Health Assessment, part 10: Pain Assessment
by Meris Shuwarger May 26, 2023 Updated: August 10, 2023 8 min read
Hi. I'm Meris. And in this video, I'm going to be talking to you about how to perform a pain assessment, including what the components of a pain assessment are, and I'll also be reviewing some different pain scales with you. I'm going to be following along using our health assessment flashcards. These are available on our website, leveluprn.com, if you want to grab your own. And if you already have a set for yourself, I would invite you to go ahead and follow along with me. Okay. Let's get started. So first up, let's talk about a pain assessment. What the components are. And I would strongly encourage you to pull out this flashcard and take a look at it because we really went into depth here on what is involved in a pain assessment. So the cool chicken, the way that we have to remember this right off the bat is to remember pain assessment with OLD CARTS. Now, I can hear some of you, "Meris, my professor taught us OPQRST." That's super. If that's how you want to assess pain, that is great. I'm telling you that this is the best information out there is to use OLD CARTS. If you worked pre-hospital EMS like I did, you are probably more familiar with PQRST or OPQRST. Use what makes sense for you. But for our purposes, we're going to go with OLD CARTS. And I'm going to rattle this off for you so that you can see this is what you need to be able to do. Onset, location, duration, characteristics, aggravating factors, relieving factors, treatment, severity. There we go, OLD CARTS. You've got to be able to rattle that off. When I was in health assessment and I had a test, I would literally sit down, they would give me scrap paper, and I would write OLD CARTS, and then I would write what it stood for.
So let's go through it. O, onset. When did the pain start? That's the question you're going to ask. Did it start five minutes ago, or has it been going on since 1983? Location. Where does it hurt? Tell me specifically. And this is a trick of the trade. I like to ask my patients, "Using one finger, show me where it hurts the most." Patients will oftentimes say, "It hurts here." "Okay. But does it hurt here, or does it hurt here?" So using one finger is a really great way to show me where it hurts. Duration. Duration means does it come and go, or is it constant? Okay. It's different than onset. How long it has lasted? It's saying, "Does it come and go? Or is it there all the time?" C for characteristics. This one tricks students all the time because it's kind of a weird question. But characteristics of the pain, it's asking you, what does the pain feel like? So I will ask my patients, "Can you describe the pain? Can you tell me what it feels like?" And I usually prompt them with some examples. Like, "Is it aching or stabbing or throbbing?" So that they understand what I'm asking them. So for instance, we have on here that nociceptive pain, meaning pain that is related to injury of nociceptive nerves, is often described as aching or throbbing, while neuropathic pain, which is related to the damage of nerves like chronic damage, is going to be described as shooting or burning. Sometimes they'll call it a numbness or a tingling. But that can help you to understand where's this pain coming from. Is it coming from the organs? Is it coming from the skin? Is it chronic neuropathy? Those sorts of things.
Now, aggravating and relieving factors. Very easy question. Does anything make it worse? Does anything make it better? Radiation is another one that's on here. And this one I forgot to say in my rattling-off OLD CARTS because I went with relieving. It's aggravating and relieving, and then radiation. Radiation means does the pain move anywhere else? So yes, you have 10 out of 10 substernal chest pain. It hurts here. But does it also feel like it goes up your jaw? Does it also feel like it goes down your arm? That is very important for me to understand because there are certain disease processes that will lead to pain radiation. So where is the pain? "Does it move anywhere else," is a question I like to ask. Treatment. What have you tried to treat this pain? This also gives me valuable information. If you say to me, "I have tried Tylenol. I have tried ibuprofen. I have tried ice. I have tried heat. I have tried elevation. I have tried compression. I have tried walking. I've tried resting." What this is telling me is you've tried a lot of things. It's not working, and it's affecting your daily life. If you say to me, "Well, I haven't really done much." That means that we have more options to try before we jump to bigger, stronger, more intense things. And then severity. Severity means I want you to rate your pain and we're going to use a pain scale to rate it.
So now, let's talk about pain scales. So as you can see here on this card, we're talking about pain scales. And we've got a bunch of different ones that we put into this nice little table for you. I'm going to review the most important, the most highly tested. CRIES is used for children less than or equal to six months. So very much like in the NICU or in any kind of care where you're caring for very small children, along with FLACC. F-L-A-C-C. That is going to be two months to seven years, actually. And this one I do want to point out. Face, Legs, Activity, Cry, and Consolability. A small child can't rate their pain. So you are going to observe them and score them in those different categories to come to plus or minus what the assumed pain they're experiencing is. A child who's not in pain is not going to be kicking their legs around and crying strongly and unable to be consoled. So we can observe that behavior and assign an estimate of that patient's pain.
