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166 PHYSICAL EXAMINATION
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UNIT 2
Processes that increase the viscosity of the blood, such as sickle cell crisis, cause
P
greater friction between molecules of the blood and, thus, higher blood pressure.
Chronic steroid use, Cushing syndrome, thyroid disease and parathyroid
P
dysfunction can all cause hypertension.
High blood pressure may result from diseases affecting other regulatory blood
P
pressure processes. For example, kidney disease, which affects the production of
antidiuretic hormone, a hormone that helps control body uid balance, can
cause hypertension. An adrenal gland tumour, or phaeochromocytoma, can
increase blood pressure because of adrenaline and noradrenaline secretion.
Overload of uids from poor renal function or indiscriminate intravenous uid
P
administration (particularly in children) can result in hypertension.
Stress can increase blood pressure. Stimulation of the sympathetic nervous system
P
increases cardiac output and vasoconstriction, thus increasing blood pressure.
A consumer’s stress level can increase when in the presence of a healthcare
P
provider. Consumers who have elevated blood pressure in an ofce or hospital
environment only are said to have ‘white coat syndrome’. When these
individuals have their blood pressure taken in the community, it is frequently
within an acceptable range.
A
Blood pressure falling below normal range is considered to be hypotension,
or low blood pressure, which results in inadequate tissue perfusion and oxygenation.
If the standing systolic blood pressure is more than 30mmHg below the supine
systolic pressure, it may indicate that the person has orthostatic hypotension. (See
Chapter 14.) Slow response by baroreceptors when an individual transitions from a
lying to a standing position can result in transitory orthostatic hypotension. When
this occurs, the individual may feel dizzy and is at risk for falls.
Processes drastically reducing circulatory blood volume, such as hypovolaemic
P
shock, cause hypotension.
Medications such as nitroglycerine (glyceryl trinitrate) and antihypertensives
P
lower blood pressure.
Anaphylactic shock, resulting from massive histamine release, and circulatory
P
collapse cause severe hypotension.
A
A difference of greater than 10 to 15mmHg between the blood pressure in each
arm is abnormal.
This difference in blood pressure between arms can be caused by coarctation of
P
the aorta, aortic aneurysm, atherosclerotic obstruction, and subclavian steal
syndrome. These conditions all result in an increased pressure proximal to the
narrowing and a decreased pressure distal to the narrowing of the aorta or
whatever is causing the obstruction.
A
A systolic blood pressure that is greater in the arms than in the legs is abnormal.
This blood pressure difference between the arms and the legs is caused by
P
constriction or obstruction of the aorta, which can result from an increase in
stroke volume ejection velocity, increased cardiac output, peripheral
vasodilation, and decreased distensibility of the aorta or major arteries.
A
A decreased pulse pressure is abnormal.
A decreased pulse pressure can result from a decreased stroke volume (cardiac
P
tamponade, shock and tachycardia) or increased peripheral resistance (aortic
stenosis, coarctation of the aorta, mitral stenosis or mitral regurgitation, and
cardiac tamponade).
A
An increased pulse pressure is abnormal.
An increased pulse pressure can result from increased stroke volume (aortic
P
regurgitation) or increased peripheral vasodilation (fever, anaemia, heat,
exercise, hyperthyroidism and arteriovenous stula).
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 167
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CLINICAL REASONING
Practice tip: Automatic blood pressure cuffs – decreasing complications
If your consumer is receiving a drug such as heparin, aspirin or other thrombolytic therapy,
this makes them susceptible to bleeding complications (Figure 6.20). If you are using an
automatic blood pressure cuff on a consumer who is having thrombolytic therapy, take the
following precautions to prevent any bleeding complications that may occur in the arm that
is being used for non-invasive blood pressure monitoring:
> Adjust the maximal ination pressure on the automatic blood pressure machine to the
individuals’ last systolic blood pressure. Otherwise, the blood pressure cuff could inate
as high as a systolic blood pressure of 200mmHg.
> Once your consumer’s blood pressure is stable, increase the intervals between
measurements. If you do not, the blood pressure cuff could inate as often as every
minute. Also, you can switch the mode from automatic to manual, so that you avoid
unnecessary inations of the blood pressure cuff.
> Place the blood pressure cuff on the arm opposite any intravenous infusions. If this is not
possible, then try the thigh as a site for blood pressure measurement.
