Chapter 4 – Pain Assessment
Subjective Assessment Overview
A subjective assessment is an important component of evaluating a client’s pain. It is often referred to as a self-report because the client is reporting and describing their own pain as opposed to your observations as a nurse (objective assessment).
A can help you better understand the meaning of a client’s pain. This kind of approach involves having an authentic conversation with the client. How do they understand pain? Some people reserve the word “pain” to describe severe sensations, so they might not refer to a mild symptom as pain. Others may associate pain with vulnerability and use alternative words to describe it. Therefore, if they initially tell you they are not in pain, try rephrasing your question using words such as discomfort, hurt, tenderness, and sensations. When probing further about their pain, it is also a best practice to use the words the client uses.
Another issue is that some clients believe “good” clients do not “complain” about pain. Thus, it is important to show that you care when you ask about the client’s pain and use a professional and serious tone. It may be helpful to use permission statements depending on the situation. For example, you may say “pain is common after this procedure, do you have any pain?”
Contextualizing Inclusivity
Although subjective assessment is an important way to evaluate pain, be aware that not everyone can verbally communicate their pain (e.g., clients who are pre-verbal or non-verbal). Therefore, you should use other types of assessment that focus on behavioural and physiological cues.
Always remember: Pain is what the client tells you it is. This important adage is worth repeating, because unconscious bias and/or long-held myths that have no evidence to support them still influence practice. In addition to institutional racism, there are out-dated beliefs that newborns and elderly do not feel as much pain as others, and that people who use illegal substances do not require pain management.
It’s your job to advocate and ensure that decisions are made based on evidence. The client’s subjective experience is as important as your objective assessment, because you can’t always observe pain.
The main components of a subjective assessment include:
- Presence of pain: do they have pain? If so, how long have they had it?
- Location of pain: where is it located?
- Severity/quantity of pain: how bad is the pain?
- Descriptors of pain: how do they describe the pain? Is it constant or intermittent?
- Associated factors and triggers of pain: are there any associated signs or symptoms with the pain? Is there anything that triggers their pain or makes it worse? What were they doing when the pain started?
- Impact of pain: how is it affecting them?
- Management of pain: have they tried to manage or treat it?
Priorities of Care
Certain cues require prompt and urgent action. New onset and severe pain are critical findings that require prompt action. This is especially true for chest pain, which could be , and is considered a first-level priority of care. In this case, ask a colleague to notify the physician or nurse practitioner while you keep the client at rest, assess pulse, blood pressure, and oxygen saturations. Depending on the setting and if appropriate, adhere to existing directives such as order an electrocardiogram and blood work, administer oxygen, initiate intravenous access, and give nitroglycerin and morphine. If you are in a home setting and/or do not have access to these treatments, call 911 if this is new onset angina for the client as they may be having a myocardial infarction. The client can chew and swallow acetylsalicylic acid (usually low-dose ASA, 81 mg) as long as there are no contraindications; this can be helpful to prevent the clot from getting bigger.
Clinical Tip: Opioid Use, Stigma, and Language Examples
misuse is a serious issue across Canada. Although opioids are beneficial when treating certain types of pain when used as prescribed, the risk for misuse has been described as a crisis in Canada as well as in other countries. Opioid misuse is also a stigmatizing condition and as a result can influence individuals to avoid treatment or not discuss their opioid use.
Try to use a cultural humility and harm reduction approach during your subjective health assessment, with non-judgemental and supporting language and an open interviewing approach. Specific strategies include:
- Do not judge clients or belittle them for their decisions.
- Avoid objectifying language in which people are labeled, such as “addict” and “abuser.”
- Use supportive language such as “substance use disorder” or “a client who uses drugs/substances.”
- Ask questions with an open mind so that you can better understand their opioid use and the reasons behind it.
- Support the agency of clients in making their own decisions even if you disagree with them.
- Use a harm-reduction approach including non-coercive strategies in which you help them minimize harm in their opioid use.
- Let them know about available supports and resources if they become interested in stopping their use.
Some clients may refuse opioid medications for fear of addiction or because of a history of opioid misuse. Thus, a client-centred and interprofessional approach to pain management is important.
Check out this additional Video to support your learning: Language. How do you talk about addiction? [7:37]
Activity: Check Your Understanding
References
Canadian Mental Health Association (2022). Harm reduction. https://ontario.cmha.ca/harm-reduction/
Greene-Moton, E., & Minkler, M. (2020). Cultural competence or cultural humility? Moving beyond the debate. Health Promotion Practice, 21(1), 1-4. https://doi.org/10.1177/1524839919884912
refers to a life-long journey in which you are humble and open to the cultural perspectives and experiences of others (Greene-Moton & Minkler, 2020).
is a type of chest pain caused by a reduction in oxygen-rich blood flow to the heart muscle.
is a powerful narcotic substance typically used for pain management such as oxycodone, morphine, and fentanyl.
