Upload
meghan-snow
View
222
Download
2
Embed Size (px)
Citation preview
1
2
[email protected]میترا حکمت افشار
دانشجوی کارشناسی ارشد پرستاری مراقبت های ویژه
دانشکده پرستاری مامایی گرگان 1388دی ماه استاد راهنما جناب آقای علی اکبر عبداللهی
اهداف
بیان اهمیت اندازه گیری درد و اصول آن مروری بر ابزارهای سنجش شدت درد
ذکر معایب و مزایای آناننحوه کار با پرسشنامه درد مک گیل
نحوه کار با پرسشنامه درد مک گیل خالصه شده
درد در بیماران بشدت بدحالمعرفی ابزارهای موجود جهت بررسی درد در
بیماران بدحال3
pain assessment
• The importance of pain assessment was identified as a necessary first step in improving the effectiveness of pain Management.
4
Principles of Assessment
• Assess and reassess .
• Reassess Intensity, Relief, And Side Effects.
• Use verbal report whenever possible .
• Document in a visible place.
• Include the family.
5
history of pain assessment
• In 1992 and again in 1994 ,the Agency for
Health Care Policy and Research (AHCPR) published
guideline for the treatment of acute pain and cancer pain.
• In 1999, the Joint
Commission on the
Accreditation of
Healthcare
Organizations (JCAHO)
released its standards on
pain management .
6
Onset
Location
Duration
Radiation
Influence of pain in daily and quality of life
7
The Role of Nursing in Pain assessment
Measurement pain tools
• One–dimensional tools
• Pain rating scales :
• Visual analog scale• Verbal rating scale• Numerical rating
scale
• Multidimensional tool
• The MCGILL pain
QUESTIONNARE
• Initial pain assessment by McCaffery and pasero
8
Visual analogue scale(VAS)
• A horizontal or
vertical line for
the patient to rate
current pain level.
• Patient can communicate by pointing
• Simple, easy to use• Needs to understand
concept of rating pain.
• Dependent on patient's prior pain experiences
9
The patient is asked to place a mark along the line to indicate the current
pain level.
10
Visual analogue scale
Advantage of Visual analogue scale
• Simple• quick to administer• and may be used before, during, and following
treatment . • The scales may also be completed throughout the
course of a day to assess change in pain intensity relative to activity or time of day.
11
limitation of visual analog scale
• Difficultly with administration in patient who has
perceptual-motor problems .
• The major disadvantage of VAS is the
assumption that pain is a unidimensional
experience.12
13
Verbal and Numeric Rating Scale
PAIN INTENSITY SCALE
14
McGill Pain Questionnaire McGill Pain Questionnaire (MPQ)(MPQ)
• The McGill Pain Questionnaire, developed
by Melzack (1975), was the first proper
multidimensional self-report pain
measuring instrument and is still the most
widely used today.15
McGill Pain Questionnaire (MPQ)
• sensory: what the pain feels like physically where it is located, how intense it is, its duration and its quality (for example,burning, ‘throbbing).
• affective: what the pain feels like emotionally —whether it is frightening, worrying and so on
.• evaluative: what the subjective overall intensity of the
pain experience is (for example, unbearable, distressing).
16
McGill Pain Questionnaire (MPQ)
• Each of the three main classes was divided
into a number of sub-classes (sixteen in
total).
17
McGill Pain Questionnaire (MPQ)
• Melzack and Torgerson (1971) then asked a sample of doctors, patients and students to rate the words in each sub-class for intensity. The first 20 questions on the McGill Pain Questionnaire consist of adjectives set out within their sub-classes, in order of intensity. Questions 1 to 10 are sensory, 11 to 15 affective, 16 is evaluative and 17 to 20 are miscellaneous.
18
McGill Pain Questionnaire (MPQ)
• codes E for pain on the surface of the body• codes I for internal pain • Codes and EI for both external and internal)• indicate present pain intensity (PPI) on a 6-point
verbal rating scale. • Finally, patients complete a set of three verbal
rating scales describing the pattern of the pain.
19
McGill Pain Questionnaire (MPQ)
• Scores are given for the different classes
(sensory, affective, evaluative and
miscellaneous), and also a total score for all the
sub-classes.
• Based on this, a pain rating index (PRI) is
calculated
20
sensory
affective
evaluated
miscellaneous PPI
Pattern E&I
22
Sections:
• (1) What Does Your Pain Feel Like?
• (2) How Does Your Pain Change with Time?
• (3) How Strong is Your Pain?
23
What Does Your Pain Feel Like?
Some of the following words below describe
your present pain.
Circle ONLY those words that best describe it.
Leave out any category that is not suitable.
Use only a single word in each appropriate
category - the one that applies best.
24
گذر زود و موقتی
فاصله فضاییای
یک روی فشار نقطه
برنده
خود مستقل کفاخود مستقل کفا
فشار - کششفشار - کشش
حسهای گوناگونحسهای گوناگون
کندیکندی
تیز تیز تند تند
گرماییگرمایی
کشش انقباض کشش انقباض
کردن منقبض کردن کردن جمع منقبض کردن جمع
ارزیابی
ترس
نحیف حسرت و غم ازشدن
- - حسی - ارزیابی احساسیمتفرقه
حسهای متفرقه
حسهای متفرقه
حس
28
- ارزیابی- تاثیرمتفرقه
How Does Your Pain Change with Time?
29
Do the following items increase or decrease your pain?
