ASSESSMENT OF PAIN
1. Both Qualitative andquantitative assessment of the patient's report of
pain is essential. The qualitative assessment involves getting a
description of the location, duration, and characteristics of the pain
(e.g., sharp, dull, burning) as well as factors affecting the pain. Ask
the patient what factors make the pain better or worse (e.g., medicine,
rest, walking, lying down).
The quantitative assessment involves determining the intensity of the
pain. Explain to the patient how to quantitate his or her pain on a rating
scale, either numeric or visual analogue, to obtain some idea of the
intensity of the pain. The scale chosen should be one that the patient is
comfortable using. The same scale should be used for future comparisons.
(See examples of pain assessment tools in Appendix A, page____.)
Ask the patient to indicate ratings for the worst, least, and average or
usual levels of pain in addition to the level of pain present during the
examination to get an appreciation of the range of the pain experience.
Remember that there are no ³norms² to these pain scales and they cannot be
used to compare one patientıs report of pain with another patient. For
example, if a patient rates his pain as 6 on a scale of 0 to 10, one
cannot conclude with any validity that he/she has more pain than one who
rates his pain as 4 or 5, even if the cause of the pain is similar.
The true value of these scales is in tracking the pain over time and
evaluating changes against therapies initiated. For most patients pain
ratings of 1 to 3 on a 0 to 10 scale are indicative of mild pain, ratings
of 4 to 5 are indicative of moderate pain, while 6 or greater represent
severe pain. However, it must be recognized that patients may use these
scales from varying perspectives and that the pain rating should be
considered in the context of the impact that pain has on daily activities
and quality of life. It is also helpful to ascertain from the patient what
pain level is acceptable or tolerable so both the patient and care giver
have a mutual understanding of the goals of care.
2. Assessment of pain in children needs to be tailored to the
developmental level and personality of the child. The faces scale can be
effective in children as young as age 3 (See Appendix A). It may also be
useful in adults with language or other communication barriers if it is
interpreted and they can point to the face that represents the intensity
of the pain. The parents or other family members can provide valuable
information based on their closer understanding of their childıs response
to pain and other distressful situations. Some children may become
withdrawn in response to pain, especially when it is severe. Other
children may respond with restlessness or regressive behavior. In
pre-verbal children (or adults with cognitive or communication
impairments) behavioral observation may be the primary means of assessing
pain and response to treatment. If the care giver is unsure whether a
behavior is indicative of pain or not, if there is reason to suspect pain,
an analgesic trial can be diagnostic as well as therapeutic.
3. The patient's report of pain must be believed. Pain is a subjective
experience: no test can prove its presence or absence. A subjective
experience, however, is no less real than an objective one.
4. Assessment of pain when opioid (narcotic) analgesics are required for
pain control, requires that the physician, and other health care
professionals guard against judging a patient's behavior as drug-seeking.
CULTURAL INFLUENCES AND BIASES ARE, UNFORTUNATELY,EXTREMELY INFLUENTIAL IN
THIS REGARD. Lack of response to pain treatment is almost always the
result of an inadequate dose and unrealistic expectations of duration of
action, assuming one is dealing with opioid responsive pain. Such patients
may indeed be "clock watchers," because they are in unrelieved misery, but
they are more appropriately viewed as relief seekers rather than drug
seekers. (See Opioid Pseudoaddiction, page ___.)
5. Perform a physical examination. Special attention should be directed
to establishing whether muscle spasm, muscle imbalance, scoliosis,
dysesthesia, other structural changes, or neurological deficits are
present.
6. Review all pertinent diagnostic studies (all imaging procedures and
laboratory studies).
7. Take a careful drug history, including recreational use of analgesic
drugs. This must be done in a non-threatening, non-judgmental way.
8. Reassure the patient that his or her pain can be controlled. A
realistic time frame should be provided to the patient and family.
Neuropathic pain will require longer to respond than nociceptive pain and
may require multiple modalities to achieve satisfactory control.
9. Ask about other symptoms and/or side effects the patient may be
experiencing (e.g., nausea, vomiting, constipation, sedation, fatigue).
10. Reassess outcome of treatment as necessary. Follow-up visits should
be frequent until stable pain relief is achieved. Assess side effects of
treatment and their influence on treatment success or failure; e.g.,
constipation may determine the difference between success or failure of
treatment with oral analgesics because relief of constipation often
relieves nausea and vomiting.
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