From Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management, p. 50, St. Louis, Mosby. McCaffery M, Pasero C. May be duplicated for use in clinical practice.

The purpose of these questions is to identify new or ongoing pain problems. If a pain problem is ongoing and the patient already has an effective pain treatment plan, steps should be taken to ensure that the plan is continued. If a treatment plan must be developed, further assessments using the Initial Pain Assessment Tool (Form 3-1, p. 51) or the Brief Pain Inventory (BPI; Form 3-2, p. 53) may be indicated.

Form 3-1 May be completed by patients or used by clinicians to interview patients. From Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management, p. 51, St. Louis, Mosby. Pasero C, McCaffery M. May be duplicated for use in clinical practice.

Form 3-2 From Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management, p. 53, St. Louis, Mosby. Pasero C, McCaffery M. May be duplicated for use in clinical practice.

Tools for Initial Overall Pain Assessment

Two tools widely used for overall initial pain assessments are referred to as Initial Pain Assessment Tool (see Form 3-1) and the BPI (see Form 3-2). Both of these were included in the cancer pain clinical guidelines published by the Agency for Health Policy and Research (Jacox, Carr, Payne, et al., 1994a), and the BPI is included in the revised cancer pain guidelines published by APS (Miaskowski, Cleary, Burney, et al., 2005). The patient or the clinician may complete these tools. Another overall pain assessment tool often used in research and clinical practice is the short-form McGill Pain Questionnaire (Melzack, 1987).

These pain assessment tools need not be used for all patients with pain. The policies and procedures of a health care agency must identify the criteria necessary for these tools to be considered. Certainly if the patient has chronic pain problems that are not satisfactorily controlled, an overall pain assessment tool should be completed. Hospices and pain treatment centers may need far more extensive initial overall assessment tools than those offered here. For patients with acute pain that is not easily controlled by the usual pain treatments (e.g., intravenous patient-controlled analgesia [IV PCA] following surgery), an overall assessment also is indicated.

Both the Initial Pain Assessment Tool and the BPI, described later, attempt to assess some aspects of suffering. Suffering, like pain, is subjective, but it goes beyond simply feeling pain. Pain may exist without suffering. Suffering eludes definition but has been characterized as an individual’s experience of threat to self, a meaning given to events such as pain or loss (Kahn, Steeves, 1996). Suffering involves the person’s evaluations of the significance or meaning of pain (Spross, 1993). To some extent, suffering is similar to an impairment in quality of life. Items on the assessment tools directed at the effects of pain on various aspects of living are an attempt to assess some aspects of the patient’s suffering.

Initial Pain Assessment Tool

The Initial Pain Assessment Tool (Form 3-1) may be completed by the patient or used to guide the clinician in collecting information about the patient’s pain. A discussion of each assessment point follows.

1. Location of pain. This is most easily and quickly accomplished by asking the patient to mark the location on the figure drawings. Alternately, the clinician may ask the patient to point to the locations of pain on his or her own bodies, and the clinician can mark figure drawings. If there is more than one site of pain, letters (A, B, C, etc.) may be used to distinguish the various sites. These letters may be used in answering the remainder of the questions.

2. Intensity. The pain rating scale used by the patient is identified. The patient is asked to rate pain intensity for present pain, worst pain, the least pain felt, and comfort-function goals (pain rating that will not interfere with necessary or desired functioning, such as ambulation and decreased anxiety). If the patient has more than one site of pain, the letter designations mentioned simplify recording. For example, for present pain intensity, the recording might be A = 4, B = 6. A time period may be specified for answering the next questions about pain intensity. For example, worst pain intensity may be asked in relation to the past 24 hours or the past week.

3. Is this pain constant? If not, how often does it occur? These questions help screen for the presence of breakthrough pain (BTP), defined as a transitory increase in pain that occurs on a background of otherwise controlled chronic pain. If the patient says the pain is constant, this rules out BTP. But if the patient say the pain is not constant, further questioning is indicated, specifically asking the patient whether there are temporary flares of pain that are more intense than the constant pain. The Screening Tool for Pain Flares—Breakthrough Pain, Form 3-6 (p. 103), and the Assessment of Pain Flares—Breakthrough Pain, Form 3-7 (p. 104), may be helpful. Roughly 50% or more of patients with chronic, constant pain also have BTP that might be overlooked.

Form 3-6 From Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management, p. 103, St. Louis, Mosby. Pasero C, McCaffery M. May be duplicated for use in clinical practice.

Form 3-7 This form may be used for clinicians to interview patients or may be completed by the patients themselves. It is appropriate for patients with chronic pain who have controlled baseline pain and breakthrough pain. This form should not be used unless baseline pain is usually controlled. These questions should be answered in relation to the type of pain flare that bothers the patient the most. Determine whether the patient has more than one type of pain flare, and consider using this assessment tool for each one. From Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management, pp. 104-105, St. Louis, Mosby. Data from Bennett, D., Burton, A. W., Fishman, S, et al. (2005). Consensus panel recommendations for the assessment and management of breakthrough pain. Pharmacol Ther, 30(5), 296-301; Hagen, N. A., Stiles, C., Nekolaichuk, C., et al. (2008). The Alberta breakthrough pain assessment tool for cancer patients: A validation study using a Delphi process and patient think-aloud interviews. J Pain Symptom Manage, 35(2), 136-152; Portenoy, R. K., Bennett, D. S., Rauck, R., et al. (2006). Prevalence and characteristics of breakthrough pain in opioid-treated patients with chronic noncancer pain. J Pain, 7(8), 583-591. Pasero C, McCaffery M. May be duplicated for use in clinical practice.

4. Quality of pain. This information is helpful in diagnosing the underlying pain mechanism. Soreness is commonly more likely to be indicative of somatic pain, whereas burning or knifelike pain is more likely to be indicative of neuropathic pain. This information may have direct implications for the type of pain treatment chosen. For example, an anticonvulsant (an adjuvant analgesic; see Section V) may be indicated for knifelike pain. One study found that the quality of pain seemed to cluster in three groups: (1) paroxysmal pain sensations, such as shooting, sharp, and radiating pains; (2) superficial pain, such as itchy, cold, sensitive, and tingling pains; and (3) deep pain, such as aching, dull, cramping, and throbbing pain (Victor, Jensen, Gammaitoni, et al., 2008).

If the patient has difficulty describing pain, the clinician should ask the patient about the appropriateness of possible descriptors, such as throbbing, shooting, sharp, cramping, aching, tender, pricking, burning, or pulling. For the patient who continues to have difficulty, try asking him or her, “What could you do to me to make me feel the pain you have?”

5. Onset, duration, variations, rhythms. To detect variations and rhythms, ask the patient, “When did this pain begin?” “Is the pain better or worse at certain times, certain hours of the day or night, or certain times of the month?”

6. Manner of expressing pain. Ask the patient if he or she is hesitant or embarrassed to discuss the pain or whether the patient tries to hide it from others. Ask the patient if using the pain rating scale is acceptable.

