Recognizing pain as a component of the primary assessment:
AddingD for discomfortto the ABCs
P a u l a T a n a b e , RN, MSN, CEN, CCRN, Chicago, Illinois
p a i n is f r e q u e n t l y t h e c h i e f s y m p t o m r e p o r t e d b y
p a t i e n t s w h o c o m e to t h e e m e r g e n c y d e p a r t -
m e n t . 1 A l t h o u g h s o m e h a v e n o t e d t h e n e e d to m a k e
p a i n m a n a g e m e n t a priority, 2 p a t i e n t s often r e c e i v e
i n a d e q u a t e p a i n relief a n d h e a l t h care p r o f e s s i o n a l s
s e e m to p a y little a t t e n t i o n to t h e a s s e s s m e n t a n d
t r e a t m e n t of p a i n in t h e e m e r g e n c y d e p a r t m e n t .
T h e A B C s are a l w a y s of first c o n c e r n in t h e
e m e r g e n c y d e p a r t m e n t . I p r o p o s e i d e n t i f y i n g discom-
fort, or pain, as t h e n e w D in t h e p r i m a r y survey, in-
c r e a s i n g t h e e m e r g e n c y n u r s e ' s a w a r e n e s s of t h e im-
p o r t a n c e of p a i n m a n a g e m e n t . R e c o g n i z i n g p a i n as a
c o m p o n e n t of t h e A B C s i n c r e a s e s t h e i m p o r t a n c e of
t h e r e c o g n i t i o n a n d t r e a t m e n t of p a i n in t h e ED
patient.
Pain control in the emergency department
T h e i n a d e q u a t e t r e a t m e n t of s e v e r e p a i n in t h e e m e r -
g e n c y d e p a r t m e n t w a s first u n d e r s c o r e d in 1987.3 One
h u n d r e d s e n i o r h o u s e officers from 14 different acci-
d e n t a n d e m e r g e n c y d e p a r t m e n t s in E n g l a n d c o m -
p l e t e d a s e v e n - i t e m q u e s t i o n n a i r e . E a c h i t e m pre-
s e n t e d a different p a t i e n t s c e n a r i o w i t h a c u t e p a i n
t h a t r e q u i r e d i n t r a v e n o u s l y a d m i n i s t e r e d p a i n anal-
g e s i c s . P h y s i c i a n s d e t e r m i n e d w h i c h drug, dose, a n d
r o u t e t h e y w o u l d u s e to t r e a t t h e pain. Results
i n d i c a t e d t h a t 50% of t h e p h y s i c i a n s w o u l d h a v e u s e d
a n i n a p p r o p r i a t e r o u t e (intramuscular), s o m e p h y s i -
c i a n s utilized t h e w r o n g drug, a n d 20% w o u l d w a i t 90
m i n u t e s before a d m i n i s t e r i n g m o r e a n a l g e s i c after in-
a d e q u a t e relief. G i v e n t h e s e r e s p o n s e s , t h e majority of
p a t i e n t s in t h e v i g n e t t e s w i t h s e v e r e p a i n w o u l d n o t
h a v e b e e n r e l i e v e d of their pain.
Wilson a n d P e n d l e t o n 4 r e v i e w e d t h e r e c o r d s of
198 p a t i e n t s w h o c a m e to t h e e m e r g e n c y d e p a r t m e n t
w i t h p a i n a n d w e r e e v e n t u a l l y a d m i t t e d to t h e h o s p i -
tal. Of t h e s e p a t i e n t s , 98% r e p o r t e d s e v e r e or m o d e r -
a t e pain, a n d only 2% r a t e d their p a i n as mild. Pain w a s
c l a s s i f i e d a s i n t r a a b d o m i n a l , m u s c u l o s k e l e t a l , or in-
Ms. Tanabe is a clinical nurse specialist, Emergency Department,
Trauma Coordinator, Northwest Community Hospital, Arlington
Heights, Illinois.
trathoracic; 56% of t h e s e p a t i e n t s r e c e i v e d no a n a l g e -
sic in t h e e m e r g e n c y d e p a r t m e n t . Of t h o s e w h o re-
c e i v e d m e d i c a t i o n , 69% w a i t e d 1 hour a n d 42%
w a i t e d m o r e t h a n 2 h o u r s before r e c e i v i n g a n a l g e s i c s .
T h i r t y - t w o p e r c e n t of t h o s e w h o r e c e i v e d m e d i c a t i o n
w e r e g i v e n a s u b o p t i m a l d o s e of a n a l g e s i c . P a t i e n t s