> Whenever permissible, rotate the cuff site and remember to remove it at least every shift
to assess the consumer’s skin.
FIGURE 6.20 Proper placement and
monitoring of an automatic blood pressure
cuff will reduce the risk of injury or
trauma to the consumer. This Caucasian
consumer had an automatic blood
pressure cuff placed on the left arm
while also receiving a heparin infusion
in that arm.
CHAPTER 6
Oxygen saturation (SpO2)
Haemoglobin is responsible for transporting oxygen from the lungs to other
parts of the body, where the oxygen can be used by other cells. Oxyhaemoglobin
) is the bright red haemoglobin that is a combination of haemoglobin
(HbO
2
and oxygen from the lungs. One haemoglobin molecule can carry a maximum
of four oxygen molecules. One hundred haemoglobin molecules together carry a
maximum of 400 (100 × 4) oxygen molecules. If these 100 haemoglobin molecules
were carrying 380 oxygen molecules they would be carrying (380/400) × 100 = 95% of
the maximum number of oxygen molecules. Thus, this would be 95% saturation.
When arterial oxyhaemoglobin saturation is measured non-invasively by a pulse
oximetry device, the symbol is charted as SpO
& Kozier, 2020).
Reasons for assessing a consumer’s oxygen saturation
There are multiple reasons for low oxygen saturation, including cardiovascular
disease, chronic obstructive pulmonary disease, pneumonia, cardiomyopathy and
dehydration. When the bloodstream does not receive enough oxygen from either
the lungs or the heart, or a disease or illness is depleting the oxygen from the
bloodstream, the organs and the brain suffer. Injury and blood loss will also cause
low oxygen saturation.
Central cyanosis, the traditional clinical sign of
marker, occurring only at 75–80% saturation. Consequently, pulse oximetry has a
wide range of applications including:
> individual pulse oximetry readings that can be invaluable in clinical situations
where hypoxaemia may be a factor; for example, in a confused elderly person
> continuous recording that can be used during anaesthesia or sedation, or to
assess hypoxaemia during sleep studies to diagnose obstructive sleep apnoea
> pulse oximetry that can replace blood gas analysis in many clinical situations
unless PaCO
> pulse oximetry that assists with determining the effectiveness of O
supplementation usage
> neonatal care – the safety limits for oxygen saturation are higher and narrower
(95–97%) than those of adults.
or acid–base state is needed
2
(Berman, Snyder, Frandsen, Kozier
2
hypoxaemia, is an insensitive
2
168 PHYSICAL EXAMINATION
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UNIT 2
Measuring oxygen saturation (pulse oximetry)
Pulse oximeters give a non-invasive estimate of the arterial haemoglobin oxygen
saturation. A probe with LEDs (light-emitting diodes) is used to generate red and infrared
light through a translucent part of the body. The probe is connected by a cable to an
oximeter device and the light waves emitted by the LED are absorbed and then reected
back. The arteriolar bed normally pulsates and absorbs variable amounts of light during
systole and diastole, as blood volume increases and decreases. The ratio of light absorbed
at systole and diastole is translated into an oxygen saturation measurement. Oxygen
saturation should always be above 95%, although in those with longstanding respiratory
disease this may be lower corresponding to disease severity.
CLINICAL REASONING
Practice tip: Reasons for low oxygen levels
When assessing a consumer who has presented with respiratory symptoms, the following
can indicate low oxygen levels:
> shortness of breath/difculty breathing/dyspnoea
> extreme fatigue
> chest tightness
> tingling ngers
> water retention (especially feet and ankles)
> chronic cough
> mental confusion.
FIGURE 6.21 A consumer with a pulse
oximeter probe attached to a nger digit
GETTY IMAGES/SE AN JUSTICE
Taking a consumer’s pulse oximetry
The oximeter probe can be applied to the earlobe, the toe, or the bridge of the nose;
however, it is most commonly sited on a nger digit (
highly vascular and this is a requirement of the oximeter device to detect the degree
of change in the light transmitted.
1. Select the probe with particular attention to correct sizing and where it is to
go. The digit should be clean (remove nail varnish).
2. Position the probe on the chosen site, avoiding excess force.
3. If a nger probe is used, the hand should be rested on the chest rather than
held in the air, in order to minimise motion artefact.