7. What relieves the pain? If the patient has had pain for a while, he or she may know which medications and doses are helpful and may have found some nondrug methods, such as cold packs, helpful. If appropriate, these methods should be continued.

8. What causes or increases the pain? A variety of activities, body positions, and other events may increase pain, and efforts can be made to avoid them or to provide additional analgesia at those times.

9. Effects of pain. These items help to identify how pain affects the patient’s quality of life and how pain interferes with recovery from illness. Information obtained in this section may be useful in developing pain management goals. If pain interferes with sleep, a major goal may be to identify a pain rating that will allow the patient to sleep through the night without being awakened by pain.

10. Other comments. No tool is comprehensive. This space simply allows for information the patient may wish to add.

11. Plan. Immediate and long-range plans can be mentioned here and developed in greater detail as time passes.

Brief Pain Inventory

The BPI (Form 3-2, p. 53) is a 9-item tool that gathers information about pain severity and rates level of pain interference with seven key areas of function. Regular use of this tool helps track progress in treating pain intensity and degree of pain interference with general activity, mood, walking ability, normal work (both work outside the home and house work), relations with other people, sleep, and enjoyment of life. The BPI is relatively short and easy for patients to complete, taking about 10 to 15 minutes. It has been used successfully with older adults (Ersek, Turner, Cain, et al., 2004; Kemp, Ersek, Turner, 2005).

The BPI assessment tool has been used extensively in research too. It has reasonable validity and reliability (Daut, Cleeland, 1982; Daut, Cleeland, Flanery, 1983) and has proven useful in a variety of clinical settings (Cleeland, Gonin, Hatfield, et al., 1994). The BPI has been translated into other languages, including Japanese (Uki, Mendoza, Cleeland, et al., 1998); Vietnamese (Cleeland, Ladinsky, Serlin, et al., 1988); Chinese (Wang, Mendoza, Gao, et al., 1996); the Philippine language (Cleeland, Nakamura, Mendoza, et al., 1996); Russian (Kalyadina, Ionova, Ivanova, et al., 2008); and French (Serlin, Mendoza, Nakamura, et al., 1995). The BPI has been shown to be reliable and valid in several patient populations, such as patients with cancer pain (Cleeland, Gonin, Hatfield, 1994) and with chronic noncancer pain (Tan, Jensen, Thornby, et al., 2004); in patients 6 months after cardiac surgery (Gjeilo, Stenseth, Wahba, et al., 2007); and in Canadian veterans with pain who are suffering from traumatic stress (Poundja, Fikretoglu, Guay, et al., 2007). A modified version of the BPI has been validated in patients with painful diabetic peripheral neuropathy (Zelman, Gore, Dukes, et al., 2005).

Questions on the BPI focus on pain during the past 24 hours.

• Question 1 asks if the patient has experienced pain other than common everyday kinds of pain and if the patient has experienced that pain today.

• Question 2 asks the patient to identify the location of that pain in the figure drawing.

• Questions 3 through 6 ask the patient to use a pain rating scale of 0 to 10 to rate pain at its worst and least in the past 24 hours and its intensity on average and right now.

• Question 7 asks about treatment or medication the patient is receiving for pain.

• Question 8 asks the percentage of pain relief provided by these treatments.

• Question 9 has seven parts that attempt to identify how much pain has interfered with the patient’s life, including general activity, mood, work, sleep, and enjoyment of life.

Pain Intensity Rating Scales

Pain intensity rating scales used in daily clinical practice deal with how much pain the patient is feeling. When a patient uses the scale to report pain, it is called a self-report scale. Numerous self-report scales for measuring pain intensity exist. They have been referred to by many different names, but often each scale has no standardized title or definition. No “best” scale exists, but some are more practical and more widely used in clinical practice than others. Following is a discussion of criteria for selecting pain rating scales for daily clinical practice and a discussion of the visual analogue scale (VAS) and specific pain rating scales appropriate for clinical use in assessing pain intensity in cognitively intact adolescents, adults, and older persons. Later in this chapter, tools for assessing patients who have difficulty with the commonly used self-report scales or who are unable to self-report are discussed.

Criteria for Selecting Pain Rating Scales for Use in Daily Clinical Practice

Criteria for selecting self-report pain rating scales for use in daily clinical practice are summarized in Box 3-2. Most important, the pain rating scale selected must have been tested and found to be reliable and valid. Reliability means that the scale consistently measures pain intensity from one time to the next, and validity means that the scale accurately measures pain intensity. Probably the most fundamental aspect of validity for pain rating scales is that they demonstrate sensitivity to changes in the magnitude of pain (Herr, Spratt, Garand, et al., 2007). For example, they must be sensitive enough to measure effects of analgesic medication. (For more detailed information about the reliability and validity of a variety of pain measures, refer to Jensen [2003] and Herr, Spratt, Mobily, et al. [2004]).

Guidelines

Box 3-2 Selecting a Pain Rating Scale for Use in Daily Clinical Practice

Research has established that the tool is:

• Reasonably valid and reliable.

• Developmentally appropriate. Some scales commonly used with adults (e.g., 0-to-10 scale) are clearly inappropriate for use with children who cannot count. On the other hand, some scales, such as the Faces Pain Scale-Revised (FPS-R) that are appropriate for young children may be appropriate for any age group, especially cognitively impaired patients.

• Easily and quickly understood by patients who have minimal formal education.

• Well liked by patients.

• Well liked by clinicians.

• Not burdensome on clinicians.

• Quickly explained.

• Easily scored and recorded.

• Easily used with patients to set pain management goals (i.e., comfort-function goals).

• Inexpensive.

• Easily disinfected (or inexpensive enough to discard, e.g., scales that are photocopied).

• Readily available. Multiple copies are easily and inexpensively made for distribution to clinicians, patients, and their families.

• Appropriate for patients of different cultures.

• Available in various languages spoken in the clinical setting (or may be translated easily).

As appears in Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management, p. 54, St. Louis, Mosby. Modified from Hester, N. O. (1995). Integrating pain assessment and management into the care of children with cancer. In D. B. McGuire, C. H. Yarbro, & B. R. Ferrell (Eds). Cancer pain management, Boston, Jones and Bartlett. May be duplicated for use in clinical practice.

Usually the main purpose of using pain rating scales in clinical practice is to identify the intensity of pain over time for the purpose of evaluating the effectiveness of interventions to relieve pain. Scales used to obtain self-reports of pain intensity fail to provide other information that is important to assessing pain and determining pain treatment. This is one of the reasons for remembering to use the Initial Pain Assessment Tool (see Form 3-1) or the Brief Pain Inventory (see Form 3-2).

Certain open-ended questions are also used in addition to the pain rating scale. Research with older adults (N = 312) has shown that an open-ended pain question such as “Tell me about your pain, aches, soreness, or discomfort” when initiating pain assessment discussions provided significantly more pain information than asking the patient to rate his or her pain or simply asking “How are you feeling?” (McDonald, Shea, Rose, et al., 2009). The latter question resulted in the least amount of information about pain. Thus, clinicians should be aware that simply asking a patient to rate the intensity of pain provides useful but not complete information about important aspects of the pain and the implications for treatment.

