Chapter 2. Patient Assessment

2.3 Pain Assessment

“Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery, 1968, as cited in Rosdahl & Kowalski, 2007, p. 704).

Pain is a subjective experience, and self-reporting pain is the most reliable indicator of a patient’s experience (RNAO, 2013). Determining pain is an important component of a physical assessment, and pain is sometimes referred to as the “fifth vital sign.”

Example of a pain scale https://commons.wikimedia.org/wiki/File:Children%27s_pain_scale.JPG
Figure 2.1 Example of a pain scale
Figure 2.2 Wong-Baker assessment of pain in children scale

Pain assessment is an ongoing process rather than a single event. A variety of pain assessment tools and visual analogues are available to help with pain assessment (see Figures 2.1 and 2.2). When someone’s pain changes notably from previous findings, a more comprehensive and focused assessment should be performed. Sudden changes may indicate an underlying pathological process (Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014). It is important to assess pain at the beginning of a physical health assessment to determine the patient’s comfort level and potential need for pain comfort measures. Any time you think your patient is in pain, the mnemonic OPQRSTUV may help guide the questions to ask your patient. See Checklist 14 for more specificity regarding this approach.

Checklist 14: Pain Assessment

Disclaimer: Always review and follow your hospital policy regarding this specific skill.

Steps

 Additional Information
O: Onset
  • When did it begin?
  • How long does it last?
  • How often does it occur?
P: Provoking, palliation
  • What brings it on?
  • What makes it better?
  • What makes it worse?
Q: Quality
  • What does it feel like?
  • Can you describe it? (patient’s own words)
R: Region, radiating
  • Where is it?
  • Does it spread?
S: Severity
  • What is the intensity (0 to 10) right now, at best, on average, at worst?
  • Are there other accompanying symptoms?
T: Treatment
  • What treatments are you currently using?
  • How effective are they?
  • Any side effects?
  • What have you used in the past?
U: Understanding
  • What do you believe is causing this symptom?
  • How is this symptom affecting you or your family?
V: Values
  • What is your comfort goal?
Data source:  RNAO, 2013

In their “Clinical Best Practice Guidelines: Assessment and Management of Pain” (2013), the Registered Nurses Association of Ontario (RNAO) has published a variety of pain assessment tools for different populations including children, non-verbal adults, adults with cancer, and neonates. Table 2.1 is an assessment tool that can be used in adults with cognitive impairment.

Table 2.1 Pain Assessment Tools for Elders with Cognitive Impairment

Note: The screening tool is for the presence/absence of pain but NOT pain intensity.

Measure

Characteristics

Considerations
Pain Assessment in Advanced Dementia (PAINAD) Scale
  • Observational behavioural tool of five items: breathing, facial expression, body language, negative vocalizations, and consolability
  • Each item rated on a scale of 0–2 for a total score from 0 (no pain) to 10 (severe pain); score 1 or 2 indicates some pain
  • For use with people having advanced dementia
  • Feasible in clinical setting – can be completed in 1-3 min.
  • Clear and concise concepts, user-friendly
  • Tool can be used for screening and follow-up
  • Evidence of reliability and validity
  • Available online at http://dementiapathways.ie/_filecache/04a/ddd/98-painad.pdf
Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
  • 60-item tool assessing four categories: facial expressions, activity/body movements, social and personality changes, and other (appetite or sleeping changes)
  • Items in each category are rated present or absent, for a total score of 60
DOLOPLUS-2 Scale
  • Observations of somatic, psychomotor, and psychosocial behaviours
  • Items scored on scale of 0–3, total score range from 0–30
  • Score of 5 or more indicates pain, maximum score 30
  • For use with people having mild or moderate cognitive impairment and with proxy rating when a person is unable to self-report
  • User friendly – takes minutes to complete
  • Validation done in non-English speaking people
  • Available online at http://www. assessmentscales.com/scales/doloplus
Data source: RNAO, 2013

Critical Thinking Exercises

  1. You are caring for a patient who has just returned from a surgical procedure. How might the assessment of acute pain differ from assessment of chronic pain?
  2. What is more important in pain assessment: the subjective or the objective data?

Attributions

Figure 2.1 Children’s pain scale by Robert Weis is used under a CC BY SA 4.0 licence.

Figure 2.2 The Wong-Baker scale for assessment of pain in children by Intermedichbo is used under a CC BY SA 4.0 licence.

License

Icon for the Creative Commons Attribution 4.0 International License

Clinical Procedures for Safer Patient Care Copyright © 2018 by Thompson Rivers University is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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