pain assessment

ways to assess a client's level of pain using different mnemonics (e.g., PQRST, COLDD SPA, OLD CARTS) and different visual analogs

1. Maria Carmela L. Domocmat, RN, MSN

2. M
an unpleasant sensory and emotional
experience, which we primarily associate
with tissue damage or describe in terms of
damage, or both (IASP)
the fifth vital sign
M
the fifth vital sign
Maria Carmela L. Domocmat, RN, MSN

3. http://static.howstuffworks.com/gif/pain-2.gif
Maria Carmela L. Domocmat, RN, MSN

4. http://static.howstuffworks.com/gif/pain-2.gif
Maria Carmela L. Domocmat, RN, MSN

5. a
Proposed by Melzack and Wall in 1965
a
Has influenced pain research and treatment
a
Pain is explained as a combination of
physiologic phenomena in addition to a
psychosocial aspect that influences the psychosocial aspect that influences the perception of pain
Maria Carmela L. Domocmat, RN, MSN

6. Maria Carmela L. Domocmat, RN, MSN

7. a
Acute pain M
Usually associated with injury of recent onset (‹6
mos)and duration (‹1 mo)
a
Chronic non-malignant pain M
Usually assoc with specific cause or injury
M
Usually assoc with specific cause or injury
M
Constant pain that persists more than 6 mos
a
Cancer pain M
Often due to compression of meninges or from the
damage to these structures following surgery,
chemotherapy, radiation, or tumor growth and
infiltration
Maria Carmela L. Domocmat, RN, MSN

8. Maria Carmela L. Domocmat, RN, MSN

9. a
Nociceptive or somatic pain M
Pain r/t tissue damage
M
Subtypes: acute and remitting or chronic and
persistent
a
Neuropathic pain
a
Neuropathic pain M
Result from direct injury to the peripheral or CNS
a
Psychogenic and idiopathic pain M
Relates to many factors that influence the patient’ s
report of pain –psychiatric conditions like anxiety or
depression, personality and coping style, cultural
norms, and social support systems
M
Idiopathic pain – pain without an identifiable etiol ogy
Maria Carmela L. Domocmat, RN, MSN

10. Characteristic of
pain
Nociceptive
superficial
Nociceptive deep somatic Nociceptive visceral Neuropathic
Origin of stimulus Skin, subcutaneous
tissue; mucosa-
mouth, nose,
sinuses, urethra,
anus
Bone joints, muscles,
tendons, ligaments;
superficial lymph nodes;
organs and capsules,
mesothelial membranes
Solid or hollow organs,
deep tumor masses, deep
lymph nodes
Damage to nociceptive pathways
Examples Pressure ulcers,
stomatitis
Arthritis, liver capsule
distension or inflammation
Deep abdominal or chest
masses, intestinal, biliary
ureteric colic
Tumor related brachial, lumbosacral
plexus or chest wall invasion, spinal cord
compression; nontumour related:
postherpetic neuralgia, postthoracotomy
syndrome, phantom pain
Description
Hot, burning,
Dull, aching
Dull, deep
Dysesthesia
(pins and needles, tingling,
Description
Hot, burning, stinging
Dull, aching
Dull, deep
Dysesthesia
(pins and needles, tingling,
burning, lancinating, shooting)
Allodynia; phantom pain, pain in numb
area
Localization to
site of stimulus
Very well defined Well defined Poorly defined Nerve or dermatome distribution
Movement No effect Worsening pain
Resident prefers to be still
May improve pain Nerve traction provokes pain, e.g. sciatic
stretch test
Referral No Yes Yes Yes
Local tenderness Yes Yes Maybe Yes
Autonomic effects No No Nausea, vomiting,
sweating, BP and heart rate
changes
Autonomic instability: warmth, sweating,
pallor, cold, cyanosis (localized to nerve
pathway)
Maria Carmela L. Domocmat, RN, MSN

