Nursing Assessment of Pain
The highly subjective nature of pain makes pain assessment and management challenges for every clinician. In assessing a patient with pain, the nurse reviews the patient’s description of the pain and other factors that may influence pain (eg, previous experience, anxiety, and age) as well as the person’s response to pain relief strategies. Documentation of the pain level as rated on a pain scale becomes part of the patient’s medical record, as does a record of the pain relief obtained from interventions.
Pain assessment includes determining what level of pain relief the acutely ill patient believes is needed to recover quickly or improve function, or what level of relief the chronically or terminally ill patient requires to maintain comfort. Part of a thorough pain assessment is to understand the patient’s expectations and misconceptions about pain. A person who understands that pain relief not only contributes to comfort but also has tens recovery is more likely to request or self administer treatment appropriately.
CHARACTERISTICS OF PAIN
The factors to consider in a complete pain assessment are the intensity, timing, location, quality, personal meaning, aggravating and alleviating factors, and pain behaviors. The pain assessment begins by observing the patient carefully, noting the patient’s overall posture and presence or absence of overt pain behaviors and asking the person to describe, in his or her own words, the specifics of the pain. The words used to describe the pain may point toward the etiology. For example, the classic description of chest pain that results from a myocardial infarction includes pressure or squeezing on the chest. A detailed history should follow the initial description of pain.
Intensity of pain:
The intensity of pain ranges from none to mild discomfort to excruciating. There is no correlation between reported intensity and the stimulus that produced it. The reported intensity is influenced by the person’s pain threshold and pain tolerance. Pain threshold is the smallest stimulus, for which a person reports pain, and the tolerance is the maximum amount of pain a person can tolerate. To understand variations, the nurse can ask about the present pain intensity as well as the least and the worst pain intensity. Various tools and surveys are helpful to patients trying to describe pain intensity.
Timing of pain:
Sometimes the etiology of pain can be determined when time aspects are known. Therefore, the nurse inquires about the onset, duration, relationship between time and intensity, and whether there are changes in rhythmic patterns. The patient is asked if the pain began suddenly or increased gradually. Sudden pain that rapidly reaches maximum intensity is indicative of tissue rupture, and immediate intervention is necessary. Pain from ischemia gradually increases and becomes intense over a longer time. The chronic pain of arthritis illustrates the usefulness of determining the relationship between time and intensity, because people with arthritis usually report that pain is worse in the morning.
Location of pain:
The location of pain is best determined by having the patient point to the area of the body involved. Some general assessment forms have drawings of human figures, and the patient is asked to shade in the area involved. This is especially helpful if the pain radiates (referred pain). The shaded figures are helpful in determining the effectiveness of treatment or change in the location of pain over time.
The nurse asks the patient to describe the pain in his or her own words without offering clues. For example, the patient is asked to describe what the pain feels like. Sufficient time must be allowed for the patient to describe the pain and for the nurse to carefully record all words that are used. If the patient cannot describe the quality of the pain, words such as burning, aching, throbbing, or stabbing can be offered. It is important to document the exact words used to describe the pain and which words were suggested by the nurse conducting the assessment.
Patients experience pain differently, and the pain experience can mean many different things. It is important to ask how the pain has affected the person’s daily life. Some people can continue to work or study, while others may be disabled. The patient is asked if family finances have been affected. For others, the recurrence of pain may mean worsening of the disease, such as the spread of cancer. The meaning attached to the pain experience helps the nurse understand how the patient is affected and assists in planning treatment.
Aggravating and Alleviating Factors:
The nurse asks the patient what if anything makes the pain worse and what makes it better and asks specifically about the relationship between activity and pain. This helps detect factors associated with pain. For example, in a patient with advanced metastatic cancer, pain with coughing may signal spinal cord compression.
The nurse ascertains whether environmental factors influence pain since they may easily be changed to help the patient. For example, making the room warmer may help the patient relax and may improve the patient’s pain. Finally, the patient is asked if pain is influenced by or affects the quality of sleep or anxiety.
Both can significantly affect pain intensity and the quality of life. Knowledge of alleviating factors assists the nurse in developing a treatment plan. Therefore, it is important to ask about the patient’s use of medication (prescribed and over the counter) and the amount and frequency. In addition, the nurse asks if herbal remedies, non pharmacologic interventions, or alternative therapies have been used with success. This information assists the nurse in determining teaching needs.
When experiencing pain, people express pain with many different behaviors. These nonverbal and behavioral expressions of pain are not consistent or reliable indicators of the quality or intensity of pain, and they should not be used to determine the presence of or the degree of pain experienced.
Patients may grimace, cry, rub the affected area, guard the affected area, or immobilize it. Others may moan, groan, grunt, or sigh. Not all patients exhibit the same behaviors, and there may be different meanings associated with the same behavior.
Sometimes in the nonverbal patient, pain behaviors are used as a proxy to assess pain. It is unwise to make judgments and formulate treatment plans based on behaviors that may or may not indicate pain. In the case of an unconscious person, pain should always be assumed to be present and treated. All patients have a right to adequate pain management.
Physiologic responses to pain, such as tachycardia, hypertension, tachypnea, pallor, diaphoresis, mydriasis, hypervigilance, and increased muscle tone, are related to stimulation of the autonomic nervous system. These responses are short-lived as the body adapts to the stress.
These physiologic signs could be the result of a change in the patient’s condition, such as the onset of hypovolemia. Using physiologic signs to indicate pain is unreliable. Although it is important to observe for any and all pain behaviors, the absence of these behaviors does not indicate an absence of pain.