Pain Assessment and

Oxygen Saturation
Katrina Francheska Arevalo-Lawsin, DNM, RN
Learning Objectives:
At the end of the lecture, the students are expected to:

•Describe pain in terms of location, duration, intensity, and etiology

•Conduct accurate pain assessment based on pain history and direct
observation

•Enumerate the questions to ask during a comprehensive pain assessment

•Understand the importance and purpose of measuring oxygen saturation
•Perform the steps in oxygen saturation measurement
Pain Assessment
Katrina Francheska Arevalo-Lawsin, DNM, RN
Introduction
Pain
• “Pain is whatever the person says it is, and exists whenever he says it does”
(Pasero & McCa ery, 2011, p. 21).

• “An unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage”
(International Association for the Study of Pain [IASP], 2012

• Pain is more than a symptom of a problem; it is a high-priority problem in itself.

• Pain presents both physiological and psychological dangers to health and recovery.
• Severe pain is viewed as an emergency situation deserving attention and prompt professional
treatment.
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Types of Pain
Pain may be described in terms of location, duration, intensity, and etiology.

Location
• The location of pain is an important consideration
• Some pains radiate (spread or extend) to other areas
• Pain may also be referred (appear to arise in di erent areas) to other parts of the body
• Visceral pain (arising from organs or hollow viscera) is often perceived in an area remote from
the organ causing the pain
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Common sites of referred pain from various body organs
Types of Pain
Duration

• Acute pain — when pain lasts only through the expected recovery period
whether it has a sudden or slow onset, regardless of its intensity

• Chronic pain — persistent pain; is prolonged, usually recurring or lasting 3

months or longer, and interferes with functioning

• NANDA International (Herdman & Kamitsuru, 2014) speci es the accepted nursing
diagnosis of Chronic Pain to be mild to severe, constant or recurring,
without an anticipated or predictable end and with a duration of greater
than 3 months.

• Cancer pain — may result from the direct e ects of the disease and its
treatment, or it may be unrelated. Over time, other diagnoses have been
included in the “malignant pain” category, such as HIV/ AIDS or burn pain,
which tend to be treated more aggressively than “noncancer pain.”
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Comparison of Acute and Chronic Pain
Types of Pain
Intensity
• Most practitioners classify intensity of pain by using a standard scale:
0 (no pain) to 10 (worst possible pain) scale.

1 to 3 Mild Pain

4 to 6 Moderate Pain

7 to 10 Severe Pain
 Types of Pain Neuropathic Pain
• Neuropathic pain is associated with
Etiology damaged or malfunctioning nerves
due to illness, injury, or undetermined
reasons.
• Neuropathic pain is typically chronic;
Nociceptive Pain it is described as burning, “electric-
shock,” and/or tingling, dull, and
aching.
Experienced when an intact, properly
functioning nervous system sends
• Episodes of sharp, shooting pain can
also be experienced.
signals that tissues are damaged,
requiring attention and proper care.
• Neuropathic pain tends to be di cult
to treat.
Transient, Intermittent, and Constant

Somatic
• Originates in the skin, muscles,
bone, or connective tissue.
• The sharp sensation of a paper
cut or aching of a sprained ankle
are common examples of somatic
pain.
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Visceral
• Results from activation of pain
receptors in the organs and/or
hollow viscera.
• Tends to be characterized by
cramping, throbbing, pressing,
or aching qualities.
• Associated with feeling sick
(e.g., sweating, nausea, or
vomiting) as in the examples of
labor pain, angina pectoris, or
irritable bowel.
Peripheral Central
Neuropathic Pain Neuropathic Pain
• Follows damage or sensitization • Results from malfunctioning
of peripheral nerves nerves in the central nervous
• e.g., phantom limb pain, post- system
herpetic neuralgia, carpal tunnel • e.g., spinal cord injury pain, post
syndrome stroke pain, multiple sclerosis
pain
Concepts Associated with Pain
Nursing Management
Assessing
• Accurate pain assessment is essential for e ective pain
management

• Pain assessment as the fth vital sign

• Pain assessment as a routine aspect of care for all clients
• A comprehensive assessment of the pain experience
(physiological, psychological, behavioral, emotional, and
sociocultural) provides the necessary foundation for optimal
pain control
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Nursing Management
Assessing
• The extent and frequency of the pain
assessment varies according to the Acute, severe pain
situation and the organizational policy.
• Focus only on location, quality, and
severity
• As the fth vital sign, pain should be • Provide interventions to control the pain
before conducting a more detailed
screened for every time vital signs evaluation
are evaluated.

