Pain Assessment Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

Objectives Explain how pain scales are used to measure pain Compare different scales Measure pain 2

Measuring pain Pain is subjective and two patients may report severity differently from each other Despite the fact that pain is specific to each person, patients can usually accurately and reproducibly indicate the severity of their symptom by using a scale Scales enhance the ability of patients to communicate the severity of their pain to health care professionals and the ability of clinicians to communicate among themselves Scales also allow the clinician to assess the effect of medications Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard Medical School, Centre for Palliative Care (2007); Beating Pain, 2 nd Ed. APCA (2012) 3

Pain scales Scientifically validated pain scales: Numeric Pain Rating Scale Wong-Baker FACES Scale: for children who can talk Observation-FLACC Scale: for children who can’t talk 4

Numeric pain rating scale Pain levels from 0-10 can be explained verbally to the patient using a scale in which 0 is no pain and 10 is the worst possible pain imaginable Patients are asked to rate their pain from 0 to 10 Record the pain level to make treatment decisions, follow-up, and compare between examinations Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard Medical School, Centre for Palliative Care (2007) 5

Three ways to assess pain in children Ask the child: FACES scale Ask the parent or caregiver – Ask about previous exposure to pain, verbal pain indicators, usual behavior or temperament Observe the child: FLACC scale The child is the best person to report their pain Children’s Palliative Care in Africa,

Wong-Baker FACES scale Use in children who can talk (usually 3 years and older) Explain to the child that each face is for a person who feels happy because he has no pain, or a little sad because he has a little pain, or very sad because he has a lot of pain Ask the child to pick one face that best describes his or her current pain intensity Record the number of the pain level that the child reports to make treatment decisions, follow-up, and compare between examinations Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard Medical School, Centre for Palliative Care (2007) 7

FLACC scale ICPCN (2009): Adapted from Merkel et al 8 Use in children less than 3 years of age or older children who can’t talk Use it like an APGAR (Appearance, Pulse, Grimace, Activity, Respiration) score, arriving at a score out of 10

FLACC scale Guide to Pain Management in Low-Resource Settings. IASP (2010) 9 CategoryScore Face Legs Activity Cry Consolability Total Pain intensityFLACC score Relaxed and comfortable0 Mild discomfort1-3 Moderate pain4-6 Severe discomfort/pain7-10 Score each of the five categories (0-2) Add the five scores together to get the total (out of 10) The total score can be related to pain intensity

Practice using FLACC scale Samuel is 18 months old. You observe that he is withdrawn, kicking his legs, and squirming. His is constantly crying or screaming, but is calmed down by breastfeeding. 10 CategoryScore Face Legs Activity Cry Consolability Total Score

Detailed pain assessments 11 Detailed pain assessments are useful for treating patients with pain Tools like the PQRST and body charts provide detailed information on location and type of pain as well as quality and response to treatment

PQRST assessment P recipitating and relieving factors – What makes the pain worse? What makes the pain better? Q uality – How would you describe the pain? What does it feel like? R adiation – Is the pain in one place or does it move around your body? S ite and S everity – Where is your pain? On a scale of 0-10, how bad is your pain? T iming and T reatment history – When did pain start? How often do you get it? – What are the patterns of the pain? Is it constant, or does it come and go? – Are you or have you been on treatment for the pain? Does it help? Beating Pain, 2 nd Ed. APCA (2012) 12

Body charts Beating Pain, 2 nd Ed. APCA (2012) 13 throbbing tingling Use the body chart to indicate areas of pain and take notes on descriptions such as burning, throbbing, or aching

Take home messages Always ask about your patient’s pain Though pain is subjective, patients aged 3 and older can accurately assess the severity of their pain – Some patients may need some time and education by the healthcare provider to understand how to use the different scales – In patients younger than 3 years, objective data can be used to assess pain Pain assessments can be a useful clinical tool in treatment and pain management Effective pain measurement leads to appropriate pain management Health workers should therefore endeavor to accurately measure a patient’s pain 14

References African Palliative Care Association. Beating Pain: a pocketguide for pain management in Africa, 2nd Ed. [Internet] Available from: African Palliative Care Association. Using opioids to manage pain: a pocket guide for health professionals in Africa [Internet] Available from: Amery J, editor. Children’s Palliative Care in Africa [Internet] Available from: Africa-Full-Text.pdf Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet] Available from: pain.org/files/Content/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_ Management_in_Low-Resource_Settings.pdf The Palliative Care Association of Uganda and the Uganda Ministry of Health. Introductory Palliative Care Course for Healthcare Professionals