Chapter 11 - Pain Assessment
what are tools we can use to help assess chronic pain in infants ?
-CRIES score- measures behavior, vital signs -FLACC scale- nonverbal scale that measures overall behavior (0-2)
what are the sources of pain
-visceral -somatic -cutaneous -referred
what is the difference between A and C fibers?
A fibers: -myelinated -larger in diameter -transmit pain signal RAPIDLY to CNS -sensation is localized and short-term, sharp C fibers: -unmyelinated -smaller in diameter -transmit pain signals SLOWLY to CNS -have "secondary" sensations (diffuse and aching) that last long
____ and ____ cultural populations are less often often prescribed and administered analgesic therapy (acting to relieve pain) than White patients
African Americans and Hispanic
Which conditions are associated with visceral pain? Select all that apply. Arthritis Appendicitis Fibromyalgia Cholecystitis Kidney stones
Appendicitis Cholecystitis
Patients with which conditions are at risk for chronic nonmalignant pain? Select all that apply. Arthritis Fibromyalgia Low back pain Skin infection Thyroid disorder
Arthritis Fibromyalgia Low back pain
fear, anxiety, fatigue
CNS
pain originates from ...?
CNS and PNS
Which criteria are assessed using the PAINAD pain assessment scale? Select all that apply. Visual acuity Consolability Facial expression Hearing ability Body language
Consolability Facial expression Body language
Which pain assessment tool is appropriate for a 2-year-old patient? FLACC scale CRIES scale PAINAD scale Faces Pain Scale-Revised (FPS-R)
FLACC scale The FLACC scale is a nonverbal pain assessment tool that is used to assess the intensity of pain in infants and children under 3 years of age by observing the facial expression, leg movement, activity level, cry, and consolability in the child; the scale gives a score from 0 to 10. The CRIES scale is a 3-point scale that helps assess postoperative pain in preterm infants and neonates. The PAINAD scale is a pain assessment tool that helps measure pain in patients with dementia. It uses breathing, vocalization, and facial expression as assessment tools. Faces Pain Scale-Revised (FPS-R) is a pain assessment tool that helps assess the intensity of pain through drawings of different facial expressions.
Which examination visualizes neurochemical changes in the brain caused by nociception? X-ray examination (x-ray film) Computerized axial tomography (CAT) scan Functional magnetic resonance imaging (fMRI) Traditional magnetic resonance imaging (MRI)
Functional magnetic resonance imaging (fMRI)
Which associated disorders may be found in a patient with neuropathic pain? Select all that apply. Herpes zoster Liver metastasis Postoperative pain Trigeminal neuralgia Distal polyneuropathy
Herpes zoster Trigeminal neuralgia Distal polyneuropathy
Opioids inhibit which part of nociception? Secretion of glutamate and adenosine triphosphate at the synaptic cleft Secretion of histamine, bradykinin, and prostaglandins at the site of injury Movement of the pain impulse across the synaptic cleft to the dorsal horn neurons Movement of the pain impulses from the spinal cord to the thalamus via the ascending fibers
Movement of the pain impulses from the spinal cord to the thalamus via the ascending fibers
does chronic pain stop when the injury heals?
NO
Is pain a normal process of aging?
NO, it indicates pathology or injury
Which type of pain does the nurse document in the medical record for a patient with herpes zoster (shingles) who reports a pain level 10/10? Somatic Visceral Nociceptive Neuropathic
Neuropathic
During a pain assessment, the nurse asks the patient, "What does your pain feel like?" The patient responds, "I have numbness and tingling and occasionally shooting pain." The nurse reports which type of pain to the provider? Neuropathic Breakthrough Nociceptive visceral Nociceptive somatic
Neuropathic The nurse reports that the patient has neuropathic pain because its characteristics including burning, shooting, and tingling. Breakthrough pain occurs beyond the chronic pain that is already being treated by appropriate analgesics. Nociceptive pain originating from visceral sites is described as aching if localized, and as cramping if poorly localized. Nociceptive pain originating from somatic sites is described as aching or throbbing.
