International Pain School

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Assessing pain & taking a pain history

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Outline

• Why is it important to assess pain?

• Why should you use tools to evaluate pain?

• What are the components of the pain assessment process?

• How to optimize pain assessment

• Pain assessment in children & in patients with impaired

communication

• Pain evaluation tools which are practical for

low-resource settings

• Conclusion: Pearls

Case

• You are working in a small rural hospital when Parmanand,

a 17 year old male, is admitted after a motorcycle accident.

• He is awake, haemodynamically stable and seems to have

fractured his left leg. He is groaning.

The surgeon tries to carry out a physical examination, but

Parmanand resists.

• Do you need to assess Parmanand’s pain?

• How would you do it?

• How should you act once you have assessed

Parmanand’s pain?

Why is it important to assess pain?• Assessment of pain is the first step in planning

pain management.• Pain assessment should be repeated to

evaluate the efficacy of pain management• Tailor the assessment tool to the patient’s age,

condition, type of pain (acute vs chronic). • Evaluate the patient’s other symptoms,

functional status and general clinical status in

parallel with the pain assessment.

Timing of the pain assessment

Pain assessment should occur at:•Each clinical encounter•Regular intervals after initiation of treatment,

e.g. a suitable interval after pharmacologic or

non-pharmacologic intervention

[15–30 minutes after parenteral drug therapy & 1 hour

after oral administration]

•Each new report of pain

Components of taking a pain historyAsk about:

• Location

• Quality

• Intensity

• Duration

• Alleviating and aggravating factors [e.g., medicines/drugs,

alcohol, herbals, movement, positioning]

• Impact on patient’s life [e.g., daily activities, work performance,

social contacts]

• Medication related side effects

• Ask and assess for other symptoms [e.g., nausea, vomiting,

constipation, confusion, depression, dyspnoea].

of the pain

How to assess a patient’s pain history: the ‘PQRST’ approachP: Provokes and Palliates

•What causes the pain?

•What makes the pain better?

•What makes the pain worse?

Q: Quality

•What does the pain feel like?

•Sharp? Dull? Stabbing? Burning?

Crushing?

R: Region and Radiation

•Where is the pain located?

•Is it confined to one place?

• Does the pain radiate? If yes, where

to?

• Did it start elsewhere and now

loclized to one spot?

S: Severity

• How severe is the pain?

T: Time

• When did the pain start?

• Is it present all the time?

• Are you pain-free at night / day?

• Are you pain-free on movement?

• How long does the pain last?

Factors influencing perception of pain• The patient is an expert about his/her body,

his self-reported pain should be accepted as

accurate.• In communicating patients, rely on the patient’s

self report; it is affected by a variety of factors. • Factors influencing a person’s experience of pain:

–positive vs. negative expectations–mood (sense of hopelessness vs. optimism)–culturally acceptable levels of ‘complaining’–coping and adaptation abilities–meaning attached to the experience of pain

Communication between patient and caregiver: listen actively

• Caregivers should not wait for the patient to report

about pain, but actively and sensitively explore

this with the patient.

• Allow patients to describe their pain in their own

words.

• Consider, that patients may report their pain

experience in socially acceptable words.

• When patients feel uncomfortable describing their

pain, health care providers can suggest a sample of

relevant descriptors, they can be written on cards.

Communication of pain: locate the pain• Patients can be requested to

indicate primary site/s of

pain by shading relevant

areas on a figure of a human

body

[front and back] OR pointing

out on their own body.

• This can indicate the

direction of radiating or

referred pain

• Schematics such as these

are used for assessing

chronic pain conditions; not

typically carried out in acute

situations.

Communication of pain: locate the painEland Colour Scale

A figurine adapted for

children

For instructions how to use

http://www.painresearch.utah.edu/cancerpain/attachb6.html

Duration of pain assessment

•D

epends on the presenting problem/s and demands of

clinic time.

Patients with communication barriersPatients with barriers to communication can affect the pain

assessment.

These include:

• Pre-verbal children

• Individuals of advanced age

• Patients with dementia

• Patients with emotional or cognitive dysfunction

• Patient does not speak the same language as the care

provider

• Patients who are seriously ill

General approach to pain assessment

•A

llow sufficient time for the assessment.

•U

se interpreter if language of communication is

second language.

•G

ive the patient the opportunity to use a rating

scale or other tool appropriate for that

population.

General approach to pain assessment cont’d

•U

se pain indicators according to the following hierarchy of importance:•P

atient self-report•P

athological conditions or procedures known to be painful•P

ain-related behaviors (e.g., grimacing, restlessness, vocalization)•R

eports of pain by family members or caretakers•P

hysiological measures (vital signs)•R

eliance on behavioral or objective indicators of pain (e.g., vital signs)

only when no suitable alternative exists

Assessment in situations of acute pain

• Control of pain does not impede the accuracy

of diagnosis.

• Do not withhold pain management because of

ongoing or planned diagnostic procedures.

• A comfortable patient will tolerate diagnostic

procedures better and will be more cooperative.

• It is also a humane duty to ensure fast provision of

pain relief.

