Page 87 Guide to Pain Management in Low-Resource Settings

Pain History and Pain Assessment 75

to fi nd an elderly woman with end-stage cancer curled
up on her bed and crying, who periodically drifts into a
semi-conscious state. How do you assess her pain?

Answer: From the patient’s initial presenting behavior
(crying and in a fetal position), it would appear that she
is in pain. Th e severity of her condition means that she
is unable to respond verbally to a pain chart or scale.
Th e health care provider would therefore need to take
a history from one of the patient’s carers (assuming
that one is present), asking what makes her pain bet-
ter or worse, how long she has been in pain, where they
Fig. 9. Pain thermometer. (Used with permission. Copyright, Dr
Keela Herr, PhD, RN, FAAN, College of Nursing, Th e University of think the pain is, and whether they think it is localized
Iowa, 2008.) or referred, and using an observational tool such as the
PAINAD. Additional questions should explore how long
the patient has been in a curled position and crying,
Case studies whether she is on any medication (including pain medi-
cation), and whether her pain is getting worse. In mo-
Case 1
ments of consciousness, even if the patient is unable to
You are working in a small, rural hospital when a
verbalize responses to questions based on a pain scale,
7-year-old girl is brought in by her 13-year-old brother.
she may be able to respond by squeezing the health
She has AIDS and is not on antiretroviral therapy.
care provider’s hand or by nodding. In that instance,
She appears to be in some pain. How do you assess
the health care provider should provide the patient
that pain?
with closed questions (e.g., with simple “Yes” and “No”
Answer: Th e imperative in this instance is to control responses), providing very clear instructions on, for ex-
the patient’s pain as quickly as possible; to achieve this, ample, squeezing their hand if the answer is “Yes.” Th is
the health care provider has to assess her pain. Because questioning could be supplemented by a quick physical
she is 7 years old, the patient should be able to verbal- examination to determine what might be causing the
ize her pain. As such, the body diagram and the Wong- patient’s pain. Consequently, the health care provider’s
Baker FACES Pain Rating Scale could be used in combi- assessment would be based on observation, a physi-
nation to achieve an initial assessment of the location, cal examination, simple questions for the patient, and a
radiation, and severity of her pain. Depending on how more comprehensive history from her carer.
severe the patient’s pain is, the health care provider may
be unable to complete a full assessment until the pain Case 3
has been managed. Th e assessment process should, You are working in a regional hospital. A week-old baby
subject to her agreement, involve both the girl and her boy is brought in by his mother. He is experiencing pro-
older brother. It would additionally be important to ex- jectile vomiting (a symptom typical of congenital hyper-
plore a brief family history to determine if the child has trophic pyloric stenosis, a condition that 1 out of 500
an adult carer or whether she is being looked after ex- babies are born with) and will need surgery. Th e baby
clusively by her older brother to ensure that appropriate appears tense and agitated and you suspect that he is in
consent is obtained to undertake possible therapeutic pain. How do you assess the pain?
interventions with the child. If an adult carer cannot be
Answer: Th e FLACC scale could be used to assess the
located quickly, it may be necessary to assess and treat
baby’s pain. What is the expression on the baby’s face?
the girl’s pain while waiting for the carer to begin to
Is he lying with his legs in a relaxed position, or are they
make her comfortable.
restless and tense, or is he kicking? Is he lying quietly, or
is he squirming or rigid? Is he crying and inconsolable?
Case 2
Alongside the FLACC score, the health care
You are working in a home-based care team that visits provider should speak to his mother to determine how
people in a rural setting. You have arrived at a house long he has been in this condition, whether he has