Assessment & Management of Pain

Tools & Resources

Pain Assessment Questionnaire

On a scale of 0-10 can you rate your pain, with 0 being no pain and 10 being the worst pain you can imagine.
When did the pain start?
Can you describe your pain? (eg. burning, stabbing, throbbing, dull, aching, sharp etc)
Does the pain change or move?
Is the pain ongoing or does it come and go?
What treatments have you tried?
Were any treatments effective?

Non-Verbal Pain Assessments

When patients struggle or aren’t able to self-report their pain, it can make it difficult to assess pain levels. Below are some validated observational tools for assessing pain in non-verbal clients, clients with cognitive impairments, and children.

Faces Pain Scale (FPS-R)

About

Rating System	The Faces Pain Scale uses drawn faces to represent pain levels on a scale of 0 to 5.
Common Use	Most commonly used with children aged 3+, may also be used for adults with cognitive impairments.
Instructions	This scale is intended to measure how the patient feel inside, not how their face looks. The pain scale is shown to the patient with these instructions: “These faces show how much something can hurt. This face [point to face above number “0”] shows no pain. The faces show more and more pain up to this one [point to the face above number “5”] – it shows very much pain. Point to the face that shows how much you hurt [right now].”

FPS-R Scale

0	1	2	3	4	5

Source: Hicks, C. L., von Baeyer, C. L., Spafford, P. A., van Korlaar, I., & Goodenough, B. (2001). The Faces Pain Scale – Revised: Toward a common metric in pediatric pain measurement. Pain, 93, 173-83.

About

Rating System
The Faces Pain Scale uses drawn faces to represent pain levels on a scale of 0 to 5.
Common Use
Most commonly used with children aged 3+, may also be used for adults with cognitive impairments
Instructions
This scale is intended to measure how the patient feel inside, not how their face looks. The pain scale is shown to the patient with these instructions: “These faces show how much something can hurt. This face [point to face above number “0”] shows no pain. The faces show more and more pain up to this one [point to the face above number “5”] – it shows very much pain. Point to the face that shows how much you hurt [right now].”

FPS-R Scale

Number	Visual
0
1
2
3
4
5

FLACC Scale (r-FLACC)

About

Rating System	FLACC stands for face, legs, activity, crying, and consolability. A total score is calculated by rating each category on a scale between 0 to 2. The result is a total score out of 10: Scale of 0 to 10, 0=no pain, 10=worst pain possible
Common Use	Children under the age of three, non-verbal adults, adults with cognitive impairments.
Instructions	Rate the patient in each of the 5 categories and add up the score.

FLACC Scale (r-FLACC)

	0	1	2
Face	No particular expression or smile.	Occasional grimace or frown, withdrawn, disinterested, sad, appears worried.	Frequent to constant quivering chin, clenched jaw, distressed looking face, expression of fright/panic.
Legs	Normal position or relaxed; usual tone and motion to limbs.	Uneasy, restless, tense, occasional tremors.	Kicking, or legs drawn up, marked increase in spasticity, constant tremors, jerking.
Activity	Lying quietly, normal position, moves easily, regular, rhythmic respirations.	Squirming, shifting back and forth, tense, tense/guarded movements, mildly agitated, shallow/ splinting respirations, intermittent sighs.	Arched, rigid or jerking, severe agitation, head banging, shivering, breath holding, gasping, severe splinting.
Cry	No cry (awake or asleep).	Moans or whimpers:occasional complaint, occasional verbal outbursts, constant grunting.	Crying steadily, screams or sobs, frequent complaints, repeated outbursts, constant grunting.
Consolability	Content, relaxed.	Reassured by occasional touching,hugging, or being talked to; distractible.	Difficult to console or comfort, pushing caregiver away, resisting care or comfort measures.

Malviya, S., Vopel-Lewis, T. Burke, Merkel, S., Tait, A.R. (2006). The revised FLACC Observational Pain Tool: Improved Reliability and Validity for Pain Assessment in Children with Cognitive Impairment. (Pediatric Anesthesia 16: 258-265).

About

Rating System
FLACC stands for face, legs, activity, crying, and consolability. A total score is calculated by rating each category on a scale between 0 to 2. The result is a total score out of 10: Scale of 0 to 10, 0=no pain, 10=worst pain possible
Common Use
Children under the age of three, non-verbal adults, adults with cognitive impairments.
Instructions
Rate the patient in each of the 5 categories and add up the score.

FLACC Scale (r-FLACC)

Face

0	No particular expression or smile.
1	Occasional grimace or frown, withdrawn, disinterested, sad, appears worried.
2	Frequent to constant quivering chin, clenched jaw, distressed looking face, expression of fright/panic.

Legs

0	Normal position or relaxed; usual tone and motion to limbs.
1	Uneasy, restless, tense, occasional tremors.
2	Kicking, or legs drawn up, marked increase in spasticity, constant tremors, jerking.

Activity

0	Lying quietly, normal position, moves easily, regular, rhythmic respirations.
1	Squirming, shifting back and forth, tense, tense/guarded movements, mildly agitated, shallow/ splinting respirations, intermittent sighs.
2	Arched, rigid or jerking, severe agitation, head banging, shivering, breath holding, gasping, severe splinting.

