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Ovid: Oxford Handbook of Palliative Care

Editors: Watson, Max S.; Lucas, Caroline F.; Hoy, Andrew M.; Back, Ian N. Title: Oxford Handbook of Palliative Care, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Symptom Management > Chapter 6a – The management of pain > Assessment of pain Assessment of pain When sorrows come, they come not single spies, But in battalions. William Shakespeare 1564–1616: Hamlet (1601) Assessment of a patient’s pain is a crucial skill, which requires a structured approach, a closely listening ear and a sharp eye. Accurate assessment is also helped by experience, and is not a ‘one-off’ event—but needs to be constantly re-evaluated by the healthcare team as more information is gathered. Assessment questions There are many approaches to assessing pain, and each professional will develop his/her own approach to taking a pain history. The specifics of pain history questions are not crucial. What is important is that there is a logical outline scheme which works. Having good assessment technique is the basis for effective palliative care, and for prompt appropriate management of a patient’s pain. P.174
Pain History Principles

  • Seek to establish a relationship with the patient
  • Encourage the patient to do most of the talking
  • Begin with a wide angle open question before clarifying and focusing with more specific ones
  • Watch the patient for clues regarding pain
  • Avoid jumping to conclusions.

Remember, as you are assessing patients, they are assessing you.

  • Eye to eye level contact
  • Clear introduction
  • Avoid over familiarity
  • Explain what you plan to do
  • Summarise back to the patient ‘Have I heard things correctly’
  • Avoid patronizing
  • Use language and terms appropriate to patient

The most extreme agony is to feel that one has been utterly forsaken. –Bettelheim, Bruno (1979). Surviving and Other Essays. New York: Knopf.

Table 6a.2 One scheme of pain assessment questions
Is the patient currently in distress due to pain? Before embarking on a full assessment it is important to achieve sufficient comfort for the patient to go through the assessment.
Is the pain related to movement? Fractures/inflammation/peritonitis/pleurisy?
Is the pain periodic? Colic: due to gastrointestinal or renal tract problems?
Is the pain worse on eating? Mouth, oesophagus or stomach problems?
Is the pain associated with passing urine or stool? Constipation, haemorrhoids, tenesmus, infection?
Is the pain associated with skin changes of colour, temperature or swelling? Pressure sore/infection/ischaemic limb/DVT/skin tumour?
Is the pain associated with altered sensation? This implies nerve damage: neuropathic pain which may occur in a dermatome (an area supplied by a peripheral nerve) sympathetic pain which occurs in the same distribution as the arterial blood supply.
Is the pain persisting? Fear or depression, poor compliance with medication, inappropriate treatment or a new pain?
What relieves the pain? What has already been tried which worked? e.g. change in position, distraction, medication?
Adapted from Thompson and Regnard2

Footnotes 2 Thomson J. W., Regnard C. (1995) Pain. In C. Regnard, J. Hockley (eds) Flow Diagrams in Advanced Cancer and Other Diseases, pp. 5–10. London: Arnold.

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