Nursing Assessment for Pain

7/29/2019 Nursing Assessment for Pain

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NURSING ASSESSMENT FOR PAIN

ASSESSING

Goal

to capture the individuals pain experience in a standardized way

to help determine type of pain and possible etiology

to determine the effect and impact the pain experience has on the

individual and their ability to function.

basis on which to develop treatment plan to manage pain

to aid communication between interdisciplinary team members.

Assessment

For the fifth vital sign, pain should be screened for every time vital signs are evaluated.

For client experiencing acute, severe pain, the nurse may focus only on the location,

quality and severity, and provide interventions to control the pain before conducting a

more detailed evaluation.

Clients with less severe or chronic pain can usually provide a more detailed description of

the experience.

Local, regional, or general anesthesia may be wearing off, or if severe pain is reported,

the medication is admistered postoperatively is frequently admistered via the intravenous

route and has a peak effect noted within 15 minutes.

It is essential that nurses listen to and believe the clients perceptions of pain.

Major components of pain:

A pain history to obtain facts of the client

Direct observation of behaviors, physical signs of tissue damage, and secondary

physiologic responses of the client.

Pain Assessment using Acronym NOPQRSTUV

Number of Pains

Origin of Pain

Palliate and Potentiate

Quality

Radiation

Severity/ Suffering

Timing and Trend

Understanding/ Impact in you

Values

DIAGNOSING

NANDAs diagnostic labels for clients experiencing pain or discomfort:

o Acute Pain

o Chronic Pain

When writing the diagnostic statement, the nurse should specify the location.

Related factors, when known, should also be part of the diagnostic statement and can

include both physiologic and psychologic factors.

Because presence of pain can affect so many faces of a persons functioning, pain may be

the etiology of other nursing diagnoses. Examples are the following:


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o Ineffective Airway Clearance related to weak cough secondary to postoperative

incisional abdominal pain

o Hopelessness related to feeling of continual pain

o Anxiety related to past experiences of poor control of pain and to anticipation of

pain

o Ineffective Coping related to prolonged continuous back pain, ineffective pain

management, and inadequate support systems

o Ineffective Health Maintenance related to chronic pain and fatigue

o Self-Care Deficit (Specify) related to poor control of pain

o Deficient Knowledge (Pain Control Measures) related to lack of exposure to

information resources.

o Impaired Physical Mobility related to arthritic pain in knee and ankle joints

o Insomnia related to increased pain perception at night

PLANNING

The established goals for the client will vary according to the diagnosis and its defining

characteristics.

Specific nursing interventions can be selected to meet the individual needs of the client.

Planning Independent of Setting

When planning, nurses need to choose pain relief measures appropriate for the client,

based on the assessment data and input from the client or support persons.

Developing a plan that incorporates a wide range of strategies in usually most effective.

Whether in acute care or in home care, it is important for everyone involved in pain

management to understand the plan of care.

Plan should be documented in the clients record.

When clients pattern and level of pain can be anticipated or is already known, regular or

scheduled administration of analgesics can provide a steady serum level.

Frequency of administration can be adjusted to prevent pain from recurring. When

persistent, continuous pain exists, analgesics should be given around the clock (ATC),

with additional prn doses available.

Nonpharmacologic interventions should be regularly scheduled.

Planning for Home Care

In preparation for discharge, the nurse needs to determine the clients and familys needs,

strengths and resources.

The accompanying Home Care Assessment describes the specific assessment data

required when establishing a discharge plan.

Using the assessment data, the nurse tailors a teaching plan for the client and family.

IMPLEMENTING

Pain management is the alleviation of pain or a reduction in pain to a level of comfort

that is acceptable to the client. It includes the two types of nursing intervention:

(a) Pharmacologic

(b) Non-pharmacologic

Nursing management of pain consists of:

(a) Independent nursing actions- noninvasive measures may be performed


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(b) Collaborative nursing actions- admistration of analgesic medication generally

requires a medical order from a primary care provider.

