Pain: Diagnosing, Assessing and Treating

GM Unit 6

Learning Goals

• Identify the correct method for assessing pain and labeling it.

• Discuss how pain is used in diagnostics. • Establish knowledge of common treatments

for pain relief.

The Physiological Purpose of Pain

• Pain is an important sensory input that gives us protection from and awareness of injury. – Pain is an important diagnostic tool. – Pain is considered the 5th vital sign, and should be

assessed regularly.

Sources or Causes of Pain• Nociceptive Pain

– This is pain that occurs due to actual stimulation of the pain receptors.

– It is an indication of damage, injury, or potential injury

• Neuropathic Pain– This is pain that is NOT a result of a

stimulated pain receptor. – It is due to damage in the pain

pathway. This may be in the peripheral fibers, the spinal cord, or the thalamus.

– Causes may be previous injury, current injury, invasion by cancer, or chronic disease.

• Psychogenic – This is pain that is caused by

misperceptions in the cognitive channels (higher brain function).

– This often occurs in people with mental illness or severe emotional trauma.

– This is not a popular diagnosis, as it may seem dismissive to the patient, and relies on a perfect medical diagnosis that actual pain is not occurring.

Sensing Pain

• Nerves that send pain signals to the CNS are called nociceptors, and are located throughout the body in skin, joints and organs. – There are no nociceptors in the brain. – There are several types of nociceptors that

respond to different type of stimuli.

In Review…

• Pain can be experienced for many reasons: – Damage to body tissues– Problems with nervous system pathways– Emotional or physical issues in the brain

• Pain is SUBJECTIVE• Pain is a physical, emotional, and social

experience

Pain as the Fifth Vital Sign

• We record and assess pain as the fifth vital sign for several reasons: – Doing so ensures that we assess it regularly. – It can effect the other vital signs and patient

emotional status.– It is an important diagnostic tool.

Assessing Pain

• Step 1: Remove your judgment. • A major barrier in accurately assess and treating pain

is the caregiver not “believing” or “trusting” the patient regarding their pain.

• Remember: Pain is what they say it is. • Women and elderly people are much more likely to be

judged or not believed in regards to pain treatment.

• Step 2: Obtain a quantified report of pain. – Record on a 0 to 10 scale in verbal patients

Assessing Pain

• Evaluate the Pain: – Ask the patient to describe the pain: Location,

quality, amount of time it has been happening, any related symptoms, injuries or factors.

• Assess the Patient as a Whole: – Does the patient’s demeanor match their report of

pain? Are there social or emotional factors that might effect this patient’s report? Does the patient’s physical state match their report of pain? What other sings or symptoms are present?

Assessing Pain in the Nonverbal Patient

• People with altered mental status, varying degrees of sedation, and children may not be able to report pain on a verbal scale. – In this case we use the faces scale and the

following factors: a noted reason that pain would exist (injury, surgery), patient behavior (crying, grimacing, irritability), vital sign changes.

Reporting Pain in the Medical Record

• ALWAYS record that pain was assessed, even if the patient said they have no pain.

• ALWAYS record the patient’s report of pain, along with your observations.

• NEVER omit a report of pain because you believe the patient is lying or dishonest.

Diagnostics: Types of Pain

• Assessments of pain amount, location, quality and duration can give hints as to the cause of the pain: – The easy and obvious: Pain related to acute injury is

localized to the site of the injury, is sharp and varies by degree of injury.

– The more difficult: • Nerve pain (pathway damage) may be poorly localized, may

vary in degree and quality (burning, tingling, etc.)• Visceral pain may be vague or dull, may refer to other body

locations, and often comes with other symptoms (nausea, hot flashes, etc.)

Chronic vs. Acute Pain

Acute• Typically related to an injury,

change or disease. • Last less than six months

(not coming and going)• Relieved when the cause of

pain is removed or healed. • Usually is reflected in vital

sign changes. • Can be successfully treated

with narcotics, etc.

Chronic• Any pain that last for longer

than sic months or is recurrent beyond six months.

• Often causes are scarring, disease, cancer, degeneration.

• May have profound emotional consequences. Not typically seen in vital sign changes.

• Difficult to treat, as narcotics and analgesics are limited in effectiveness.

Treating Pain: Medications

Anesthetics• Removes the sensation of

pain entirely (via reducing consciousness or numbing an area)

• May be general (putting the patient “Under”) or regional (epidurals)

Analgesics• Reduce the sensation of

pain (usually by blocking pain receptors or limiting the bodies ability to respond)

• Two types: Narcotic (morphine, hydrocodone, etc.) and Non Narcotic (Tylenol, NSAIDS)

Drug Types

Narcotics• Act on the central nervous system to

reduce the brain’s reception of pain. • Do not reduce the inflammatory

response. • Can depress respirations, cause

constipation, sedation. • Risks of addiction and overdose with

unregulated use. • Commonly abused. • Tolerance Issues: long term use

associated with reduced effectiveness (permanent).

Non Narcotics• Act in the peripheral system to

block pain sensors or reduce inflammation.

• No risk of abuse or dependence.

• Side effect with over use include toxicity, damage to stomach, liver, etc.

• Ceiling Effect: doses above a certain point do not increase effects, only adverse reactions.

Other Medications to Reduce Pain

• Steroids:– Reduce inflammatory

response, but can weaken immune system, cause other side effects.

• Antidepressants, Anticonvulsants: – Alter brain chemistry to

change the reception of pain. Usually used in chronic and verve pain.

Alternate Treatments for Pain• Physical Therapy:

– Can correct issues with musculoskeletal pain.

– May include hot/cold, water therapy, massage, etc. to treat pain and reduce inflammation.

• Surgery: – Can remove pain causing

structures. – May cause scarring = more

pain.

• Psychological/Behavioral Approach: – Focus on thoughts,

emotions, biofeedback. • Alternative/

Complementary Treatments: – Acupuncture– Massage– Medication and Relaxation – Energy Work (Reiki)

Developing a Pain Treatment Plan

• Things to address: – Label it as chronic or acute. – Can the cause be removed or reduced?– What is the severity, and how much is this pain

effecting the patient’s life? – Avoid long term prescriptions of narcotics. – Encourage a MULTIDISCIPLINARY approach. • Ex: Medications, physical therapy, massage for chronic

pain.

Legal Issues with Pain Treatment

• Practitioners feel a lot of pressure from patients to prescribe certain types of pain medications, even when they are not the best and safe choice.

• Safety issues also arise when patients “Doctor Shop” and practitioners do not check all of the medications a person is on, leading to redundant prescriptions.

Nursing Dilemma: The “Drug Seeker”

• This is a common term for a patient who comes into the ER or Hospital frequently for treatment of issues related to pain.

• They may be diagnosed with chronic pain issues, and take several types of pain medication, be demanding with dosing, and show little evidence of pain in assessment.

• What can you do?

Solutions to the “Drug Seeker”

• Give doses as ordered, so long as you feel it is safe. • Do not judge your patient. Judging is easy,

empathizing is hard. • Look for underlying psychological issues, signs of

addiction. • Educate to alternative treatments, dangers of

abuse honestly. • Discuss concerns with other HCPs and develop a

plan when real problems are identified.

Ethical Resolutions

• Remember, believe your patient and be their advocate.

• Offer narcotics only when they are a legitimately sound medical option.

• Offer alternatives and encourage treating the cause of pain.

Patients will make their own choices, but ethical and legal responsibility says that medical professionals are responsible for patient safety and education.