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Nursing Practice Keywords: Adult/Assessment/ Review ●This article has been double-blind peer reviewed Pain is a personal experience but may be difficult to communicate. It is vital that nurses know how best to assess it to ensure the optimal treatment is given

part 3 of 3: pain management The importance of assessing pain in adults

In this article... 5 key Core elements of a pain assessment points Pain can be Tools to help self-report pain 1acute or chronic Common sites of in nature Pain 2assessments Author Amelia Swift is senior lecturer in comforting and elicits empathy and help are crucial to nursing at the University of Birmingham. (Buenaver et al, 2007). Health professionals ascertain the best Abstract Swift A (2015) Pain management want to understand patients’ pain because treatment and 3: The assessment of pain in adults. that will help them to diagnose the monitor any Nursing Times; 111: 41, 12-17. problem, select an effective treatment pro- underlying causal Pain affects patients physically and gramme and monitor their progress. condition emotionally, so successfully managing the Patients may pain they experience is a key component Purpose of pain assessment 3not always of their recovery. This third article in a A pain assessment is conducted to: volunteer series on pain looks at why it is important » Detect and describe pain to help in the information about to assess pain in adults and how this can diagnostic process; the pain they are best be done. The causes and symptoms » Understand the cause of the pain to experiencing so of chronic and acute pain are detailed, help determine the best treatment; may need to be along with the different assessment tools » Monitor the pain to determine asked about it that can be used and for which patients whether the underlying disease or Various pain they are suitable. disorder is improving or deteriorating, 4assessment and whether the pain treatment is tools exist to cater ain is a personal experience, and working. for patients’ every experience of it is unique. The content and scope of the assess- different It is not just a physical sensation ment depends on its purpose and the type capabilities Pbut is bound up with an emo- of pain. Acute pain is caused by a short- Pain severity tional response and an act of reasoning; lived pathological process, such as a sur- 5should be this is why pain is known as a multidimen- gical incision or a sprain. Provided this documented to sional experience (Fillingim et al, 2014). pain is treated and there is no nerve track efficacy of Pain also has physical and emotional con- damage, it usually resolves as the body treatments and sequences; it can make us lead to fatigue, heals (Grichnik and Ferrante, 1991). interventions and irritability, depression or inability to carry lasts for a prolonged time – recovery out activities of daily living (Leadley et al, at least three months (this is the time at 2014). Chronic pain also affects social and which tissue healing should be complete) economic wellbeing, restricting work and (Hughes, 2008). The term describes com- social activities (Morgan et al, 2011). plex where there may have been a Pain is difficult to explain and use of pathological trigger but, although healing analogies is common (Schott, 2004). For has taken place, the pain continues – for example, “It feels like my head is in a vice” example, chronic low . Another immediately communicates what the type of chronic pain relates to ongoing patient is feeling, while “This pain is pathological processes, such as osteoar- killing me” demonstrates the psycholog- thritis, and to pains that are caused by ical impact of pain. Patients need to com- damage to, or dysfunction of, the nervous municate pain because they want others to system; this includes pains as diverse as Phrases like “my head feels like it’s in a vice”

Alamy know how they feel because that is post-stroke pain and diabetic neuropathy. can help nurses get a sense of pain severity

