancer Pain
-often due to the compression of peripheral nerves or meninges or from the damage to the
structures following surgery, chemotherapy, radiation, or tumor growth and infiltration
PHYSIOLOGIC RESPONSES TO PAIN
-Pain elicits stress response in the human body triggering the sympathetic nervous
system, resulting in physiologic responses such as the following:
Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide
Focus on pain, reports of pain, cries and moans, frowns and facial grimaces
Decrease in cognitive function, mental confusion, altered temperament, high
somatization, and dilated pupils
Increased heart rate, peripheral, systemic, and coronary vascular resistance, blood
pressure
Increased respiratory rate and sputum retention resulting in infection and
atelectasis
Decreased gastric and intestinal motility
Decreased urinary output resulting in urinary retention, fluid overload, depression
of all immune responses
Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone,
glucagons, decreased insulin, testosterone
Hyperglycemia. Glucose intolerance, insulin resistance, protein catabolism
Muscle spasm resulting in impaired muscle function and immobility, perspiration
FACTORS AFFECTING THE PAIN EXPERIENCE
1. Ethnic and Cultural Values
2. Developmental Stage
3. Environment and Support People
4. Past Pain Experiences
5. Meaning of Pain
6. Anxiety and Stress
HEALTH ASSESSMENT
1. COLLECTING SUBJECTIVE DATA
Pain is a subjective phenomenon and thus the main assessment lies in the clients
reporting. The clients description of pain is quoted. The exact words used to
describe the experience of pain are used to help in the diagnosis and management.
A. History of Present Illness
Use the COLDSPA mnemonic as a guideline to collect information. In addition
the following questions help elicit important information .
Character: Describe the pain in your own words. How does it feel, look sound, smell
and so forth?
Clients are quoted so that terms used to describe their pain may indicate the type and
source. The most common terms used are: throbbing, shooting, stabbing sharp,
cramping, gnawing, hot-burning, aching, heavy, tender, splitting, tiring-exhausting,
sickening, fearful, punishing.
Onset: When did the pain begin?
The onset of pain is an essential indicator for the severity of the situation and
suggests a source.
Location: Where is the pain located? Does it radiate or spread? The location of the
pain helps to identify the underlying cause.
Duration: How long does the pain lasts? Does it recur?Is the pain continuous or
intermittent?
Understanding the course of the pain provides a pattern that may help to determine
the source.
Severity: How bad is it?
To determine the degree of perceived pain.

Pattern: What factors relieve your pain? What factors increase your pain?
Identifying factors that relieve or increase pain helps to determine the source and the
plan of care.
Associated factors: Are there any concurrent symptoms accompanying the pain?
Accompanying symptoms also help to identify the possible source. For example, right
lower quadrant pain associated with nausea, vomiting and the inability to stand up
straight is possibly associated with appendicitis.
B. Past Health History
Have you had any previous experience with pain?
Past experiences of pain may shed light on the previous history of the client in
addition to possible positive or negative expectations of pain therapies.
C. Family History
Does any in your family experience pain?
To assess possible family-related perception or any past experiences with person
in pain.
How does pain affect your family?
To assess how much the pain is interfering with the clients family relations.
D. Lifestyle and Health Practices
What are your concerns about pain?
Identifying the clients fears and worries helps in prioritizing the plan of care and
providing adequate psychological support.
How does your pain interfere with the following?
-General Activity
-Mood/Emotions
-Concentration
-Physical Ability
-Work
-Relations with other people
-Sleep
-Appetite
-Enjoyment of life
These are the main lifestyle factors that pain interferes with. The more the pain
interferes with the clients ability to function in his/her daily activities, the more it will
reflect on the clients psychological status and thus the quality of life.
2. COLLECTING OBJECTIVE DATA:Physical Examination
Objective data are collected by using one of the pain assessment tools.
The main tool used are the Verbal Descriptor Scale(VDS), Wong-Baker Faces
Scale, Numeric Rating Scale(NRS) and Visual Analog Scale(VAS).
Verbal Descriptor Scale(VDS)
-Ranges pain on a scale between mild, moderate, and severe.
Wong-Baker Faces Scale(FACES)
-Shows different facial expression where the client is asked to choose the face
that best describes the intensity or level of pain being experienced;this works
well with pediatric clients.
Numeric Rating Scale(NRS)
-Rates pain on a scale from 0 to 10 where o reflects no pain and 10 reflects
pain at its worst.
Visual Analog Scale(VAS)
-Rates pain on a 10cm continuum numbered from 0 to 10 where 0 reflects no
pain and 10 reflects pain at its worst.
Physical Assessment(Patients with Pain)
General Observations
Inspection:
1.Observe posture.
-Client appears to be slumped with the shoulders not straight indicate being
disturbed or uncomfortable.

-Client is inattentive and agitated.