4. Allow several seconds for the pulse oximeter to detect the pulse and calculate
the oxygen saturation.
5. Look for a displayed waveform. Without this, any reading is meaningless.
6. Read off the displayed oxygen saturation and pulse rate.
Be cautious interpreting gures where there has been an instantaneous
change in saturation; for example, 99% falling suddenly to 85%. This is
physiologically not possible.
7. If in doubt, rely on your clinical judgement, rather than the value given by
the machine.
8. Record the pulse oximetry reading accurately.
Figure 6.21). These areas are
URGENT FINDING
False SpO2 when carbon monoxide poisoning is suspected
Consumers with suspected smoke inhalation or carbon monoxide poisoning will have an
inaccurate pulse oximetry reading. This is because carbon monoxide attaches itself to haemoglobin molecules, preventing the uptake of oxygen molecules. The oximeter does not differentiate
between oxyhaemoglobin or the haemoglobin molecules with carbon monoxide molecules
attached. In this situation the oximeter will give a normal reading when this is not the case. This
is a dangerous scenario so, for this reason, pulse oximetry should not be used on individuals
who may have inhaled smoke (e.g. in a house re). In these cases, urgent specialised blood tests
(arterial blood gases) will need to be taken to identify accurate oxygenation levels.
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 169
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Variables affecting pulse oximetry
The function of a pulse oximeter is affected by many variables.
> Poor positioning of the probe can cause inaccurate readings due to various
problems. This can be a particular problem with very small ngers and very large
ones. Make sure the probe is well on the nger.
> In the case of a consumer with cold hands and feet, and/or a very weak pulse,
a pulse oximeter may display a reading that may not be accurate.
> An irregular heartbeat, or the consumer moving, shivering or tting can cause
inaccurate recordings of pulse oximetry readings.
> It should be noted that pulse oximetry does not give an indication of a
consumer’s ventilation, only their oxygenation status; therefore, it can give
a false sense of security if supplemental oxygen is being given. In addition,
there may be a delay between the occurrence of a potentially hypoxaemic
event such as respiratory obstruction and a pulse oximeter detecting low
oxygen saturation.
> It is important to remember that pulse oximetry is only one way of
monitoring breathing. It is also necessary, as a minimum, to record
respiratory rate and, if pulse oximetry is used, the amount of oxygen they are
receiving must be recorded.
> A single one-off reading often is not much use; trends over a period of time give
more information.
> As with all clinical assessments the ‘whole picture’ must be looked at.
(Adapted from Berman et al., 2020)
CHAPTER 6
REFLECTION IN PRACTICE
Using clinical judgement when taking vital signs
Mr Godfrey is a 75-year-old man hospitalised for pneumonia. He has a history of confusion
and combative behaviour, particularly at night. His IV had to be replaced last night because, in his
confusion and agitation, he pulled it out. You are working the night shift, and it is 2:00 a.m.
Mr Godfrey is in a sound sleep, and appears comfortable. He has vital signs ordered to be
taken every 4 hours. His vital signs were last taken at 10:00 p.m. and were as follows:
> Respirations: 14 per minute
> Pulse: 90 beats per minute
> Blood pressure: 132/88mmHg LA (supine)
> Temperature: 37.1°C (aural)
> SpO
98%, on a Hudson mask at 8L/min.
2
> What are the major issues related to completing Mr Godfrey’s vital signs at this
present time?
> What are the possible actions you could take, and what are the potential consequences
of each?
CLINICAL REASONING
Providing end-of-life care
The majority of Australians over 65 die in healthcare facilities, with 50% dying in the
acute care setting, 36% in residential aged care facilities, and 14% dying elsewhere
(AIHW, 2021). Providing care to people who are near the end of life includes qualityof-life considerations, and care that focuses on assessing the physical, psychosocial and
spiritual needs of the individual and their families.
Identifying that a person is in the last days or weeks of life can be challenging, and the
withdrawing of treatment can be a complex process. However, there are guidelines and
polices available to aid healthcare professionals to provide the best care for the dying
person (CareSearch, 2021). Care of an individual who is imminently dying involves both
>>
170 PHYSICAL EXAMINATION
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UNIT 2
>>
clinical and ethical considerations, and care based on the needs of the person and their
specic clinical context. The individual’s needs will vary depending on age, disease status,
and social and cultural context. The Australian Commission on Safety and Quality in Health
Care (2021) has developed guidelines on delivering comprehensive end-of-life care for
different settings, to ensure appropriate person- and family-centred care.
