ASSESSMENT AND DIAGNOSIS

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Overview

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Importance of Pain Assessment

Pain is a significant predictor of morbidity and mortality.

Screen for red flags requiring immediate investigation and/or referralIdentify underlying causePain is better managed if the underlying causes are determined and addressedRecognize type of pain to help guide selection of appropriate therapies for treatment of painDetermine baseline pain intensity to future enable assessment of efficacy of treatment

Forde G, Stanos S. J Fam Pract 2007; 56(8 Suppl Hot Topics):S21-30; Sokka T, Pincus T. Poster presentation at ACR 2005.

Speakers Notes

Appropriate assessment of patients presenting with pain is crucial in order to determine whether they are suffering from a condition that requires immediate management or referral. It can also help ensure optimal treatment of pain through identification of the underlying cause of the pain and recognition of the pathophysiologic mechanism behind the pain, which can help guide treatment selection. Finally, determining baseline pain intensity enables future assessment of treatment efficacy in order to guide titration and modification of the analgesic regimen.

References

Forde G, Stanos S. Practical management strategies for the chronic pain patient. J Fam Pract 2007; 56(8 Suppl Hot Topics):S21-30.

Sokka T, Pincus T. Pain as a Significant Predictor of Premature Mortality over 5 Years in the General Population, Independent of Age, Sex and Acutely Life-Threatening Diseases. Poster presentation at ACR 2005.

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Comprehensive Pain Assessment

National Pharmaceutical Council, Joint Commission on Accreditation of Healthcare Organizations. Pain: Current Understanding of Assessment, Management, and Treatments. Reston, VA: 2001; Passik SD, Kirsh KL CNS Drug 2004; 18(1):13-25.

Characterize pain

location, distribution, duration, frequency, quality, precipitants

Take detailed history (e.g., comorbidities, prior treatment)

Conduct physical examination

Clarify etiology, pathophysiology

Complete risk assessment

Assess effects of pain on patients function

Speakers Notes

For patients with chronic pain comprehensive assessment is essential.

A comprehensive pain assessment has multiple components, including:

Complete pain assessment of location, duration, frequency, quality, etc.Complete medication historyPhysical examAssessment of patient functionRisk assessmentMedical clarification of comorbidities, possible pain sources and aberrant pain

References

National Pharmaceutical Council, Joint Commission on Accreditation on Healthcare Organizations. Pain: Current Understanding of Assessment, Management, and Treatments. Reston, VA: 2001.

Passik SD, Kirsh KL. Opioid therapy in patients with a history of substance abuse. CNS Drugs 2004; 18(1):13-25.

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Assessment of Acute Pain

Site of painCircumstances associated with pain onsetCharacter of painIntensity of painAssociated symptoms (e.g., nausea)Comorbidities

TreatmentCurrent and previous medications, including dose, frequency of use, efficacy and side effectsRelevant medical historyPrior or coexisting pain conditions and treatment outcomesPrior or coexisting medical conditionsFactors influencing symptomatic treatment

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 3rd ed. ANZCA & FPM; Melbourne, VIC: 2010.

Speakers Notes

This slide lists information that should be gathered in the course of taking a pain history.

Reference

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 3rd ed. ANZCA & FPM; Melbourne, VIC: 2010.

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Acute Pain Evaluation and Treatment

Ayad AE et al. J Int Med Res 2011; 39(4):1123-41.

Refer to specialist

Yes

No

Speakers Notes

This slide presents a simple flowchart for the management of acute pain.

Patients presenting with acute pain should be evaluated by obtaining a medical history and performing a physical examination. Factors that may influence choice and dose of analgesic should be evaluated, including comorbid medical conditions or laboratory anomalies and current medications with potential for drug interactions.

Next, pain severity should be quantified using a rating scale. Pain-related disability and functional impairment should likewise be quantified.

Patients with severe or disabling pain requiring opioids may required referral to a specialist for treatment. Other patients should be treated with appropriate analgesics and educated about doses, expected time to response, possible side effects, etc. Clinicians should also stress the benefits of behavioral interventions such as exercise and relaxation. The presence of anxiety and/or depression should be evaluated and these conditions should be treated as necessary. Finally, pain severity and functional impairment should be re-assessed at regular intervals and the treatment adjusted based on assessment of response.

