Pain Assessment Slide neuralgia by mikeholy


									                 Pain Assessment
       ผู้ช่วยศาสตราจารย์แพทย์หญิงลักษมี ชาญเวชช์
โรงพยาบาลวัฒโนสถ ศูนย์การแพทย์โรงพยาบาลกรุงเทพ
                  งานประชุมโรงพยาบาลพระจอมเกล้าฯ เพชรบุรี

                                          10 มีนาคม 2551
•   Important of pain assessment
•   Barriers in pain assessment
•   Standards of pain management
•   Tools for pain measurement
How is the assessment of
          pain important?
• “…whatever the experiencing person says it
  is, existing whenever s/he says it does”
• A subjective experience so we should have
  self reporting as a reliable indicator

•   McCaffery M. 1968
• An unpleasant sensory and emotional
  experience associated with actual or
  potential tissue damage, or described in
  terms of such damage

• Pain is a complex experience that
  includes multiple dimensions (sensory,
  affective, cognitive)

  International association for the study of pain® 1979
Pain Assessment: Goals

• Characterize the pain
• Identify pain syndrome
• Infer pathophysiology
• Evaluate physical and
  psychosocial comorbidities
• Assess degree and nature of disability
• Develop a therapeutic strategy
Characteristics of Nociceptive Pain
Characteristics of Neuropathic Pain
Characteristics of Neuropathic Pain
Pain Syndromes

• Acute pain          • Recent onset,
                        transient, identifiable
                      • Persistent or recurrent
• Chronic pain          pain, beyond usual
                        course of acute illness
                        or injury
• Breakthrough pain   • Transient pain, severe
                        or excruciating, over
                        baseline of moderate
Identify Pain Syndromes
• Syndrome identification can direct assessment
  and predict treatment efficacy
• Cancer pain syndromes
     •   Bone pain
     •   Pathologic fracture
     •   Cord compression
     •   Bowel obstruction
• Noncancer-related pain syndromes
     •   Atypical facial pain
     •   Failed low-back syndrome
     •   Chronic tension headache
     •   Chronic pelvic pain of unknown etiology
Barriers to appropriate of pain assessment

     • Clinician
     • Patient
     • System
Clinician-Related Barriers to Pain Assessment

 • Lack of pain training in medical
 • Insufficient knowledge
 • Lack of pain-assessment skills
 • Rigidity or timidity in prescribing
 • Fear of regulatory oversight
Patient-Related Barriers to Pain Assessment

 • Reluctance to report pain
 • Reluctance to take opioid drugs
 • Poor adherence
System-Related Barriers to Pain Assessment

 • Low priority given to symptom
 • Unavailability of opioid
 • Inaccessibility of specialized
 • Lack of insurance coverage
   for outpatient pain medication
Pain Assessment Standard
• Pain as the fifth vital sign
• Joint Commission on Accreditation
  of Healthcare Organizations
• Should be documented: flow sheet
The Pain as the 5th Vital Sign
• In 1996, the American Pain Society
  (APS) introduced the phrase “pain as
  the 5th vital sign.”
• Pain assessment is as important as
  assessment of the standard four vital
  signs and that clinicians need to take
  action when patients report pain
• A concept for pain assessment
• More or less frequent assessment
  may be appropriate
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)

 • 6 standards for pain management
 • Apply to all patients in healthcare
 • Implementation of strategies
   required in 2001 to continue

   – Comprehensive Accreditation Manual for Hospitals
JCAHO Standards… cont
• Recognition of the right of the individual
  to appropriate assessment and
  management of pain
• Assessment of pain, and also the nature
  and intensity of pain, in all patients
• Establishment of policies and
  procedures that support the appropriate
  prescribing of effective pain medications
JCAHO Standards… cont
• Education of patients and their families
  about effective pain management
• Addressing of the needs of the individual
  for symptom management in the discharge
  planning process
• Integration of pain management into the
  organization’s performance measurement
  and improvement program
      Patients Rights
As a patient in this hospital, you can expect:
• To receive information about pain and pain
  relief measures
• Treatment by concerned staff committed to
  pain prevention and management
• A quick response to your reports of pain
• Your reports of pain will be believed
• State-of-the-art pain management
• Dedicated pain relief specialists
    Patient Responsibilities
As a patient in this hospital, you are
  expected to:
• Ask you health care providers what to
  expect regarding pain and its management
• Discuss pain relief option with doctors
  and nurses
• Work with healthcare providers to develop
  pain management plans
• Report pain when it first begins
• Help healthcare providers measure pain
  at all stages of your care
• Tell healthcare providers if pain is not
Initial Assessment of Pain
• Standard pain intensity tool throughout
  the hospital (> 1 if pediatric and adult
  populations: Wong-Baker smile/frown,
  visual analogue, 1-10 scale)
• Displayed at bedside
• Regular charting of pain as the 5th vital
• Standardized assessment sheets to
  document effects and treatment of
• Develop trigger for review of pain
  management plan (e.g >4 pain or side
  effect such as respiratory depression)
Comprehensive Pain Assessment

