Assessment and diagnosis for successful pain management
To provide optimal patient care, nurses require appropriate knowledge, skills and attitudes towards pain, pain assessment and its management. This must be based on the best available evidence to prevent patients from suffering harm (NMC, 2008 ). It is unacceptable for patients to experience unmanaged pain or for nurses to have inadequate knowledge about pain and a poor understanding of their professional accountability in this aspect of care (Dimond, 2002).
Pain - The fifth vital sign
Pain has been identified as the fifth vital signs by Australian and New Zealand College of Anaesthetists and the Chronic pain Coalition in an attempt to facilitate accountability for pain assessment and management (Chronic Pain Policy Coalition, 2007; ANZCA, 2005).
Pre-registration nursing programmes should incorporate pain as a compulsory component, to equip future nurses with the knowledge, skills and attitude to carry out appropriate pain assessment and management from the start of their professional careers. This could result in all patients receiving a higher standard of pain assessment and management in the future and reduce the incidence of unnecessary suffering (Wilson, 2007).
Why is assessment important?
Assessment of a patient’s experience of pain is a crucial component in providing effective pain management. A systematic process of pain assessment, measurement and re-assessment (re-evaluation), enhances the health care teams’ ability to achieve:
- a reduced experience of pain;
- increased comfort;
- improved physiological, psychological and physical function;
- increased satisfaction with pain management.
Pain is not a simple sensation that can be easily assessed and measured. Nurses should be aware of the many factors that can influence the patients overall experience and expression of pain, and these should be considered during the assessment process.
Pain assessment and measurement
The pain assessment involves:
- an overall appraisal of the factors that may influence a patients experience and expression of pain (McCaffery and Pasero 1999)
- acomprehensive process of describing pain and its effect on function;
- an awareness of the barriers that may affect nurses assessment andmanagement of pain. These include:
- - inadequate skills, knowledge, attitudes and beliefs about pain, its assessment and management and the nurses experience (Hall-Lord and Larsson, 2006);
- - poor documentation of pain, its assessment, management and re-evaluation;
- - patients’ age, type and stage of illness (Hall-Lloyd and Larson, 2006) - older people are less likely to report pain despite evidence showing that they are more likely to experience at least one concurrent problem with pain, for example, musculoskeletal pain or pain associated with peripheral vascular disease (British Pain Society and British Geriatric Society, 2007);
- - Myths and misconceptions about pain and its management, for example, fear that patients with acute pain can easily become addicted to their pain medication (McCaffery et al, 2005).
Pain should be measured using an assessment tool that identifies the quantity and/or quality of one or more of the dimensions of the patients’ experience of pain. This includes the:
- intensity of pain;
- intensity and associated anxiety and behaviour.
Measuring pain enables the nurse to assess the amount of pain the patient is experiencing.
Patients’ self-reporting (expression) of their pain is regarded as the gold standard of pain assessment measurement as it provides the most valid measurement of pain (Melzack and Katz, 1994).
Self-reporting can be influenced by numerous factors including mood, sleep disturbances and medications and may result in patients not reporting pain accurately (Peter and Watt-Watson, 2002). For example, they may fail to report their pain because of the effects of sedation or lethargy and reduced motivation as a consequence of sleep deprivation. Some may suffer in silence as they do not want to bother busy nurses.
Nurses often appear to distrust patients’ self-reporting of their pain, which suggests that they have their own benchmark of what is acceptable and when and how patients should express their pain (Watt-Watson et al, 2001).
Documentation of pain by nurses has been shown to be poor, and even high pain scores do not result in nurses administering more analgesics (Watt-Watson et al, 2001).
Pain assessment tools
The range of pain measurement tools is vast, and includes both uni-dimensional and multi-dimensional methods (Table 1).
- measure one dimension of the pain experience, for example, intensity;
- are accurate, simple, quick, easy to use and understand;
- are commonly used for acute pain assessment;
- have verbal rating scale and the verbal descriptor scales, for example, none, mild, moderate, severe and are commonly used for postoperative pain assessment (Table 2) (ANZCA, 2005).
