Assessment of pain

Assessment involves the measurement of both physiological responses to nociception and the patient's verbal and behavioral communications (pain behavior). Acute pain is viewed as a biologically advantageous and time-limited experience or state ( Cha.p.m.§.D ®L§/: 1992). Sympathetic responses may indicate the presence of acute pain, but over time these responses habituate and their absence does not exclude pain. In the communicative patient, the location of pain should be consistent with the injury or the surgical procedure. If not, another process should be considered.

Pain may be rated as 'mild', 'moderate', or 'severe'. Alternatively, a visual or a verbal analog scale from zero (no pain) to 10 (the worst pain that can be imagined) may be used (Fig 1).

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Fig. 1 Examples of pain intensity rating scales.

Although such scores condense a multidimensional experience into a single rating, they are useful management tools if recorded at regular intervals (e.g. every second waking hour) together with other parameters to provide a profile of the pain state. Pain on movement should also be recorded as 'mild', 'moderate', or 'severe' in order to trigger appropriate interventions. It cannot be assumed that patients will progress at the same rate, and in more complex cases measurements should be taken more regularly. The power of such data may be increased by assessing other components. Thus the ratings may be changed so that zero indicates no unpleasantness or distress and 10 indicates severe unpleasantness or distress. A satisfaction scale may similarly be constructed. Intubated patients may experience difficulties in communicating about their pain. Possible solutions are to indicate painful areas on a body chart and words to describe their pain from a descriptive list. Patients experience procedural and activity-related pain which should be treated proactively with regular assessments of outcome. Incorporating the information into a flowchart will standardize documentation and help to improve clinical practice. More comprehensive tools exist, such as the McGill Pain Questionnaire, which are part of a comprehensive multidisciplinary assessment.

The components of the pain experience are shown in Fig..2.

Fig. 2 Diagram adapted from Loeser's formulation identifying the different components of the pain experience. This emphasizes that nociception, neuropathy, pain, and suffering are personal and private events whose existence can only be inferred. Only pain behavior can be observed and quantified by independent observers.

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