In order to select the most appropriate treatment is necessary to identify the mechanism of injury how it happened. Some key questions include:. The words patients use to describe their pain can often help to differentiate between pain arising from either nociceptive or neuropathic mechanisms Box 2 , although there is some crossover and other knowledge will need to be used to determine the main cause of the pain. Pain is usually easier to locate accurately when it is acute and somatic - that is, related to some sort of superficial tissue damage.
Deeper pain and chronic pain tend to be harder to pinpoint. Pain may have a specific cause, such as osteoarthritis of the hip, but the pain from this is often felt in a number of places including the back, groin and knee Izumi et al, Pain that arises from disease or injury to hollow organs viscera may also be felt in a distant cutaneous site.
Fig 2 attached gives examples of the locations of referred pain. In many cases, patients can explain or point to the site of pain but if that is not possible - usually because of complexity - they can draw their pain onto a body diagram Fig 3, attached. This involves moving the site of their pain and other sensory symptoms such as pins and needles on a black body diagram. Patients spontaneously choose to use different types of shading to denote different sensations, so these prove to be an effective communication tool.
Body diagrams can also offer an insight into the psychological impact of pain: distress and frustration are often marked with shading that is very dense, with longer lines that sometimes extend beyond the body Fishbain et al, ; again, the patient makes a spontaneous choice without guidance to use the tool in this way, providing health professionals with a valuable insight. Some types of pain are associated with specific symptoms - for example, sweating, pallor, nausea and vomiting are common in patients experiencing abdominal pain, while aura flashing lights, blurred vision, weakness, numbness, difficulty speaking is often associated with migraine.
Noting these symptoms is therefore relevant when trying to diagnose the cause of a pain. Symptoms associated with pain should also be investigated, such as disrupted sleep, depression, anxiety and inability to work. Post-operative pain is an example of an acute pain that should gradually improve over a relatively short period until the patient is pain free and able to return to, more or less, normal levels of activity. However, many patients find that their activity, sleep and mood may be disrupted by pain for weeks following surgery Leegaard et al, ; Wiggins, Althaus et al identified the gradual improvement in post-operative pain for most people, and also demonstrated that those who have poor rate of improvement in pain in the early days are more likely to go on to develop a chronic pain state pain that does not go away.
It is important, therefore, not to just monitor pain over time but also ensure both patients and nurses understand the important of pain management.
Variation in intensity of pain and interference with activities can help to differentiate between different causes of pain. Neuropathic pain - that is pain caused by a damage or dysfunction of the nerves and nervous system, such as painful diabetic neuropathy - tends to be worse at night, and also becomes progressively worse over the course of the day Gilron et al, Arthritic pain tends to be at its worst on waking but reduces over the course of the day Buttgereit, ; Cutolo et al, Post-operative pain also tends to be worse in the morning than later in the day Boscariol et al, This section of the assessment helps diagnose the cause of the pain and also target treatment effectively.
Many pains will be exacerbated by movement: in musculoskeletal pains the exact movements that lead to an increase in pain can help specialists to understand which structures are involved and how; and this can be particularly import in common disorders like low back pain Konstantinou et al, Chest pain can be due to a host of different causes and establishing a link to inspiration, ingestion of food, body position, exercise, or emotion and stress can be the key to differentiating between pleural, gastric and cardiac causes.
Neuropathic pain - for example, trigeminal neuralgia or post-herpetic neuralgia - do not tend to be made worse by movement but may be exacerbated significantly by an innocuous stimulus such as the skin being brushed lightly by a cotton bud or contact with something cold or hot; this is called allodynia. Patients with neuropathic pain also experience a reduction in their threshold to respond to a potentially noxious stimulus. As an example, imagine someone pressing the end of an unfolded paper clip - a blunt point - onto the skin; the pressure needed to evoke pain will be less in the area of neuropathic pain than it would be in areas of normal skin; this is called hyperalgesia.
These concepts are outlined clearly by Jensen and Finnerup Musculoskeletal pain usually responds well to rest; for acute soft-tissue damage, the mnemonic RICE rest, ice, compression and elevation. In chronic pain, RICE is inappropriate because disuse exacerbates pain as muscles weaken.
The patient becomes less supple and flexible, and has a heightened pain response to attempts to build up activity levels again. Acute pain related to tissue damage tends to respond well to pain-relieving medication such as paracetamol, opioids and non-steroidal anti-inflammatory drugs NSAIDs or agents. Chronic pain does not tend to respond as well to these drugs, although they may bring partial relief.
