Pain Assessment Management

1. Dr. Rabinarayan Tripathy

2. PAIN

3. PAIN
An unpleasant sensory and
emotional experience
associated with actual or
potential damage *
POENA = Penalty / Punishment
*International Association for Study of Pain, 1979

4. Pain limits function
• Limited range of
motion
• Decreased attention
span
• Confusion
• Fear of being touched

5. Why there is Pain ?
1. Irritation Of Peripheral Nr. Endings In
Superficial Tissue By Harmful Stimuli.
2. Irritation Of Sensory Nr. Trunk Or Root.
3. Excessive Tension.
4. Ischemia Of Deeper Tissue Or Viscera.
5. Sensation Originating In The Brain Causing
Psychogenic Pain

6. CLASSIFICATION
1. Superficial - Irritation to Peripheral Nr.
Endings / Sensory Nr. Trunk Or Root. Sharp
2. Segmental – occurs in particular
dermatome supplied by particular sensory
nr. Trunk or root.
3. Deep – Irritation of deep st. (Organ pain)
pain conveyed to brain by ANS (somatic nr.)
4. Psychogenic – functional, emotional,
lesion in spinothalamic tract.

7. Recognizing Pain
• ASK - Asking patients about pain.
• LOOK - Observation of the patient,
especially of any changes from the normal
appearance of that person.
• INVESTIGATE - Investigation of any changes
in behavior that might be related to pain.
This is especially important in the person
with dementia or confusion.

8. feature
Common Feature
1. Site
2. Type
3. Origin
4. Duration.
5. Progress
Specific Feature
1. Movement
2. Aggravating Factor.
3. Reliving Factor,
4. Relation To Normal
Act.
5. Associated Symptoms

9. SITE

10. Right Upper Quadrant Pain
• Acute Cholecystitis and Biliary Colic
• Acute Hepatitis or Abscess
• Hepatomegaly due to CHF
• Perforated Duodenal Ulcer
• Herpes Zoster
• Myocardial Ischemia
• Right Lower Lobar Pneumonia

11. Left Upper Quadrant Pain
 Acute Pancreatitis
 Gastric ulcer
 Gastritis
 Splenic enlargement, rupture,
infarction
 Myocardial ischemia
 Left lower lobe pneumonia

12. Right lower Quadrant Pain
• Appendicitis
• Regional Enteritis
• Small bowel obstruction
• Leaking Aneurysm
• Ruptured Ectopic Pregnancy
• PID
• Twisted Ovarian Cyst
• Ureteric Calculi
• Hernia

13. Left Lower Quadrant Pain
• Diverticulitis
• Leaking Aneurysm
• Ruptured Ectopic pregnancy
• PID
• Twisted Ovarian Cyst
• Ureteric Calculi
• Hernia
• Regional Enteritis

14. Periumbilical Pain
• Disease of transverse colon
• Gastroenteritis
• Small bowel pain
• Appendicitis
• Early bowel obstruction

15. SEVERITY / ASSESSMENT ?
ONE MAN’S ACHE CAN BE ANOTHER MAN’S AGONY

16. TYPE
1. Burning – heart burn, superficial ulcer, peptic ulcer
2. Intermittent claudicating - nr. Insufficiency.
3. Rest pain – vascular insufficiency
4. Scalding - urethritis
5. Throbbing - abscess
6. Shooting - sciatitica
7. Pricking - neuritis
8. Distending – fullness in walled st.
9. Twisting – int. Volvulus, torsion of testis, ovarian cyst
10. Constricting – chest, neck
11. Colicky – rhythmic, intermittent, spasm in tubular st.

17. LAXANA ACCORDING TO
AVASTHA

18. ORIGIN
a) Acute onset - pain reaches its
maximum intensity with in hours.
E.g. Acute inflammation
b) Chronic onset – starts insidiously &
takes weeks to reach its maximum
intensity.

19. DURATION
a) How long.
b) How often

20. PROGRESS
a. Begins at peak remain same
until it disappears
b.Begins at peak & decline slowly
c. Increases steadily
d.Fluctuate

21. MOVEMENT
Radiation
Referred
Shifting or migration

22. Radiation of Pain
Pain penetrating posterior in duodenal ulcer

23. REFERRED PAIN
Cortical Confusion – Inability of the CNS to differentiate
between the visceral & somatic sensory impulses having
common area of representation in the brain.

24. Referred pain
Cortical Confusion – Inability of the CNS to differentiate
between the visceral & somatic sensory impulses having
common area of representation in the brain.

