1. Pain Assessment: The Fifth Vital Sign
Health Assessment Across the Lifespan
NRS 102

2. Structure and Function
Neuroanatomic pathway
Nociception
Neuropathic pain
Sources of pain
Types of pain

3. Neuroanatomic Pathway
Nociceptors
Interneurons
Anterolateral spinothalamic tract

4. Neuroanatomic Pathway (cont.)

5. Nociception
Transduction
Transmission
Perception
Modulation

6. Nociception (cont.)

7. Neuropathic Pain Abnormal processing of pain message
Most difficult type of pain to assess and treat
Neurochemical level

8. Sources of Pain Visceral pain Deep somatic pain Cutaneous pain
Referred pain
Visceral pain originates from larger interior organs. The pain can stem from direct injury or stretching. Examples include ureteral colic, acute appendicitis, ulcer pain, and cholecystitis. It is transmitted by ascending nerve fibers along with nerve fibers of the autonomic nervous system, hence presentation is with autonomic responses (vomiting, nausea, pallor, and diaphoresis).
Deep somatic pain comes from blood vessels, joints, tendons, muscles, and bone. Injury may result from pressure, trauma, or ischemia.
Cutaneous pain is derived from skin surface and subcutaneous tissues. The injury is superficial, with a sharp, burning sensation.
Referred pain is felt at a particular site but originates from another location. Both sites are innervated by the same spinal nerve, and it is difficult for the brain to differentiate the point of origin.

9. Common Sites for Referred Pain
© Pat Thomas, 2006.

10. Types of Pain Acute pain Chronic pain Short term Self-limiting
Follows a predictable trajectory
Dissipates after injury heals
Chronic pain
Continues for 6 months or longer
Types are malignant (cancer related) and nonmalignant
Does not stop when injury heals

11. Subjective Data—Health History
Pain assessment questions
Pain assessment tools

12. Pain Assessment Questions
Questions to ask:
Where is your pain?
When did your pain start?
What does your pain feel like?
How much pain do you have now?
What makes the pain better or worse?
How does pain limit your function/activities?
How do you behave when you are in pain? How would others know you are in pain?
What does pain mean to you?
Why do you think you are having pain?
Note to faculty: Because of the amount of text used on this screen, each bullet point is set to appear on a mouse click. This will prevent your students from reading ahead and being distracted.

13. Pain Assessment Tools Initial pain assessment Brief pain inventory
Pain rating scales
Numeric rating scales
Descriptor scale

14. Initial Pain Assessment
From McCaffery M, Pasero C: Pain: Clinical manual, ed 2, St. Louis, 1999, Mosby.

15. Brief Pain Inventory
From McCaffery M, Pasero C: Pain: Clinical manual, ed 2, St. Louis, 1999, Mosby.

16. Objective Data—Physical Exam
Joints—note
Size/contour/circumference
AROM/PROM
Muscles/skin—inspect
Color/swelling
Masses/deformity
Sensation changes

17. Objective Data—Physical Exam (cont.)
Abdomen—inspect and palpate
Contour/symmetry
Guarding/organ size
Pain behavior—inspect
Nonverbal cues
Acute pain behavior
Chronic pain behavior

18. Acute Pain Behaviors Guarding Grimacing Vocalizations such as moaning
Agitation, restlessness
Stillness
Diaphoresis
Change in vital signs
Note to faculty: Because of the amount of text used on this screen, each bullet point is set to appear on a mouse click. This will prevent your students from reading ahead and being distracted.

19. Chronic Pain Behaviors
Bracing
Rubbing
Diminished activity
Sighing
Change in appetite
Being with other people
Movement
Exercise
Prayer
Sleeping
Note to faculty: Because of the amount of text used on this screen, each bullet point is set to appear on a mouse click. This will prevent your students from reading ahead and being distracted.

20. Sample Charting

21. Abnormal Findings Reflexive sympathetic dystrophy
Follows trauma to the nerve
Most commonly appears in 40- to 60-year-old men and women

22. Which type of pain would cholecystitis (gallbladder disease) cause?
Somatic
Visceral
Cutaneous
Chronic
Correct Answer: B. Visceral.

23. What anticipated finding regarding patients with chronic pain should guide a nurse’s care planning?
Patients with chronic pain have trouble sleeping.
Patients with chronic pain show elevated blood pressures.
Patients with chronic pain need less medication.
Patients with chronic pain may show few or no outward signs of pain.
Correct Answer: D. Patients with chronic pain may show few or no outward signs of pain.