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Box 1. signs of pain fig 1. Cues used to prompt pain assessment processes Behavioural signs S Site ● Verbalisation (crying out, crying, sobbing) O Onset ● Agitation, restlessness ● Abnormal stillness, rocking, writhing Provoking or palliating factors P C Character ● Facial expression (tense, grimace, distorted) Quality Q R Radiation ● Position (guarding, curled, holding Radiation R A Associations tightly) Severity S T Time course Physiological signs ● Increased respiratory rate Time T E Exacerbating and relieving ● Increased heart rate factors ● Increased blood pressure ● Pallor S Severity ● Sweating ● Nausea ● Vomiting unable to participate in the assessment able to identify an event that triggered it process, it is recommended that a tool and the lack of an identifiable and treatable specifically designed to assess pain in non- pathology can be worrying to them. Initial assessments will cover a lot of verbal older adults is used: a comprehensive Questions about onset of pain reveal ground because they are used as part of a review of 17 of these can be found on the what patients know or believe about what much wider exercise designed to help City of Hope Pain and Palliative Care is happening to them. Their understanding health professionals understand why Resource Center’s website (Bit.ly/PainNOA). can have a significant influence on their patients are seeking treatment, what Health professionals should not assume ability to cope, follow instructions and treatment and interventions have been that a patient cannot participate in a pain respond to treatment. Taking chest pain tried, and their understanding of their assessment. People with dementia can as an example, many people associate current situation. Pain assessments after often use self-report pain scales but they this with myocardial infarction and this point may focus on a smaller range may need to be re-taught how to do so each there is evidence that, even when MI is of the pain experience to monitor time (Kaasalainen et al, 2013). Almost ruled out, patients still experience fear, treatment, the patient’s recovery or the universally, patients change their “normal” stress and a sense of loss of strength course of the disease. behaviour when they are in pain, so (Jerlock et al, 2005). Up to 20% of the European population knowing individual patients and their experiences chronic pain (van Hecke et al, normal demeanour is vital. The cause of pain 2013) and so it is likely that patients in the In order to select the most appropriate acute-pain setting may have both acute Common elements of the treatment is necessary to identify the pain and chronic pain. assessment mechanism of injury (how it happened). Core information is common to all pain Some key questions include: Patient participation assessments. Mnemonics or initials can be » Is this pain related to tissue damage? This Patients vary in their ability to lead or par- helpful cues for remembering the contents type of pain is called nociceptive pain, ticipate in discussions about their pain of the essential baseline information. Two physiological pain, inflammatory pain and it is important for nurses to consider of the most popular cues are PQRST and and tissue damage pain. It can be this before choosing the most appropriate SOCRATES (Fig 1). caused by direct trauma to the tissues assessment strategy. Self-report of pain The emphasis placed on the different (for example, burn, surgery, graze, using a guided question set is the best way components of the assessment depends on sprain) or ongoing disease process to assess pain (MacIntyre and Schug, 2014). the context in which it takes place. As an (such as arthritis). It can be superficial When patients cannot verbally report example, people with chronic pain can (related to the skin and muscle), which pain, there are a range of other options, experience long-term mood changes is called somatic pain, or deep and including pain rating scales, to which the (Eccleston et al, 2013) and so the emotional related to the organs (for example, patient can point if able to do so. The impact of pain forms a major part of the bowel, pancreas, heart), which is called Wong-Baker FACES has been treatment plan – often more attention is visceral pain. endorsed by many groups as an effective paid to these emotional components in » Is this pain related to nerve damage or a tool for use in people with mild-to-mod- chronic pain than in acute pain. disorder of the nerves or nervous system? erate cognitive impairment (Scherder et al, This sort of pain is called neurogenic 2009), even though it is better known as a Onset of pain pain, neuropathic pain, central pain tool used with children. Pain is often associated with an injury or and . It can be caused Some tools, such as the COMFORT scale disease process but can also emerge slowly, by direct trauma to the nerves due to (Bit.ly/COMFORTScale; Van Dijk et al, 2000), usually in relation to a progressive disease compression, cutting or chemical focus on behavioural signs of pain (Box 1), or disorder, such as osteoarthritis or insult; malfunction or disease-related which may also include physiological degenerative nerve disorders. With some damage of the nerves (such as diabetic changes. When a person with dementia is kinds of chronic pain, patients may not be neuropathy, alcoholic neuropathy