Patients may also be taking adjuvant pain-relieving drugs, such as antidepressants and anticonvulsants, which are more usually associated with chronic pain and, in particular, neuropathic pain.
A number of different issues need to be covered in a medication assessment:. When patients experience side-effects, for example nausea and vomiting, as a result of taking opioids, they may feel that pain is preferable to the side-effects - this will prevent them from using the drug in the most helpful way.
Side-effects, including constipation, cognitive blunting and sedation hangover effects, are important predictors of adherence to acute and chronic pain management strategies. For each of these therapies, it is important to elicit from the patient how they have been used and how much benefit - if any at all - the patient has experienced. There are many patient forums that provide examples of how patients can feel judged during this part of the assessment, sensing that the health professionals are making negative judgements of their efforts to find strategies and therapies to help them cope with the pain.
It is important to use a systematic approach to determine whether each strategy was used in a helpful way, and whether it came at a financial or physical cost that the patient cannot bear indefinitely. Severity or intensity of pain is the aspect commonly used to track recovery, response to treatment or illness trajectory.
Simple numeric scales are effective and, by repeating measurements over time, it is possible to develop a graphical trend showing how pain varies with time and with activities.
Common tools include the numerical rating scale NRS , which involves asking the patients to rate their pain intensity on a scale of , in which 0 means no pain at all and 10 is the worst pain they have ever experienced or the worst imaginable pain.
The NRS works well for adults Williamson and Hoggart, and has sufficient sensitivity to enable patients to communicate changes in their pain over time. An alternative is the visual analogue scale VAS , which is usually presented to the patient in the form of a mm line drawn on paper, or a plastic ruler with a slider; the anchors are the same as on the NRS.
The verbal rating scale VRS consists of a list of words denoting increasing pain intensity:. The most important factor in pain assessment is the self-report of the patient. However, some patients may be reluctant to trigger the assessment so it is vital for nurses to prompt discussion of pain with patients. Pain assessment can be complicated , especially in the initial stages and when there is no obvious acute cause; however, even a simple assessment of pain site and severity can provide enough information for treatment to be started.
Tagged with: Assessment skills: pain. We really do need to get to grips with effective pain management. It exhausts you to a zombie like state -just imagine the patients with long term chronic pain. We are expecting them to maintain their independence and dignity. I will be much more attentive and empathetic having gained insight into pain on a through personal experience. Sign in or Register a new account to join the discussion. You are here: Pain management.
Pain management 3: the importance of assessing pain in adults. Abstract Pain affects patients physically and emotionally, so successfully managing the pain they experience is a key component of their recovery. This article has been double-blind peer reviewed Scroll down to read the article or download a print-friendly PDF here Click here to see other articles in this series. Box 1. Signs of pain Behavioural signs Verbalisation crying out, crying, sobbing Agitation, restlessness Abnormal stillness, rocking, writhing Facial expression tense, grimace, distorted Position guarding, curled, holding tightly Physiological signs Increased respiratory rate Increased heart rate Increased blood pressure Pallor Sweating Nausea Vomiting.
Box 2. Also in this series Pain management 1: physiology - how the body detects pain stimuli Pain management 2: transmission of pain signals to the brain.
Althaus A et al Distinguishing between pain intensity and pain resolution: using acute post-surgical pain trajectories to predict chronic post-surgical pain. European Journal of Pain; 4, Borge CR et al Pain and quality of life with chronic obstructive pulmonary disease. Boscariol R et al Chronobiological characteristics of postoperative pain: diurnal variation of both static and dynamic pain and effects of analgesic therapy.
Canadian Journal of Anaesthesia; 9, Buenaver LF et al Pain-related catastrophizing and perceived social responses: Inter-relationships in the context of chronic pain. Pain ; 3, Buttgereit F How should impaired morning function in rheumatoid arthritis be treated? Scandinavian Journal of Rheumatology, Supplement; Cutolo M et al Circadian rhythms: glucocorticoids and arthritis. Annals of the New York Academy of Sciences; Dobratz MC Word choices of advanced cancer patients: frequency of nociceptive and neuropathic pain.
Eccleston C et al Psychological approaches to chronic pain management: evidence and challenges. British Journal of Anaesthesia; 1, Journal of Pain; 3, Fishbain DA et al A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs.
Pain Medicine; 4: 2, Gilron I et al Chronobiological characteristics of neuropathic pain: clinical predictors of diurnal pain rhythmicity. Das Moenchtum PDF. Das Rechtsinstitut der Liebhaberei. Deuteronomium PDF. Developmental Tasks PDF.
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