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28 Apr 2021

ECT4Health - Understanding Pain assessment - Tricky

Are you assessing pain ?
One of the most neglected skill sets of a clinician, is pain assessment.   Much has been written over the years but two themes reign supreme:
1 - pain is what the patient says it is.
2 - we are not good at assessment of pain.
As a subjective phenomenon, it is difficult to measure. So, do you use a system?  Have you got a template or a mnemonic you use when assessing a patient for pain.
I like OPQRST:
O - Onset 
Asking about what brought the pain on.  Was it sudden, or a chronic ache that has been there long term. This lets the nurse drill down on any acute change in the pain.
P - Palliation/Provocation
Palliatition is easing or symptoms and provocation is worsening.  So ask your patient what makes their pain better or worse.  Has positioning, analgesia at home, or hot/cold pack made any differences?  Is the pain worsened on movement, palpating, or position?  In chest /abdo pain, dies deep breathing alter the pain?  In leg ulcer patients, is their pain worse when they hang their legs down (venous congestion) or worse when elevating (arterial) - called claudication; this is the difference between venous or arterial disease.
Q - Quality
Asking the patient to describe pain.  This can be difficult for the patient to articulate, so I use this question like a multi choice question.  People might identify if you say others describe their pain as “sharp, dull, stabbing, burning, shooting, electric, heaviness, aching, pressure, throbbing, spasming, cramping etc”.  Is there altered sensation like numbness, pins n needles or intermittent tingling? Can you think of others?
R - Region and Radiation
Where exactly is the pain at its worst?  Can they pinpoint the pain by pointing to where it hurts most?  Some is vague regional pain eg. abdominal or cardiac pain, others are isolated pains like fractures, and epigastric pain.
Ask the patient if the pain radiates or spreads from a focal point to somewhere else.  Typically, cardiac pain radiates from the centre of the chest into the neck, jaw, teeth and arms (L>R).  Some abdominal pain can radiate to the shoulders, and some back pains can send electric shooting pain down the buttocks and back of the legs (sciatica).  
S - Severity
Pain scores have been around for a long time in visual (Wong-BakerFace scale, slide rule descriptor) and numeric 0-10 scoring systems.  These are hard for many patients to interpret and the most inaccurate part of a pain assessment.  Part of the problem with their use is inconsistency that nurses and paramedics apply the pain score.  
0 is no pain.  10 is the worst pain experienced.  It is finite, it is recognisable and it is something that the patient needs to reflect on NOT imagine.   You can not imagine a pain you have never felt, so stop expecting a patient to do this.  Never say - “10 is the worst pain imaginable”.  It isn’t.  10 will only ever be the worst they’ve remembered.  So should your patient suggest they have never experienced pain worse than this pain right now; then take them at their word, and record it as 10.  Soon you will intervene to ease the pain, so you will want to reevaluate the score after positioning or giving analgesia.  0 = no pain: 10 is the worst they’ve ever experienced.  Even if they are laughing or won’t get off their phone!!  Frustrating I know, but it’s not a number they need to get right, nor one that you should judge them on.
T - Time 
Get a time line on the patient pain.  How long have they had this pain, is it there now?  If not when was it there, and for how long?  If it is intermittent, how long is each episode?
Now the data is collected, a physical inspection or palpation may be valuable to aid your assessment.  Use range of movement assessment to put limbs through their paces.  Observe patient posture, positioning and any self protective guarding.  Look for inflammatory signs - red, hot, swollen.  And obtain a tidy medical history, including medications the patient is on.... I use AMPLE and I’ll look at that in the next blog.
So that’s it.  OPQRST.  In a simple template you can follow every time you’re assessing pain.  I hope it was a helpful refresher. 
I’d love to hear your thoughts and opinions, tips and tricks.