There are few objective findings on which the assessment of pain can rely. Pain is a subjective phenomenon, and thus, the main assessment lies in the client’s reporting. The client’s description of pain is quoted. The exact words used to describe the experience of pain are used to help in the diagnosis and management. The pain and its onset, duration, causes, and alleviating and aggravating factors are assessed. Then the quality, intensity, and effects of pain on the physical, psychosocial, and spiritual aspects are questioned. Past experience with pain in addition to past and current therapies are explored.
In preparation for the interview, clients are seated in a quiet, comfortable, and calm environment with minimal interruption. Explain to the client that the interview will entail questions to clarify the picture of the pain experienced in order to develop the plan of care.
There are many assessment tools, some of which are specific to special types of pain. The main issues in choosing the tool are its reliability and its validity. Moreover, the tool must be clear and, therefore, easily understood by the client and require little effort from the client and the nurse.
Select one or more pain assessment tools appropriate for the client. There are many pain assessment scales, such as the following:
Numeric Rating Scale (NRS) (Box 7-1)
Behavioral Pain Scale (BPS) (Box 7-2)
Faces Pain Scale (FPS), Faces Pain Scale - Revised (FPS-R), including the Wong-Baker FACES Scale (Box 7-3)
McCaffrey Initial Pain Assessment Tool (see Box 7-4)
All of these and other scales can be found online. Most of these scales have been shown to be reliable measures of client pain. The three most popular scales are the NRS (Box 7-1), the Verbal Descriptor Scale, and the FPS (Box 7-3), although VASs are often mentioned as very simple. The NRS has been shown to be the best for older adults with no cognitive impairment and the FPS-R for cognitively impaired adults (Flaherty, 2012).
The Baker and Wong FACES Pain Scale (Wong-Baker FACES Foundations, 2015) is used for adults and especially for children to assess pain. See Box 7-3.
The BPS (Payen et al., 2001) has been used to assess pain in persons unable to verbally express their level of pain. As noted in the third category, the original intent was for ventilated clients. See Box 7-2.
Effective pain assessment tools suitable for the client’s initial assessment are the McCaffrey Initial Pain Assessment Tool (see Box 7-4) (McCaffery & Pasero, 1999) and the Brief Pain Inventory (Short Form)
| Question | Rationale |
|---|---|
| Are you experiencing pain now or have you in the past 24 hours? | This helps establish the presence or absence of perceived pain. |
| Where is the pain located? | The location of pain helps identify the underlying cause. |
| Does it radiate or spread? | Radiating or spreading pain helps identify the source. For example, chest pain radiating to the left arm is most probably of cardiac origin, while pain that is pricking and spreading in the chest muscle area is probably musculoskeletal in origin. |
| Are there any other concurrent symptoms accompanying the pain? | Accompanying symptoms also help identify the possible source. For example, right lower quadrant pain associated with nausea, vomiting, and the inability to stand up straight is possibly associated with appendicitis. |
| When did the pain start? | The onset of pain is an essential indicator for the severity of the situation and suggests a source. |
| What were you doing when the pain first started? | This helps identify the precipitating factors and what might have exacerbated the pain. |
| Is the pain continuous or intermittent? | The pain pattern helps identify the nature of the pain and may assist in identifying the source. |
| If intermittent pain, how often do the episodes occur and for how long do they last? | Understanding the course of the pain provides a pattern that may help determine the source. |
| Question | Rationale |
| Describe the pain in your own words. | Clients are quoted so that terms used to describe their pain may indicate the type and source. The most common terms used are throbbing, shooting, stabbing, sharp, cramping, gnawing, hot/burning, aching, heavy, tender, splitting, tiring/exhausting, sickening, fearful, and punishing. |
| What factors relieve your pain? | Relieving factors help determine the source and the plan of care. |
| What factors increase your pain? | Identifying factors that increase pain helps determine the source and helps in planning to avoid aggravating factors. |
| Are you on any therapy to manage your pain? | This question establishes any current treatment modalities and their effect on the pain. This helps in planning the future plan of care. |
| Is there anything you would like to add? | An open-ended question allows the client to mention anything that has been missed or the issues that were not fully addressed by the above questions. |
| Question | Rationale |
|---|---|
| Have you had any previous experience with pain? | Past experiences of pain may shed light on the previous history of the client in addition to possible positive or negative expectations of pain therapies. |
| Question | Rationale |
|---|---|
| Does anyone in your family experience pain? | This helps assess the possible family-related perceptions or any past experiences with persons in pain. |
| How does pain affect your family? | This helps assess how much the pain is interfering with the client’s family relations. |
| Question | Rationale |
|---|---|
| What are your concerns about pain? | Identifying the client’s fears and worries helps in prioritizing the plan of care and providing adequate psychological support. |
| How does your pain interfere with the following? | These are the main lifestyle factors that pain interferes with. The more the pain interferes with the client’s ability to function in their daily activities, the more it will reflect on the client’s psychological status and thus the quality of life. |
Objective data for pain are collected by observing the client’s movement and responses to touch or descriptions of the pain experience. Many of the pain assessment tools incorporate a section to evaluate the objective responses to pain. Key points to remember during a physical examination for pain include the following:
Choose an assessment tool that is reliable and valid to the client’s culture.
Explain to the client the purpose of rating the intensity of pain.
Respect the client’s behavior toward pain and the terms used to express it.
Understand that different cultures express pain differently and maintain different pain thresholds and expectations.
Note: Refer to Chapter 2, Performing Physical Assessment Skills and Techniques, appropriate to affected body area. Body system assessments will include techniques for assessing pain (e.g., palpating the abdomen for tenderness or palpating the joints for tenderness or pain).
| ASSESSMENT PROCEDURE | NORMAL FINDINGS | ABNORMAL FINDINGS |
|---|---|---|
| ||
It is hard to evaluate pain in neonates and infants. Behaviors that indicate pain are used to assess their pain.
A pain assessment tool that serves well for the client’s initial assessment is the Initial Pain Assessment for Pediatric Use Only (About Kids Health, 2009).
Older people often suffer from pain related to chronic disorders, which is often undertreated. Untreated pain can lead to anxiety, depression, isolation, functional decline, and confusion. Aggressive or combative behaviors in the demented elderly may be the result of untreated pain.
Pain is a universal human experience, but how people respond to it varies with the meaning placed on pain and the response to pain that is expected in the culture in which the person is raised. There are certain patterns of pain expression that vary across cultures. Pain can have several meanings between different cultures that lead to these difference response patterns. The most important factor is this: DO NOT STEREOTYPE! Even though there are tendencies for people from a particular cultural background to exhibit certain characteristics, many people of that culture will not. The nurse must assess what the person says about pain and how the person perceives pain.
| Angina Decreased cardiac output Paralytic ileus/small bowel obstruction Sickling crisis Peripheral nerve compression Corneal ulceration | Endocarditis Peripheral vascular insufficiency Osteoarthritis Joint dislocation Pathologic fractures Renal calculi |