Pain Assessment, Clinical History, and Examination
Paula S. McCauley
CASE STUDY You are a novice Advanced Practice Registered Nurse and have been hired by the orthopedic service in your organization to establish a service for pain management. Your first referral is Marie Smith, a 58-year-old female who presented to the emergency department for evaluation of severe low back pain. Her work-up is positive for spinal stenosis and degenerative disk disease at L5-S1. The orthopedist has informed her that she is not a surgical candidate and opted to treat her medically. He prescribed ibuprofen 800 mg 4 times a day and referred her to your pain management service for further evaluation.
As a new provider, where do you start?
Introduction: Pain Assessment
The International Association for the Study of Pain (IASP, 2017) defines pain as a combined sensory, emotional, and cognitive phenomenon: “an unpleasant sensory and emotional experience that we primarily associate with tissue damage or describe in terms of such damage, or both.” Pain is a personal, subjective experience influenced by cultural beliefs and other psychological variables (IASP, 2017). Pain is the most common symptom that brings patients to see a provider, and it is often the first sign of an ongoing pathologic process. Depending on the individual circumstances, the same physical lesion or disease state can produce different levels of pain and need for pain relief.
▶ KEY POINT
You, as the provider they have sought out for care of their circumstances, must keep in mind that the patient’s subjective reporting of pain, not your impression of their pain, is the basis for pain assessment and treatment (Gomella & Haist, 2007).
Pain medicine has been shaped largely by the biopsychosocial model, first identified by Gordon Waddell in 1987. The biopsychosocial model established that clinicians need to understand pain from the biomedical perspective as well as the impact of the patient’s perception and their social context. Pain includes three distinct components: a sensory-discriminatory component, a motivational-affective component, and a cognitive-evaluative component. This framework requires that you have an
understanding of the characteristics of the pain, the psychological responses to pain, how and why the pain has changed this person’s life, and the implications for recovery (Azari, Zevin, & Potter, 2007).
understanding of the characteristics of the pain, the psychological responses to pain, how and why the pain has changed this person’s life, and the implications for recovery (Azari, Zevin, & Potter, 2007).
Pain management has more recently been shaped by patient- and family-centered care. The Agency for Healthcare Research and Quality produced a guide of evidence-based strategies through its Patient and Family Advisory Council that promotes patient- and family-centered care and includes the domain of pain management. Evaluation of the patients’ perspective of a need for help with pain-centered care and healthcare providers’ focus on pain management revealed major gaps in care. Patients focused on pain assessment, explanation of therapies, and adjunct therapies. Healthcare providers focused on aspects such as medication administration, or reduction in call light usage. Based on their evaluation, the council created a bundle of strategies that may guide development of a personalized plan of care for pain management. These strategies include a redesigned pain management assessment, a menu of pain control, and comfort options (Bookout, Staffileno, & Budzinsky, 2016).
For everyday clinical practice, it is necessary to have outcome measures that are practical and comprehensive enough to be easily used for all patients. Your initial assessment must establish if the pain is acute or chronic and the adverse effects it has created for the patient including physiologic, emotional, and psychological aspects. Your assessment must be systematic, comprehensive, and include evaluation of all the following: (1) type, (2) frequency, (3) location, (4) intensity, (5) modifying factors, (6) effects of treatments, (7) functional impact, and (8) psychosocial impact on the patient. There are multiple instruments available to assess pain. A comprehensive approach to the measurement of pain will include a combination of instruments such as verbal rating scales, numeric rating scales (NRSs), behavioral observation scales, and physiologic responses (Fink, 2000; Gomella & Haist, 2007; Melzack & Katz, 2001; Turk et al., 2003).
One example of a comprehensive approach is based on the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (Turk et al., 2003) recommendations. The IMMPACT recommended six core outcome domains: pain, physical functioning, emotional functioning, patient ratings of improvement and satisfaction with treatment, other symptoms and adverse events during treatment, and patient’s disposition and characteristics data (Table 3-1; Turk et al., 2003).
Based on the IMMPACT recommendations, the Norwegian Pain Society created a 4-page, 31-item screening questionnaire that covers the IMMPACT-recommended outcome domains. The questionnaire includes questions on coping and catastrophizing, health-related quality of life, economic impact of the pain condition, social security status, and any ongoing litigation or compensation process (Turk et al., 2003).
Classification of Pain
Acute Pain
Acute pain is caused by noxious stimulation because of injury, a disease process, or the abnormal function of muscle or viscera. The most common forms of acute pain include posttraumatic, postoperative, and obstetric pain as well as pain associated
with acute medical illnesses, such as myocardial infarction, pancreatitis, and renal calculi. Most forms of acute pain are self-limited or resolve with treatment in a few days or weeks (Azari et al., 2007).
with acute medical illnesses, such as myocardial infarction, pancreatitis, and renal calculi. Most forms of acute pain are self-limited or resolve with treatment in a few days or weeks (Azari et al., 2007).
