When evaluating a patients pain, the nurse knows that an example of acute pain would be

Nurses can help patients more accurately report their pain by using these very specific PQRST assessment questions:

P = Provocation/Palliation

What were you doing when the pain started? What caused it? What makes it better or worse? What seems to trigger it? Stress? Position? Certain activities?

What relieves it? Medications, massage, heat/cold, changing position, being active, resting?

What aggravates it? Movement, bending, lying down, walking, standing?

Q = Quality/Quantity

What does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting or stretching.

R = Region/Radiation

Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves around? Did it start elsewhere and is now localized to one spot?

S = Severity Scale

How severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last?

T = Timing

When/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? What were you doing when you first experienced it? When do you usually experience it: daytime? night? early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?

Documentation

In addition to facilitating accurate pain assessment, careful and complete documentation demonstrates that you are taking all the proper steps to ensure that your patients receive the highest quality pain management. It is important to document the following:

• Patient’s understanding of the pain scale. Describe the patient’s ability to assess pain level using the 0-10 pain scale.
• Patient satisfaction with pain level with current treatment modality. Ask the patient what his or her pain level was prior to taking pain medication and after taking pain medication. If the patient’s pain level is not acceptable, what interventions were taken?
• Timely re-assessment following any intervention and response to treatment. Quote the patient’s response.
• Communication with the physician. Always report any change in condition.
• Patient education provided and the patient’s response to learning. Don’t write “patient understands” without a supportive evaluation such as patient can verbalize, demonstrate, describe, etc.

For acute medical and surgical pain in children

Introduction

Aim

Definition of Terms

Assessment 

Pain Assessment Tools

Physiological Indicators

Key Considerations

Special Considerations

Companion Documents

Links

Education 

Evidence Table

Introduction

Pain assessment is crucial if pain management is to be effective. Nurses are in a unique position to assess pain as they have the most contact with the child and their family in hospital. Pain is the most common symptom children experience in hospital. Acute pain (noiciception) is associated with tissue damage and an inflammatory response, it is self limiting of short duration and does not involve neural tissue.
Pain is multidimensional therefore assessment must include the intensity, location, duration and description, the impact on activity and the factors that may influence the child’s perception of pain (bio psychosocial phenomenon) The influences that may alter pain perception and coping strategies include social history/issues, cultural and religious beliefs, past pain experiences and the first pain experience. In addition family response to their child in pain can have a negative or positive influence.

Aim

The guideline specifically seeks to provide nurses with information regarding

• Indications for pain assessment
  
• Type of tools used for pain assessment
  
• Documentation of pain assessment

Definition of Terms

Pain:

• “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery, 1989)
• “Pain is an unpleasant sensory and emotional experience, associated with, or resembling that associated with, actual or potential tissue damage” (IASP 2020)

Pain assessment: is a multidimensional observational assessment of a patients’ experience of pain.

Pain measurement tools: are instruments designed to measure pain.

Assessment

Pain assessment is a broad concept involving clinical judgment based on observation of the type, significance and context of the individual’s pain experience. 
There are challenges in assessing paediatric pain, none more so than in the pre-verbal and developmentally disabled child. Therefore physiological and behavioural tools are used in place of the self-report of pain. However in children with developmental disabilities there can be incorrect assumptions and there is a risk of under-treating pain. It is important to take behavioral cues identified by parents and caregivers to improve pain assessment in these children.

Pain assessment in infants and children is also challenging due to the subjectivity and multidimensional nature of pain. The dependence on others to assess pain, limited language, comprehension and perception of pain expressed contextually. In some children it can be difficult to distinguish between pain, anxiety and distress.

Assessment and documenting pain is needed in order to improve management of pain. When assessing a child’s level of pain careful consideration needs to be given to their:

• cognitive ability
• environment (hospital)
• anxiety
• cause of pain (eg: post-operative)

Pain measurement quantifies pain intensity and enables the nurse to determine the efficacy of interventions aimed at reducing pain.

A pain assessment should be conducted during a patient’s admission. (link to Nursing Assessment nursing clinical guideline)

Points to consider:

• pain history
• location of pain
• intensity of pain
• cognitive development and understanding of pain

When to assess pain?

• Pain scores should be documented for all children at least once per shift in Flow Sheet: ( http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Observation_and_Continuous_Monitoring/) 
  
• Children with pain should have pain scores documented more frequently.
  
• Children who are receiving oral analgesia should have pain scores documented at least 4 hourly during waking hours.
  
