Pain assessment tools nursing

What improves or exacerbates the condition? What were you doing when it started? Does position or activity make it worse? Q: Quality and Quantity of symptoms: Is it dull, sharp, constant, intermittent, throbbing, pulsating, aching, tearing or stabbing? R: Radiation or Region of symptoms: Does the pain travel, or is it only in one location? Has it always been in the same area, or did it start somewhere else?

S: Severity of symptoms or rating on a pain scale. Does it affect activities of daily living such as walking, sitting, eating, or sleeping? T: Time or how long have they had the symptoms. Is it worse after eating, changes in weather, or time of day? Active, attentive listening: Attention to the details of what the patient is saying either in a verbal or nonverbal manner.

Empathy: Demonstrate that you understand and feel for the patient, recognition of their current situation and perceived feelings, and communicating in a nonjudgmental, unbiased way of acceptance.

Share hope: Ensure in the patient a sense of power, hope in an often hopeless environment, and the possibility of a positive outcome. Share humor: Fosters a relationship of emotional support, establishes rapport, acts as a positive diversion technique, and promotes physical and mental well being. Cultural considerations play a role in humor.

Touch: Touch may be a source of comfort or discomfort for a patient, wanted or unwanted; observe verbal and nonverbal cues with touch; holding a hand, conducting a physical assessment, performing a procedure. Therapeutic silence: Fosters an environment of patience, thought and reflection on difficult decisions, and allows time to observe any nonverbal signs of discomfort the patient typically breaks the silence first.

Provide information: During an assessment and care, inform the patient as to what is about to happen, explain findings and the need for further testing or observation to promote trust and decrease anxiety.

Clarification: Ask questions to clear up ambiguous statements, ask the client or patient to rephrase or restate confusing remarks so wrong assumptions are clarifiable and a missed opportunity for valuable information forgone. Focusing: Brings the focus of the conversation to an essential area of concern, eliminating vague or rambling dialogue, centers the assessment on the source of discomfort and pertinent details in the history.

Asking relevant questions: Questions are general at first then become more specific; asked in a logical, consecutive order; open-ended, close-ended, and focused questions may be useful during an assessment. Summarizing: Provides a review of assessment findings, offers clarification opportunities, informs the next step in the admission and hospitalization process.

Self-disclosure: Promotes a trusting relationship, the feeling that the patient is not in this alone, or unique in their current circumstances; provides a framework for hope, support, and respect.

Confrontation: You may have to confront the patient after a trustful rapport has been established, discussing any inconsistencies in the history, thought processes, or inappropriate behavior. Initial vital sign measurements: temperature recorded in Celsius in most institutions, respiratory rate, pulse rate, blood pressure with appropriate sized cuff, pulse oximetry reading and note if on room air or oxygen; accurately measured weight in kilograms with the proper scale and height measurement, so body mass index BMI is calculable for dosing weights and nutritional guidelines.

Be alert for any malodors from the body including the oral cavity; fecal odor, fruity-smell, odor of alcohol or tobacco on the breath. Percussion is an advanced technique requiring a specific skill set to perform. Therefore, it is a skill practiced by advanced practice nurses as opposed to a bedside nurse on a routine basis. Important in examination of the heart, blood pressure, and gastrointestinal system.

Abdominal assessment follows the techniques in this sequence: inspection, auscultation, percussion, and palpation. Auscultate bowel sounds for at least 15 seconds in each quadrant using the diaphragm of the stethoscope, starting with the lower right-hand quadrant and moving clockwise.

If a fistula is present for hemodialysis, assess for a thrill or bruit, document presence or absence. Notify managing healthcare provider immediately if absent. Blood tests CBC, chemistry, bedside glucose, pregnancy test, urinalysis, cardiac enzymes, coagulation studies.

Clinical Significance Often the initial history and physical examination lead to the identification of life- or limb-threatening conditions that can be stabilized promptly, ensuring better patient outcomes. The nurse should be familiar with the otoscope, penlight, stethoscope bell and diaphragm , thermometer, bladder scanner, speculum, eye charts, cardiac and blood pressure monitors, fetal doppler and extremity doppler, and sphygmomanometer.

Alcohol swabs, sanitizer, or soapy water to clean equipment after use, such as with stethoscopes, to decrease the likelihood of cross-contamination of pathogens from inanimate objects follow any manufacturer guidelines or institutional policies. Calculation devices for BMI, conversion from pounds to kilograms, kilograms to pounds, Celsius to Farenheight.

Multidimensional measurement tools capture multiple aspects of a patient's pain experience but can be cumbersome to administer in busy clinical settings. Aim: We conducted a systematic review to identify brief multidimensional pain assessment tools that nurses can use in both ambulatory and acute care settings. Eligible English-language articles were systematically screened and data were extracted independently by two raters.

Face 2 hurts just a little. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. The scale has five criteria, which are each assigned a score of 0, 1, or 2. Table Eight physiological and behavioral indicators are scored on a scale of 1 to 5 to assess pain and sedation. See Table Each item is scored from , When totaled, the score can range from 0 no pain to 10 severe pain. Comfort-function goals encourage the patient to establish their level of comfort needed to achieve functional goals based on their current health status.

For example, one patient may be comfortable ambulating after surgery and their pain level is 3 on a 0-to pain intensity rating scale, whereas another patient desires a pain level of 0 on a 0-to scale in order to feel comfortable ambulating.

Using the previous example, if a patient had established a comfort-function goal of 3 to ambulate and the current pain rating was 6, the nurse would provide appropriate interventions, such as medication, application of cold packs, or relaxation measures.

Documentation of the comfort-function goal, pain level, interventions, and follow-up are key to effective, individualized pain management. Figure Quality What does the pain feel like? What were you doing when the pain started? Is the pain constant or does it come and go? Pain is the most common symptom children experience in hospital. Acute pain noiciception is associated with tissue damage and an inflammatory response, it is self limiting of short duration and does not involve neural tissue.

In addition family response to their child in pain can have a negative or positive influence. There are challenges in assessing paediatric pain, none more so than in the pre-verbal and developmentally disabled child. Therefore physiological and behavioural tools are used in place of the self-report of pain. However in children with developmental disabilities there can be incorrect assumptions and there is a risk of under-treating pain.

It is important to take behavioral cues identified by parents and caregivers to improve pain assessment in these children. Pain assessment in infants and children is also challenging due to the subjectivity and multidimensional nature of pain. The dependence on others to assess pain, limited language, comprehension and perception of pain expressed contextually. In some children it can be difficult to distinguish between pain, anxiety and distress. Assessment and documenting pain is needed in order to improve management of pain.

Pain measurement quantifies pain intensity and enables the nurse to determine the efficacy of interventions aimed at reducing pain. Tools used for pain assessment at RCH have been selected on their validity, reliability and usability and are recognized by pain specialists to be clinically effective in assessing acute pain.