Unfortunately, pain rating scales seem to invite creativity. Sometimes colors are added to a preexisting scale such that different colors are used to indicate different intensities of pain, or colors are added to a faces scale. Some of the problems with this practice are that some health care facilities do not have copiers that duplicate in color and that research into colors as indicators of pain intensity is limited. Colors are subject to personal preferences and cultural differences and are best avoided. Another change to a preexisting valid and reliable scale is drawing hats on a faces rating scale. When a validated and reliable scale is changed in any of these ways, additional research is required to establish the reliability and validity of the new scale. Sometimes clinicians develop and use an entirely new scale without testing it for reliability and validity. Such energy is better spent on promoting the routine use of a single, simple pain rating scale that has already been established as being valid and reliable.

As stated in Box 3-2, the tool also should be sufficiently graded so it can capture changes in pain intensity and should be easily understood, easy to score, and liked by patients and staff. The tool should place a low burden on staff; that is, it should be quickly explainable and easily scored. It should also be inexpensive and easy to duplicate. The tool should also be appropriate for patients of various cultures and available in several languages.

Visual Analogue Scale

The tool that is probably used most frequently in research but is inappropriate for clinical use is the VAS. It is difficult to say how long pain rating scales have been used, but the VAS has been used for assessment of subjective phenomena such as loudness of a sound for more than 80 years (Freyd, 1923; Hayes, Patterson, 1921). At some point the VAS began to be used in pain research, and it is a reliable and valid instrument (Huskisson, 1974; Jenson, Karoly, 2001).

Currently, the term VAS is used loosely and inaccurately to refer to several different pain intensity scales such as the Numerical Rating Scale (NRS). However, the VAS has a fairly precise definition as a horizontal (sometimes vertical) 10-cm line (100 mm) with word anchors at the extremes, such as “no pain” on one end and “pain as bad as it could be” on the other end (Figure 3-1). The patient is asked to make a mark on the line to represent pain intensity. In this manual, the term VAS refers only to a horizontal or vertical straight line with word anchors at the ends.

Figure 3-1 This horizontal visual analog scale (VAS) for rating pain intensity is a 10-cm line with word anchors. Patients are asked to mark the line. Although the VAS is frequently used in research, it is not recommended for clinical practice because scoring is time-consuming. From Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management, p. 55, St. Louis, Mosby. Pasero C, McCaffery M. The scale is in the public domain. May be duplicated for use in clinical practice.

Probably because the VAS is reliable and valid and is commonly used in research, it is sometimes used in clinical practice. However, it has several disadvantages in that setting. Although the VAS is usually easy to administer (unless the patient has an injury to the arm or hand or is lying down) and easy to reproduce, scoring is time consuming. As mentioned, the patient is asked to mark the line to indicate the level of pain. A number is then obtained by measuring in millimeters up to the point the patient has indicated. Also, without specific numbers being arranged along the VAS line, it is difficult to use the scale to discuss pain rating goals with the patient, especially over the telephone. Further, patients tend to have more difficulty understanding and using a VAS than the other scales such as the NRS (Herr, Spratt, Mobily, et al., 2004; Jensen, Karoly, 1992; Peters, Patijn, Lame, 2007). In research comparing the VAS with the verbal descriptor scale (VDS) and with 11-point and 21-point numeric box scales, patients made more mistakes using the VAS (Peters, Patijn, Lame, 2007). (A box scale shows connected boxes along a vertical or horizontal line with numbers in the boxes, such as 0 to 10 or 0 to 20. Figure 3-2 is an example.)

Figure 3-2 Horizontal 0-to-10 box scale. From Pasero, C., McCaffery, M. Pain assessment and pharmacologic management, p. 56, St. Louis, Mosby. The scale is in the public domain. May be duplicated for use in clinical practice.

Recommended Pain Intensity Rating Scales

After we (the authors) considered a wide array of pain intensity rating scales, the self-report scales we now recommend for use in clinical practice with cognitively intact adolescents, adults, and older adults consist of the NRS plus a faces pain rating scale (Box 3-3). This gives the patient a choice of using either the NRS or a faces scale. Some patients are unable to understand the NRS but are able to use one of the faces scales. Other patients simply do not like the NRS. For example, in a study of 267 hospitalized patients ranging in age from 16 to 91 years, almost half preferred the Wong-Baker FACES Pain Rating Scale (FACES) to the 0 to 10 NRS or the VAS (Carey, Turpin, Smith, et al., 1997).

1. Numerical Rating Scale (NRS) using 0 to 10 (0 = no pain; 10 = worst possible pain) presented visually. Patients are asked to report a number or mark the scale. OR:

2. The NRS combined with one of the following:

• Wong-Baker FACES Pain Rating Scale (FACES). OR:

• Faces Pain Scale-Revised (FPS-R), again using 0 to 10 to represent the faces.

From Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management, p. 56, St. Louis, Mosby. Pasero C, McCaffery M. May be duplicated for use in clinical practice.

Specifically, we suggest a horizontal NRS using 0 to 10 (0 = no pain; 10 = worst possible pain) presented visually. The patient is asked to report a number or mark the scale. Or the patient may choose a faces scale. We recommend that the NRS be combined with either (a) the Wong-Baker FACES Pain Rating Scale (FACES), using 0 to 10 to represent the 6 faces; or (b) the Faces Pain Scale-Revised (FPS-R), again using 0 to 10 to represent the 6 faces (Figures 3-3 and 3-4). No single-word anchor has been identified as being the best one for the number 10 on the 0 to 10 scale. Examples of word anchors that have been used fairly frequently are “worst imaginabale pain,” “worst possible pain,” “most intense pain imaginable,” “terrible pain,” and “pain as bad as it can be.”

Figure 3-3 Example of how the Numerical Rating Scale (NRS) can be combined with the Wong-Baker FACES Pain Rating (FACES) in a horizontal format with a 0-to-10 metric and placed on the same paper or card to present to patients. They have a choice of pain rating scales. If the NRS is not easily understood, the FACES scale is an alternative. From Hockenberry, M. J., Wilson, D., & Winkelstein, M. L. (2005). Wong’s essentials of pediatric nursing, ed 7, St Louis, Mosby, p. 1259. Used with permission. From Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management, p. 56, St. Louis, Mosby. Permission to use the FACES scale for purposes other than clinical practice can be obtained at http://www.us.elsevierhealth.com/FACES/. The NRS is in the public domain. May be duplicated for use in clinical practice.

Figure 3-4 Example of how the Numerical Rating Scale (NRS) can be combined with the FPS-R in a horizontal format with a 0-to-10 metric and placed on the same paper or card to present to patients. Patients have a choice of pain rating scales. If the NRS is not easily understood, the FPS-R scale is an alternative. As appears in Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management, p. 57, St. Louis, Mosby. This figure has been reproduced with permission of the International Association for the Study of Pain. May be duplicated for use in clinical practice. Permission to use the FPS-R for purposes other than clinical practice or research can be obtained by e-mailing IASPdesk@iasp-pain.org. The NRS is in the public domain.