r e c e i v e d m e d i c a t i o n for m u s c u l o s k e l e t a l p a i n in 51%
of c a s e s , followed b y a d m i n i s t r a t i o n to 41% of p a t i e n t s
w i t h i n t r a a b d o m i n a l pain. I n t r a t h o r a c i c p a i n w a s
t r e a t e d only 39% of t h e time. A g a i n , i n a d e q u a t e p a i n
management practices were demonstrated.
Mary* is a 3-year-old w h o c o m e s to your emer-
g e n c y d e p a r t m e n t after falling and s u s t a i n i n g a large
laceration to her forehead that requires sutures. What
is your intervention? Do you g e t the p a p o o s e board to
restrain the child or go to the narcotic cabinet for pain
medication?
S e l b s t a n d Clark 1 c o m p a r e d a n a l g e s i c u s e in t h e
e m e r g e n c y d e p a r t m e n t for p e d i a t r i c , adult, a n d el-
d e r l y clients w h o h a d sickle cell crisis, long b o n e frac-
tures, or s e c o n d - or third- d e g r e e b u r n s . Children re-
c e i v e d s t a t i s t i c a l l y s i g n i f i c a n t less a n a l g e s i c s t h a n
a d u l t s (p = 0;001), a n d children y o u n g e r t h a n 2 y e a r s
of a g e r e c e i v e d s t a t i s t i c a l l y s i g n i f i c a n t less (p < 0.01)
a n a l g e s i c s t h a n older children. No differences w e r e
f o u n d b e t w e e n a d u l t s a n d older adults.
W h e n all a g e g r o u p s w e r e c o m b i n e d , only 40%
of p a t i e n t s r e c e i v e d a n y a n a l g e s i c s . Of t h e p a t i e n t s
w i t h sickle cell d i s e a s e , 87% r e c e i v e d m e d i c a -
tions; 37% of p a t i e n t s w i t h lower e x t r e m i t y fracture
r e c e i v e d a n a l g e s i c s ; a n d only 24% of p a t i e n t s w i t h
s e c o n d oi t h i r d - d e g r e e b u r n s r e c e i v e d m e d i c a -
tion. This s t u d y u n f o r t u n a t e l y confirms p r e v i o u s
s t u d i e s 1, 3, 4: ED p a t i e n t s in p a i n are r e c e i v i n g i n a d e -
quate analgesia.
*All patient names used in this article are pseudonyms.
No reprints available from author.
Correspondence: Paula Tanabe, RN, MSN, CEN, CCRN, 3843 N.
Nottingham, Chicago, IL 60634.
J EMERGNURS1995;21:299-304
Copyright 9 1995 by the Emergency Nurses Association.
0099-1767/95 $5.00 + 0 18/1/65028
August 1995 299
JOURNAL OF E M E R G E N C Y NURSINGfranabe
A 1994 study demonstrates that pain relief for the
ED pediatric client continues to be inadequate. Rec-
ords of 99 pediatric trauma victims with a fracture of
the pelvis, long bones, ankle, wrist, or clavicle were
analyzed. Only 62% of these victims received any an-
algesia in the emergency department, again demon-
strating inadequate pain m a n a g e m e n t practices. Pa-
tients with an associated head injury received fewer
analgesics than those without head injury.5 This study
supports previous findings in the pediatric ED client.1
R e c o r d s of 99 p e d i a t r i c
trauma victims with a
f r a c t u r e of t h e p e l v i s , l o n g
b o n e s , a n k l e , w r i s t , or
clavicle were analyzed. Only
62% of t h e s e v i c t i m s
r e c e i v e d a n y a n a l g e s i a in
the emergency department.
Ethnicity is a risk factor for inadequate ED anal-
gesia. 6 The administration of analgesics for ED pa-
tients with isolated long bone fractures was compared
in a Hispanic versus non-Hispanic population. His-
panics were more than twice as likely to receive no
analgesics. This was the first study to identify poten-
tial risk factors, particularly ethnicity, for inadequate
pain management.
Table 1
Misunderstood terms associated with opioid use
A d d i c t i o n : A p a t t e r n of c o m p u l s i v e d r u g u s e
