NURSING ASSESSMENT FOR PAIN ASSESSING Goal to capture the individuals pain experience in a standardized way to help determine

ne type of pain and possible etiology to determine the effect and impact the pain experience has on the individual and their ability to function. basis on which to develop treatment plan to manage pain to aid communication between interdisciplinary team members. Assessment For the fifth vital sign, pain should be screened for every time vital signs are evaluated. For client experiencing acute, severe pain, the nurse may focus only on the location, quality and severity, and provide interventions to control the pain before conducting a more detailed evaluation. Clients with less severe or chronic pain can usually provide a more detailed description of the experience. Local, regional, or general anesthesia may be wearing off, or if severe pain is reported, the medication is admistered postoperatively is frequently admistered via the intravenous route and has a peak effect noted within 15 minutes. It is essential that nurses listen to and believe the clients perceptions of pain. Major components of pain: A pain history to obtain facts of the client Direct observation of behaviors, physical signs of tissue damage, and secondary physiologic responses of the client. Pain Assessment using Acronym NOPQRSTUV Number of Pains Origin of Pain Palliate and Potentiate Quality Radiation Severity/ Suffering Timing and Trend Understanding/ Impact in you Values

DIAGNOSING NANDAs diagnostic labels for clients experiencing pain or discomfort: o Acute Pain o Chronic Pain When writing the diagnostic statement, the nurse should specify the location. Related factors, when known, should also be part of the diagnostic statement and can include both physiologic and psychologic factors. Because presence of pain can affect so many faces of a persons functioning, pain may be the etiology of other nursing diagnoses. Examples are the following:

o Ineffective Airway Clearance related to weak cough secondary to postoperative incisional abdominal pain o Hopelessness related to feeling of continual pain o Anxiety related to past experiences of poor control of pain and to anticipation of pain o Ineffective Coping related to prolonged continuous back pain, ineffective pain management, and inadequate support systems o Ineffective Health Maintenance related to chronic pain and fatigue o Self-Care Deficit (Specify) related to poor control of pain o Deficient Knowledge (Pain Control Measures) related to lack of exposure to information resources. o Impaired Physical Mobility related to arthritic pain in knee and ankle joints o Insomnia related to increased pain perception at night PLANNING The established goals for the client will vary according to the diagnosis and its defining characteristics. Specific nursing interventions can be selected to meet the individual needs of the client. Planning Independent of Setting When planning, nurses need to choose pain relief measures appropriate for the client, based on the assessment data and input from the client or support persons. Developing a plan that incorporates a wide range of strategies in usually most effective. Whether in acute care or in home care, it is important for everyone involved in pain management to understand the plan of care. Plan should be documented in the clients record. When clients pattern and level of pain can be anticipated or is already known, regular or scheduled administration of analgesics can provide a steady serum level. Frequency of administration can be adjusted to prevent pain from recurring. When persistent, continuous pain exists, analgesics should be given around the clock (ATC), with additional prn doses available. Nonpharmacologic interventions should be regularly scheduled. Planning for Home Care In preparation for discharge, the nurse needs to determine the clients and familys needs, strengths and resources. The accompanying Home Care Assessment describes the specific assessment data required when establishing a discharge plan. Using the assessment data, the nurse tailors a teaching plan for the client and family. IMPLEMENTING Pain management is the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client. It includes the two types of nursing intervention: (a) Pharmacologic (b) Non-pharmacologic Nursing management of pain consists of: (a) Independent nursing actions- noninvasive measures may be performed

(b) Collaborative nursing actions- admistration of analgesic medication generally requires a medical order from a primary care provider. Individualizing Care for the Clients with Pain 1) Establishing a trusting relationship. 2) Consider the clients ability and willingness to participate actively in pain relief measures. 3) Use a variety of pain relief measures. 4) Provide measures to relieve pain before it becomes severe. 5) Use pain-relieving measures that the client believes are effective it has been recognized that clients are the authorities about their own pain. 6) The selection of pain relief measures should be aligned with the clients report of the severity of the pain. 7) If a pain relief measure is ineffective, encourage the client to try it again before abandoning it. 8) Maintain an unbiased attitude about what may relieve the pain. 9) Keep trying. Do not ignore a client because pain persists despite failed attempts to alleviate the discomfort. 10) Prevent harm to the client. 11) Educate the client and caregivers about pain. Monitoring Pain in the Home Setting Teach client to keep a pain diary to monitor pain onset, activity before pain, pain intensity, use of analgesics or other relief measures, and so on. Instruct client to contact a health care professional if planned control measures are ineffective. 1) Pain Control Teach the use of preferred and selected pharmacologic techniques. Discuss the actions, side effects, dosages and frequency of administration of prescribed analgesics. Suggest ways to handle side effects of medication. Provide accurate information about tolerance, physical dependence, and addiction if opioid analgesics are prescribed and these topics are of concern. Instruct the client to use pain control measures before the pain becomes severe. Inform the client of the effects of untreated pain. Demonstrate and have the client or caregiver return demonstrate appropriate skills to administer analgesics. If home pump is being used, caregivers need to be able to: (a) Demonstrate stopping and starting the pump. (b) Change the medication cartridge and tubing (c) Adjust the delivery dose (d) Demonstrate site care (e) Identify signs indicating the need to change in injection site. (f) Describe care of pump and insertion site when the clients ambulatory, bathing, sleeping or travelling. (g) Perform problem solving for pumps when alarms are activated. (h) Change the battery. 2) Resources