Numerical Rating Scale: The NRS is sometimes presented as a 0 to 5 scale or as a vertical line, but in this manual, unless otherwise specified, NRS refers to a 0 to 10 horizontal scale with numbers between 0 and 10. Although occasionally the 0 to 5 scale is appropriate for patients who are unable to comprehend more items on a scale, the 0 to 10 is now widely accepted. In a survey of health care professionals that asked them which scale they preferred for use in clinical practice, the majority (70%) favored 0 to 10 (von Baeyer, Hicks, 2000). Regarding use of the horizontal line, it is worth noting that research indicates that the vertical VAS may be more sensitive and easier for patients to use, especially patients who are under the stress of having a narrowed visual field (Gift, 1989; Gift, Plaut, Jacox, 1986). Further, some research has found that the vertical format may be more easily understood by older persons (Herr, Garand, 2001; Herr, Mobily, 1993). Therefore, the vertical NRS (Figure 3-5, A) may be advisable for some patient populations or may be presented as an alternative to patients who have difficulty with the horizontal scale (Figure 3-5, B).

Figure 3-5 The vertical version (A) of the numeric rating scale may be more easily understood than the horizontal version (B). From Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management, p. 58, St. Louis, Mosby. The scale is in the public domain. May be duplicated for use in clinical practice.

The reliability and validity of the 0 to 10 NRS are well established (Jensen, Karoly, 1992). Other major strengths of the 0 to 10 NRS are that most patients and clinicians are familiar with it, and it is easily administered. The universal adoption of a 0 to 10 NRS has been promoted for some time (Dalton, McNaull, 1998; Paice, Cohen, 1997; von Baeyer, Hicks, 2000). Also, numeric scales are well liked. In a group of younger adults and a group of older adults, one study compared the VAS, a 21-point numeric rating scale, a verbal descriptor scale, the 11-point (0 to 10) verbally presented numeric rating scale, and a faces pain scale (Herr, Spratt, Mobily, et al., 2004). Both the younger and the older groups preferred the 21-point numeric rating scale. Research conducted with younger and older surgical patients suggests that the 0-10 NRS has good psychometric properties and is the preferred scale when compared to a verbal descriptor scale, a horizontal VAS, and a vertical VAS (Gagliese, Weizblit, Ellis, et al., 2005).

Probably the most frequent way the NRS is presented is verbally, without a visual aid. This method is appealing because, unless the patient’s ability to speak is compromised, such as in the presence of an endotracheal tube, the patient can provide verbal responses at any time and in any position and regardless of difficulty in using the arms or hands. However, presentation of the NRS without a visual aid is not recommended because of the high error rate. Research has shown that when the NRS is presented verbally, without a written copy of the scale, patients make more mistakes, such as giving a score higher than 10 or a number between whole numbers (Herr, Spratt, Garand, 2007). However, when a 21-point box scale (numbers in boxes from 0 to 100 in increments of 5) and a verbally administered 0 to 10 box scale were compared, the results supported the validity of a verbally administered 0 to 10 point scale while showing a visual of the box scale, strongly suggesting that the NRS should be shown visually along with asking the patient to verbally rate pain on a 0 to 10 scale (Jensen, Miller, Fisher, 1998).

Therefore, when the NRS is used, every effort should be made to show the patient a copy of the scale. Patient reporting-error rates when using the 0 to 10 NRS in the absence of a visual presentation are sufficiently great for some to suggest that hospitals rethink their choice of using 0 to 10 without a visual aid (Feldt, 2007). Rather than abandoning the highly popular verbally presented 0 to 10 scale, a more practical solution is to make multiple copies of the 0 to 10 NRS along with whichever faces scale is chosen and post them in patients’ rooms, clinic areas, treatment rooms and other places where patients and clinicians might discuss pain.

As discussed earlier, pain rating scales seem to invite change and creativity without testing for reliability or validity. One problem with the 0 to 10 self-report scale is that some clinicians try to attach behaviors to each of the numbers. In one study of sedated patients, researchers tried to substitute behaviors for the sedated patients’ self-report of pain, overriding the patients’ stated pain levels (Salmore, 2002). However, there is no evidence that pain ratings by a sedated patient are less reliable than behaviors. The study in question requires further investigation.

When patients, such as very cognitively impaired patients and unconscious patients, are unable to self-report pain one must begin to rely on known pathology and behavioral indicators (see Box 3-9, p. 123). Otherwise, the gold standard for measuring pain intensity is a self-report, such as a number or word.

Box 3-9 Hierarchy of Pain Assessment Techniques

1. Attempt first to elicit a self-report of pain from patient. If patient is unable to give a self-report, explain why and proceed with the following steps.

2. Identify pathologic conditions and common problems or procedures that may cause pain.

3. Observe for behaviors recognized as pain-related in older persons with dementia. A behavioral assessment tool may be used.

4. Solicit information from caregivers and family members familiar with the older adult about possible indicators of pain.

5. Attempt an analgesic trial and observe changes in the patient’s behavior.

Note: In the absence of a self-report, when any information indicating pain is obtained in any of items 2 through 5, clinicians may assume pain is present (APP). The abbreviation APP may be documented if approved by institutional policy and procedure. (Pasero, C., & McCaffery, M. [2002]. Pain in the critically ill. Am J Nurs, 102(1), 59-60.)

From Pasero, C., & McCaffery M. (2011). Pain assessment and pharmacologic management, p. 123, St. Louis, Mosby. Data from McCaffery M, & Pasero C. (1999). Assessment: Underlying complexities, misconceptions, and practical tools. In M. McCaffery, & C. Pasero. Pain: Clinical manual, ed 2, St. Louis, Mosby; Herr, K., Coyne, P., Key, T., et al. (2006). Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Manag Nurs, 7(2), 44-52. Pasero C, McCaffery M. May be duplicated for use in clinical practice.

Another problem we (the authors) have seen across the United States is clinicians’ attaching behaviors to each number on the NRS and asking patients to state a number to indicate their pain levels. These scales are seldom published but are nevertheless used in clinical practice in some institutions. In one example of a 0 to 10 NRS with behaviors attached to each number, the number 5 was accompanied by the statement that pain “can’t be ignored for more than 30 minutes.” This has not been researched and is negated by the statements of many patients who have practiced learning to ignore pain. This also requires timing how long patients can ignore pain, which is cumbersome, time consuming, and a little on the humorous side. The same scale stated with the number 7 that pain “interferes with sleep,” again contradicted by patients who have learned to use sleep as a coping mechanism. (Readers may want to review the section on the acute pain model, presented earlier in this manual, on pp. 28-29). Again, on the humorous side, that same scale stated with the number 10 that “pain makes you pass out.” Again, no research substantiates this, and it makes it almost impossible for patients to rate pain as a 10 because they would be unconscious. Patients’ behavioral responses vary enormously and cannot be pigeonholed at one particular level of pain. Patients cannot be told how they have to behave in order to rate their pain at a particular level.