c h a r a c t e r i z e d by a c o n t i n u e d c r a v i n g for a n o p i o i d
a n d t h e n e e d to u s e t h e o p i o i d for e f f e c t s o t h e r
t h a n p a i n relief.
Physical dependence: A p h y s i o l o g i c r e s p o n s e w h e n
a n o p i o i d is w i t h d r a w n a b r u p t l y after c o n t i n u e d
use.
Tolerance: A n i n v o l u n t a r y p h y s i o l o g i c r e s p o n s e of
t h e b o d y to r e p e a t e d o p i o i d u s e , r e s u l t i n g in t h e
n e e d for larger d o s e s to o b t a i n t h e s a m e a n a l g e s i c
effect.
A d a p t e d f r o m A m e r i c a n P a i n Society. Principles of a n a l g e s i c
u s e in t h e t r e a t m e n t of a c u t e p a i n a n d c a n c e r pain. 3rd ed.
Skokie, Illinois: A m e r i c a n P a i n Society, 1992; a n d W a t t - W a t -
s o n J, Ivers D o n o v a n M. Pain m a n a g e m e n t : n u r s i n g p e r s p e c -
tive. St. Louis: Mosby-Year Book, 1992. U s e d w i t h p e r m i s s i o n .
300 Volume21, Number 4
Lewis et 81. 7 reviewed the records of 401 patients
ages I to over 70 at eight different emergency depart-
ments; all patients had diagnosed fractures. Only 30%
of these patients received any analgesics. No differ-
ences were found related to age, setting of the emer-
gency department, or fracture site. Patients admitted
to the hospital received a statistically significant
(p < 0.001) greater amount of analgesics than those
patients discharged from the emergency department.
This very recent study again demonstrates inade-
quate pain m a n a g e m e n t practices that exist today in
emergency departments.
"Oligoanalgesia," the underuse of analgesics for
patients with painful conditions, has been clearly
demonstrated in the ED patient. 4
Barriersto adequatepain treatment
Why do ED patients consistently receive inadequate
analgesia?
Barriers r e l a t e d to h e a l t h c a r e p r o f e s s i o n s
One reason for inadequate analgesia may lie in the in-
adequate education of physicians and nurses, s-l~
Nurses frequently confuse the terms addiction, p h y s -
ical dependence, and tolerance 11 (Table 1). Confusion
regarding these terms m a y result in an unrealistic fear
by the nurse of addiction for the patient. The inci-
dence of addiction caused by short-term use of opi-
oids is extremely low 12 and has been reported to be
less than 1%.s Emergency nurses should not withhold
pain medication for fear of the development of addic-
tion or physical dependence.
The risk of respiratory depression after the ad-
ministration of opioids is frequently a concern of
nurses, is However, the incidence of respiratory de-
pression is u n c o m m o n and should not preclude the
administration of high doses of opioids for the treat-
ment of acute pain. It is true that high doses of opi-
oids in a patient who has never received opioids can
increase the risk of respiratory depression, especially
if the patient falls asleep after the pain is relieved, 14
and that respiratory status should be closely moni-
tored. Physical stimulation is frequently enough to
prevent hypoventilation,14 and significant episodes of
respiratory depression can be treated with naloxone.
Although the risk does exist, respiratory depression is
u n c o m m o n and should not be a barrier to administra-
tion of adequate analgesics. Frequent monitoring is
necessary; if respiratory depression occurs, it can be
treated as described.
Recently the incidence of side effects from high
doses of narcotics administered in the emergency de-
partment was studied. Seventy-two patients from five
study centers received an average of 173 m g of me-