Pain assessment in children

• Children, even newborns, feel pain.

• ‘QUESTT’ approach

–Question the child if verbal, and the parent/guardian

in both the verbal and non-verbal child

–Use pain rating scales if appropriate

–Evaluate behavior and physiological changes

–Secure the parent’s involvement

–Take the cause of pain into account

–Take action and evaluate the results

When possible: carry out the assessment in the presence of family/guardian

Pain assessment in children

• Neonates: 0-1 month• Behavioral observation, done accompanied by

child’s family/guardian to discern between

‘normal’ and ‘abnormal’ behavior, is the only way

of assessment at this age• Lack of behavioral responses [facial expressions

e.g. crying, and discomforted movement] does

not always mean absence of pain• Behavioral responses are not necessarily

accurate indicators of the neonate’s level of pain

Pain assessment in children

Infants may exhibit the following when experiencing

pain:

•Body rigidity/thrashing

•Facial expression of pain [brows lowered and drawn

together, eyes tightly closed, mouth open and squared]

•Loud and intense cries

•Inconsolability, hypersensitivity / irritability

•Draw knees to chest

•Poor food intake, poor sleep

Infants: 1 month to 1 year

Pain assessment in children

Toddlers may exhibit the following when experiencing

pain:

• Verbal aggression, intense cries

• Regressive behavior / withdrawal

• Physical resistance, guard painful part of the body

• Poor sleep

• May require play and drawings to get an accurate

assessment of their pain

• Some may express their pain using simple language.

Toddlers: 1-2 years

Assessing behavioral signs of painFLACC Pain Scale (<2,5 years)

Assessing behavioral signs of pain

How to Use the FLACC

In patients who are awake:

Observe for 1 to 5 minutes or longer. Observe legs and body

uncovered. Reposition patient or observe activity. Assess body for

tenseness and tone. Initiate consoling interventions if needed.

In patients who are asleep:

Observe for 5 minutes or longer. Observe body and legs

uncovered. If possible, reposition the patient. Touch the body and

assess for tenseness and tone

FLACC Pain Scale (<2,5 years)

Assessing behavioral signs of pain

Interpreting the FLACC Score

Each category is scored on a 0–2 scale, which results in a

total score of 0–10.

0 -- Relaxed and comfortable

1–3 -- Mild discomfort

4–6 -- Moderate pain

7–10 -- Severe discomfort or pain or both

FLACC Pain Scale (<2,5 years)

Pain assessment in children

The pre-schooler may exhibit the following during pain:

•may verbalize his/her pain

•Thrash arms and legs, pushes stimuli away before they are

applied

•Be uncooperative, need physical restraint

•Cling to their parent/guardian, need emotional support [e.g.

hugs]

•Poor sleep

•Carry out the assessment using simple language and sympathetic

demeanor

Pre-school: 3-5 years

Self report

The OUCHER is a poster developed for children to help them communicate how much pain or hurt they feel. 

There are two scales on the OUCHER:  a number scale for older children and a picture scale for younger children.

OUCHER Scale (< 3 years)

It is possible to adapt the photos on the scale to different ethnicities (USA): •Caucasian•African American•Hispanic•Asian - Boy•Asian - Girl•First Nations (Canada- Boy•First Nations - Girl

For instructions how to use the scale: http://www.oucher.org/the_scales.html

Pain assessment in children

The school-age child may exhibit the following during pain:

•Verbalize their pain

•May even ask what causes their pain; may need age-sensitive

explanations: ‘You have pain in your stomach because you have a

lump there which is making it hurt.’

•Influenced by cultural beliefs, experience pain-related nightmares

•Stalling behaviors [e.g. ‘wait a minute’, ‘I’m not ready’]

•Muscular rigidity [e.g. clenched fists, white knuckles, gritted

teeth, contracted limbs, stiff body, closed eyes, wrinkled forehead]

•Reservation in fear of consequences [e.g. injection]

•All behaviors of pre-schoolers

School-age: 6-12 years

Age: > 6 years

Pain assessment in older children

• can also be used in

adults unable to use

numerical scales

verbal rating scale

Pain assessment in children

Adolescents may exhibit the following during pain:

•Verbalize their pain

•Peer pressure: deny pain in the presence of peers

•Changes in sleep pattern or appetite

•Health care provider

should avoid confrontation, engage conversation

focused on the adolescent rather than the problem

[informal questions about friends, school, hobbies,

family, soccer …]

Adolescents: 13-18 years

Pain assessment in adolescents and adults

0 – 3 OR no to mild pain = no change in therapy

4 – 7 OR moderate pain = initiate or change

therapy

8 – 10 OR severe pain = emergency treatment

Numerical and verbal rating scales (>12 years)

How to use the scale? Example of what to say to a

patient:

‘On a scale of 0 to 10, when ‘0’ represents NO PAIN and ’10’

represents the WORST PAIN IMAGINABLE, how much pain do you

have now?’

