Nursing assessment for Pain Management

A. Nursing assessment

1. Subjective data - review past family history in terms of pain & review lifestyle & health

habits to determine how the pain interferes with the client's life. Ask open-ended

questions and quote as you document.

2. Objective data (see in Weber or Taylor)

Verbal-descriptor Scale (VDS)

Wong-Baker Faces Scale (FACES)

Numeric Rating Scale (NRS) 0-10

Visual Analog Scale (VAS)

B. WILDA scale

1. words that describe pain

2. intensity of pain

3. location of pain

4. duration of pain

5. aggravating or alleviating factors

6. any other symptom or sign nausea or vomiting (associated factors)

C. COLDSPA

1. character

2. onset

3.location

4. duration

5. severity

6. pattern

7. associated factors

D. Assessment procedure

1. observe posture, facial expression

2. measure vitals signs

3. perform physical assessment (inspect first, palpate last)

4. utilize exact client statements (quote)

5. validate & document data

E. General assessments of pain

1. patient's verbalization & description of pain

2. duration of pain

3. location of pain

4. quantity & intensity of pain

5. quality of pain

6. chronology of pain

7. aggravating & alleviating factors

8. physiologic indicators of pain (ie. respirations)

9. behavioral responses

10. effect of pain on activities & lifestyle

* 1379 Taylor assessment of special populations ie age-related, cognitive-impaired.

F. Nursing Interventions

1. establishing trusting nurse-patient relationship * most important

2. initiating nonpharmacologic pain relief measures. ie. ambulate, massage

3. considering ethical & legal responsibility to relieve pain

4. teaching patient about pain

G. Non medicinal pain control:

1. relaxation

2. distraction

3. meditation

4. massage

5. therapeutic touch

6. hypnosis subconscious state

7. biofeedback non-medicinal, machine monitors physiological values. Patient taught

relaxation, ie deep breathing, guided imagery. leads to changes in settings on machine,

used for pain control

8. acupuncture- needles inserted at pressure points

9. acupressure pressure points used (no needles) releases endorphins

10. cutaneous stimulation (TENS) external, low-frequency electrical stimulation used

to inhibit nerve transmission, ↓pain. Gate Control Theory, inhibits transmission of

local pain stimuli

11. heat & cold application

H. Invasive Medicinal Pain Control: pg 1395

1. Patient-Controlled Analgesia (PCA) calibrated by anesthesiologist, locked in

pump. Patient can control delivery of narcotic analgesic with calibrated pump by

pushing pump. Pump can administer a preset dose per time period, or patient-

controlled administration of drug (or both). Nurse needs to assess every two hours:

O₂ saturation, BP., respirations, LOC

2. Epidural analgesia postop, labor & delivery, or chronic pain. catheter placed in

epidural space (not spinal cord) between the vertebra & spinal cord covering. Can

be one time administration ie. back pain, or continuous (stays in place) & removed

at a later time. check blood pressure - tends to be higher with a rapid dose.

some drugs used: Delotid, Morphine, Demerol (can cause nausea), with all

check BP, respirations, GI, assess LOC.

See table 1398 (41-1) Care of Patients receiving epidural opoiods.

Keep Narcan (Naloxone) at bedside as an antidote for narcotics

3. Local Anesthesia block nerves directly

ie. dentist office

no systemic effect

"Emla cream" (lidocaine cream)- placed 30 minutes to 1hr prior is a local topical

anesthetic used for IV insertion for children or sutures

I. Numeric Sedation Scale

1. awake & alert no action needed

2. occasionally drowsy but easy to arouse no action

3. frequently drowsy, drifts off to sleep during conversation: reduce dose or just

monitor patient

4. somnolent with minimal or no response to stimuli, discontinue opioid, consider use

of naloxone (Narcan), check respirations

III. Nursing Diagnoses pg 1394 analgesic ladder know

1. pain noted - give nonopioid adjuvent + - (NSAIDs ↓need for narcotics)

2. pain persisting or ↑, give opioid for mild to mod. pain. nonopioid +, adj. + -

3. pain persisting or ↑, give opioid for mod. to severe pain, nonopioid +, adj. + -

4. freedom from cancer pain