11. Maria Carmela L. Domocmat, RN, MSN

12. M
raised heart rate, pulse, temperature,
respiratory rate, blood pressure or sweating M
abnormal color of skin, discharge from eyes,
nose, vagina or rectum M
lesions to oral or rectal mucosa, skin
M
lesions to oral or rectal mucosa, skin
M
distension of the abdomen, swelling of limbs,
swelling of body joints M
abnormal results on testing urine (e.g. presence
of blood, leucocytes, glucose) M
functional decrease in mobility, range of
movement, activity, endurance, and increase in
fatigue
M
changes in posture-standing, sitting, reclining
Maria Carmela L. Domocmat, RN, MSN

13. Maria Carmela L. Domocmat, RN, MSN

14. M
aggression, resistance, withdrawal,
restlessness
M
facial expression: grimacing, fear, sadness,
disgust
verbalizations: self reports of pain, requests
M
verbalizations: self reports of pain, requests for analgesia, requests for help, sighing,
groaning, moaning, crying, and unusual
silence.
Maria Carmela L. Domocmat, RN, MSN

15. http://www.hospicepatients.org/images/capqf2.gif
Maria Carmela L. Domocmat, RN, MSN

16. Maria Carmela L. Domocmat, RN, MSN

17. Maria Carmela L. Domocmat, RN, MSN

18. M
Location
M
Severity M
Verbal descriptor Scale (VBS)
M
Visual Analog Scale (VAS)
M
Numeric Rating Scale (NRS)
M
Numeric Rating Scale (NRS)
M
Wong-Baker Faces Pain Scale (FACES)
M
Associated features
M
Attempted treatments, medications, related
illness, impact on daily activities
Maria Carmela L. Domocmat, RN, MSN

19. M
Ask patient to describe pain and how the
pain started
M
Is it related to a site of injury, movement, or
time of day?
What is the quality of pain
–
sharp, dull,
M
What is the quality of pain
–
sharp, dull,
burning?
M
Ask if pain radiates (spread around) or follow
a specific pattern
M
What makes pain better or worse?
Maria Carmela L. Domocmat, RN, MSN

20. M
Attempted treatments, medications, related
illness, impact on daily activities
a
Ask any treatments the patient has tried (meds, PT,
alternative meds)
a
Comprehensive med history (rationale: helps you identify drugs with analgesics and reduce their identify drugs with analgesics and reduce their efficacy)
a
Identify any morbid condition (e.g., arthritis, DM,
HIV/AIDS, substance abuse, sickle cell disease, or
psychiatric disorder) (rationale: these can have a
significant effects on patient’s experience of pain )
a
Inquire about effects of pain in ADL, mood, sleep,
work, and sexual activity (rationale: chronic pain is
the leading cause of disability and impaired
performance at work)
Maria Carmela L. Domocmat, RN, MSN

21. M
Location: where is it? Does it radiate?
M
Quality: what is it like?
M
Quantity or severity: how bad is it?
M
Timing: When did (does) it start? How long does it last? How often does it come? it last? How often does it come?
M
Setting in which it occurs: include environmental
factors, personal activities, emotional reactions,
or other circumstances that may have
contributed to the illness
M
Remitting or exacerbating factors: is there any
thing that makes it better or worse? M
Associated manifestations: have you noticed
anything else that accompanies it?
Maria Carmela L. Domocmat, RN, MSN

22. M
OPQRST a
P:palliating or provoking factors
a
Q: quality of pain (what words does the person
use to describe pain)
a
R:
radiation of pain (does the pain extend from
a
R:
radiation of pain (does the pain extend from
the site)
a
S:severity of pain (intensity, can be measured
using pain scales)
a
T:timing (occasional, intermittent, constant)
Maria Carmela L. Domocmat, RN, MSN

23. M
OLD CARTS a
Onset
a
Location
a
Duration C
haracter
a
C
haracter
a
Aggravating/Alleviating Factors
a
Radiation
a
Timing
a
Severity
Maria Carmela L. Domocmat, RN, MSN

