8. Pain Assessment

7/25/2019 8. Pain Assessment

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Pain Assessment

.ndrNur Surya Wirawan


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Pain is whatever the experiencing

person says it is, existing whenever

he or she says it does.

Margo McCaffrey, RN 1980


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Mantan Presiden APS Dr ames !amp"e##

menyata$an% tanda vital merupakan hal

yang sangat penting. ika nyeri dinilai

sama seperti tanda!tanda vital lainnya,

maka kita dapat mem"erikan pera#atan

yang le"ih "aik.


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Pain% &he 'i(th )ita# Sign*

Pu#se

+#ood pressure

&emperature

espiratory rate

Pain:The Fifth

Vital Sign

American Pain Society (APS) has redefned PAIN as the 5thvital sign Health care proessional has to assess patients or pain every time


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de(inition

Pain is an unp#easant sensory and

emotiona# experience associated with

actua# or potentia# tissue damage, or

descri"ed in terms o( such damage.

Pain is a#ways su"-ective

internationa# association (or the study o( pain /ASP 0


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Ma-or goa# o( pain assessment is to use

the most appropriate diagnostic and

therapeutic considerations to de(ine its

cause and to direct its treatment


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pain history princip#es

See$ to esta"#ish a re#ationship with the

patient

1ncourage the patient to do most o( the

ta#$ing

+egin with a wide ang#e open 2uestion

"e(ore c#ari(ying and (ocusing with more

speci(ic ones

Watch the patient (or c#ues regarding pain

Avoid -umping to conc#usions


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+arrier in the assessment o( pain

&he mu#tidimensiona# nature o( the su"-ectivecomp#aint o( pain

&he #ac$ o( a c#ear#y de(ined #anguage o( pain

Poor communication "etween the patient andphysician a"out pain3 (or examp#e % 4nder5reporting "y the patient and under5

assessing "y the physician or nurse


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Pain Assessment

O nsetWhen did it "egin6 7ow #ong does it #ast6 7ow o(ten does it occur6

P recipitating8A##eviating 'actors% What "rings it on6 What ma$es it "etter6 What ma$es it worse6

Qua#ity o( Pain% As$ the patient to descri"e the pain using words #i$e sharp,

du##, sta""ing, "urning

Radiation Does pain exist in one #ocation or radiate to other areas6

Severity 7ave patient use a descriptive, numeric or visua# sca#e to rate

the severity o( pain.


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T reatment

What medications and treatments are you current#y

using6 7ow e((ective are these6 Do you have any sidee((ects (rom the medications and treatments6

4nderstanding /mpact on you05 activity% does it stop you doing this 6

5 s#eep%does it stop you s#eeping 6

5 mood% does it ma$e you unhappy or depressed6

)a#ue What is your goa# (or this symptom6 What is your com(ort goa# or

accepta"#e #eve# (or this symptom 9n a sca#e o( : to ;: with : "eing

none and ;: "eing worst possi"#e06 Are there any other views or

(ee#ings a"out this symptom that are important to you or your

(ami#y6


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1ach pain needs a separate assessment


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&o measure pain intensity or severity

Use Pain Scores


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A#at peni#aian nyeriSu"ye$ti(

Numeric ating Sca#e

Sca#e )er"a# Descriptor

Sca#e )isua# Ana#og

'aces Pain Sca#e


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Pain Assessment Tools:Wong-Baker


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Pain Assessment Tools:Non5)er"a# Pain Sca#e '>A!!0

"h A t $ l


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Patient

ale to

comm#nicate

!ell

N8

&%S

"hoose o Assessment $ools

>aces painassessment

scale(>ig A)

V7S painassessment

scale(>ig ;)

N7Sassessment

scale(>ig ")

VASassessment

scale(>ig :)

No pain ?ittle pain 3edi#m pain ?arge pain 4o possile pain

>ig ; V7S@

2 ' * + , 5 - . / 0

>ig " N7S'

3oderate painNo Pain4orst

possile pain

Vis#al analog#e scale (VAS)>ig : VAS'

No pain 4orstpossile pain

' adapted rom 3c"aery 3B pasero " painC "linical 3an#al '000 !ith permission rom %lsevier@ 4ith permission rom %lsevier

>ig A 4ongD;aer aces Pain 7ating Scale@

2 ' * + , 5No h#rt H#rts

?ittle itH#rts

?ittle moreH#rts

%ven moreH#rts

4hole lotH#rts4orst

Alternativecoding2 * , - / '


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!/&/!A> !A1 PA/N 9+S1)A&/9N &99>


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3I?: 38:%7A$% S%V%7%


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Pain Se&erit'

?uides urgency o( treatment

?uides type o( drug on the W79 >adder

which is #i$e#y to "e e((ective


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&hree Step >adder W79,

;@B$ essential

concepts

%y mouth

%y the clock

%y the ladder

%y individual

&ith attention to

detail

+y this moda#ity C @: o( cancer pain can "ere#ieved


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important princip#es assessment o( pain

Accept the patientEs descriptionAssess the pain care(u##y

7istory

1xamination

/nvestigation

Assess each painAssess the extent o( the patientEs diseaseAssess the other (actors which may in(#uence pain

Physica# F psycho#ogica# F socia# F cu#tura# 5 spiritua#

eassess


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reassessment

epeated review is important

/ncorrect diagnosis 6

9ther (actors, eg. Depression 6


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Tanks "or (istening

?ie is

Documents

8. Pain Assessment