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In developing procedures and guidelines for pain assessment, it is important to remember that the first goal of Pain as the 5th Vital Sign to determine if pain is present. The second goal is to determine the intensity of the pain. The NRS is a measure of pain intensity. The third goal of pain assessment is to determine the significance of the pain. Achievement of the third goal will usually require more comprehensive pain assessment. It is reasonable to expect that a pain score of 4 or higher would trigger a comprehensive pain assessment and prompt intervention. It is likely that in the near future VHA will establish a standard threshold for comprehensive pain assessment based on national experience.
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SECTION 5: COMPREHENSIVE PAIN ASSESSMENTAssessing the “Person with Pain” According to the International Association for the Study of Pain (IASP)3, Pain is an unpleasant sensory and emotional experience associated with actual and potential tissue damage or described in terms of such damage.
Pain is a complex perceptual experience involving all domains of an individual's life, not just physical pathology. It is a subjective phenomenon that is uniquely experienced by each person.
Understanding and appropriately treating patients experiencing pain requires an accurate evaluation, not only of the organic pathology that may be causing the pain, but also a myriad of behavioral and psychosocial factors, each of which contributes to the subjective report.4 Thus, it is imperative that practitioners assess the “person with pain,” not just the pain alone.5 Overview of the Comprehensive Pain Assessment Process Reliable and comprehensive assessment of pain is the cornerstone of effective pain management.
Routine screening for the presence of pain is the first step in an ongoing process of comprehensive pain assessment, prescriptive planning for optimal pain management, delivery of interventions targeting pain, and reassessment and refinement of the pain management plan.
Effective pain management hinges on the availability of a thorough and reliable assessment of pain.
Pain assessment is an interactive and collaborative process involving the patient and family, nurse, physician, and other providers, as appropriate to the clinical setting. It is the basis for selecting an appropriate intervention. Healthcare providers must accept and respect patients’ reports of pain and proceed with appropriate assessment and treatment.
Comprehensive assessment of pain is informed by a biopsychosocial model that emphasizes the important interaction of biological, psychological, and social/cultural contributors to the experience of pain. Assessment also attends to the potential negative impacts of pain on such areas as sleep, mood, activity, appetite, energy, and functioning, including social functioning and relationships.
The primary mode of pain assessment is the clinical interview. The interview is commonly supported by direct observation of the patient’s behavioral manifestations of pain (for example, rubbing affected body parts, bracing, guarding, facial grimacing, sighing) and other signs of physiological stress and arousal.
Other common components of the comprehensive pain assessment process include:
• A thorough and focused physical examination
• Additional medical diagnostic procedures ______________________________________________________________________________________________
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• The use of standardized paper-and-pencil questionnaires and inventories There is a wide array of pain assessment tools and resources that may be useful in developing pain assessment procedures and guidelines for your facility.6 The list of pain assessment resources provided in Section 6 of this toolkit includes both publications and Web sites that provide excellent examples of pain assessment tools and guidelines.
In most settings, pain assessment is interdisciplinary in nature, routinely involving physicians, nurses. When evaluating complex, chronic pain conditions, additional healthcare professionals (e.g., rehabilitation medicine specialists, pharmacists, psychologists) often participate in the comprehensive pain assessment and treatment planning process. Their perspectives are all respected as critical to the development of a reliable and comprehensive understanding of the patient’s pain and associated problems. It is through this interdisciplinary process that a comprehensive and multi-modal plan for effective pain management can be developed and implemented.
Components of the Comprehensive Pain Assessment Interview
In assessing pain, important questions to ask include, but are not limited to, the following:
• Are you having pain now?
• Where is your pain?
• What does it feel like?
• Is the pain always there? Does the pain come and go?
• How long have you had the pain?
• What makes the pain better?
• What makes the pain worse?
• Are you experiencing any other symptoms?
• How does the pain affect your activity, sleep, appetite, mood, social functioning and relationships, energy, and overall quality of life?
• On a scale of 0 to 10, what number represents your (functional) tolerable level of pain?
Documenting the Comprehensive Pain Assessment At the present time, the VHA has not distributed standardized protocols or electronic templates for documenting the results of comprehensive pain assessments. However, many facilities may have established clinical pathways for pain or other pain documentation packets that can be used as local templates for documentation. Examples of local pain assessment templates are provided in Section 6 of this toolkit.
Documentation of the comprehensive pain assessment should include the following key
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• Complete description of the pain experience, including information about its prevalence (e.g., constant, intermittent, episodic, recurring), location(s), character, duration, factors that influence pain, effects on functioning, sleep, appetite, and mood, etc.
