So, how are we going to assess?

The amount of pain one of our patients is it

Well usually the answer to this question is remarkably simple

Now let me ask you is pain a sign, or is pain a symptom

Pain is a symptom. It's not something. We see it's something the patient reports to us

and this takes us way back to

1968 and the most famous quote in pain management from Margo McCaffrey, and it goes
something like this

Pain is whatever the patient says it is

Existing wherever and whenever they say it does

So if the patient says to me, I've got a pain that means they've got a pain

if the patient says to me

I've got a really bad pain that means they've got a really bad pain

if the patient says the pains in my elbow that means the pains in their elbow, it's that
simple [the]

[patient] is the only arbiter and judge of their pain

And we have to believe them. It's that simple

Or is it that simple because nurses and doctors are absolutely rubbish at believing their
patients pain very often

Very often you'll be talking to a patient

You'll assess their pain in great detail and at the end of it. They'll say something

You know that [is] such a relief [that] someone at last believes me that my pain is real

This means the [bintang] nurses and doctors who really don't believe I've got pain
absolutely terrible. We have to believe

Patients if the patient says I've got a problem. They've got a problem. It's that simple don't
complicate it

Now I know you get conditions like munchausen's where the [patient] save you how pain if
they don't have pain?

But not very many not very many in my experience. There's probably more patients under
report pain than

over report pain, so don't worry [about] the obscure conditions just worry about the
99.9% your patience and believe exactly what they say

Pain is whatever the experience in person says it is

Existing whenever they say it does at whatever level they say that pain is existing

It really is quite simple

Now what else can we say about pain?

Well, we should assess pain when the patient is at rest and when the patient is moving

now this can be particularly important in the surgical situation in the post-operative
situation a

Patient might be lying there perfectly still and in bed and their pain can be low

But then when they move or when the cough or when they take a deep breath the pain
shoots up and gets way worse

So there's no point you assessing the pain when they're lying there still

Because if they can't deep breathe in the [carn] coughed they're going to get hypostatic
pneumonia and die

If they can't move the legs then they get a deep venous thrombosis and pulmonary
embolism

And they're going to die if they can't move they're going to get pressure sores and
infections and osteomyelitis

All the complications of immobility so we have to assess pain

When the patient is still and when the patient is undergoing activity like deep breathing or
coughing

Another thing to assess pain is before and after analgesics

So we want to know what level the patient has before we give analgesics

especially in the acute care situation

And we want to know how much pain the patient has got after the analgesics that way we
can evaluate

the effectiveness of our or our analgesic

Intervention we have to know if things are working or not

Now normally I assess pain with [their] adults and even [children] on a numerical rating
scale

And it's as simple as this zero is no pain

Ten is the worst possible pain. You've ever experienced. What number is your pain?

and as long as we take our time to communicate with our [patients] on this an
Individual patient will usually usually be quite consistent

So before I'm analgesics. They're penguins are six after analgesics hopefully their pains
down to a two or one

One patient can [be] quite consistent with a numerical rating scale one to ten. I normally
find it the most effective

But you can have visual analogue scales as well

Sometimes you'll have [for] children you have like a very crying face

And they're not so crying facing a normal face and a happy face and you can ask them to
say where they are on that continuum

Well, you can have a line

Really bad pain no pain at all just ask the patient to mark where they are wondering that
that's another way to do it

Well, you can have a verbal rating scale would you say you have no pain mild pain moderate
pain or severe pain?

That's that's another way you can do it

Of course some patients have more than one pain

And if they have more than one pain if the ab pain into the parts of the body then we
should assess each pain separately and monitor the Progress or deterioration of each pain

separately and also monitor [the] effects of analgesia on each pain

separately

Now everyone in the world who does any clinical work at all knows what?

pqrs tears

P's atrial contraction qrs is ventricular contraction t is repolarization of the ventricles

Everyone knows that

They don't stand for anything in The Cardiac cycle, they're just pqrs to the randomly
[assigned] letters

There's quite a good for assessing pain. We can write down Pqrst, and then assess the
patient's pain using the pqrs to your pain and P stands for provoking Factors

Tell me what is it that makes the pain worse is there anything makes it better?

Is there anything brings it on is there anything that relieves your pain? What are the
provoking factors the p of pain?

Q is for quality?

