Page 80 Guide to Pain Management in Low-Resource Settings

68 Richard A. Powell et al.

Q = Quality culturally acceptable levels of “complaining,” a sense
• What does the pain feel like? of hopelessness, diminished morale, coping and ad-
• Is it sharp? Dull? Stabbing? Burning? Crushing? aptation abilities, and the meaning attached to the

R = Region and Radiation experienced pain). Consequently, the health care pro-
• Where is the pain located? vider should accept the patient as an expert on his or
• Is it confi ned to one place? her own body, and accept that while some patients
• Does the pain radiate? If so, where to? may exaggerate their pain (e.g., to be seen earlier in
• Did it start elsewhere, and is it now localized to a hospital), this will generally be the exception rath-
one spot? er than the norm. Moreover, evidence suggests that
health care providers’ observational pain report can-
S = Severity
not be assumed to be an accurate indicator of the pa-
• How severe is the pain?
tient’s pain.
T = Time (or Temporal)
Second, as much as is possible within a time-
• When did the pain start?
constrained service setting, allow patients to describe
• Is it present all the time?
their pain in their own words (the fact that patients may
• Are you pain-free at night or during the day?
report socially acceptable answers to the health care
• Are you pain-free on movement?
provider demands a sensitive exploration of what is ex-
• How long does the pain last?
pressed). For patients who feel uncomfortable express-
At the patient’s fi rst assessment, the pain assess- ing themselves, the health care provider can provide a
ment process should be a constituent part of a wider sample of relevant words written on cards from which
comprehensive patient assessment that could include the patient can select the most appropriate descriptors.
additional questions: Th e primary intention here is to listen to the patient
• Is there a history of pain? rather than make any potentially false assumptions and
• What is the patient’s diagnosis and past medical erroneous clinical decisions.
history (e.g., diabetes, arthritis)? Th ird, listen actively to what the patient says.
• Is there a history of surgical operations or medi- Rather than engage the patient in a distracted man-
cal disorders? ner, the health care provider should focus attention on
• Has there been any recent trauma? the patient, observing behavioral and body language,
• Is there a history of heart disease, lung problems, and paraphrasing words when necessary to ensure that
stroke, or hypertension? what is expressed is clearly understood. In emotionally
• Is the patient taking any medication (e.g., to re- charged encounters, the health care provider must also
duce the pain; if so, did it help the patient?) actively listen for nonverbal descriptors.
• Does the patient have any allergies (e.g., to food Fourth, the location of the pain across the body
or medicines)? can be determined by showing the patient a picture of
• Does the pain hurt on deep inhalation? the human body (at least the front and back) (see Ap-
• What is the patient’s psychological status (e.g., pendix 1 for an example of a body diagram), requesting
depression, dementia, anxiety)? that they indicate the primary and multiple (if appropri-
• What is the patient’s functional status, including ate) areas of pain, and demonstrate the direction of any
activities of daily living? radiated pain.
Fifth, pain scales (of varying complexity and
What can be done to ensure an methodological rigor) can be used to determine the se-
eff ective pain assessment process? verity of the expressed pain (see below for some exam-
ples).
First, in general, accept the patient’s self-reported pain Sixth, while it is important to manage an indi-
as accurate and the primary source of information. vidual’s pain as soon as is possible (i.e., one is not obli-
Pain is an inherently subjective experience, and the pa- gated to wait for a diagnosis), in the assessment process
tient’s expression of this experience (be it behavioral the health care provider should also diagnose the cause
or verbal) can be infl uenced by multiple factors (e.g., of that pain and treat if possible, thus ensuring a longer-
gender diff erences, socially acceptable pain thresholds, term resolution to the presenting pain problem.