peridine intravenously during the performance of a
painful procedure. Although statistically significant
(p < 0.05) d e c r e a s e s in respiratory rate (20 breaths/
min to 17 breaths/min), blood pressure, and heart rate
did occur, none of the d e c r e a s e s were clinically
significant and did not require any intervention. The
respiratory rates never d e c r e a s e d below 10 per minute,
and no ventilatory a s s i s t a n c e or narcotic reversal w a s
n e c e s s a r y for any of the patients. There were six in-
s t a n c e s of vomiting. Decreases in blood pressure did
not require intervention. In fact, the d e c r e a s e s in blood
pressure a n d heart rate help d e m o n s t r a t e a d e q u a t e
pain m a n a g e m e n t during the procedures.15 This study
clearly d e m o n s t r a t e s the safety of high doses of nar-
cotics in the e m e r g e n c y department.
Numerous other beliefs contribute to the inade-
quate m a n a g e m e n t of pain (Table 2). One myth that
I believe to be true is that p a t i e n t s m u s t look like they
are in pain to actually be in pain. How often have we
honestly thought, "I d o n ' t believe Mr. X is in pain; look
at him sleeping!" I beIieve m a n y health care provid-
ers think that p a t i e n t s m u s t exhibit physiologic signs
of pain to validate the true existence of pain. This is
not true. Patients with chronic pain, and some pa-
tients with acute pain, have physiologically adapted.
These p a t i e n t s will not have an i n c r e a s e d heart rate
or blood pressure. 16 For example, patients who are re-
ceiving [~-blockers cannot exhibit an i n c r e a s e d heart
rate or blood pressure. 16
Cultural factors also influence p a t i e n t s ' r e s p o n s e s
to pain. Many cultures flown on facial grimacing,
writhing in pain, or other responses. Such patients
suffer quietly. Oriental p a t i e n t s are an example of pa-
tients in this category.
Another commonly held belief is that p a t i e n t s will
complain of pain and use the word "pain". 17 How of-
ten has a p a t i e n t with c h e s t pain b e e n a s k e d if he or
she is h a v i n g pain and r e s p o n d e d "no." When another
nurse or p h y s i c i a n u s e s a slightly different term, such
as pressure, the p a t i e n t emphatically responds "yes,"
and rates the pain as "10" on a 10-point scale, with
10 equaling the worst possible pain. Other terms fre-
quently u s e d for " p a i n " include discomfort, soreness,
or aching.
Regardless of the words u s e d to d e s c r i b e their
discomfort, p a t i e n t s m a y not report it at all if they are
afraid of the m e a n i n g of pain and are concerned that
a cause for their pain m a y be found. Such patients m a y
even d e n y it. is Patients e x p e r i e n c i n g myocardial
infarction provide a good example of this. They often
d e n y chest pain for several hours before coming to the
e m e r g e n c y department.
It's a typical "crazy" day in your e m e r g e n c y de-
partment. Mr. Smith is brought to the department b y
Tanabe/JOURNAL OF E M E R G E N C Y NURSING