Assessing and planning care for the dying person is based on the fundamental
principles of recognising dying, communication and decision-making, and
encompasses reviewing the individual’s:
> medical condition and care
> need for interventions
> personal care needs, such as bathing and feeding.
It also involves:
> communicating with the dying person, family/carer(s), including explanation of the plan of care
> documentation completed as per local health service documentation policies.
The key concerns for a person at the end of life relate to:
> pain and symptom management
> preparation for the end of life
> relationships between the consumer, family members and healthcare providers
> achieving a sense of completion (Steinhauser et al., 2000).
Assessing and managing a person at end of life does not necessarily imply use of
equipment or invasive tests. However, assessing changes in signs and symptoms can be
gathered from talking with, observing and examining the individual. Symptom management
is specic to the person who is dying and their response to care interventions. Assessment
is based on signs and symptoms of:
> pain
> restlessness and agitation
> skin integrity
> fever
> nausea and/or vomiting
> respiratory secretions
> breathlessness
> emotional or psychological distress.
Examples of signs and symptoms that are suggestive that a person is in the nal
stage of end of life include agitation, Cheyne–Stokes breathing, deterioration in level of
consciousness, mottled skin, and noisy respiratory secretion.
Further information can be obtained from the following:
> AIHW (Australian Institute of Health and Welfare). (2021). Interfaces between the aged
care and health systems in Australia – where do older Australians die? (June). Retrieved
from https://www.aihw.gov.au/getmedia/56c1f616-8b2c-493e-8e1c-2db5083ad59d/
aihw-age-106.pdf.aspx?inline=true
> Australian Commission on Safety and Quality in Health Care. (2021). Delivering and
supporting comprehensive end-of-life care: a user guide. Sydney: ACSQHC. Retrieved
from https://www.safetyandquality.gov.au/our-work/end-life-care
> CareSearch. (2021). Care of the dying person – clinical evidence – nding evidence –
evidence. Retrieved from https://www.caresearch.com.au/tabid/6220/Default.aspx
> Palliative Care Australia. (2018). National Palliative Care Standards (5th ed). Retrieved
from https://palliativecare.org.au/wp-content/uploads/dlm_uploads/2018/02/
PalliativeCare-National-Standards-2018_web-3.pdf
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 171
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PAIN
Pain is ‘an unpleasant sensory and emotional experience associated with, or
resembling that associated with, actual or potential tissue damage’ (IASP, 2020). It
is a complex sensory experience that has received signicant clinical attention over
the last 40 years. Pain has become the focus of many clinical research projects as a
single clinical phenomenon, not just as a symptom of clinical pathology.
Perception of pain
Pain is a unique, subjective, personal experience that most people experience some
time in their lives. There is a small percentage of people who do not feel pain due
to a genetic condition (Hellier, 2016). Pain affects a person’s physical, psychological
and social being. It is vital to remember that not every person experiences the same
level of pain in response to similar stimuli. Sometimes the source of the pain cannot
be identied, and this may be due to the result of multi-layered brain systems.
A person’s response to pain can be inuenced by their previous pain experience,
their mood, beliefs about pain, culture and their ability to cope. Pain is what an
individual perceives it to be; so it is important to remember that a consumer’s report
is the most reliable indicator of their pain status.
Source of pain
The source of the pain refers to its origin in the body. Pain can be grouped by its
origin as well as its duration. Cutaneous, somatic, visceral and referred pain are
the types of pain grouped by origin. Cutaneous pain arises from the stimulation of
cutaneous nerves. This pain usually has a burning quality. Somatic pain originates
from bone, tendons, ligaments, muscles and nerves, and is frequently caused by
musculoskeletal injury. Visceral pain arises from the organs. Diseased organs can
change size, usually resulting in stretching of the organ, leading to pain. Acute
appendicitis is an example of visceral pain. Referred pain is perceived in a location
other than where the pathology is occurring. The location of the referred pain is in
the dermatome of the spinal cord that is innervating the affected viscera and where
the organ was located in its embryonic stage. An example of referred pain is the
pain of pancreatitis felt on the left shoulder.