Cry

0	No cry (awake or asleep).
1	Moans or whimpers:occasional complaint, occasional verbal outbursts, constant grunting.
2	Crying steadily, screams or sobs, frequent complaints, repeated outbursts, constant grunting.

Consolability

0	Content, relaxed.
1	Reassured by occasional touching,hugging, or being talked to; distractible.
2	Difficult to console or comfort, pushing caregiver away, resisting care or comfort measures.

Other Non-Verbal Indicators

Vocalizations such as sighing, moaning, groaning and heavy breathing
Body movements such as rigidity/tenseness of body, fidgeting, rocking and guarding
Changes in interpersonal interactions such as aggression, combativeness or social withdrawal
Changes in activity such as decreased appetite, decreased sleep/rest and changes in routine behaviours
Mental status changes including crying, increased confusion and irritability

Context & Considerations

Multimodal Treatments

Depending on the severity of the pain, you may want to consider using non-narcotic as well as narcotic options of pain relief. Non-medicinal treatment options — like RICE: rest, ice, compression, elevation — can provide relief of injured areas or limbs. Distraction techniques, such as meditation and deep breathing exercises, may also help alleviate pain.

Vital Signs

Changes in vital signs — such as an increased heart rate or blood pressure — can indicate increased pain. It can also indicate decreased oxygen saturation that’s associated with narcotized patients.

Acute vs. Chronic Pain

It’s important to understand the difference between acute and chronic pain:

Acute Pain	A sudden onset of pain typically as a result of tissue damage, usually temporary in nature such as surgery, bone fracture, burns, lacerations, etc.
Chronic Pain	Lasts longer than 6 months, where pain signals remain active in the nervous system for months or years such as headaches, back pain, fibromyalgia, etc.

Cultural Awareness

Culture can impact behaviour and communication when assessing pain. For more information on culturally competent care please refer to the best practice guideline Embracing Cultural Diversity in Health Care.

PPE

PPE & Pain Assessment Challenges

When working with clients who are non-verbal or have difficulty hearing, masks can make assessing pain much more difficult. When you and your client are wearing a mask, it becomes harder for you to hear one another and more challenging for you to read your clients’ facial expressions.

Communication Supports

Hand gestures such as asking clients to show a thumbs up or down to signal changing levels of pain
A whiteboard or pad of paper to communicate with
Picture Support – e.g. simple images that represent concepts like pain, hunger, etc.
Visual aids for instructions (i.e. bed repositioning, tracheal suctioning etc)

Virtual Care

Virtual Etiquette

Conduct virtual sessions in a confidential environment.
Remove visual distractions behind you.
Place camera at eye level and look directly into the camera when possible. This shows clients you’re listening and paying attention.
Ensure your ID badge is visible.
Be punctual & prepared — gather all relevant patient information prior to starting the session.
Ask to be introduced to everyone present in the room, including people who may be off camera.
Mute your microphone when you’re not speaking.

Conducting Virtual Care Sessions

Conversation Framework

To keep virtual conversations organized and productive, create a conversation framework or agenda. You can keep this visible on your computer desktop to refer to during the session. Try to keep agenda items to those with the highest priority.

Addressing Disappointment

Acknowledge that clients may feel disappointed that their appointment is being conducted virtually by saying something like “I wish we could be meeting in person.”

Difficult Conversations

Some topics of conversation are difficult to initiate in virtual settings. Ask your client’s permission to discuss difficult topics or when transitioning to new topics.

Responding to Emotion

Providing emotional support to clients can be more challenging in virtual environments. Virtual care may make it harder to read clients’ emotions and demonstrate empathy for them. We’re also not able to use non-verbal supports like touch. To overcome these challenges:

Watch and listen for signs your client may be upset, like crying, long pauses or repeating questions
Use nodding as a way to show clients you’re listening, even if you may be silent
Provide space for the client to express themselves by pausing and waiting for them to speak
Take regular pauses to check-in with clients, and ask them for permission to go on with the conversation

Client Understanding

During virtual care, issues can arise that make conveying information to clients more difficult (e.g. technical issues, sound quality, memory/comprehension). At the end of the virtual care session, check in with your client to ensure they understand the information you’ve provided. Give them the opportunity to ask questions to clarify anything they may not understand. It may also be helpful to provide additional materials for clients to review on their own time.

Technical Tips

Sound Quality

When your voice echoes or reverberates in the room it can make it harder for clients to hear you during video calls. Here are a few ways you can improve sound quality:

Use headphones with a microphone (instead of the microphone on your computer) to ensure clear sound quality
Test the sound quality of your equipment before appointments, as some equipment can produce unwanted hissing or static noises
Place pillows or blankets around your computer area to help “dampen” the sound and reduce echoes, making it easier for clients to hear you

Framing

Use books or a box to raise your computer monitor up to eye level – this will allow you to look directly at the camera (instead of the screen). Make sure your face is in view and framed in the centre of the screen so that clients can see your facial expressions clearly.

Lighting

Make sure you’re well-lit. To do this, sit in front of a light source so that the light is directed at your face. Avoid sitting with your back to a window or other light source – this will cause you to be “back-lit”.

Tools

Context

PPE

Virtual Care