the paramedics; h e has fallen at a construction site and
sustained an obvious fracture to his distal tibia. Mr.
Smith is very cooperative and does not report any pain
during your initial assessment. After performing your
a s s e s s m e n t , what do you do next? Do you perform a
pain assessment, or do you continue with your other
patients? Mr. Smith does not indicate that h e is in
pain, h e looks comfortable, and the place is "up for
grabs."
In a b u s y ED setting, p a t i e n t s observe the emer-
g e n c y nurse in the chaotic environment and conclude
that m a n a g i n g their pain is not as important as every-
thing else the ED nurse is doing. Mr. Smith probably
w a s h a v i n g a great deal of pain, b u t m a y not have
w a n t e d to bother the nurse. 18
Patients with cognitive or l a n g u a g e i m p a i r m e n t s
m a y not report the e x i s t e n c e of pain. is Patients with
various cultural b a c k g r o u n d s who m a y not speak En-
glish, the elderly, children, or developmentally delayed
individuals require special attention to pain assess-
ment. 12
Don Jones is a 25-year-old man who c o m e s to the
e m e r g e n c y department with sudden onset of severe
right lower quadrant pain, nausea, and a temperature
of 102 ~ F. After the patient has been e x a m i n e d b y the
ED physician, a surgeon is contacted. He can evalu-
ate the patient in 45 minutes. The surgeon requests
that no analgesics be given before his evaluation, be-
cause analgesics would m a k e his physical examina-
tion unreliable.
The withholding of pain m e d i c a t i o n until a diag-
nosis is m a d e is a s t a n d a r d of practice that continues
to exist in many e m e r g e n c y d e p a r t m e n t s . This re-
m a i n s a controversial topic in e m e r g e n c y medicine,
although the fact that there is at least discussion m a y
m e a n hope for c h a n g e in practice. A c c o r d i n g to The
A m e r i c a n Pain Society, "In cases in which the cause
Table 2
M y t h s r e l a t e d to h e a l t h c a r e p r o f e s s i o n a l s t h a t a r e
b a r r i e r s to e f f e c t i v e p a i n c o n t r o l
1. H e a l t h care p r o f e s s i o n a l s do p o s s e s s k n o w l e d g e
r e g a r d i n g a d e q u a t e p a i n m a n a g e m e n t principles.
2. O b v i o u s p a t h o l o g i c c o n d i t i o n s , t e s t r e s u l t s , a n d / o r
t h e t y p e of s u r g e r y d e t e r m i n e t h e e x i s t e n c e a n d
i n t e n s i t y of pain.
3. P a t i e n t s in p a i n a l w a y s h a v e o b s e r v a b l e signs.
4. P a t i e n t s will r e p o r t t h e y are in p a i n a n d w i l l u s e
t h e t e r m pain.
5. P a t i e n t s are n o t t h e e x p e r t s a b o u t t h e i r pain;
h e a l t h care p r o f e s s i o n a l s are.
A d a p t e d f r o m W a t t - W a t s o n J, Ivers D o n o v a n M. P a i n m a n -
a g e m e n t : n u r s i n g p e r s p e c t i v e . St. Louis: M o s b y - Y e a r Book,
1992. U s e d w i t h p e r m i s s i o n .
August 1995 3 0 1
JOURNAL OF E M E R G E N C Y NURSINGFFanabe
