How can I assess the severity of a patient's pain?

Comprehensive Pain Assessment for Determining Severity

To accurately assess pain severity, use a standardized approach that combines numerical rating scales, qualitative descriptors, and evaluation of functional impact on the patient's life. 1

Initial Pain Screening

• Ask the key screening question: "What has been your worst pain in the last 24 hours on a scale of 0–10?" where 0 is no pain and 10 is the worst imaginable pain 1
• Consider pain scores ≥3 or any pain that distresses the patient as clinically significant and requiring further assessment 1
• For routine monitoring, assess average pain and pain "right now" in addition to worst pain 1

Pain Assessment Tools

Recommended Standardized Scales

• Numerical Rating Scale (NRS): Patient rates pain from 0-10 (most preferred by patients) 2, 1
• Visual Analog Scale (VAS): 10-cm line with "no pain" on left and "worst pain imaginable" on right 1
• Verbal Descriptor Scale (VDS): Series of phrases describing different pain levels (no pain, mild, moderate, severe, extreme) 1
• Faces Pain Scale (FPS): Series of facial expressions showing increasing distress (useful for language barriers or cognitive impairment) 1

Comprehensive Pain Assessment Components

Pain Characteristics

• Type and quality: Ask patients to describe their pain using descriptors that may indicate underlying pathophysiology 1:
  • Aching, throbbing, pressure-like: Often indicates somatic pain (skin, muscle, bone) 1
  • Aching, cramping, gnawing, sharp: Often indicates visceral pain (organs) 1
  • Shooting, sharp, stabbing, tingling, burning: Often indicates neuropathic pain (nerve damage) 1

Pain History

• Onset and duration: When did pain begin and how has it progressed? 1
• Pattern: Is pain constant, intermittent, or breakthrough? 1
• Aggravating and alleviating factors: What makes pain better or worse? 1
• Previous treatments: What has been tried and what was the response? 1

Functional Impact Assessment

• Interference with daily activities: How does pain affect work, social life, sleep, appetite, sexual functioning? 1
• Impact on mood and coping: Assess for depression, anxiety, catastrophizing 1, 3
• Effect on quality of life: Overall impact on well-being and function 1

Special Populations

Non-verbal or Cognitively Impaired Patients

• Observe pain-related behaviors when self-reporting is not possible 1:

  • Facial expressions: Frowning, grimacing, wrinkled forehead, closed/tightened eyes 1
  • Vocalizations: Sighing, moaning, groaning, calling out 1
  • Body movements: Rigid posture, guarding, fidgeting, restricted movement 1
  • Changes in interactions: Aggression, withdrawal, decreased social interaction 1
  • Changes in routine activities: Refusing food, increased rest, sleep pattern changes 1
  • Mental status changes: Crying, increased confusion, irritability 1

• Use validated observational tools for non-verbal patients 1:

  • Pain Assessment IN Advanced Dementia (PAINAD) 1
  • Critical Care Pain Observation Tool (CPOT) 1
  • Behavioral Pain Scale (BPS) 1

Interpreting Pain Severity

Pain Severity Classification

• Mild pain: Generally 1-3 on a 0-10 scale; minimal impact on function 1, 4
• Moderate pain: Generally 4-6 on a 0-10 scale; interferes with some activities 1, 4
• Severe pain: Generally 7-10 on a 0-10 scale; significant functional impairment 1, 4

Multidimensional Assessment

• Consider combining three dimensions for comprehensive severity assessment 4:
  • Pain intensity (0-10)
  • Pain-related interference with activities (0-10)
  • Pain-related distress (0-10)

Common Pitfalls to Avoid

• Underestimation of pain: Healthcare providers tend to underestimate patients' pain, particularly with increasing clinical experience 5
• Relying solely on numerical ratings: Pain is multidimensional and requires assessment beyond just intensity 3, 4
• Ignoring psychosocial factors: Psychological distress can amplify pain perception and should always be assessed 1, 3
• Inconsistent assessment: Use the same pain scale consistently for the same patient to track changes over time 1
• Cultural barriers: Be aware that cultural factors influence pain expression and reporting 1

Documentation Recommendations

• Record all three dimensions: pain intensity, interference with function, and emotional distress 4
• Document the specific pain assessment tool used 1
• Note the context of pain assessment (at rest, with movement, etc.) 1
• Include the patient's own description of their pain in their words 1

By systematically assessing these aspects of pain, clinicians can develop a comprehensive understanding of pain severity that guides appropriate treatment decisions and monitors outcomes effectively.