Individualizing Care for the Clients with Pain

1) Establishing a trusting relationship.

2) Consider the clients ability and willingness to participate actively in pain relief

measures.

3) Use a variety of pain relief measures.

4) Provide measures to relieve pain before it becomes severe.

5) Use pain-relieving measures that the client believes are effective it has been recognized

that clients are the authorities about their own pain.

6) The selection of pain relief measures should be aligned with the clients report of the

severity of the pain.

7) If a pain relief measure is ineffective, encourage the client to try it again before

abandoning it.8) Maintain an unbiased attitude about what may relieve the pain.

9) Keep trying. Do not ignore a client because pain persists despite failed attempts to

alleviate the discomfort.

10) Prevent harm to the client.

11) Educate the client and caregivers about pain.

Monitoring Pain in the Home Setting

Teach client to keep a pain diary to monitor pain onset, activity before pain, pain

intensity, use of analgesics or other relief measures, and so on.

Instruct client to contact a health care professional if planned control measures are

ineffective.

1) Pain Control

Teach the use of preferred and selected pharmacologic techniques.

Discuss the actions, side effects, dosages and frequency of administration of

prescribed analgesics.

Suggest ways to handle side effects of medication.

Provide accurate information about tolerance, physical dependence, and addiction

if opioid analgesics are prescribed and these topics are of concern.

Instruct the client to use pain control measures before the pain becomes severe. Inform the client of the effects of untreated pain.

Demonstrate and have the client or caregiver return demonstrate appropriate skills

to administer analgesics. If home pump is being used, caregivers need to be able

to:

(a) Demonstrate stopping and starting the pump.

(b) Change the medication cartridge and tubing

(c) Adjust the delivery dose

(d) Demonstrate site care

(e) Identify signs indicating the need to change in injection site.

(f) Describe care of pump and insertion site when the clients

ambulatory, bathing, sleeping or travelling.

(g) Perform problem solving for pumps when alarms are activated.

(h) Change the battery.

2) Resources


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Provide appropriate information about how to access community, resources, home

care agencies, and associations that offer self-help groups and educational

materials.

Barriers to Pain Management

These may involve attitudes of the nurse or the client as well as knowledge deficits.

Clients respond to pain experiences based on their culture, personal experiences, and the

meaning the pain has for them.

Clients and families may lack knowledge of the adverse effects of pain and may have

misinformation regarding the use of analgesics.

Clients may not report pain because they expect nothing can be done, they think it is not

severe enough, or they feel it would distract or prejudice the health care provider.

Another barrier to effective pain management is the fear of becoming addicted, especially

when long-term opioid use is prescribed.

Pseudoaddiction is a condition that results from the undertreatment of pain where the

client may become focused on obtaining medications, may clock watch, and may

otherwise seem inappropriately drug seeking.

Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve

when the pain is treated effectively.

Key Management in Pain Management

Acknowledging and Accepting Clients Pain. Nurses have a duty to ask client about their pain

and to believe their reports of discomfort. Consider these four ways of communicating

this belief:(a) Acknowledge the possibility of the pain.

(b) Listen attentively to what the client says about the pain, restating your

understanding of the reported discomfort.

(c) Convey that you need to ask about the pain because, despite some similarities,

everybodys experience is unique.

(d) Attend the clients needs promptly.

Assisting Support Persons. Support persons often need assistance to respond in a helpful manner

to the person experiencing pain.

Reducing Misconceptions about Pain. This will remove one of the barriers to optimal pain relief.

Reducing Fear and Anxiety. It is important to help relieve strong emotions capable of amplifyingpain.

Preventing Pain. A preventive approach to pain in management involves the provision of

measures to treat the pain before it occurs.

Preemptive analgesia- the administration of analgesics prior to an invasive or

operative procedure in order to treat pain before it occurs.

EVALUATING

The goals established in the planning phase are evaluated according to specific desired

outcomes, also established in the phase.

