Pain Assessment ผู้ช่วยศาสตราจารย์แพทย์หญิงลักษมี ชาญเวชช์ โรงพยาบาลวัฒโนสถ ศูนย์การแพทย์โรงพยาบาลกรุงเทพ งานประชุมโรงพยาบาลพระจอมเกล้าฯ เพชรบุรี 10 มีนาคม 2551

Objective 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 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 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

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 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 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 as the fifth vital sign Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Should be documented: flow sheet Pain Assessment Standard

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 The Pain as the 5th Vital Sign

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:

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

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 Patients Rights

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 Patient Responsibilities

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 5 th 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

Diagnostic studies

Tools for pain measurement

Unidimensional

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 Copyrighted by Mosby, Inc. Pain Intensity Rating

Sample of Child’s FACES Pain Rating Scale

Pain and Disability Nociception Other physical symptoms Physical impairment NeuropathicPsychologic Social isolation mechanismsprocessesFamily distress Sense of loss or inadequacy Adapted with permission from Portenoy RK. Lancet. 1992;339:1026. Pain Disability

Multidimensional

BPI

Neuropathic Pain Scales

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

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