Pain assessment

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Learn about the process and goals of pain assessment to provide the information necessary to initiate optimal pain treatment strategies.

An accurate assessment of pain is essential to determine the best pain relief method. In addition to describing the intensity of pain (how much pain and how painful it is), an assessment will tell health care professionals about whether the pain is acute or chronic and the location of the pain. Chronic and acute pain treatment strategies can be different, so it is important to understand what type of pain your child is having. Assessment will also help to distinguish between pain and related feelings of discomfort, fear, and anxiety.

Because of the individual nature of pain, assessment is not easy. Only your child truly knows how the pain feels. Like sadness or fear, only the individual who is experiencing it can tell how intense it is or how much it bothers them.

Pain assessment cannot be absolutely precise. Unlike reading a temperature with a thermometer, there is no objective measure to tell us how much pain someone is in. But using a variety of methods in combination, a reasonably accurate assessment of pain is possible.

Father talking to toddler daughter

Assessment has three components each contributing to the overall picture. These components include:

  • a self-report
  • an observer's report
  • physical changes.
  • 1) Self report — What your child says about their pain

    Although what your child reports about their pain is the most subjective measure of all, it is probably the most important. Since pain is individual, only your child knows what the pain is like for them. Injuries that look bad may not be that painful, and injuries or disease that cannot be seen at all may be very painful. Just because you can't see the cause of pain does not mean that the pain doesn't exist.

    This assessment method can only be used if your child can respond verbally. It involves a health care professional asking questions about the pain and the child responding. These questions may be similar to ones you would ask if your child came and told you they were in pain or you noticed they were guarding a body part that they may have injured.

    These questions include:

    • Do you have a hurt/owie/pain?
    • Can you show me where it hurts? Does the hurt go anywhere else on or in your body?
    • When did the hurt start? How long has the hurt been there?
    • Do you know what might have started the hurt?
    • How much does it hurt? (Here, your child may be asked to use a pain intensity scale. For example, on a scale of 0 to 10, 0 meaning no pain and 10 meaning severe pain, how much do you hurt?)
    • Can you tell me words that might describe the hurt? (The child may be given key words if they don't come up with their own, such as “sharp”, “pins and needles”, “burning.”)
    • What helps to take away the hurt? (Medicines you've had before, massage, heat/cold, playing with your friends?)

    Helping children describe their pain

    When it comes to your child describing their own pain, their age, individuality, and other factors must be taken into consideration. Children who have yet to learn to talk will not be able to describe details of their pain at all. Children with a limited vocabulary may use words like "owie" which must be interpreted by their parents and caregivers.

    Children who are capable of expressing and describing their pain in detail may choose not to do so because of social pressures and cultural expectations. Children are sometimes taught that they should endure pain and that crying is for "sissies." These beliefs, which can apply to all cultures and ages and to both sexes, may affect the way your child expresses and reports pain.

    Often when asked a question children will answer with what they believe people want to hear. A child may play down the extent of pain to please their parent or other care givers.

    Children may play down the extent of their pain out of fear. Your child may think that if they report their pain as severe, they will have to stay longer in the hospital, away from their family, friends, and home. In many cases, this may not be true.

    The way children are asked about pain may direct them to an answer. For example, asking "that doesn't really hurt, does it?" may cause your child to under-report their pain. If your child is not asked about pain, they may say nothing even though they are indeed in pain.

    Two things may be done to increase the chances of an honest answer from a child. First, research has shown that if a child has been instructed on the importance of providing an absolutely honest answer before the question is asked, they are more likely to tell the truth. For example, before your child is asked to assess the amount of their pain, they should be told that "it is very important that you tell us about your pain so that we can help you." Second, questions should be phrased in the most neutral way as possible, without any language that suggests answering one way or another.

    If a truthful response has been encouraged to questions about pain, the responses should be believed. Children should feel they are part of the process of pain assessment and relief. Believing what they report encourages this feeling and helps give them and their parents a sense of control that is ultimately beneficial.

    2) An observer's report

    Your child is likely to express pain through changes in their behaviour. A child pulling on their ear may be a sign of pain. High pitched and persistent crying is a common sign of pain in an infant. A child not moving or guarding and protecting a part of their body may indicate that pain is present.

    Health-care professionals may use behavioural pain scales and specific measures of behaviour, such as movement and facial expressions, and the qualities of a child's cries to determine the intensity of the child's pain. Parents can be especially helpful in assessing pain by observing behaviour changes. Health-care professionals might ask parents the following questions:

    • Do you think that your child is in pain? How do you know? Where is the pain?
    • How much pain do you think they have? (Here the parent may be asked to use a pain intensity scale.)
    • Has your child had difficulty sleeping since the pain started?
    • Have you noticed any changes in your child's mood, appetite, or interest in favourite activities?
    • What do you think helps your child deal with the pain?

    3) Physical changes — How the body reacts

    Pain can also be assessed by measuring the body's physiological responses. Typically, an increase in heart rate, breathing rate and the presence of sweating, among other indicators, can be caused by pain. However, while useful, these measures can also have other causes, and a person in pain may not exhibit these changes. Generally, health-care professionals combine these physiological measures with the other two methods of assessment.

    In addition to these three assessment methods, a history of pain will be recorded. Parents and their children may be asked the following:

    • Has your child had pain before and how did they cope?
    • What helped/hindered the pain relief?

    A pain assessment will also take into consideration your child's emotional, family, and cultural circumstances, and previous experiences with pain.

    The emotional context within which your child experiences pain is extremely important. Some children may be willing to suffer in pain, knowing that the surgery they have just undergone will improve their lives. Other children may be very depressed, confused, or angry about their pain. These emotional extremes, and many in between, have an impact on the amount and intensity of pain in children.

    Which part of assessment is most important?

    Although all three of the assessment methods will be used, how much weight is given to each method will depend on the child's age and developmental capacity, and the situation. For example, an infant or a child who has a neurological or cognitive disability will not be able to self-report in the same manner as an older, typically developing child. In these cases, observational reports and physiological measures will be relied upon more heavily. Conversely, the self-reports of a school-aged child or a teenager in pain may be relied upon more heavily than the reports of parents or other caregivers.

    Changing needs of pain relief

    Pain and pain relief needs change over time. This means assessment is a continuing process. A single assessment is only a snapshot of what the pain is like at that moment. Multiple assessments provide a changing picture and can reveal an overall sense of how much pain your child is in and how well the pain relief strategies are working. As a child heals, the need for pain relief may be reduced. If a child's condition worsens, the need for additional pain relief measures may increase. Additionally, some pain relief methods work better than others, depending on the condition and individual nature of the child.

    Continuing, repeated assessments will help health professionals determine if a pain relieving strategy is working, and will provide the information necessary to initiate optimal pain treatment strategies.

    Last updated: September 15th 2009