COMFORT, REST, ACTIVITY, AND MOBILITY

  1. Pain - the “fifth vital sign” in the care of patients; a complex subjective sensation; unpleasant sensory and emotional experience associated with real or potential tissue damage. Pain is considered to be whatever the person experiencing it says it is, existing whenever he or she says it does.

    1. Classifications:
      1. Acute pain: lasts typically less than 1 mo.; characterized by tachycardia, tachypnea, increased BP, diaphoresis, dilated pupils.
      2. Chronic pain: persists or is recurring for longer than 3 months; often characterized by lassitude, sleep disturbance, decreased appetite, weight loss, diminished libido, constipation, depression.
      3. Somatogenic (organic/physiological):
        1. Nociceptive: somatic or visceral pain sensations, normal pain transmission, such as aching or pressure (e.g., cancer pain, chronic joint and bone pain).
        2. Neuropathic: aberrant processes in peripheral and/or central nervous system; part of a defined neurological problem; sensations such as sharp, burning, shooting pain (e.g., nerve compression, polyneuropathy, central pain of stroke, phantom pain after amputation).
      4. Psychogenic (without organic pathology sufficient to explain pain).
    2. Components of pain experience - pain related to:
      1. Stimuli - sources: chemical, ischemic, mechanical trauma, extremes of heat/cold.
      2. Perception - viewed with fear by children, can be altered by level of consciousness, interpreted and influenced by previous and current experience, is more severe when alone at night or immobilized.
      3. Response - variations in physiological, cultural, and learned responses; anxiety is created; pain seen as justified punishment; pain used as means for attention-getting.
    3. Assessment:
      1. Subjective data :

        1. Site - medial, lateral, proximal, distal.
        2. Strength:
          1. Certain tissues are more sensitive.
          2. Change in intensity.
          3. Based on expectations.
          4. Affected by distraction or concentration, state of consciousness.
          5. Described as slight, medium, severe, excruciating.
        3. Quality - aching, burning, crushing, dull, piercing, shifting, throbbing, tingling.
        4. Antecedent factors - physical exertion, eating, extreme temperatures, physical and emotional stressors (e.g., fear).
        5. Previous experience - influences reaction to pain.
        6. Behavioral clues - demanding, worried, irritable, restless, difficult to distract, sleepless.

          Required Pain Assessment on Admission for Hospitalized Patients

          Do you have pain now? Have you had pain in the recent past? If “yes” to either question, the following data are obtained:

          1. Pain intensity (use a scale appropriate for the patient population)

          2. Location (ask patient to mark on diagram or point to the site)
          3. Quality, patterns of radiation, character (use patient’s own words)
          4. Onset, duration, variations, and patterns
          5. Alleviating and aggravating factors
          6. Present pain management regimen and effectiveness
          7. Pain management history (medication history, barriers to reporting pain and using analgesics, manner of expressing pain)
          8. Effects of pain (impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration)
          9. Patients pain goal (pain intensity and goals related to function, activities, quality of life)
          10. Physical examination/observation of site(s) of pain

      2. Objective data:
        1. Verbal clues - moaning, groaning, crying.
        2. Nonverbal clues - clenching teeth, grimacing, splinting of body parts, body position, knees drawn up, involuntary reflex movements, tossing/turning, rhythmic rubbing movements, voice pitch and speed, eyes shut.
        3. Physical clues - breathing irregularities, abdominal distention, skin color changes, skin temperature changes, excessive salivation, perspiration.
        4. Time/duration - onset duration, recurrence, interval, last occurrence.
    4. Analysis/nursing diagnosis:
      1. Pain, acute or chronic, related to specific patient condition.
      2. Activity intolerance related to discomfort.
      3. Sleep pattern disturbance related to pain.
      4. Fatigue related to state of discomfort or emotional stress.
      5. Ineffective individual coping related to chronic pain.