Pain - The Fifth Vital Sign
• Pain is a complex, subjective experience
that originates from the central nervous
system (CNS) or the peripheral nervous
system (PNS) or both
• Nerve endings known as nociceptors
located within the skin are designed to
detect painful sensations from the
periphery and transmit them to the CNS
• Pain occurs on cellular level, and may recur
after initial injury heals
Nociception
• This term describes how stimuli are
perceived as pain. It has 4 phases:
– Transduction - actual injury or trauma,
that causes release of chemicals that
signal pain message to along afferent
fibers to spinal cord, stopping at dorsal
horn
– Transmission - occurs when the pain
impulse moves from the spinal cord to
the brainstem or thalamus
Nociception
• Perception - conscious awareness of
painful sensation; manifestation of
pain is now possible
• Modulation - inhibits the pain
perception by producing another set
of transmitters that slow down pain
impulse (serotonins and endogenous
opioids)
Neuropathic Pain
• Does not fit the nociceptive model
with its predictable phases
• More difficult to assess and treat,
because causes not well understood
• Often occurs after original injury
heals
• Occurs on neurochemical level that is
undetectable on CAT scan or X-ray
Sources of Pain
• Visceral - in large interior organs
that have been injured, stretched by
tumors, become distended or
contracted; e.g. gall stones,
appendicitis
• Deep somatic pain - in blood vessels,
joints, tendons, muscles, or bone from
pressure, trauma or ischemia; e.g.
fracture, leg cramp
More Pain
• Cutaneous pain - from skin surface
and cutaneous tissues that have been
injured; e.g. paper cut, chemical burn,
sunburn
• Referred pain - felt in one site but
originates in another; e.g.
periumbilical pain in acute
appendicitis; shoulder pain with
ectopic pregnancy
• Psychogenic pain - old term - no
longer used- may be neuropathic
Types of Pain by Duration
• Acute - short-term, following a
predictable pattern; e.g. pain after
surgery, during labor and delivery - is self
protective, as patient will safeguard self
from further injury
• Chronic - pain that lasts longer than 6
months
– Malignant - from cancerous cells that crowd
out other cells and create necrosis and
stretching which leads to pain
– Non-Malignant - often from musculoskeletal
origin and neuropathic in nature
Pain Assessment
• “Pain is whatever the experiencing
person says it is” (McCaffery, 1968)
• Pain report is subjective data and is
the most reliable way to detect pain
• Cultural and gender differences in
manifestation of pain
• Many pain assessment scales (p. 184 -
187)
Objective Measurement of Pain
• During physical exam assess:
– Joints - for inflammation, swelling,
deformity, limitation in Range of Motion
– Muscles and skin - bruising, lesions, open
wounds, atrophy, change in hair
distribution (vascular issues)
– Abdomen - swelling, herniation, organ
enlargement
– Non-verbal behaviors - grimaces,
splinting = protect the hurt part by
holding it
Skin, Hair and Nail Assessment
• Skin is body’s largest organ
• Functions:
– Protection
– Prevents penetration
– Perception/sensation
– Temperature regulation
– Identification
– Communication
– Wound repair
– Absorption and excretion
– Production of vitamin D
Skin – 3 Layers
• Layer #1 of Skin:
– Epidermis- outer layer that is thin, but tough and has 2
layers:
• Stratum germinativum- inner basal cell level that
forms new cells and contains the melanocytes that
produce melanin whiich give tone to skin
• Stratum corneum - outer layer of dead
keratinized cells that are closely packed and
constantly shedding and being replaced from below
– Epidermis is thin except for palms and soles, usually, and
avascular
Skin
– Layer #2 Dermis
• Inner supportive layer, with connective
tissue or collagen; has elastic properties that
allow skin to stretch
• Dermis houses the nerves, sensory
receptors, blood vessels and lymphatics
– Layer #3 Subcutaneous Layer
• Adipose (fat) tissue that stores energy,
provides insulation and cushioning
– Skin color depends on amount of melanin
produced, carotene, and red/purple from
vascular bed, thickness of skin, and presence of
edema
Hair
• All hairs arise from the dermis
through the epidermis
• Hairs are keratin threads
– Fine, faint vellus hair covers most of
body
– Darker, thicker terminal hair covers
scalp, eyebrows, and axilla, pubic area
and male face and chest after puberty
Skin Glands
• Sebaceous glands – produce productive lipid
sebum that is secreted through hair follicles;
forms emulsion that slows water loss from skin.