-Client might be guarding affected area and have breathing patterns reflecting
distress.
2. Observe facial expression.
-Clients facial expressions indicate distress and discomfort, including frowning,
moans, cries and grimacing.
-Eye contact is not maintained, indicating discomfort
3. Inspect joints and muscles.
-Edema of a joint may indicate injury.
-Pain may result in muscle tension.
4. Observe skin for scars, lesions, rashes, changes or discoloration.
-Bruising, wounds, or edema maybe the result of injuries or infections, which may
cause pain.
Vital Signs
Inspection
1. Measure heart rate.
-Increased heart rate may indicate discomfort or pain.
2. Measure respiratory rate.
-Respiratory rate may be increased, and breathing may be irregular and shallow.
3. Measure blood pressure.
-Increased blood pressure often occurs in severe pain.
3.VALIDATING AND DOCUMENTING FINDINGS
Validate the pain assessment data you havecollected. This isnecessary to verify
that the data are reliable and accurate.
Document the assessment data following the health care facility or agency policy.
4.ANALYSIS OF DATA
Selected Nursing Diagnoses
Wellness Diagnoses
Readiness for enhanced spiritual well-being related to coping with prolonged
physical pain
Readiness for enhanced comfort level
Risk Diagnoses
Risk for Activity Intolerance related to chronic pain and immobility
Risk for Constipation related to nonsteroidal anti-inflammatory agents or opiates
intake or poor eating habits
Risk for spiritual distress related to anxiety, pain, life change and chronic illness
Risk for Powerlessness related to chronic pain, healthcare environment, pain
treatment-related regimen
Actual Diagnoses
Acute Pain related to injury agents(biological,chemical, physical, or
psychological)
Chronic Pain related to chronic inflammatory process or rheumatoid arthritis
Ineffective Breathing Pattern related to abdominal pain and anxiety
Disturbed Energy Field related to pain and anxiety
Fatigue related to stress of handling chronic pain
Impaired physical mobility related to stress of handling chronic pain
Bathing/Hygiene Self-Care Deficit related to severe pain

PEDIATRIC AND GERIATRIC ADAPTATIONS TO PAIN

INFANT
-perceives pain
-responds to pain with increased sensitivity
-older infant tries oavoid pain, for example. Turns away and physically resists
Selected Nursing Interventions:
1. Give a glucose pacifier.

2. Use tactile stimulation

3. Play music or tapes of a heartbeat.
TODDLER AND PRESCHOOLER
-develops the ability to describe pain and its intensity and location
-often responds with crying and anger because child perceives pain as a threat to security
-may consider pain as a punishment
-feels sad
-may learn there are gender differences in pain expression
-tends to hold someone accountable for the pain
Selected Nursing Interventions:
1. Distract the child with toys,books, pictures. Involve the child in blowing bubbles
as a way of blowing away the pain.
2. Appeal to the childs belief in magic by using a magic blanket or glove to take
away the pain.
3. Hold the child to provide comfort.
4. Explore misconceptions about pain.
SCHOOL-AGE CHILD
-tries to be brave when facing pain.
-rationalizes in attempt to explain the pain.
-responsive to explanations
-can usually identify the location and describe the pain
-with persistent pain, may regress to an earlier stage of development
Selected Nursing Interventions:
1. Use imagery to turn off pain switches.
2. Provide a behavioral rehearsal of what to expect and how it will look and feel.
3. Provide support and nurturing.
ADOLESCENT
-may be slow to acknowledge pain
-recognizing pain or giving in may be considered weakness
-wants to appear brave in front of peers and not report pain
Selected Nursing Interventions:
1. Provide opportunities to discuss pain.
2. Provide privacy.
3. Present choices for dealing with pain.Encourage music or TV for distraction.
ADULT
-behaviors exhibited when experiencing pain may be gender-based behaviors learned as a
child
-may ignore pain because to admit it is perceived as a sign of weakness or failure
-fear of what pain means may prevent some adults from taking action
Selected Nursing Interventions:
1. Deal with any misconceptions about pain.
2. Focus on the clients control in dealing with the pain.
3. Allay fears and anxiety when possible.
ELDERLY
-may have multiple conditions presenting with vague symptoms
-may perceive pain as part of the aging process
-may have decreased sensations or perceptions of the pain
-lethargy, anorexia, and fatigue may be indicators of pain
-may withhold complaints of pain because of fear of the treatment, of any lifestyle
changes that may be involved, or of becoming dependent
-may describe pain differently,thatis,as ache, hurt, or discomfort
-may consider it unacceptable to admit or show pain
Selected Nursing Interventions:
1. Thorough history and assessment is essential.
2. Spend time with the client and listen carefully.
3. Clarify misconceptions.
4. Encourage independence whenever possible.

