Assessing and Documenting Pain

Assessment and documentation of pain, systematically and consistently, guides the identification of
unrelieved pain and the evaluation of treatment-related change. Since the goal of therapy is to
alleviate pain and improve function, assessment should focus on pain and functional status.
Healthcare professionals are encouraged, within their scope of practice, to:

 Routinely assess all patients for pain. All pain should be evaluated with a complete history and
physical, with laboratory and diagnostic tests when indicated.

 Work with a multidisciplinary team to develop and implement a comprehensive treatment plan utilizing
appropriate pharmacologic and nonpharmacologic interventions for treatment of pain and suffering.

 Regularly re-evaluate the effectiveness of the treatment plan and adjust as needed.

 Document the complete assessment and plan of care in a clear, consistent, and accurate manner.

 Treat side effects.

 Be mindful of the risks of addiction and diversion of controlled substances and minimize risks using an
opioid treatment plan.

 Recognize that people with chemical dependency also deserve to have pain effectively treated and
that opioids may be a part of treatment.

 Refer and consult with specialists as necessary.

 Comply with all state and federal laws and encourage changes to promote improved pain
management. (Pain and Policy Studies Group, 2012b)

The most critical aspect of pain assessment is that it be done on a regular basis using a standard
format. Pain should be re-assessed after each intervention to evaluate the effect and determine
whether the intervention should be modified. The time frame for re-assessment should be directed by
the needs of the patient and the hospital or unit policies and procedures.

The mainstay of pain assessment has traditionally been the patient self-report. Family caregivers can
be used as proxies for patient reports, especially in situations in which communication barriers exist,
such as cognitive impairment or language difficulties. Family members who act as proxies typically, as
a group, report higher levels of pain than patient self-reports, but there is individual variation (JNCI,
2011).

Both physiologic and behavioral responses can indicate the presence of pain and should be noted as
part of a comprehensive assessment, particularly following surgery. Physiologic responses include
tachycardia, increased respiratory rate, and hypertension. Behavioral responses include splinting,
grimacing, moaning or grunting, distorted posture, and reluctance to move. A lack of physiologic
responses or an absence of behaviors indicating pain may not mean there is an absence of pain.

Good documentation allows communication among clinicians about the current status of the patient’s
pain and responses to the plan of care. The Joint Commission requires documentation of pain
assessment and the consideration of pain as the fifth vital sign as a means of prompting clinicians to
re-assess and document pain whenever vital signs are obtained. Documentation is also used as a
means of monitoring the quality of pain management within the institution.
 Initial Assessment
The initial evaluation of pain should include a description of the pain. One such system of evaluation
uses the OPQRSTUV characteristics:

O Onset: “When did it start? How long does it last? How often does it occur?”

P Palliative or provocative factors: “What makes it less intense?”

Q Quality: “What is it like?”

R Radiation: “Does it spread anywhere else?”

S Severity: “How severe is it?”

T Temporal factors: “Is it there all the time, or does it come and go?”

U Understanding/impact on you

 “What do you believe is causing this symptom?”

 “How is this symptom affecting you and/or your family?”

V Values

 “What is your goal for this symptom?”

 “What is your comfort goal or acceptable level for this symptom (on a scale of 0 to 10 with 0 being
none and 10 being the worst possible)?”

 “Are there any other views or feelings about this symptom that are important to you or your family?”
(EAU, 2013)

Pain Assessment Tools

Selecting a pain assessment tool should be a collaborative decision between patient and healthcare
provider to ensure that the patient is familiar with the scale. If the clinician selects the tool,
consideration should be given to the patient’s age, physical, emotional, and cognitive status, and
personal preferences. Patients who are alert but unable to talk may be able to point to a number or a
face to report their pain. The pain tool selected should be used on a regular basis to assess pain and
the effect of interventions; it should not, however, be used as the sole measure of pain (AHRQ, 2008).

Pain assessment tools can be generally divided into three categories:

 Quantitative measures are used to judge the “amount” of pain.

 Qualitative measures are used to differentiate among possible etiologies.

 Distress measures provide information about how much the pain interferes with the person’s life.
Distress measures can include, for example, an assessment of emotional distress, family dysfunction,
or financial pressures related to pain. (Dept. of Veterans Affairs, 2010a)

Pain Scales
Many pain intensity measures have been developed and validated. Most measure only one aspect of
pain (ie, pain intensity) and most use a numeric rating. Some tools, such as the Pain Scale for
Professionals, measure both pain intensity and pain unpleasantness and use a sliding scale that allows
the patient to identify small differences in intensity. The following illustrations show some commonly
used pain scales.

