Assessing pain key to proper treatment: using a pain rating scale is a good starting point for developing an appropriate pain management strategy.

"PAIN IS what the patient says it is." How many nurses really believe this statement? Indeed, how many actually take the time to thoroughly assess pain from the patient's perspective? This is an important question, as information from the patient is the key starting point to effective pain management. (1) Furthermore, nurses are in a perfect position to perform pain assessment and then intervene with, and evaluate strategies for pain management. (2) Patients have indicated that pain relief is one of the most important aspects of nursing care. (3)

The effective management of pain may fail for a number of reasons, most notably due to inappropriate or non-existent pain assessment, leading to inefficient prescribing of analgesia. In addition, health care professionals lack knowledge about pain, and may hold inappropriate beliefs and attitudes to pain management, in particular relating to opioid drug use. (3)

The physiological function of pain is to provide information about noxious stimuli causing actual or potential tissue injury, thus enabling the body to protect itself from greater damage. (4) Pain can be categorised into two main types, depending on its origin: nociceptive, arising from specialised terminal nerve branches of sensory nerves known as nociceptors; and neuropathic, caused by nerve damage.

While the sensation of pain is generated by actual or potential tissue damage, the response to pain may be modified by psychological, social and cultural influences. For example, anxiety, anger and fear may increase the perception of pain, and cultural beliefs, upbringing and social situation may affect the experience and expression of pain. Almost 40 years ago, English nurse and physician Cicely Saunders developed the concept known as "total pain". This incorporates the aspects of physical, psychological, social, emotional and spiritual suffering experienced by those with pain, particularly those in the terminal stages of illness. (6) The influence of these factors on the pain experience should always be included in an holistic pain assessment.

Accurate assessment is vital in order to provide effective pain management. "If a person has not be thoroughly assessed, then their pain cannot be properly treated". (7) Individual pain assessment should be carried out in an unhurried manner on a regular basis, especially when introducing or changing pain management strategies. (3) Pain should be assessed during both rest and activity, as levels can vary significantly. Assessment must include all relevant factors that will influence the choice of pain management interventions. A full pain assessment should also include a patient history to establish:

* underlying causes for the pain

* whether the pain is acute or chronic

* current interventions, both nursing and medical, as well as complementary

* related symptoms, such as nausea and breathlessness

* psychosocial effects, for example mood, sleep, family/social role

* coping strategies 

* significance and meaning of pain for the patient. (5,8)

Self-assessment rating scales

When assessing pain severity or intensity, it is useful to employ a self assessment pain rating scale. The most commonly used is the visual analogue scale (VAS). The VAS consists of a straight line, usually 100 millimetres long, with descriptive anchors at either end. The anchors represent the extremes of the phenomenon being measured. The patient is asked to place a mark on the line at the point that best describes their opinion of symptom severity. Other versions of this type of scale are an oral 0 to 10 scale (with "0" being no pain and "10" being worst pain imaginable), a descriptive scale, which offers patients the choice of several symptom descriptions, ranging from no pain to excruciating pain, and the pain "thermometer", which offers a pain scale in diagramatic form.

There are some instances where the usual type of pain assessment scale will not be suitable. Assessment tools that focus on behavioural and physiological signs of pain have been developed for infants and toddlers and cognitively impaired individuals. (9,12) These may also be useful for patients with learning disabilities or those unable to communicate verbally. (11) For young children, it is useful to include the parents' perception of their child's pain as well. (10) The Wong-Baker faces pain rating scale (see p15) is a self-assessment scale that has been specifically designed for children. It is similar in function to the VAS, but uses different facial expressions to represent levels of pain. (12) Cognitively impaired and non-English speaking patients may also find the faces-type scale easier to use than the VAS. (13)

Once completed, an accurate and full pain assessment should provide clear information that will guide the development and implementation of an appropriate pain management strategy. This strategy should address all the aspects of the patient's pain, not just the physical symptoms, and may incorporate both pharmacological and non-pharmacological treatments.

REFERENCES

(1) Waugh, L. (1988) Psychological aspects of cancer pain. The Professional Nurse; 3: 12, 504-508.

(2) Herr, K. (2002) Chronic pain challenges and assessment strategies. Journal of Gerontological Nursing; 28: 1, 20-27.

(3) Carr, E. (1997) Overcoming barriers to effective pain control Professional Nurse; 12; 6, 412-416.

(4) Tortora, G.J. and Grabowski, S.R. (2002) Principles of anatomy and physiology. 10th ed. Hoboken: John Wiley.

(5) Brant, J. (2003) Pain management. In: Pulliative Care Nursing A Guide to Practice. 2nd ed (O'Connor, M. and Aranda, S. Eds). Melbourne: Ausmed Publications, 101-114.

(6) Saunders, C. (1964) Care of patients suffering from terminal illness at St. Joseph's Hospice, Hackney, London; Nursing Mirror; 14 February, vii-x.

(7) Downing, J. (19991 Pain in the Patient with Cancer, Nursing Times Clinical Monographs No 5. London: NT Books.

(8) Nicol, M., Bavin C., Bedford-Turner S., Cronin, P. and Rawlings Anderson, K. (2000) Essential nursing skills. Edinburgh: Mosby.

(9) Agarwal, K. (2002) Pain topics: assessment of pain in patients with dementia. Pain Relief Connection. [Online], Boston: Massachusetts General Hospital, Available from URL: http://www.massgeneral.org/painrelief/Newsletter/prcvol1_9.pdf [Accessed 20 June 2003].

(10) Howard, A. (2001) Treating children's wound pain in the community. Nursing Times; 97: 14, NTPlus 57-58.

(11) Davies, D. and Evans, L. (2001) Assessing pain in people with profound learning disabilities. British Journal of Nursing, 10: 8, 513-516.

(12) Wong, D.L., Hockenberry-Eaton, M., Wilson, D., Winkelstein, M.L. and Schwartz, P. (2001) Wong's Essentials of Pediatric Nursing. 6th edn. St. Louis: Mosby.

(13) Rook, J.L. 11996) Wound care pain management. Advances in Wound Care; 9: 6, 24-31.

Wayne Naylor, RCpN, OncCert, Dip Nsg, BSc (Hons), is a clinical nurse specialist at Wellington Hospital's Cancer Centre.