of a c u t e p a i n is u n c e r t a i n , e s t a b l i s h i n g a d i a g n o s i s is
a priority, b u t s y m p t o m a t i c t r e a t m e n t of o a i n should
b e g i v e n w h i l e t h e i n v e s t i g a t i o n is p r o c e e d i n g . W i t h
o c c a s i o n a l e x c e p t i o n s (e.g., t h e initial e x a m i n a t i o n of
t h e a c u t e a b d o m e n ) , it rarely is justified to defer an-
a l g e s i a until a d i a g n o s i s is m a d e . In fact, a c o m f o r t a b l e
p a t i e n t is b e t t e r a b l e to c o o p e r a t e w i t h d i a g n o s t i c
p r o c e d u r e s . " 14
A t t h e 1994 a n n u a l m e e t i n g of t h e S o c i e t y of A c -
ademic Emergency Medicine, research was presented
c h a l l e n g i n g t h e n o t i o n of w i t h h o l d i n g a n a l g e s i c s for
t h e ED p a t i e n t w i t h a c u t e a b d o m i n a l pain. S e v e n t y -
o n e a d u l t p a t i e n t s w h o c a m e to t h e e m e r g e n c y
d e p a r t m e n t w i t h a b d o m i n a l p a i n s e v e r e e n o u g h to
Research was presented
c h a l l e n g i n g t h e n o t i o n of
w i t h h o l d i n g a n a l g e s i c s for
t h e ED p a t i e n t w i t h a c u t e
a b d o m i n a l pain.
w a r r a n t u s e of o p i o i d s w e r e r a n d o m l y a s s i g n e d to re-
c e i v e e i t h e r a p l a c e b o of n o r m a l saline solution or
m o r p h i n e sulfate. P a i n s c o r e s w e r e m e a s u r e d in t h e
p a t i e n t s before a n d after m e d i c a t i o n . P a i n relief w a s
c o m p a r e d for b o t h groups, a n d t h e a c c u r a c y of provi-
sional or differential d i a g n o s i s w a s c o m p a r e d w i t h t h e
final d i a g n o s i s . P a t i e n t s w h o r e c e i v e d m o r p h i n e h a d
a s i g n i f i c a n t l y g r e a t e r i m p r o v e m e n t in p a i n s c o r e s
Table 3
Patient-related m y t h s that are barriers to effective
pain control
1. Pain is to be expected w i t h diagnosis and dis-
ease.
2. I have no control over m y pain.
3. I shouldn't ask for anything for pain, unless I'm
desperate.
4. I should w a i t as long as possible before asking for
pain medication.
5. Opioids cause too m a n y problems, such as addic-
tion.
5. Only opioids are strong enough to control pain.
A d a p t e d from Watt-Watson J, Ivers Donovan M. Pain man-
agement: nursing perspective. St. Louis: Mosby: 1992; and
McCaffery M, Beebee A. Pain: clinical manual for nursing
practice. St. Louis: Mosby, 1989.
302 Volume 21, Number 4
( p < 0.01) c o m p a r e d w i t h t h e p l a c e b o group. No
differences in t h e a c c u r a c y of d i a g n o s i s w e r e found
b e t w e e n t h e p l a c e b o a n d m o r p h i n e groups. In fact,
there was a trend toward a more accurate diagnosis
in t h e m o r p h i n e group (p = 0.08). The r e s e a r c h e r s
c o n c l u d e t h a t t h e a d m i n i s t r a t i o n of opioids to p a t i e n t s
w i t h a c u t e a b d o m i n a l p a i n d o e s n o t alter t h e ability to
m a k e a n a c c u r a t e d i a g n o s i s . 19 This is an i m p o r t a n t
