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Chapter 10 Pain History and Pain Assessment

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Chapter 10 Pain History and Pain Assessment Guide to Pain Management in Low-Resource Settings Chapter 10 Pain History and Pain Assessment Richard A. Powell, Julia Downing, Henry Ddungu, and Faith N. Mwangi-Powell Th e eff ective clinical management of pain ultimately treatment may be delivered to manage the pain. It is depends on its accurate assessment. Th is entails a com- important, however, that this treatment interven- prehensive evaluation of the patient’s pain, symptoms, tion be evaluated via subsequent pain assessments to functional status, and clinical history in a series of as- determine its eff ectiveness. Th e patient’s pain should sessments, depending on the patient’s presenting needs. therefore be assessed on a regular basis and the result- Such assessments rely in part on the use of evaluation ing treatment options modifi ed as required to ensure tools. To varying degrees, these tools attempt to locate eff ective pain relief. and quantify the severity and duration of the patient’s subjective pain experience in a valid and reliable man- Are there key elements to the pain ner to facilitate, structure, and standardize pain com- munication between the patient and potentially diff er- assessment process? ent health care providers. Bates (1991) suggests that the critical components of the pain assessment process include a determination of How do you learn about a its: location; description; intensity; duration; alleviating patient’s pain? What is the pain and aggravating factors (e.g., the former might include assessment process? herbal medications, alcohol or incense); any associative factors (e.g., nausea, vomiting, constipation, confusion, Where pain levels permit (i.e., where severe clinical or depression), to ensure that the pain is not treated in needs do not demand immediate intervention), the as- isolation from comorbidities; and its impact upon the sessment process is essentially a dialogue between the patient’s life. patient and the health care provider that addresses the Th ese components are most commonly embod- nature, location, and extent of the pain, looks at its im- ied in the “PQRST” approach: Provokes and Palliates, pact on the patient’s daily life, and concludes with the Quality, Region and Radiation, Severity, and Time (or pharmaceutical and nonpharmaceutical treatment op- Temporal). In this approach, typical questions asked by tions available to manage it. a health care provider include: P = Provokes and Palliates Is pain assessment a one-off process? • What causes the pain? • What makes the pain better? Rather than an isolated event, the assessment of pain • What makes the pain worse? is an ongoing process. Following the initial assessment, Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th is material may be used for educational and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property 67 as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and drug dosages. Th e mention of specifi c pharmaceutical products and any medical procedure does not imply endorsement or recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text. 68 Richard A. Powell et al. Q = Quality culturally acceptable levels of “complaining,” a sense • What does the pain feel like? of hopelessness, diminished morale, coping and ad- • Is it sharp? Dull? Stabbing? Burning? Crushing? aptation abilities, and the meaning attached to the R = Region and Radiation experienced pain). Consequently, the health care pro- • Where is the pain located? vider should accept the patient as an expert on his or • Is it confi ned to one place? her own body, and accept that while some patients • Does the pain radiate? If so, where to? may exaggerate their pain (e.g., to be seen earlier in • Did it start elsewhere, and is it now localized to a hospital), this will generally be the exception rath- one spot? er than the norm. Moreover, evidence suggests that health care providers’ observational pain report can- S = Severity not be assumed to be an accurate indicator of the pa- • How severe is the pain? tient’s pain. T = Time (or Temporal) Second, as much as is possible within a time- • When did the pain start? constrained service setting, allow patients to describe • Is it present all the time? their pain in their own words (the fact that patients may • Are you pain-free at night or during the day? report socially acceptable answers to the health care • Are you pain-free on movement? provider demands a sensitive exploration of what is ex- • How long does the pain last? pressed). For patients who feel uncomfortable express- At the patient’s fi rst assessment, the pain assess- ing themselves, the health care provider can provide a ment process should be a constituent part of a wider sample of relevant words written on cards from which comprehensive patient assessment that could include the patient can select the most appropriate descriptors. additional questions: Th e primary intention here is to listen to the patient • Is there a history of pain? rather than make any potentially false assumptions and • What is the patient’s diagnosis and past medical erroneous clinical decisions. history (e.g., diabetes, arthritis)? Th ird, listen actively to what the patient says. • Is there a history of surgical operations or medi- Rather than engage the patient in a distracted man- cal disorders? ner, the health care provider should focus attention on • Has there been any recent trauma? the patient, observing behavioral and body language, • Is there a history of heart disease, lung problems, and paraphrasing words when necessary to ensure that stroke, or hypertension? what is expressed is clearly understood. In emotionally • Is the patient taking any medication (e.g., to re- charged encounters, the health care provider must also duce the pain; if so, did it help the patient?) actively listen for nonverbal descriptors. • Does the patient have any allergies (e.g., to food Fourth, the location of the pain across the body or medicines)? can be determined by showing the patient a picture of • Does the pain hurt on deep inhalation? the human body (at least the front and back) (see Ap- • What is the patient’s psychological status (e.g., pendix 1 for an example of a body diagram), requesting depression, dementia, anxiety)? that they indicate the primary and multiple (if appropri- • What is the patient’s functional status, including ate) areas of pain, and demonstrate the direction of any activities of daily living? radiated pain. Fifth, pain scales (of varying complexity and What can be done to ensure an methodological rigor) can be used to determine the se- eff ective pain assessment process? verity of the expressed pain (see below for some exam- ples). First, in general, accept the patient’s self-reported pain Sixth, while it is important to manage an indi- as accurate and the primary source of information. vidual’s pain as soon as is possible (i.e., one is not obli- Pain is an inherently subjective experience, and the pa- gated to wait for a diagnosis), in the assessment process tient’s expression of this experience (be it behavioral the health care provider should also diagnose the cause or verbal) can be infl uenced by multiple factors (e.g., of that pain and treat if possible, thus ensuring a longer- gender diff erences, socially acceptable pain thresholds, term resolution to the presenting pain problem. Pain History and Pain Assessment 69 How long should an assessment take? What are the challenges for pain Th e time needed for assessment will vary according to assessment with the young? individual patients, their presenting problems, and the Th e term “the young” refers to children of varying ages specifi c demands on clinic time. For example, the pa- and cognitive development: neonates (0–1 month); in- tient may be in such severe pain that they are unable fants (1 month to 1 year); toddlers (1–2 years); pre- to provide any meaningful information to produce a schoolers (3–5 years); school-aged children (6–12 comprehensive pain history. Similarly, there will be oc- years); and adolescents (13–18 years). Children at each casions when the assessment has to be relatively brief stage of development pose distinct challenges to eff ec- (investigating the intensity, quality, and location of the tive pain assessment. pain) so that urgently required eff ective pain manage- ment can be provided quickly. Neonates (0–1 month) It is also important to remember that, in gen- At this age, behavioral observation is the only way to eral terms, it is the quality of the pain assessment that assess a child. Observation can be conducted with the results in eff ective pain management rather than the involvement of the child’s family or guardian, who can quantity of time spent on it. advise on what are “normal” and “abnormal” behav- ior patterns (e.g., whether or not the child is unusu- Does pain assessment diff er ally tense or relaxed). Importantly, for all children, with children and young people? the health care provider should follow national ethi- cal guidelines concerning the presence of a parent or Th e response to this question is mixed. On the one guardian at the assessment process and any associated hand, no, it does not, because, despite the previously issues (e.g., informed consent).
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