Which condition is associated with deep somatic pain? Tendinitis Stomach and intestinal pain Back pain upon changing positions Coronary syndrome with pain in the neck
Tendinitis
Which is the purpose of functional magnetic resonance imaging (fMRI)? To determine the source of pain To help control the pain To find a genetic link for the pain To assess the intensity of the pain
To help control the pain
which pain rating scale uses words to describe the patient's feelings and the meaning of the pain for the person
Verbal Descriptor Scale
which pain rating scale lets the patient make a mark along a 10-cm horizontal line from "no pain" to "worst pain imaginable"
Visual Analogue Scale
what is an example of referred pain?
an inflamed appendix in the right lower quadrant of the abdomen may have referred pain in the periumbilical area the pain from an acute coronary disease may be felt in the left arm or neck
how can children less than 2 years old tell you their pain?
behavioral, sleep, eat, vital signs, cry
a transient spike in pain level, moderate to severe in intensity, in an otherwise controlled pain system
breakthrough pain
what can be a result from end-of-dose medication failure?
breakthrough pain
tachycardia, elevated blood pressure, increased myocardial oxygen demand, increased cardia input
cardiac
why should pain be avoided during gestation?
causes stress on fetus
arthritis, low back pain, or fibromyalgia are examples of what type of pain?
chronic nonmalignant pain
diagnosed when the pain continues for 6 months or longer. can be malignant or nonmalignant
chronic pain
signs such as bracing, rubbing, diminished activity, sighing, and change in appetite show..?
chronic pain behaviors
pain that is derived from the skin surface and subcutaneous tissues
cutaneous pain
pain that is described as superficial, sharp, or burning
cutaneous pain
pain that comes from sources such as the blood vessels, joints, tendons, muscle, and bone
deep somatic pain
which pain rating scale lists words that describe different levels of pain intensity such as no pain, mild pain, moderate pain, and severe pain
descriptor scale
how does dementia affect pain?
does not impact the ability to feel pain, but it does impact the person's ability to effectively use self-report instruments (asses body language instead of verbal communication)
increased adrenergic activity
endocrine
nausea, vomiting, ileus (intestinal obstruction by food?)
gastrointestinal
impaired cellular immunity, impaired wound healing
immune
Where are nociceptors located?
in the skin, connective tissue, muscle, thoracic, abdominal and pelvic viscera
_____ are insufficient until birth
inhibitory transmitters
this phase in the nociceptive pain inhibits the pain message. if not for this the experience of pain would continue from childhood injuries to adulthood
modulation
spasm, joint stiffness
musculoskeletal
burning, shooting, and tingling
neuropathic pain
pain that does not adhere to the typical and rather predictable phases in nociceptive pain. it is pain due to lesion or disease. this type of pain is most difficult to assess and treat.
neuropathic pain
pathologic pain develops by what 2 main processes?
nociceptive and/or neuropathic processing
aching, throbbing
nociceptive pain
develops when functioning and intact nerve fibers in the periphery and CNS are stimulated
nociceptive pain
special nerve endings called ____ are designed to detect painful sensations from the periphery and transmit them to the CNS
nociceptors
which pain rating scale asks the patient to choose a number that rates the level of pain for each painful site (0-10)
numeric rating scales
low urine output
oliguria
which type of pain assessment tool would you use for chronic pain conditions or particularly problematic acute pain problems?
overall pain assessment tools
this phase in nociceptive pain signifies the conscious awareness of a painful sensation
perception
what do opioid medications do ?
produce pain relief and euphoria
the pain impulse moves form the level of the spinal cord to the brain in this stage of nociceptive pain
transmission
T/F: pain should not be something you tolerate or accept
true
how can children 4-5 years tell you their pain?
using the Wong-Baker FACES pain rating scale
the puncture of a vein as part of a medical procedure, typically to withdraw a blood sample
venipuncture
pain that is described as dull, squeezing, deep, cramping
visceral pain
in fetal development, ascending sensory fibers, neurotransmitters, and connections to the thalamus are developed by what week of gestation?
