2AIM Provide overview of Pain Assessment Describe various methods of pain assessmentProvide familiarity with various pain scalesFacilitate the ability to choose appropriate pain scales for different patient groupsAssess treatment of pain
3Definition of Pain International Association for the Study of Pain An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damageSensory, emotional, cognitive, and behavioral components that are interrelated with environmental, developmental, socio-cultural, and contextual factors
4Pain AssessmentBy its very definition, pain is an internal, subjective experience that cannot be directly observed by others or measured by the use of physiologic markers or bioassays.The assessment of pain, therefore, relies largely (and in many cases exclusively) upon the use of self-report.
5Pain AssessmentThough the self-report of pain or any other construct is subject to a number of biases, a good deal of effort has been invested in testing and refining self-report methodology within the field of human pain research.
6Pain AssessmentThe Joint Commission in the United States has set standards for the assessment of pain in hospitalized patients.
7Pain AssessmentPain assessment should be ongoing, individualized, and documented.Patients should be asked to describe their pain in terms of the following characteristics: location, radiation, mode of onset, character, temporal pattern, exacerbating and relieving factors, and intensity.
8Pain AssessmentAlthough pain cannot be considered vital, nor is it a sign, the suggestion that it be routinely measured along with temperature, pulse, blood pressure, and respiratory rate is a powerful reminder to health care providers to attend to their patients' suffering.
9Pain AssessmentUnfortunately, simple routine documentation of pain levels has not been shown in and of itself to lead to any improvement in the quality of pain management. However, proper assessment is still a desirable goal before appropriate treatment.
10Assessing Pain Question the patient Use pain rating scales Evaluate behavior & physiologic signsSecure family’s involvementTake action and assess effectiveness
11Assessing PainThe 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.
12Assessing PainThe American Pain Society guidelines for the treatment of acute and cancer pain suggest that each of the following assessment steps occur.The patient's self-reported pain is charted and displayed.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)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.
13Question The Patient Obtain a detailed assessment of pain HPI, description of pain, experience with pain medications, use of non-pharmacologic techniques, family experience with painQuality, location, duration, intensity, radiation, relieving & exacerbating factors, & associated symptomsUse appropriate pain scaleCognitively impaired adults, Sedated patients ChildrenPain can be multi-dimensional and therefore, tools can be limitedDirectly ask patients and or family when appropriate
14SOCRATES Site - Where is the pain? Onset - When did the pain start, was it sudden or gradual?Character - What is the pain like?Radiation - Does the pain radiate anywhere?Associations - Any other signs or symptoms associated with the pain?Time course - Does the pain follow any pattern?Exacerbating/Relieving factors - Does anything change the pain?Severity - How bad is the pain?
15Question the Patient May not be straight forward especially in Cognitively impaired adultsThe learning disabledSedated patients in an ICU or operating room settingChildrenUse a variety of words to describe pain, such as owie, boo-boo, ouch, hurt, ow owKnow words in other languagesSpanish: Ay ay, duele, lele, dolor
16Use Pain Rating ScalesSelect a scale that is suitable for the patients abilities, age, and preferencesTeach patient to use scale before pain is expected, such as preoperativelyUse same scale with the patient each time pain is assessed
17Types of Pain Rating Scales Single Dimensional ScalesVisual Analog Scale (VAS)Numerical Rating Scale (NRS)Verbal Descriptor Scale(s) (VDS)
18Types of Pain Rating Scales Multidimensional ScalesMcGill Pain QuestionnaireShort-Form McGill Pain QuestionnaireBrief Pain InventoryScales for Neuropathic Pain
20Visual Analog ScaleThe VAS is most commonly a straight 100-mm line without demarcations that has the words “no pain” at the left-most end and “worst pain imaginable”(or something similar) at the right-most end.Benefits of the VAS is that it has been validated and shown to be sensitive to changes in a patient's pain experience.It is quick to use and relatively easy to understand for most patients.It avoids the imprecise use of descriptive words to describe pain and allows a meaningful comparison of measurements over time.
21Visual Analog ScaleDisadvantages of the VAS is that it attempts to assign a single value to a complex, multidimensional experience.Some patients have trouble deciding how to represent their pain sensation. They often have no real concept of what “worst pain imaginable” actually means because every experience of pain is different.It has a false ceiling at the upper-most end. If a patient later time decides that the pain has become worse, the patient has no way to document this change if it was already at maximum.
