Pain Management
Subtopic:
Assessment OF Pain
Assessment Introduction
Effective pain management starts with a comprehensive evaluation. A detailed physical examination is essential, alongside consideration of psychological, social, cultural, and spiritual dimensions that can influence the pain experience. (For background, refer to the Pain Introduction – link to Pain Introduction if needed).
During pain assessment, remember these key aspects:
Physical Examination: Conduct a thorough physical assessment. Document all findings both in written notes and directly on a body diagram. Limit further investigations to those directly impacting treatment decisions. Assess the stage and extent of the underlying condition.
Influencing Factors: Beyond physical aspects, explore psychological, social, cultural, and spiritual elements that might shape the patient’s pain experience. These factors are crucial for a holistic understanding.
Targeted Questioning: Utilize specific questions to effectively gather essential pain information.
Specific Questions to Ask
To gain a clear picture of the patient’s pain, ask about:
Pain Onset: “When did you first notice the pain starting?”
Pain Character: “Can you describe what the pain feels like?”
Pain Location and Spread: “Where exactly is the pain located? Does it move or spread to other areas?”
Pain Type: “What kind of pain would you say it is?” (e.g., sharp, burning, aching)
Pain Duration and Changes Over Time: “How long have you been experiencing this pain? Has the pain changed in any way since it began?”
Aggravating, Relieving, and Impact Factors: “What makes the pain worse? What makes it better? How does the pain affect your daily activities, your mood, and your sleep?”
Previous Medication Effects: “Have you taken any medications for this pain before? If so, were they helpful? Did you experience any side effects?”
Personal Meaning of Pain: “What does this pain mean to you personally? Is it connected to any worries you have, especially about your health or long-term condition?” This is particularly important in situations of serious illness or end-of-life care.
PQRST Pain Assessment
The PQRST method is a structured approach to pain assessment, using a helpful mnemonic:
P – Provoking/Palliating Factors: “What triggers or worsens your pain? What, if anything, provides relief?”
Q – Quality: “Describe your pain in detail. What words would you use to explain how it feels?”
R – Region/Radiation: “Where is the main location of your pain? Does it spread out or radiate to other areas?”
S – Severity: “Using a pain scale (e.g., 0-10), how intense is your pain right now? (Use a body chart to pinpoint the location). How much does the pain impact your daily life?”
T – Timing: “When does the pain occur? Is it constant, or does it come and go? Are there specific times of day or night when the pain is worse? Have you had any treatments for this pain before?”
PQRST Pain Assessment
| PQRST | Questions |
| P – Position | – Where is the pain located? – Can you pinpoint the exact spot of your pain? – Does the pain extend to a larger area? – Mark the most painful point. |
| P – Precipitating Factors | – Are there actions or conditions that make your pain worse, such as eating, bowel movements, or general movement? – What actions or conditions make your pain better or provide relief? – Does resting make the pain subside? – Does pain lessen after a bowel movement? – Does pain improve after wound drainage? – Do heat or cold applications help manage the pain? – Does prayer or support from friends offer comfort? – Have you used any medications, pain relievers, or herbal remedies? Are they effective? – Have any treatments reduced or eliminated the pain? |
| Q – Quality | – What words would you use to describe the sensation of your pain? – How would you characterize your pain using descriptive terms like nociceptive or somatic pain qualities? |
| R – Radiation | – Where did the pain start initially? – Does the pain spread or extend to other areas of your body? |
| S – Severity | – Using a scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate your pain level? – How much does the pain interfere with your daily activities and routines? – Does the pain hinder your ability to participate in normal activities such as sleeping, moving around, sitting, or eating? |
| T – Timing | – How long have you been experiencing this pain? – Is the pain constant, or does it come and go intermittently? – Does the pain intensity change or worsen at specific times during the day or night? |
| Meaning of Pain | 1. What are your concerns or anxieties related to this pain? 2. What do you believe is the cause of your pain? 3. What personal significance or meaning does this pain hold for you? 4. Possible interpretations: “feeling punished,” 5. “believing death is near,” 6. “lack of hope,” 7. “acceptance of suffering as fate,” 8. “sense of being consumed by pain.” |
Pain Assessment Tools
Pain assessment tools are valuable aids in evaluating and tracking a patient’s pain experience. These instruments offer a structured way to quantify pain intensity over time. Their primary benefits include:
Quantifying Pain Intensity: Assessing and determining the level of pain a patient is experiencing.
Monitoring Pain Fluctuations: Tracking changes in pain levels as treatment progresses, allowing for adjustments to care.
Evaluating Intervention Effectiveness: Measuring the success of pain management strategies and treatments.
It is crucial to employ straightforward methods when assessing pain. Initially, pinpointing the location of the pain, and noting if it is present in single or multiple body areas, is fundamental. Regular pain evaluations are recommended, typically every 4 to 6 hours, or more frequently for severe pain cases.
