The goal of the initial pain assessment is to characterize an
individual's pain by location, intensity, and etiology. A pain assessment should include a detailed history, physical
examination, psychological assessment, and diagnostic evaluation. But the single most reliable indicator of the existence and intensity of
pain is the patients self-report of pain. The patients' report of pain should be the primary source of information, since it is more accurate
than the observations or others.
The American Pain Society guidelines for the treatment of acute and cancer pain suggest that each of the following
assessment steps occur.
1. The patient's self-reported pain is charted and displayed.
2. The intensity of pain and discomfort are assessed and documented at regular intervals (i.e. prior to administration of
medication and then after administration of medications).
3. The degree of pain intensity is measured after allowing sufficient time to pass in order to ensure that a specific pain
intervention treatment has occurred.
The New Joint Commission Standards also highlight the need for comprehensive pain assessment in all individuals (not just
patients in acute pain and cancer pain). Pain assessment should occur if pain is identified during the initial pain assessment. A more comprehensive
pain assessment is performed when warranted by the patient's condition. The results of this more comprehensive pain assessment, including a measurement
of pain intensity and quality, are recorded so that regular assessment and follow up can occur.
The Patients Right to Pain Assessment
The Joint Commission Standard asserts that patients served "have that right to appropriate assessment and management of
pain". This acknowledges that although pain can be a common experience, unrelieved pain has adverse physiological and psychological effects.
Therefore, staff must respect and support each right to pain management. To fulfill the patient's right to pain assessment, the following steps
1. Initial pain assessment and regular reassessment of pain.
2. Education of healthcare providers with regards to pain assessment and management.
3. Education of patients with pain and their families when appropriate.
4. Communication to patients and families that pain management is an important aspect of care.
A healthcare organization can implement the standard in several different ways with the goal being that each patient's
pain is recognized and treated appropriately. One approach would be asking every patient screening questions regarding pain on admission (i.e.
do you have pain now? And have you had pain in the past several weeks or months?). An alternative approach would be to consider Pain the Fifth
Vital Sign. This means that staff would assess and record pain intensity along with temperature, pulse, respiration, and BP. In both approaches,
the patient may say yes and admit to pain. This behooves staff to provide additional pain assessment.
1. Pain intensity using a pain intensity rating scale appropriated for the patient's age. Pain intensity rating should be
attained for pain now, worse pain, and least pain.
2. Location: The patient should be asked to mark the site or sites of pain on a pain diagram.
3. Quality and patterns of radiation.
4. Onset duration and variation of patterns.
5. Alleviating and aggravating factors.
6. Present pain management regimen and effectiveness.
7. Pain management history including medication history.
Patient may have pain at more than one site and should be encouraged to report as many sites that are relevant. Healthcare
organizations may need to utilize more than one pain intensity scale based on the needs of its various patients. Adults should be encouraged to
use those 0-10 numeric scales. If they are unable to understand or unwilling to use this scale, the
Wong-Baker Pain Faces Scale can be used. A healthcare organization
serving both adults and children could use two scales, one for each of its populations.
Pain Assessment Tailored to Distinct Populations
Different populations have different pain. Therefore different pain assessment techniques and
management strategies will be appropriate depending on the population. Five general populations will be discussed: elderly (burn survivors),
infants and children (burn survivors), cancer and AIDS patients, patients at the end of life, and patients who have difficulty communicating
Many elderly patients, including ones that were burned, suffer from conditions that are a source of chronic pain, such as
arthritis, bone and joint disorders, back problems, gout, and peripheral vascular disease. Many of those patients believe that pain is a normal
consequence of that aging process. Many elderly patients are reluctant to report pain due to several myths on the elderly and people complain of
pain and are unreliable pain reporters. Finally, many elderly fear being perceived as bothersome, hypochondriacs, or addicts. All of these contribute
to the likelihood that pain will be under reported in many elderly patients.
Infants and Children
Pediatric patients are often under treated for post op pain. Part of the reason for under medication maybe that children
exhibit and cope with pain differently than adults do. They may be less verbal that adults. Children may exhibit a wide range of responses to
pain as: crying or fussing, making a distressed face, holding or touching a place that hurts, become very quite, or sleep excessively.
The healthcare staff may need to use a pain assessment tool designed for children, such as the Wong-Baker Faces pain scale.
However, even a face scale will not help determine an infant's level of pain. The staff must rely on contextual information, diagnosis, and the
infant's response to routine comfort measures for determining an infant's pain level. The staff must also learn to assess facial expressions,
body movements, crying, groaning, and/or changes in vital signs. The Barrier and Attia's Observational Instrument and the Modified Infant Pain
Scale have been used to accurately assess pain in this age group.
Patients with AIDS and Patients with Cancer
Although patients with AIDS suffer pain comparable to that of patients with cancer, the former patients are twice as likely
to be under treated for pain. One reason is that the focus tends to be on treating potentially reversible problems such as quelling and opportunistic
infection. In addition, certain drugs that fight the opportunistic infections also cause neuropathic pain syndromes in HIV patients. Patients with
cancer can have transient pain, long-term pain or both. Pain can be related to either the disease process or treatment.
Patients at the End of Life
There is no data to show that fostering effective pain management for patients at the end of life shortens life. On the other
hand, in all instances where the primary care of therapy is to alleviate pain and suffering and not to promote death, pain management is deemed to be
ethical and appropriate. When pain and suffering are resistant to treatment, sedation may be therapeutic and medically appropriate to provide pain
relief, but only if this is consistent with the wishes of the patient.
Patients with Difficulty Communicating
Adults who have difficulty communicating their pain require special consideration. This group includes patients with cognitive
or sensory impairments as well as patients who do not verbally communicate pain or do not speak English. As with infants and children, cognitively
impaired patients may signal pain or discomfort via behavioral factors.
Assessment and Reassessment of Pain
Pain should be assessed and reassessed at regular intervals to ensure that the individual's pain is being relieved. Patients with
acute pain (i.e. patients who have just had surgery), the frequency of pain assessment can be based on the type of surgery performed and the severity of
pain. For patients with chronic pain (i.e. patients with burns, cancer or arthritis), healthcare providers should evaluate pain every time the patient is
assessed. Subsequent pain assessment should involve the clinician evaluating the effectiveness and management plan. If pain is not relieved, the clinician
should determine whether the pain is related to the progression of the disease, vs. being related to a new cause, vs. being related to the treatment.