Multi-dimensional pain assessment tools
- provide information about the qualitative and quantitative aspects of pain;
- may be useful if neuropathic pain is suspected;
- require patients to have good verbal skills and sustained concentration, as they take longer to complete than uni-dimensional tools.
Observational tools may be used with patients who are unconscious/sedated and cognitively impaired to assess physiological responses and/or behaviours, for example, facial expressions, limb movements, vocalisation, restlessness and guarding.
Global scales may be useful at the end of a pain management intervention to measure the patient’s perception of the overall effectiveness of an intervention. They examine the inconvenience or unpleasantness of the intervention and the personal meaningfulness of any improvement in the patient’s pain and function (ANZCA, 2005).
A global scale may be used to rate the effectiveness of patient controlled analgesia for acute pain management and transcutaneous electrical nerve stimulation in chronic pain management.
Table 1: Pain assessment tools
Uni-dimensional measurement tools (selection):
- Visual analogue scales
- Verbal rating scales
- Graphic rating scales
- Numerical rating scales
- Verbal descriptor scales
- Body diagrams
- Computer graphic scales
- Picture scales
- Coin scales
Multi-dimensional pain measurement tools (selection):
- McGill pain questionnaire (short and long)
- Brief pain inventory (short and long)
- Behavioural pain scales
- Pain/comfort journal
- Multidimensional pain inventory
- Pain information and beliefs questionnaire
- Pain and impairment relationship scale
- Pain cognition questionnaire
- Pain beliefs and perceptions inventory
- Coping strategies questionnaire
- Pain disability index
- Hospital anxiety and depression questionnaire (HAD scale)
- Neuropathic signs and symptoms ( Leeds assessment of neuropathic symptoms and signs (LANSS) (Bennett, 2001).
- Cognitively impaired/dementia pain scales (Abbey, Pain assessment check list for seniors with severe dementia (PACSLAC) (Royal College of Physicians (RCP) et al, 2007).
Fundamental to the pain assessment process are the patients’ general medical and pain history and a clinical physical examination for both acute and chronic pain. An outline of this assessment process is listed in Table 3.
Table 2: Clinical history and examination
(adapted from Rowbotham and Macintyre, 2002; Jensen et al, 2003; ANZCA, 2005)
Location and description of pain:
- Is the pain a primary complaint or a secondary complaint associated with another condition?
- What is the location of the pain and does it radiate?
- Describe the onset and circumstances associated with it.
- How intensity is the pain, for example, at rest, on movement and factors that exacerbate or relieve pain.
- Describe the character of pain using quality/sensory descriptors for example, sharp, throbbing, burning. Assessment should observe for signs of neuropathic pain including descriptions such as shooting, burning, stabbing, allodynia (pain associated with gentle touch).
- How long does the pain last, for example, continuous, intermittent.
Assessment of functional and medical problems should consider:
- Symptoms associated with the pain, for example, nausea. This can help to identify an underlying cause for pain and also identify the need for symptom management.
- Effect of pain on activities, for example, mobility, sleep.
- Medications/treatments and their effect on pain.
- Medical and drug history.
- Family history.
- Psychosocial assessment, for example, anxiety, coping skills, occupation.
- Physical examination.
- Evaluation of disability associated with the pain.
Factors relevant to effective treatment:
- Patient’s beliefs about pain, expectations and preference of treatment.
- Coping mechanisms, for example, using distraction techniques such as walking or reading.
- Patient’s knowledge of pain management techniques and expectation of outcome.
- Ability to use appropriate pain measurement tools.
- Family expectations and beliefs about pain and the patient’s illness.
Chronic pain (consider above also):
Questions to consider for patients with chronic pain:
- Was the onset of pain related to trauma or was it insidious?
- How long has the patient had pain?
- Ask the patient how and why any injury associated with pain occurred?
- Where is the pain? (Is there more than one location?)
- Does the patient have referred pain?
- Is the patient pain free under any circumstances?
- What movements make pain worse?
- Is there any weather that makes the pain worse?
- What relieves pain?
- What is the level of pain described by the patient and using an assessment scale?