• A simple screening question such as Less severe, chronic pain

“Are you experiencing any discomfort
• Can usually provide a more detailed
right now?” will usually su ce. description of the experience
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Nursing Management
Assessing
Major barriers to better pain control for both nurses and
clients relate to: (Pasero & McCa ery, 2011).

• Failure to assess pain “Do you have any discomfort to report?”

• Underestimation of pain
• failure to accept the client’s report of pain
• failure to act on the client’s report of pain
“Do you have any complaints of pain?”
• concerns about addiction
Given that many clients will not voice their pain unless asked
about it, pain assessments must be initiated by the nurse.

It is also essential that nurses listen to and believe the client’s

statements of pain.
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Why clients may
be reluctant to
report pain
 Pain Assessment
Pain History Direct Observation

• Behaviors
• Physical signs of tissue
To obtain facts from the client damage
• Secondary physiological
responses of the client

Goal
to gain an objective understanding of a subjective experience
Pain Assessment
Pain History
• Provide an opportunity for clients to express in their
own words how they view the pain and the situation.

• Each person’s pain experience is unique

• Client is the best interpreter of the pain experience

The initial pain assessment for someone in severe

acute pain should focus on the following:
• Previous pain treatment and e ectiveness
• When and what analgesics were last taken
• Other medications being taken
• Allergies to medications.
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 Pain Assessment
Pain History
For the person with chronic pain, the nurse may focus on:
• Client’s coping mechanisms
• E ectiveness of current pain management
• Ways in which the pain has a ected the client’s body
• Thoughts and feelings
• Activities
• Relationships

Data that should be obtained in a comprehensive pain history include pain

location, intensity, quality, patterns, precipitating factors, alleviating factors,
associated symptoms, e ect on ADLs, coping resources, and a ective responses.
Other data include past pain experiences and the meaning of pain to the client, as
previously discussed.
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Comprehensive Pain History:
Questions to Ask
Pain History
Location
• To ascertain the speci c location of the pain, ask the client to point to the site
of the discomfort.

• A chart consisting of drawings of the body can assist in identifying pain

locations. The client marks the location of pain on the chart. This tool can be
especially e ective with clients who have more than one source of pain. A
client who has multiple pain sites of di erent character can use symbols to
draw the distribution of di erent pain types (e.g., circle aching areas, mark
areas where shock-like pain is felt with an X).

• When assessing the location of a child’s pain, the nurse needs to understand
the child’s vocabulary. For example, “tummy” might refer either to the
abdomen or to part of the chest. Asking the child to point to the pain helps
clarify the child’s word usage to identify location. The use of gure drawings
can assist in identifying pain locations. Parents can also be helpful in
interpreting the meaning of a child’s words.

• When documenting pain location the nurse may use various body landmarks.
Further clari cation is possible with the use of terms such as proximal, distal,
medial, lateral, and di use.
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Pain History
Pain Intensity or Rating Scales
• The single most important indicator of the existence and intensity of pain is the client’s report
of pain.

• The use of pain intensity scales is an easy and reliable method of determining the client’s pain
intensity. Such scales provide consistency for nurses to communicate with the client (adults
and children over the age of 7) and other health care providers.

An 11-point pain intensity scale with word modifiers

Pain History
Determine the extent of pain awareness and degree of interference with functioning

0 No pain

2 Awareness of pain only when paying attention to it

4 Can ignore pain and do things

6 Cannot ignore pain, interferes with functioning

8 Impairs ability to function or concentrate

10 Intense incapacitating pain

It is believed that the degree to which pain interferes with functioning is a good marker
for the severity of pain, especially for those with chronic pain.
ALWAYS REMEMBER!
Perception is reality. The client’s self-report
of pain is what must be used to determine
pain intensity. The nurse is obligated to record
the pain intensity as reported by the client.
Pain History
Pain Intensity or Rating Scales
• When noting pain intensity it is important to determine any related factors that may be a ecting
the pain. When the intensity changes, the nurse needs to consider the possible cause.

