Pain Assessment
TERMS
anxiety
assess
comprehensive pain assessment
confidentiality
confusion
disclosure
discomfort
documentation
duration
fifth vital sign
intensity
location
mental status
onset
open-ended questions
pain scale
physical assessment
self efficacy
severity
therapeutic presence
type
vital signs
QUICK LOOK AT THE CHAPTER AHEAD
Using the nursing process, the nurse must be able to assess the client in order to identify pain as a problem. A comprehensive pain assessment is an essential step in designing interventions appropriate for each specific instance of pain. Streamlining the assessment process requires structure as well as innovation, especially in an attempt to reduce barriers to the assessment process. Pain is a primary barrier in the assessment process.
Developing a comprehensive pain history includes interviewing the client for a subjective history of pain, using a pain scale to rate intensity or severity. Investigating symptoms that accompany the pain and comorbidities that impact mood, habits, and ability to participate in activities of daily living is also essential. Physical assessment for pain involves identification of objective signs of pain. It is not the goal of the pain assessment to diagnose the cause of pain. A rapid head-to-toe assessment can identify contributing factors as well as barriers to assessment. Documentation is the final step in a comprehensive pain assessment.
A rapid pain assessment includes:
Type
Severity
Location
Onset
Duration
History of previous pain
CASE STUDY
Mr. N., a 27-year-old chemical engineer, presents to the emergency room complaining of abdominal pain, nausea, vomiting and diarrhea for two days. He describes the pain as being most severe in the lower right quadrant and at the umbilicus. On physical exam, the nurse notes guarding behavior and rebound tenderness. Mr. N. reports he initially thought it was food poisoning, but no one else who ate sushi with him two evenings ago has been sick. Using open-ended questions, the nurse encourages Mr. N. to describe the duration and quality of his pain. She shows him a linear numeric pain scale and he describes the severity of his pain as “6 to 8.” He explains that the pain interferes with his sleep. When asked, he states he has never experienced such severe pain: “8 out of 10.” Self-prescribed Pepto-Bismol has not relieved the pain, nor has a heating pad.
COMPREHENSIVE PAIN ASSESSMENTPrior to designing or implementing an intervention for a client’s symptom or problem, the nurse must be able to assess the problem. A comprehensive pain assessment is essential to identifying interventions appropriate for each specific client and each specific episode of pain. Assessing for pain includes collecting both subjective and objective data. Initial, rapid assessment of the client in pain should include identification of the type, severity (or intensity), onset, duration, location, and previous history of the pain. Both effective and ineffective self-care strategies should also be elicited. The pain experience should be described in the client’s words. Some clients may avoid using the word pain and may actually deny pain as a problem, preferring to use a word such as “discomfort” instead. Acknowledgement of the client’s personal description is essential to establishing effective communication, and this description should be adhered to in subsequent assessments.
Complaints of pain should be described in the client’s words; these descriptive words can offer insight into the type, severity, and cause of the pain.
Does the client mean pain when he says discomfort?
Assessment of the client in pain should include identification of the type, severity (or intensity), onset, duration, location, and previous history of the pain.Additional data in a comprehensive pain assessment includes identification of physiological signs and symptoms of pain, vital signs, a medical history, and assessment of psychosocial and cultural factors (Table 2-1). The American Pain Society has challenged all healthcare systems to regard pain as the fifth vital sign. Considering pain as a vital sign would ensure that pain is monitored on a regular basis and ideally would signal a need for further assessment and treatment.
Frequently, clients do not seek medical care until their symptoms interfere with everyday life or are resistant to attempts at self-care.Incomplete data collection, especially when related to healthcare provider biases or assumptions about pain, can lead to failure to offer useful interventions or cause further harm to the client. The client’s pain sometimes impedes comprehensive assessment. Full assessment can be time-consuming; a variety of assessment and documentation strategies are useful in streamlining the task of assessing the client in pain.
A physical examination is done in addition to a pain history, not as a replacement for the history. A client’s self-reported history reveals subjective symptoms. A physical exam identifies objective signs. Pain is a subjective phenomenon.Assessment Strategies
Assessment is a transpersonal relationship, a sharing exchange between caregiver and client. The client trades knowledge or information for high-quality nursing care. The caregiver would be unable to design a plan of care that is specific to the needs of the client without assessment information. In using the assessment to identify problems and past interventions, the healthcare professional provides the structure for the exchange. Several strategies are useful in structuring and streamlining the assessment process.
