Types of pain and assessment of pain

Types of pain and assessment of pain
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1. TYPES OF PAIN & ASSESMENT OF PAIN PRESENTER: DR.M.MADHU CHAITANYA MODERATOR: DR. RAMYA KIRAN( SR) 1

2. Definition Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. 2

3. Signs and Symptoms of pain: Increased respiratory rate Increased heart rate Peripheral vasoconstriction Pallor Elevated B.P. Increased Blood Glucose Levels Diaphoresis Dilated pupils Moaning Guarding the area Restlessness Irritability 3

4. Types of Pain is classified Based on duration Based on location Based on intensity Based on etiology 4

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6. Acute pain When pain lasts only through the expected recovery period, it is described as acute pain. Acute pain is protective, has an identifiable cause, is of short duration, and has limited tissue damage and emotional response. It eventually resolves, with or without treatment, after an injured area heals. 6

7. Acute pain Complete pain relief is not always achievable, but reducing pain to a tolerable level is realistic. Unrelieved acute pain can progress to chronic pain. 7

8. Chronic pain Chronic pain is the pain that lasts longer than 3- 6 months and is constant or recurring with a mild-to-severe intensity. It does not always have an identifiable cause and leads to great personal suffering. Examples: arthritic pain, head ache, peripheral neuropathy. 8

9. Chronic pain The possible unknown cause of chronic pain, combined with the unrelenting nature and uncertainty of its duration, frustrates a patient, frequently leading to psychological depression and even suicide. Associated symptoms of chronic pain include fatigue, insomnia, anorexia, weight loss, hopelessness, and anger. 9

10. CHRONIC PAIN MAY BE : Chronic non cancer pain Chronic cancer pain Chronic episodic pain. 10

11. Chronic non cancer pain: • The chronic pain that resulted due to non cancer disease conditions is termed as chronic non cancer pain. 11

12. Chronic cancer pain: Cancer pain is the pain that is caused by tumor progression and related pathological processes, invasive procedures, toxicities of treatment, infection, and physical limitations. Approximately 70% to 90% of patients with advanced cancer experience pain. 12

13. Chronic episodic pain: Pain that occurs sporadically over an extended period of time is episodic pain. Pain episodes last for hours , days , or weeks . Examples are migraine headaches . 13

14. Classification based on location: This is based on the site at which the pain is located. Headache Back pain Joint pain Stomach pain Cardiac pain Referred pain: pain due to problems in other areas manifest in different body part. cardiac pain may be felt in the shoulder or left arm, with or without chest pain. 14

15. Based on intensity: 15

16. Based on intensity: Mild pain : Pain scale reading from 1 to 3 is considered as mild pain Moderate pain : Pain scale reading from 4 to 6 is considered as moderate pain Severe pain: Pain scale reading from 7 to 10 is considered as severe pain 16

17. Classification of pain based on etiology: 17

18. Nociceptive pain: Nociceptive pain is experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care. For example, the pain experienced following a cut or broken bone alerts the person to avoid further damage until it is properly healed. Once stabilized or healed, the pain goes away 18

19. Somatic pain: This is the pain that is originating from the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain 19

20. Visceral pain: Visceral pain is pain that results from the activation of nociceptors of the thoracic, pelvic, or abdominal viscera (organs). Characterized by cramping, throbbing, pressing, or aching qualities. Examples: labor pain, angina pectoris, or irritable bowel. 20

21. Neuropathic pain Neuropathic pain is associated with damaged or malfunctioning nerves due to illness , injury, or undetermined reasons. Examples: Diabetic peripheral neuropathy Phantom limb pain Spinal cord injury pain 21

22. It is usually chronic. it is described as burning , “electric-shock,” and/or tingling , dull , and aching. Neuropathic pain tends to be difficult to treat. Neuropathic pain is of two types based on which parts of the nervous system is damaged. Peripheral Neuropathic Pain Central Neuropathic Pain 22

23. Peripheral neuropathic pain: Due to damage to peripheral nervous system Eg : P hantom limb pain Central neuropathic pain: Results from malfunctioning nerves in the central nervous system (CNS). Eg : spinal cord injury pain, Post-stroke pain . 23

24. Factors Influencing Pain 1. Developmental factors 2. Physiological factors - fatigue, genes, neurological functioning 3. Social factors - attention, previous experience, family and social support, spiritual factors. 4. Psychological factors - anxiety, coping style. 5. Cultural factors 24

25. Pain Assessment P recipitating /Alleviating Factors: – What causes the pain? What aggravates it? Has medication or treatment worked in the past? Q uality of Pain : – Ask the patient to describe the pain using words like “sharp”, dull, stabbing, burning” R adiation – Does pain exist in one location or radiate to other areas? S everity – Have patient use a descriptive, numeric or visual scale to rate the severity of pain. T iming – Is the pain constant or intermittent, when did it begin. 25

26. Pain Assessment Assess for objective signs of pain: Facial expressions – facial grimacing (a facial expression that usually suggests disgust or pain), frowning (facial expression in which the eyebrows are brought together, and the forehead is wrinkled), sad face. Vocalizations - crying, moaning Body movements – guarding , resistance to moving 26

27. Grimacing Frowning 27

28. Pain Assessment Tools: These are various tools that are designed to assess the level of pain. The most commonly used tools are: 1. Verbal Rating Scale 2. Numeric Rating Scale 3. Wong Baker’s Faces Pain Scale 28

29. Verbal Rating Scale 29

30. Numeric Rating Scale 30 How to use? Ask the child using numbers from 0 = no pain through to 10 being the worst pain A reduction of 30% or 2 points and more from baseline positive response for Rx. Disadvantage –Digital scale reduces the capacity to detect subtle changes

31. Wong Baker’s Faces Pain Scale 31 How to use?  Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain.   Face 0  is very happy because he doesn't hurt at all.   Face 2  hurts just a little bit.   Face 4  hurts a little more.   Face 6  hurts even more.   Face 8  hurts a whole lot.  Face 10  hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling.