These attempts to assign behaviors to pain levels seem to reflect the desire to make pain levels uniform within and among patients. However, what is a 7 for one patient on a scale of 0 to 10 is not going to be a 7 for all other patients. And a given level of pain that is a 7 for a patient on one day may not be a 7 for that patient the next day. Some patients with chronic pain have commented that as their pain increases over time, what they had considered severe pain is now what they would rate as moderate pain.

One error, mentioned earlier, that is fairly common in research and clinical practice is that some patients select a point between numbers on a 0 to10 scale, such as 6.5. This deserves some explanation. Although difficult to handle when a computer is programmed to accept only 11 points of scale, a review of research shows that people can actually distinguish among 21 levels of pain (Jensen, Miller, Fisher, 1998). Further, research with older adults that compared a faces scale, a 0 to 5 verbal rating scale, and a vertical and a horizontal 21-point box scale, the horizontal 21-point box scale emerged as the best scale with respect to psychometrics and regardless of mental status (Chibnall, Tait, 2001). But the 0 to 10 scale is well entrenched, and using a 0 to 20 scale in clinical practice does not seem practical at this time. However, even when compared with the VAS, a 21-point box scale may be the instrument of choice for research in mixed populations, such as various levels of cognitive ability (Herr, Spratt, Mobily, et al., 2004; Peters, Patijn, Lame, 2007).

The 0 to 10 NRS has been translated into many languages. A few translations are seen in Figure 3-6 (p. 60). Further, there is preliminary evidence that a 0 to 10 NRS (presented with a visual) has higher reliability in illiterate patients when compared to the VAS or a verbal rating scale (such as no pain, mild, moderate, severe, unbearable) (Ferraz, Quaresma, Aquino, et al., 1990). Results are difficult to generalize because the study was conducted only with Portuguese patients.

Figure 3-6 Translations of 0-10 numerical rating scale.
*Courtesy of Pain-Management Committee, St. Francis Medical Center, Honolulu, NY.
^†Compiled by Josephine Musto, St. Vincent’s Hospital and Medical Center, New York, NY. From Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management, pp. 60–65. St. Louis, Mosby. These scales are in the public domain. May be duplicated for use in clinical practice.

Wong-Baker FACES Pain Rating Scale: Work on the Wong-Baker FACES Pain Rating Scale (henceforth referred to as the FACES scale) began in 1981 by Donna Wong, a nurse consultant, and Connie Morain Baker, a child life specialist, who were working in a burn unit. In 1988, Wong and Baker published a study of 150 children aged 3 to 18 years. The FACES scale was presented in a circular format and was compared to five other scales: (1) a simple descriptive scale with numbers assigned to five adjectives on a horizontal line; (2) a numeric scale with the numbers 0 to 10 on a horizontal line; (3) a five-glasses scale in which the glasses contained varying amounts of water, ranging from no water to a full glass; (4) a chips scale using five white plastic chips; and (5) a color scale that included six colors. This study demonstrated the initial reliability and validity of the FACES scale, and no single scale demonstrated superior validity or reliability. The most preferred scale was the FACES scale. Because the FACES scale was presented in a circular format, the results of this study are difficult to compare with those of the numerous other studies in which these faces and other faces scales are presented to children and adults in a horizontal format. Other information concerning the development of this scale and its use in children is available at http://www.mosbysdrugconsult.com/WOW/faces.html and http://www.mosbysdrugconsult.com/WOW/facesStatisticalAnalysis.html. Unfortunately, several studies of reliability and validity listed at this website are unpublished.

The FACES scale was developed for use with children, but is it appropriate for some adults? Indeed, some studies of adults have revealed that they often prefer the faces scales to other scales. For example, in one study of 267 adults, the FACES, VAS, and NRS were compared, and the FACES was preferred (Carey, Turpin, Smith, et al., 1997). In another study of children and their parents, a comparison of five faces scales revealed that the parents as well as the children preferred the FACES scale (Chambers, Giesbrecht, Craig, et al., 1999). The cartoon-like features of this scale seem to contribute to this preference. The high preference for the FACES scale is one reason for combining the FACES scale with the NRS to give adults a choice in pain rating scales (see Figure 3-3, p. 56). Of the various faces scales, the FACES scale is currently probably the most widely used in both children and adults in the United States.

In a study of 37 older adults in a long-term care facility, some of whom were cognitively impaired and others cognitively intact, pain was assessed using the VAS, VRS, McGill Word Scale (Melzack, 1975), and FACES scale (Wynne, Ling, Remsburg, 2000). The FACES scale was completed by 61% of the participants, the McGill Word Scale by 51%, and the VAS by 57%. Patients with cognitive impairment had more difficulty completing the instruments. Nevertheless, more participants were able to complete the FACES scale than the other scales.

The FACES scale meets many of the criteria for selecting a pain rating scale for use in clinical practice (see Box 3-2, p. 54). The faces do not depict age, gender, or culture. The FACES scale has been translated into several languages (Figure 3-7, pp. 66-67; translations are available at http://www.mosbysdrugconsult.com/WOW/faces Translations.html). It is therefore appropriate for patients of various cultures. It is often preferred by adults when they compare it to other scales. It is quickly explained and easily scored, easily and quickly understood, well-liked by clinicians and patients, and inexpensive to duplicate.

Figure 3-7 Translations of Wong-Baker FACES Pain Rating Scale. From Hockenberry, M. J., Wilson, D., & Winkelstein, M. L. (2005). Wong’s essentials of pediatric nursing, ed 7, St. Louis, Mosby, p. 1259. Used with permission. From Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management, p. 66-67, St. Louis, Mosby. Permission to use the FACES scale for purposes other than clinical practice can be obtained at http://www1.us.elsevierhealth.com/FACES/. The NRS is in the public domain. May be duplicated for use in clinical practice.

No pain rating scale is perfect, and several objections have been made regarding the use of the FACES scale. One frequently mentioned concern has been that the presence of tears in the last face, depicting the greatest pain, might cause both children and adults to be reluctant to select that face if they were not crying or if they wanted to appear more stoic. Similarly, tearful patients may avoid selecting a face that shows no tears. The instructions for the scale attempt to avert this problem by telling a patient that a person does not have to cry to select the tearful face or may be crying and select a face without tears. Still, patients have been concerned. In a pilot study of 267 adults conducted in preparation for comparing scales that included the FACES scale, clinicians found that patients who selected the faces with tears said something about the tears, highlighting the need to include the instruction that one does not have to be crying to select the face with tears (Carey, Turpin, Smith, et al., 1997).

Some clinicians have asked about simply eliminating the tears on the FACES scale when they copy it for clinical use. However, this could affect the validity of the scale.

In one study of parents and their children, a similar problem occurred in adults’ understanding of the instructions for using the FACES scale (Chambers, Giesbrecht, Craig, et al., 1999). The researchers reported that some parents experienced difficulty understanding how to apply the scale to judge pain in their children when they were given the same verbal instructions as their children received, which included the statement that a person does not have to cry to select the last face with tears. Nevertheless, as an example, one parent commented that the child had a lot of pain but that his face never looked like the face with tears, so the adult selected a face at the lower end of the scale. This requires further investigation but suggests that when the FACES scale is used with adults, directions that are given for children may need to be clarified for the adults.