22Verbal Descriptive Scale The verbal descriptor scale is a list of words, ordered in terms of severity from least to most, that describe the amount of pain that a patient may be experiencing.Patients are asked to either circle or state the word that best describes their pain intensity at that moment in time.The benefits of VDS instruments are that they have been validated and are simple for patients to understand and quick to use.A disadvantage is that a VDS forces patients to select words that are not of their own choosing to describe their pain.Changes in pain over time are difficult to interpret and probably have different meanings to each individual.This may especially be a problem with the VDS when only a limited number of possible choices are offered to the patient (i.e. only four to six words).
25Numerical Rating Pain Scale The numerical rating scale offers the individual in pain to rate their pain score.It is designed to be used by those over the age of 9.In the numerical scale, the user has the option to verbally rate their scale from 0 to 10 or to place a mark on a line indicating their level of pain.0 indicates the absence of pain, while 10 represents the most intense pain possible.
26Numerical Rating Pain Scale The Numerical Rating Pain Scale allows the healthcare provider to rate pain as mild, moderate or severe, which can indicate a potential disability level.Attempts have been made to define what is considered a meaningful change in the NRS.At least a 30% reduction or an absolute reduction in the value of at least 2 has been suggested as representing meaningful pain relief to patients
27Numerical Rating Pain Scale Disadvantages of the NRS and VNS are similar to those of the VAS in that they attempt to assign a single number to the pain experience.They also have the same ceiling effect in that if a value of “10” is chosen and the pain worsens, the patient officially has no way to express this change.In practice, at least with the VNS, patients often rate their pain as some number higher than 10 (e.g., “15 out of 10”) in an attempt to express their extreme level of pain intensity.
28Wong Baker Faces Pain Scale The Wong Baker Faces Pain Scale combines pictures and numbers to allow pain to be rated by the user.It can be used in children over the age of 3, and in adults.The faces range from a smiling face to a sad, crying face.A numerical rating is assigned to each face, of which there are 6 total.
32McGill Pain Questionnaire (MPQ) The MPQ and its brief analog, the short-form MPQ, are among the most widely used measures of pain.In general, the MPQ is considered to be a multidimensional measure of pain quality; however, it also yields numerical indices of several dimensions of the pain experience.Researchers have proposed three dimensions of the experience of pain: sensory-discriminative, affectivemotivational, and cognitive-evaluative.The MPQ was created to assess these multiple aspects of pain.Groups 1-10= somatic in natureGroups 11-15= affectiveGroup 16= evaluativeGroup 17-20= miscellaneous words that are used in the scoring process.
33McGill Pain Questionnaire The McGill Pain Questionnaire consists of groupings of words that describe pain.The person rating their pain ranks the words in each grouping. Some examples of the words used are tugging, sharp and wretched.Once the person has rated their pain words, the administrator assigns a numerical score, called the Pain Rating Index.Groups 1-10= somatic in natureGroups 11-15= affectiveGroup 16= evaluativeGroup 17-20= miscellaneous words that are used in the scoring process.
34McGill Pain Questionnaire Groups 1-10 = Somatic in natureGroups = AffectiveGroup 16 = EvaluativeGroup = Miscellaneous words that are used in the scoring process.
35Groups 1-10= somatic in nature Groups 11-15= affectiveGroup 16= evaluativeGroup 17-20= miscellaneous words that are used in the scoring process.
37McGill Pain Questionnaire The benefits of the MPQ are that it is valid, reliable, and consistent in its ability to assign seemingly appropriate descriptions to a given pain experience.The MPQ may be able to discriminate between different types of pain syndromes. Moreover, it has been shown to be sensitive to changes in the amount of pain experienced by patients in response to receiving various analgesic therapies in both the acute and chronic setting.One disadvantage of the MPQ is its length. The MPQ should take from 5 to 15 minutes to complete, which for some patients may be seen as more trouble than it is worth.In addition, this amount of time is prohibitive for use on a repeated basis over a short period (e.g., in a clinical acute pain setting).Groups 1-10= somatic in natureGroups 11-15= affectiveGroup 16= evaluativeGroup 17-20= miscellaneous words that are used in the scoring process.