32. FLACC -   F ace,  L egs,  A ctivity,  C ry and  C onsol ability.     Behavioral  2 months-8 years and also used up to 18 years for children with cognitive impairment and/or developmental disability (always elicit support from parents or caretaker to help with pain assessment) It may be difficult to assess children with cognitive impairment and/or are non-verbal . Ask the parent or caretaker to help you explain their child’s pain behavior.  32

33. How to use FLACC Each category (Face, Legs etc) is scored on a 0-2 scale, which results in a total pain score between 0 and 10. The person assessing the child should observe them briefly and then score each category according to the description supplied. FLACC has a high degree of usefulness for cognitively impaired and many critically ill children  33

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35. Physiological indicators Heart rate may increase Respiratory rate and pattern may shift from normal ie : increase, decrease or change pattern Blood pressure may increase Oxygen saturation may decrease 35

36. A: Quantity or severity or intensity of pain Instruments for intensity assessment: Uni dimensional Multi dimensional 1.Verbal rating scales 1 . Mc Gill pain questionnaire 2.Binary scale 2. Brief pain inventory 3.Numerical rating scale 3. West Haven –Yale pain inventory 4.Faces rating scale 4. Medical outcome study 36 item short form(SF-36)health survey 5.Visual analog scale 36

37. Unidimensional instruments: 1.Verbal rating scales(VRS) Response is noted as None , mild , moderate or severe Advantage- short , easy to express and understand especially in elderly Disadvantage- lack of reproducibility 2. The binary scale e.g. do you have a 60% reduction in your pain? “Yes/no” Advantage-short, easy to express and understand. Disadvantage-lack of reproducibility 37

38. The visual analog scale (VAS) The distance from no pain to the patient mark indicates the severity of pain numerically Advantage-simple, efficient , valid, and minimally intrusive Disadvantage-more time consuming than others & some difficulty in understanding in elderly 38

39. Multi dimensional instruments: The Mc Gill pain questionnaire(MPQ)- Defines pain in 3 major dimensions by 20 set of descriptive words divided as 10 sets describes sensory- discriminative ( nociceptive pathway) 5 sets describe motivational –affective (reticular and limbic structure) 1 set describe cognitive evaluative 4 sets describe miscellaneous dimensions. Advantage - helps in diagnosis as choice of descriptive words that characterize the pain correlates well with pain syndromes. Disadvantage – high level of anxiety and psychological disturbances can obscure the MPQ discriminative capacity. 39

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41. 2. Brief pain inventory(BPI): Measures both the intensity of pain (sensory dimension) and its interference with the patient life(reactive dimension) Advantage- valid for cancer pain and various pain syndromes shows good sensitivity to T/t. Helps in comparing international trials with different culture and population 41

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43. Memorial Pain Assessment Card Pain assessment tool for cancer patients Consists of three separate visual analog scales and assesses pain , pain relief and mood. Card includes a set of adjectives to describe pain intensity 43

44. B:Assesment of Quality or nature of pain Important for diagnosing the nature or character of pain whether it is nociceptive or neuropathic or a mixed nature. 44

45. Screening tools for Neuropathic pain: 1.Leeds assessment of neuropathic symptoms and signs: It has two components in form of symptoms and signs For Each item binary response is noted-yes/no Scores ≥12/24 indicates pain is likely to be neuropathic Use is limited- because of need for clinical examination and pinprick testing 45

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47. 2. Neuropathic pain questionnaire(NPQ) The NPQ is a self questionnaire consisting of 12 items : 10 related to sensations or sensory responses 2 related to affect Each item is scored on a scale of 0(no pain ) to 100(worst possible pain) 47

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49. 3.Douleur Neuropathique en 4(DN 4) questions: Consists of 7 items related to symptoms and 3 items related to physical examination Each item is scored 1(yes) or 0(no) sum of all ten items is taken as total score score of ≥ 4 as neuropathic pain 49

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51. 4. Pain detect: Patient based self report questionnaire consisting of 9 items: 7 sensory descriptions and 2 related to spatial(radiating) and temporal characteristics. Sensory descriptions are scored on a scale of 0 (no) to 5 (very strongly) Radiating pain as 1(yes) or 0 (no) Score ≥ 19 indicates neuropathic pain likely ≤ 12 unlikely neuropathic pain Note –no clinical examination is needed 51

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53. 5. ID -Pain It is a self questionnaire consisting of 5 sensory description and 1 item regarding pain located in the joints. Higher scores indicates neuropathic pain ID –pain - Pins and needles Electric shocks Hot/ burning - Numb Is the pain made worse with touch of clothing or bed sheets Is the pain limited to your joints (- 1) 53

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