Pain assessment

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Pain is an individual multi-factorial, subjective experience influenced among other things by culture, previous pain experiences, beliefs and mood.

Reliable and accurate assessment of acute pain is necessary to ensure patients experience safe, effective and individualised pain management.

Self-report should always be used whenever appropriate as pain is a subjective experience. When assessing pain our own judgements can affect the assessment of the patient’s pain therefore by using a pain scoring tool, allows for a more objective assessment.

Please note this guidance is for use in in-patients and is not designed for managing patients with chronic pain.

At Raigmore Hospital the Acute Pain Team includes:

Consultant Anaesthetist - Department of Anaesthesia
Clinical Nurse Specialists, Acute Pain Service
Senior Pharmacist - Pharmacy Department

Advice can be sought in office hours - 08.00 – 16.00 (page 1003 or 6056)
out of hours please contact the ITU anaesthetist.

Acute pain assessment tool

Nausea and Vomiting assessment tool

Nausea and vomiting may occur in the post-operative period and is often associated with the use of opioid analgesics. If this side-effect is not treated it may be as unpleasant for the patient as ongoing pain. Use of an assessment tool will also allow assessment of the efficacy of any anti-emetics given.  The nausea and vomiting score is used as follows:

Nausea Score
0 = None
1 = Intermittent nausea
2 = Nausea and/or vomiting - helped by treatment
3 = Nausea and/or vomiting - persistent despite treatment

 

 Measuring nausea and vomiting
 
  • All patients must have nausea scores measured at the same time as their vital signs, using the above scoring tool.
  • The post-operative nausea and vomiting guidelines within this manual will give advice on anti-emetic prescriptions and other factors which need to be considered.
  • If the nausea score = 1, the patient should be offered anti-emetics as they may be helpful.
  • A nausea score of 3 is unacceptable. Refer to the Post-operative Nausea and Vomiting guidelines for assistance in management.
Sedation score tool

Side-effects of opioid analgesics include sedation and respiratory depression. Sedation usually precedes respiratory depression and is therefore an early indication of potential respiratory depression.  

Sedation score 
S = Normal sleep
0 = Awake
1 = Mildly sedated - awakes to verbal stimuli
2 = Moderately sedated - unrousable OR difficult to awaken
3 = Severely sedated - unrousable OR difficult to awaken
Verbal stimuli Speaking to the patient in a normal voice using his/her name, standing beside their bed. The patient should wake to this. 
Touch stimuli Patient should be touched and gently shaken on the shoulder and this should wake the patient.

 

 Measuring sedation score
 
  • Sedation score should be recorded at the same time as the patient's vital observations using the above scoring tool.
  • Only qualified nursing staff may assess patients.
  • If the sedation score = 3, the following must be carried out immediately:
  1. Call for help, call 2222 and start CPR if necessary.
  2. Administer 10L/min of oxygen via Hudson face mask.
  3. Give naloxone intravenously in 100 microgram increments every minute, until the patient's sedation score is 0 or 1.
  4. Contact ward doctor, who should review opioid analgesia.
  5. Contact the Acute Pain Nurse or Intensive Care Unit Anaesthetist so that we are aware of this patient and can give assistance if required. 

 

Pain assessment tool for people with dementia

Please note this guidance is for use in in-patients and is not designed for managing patients with chronic pain

This guidance is for adult patients with dementia who cannot verbalise. 

There is evidence to suggest that people with dementia are likely to receive less pain relief in hospital than people who do not have dementia and this becomes a greater problem the more severe the cognitive impairment (Scherder et al, 2005). Hence, the more confused and disorientated, a person is the less likely they are to receive effective pain control.

Pain assessment for people with dementia may be more complex and should be based on the principles of effective communication, allowing time to assess pain and using pain assessment tools.

In the same way as assessing the cognitive status of a person, when assessing for pain the room should be well lit and communication aids such as glasses and hearing aids should be in place.

Common behaviours associated with pain are vocalisations, grimacing, flinching, guarding of painful part, aggressive behaviour and restlessness, and pulling out tubes from painful parts of the body.

When attempting to detect pain in those with advanced dementia, nurses need to focus on such areas as noisy breathing, negative vocalisation, absence of relaxed body posture and looking tense and fidgeting.

Many people with cognitive impairment who can report the presence of pain have difficulty in quantifying their pain. This would include pain intensity on a 0-10 scale. There are pain assessment scales specifically designed for people with dementia. The Abbey Pain Scale is pain assessment tool for measuring pain in people with dementia who can not verbalise.

Pain Assessment

• Round the clock medication as opposed to ‘as required’ .
• Observe facial expression.
• Enquire systematically about whether they are in pain.
• In the case of major surgery it is important to give pain medication on a scheduled basis.
• Obtain as much information from relatives and carers to assist you in recognising when the person with dementia may be distressed.

Abbey Pain Scale

Pain assessment in patients who are unable to communicate/express their pain can be particularly challenging. 
For example, patients with dementia or patients with other languages. Observations such as facial expressions, behavioural or vital signs can be useful.
Other pain assessment tools such as verbal rating scale and visual analogue scale can be used.

For further information see Paediatric Pain Guidelines and for other languages contact the Acute Pain Team

 

At Raigmore Hospital the Acute Pain Team includes:

Consultant Anaesthetist - Department of Anaesthesia
Clinical Nurse Specialists, Acute Pain Service
Senior Pharmacist - Pharmacy Department

Advice can be sought in office hours - 08.00 – 16.00 (page 1003 or 6056)
out of hours please contact the ITU anaesthetist.

Editorial Information

Last reviewed: 30 November 2018

Next review: 30 November 2020

Author(s): Acute Pain Team, Raigmore

Version: 2

Approved By: TAM subgroup of ADTC

Reviewer Name(s): Acute Pain Nurse Specialist

Document Id: TAM101