Pain

Pain is a feeling of physical or emotional discomfort that’s different for every person and can range from mild to severe.

When assessing your patient’s pain, follow the steps of the Clinical Judgment Measurement Model or CJMM to make clinical decisions about patient care.

Now, to better assess and intervene for your patient’s pain, let’s review the physiology of pain. So, the pain process is called nociception which involves pain receptors, which are free nerve endings called nociceptors located throughout the body, that send pain signals to the central nervous system.

There are four main processes involved in pain signaling: transduction, transmission, perception, and modulation. First, transduction is when a painful stimulus is converted into an electrical signal.

This stimulus can be mechanical, like pinching someone; chemical, like a strong acid causing damage to the skin; or thermal, like spilling hot coffee on your lap.

Next, the pain signal is transmitted from the site of injury by nerve fibers to the spinal cord. During this time, the body uses motor reflexes to protect itself by moving away from the stimuli that’s causing the pain; for example, pulling back from someone pinching you, or wiping the hot coffee off your leg.

Then, perception occurs when the pain signal reaches the cerebral cortex. This is where an individual consciously perceives pain and its characteristics like location, intensity, and what makes the pain better or worse.

And finally, modulation refers to how the brain regulates pain by sending inhibitory messages to the spinal cord to slow transmission of the pain signal and to release endogenous opioids, or the body’s natural pain killers.

For example, if a runner sprains their ankle, they may not feel the pain fully until after the race due to the effects of endogenous opioids.

Now, pain can be classified as acute or chronic. First, acute pain has a sudden onset and can be caused by trauma like cutting your finger, or chest pain from a myocardial infarction.

It typically resolves within three months, or whenever the underlying cause resolves. In contrast, chronic pain is mainly caused by long-term disorders like endometriosis, rheumatoid arthritis, or Crohn disease.

It has a gradual onset and lasts more than three to six months, which is past the normally expected healing time. Alright, let’s use the Clinical Judgment Measurement Model to guide the care of a patient who is in pain.

First, assess your patient to recognize important cues. When doing your assessment, remember that the most reliable indicator of pain is your patient’s own report of pain.

There are several pain assessment tools that can help you to assess your patient’s pain. Usually, adults report their pain numerically on a zero to ten scale, with zero meaning no pain, and ten meaning the worst pain they can imagine.

There’s also a verbal scale which allows patients to describe their pain using adjectives, like “mild,” “moderate,” and “severe.” In addition, the Wong-Baker scale has faces drawn on it, each representing a level of pain, where the patient points to the face that depicts how they feel.

The Wong-Baker scale is useful for patients who can’t verbally express themselves clearly, like children, or those who don’t speak the same language as the nurse.

Additionally, there are nonverbal cues that indicate a patient is in pain, such as irritability, restlessness, grimacing, and moaning.

The nurse should also check the patient's vital signs since pain can cause changes to temperature, pulse, blood pressure, and respiratory rate.

In addition to the severity of the patient’s pain, there is other information the nurse will collect about pain. To help you remember all the components of a pain assessment, you can use the mnemonic COLDSPA.

C is for Character, which is how your patient describes their pain in their own words, like dull, sharp, or throbbing. O is for Onset, or when your patient first noticed their pain.

L is for Location. Ask your patient to point to where the pain is located on their body for this assessment and ask them to tell you if it refers or radiates to another part of their body.

D is for Duration, which is how long their pain has lasted. S is for Severity.

Use a pain scale for this assessment, so your patient can rate their pain’s intensity. P is for Pattern, which includes factors like movement or touching that makes their pain feel better or worse.

Lastly, A is for Associated factors, which is how the pain has impacted their daily activities, like their ability to work or sleep.

Next, you’ll analyze cues by determining the relationship between the cues and linking them to your patient’s history and clinical presentation.

For example, if they report 8 out of 10 abdominal pain, you will connect this to other cues like a history of an abdominal laparoscopic procedure, as well as abdominal splinting, grimacing, and teeth clenching.

The next step is to determine a priority hypothesis related to pain, such as acute pain or chronic pain. Now, pain itself isn’t life-threatening, however, the underlying cause can be, so you will rank the hypotheses by considering whether it’s potentially life-threatening, like pain associated with a myocardial infarction, or a less immediate concern like chronic pain from rheumatoid arthritis.

Once a priority hypothesis is established, you are ready to generate solutions to address your patient’s pain, along with the expected outcome that the patient will report that their pain is at an acceptable level within one hour of treatment.

Okay, once the solutions have been generated, you'll take action to implement solutions by providing pharmacologic and nonpharmacologic pain interventions.

Finally, remember to evaluate whether the expected outcomes have been met by reassessing your patient’s pain level to determine whether their condition is improving, declining, or unchanged.

If your patient’s condition is declining or hasn’t changed, revise the plan of care and take additional actions to meet the expected outcome.

Alright, as a quick recap.... Pain is a feeling of physical or emotional discomfort that’s different for every person and can range from mild to severe.

When assessing your patient’s pain, you will go through the steps of the Clinical Judgment Measurement Model to make clinical decisions about patient care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.