Assessment of Pain:Pain rating Scales

PST 417

Adedokun O.E

What is pain?

• Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described by the patient in terms of such damage

• An unpleasant emotional experience initiated by noxious stimulus and transmitted over a specialized neural network to the central nervous system where it is interpreted as such

What is pain?

• Pain is a perception of the activity of nociception in the spinal cord, brainstem, and cortex

• It is the most common reason for seeking healthcare

• Chronic pain is the most common cause of long-term disability

• Pain serves as a protective mechanism for warning of actual or potential tissue damage

Dimensions of pain

Pain Assessment

• Diagnosis and assessment of acute pain requires frequent and consistent assessment.

• Pain assessment is critical to optimal pain management and interventions

• Should be ongoing, individualized and documented

Reasons for assessment

• To determine if patient is manageable.

• Diagnosis.

• Plan intervention

• Monitor progress.

• Intervention modification.

• Pain control or modification.

Pain Assessment

Pain should be assessed using a multidimensional approach

• Description of pain• What does the pain feel like?• Burning, sharp, dull, throbbing, radiating, shooting,

cramping

• Intensity/severity – average, least, worst and current pain

• Temporal features – onset, course, pattern

• Location - focal, multifocal, generalised, referred, superficial, deep.

Pain Assessment

• Duration • Is the pain constant?• How long does a particular episode last?

• Aggravating and Alleviating factors• Movement or change in posture, medications,

temperature, activity

Pain Assessment

• Associated symptoms• Nausea, vomiting, confusion, sleepiness, itchiness,

weakness.• Changes in appetite, sexual functioning, irritability, ability

to concentrate.

• Patient’s knowledge and belief about pain.• May make patient exaggerate or underrate their pain

Pain rating Scales

• Patients’ self-report is the ideal for pain assessment

• Pain rating scale can be one-dimensional (unidimensional) or multidimensional

• A pain assessment tool requires reliability and validity

• Precision is necessary and the tool should not be too cumbersome to use by the patient as they may give up or give inaccurate responses if tired and in pain.

Pain rating Scales

• The appropriate tool for each patient must be utilized

• Documentation is important

• Factors that affect choice of tool include ease of administration and time it takes to administer.

Verbal Rating Scales (VRS)

• The VRS consists of a list of adjectives describing pain intensity.

• The VRS has descriptions of no pain and extreme pain with other adjectives in between to describe the pain

• The VRS is easy to administer, score and comprehend

Verbal Rating Scales (VRS)

• Disadvantages• Limited selection of descriptors• Patient tend to select moderate grades than extremes• Not very reliable in illiterate patients

Visual Analogue Scale (VAS)

• A VAS is usually a horizontal line, 10 cm in length, anchored by word descriptors at each end

• The patient marks on the line the point that they feel represents their perception of their current state.

• The VAS score is determined by measuring in millimetres from the left hand end of the line to the point that the patient marks.

• Mechanical VAS looks like a ruler with a red line that can be moved by the patient

Visual Analogue Scale (VAS)

Visual Analogue Scale (VAS)

Disadvantages

• Scoring is time consuming and involves more steps (therefore there is more opportunity for error)

• Patients especially those with cognitive problems may find it difficult to understand

• Requires motor control

Numeric rating Scale• It is a unidimensional measure of pain intensity

• The patient rates pain on a 0 to 10 scale• 0 is no pain• 10 is worst pain imaginable

• Advantages• Simplicity, reproducibility, easy comprehensibility.• Sensitivity to small changes in pain.• Children at 5ys who can count and have concept about

numbers can use this scale.

Numeric Rating Scale

Quadruple Visual Analogue Scale (QVAS)

The QVAS is based on four specific factors:

• Pain level at the time of the current office visit;

• Typical or average pain since the last visit (or since the initial visit or since the onset of the condition)

• Pain level at its best since the last visit, time of onset of the condition

• Pain level at its worst since the last visit, time of onset of the condition.

Quadruple Visual Analogue Scale (QVAS)

• The scores from the factors above are averaged and then multiplied by 10 to yield a score from zero to 100. The final score is then categorized as "low-intensity" (pain < 50) or "high-intensity" (pain > 50).

McGill Pain Questionnaire

• It is a three-part multidimensional pain assessment tool

• It assesses both the quality and intensity of pain

• It was developed at by Dr. Melzack at McGill University in Montreal Canada

• The McGill Pain Questionnaire can be used to evaluate a person experiencing significant pain.

• It was developed for adults with chronic pain

• Most frequently used multidimensional test

McGill Pain Questionnaire

• Contains descriptive words from three major dimensions of pain (sensory, affective, evaluative) which are further sub-divided into 20 classes each containing words of various degrees.

