Pain assessment: the cornerstone to optimal

pain management
REGINA FINK, RN, PHD, AOCN

processes such as cancer, HIV/AIDS, arthritis, fibromyalgia, and

CME CME, Part 1 of 3
diabetes. Chronic pain can also accompany an injury that has
Target audience: All physicians not resolved over time, such as reflex sympathetic dystrophy, low
Learning objectives:
D back pain, or phantom limb pain.
1. Understand why pain assessment is key to successful pain man- In the USA, 23.3 million surgical procedures are performed
agement.
IRE
each year, and most, if not all, result in some form of pain (3–6).
2. Define and explain 5 key components of the WILDA approach Pain in persons with cancer also remains a significant problem,
to pain assessment.
with studies suggesting that as many as 30% to 40% of cancer
XP

3. Know how to assess pain in nonverbal or cognitively impaired

patients at diagnosis and 70% to 80% of cancer patients under-
patients.
4. Identify patient populations requiring special consideration going therapy or in the end stages of life have unrelieved pain
TE

when planning optimal pain assessment and management. (7–12). The Mayday Fund survey noted that pain is a part of life
for many Americans, with 46% of respondents reporting pain at
Faculty credentials/disclosure:
some time in their lives (13). It has been estimated that 9% of
DI

Regina Fink, RN, PhD, AOCN, is a research nurse scientist at the Uni-
versity of Colorado Hospital in Denver. Dr. Fink has held positions the US adult population suffers from moderate to severe chronic
RE

as oncology and pain clinical nurse specialist. She is co–principal in- nonmalignant pain (14).
vestigator of a National Institutes of Health grant on palliative care Despite the existence of evidence-based guidelines, acute
EC

and is on the speakers bureaus of Purdue Pharmaceuticals, Anestra pain is not adequately addressed by health care professionals (15).
Corporation, and Roxane Laboratories. Suboptimal pain management is not the result of lack of scien-
Before beginning this activity, please read the instructions for CME tific information, considering the explosion of research on pain
CM

on p. 321. This page also provides important information on assessment and treatment. Yet reports documenting the inabil-
method of physician participation, estimated time to complete the ity of health care professionals to use this information continue
educational activity, medium used for instruction, date of release, to appear in the literature. Studies have found that two of the
and expiration. The quiz, evaluation form, and certification appear chief barriers for health care professionals are poor pain assess-
on pp. 321–323 as well. ment and lack of knowledge about pain (16, 17). Additionally,
clinicians’ personal belief systems, attitudes, and fears can directly
influence the manner in which they and their patients respond
Pain assessment is critical to optimal pain management interventions. to the varied dimensions of pain management.
While pain is a highly subjective experience, its management necessi- Recognition of the widespread inadequacy of pain manage-
tates objective standards of care. The WILDA approach to pain assess- ment has prompted efforts to correct the problems by a wide va-
ment—focusing on words to describe pain, intensity, location, duration, riety of organizations, including the Agency for Health Care
and aggravating or alleviating factors—offers a concise template for Policy and Research, the Joint Commission on Accreditation of
assessment in patients with acute and chronic pain.
Healthcare Organizations (JCAHO), the American Pain Soci-
ety, and the Oncology Nursing Society. The development of prac-

A
ccording to the International Association for the Study tice guidelines and standards reflects the national trend in health
of Pain, pain is an unpleasant sensory and emotional ex- care to assess quality of care in high-incidence patients by moni-
perience arising from actual or potential tissue damage toring selected patient outcomes, as well as the assessment and
(1). Clinically, pain is whatever the person says he or she is ex- management of pain. JCAHO surveyors routinely inquire about
periencing whenever he or she says it occurs (2). Pain is com- pain assessment and management practices and quality assurance
monly categorized along a continuum of duration. Acute pain activities in both inpatient and outpatient care areas.
usually lasts hours, days, or weeks and is associated with tissue
damage, inflammation, a surgical procedure, or a brief disease From University of Colorado Hospital, Denver.
process. Acute pain serves as a warning that something is wrong. Corresponding author: Regina Fink, RN, PhD, AOCN, University of Colorado Hos-
Chronic pain, in contrast, worsens and intensifies over time and pital, 4200 E. Ninth Avenue, Box A021-255, Denver, Colorado 80262 (e-mail:
persists for months, years, or a lifetime. It accompanies disease [email protected]).