• (11) movement • (12) sleep or rest • (13) lying down • (14) distraction (TV reading
etc.) • (15) urination or defecation • (16) tension • (17) bright lights • (18) loud noises • (19) going to work • (20) mild exercise • (21) fatigue
• (1) liquor • (2) stimulants such as coffee • (3) eating • (4) heat • (5) cold • (6) damp • (7) weather changes • (8) massage or use of a
vibrator • (9) pressure • (10) no movement
30
How Strong is Your Pain?
the following 5 words represent the intensity of pain:
mild
discomforting
distressing
horrible
excruciating
31
32
33
Wha
t dos
e yo
ur p
ain
feel
like
?W
hat dose your pain change with tim
e?
How strong your pain feel like?
Interpretation:
minimum pain score: 0 (would not be
seen in a person with true pain)
maximum pain score: 78
The higher the pain score the greater the
pain.
35
Comparison of pain scores using MPQ obtained from women during labor , And from patients in a general pain clinic and an emergency department.
36
Criticisms
the need to have extensive understanding of the English language.
Need to time consuming
sufficient attention span
normal cognitive state.
37
McGill short painquestionnaire
• Measures quality of pain
• Uses 15 descriptor words to measure sensory
and affective dimension of pain.
• Can be used in conjunction with a pain intensity
scale Gives more information about the patient's
pain.38
THE SHORT-FORM McGill PAIN QUESTIONNAIRE
When it use?. when the time to obtain information from
patients is limited
when more information is desired than that provided by intensity measures such as the VAS or NRS.
39
Sen
sory
dim
ensi
onA
ffec
tive
dim
ensi
on
Intensity scale
VASVASPresent pain intensity
PRI –T SCORES
Comparison of total pain rating index (PRI-T)scores using the (SF-MPQ) for acute and chronic pain conditions. from various pain condition are as follows: labour pain ,musculoskeletal pain and postsurgical pain. abdominal hysterectomy ,acute headache ,herpes zoster and postherapetic neuralgia ,mucositis , angioplasty sheath removal, fibromyalgia and rheumatoid arthritis, atypical facial pain ,artheritis, osteoarthritis and chronic cancer pain.
With patients who are less responsive or
unconscious the nurse must look to
additional pain indicators.
42
PAIN ASSESSMENT in less responsive or unconscious
Altered body movements showing restlessness
vocalizations (e.g. 'moaning and groaning)
and facial expressions (grimacing or
clenched teeth) 43
Changes in physiological parameters ?
The Changes occur in physiological
parameters, including cardiovascular (elevated
blood pressure and heart rate)and respiratory but
are not always accurate due to the underlying or
drug therapy, and should be used with other
forms of assessment.
44
Factors contributing to pain and discomfort in the critically ill
Physical
Psychosocial
Intensive Care Unit Environment or Routine Procedural
45
Factors contributing to pain and discomfort in the critically ill
physical factor
Wounds-post-trauma, postoperative, or post
procedural
Sleep disturbance and deprivation
Immobility, inability to move to a comfortable
position because of tubes, monitors, restraints
46
47
Factors contributing to pain and discomfort in the critically ill
Psychosocial
Anxiety and depression
Impaired communication, inability to report and
describe pain .
Fear of pain, disability, or death
Separation from family
lack of pleasant distractions
47
Factors contributing to pain and discomfort in the critically ill
Intensive Care Unit Environment
Continuous noise from equipment and staff
Continuous or unnatural patterns of light
Awakening and physical manipulation every 1-2 h for vital signs or
positioning
Continuous or frequent invasive, painful procedures Competing
priorities in care: unstable vital signs, bleeding, dysrhythmias, poor
ventilation-may take
Precedence over pain management.
48
PROCEDURAL PAIN
49
Objective pain measures for use with critical care adult unable to self report
The Behavioral Pain Rating Scale (BPRS)
The Behavioral Pain Scale(BPS)
Pain Behavior Assessment Tool (PBAT)
Critical –Care Pain Observation Tool (CPOT)
Pain Assessment And Intervention Notation algoritm .(Pain Algoritm).
Nonverbal pain scale .(NVPS)
50
Objective pain measures for use with critical care adult unable to self report
Research on the measurement of pain in critically
ill adults who cannot self-report (referred to as
nonverbal ICU patients) has emerged only within
the past 2 decades. However ,no measure of pain
in nonverbal ICU patients is accepted as the
“gold standard.” 51
AbstractAbstract:
• Critically ill patients experience significant levels of pain and discomfort from multiple intrinsic
and extrinsic sources while in the intensive care unit (ICU).
• The use of objective pain measures in nonverbal patients is an essential alternative approach
for pain assessment when self-reports are unavailable.
• This paper provides a critical review of the psychometric properties of 6 objective pain
measures that were developed to assess pain in nonverbal adult patients in the ICU.
• .52
Although 2 of the 6 objective pain measures
showed good evidence of validity and
reliability, none has undergone vigorous
validation or has been accepted as a
standardized measure.
53
مطالببندیبندیجمع
54
American Pain Foundationwww.painfoundation.org or 1-888-615-PAIN
Alliance of State Pain Initiativeswww.aspi.wisc.edu or 1-608-265-4013Maryland Pain Initiative:
www.marylandpaininitiative.org or 1-410-783-0199 (voicemail)
American Pain Societywww.ampainsoc.org or 1-847-375-4715
American Society for Pain Management Nursingwww.ASPMN.org or 1-888-342-7766
American Chronic Pain Associationwww.theacpa.org or 1-800-533-3231
55
Reference
Text Book Of Pain Ronaid Melzack &Patrick D.Wall
Critical Care Nursing Thelans 2008
Black &Hawks 2005
Pain Management 2006 Black Well
56
Thank you for your attention04/18/23