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Pain Assessment
ผูช
้ ว่ ยศาสตราจารย์แพทย์หญิงลักษมี ชาญเวชช์
โรงพยาบาลวัฒโนสถ ศูนย์การแพทย์โรงพยาบาลกรุงเทพ
งานประชุมโรงพยาบาลพระจอมเกล้าฯ เพชรบุรี
10 มีนาคม 2551
Objective
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Important of pain assessment
Barriers in pain assessment
Standards of pain management
Tools for pain measurement
How is the assessment of
pain important?
Pain
• “…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
Pain
• 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
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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
• Chronic pain
• Breakthrough pain
• Recent onset,
transient, identifiable
cause
• Persistent or recurrent
pain, beyond usual
course of acute illness
or injury
• Transient pain, severe
or excruciating, over
baseline of moderate
pain
Identify Pain Syndromes
• Syndrome identification can direct assessment
and predict treatment efficacy
• Cancer pain syndromes
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Bone pain
Pathologic fracture
Cord compression
Bowel obstruction
• Noncancer-related pain syndromes
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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
school
• Insufficient knowledge
• Lack of pain-assessment skills
• Rigidity or timidity in prescribing
practices
• 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
control
• Unavailability of opioid
analgesics
• Inaccessibility of specialized
care
• Lack of insurance coverage
for outpatient pain medication
Pain Assessment Standard
• Pain as the fifth vital sign
• Joint Commission on Accreditation
of Healthcare Organizations
(JCAHO)
• 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
facilities
• Implementation of strategies
required in 2001 to continue
accreditation
– Comprehensive Accreditation Manual for Hospitals
1999: www.jcaho.org
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
relieved
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
sign
• Standardized assessment sheets to
document effects and treatment of
complications
• 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,
burning
• Exacerbating/alleviating factors—position,
activity, weight bearing, cutaneous
stimulation
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.,
angina)
• Paroxysmal:
– neuropathic pain
• Continuously fluctuating pain:
– musculoskeletal pain
Characteristics for the Pain Type (cont.)
Quality
• 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
Tools
for pain measurement
•Unidimensional
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
Nociception
Disability
Pain
Other physical symptoms
Physical impairment
Neuropathic
mechanisms
Psychologic
processes
Social isolation
Family distress
Sense of loss or inadequacy
Adapted with permission from Portenoy RK. Lancet. 1992;339:1026.
•Multidimensional
BPI
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
administration,
2) within one hour of oral drug
administration,
3) with each report of new or changed
pain
Conclusions
• 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