Collection and analysis of pain data by the nurse of pain felt by the patient from both an objective and subjective perspective.
Objective:
To know etiology, intensity, location, type, onset, duration, and relief of pain presented by the patient.
Equipment:
Pain assessment scales: visual analog and pediatric.
Material:
– Nursing records.
Procedure:
– Preserve the patient’s privacy. – Assess the patient to know the pain he/she feels objectively and subjectively. a) Subjective assessment – Ask the patient about the intensity of the pain (see scales section), ask the patient about the location, irradiation, if it increases or decreases with activity and if he/she knows what the cause may be. – Observe the patient’s behavior in the face of pain. – Assess the type of pain: acute-chronic, dull, throbbing, lacerating, continuous-intermittent, somatic, visceral or neuropathic. – Assess for signs of anxiety. – If analgesia has been taken, ask about the analgesic effect and duration. b) Objective assessment – Take blood pressure, heart rate and respiratory rate, assess for changes. – Assess the presence of nausea and vomiting, changes in temperature, alteration of muscle tone (facial muscle tension), pupil dilation, insomnia, weakness, exhaustion. – Observe for disordered behavior: crying, moaning, nervousness, etc. – Record in the nursing documentation: the results of the objective and subjective assessment of pain as well as the patient’s response.
Observations
– Aspects to take into account when assessing pain in children: 1. Preverbal stage (0-3 years): crying is the main indicator, facial expressions such as grimaces, wrinkled forehead, tightly closed eyes, etc. significant body movements, opening of hands, tightly clenched fists, muscle stiffness, sleep pattern alterations (lethargy or irritability), refusal of food. 2. In children 4-8 years of age, the intensity of pain will be assessed with the Wong and BaKer Scale (drawings of faces). 3. In children aged 9-14 years, the same scale is used as in adults.
– Scales 1. Visual analog scale (VAS): Scout-Huskinson 1976. It consists of asking the patient on a ruler graduated from 0 to 10 the numerical value of his pain, as follows:
0 10 No pain Severe pain
According to the point indicated on the line segment is expressed:
2. Verbal rating scale: 1948 Keele It assesses in points different intensities of pain: 0 – No pain. 1 – Mild pain. 2 – Moderate pain. 3 – Severe pain 4 – Excruciating pain
3. Wong and Baker scale. Facial Drawing Scale (2001). Can be used with children 3 years of age and older.
0-does not hurt 2- hurts a little bit 4- hurts a little more 6-it hurts even more 8-hurts a lot 10- the worst pain
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