24. Maria Carmela L. Domocmat, RN, MSN

25. M
This is a simple descriptive pain intensity
scale that ranges painintensity from no pain
to worst pain.
Maria Carmela L. Domocmat, RN, MSN

26. a
P: palliating or provoking factors
a
Q: quality of pain (what words does the person
use to describe pain)
a
R: radiation of pain (does the pain extend from the site) the site)
a
S: severity of pain (intensity, can be measured
using pain scales)
a
T: timing (occasional, intermittent, constant)
M
Registered Nurses' Association of Ontario
(RNAO) Recommended Verbal Assessment
a
(RNAO, 2007)
Maria Carmela L. Domocmat, RN, MSN

27. COLDSPA
CCCC
haracter
O
nset
L
ocation
COLDSPA
L
ocation
D
uration
S
everity
P
attern
A
ssociated Factors
Maria Carmela L. Domocmat, RN, MSN

28. M
Character: describe the sign or symptom;
how does it feel, look, sound, smell, and so
forth?
M
Onset: when did it begin?
M
L
ocation: where is it?, does it radiate
M
L
ocation: where is it?, does it radiate
M
Duration: how long does it last?
M
Severity: how bad is it?
M
Pattern: what makes it better? what makes it
worse?
M
Associated Factors: what other symptom
occur with it?
Maria Carmela L. Domocmat, RN, MSN

29. Maria Carmela L. Domocmat, RN, MSN

30. a
Simple descriptive pain intensity scale
a
Ranges pain on a scale between mild, moderate
and severe
Maria Carmela L. Domocmat, RN, MSN

31. Maria Carmela L. Domocmat, RN, MSN

32. Visual Analog Scale (VAS)
a
Rates pain on a 10 cm continuum numbered from
0 to 10 where 0 reflects no pain and 10 reflects
pain at its worst
http://www.queri.research.va.gov/ptbri/HTM/HSRD08_Walker_files/slide0
033_image011.jpg
Maria Carmela L. Domocmat, RN, MSN

33. Maria Carmela L. Domocmat, RN, MSN

34. M
a verbal tool where a scale of 0-10 pain
intensity is asked to the patient. The patient
then states pain from 0-10where 0 is no pain
and 10 is worst pain
Maria Carmela L. Domocmat, RN, MSN

35. http://understandingpain.files.wordpress.com/2010/07/pain_scale1.png
Maria Carmela L. Domocmat, RN, MSN

36. Maria Carmela L. Domocmat, RN, MSN

37. M
Shows different facial expression where the
client is asked to choose the face that best
describes the intensity or level of pain
M
espfor pediatric client
Maria Carmela L. Domocmat, RN, MSN

38. http://pacificu.edu/optometry/ce/courses/22746/images/clip_image002.j
pg
Maria Carmela L. Domocmat, RN, MSN

39. Maria Carmela L. Domocmat, RN, MSN

40. Maria Carmela L. Domocmat, RN, MSN

41. M
The Abbey Pain Scale is suitable for residents
with dementia who cannot verbalisetheir
pain, and may also be useful for cognitively
intact residents who aren't willing or cannot
talk about their pain. talk about their pain.
http://www.racgp.org.au/silverbookonline/images/tools_abbey_pain_scale
.gif
Maria Carmela L. Domocmat, RN, MSN

42. http://www.racgp.org.au/silverbookonline/images/tools_abbey_pain_scale
.gif
Maria Carmela L. Domocmat, RN, MSN

43. Maria Carmela L. Domocmat, RN, MSN

44. Maria Carmela L. Domocmat, RN, MSN

45. M
The Resident's Verbal Brief Pain Inventory is
suitable for residents able to verbalize their
pain. The same scale/s selected for the
individual resident should be for
reassessment. reassessment.
http://www.racgp.org.au/silverbookonline/images/tools_pain_inventory.gif
Maria Carmela L. Domocmat, RN, MSN

46. http://www.racgp.org.au/silverbookonline/images/tools_pain_inventory.gif
Maria Carmela L. Domocmat, RN, MSN