Now, FACES, also known as Wong-Baker. The FACES pain scale is what many people think of when they think of the pain scale, and it's the image of different faces on a number line. This is very helpful for children who are old enough to communicate, but not old enough to understand how to rate their pain numerically, right? So we're going to show them that chart and say, "Hey, how bad is your pain? Which one of these faces feels like your pain?" And then that will help us to understand what they're feeling. This can be used for children who are greater than or equal to three years of age, okay? So I'm not using this for the itty-bitties. Greater than or equal to three years of age. There's Oucher, which is one that uses photographs, real-life photographs, and then there's the numeric pain scale. The numeric pain scale should not be used in anybody unless they are greater than or equal to eight years of age. And again, I can't necessarily use this pain scale just because you're an adult. Do we have average cognitive capacity? Are you comatose? Are you intubated? Then I can't say, "Sir, can you rate your pain, please?" So we're going to have to use specific pain scales for ICU or other things along those lines.
Now, with the pain scale, when we talk about the numeric, this is the way that I like to ask my patients. Can you rate your pain for me on a scale from zero to 10, where zero is no pain and 10 is the worst pain you have ever experienced? I want you to understand that your patient's report of pain is subjective, but should be considered factual. So personally, I have had more than 55 surgeries in my life. I have a chronic and complex medical history. My perception of pain is wildly different than my six-year-old daughters, right? She hasn't experienced much pain in her life. She doesn't have a lot to compare it to. So her 10 and my 10 are very different. But if she says it's nine and I say it's a nine-- which she's six. You shouldn't be using numeric pain scale. But I'm just saying if one patient says it's nine and they look fine, you're still going to write that it's nine. It is not up to us to assign some sort of judgment to what the patient says. We are simply assessing and recording. That is the hill that I will die on when it comes to caring for patients in pain. It is wildly important to remember to treat patients' pain.
I also want you to understand very briefly that chronic pain, which is pain that's been going on for a long time, it might not alter their vital signs at all. If I have chronic back pain, we're not going to see the normal elevation in vital signs that we might see where we would expect the temperature-- I'm sorry. Not temperature, the pulse, the respiratory rate, the blood pressure to all go up. That's expected with acute pain. If I'm having appendicitis, yeah, I'm going to be in a lot of distress. It's going to hurt very acutely. But chronically, my body has learned how to adapt and compensate. So just because I don't appear to be in pain, just because my vital signs are all within normal limits, does not mean that I am not in severe pain. So your patient's pain is what they say it is, okay? All right. Please stay to the end because I've got some great quiz questions to test your knowledge of key facts from this video.
How can the nurse assess the characteristics of a patient's pain? Ask your patient to describe what it feels like, such as aching or stabbing. The nurse can utilize the FACES or Wong-Baker scale for children greater than or equal to which age? Children greater than or equal to three years of age may use the Wong-Baker or FACES scale. I really hope that review was helpful for you. I would love to hear any comments that you have. And if you have a great way to remember something, I would love to hear that as well, and I know that other students across the country would too. What you're doing is really hard, but you're doing it really well, and I'm super proud of you. Thanks for studying with me.
Okay. So this really is the hill that I will die on. Another thing is that if you have a patient who takes pain medication at home and they-- let's just make something up. They take 10 milligrams of OxyContin twice a day every day at home. And they come to the emergency room, and they are telling you that they're in 9 out of 10 pain, you can't just rely on the patient's home medications to be sufficient pain medication. I'm not suggesting that we throw opiates at everybody by any means, but I am just saying I want you to think critically. And when you have patients who have chronic pain, patients who take pain medication at baseline, really think critically and think how are those interventions going to affect that patient. The patient that has the chronic pain, and they're having to take chronic opiates to manage that pain, they're not going to respond to two milligrams of morphine the way an opiate-naïve patient is. So again, I'm not advocating that we throw heavy doses of narcotics at everybody. I'm just suggesting to you that you really got to think critically about what your patient's baseline is and not adding your own interpretations of what they may or may not be feeling into the mix.
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