Table 2-1 Rapid Pain Assessment | ||||||||||||||
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Pain is a subjective experience. The client’s perspective is the most important source for assessment. Concentrating on the perspectives of others, such as spouse, family, or other healthcare providers, may result in barriers to pain relief.Privacy
Privacy is fundamental to the assessment process. Much of the information revealed during assessment is of a personal nature, not easily shared under uncomfortable circumstances. A private, comfortable area should be available to conduct assessment activities. In addition to protecting the client and maintaining confidentiality, it is also a matter of health provider judgment whether to exclude the significant other from all or part of the assessment process. For many clients, the presence of a spouse or parent is a comfort, but in other instances, the nature of the information shared is confidential. Clients may choose to protect family from knowledge of the severity of the pain. Methods of pain relief may also be confidential. Without privacy, the facts of the client’s pain may not be fully disclosed. In another circumstance, the significant other may attempt to answer all assessment questions for the client. In this situation, only the significant other’s perception of the client’s pain is assessed. Pain is a subjective experience. Assessment should primarily include the client’s perspective. Use of the significant other’s input in addition to thorough client assessment may be useful.
By denying pain, or lying about severity or intensity of pain, clients may choose to protect family members from knowing how bad the pain truly is.
Without privacy, the facts of the client’s pain may not be fully disclosed.Comfort
When a client is uncomfortable, assessment may be hindered. The environment in which an assessment is conducted should be clean, well lit,
and relatively free of distractions. A chair may be more comfortable than an exam table for some clients. The temperature of the area should be warm enough for the client who is only partially clothed, or a blanket should be provided. Attempts should be made to minimize interruptions. When the nurse must respond to multiple requests or tasks during the assessment, important information may be missed. It is also important to maintain control of the interview, restricting the discussion primarily to the area of desired information. Many clients, especially the elderly or isolated clients, regard the assessment interview as an opportunity to visit or socialize. Assessment is essential to providing client care. Through minimizing distractions, interruptions, and extraneous information, the process will take less time and be more productive.
and relatively free of distractions. A chair may be more comfortable than an exam table for some clients. The temperature of the area should be warm enough for the client who is only partially clothed, or a blanket should be provided. Attempts should be made to minimize interruptions. When the nurse must respond to multiple requests or tasks during the assessment, important information may be missed. It is also important to maintain control of the interview, restricting the discussion primarily to the area of desired information. Many clients, especially the elderly or isolated clients, regard the assessment interview as an opportunity to visit or socialize. Assessment is essential to providing client care. Through minimizing distractions, interruptions, and extraneous information, the process will take less time and be more productive.
Multiple interruptions during the assessment process may result in incomplete information and diminished trust in the caregiver-client relationship.Structure the Assessment Interview
As in many client interactions, it is important to remember to ask open-ended questions during the pain assessment, allowing the client freedom to respond. This practice will enhance information shared and prevent caregiver biases from obscuring client data. Incorporating a framework into the assessment process assists in obtaining data and identifying missing elements. Two examples of assessment framework commonly used by nurses include head-to-toe assessment and functional health patterns. Choosing a framework should reflect the nurse’s personal comfort and knowledge, as well as the structure of documentation required.
The use of open ended questions in the assessment interview is one way to prevent caregiver bias and gives the client a voice in his pain management.
Examples of open-ended questions:
Tell me about your pain.
Describe how you are feeling.
What does it feel like?
Tell me how this began.
What other experiences have you had with pain?
Therapeutic Presence
While conducting a pain assessment, the provider utilizes therapeutic presence, projecting an air of caring concern. Clients will not share information with a professional whom they perceive to be uninterested
or distracted. Body language is one component of this presence. During the interview, the provider should appear receptive with professional dress and posture, and hands still and visible. The provider should sit at the same level as the client, avoiding a position of authority over the client. When culturally appropriate, the provider should also maintain eye contact. The provider should speak in a clear, calm tone, using language and terms easily understood by the client and verifying the client’s understanding of the questions asked.
or distracted. Body language is one component of this presence. During the interview, the provider should appear receptive with professional dress and posture, and hands still and visible. The provider should sit at the same level as the client, avoiding a position of authority over the client. When culturally appropriate, the provider should also maintain eye contact. The provider should speak in a clear, calm tone, using language and terms easily understood by the client and verifying the client’s understanding of the questions asked.
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