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Box 2. The words patients use to describe their Change in pain over time descriptors pain can often help to differentiate Post-operative pain is an example of an for pain between pain arising from either nocicep- acute pain that should gradually improve Nociceptive words tive or neuropathic mechanisms (Box 2), over a relatively short period until the Somatic (cutaneous) although there is some crossover and other patient is pain free and able to return to, ● Aching knowledge will need to be used to deter- more or less, normal levels of activity. ● Stabbing mine the main cause of the pain. However, many patients find that their ● Squeezing activity, sleep and mood may be disrupted ● Throbbing Site and radiation by pain for weeks following surgery ● Sharp The site of pain often provides informa- (Leegaard et al, 2010; Wiggins, 2009). ● Tender tion about the patient’s diagnosis and Althaus et al (2014) identified the ● Dull therefore informs future treatment. Pain is gradual improvement in post-operative ● Heavy usually easier to locate accurately when it pain for most people, and also demon- is acute and somatic – that is, related to strated that those who have poor rate of Visceral (organs) some sort of superficial tissue damage. improvement in pain in the early days are ● Cramping Deeper pain and chronic pain tend to be more likely to go on to develop a chronic ● Gnawing harder to pinpoint. pain state (pain that does not go away). It is ● Aching Pain may have a specific cause, such as important, therefore, not to just monitor ● Pressing osteoarthritis of the hip, but the pain from pain over time but also ensure both ● Pulling this is often felt in a number of places patients and nurses understand the impor- Sources: Wylde et al, 2011; Dobratz, 2008) including the back, groin and knee (Izumi tant of pain management. et al, 2014). Pain that arises from disease Variation in intensity of pain and inter- Neuropathic words (Lin et al, 2011) or injury to hollow organs (viscera) ference with activities can help to differen- ● Burning may also be felt in a distant cutaneous site. tiate between different causes of pain. ● Tingling Fig 2 gives examples of the locations of Neuropathic pain – that is pain caused by a ● Numb referred pain. damage or dysfunction of the nerves and ● Sensitive In many cases, patients can explain or nervous system, such as painful diabetic ● Electrical point to the site of pain but if that is not neuropathy – tends to be worse at night, ● Cold/cool possible – usually because of complexity – and also becomes progressively worse over ● Sharp they can draw their pain onto a body dia- the course of the day (Gilron et al, 2013). ● Cramping gram (Fig 3). This involves moving the site Arthritic pain tends to be at its worst on ● Pressure of their pain and other sensory symptoms waking but reduces over the course of the ● Sore such as pins and needles on a black body day (Buttgereit, 2011; Cutolo et al, 2006). ● Shooting diagram. Patients spontaneously choose to Post-operative pain also tends to be worse ● Achy use different types of shading to denote in the morning than later in the day (Bos- ● Throbbing different sensations, so these prove to be cariol et al, 2007). ● Dull an effective communication tool. Sources: Lin et al, 2011 Body diagrams can also offer an insight Exacerbating and relieving factors into the psychological impact of pain: dis- This section of the assessment helps diag- tress and frustration are often marked nose the cause of the pain and also target resulting from, for example, diabetes with shading that is very dense, with treatment effectively. Many pains will be or excessive alcohol intake respectively, longer lines that sometimes extend beyond exacerbated by movement: in musculo- multiple sclerosis, spinal cord damage); the body (Fishbain et al, 2003); again, the skeletal pains the exact movements that damage to central nervous system patient makes a spontaneous choice lead to an increase in pain can help