Table 3-1. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT)-Recommended Six Core Outcome Domains | ||
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▶ KEY POINT
The initial assessment when evaluating and classifying pain is to differentiate if it is acute, chronic, or a combination of both. Most pain can be further classified as inflammatory or nociceptive, neuropathic, or idiopathic (Azari et al., 2007).
Acute pain is typically associated with a systemic neuroendocrine stress response proportional to the pain’s intensity. There are two types of acute pain: neuropathic and nociceptive. Neuropathic pain arises from disordered nerve signals. It is described by patients as burning, electrical, or shock-like pain. Classic examples are poststroke pain, tumor invasion of the brachial plexus, and herpetic neuralgia. Nociceptive pain serves to detect, localize, and limit tissue damage and is further divided into somatic or visceral.
Somatic pain
Somatic pain is the result of direct mechanical or chemical stimulation of nociceptors and normal neural signaling to the brain. It tends to be localized, aching, throbbing, and cramping. The classic example is bone metastases. Deep somatic pain arises from muscles, tendons, joints, or bones and has a dull, aching quality and is less well localized. The intensity and duration of the stimulus affect the degree of localization. Vrooman and Rosenquist (2013) use an example: pain following brief minor trauma to the elbow joint is localized to the elbow, but severe or sustained trauma can cause pain in the whole arm.
Visceral pain
Visceral pain is caused by nociceptors in organ systems such as gastrointestinal and respiratory systems. It may be due to a disease process or abnormal function involving an internal organ or its covering such as parietal pleura, pericardium, or peritoneum. Visceral pain is a deep or colicky type of pain classically associated with disorders or diseases such as pancreatitis or myocardial infarction. It is dull, diffuse,
and usually midline, frequently associated with abnormal sympathetic or parasympathetic activity causing symptoms such as nausea, vomiting, sweating, and changes in blood pressure and heart rate (Vrooman & Rosenquist, 2013). Parietal pain is typically sharp and is either localized to the area around the organ or referred to a distant site. Two examples include: pain associated with disease processes involving the peritoneum or pleura over the diaphragm that is frequently referred to the neck and shoulder; or pain from disease processes affecting the parietal surfaces of the peripheral diaphragm that is referred to the chest or upper abdominal wall (Vrooman & Rosenquist, 2013).
and usually midline, frequently associated with abnormal sympathetic or parasympathetic activity causing symptoms such as nausea, vomiting, sweating, and changes in blood pressure and heart rate (Vrooman & Rosenquist, 2013). Parietal pain is typically sharp and is either localized to the area around the organ or referred to a distant site. Two examples include: pain associated with disease processes involving the peritoneum or pleura over the diaphragm that is frequently referred to the neck and shoulder; or pain from disease processes affecting the parietal surfaces of the peripheral diaphragm that is referred to the chest or upper abdominal wall (Vrooman & Rosenquist, 2013).
On your initial assessment, it is important to document the degree of pain because it identifies patients with severe pain and facilitates treatment. Acute pain assessment will determine duration, location, quality, severity, and exacerbating and relieving factors. Pain assessment should include nonverbal signs, such as tachycardia, tachypnea, and changes in patient expression and movements; the patient’s report of pain; and any response to treatment. Periodic pain reassessment is needed because pain is dynamic and changes with time (Ducharme, 2016). Acute pain is typically associated with a systemic neuroendocrine stress response that is proportional to pain intensity. The efferent limb is mediated by the sympathetic nervous and endocrine systems. Sympathetic activation increases sympathetic tone to all viscera and releases catecholamines from the adrenal medulla. Hormonal responses result from increased sympathetic tone and from hypothalamically mediated reflexes. Moderate to severe acute pain may adversely affect perioperative morbidity, mortality, and convalescence (Vrooman & Rosenquist, 2013). Systemic effects can be categorized by systems and are included in Table 3-2.
Chronic Pain
Chronic pain persists beyond the usual course of an acute disease or beyond the time normally associated with healing from an acute or subacute injury (usually 2-12 weeks). When pain fails to resolve because of either abnormal healing or inadequate treatment, it becomes chronic (Azari et al., 2007). Chronic pain may be nociceptive, neuropathic, or mixed, and psychological mechanisms or environmental factors frequently play a major role. It may be constant, intermittent, or related to physical activity (Vrooman & Rosenquist, 2013). Chronic pain sufferers often experience several types of pain. An illustration of this is chronic low back pain because of osteoarthritis, which is normally classified as inflammatory but may include associated irritation of the nerves and the associated sensory activation in the periphery with sensitization of the central nervous system (Azari et al., 2007). Patients with chronic pain will often have alternations in their neuroendocrine stress responses and have sleep and affective disturbances.
The most common forms of chronic pain include those associated with musculoskeletal disorders; chronic visceral disorders; lesions of peripheral nerves, nerve roots, or dorsal root ganglia (diabetic neuropathy and postherpetic neuralgia); lesions of the central nervous system (stroke, spinal cord injury, and multiple sclerosis); and cancer pain. The pain associated with some disorders such as cancer and chronic back pain is often mixed (Vrooman & Rosenquist, 2013). Systemic responses to chronic pain are included in Table 3-3.
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