 Provide appropriate information about how to access community, resources, home care agencies, and associations that offer self-help groups and educational materials. Barriers to Pain Management These may involve attitudes of the nurse or the client as well as knowledge deficits. Clients respond to pain experiences based on their culture, personal experiences, and the meaning the pain has for them. Clients and families may lack knowledge of the adverse effects of pain and may have misinformation regarding the use of analgesics. Clients may not report pain because they expect nothing can be done, they think it is not severe enough, or they feel it would distract or prejudice the health care provider. Another barrier to effective pain management is the fear of becoming addicted, especially when long-term opioid use is prescribed. Pseudoaddiction is a condition that results from the undertreatment of pain where the client may become focused on obtaining medications, may clock watch, and may otherwise seem inappropriately drug seeking. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when the pain is treated effectively. Key Management in Pain Management Acknowledging and Accepting Clients Pain. Nurses have a duty to ask client about their pain and to believe their reports of discomfort. Consider these four ways of communicating this belief: (a) Acknowledge the possibility of the pain. (b) Listen attentively to what the client says about the pain, restating your understanding of the reported discomfort. (c) Convey that you need to ask about the pain because, despite some similarities, everybodys experience is unique. (d) Attend the clients needs promptly. Assisting Support Persons. Support persons often need assistance to respond in a helpful manner to the person experiencing pain. Reducing Misconceptions about Pain. This will remove one of the barriers to optimal pain relief. Reducing Fear and Anxiety. It is important to help relieve strong emotions capable of amplifying pain. Preventing Pain. A preventive approach to pain in management involves the provision of measures to treat the pain before it occurs. Preemptive analgesia- the administration of analgesics prior to an invasive or operative procedure in order to treat pain before it occurs. EVALUATING The goals established in the planning phase are evaluated according to specific desired outcomes, also established in the phase. To assist in the evaluation process, flow sheet records or a client diary may be helpful. If outcomes are not achieved, the nurse and client need to explore the reasons before modifying the care plan. The nurse might consider the following questions: o Is adequate analgesic given? o Were the clients beliefs, expectations and values about pain therapy considered?

o Were appropriate instructions provided to allay misconceptions about pain management? o Did the client and support people understand the instructions about pain management? o Is the client receiving adequate support for both physical pain and emotional distress? o Has the clients physical condition changed, necessitating modifications in intervention? o Should selected intervention strategies be reevaluated?

INCONTINENCE Fecal incontinence (FI), commonly referred to as bowel control problems, is the inability to hold a bowel movement until reaching a bathroom. FI also refers to the accidental leakage. A feces is another name for stool. Nearly 18 million U.S. adult. FI is not always a part of aging, but it is more common in older adults. FI is slightly more common among women. Risk factors for FI: o diarrhea o a disease or injury that damages the nervous system o poor overall healthmultiple chronic, or long-lasting, illnesses o a difficult childbirth with injuries to the pelvic floorthe muscles, ligaments, and tissues that support the uterus, vagina, bladder, and rectum Symptoms of FI includes diarrhea constipation muscle damage or weakness nerve damage loss of stretch in the rectum hemorrhoids pelvic floor dysfunction Diagnoses for FI Health care providers diagnose FI based on a patients medical history, physical exam, and medical test results. People with concerns about FI should see a health care provider, who may ask the following questions: When did FI start? How often does FI occur? How much stool leaks? Does the stool just streak the underwear? Does just a little bit of solid or liquid stool leak out? Or does complete loss of bowel control occur? Does FI involve a strong urge to have a bowel movement or does it happen without warning? For people with hemorrhoids, do hemorrhoids bulge through the anus? How does FI affect daily life? Do certain foods seem to make FI worse? Can gas be controlled? Based on answers to these questions, a health care provider may refer the patient to a doctor who specializes in problems of the digestive system, such as a gastroenterologist,