Tell me about the quality of your pain is it deep or is it superficial is It crushing is it sharp [is]
it dull is Ignoring is it burning to tell tell me [about] the quality of your pain
[p] [q] [r]

R is for region and radiation

So where is the pain you can even map that on a body outline if you want? Where is the
pain?

Whereabouts is it how much area is it occupying and is it radiating anywhere?

Is it referring anywhere so region radiation referral? Where's it going?

Does it start somewhere and then go somewhere else?

region radiation [referring] with the pain

s is for Severity how bad is the pain and for that we can [use] the numerical rating scales?
We've just discussed

t is four times

What are the timings of the pain when does it come on?

how long [does] it last for how frequent is the pain the pqrst of pain

And by the time you have sat down and gone through all those with the patient we can
learn quite a lot of clinical diagnostic [information] about that from that we can in start to
infer what's wrong with our patients and the fact that you've done that in detail means the
patient will really get the benefit of

Believing that you are taking the pain seriously and as we've already said that can help

Now I'm not saying there's no signs of pain at all there can be autonomic changes

so classically in pain

We are taught that the heart rate goes [up] the blood pressure goes [up] the response rate
goes up in the patient becomes

What you would expect from sympathetic stimulation?

And this is very often true when someone's in acute pain typically that heart rate goes up
their blood pressure goes [up]

Their respire true rate goes up and they become sweaty But it's also possible that in pain
the vasovagal parasympathetic effect can predominate

parasympathetic effect can predominate Vasovagal sort of response

Mediated by the vagus nerve which of course is the tenth cranial nerve the body's main
parasympathetic nerve

What will that do [to] your heart rate?

What will vagal parasympathetic innervation do to your heart rate?

Well that will slow it down won't it

It'll allow your blood vessels to dilate

It will [reduce] your respiratory rate

So actually with a vasovagal response to pain you're actually going to get a hypotensive
bradycardic response

And there's been some recent research carried out on this son actually

people who have what's described as an extrovert personality tend to get hypertension and
tachyCardia with pain

People who are described as an erotic?

Personality type they often the blood pressure goes down and the pulse goes down

Quite how [many] [defined] those personality [trait] [you] [should] have to do pSychology
tests?

But the point is no this no clinically you need to know this very often when patients in pain

Yes, their blood pressure will go up and the heart rate will go up, but in a fair old sized

Minority of patients in many patients when they're in pain the heart rate will go down

They'll vaso dilate the blood pressure will go down and of course that makes them feel faint

You can have a syncope with pain mediated by valuable parasympathetic activity

Children of course very hard to work with if they're you know young children?

In my experience the main way, I can tell a child is in pain is by the type of cry

Now I remember when I was a young student

I was on a ward with two very experienced pediatric nurses a child had start crying and
that's a

Another time the child would cry and say [oh], that's a painful. Cry. You just get to know the
difference

There's painful cries and non painful cries

So [we're] if you're working with [children] you that is the sort of thing you'll get to know

look at their facial expressions the crying the physical Movement and their vital signs, But it
is hard to tell with children

So we need to assume that there are in pain whenever. There's any reason to do so and of
course neonates

Young children who can't yet speak feel just as much as pain as anyone else

And it's absolutely horrendous to think that

Not that long ago

But maybe as late as the 1970s you actually had a neath the tests who believed the children
didn't feel pain

And this is this is [a] horror story

But they believe that young children couldn't feel pain therefore. You don't need to anissa
ties them

Just just give them a muscle relaxant. So they don't squirm about don't worry about it
because they don't feel pain

The criminal and the Arrogance of that is just beyond belief thinking that I'm so clever. I
know someone else doesn't feel

neonates do for your pain

And of course we now know that fetuses feel pain as well

now you can argue about what stage of pregnancy the fetus starts to feel pain at

fetus is Sensitive to pain in the later stages of [pregnancy]. There's no debate about it in the
third trimester, but you know nervous tissue develops on from very very early on in Fetal
development

So if there's any clinical procedures being carried out on a fetus

They should be anetha ties just [the] same as anyone else should be [anything]

And while we seem [to] be talking about age of course old people feel [the] feel pain pretty
well, the same as anyone else

we always have to assume or people are able to feel [pain] even if they can't express it
because of alzheimer's disease for

Treat it as we would want to be true if we have that amount of pain