PAIN ASSESSMENT AND MEASUREMENT TOOLS

Definition

One of the most enduring definitions of pain is simply that “pain" is "what the person
says it is, existing when the person says it does”(McCaffery, 1968). Therefore the
standard for assessing the existence and intensity of pain is what the patient reports it
is (Pasero & McCaffery, 2001).

Pain assessment and measurement is a complex subject. During clinical assessment

you may need to perform a comprehensive pain assessment whereas at other times a
quick pain rating scale may be sufficient to monitor the patients’ response to therapy.

Pain is a subjective, multifaceted phenomenon which is influenced by many factors.

These factors include culture, individual differences and past experiences of pain
(Bourbonnais et al., 2004).

Pain can be acute or chronic and obviously can also be a mix of both – e.g. acute on
chronic pain. By definition, acute pain is brief in duration and is related to specific
pathological processes. Chronic pain is pain that continues beyond the expected
healing timeframe, and is usually defined as persisting for greater than six months. In
prolonged or chronic pain, psychological, interpersonal and environmental factors will
also impact on the pain experience (Yonan & Wegener, 2003).

Loeser (1982) identified that pain is a multidimensional, multilevel experience with four
components:

1. Nociception (stimulation of nerve fibres)

2. Pain (interpretation of this stimulation)
3. Suffering (affective and cognitive responses associated with pain)
4. Pain Behaviour (observable response of the individual)

Definitions

o Nociceptive Pain: Results from activation of primary afferent neurons by

noxious stimuli.
o Neuropathic Pain: Caused by a primary lesion of dysfunction of the nervous
system.
o Hyperalgesia: An increased response to stimulus that is normally painful.
o Allodynia: Pain caused by non noxious stimuli.

Assessment of Pain

Pain assessment must be performed within the context of other symptoms because the
pain may impact on the expression of experiences of other symptoms (Bruera &
Watanabe, 1994).

There are a number of pain assessment tools which aim to quantify the persons’ pain.
Some of the more commonly encountered tools are the numeric rating scale, the visual
analogue scale, the verbal descriptor rating scale (VDS), the revised Faces Pain Scales
and the Wong Baker Faces Pain Scales.

The Verbal Descriptor Rating Scale (VDS) was developed by Keele in 1948 and uses 3
to 5 numerically ranked words (Coll et. al., 2004). These words include none, slight,
mild, moderate, and severe. This tool has been criticised because it restricts choice to
5 words and has the potential for ambiguity.

The Numeric Rating Scale (NRS) generally uses a horizontal score from 0 to 10. 0
indicates no pain and a score of 10 indicates severe pain. The NRS is simple to use and
does not rely on good English language comprehension. Its main disadvantage is
unreliability in people who may not be able to differentiate between the numbers
(Flaherty, 1996 – as cited in Coll et. al., 2004).

A criticism of both the VDS and NRS is that they ask the person to choose one word or
number, thus restricting choice. However, the NRS continues to be a popular choice
(Jensen et. al., 2001).

The Visual Analogue Scale (VAS) was developed over 70 years ago (Coll et. al., 2004).
This scale consists of a horizontal line with the left side representing no pain and the
right side representing ‘unbearable’ pain. The patient is asked to indicate the place on
the scale that marks their level of pain (op. cit.). This tool is reported as being
confusing and can be difficult to use, even with explanation (op. cit.).

Other tools in use are the Wong-Baker Faces Pain Rating Scale (WBFPS) and the
Revised Faces Pain Scale (FPS-R). Both of the Faces Pain Scales consist of six simple drawings of
faces, which have expressions ranging from neutral or smiling to crying and very distressed. These scales are
useful in cognitively impaired patients or those unable to comprehend English (Yonan & Wegener, 2003).

Wong-Baker Faces Pain Rating Scale (WBFPS)

 Revised
Faces Pain Scale (FPS-R)

There are a number of mnemonics in use to act as a prompt when taking a pain
history.

PQRST

P- Provokes/Palliates/Precipitates.

 What makes the pain better/worse?

Q- Quality.

 Ask the patient to describe the pain. “If I had to have your pain, what would it
feel like?” This can help describe the pain as either
o nociceptive (near site of injury, boring, aching, bruised) or
o neuropathic (not near site of injury, often follows distribution of a nerve,
burning, shooting, stabbing)

R- Region(s)/Radiation

 Ask about location(s)

 Does it travel (radiate) anywhere?

S- Severity/Symptoms

 Use a pain rating scale (NRS or VAS)

 Are there any other symptoms? E.g. nausea, vomiting, depression

T- Time/Temporal Relations

 Duration
 Constant or intermittent (colicky)
 Any particular time or time pattern?

References:

 Bourbonnais , F.F., Perreault, A., & Bouvette, M. (2004) Introduction of a pain

 and symptom assessment tool in the clinical setting – lessons learned. Journal of
Nursing Management. 12(3):194-200.
 Bruera, E., and Watanabe, S. (1994) New Developments in the assessment of
pain in cancer patients. Supportive Care Cancer. 2:312-318.
 Coll, A.M., Ameen, J., and Mead,D. (2004) Post operative pain assessment tools
in day surgery: A literature review. Journal of Advanced Nursing. 46(2):124-133.
 Jensen, M.P., Smith, D.G., Ende, D.M., & Robinson, L.R. (2001) Pain site and the
effects of amputation pain: Further clarification of the memory of mild, moderate
and severe pain. Pain 91:317-322
 Loeser, J.D. (1982) Concepts of pain. In: Stanton-Hicks, M. and Boas, R. (eds)
Chronic Low Back Pain. New York: Raven Press. pp145-148.
 McCaffery, M.S. (1968) Nursing theories related to cognition, bodily pain, and
man – environment interactions. Los Angeles: UCLA Students’ Store.
 Pasero, C., & McCaffery, M.S. (2001) The Patient's Report of Pain: Believing vs.
accepting. There's a big difference. American Journal of Nursing 101(12):73-74.

 Yonan, C., and Wegener, S.T. (2003) Assessment and management of pain in
the older adult. Rehabilitation Psychology. 48(1):4-1