Chapter 4 – Pain Assessment
Summary: Subjective Assessment and Pain Assessment Tools
Subjective assessment of pain is an integral step of pain management. Be aware of your own biases concerning pain: do not make assumptions. The main focus of subjective assessment is self-report, which can be elicited through a verbal account or having the client point or write it down.
The use of pain tools is also important in combination with subjective and objective forms of assessment. Many tools are available to assess pain; we have introduced you to a few, but you will come across others in your clinical practice and from reading the literature. Best practices in tool selection should focus on the reason for the assessment, developmental considerations, and the client situation and acuity. Another part of decision-making considering tool selection is related to where you work, as units and areas of care will commonly identify specific tools and procedures in using these tools. They may also provide training related to tool implementation, with the goal of ensuring all healthcare practitioners use it consistently and as it was designed. See summary in Table 4.
Table 4: Summary of pain tools.
| Tools | Description |
| Numerical Rating Scale | Most commonly used tool with older children and adults who are able to rate their pain on a scale of zero to 10. Recall: this tool focuses on rating of pain severity only. |
| PQRSTU mnemonic | Commonly used in many settings and populations when a more comprehensive understanding of pain is needed, beyond intensity. |
| Brief Pain Inventory | Used to elicit a more comprehensive understanding of pain and is often used in primary care settings, in-patient units, and to assess chronic pain. |
| Abbey Pain Scale and PAIC15 | Commonly used for older clients with cognitive impairments such as dementia. |
| FACES Pain Scale-Revised Version | Often used with young children, who can point to the face that corresponds to their pain level |
| FLACC Pain Tool | Used with pre-verbal or non-verbal children as young as 2 months of age or any children who are too distressed or sedated to accurately self-report. It has also been used with other populations including non-verbal adults with cognitive impairment and critically ill adults. |
| Behavioral Pain Scale and the Critical-Care Pain Observation Tool. | Common tools used in critical care that have a focus on behavioural dimensions of pain. |
Clinical Tip
Pain intensity ratings are often categorized by healthcare providers as follows:
- 1–3: Mild pain.
- 4–6: Moderate pain.
- 7–10: Severe pain (and sometimes a 10 or above may be described as very severe).
These ratings and categories can be useful to provide a baseline for pre- and post-pain treatment so you know whether treatment has been effective for this specific client. However, the categories above are qualitative descriptors that have a subjective element to them and the potential for bias. For example, you might categorize a client’s pain as moderate if they have rated it a five, but if asked, the client might describe their pain as severe. Therefore, it is important to engage in comprehensive assessments that are client-centred and be careful about making judgements about the “number” the client provides.
Determining whether treatment is needed is dependent on the acuity of the situation and the specific client. Each situation is different in terms of an acceptable level of pain. For example:
- In an acute care situation when a client is having angina pain, treatment should result in no pain. With angina pain, think about the pathological processes leading to the pain (i.e., narrowing coronary arteries in which insufficient blood and oxygen is feeding the heart muscle). Treatment should resolve this pathological process and result in no pain.
- In a client who has chronic pain related to arthritis, typically treatment should result in no pain or to a level that is manageable for the client and does not significantly interfere with their functioning.
Depending on the situation, remember that treatment includes many possibilities such as medication, repositioning, activity, distraction, and other modalities.
Priorities of Care
Some of the main priorities of care related to pain assessment include:
- Angina pain: this is a critical finding that requires immediate action.
- A significant increase in pain, particularly when rated higher on intensity scales and the pain does not respond to treatment (e.g., medication). An increase in pain should prompt you to think critically about what is going on and what could be causing the increase. In this case, a full subjective and objective assessment of the pain is required and it should be promptly reported to the physician or nurse practitioner.
- Inadequately managed postoperative pain is of concern because of the physiological effects of pain on the body, such as tachycardia and hypoxia. Additionally, poorly controlled postoperative pain has been correlated with prolonged opioid use (Goesling et al., 2016). Thus, if the prescribed medications are not controlling the pain, you should do a full subjective and objective assessment of the pain and discuss with the healthcare team alternative medications and pain management approaches.
- Pain upon movement with a suspected fracture. Complications associated with fractures include and blood vessel damage, which can cause distal to the fracture due to a disruption in blood flow, nerve damage, and (usually associated with hip and pelvis fractures). Therefore, during the acute period you should immobilize the affected area/limb and continually assess peripheral blood flow (temperature, pulses), quality of breathing, breath sounds, respiration rate, and heart rate. When blood flow is disrupted distal to the periphery, this can cause cool skin temperature and decreased pulse force or absent pulse in the affected limb. Notify the physician or nurse practitioner of this pain and any associated critical findings immediately.
- Back pain associated with potential spinal cord compression: this is a serious issue that may require urgent intervention. The client should remain at rest while you report findings to the physician or nurse practitioner. Compression may be suspected with new onset and severe back pain associated with loss of bladder and/or bowel function and numbness and tingling in the arms and/or legs.
Activity: Check Your Understanding
References
Goesling, J., Moser, S., Zaidi, B., Hassett, A., Hilliard, P., Hallstrom, B., Clauw, D., & Brummett, C. (2016). Trends and predictors of opioid use following total knee and total hip arthroplasty. Pain, 157(6), 1259-1265. https://doi.org/10.1097/j.pain.0000000000000516
refers to bleeding from a damaged blood vessel, when severe it can cause hypovolemic shock with signs of tachycardia and hypotension.
is a deficit of oxygen-rich blood to tissue.
is a serious issue in which a blood clot travels from a blood vessel to the lungs, blocks an artery, and suddenly blocks blood flow can lead to symptoms such as sudden shortness of breath and chest pain.