Pain pathophysiology comprises two categories: nociceptive and neuropathic.
It is important to identify which category of pain a consumer is experiencing as
treatment is different for each.
CHAPTER 6
Nociceptive pain
Nociceptive pain arises from somatic or visceral stimulation. Nociception, or
pain perception, is a multistep process that involves the nervous system as well as
other body systems (Figure 6.22). A noxious stimulus occurs, which stimulates the
nociceptors (receptive neurones of pain sensation that are located in the skin
and various viscera). The noxious stimulus can be many things (e.g. trauma, burn,
chemical exposure, internal body inammation, internal body growth of tissue).
Transduction of the noxious stimulus travels to the spinal cord via the nociceptors.
This transduction causes the conversion of one energy (travelling stimulus)
from another (noxious stimulus). Cell damage from the noxious stimulus causes
the release of certain chemicals or sensitising nociceptors. Prostaglandins (PG),
bradykinins (BK), serotonin (5 HT), substance P (SP), hydrogen (H
histamine (H) and leukotrienes are all sensitising substances. Substance P is unique
because it is released only when pain bres are stimulated.
Activating the sensitising substances leads to an action potential in which the
pain sensation is moved via afferent nerves to the spinal cord. Two types of nerve
bres participate in the action potential: A-delta bres, myelinated neurones that
transmit acute, sharp, shooting and localised pain; and C bres, nonmyelinated
+
), potassium (K+),
172 PHYSICAL EXAMINATION
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2
Transmission
Spinothalamic
tract neurone
Perception
3
of pain
UNIT 2
1
Transduction
Cell damage from the noxious
stimulus causes the release of
PG, BK, 5 HT, SP, H , K , H, and
leukotrienes
+Na+Na+
++ +++ ++ +++- - - - -
K
++ +++ ++ +++
+Na+Na+
Action potential is created and
moves to the spinal cord via
afferent nerve bres
++ +++ - - - - -- - - - -
+
++ +++
- - - - -
Na
Na
Cortex and limbic
systems perceive
the pain
3
Pain impulse
is carried via
the spinothalamic
tract to the brain
Spinothalamic
Opioid
receptors
Nociceptor
tract neurone
4
Modulation
Neurotransmitters
and endogenous
opioids are released
from the brain stem
2
4
+ +
+
K
- - - - -- - - - -
Nociceptor
1
Opioid
receptors
x
Pain transmission
is blocked and
analgesia
is produced
Nociceptor
Neurone from
brain strem
FIGURE 6.22 Nociception
neurones that transmit dull, throbbing, and poorly localised pain. These nerve
bres carry the pain impulse from the spinal cord via the spinothalamic tract to the
brain stem and thalamus. The thalamus relays information to the cortex (which
is capable of identifying past pain memories) and to the limbic system (where the
emotional component of pain is formed). It is in these areas of the brain that pain is
consciously perceived.
The last step of nociception is modulation. Modulation is the inhibition of
nociceptor impulses. Neurones from the brain stem release neurotransmitters
(e.g. serotonin, norepinephrine [NE], gamma-aminobutyric acid [GABA], 5 HT,
and endogenous opioids [e.g. enkephalins, dynorphins and β-endorphins]) as the
substances block the transmission of pain and produce analgesia.
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 173
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Neuropathic pain
Neuropathic pain can result from injury or lesions in the central nervous system
(CNS) or the peripheral nervous system (PNS). This can cause
such as numbness, tingling, electrical or burning sensations, for example that
experienced with lower back pain or herpes zoster. Neuropathic pain may be
difcult to treat clinically; however, with careful diagnosis and use of combination
treatments, there is an excellent chance of improving the pain and the consumer
returning to normal function.
paraesthesia,
Types of pain
Acute, cancer and chronic (persistent) pain is pain that is grouped by duration.
Acute pain has a sudden onset, a duration of 3–6 months and has a likely limited
duration. It ranges in intensity from mild to severe. It usually has an identiable
cause, such as surgery or trauma. Cancer pain is pain of more than 6 months
duration. This persistent pain can be due to a tumour, inammation, blocked ducts,
pressure on other body parts, treatment and necrosis. Chronic (persistent) pain also
lasts more than 6 months. It can occur with and without an identiable cause.