Another concern arises over the fact that a smiling face rather than a neutral face is placed at the beginning of the scale to denote no pain. In the FACES scale, the second face has a slight smile, and the third face is neutral. Some other faces scales, such as the FPS-R described next, begin with a neutral face to represent no pain. A person with no pain who is not smiling might select the third neutral face on the FACES scale, resulting in falsely high pain ratings. One study comparing five faces scales, two beginning with a smiling face and three beginning with a neutral face, used by children 5 to 12 years old and their parents, found that both the children and their parents gave higher pain scores when the smiling faces scales were used (Chambers, Giesbrecht, Craig, et al., 1999). The implications of these findings have been disputed by Wong and Baker (2001). However, another study of children and their parents comparing five faces scales, including the FACES scale and a color scale, found that scales beginning with a smiling face produced significantly higher pain ratings (Chambers, Hardial, Craig, et al., 2005). Children’s pain ratings were the highest when the FACES scale was used.

Thus, when adults as well as children use the smiling faces scales, higher pain ratings may result than when faces scales begin with a neutral face. This problem can be circumvented by using a faces scale that begins with a neutral face, and we suggest the FPS-R, presented next.

Another objection to the FACES scale is the difficulty in obtaining studies of reliability and validity. As mentioned earlier, on the website that lists studies of the reliability and validity of the FACES scale, several are unpublished and difficult to obtain.

Faces Pain Scale-Revised: The FPS-R is a modification of a scale with seven faces developed by Bieri, Reeves, Champion, and others (1990). A scale with seven faces does not adapt well to the 0 to 10 metric used by the majority of pain scales. The revised scale has six faces, so it is easily presented with the 0 to 10 metric (see Figure 3-4, p. 57) (Hicks, von Baeyer, Spafford, et al., 2001). Although numbers beneath the faces are not used when the scale is shown to young children, they are developmentally appropriate to use with adults. In fact by the age of eight years most children are able to use a 0 to 10 scale (Spagrud, Piira, von Baeyer, 2003).

The FPS-R was developed for use in preschool and school-age children. Initially, two studies were designed to establish the psychometric properties of the scale in children experiencing nonclinical pain and clinical pain (Hicks, von Baeyer, Spafford, et al., 2001). Comparing the FPS-R and the VAS, the validity of the FPS-R was established in a study of 76 children aged 5 to 12 years old having ear piercing. The next study established validity of the FPS-R in a group of 90 children 4 to 12 years of age experiencing clinical pain associated with hospitalization. The FPS-R was compared with a color analog scale and the VAS.

Studies have also shown that the FPS-R is appropriate for adults. One study compared the FPS-R with a verbal descriptor scale, the NRS and the Iowa Pain Thermometer in 40 cognitively intact and 28 cognitively impaired older minority adults, including African-Americans (74%), Hispanics (16%), and Asians (10%) (Ware, Epps, Herr, et al., 2006). The study was conducted in an acute care facility in the southern United States. The reliability and validity of the FPS-R were supported in this group, and the FPS-R was preferred by African-Americans and Hispanics and those who were cognitively impaired.

Another study of adults in Spain compared the Spanish version of the FPS-R with a pain thermometer (Miro, Huguet, Nieto, et al., 2005). Using five hypothetic painful situations, 177 cognitively intact subjects aged 65 years and older were asked to rate pain. The study provided preliminary evidence of the scale’s reliability and validity in this group. Also, subjects preferred the FPS-R. The study established the usefulness of the FPS-R in cognitively intact elderly patients.

In a study conducted in China of 173 Chinese surgical patients, aged 18 to 78 years, reliability, validity, and scale preference were studied by comparing the FPS-R, VAS, NRS, and a verbal descriptor scale (Li, Liu, Herr, 2007). Patients were interviewed preoperatively and asked to rate any vividly recalled pain and anticipated postoperative pain intensity. Then they were asked for pain intensity ratings on the day of surgery through the sixth postoperative day. On the last day they were asked their scale preference. All four scales had good reliability and validity. The FPS-R had a low error rate, and almost half of the subjects preferred the FPS-R. The researchers concluded that the FPS-R was the best one for Chinese adults.

In summary, the reliability and validity of the FPS-R has been established in the following groups of adults:

• Cognitively impaired and intact older adults who were Asian, African-American, or Hispanic. The last two groups preferred the FPS-R.

• Cognitively intact elderly Spanish patients; most preferred the FPS-R.

• Cognitively intact Chinese adults ranging in age from 18 to 78 years old; almost half preferred the FPS-R; the FPS-R had a low error rate.

These studies ensure that the FPS-R meets some of the criteria for selecting a pain rating scale for use with adults in daily clinical practice (see Box 3-2, p. 54). Research establishes it as being reasonably valid and reliable in children and adults. It is developmentally appropriate not only for children but also for adults as young as 18 years and for cognitively intact and cognitively impaired elderly. It is easily understood and well liked by patients. It has demonstrated appropriateness for patients of various cultures, such as minorities, Chinese, and Spanish. Further, the tool is available in approximately 30 languages (Figure 3-8). It is inexpensive and easily explained, scored, and recorded.

Figure 3-8 Translations of Faces Pain Scale-Revised. From Hicks, C. L, von Baeyer, C. L., Spafford, P. A., et al. (2001). The Faces Pain Scale-Revised: Toward a common metric in pediatric pain measurement. Pain, 93, 173-183. As appears in Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management, pp. 69-85, St. Louis, Mosby. Permission to use the FPS-R for purposes other than clinical practice or research can be obtained by e-mailing IASPdesk@iasp-pain.org. This figure has been reproduced with permission of the International Association for the Study of Pain. May be duplicated for use in clinical practice.

The FPS-R minimizes some concerns associated with the FACES scale. The first face is neutral, not smiling, so it lowers the possibility of artificially high scores. Tears, which might be objectionable to some patients, are not shown on any of the faces of the FPS-R scale, including the one that denotes the most severe pain.

Principles of Using Pain Rating Scales

Whichever pain rating scale is chosen for a patient should be used consistently with that patient. Using the same pain rating scale makes it possible to compare the pain ratings. Also, using the same scale is obviously easier for the patient than switching from one scale to another. Further, using the same pain rating scales and the same metric (that is, 0 to 10) throughout the institution facilitates communication about patients’ pain. Standardization is helpful within a given health care system, so that the same scale is used in the emergency department, the hospital, and the outpatient care services. A standard pain rating scale minimizes confusion for both patients and staff.

The primary reason for using pain rating scales is to evaluate the effectiveness of pain treatment plans. Reassessment is essential. The frequency with which pain ratings are obtained depends on the situation. The Guideline for the Management of Cancer Pain in Adults and Children (Miaskowski, Cleary, Burney, et al., 2005) recommends that at “a minimum pain should be reassessed and documented:

• at regular intervals after a management plan is initiated,

• with each new report of pain; and

• at an appropriate interval after each pharmacologic or nonpharmacologic intervention, such as 15 to 30 minutes after parenteral drug therapy or 1 hour after oral administration of an analgesic” (p. 28).