Appear everywhere but soles and palms, mainly on
scalp, forehead, face, chin
• Sweat glands
– Eccrine – open directly onto skin surface
and produce sweat – regulates
temperature
– Apocrine – open into hair follicles and
produce thick, milky secretion that
reacts with body flora to produce musky
odor; active during puberty, decreases
with aging
Nails
• Hard keratin plates on dorsal edges
of fingers and toes
• Have fine, longitudinal ridges that
become more prominent with aging
• Pink color is from very vascular nail
bed (therefore paler pink with
anemia)
• New nail forms in matrix, which is
protected by nail folds and cuticles
Age Related Changes
• Skin – loses elasticity and gets thinner –
looks more lax and wrinkled, loses collagen,
more prone to injury
• Glands – fewer sweat glands, more prone to
heat stroke
• Lifestyle habits have effect – sun
exposure, smoking
• Hair - fewer functioning melanocytes –
graying; balding determined by genetics
• Nails – grow more slowly, less luster, ridges
Subjective Data
• Review subjective data collection on
p. 225 – 229
• Notice how detailed and
comprehensive these questions are
• Follow-up questions, depending on
answers given
Objective Data Assessment
Skin Assessment gives important clues to
circulation, nutritional status, signs of
systemic disease and lifestyle
Usually this assessment is incorporated into
other body system assessment, but it is easy
to start with handshake and look at nails and
temperature of skin
Special attention to skin folds that can be
infected or have skin breakdown
Lighting very important, especially for dark
pigmented skin or assessing rashes
Inspect and Palpate
• Color – skin tone and consistency (even or
uneven?)
– Pigmentation – freckles, nevi (moles),
birthmarks
– Danger signs: ABCDE: Asymmetry, Borders
irregular, Color variation, Diameter >6mm,
Elevation or Enlargement
– Pallor, Erythema, Cyanosis
• Temperature – warm, cool, localized differences
• Moisture – diaphoretic (sweaty) or dehydrated
• Texture – smooth, and firm or dry and rough (even
or uneven?)
• Thickness – calluses often occupation related
More Inspect and Palpate
• Edema – fluid in intercellular spaces
– Rate 1+ - 4+ depending on severity of pitting
• Mobility and turgor - measure of elasticity
– Less in dehydration or with edema
• Vascularity or bruising – abuse, clotting
problems
• Document tattoos – inquire where acquired
• Lesions, skin ulcers - palpate wearing
gloves if open skin or rash ***KNOW
PRIMARY LESIONS p. 252 - 253
• Assess for infestation or infection –
fungus common in skin folds, or tinea
capitis (ringworm)
Hair and Nail Assessment
• Hair • Nails
• Color • Shape and
• Texture Contour
– fine, thick, • Consistency
straight, curly,
kinky • Color
• Distribution • Capillary refill
• Lesions
• Hygiene
Organizing the Data
• Identifying Nursing Diagnoses
• Possibilities:
– Impaired skin integrity
– Risk of infection
– Self-care deficit (cast, etc)
– Body-image disturbance ( serious acne,
psoriasis, etc)
• E.g. Altered skin integrity related to insect bites
as evidenced by red wheals on both lower legs and
forearms
– Self-care deficit related to obesity as
evidenced by poor hygiene on both feet
Common Alterations
• Diabetes: Infection, ulceration
• Liver disease: Jaundice, spider angioma
• Scleroderma – thickening of skin with hair
loss – due to overgrowth of collagen
• Cancer- melanoma, basal cell, squamous cell,
Kaposi sarcoma – assoc with AIDS, dark
splotches
• Protein malnutrition- changes in hair,
kwashiorkor
• Vitamin deficiencies- petechiae (tiny
bleeds under skin), purpura, hyperkeratosis
More Common Alterations
• Fluid Balance- excess (edema) and
deficit (dehydration)
• Impaired oxygenation-
– CAD - pallor, cyanosis, flushing
– PVD- cold, mottled, pale , necrosis,
gangrene
• Infection & Infestation
– Bacterial- impetigo, folliculitis,
furuncles, boils, carbuncles
– Viral and fungal infections
– Infestations (lice)