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Initial Pain Assessment
The initial assessment should occur with each new report of pain and should focus on identifying the cause of the pain and developing a pain management plan. Subsequent assessments should evaluate the effectiveness of the plan and, if pain is unrelieved, determine whether the cause is related to the progression of disease, a new cause of pain, or the cancer treatment.
The initial evaluation of pain should include:
Health professionals should ask about pain, and the patient's self-report should be the primary source of assessment. The self-report should include a description of the pain; its location, intensity/severity, and aggravating and relieving factors; and the patient's cognitive response to pain. Neither behavior nor vital signs should be used in lieu of a self-report.47 It is brief, easy-to-use assessment tools that reliably document pain intensity and pain relief and to relate these to other dimensions of pain such as mood. One routine Clinical approach to pain assessment and management is summarized by the mnemonic "ABCDE":
Assess pain systematically
Believe the patient and family in their reports of pain and what relieves it
Choose pain control options appropriate for the patient, family, and setting
Deliver interventions in a timely, logical, and coordinated fashion
Empower patients and.their families
Enable them to control their course to the greatest extent possible.
Ask patients to describe their pain: the descriptive words they use can provide valuable clues as to the cause. For example, patients who describe back pain that radiates like a tight band around their chest and worsens with coughing or defecation should be evaluated for potential spinal cord compression, a complication of vertebral body metastasis. Patients who describe their pain as "burning" or "tingling" are likely to have a neuropathic cause of pain--particularly when it is associated with subjective numbness, loss of sensation, and weakness.131
Three commonly used self-report assessment tools:
An assessment of pain intensity should include an evaluation of not only the present pain intensity but also pain at its least and worst. Knowing factors that aggravate or relieve pain helps clinicians to design a pain treatment plan. The initial pain assessment should elicit information about changes in activities of daily living, including work and recreational activities, sleep patterns, mobility, appetite, sexual functioning, and mood.
A psychosocial assessment should emphasize the effect of pain on patients and their families, as well as patients' preferences among pain management methods. Patients who are able to answer should be asked about the effectiveness of past and present pain treatments, such as antineoplastic therapy or specific pharmacologic and nonpharmacologic therapies.
The clinician should perform a physical and necrologic examination related to the pain report. The painful area should bezcarefully examined to determine if palpation or manipulation of the site exacerbates the pain. Common sites of pain referral should be evaluated (e.g., shoulder pain may emanate from subdiaphragmatic abdominal sources; knee and hip pain may be referred from lumbar spine lesions). In addition, the patient should be observed for cues that indicate pain, e.g., distorted posture, impaired mobility, guarding the painful area, restricted movement of a limb, anxiety, attention seeking, or depression. However, absence of these behaviors should not be interpreted to mean that the patient has no pain.
Neurologic examination should be focused. For example, pain in the head and neck region requires careful cranial nerve examination to exclude intracranial pathology and lesions at the base of the skull, that may require definition by specialized magnetic resonance imaging (MRI) or computed tomography (CT). Neck or back pain require careful motor, sensory, and reflex examination of the arms and legs, as well as evaluation of rectal and urinary sphincter function to exclude plexopathy and spinal cord lesions. Appropriate diagnostic tests should be performed to determine the cause of the pain and the extent of disease, and patients should be offered analgesia to facilitate these evaluations (e.g., to allow the patient to lie flat for CT or MRI scans). It is important to correlate the results of these studies with physical and necrologic findings to assure that appropriate areas of the body have been imaged and that identified abnormalities do in fact explain the patient's pain. Pain may be the first sign nf tumor recurrence or progression and may appear or increase before changes are evident in imaging studies; therefore, imaging studies may have to be repeated.
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