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hair, nail changes) Sources: References 8 and 10. Table 10. Assessment of Patients With Barriers to Communication Patient Populations • Infants and children • Individuals of advanced age (e.g., older than 85 years) • Adults with emotional or cognitive disturbances • Patients with cultural, educational, or language barriers to communication • Intubated patients • Patients who are seriously ill General Approach • Allow sufficient time for the assessment. • Give patient the opportunity to use a rating scale or other tool appropriate for that population. • Use indicators of pain according to the following hierarchy of importance: Patient self-report Pathological conditions or procedures known to be painful Pain-related behaviors (e.g., grimacing, restlessness, vocalization) Reports of pain by family members or caretakers Physiological measures (vital signs). • Rely on behavioral or objective indicators of pain (e.g., vital signs) only when no suitable alternative exists. Sources: References 5, 7, and 11. depression, the impact of the pain on the patient’s mood, satisfaction, quality of life, and cognitive functioning also requires thorough exploration. Key elements of this evaluation include a more comprehensive psychosocial assessment, psychiatric evaluation, psychometric testing (as appropriate), and assessment of function and any disability (see Table 14).9,18 b. Physical examination The initial assessment of a patient with pain includes a physical examination. The clinician uses this examination to help identify the underlying cause(s) of the pain and reassure the patient that his or her complaints of pain are taken seriously.8 During this examination, the clinician appraises the patient’s general physical condition, with special attention to the musculoskeletal and neurological systems and site(s) of pain (see Table 15). The clinician also may evaluate the effect of various physical factors (e.g., motion, applied heat or cold, deep breathing, changes in position) on the pain and/or performance measures of physical function (e.g., range of motion, ability of patient to carry out activities of daily living). Patients with some types of pain (e.g., chronic and/or neuropathic pain) require more extensive neurological and musculoskeletal assessment. For example, a clinician may need to use a dermatome map to determine the origin of neuropathic pain or perform a formal assessment of disability in a patient who is applying for disability benefits. c. Diagnostic studies The need for and type of diagnostic studies are determined by characteristics of the pain and suspected underlying condition. Appropriately selected tests can lead to accurate diagnosis and improve outcomes (e.g., reduce pain and adverse effects of therapy, improve function and quality of life).9 However, diagnostic studies are meant to supplement, not replace, a comprehensive patient history and physical examination. Table 16 summarizes examples of diagnostic studies used in patients with pain. 24 Pain: Current Understanding of Assessment, Management, and Treatments Section II: Assessment of Pain Table 11. Assessment Challenges and Approaches in Special Populations Population Challenges Approaches Elderly Under-reporting of discomfort due to fear, cultural Avoid time pressure in assessment factors, stoicism Evaluate for impairments that limit ability to Impairments (e.g., hearing, vision, comprehension, communicate verbal skills) may limit ability to communicate Use tools that the elderly find easy to use Difficulty with visually oriented or complex (e.g., FPSa) assessment tools Be aware of changes in various parameters in elderly patients (impaired ADLs, social function, walking) that may be indicative of unrelieved pain Infants and children Difficulty communicating (e.g., pre-verbal) Select an approach that is consistent with the patient’s Difficulty discriminating between anxiety developmental stage and pain intensity For infants, rely on indicators such as crying and reflex withdrawal In toddlers, watch for pursed lips, wide opening of eyes, rocking, rubbing, defensive behavior (e.g., biting, hitting, kicking, running away) Use age-appropriate assessment tools for children 3 years or older (e.g., Oucher picture scale, FPS, “thermometer” NRSa) Patients of different Different languages Use words such as “pain,” “hurt,” and “ache” cultural or language Different behavioral responses to pain Use assessment tools in appropriate language backgrounds Different treatment preferences Provide patient education materials in native language, when possible Sources: References 7 and 11-16. aSee Table 17 for information about FPS and NRS. ADLs: activities of daily living; FPS: Faces Pain Scale; NRS: numeric rating scale. B. M EASUREMENT OF PAIN : C OMMON A SSESSMENT T OOLS Tools for pain assessment include unidimensional scales and multidimensional tools. The former (i.e., rating scales) usually assess a single dimension of pain, patient self-report of pain intensity. Although useful for assessing acute pain of clear etiology (e.g., postoperative pain), rating scales may oversimplify the assessment of some types of pain.12 Therefore, experts recommend the use of multidimensional tools in the assessment of complex or persistent pain. 1. Unidimensional Scales Rating scales provide a simple means for patients to rate pain intensity. Typical scales use numeric (e.g., 0-10), verbal
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