1. PAIN ASSESSMENT
DR LEE OI WAH
PENGARAH HCM

2. REV : SOURCES OF PAIN
 Cutaneous Pain
 Somatic Pain
 Visceral Pain
 Referred Pain
 Neuropathic Pain
 Breaktrhough pain
 Phantom limb sensation
 Psychogenic Pain

3. REV : FACTORS AFFECTING
PAIN
 Perception of Pain
 Socio Cultural Factors
 Age
 Gender
 Meaning of Pain
 Anxiety
 Past experience with Pain

4. INTRODUCTION
 Pain is both a physical and a psychological
phenomenon
 The pain experience is subjective
 Meaningful evaluation and successful treatment of a
patient with pain requires quantification of the
patient’s pain
5th Vital Sign: Doctors’ training module: Pain

5. WHY MEASURE PAIN?
 For documentation
 Produces a baseline to assess therapeutic
interventions e.g. administration of analgesic drugs
 Facilitates communication between staff looking after
the patient
5th Vital Sign: Doctors’ training module: Pain

6. CLINICAL TECHNIQUES FOR
MEASUREMENT OF PAIN
 Self reporting by the patient (best method)
 Observer assessment
 Observation of behaviour and vital signs
 Functional assessment
5th Vital Sign: Doctors’ training module: Pain

7. PAIN MEASUREMENT
 Unidimensional scales
 Numerical Rating Scale (NRS)
 Verbal Analogue Score (VAS)
 Categorical Scale or Verbal rating
scale
 Multidimensional scales
 Brief Pain Inventory (BPI)
 McGill Pain Questionnaire (MPQ)
 Memorial Pain Assessment Card
5th Vital Sign: Doctors’ training module: Pain

8. PAIN MEASUREMENT
Scales used in children / infants and in cognitively
impaired patients
 Wong Baker Faces Scale
 FLACC scale
 Observational scale
 Functional scale
5th Vital Sign: Doctors’ training module: Pain

9. Combination Rating Scale (NRS & VAS)
*Recommended for Ministry of Health*
“On a scale of ‘0’ – ‘I0’ (show the pain scale), if
‘0’ = no pain and ‘10’ = worst pain you can imagine,
what is your pain score now?”
•Patient is asked to slide the indicator along the scale to show
the severity of his/her pain.
•Nurse records the number on the scale (zero to 10)
5th Vital Sign: Doctors’ training module: Pain

10. WHEN SHOULD PAIN BE MEASURED?
 At Rest
 Movement, coughing and deep breathing
Frequency of assessment should be increased if the
pain is poorly controlled
or if the pain stimulus or treatment interventions are
changing
5th Vital Sign: Doctors’ training module: Pain

11. HOW TO ASSESS PAIN:
 Important to :
 listen and believe the patient
 Take a pain history :
 “Tell me about your pain…”
5th Vital Sign: Doctors’ training module: Pain

12. HOW TO ASSESS PAIN IN ADULT
P : Place or site of pain
 “Where does it hurt?”
(a body chart might help describe
their pain)
A : Aggravating factors
 “What makes the pain worse?”
I : Intensity (NRS or VAR)
 “How bad is the pain?”
N : Nature and neutralizing
factors
 “What does it feel like” “What makes the
pain better?”
5th Vital Sign: Doctors’ training module: Pain

13. DETAILED HISTORY
 Goal is to characterize pain by location,
intensity, and etiology
 Listen to descriptive words about
quality, location, radiation
 Evaluate intensity or severity,
aggravating factors (have patient keep a
log)
 Impact on activity, mood, mentation,
sleep, functioning in daily activities

14. DETAILED HISTORY (CONT’D)
 Previous episodes, relation to physical
or stress-related etiological factors
 Previous diagnostics and findings
 Previous treatment and its effects
 Concurrent medical problems (cardiac,
respiratory, anxiety, depression)

15. ASSESSING PAIN IN CHILDREN
Q Question the child
U Use pain rating scales
Evaluate behavioural and
E physiological changes
S Secure the parents’ involvement
Take the cause of pain into
T account
T Take action and evaluate results

16. WHEN SHOULD PAIN BE
ASSESSED ?
1. At regular intervals – as the 5th vital sign
during routine observation of BP, heart
rate, respiratory rate and temperature).
This can be 4 hourly, 6 hourly or 8 hourly
2. On admission of patient
3. On transfer-in of patient
5th Vital Sign: Doctors’ training module: Pain

17. WHEN SHOULD PAIN BE
ASSESSED ?
4. At other times apart from scheduled
observations:
- Half to one hour after administration
of analgesics and nursing
intervention for pain relief
- During and after any painful
procedure in the ward e.g. wound
dressing
- Whenever the patient complains of
pain
5th Vital Sign: Doctors’ training module: Pain