• Sensory (sections 1-10), Affective (sections 11-15), Evaluative (section 16), and Miscellaneous (sections 17-20)

• An overall score (pain rating index) for each major dimension is obtained from the sum of the ranks of the chosen word within the group. Total score ranges from 0-78

McGill Pain Questionnaire

•Advantages• It is valid and reliable• It may be able to differentiate between different

types of pain syndromes

•Disadvantage• It can be time-consuming

Brief Pain Inventory (BPI)

• BPI assesses pain severity and its impact on functioning using Numerical Rating Scale

• The patient is asked to rate the severity of pain now, at its worst, least and average within the past 24hrs and at the time the rating is done.

• It requires the patient to represent the location of pain on a schematic diagram of the body.

• BPI correlates with activity, sleep and social interaction.

Brief Pain Inventory (BPI)

•Assessment Areas: • Severity • Impact of pain on function• Location of pain•Pain medications and amount of pain relief in the

past 24 hours or the past week.

Pain Diaries

• Helps in evaluating the relationship between pain and daily activities.

• Pain can be described using numerical rating scale during activities e.g. standing, walking, sitting, routine works.

• Evaluation is done on hourly basis.

• Use of medications and alcohol and emotional response can also be recorded.

• It reflects pain more accurately than a retrospective description.

Paediatric Pain Assessment

• Most paediatric patient are unable to provide self report.

• Major cognitive process is though senses (eyes, ears, hands).

• Look at types of pain behaviours – cry, facial, verbal, torso, touch and legs.

• Question the child about the pain and believe the patient and family

• Take the child’s behavioural cues into account

• Note any physiological cues that may indicate patient is in pain

Behavioural indicators of pain in Children

• Irritability

• Unusual posture

• Reluctance to move

• Disturbed sleep pattern

• Unusual quietness

• Restlessness

• Sobbing

• lethargy

• Screaming• Aggressiveness• Increased clinging• Loss of appetite• Whimpering

Premature Infant Pain Profile

• It is a comprehensive assessment tool used to assess pain in preterm and term neonates

• The pain intensity is determined by measuring behavioural indicators such as facial expressions, physiological indicators(heart rate, oxygen level) and considering contextual indicators such as child’s gestational age at birth as well as their sleep/wake state.

• The indicators are scored together to provide an indicator of acute pain.

Neonatal Facial Coding System

Neonatal Facial Coding System

Face, Leg, Activity, Cry, Consolability Scale (FLACC)

• It is used in non-verbal children

• Indicators – facial expression, leg movement, activity, cry and consolability

• Intended for children ages 2 months to 8 years

Face, Leg, Activity, Cry, Consolability Scale (FLACC)

Wong – Baker faces pain rating Scale

•Used in children that are verbal

• For children aged 3 and older

• Six cartoon faces ranging from smiling to crying

Wong – Baker faces pain rating Scale

Pain thermometerUsed for children over 7 years of age

It is an adaptation of the verbal descriptive scale.

It has a range of words that describe varying levels of pain.

Pain Thermometer

Pain assessment in cognitively impaired patient• Patients’ self-report is the gold standard of pain assessment.

• However, pain tools that rely on verbal self-report, such as the 0 to 10 numeric rating scale, may not be appropriate for use in nonverbal or cognitively impaired patients.

• It is important to obtain feedback from the patient by asking the patient to nod his head, squeeze your hand, move his eyes up and down, or raise his fingers, hand, arm, or leg to signal the presence of pain.

Pain assessment in cognitively impaired patient

• The following questions can be used as a template for assessment of pain in the nonverbal patient:

•After reviewing the patient’s history, is there a reason for this patient to be experiencing pain?

•When the patient experienced pain in the past, how did he or she usually act? (family or relatives could be questioned)

Pain assessment in cognitively impaired patient

•What is the family/spouse’s thoughts or interpretation of the patient’s behaviour?

•Do they believe that the patient is having pain? Why do they feel this way?

•Has the patient been treated for pain previously? What pharmacologic or non-pharmacologic interventions were used?

Behavioural Rating Scale

Behavioural cues in non – verbal patients

• Guarding—Abnormally stiff, interrupted or rigid movement while moving the joint or body from one position to an other

• Bracing—A stationary position in which a fully extended limb supports and maintains an abnormal distribution of weight

• Rubbing—Any contact between hand and injured area (i.e., touching, rubbing, or holding the painful area)

Behavioural cues in non – verbal patients

• Grimacing—Obvious facial expression of pain that may include furrowed brow, narrowed eyes, tightened lips, corners of mouth pulled back and clenched teeth

• Sighing—Obvious exaggerated exhalation of air usually accompanied by the shoulders first rising and then falling; patients may expand their cheeks first