health assesment lecture

• The International Association for the Study of Pain (IASP)

  has defined pain as “an unpleasant sensory and emotional

  experience, which we primarily associate with tissue damage

  or describe in terms of such damage” (IASP, 2011). The most

  important definition of pain as it is experienced is that by

  McCaffery and Pasero (1999): “Pain is whatever the person

  says it is.” It is important to remember this definition when

  assessing and treating pain.
• Recent literature has emphasized the importance and under-treatment of pain, and has recommended that pain be the fifth vital sign
• Some states have passed laws necessitating the adoption of an assessment tool and documenting pain assessment in client records along with temperature, pulse, heart rate, and blood pressure
• The Joint Commission has established standards for pain assessment and management
• Inadequate treatment of acute pain has been shown to result in physiologic, psychological, and emotional distress that can lead to chronic pain
• Healthy People has added a new topic for 2020 that includes pain as it affects "Health-Related Quality of Life and Well-Being"
• Health-related quality of life (HRQoL)


  A multidimensional concept that includes domains related to physical, mental, emotional and social functioning. It goes beyond direct measures of population health, life expectancy and causes of death, and focuses on the impact health status has on quality of life
• Pain


  A combination of physiologic phenomena but with psychosocial aspects that influence perception of the pain
• Pathophysiology of pain


  1. Transduction

  2. Transmission

  3. Perception

  4. Modulation
• Nociceptors


  • Sensory receptors that detect signals from damaged tissue and chemicals released from the damaged tissue
  • Located at the peripheral ends of both myelinated nerve endings of type A fibers or unmyelinated type C fibers
  • Three types: mechanosensitive, temperature-sensitive, and polymodal
• Nociceptors are distributed in the body, skin, subcutaneous tissue, skeletal muscle, joints, peritoneal surfaces, pleural membranes, dura mater, and blood vessel walls, but not located in the parenchyma of visceral organs
• Transduction of pain


  1. Noxious stimulus results in tissue injury or damage stimulating the nociceptors

  2. Inflammatory process leads to release of cytokines and neuropeptides

  3. Activation of primary afferent nociceptors (A-delta and C fibers)
• 1. delta primary afferent fibers


  Small-diameter, lightly myelinated fibers that transmit fast pain to the spinal cord within 0.1 second, felt as pricking, sharp, or electric-quality sensation, usually caused by mechanical or thermal stimuli
• C fibers


  Unmyelinated, primary afferent fibers that transmit slow pain within 1 second, felt as burning, throbbing, or aching, usually caused by mechanical, thermal, or chemical stimuli resulting in tissue damage
• Transmission of pain


  1. Inflammatory process results in conduction of impulse in primary afferent neurons to the dorsal horn of the spinal cord

  2. Neurotransmitters released and concentrated in the substantia gelatinosa

  3. Output neurons from the dorsal horn cross the anterior white commissure and ascend the spinal cord in the anterolateral quadrant in ascending pathways
• The anterolateral tracts relay sensations of pain, temperature, nondiscriminative (crude) touch, pressure, and some proprioceptive sensation
• The process of pain perception is still poorly understood
• Emotional status (depression and anxiety)


  Affects directly the level of pain perceived and thus reported by clients
• Hypothalamus and limbic system


  • Responsible for the emotional aspect of pain perception
• Frontal cortex


  • Responsible for the rational interpretation and response to pain
• Modulation of pain is a difficult phenomenon to explain
• Modulation of pain


  1. Changes or inhibits the pain message relay in the spinal cord

  2. The descending modularly pain pathways either increase (excite) or inhibit pain transmission
• Endogenous neurotransmitters involved with modulating pain


  • Endogenous opioids, such as endorphins and enkephalins
  • Serotonin
  • Norepinephrine (noradrenaline)
  • Gamma-aminobutyric acid (GABA)
  • Neurotensin
  • Acetylcholine
  • Oxytocin
• Pain elicits a stress response in the human body that triggers the sympathetic nervous system
• Physiologic responses to pain

  • Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide
  • Focus on pain, reports of pain, cries and moans, frowns and facial grimaces
  • Decrease in cognitive function, mental confusion, altered temperament, high somatization, and dilated pupils
  • Increased heart rate; peripheral, systemic, and coronary vascular resistance; increased blood pressure
  • Increased respiratory rate and sputum retention, resulting in infection and atelectasis
• Joint Commission Standards for Pain Management

  • Require health care providers and organizations to improve pain assessment and management for all patients
• Patients have a right to

  Appropriate pain assessment and management
• Pain assessment and management

  1. Screen initially

  2. Assess periodically (nature and intensity)

  3. Record pain assessment results

  4. Follow-up with reassessments
• Assess staff for


  Level of knowledge in pain assessment and management
• Educate staff


  In pain assessment and management as needed
• Organizational policies and procedures

  • Support appropriate ordering or prescribing of effective pain medications
• Discharge planning process


  Address patient needs for symptom management
• Collect data


  To monitor the appropriateness and effectiveness of pain management
• Pain classification


  • Duration
  • Location
  • Etiology
  • Severity
• Types of pain based on duration and etiology

  • Acute pain
  • Chronic nonmalignant pain
  • Cancer pain
• Acute pain


  Usually associated with a recent injury
• Chronic nonmalignant pain


  Usually associated with a specific cause or injury and described as a constant pain that persists for more than 6 months
• 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
• Pain location classifications


  • Cutaneous pain (skin or subcutaneous tissue)
  • Visceral pain (abdominal cavity, thorax, cranium)
  • Deep somatic pain (ligaments, tendons, bones, blood vessels, nerves)
• Pain location


  • Perceived at the site of the pain stimuli
  • Radiating (perceived both at the source and extending to other tissues)
  • Referred (perceived in body areas away from the pain source)