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diagram, when possible.) Quality What does the pain feel like? Intensity (severity) How severe is the pain right now? (Use numeric rating scale to Associated symptoms obtain score, when possible.) Exacerbating or alleviating factors What increases or decreases the pain? Management strategies Past and current: What methods have you used to manage the pain? • Medications ( “natural,” What methods have worked? nonprescription, and prescription) • Nonpharmacologic treatments • Coping strategies (e.g., prayer, distraction) Relevant Prior illnesses How is your general health? medical history (including psychiatric illnesses and chemical dependence), surgeries, and accidents Coexisting acute or chronic illnesses Have you had any problems with pain in the past? Prior problems with pain and If so, how did you manage the pain? treatment outcomes Relevant family Health of family members How is the health of your family? history Family history of chronic pain Do any family members have problems with pain? or illnesses Psychosocial Past or current: Are there any recent sources of increased stress? history • Developmental, marital, or How has the pain affected your mood? vocational problems • Stressors or depressive symptoms • “Reinforcers” of the pain (e.g., compensation-litigation issues) Impact of the Impact of the pain on the patient’s: How has the pain affected your work and relationships pain on the • Work with others? patient’s daily life • Other daily activities (e.g., How is your sleep? chores, hobbies) How is your appetite? • Personal relationships • Sleep, appetite, emotional state Patient’s expectations Expectations and goals for pain What are your goals for treatment? and goals management in regard to pain intensity, daily activities, and quality of life Sources: References 5 and 7-8. influence the pain and/or its management ■ Relevant family history ■ Current and past psychosocial issues or factors that may influence the pain and its management ■ The impact of the pain on the patient’s daily life and functioning ■ The patient’s and family’s knowledge of, expectations about, and goals for pain management. Careful characterization of the pain facilitates diagnosis and treatment (see Table 9). Assessment tools (e.g., rating scales, questionnaires) play an important role in this process (see II.B). Both the choice of tool and the general approach to assessment should reflect the needs of the patient. The assessment of pain in some patients warrants special consideration. Tables 10 and 11 summarize approaches to assessment in patients with impaired ability to communicate. Tables 12 and 13 review recommended pre- and post-operative assessment and management methods for perioperative pain, including pain after the surgery (postoperative pain). Patient education about these methods is a key element of the initial assessment of a surgical patient. As unrelieved pain has adverse physical and psychological consequences, clinicians should encourage the reporting of pain by patients who are reluctant to discuss pain or who deny pain that is likely to be present (JCAHO standard PE1.4, 2000). The initial assessment of a patient with chronic pain, especially chronic noncancer pain (CNCP), also warrants special consideration. Associated neural remodeling (central sensitization) means that the pain may exist without an apparent physical cause (see I.B.8). In such cases, the clinician needs to avoid attributing the pain to psychological causes and to accept and respect the patient’s self-report of pain.5 Other clinicians often have seen and/or treated patients with CNCP. Therefore, past medical records, test results, and treatment histories need to be obtained. Given the link between chronic pain and National Pharmaceutical Council 23 Section II: Assessment of Pain Table 9. Characteristics of Pain Types Characteristic Pain Types and Examples Location and Localized pain: pain confined to site of distribution origin (e.g., cutaneous pain, some visceral pain, arthritis, tendonitis) Referred pain: pain that is referred to a distant structure (e.g., visceral pain such as angina, pancreatitis, appendicitis, acute cholecystitis) Projected (transmitted) pain: pain transferred along the course of a nerve with a segmental distribution (e.g., herpes zoster) or a peripheral distribution (e.g., trigeminal neuralgia) Dermatomal patterns: peripheral neuropathic pain Nondermatomal: central neuropathic pain, fibromyalgia No recognizable pattern: complex regional pain syndrome Duration and Brief flash: quick pain such as a needle periodicity stick Rhythmic pulses: pulsating pain such as a migraine or toothache Longer-duration rhythmic phase: intestinal colic Plateau pain: pain that rises gradually or suddenly to a plateau where it remains for a prolonged period until resolution (e.g., angina) Paroxysmal: neuropathic pain Continuously fluctuating pain: musculoskeletal pain Quality Superficial somatic (cutaneous) pain: sharp pricking or burning Deep somatic pain: dull or aching Visceral pain: dull aching or cramping Neuropathic pain: burning, shock-like, lancinating, jabbing, squeezing, aching Associated signs Visceral pain: “sickening feeling,” and symptoms nausea, vomiting, autonomic symptoms Neuropathic pain: hyperalgesia, allodynia Complex regional pain syndrome: hyperalgesia, hyperesthesia, allodynia, autonomic changes, and trophic changes (skin,
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