Weber

Health Assessment in Nursing

Chapter 08:
Pain Assessment

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Question

Tell whether the following statement is

True or False.
An unpleasant sensory and emotional
experience, which we primarily associate
with tissue damage, is termed pain.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

True.
An unpleasant sensory and emotional
experience, which we primarily associate
with tissue damage, is termed pain.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Structure and Function
• Definition
– International Association for the
Study of Pain (ISAP): Unpleasant
sensory and emotional experience
that we primarily associate with
tissue damage or describe in terms
of such damage, or both

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Structure and Function
• Pathophysiology of pain summarized by
processes
– Transduction
– Transmission
– Modulation
– Perception
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Structure and Function

• Classification of pain
– Acute: Associated with an injury of
recent onset, duration less than 6
months or less than 1 month

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Structure and Function

• Classification of pain (cont’d)

– Chronic non-malignant: Associated
with a specific cause or injury and is
described as constant pain that
persists more than 6 months

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Structure and Function

• Classification of pain (cont’d)

– Cancer pain: Often due to the
compression of peripheral nerves or
meninges or from the damage to
these structures following surgery,
chemotherapy, radiation, or tumor
growth and infiltration

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Structure and Function

• Other descriptors of pain:

– Transient pain
– Tissue injury pain
– Chronic neuropathic pain

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Structure and Function
• Physiologic responses to pain
– Emotional and psychological
– Physical appearance
– Increased vital signs
– Decreased gastrointestinal and
urinary function
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Structure and Function

• Physiologic responses (cont’d)

– Increased release of hormones and
neurotransmitters
– Metabolic disturbances
– Muscular dysfunction

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Question

Tell whether the following statement is

True or False.
A normal respiratory rate ranges from
15 to 21 breaths per minute.

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Answer

False.
A normal respiratory rate ranges from
12 to 20 breaths per minute.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Health Assessment
• Perform nursing assessment
– Collect subjective data
•Review past and family histories in
terms of pain
•Review health habits to determine
how the pain interferes with the
client’s life
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Health Assessment

• Perform nursing assessment (cont’d)

– Collect objective data
•Verbal Descriptor Scale (VDS)
•Wong-Baker Faces Scale (FACES)

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Health Assessment

• Perform nursing assessment (cont’d)

– Collect objective data
•Numeric Rating Scale (NRS)
•Visual Analog Scale (VAS)

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Tools for Assessing Pain

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Tools for Assessing Pain

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Tools for Assessing Pain

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Health Assessment

• Assessment procedure
– Observe posture, facial expression
– Measure vital signs
– Perform physical assessment

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Health Assessment

• Validate and document data

– Reliable and accurate

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Question

Which is an appropriate pain assessment

tool for pediatric clients?
a. Verbal Descriptor Scale
b. Numeric Rating Scale
c. Visual Analog Scale
d. Wong-Baker Faces Scale
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Answer
d. Wong-Baker Faces Scale (FACES)
Rationale: An appropriate pain assessment
tool for pediatric clients is Wong-Baker
Faces Scale. Verbal Descriptor Scale,
Numeric Rating Scale and Visual Analog
Scale are other pain assessment tools for
collecting objective data from the clients.

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Analysis of Data

• Diagnostic reasoning: Possible

conclusions
– Used to make clinical judgments
about the status of client’ s pain

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Analysis of Data

• Selected nursing diagnosis

– Examples: Wellness diagnosis
– Readiness for enhanced spiritual
well-being and comfort level

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Analysis of Data

• Selected nursing diagnosis (cont’d)

– Examples: Risk diagnosis
– Risk for powerlessness related to
chronic pain, healthcare
environment, pain treatment-related
regimen

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Analysis of Data

• Selected nursing diagnosis (cont’d)

– Examples: Actual diagnosis
– Ineffective breathing pattern related
to abdominal pain and anxiety
– Fatigue related to stress of handling
chronic pain

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Analysis of Data

• Examples: Collaborative problems

– PC: Angina
– PC: Endocarditis
– PC: Peripheral vascular insufficiency

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Analysis of Data

• Medical problems
– After grouping the data, the client’s
signs and symptoms may require
medical diagnosis and treatment

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 End of Presentation

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