236 BUMC PROCEEDINGS 2000;13:236–239

 Assessment of the patient experiencing pain is the corner-
stone to optimal pain management. However, the quality and
utility of any assessment tool is only as good as the clinician’s
ability to thoroughly focus on the patient. This means listening
empathically, believing and legitimizing the patient’s pain, and
understanding, to the best of his or her capability, what the pa-
tient may be experiencing. A health care professional’s empathic
understanding of the patient’s pain experience and accompany-
ing symptoms confirms that there is genuine interest in the pa-
tient as a person. This can influence a positive pain management
outcome. After the assessment, quality pain management de-
pends on clinicians’ earnest efforts to ensure that patients have
access to the best level of pain relief that can be safely provided.
Clinicians most successful at this task are those who are knowl-
edgeable, experienced, empathic, and available to respond to
patient needs quickly.

THE WILDA APPROACH TO PAIN ASSESSMENT

Pain assessment should be ongoing (occurring at regular in-
tervals), individualized, and documented so that all involved in
the patient’s care understand the pain problem. Using the
WILDA approach (Figure 1) ensures that the 5 key components
to a pain assessment are incorporated into the process.
Pain assessment usually begins with an open-ended inquiry:
“Tell me about your pain.” This allows the patient to tell his or
her story, including the aspects of the pain experience that are
most problematic. The clinician must listen closely to these first
words. Patients in pain want to tell their stories, and clinicians
need to take time to listen. Stories are narratives that provide
meaning in our lives. They can teach, heal, validate, offer reflec-
tion, and shape how patients are cared for. Storytelling provides
a different lens through which an experience can be viewed.
Figure 1. A pocket card for health care providers summarizes the WILDA
Words approach to pain assessment. Copyright ©1996, Regina Fink, University
A patient’s statement, “I have pain,” is not descriptive enough of Colorado Health Sciences Center.
to inform a health care professional about pain type. Asking pa-
tients to describe their pain using words will guide clinicians to of choice in patients who can tolerate them (i.e., those who are
the appropriate interventions for specific pain types. Patients may not at risk for gastrointestinal bleeding or renal failure). Addi-
have more than 1 type of pain. The following questions should tionally, muscle relaxants, bone-seeking radiopharmaceuticals
be asked of patients: such as strontium 89 (Metastron), certain biphosphonates
• What does your pain feel like? (pamidronate), and opioid drugs can also be helpful.
• Because various pain types are described using different words, Visceral pain. Pain described as squeezing, pressure, cramp-
what words would you use to describe the pain you are hav- ing, distention, dull, deep, and stretching is visceral in origin.
ing? Visceral pain is manifested in patients after abdominal or tho-
Neuropathic pain. This type of pain can be described as burn- racic surgery. It also occurs secondary to liver metastases or bowel
ing, shooting, tingling, radiating, lancinating, or numbness. or venous obstruction. Opioids are the treatment of choice.
Sometimes patients say that their pain is like a fire or an electri- However, caution should be taken when using this class of drugs
cal jolt. This type of pain can be due to nerve disorders; nerve with patients who have bowel obstructions.
involvement by a tumor pressing on cervical, brachial, or lum-
bosacral plexi; postherpetic neuralgia; or peripheral neuropathies Intensity
secondary to treatment (chemotherapy, radiation fibrosis). Typi- The ability to quantify the intensity of pain is essential when
cally, opioids alone will not help neuropathic pain; antidepres- caring for persons with acute and chronic pain. Though no scale
sants, anticonvulsants, and benzodiazepines may be used as an is suitable for all patients, Dalton and McNaull (18) advocate a
adjuvant treatment. universal adoption of a 0 to 10 scale for clinical assessment of
Somatic pain. Described as achy, throbbing, or dull, somatic pain intensity in adult patients. Standardization may promote
pain is typically well localized. Somatic pain accompanies arthri- collaboration and consistency among caregivers in multiple set-
tis, bone or spine metastases, low back pain, and orthopaedic pro- tings—inpatient, outpatient, and home care environments. Us-
cedures. Nonsteroidal anti-inflammatory drugs are the treatment ing a pain scale with 0 being no pain and 10 being the worst pain

