Aims

To obtain a clear description of the patient’s pain and if possible to identify the cause(s) of the pain in order to develop a pain management plan in conjunction with the patient and family.  

Actions

If the pain is severe and overwhelming immediate treatment may be required before further assessment.  Adjust the dose according to current analgesic use and seek specialist advice.

• Obtain the patient’s own description of their pain. Most patients have more than one pain.
• Assess each pain separately and if possible identify the likely cause of the pain.
• Pain is often poorly assessed and inadequately managed in people with cognitive impairment. Seek specialist advice and refer to Pain assessment – cognitive impairment guideline.
• Breakthrough and incident pain: a transient exacerbation of pain which occurs either spontaneously (breakthrough) or in relation to a trigger (incident pain) in someone who has mainly stable or adequately relieved background pain.

• Ask about:
  • site and radiation; a body diagram can help
  • character; a list of descriptive words may help
  • onset, intensity and severity; a rating scale can help
  • timing and duration
  • exacerbating factors
  • relieving factors, including medication
  • response to previous medication and treatment
  • effect on function, sleep and mood
  • associated symptoms.

• Use a structured pain assessment tool to record the patient’s pain.
• Examine the patient to try and determine the cause of pain for example tender hepatomegaly, abnormal sensation.
• Assess the impact of the pain on the patient and family. Consider if other factors, such as emotional, psychological or spiritual distress, are having an effect on pain perception.
• Consider appropriate investigations to try and determine the cause of the pain.

• Try and make a diagnosis of the cause of the pain and discuss this with the patient and family.
  • Obtain the patient’s own description of their pain. Most patients have more than one pain.
  • Assess each pain separately and if possible identify the likely cause of the pain.
  • Pain is often poorly assessed and inadequately managed in people with cognitive impairment. Seek specialist advice and refer to Pain assessment - cognitive impairment

Breakthrough and incident pain: a transient exacerbation of pain which occurs either spontaneously (breakthrough) or in relation to a trigger (incident pain) in someone who has mainly stable or adequately relieved background pain.

• Ask about:
  • site and radiation; a body diagram can help
  • character; a list of descriptive words may help
  • onset, intensity and severity; a rating scale can help
  • timing and duration
  • exacerbating factors
  • relieving factors, including medication
  • response to previous medication and treatment
  • effect on function, sleep and mood
  • associated symptoms

• Use a structured pain assessment tool to record the patient’s pain.
• Examine the patient to try and determine the cause of pain for example tender hepatomegaly, abnormal sensation.
• Assess the impact of the pain on the patient and family. Consider if other factors, such as emotional, psychological or spiritual distress, are having an effect on pain perception.
• Consider appropriate investigations to try and determine the cause of the pain.
• Try and make a diagnosis of the cause of the pain and discuss this with the patient and family.
• Address all the points above

Causes of pain

• Disease related - direct invasion by cancer, distension of an organ, pressure on surrounding structures:
  • bone pain: worse on pressure or stressing bone or weight bearing
  • nerve pain: burning, shooting, tingling, jagging, altered sensation, dermatomal distribution - consider spinal cord compression
  • liver pain: hepatomegaly, right upper quadrant tenderness, referred pain shoulder tip
  • raised intracranial pressure: headache, nausea or both, often worse in the morning or with lying down
  • colic: intermittent cramping pain. Consider bowel obstruction, bladder spasm. Consider adjuvant therapies (refer to Pain management guideline).
• Treatment-related pain: chemotherapy neuropathy, constipation due to opioids, radiation-induced mucositis.
• Debility: pressure sores, severe cachexia, oral candidiasis.
• Other unrelated illnesses: arthritis, osteoporosis, vascular disease, gastritis.

• Agree a pain management plan, including goals of treatment, in conjunction with the patient and family.
• Agree arrangements for regular review.
• Different pains may require different interventions to control them. Refer to Pain management and Neuropathic pain guidelines.

• Consider having a pain chart/diary at the patient’s home.
• Provide written explanations about opioids.