How to Identify Pain in Care Settings

When identifying pain in an individual who can verbalise their feelings it is important to obtain relevant and helpful information regarding the pain they are experiencing.

The Royal College of Nursing suggests that pain assessment should help to identify:

• The intensity of the pain.
• The intensity of the associated anxiety and behaviour.

Reassessment of an individual’s pain is also important. If someone is under your care long term and they have ongoing issues with pain, it is important to keep assessing pain.

The Nursing Times outlines that re-evaluating pain regularly can help to:

• Reduce the experience of pain.
• Increase comfort.
• Improve physiological and psychological function.
• Increase satisfaction with pain management.

The types of pain assessment tools

There are two main types of pain assessment tools:

• Uni-dimensional tools: These measure one dimension of the pain such as intensity or location. They are accurate and simple to use and understand. They are best used for acute pain. These include simple verbal descriptors of the pain.
• Multi-dimensional tools: These provide more qualitative and quantitative information about the pain. They require the individual to have good verbal skills and cognitive ability. An example of this is the brief pain inventory.

How to identify pain in adults

If an adult can verbalise their pain accurately, several verbal assessment tools can be used.

In instances of acute or breakthrough pain, it is helpful to ask the individual to:

• Rate the pain on a scale of 0–10.

Or

• Describe the pain as mild, moderate or severe.

The Royal College of Nursing outlines that, to properly identify pain and assess it as to whether further escalation is required.

It is important to identify:

• How bad the pain is, is it getting worse?
• When it began.
• Where it is occurring.
• If it is moving.
• What kind of pain it is.

In an instance of acute or new pain, healthcare professionals should also obtain observations if trained to do so. Knowing an individual’s heart rate, blood pressure and respiration rate can help assess pain.

Pain should always be escalated in some way as a priority and should ethically and lawfully be controlled.

Identifying chronic pain is more complex. Ongoing assessment of chronic pain and identification of developing pain can be done using a multi-dimensional assessment tool such as a pain inventory, where the pain is assessed not only by its presence but by its impact upon the person in several ways.

How to identify pain in the elderly – possible barriers

Some elderly individuals may require different pain identification methods. As part of effective pain identification, the Royal College of Nursing outlines it is important to understand the barriers of effective communication regarding pain.

The elderly may have barriers to their communication of pain including:

• Hearing difficulties.
• Speech and language barriers.
• Cognitive impairment both acute and severe.

Several pain scales can be used to help effective communication of pain, despite these barriers.

Healthcare professionals should be alert to the possibility of pain in older people, and to the fact that older people are often reluctant to acknowledge and report pain.

How to identify pain in the elderly – communication barriers

Common communication barriers may include:

• Hearing impairment.
• Speech and language difficulties.

The British Pain Society has provided guidelines for pain assessment in the elderly to improve pain identification in those with communication barriers.

• Pain identification should use more understandable descriptors to identify pain, such as aching or hurting.
• Pain location should be assessed using accessible means, such as pointing to where the pain is on themselves or pointing on a pain map.
• Improve an individual’s ability to undertake an assessment, such as making sure hearing aids are working or putting on their glasses.
• Self-report assessment scales should be offered in an accessible format to suit the strengths of the individual.
• People with moderate to severe communication problems should be offered additional assistance with self-report through the use of suitably adapted scales.

 Identifying pain in the elderly – cognitive barriers

The British Pain Society gives further guidelines on identifying and assessing pain in the elderly with cognitive impairments:

• In people with very severe impairment, an observational assessment such as the Abbey Pain Scale may be required. This focuses on the presence of certain pain indicators and behaviours.
• Pain behaviours differ between individuals, so assessment should include insights from familiar carers and family members to interpret the meaning of their behaviours.
• Careful physical examination should be undertaken to identify any treatable causes such as sores or wounds.

As per the Mental Capacity Act, a lack of capacity must be established by assessment, and individuals should always be facilitated to be included in decisions made regarding their care where possible despite these kinds of barriers.

Identifying pain in the elderly – assessment tools

The British Pain Society offers the best suggestions for pain assessments in different situations:

What is the Abbey Pain Scale?

This is a useful tool in pain identification in those who are elderly, palliative or who are unable to make their pain needs known due to varying levels of consciousness.

The assessment gets the assessor to give a score concerning six non-verbal pain cues.

These are:

• Verbalisation.
• Facial expression.
• Change in body language.
• Behavioural change.
• Psychological change.
• Physical changes.