38Short-Form McGill Pain Questionnaire The more frequently used short form of the MPQ consists of 15 representative words that form the sensory (11 items) and affective (4 items) categories of the original MPQ.Each descriptor is ranked on a 0 (“none”) to 3(“severe”) intensity scale. The PPI, along with a VAS, are also included. The short form correlates highly with the original scale, can discriminate among different pain conditions, and may be easier than the original scale for geriatric patients to use.Groups 1-10= somatic in natureGroups 11-15= affectiveGroup 16= evaluativeGroup 17-20= miscellaneous words that are used in the scoring process.
39Short-Form McGill Pain Questionnaire Groups 1-10= somatic in natureGroups 11-15= affectiveGroup 16= evaluativeGroup 17-20= miscellaneous words that are used in the scoring process.
40Special PopulationsCommon populations that are challenging to assess painChildrenCognitively impaired adultsAdults whose cognition is temporarily impaired, by medication or illnessThe learning disabledSedated patients in an ICU or operating room setting
42Physiological Indications of Acute Pain Dilated pupilsIncreased perspirationIncreased rate/ force of heart rateIncreased rate/depth of respirationsIncreased blood pressureDecreased urine outputDecreased peristalsis of GI tractIncreased basal metabolic rate
43Possible Physiologic Signs of Pain Pallor or flushingDiaphoresis, palmar sweating O2 saturation Vagal toneEEG changes
48DolorimeteryDolorimetry has been defined as "the measurement of pain sensitivity or pain intensity.“A dolorimeter is an instrument used to measure pain threshold and pain tolerance.Introduced in 1940 by James D. Hardy of Cornell UniversityThere are several kinds of dolorimeters that have been developed.Dolorimeters apply steady pressure, heat, or electrical stimulation to some area, or move a joint or other body part and determine what level of heat or pressure or electric current or amount of movement produces a sensation of pain.
50Pediatric Pain Barriers are often present and include: Belief that children, especially infants, do not feel pain the way adults doLack of routine pain assessmentLack of knowledge in pain treatmentBelief that preventing pain in children takes too much time and effort
51Pediatric PainWell documented that children are often undertreated for painSpecifically in neonates:Studies show that neonates can experience pain by 26 weeks of gestationMature afferent pain transmissionUntreated pain in neonates lead to increased distress and altered pain response in the futureHistorically children and infants received less post-operative analgesia than adults
52Assessment in Children, Neonates & Infants ChallengingCombines physiologic and behavioral parametersMany scales available
53Possible Signs of Pain in Neonate: Behavioral Variables, cont. Facial expression (most reliable sign):Eyes tightly closed or openedMouth opened, squarishFurrowing or bulging of browQuivering of chinDeepened nasolabial fold
54Facial Expression of Physical Distress NASO-LABIAL FOLDdeepened54
55Children with Cognitive Impairment Often unable to describe painAltered nervous system and experience pain differentlyUse behavioral observation scalesCan apply to intubated patientsMust use appropriate observational scales
56QuestionWhich of the following is indicative of pain in a neonate receiving a circumcision?A Decrease in insulinDecrease in O2 SaturationVigorous withdrawal to painDecrease in transcutaneous PCO2BradycardiaAnswer B
57Pediatric Pain Scales Neonates, infants, toddlers (<3 years) Pain assessment it largely observationalCannot distinguish between pain, fear, anxiety, distressExamples of pain scales in this population:CRIES, PIPP, FLACC, Comfort
58Pediatric Pain Scales Toddlers to school age children (3-8) Self Report ScalesVisual Analog (VAS): Age 5+Faces/Oucher Scale/ Wong- Baker: Age 3+Observational ScalesFLACC: Age 2 mos- 7 yearsCHEOPS scale age 1-7 years
59COMFORT Observer Pain Scale The COMFORT Scale is a behavioral, unobtrusive pain scale that may be used by a healthcare provider when a person cannot describe or rate their pain.Unconscious and ventilated infants, children and adolescents.This scale has eight indicators (categories)Validated for newborn to 3 years oldReported use of up to 17 years oldThe COMFORT Scale provides a pain rating between 9 and 4517-26 generally indicates adequate sedation and pain control.