• Several factors a ect the perception of intensity:

(a) the amount of distraction, or the client’s concentration on another event
(b) the client’s state of consciousness
(c) the level of activity
(d) the client’s expectations

• Not all clients understand or relate to numerical pain intensity scales. These include preverbal
children, older adults with impairments in cognition or communication, and people who do not
speak English. For these clients the Wong-Baker FACES Rating Scale may be easier to use.
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 Pain History

The Wong-Baker FACES Rating Scale

Brief word instructions:

Point to each face using the words to describe the pain intensity. Ask the child to choose the face
that best describes own pain and record the appropriate number.

Copyright 1983, Wong-Baker FACES® Foundation. www.WongBakerFACES.org. Used by permission of The WongBaker FACES® Foundation. Originally published in Whaley & Wong’s Nursing Care of Infants and Children, ©Elsevier Inc.
Pain History
Other Types of Pain Scales
Brief Pain Inventory (BPI)
Short Form McGill Pain Questionnaire (SF-MPQ)
— These scales include a numeric intensity rating and other aspects of chronic pain, such as verbal descriptors,
pictures for the clients to draw the pain they are experiencing, and indicators of mood (D’Arcy, 2011)

Observation of Behavior
— Used when clients are unable to verbalize their pain for reasons of age, mental capacity, medical interventions, or
other reasons.

FLACC Scale
— Has been validated in children 2 months to 7 years old and rates pain behaviors as manifested by Facial
expressions, Leg movement, Activity, Cry, and Consolability measures that yield a score of 0 to 10

PAINAD
— Designed for older adults with advanced dementia
— This scale looks at ve speci c indicators: breathing, vocalization, facial expression, body language, and
consolability (D’Arcy, 2011; Pasero & McCa ery, 2011)
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 Pain History
Other Types of Pain Scales
• For e ective use of pain rating scales, clients need not only to
understand the use of the scale but also to be educated about
how the information will be used to determine changes in
their condition and the e ectiveness of pain management
interventions.

• Clients should also be asked to indicate what level of comfort

is acceptable so that they can perform speci c activities.

• To align the client’s goals and expectations with reality, it is

important to note that acute pain can typically be decreased
by 50% and chronic pain can be decreased by 25%.
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Pain History
Pain Quality
• Descriptive adjectives help people
communicate the quality of pain.

• It is important to record the description

verbatim.

Commonly Used Pain Descriptors

Pain History
Pattern
• The pattern of pain includes:
Time of Onset
Duration
Recurrence or intervals without pain

• The nurse therefore determines when the pain began; how long the pain lasts; whether it
recurs and, if so, the length of the interval without pain; and when the pain last occurred.

• Attention to the pattern of pain helps the nurse anticipate and meet the needs of the client, as
well as recognize patterns of grave concern (e.g., chest pain only on exertion)
Pain History
Precipitating Factors

Physical and Emotional Extreme Physical

Environmental Factors
Stressors Exertion
• Extreme cold or heat and extremes of • Strong emotions can trigger a migraine • Can trigger muscle spasms in the neck,
humidity headache or an episode of chest pain shoulders, or back
• People with rheumatic conditions have
worse pain on cold, damp days or just
before a storm
Pain History
Alleviating Factors

• Nurses must ask clients to describe anything that they have

done to alleviate the pain (e.g., home remedies such as herbal
teas, medications, rest, applications of heat or cold, prayer, or
distractions like TV).

• It is important to explore the e ect any of these measures had

on the pain, whether or not relief was obtained, or whether the
pain became worse.

• It is helpful to recommend a diary be kept to gather this

information.
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Pain History These symptoms may relate to the
onset of the pain or they may result
from the presence of the pain.
Associated Symptoms

Nausea and Vomiting Diarrhea Dizziness

 Pain History
E ect on Activities of Daily Living
Knowing how ADLs are a ected by pain helps the nurse understand the client’s perspective on
the pain’s severity. The nurse should ask the client to describe how the pain has a ected
the following aspects of life:

• Sleep
• Appetite
• Concentration A rating scale of none, a
• Work/school little, or a great deal, or
• Interpersonal relationships
another range can be used to
• Marital relations/sex
• Home activities determine the degree of
• Driving/walking alteration in ADLs.
• Leisure activities
• Emotional status
(mood, irritability, depression, anxiety)
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Pain History
Coping Resources
• Each individual will exhibit personal ways of coping
with pain.
• Nurses can encourage and support the client’s use of
methods known to have helped in modifying pain,
unless they are speci cally contraindicated.
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Coping Strategies
• Seeking quiet and solitude
• Learning about their condition
• Pursuing interesting or exciting
activities (for distraction)
• Saying prayers (or engaging in other
meaningful rituals)
• Socializing (with family, friends,
support groups, etc.)
 Pain History
A ective Responses
• A ective responses vary according to the situation, the degree and duration of pain, the
interpretation of it, and many other factors.

• The nurse needs to explore the client’s feelings of anxiety, fear, exhaustion, level of
function, depression, or a sense of failure.

• Because many people with chronic pain become depressed and potentially suicidal, it may
also be necessary to assess the client’s suicide risk.

“Do you ever feel so bad that you want to die?”

“Have you considered harming yourself or others recently?”
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Pain Assessment
Observation of Behavioral and Physiological Responses

• A client’s self-report is the gold standard for

pain assessment.

• Not all clients, however, are able to self-

re p o r t . T h i s g ro u p , re f e r re d t o a s
“nonverbal” clients, includes the very
young, individuals who are cognitively
impaired, critically ill, or comatose, and
some individuals at end of life. These clients
are de nitely a challenge as the nurse
provides e ective pain management
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 Pain Assessment
Observation of Behavioral and Physiological Responses
Purposeless Body Rhythmic Body
Facial Expression
Movements Movements
• First indication of pain, and it may be the • Tossing and turning in bed or inging the • Rubbing
only one. arms about • Early in the onset of acute pain, the
• Clenched teeth, tightly shut eyes, open sympathetic nervous system is stimulated,
somber eyes, biting of the lower lip, and resulting in increased blood pressure,
other facial grimaces pulse rate, respiratory rate, pallor,
Behavioral Changes diaphoresis, and pupil dilation. An adult or
child may assume a fetal position and rock
back and forth when experiencing
Vocalizations • Confusion and restlessness may be abdominal pain.
indicators of pain in both cognitively intact
and cognitively impaired
• During labor a woman may massage her
• Moaning, groaning, crying, and screaming abdomen rhythmically with her hands.
• Older adults with chronic pain may
become agitated or aggressive

Immobilization of the Involuntary Movements Physiological Responses

body part
• The client with chest pain often holds the • Re exive jerking away from a needle • Early in the onset of acute pain, the
left arm across the chest. inserted through the skin indicate pain. sympathetic nervous system is stimulated,
• A person with abdominal pain may assume • An adult may be able to control this re ex; resulting in increased blood pressure,
the position of greatest comfort, often with however, a child may be unable or pulse rate, respiratory rate, pallor,
the knees and hips exed, and move unwilling to do so diaphoresis, and pupil dilation.
reluctantly.
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Pain Assessment
Daily Pain Diary
• Time of onset of pain
• For clients who experience chronic pain, a daily diary may help • Activity or situation
the client and health care provider identify pain patterns in • Physical pain character (quality) and
addition to factors that exacerbate or mediate the pain intensity level (0–10)
experience.
• Emotions experienced and intensity
level (0–10)
• In home care, the family or other caregiver can be taught to
complete the diary with the family member who is unable to do • Use of analgesics or other relief
so alone. measures (intervention)
• Pain rating after intervention taken
• Comments
 Pain Assessment
Daily Pain Diary

• Pain diaries have been shown to improve pain management.

• They avoid “recall bias” and allow clients to understand and express their pain
experience and possibly determine patterns that can help providers suggest better
interventions.

• The diary may also increase clients’ sense of control by helping them use medication
more e ectively.

• The recorded data in the diary provides the basis for developing or modifying the plan
for care.

• For this tool to be e ective, it is important for the nurse to educate the client and family
about the value and use of the diary in achieving e ective pain control.

