Pain Assessment Guidelines Regulations for Specific Practice Settings

Screening for pain should be a part of a routine assessment, and this has led several organizations such as the Veterans Health Administration (VHA) and the American Pain Society (APS) to declare pain as the fifth vital sign. Many states have adopted a bill of rights for patients in pain. In 2001, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) incorporated pain as the fifth vital sign in its

accreditation standards. According to the JCAHO, patients have a right to appropriate assessment and management of their pain and education regarding their pain. Following initial assessment of pain, reassessment should be done as needed based on medication choice and the clinical situation.

Methods of Pain Assessment

A patient-oriented approach to pain is essential, and methods do not differ greatly from those used in other medical conditions. A comprehensive history (medical, family, and psychological) and physical are necessary to evaluate underlying disease processes for the source of pain and other factors contributing to the pain. 0 A thorough assessment of the characteristics of the pain should be completed, including questions about the pain (onset, duration, location, quality, severity, and intensity), pain relief efforts, and efficacy and side effects of current and past treatments for pain. A common mnemonic for pain assessment is PQRST (Palliative/precipitating, Quality, Radiation, 25

Severity, and Time). Some clinicians have suggested the addition of U (you) to this mnemonic.26 During the pain interview, the impact of the pain on the patient's functional status, behavior, and psychological states should also be assessed. Evaluation of psychological status is especially important in patients with chronic pain since depression and affective disorders might be common comorbid conditions. A history of drug and alcohol should be elicited due to the potential for addiction in patients who might require opiates or other pain medications with a potential for abuse. Other conditions, such as renal or hepatic dysfunction, diabetes, and conditions that effect bowel function, can influence therapy choices and goals. A discussion of the patient's expectations and goals with respect to pain management (level of pain relief, functional status, and quality of life) should also be part of any pain interview.

Pain Assessment Tools

Pain, particularly acute pain, might be accompanied by physiologic signs and symptoms, but there are no reliable objective markers for pain. Many tools have been designed for assessing the severity of pain including rating scales and multidimensional pain assessment tools.

Rating scales provide a simple way to classify the intensity of pain, and should be

selected based on the patient's ability to communicate (Fig. 33-1). Numeric scales are widely used and ask patients to rate their pain on a scale of 0 to 10, with 0 indicating no pain and 10 being the worst pain possible. Using this type of scale, 1 to 3 is considered mild pain, 4 to 6 is moderate pain, and 8 to 10 is severe pain. The visual analog scale (VAS) is similar to the numerical scale in that it requires patients to place a mark on a 10-cm line where one end is no pain, and the worst possible pain is on the other end. For patients who have difficulty assigning a number to their pain, a categorical scale might be an option to communicate the intensity of the pain experi ence. Examples of this include a simple descriptive list of words and the Wong-Baker FACES of Pain Rating Scale.

Multidimensional assessment tools obtain information about the pain and impact on quality of life, but are often more time-consuming to complete. Examples of these types of tools include the Initial Pain Assessment Tool, Brief Pain Inventory, McGill Pain Questionnaire, the Neuropathic Pain Scale, and the Oswestry Disability Index.29-33

-A 10-crn baseline is recommended for VA5 scales.

FIGURE 33-1. Pain rating scales. (From Ref. 27.)

-A 10-crn baseline is recommended for VA5 scales.

FIGURE 33-1. Pain rating scales. (From Ref. 27.)

Pain Assessment in Challenging Populations

Children. Pain interviews can be conducted with children as young as 3 or 4 years of age; however, communication might be limited by vocabulary.34 Terms familiar to children such as hurt, owie, or boo boo might be used to describe pain. The VAS is best used with children older than 7 years. Other scales based on numbers of objects (e.g., pokers chips), increasing color intensity, or faces of pain might be helpful for children between 4 and 7 years of age. In children younger than 3 to 4 years, behavioral or physiologic measures, such as pulse or respiratory rate, might be more appropriate. Pain assessment in newborns and infants relies on behavioral observation for such clues as vocalizations (crying and fussing), facial expressions, body movements (flailing of limbs and pulling legs in), withdrawal, and change in eating and sleeping habits. 5 Preschool children experiencing pain might become clingy, lose motor and verbal skills, and start to deny pain because treatment might be linked to discomfort or punishment. School-age children might exhibit aggressiveness, nightmares, anxiety, and withdrawal when in pain, while adolescents might respond to pain with opposi-tional behavior and depression.

Elderly. Most of the previously discussed pain scales can be used in older persons who are cognitively intact or with mild dementia. The pain thermometer and FACES of pain have been studied in older persons. In persons with moderate-to-severe dementia or those who are nonverbal, observation of pain behaviors, such as guarding or grimacing, provides an alternative for pain assessment. The Pain Assessment in Advanced Dementia (PAINAD) tool might be used to quantify signs of pain and involves observing the older adult for 15 minutes for breathing, negative vocalizations, facial expression, body language, and consolability.36 Regardless of which pain assessment tool is used, the practitioner should first determine if the patient understands the concept of scale to ensure reliability of the instrument.

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