pain assessment hcm
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TRANSCRIPT
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
5th Vital Sign: Doctors’ training module: Pain
Assessment
CLINICAL TECHNIQUES FOR
MEASUREMENT OF PAIN
Self reporting by the patient (best method)
Observer assessment
Observation of behaviour and vital signs
Functional assessment
5th Vital Sign: Doctors’ training module: Pain
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
5th Vital Sign: Doctors’ training module: Pain
Assessment
PAIN MEASUREMENT
Scales used in children / infants and in cognitively impaired patients
Wong Baker Faces Scale
FLACC scale
Observational scale
Functional scale
5th Vital Sign: Doctors’ training module: Pain
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)
5th Vital Sign: Doctors’ training module: Pain
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
5th Vital Sign: Doctors’ training module: Pain
Assessment
HOW TO ASSESS PAIN:
Important to :
listen and believe the patient
Take a pain history :
“Tell me about your pain…”
5th Vital Sign: Doctors’ training module: 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?”
5th Vital Sign: Doctors’ training module: Pain
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
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
5th Vital Sign: Doctors’ training module: Pain
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
5th Vital Sign: Doctors’ training module: 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
5th Vital Sign: Doctors’ training module: Pain
Assessment
Who does Pain Assessment? - All nurses
- All Doctors
- All Student nurses
- All medical students
….. Everyone!
5th Vital Sign: Doctors’ training module: Pain
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
5th Vital Sign: Doctors’ training module: Pain
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
5th Vital Sign: Doctors’ training module: Pain
Assessment
Observation Chart
Patient’s Name : RN : DOA :
Age :
Ward :
DATE TIME BP PULSE RESP
RATE
TEMP PAIN
SCORE
ACTION
TAKEN
COMMENTS
5th Vital Sign: Doctors’ training module: Pain
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