Since pain is subjective, self-report is considered the Gold Standard and most accurate measure of pain. The PQRST method of assessing pain is a valuable tool to accurately describe, assess and document a patient’s pain. The method also aids in the selection of appropriate pain medication and evaluating the response to treatment. Show Nurses can help patients more accurately report their pain by using these very specific PQRST assessment questions: P = Provocation/PalliationWhat were you doing when the pain started? What caused it? What makes it better or worse? What seems to trigger it? Stress? Position? Certain activities? What relieves it? Medications, massage, heat/cold, changing position, being active, resting? What aggravates it? Movement, bending, lying down, walking, standing? Q = Quality/QuantityWhat does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting or stretching. R = Region/RadiationWhere is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves around? Did it start elsewhere and is now localized to one spot? S = Severity ScaleHow severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last? T = TimingWhen/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? What were you doing when you first experienced it? When do you usually experience it: daytime? night? early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally? DocumentationIn addition to facilitating accurate pain assessment, careful and complete documentation demonstrates that you are taking all the proper steps to ensure that your patients receive the highest quality pain management. It is important to document the following:
Assessment and diagnosis for successful pain management To provide optimal patient care, nurses require appropriate knowledge, skills and attitudes towards pain, pain assessment and its management. This must be based on the best available evidence to prevent patients from suffering harm (NMC, 2008 ). It is unacceptable for patients to experience unmanaged pain or for nurses to have inadequate knowledge about pain and a poor understanding of their professional accountability in this aspect of care (Dimond, 2002). Pain - The fifth vital signPain has been identified as the fifth vital signs by Australian and New Zealand College of Anaesthetists and the Chronic pain Coalition in an attempt to facilitate accountability for pain assessment and management (Chronic Pain Policy Coalition, 2007; ANZCA, 2005). EducationPre-registration nursing programmes should incorporate pain as a compulsory component, to equip future nurses with the knowledge, skills and attitude to carry out appropriate pain assessment and management from the start of their professional careers. This could result in all patients receiving a higher standard of pain assessment and management in the future and reduce the incidence of unnecessary suffering (Wilson, 2007). Why is assessment important?Assessment of a patient’s experience of pain is a crucial component in providing effective pain management. A systematic process of pain assessment, measurement and re-assessment (re-evaluation), enhances the health care teams’ ability to achieve:
Pain is not a simple sensation that can be easily assessed and measured. Nurses should be aware of the many factors that can influence the patients overall experience and expression of pain, and these should be considered during the assessment process. Pain assessment and measurementThe pain assessment involves:
Measuring pain Pain should be measured using an assessment tool that identifies the quantity and/or quality of one or more of the dimensions of the patients’ experience of pain. This includes the:
Measuring pain enables the nurse to assess the amount of pain the patient is experiencing. Patients’ self-reporting (expression) of their pain is regarded as the gold standard of pain assessment measurement as it provides the most valid measurement of pain (Melzack and Katz, 1994). Self-reporting can be influenced by numerous factors including mood, sleep disturbances and medications and may result in patients not reporting pain accurately (Peter and Watt-Watson, 2002). For example, they may fail to report their pain because of the effects of sedation or lethargy and reduced motivation as a consequence of sleep deprivation. Some may suffer in silence as they do not want to bother busy nurses. Nurses often appear to distrust patients’ self-reporting of their pain, which suggests that they have their own benchmark of what is acceptable and when and how patients should express their pain (Watt-Watson et al, 2001). Documentation of pain by nurses has been shown to be poor, and even high pain scores do not result in nurses administering more analgesics (Watt-Watson et al, 2001). Pain assessment tools The range of pain measurement tools is vast, and includes both uni-dimensional and multi-dimensional methods (Table 1). Uni-dimensional tools These tools:
Multi-dimensional pain assessment tools These tools:
Observational tools may be used with patients who are unconscious/sedated and cognitively impaired to assess physiological responses and/or behaviours, for example, facial expressions, limb movements, vocalisation, restlessness and guarding. Global scales may be useful at the end of a pain management intervention to measure the patient’s perception of the overall effectiveness of an intervention. They examine the inconvenience or unpleasantness of the intervention and the personal meaningfulness of any improvement in the patient’s pain and function (ANZCA, 2005). A global scale may be used to rate the effectiveness of patient controlled analgesia for acute pain management and transcutaneous electrical nerve stimulation in chronic pain management.