The pain can remain even after an initial injury is healed. Back pain and
bromyalgia are examples of chronic (persistent) pain.
Variables affecting pain
A consumer’s past response to pain, as well as successful pain reduction measures,
greatly inuence future pain management. Indeed a consumer’s age, sex, previous
experience with pain, and cultural expectations can affect their response to pain.
CHAPTER 6
Age
Studies indicate that pain is perceived by our youngest members of society –
neonates. As children grow, they learn how to respond to pain by modelling
others’ behaviours, and pain management can be learned via direct and indirect
observation. Children can learn how to communicate their pain (crying/
verbalising), when to seek help, and whom they should seek out for care. As they
reach adolescence, children may become more stoic about pain.
Older adults, especially those who have chronic pain, may also not complain
about their pain until it becomes debilitating. This failure to seek treatment for
pain is frequently due to the perception that the pain means something is seriously
wrong, or the consumer may not have the resources to seek treatment. Older adults
also have a lifetime of experiences with different types of pain, and that greatly
inuences how they choose to deal with new pain. Conditions such as hearing loss,
loss of speech, and aphasia can all hamper communication of needs regarding pain.
Further, older individuals with cognitive impairment may not have the capacity to
give a reliable report during assessment. To conduct a comprehensive assessment,
include the consumer’s self-report and the caregiver’s report, and observe the person
using pain assessment tools during your assessment. Behaviours that suggest that
pain is present are changes in facial expressions, vocalisations, changes in activity
patterns and interpersonal interactions.
Sex
Studies have shown that females have a lower pain tolerance or threshold than
males and report pain more frequently. Females tend to dwell on the psychological
aspects of pain, whereas males emphasise its physiological aspects (Keogh, 2014;
Keogh & Arendt-Nielsen, 2004). In many cultures, men stoically endure pain
without seeking medical help, whereas women express pain more openly
and verbally.
Culture
A cultural group’s norms, expectations and acceptance of pain as a normal part
of life can inuence how a person experiences pain. This can be further shaped
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by their individual experiences and learnings. It is important to approach each
consumer in a culturally safe way. Refer to Chapter 4 for more detailed information
on cultural safety.
UNIT 2
Healthcare professionals
A healthcare professional’s knowledge of pain management may affect how the
person in pain is treated. Studies have shown that there is a deciency of adequate
education regarding pain management for healthcare professionals (Watt-Watson
et al., 2002). Gender differences between healthcare professionals and the
person in pain may also determine differences in treatments (Safdar et al., 2009).
Poorer management for their pain may be provided to females, ethnic and racial
populations (Burgess et al., 2014). Collaboration between the consumer in pain and
the healthcare professional can lead to improved care.
Effects of pain on the body
Pain affects everyone in different ways. Acute pain usually manifests itself differently
from chronic (persistent) pain, although there are some common elements.
Physiological responses to pain occur during the acute stage of pain. These include
tachycardia, tachypnoea, hypertension, diaphoresis, dilated pupils and an altered
immune response. Additional responses to pain include complaints of pain, crying,
moaning, frowning, anger, fear, anxiety, depression, suicidal ideation, decreased
appetite, sleep deprivation, altered concentration, pacing, rubbing the affected body
part, and protecting or splinting the affected body part. These responses to pain are by
no means all-inclusive. Pain can affect every system in the human body, and unrelieved
pain can take its toll on the health of the consumer over time. Just as pain is a unique
experience for the person in pain, so is the consumer’s response to pain.
Pain assessment
A comprehensive pain assessment should be conducted on each consumer in a
healthcare setting. Further, a consumer should be referred for a pain assessment as
determined by their health status and the availability of care. Pain is to be measured
in terms of intensity and quality appropriate to the consumer’s age and then
documented in their records. Pain is a critical vital sign of a consumer’s wellbeing,
thus assessment of pain is mandatory.
Many consumers present to the healthcare system with a principal complaint of
pain. Assessing pain comprehensively is commonly guided by a framework such as
the mnemonic OPQRST: Onset, Position/Palliates, Quality, Radiates, Severity, Time +
Treatment. This is a useful tool for people who can self-report pain (ensure you
consider age, verbal and cognitive ability).
The approach using OPQRST as an assessment tool
> Onset – did anything provoke the pain: ‘What were you doing when the pain
started (exercise, activity, resting)?’ ‘Was it a sudden or gradual onset, or an
ongoing chronic issue?’