To assist in the evaluation process, flow sheet records or a client diary may be helpful.

If outcomes are not achieved, the nurse and client need to explore the reasons before

modifying the care plan. The nurse might consider the following questions:

o Is adequate analgesic given?

o Were the clients beliefs, expectations and values about pain therapy considered?


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o Were appropriate instructions provided to allay misconceptions about pain

management?

o Did the client and support people understand the instructions about pain

management?

o Is the client receiving adequate support for both physical pain and emotional

distress?

o Has the clients physical condition changed, necessitating modifications in

intervention?

o Should selected intervention strategies be reevaluated?


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INCONTINENCE

Fecal incontinence (FI), commonly referred to as bowel control problems, is the inability

to hold a bowel movement until reaching a bathroom. FI also refers to the accidental

leakage.

A feces is another name for stool.

Nearly 18 million U.S. adult. FI is not always a part of aging, but it is more common inolder adults. FI is slightly more common among women.

Risk factors for FI:

o diarrhea

o a disease or injury that damages the nervous system

o poor overall healthmultiple chronic, or long-lasting, illnesses

o a difficult childbirth with injuries to the pelvic floorthe muscles, ligaments, and

tissues that support the uterus, vagina, bladder, and rectum

Symptoms of FI includes diarrhea

constipation

muscle damage or weakness

nerve damage

loss of stretch in the rectum

hemorrhoids

pelvic floor dysfunction

Diagnoses for FIHealth care providers diagnose FI based on a patients medical history, physical exam,

and medical test results. People with concerns about FI should see a health care provider, who

may ask the following questions:

When did FI start?

How often does FI occur?

How much stool leaks? Does the stool just streak the underwear? Does just a little bit of

solid or liquid stool leak out? Or does complete loss of bowel control occur?

Does FI involve a strong urge to have a bowel movement or does it happen without

warning?

For people with hemorrhoids, do hemorrhoids bulge through the anus?

How does FI affect daily life?

Do certain foods seem to make FI worse?

Can gas be controlled?

Based on answers to these questions, a health care provider may refer the patient to a

doctor who specializes in problems of the digestive system, such as a gastroenterologist,


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proctologist, or colorectal surgeon. The specialist will perform a physical exam and may suggest

one or more of the following tests, which may be performed at a hospital or clinic: Anal manometry

Magnetic resonance imaging (MRI)

Anorectal ultrasonography

Proctography

Proctosigmoidoscopy

Anal electromyography

Treatment for FI

eating, diet, and nutrition

(a) eating the right amount of fiber

(b) getting plenty of drink

medication

pelvic floor exercises

bowel training

surgery

(a) sphincteroplasty

(b) electrical stimulation

electrical stimulation

FLATULENCE

Flatulence is the presence of excessive flatus in the intestines and leads to stretching and

inflation of the intestines (intestinal distention).

It can occur in the colon from a variety of causes, such as foods, abdominal injury, or

narcotics.

Most gases that are swallowed are expelled through the mouth by eructation. However,

large amount of gas can accumulate in the stomach. The gases formed in the large

intestine are chiefly absorbed through the intestinal capillaries into the circulation.

If the gas is propelled by increase colon activity before it can be absorbed, it may be

expelled through the anus.

If excessive gas cant be expelled through the anus, it may be necessary to insert a rectal

tube to remove it.

Flatulence is very common, and everyone experiences it. Most men pass wind 14-25

times a day, and most women between 7 and 12 times a day.

Most people produce about 1-3 pints a day and pass gas about 14 times a day.

Some medical conditions can cause flatulence, such as constipation and irritable bowel

syndrome. Medication can help to control the symptoms.

The major components of the flatus, which are odorless, by percentage are:

o Nitrogen: 2090%

o Hydrogen: 050%

o Carbon dioxide: 1030%

o Oxygen: 010%

o Methane: 010%

Three primary source of flatus

(a) Action of bacteria on the chyme in the large intestine

(b) Swallowed air


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(c) Gas that diffuses between the bloodstream and the intestine

How to prevent

Avoid foods which contain sugars that the digestive system can't break down.