When pain is out of control, such as a 10 on a scale of 0 to 10, and a rapidly acting analgesic is used, pain ratings every 5 minutes may be appropriate. However, at the beginning of treatment, asking the patient for a pain rating may be entirely inappropriate. When a patient is obviously in pain or is not focused enough to learn to use a pain rating scale, pain treatment should proceed without pain ratings. Once a patient can use a pain rating scale, pain assessment may be necessary as often as every 15 minutes until pain is brought under control, then every 1 to 2 hours for 24 hours, followed by every 4 hours. Once pain has been well controlled, however, in hospitalized patients, obtaining pain ratings every 8 to 12 hours may be sufficient; in nursing homes a daily or even weekly pain assessment may be appropriate. In home care, once pain has been controlled, patients are not ordinarily asked to keep records of pain ratings.

An intricate part of using pain rating scales to evaluate pain management is to set goals for treatment. These may be referred to as comfort-function goals and are discussed later. Basically, it is essential to know what pain rating is necessary for individual patients.

Teaching Patients and Families How to Use a Pain Rating Scale

It is not unusual for clinicians to claim that patients cannot use pain rating scales. However, even in cognitively impaired elderly patients in nursing homes, 83% who report pain are able to use at least one type of pain rating scale (Ferrell, Ferrell, Rivera, 1995). Another study that included older cognitively impaired minority patients used a verbal descriptor scale (no pain, mild pain, moderate pain, severe pain, extreme pain, and most intense pain imaginable), a 0 to 10 NRS, a FPS-R, and an Iowa Pain Thermometer (Figure 3-9, p. 87) and found that all these scales were relatively easy for these patients to use (Ware, Epps, Herr, et al., 2006). Therefore, most adolescents and adults who are not cognitively impaired should be able to learn to use a pain rating scale. It is simply a matter of having a plan that ensures that when patients are admitted to clinical settings, someone is responsible for teaching all patients about the pain rating scale, having patients demonstrate their understanding of it, and documenting this in the records.

Figure 3-9 Iowa Pain Thermometer (IPT). From Herr, K., Spratt, K., Spratt, K. F., et al. (2006). Evaluation of the Iowa Pain Thermometer and other selected pain intensity scales in younger and older adult cohorts using controlled clinical pain: A preliminary study. Pain Manag Nurs, 7(2), 44-52. From Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management, p. 87, St. Louis, Mosby. May be duplicated for use in clinical practice.

The steps for teaching the 0 to 10 NRS are in Box 3-4 on p. 86. Steps 1, 2, and 3 provide information; steps 4 and 5 ask the patient to demonstrate understanding of the information; and Step 6 focuses on the goals for comfort and function/recovery. Along with each step are specific examples of what may be said to the patient and family. A teaching brochure titled “Understanding Your Pain: Using a Pain Rating Scale” is patterned after the steps in Box 3-4 and is available at www.endo.com.

Guidelines

Box 3-4 Teaching Patients and Their Families How to Use a Pain Rating Scale

Step 1. Show the pain rating scale to the patient and family and explain its primary purpose.

Example: “This is a pain rating scale that many of our patients use to help us understand their pain and to set goals for pain relief. We will ask you regularly about pain, but any time you have pain you must let us know. We don’t always know when you hurt.”

Step 2. Explain the parts of the pain rating scale. If the patient does not like it or understand it, switch to another scale (e.g., vertical scale, FACES).

Example: “On this pain rating scale, 0 means no pain and 10 means the worst possible pain. The middle of the scale, around 5, means moderate pain. A 2 or 3 would be mild pain, but 7 and higher means severe pain.”

Step 3. Discuss pain as a broad concept that is not restricted to a severe and intolerable sensation.

Example: “Pain refers to any kind of discomfort anywhere in your body. Pain also means aching and hurting. Pain can include pulling, tightness, burning, knifelike feelings, and other unpleasant sensations.”

Step 4. Verify that the patient understands the broad concept of pain.

Ask the patient to mention two examples of pain he or she has experienced.

If the patient is already in pain that requires treatment, use the present situation as the example.

Example: What to say if the patient is not in significant the pain: “I want to be sure that I’ve explained this clearly, so would you give me two examples of pain you’ve had recently?”

If the patient’s examples include various parts of the body and various pain characteristics, that indicates that he or she understands pain as a fairly broad concept.

Example: The patient might say, “I have a mild, sort of throbbing headache now, and yesterday my back was aching.”

Step 5. Ask the patient to practice using the pain rating scale with the present pain or to select one of the examples mentioned.

Examples: “Using the scale, what is your pain right now?” “What is it at its worst?” Or “Using the pain rating scale and one of your examples of pain, what is that pain usually?” “What is it at its worst?”

Step 6. Set goals for comfort and function/recovery. Ask patients what pain rating would be acceptable or satisfactory, considering the activities required for recovery or for maintaining a satisfactory quality of life. (Research strongly suggests that pain rating goals of 4 or more on a 0-to-10 scale are not appropriate.)

Example: For a surgical patient: “I have explained the importance of coughing and deep breathing to prevent pneumonia and other complications. Now we need to determine the pain rating that will not interfere with this so that you may recover quickly. If you’re not sure, you can guess, and we can change it later.”

Example: For a patient with chronic pain or a terminally ill patient: “What do you want to do that pain keeps you from doing? What pain rating would allow you to do this?”

From Pasero, C., & McCaffery, M. Pain assessment and pharmacologic management, p. 86, St. Louis, Mosby. McCaffery M, Pasero C. May be duplicated for use in clinical practice.

Patients tend to have a narrow concept of the word pain, often restricting its use to excruciating and intolerable sensations. The patient’s concepts of pain may be expanded by explaining that pain includes several different uncomfortable sensations, such as tightness and pressure, and by using the words aching and hurting (Step 3). In a study of four different ethnic groups—Hispanics, American Indians, blacks, and whites—participants were asked to describe and rate painful experiences. Findings revealed that in all groups, the word ache was used for mild pain, hurt for moderate pain, and pain for the most intense discomfort (Gaston-Johansson, Albert, Fagan, et al., 1990).

Setting the Comfort-Function Goal

How much pain is too much pain? When clinical practice guidelines first began to be published, the need for a goal was recognized. One of the first guidelines stated: “Determine the level of pain above which adjustment of analgesia or other interventions will be considered” (Acute Pain Management Guideline Panel, 1992, p. 7). The primary reason for using pain rating scales is to evaluate the effectiveness of the pain treatment plan. To do this, it is essential to set goals, as described in Box 3-4, Step 6. In a review of studies of primary care physicians’ goals for pain treatment, goals for pain relief were the single best predictor of the quality of pain management (Green, Anderson, Baker, et al., 2003).