  • History
  • Physical examination
  • Appropriate laboratory and
    radiologic tests
Pain History
• Temporal features—onset, duration,
  course, pattern
• Intensity—average, least, worst, and
  current pain
• Location—focal, multifocal, generalized,
  referred, superficial, deep
• Quality—aching, throbbing, stabbing,
• Exacerbating/alleviating factors—position,
  activity, weight bearing, cutaneous
Characteristics for the Pain Type
 Location and distribution
 • Localized pain:
    – pain confined to site of distribution origin (e.g., cutaneous
      pain, some visceral pain, arthritis)
 • Referred pain:
    – pain that is referred to a distant structure (e.g., visceral
      pain such as angina, appendicitis)
 • Projected (transmitted) pain:
    – pain transferred along the course of a nerve with a
      segmental distribution (e.g., herpes zoster) or a
      peripheral (e.g., trigeminal neuralgia)
 • Dermatomal patterns:
    – peripheral neuropathic pain
 • Nondermatomal:
    – central neuropathic pain, fibromyalgia
 • No recognizable pattern: CRPS
Characteristics for the Pain Type (cont.)
 Duration and periodicity
 • Brief flash:
    – quick pain such as a needle stick
 • Rhythmic pulses:
    – pulsating pain such as a migraine or toothache
 • Longer-duration rhythmic phase:
    – intestinal colic
 • Plateau pain:
    – pain that rises gradually or suddenly to a plateau where it
      remains for a prolonged period until resolution (e.g.,
 • Paroxysmal:
    – neuropathic pain
 • Continuously fluctuating pain:
    – musculoskeletal pain
Characteristics for the Pain Type (cont.)

• Superficial somatic (cutaneous) pain:
   – sharp pricking or burning
• Deep somatic pain:
   – dull or aching
• Visceral pain:
   – dull aching or cramping
• Neuropathic pain:
   – burning, shock-like, lancinating, jabbing,
     squeezing, aching
Characteristics for the Pain Type

Associated signs and symptoms
• Visceral pain:
   – “sickening feeling,”nausea, vomiting,
     autonomic symptoms
• Neuropathic pain:
   – hyperalgesia, allodynia
• Complex regional pain syndrome:
   – hyperalgesia, hyperesthesia, allodynia,
     autonomic changes, and trophic
Physical Examination of a Patient With Pain
Physical Examination of a Patient With Pain
Physical Examination of a Patient With Pain
Diagnostic studies
for pain measurement
Pain Intensity Rating
                                       Pain Intensity Rating

From Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Schwartz P: Wong’s Essentials of Pediatric Nursing, 6/e,
St. Louis, 2001, P. 1301. Copyrighted by Mosby, Inc.
Sample of Child’s FACES Pain Rating Scale
    Pain and Disability



                                               Other physical symptoms
                                               Physical impairment

Neuropathic      Psychologic                   Social isolation
mechanisms       processes                     Family distress
                                               Sense of loss or inadequacy

      Adapted with permission from Portenoy RK. Lancet. 1992;339:1026.
Neuropathic Pain Scales
Neuropathic Pain Scales (cont.)
Neuropathic Pain Scales (cont.)
Cries score
Pain Assessment Techniques
• In infants, behavior must be
  interpreted by using physiological and
  behavioral measures
• CRIES is useful for neonates from 32
  weeks to infants of up to 1 year
• FLACC (full term neonate – 7 years)
• Preschool children (ages 3 to 7) are in
  a transition group in which verbal
  abilities are developing.
Frequency of re-assessment
Acute setting of pain
1) within 30 minutes of parenteral drug
2) within one hour of oral drug
3) with each report of new or changed
• Important of pain assessment
  – Effective pain management
• Standards of pain management
  – Patient rights
  – Hospital accreditaion
• Tools for pain measurement
  – Simple and appropriate
  – Documentation
Thank you

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