study that challenges long-term medical practices.
After a p a t i e n t c o m e s to t h e e m e r g e n c y d e p a r t -
m e n t w i t h a c u t e pain, t h e p a i n no longer s e r v e s a
useful function. A c u t e p a i n c a n c a u s e skeletal m u s c l e
s p a s m , v a s o s p a s m , i m p a i r m e n t of g a s t r o i n t e s t i n a l
a n d g e n i t o u r i n a r y functions, a n d other p a t h o p h y s i o -
logic r e a c t i o n s t h a t m a y l e a d to c o m p l i c a t i o n s . 2~ Spe-
cific p a t i e n t s i g n s and s y m p t o m s (e.g., neurologic defi-
cits) m a y contraindicate t h e administration of analge-
sics; however, t h e s e scenarios should b e the exception
a n d not t h e role. The belief t h a t p a t i e n t s cannot receive
m e d i c a t i o n until a diagnosis is m a d e is a serious barrier
to a d e q u a t e p a i n relief in the ED population.
Patient-related barriers
P a t i e n t s t h e m s e l v e s m a y p r e s e n t a s e p a r a t e s e t of
barriers to a d e q u a t e p a i n control in t h e e m e r g e n c y
d e p a r t m e n t (Table 3). M a n y p a t i e n t s are afraid of opi-
oids a n d will refuse to t a k e t h e s e m e d i c a t i o n s w h e n
offered. 17 T h e c a m p a i g n of "just s a y no to d r u g s " m a y
h a v e h a d a n e g a t i v e effect for s o m e p a t i e n t s w i t h
a c u t e pain. M o r e p a t i e n t s n o w s e e m fearful of receiv-
i n g o p i o i d s a n d of t h e c h a n c e of addiction. It is t h e
e m e r g e n c y n u r s e ' s r e s p o n s i b i l i t y to correct s u c h m i s -
p e r c e p t i o n s b y t h e p a t i e n t a n d to r e a s s u r e t h e p a t i e n t
of m e d i c a t i o n safety. It is also t h e n u r s e ' s e t h i c a l ob-
l i g a t i o n to h o n o r a p a t i e n t ' s refusal o n c e a d e q u a t e ex-
planations have been provided and alternative meth-
o d s of p a i n relief h a v e b e e n s o u g h t .
P a t i e n t s e x p e c t p a i n from d i a g n o s t i c p r o c e d u r e s
a n d d i s e a s e s . 17 It is true t h a t m a n y d i a g n o s t i c a n d
t h e r a p e u t i c p r o c e d u r e s p e r f o r m e d in t h e e m e r g e n c y
d e p a r t m e n t a r e painful, a n d u n n e c e s s a r i l y so. T h e r e
are i n s t a n c e s in w h i c h p a i n from t h e s e p r o c e d u r e s c a n
b e m i n i m i z e d . T h e u s e of m u s i c d u r i n g l a c e r a t i o n re-
pair c a n d e c r e a s e pain. 21 T h e a d m i n i s t r a t i o n of con-
s c i o u s s e d a t i o n for t h e r e l o c a t i o n of d i s l o c a t e d shoul-
d e r s or h i p s is very effective in r e d u c i n g pain.
I m p l e m e n t a t i o n o f A g e n c y f o r H e a l t h Care P o l i c y
and Research guidelines---Assessment practices
T h e k e y to a d e q u a t e p a i n relief is m a k i n g p a i n a pri-
ority, p e r f o r m i n g an a c c u r a t e p a i n a s s e s s m e n t , a n d
r e a s s e s s i n g p a i n after t h e a d m i n i s t r a t i o n of a n a l g e -
sics.
 Tanabe/JOURNAL OF EMERGENCY NURSING