- Is there a pattern to pain when the patient gets up in the morning? Does pain increase as day goes on? This indicated whether the pain gets worse with activity.
- What effect do analgesic medicines have on the pain?
- Does pain wake the patient?
- Does the patient have psycho- physiological responses following severe pain, for example, lethargy, nausea, changes in mood?
- Ask the patient to describe their pain?
- Is there any numbness or loss of muscle strength associated with the pain?
- Do normal stimuli make pain worse, for example, light touch, shower?
- Is pain tolerable for most of day?
Questions about common problems associated with pain:
- Is the pattern of pain unusual?
- Is the pain intermittent?
- Is the pain chronic?
- Does the pain stop the patient carrying out usual activities?
- Does the pain have a neuropathic component or elements of complex regional pain syndrome when the patient complains of a chronic burning pain in one limb?
- Are there psycho-physiological responses to the pain?
Guidelines for the assessment of pain
There are numerous guidelines and recommendations that incorporate acute and long-term pain assessment and measurement. However, there is no single national guideline and many trusts have developed their own.
There are a variety of algorithms available for the assessment and management of patients with acute and post-operative pain and long-term painful conditions (Jensen et al, 2003).
The Oxford Pain Internet Site conducts evidence-based medicine systematic reviews and is a good guide for practice.
Pain assessment for groups with specific needs
The assessment and measurement of pain in specific groups of patients requires additional considerations, for example children, those with language barriers and older adults (RCP et al, 2007).
Older adults may use a range of words other than ‘pain’ to describe their pain experience. A patient who has a cognitive impairment may have difficulty using a variety of pain measurement tools, however simple self-report tools have been shown to be effective.
An observational assessment of pain behaviour may be more appropriate for people with sever cognitive impairment, for example, the Abbey pain scale or Pain Assessment Checklist for Seniors with Limited Ability to Communicate.
Visually impaired patients may not be able to use a visual analogue scale and may benefit from using a verbal rating scale that is adapted to their needs.
Australian and New Zealand College of Anaesthetists (ANZCA) 2005. Acute pain management; scientific evidence.
Bennett, M. (2001) The LANSS pain scale; the Leeds assessment of neuropathic symptoms and signs. Pain; 92: 1-2, 147-157.
British Pain Society and British Geriatric Society, (2007) The Assessment of Pain in Older People - National Guidelines .
Dimond, B. (2002). Legal Aspects of Pain Management. Salisbury: Quay Books.
Hall-Lord, M.L., Larsson BW. (2006) Registered nurses’ and student nurses’ assessment of pain and distress related to specific patient and nurse characteristics. Nurse Education Today; 26: 5, 377-387.
Jensen, T.S. et al. (2003) Clinical Pain Management: Chronic Pain. London: Arnold.
McCaffery, M., Pasero, C. (1999) Pain: A Clinical Manual. St Louis, MO: Mosby.
McCaffery, M.R. et al (2005) Pain management: cognitive restructuring as a model for teaching nursing students. NurseEducator; 30: 5, 226-230.
Melzack, R., Katz, J. (1994). Pain measurement in persons in pain. In: Wall, P.D., Melzack, R. Textbook of Pain. London: Churchill Livingstone.
Nursing and Midwifery Council (2008) The Code; Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC.
Peter, E., Watt-Watson, J. (2002). Unrelieved pain: an ethical and epistemological analysis of distrust in patients. Canadian Journal of Research; 34: 2, 65-80.
RoyalCollegeof Physicians, British Geriatrics Society, British Pain Society (2007) The Assessment of Pain in Older People; National Guidelines. Concise guidance on good practice series, No 8. London: RCP.
Rowbotham, D.J., Macintyre, P.E. (2002) Clinical Pain Management: Acute Pain. London: Arnold.
Watt-Watson, J.B. et al (2001). Relationship between nurses’ knowledge and pain management outcomes for their postoperative cardiac patients. Journal of Advanced Nursing; 36: 4, 535-545.
Wilson, B. (2007) Nurses knowledge of pain. Journal of Clinical Nursing; 16: 6, 1012-1020.