Pain assessment

A patients report is clearly the best indicator of pain. Learning

how to perform a thorough pain assessment is essential for
evaluating a patients level of pain and for developing a plan for
pain management. With improved pain control, your patient can
get up sooner and breathe deeper, thus preventing a variety of
potential complications such as pneumonia and thromboembolism.

To manage pain effectively, you must

assess, understand, and treat the patients pain and then
reassess the pain on an ongoing basis. The Joint
Commission emphasizes that every patient has a right to
pain assessment and treatment. That means you must
assess the nature and intensity of the pain and document
your findings in a way that facilitates further assessment
and follow-up. In that context, pain is indeed the fifth
vital sign.

Based on your assessment and the patients pain rating

or score, you will implement interventions that best
alleviate that patients pain. The goal is to treat the pain
before it becomes moderate or severe. So, be sure you
instruct the patient to notify you when pain reaches a
mild level. After you implement the appropriate
interventions, reassess the pain no later than 1 hour
afterwards. For pharmacological interventions, reasonable time frames for
reassessment are 30 to 45 minutes for oral medication, 15 to 30 minutes for
intramuscular administration of analgesics, and 5 to 15 minutes for intravenous
medications.

Pain assessment begins with asking the patient if he has pain. If the answer is yes,
perform a thorough pain assessment, including the intensity, quality, location, timing
(onset, duration, frequency), symptoms, treatments (prescription and
nonprescription), effects on function/daily activities, and what has and has not worked
in the past. Merely asking the patient to rate his pain is not enough. The more
information you gather, the better you can manage the patients pain. Ask the
following questions when your patient reports pain:
When did the pain start?
How long have you had the pain?
Does it come and go or is it continuous?
Where is the pain located? Does it radiate to other areas?
Describe your pain.
Is there a specific factor that triggers the pain?
Does the pain have any specific pattern?
Does anything make it better or worse?
Does it vary with the time of day?
Is the pain new or have you had this pain before? If so, when?
Does the pain cause any other symptoms?
What do you do take to ease the pain?
What other treatments do you use to relieve the pain?
How severe is the pain? (Remember to use a pain scale to determine this.)
How does the pain affect your life? Your daily activities?
What is your goal for pain relief? (Remember that a pain score of 3 or less is
 recommended to promote healing.)

A frequently used mnemonic, PQRST, may help you

remember to assess pain comprehensively.

Provoked: What causes pain? What makes

P
it better or worse?

Quality: What does it feel like? Dull?

Q
Sharp? Stabbing? Burning? Crushing?

Region/radiation: Where is the pain? Is it

R
always only in that spot or does it spread?

Severity: What is the intensity of the pain?

S
(Use a pain scale for this.)

Timing: When did it start? How often does

T it occur? How long does it last or is it
continuous?

Determining pain intensity

Many scales have been developed to help patients measure and communicate the
intensity of their pain. Use of a pain scale also helps ensure consistency among
caregivers in determining the intensity of a patients pain. Make sure to use the scale
that is right for a specific age group or based on your patients ability to communicate.
Ask the patient to rate the pain using the appropriate pain scale.

A word of caution, though: It is not always

safe to rely only on a number. Just as pain is
subjective and individualized, so is each
patients ability to quantify his own pain,
even when you explain what the numbers
mean. Thats why the other aspects of
communication with a patient about his pain
are so crucial. They will help you get more
of a sense of how much discomfort the
patient has, regardless of which number he
selects. For example, you might ask a
patient at what number he feels he would
be able to walk down the hall without
assistance. That will help you formulate a realistic goal for pain relief based on how
pain affects the patients ability to function.

The most common pain scales are described

below.

A numerical rating scale (NRS): This

commonly used approach requires that the
patient rate his pain on a scale from 0 to 10,
with 0 indicating no pain and 10 reflecting
the worst possible pain. (Note that numeric
rating scales are often misrepresented as a
scale from 1 to 10. That does not give the
patient a way to indicate no pain at all.) You
can use a printed representation of the scale
or just administer it verbally. It is
appropriate for use with children old enough to understand numbers and with adults.
Generally, you would interpret the pain scores as:
0 = no pain
1-3 = mild pain
4-6 = moderate pain
7-10 = severe pain
 A visual analog scale (VAS): This also requires that the patient rate his pain from
no pain to the worst possible pain, but without the use of numbers. Using this type of
scale, youd ask the patient to select a point on a line drawn between those two
extremes to represent how intense he feels his pain is. Again, this is suitable for use
with older children and adults.

An image or pictorial scale: For patients who

cannot understand or respond to a numeric or
visual analog scale, pain assessment scales that
present a series of faces are often effective. This
includes young children, adults with cognitive
difficulties, and patients who do not speak the
same language as the nurse. A commonly used
scale of this type is the Wong-Baker FACES
Rating Scale, which depicts six cartoon-like
drawings ranging from a smiling face to a crying
face. Another scale of this type is the Oucher
pain scale, which presents photos of faces with
expressions ranging from neutral to extremely
distressed. The Oucher is available in several
ethnic variations.

When a patient cannot communicate

A pains self-report of pain is always your
first and best strategy, but when a patient
cannot communicate, for whatever reason,
try the following approaches, in the order
presented here.
1. See if the patient has a diagnosis or problem
that usually causes pain (objective data).
2. Look for behavior that might indicate pain,
such as crying, diaphoresis, groaning,
grimacing, or restlessness (objective data).
3. Ask family members or others close to the
patient if they believe the patient has pain
(subjective second-party data).
4. Check for physiologic responses that might indicate pain, such as elevated pulse and
respiratory rates (objective data). Keep in mind that such signs are considered the
least reliable because, although they may be elevated initially, they often stabilize
quickly. Thus, pain can continue in the absence of vital-sign changes.

Effects of unrelieved pain

Understanding the harmful effects of pain is just as important as understanding the
harmful effects of other problems left untreated, such as hypertension or
thrombophlebitis. Physiologically, pain that is not relieved in a timely manner stresses
many body systems. The endocrine and cardiovascular systems respond with
increased activity, and the bodys metabolism speeds up. The respiratory,
genitourinary, and gastrointestinal systems reduce their function. The musculoskeletal
system becomes erratic, causing muscle spasms, fatigue, and altered function.
Mobility decreases, and the immune system becomes depressed, thus making the
patient susceptible to illness and delayed recovery.

Unrelieved acute pain can lead to chronic pain. Both reduce the patients quality of
life. Patients who cannot sleep, eat, or experience life without pain may experience
ever-worsening hopelessness.

A reminder about bias

It is easy to agree that nursing assessments
must be free of bias and preconceived
notions and misconceptions about pain and
pain relief, but it is not always so easy to put
into practice. This is something you might
have to remind yourself about often. Some
of the more common myths about pain are
listed below.
Patients who have a history of substance
abuse (including alcohol abuse):
are already medicated and do not
require additional analgesia.
tend to overreact to or exaggerate pain.
are drug seekers.
are not truthful about how they perceive pain.
Administering analgesics, especially opioids, regularly will lead to addiction.
Patients who have minor illnesses, injuries, or surgery have less pain than those
with major alterations.
Hospitalized patients should expect to have pain.
Chronic pain is psychological.
Patients who do not complain do not have pain.
Patients who are unconscious/asleep do not have pain.
Infants, especially newborns, do not feel pain.
Patients with dementia cannot feel or accurately report pain.
As people age, they should expect to have pain and to report more pain.
Strong analgesics are unsafe for older adults.

Remember, these are myths. Do not allow them to affect your objective assessment
and management of any patients pain.

References

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