proctologist, or colorectal surgeon. The specialist will perform a physical exam and may suggest one or more of the following tests, which may be performed at a hospital or clinic: Anal manometry Magnetic resonance imaging (MRI) Anorectal ultrasonography Proctography Proctosigmoidoscopy Anal electromyography Treatment for FI eating, diet, and nutrition (a) eating the right amount of fiber (b) getting plenty of drink medication pelvic floor exercises bowel training surgery (a) sphincteroplasty (b) electrical stimulation electrical stimulation FLATULENCE Flatulence is the presence of excessive flatus in the intestines and leads to stretching and inflation of the intestines (intestinal distention). It can occur in the colon from a variety of causes, such as foods, abdominal injury, or narcotics. Most gases that are swallowed are expelled through the mouth by eructation. However, large amount of gas can accumulate in the stomach. The gases formed in the large intestine are chiefly absorbed through the intestinal capillaries into the circulation. If the gas is propelled by increase colon activity before it can be absorbed, it may be expelled through the anus. If excessive gas cant be expelled through the anus, it may be necessary to insert a rectal tube to remove it. Flatulence is very common, and everyone experiences it. Most men pass wind 14-25 times a day, and most women between 7 and 12 times a day. Most people produce about 1-3 pints a day and pass gas about 14 times a day. Some medical conditions can cause flatulence, such as constipation and irritable bowel syndrome. Medication can help to control the symptoms. The major components of the flatus, which are odorless, by percentage are: o Nitrogen: 2090% o Hydrogen: 050% o Carbon dioxide: 1030% o Oxygen: 010% o Methane: 010% Three primary source of flatus (a) Action of bacteria on the chyme in the large intestine (b) Swallowed air

(c) Gas that diffuses between the bloodstream and the intestine How to prevent Avoid foods which contain sugars that the digestive system can't break down. Still aim to eat a healthy, balanced diet that includes at least five portions of fruit and vegetables a day. Avoid eating foods that are high in unabsorbable carbohydrates. Instead, go for foods that are easy to digest, such as potatoes, rice and bananas. HEMMOROIDS Hemorrhoids are swollen and inflamed veins around the anus or in the lower rectum. The rectum is the last part of the large intestine leading to the anus. Types of hemorrhoids: (a) External hemorrhoids- are located under the skin around the anus. (b) Internal hemorrhoids- develop in the lower rectum. Internal hemorrhoids may protrude, or prolapse, through the anus. About 75 percent of people will have hemorrhoids at some point in their lives. Hemorrhoids are most common among adults ages 45 to 65.2 Hemorrhoids are also common in pregnant women. Symptoms of hemorrhoids includes Anal itching Anal ache or pain, especially while sitting Bright red blood on toilet tissue, stool, or in the toilet bowl Pain during bowel movements One or more hard tender lumps near the anus Signs and tests A doctor can often diagnose hemorrhoids simply by examining the rectal area. If necessary, tests that may help diagnose the problem include: Stool guaiac (shows the presence of blood) Sigmoidoscopy Anoscopy Barium enema x ray. Treatment for Hemorrhoids Over-the-counter corticosteroid creams can reduce pain and swelling. Hemorrhoid creams with lidocaine can reduce pain. Witch hazel (applied with cotton swabs) can reduce itching. Other steps for anal itching include: Wear cotton undergarments. Avoid toilet tissue with perfumes or colors. Try not to scratch the area. Sitz baths can help you to feel better. Sit in warm water for 10 to 15 minutes. Stool softeners help reduce straining and constipation. For cases that don't respond to home treatments, a surgeon or gastroenterologist can apply heat treatment, called infrared coagulation, to shrink internal hemorrhoids. This may help avoid surgery. Surgery that may be done to treat hemorrhoids includes rubber

band ligation or surgical hemorrhoidectomy. These procedures are generally used for patients with severe pain or bleeding who have not responded to other therapy. 1. At-home Treatments Simple diet and lifestyle changes often reduce the swelling of hemorrhoids and relieve hemorrhoid symptoms. Eating a high-fiber diet can make stools softer and easier to pass, reducing the pressure on hemorrhoids caused by straining. Fiber is a substance found in plants. The human body cannot digest fiber, but fiber helps improve digestion and prevent constipation. Good sources of dietary fiber are fruits, vegetables, and whole grains. On average, Americans eat about 15 grams of fiber each day.3 The American Dietetic Association recommends 25 grams of fiber per day for women and 38 grams of fiber per day for men.3 Doctors may also suggest taking a bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel). Other changes that may help relieve hemorrhoid symptoms include o drinking six to eight 8-ounce glasses of water or other nonalcoholic fluids each day o sitting in a tub of warm water for 10 minutes several times a day o exercising to prevent constipation o not straining during bowel movements Over-the-counter creams and suppositories may temporarily relieve the pain and itching of hemorrhoids. These treatments should only be used for a short time because long-term use can damage the skin.

2. Medical Treatment Rubber band ligation. The doctor places a special rubber band around the base of the hemorrhoid. The band cuts off circulation, causing the hemorrhoid to shrink. This procedure should be performed only by a doctor. Sclerotherapy. The doctor injects a chemical solution into the blood vessel to shrink the hemorrhoid. Infrared coagulation. The doctor uses heat to shrink the hemorrhoid tissue.