Pain Intensity Scales

Simple Descriptive Pain Intensity Scale*

I I I I I I
No Mild Moderate Severe Very Worst
pain pain pain pain severe possible
pain pain

0-10 Numeric Pain Intensity Scale*

0 2 3 4 5 6 7 8 9 10
I I I I I I I I I I
No Moderate Worst
pain pain possible
pain

Visual Analog Scale (VAS)I"

I I
No Pain as bad
pain as it could
possibly be

* If usedas a graphicratingscale, a lO-cm baselineis recommended.

tA 10-cm baseline is recommendedtor VAS scales.
Figure 1
Pain intensity scales
From Acute Pain Management Guideline Panel.
Acute pain management in adults: operative
procedures--quick reference guide for clinicians.
Rockville, Maryland: Agency for Health Care
Policy and Research, Public Health Service, US
Department of Health and Human Services, 1992.
AHCPR publication no. 92-0019.

In 1992, t h e A g e n c y for H e a l t h Care Policy a n d i n t e n s i t y s c a l e s exist t h a t are e a s y for t h e p a t i e n t a n d

R e s e a r c h (AHCPR) p u b l i s h e d clinical p r a c t i c e g u i d e -
lines, " A c u t e P a i n M a n a g e m e n t : O p e r a t i v e or M e d i -
cal P r o c e d u r e s a n d T r a u m a . " 12 T h e s e g u i d e l i n e s w e r e
d e v e l o p e d b y a large m u l t i d i s c i p l i n a r y p a n e l of p a i n
m a n a g e m e n t e x p e r t s a n d h a v e b e c o m e a c c e p t e d as
t h e s t a n d a r d of care in p a i n m a n a g e m e n t . T h e s e
guidelines address pain assessment and reassess-
m e n t principles, as well a s p h a r m a c o l o g i c a n d non-
p h a r m a c o l o g i c p a i n m a n a g e m e n t s t r a t e g i e s . (The
p u b l i c a t i o n c a n b e o b t a i n e d at no c o s t b y calling [800]
358-9295.)
The patient--not health care professionals--is
t h e m o s t reliable s o u r c e of p a i n information. P a t i e n t s
s h o u l d b e a s k e d to d e s c r i b e n o t only t h e p r e s e n c e , lo-
cation, a n d i n t e n s i t y or s e v e r i t y of pain, b u t also
a n y a g g r a v a t i n g or relieving factors a s s o c i a t e d w i t h
pain. 12
T h e m o s t a c c u r a t e p a i n a s s e s s m e n t is a c c o m -
p l i s h e d b y u s e of a p a i n a s s e s s m e n t tool. Various p a i n
n u r s e to use, in a d d i t i o n to b e i n g reliable a n d valid 12
(Figure 1). S o m e tools p r o v i d e a m o r e t h o r o u g h p a i n
a s s e s s m e n t , i n c l u d i n g t h e c o g n i t i v e a n d affective as-
p e c t s of pain, b u t are often difficult to a d m i n i s t e r in
t h e critical c a r e a n d ED e n v i r o n m e n t . 16 Until other in-
s t r u m e n t s are available to q u i c k l y a s s e s s t h e c o g n i t i v e
a n d affective a s p e c t s of pain, s i m p l e p a i n i n t e n s i t y
s c a l e s are t h e b e s t i n d i c a t o r s of a p a t i e n t ' s d e g r e e of
pain.
Pain r e a s s e s s m e n t s s h o u l d b e b a s e d on t h e
i n t e n s i t y of pain. 12 Pain s h o u l d a l w a y s b e r e a s s e s s e d
after m e d i c a t i o n or a n o t h e r i n t e r v e n t i o n is provided.
It is v e r y e a s y to a d m i n i s t e r a p a i n m e d i c a t i o n a n d
a s s u m e t h a t a n a l g e s i a h a s b e e n provided, w i t h o u t
ever r e a s s e s s i n g t h e p a t i e n t ' s condition. U n e x p e c t e d
i n t e n s e p a i n s h o u l d b e i m m e d i a t e l y e v a l u a t e d to d e -
t e r m i n e a c a u s e . If p a i n is n o t r e l i e v e d or different in-
t e r v e n t i o n s are used, t h e f r e q u e n c y of p a i n a s s e s s -
ments should be increased.

August 1995 303

JOURNAL OF E M E R G E N C Y NURSING/Tanabe

The use of pain flow s h e e t s can help improve pain
control by cuing the e m e r g e n c y nurse to w h e n and
h o w to r e a s s e s s p a i n . 12, 16 T h e s e flow s h e e t s c a n i n c l u d e
m e d i c a t i o n r o u t e , t i m e , r e s p o n s e , a n d s o forth. T h e l a s t
i t e m , p a t i e n t ' s r e s p o n s e , is key. T h e flow s h e e t a t
N o r t h w e s t C o m m u n i t y H o s p i t a l p r o v i d e s a c o l u m n for
"response" listed after every medication. Pain assess-
m e n t c o m p o n e n t s c a n b e i n c l u d e d i n t h e ED n u r s i n g
flow s h e e t , or a s e p a r a t e flow s h e e t c a n b e d e s i g n e d .
S~nnmry
Incorporating discomfort as the D in our primary as-
s e s s m e n t m a y result in pain m a n a g e m e n t b e c o m i n g
a higher priority in care.
I t h a n k J u d y Paice, RN, PhD, for her expert review of this
manuscript.
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304 Volume 21, Number 4