special- tissue (for example, stroke); or loss of without guidance to use the tool in this ists to understand which structures are sensory input to the spinal cord and way, providing health professionals with a involved and how; and this can be particu- brain (such as phantom pain, brachial valuable insight. larly import in common disorders like low plexus avulsion). back pain (Konstantinou et al, 2012). Chest » Is this pain a mixture of both of the above? Associations of pain with pain can be due to a host of different causes This sort of pain is complex and it is other symptoms and establishing a link to inspiration, often difficult to differentiate between Some types of pain are associated with ingestion of food, body position, exercise, the different components. A good specific symptoms – for example,or emotion and stress can be the key to example would be chronic (long-term) sweating, pallor, nausea and vomiting are differentiating between pleural, gastric back pain. common in patients experiencing abdom- and cardiac causes. » Is there an absence of a pathological inal pain, while aura (flashing lights, Neuropathic pain – for example, explanation for the pain? Some forms of blurred vision, weakness, numbness, diffi- trigeminal or post-herpetic chronic pain appear to have no obvious culty speaking) is often associated with neuralgia – do not tend to be made worse pathological cause, yet the pain is very migraine. Noting these symptoms is there- by movement but may be exacerbated real. This pain can be triggered by a fore relevant when trying to diagnose the significantly by an innocuous stimulus painful episode after which the pain cause of a pain. Symptoms associated with such as the skin being brushed lightly by a never resolved or alterations to the way pain should also be investigated, such as cotton bud or contact with something cold in which the nervous system manages disrupted sleep, depression, anxiety and or hot; this is called . Patients pain signals. inability to work. with neuropathic pain also experience a

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fig 2. referred pain sites There are many patient forums that provide examples of how patients can feel judged during this part of the assessment, sensing that the health professionals are making negative judgements of their efforts to find strategies and therapies to Lung and diaphragm help them cope with the pain. It is Thymus Spleen Thymus important to use a systematic approach to Heart determine whether each strategy was used in a helpful way, and whether it came at a Stomach Liver and Liver and gallbladder financial or physical cost that the patient gallbladder Pancreas cannot bear indefinitely. Small intestine Appendix Severity of pain Ovary Severity or intensity of pain is the aspect Colon commonly used to track recovery, response Kidney to treatment or illness trajectory. Simple numeric scales are effective and, by Urinary bladder repeating measurements over time, it is possible to develop a graphical trend showing how pain varies with time and Ureter with activities. With acute pain this should be readily accessible on the patient’s chart so analgesia and recovery can be evaluated; reduction in their threshold to respond to » How is the patient taking the drug (how patients with chronic pain could be asked a potentially . As an often, how much)? to keep a diary. example, imagine someone pressing the » How long has the drug been used by the Common tools include the numerical end of an unfolded paper clip – a blunt patient? This will help to determine rating scale (NRS), which involves asking point – onto the skin; the pressure needed potential high-risk issues such as the the patients to rate their pain intensity on to evoke pain will be less in the area of risk of thrombosis in NSAID use; a scale of 0-10, in which 0 means no pain at neuropathic pain than it would be in areas » How satisfied is the patient with the all and 10 is the worst pain they have ever of normal skin; this is called . drugs and how are they being taken? experienced or the worst imaginable pain. These concepts are outlined clearly by » How much pain relief is the patient Although the anchor of “worst pain imagi- Jensen and Finnerup (2014). getting? nable” is often used at the end of the scale, Relieving factors, also called palliating » What side-effects is the patient patients find this difficult to understand factors, often give helpful insight into the experiencing? and prefer