61CRIES Pain ScaleThe CRIES Pain Scale is often used in the neonatal healthcare setting.CRIES is an observer-rated pain assessment tool which is performed by a healthcare practitioner such as a nurse or physician.CRIES assesses crying, oxygenation, vital signs, facial expression and sleeplessness.The CRIES Pain Scale is generally used for neonates, from 32 weeks gestation to 6 months old.
63FLACC Pain ScaleFLACC stands for face, legs, activity, crying and consolability.It is an observer rated pain scale, performed by a healthcare practitioner such as a doctor or a nurse.The FLACC pain scale was designed for neonates at 2 months, may be useful up to 7 years of age.However, some practitioners in adult settings may use the FLACC pain scale for people who are unable to communicate their pain.FLACC provides a pain assessment scale between 0 and 10.
65Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) The CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) is a behavioral scale for evaluating postoperative pain in young children.Six items: Cry, Facial, Child Verbal, Torso, Touch, and LegsIt can be used to monitor the effectiveness of interventions for reducing the pain and discomfort.Patients:The initial study was done on children 1 to 5 years of age.According to Furnish (2013) it is intended for ages 1-7.It has been used in studies with adolescents but this may not be an appropriate instrument for that age group.
67Oucher Scale Available in three ethnic versions Suitable for a 3-7 years of ageEmpowers the child to express pain experienceMay reflect mood instead of pain
68Oucher Photographic / Numeric Pain Scale White child, 3 year-old male Black child, 3 year-old male Hispanic child, 3 year-old male68
69Premature Infant Pain Profile (PIPP) Developed at the Universities of Toronto and McGill in Canada.Used for infants less than 36 weeks gestationScores <6= minimum Pain, 6-12 = mild-moderate Pain, >12 = moderate to severe painScoring instructions:Score gestational age before examining infant.Score the behavioral state before the potentially painful event by observing the infant for 15 seconds .Record the baseline heart rate and oxygen saturation.Observe the infant for 30 seconds immediately following the painful event.Score physiologic and facial changes seen during this time and record immediately.
71Neonatal Infant Pain Scale (NIPS) The Neonatal Infant Pain Scale (NIPS) is a behavioral scale and can be utilized with both full-term and pre-term infants.From birth to one year of ageThe tool was adapted from the CHEOPS scale and uses the behaviors that nurses have described as being indicative of infant pain or distress.
73Neonatal Infant Pain Scale (NIPS) Total pain scores range from 0-7. The suggested interventions based upon the infant's level of pain are listed below.The difficulty with any tool that is not self report is the ability to differentiate between pain and agitation, however, the non-pharmacological intervention may help differentiate between these two (i.e. changing the wet diaper, feeding the infant, repositioning, etc).
74N-PASS: Neonatal Pain, Agitation and Sedation Scale
76Children between 3-8 years Usually have a word for painCan articulate more detail about the presence and location of pain; less able to comment on quality or intensityExamples:Color scalesFaces scales76
77Children older than 8 years Use the standard visual analog scaleSame used in adults77
78QuestionA pain physician is concerned that a patient's pain may be neuropathic in nature. An appropriate screening tool to assess for this is:Numeric Rating ScaleVisual Analog ScaleMcGill Pain QuestionairepainDETECT
79Neuropathic Pain Scale The Neuropathic Pain Scale (NPS) has been described (Galer and Jensen, 1997) and attempted to discriminate between four diagnostic categories of neuropathic pain using single descriptors.Only post-herpetic neuralgia could be distinguished from the other diagnostic groups (reflex sympathetic dystrophy, diabetic neuropathy and peripheral nerve injury).
93ReferencesInternational Association for the Study of Pain: Pain Definitions [cited 10 Sep 2011]. "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" Derived from Bonica JJ. The need of a taxonomy. Pain. 1979;6(3):247–8. doi: / (79) PMIDTurk DC, Dworkin RH. What should be the core outcomes in chronic pain clinical trials?. Arthritis Res. Ther ;6(4):151–4. doi: /ar1196. PMIDHart RP, Wade JB, Martelli MF. Cognitive impairment in patients with chronic pain: the significance of stress. Curr Pain Headache Rep. 2003;7(2):116–26. doi: /s PMIDBruehl S, Burns JW, Chung OY, Chont M. Pain-related effects of trait anger expression: neural substrates and the role of endogenous opioid mechanisms. Neurosci Biobehav Rev. 2009;33(3):475–91. doi: /j.neubiorev PMID