Visual Analog Scale

The Visual Analog Scale. The left endpoint corresponds to “no pain” and the right endpoint (100) is defined as “pain as intense as it can be.”

†A 10-cm baseline is recommended for VAS scales.

Source: Adapted from Acute Pain Management Guideline Panel, 1992 (AHCPR, 1994). Public domain.

Numeric Rating Scale

The Numeric Rating Scale. Indicated for adults and children (>9 years old) in all patient care settings in which patients are able to use

numbers to rate the intensity of their pain. The NRS consists of a straight horizontal line numbered at equal intervals from 0 to 10 with

anchor words of “no pain,” “moderate pain,” and “worst pain.” Source: Adapted from Acute Pain Management Guideline Panel, 1992 (AHCPR,

1994). Public domain.

The Pain Scale for Professionals

The Pain Scale for Professionals. The patient slides the middle part of the device to the right and left and views the amount of red as a

measure of pain sensation. The arrow at the left means “no pain sensation” and the arrow at the right indicates the “most intense pain

sensation imaginable.” The sliding part of the device is moved on a different axis for the unpleasantness scale. The arrow at the left means

“not at all unpleasant” and the arrow at the right represents pain that is the “most unpleasant imaginable.” Source: The Risk Communication

Institute. Used with permission.

Simpler tools such as the verbal rating scale (VRS) classify pain as mild, moderate, or severe. Some
studies indicate that older adults prefer to characterize their pain using the VRS. The description can
be translated to a number for charting (see following table) and works particularly well if everyone on
the unit uses the same scale.

Verbal R ating Sc ale ( VRS)

Description Points Assigned

No pain 0

Mild pain 2

Moderate 5

Severe 10

For patients with limited cognitive ability, scales with drawings or pictures, such as the Wong-Baker
FACES™ scale, are useful. Patients with advanced dementia may require behavioral observation to
determine the presence of pain; tools such as the PAIN-AD are available for this patient population.

Wong-Baker Faces™ Pain Rating Scale

The Wong-Baker FACES scale is especially useful for those who cannot read English and for pediatric patients. Source: Copyright 1983, Wong-

Baker FACES™ Foundation, www.WongBakerFACES.org. Used with permission.

Pain Questionnaires
Pain questionnaires typically contain a variety of verbal descriptors that help patients distinguish
different kinds of pain. The McGill Pain Questionnaire, for example, asks patients to describe
subjective psychological feelings of pain. Pain descriptors such as pulsing, shooting, stabbing, burning,
grueling, radiating, and agonizing (and more than seventy other descriptors) are grouped together to
convey a patient’s pain response. Typically, patients describe deep-tissue pain as dull, aching, and
cramping, while nerve-related pain tends to be more sporadic, shooting, or burning.

The McGill Pain Questionnaire was developed by Melzack in 1971. It is an assessment tool that
combines a list of questions about the nature and frequency of pain with a body-map diagram to
pinpoint its location. The questionnaire uses word lists separated into four classes to assess the total
pain experience. The categories are:
 1. Sensory, which contains words describing pain in terms of time, space, pressure, heat, and
brightness.

2. Affective, which describes pain in terms of tension, fear, and autonomic properties.

3. Evaluative

4. Miscellaneous

After patients are finished rating their pain words, the administrator allocates a numerical score, called
the “Pain Rating Index.” Scores vary from 0 to 78, with the higher score indicating greater pain (Srouji
et al., 2010).

The Brief Pain Inventory (BPI), developed by the World Health Organization, also uses the
questionnaire format to measure pain. The ability to resume activity, maintain a positive affect or
mood, and sleep are relevant functions for patients. The BPI uses a numeric rating scale to assess
difficulties with:

1. Walking

2. General activity

3. Mood

4. Sleep

Assessment of Cognitively Intact Adults

For the cognitively intact adult, assessment of pain intensity in the clinical setting is most often done
by using the 0 to 10 numeric rating scale or the 0 to 5 Wong-Baker faces scale, or the VRS. Once
patients know how to use a pain intensity scale, they should establish “comfort-function” goals. With
the clinician’s input, patients can determine the pain intensity at which they are easily able to perform
necessary activities with the fewest side effects. For example, a patient on morphine may report a
pain level of zero but be unable to stay awake enough to talk with her family. The patient must decide
how much discomfort she can tolerate and still do what is important to her (AHRQ, 2008).

Assessment of Cognitively Impaired Adults

The assessment of pain in communication-impaired patients, such as those with severe cognitive
impairment, is a significant challenge. Cognitively impaired patients tend to voice fewer pain
complaints but may become agitated or manifest unusual or sudden changes in behavior when they
are in pain. Caregivers may have difficulty knowing when these patients are in pain and when they are
experiencing pain relief. This makes the patient vulnerable to both under-treatment and over-
treatment.