Uni-dimensional measurement tools (selection):
Multi-dimensional pain measurement tools (selection):
Clinical historyFundamental to the pain assessment process are the patients’ general medical and pain history and a clinical physical examination for both acute and chronic pain. An outline of this assessment process is listed in Table 3.
(adapted from Rowbotham and Macintyre, 2002; Jensen et al, 2003; ANZCA, 2005) Acute pain
Location and description of pain:
Assessment of functional and medical problems should consider:
Factors relevant to effective treatment:
Questions to consider for patients with chronic pain:
Questions about common problems associated with pain:
Guidelines for the assessment of painThere are numerous guidelines and recommendations that incorporate acute and long-term pain assessment and measurement. However, there is no single national guideline and many trusts have developed their own. There are a variety of algorithms available for the assessment and management of patients with acute and post-operative pain and long-term painful conditions (Jensen et al, 2003). The Oxford Pain Internet Site conducts evidence-based medicine systematic reviews and is a good guide for practice. Pain assessment for groups with specific needsThe assessment and measurement of pain in specific groups of patients requires additional considerations, for example children, those with language barriers and older adults (RCP et al, 2007). Older adults may use a range of words other than ‘pain’ to describe their pain experience. A patient who has a cognitive impairment may have difficulty using a variety of pain measurement tools, however simple self-report tools have been shown to be effective. An observational assessment of pain behaviour may be more appropriate for people with sever cognitive impairment, for example, the Abbey pain scale or Pain Assessment Checklist for Seniors with Limited Ability to Communicate. Visually impaired patients may not be able to use a visual analogue scale and may benefit from using a verbal rating scale that is adapted to their needs. Australian and New Zealand College of Anaesthetists (ANZCA) 2005. Acute pain management; scientific evidence. Bennett, M. (2001) The LANSS pain scale; the Leeds assessment of neuropathic symptoms and signs. Pain; 92: 1-2, 147-157. British Pain Society and British Geriatric Society, (2007) The Assessment of Pain in Older People - National Guidelines . Chronic Pain Policy Coalition (2007). A New Pain Manifesto. www.paincoalition.org.uk/ Dimond, B. (2002). Legal Aspects of Pain Management. Salisbury: Quay Books. Hall-Lord, M.L., Larsson BW. (2006) Registered nurses’ and student nurses’ assessment of pain and distress related to specific patient and nurse characteristics. Nurse Education Today; 26: 5, 377-387. Jensen, T.S. et al. (2003) Clinical Pain Management: Chronic Pain. London: Arnold. McCaffery, M., Pasero, C. (1999) Pain: A Clinical Manual. St Louis, MO: Mosby. McCaffery, M.R. et al (2005) Pain management: cognitive restructuring as a model for teaching nursing students. NurseEducator; 30: 5, 226-230. Melzack, R., Katz, J. (1994). Pain measurement in persons in pain. In: Wall, P.D., Melzack, R. Textbook of Pain. London: Churchill Livingstone. Nursing and Midwifery Council (2008) The Code; Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC. Peter, E., Watt-Watson, J. (2002). Unrelieved pain: an ethical and epistemological analysis of distrust in patients. Canadian Journal of Research; 34: 2, 65-80. RoyalCollegeof Physicians, British Geriatrics Society, British Pain Society (2007) The Assessment of Pain in Older People; National Guidelines. Concise guidance on good practice series, No 8. London: RCP. Rowbotham, D.J., Macintyre, P.E. (2002) Clinical Pain Management: Acute Pain. London: Arnold. Watt-Watson, J.B. et al (2001). Relationship between nurses’ knowledge and pain management outcomes for their postoperative cardiac patients. Journal of Advanced Nursing; 36: 4, 535-545. Wilson, B. (2007) Nurses knowledge of pain. Journal of Clinical Nursing; 16: 6, 1012-1020. |