Still aim to eat a healthy, balanced diet that includes at least five portions of fruit and

vegetables a day.

Avoid eating foods that are high in unabsorbable carbohydrates. Instead, go for foods that

are easy to digest, such as potatoes, rice and bananas.

HEMMOROIDS

Hemorrhoids are swollen and inflamed veins around the anus or in the lower rectum. The

rectum is the last part of the large intestine leading to the anus.

Types of hemorrhoids:

(a) External hemorrhoids- are located under the skin around the anus.

(b) Internal hemorrhoids- develop in the lower rectum. Internal hemorrhoids may

protrude, or prolapse, through the anus.

About 75 percent of people will have hemorrhoids at some point in their lives.

Hemorrhoids are most common among adults ages 45 to 65.2 Hemorrhoids are also

common in pregnant women.

Symptoms of hemorrhoids includes

Anal itching

Anal ache or pain, especially while sitting

Bright red blood on toilet tissue, stool, or in the toilet bowl Pain during bowel movements

One or more hard tender lumps near the anus

Signs and tests

A doctor can often diagnose hemorrhoids simply by examining the rectal area. If

necessary, tests that may help diagnose the problem include:

Stool guaiac (shows the presence of blood)

Sigmoidoscopy

Anoscopy Barium enema x ray.

Treatment for Hemorrhoids

Over-the-counter corticosteroid creams can reduce pain and swelling. Hemorrhoid

creams with lidocaine can reduce pain. Witch hazel (applied with cotton swabs) can reduce

itching. Other steps for anal itching include:

Wear cotton undergarments.

Avoid toilet tissue with perfumes or colors.

Try not to scratch the area.

Sitz baths can help you to feel better. Sit in warm water for 10 to 15 minutes. Stool

softeners help reduce straining and constipation.

For cases that don't respond to home treatments, a surgeon or gastroenterologist can

apply heat treatment, called infrared coagulation, to shrink internal hemorrhoids. This

may help avoid surgery. Surgery that may be done to treat hemorrhoids includes rubber


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band ligation or surgical hemorrhoidectomy. These procedures are generally used for

patients with severe pain or bleeding who have not responded to other therapy.

1. At-home Treatments

Simple diet and lifestyle changes often reduce the swelling of hemorrhoids and relieve

hemorrhoid symptoms. Eating a high-fiber diet can make stools softer and easier to pass,

reducing the pressure on hemorrhoids caused by straining.

Fiber is a substance found in plants. The human body cannot digest fiber, but fiber helps

improve digestion and prevent constipation. Good sources of dietary fiber are fruits,

vegetables, and whole grains. On average, Americans eat about 15 grams of fiber each

day.3 The American Dietetic Association recommends 25 grams of fiber per day for

women and 38 grams of fiber per day for men.3

Doctors may also suggest taking a bulk stool softener or a fiber supplement such as

psyllium (Metamucil) or methylcellulose (Citrucel).

Other changes that may help relieve hemorrhoid symptoms includeo drinking six to eight 8-ounce glasses of water or other nonalcoholic fluids each

day

o sitting in a tub of warm water for 10 minutes several times a day

o exercising to prevent constipation

o not straining during bowel movements

Over-the-counter creams and suppositories may temporarily relieve the pain and itching

of hemorrhoids. These treatments should only be used for a short time because long-term

use can damage the skin.

2. Medical Treatment

Rubber band ligation. The doctor places a special rubber band around the base of the

hemorrhoid. The band cuts off circulation, causing the hemorrhoid to shrink. This

procedure should be performed only by a doctor.

Sclerotherapy. The doctor injects a chemical solution into the blood vessel to shrink the

hemorrhoid.

Infrared coagulation. The doctor uses heat to shrink the hemorrhoid tissue.

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Nursing Assessment for Pain