Pain assessment hcm

PAIN ASSESSMENT

DR LEE OI WAH

PENGARAH HCM

REV : SOURCES OF PAIN

Cutaneous Pain

Somatic Pain

Visceral Pain

Referred Pain

Neuropathic Pain

Breaktrhough pain

Phantom limb sensation

Psychogenic Pain

REV : FACTORS AFFECTING

PAIN

Perception of Pain

Socio Cultural Factors

Age

Gender

Meaning of Pain

Anxiety

Past experience with Pain

INTRODUCTION

Pain is both a physical and a psychological phenomenon

The pain experience is subjective

Meaningful evaluation and successful treatment of a patient with pain requires quantification of the patient’s pain

5th Vital Sign: Doctors’ training module: Pain

Assessment

WHY MEASURE PAIN?

For documentation

Produces a baseline to assess therapeutic interventions e.g. administration of analgesic drugs

Facilitates communication between staff looking after the patient


Assessment

CLINICAL TECHNIQUES FOR

MEASUREMENT OF PAIN

Self reporting by the patient (best method)

Observer assessment

Observation of behaviour and vital signs

Functional assessment


Assessment

PAIN MEASUREMENT

Unidimensional scales

Numerical Rating Scale (NRS)

Verbal Analogue Score (VAS)

Categorical Scale or Verbal rating scale

Multidimensional scales

Brief Pain Inventory (BPI)

McGill Pain Questionnaire (MPQ)

Memorial Pain Assessment Card


Assessment

PAIN MEASUREMENT

Scales used in children / infants and in cognitively impaired patients

Wong Baker Faces Scale

FLACC scale

Observational scale

Functional scale


Assessment

Combination Rating Scale (NRS & VAS)

*Recommended for Ministry of Health*

“On a scale of ‘0’ – ‘I0’ (show the pain scale), if ‘0’ = no pain and ‘10’ = worst pain you can imagine, what is your pain score now?” •Patient is asked to slide the indicator along the scale to show

the severity of his/her pain.

•Nurse records the number on the scale (zero to 10)


Assessment

WHEN SHOULD PAIN BE MEASURED?

At Rest

Movement, coughing and deep breathing

Frequency of assessment should be increased if the

pain is poorly controlled

or if the pain stimulus or treatment interventions are

changing


Assessment

HOW TO ASSESS PAIN:

Important to :

listen and believe the patient

Take a pain history :

“Tell me about your pain…”


Assessment

HOW TO ASSESS PAIN IN ADULT

P : Place or site of pain “Where does it hurt?”

(a body chart might help describe their pain)

A : Aggravating factors “What makes the pain worse?”

I : Intensity (NRS or VAR) “How bad is the pain?”

N : Nature and neutralizing factors

“What does it feel like” “What makes the pain better?”


Assessment

DETAILED HISTORY

Goal is to characterize pain by location, intensity, and etiology

Listen to descriptive words about quality, location, radiation

Evaluate intensity or severity, aggravating factors (have patient keep a log)

Impact on activity, mood, mentation, sleep, functioning in daily activities

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DETAILED HISTORY (CONT’D)

Previous episodes, relation to physical

or stress-related etiological factors

Previous diagnostics and findings

Previous treatment and its effects

Concurrent medical problems (cardiac,

respiratory, anxiety, depression)


ASSESSING PAIN IN CHILDREN

Q Question the child

U Use pain rating scales

E Evaluate behavioural and physiological changes

S Secure the parents’ involvement

T Take the cause of pain into account

T Take action and evaluate results

WHEN SHOULD PAIN BE

ASSESSED ?

1. At regular intervals – as the 5th vital sign

during routine observation of BP, heart

rate, respiratory rate and temperature).

This can be 4 hourly, 6 hourly or 8 hourly

2. On admission of patient

3. On transfer-in of patient


Assessment

WHEN SHOULD PAIN BE

ASSESSED ?

4. At other times apart from scheduled

observations:

- Half to one hour after administration

of analgesics and nursing

intervention for pain relief

- During and after any painful

procedure in the ward e.g. wound

dressing

- Whenever the patient complains of

pain


Assessment

WHO SHOULD BE ASSESSED?