Behavioral assessment tools are helpful in assessing pain and evaluating interventions in cognitively
impaired adults. There are two types of tools: (1) pain behavior scales, and (2) pain behavior
checklists. The number or intensity of behaviors is not a pain intensity score and no research as yet
confirms that a pain behavior score correlates with pain intensity. It is unsafe to use pain behavior
scores as pain intensity scores because a patient with only a few behaviors may have as much pain as
a patient with many more behaviors (AHRQ, 2008).
Behavioral Pain Scale
The Behavioral Pain Scale (BPS) was developed for use with critically ill patients in the ICU. It
evaluates and scores three categories of behavior on a 1–4 scale:

1. Facial expression: 1 for relaxed to 4 for grimacing

2. Upper-limb movement: 1 for no movement to 4 for permanently retracted

3. Ventilator compliance: 1 for tolerating ventilator to 4 for unable to control ventilation

(AHRQ, 2008)

A cumulative score above 3 may indicate pain is present; the score can be used to evaluate
intervention, but cannot be interpreted to mean pain intensity. The patient must be able to respond in
all categories of behavior—for example, the BPS should not be used in a patient who is receiving a
neuromuscular blocking agent (AHRQ, 2008).

Checklist for Seniors with Limited Ability to

Communicate
Behavior checklists differ from pain behavior scales in that they do not evaluate the degree of an
observed behavior and do not require a patient to demonstrate all of the behaviors specified, although
the patient must be responsive enough to demonstrate some of the behaviors. These checklists are
useful in identifying a patient’s “pain signature”—the pain behaviors unique to that individual (AHRQ,
2008).

The Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) evaluates
sixty behaviors such as facial expressions, activities, and mood. A checkmark is made next to any
behavior the patient exhibits. The total number of behaviors may be scored but, again, this cannot be
equated with a pain intensity score. It is unknown if a high score represents more pain than a low
score. In other words, a patient who scores 10 out of 60 behaviors does not necessarily have less pain
than a patient who scores 20. However, in an individual patient, a change in the total pain score may
suggest more or less pain (AHRQ, 2008).

Advanced Dementia Scale (PAINAD)

The Pain Assessment in Advanced Dementia Scale (PAINAD) can be used when severe dementia is
present. This tool was developed by a team of clinicians at the E.N. Rogers Memorial VA Hospital in
Bedford, Massachusetts and involves the assessment of breathing, negative vocalization, facial
expression, body language, and consolability.

Pain Assessment in Advanced Dementia (PAINAD)

0 1 2 Score*

Breathing Normal Occasional labored Noisy labored

breathing breathing
 Pain Assessment in Advanced Dementia (PAINAD)

0 1 2 Score*

Short period of Long period of

hyperventilation hyperventilation

Cheyne-Stokes
respirations

Negative None Occasional Repeated, troubled

vocalization moan/groan calling out

Low level speech with Loud moaning or

a negative or groaning
disapproving quality
Crying

Facial Smiling or Sad Facial grimacing

expression inexpressive
Frightened

Frown

Body Relaxed Tense Rigid

language
Distressed Fists clenched

Pacing Knees pulled up

Fidgeting Pulling/pushing away

Striking out

Consolability No need to Distracted or Unable to console,

console reassured by voice or distract, or reassure
touch

PAINAD Scoring: 1-3 = Mild; 4-6 = Moderate; 7-10 = Severe Total:

* Some institutions have developed policies in which a PAINAD score of four or
greater must be addressed in the nursing care plan. Public domain.

Pain Assessment in Children

Accurate pain measurements in children are difficult to achieve. Three main methods are currently
used to measure a child’s pain intensity:

1. Self-reporting: what a child is saying using age-appropriate numeric scales, pictorial

scales, or verbal scales.
 2. Behavioral measures: what a child is doing using motor response, behavioral responses,
facial expression, crying, sleep patterns, or decreased activity or eating.

3. Physiologic measures: how the body is reacting using changes in heartrate, blood
pressure, oxygen saturation, and palm sweating.

Self-report measures are optimal and the most valid (Srouji et al., 2010).

Both verbal and nonverbal reports require a certain level of cognitive and language development for
the child to understand and give reliable responses. Children’s capability to describe pain increases
with age and experience, and changes throughout their developmental stages. Although observed
reports of pain and distress provide helpful information, particularly for younger children, they are
reliant on the individuals completing the report (Srouji et al., 2010).