18. WHO SHOULD BE ASSESSED?
 All inpatients
 Including patients in labour room, recovery room
(OT), High dependency units, Coronary Care Units
 All patients in Emergency department
 Ambulatory care units
 Exclusion
 Patients in NICU
5th Vital Sign: Doctors’ training module: Pain

19. Who does Pain Assessment?
- All nurses
- All Doctors
- All Student nurses
- All medical students
….. Everyone!
5th Vital Sign: Doctors’ training module: Pain

20. WHICH TOOL TO USE
TO MEASURE PAIN?
 Usethe standard tool for pain assessment as
recommended by Ministry of Health, Malaysia
 For adult patients, use the combined NRS / VAS
scale
 For paediatric patients 1 month to 3 years old, use
the FLACC
 For paediatric patients > 3-7 years, use the Wong-
Baker FACES scale
 For paediatric patients >7 years, use the combined
NRS/VAS scale (same as for adults)
*Always use the same tool for the same patient
5th Vital Sign: Doctors’ training module: Pain

21. SUMMARY OF ASSESSMENT TOOLS FOR
PAEDIATRICS
0-1 month 1 mth – 3 yrs 3-7 years > 7 years
OPS OPS OPS Coloured analogue
NFCS COMFORT COMFORT scale
CRIES CHEOPS CHEOPS Horizontal
NIPS TPPPS TPPPS linear
COMFORT Nurse FACES analogue
CHEOPS observation Poker chip Adjective self
LIDS Parental Colour scales report
PIPP observation OUCHER APPT
FLACC Horizontal Ladder scale
linear
analogue
VAS
CAS
FLACC

22. IS IT POSSIBLE TO GET A PAIN
SCORE IN ALL PATIENTS??
 Some groups where pain score may be difficult
to elicit may be
 Adult cognitively impaired patients
 Use FLACC score where possible
 Patients with severe head injury
 Patients with language barriers
 Use the visual analogue scale if possible
 “Unable to score” may be recorded if all efforts
to get a pain score have failed
5th Vital Sign: Doctors’ training module: Pain

23. Observation Chart
Patient’s Name : RN : DOA :
Age :
Ward :
DATE TIME BP PULSE RESP TEMP PAIN ACTION COMMENTS
RATE SCORE TAKEN
5th Vital Sign: Doctors’ training module: Pain

24. WONG-BAKER FACES PAIN
RATING SCALE
 This scale can be used with young children
(sometimes as young as 3 years of age). It also
works well for many older children and adults as
well as for those who speak a different language.
Explain that each face represents a person who may
have no pain, some pain, or as much pain as
imaginable. Point to the appropriate face and say:
 (0) "This face is happy and does not hurt at all."
(2) "This face hurts just a little bit."
(4) "This face hurts a little more."
(6) "This face hurts even more."
(8) "This face hurts a whole lot."
(10) "This face hurts as much as you can imagine,
but you don't have to be crying to feel this bad."

25. FACES FOR 3-7YEARS
Wong-Baker FACES pain rating scale
This is a self report tool consisting of 6 cartoon faces.
Ask the child to choose a face which best describes his/her pain ?
Multiply the score below the face by 2 , to get a maximum total
score of 10.
Be careful as some children might confuse the faces as a measure
of happiness

26. FLACC Scale
This is a behavior scale that has been
tested with children age 3 months to 7
years. Each of the five categories (Faces,
Legs, Activity, Cry, Consolability) is
scored from 0-2 and the scores are
added to get a total from 0-10.
Behavioral pain scores need to be
considered within the context of the
child's psychological status, anxiety and
other environment factors.

27. 2
0 1
Frequent to
No particular Occasional grimace or
Face constant frown,
expression or frown, withdrawn
clenched jaw,
smile disinterested
quivering chin
0 2
1
Legs Normal position Kicking, or legs
Uneasy, restless, tense
or relaxed drawn up
0
1 2
Lying quietly,
Activity Squirming, shifting back Arched, rigid, or
normal position,
and forth, tense jerking
moves easily
2
0 1
Crying steadily,
Cry No cry Moans or whimpers,
screams or sobs,
(awake or asleep) occasional complaint
frequent complaints
1
2
Consola 0 Reassured by occasional
Difficult to console
bility Content, relaxed touching, hugging or
or comfort
"talking to, distractible

28. PAIN SIGNS IN COGNITIVELY
IMPAIRED
 Facial expressions
 Verbalizations
 Body Movement
 Change in Interaction
 Change in Activity or Routine
 Mental Status Changes