JULY 2000 PAIN ASSESSMENT: THE CORNERSTONE TO OPTIMAL PAIN MANAGEMENT 237
imaginable, a numerical value can be assigned to the patient’s
perceived intensity of pain. Asking patients to rate their present
pain, their pain after an intervention, and their pain over the
past 24 hours will enable health care providers to see if the pain
is worsening or improving. Also, inquiring about the pain level
acceptable to the patient will help clinicians understand the
patient’s goal of therapy. The Wong/Baker faces rating scale is a
visual representation of the numerical scale (19) (Figure 2).
Although the faces scale was developed for use in pediatric pa-
tients, it has also proven useful with elderly patients and patients
with language barriers.
Figure 2. The reverse side of the pocket card shown in Figure 1 displays the Wong/
Location Baker faces rating scale, useful with children, the elderly, and patients with lan-
Most patients have 2 or more sites of pain. Thus, it is impor- guage barriers.
tant to ask patients, “Where is your pain?” or “Do you have pain
in more than one area?” The pain that the patient may be refer- ment (21). Patients may be reluctant to tell their health care
ring to may be different than the one the nurse or physician is providers when they have pain, may attempt to minimize its se-
talking about. Having the patient point to the painful area can verity, may not know they can expect pain relief, and may be
be more specific and help to determine interventions. concerned about taking pain medications for fear of deleterious
effects. A comprehensive approach to pain assessment includes
Duration evaluating patients’ knowledge and beliefs about pain and its
Breakthrough pain refers to a transitory exacerbation or flare management and reviewing common misconceptions about an-
of pain occurring in an individual who is on a regimen of anal- algesia. Several common myths need to be discussed openly:
gesics for continuous stable pain (20). Patients need to be asked, • Pain is a part of life. I just need to bear it.
“Is your pain always there, or does it come and go?” or “Do you • I shouldn’t take my pain medication until I really need it or
have both chronic and breakthrough pain?” Pain descriptors, else it won’t work later.
intensity, and location are important to obtain not only on break- • I don’t want to become an addict.
through pain but on stable (continuous) pain as well. • I don’t want to get constipated so I’d better not take my pain
medication.
Aggravating/alleviating factors • I don’t want to bother the doctor or nurse; they’re busy with
Asking the patient to describe the factors that aggravate or other patients.
alleviate the pain will help plan interventions. A typical ques- • If it’s morphine, I must be getting close to the end.
tion might be, “What makes the pain better or worse?” Analge- • My family thinks I get confused on pain medication; I’d bet-
sics, nonpharmacologic approaches (massage, relaxation, music ter not take it.
or visualization therapy, biofeedback, heat or cold), and nerve Discussing these myths during the assessment process not
blocks are some interventions that may relieve the pain. Other only legitimizes patients’ concerns but provides an opportunity
factors (movement, physical therapy, activity, intravenous sticks to educate patients and families about pain medications and how
or blood draws, mental anguish, depression, sadness, bad news) they work. At times patients and family members believe that
may intensify the pain. behavior such as complaining about pain or inadequate pain re-
Other things to include in the pain assessment are the pres- lief may result in substandard care (22). Realizing that they have
ence of contributing symptoms or side effects associated with pain limited time with their health care providers, patients may pri-
and its treatment. These include nausea, vomiting, constipation, oritize the time available to them. Assuming that “good” patients
sleepiness, confusion, urinary retention, and weakness. Some will receive more time and attention, patients decide for them-
patients may tolerate these symptoms without aggressive treat- selves that discomfort is not part of the good patient role. This
ment; others may choose to stop taking analgesics or adjuvant is another misconception to discuss with the patient.
medications because of side effect intolerance. Adjustments, al-
terations, or titration may be all that is necessary. ASSESSING PAIN IN NONVERBAL OR COGNITIVELY IMPAIRED
Inquiring about the presence or absence of changes in appe- PATIENTS
tite, activity, relationships, sexual functioning, irritability, sleep, Patients’ self-report is the gold standard of pain assessment.
anxiety, anger, and ability to concentrate will help the clinician However, pain tools that rely on verbal self-report, such as the 0
understand the pain experience in each individual. Additionally, to 10 numeric rating scale, may not be appropriate for use in
the clinician should discern how pain is perceived by the patient nonverbal or cognitively impaired patients. Additionally, reli-
and his or her family or significant other and what works and ance on nonverbal cues—e.g., changes in vital signs, moaning,
doesn’t work to help the pain. facial grimacing, or muscle tenseness—is not practical or reliable.
Diverse responses to pain atypical of conventional pain behav-
PATIENTS’ KNOWLEDGE AND BELIEFS ABOUT PAIN iors have been noted in patients with Alzheimer’s disease by
Patients’ knowledge and beliefs about pain are assumed to Marzinski (23). For example, a patient who normally rocked and
play a role in pain perception, function, and response to treat- moaned became quiet and withdrawn when experiencing pain.

238 BAYLOR UNIVERSITY MEDICAL CENTER PROCEEDINGS VOLUME 13, NUMBER 3

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all concerned.

JULY 2000 PAIN ASSESSMENT: THE CORNERSTONE TO OPTIMAL PAIN MANAGEMENT 239