Differentiating acute and chronic pain
Acute pain may cause certain physiologic and behavioral changes that you won’t observe in a patient with chronic pain.
TYPE OF PAIN | PHYSIOLOGIC EVIDENCE | BEHAVIORAL EVIDENCE |
Acute | ♦ Increased respirations ♦ Increased pulse ♦ Increased blood pressure ♦ Dilated pupils ♦ Diaphoresis | ♦ Restlessness ♦ Distraction ♦ Worry ♦ Distress |
Chronic | ♦ Normal respirations, pulse, blood pressure, and pupil size ♦ No diaphoresis | ♦ Reduced or absent physical activity ♦ Despair or depression ♦ Hopelessness |
Achieving adequate pain control depends on effectively assessing, treating, and monitoring pain. Pain is referred to as the fifth vital sign alongside temperature, pulse, blood pressure, and respiration. To provide the best care possible, work with physicians and other members of the health care team to develop an individualized pain management program for each patient.
Pain has a sensory component and a reaction component. The sensory component involves an electrical impulse that travels to the central nervous system, where it’s perceived as pain. The response to this perception is the reaction component.
Pain is highly subjective and unique to the person experiencing it. Any report of pain must be assessed and addressed.
Pain also manifests differently according to each patient’s beliefs, culture, and age.
An older adult may not report pain and may metabolize and experience the effects of analgesic drugs differently than a younger patient. To assess pain in an older patient with cognitive dysfunction, use such cues as behavior (motor responses, facial expressions, crying) and physiologic changes (increased blood pressure and heart rate) in addition to self-reporting.
Children metabolize drugs differently from adults and may experience the effects of analgesics differently. When assessing pain in a child, use verbal, numeric, or picture scales to help determine the child’s pain level in addition to direct questions. Also watch for behavioral cues (facial expressions, crying) and physiologic changes (increased blood pressure and heart rate) to help determine the child’s pain level.During the course of an illness, a patient may experience acute pain, chronic pain, or both.
Acute pain is caused by tissue damage from injury or disease. It varies in intensity from mild to severe and lasts briefly. It’s considered a protective mechanism because it warns of current or potential damage or organ disease. It may result from a traumatic injury, from surgical or diagnostic procedures, or from a medical disorder.
Chronic pain is pain that has lasted 6 months or longer and is ongoing. Although it may be as intense as acute pain, it isn’t a warning of tissue damage. (See Differentiating acute and chronic pain.)
PQRST: The alphabet of pain assessment
Use the PQRST mnemonic device to obtain more information about the patient’s pain. Asking these questions elicits important details about his pain.
Provocative or palliative
Ask the patient:
♦ What provokes or worsens your pain?
♦ What relieves your pain or causes it to subside?
Quality or quantity
Ask the patient:
♦ What does the pain feel like? For example, is it aching, intense, knifelike, burning, or cramping?
♦ Are you having pain right now? If so, is it more or less severe than usual?
♦ To what degree does the pain affect your normal activities?
♦ Do you have other symptoms along with the pain, such as nausea or vomiting?
Region and radiation
Ask the patient:
♦ Where is your pain?
♦ Does the pain radiate to other parts of your body?
Severity
Ask the patient:
♦ How severe is your pain? How would you rate it on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable?
♦ How would you describe the intensity of your pain at its best? At its worst? Right now?
Timing
Ask the patient:
♦ When did your pain begin?
♦ At what time of day is your pain best? At what time of day is it worst?
♦ Is the onset sudden or gradual?
♦ Is the pain constant or intermittent?
Pain assessment
It’s important for the nurse to have good pain assessment skills. The most valid assessment of pain comes from the patient’s own reports of his pain. (See PQRST: The alphabet of pain assessment.)
Many pain assessment tools are available. Whichever you choose, make sure that it’s used consistently so that everyone on the health care team is speaking the same language when addressing the patient’s pain.
The three most common pain assessment tools used by clinicians are the visual analog scale (see Visual analog scale, page 438), the numeric rating scale (see Numeric rating scale, page 438), and the FACES scale (see Wong-Baker FACES pain rating scale, page 438). The patient may exhibit many physiologic and psychological responses to pain, and the nurse should watch for these during a pain assessment. (See Pain behavior checklist, page 439.)
Numeric rating scale
A numeric rating scale can help the patient to quantify his pain. To use this scale, ask the patient to choose a number from 0 (indicating no pain) to 10 (indicating the worst pain imaginable) to reflect his current level of pain. He can either circle the number on the scale or state the number that best describes his pain.
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Wong-Baker FACES pain rating scale
A child or an adult with language difficulties may not be able to express the pain he’s feeling. In such instances, you can use the pain intensity scale below. To use this scale, ask the patient to choose the face that best represents the severity of his pain on a scale from 0 to 10.
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From Hockenberry, M.J., Wilson, D.: Wong’s Essentials of Pediatric Nursing, 8th ed. St. Louis, 2009, Mosby. Used with permission. Copyright Mosby.
Pain behavior checklist
A pain behavior is something that a patient uses to communicate pain, distress, or suffering. Place a check in the box next to each behavior that you observe or infer while talking with the patient.
□ Grimacing □ Moaning □ Sighing □ Clenching the teeth □ Holding or supporting the painful body area □ Sitting rigidly □ Frequently shifting posture or position □ Moving in a guarded or protective manner □ Moving very slowly □ Limping □ Taking medication | □ Using a cane, a cervical collar, or another prosthetic device □ Walking with an abnormal gait □ Requesting help with walking □ Stopping frequently while walking □ Lying down during the day □ Avoiding physical activity □ Being irritable □ Asking such questions as, “Why did this happen to me?” □ Asking to be relieved from tasks or activities |
Pharmacologic pain management
Two classes of medications are commonly used for pain management:
♦ nonopioids
♦ opioids.
Nonopioids are the first choice for managing mild pain. They decrease pain by inhibiting inflammation at the injury site. Examples of nonopioids are:
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