25. Shifting or migration of Pain
Peri-umblical referred pain shifted to rt. Iliac fossa due
to involvement of parietal peritoneum

26. AGGRAVATING FACTOR
• Hot spice food – peptic ulcer
• Jolting – billiary, renal colic
RELIEVING FACTOR
• Propped up position – hiatus hernia with reflux
oesophagitis
RELATION TO NORMAL ACT
• Exertion – myositis.
• Pain at the end of micturition – trigonitis, prostatitis
ASSOCIATED SYMPTOM
• Fever – acute inflammation
• Sweating & cold limb – hemorrhagic pancreatitis

28. Pain scales
A variety of scales can be used to
describe the intensity of pain:
• Numeric: From 0-10
• Word labels: “No pain" to "worst
possible pain“
• Cartoons: A series of facial
expressions

29. Visual Analogue Scale
WHAT IS THE INTENSITY OF PAIN RIGHT NOW ?

30. Numeric Rating Scale
0 1 2 3 4 5 6 7 8 9 10
None mild moderate severe

31. Verbal Rating Scale
No Distress Unbearable
Distress
0 1 2 3 4 5 6 7 8 9 10
None
Annoing
Uncomfortable
Dreadful
Horible
Agonizing

32. Simple Descriptive Pain Intensity Scale
NONE MILD MODERATE SEVERE VERY SEVERE WORST
POSSIBLE

33. Wong-Baker faces of pain
4 to 16 yrs

34. Faces pain Scale-revised
4 to 16 yrs

35. Oucher Pain Scale
3 to 12 yrs
McGill Pain Index

36. Checklist of Non-Verbal Indicators
(CNVI) Scale
Vocal complaint 0 1
Facial grimaces and winces 0 1
Bracing 0 1
Restlessness 0 1
Rubbing 0 1
TOTAL

37. FLACC SCALE
Facial expression 0 1 2
Leg movement 0 1 2
Activity 0 1 2
Cry 0 1 2
Consolability 0 1 2
TOTAL SCORE

38. FRAAC Pain Assessment Tool
Facial expression 0 1 2
Respiration 0 1 2
Activity 0 1 2
Audibility 0 1 2
Cry & Consolability 0 1 2
TOTAL SCORE

39. FRAAC Pain Assessment Tool

40. The Pain Assessment in Advanced Dementia (PAINAD)
Total scores range from 0 to 10 with a higher score indicating more severe pain
(0=“no pain” to 10=“severe pain”).

41. Why is Pain Management
Important ?
• Relief of pain can
improve function.
• Good pain control
allows better
interactions with
family
• Relief of pain improves
quality of life

42. Management of pain:
Non-drug therapy
Physical
• Reflexology or
therapeutic touch
• Repositioning
• Exercise/Activities
• Back rub
• Relaxation breathing
• Comfort foods
Environmental
• Quiet environment
• Soft music
• Dim lights
• Aromatherapy
• Imagery or
visualization

43. Management of pain:
Non-drug therapy
Psychosocial
• Verbal support
• Reassurance
• Distraction
• Visitors
• Imagery
Visualization
Spiritual
• Prayer or other
ritual, spiritual
reading as indicated
• Spiritual support
and counseling

44. Five rights
• Right person?
• Right drug?
• Right dose?
• Right/best route of
administration?
• Right time?

45. Management of mild pain: Drug therapy
• OTC (over-the-counter) medications
resolve mild pain
• Relief varies with the person
• Duration is 4 to 6 hours for most
products
• Caution: No more than 2 grams of
acetaminophen in 24 hours

46. Drug therapy: Moderate pain
• Pain of this severity is common
in frail older adults
• Regular interval dosing may
result in less total medication
• Often requires opiod (narcotic)
medications

47. Drug therapy: Severe pain
• Less common
• More often associated with an
acute problem
• Often requires long-acting opioid
(narcotic) with short acting
opioid for ‘breakthrough’ pain

48. Management of Pain:
Drug therapy
Different medications are selected based on
severity of pain
• Mild: OTC drugs can be used
• Moderate: Drugs that combine a mild opioid
(narcotic) with OTC
• Severe: Opioid (narcotic)
over the counter (OTC) drugs like aspirin, acetaminophen,
naproxen or ibuprofen.

49. Side effects of Opioids
• Constipation
• Confusion
• Slowed breathing
• Rash or nausea

50. Adjunct analgesics
• Antidepressants
• Anti-seizure medications
• Prednisone/dexamethasone

51. Ongoing Care
• Medicines may become less effective
with time,
• The pain itself may change, and
• The person’s response to medicine
may also change.
With reassessment, the pain management
program can be adjusted so that it
continues to be effective.

52. Summary of pain management
• Non drug therapies can be very
effective
• Drug management depends on
–Level of pain
–Tolerance of individual patient
–Side effects
• Continuous reassessment is vital

53. Thank you for
bearing pain