Pain assessment among the aged •T

he UN definition of ‘older people’ may not apply for sub-

Saharan Africa where complex and multi-dimensional socio-

cultural definitions exist [e.g. seniority status, number of

grandchildren]•I

t is challenging to assess pain among geriatric patients with

multi-morbidity, poli-pharmacy and dementia•V

isual and hearing impairment may be obstacles•U

se behavior-based proxies in non-communicative cases•I

n principle, for the geriatric patient: Ask for Pain

Pain evaluation tools practical for low-resource settings• One-dimensional tools can be practical because they:

take shorter time to administer

require lower levels of patient’s education

are validated in linguistically and culturally diverse

settings

• Examples include: African Palliative Outcome Scales

(APOS), Numerical Rating Scale [NRS], Verbal Descriptor

Scale [VDS], FLACC Behavioral Pain Scale, Wong-Baker

FACES Pain Rating Scale, the Pain Thermometer

Example for Multidimensional Pain Evaluation

Rated using the hand scale:

Clenched hand represents ‘no hurt’.

Five extended digits represents ‘overwhelming/worst’

Each extended digit indicates increasing level of pain.

APCA African Palliative Outcome Scale

Observe for 5 min

Interpretation: moderate pain = 4-6, severe pain = 7-10

Pain assessment in Dementia

Observational Scale: PAINAD

The Universal Pain Assessment Tool

Conclusion: Pearls I

• Pain assessment should be part of the daily

routine (“5th vital sign”). • Tailor the assessment to the patient [e.g. age,

cognitive ability, literacy level]. • Aim to use validated pain assessment tools –

this helps to standardize the process of

assessment. • Pain assessment is not an “academic

exercise”: assessment should be used planning

management of pain.

Conclusion: Pearls II

• Once you have made an assessment, interpret

it and carry out the relevant therapeutic

intervention: • ≤ 3/0-10 scale no change in therapy is

typically necessary• ≥ 3/0-10 scale typically analgesic therapy

should be administered or current regimen

changed• pain emergency, typically intensity of 9-

10/10 analgesic therapy should given

immediately & intravenously, if appropriate.

Conclusion: Pearls III

Interview the patient about which factors aggravate

or relieve the pain. Can help to identify the etiology of

pain, e.g.,

• pain worst at early morning hours: inflammation?• pain constant and severe: chronic pain disease?• pain decreases with movement: osteoarthritis?• pain worse on coughing/sneezing: radicular pain?• pain is alleviated with a cool pack: inflammation?• pain is alleviated with heat: muscular pain?

Conclusion: Pearls IV

• Pain descriptors help to differentiate the

aetiology of the pain and point to a therapeutic

strategy:• ‘burning’, ‘shooting’, ‘electrical’ -> think pain is

of neuropathic origin.• ‘dull’, ‘aching’, drilling, etc -> think pain is of

nociceptive origin.

Case study

• You are working in a small rural hospital when

Parmanand,

a 17 year old male, is admitted after a motorcycle

accident.

• He is awake, haemodynamically stable and seems to

have fractured his left leg. He is groaning.

The surgeon tries to carry out a physical examination,

but Parmanand resists.

• Do you need to assess Parmanand’s pain?

• How would you do it?

• How should you act once you have assessed

Parmanand’s pain?

Discussion of Case

• Permanand seems to be in intense pain and so it is

imperative to control his pain as quickly as possible.

• Permanand is of an age that he can verbalize his pain,

therefore, ask him to assess the intensity of his pain.

• Use verbal descriptor scale or numerical pain scale.

• If there is no acute volume loss, initiate analgesia before

further diagnostic procedures

• When the pain is severe, management should be

intravenous and opioid based.

• Using the body diagram in this acute situation

is not necessary.

This talk was originally prepared by:

Talks in the International Pain School include the following:

International Pain School

Physiology and pathophysiology of pain Nilesh Patel, PhD, Kenya

Assessment of pain & taking a pain historyYohannes Woubished, M.D, Addis Ababa, Ethiopia

Clinical pharmacology of analgesicsand non-pharmacological treatments

Ramani Vijayan, M.D. Kuala Lumpur, Malaysia

Postoperative – low technology treatment methodsDominique Fletcher, M.D, Garches & Xavier Lassalle, RN, MSF, Paris, France

Postoperative– high treatment technology methodsNarinder Rawal, M.D. PhD, FRCA(Hon), Orebro, Sweden

Cancer pain– low technology treatment methods Barbara Kleinmann, MD, Freiburg, Germany

Cancer pain– high technology treatment methodsJamie Laubisch MD, Justin Baker MD, Doralina Anghelescu MD, Memphis, USA

Palliative CareJamie Laubisch MD, Justin Baker MD, Memphis, USA

Neuropathic pain - low technology treatment methodsMaija Haanpää, MD, Helsinki & Aki Hietaharju, Tampere, Finland

Neuropathic pain – high technology treatment methodsMaija Haanpää, M.D., Helsinki & Aki Hietaharju, M.D., Tampere, Finland

Psychological aspects of managing pain Etleva Gjoni, Germany

Special Management Challenges: Chronic pain, addiction and dependence, old age and dementia, obstetrics and lactation

Debra Gordon, RN, DNP, FAAN, Seattle, USA

International Pain School

The project is supported by these organizations: