Chapter 11: Pain Assessment

Evidence-Based Assessment and Clinical Judgment

• Definition of Evidence-Based Assessment (EBA): It is a systematic collection and evaluation of patient data using assessment methods and tools supported by the best available research evidence, combined with clinical expertise and consideration of the patient’s individual circumstances and preferences.
• Assessment as the Point of Entry: This is an ongoing process involving the collection of data about an individual’s health state. To be effective, the data must be organized, factual, and complete, forming a database that leads to clinical judgment and diagnosis.
• Diagnostic Reasoning: This is the process of analyzing health data and drawing conclusions to identify diagnoses.
  • Novice vs. Expert: Clinical reasoning maturity levels differ; experts use intuition and pattern recognition, while novices follow rules and organized processes.
  • Cues: A cue is a piece of information, a sign, or a symptom. Examples include a patient reporting shortness of breath or the observation of a fever of $38.5^{\circ}\text{C}$.
  • Sign (Objective): Information observed by the nurse, such as a fever or lab result.
  • Symptom (Subjective): Information reported by the patient, such as chest pain rated $7/10$.
• Clinical Manifestations: These refer to how a disease or condition shows up in a patient (e.g., crackles heard in the lungs of a patient with pneumonia).
• Data Clustering: Grouping data that appears related or associated helps recognize patterns based on previous experience.
• Logical Reasoning Pathways: Assessment leads to diagnosis through abductive, deductive, inductive, and logical reasoning.
• Data Validation: Nurses must check data for accuracy and look for gaps or missing information. For example, validating a blood pressure reading by ensuring proper technique.

The Clinical Judgment and Nursing Process

• Step 1: Assessment (Recognize Cues): Gathering data through complete assessment, medical records, patient interviews, and physical assessment.
• Step 2: Diagnosis (Analyze Cues): Analyzing data to determine the specific diagnosis.
• Step 3: Planning (Prioritize Hypotheses & Generate Solutions): Collaborating with the client to formulate goals and outcomes.
  • SMART Goals: Goals must be Specific, Measurable, Attainable, Realistic, and Timely.
  • Example: A patient with an oxygen saturation of $88\%$ has a goal to maintain saturation above $92\%$ within $24\,\text{hours}$.
• Step 4: Implementation (Take Action): Executing planned interventions and independent nursing actions.
• Step 5: Evaluation (Evaluate Outcomes): Determining if goals were met and if reassessment is required.
• Critical Thinking: The ability to actively and skillfully analyze patient information, question assumptions, apply knowledge, and make safe, evidence-based clinical decisions rather than relying on routine actions.
• Determining Priority Problem Levels:
  • First-level Priority: Emergent, life-threatening, and immediate (e.g., airway or breathing issues).
  • Second-level Priority: Next in urgency, requiring attention to avoid further deterioration.
  • Third-level Priority: Important to health but can be addressed after more urgent problems.

Types of Clinical Databases

• Complete (Total Health) Database: Describes current and past health states and forms a baseline for all future changes. Typically conducted in primary care settings.
• Focused or Problem-Centered Database: A "mini" database for a specific problem, used in all settings (hospital, primary care, long-term care).
• Follow-up Database: Evaluates the status of identified problems at regular intervals for both short-term and chronic conditions.
• Emergency Database: Rapid collection of data compiled concurrently with lifesaving measures in an emergency department (ED) setting.
• Holistic Model: Considers the interdependent functioning of mind, body, and spirit.
• Social Determinants of Health: Factors influencing well-being, including environment, healthcare access, community, education, and economic stability.

Vital Signs: Temperature

• Mechanism of Regulation: Regulated by the hypothalamus to maintain a mean core temperature of $37^{\circ}\text{C}$ ($98.6^{\circ}\text{F}$) at rest.
• Influencing Factors:
  • Diurnal Cycle: Variations of $1^{\circ}\text{F}$ to $1.5^{\circ}\text{F}$, with a trough in the early morning and a peak in the late afternoon.
  • Menstruation: Midcycle progesterone secretion during ovulation causes a rise of $0.5^{\circ}\text{F}$ to $1.0^{\circ}\text{F}$ until menses.
  • Exercise: Moderate to hard exercise increases body temperature.
  • Age: Infants have less effective heat control. Older adults generally have lower temperatures, with a mean oral reading of $36.2^{\circ}\text{C}$ ($97.2^{\circ}\text{F}$).
• Normal Ranges by Route:
  • Oral: $35.8^{\circ}\text{C}$ to $37.3^{\circ}\text{C}$ ($96.4^{\circ}\text{F}$ to $99.1^{\circ}\text{F}$).
  • Rectal: Measures $0.4^{\circ}\text{C}$ to $0.5^{\circ}\text{C}$ ($0.7^{\circ}\text{F}$ to $1^{\circ}\text{F}$) higher than oral.
• Measurement Procedures:
  • Oral: Place mercury-free glass thermometer at the base of the tongue in posterior sublingual pockets. Wait $15\,\text{minutes}$ if the patient consumed hot/cold liquids and $2\,\text{minutes}$ if they smoked.
  • Rectal: Most accurate. Insert lubricated probe $2$ to $3\,\text{cm}$ ($1\,\text{in}$) in adults, directed toward the umbilicus. For infants, do not insert more than $2.5\,\text{cm}$ ($1\,\text{in}$) to avoid perforation.
  • Tympanic Membrane (TMT): Share vascular supply with the hypothalamus (internal carotid artery). Pull pinna up and back for adults; straight down for children under age $3$.
  • Temporal Artery (TAT): Uses infrared emissions from the temporal artery. Slide across the forehead. Takes about $6\,\text{seconds}$.

Vital Signs: Pulse and Heart Rate

• Technique: Use the pads of the first three fingers to palpate the radial pulse at the flexor aspect of the wrist. If the rhythm is regular, count for $30\,\text{seconds}$ and multiply by $2$. For irregular rhythms or children, count for a full minute.
• Normal Resting Adult Range: $50$ to $95\,\text{beats per minute (bpm)}$.
  • Bradycardia: Heart rate less than $50\,\text{bpm}$. Common in well-trained athletes.
  • Tachycardia: Heart rate over $95\,\text{bpm}$. Occurs with anxiety or increased exercise.
• Rhythm: Normally regular.
  • Sinus Arrhythmia: Common in children/young adults; heart rate speeds up with inspiration and slows with expiration.
• Force (Three-Point Scale):
  • 3+: Full, bounding.
  • 2+: Normal.
  • 1+: Weak, thready.
  • 0: Absent.

Vital Signs: Respirations and Oxygen Saturation

• Respiration Technique: Do not mention you are counting respirations. Maintain the position used for the radial pulse and count for $30\,\text{seconds}$, or a full minute if an abnormality is suspected.
• Normal Adult Rate: $10$ to $20\,\text{breaths/min}$ (some healthy ranges go up to $25\,\text{breaths/min}$).
  • Tachypnea: Rate $> 25\,\text{breaths/min}$.
  • Bradypnea: Rate $< 8$ to $12\,\text{breaths/min}$.
• Oxygen Saturation ($SpO_2$): Assessed via pulse oximeter.
  • Normal: $97\%$ to $99\%$ on room air.
  • Ear lobe probes: Used if peripheral vasoconstriction is present as they are more accurate for lower saturations.

Vital Signs: Blood Pressure

• Definitions:
  • Systolic Pressure: Maximum pressure against the artery wall during ventricular contraction.
  • Diastolic Pressure: Elastic recoil pressure between contractions.
  • Pulse Pressure: Difference between systolic and diastolic, reflecting stroke volume.
  • Mean Arterial Pressure (MAP): The average pressure in arteries; a MAP of $\\ge 60\,\text{mmHg}$ is needed for organ perfusion.
• Determining Factors: Cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of vessel walls.
• Measurement Procedure:
  • Cuff Size: Width should equal $40\%$ of arm circumference; bladder length should equal $80\%$.
  • Technique: Palpate brachial artery. Inflate cuff until pulsation is obliterated, then go $20$ to $30\,\text{mmHg}$ beyond to avoid missing an auscultatory gap.
  • Deflation: Deflate slowly at $2\,\text{mmHg}$ per heartbeat.
• Korotkoff Sounds:
  • Phase I: First clear repetitive tapping (Systolic pressure).
  • Phase IV: Muffling of sound.
  • Phase V: Final disappearance of sound (Diastolic pressure).
• Hypertension (HTN) Guidelines (AHA):
  • Stage 1: $130$ to $139\,\text{systolic}$ or $80$ to $89\,\text{diastolic}$.
  • Stage 2: $\\ge 140\,\text{systolic}$ or $\\ge 90\,\text{diastolic}$.
• Orthostatic Hypotension: A drop in systolic $\\ge 20\,\text{mmHg}$ or diastolic $\\ge 10\,\text{mmHg}$ after a change in position.

Pain Assessment: Pathophysiology and Phase

• Nociceptive Pain: Develops when functioning and intact nerve fibers in the periphery and CNS are stimulated by tissue damage. It involves four phases:
  1. Transduction: Noxious stimuli cause tissue to release chemicals (Substance P, histamine, prostaglandins, serotonin, bradykinin). Action potentials move along afferent fibers.
  2. Transmission: The pain impulse moves from the spinal cord to the brain via the spinothalamic tract to the thalamus.
  3. Perception: Consciousness of the pain signal. Cortical structures like the limbic system account for the emotional response.
  4. Modulation: Built-in mechanism to slow down and inhibit pain. Descending pathways release neurotransmitters (serotonin, norepinephrine, GABA, endogenous opioids like beta-endorphins) to produce an analgesic effect.
• Neuropathic Pain: Pain due to a lesion or disease in the somatosensory system. Often persists long after an injury heals. It involves abnormal processing that is difficult to treat.
  • Mechanisms: Spontaneous firing of nerve fibers, "neuronal wind-up."
  • Causes: Diabetes mellitus, shingles (herpes zoster), HIV/AIDS, sciatica, trigeminal neuralgia, chemotherapy, and phantom limb pain.

Classifications and Sources of Pain

• Visceral Pain: Originates from large interior organs (e.g., stomach, intestine). Caused by injury, stretching, or distention. Symptoms include nausea, vomiting, pallor, and diaphoresis.
• Deep Somatic Pain: Comes from blood vessels, joints, tendons, muscles, and bone. Described as aching or throbbing.
• Cutaneous Pain: Derived from skin surface and subcutaneous tissues; sharp, burning sensation.
• Referred Pain: Felt at one site but originates from another (e.g., heart pain felt in the left arm). Both sites are innervated by the same spinal nerve.
• Acute Pain: Short-term, self-limiting, and self-protective. Dissipates after healing.
• Chronic (Persistent) Pain: Continues for $6\,\text{months}$ or longer. Does not stop when injury heals. Can be malignant (cancer-related, often due to tumor stretching organs) or nonmalignant.
• Breakthrough Pain: Transient spike in pain level of moderate to severe intensity in an otherwise controlled pain syndrome.

Pain Assessment Tools and Techniques

• Subjective Data: Pain is always subjective; the patient's self-report is the gold standard.
• PQRST Method:
  • P (Provocation/Palliation): What makes it worse or better?
  • Q (Quality/Quantity): What does it feel like (sharp, dull, etc.)?
  • R (Region/Radiation): Where is it? Does it spread?
  • S (Severity Scale): Rate on a scale of $0$ to $10$.
  • T (Timing): When did it start? How long does it last?
• Formal Scales:
  • Brief Pain Inventory: Rates pain within the last $24\,\text{hours}$ and its impact on mood, sleep, and activity.
  • Short-form McGill Pain Questionnaire: Patient ranks descriptors by intensity.
  • Faces Pain Scale-Revised (FPS-R): Used for children (ages $4$ to $5$+); uses $6$ drawings from "no pain" ($0$) to "very much pain" ($10$).
  • CRIES Tool: For postoperative pain in preterm and term neonates. Evaluates Crying, Requires $O_2$ for sat $> 95\%$, Increased vital signs, Expression, and Sleeplessness.
  • FLACC Scale: Nonverbal tool for infants and toddlers up to age $3$. Assesses Face, Legs, Activity, Cry, and Consolability.
  • PAINAD Scale (Pain Assessment in Advanced Dementia): Evaluates breathing, negative vocalization, facial expression, body language, and consolability. A score of $4$ or more requires treatment.

Developmental Competence Across the Lifespan

• Infants:
  • By $20\,\text{weeks}$, ascending pathways for pain are in place. Perception is seen at about $30\,\text{weeks}$.
  • Preterm infants are more sensitive to pain due to insufficient inhibitory neurotransmitters.
  • Repetitive poorly controlled pain in infancy can cause permanent changes in the CNS.
  • Blood pressure is not checked routinely in children under age $3$.
• Aging Adults:
  • Pain is NOT a normal part of aging. It often relates to comorbidities like arthritis or osteoporosis.
  • Older adults may underreport pain due to fear of dependency, invasive procedures, or drug addiction.
  • Temperature regulation is less effective, making fever less likely but hypothermia a greater risk.
  • Systolic BP often increases as the aorta and major arteries stiffen, leading to a widened pulse pressure.
• Gender: Testosterone may diminish pain sensitivity; estrogens play a role in inflammation.

Holistic and Risk Considerations

• The Opioid Epidemic: Identified as a public health emergency in 2017. Opioids connect with mu-opioid receptors, providing pain relief and euphoria but carrying risks of physical dependence and respiratory depression.
• Peripheral Neuropathy (PN): Symmetric damage to peripheral nerves (numbness/tingling). Chemotherapy-induced PN often presents in a "glove and stocking" pattern.
• Complex Regional Pain Syndrome (CRPS) / RSD: A chronic progressive nerve condition where an innocuous stimulus (like a light touch) causes severe pain. Often treated with a combination of medications (prednisone, amitriptyline) and physical therapy to regain limb function.
• Cardiovascular Risk Stratification: Major risk factors for HTN include smoking, dyslipidemia, diabetes mellitus, and family history.
• Lifestyle Modifications for HTN: Weight loss, limiting alcohol, aerobic exercise, sodium reduction, and smoking cessation.