• Review the diary each visit, asking questions, sharing observations, and providing hints.
• Determining the client’s ability to use the diary is essential.
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Measuring Oxygen
Saturation
Katrina Francheska Arevalo-Lawsin, DNM, RN
Oxygen Saturation
Pulse Oximeter
A pulse oximeter is a noninvasive device that estimates a client’s arterial blood oxygen
saturation (SaO2) by means of a sensor attached to any of the following:

Finger Toe Nose Earlobe Forehead

The oxygen saturation value is the percent of all hemoglobin binding sites that are occupied
by oxygen.

The pulse oximeter can detect hypoxemia (low oxygen saturation) before clinical signs and
symptoms, such as a dusky color to skin and nail beds, develop.
 Earlobe

Nose

Forehead

Toe
Oxygen Saturation
Pulse Oximeter Two light-emitting diodes Photodetector
(Two parts) One red, the other infrared that transmit light Placed directly opposite the LEDs (e.g., the other
through nails, tissue, venous blood, and arterial side of the nger, toe, or nose).
blood

• Because the photodetector measures the

amount of red and infrared light absorbed
by oxygenated and de- oxygenated
hemoglobin in peripheral arterial blood, it
is reported as SpO2.

• Normal oxygen saturation is 95% to 100%,

and below 70% is life threatening.
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Pulse Oximeter

With adhesive sensor

Oxygen Saturation
Pulse Oximeter
• Pulse oximeters with various types of sensors are available from several
manufacturers.

• The oximeter unit consists of an inlet connection for the sensor cable, and
a faceplate that indicates (a) the oxygen saturation measurement and (b)
the pulse rate.

• Cordless units are also available.

• A preset alarm system signals high and low SpO2 measurements and a
high and low pulse rate. The high and low SpO2 levels are generally
preset at 100% and 85%, respectively, for adults. The high and low
pulse rate alarms are usually preset at 140 and 50 beats/min for adults.
These alarm limits can, however, be changed using the manufacturer’s
directions.
Oxygen Saturation
Pulse Oximeter

Fingertip oximeter sensor (adult) Fingertip oximeter sensor (cordless)

Oxygen Saturation
Factors A ecting Oxygen Saturation Readings
Among the factors in uencing oxygen saturation readings are hemoglobin levels, circulation,
activity, and exposure to carbon monoxide.

Hemoglobin Levels Activity

If the hemoglobin is fully saturated with oxygen, the SpO2 Shivering or excessive movement of the sensor site may
will appear normal even if the total hemoglobin level is interfere with accurate readings.
low

Circulation Carbon Monoxide Poisoning

The oximeter will not return an accurate reading if the Pulse oximeters cannot discriminate between hemoglobin
area under the sensor has impaired circulation saturated with carbon monoxide versus oxygen.
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 Measuring Oxygen Saturation
Purpose Assessment
• The best location for a pulse oximeter sensor
To estimate the arterial blood
based on the client’s age and physical condition.
oxygen saturation
Unless contraindicated, the
nger is usually selected for adults.

To detect the presence of • The client’s overall condition including risk factors
hypoxemia before visible signs for development of hypoxemia (e.g., respiratory or
develop cardiac disease) and hemoglobin level

• Vital signs, skin color and temperature, nail bed

color, and tissue perfusion of extremities as
baseline data

• Adhesive allergy
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Measuring Oxygen Saturation
Planning

• Many hospitals and clinics have pulse Equipment

oximeters readily available for use with other
vital signs equipment (or even as an integrated • Nail polish remover as needed
part of the electronic blood pressure device).
• Alcohol wipe
• Other facilities may have a limited supply of
oximeters, and the nurse may need to request • Sheet or towel
it from the central supply department.
• Pulse oximeter
Measuring Oxygen Saturation

DELEGATION
Application of the pulse oximeter sensor and
recording of the SpO2 value may be delegated to
UAP. The interpretation of the oxygen saturation
value and determination of appropriate responses
are done by the nurse.
Measuring Oxygen Saturation

INTERPROFESSIONAL PRACTICE
Measuring oxygen saturation may be within the scope
of practice for many health care providers. For
example, in addition to nurses, respiratory therapists
may check the client’s oxygen saturation before,
during, and after treatment. Although these therapists
may verbally communicate their ndings and plan to
the health care team members, the nurse must also
know where to locate their documentation in the
client’s medical record.
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Measuring Oxygen Saturation
Preparation
Check that the oximeter equipment is functioning properly

Procedure
1. Prior to performing the procedure, introduce self and verify the client’s identity using
agency protocol. Explain to the client what you are going to do, why it is necessary, and
how he or she can participate. Discuss how the results will be used in planning further care
or treatments.

