Because these questionnaires are often long and tedious to administer, abbreviated versions simplify the task without losing the multidimensional assessment. Some Observation of physiologic and behavioral responses Although behavioral patterns and vital signs are inferior to self-report in the accurate assessment of pain in some circumstances, self-report is not feasible: In the postoperative period, when the patient is still under the influence of anesthetics; in the absence of adequate verbal skills, such as in neonates and children younger than 3 years; and in the cases of mentally challenged patients and some geriatric patients with regression of linguistic ability. In such circumstances, the severity of pain can be estimated only from the patients’ physiologic and behavioral responses. Physiologic responses to pain, which are numerous, are seen in the respiratory, cardiovascular, gastrointestinal, urinary, neuroendocrine, and metabolic systems. Many of these responses can be attenuated or eliminated through the provision of adequate analgesia. A nonspecific increase in minute ventilation occurs with painful stimuli. However, with chest and upper abdominal injuries and wounds, abdominal distension may occur, possibly resulting in reductions in vital capacity, tidal volume, residual volume, functional residual capacity, and 1-second forced expiratory volume. The most widely appreciated, and perhaps most easily identified, responses to acute painful stimuli occur in the cardiovascular system as a result of increased sympathetic tone. Heart rate, stroke volume, blood pressure, and cardiac work are decreased. Patients in pain often reduce their physical activity, resulting in increased venous stasis and platelet aggregation and, ultimately, an increased risk of deep-vein thrombosis. Nausea, vomiting, and ileus are considered gastrointestinal autonomic concomitants of pain. General hypomotility of the urinary tract and difficulty Case study 4 A 41-year-old male with no significant history past medical history was rushed to the emergency section of a tertiary medical facility in La Paz. The patient, Azante, had complained of excruciating pain in the lower abdomen about 36 hours before the presentation. On admission, he explained how the pain had worsened progressively and radiated to the mid-abdomen about 24 hours before the presentation. He explained how a few posture changes had initially helped relieve pain radiation to the abdomen, but reliefs were not sustained. As a manual labor worker in a cement factory, Azante lifts heavy tools and raw materials in an average excess of 50-75kg. He had initially presented at a local clinic with complaints of a possible hernia and was administered a slow-release formulation of diclofenac sodium 100 mg. However, the pain worsened acutely and resulted in nearly fainting spells a few hours before the presentation. On admission, Azante described how the pain comes on suddenly, radiates to the mid-abdomen section, and dissipates subsequently. The cycle of pulsating pain had occurred repeatedly over the past few weeks. Review of signs and symptoms ● Respiratory Rate: 19. ● Body Temperature: 36.6 deg.C. ● Oxygen Saturation: 72% on room air. ● Weight: 72 kg. ● Height: 168 cm. ● Heart Rate: 76 b/min. A CT scan showed no conclusive evidence of a hernia in progress or healing.
examples include the short-form MPQ, the MtdiMuh, the Faschingbauer abbreviated MMPI (short versions of the MMPI), and the Memorial Pain Assessment Card.
in urination are likely mediated by the same autonomic stimulation. Suprasegmental reflex responses lead to increased sympathetic tone and catecholamine secretion. Increased catabolic hormone secretion leads to increases in serum levels of adrenocorticotropic hormone, antidiuretic hormone, growth hormone, cyclic AMP, glucagon, aldosterone, and renin/angiotensin II. The effects are predictable and include sodium and water retention, as well as increased levels of blood glucose, free fatty acids, ketone bodies, and lactate. Physiologic measurements to assess the intensity of pain such as topographic mapping of the brain and analyses of blood or urine for determination of changes in circulating neurotransmitters and other chemicals have been made. These modalities still need much refinement and are not currently appropriate for clinical application. Two observational tools based on the behavioral response have been proposed for the assessment of pain in neonates and young children. For the neonatal group, five behavioral responses were chosen for observation—brow bulge, eye squeeze, nasolabial furrow, open mouth, and crying. Each response is given a score of 1 if present, with a maximal score of 5. For the pediatric group, behavioral responses were assessed. A pediatric pain chart is another model proposed for the observation of behavior after surgery. Mechanical methods of reporting pain intensity have been proposed, such as squeezing a piece of calibrated equipment to demonstrate the intensity of pain. However, such methods generally prove inferior to verbal report methods. Past medical history Azante has had no prior abdominal surgery. He walks at least 7,500 steps per day and smokes just over a pack of cigarettes daily. He drinks alcohol at social events but insists he is no heavy drinker. When queried about recreational drug use, Azante denied ever trying out any recreational drug and denied any form of OTC abuse. Physical exam report On admission, Azante is alert and oriented and in apparent distress. His abdomen was tender to palpitation without a rebound in the right power quadrant. No rigidity or guarding and bowel sounds are present throughout. Azante also showed no signs of cerebrovascular tenderness or focal deficits. Therapy plan In addition to a department-wide effort to take consults on Azante’s case, a review request was sent to the pain management team for pain assessment. This was considered a first-step approach in stabilizing Azante before considering the possible administration of antibiotics. On the pain numerical scale, Azante described his pain as a 7 out of 10. Pain management The pain assessment team recommended the following medications for acute pain management: ● IV Pentazocine 30 mg stat (can be repeated any other day). ● IV Diclofenac titrated to effect pain relief. ● PO Diclofenac + Misoprostol (When switched from IV medications).
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Book Code: PYCA2725
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