Reference

Ayad AE et al. Expert panel consensus recommendations for the pharmacological treatment of acute pain in the Middle East region. J Int Med Res 2011; 39(4):1123-41.

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History

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Clinical Assessment of Pain

Wood S. Assessment of pain. Nursing Times.net 2008. Available at: http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/assessment-of-pain/1861174.article. Accessed: October 7, 2013.

Functional Assessment

Psychological Assessment

Medication History

Speakers Notes

Clinical assessment of pain should include functional and psychological assessments and medication history.

Reference

Wood S. Assessment of pain. Nursing Times.net 2008. Available at: http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/assessment-of-pain/1861174.article. Accessed: October 7, 2013.

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Pain History Worksheet

Site of pain

What causes or worsens the pain?

Intensity and character of pain

Associated symptoms?

Pain-related impairment in functioning?

Relevant medical history

Ayad AE et al. J Int Med Res 2011; 39(4):1123-41.

Speakers Notes

A pain history and examination worksheet can be used to gather a pain history. Patients can use such a worksheet to record their pain and functional impairment. Most worksheets will include pictures of the human body (front and back) on which patients can mark the areas where they feel pain. Worksheets will cover various aspects of pain, such as:

Site of pain What causes or worsens the pain? (e.g., activity)Intensity and character of painRate severity on a scale of 0 (no pain) to 10 (worst possible pain) and evaluate changes in severityDescribe the painCheck whether the pain is continuous or intermittentAssociated symptomsEffect of pain on sleepCurrent level of depressionIs the pain associated with other symptoms?Pain-related impairment in functioning? (no limitation, mild limitation or significant limitation)Relevant medical history

Reference:

Ayad AE et al. Expert panel consensus recommendations for the pharmacologic treatment of acute pain in the middle east region. J Int Med Res 2011; 39(4):1123-41.

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Pain Assessment: PQRST Mnemonic

Provocative and Palliative factors

Quality

Region and Radiation

Severity

Timing, Treatment

Budassi Sheehy S, Miller Barber J (eds). Emergency Nursing: Principles and Practice. 3rd ed. Mosby; St. Louis, MO: 1992.

Speakers Notes

The PQRST mnemonic can be used to assess pain:

Assess Provocative (aggravating) and Palliative (relieving) factorsAssess the Quality of the pain: Burning, stabbing, stinging, dull, sharp, throbbing, shooting, aching, tingling, heaviness, tightnessAssess the Region (location) of the pain, RadiationAssess the Severity of the pain (use pain intensity scale)Assess the Timing of the pain (when does it occur, how long does it persist), as well as Treatments that have been tried

Reference

Budassi Sheehy S, Miller Barber J (eds). Emergency Nursing: Principles and Practice.3rd ed. Mosby; St. Louis, MO: 1992.

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Assessing Acute Pain

Visual analog scale (VAS)Self-rating on a 0100 mm scaleNumerical rating scaleSelf-rating on a 11-point scale: 0 = no pain to 10 = worst painTime-specific pain intensityMy pain at this time is: none, mild, moderate, severe (0 to 3 rating)Time-specific pain reliefMy pain relief at this time is: none, a little, some, a lot, complete (0 to 4 rating)

American Pain Society (APS) questionnaire The degree to which pain interferes with patient function, such as mood, walking and sleepBrief Pain Inventory (BPI)Evaluates severity, impact and impairment on daily living, mood and enjoyment of life

Coll AM et al. J Adv Nursing 2004; 46(2): 124-133; Dihle A et al. J Pain 2006; 7(4):272-80; Keller S et al. Clin J Pain 2004; 20(5):309-18.

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Speakers Notes

Optimal acute pain management is dependent on having an accurate means for assessing the severity and quality of the pain. Ideally, the method employed to determine pain intensity and pain-associated disabilities should be easy to administer, have a low respondent burden (selection may depend on the literacy, numeracy and cognitive abilities of the patient) and be easy to use and interpret so as to better guide treatment selection and adjustment.

References

Coll AM et al. Postoperative pain assessment tools in day surgery: literature review.J Adv Nursing 2004; 46(2):124-33.

Dihle A et