the anchor “worst pain ever patient’s actual or potential response to » What management strategies are in experienced” (Yokobe et al, 2014). therapy. Musculoskeletal pain usually place to manage side-effects? The NRS works well for adults (Wil- responds well to rest; for acute soft-tissue It is useful to note that pain reduction liamson and Hoggart, 2005) and has suffi- damage, the mnemonic RICE (rest, ice, only becomes clinically meaningful to a cient sensitivity to enable patients to com- compression and elevation). patient when it is in the region of 30% or municate changes in their pain over time. In chronic pain, RICE is inappropriate more (Mease et al, 2011; Lee et al, 2003). An alternative is the visual analogue scale because disuse exacerbates pain as mus- When patients experience side-effects, (VAS), which is usually presented to the cles weaken. The patient becomes less for example nausea and vomiting, as a patient in the form of a 100mm line drawn supple and flexible, and has a heightened result of taking , they may feel that on paper, or a plastic ruler with a slider; the pain response to attempts to build up pain is preferable to the side-effects – this anchors are the same as on the 0-10 NRS. activity levels again. will prevent them from using the drug The verbal rating scale (VRS) consists of a Acute pain related to tissue damage in the most helpful way. Side-effects, list of 4-6 words denoting increasing pain tends to respond well to pain-relieving including constipation, cognitive blunting intensity: such as paracetamol, opioids and sedation hangover effects, are impor- » No pain; and non-steroidal anti-inflammatorytant predictors of adherence to acute and » Mild pain; drugs (NSAIDs) or agents. Chronic pain chronic pain management strategies. » Moderate pain; does not tend to respond as well to these This section of the assessment (deter- » Severe pain. drugs, although they may bring partial mining the exacerbating and relieving In terms of ease of use or adherence relief. Patients may also be taking adjuvant factors) should also be used to identify by adults, the NRS tends to be more pain-relieving drugs, such as antidepres- patients’ use of alternative and comple- effective than the VAS and the VRS sants and anticonvulsants, which are more mentary therapy as well as therapies and (Hjermstad et al, 2011) and is the one usually associated with chronic pain and, that have already been tried chosen in many clinical settings. in particular, neuropathic pain. A number or are currently being used. For each of of different issues need to be covered in a these therapies, it is important to elicit Conclusion medication assessment: from the patient how they have been used The most important factor in pain assess- » What is prescribed (drug, dose, and how much benefit – if any at all – the ment is the self-report of the patient. How-

Peter Lamb Peter timing, route)? patient has experienced. ever, some patients may be reluctant to

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fig 3. pain site indicator body diagram

The blank body diagram (left) is ready for the patient to complete. On the right an example body diagram shows a possible representation of pain experienced by someone with chronic obstructive pulmonary disease (extrapolated from Borge et al, 2011). trigger the assessment so it is vital for Fishbain DA et al (2003) A structured evidence- descriptors: implications for assessment of pain nurses to prompt discussion of pain with based review on the meaning of nonorganic quality. European Journal of Pain; 15: 6, 628-633. physical signs: Waddell signs. Pain Medicine; 4: 2, MacIntyre PE, Shug SA (2014) Acute Pain patients. Pain assessment can be compli- 141-181. Management: A Practical Guide. Boca Raton, FL: cated, especially in the initial stages and Gilron I et al (2013) Chronobiological CRC Press. when there is no obvious acute cause; how- characteristics of neuropathic pain: clinical Mease PJ et al (2011) Estimation of minimum ever, even a simple assessment of pain site predictors of diurnal pain rhythmicity. Clinical clinically important difference for pain in Journal of Pain; 29: 9, 755-759. fibromyalgia.Arthritis Care & Research; 63: 6, and severity can provide enough informa- Grichnik KP, Ferrante FM (1991) The difference 821-826. tion for treatment to be started. NT between acute and chronic pain. Mount Sinai Morgan CL et al (2011) The relationship between Journal of Medicine; 58: 3, 217-220. self-reported severe pain and measures of References Hjermstad MJ et al (2011) Studies comparing socio-economic disadvantage. European Journal Althaus A et al (2014) Distinguishing between pain Numerical Rating Scales, Verbal Rating Scales, and of Pain; 15: 10, 1107-1111. intensity and pain resolution: using acute Visual Analogue Scales for assessment of pain Scherder E et al (2009) Pain in dementia. Pain; post-surgical pain trajectories to predict chronic intensity in adults: a systematic literature review. 