It is important to recognize that standard pain measurement tools often do not account for anxiety, which can skew pain scores. Anxiety and pain can share similar behavioral expressions, potentially leading to the measurement of anxiety rather than pure pain intensity.
A variety of pain assessment tools are available for both adults and children. A useful initial tool is a body chart, where patients can visually mark the areas of their body where they feel pain.
Types of Pain Assessment Tools
Numerical Rating Scale (NRS)
The Numerical Rating Scale is a frequently used pain assessment tool. It requires the patient to rate their pain intensity using numbers. Typically, this scale ranges from:
0 to 10: Where “0” signifies “no pain” and “10” represents “the most severe pain imaginable”.
A simplified version may utilize a reduced range:
0 to 5: Providing a smaller numerical scale for rating pain.
Another variation includes descriptive words:
Verbal Descriptor Scale: This uses terms like “mild pain,” “mild to moderate pain,” and “moderate pain” to categorize pain levels.
Hand Scale
The Hand Scale employs hand gestures to visually represent pain intensity. A closed fist signifies the absence of pain, or “no hurt”. Conversely, fully outstretched fingers indicate the most extreme pain, described as “hurts worst”.
Cultural Sensitivity is Key: It is vital to be aware that hand gestures can have different meanings across cultures. Therefore, clear explanation of the scale to the patient is essential.
Example Explanation: You might explain the scale by asking the patient to rate their pain from 0 to 5, where:
0: Represents no pain whatsoever.
1: Indicates a slight level of pain.
2: Signifies a moderate increase in pain.
3: Denotes a considerable amount of pain.
4: Represents a substantial degree of pain.
5: Indicates overwhelming pain – the most intense pain imaginable.
The Faces Pain Scale (Wong-Baker Faces Pain Rating Scale)
This scale uses a series of cartoon faces to represent different levels of pain. It typically presents six faces ranging from:
A very happy, smiling face to represent “no pain.”
Progressing through faces with increasingly frowning and distressed expressions.
Ending with a deeply saddened, crying face to indicate “the worst possible pain.”
Important Considerations for Use:
Training is Key: It is essential to properly instruct patients on how to accurately use this tool. Ensure they understand they are rating their pain intensity, not their emotional state.
Cultural Context: Experiences with the Faces Scale can vary geographically. For example, in some African contexts, the Hand Scale has been found to be more readily accepted and preferred by patients for pain assessment.
Pain Assessment in Children
Pain management in children presents unique challenges. While sharing similarities with adult pain management, there are specific factors to consider when assessing and treating pain in pediatric patients.
Debunking Myths: Pain in Children – Facts vs. Misconceptions
| Myth | Fact |
| Newborns do not experience pain. | Newborns possess a fully developed capacity to feel pain. |
| Young children cannot process or remember pain. | Children of all ages have the ability to experience and recall pain. |
| Children become accustomed to repeated pain. | Repeated painful procedures can still cause significant distress and pain. |
| Children cannot communicate pain location. | Children can effectively indicate where they are experiencing pain. |
| Opioids should be avoided due to addiction risk. | Psychological addiction to opioid pain medications is rare in children. |
| Immature nervous system means less pain felt. | Pain perception is effective even without complete nerve development. |
| Younger children have lower pain tolerance. | Pain tolerance generally increases as children grow older. |
| Children always verbally express pain. | Children may not always communicate pain due to fear or communication barriers. |
| Children are unaware of chronic pain. | Children may not recognize or fully understand the concept of chronic pain. |
Goals of Pain Measurement in Children:
Determine Pain Intensity: To accurately assess and quantify the level or severity of pain the child is experiencing.
Identify Pain Location: To pinpoint the specific area or areas of the child’s body where pain is felt.
Evaluate Treatment Effectiveness: To measure how well pain management strategies are working and if adjustments are needed.
Barriers to Pain Assessment and Measurement in Children
Assessing pain in children can be particularly challenging due to several factors that hinder accurate evaluation:
Limited Age-Appropriate Tools: A restricted selection of pain assessment instruments are specifically designed and validated for use across all pediatric age ranges. This means finding the right tool for a baby is different from finding one for a teenager.
Knowledge of Suitable Tools: Healthcare providers may lack sufficient understanding of which pain assessment tools are most appropriate for different age groups within the pediatric population. Knowing which tool works best for a toddler versus a school-aged child is not always straightforward.
Insufficient Training in Tool Use: Inadequate education and practical experience in the correct application of pain assessment tools can limit their effective use. Even with good tools, if staff aren’t trained to use them properly, the assessment won’t be accurate.