The purpose of establishing a comfort-function goal is to identify how much pain can exist without interfering with the function and quality of life; that is, activities that the patient needs or wishes to perform. Goals should be as concrete as possible. For example, identifying a pain rating of 3 for accomplishing recovery is too general, whereas identifying a pain rating of 3 for ambulation is much more concrete. The goal is always established by working with the patient and identifying goals that are consistent with what the patient wants. An examination of longitudinal data from quality assurance studies revealed that charted goals for pain relief were often higher than the goals patients reported wanting (Ward, Gordon, 1996). However, clinicians should not establish comfort-function goals in the absence of input from patients.

Comfort-function goals are appropriate for both acute pain and persistent pain, and they encompass physical as well as emotional status and cognitive-behavioral activities. The patient should be assured that reported pain ratings above the goal will result in consideration of additional interventions.

When a clinician works with a patient to set comfort-function goals, the patient must understand that the intent is not to identify the highest pain level the patient can tolerate, but rather to identify how much pain can exist without interfering with function. In other words, what level of pain may be noticeable but not bothersome?

With some patients, such as those with persistent pain, multiple goals may be appropriate, but for most patients, setting more than one goal can be avoided by identifying the pain levels that would allow the patients to perform the function that is most painful but also of great importance. Following are examples of how this is done in various settings.

Patient Example

In an acute pain setting such as postoperative pain, pain may not yet exist but is anticipated. Whenever possible, the comfort-function goal should be identified before pain occurs. In such cases, the clinician may know better than the patient which recovery activities probably will be the most painful but are of great importance to recovery. So the clinician may explain that using an incentive spirometer may be quite uncomfortable but is essential for avoiding complications postoperatively. The clinician may then ask the patient, “What pain rating would make it easy for you to use your incentive spirometer frequently?” The patient may reply that a pain rating of 2 would be all right. The pain rating would then be documented as “2/10 to use incentive spirometer.” This can be renegotiated postoperatively if necessary.

By setting a goal for one of the most painful postoperative activities, the hope is that achieving that goal at all times will suffice to make possible other, less painful activities such as ambulation and sleep. Note that the patient is asked to identify a pain rating that makes it easy to perform the painful activity. Again, the emphasis is not placed on what the patient can tolerate but on a goal that makes important activities easy to perform.

Patient Example

Incident pain may also require setting a goal. A patient with chronic noncancer pain that is well controlled may be unable to participate in physical therapy because of the pain it causes. The patient is then asked, “What level of pain would make it easy for you to fully participate in physical therapy?” The patient may answer that a pain rating of 3 would be sufficient. That becomes the comfort-function goal, 3/10 to participate in physical therapy. The plan may be to provide an oral analgesic 1 hour prior to physical therapy.

Patient Example

A patient with persistent pain may be unable to achieve satisfactory quality of life. The patient may be asked, “What is it that you can do and want to do, but pain keeps you from doing?” Answers vary and range from walking the dog around the block to being less depressed or having pain interfere less with concentration. Patients with persistent pain of nonmalignant origin may not have been approached with the idea of setting their own priorities and may not expect pain to be less than a 5 which, as discussed, has been shown to interfere significantly with function.

A study of patients with moderate to severe persistent pain related to osteoarthritis (OA), metastatic cancer, and low back pain were found to prefer the terms manageable and tolerable when describing a day of pain control to the term acceptable (Zelman, Smith, Hoffman, et al., 2004). Many of the participants objected to the phrase “an acceptable day of pain control” because it suggested that it would be possible to have days when their painful situations were acceptable or when they could experience full pain relief, a condition they felt was not possible. On the other hand, interviews with some patients indicated that it may be that patients whose pain is well controlled do not object to the term acceptable. Thus, objection to the term acceptable may indicate that pain is not well controlled.

The patients in the study identified that a manageable or tolerable day of pain control included (1) taking the edge off pain (note that this phrase may signal that pain should be reduced); (2) performing valued activities; (3) relief from dysphoria and irritability; (4) reduced adverse effects caused by medications; and (5) feeling well enough to socialize. These may be common themes in setting goals with patients who have persistent pain.

When patients are asked what level of pain they desire, some will report zero. The process of setting comfort-function goals helps set realistic goals because zero pain is not always possible. In fact, research involving patients with rheumatic diseases showed that on a 100-mm VAS, patients may interpret scores of less than 10 mm as no pain and that scores less than 25 mm may be considered to be relatively normal (Sokka, 2005). However, once the goal is achieved, such as a pain rating of 2 out of 10, the possibility of even better pain relief can always be considered. Over time or with experience, goals may change. For example, if a patient find that the pain rating goal is too high to facilitate frequent use of the incentive spirometer postoperatively, it should be changed to a lower number.

For some patients, especially those with persistent uncontrolled pain, setting goals may take place in stages. For example a patient, in sickle cell crisis may have had uncontrolled severe pain that has lasted for days and deprived him or her of sleep. The first objective may be to provide enough relief for the patient to get uninterrupted sleep. Once this is achieved, another goal related to activities may be established.

It may be difficult to engage some patients with chronic persistent pain of noncancer origin in pain management plans. They may be depressed and reluctant to participant for fear of failure (Filoramo, 2007). Many have tried multiple methods of pain control that have failed, or they have failed to accomplish their goals in the past. It is especially important in these cases to set goals that are concrete, that incorporate the patient’s personal goals, and that occur in stages that are achievable. For example, beginning with a goal that establishes a pain rating of 3 out of 10 when walking for 5 minutes may be relatively easy for a patient to accomplish. After this goal is achieved, the next goal might be to walk for 10 minutes. This approach incorporates the concept of pacing; that is, stopping an activity before it becomes painful. In this way, a patient begins to believe that improvement in function is attainable and becomes more strongly committed to the plan of care.

Not only does setting a comfort-function goal help the entire team, including the patient and family, to know what the pain-treatment plan should achieve, it also helps the patient to see how pain relief contributes to recovery or improves quality of life. Not all patients understand the importance of pain relief or the possible harmful effects of pain. Some patients do not expect to have their pain relieved, are frightened of taking opioid analgesics, or value a stoic response to pain. These patients may be reluctant to set a low pain rating as the goal. By setting pain rating goals that correspond to function, patients learn that pain relief helps them to recover faster from circumstances such as surgery. In cases of persistent pain, patients learn that pain control puts them back in control of their daily lives rather than allowing pain to control their lives.

The patient’s comfort-function goal should be visible on all records where pain ratings are recorded, such as bedside flow sheets. Whether the goal has been achieved or not should also be routinely included at change-of-shift hand-off reports. If the pain rating is below the goal, documentation should show which efforts were made to achieve the desired goal. For outpatient pain management, a diary or flow sheet kept by the patient (discussed later; see Form 3-11, p. 116) is one way to document and make visible progress toward goals. Establishing comfort-function goals for individual patients and holding clinicians accountable for attempting to achieve those goals may help clinicians to avoid basing pain-management decisions on their own biases.

Form 3-11 From Pasero, C., & McCaffery M. Pain assessment and pharmacologic management, p. 116, St. Louis, Mosby. Pasero C, McCaffery M. May be duplicated for use in clinical practice.