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(word), or visual (image) descriptors to quantify pain or pain relief. The tool should be appropriate for the patient’s developmental, physical, emotional, and cognitive status, as well as reliable, valid, and easy to use.5 Examples of these scales include the following (see Table 17): ■ Numeric rating scale (NRS): The NRS is the most commonly used rating scale. Patients rate their pain on a 0-to-10 scale or a 0-to-5 scale, with 0 representing “no pain at all” and 5 or 10 representing “the worst imaginable pain.” Pain intensity levels are measured at the initial encounter, following treatment, and periodically, as suggested by guidelines and the clinical situation. ■ Visual analog scale (VAS): The VAS consists of a 10-cm line, with anchors at either end. One end is marked “no pain” and the other end is marked National Pharmaceutical Council 25 Section II: Assessment of Pain Table 12. Preoperative Assessment and Patient Education Recommendations • Establish a positive relationship with patients and/or families. • Obtain a pain history. • Educate the patient about pain assessment (e.g., methods, frequency) and pharmacologic and nonpharmacologic management strategies. • Explore concerns/dispel misconceptions about use of pain medications, side effects, and addiction. • Develop a strategy for postoperative analgesia in collaboration with the patient based on type of surgery, expected severity of postoperative pain, underlying medical conditions, the risk-benefit ratio and costs of available techniques, and patient’s preferences and/or previous experience(s) with pain. • Involve the patient in selecting an appropriatea pain measurement tool (e.g., NRS, VAS), and review its features with the patient. • Educate the patient (and/or families) about their responsibilities in pain management (e.g., providing a factual report of pain, preventing or halting pain before it has become well established). Negotiate a criterion (e.g., a score of 3-4 on a 10-point pain intensity scale) that will result in a dose increment or other intervention. • Document the patient’s preferred pain assessment tool and the goals for pain control (pain score). Sources: References 5 and 17. aFactors that help to determine the appropriate tool include: 1) the patient’s age; physical, emotional, or cognitive status; and preference; 2) the assessor’s expertise, time, and degree of effort available; and 3) the institution’s requirements for monitoring and documentation for quality assurance purposes. NRS: numeric rating scale; VAS: visual analog scale. Table 13. Postoperative Assessment and Patient Education Recommendations • Assess multiple indicators of pain, including 1) patient perceptions (self-report), 2) cognitive attempts to manage pain, 3) behavioral responses (e.g., splinting the operative site, distorted posture, decreased mobility, insomnia, anxiety, depression), and 4) physiological responses (vital signs). • Accept the patient self-report, and only substitute behavior and/or physiological responses if the patient is unable to communicate. • Measure pain at rest and during activity (e.g., moving, deep breathing, coughing). • Assess pain frequently during the immediate postoperative period: 1) at regular intervals, consistent with surgery type and pain severity (e.g., every 2 hours while awake for 1 day after surgery); 2) with each new report of pain; and 3) at a suitable interval after each analgesic intervention (e.g., 30 minutes after parenteral drug therapy, and 1 hour after oral analgesics). Increase the frequency of assessment for changing interventions or inadequate pain control. • Record pain intensity and response to any interventions (including side effects) in a visible and accessible place (e.g., bedside chart). • Immediately evaluate instances of unexpected intense pain, particularly if sudden or associated with evidence of potential complications.a • Consider all reasons for any discrepancies between a patient’s self-report of pain and his or her behavior. Such discrepancies may reflect good coping skills or diversionary activities (e.g., distraction, relaxation techniques). Alternatively, a patient may be denying pain because of stoicism or fear of inadequate pain control. • Give special consideration to needs of special populations, and be aware of potential barriers to effective communication (e.g., mental, cognitive, or hearing impairments; language barriers; cultural traditions). • Revise the management plan, as needed, if pain behavior is observed or the patient expresses feelings of inadequate pain control. • Prior to patient discharge, review with the patient the interventions used and their efficacy; provide specific discharge instructions regarding outpatient pain management. Sources: References 5 and 17. aSigns such as fever, hypertension, tachycardia, or oliguria may be indicative of complications including wound dehiscence, infection, or deep venous thrombosis. “pain as bad as it could be” or “the worst imaginable pain.” The patient marks the place on the line to indicate his or her pain intensity. The clinician then measures the line with a ruler and assigns a score.28 ■ Categorical scales: Categorical scales provide a simple means for patients to rate pain intensity using verbal or visual descriptors of the pain. Melzack and Torgerson29 introduced a scale with five verbal descriptors (i.e., mild, discomforting, distressing, horrible, and
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