Pain Assessment Hierarchy

Multiple pain assessment tools exist to assist in the measurement (rating) of pain. These tools must be valid, appropriate to the individual patient and applied consistently. Additionally, a pain assessment hierarchy is available to frame the measurement of pain in the critically ill patient, many of whom may not be able to self-report their pain intensity due to sedation, altered level of consciousness, etc.

• Self-reporting. Pain is a subjective experience; therefore, the patient's self-report of pain is thought to be the most reliable method to determine pain level and should always be attempted first. But pain intensity does not have to be verbalized. Patient may point to a pain intensity tool, hold up fingers to indicate a pain intensity number, blink or nod when the correct pain intensity number is stated by a caregiver, etc.
• Potential causes of pain. Not all patients can self-report, so searching for reasons for pain such as recent trauma, surgery, infection, turning, suctioning, etc. is important. Pain should be treated PRIOR to known painful activities or procedures.
• Observe behaviors. This is a valuable assessment technique used in conjunction with searching for potential causes of pain in the patient who cannot self-report. Use of an appropriate behavioral pain-rating tool may be considered, but effectiveness is dependent on the patient being able to elicit a response in all categories within the tool. (e.g., if the vocalization such as groaning is listed but the patient is intubated, this tool would not be appropriate. Likewise, if the tool requires assessment of four limbs, but the patient is a paraplegic, this tool would not be useful.) Key point: A common mistake is to equate a self-reported pain intensity score to the score obtained using a behavioral pain-rating tool. This is incorrect! They are not the same! Behavioral pain scores do NOT equate to pain intensity scores. Behavioral pain scores are based on observed BEHAVIOR while pain intensity scores are self-reported and based on the patients' sensory experience.
• There are many behavioral tools available. The Critical Care Pain Observation Tool (CPOT) is one such scale (see Table 11.11). It is designed specifically for the critically ill patient who is unable to self-report, with construction flexibility to capture both the intubated and non-intubated patient. key point: A behavioral pain score of >2 is considered unacceptable, and pain reduction interventions should be considered.
• Proxy reporting. Reporting of pain by persons who know the patient well, such as family members, significant other, parent, child, or caregiver can be credible.
• Analgesic trial. Observe patient closely after pain reduction intervention(s).
• Vital signs, including increases in heart and/or respiratory rate or blood pressure, are NOT considered sensitive indicators of pain

Table 11.11