The score then gets added to identify the pain as mild, moderate or severe.

How to identify pain in palliative individuals

Pain identification and assessment in palliative patients will vary depending on how advanced their illness is.

NHS England has set guidelines for palliative pain management. Verbal identification of pain is, as always, most accurate and subjective. Carers should try to identify the pain, or pains, of the individual, where these are and what may cause them. Assessment tools may aid self-reporting.

Tools such as:

• Body maps to show site and radiation of pain.
• List of descriptors for the pain.
• A scale to identify the intensity.

Carers should also consider the impact of outside sources of stress and anxiety which may exacerbate pain. Things such as emotional, financial or spiritual distress can affect an individual’s pain perception.

Once pain is identified it should be documented on appropriate care plans to better understand the individual’s pain, manage their expectations and identify their preferred outcomes, and more effectively manage the pain ongoing. Breakthrough or worsening pain should always be escalated and managed appropriately.

As a person enters their last days of life, they may lack the cognitive or communication levels to self-report pain. Assessments should be more observational, monitoring for signs of restlessness or distress. The Abbey Pain Scale may be used to identify pain in this manner.

What are the barriers to identifying pain in children?

Children may have reduced ability to communicate pain. The British Pain Society states that unrelieved pain can be dangerous in children as it can cause physiological as well as psychological complications.

Unrelieved pain can cause:

• Anxiety, distress and feelings of helplessness.
• Avoidance of activities.
• Sleep disturbances.
• Loss of appetite.

As pain is subjective, self-reporting of pain is seen as the most accurate pain assessment.

Barriers to this may be:

• Cognitive ability.
• Developmental age.
• Clinical condition.

Pain identification in children

Observations of:

• Behavioural signs.
• Physiological signs.

Can help to determine if a child is in pain. Children will have a higher rate of breathing and pulse rate when in pain. They may also show visible signs of distress through their behaviour.

Parents and carers should be consulted on the child’s usual behaviour and signs of discomfort or pain. This can be particularly useful in instances where the child has special needs.

Deciding on an appropriate scale of pain assessment will aid in pain identification.

What is the assessment tool?

The National Institute of Health and Care Excellence (NICE) recommends that in ages 0–3 years or infants that can’t communicate verbally a FLACC assessment should be used.

FLACC stands for:

• Faces.
• Legs.
• Activity.
• Cry.
• Consolability.

Each element should be observed for 1–2 minutes; a score is allocated to each one and an overall score of 0–10 is given to assess the pain.

There is also a revised FLACC, which involves the parent or carer assessing each area and having input on observed behaviour and its meaning. This can be used with children who have behavioural or cognitive impairments.

In ages 3 years or above, a faces pain scale can be used to assess and identify pain. This is a self-reporting tool, where the infant can point to the face that they feel is most appropriate for the pain they are feeling.

Children aged 5 years and above who can verbalise and have the cognitive ability can self-report on a visual analogue/numerical scale.

Children should be encouraged to describe their pain on a scale from 0–10 and can point to the score on a visual scale if needed.

It is also important to try to assess:

• History of the pain.
• Location of the pain.
• Description of the pain, i.e. sharp, shooting, aching or burning.

Care planning for pain

Care plans used for pain management should aim to:

• Improve assessment.
• Improve reassessment.
• Outline desired outcomes.
• Include the individual where possible.
• Include the individual’s carers or parents when appropriate.

The use of care plans and documentation should achieve these outcomes and improve pain management and the individual’s experience of the care they are receiving.

Care planning for pain improves the individual’s involvement in their care and choices. It creates an open dialogue and a plan that the individual can follow. It improves an individual’s ability to self-report pain and when a management plan is not offering acceptable management.

Care planning for acute pain

When care planning for acute pain, it is important to use the assessments already discussed. The outcomes of these assessments should be documented and the pain should be escalated either as an emergency or to the individual’s doctor or nursing team.

Observations such as:

• Temperature.
• Blood pressure.
• Pulse.
• Oxygen levels.
• Respiratory rate.

Should be undertaken if trained to do so, and documented to identify any worsening of the individual’s condition. These should be escalated as appropriate.

The individual can be encouraged and helped to use self-management approaches such as repositioning or heat/cold packs.

Reassessment using appropriate documentation and assessment tools should be undertaken to assess the efficacy of the interventions. Documentation of these interventions and outcomes can improve communication within the interdisciplinary team and between the individual and their care staff.