Difficulty Interpreting Scores: Understanding and making sense of pain scores obtained from children can be complex, requiring careful consideration of various influencing factors. A child’s pain score might be affected by their mood or fear, not just the pain itself.
Distinguishing Pain from Anxiety: It can be hard to differentiate between behaviors indicating pain and those related to anxiety, as children may express both similarly. A child crying might be in pain, or they might just be scared, and telling the difference can be tough.
Understanding Child Pain Experience: Limited insight into the unique ways children perceive and express pain can be a barrier to accurate assessment. Children don’t experience or describe pain like adults, and this needs to be understood.
Child Reluctance to Report Pain: Various reasons can make children hesitant to communicate their pain experience. These include:
Fear of Medical Staff: Anxiety related to doctors, nurses, or hospitals.
Fear of Diagnosis: Worry about being seriously ill or what pain might mean.
Not Wanting to Burden Others: Hesitation to trouble parents or caregivers with their discomfort.
Fear of Procedures: Apprehension about injections or other potentially painful treatments.
Desire to Go Home: Eagerness to leave the medical setting, leading them to downplay pain.
Assessment Process of Pain in Children
Utilizing a structured approach can greatly improve pain assessment in children. The QUESTT framework offers a useful guideline for evaluating and managing pediatric pain:
QUESTT Breakdown:
| Step | Questions/Tools |
| Q – Question the child | 1. “Do you feel any discomfort or pain right now?” 2. “Can you show me on your body where it hurts the most?” 3. “Does the pain spread anywhere else or is it just in one spot?” 4. “When did you first start feeling this pain or discomfort?” 5. “Do you have any idea what might have caused your pain to start?” 6. “Using a pain scale, can you tell me how much it hurts right now?” 7. “Is there anything that makes your pain feel better or go away?” (If the child cannot communicate, ask parents/caregivers these questions). |
| U – Use pain rating scales | – Eland-Froggatt Tool (Body Map): This tool aids in assessing pain across multiple locations and at different intensities. Have the child assign colors to pain levels (e.g., green = no pain, yellow = mild, orange = moderate, red = severe). Then, ask them to color in a body outline indicating pain locations and intensities using their chosen colors. – Faces Pain Scale: (Already described previously) – Hand Scale: (Already described previously) |
Evaluate Behavior and Physiological Changes
Observe Behavioral Responses: Pay close attention to the child’s actions and reactions. Look for non-verbal cues that might indicate pain, such as:
Facial expressions: Grimacing, furrowed brow, tightened jaw, crying.
Body movements: Restlessness, guarding, limping, reluctance to move, unusual postures.
Vocalization: Whimpering, groaning, screaming, changes in cry pattern (e.g., high-pitched, inconsolable).
Social interaction: Withdrawal, irritability, decreased playfulness.
Sleep patterns: Disturbed sleep, frequent awakenings.
Monitor Physiological Responses: Assess vital signs and other physical indicators that can accompany pain, including:
Heart rate: Increased rate.
Respiratory rate: Increased or irregular breathing.
Blood pressure: Elevated blood pressure.
Skin: Sweating, pallor, flushing.
Oxygen saturation: May decrease in severe pain.
Secure Caregiver Involvement
Active Listening: Thoroughly listen to the perspectives of mothers, fathers, and other primary caregivers. They possess valuable insights into the child’s usual behavior and pain responses.
Shared Decision-Making: Involve parents and caregivers actively in discussions about pain assessment and management plans. Their understanding and cooperation are crucial for effective pain control.
Behavioral Insight: Consider caregivers’ observations regarding subtle shifts in the child’s typical behavior patterns. They often notice early signs of discomfort that might be missed by others.
Comfort Strategies: Seek input from caregivers regarding strategies that have been effective in comforting the child in the past. Utilize their knowledge of what works best for their child.
Take the Cause of Pain into Account
Underlying Condition: Consider the child’s medical history, diagnosis, and the underlying medical problem or injury that is likely causing the pain. Understanding the source is key to appropriate management.
Pain Type Description: Obtain detailed descriptions of the pain characteristics (e.g., sharp, dull, constant, intermittent) to help determine the potential cause and guide treatment choices.
Take Action and Evaluate Results
Comprehensive Pain Assessment and Plan: Based on the QUESTT assessment, formulate a clear pain management plan tailored to the child’s specific needs.
Regular Reassessment: Frequently reassess the child’s pain using pain rating scales and behavioral observations to monitor the effectiveness of the treatment plan.
Plan Adjustment: Be prepared to modify the pain management strategy based on ongoing reassessment findings. Adjustments may include changes in medication, dosage, or non-pharmacological interventions.
Pain Diaries for Chronic Pain: For children with chronic pain, utilize pain diaries to track pain patterns, treatment effectiveness, and identify triggers over time. This aids in continuous re-evaluation and long-term pain management adjustments.