Behavioral measures consist of assessment of crying, facial expressions, body postures, and
movements. They are more frequently used with neonates, infants, and younger children where
communication is difficult. Physiologic measures include assessment of heart rate, blood pressure,
respiration, oxygen saturation, palmar sweating, and sometimes neuroendocrine responses. They are
generally used in combination with behavioral and self-report measures, as they are usually valid for
short-duration acute pain and differ with the general health and maturational age of the infant or
child. In addition, similar physiologic responses also occur during stress, which results in difficulty
distinguishing stress versus pain responses (Srouji et al., 2010).

Assessing Pain in Infants

The most common pain measures used for infants are behavioral. These measures include crying,
facial expressions, body posture, and movements. The quality of these behaviors depends on the
infant’s gestational age and maturity. Preterm or acutely ill infants, for example, do not elicit similar
responses to pain due to illness and lack of energy. In addition, interpretation of crying in infants is
especially difficult, as it may indicate general distress rather than pain. Cry characteristics are also not
good indicators in preterm or acutely ill infants, as it is difficult for them to produce a robust cry
(Srouji et al., 2010).

Numerous scales are currently available to measure behavioral indicators in infants, the most common
being the Neonatal Facial Coding System (NFCS) and the Neonatal Infant Pain Scale (NIPS). Other
scales used with infants are composite measurement scales, meaning they use a combination of
behavioral and physiologic measures. Some scales also take into consideration gestational age and the
general behavioral state of the infant. Examples of these scales are The Premature Infant Pain Profile
(PIPP), Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES), and the Maximally
Discriminate Facial Movement Coding System (MAX) (Srouji et al., 2010).

Assessing Pain in Toddlers

In toddlers, verbal skills remain limited and quite inconsistent. Pain-related behaviors are still the
main indicator for assessments in this age group. Nonverbal behaviors such as facial expression, limb
movement, grasping, holding, and crying, are considered more reliable and objective measures of pain
than self-reports. Most children of this age are capable of voluntarily producing displays of distress,
 with older children displaying fewer pain behaviors (eg, they cry, moan, and groan less often) (Srouji
et al., 2010).

Most 2-year-old children can report the incidence and location of pain, but do not have the adequate
cognitive skills to describe its severity. Three-year-old children, however, can start to differentiate the
severity of pain, and are able to use a three-level pain intensity scale with simple terms like “no pain,”
“little pain” or “a lot.” Children in this age group are usually able to participate in simple dialogue and
state whether they feel pain and “how bad it is” (Srouji et al., 2010). Common pain scales used in
toddlers are:

 The Children’s Hospital of Eastern Ontario Pain Scales (CHEOPS)

 The Faces Legs Activity Cry Consolability Scale (FLACC)

 The COMFORT Scale

 The Observational Scale of Behavioral Distress (OSBD)

 Observational Pain Scale (OPS)

 The Toddler-Preschooler Postoperative Pain Scale (TPPPS) (Srouji et al., 2010)

Assessing Pain in Preschoolers

By the age of four years, most children are usually able to use 4- to 5-item pain discrimination scales.
Their ability to recognize the influence of pain appears around the age of five years, when they are
able to rate the intensity of pain. Facial expression scales are most commonly used with this age
group to obtain self-reports of pain. These scales require children to point to the face that represents
how they feel or the amount of pain they are experiencing. The following section describes scales
commonly used with this age group:

 The Child Facial Coding System (CFCS)

 Poker Chip Tool

 Faces Pain Scale

 The OUCHER Scale (Srouji et al., 2010)

Assessing Pain in School-Aged Children

Healthcare professionals depend more comfortably on self-reports from school-aged children.
Although children at this age understand pain, their use of language to report it is different from
adults. At roughly 7 to 8 years of age children begin to understand the quality of pain. Self-report,
visual analog, and numerical scales are effective in this age group. A few pain questionnaires have
also proven effective for this age (eg, pediatric pain questionnaire, adolescent pediatric pain tool). A
brief discussion of these tools is presented in this course:

 Visual Analogue Scale (VAS)

 Pediatric Pain Questionnaire

 Adolescent Pediatric Pain Tool (APPT) (Srouji et al., 2010)

Assessing Pain in Adolescents

Adolescents tend to minimize or deny pain, especially in front of friends, so it is important to provide
them with privacy and choice. For example, they may or may not choose to have parents present.
They expect developmentally appropriate information about procedures and accompanying sensations.
Some adolescents regress in behavior under stress. They also need to feel able to accept or refuse
strategies and medications to make procedures more tolerable. To assess pain, specifically chronic
pain, the adolescent pediatric pain tool (APPT) or the McGill pain questionnaire are helpful (Srouji et
al., 2010).