47. Maria Carmela L. Domocmat, RN, MSN

48. http://img.medscape.com/fullsize/migrated/452/694/pn452694.tab3.gif
Maria Carmela L. Domocmat, RN, MSN

49. Maria Carmela L. Domocmat, RN, MSN

50. M
Observe posture a
Normal findings: M
Posture is upright when the client feels comfortabl e,
attentive and
M
without excessive changes in position and posture
M
without excessive changes in position and posture
a
Abnormal findings: M
client appears to be slumped with the shoulders not
straight (indicates being disturbed/uncomfortable)
M
May be guarding affected area and have breathing
patterns reflecting distress
Maria Carmela L. Domocmat, RN, MSN

51. M
Observe facial expression a
Normal findings: M
Smiles with appropriate facial expressions
M
Maintains adequate eye contact
a
Abnormal findings:
Facial expression may indicate distress and discomf ort
M
Facial expression may indicate distress and discomf ort r
Frowning
r
Moans
r
Grimacing
r
Cries
r
Fear
r
Sadness
r
Disgust
M
Eye contact is not maintained, indicating discomfor t
Maria Carmela L. Domocmat, RN, MSN

52. M
Inspect joints and muscles a
Normal findings: M
Joints appear normal – no edema
M
Muscles appear relaxed
a
Abnormal findings:
a
Abnormal findings: M
Edema of joints may indicate injury
M
Pain may result in muscle tension
Maria Carmela L. Domocmat, RN, MSN

53. M
Observe skin for scars, lesions, rashes,
changes or discolorations
a
Normal findings: M
No inconsistency, wounds, or bruising is noted
a
Abnormal findings:
a
Abnormal findings: M
Bruising, wounds, or edema may be the result of
injuries or infections, which may cause pain
Maria Carmela L. Domocmat, RN, MSN

54. Maria Carmela L. Domocmat, RN, MSN

55. M
HR a
Normal finding: 60-100 bpm
a
Abnormal finding: increased HR may indicate
discomfort or pain
Maria Carmela L. Domocmat, RN, MSN

56. M
RR a
Normal finding: 12-20 breathes per min
a
Abnormal finding: RR may be increased;
breathing may be irregular and shallow
Maria Carmela L. Domocmat, RN, MSN

57. M
BP a
Normal finding:100-130/60-80
a
Abnormal finding: increased BP often occurs in
severe pain
Maria Carmela L. Domocmat, RN, MSN

58. M
Other observations r/t specific part a
Palpation of abdomen
a
ROM tests for joints
Maria Carmela L. Domocmat, RN, MSN

59. Maria Carmela L. Domocmat, RN, MSN

60. M
Validate your data
M
Document data
M
Possible conclusions
Maria Carmela L. Domocmat, RN, MSN

61. M
Actual diagnoses a
Acute pain r/t injury agents (biological,
chemical, physical or psychological)
a
Chronic pain r/t chronic inflammatory process of rheumatoid arthritis rheumatoid arthritis
a
Ineffective breathing pattern r/t abdominal pain
and anxiety
a
Fatigue r/t stress of handling chronic pain
a
Impaired physical mobility r/t chronic pain
a
Bathing /hygiene self-care deficit r/t severe pain
(specify)
Maria Carmela L. Domocmat, RN, MSN

62. M
Risk diagnoses a
Risk for activity intolerance r/t chronic pain and
immobility
a
Risk for constipation r/t nonsteroidal anti- inflammatory agents or opiates intake or poor inflammatory agents or opiates intake or poor eating habits
a
Risk for spiritual distress r/t anxiety, pain, life
changes, and chronic illness
a
Risk for powerlessness r/t chronic pain,
healthcare environment, pain treatment-related
regimen
Maria Carmela L. Domocmat, RN, MSN

63. M
Wellness diagnoses a
Readiness for enhanced spiritual well-being r/t
coping with prolonged physical pain
a
Readiness for enhanced comfort level
Maria Carmela L. Domocmat, RN, MSN