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Joint Commission on Accreditation of Healthcare Organization (JCAHO) recently introduced standards for pain assessment and management relevant to multiple health care disciplines and settings (see V.B.1). These standards stress patients’ rights to appropriate assessment and management of pain (JCAHO Standard RI 1.2.8, 2000) and emphasize that pain should be assessed in all patients (JCAHO Standard PE1.4, 2000).4 Multiple additional clinical practice guidelines (CPGs) for pain management have emerged since the first guideline for pain management in 1992 (see V). Thus, the means for improved pain assessment and management are readily available. Successful pain management depends, in part, on clinician adherence to such standards and guidelines and commitment to some core principles of pain assessment and management (Table 7). 2. Goals and Elements of the Initial Assessment Important goals of the initial assessment of pain include establishing rapport with the patient and providing an overview of the assessment process.8 These processes help to engage the patient, foster appropriate treatment expectations, and promote a coordinated approach to management. The clinician’s primary objective is to obtain information that will help identify National Pharmaceutical Council 21 Section II: Assessment of Pain Table 7. Core Principles of Pain Assessment and Management • Patients have the right to appropriate assessment and management of pain (JCAHO Standard RI 1.2.8, 2000). Pain (should be) is assessed in all patients (JCAHO Standard PE1.4, 2000). • Pain is always subjective.1 Therefore, the patient’s selfreport of pain is the single most reliable indicator of pain.5 A clinician needs to accept and respect this self-report, absent clear reasons for doubt. • Physiological and behavioral (objective) signs of pain (e.g., tachycardia, grimacing) are neither sensitive nor specific for pain.5 Such observations should not replace patient self-report unless the patient is unable to communicate.5 • Assessment approaches, including tools, must be appropriate for the patient population. Special considerations are needed for patients with difficulty communicating. Family members should be included in the assessment process, when possible. • Pain can exist even when no physical cause can be found. Thus, pain without an identifiable cause should not be routinely attributed to psychological causes. • Different patients experience different levels of pain in response to comparable stimuli. That is, a uniform pain threshold does not exist. • Pain tolerance varies among and within individuals depending on factors including heredity, energy level, coping skills, and prior experiences with pain. • Patients with chronic pain may be more sensitive to pain and other stimuli. • Unrelieved pain has adverse physical and psychological consequences. Therefore, clinicians should encourage the reporting of pain by patients who are reluctant to discuss pain, deny pain when it is likely present, or fail to follow through on prescribed treatments (JCAHO standard PE1.4, 2000). • Pain is an unpleasant sensory and emotional experience, so assessment should address physical and psychological aspects of pain. Sources: References 1 and 4-7. aThe Pain as the 5th Vital Sign initiative is a concept, not a guide, for pain assessment. Whereas assessing pain with each assessment of the standard four vital signs is appropriate in some clinical situations, more or less frequent assessment may be appropriate in others. the cause of the pain and guide management. A patient history, physical examination, and appropriate diagnostic studies are typically conducted for this purpose. a. Patient history The patient’s self-report of pain is the most reliable indicator of pain.5 Physiological and behavioral (objective) signs of pain (e.g., tachycardia, grimacing) are neither sensitive nor specific for pain and should not replace patient self-report unless the patient is unable to communicate.5 Therefore, talking to patients and asking them about their pain (i.e., obtaining a “pain history”) is integral to pain assessment. The pain history usually is obtained as part of the patient history, which includes the patient’s past medical history, medications, habits (e.g., smoking, alcohol intake), family history, and psychosocial history. Obtaining a comprehensive history provides many potential benefits, including improved management, fewer treatment side effects, improved function and quality of life, and better use of health care resources.9 The manner in which information is elicited from the patient is important. Ideally, the clinician should afford ample time, let the patient tell the story in his or her own words, and ask open-ended questions. Information to be elicited during the initial assessment of pain includes (see Table 8): ■ Characteristics of the pain (e.g., duration, location, intensity, quality, exacerbating/alleviating factors) ■ Present and past pain management strategies and their outcomes ■ Past and present medical problems that may 22 Pain: Current Understanding of Assessment, Management, and Treatments Section II: Assessment of Pain Table 8. Information From the Patient History Parameter Information To Be Obtained Sample Questions Pain characteristics Onset and duration When did the pain begin? Location(s) Where does it hurt? (Use
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