2. 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
Maria Carmela L. Domocmat, RN, MSN
5. Proposed by Melzack and Wall in 1965
Has influenced pain research and treatment
Pain is explained as a combination of
physiologic phenomena in addition to a
psychosocial aspect that influences the
perception of pain
Maria Carmela L. Domocmat, RN, MSN
7. Acute pain
Usually associated with injury of recent onset (‹6
mos)and duration (‹1 mo)
Chronic non-malignant pain
Usually assoc with specific cause or injury
Constant pain that persists more than 6 mos
Cancer pain
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
9. Nociceptive or somatic pain
Pain r/t tissue damage
Subtypes: acute and remitting or chronic and
persistent
Neuropathic pain
Result from direct injury to the peripheral or CNS
Psychogenic and idiopathic pain
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
Idiopathic pain – pain without an identifiable etiology
Maria Carmela L. Domocmat, RN, MSN
10. Characteristic of Nociceptive Nociceptive deep somatic Nociceptive visceral Neuropathic
pain superficial
Origin of stimulus Skin, subcutaneous Bone joints, muscles, Solid or hollow organs, Damage to nociceptive pathways
tissue; mucosa- tendons, ligaments; deep tumor masses, deep
mouth, nose, superficial lymph nodes; lymph nodes
sinuses, urethra, organs and capsules,
anus mesothelial membranes
Examples Pressure ulcers, Arthritis, liver capsule Deep abdominal or chest Tumor related brachial, lumbosacral
stomatitis distension or inflammation masses, intestinal, biliary plexus or chest wall invasion, spinal cord
ureteric colic compression; nontumour related:
postherpetic neuralgia, postthoracotomy
syndrome, phantom pain
Description Hot, burning, Dull, aching Dull, deep Dysesthesia (pins and needles, tingling,
stinging burning, lancinating, shooting)
Allodynia; phantom pain, pain in numb
area
Localization to Very well defined Well defined Poorly defined Nerve or dermatome distribution
site of stimulus
Movement No effect Worsening pain May improve pain Nerve traction provokes pain, e.g. sciatic
Resident prefers to be still stretch test
Referral No Yes Yes Yes
Local tenderness Yes Yes Maybe Yes
Autonomic effects No No Nausea, vomiting, Autonomic instability: warmth, sweating,
sweating, BP and heart rate pallor, cold, cyanosis (localized to nerve
changes pathway)
Maria Carmela L. Domocmat, RN, MSN
12. raised heart rate, pulse, temperature,
respiratory rate, blood pressure or sweating
abnormal color of skin, discharge from eyes,
nose, vagina or rectum
lesions to oral or rectal mucosa, skin
distension of the abdomen, swelling of limbs,
swelling of body joints
abnormal results on testing urine (e.g. presence
of blood, leucocytes, glucose)
functional decrease in mobility, range of
movement, activity, endurance, and increase in
fatigue
changes in posture-standing, sitting, reclining
Maria Carmela L. Domocmat, RN, MSN
18. Location
Severity
Verbal descriptor Scale (VBS)
Visual Analog Scale (VAS)
Numeric Rating Scale (NRS)
Wong-Baker Faces Pain Scale (FACES)
Associated features
Attempted treatments, medications, related
illness, impact on daily activities
Maria Carmela L. Domocmat, RN, MSN
19. Ask patient to describe pain and how the
pain started
Is it related to a site of injury, movement, or
time of day?
What is the quality of pain –sharp, dull,
burning?
Ask if pain radiates (spread around) or follow
a specific pattern
What makes pain better or worse?
Maria Carmela L. Domocmat, RN, MSN
20. Attempted treatments, medications, related
illness, impact on daily activities
Ask any treatments the patient has tried (meds, PT,
alternative meds)
Comprehensive med history (rationale: helps you
identify drugs with analgesics and reduce their
efficacy)
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)
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. Location: where is it? Does it radiate?
Quality: what is it like?
Quantity or severity: how bad is it?
Timing: When did (does) it start? How long does
it last? How often does it come?
Setting in which it occurs: include environmental
factors, personal activities, emotional reactions,
or other circumstances that may have
contributed to the illness
Remitting or exacerbating factors: is there any
thing that makes it better or worse?
Associated manifestations: have you noticed
anything else that accompanies it?
Maria Carmela L. Domocmat, RN, MSN
22. OPQRST
P:palliating or provoking factors
Q: quality of pain (what words does the person
use to describe pain)
R:radiation of pain (does the pain extend from
the site)
S:severity of pain (intensity, can be measured
using pain scales)
T: timing (occasional, intermittent, constant)
Maria Carmela L. Domocmat, RN, MSN
23. OLD CARTS
Onset
Location
Duration
Character
Aggravating/Alleviating Factors
Radiation
Timing
Severity
Maria Carmela L. Domocmat, RN, MSN
25. This is a simple descriptive pain intensity
scale that ranges pain intensity from no pain
to worst pain.