• Children on complex analgesia such as intravenous opioid and/ or ketamine, epidurals or regional analgesia should have hourly pain and sedation scores documented.
  
• Assess and document pain before and after analgesia, and document effect.
  
• Assess and document pain on activity such as physiotherapy.
  

Pain Assessment Tools

Tools used for pain assessment at RCH have been selected on their validity, reliability and usability and are recognized by pain specialists to be clinically effective in assessing acute pain. All share a common numeric and recorded as values 0-10 and documented on the clinical observation chart as the 5th vital sign. 
The importance of using the same numeric value (0-10) is that the number relates to the same pain intensity in each tool.

Three ways of measuring pain:

• Self report - what the child says ( the gold standard)
  
• Behavioural –how the child behaves 
  
• Physiological –clinical observations

Pain Assessment Tools used at RCH

There are three main tools used for the neonate, infant and child 3-18 years these tools reflect a combination of self-report and behavioural assessment.

1.     FLACC - The acronym FLACC stands for Face,Legs, Activity, Cry and Consolability. 

Behavioural 

• 2 months-8 years and also used up to 18 years for children with cognitive impairment and/or developmental disability (always elicit support from parents or carers to help with pain assessment)
  
• It may be difficult to assess children with cognitive impairment and/or are non-verbal. Ask the parent or carer to help you explain their child’s pain behaviour. 
  

How to use FLACC

Each category (Face, Legs etc) is scored on a 0-2 scale, which results in a total pain score between 0 and 10. The person assessing the child should observe them briefly and then score each category according to the description supplied.
FLACC has a high degree of usefulness for cognitively impaired and many critically ill children 

2.     Wong-Baker faces pain scale 3-18yo 
Self report

How to use? 
Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn't hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling.

3.     Visual Analogue scale 8-years and older

Self report

How to use?

Ask the child using numbers from 0 = no pain through to 10 being the worst pain

Physiological indicators

• heart rate may increase
• respiratory rate and pattern may shift from normal ie: increase, decrease or change pattern
• blood pressure may increase
• oxygen saturation may decrease

Physiological indicators in isolation cannot be used as a measurement for pain. A tool that incorporates physical, behavioural and self report is preferred when possible.

Key considerations

• assess pain using a developmentally and cognitively appropriate pain tool
• reassess pain after interventions given to reduce pain (eg. Analgesia) have had time to work
• assess pain at rest and on movement
• investigate higher pain scores from expectation
• document pain scores
• use parent/guardian pain behaviour knowledge for children with cognitive impairment.

Special Considerations

Multi language Wong Baker and Numeric tools are available if needed

https://www.briggshealthcare.com/Wong-Baker-Faces-Pain-Rating-Scale-8-Languages

Modified PAT Tool is used in the Neonatal Intensive Care Unit                   

http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neonatal_Pain_Assessment/

Comfort B   is used for Ventilated paediatric patients assessing both pain and sedation         

http://www.rch.org.au/picu_intranet/guidelines/Nursing_management_of_the_patient_with_invasive_mechanical_ventilation_in_PICU/

Companion Documents

• Anaesthesia and Pain Management CPGs and learning packages  http://www.rch.org.au/anaes/
• Observation and Continuous Monitoring Nursing Guideline http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Observation_and_Continuous_Monitoring/
• Nursing Assessment Nursing Guideline  http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_Assessment/

Further information on pain management principles and assessing pain in children can be found here:

• http://www.rch.org.au/uploadedFiles/Main/Content/anaes/pain_management_principles.pdf
  
• http://www.rch.org.au/uploadedFiles/Main/Content/anaes/Pain_assessment.pdf

Links

• Parent support documents “Pain Pain Go Away” 
• ANZCA www.anzca.edu.au
• ISPPhttp://childpain.org/
• WHOhttp://www.who.int/en/

Education

• Supported through the Anaesthesia and pain management web site
  
• Competencies
  
• Presentation to ward nurses
  
• Presentation to RCH nursing programs
  
• Pain tools supplied to all staff

Evidence Table 

The evidence table for this guideline can be viewed by clicking here. 

Please remember to  read the disclaimer. 

The development of this nursing guideline was coordinated by Sueann Penrose, CNC, Children's Pain Management Service, and approved by the Nursing Clinical Effectiveness Committee. Updated August 2022.  

When assessing a patient's pain the nurse knows that the most reliable indicator of pain would be?

When assessing the characteristics of a patient's pain the nurse should ask which question?

How would you measure your patient's pain?

How often is pain assessed for an acute care patient?