All inpatients

Including patients in labour room, recovery room (OT), High dependency units, Coronary Care Units

All patients in Emergency department

Ambulatory care units

Exclusion

Patients in NICU


Assessment

Who does Pain Assessment? - All nurses

- All Doctors

- All Student nurses

- All medical students

….. Everyone!


Assessment

WHICH TOOL TO USE

TO MEASURE PAIN?

Use the standard tool for pain assessment as

recommended by Ministry of Health, Malaysia

For adult patients, use the combined NRS / VAS

scale

For paediatric patients 1 month to 3 years old, use

the FLACC

For paediatric patients > 3-7 years, use the Wong-

Baker FACES scale

For paediatric patients >7 years, use the combined

NRS/VAS scale (same as for adults) *Always use the same tool for the same patient


Assessment

SUMMARY OF ASSESSMENT TOOLS FOR

PAEDIATRICS 0-1 month 1 mth – 3 yrs 3-7 years > 7 years

OPS

NFCS

CRIES

NIPS

COMFORT

CHEOPS

LIDS

PIPP

OPS

COMFORT

CHEOPS

TPPPS

Nurse

observation

Parental

observation

FLACC

OPS

COMFORT

CHEOPS

TPPPS

FACES

Poker chip

Colour scales

OUCHER

Horizontal

linear

analogue

VAS

CAS

FLACC

Coloured analogue scale

Horizontal

linear

analogue

Adjective self

report

APPT

Ladder scale

IS IT POSSIBLE TO GET A PAIN

SCORE IN ALL PATIENTS??

Some groups where pain score may be difficult to elicit may be Adult cognitively impaired patients

Use FLACC score where possible Patients with severe head injury

Patients with language barriers Use the visual analogue scale if possible

“Unable to score” may be recorded if all efforts to get a pain score have failed


Assessment

Observation Chart

Patient’s Name : RN : DOA :

Age :

Ward :

DATE TIME BP PULSE RESP

RATE

TEMP PAIN

SCORE

ACTION

TAKEN

COMMENTS


Assessment

WONG-BAKER FACES PAIN

RATING SCALE

This scale can be used with young children (sometimes as young as 3 years of age). It also works well for many older children and adults as well as for those who speak a different language. Explain that each face represents a person who may have no pain, some pain, or as much pain as imaginable. Point to the appropriate face and say:

(0) "This face is happy and does not hurt at all." (2) "This face hurts just a little bit." (4) "This face hurts a little more." (6) "This face hurts even more." (8) "This face hurts a whole lot." (10) "This face hurts as much as you can imagine, but you don't have to be crying to feel this bad."

FACES FOR 3-7YEARS

Wong-Baker FACES pain rating scale

This is a self report tool consisting of 6 cartoon faces.

Ask the child to choose a face which best describes his/her pain ?

Multiply the score below the face by 2 , to get a maximum total

score of 10.

Be careful as some children might confuse the faces as a measure

of happiness

FLACC Scale This is a behavior scale that has been tested with children age 3 months to 7 years. Each of the five categories (Faces, Legs, Activity, Cry, Consolability) is scored from 0-2 and the scores are added to get a total from 0-10. Behavioral pain scores need to be considered within the context of the child's psychological status, anxiety and other environment factors.

Face

0

No particular

expression or

smile

1

Occasional grimace or

frown, withdrawn

disinterested

2

Frequent to

constant frown,

clenched jaw,

quivering chin

Legs

0

Normal position

or relaxed

1

Uneasy, restless, tense

2

Kicking, or legs

drawn up

Activity

0

Lying quietly,

normal position,

moves easily

1

Squirming, shifting back

and forth, tense

2

Arched, rigid, or

jerking

Cry

0

No cry

(awake or asleep)

1

Moans or whimpers,

occasional complaint

2

Crying steadily,

screams or sobs,

frequent complaints

Consola

bility

0

Content, relaxed

1

Reassured by occasional

touching, hugging or

"talking to, distractible

2

Difficult to console

or comfort

PAIN SIGNS IN COGNITIVELY

IMPAIRED

Facial expressions

Verbalizations

Body Movement

Change in Interaction

Change in Activity or Routine

Mental Status Changes


Health & Medicine

Pain assessment hcm