If the individual is suffering acute pain post-surgery or post-injury they may have a care plan as outlined by the care team they are under. This may include medications, physical management or physiotherapy. These plans enable the patient to know their care will be managed and how that aim will be reached.

Care planning for chronic pain

Care planning becomes more complex in chronic pain, as chronic pain is managed holistically and with many different means.

NICE outlines that care planning in chronic pain should heavily involve the individual and focus on improving outcomes by opening communication between the individual and their healthcare team.

Care planning should:

• Discuss and outline the individual’s priorities regarding their pain.
• Describe how they self-manage now and how they prefer to treat their pain.
• Outline to the individual the evidence for risks and benefits of management options available in their case.
• Identify the individual’s strength in pain management and manage their expectations regarding their pain.
• Talk about how pain affects the individual’s life and how their life may affect their pain:
  – Stressful life events.
  – Difficulties with employment, housing and income.
  – Day-to-day events such as sleep.
  – Current or past history of substance misuse.

Development or change in chronic pain should be documented along with the prevalence of the pain on re-assessments. This will help to inform future pain management and if current pain management is effective.

The use of care plans can help individuals alleviate pain and help future management.

Care planning for the elderly and palliative individuals

Often individuals who are elderly or under palliative care will have care plans which include their preferences on pain management. At times advanced care planning and decisions may have been made outlining wishes for pain management. These care plans can exist in many different environments.

To make these care plans for pain management it is important to:

• Understand the individual’s usual level of pain and its management.
• Have an understanding of their underlying health conditions.
• Understand their goals concerning pain and its management.
• Know their preferences about treatment.
• Include their family or carers in what their baseline is.

Using these care plans can inform your response to reported pain. Documenting a change in pain levels using the appropriate assessment and escalating this in a care plan can improve future pain management, and can improve communication between the interdisciplinary team.

Care planning for children

Care planning for pain in children should include the child when possible but should also include their parents or guardian.

Managing pain in children can be made a lot easier by using information from those who know the child better.

Care plans can help to communicate to the child how their pain can be managed and how it will be assessed. This can either be in the short term, i.e. a post-operative plan for pain management, or long-term pain management from chronic conditions. They can also improve relations and build trust between care staff and parents or carers.

The use of care plans can aid the management of pain and inform reassessment.

What is a pain diary?

A pain diary is a useful tool in empowering individuals to self-report pain. They are often used by those suffering from chronic or palliative pain.

The individual uses the diary to document:

• Time and date.
• The type of pain.
• Where the pain is.
• The severity of the pain.
• What makes it better or worse.
• What medicines and treatments the individual has tried.

A pain diary can help identify pain and its causes in the day-to-day setting and highlight any self-management which may relieve pain. It can also be used by individuals to better communicate pain to their physician or care team.

The National Institute of Health and Care Excellence suggests that electronic diaries may be more accurate and easier to update.

A pain diary can be useful to carers and the wider interdisciplinary team. It can be used to:

• Identify if the pain is worsening or more frequent.
• Identify new sources of pain.
• Review if pain relief strategies are effective.
• Identify any self-management that works.

The pain diary can identify if the individual requires escalation for more pain management. It improves communication between the individual and their care team.

What are the effects of acute pain?

The effects of acute pain, while short term, can be far-reaching for the individual:

The physiological effects of acute pain are:

• Raised respiratory rate.
• Raised pulse.
• Raised blood pressure.

The psychological effects can be:

• Acute anxiety and stress.
• Future fear or avoidance.

Social effects may include:

• Decreased ability to take part in daily living.
• Avoidance of activities that may cause further pain.

What are the effects of chronic pain?

Chronic pain will often not have any physical indicators and is often known as an invisible illness. Chronic pain can have a much broader effect on an individual due to its nature. It is therefore suggested that a much broader treatment plan is given to holistically manage chronic pain.

Physiologically, chronic pain causes:

• Ongoing pain and discomfort.
• Reduced mobility in some cases.

Psychologically, chronic pain has been linked to:

• Depression and anxiety.
• Lack of sleep.
• Fear and avoidance.
• Low mood.

Socially, chronic pain can impact:

• Quality of life.
• Ability to undertake daily tasks of living.
• Ability to take on employment.
• Social roles and social identity.

Those with chronic pain will often have a specialist team that will work to manage the individual’s pain and make them a care and management plan.