2. Perform hand hygiene and observe appropriate infection prevention procedures.

3. Provide for client privacy.

 Measuring Oxygen Saturation
Procedure

4. Choose a sensor appropriate for the client’s weight, size, and desired location.
Because weight limits of sensors overlap, a pediatric sensor could be used for a small adult.

— If the client is allergic to adhesive, use a clip or sensor without adhesive.

— If using an extremity, apply the sensor only if the proximal pulse and capillary re ll at the
point closest to the site are present. If the client has low tissue perfusion due to peripheral
vascular disease or therapy using vasoconstrictive medications, use a nasal sensor or a
re ectance sensor on the forehead. Avoid using lower extremities that have a compromised
circulation and extremities that are used for infusions or other invasive monitoring.
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Measuring Oxygen Saturation
Procedure

5. Prepare the site.

— Clean the site with an alcohol wipe before applying the sensor.
— It may be necessary to remove a female client’s dark nail polish.

Rationale: Nail polish may interfere with accurate measurements although the data about this
are inconsistent.

Alternatively, position the sensor on the side of the nger rather than perpendicular to the nail
bed.

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Measuring Oxygen Saturation
Procedure
6. Apply the sensor, and connect it to the pulse oximeter.

— Make sure the LED and photodetector are accurately aligned, that is, opposite each other
on either side of the nger, toe, nose, or earlobe. Many sensors have markings to facilitate
correct alignment of the LEDs and photodetector.

— Attach the sensor cable to the connection outlet on the oximeter. Turn on the machine
according to the manufacturer’s directions. Appropriate connection will be con rmed by an
audible beep indicating each arterial pulsation. Some devices have a wheel that can be turned
clockwise to increase the pulse volume and counterclockwise to decrease it.

— Ensure that the bar of light or waveform on the face of the oximeter uctuates with each
pulsation.
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Measuring Oxygen Saturation
Procedure

7. Set and turn on the alarm when using continuous monitoring.

— Check the preset alarm limits for high and low oxygen saturation and high and low pulse
rates. Change these alarm limits according to the manufacturer’s directions as indicated.

— Ensure that the audio and visual alarms are on before you leave the client. A tone will be
heard and a number will blink on the faceplate.
Measuring Oxygen Saturation
Procedure

8. Ensure client safety.

— Inspect and/or move or change the location of an adhesive toe or nger sensor every 4
hours and a spring-tension sensor every 2 hours.
— Inspect the sensor site tissues for irritation from adhesive sensors.

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Measuring Oxygen Saturation
Procedure
9. Ensure the accuracy of measurement.
— Minimize motion artifacts by using an adhesive sensor, or immobilize the client’s monitoring
site.
Rationale: Movement of the client’s nger or toe may be misinterpreted by the oximeter as
arterial pulsations.

— If indicated, cover the sensor with a sheet or towel to block large amounts of light from
external sources (e.g., sunlight, procedure lamps, or bilirubin lights in the nursery).
Rationale: Bright room light may be sensed by the photo- detector and alter the SpO2 value.

— Compare the pulse rate indicated by the oximeter to the radial pulse periodically.
Rationale: A large discrepancy between the two values may indicate oximeter malfunction.

10. Document the oxygen saturation on the appropriate record at designated

intervals.
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Takeaway Points
• Pain is “whatever the person says it is, and exists whenever he says it does.” It is a
subjective sensation to which no two people respond in the same way. It can directly impair
health and prolong recovery from surgery, disease, and trauma.

• Types of pain may be described in terms of location, duration, intensity, and etiology.
• Pain threshold is generally similar in all people, but pain tolerance and response vary
considerably among individuals.

• Overall client goals include preventing, modifying, or eliminating pain so that the client is
able to partly or completely resume usual daily activities and to cope more e ectively with the
pain experience.

• A pulse oximeter measures the percent of hemoglobin saturated with oxygen. A normal
result is 95% to 100%.

• Pulse oximeter sensors may be placed on the nger, toes, nose, earlobe, forehead, or
around the hand or foot of the neonate.
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