• Summary of impressions and diagnosis(es)
• Detailed plan for pain management/treatment
• Specific timeframe for reassessment Sites that utilize VISTA software, particularly Computerized Patient Record System (CPRS), Clinical Reminders, Education Topics and Health Factors, Text Integration Utilities (TIU) Progress Notes, and Health Summary reports, could develop aids to support their local pain management efforts.
Footnotes in Sections 1 through 5 Gordon, D., Dahl, J., & Stevenson, K. (Eds.) (1996). Building an institutional commitment to pain management: The Wisconsin resource manual for improvement. Wisconsin Pain Initiative.
Madison, WI: University of Wisconsin-Madison.
Jenses, M.P. & Karoly, P. (1992). Self-report scales and procedures for assessing pain in adults. In D.C. Turk & R. Melzack (Eds.), Handbook for pain assessment. (pp. 135-151). New York: Guilford Press.
International Association for the Study of Pain. (1979). Pain terms: A list with definitions and notes on usage. Pain, 6, 249-252.
Loesser, J.D., & Melzack, R. (1999). Pain: An overview. Lancet, 353, 1607-1609.
Turk, D.C., & Okifuji, A. (1999). Assessment of patient’s reports of pain: An integrated perspective. Lancet, 353, 1784-1788.
Turk, D.C., & Melzack, R. (1992). Handbook of pain assessment. New York: Guilford Press.
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SECTION 6: EDUCATIONAL AND RESOURCE INFORMATIONThis section provides information to assist individuals and facilities in the successful implementation of the VHA National Pain Management Strategy, including the Pain as the 5th Vital Sign initiative.
VHA National Pain Management Policy
1. Purpose: The purpose of the VHA National Pain Management Strategy is to develop a system-wide approach to pain management that will reduce suffering by veterans experiencing acute and chronic pain associated with a wide range of illnesses, including terminal illness.
2. Background: Pain is a significant healthcare problem in the United States; a substantial portion of the population is afflicted with pain each year. Recent surveys and studies have determined that 20% to 30% of the population annually suffers from acute pain and/or chronic pain syndromes. Further, the incidence and severity of pain increase with increasing age, resulting in a disproportionately large amount of chronic pain occurring in individuals over 60 years of age. Control of cancer pain remains a substantial, unresolved problem with 75% of advanced cancer patients experiencing “moderate” to “very severe” pain.
The knowledge and techniques to control most pain are known, but they are often not applied effectively. Proactive, aggressive management of both acute and chronic pain is universally recognized as an essential component of healthcare; however, substantial evidence indicates that neither acute nor chronic pain is managed adequately within most U.S. healthcare systems. It is essential that VHA develop a systematic approach to pain management that assures that pain is recognized and treated promptly and effectively.
3. Objectives: The overall objective of this policy is to prevent pain and suffering in persons
using the veterans healthcare system. The specific objectives of this policy are to:
• Provide a system-wide VHA standard of care for pain management that will reduce suffering from preventable pain.
• Assure that pain assessment is performed in a consistent manner.
• Assure that pain treatment is prompt and appropriate.
• Include patients and families as active participants in pain management.
• Provide for continual monitoring and improvement in outcomes of pain treatment.
• Provide for an interdisciplinary, multi-modal approach to pain management.
• Assure that clinicians practicing in the VHA healthcare system are adequately prepared to assess and manage pain effectively.
• Pain Assessment and Treatment. Procedures for early recognition of pain and prompt effective treatment shall be implemented by all VA medical treatment facilities. VHA will implement Pain as the 5th Vital Sign in all clinical settings to assure consistent assessment of pain. Pain management protocols will also be established and implemented in all clinical settings.
The complexity of chronic pain management is often beyond the expertise of a single practitioner, especially for patients whose pain problems are complicated by homelessness, posttraumatic stress disorder, combat injuries, and substance abuse.
Primary care providers should have ready access to resources such as pain specialists and multidisciplinary pain clinics and centers to effectively evaluate and manage these complex patients. Pain management is an integral part of palliative and end-of-life care.
The expertise of hospice and palliative care clinicians should be available to all patients with serious, life-limiting illnesses. Patient and family education about pain and its management should be included in the treatment plan, and patients should be encouraged to be active participants in pain management.
• Evaluation of Outcomes and Quality of Pain Management. All VHA medical facilities will implement processes for measuring outcomes and quality of pain management with the goal of continuous improvement. Electronic data monitoring of pain assessment and effectiveness of pain management interventions will be implemented. Patient satisfaction will be monitored on an ongoing basis.