20 weeks
what is pain?
-whatever the experiencing person says it is, existing whenever he or she says it does -If the patient says it's a 10, we document a 10, but do write down if she is able to walk
what conditions may cause neuropathic pain?
-diabetes -herpes zoster (shingles) -HIV/AIDS -phantom limb pain -chemotherapy -stroke -multiple sclerosis -tumor
nociceptive pain can be divided into what 4 categories?
1. transduction 2. transmission 3. perception 4. modulation
Which pathologic disorders are associated with nociceptive pain? Select all that apply Arthritis Mechanical back pain Central poststroke pain Carpal tunnel syndrome Complex regional pain syndrome
Arthritis Mechanical back pain
Which is an expected finding in a patient with diabetic peripheral neuropathy? Burning pain in feet bilaterally Brittle nails with pale, shiny, dry skin Severe stabbing or piercing pain in face Burning, shooting pain in glove-and-stocking manner
Burning pain in feet bilaterally The diabetic patient with peripheral neuropathy shows symptoms of burning pain in the feet bilaterally, which worsens during the night. The patient with reflexive sympathetic dystrophy has brittle nails, and the skin appears pale, dry, and shiny. Patients with trigeminal neuralgia have severe stabbing or piercing pain in the facial area. Cancer patients who undergo chemotherapy may develop chemotherapy-induced peripheral neuropathy. This symptom manifests as burning, shooting pain in glove-and-stocking manner.
Which pain scale would the nurse use to assess the pain level in a 6-year-old child? Faces pain scale Visual analog scale Numeric rating scale Verbal descriptor scale
Faces pain scale
Which neurotransmitters are released at the site of injury? Select all that apply. Glutamate Histamine Bradykinin Prostaglandin Gamma-aminobutyric acid
Histamine Bradykinin Prostaglandin
A patient with carpal tunnel syndrome reports having a tingling and burning sensation in the thumb, middle, and index fingers. Which type of pain would the nurse report to the provider? Referred Cutaneous Nociceptive Neuropathic
Neuropathic The presence of a tingling, burning sensation in the thumb, middle, and index fingers indicates that the patient has neuropathic pain. It is caused by impaired processing of the pain impulses from the site of injury to the nerve fibers. The patient with referred pain has an injury at a particular site, but experiences pain at other sites of the body. Referred pain is caused by damage to a spinal nerve, which sends signals to two different parts of the body. If the patient has pain resulting from skin surface damage, it indicates that the patient has cutaneous pain. Nociceptive pain is associated with aching, throbbing, and a cramping sensation. Because the patient does not report having any aching or throbbing sensation, the nurse would not interpret that the patient has nociceptive pain.
what pain assessment tool can be used for people with dementia?
PAINAD scale
A patient with joint pain has edema and skin discoloration at the knees. The patient feels severe knee pain when the nurse touches the affected area with a cotton swab. The nurse also observes the patient has pale, dry, shiny skin and brittle nails. Which would the nurse anticipate administering to the patient? Select all that apply. Aspirin Pregabalin Prednisone Amitriptyline Acetaminophen
Pregabalin Prednisone Amitriptyline The presence of pale, dry skin, brittle nails, joint pain, edema, and discoloration of the affected extremity indicates that the patient has complex regional pain syndrome (CRPN). Damaged nerves result in impaired functioning of the sensory, motor, and autonomic nerves. Because of nerve damage, the patient feels severe pain even with the contact of a cotton swab. Pregabalin, prednisone, and amitriptyline block the pain impulses from the damaged nerves and help alleviate pain and inflammation. Therefore the primary health care provider would prescribe these medications to the patient. Aspirin and acetaminophen reduce prostaglandin levels and alleviate nociceptive pain. These drugs do not repair damaged nerve fibers and do not alleviate neuropathic pain.