145: 3, 276-278. post-surgical pain. European Journal of Pain; 18: 4, Journal of Pain & Symptom Management; 41: 6, Schott GD (2004) Communicating the experience 513-521. 1073-1093. of pain: the role of analogy. Pain; 108: 3, 209-212. Borge CR et al (2011) Pain and quality of life with Hughes J (2008) Pain Management: From Basics van Dijk M et al (2000) The reliability and validity chronic obstructive pulmonary disease. Heart & to Clinical Practice. London: Churchill Livingstone. of the COMFORT scale as a postoperative pain Lung; 40: 3, e90-101. Izumi M et al (2014) Pain referral and regional instrument in 0 to 3-year-old infants. Pain; 84: 2-3, Boscariol R et al (2007) Chronobiological deep tissue hyperalgesia in experimental human 367-377. characteristics of postoperative pain: diurnal hip pain models. Pain; 155: 4, 792-800. van Hecke O et al (2013) Chronic pain variation of both static and dynamic pain and Jensen TS, Finnerup NB (2014) Allodynia and epidemiology and its clinical relevance. British effects of therapy. Canadian Journal of hyperalgesia in neuropathic pain: clinical Journal of Anaesthesia; 111: 1, 13-18. Anaesthesia; 54: 9, 696-704. manifestations and mechanisms. Lancet Wiggins SA (2009) Family exemplars during Buenaver LF et al (2007) Pain-related Neurology; 13: 9, 924-935. implementation of a home pain management catastrophizing and perceived social responses: Jerlock M et al (2005) Living with unexplained intervention. Issues in Comprehensive Pediatric Inter-relationships in the context of chronic pain. chest pain. Journal of Clinical Nursing; 14: 8, Nursing; 32: 4, 160-179. Pain; 127: 3, 234-242. 956-964. Williamson A, Hoggart B (2005) Pain: a review of Buttgereit F (2011) How should impaired morning Kaasalainen S et al (2013) A comparison between three commonly used pain rating scales. Journal of function in be treated? behavioral and verbal report pain assessment tools Clinical Nursing; 14: 7, 798-804. Scandinavian Journal of Rheumatology, for use with residents in long term care. Pain Wylde V et al (2011) Acute postoperative pain at Supplement; 125: 28-39. Management Nursing; 14: 4, e106-114. rest after hip and knee arthroplasty: severity, Cutolo M et al (2006) Circadian rhythms: Konstantinou K et al (2012) Development of an sensory qualities and impact on sleep. glucocorticoids and arthritis. Annals of the New assessment schedule for patients with low Orthopaedics & Traumatology: Surgery & York Academy of Sciences; 1069: 289-299. back-associated leg pain in primary care: a Delphi Research; 97: 2, 139-144. Dobratz MC (2008) Word choices of advanced consensus study. European Spine Journal; 21: 7, Yokobe J et al (2014) Preference for different cancer patients: frequency of nociceptive and 1241-1249. anchor descriptors on visual analogue scales neuropathic pain. American Journal of Hospice & Leadley RM et al (2014) Healthy aging in relation among Japanese patients with chronic pain. Palliative Medicine; 25: 6, 469-475. to chronic pain and quality of life in Europe. Pain PLoS One; 9: 6, e99891. Eccleston C et al (2013) Psychological approaches Practice; 14: 6, 547-558. to chronic pain management: evidence and Lee JS et al (2003) Clinically important change in challenges. British Journal of Anaesthesia; 111: 1, the visual analog scale after adequate pain control. For more on this topic go online... 59-63. Academic Emergency Medicine; 10: 10, 1128-1130. How to ensure acute pain in older Fillingim RB et al (2014) The ACTTION-American Leegaard M et al (2010) Interference of Pain Society Pain Taxonomy (AAPT): an postoperative pain on women’s daily life after early people is appropriately assessed evidence-based and multidimensional approach to discharge from cardiac surgery. Pain Management and managed classifying chronic pain conditions. Journal of Pain; Nursing; 11: 2, 99-107. Bit.ly/NTAcutePainOlderPeople 15: 3, 241-249. Lin CP et al (2011) Frequency of chronic pain

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