Maria Carmela L. Domocmat, RN, MSN
26. P: palliating or provoking factors
Q: quality of pain (what words does the person
use to describe pain)
R: radiation of pain (does the pain extend from
the site)
S: severity of pain (intensity, can be measured
using pain scales)
T: timing (occasional, intermittent, constant)
Registered Nurses' Association of Ontario
(RNAO) Recommended Verbal Assessment
(RNAO, 2007)
Maria Carmela L. Domocmat, RN, MSN
27. Character
Onset
COLDSPA Location
Duration
Severity
Pattern
Associated Factors
Maria Carmela L. Domocmat, RN, MSN
28. Character: describe the sign or symptom;
how does it feel, look, sound, smell, and so
forth?
Onset: when did it begin?
Location: where is it?, does it radiate
Duration: how long does it last?
Severity: how bad is it?
Pattern: what makes it better? what makes it
worse?
Associated Factors: what other symptom
occur with it?
Maria Carmela L. Domocmat, RN, MSN
32. Visual Analog Scale (VAS)
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
34. a verbal tool where a scale of 0-10 pain
intensity is asked to the patient. The patient
then states pain from 0-10 where 0 is no pain
and 10 is worst pain
Maria Carmela L. Domocmat, RN, MSN
37. Shows different facial expression where the
client is asked to choose the face that best
describes the intensity or level of pain
esp for pediatric client
Maria Carmela L. Domocmat, RN, MSN
41. The Abbey Pain Scale is suitable for residents
with dementia who cannot verbalise their
pain, and may also be useful for cognitively
intact residents who aren't willing or cannot
talk about their pain.
http://www.racgp.org.au/silverbookonline/images/tools_abbey_pain_scale
.gif
Maria Carmela L. Domocmat, RN, MSN
45. 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.
http://www.racgp.org.au/silverbookonline/images/tools_pain_inventory.gif
Maria Carmela L. Domocmat, RN, MSN
50. Observe posture
Normal findings:
Posture is upright when the client feels comfortable,
attentive and
without excessive changes in position and posture
Abnormal findings:
client appears to be slumped with the shoulders not
straight (indicates being disturbed/uncomfortable)
May be guarding affected area and have breathing
patterns reflecting distress
Maria Carmela L. Domocmat, RN, MSN
51. Observe facial expression
Normal findings:
Smiles with appropriate facial expressions
Maintains adequate eye contact
Abnormal findings:
Facial expression may indicate distress and discomfort
Frowning
Moans
Grimacing
Cries
Fear
Sadness
Disgust
Eye contact is not maintained, indicating discomfort
Maria Carmela L. Domocmat, RN, MSN
52. Inspect joints and muscles
Normal findings:
Joints appear normal – no edema
Muscles appear relaxed
Abnormal findings:
Edema of joints may indicate injury
Pain may result in muscle tension
Maria Carmela L. Domocmat, RN, MSN
53. Observe skin for scars, lesions, rashes,
changes or discolorations
Normal findings:
No inconsistency, wounds, or bruising is noted
Abnormal findings:
Bruising, wounds, or edema may be the result of
injuries or infections, which may cause pain
Maria Carmela L. Domocmat, RN, MSN
55. HR
Normal finding: 60-100 bpm
Abnormal finding: increased HR may indicate
discomfort or pain
Maria Carmela L. Domocmat, RN, MSN
56. RR
Normal finding: 12-20 breathes per min
Abnormal finding: RR may be increased;
breathing may be irregular and shallow
Maria Carmela L. Domocmat, RN, MSN
57. BP
Normal finding:100-130/60-80
Abnormal finding: increased BP often occurs in
severe pain
Maria Carmela L. Domocmat, RN, MSN
58. Other observations r/t specific part
Palpation of abdomen
ROM tests for joints
Maria Carmela L. Domocmat, RN, MSN
61. Actual diagnoses
Acute pain r/t injury agents (biological,
chemical, physical or psychological)
Chronic pain r/t chronic inflammatory process of
rheumatoid arthritis
Ineffective breathing pattern r/t abdominal pain
and anxiety
Fatigue r/t stress of handling chronic pain
Impaired physical mobility r/t chronic pain
Bathing /hygiene self-care deficit r/t severe pain
(specify)
Maria Carmela L. Domocmat, RN, MSN
62. Risk diagnoses
Risk for activity intolerance r/t chronic pain and
immobility
Risk for constipation r/t nonsteroidal anti-
inflammatory agents or opiates intake or poor
eating habits
Risk for spiritual distress r/t anxiety, pain, life
changes, and chronic illness
Risk for powerlessness r/t chronic pain,
healthcare environment, pain treatment-related
regimen
Maria Carmela L. Domocmat, RN, MSN
63. Wellness diagnoses
Readiness for enhanced spiritual well-being r/t
coping with prolonged physical pain
Readiness for enhanced comfort level
Maria Carmela L. Domocmat, RN, MSN