> Position or Palliates
pain better or worse?’
> Quality
> Radiates
> Severity – it is important to remember that pain is subjective and relative to each
> Time – this is a reference to when the pain started or how long ago it started:
> Treatment – self-treatment: ‘Have you attempted to relieve the pain?’ ‘Have you
– a description of the pain: ‘What does the pain feel like?’ ‘What words
would you use to describe the pain (sharp/ dull/crushing)?’
– does the pain radiate: ‘Point to where it hurts the most. Where does
your pain go from there?’ ‘Does the pain move anywhere else?’
individual consumer. ‘On a scale of 1 to 10, 1 being minimal pain and 10 the
worst pain imaginable, how would you rate your pain?’
‘When did the pain start?’ ‘How long did it last for?’
taken any medication for it?’
– the site of the pain: ‘Where is the pain?’ ‘What makes the
(Adapted from Ahmadi et al., 2016; and Hui & Bruera, 2014)
EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 175
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Many healthcare institutions have their own pain assessment ow sheet that
incorporates these main pain assessment features.
Pain intensity rating scales are available to assess the severity of a consumer’s
pain experience (
Figure 6.23). The Visual Analog Scale (VAS) is perhaps the easiest
to use in any setting because it requires no additional resources. The VAS contains
a 10cm line; one end is labelled ‘no pain’ and the other end is labelled ‘most
severe pain imaginable’. The consumer indicates where on the spectrum their pain
currently lies. This is noted and used as a reference for current and future pain
assessment to trend the consumer’s verbal reports of pain.
Simple Descriptive Pain Intensity Scale
CHAPTER 6
No
pain
0 1 2 3 4 5 6 7 8 9 10
No
pain
FIGURE 6.23 Pain Intensity Scale
SOURCE: ACUTE PAIN MANAGEMENT: OPERATIVE OR MEDICAL PROCEDURES AND TRAUMA. QU ICK REF ERENCE G UIDE NO. 1A. C LINICA L PRAC TICE GUI DELINE ( AHCPR P UBLIC ATION NO. 92 -003 2),
BY THE AC UTE PAI N MANAG EMENT GU IDELIN E PANEL, 199 2, ROCK VILL E, MD: AGE NCY FOR HE ALTH CA RE POLI CY AND RE SEARC H [NOW AGE NCY FOR HE ALTHC ARE RES EARC H AND QUAL ITY ].
Mild
pain
Moderate
pain
0–10 Numeric Pain Intensity Scale
Moderate
pain
Severe
pain
Very
severe
pain
Worst
possible
pain
Worst
possible
pain
Categorical pain intensity scales include:
> the Pain Intensity Scale (Acute Pain Management Guideline Panel, 1992)
(
Figure 6.23), a quick and easy tool to implement
> the Faces, Legs, Activity, Cry and Consolability (FLACC) pain scale, used for
children 6 months to 5 years who cannot verbalise (
Table 6.8). This scale, initially
used to assess post-operative pain levels in children, is also accurate and reliable
in all children with pain (Kochman et al., 2017).
> the Wong–Baker FACES Pain Rating Scale (Figure 6.24), is recommended for children
over the age of 3 years. It is important that the nurse explains this scale to the
child at each assessment encounter.
FIGURE 6.24 Wong–Baker FACES Pain Rating Scale
* Please note you may also see a FACES pain scale that is endorsed by the International Association for the Study of Pain (IASP)
at http:// www.iasp-pain.org/Education/Content.aspx?ItemNumber=1519
SOURC E: © 1983 WON G-BAKE R FACES FOU NDATION. W WW.WONGB AKERFA CES.ORG. U SED WITH P ERMISSI ON. ORIGIN ALLY PUBL ISHED IN WHALEY & WONG’S NURSI NG CARE OF
INFANTS AND CHILDREN. © ELSE VIER IN C.
With each scale, the consumer has control over each of his or her own pain
assessment encounters. These reports can provide information on whether the
individual’s pain is alleviating or worsening. This information also allows the nurse
to evaluate the effectiveness of the consumer’s pain regimen.
Assessing pain in consumers who are unable to communicate poses a
challenge for nurses (Hockenberry & Wilson, 2018). Many pain tools have been
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