A patient with a severe muscle cramp tells the nurse, "The pain is a little better when I massage the muscle or apply a cold pack." Which criterion of the PQRST method of pain assessment is addressed in the patient's statement? Severity Scale Quality/Quantity Region/Radiation Provocation/Palliation
Provocation/Palliation PQRST is a pain assessment scale; it stands for Provocation/Palliation, Quality/Quantity, Region/Radiation, Severity Scale, and Timing. Because the patient is describing methods that provide comfort and relieve the pain, it indicates that the patient is addressing Provocation/Palliation. If the patient reports about severity of pain on a scale of 0 to 10, then it indicates that the patient is addressing Severity. When addressing the Quality/Quantity of the pain, the patient describes the pain felt. If the patient reports about the site of pain, then the patient is addressing Region/Radiation.
Which phase of nociceptive pain involves the release of bradykinin and prostaglandins? Perception Modulation Transmission Transduction
Transduction
what are the initial pain assessment questions?
Where is your pain? When did your pain start? What does your pain feel like? -Burning, stabbing, aching Throbbing, fire life, squeezing How much pain do you have now? What makes your pain better or worse? How does pain limit your function or activities? How do you usually behave when you are in pain? How would others know you are in pain? What does this pain mean to you? Why do you think you are having pain?
what are examples of nociceptive pain?
aching/throbbing pain -skinned knee -kidney stones -menstrual cramps -muscle strain -arthritic joint pain -venipuncture- the puncture of a vein as part of a medical procedure, typically to withdraw a blood sample
what are the 2 types of pain?
acute (started recently) less thna 2 weeks chronic (persistant) more than 2 weeks
short term and self-limiting pain (surgery, trauma, kidney stones)
acute pain
signs such as guarding, grimacing, moaning, agitation, restlessness, stillness, diaphoresis(sweating), or change in vital signs show ..?
acute pain behaviors
what is incident pain and provide an example
an acute type of pain that happens predictably when certain movements take place ex: pain in the lower back on standing or whenever turning a hospitalized patient from side to side
pain that is described as aching or throbbing
deep somatic pain
The patient with severe pain after surgery that is uncontrolled by regular analgesic administration is tachycardic and hypertensive. The nurse assesses the patient for which additional physiologic changes caused by uncontrolled pain? Select all that apply. Oliguria Joint stiffness Decreased respiratory rate Decreased adrenergic activity Decreased myocardial oxygen demand
oliguria joint stiffness If pain is not properly managed, the patient may have several uncontrolled pain responses, including oliguria, and joint stiffness. Severe pain increases, rather than decreases, the respiratory rate, adrenergic activity, and myocardial oxygen demand.
depression, isolation, limited mobility and function, confusion, family distress, diminished quality of life are all examples of..?
poorly controlled chronic pain
hypoventilation, hypoxia, decreased cough, atelectasis (collapse of the lung)
pulmonary
pain that is felt at a particular site but originates from another location
referred pain
oliguria (low urine output), urinary retention (inability to completely or partially empty the bladder)
renal (kidney)
pain that originates from musculoskeletal tissues or body surfaces
somatic pain
which type of pain assessment tool asks the patient to rate the pain within the past 24 hours using graduated scales (0-10) with respect to its impact on areas such as mood, walking ability, and sleep
the brief pain inventory
which type of pain assessment tool asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain
the short-form McGill Pain Questionnaires
how can children over 2 years old tell you their pain?
they can point
occurs when a noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery. Chemicals such as substance P, histamine, prostaglandins, serotonin, and bradykinin are released
transduction
pain that originates from the larger internal organs (stomach, intestine, gallbladder, pancreas. dull, squeezing, deep, cramping
visceral pain