FEVER ASSESSMENT
Body temperature- reflects the balance between the heat produced and the heat lost from
the body, measured in heat unitscaleed degrees.
2 Kinds of Body Temperature:
A. Core Temperature- is the temperature of the deep tissues of the body, such as the
abdominal cavity and pelvic cavity.It remains relatively constant.
B. Surface temperatures-is thetemperature of the skin, the subcutaneous tissue, and
fat. It, by contrast, rises and fall in response to environment.
Variations in Normal Temperature by Age
Newborns: 36.8 C(98.2 F)
1 year: 36.8 C(98.2 F)
5-8 years: 37 C(98.6)
10 years: 37 C(98.6)
Teen: 37 C(98.6)
Adult: 37 C(98.6)
Older Adult(>70 y/o):37 C(98.6)
Heat Production
Factors affecting the bodys heat production:
1. Basal Metabolic Rate(BMR)
-rate of energy utilization in the body required to maintain essential activities such
as breathing
-in general, the younger the person, the higher the BMR
2. Muscle Activity-including shivering, increases the metabolic rate
3. Thyroxine Output- increased thyroxine output increases the rate of cellular
metabolism(chemical thermogenesis)
4. Epinephrine, norepinephrine, and sympathetic stimulation
-these hormones immediately increase the rate of cellular metabolism in many body
tissues
5. Fever- increases the cellular metabolic rate and further increases the bodys
temperature further.
Heat Lost
1. Radiation-transfer of heat from the surface of one object to surface if another
without contact between two objects
-ex. Heat lost by a nude person standing in a normal room temperature
2. Conduction-transfer of heat from one molecule to a molecule of lower temperature
-cannot take place without contact between the molecules and normally accounts for
minimal heat loss except, for example, when a body is immersed in a cold water.
3. Convection- dispersion of heat by air currents
4. Vaporization- continuous evaporation of moisture from the respiratory tract and from
the mucosa of the mouth and from the skin. This continuous and unnoticed water loss is
called insensible water loss and the accompanying heat loss is called insensible heat
loss.
FACTORS AFFECTING BODY TEMPERATURE
1. Age
-Infants are greatly influenced by the temperature of the environment and must be
protected from extreme changes.
-Childrens temperature continue to be more variable than those of adults until
puberty.
-Many older people, particularly thoseover 75 years old, are at risk of
hypothermia for a variety of reasons, such as inadequate diet, loss of SQ fat, lack
of activity, and reduced thermoregulatory efficiency.
-Older people are also particularly sebsitive to extremes in the environmental
temperature due to decreased thermoregulatory controls.

2. Diurnal Variations(Circadian Rhythms)

-Body temperatures normally change throughout the day, varying as much as
1.0C(1.8 F)between the early morning and the late afternoon.
-The point of highest body temperature is usually reached between 8PM and midnight
and the lowest point is reached during sleep between 4AM and 6AM
3. Exercise
-Hard work or strenuous exercise can increase body temperature to as high as 38.3 to
40C(101 t0 104 F)measured rectally.
4. Hormones
-Women usually experiences more hormone fluctuations than men. In women,
progesterone secretion at the time of ovulation raises body temperature by about 0.3 to
0.6C
5.Stress
-Stimulation of the sympathetic nervous system can increase the production of
epinephrine and norepinephrine, thereby increasing metabolic activity and heat
production.
6. Environment
-Extremes in environmental temperatures can affect a persons temperature regulatory
sytems.
ALTERATIONS IN BODY TEMPERATURE
Pyrexia/hyperthermia/fever
-a body temperature above the usual range
Hyperpyrexia
-a very high fever such as 41C(105.8F)
FOUR COMMON TYPES OF FEVER
1.Intermittent Fever
-the body temperature alternates at regular intervals between periods of fever and
periods of normal or subnormal temperatures
2. Remittent Fever
-a wide range of temperature fluctuations(more than 2C) occurs over the 24-hour period,
all of which are above normal
3. Relapsing Fever
-short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal
temperature
4. Constant Fever
-the body temperature fluctuates minimally but always remains above normal
Fever spike- a temperature that rises to fever level rapidly following a normal
temperature and then returns to normal within a few hours
CLINICAL SIGNS OF FEVER
Onset
Increased heart rate
Increased respiratory rate and depth
Shivering
Pallor, cold skin
Complaints of feeling cold
Cyanotic nail beds
gooseflesh appearance of the skin
Cessation of sweating
Course
Absence of Chills
Glassy-eyed appearance
Increased pulse and respiratory rate
Increased thirst
Mild to severe dehydration
Drowsiness, restlessness,, delirium or convulsions

 Herpetic lesions of the mouth

Loss of appetite
Malaise, weakness and aching muscles
Defervescence(fever abatement)
Skin that appears flushed and feels warm
Sweating
Decreased shivering
Posiible dehydration
NURSING INTERVENTIONS FOR CLIENTS WITH FEVER
1. Monitor vital signs.
2. Assess skin color and temperature.
3. Monitor WBC, hematocrit value, and other pertinent laboratory reports for
indications of infection or dehydration.
4. Remove excess blankets when the client feels warm, but provide extra warmth
when the clients feels chilled.
5. Provide adequate nutrition and fluids to meet increased metabolic demands and
prevent dehydration.
6. Measure intake and output.
7. Reduce physical activity to limit heat production, especially during the flush
stage.
8. Administer antipyretics(drugs that reduce the level of fever as ordered.
9. Provide oral hygiene to keep the mucous membranes moist.
10. Provide a tepid sponge bath to increase heat loss through conduction.
11. Provide dry clothing and bed linens.