• Argyll & Bute HSCP and Highland HSCP
  • Secondary Care.

Pain is an individual multi-factorial, subjective experience influenced among other things by culture, previous pain experiences, beliefs and mood. 

Reliable and accurate assessment of acute pain is necessary to ensure patients experience safe, effective and individualised pain management. 

Self-report should always be used whenever appropriate as pain is a subjective experience. When assessing pain our own judgements can affect the assessment of the patient’s pain therefore by using a pain scoring tool, allows for a more objective assessment. 

Assessment of the intensity of acute pain at rest after surgery/trauma is important for making the patients comfortable in bed. However, adequate relief of dynamic pain during mobilisation, deep breathing and coughing is more important for reducing risks of complications after surgery/trauma, and to promote the return to normal function. 

The Functional activity Scale (FAS) score is a simple three-level ranked categorical score designed to be applied at the point of care (Scott 2008). Its fundamental purpose is to assess whether the patient can undertake appropriate activity at their current level of pain control and to act as a trigger for intervention should this not be the case. Disadvantages of the FAS score are that it has not been independently validated and clinical staff need to be educated in its application. 

The pain measurement tool chosen should be appropriate to the individual patient and the clinical context. Developmental, cognitive, emotional, language and cultural factors should also be considered. 

 Please note this guidance is for in-patients and is not designed for managing patients with chronic pain. 

Quick reference guide

At Raigmore Hospital the Acute Pain Team includes:

  • Consultant Anaesthetist, Department of Anaesthesia
  • Clinical Nurse Specialists, Acute Pain Service
  • Senior Pharmacist, Pharmacy Department

Advice can be sought in office hours: 08.00 to 16.00 (page 1003 or 6056)
Out of hours please contact the ITU anaesthetist.

Acute pain assessment tool

Nausea and vomiting assessment tool

Sedation score tool

Pain assessment tool for people with dementia

Please note this guidance is for use in in-patients and is not designed for managing patients with chronic pain

This guidance is for adult patients with dementia who cannot verbalise. 

There is evidence to suggest that people with dementia are likely to receive less pain relief in hospital than people who do not have dementia and this becomes a greater problem the more severe the cognitive impairment (Scherder et al, 2005). Hence, the more confused and disorientated, a person is the less likely they are to receive effective pain control.

Pain assessment for people with dementia may be more complex and should be based on the principles of effective communication, allowing time to assess pain and using pain assessment tools.

In the same way as assessing the cognitive status of a person, when assessing for pain the room should be well lit and communication aids such as glasses and hearing aids should be in place.

Common behaviours associated with pain are vocalisations, grimacing, flinching, guarding of painful part, aggressive behaviour and restlessness, and pulling out tubes from painful parts of the body.

When attempting to detect pain in those with advanced dementia, nurses need to focus on such areas as noisy breathing, negative vocalisation, absence of relaxed body posture and looking tense and fidgeting.

Many people with cognitive impairment who can report the presence of pain have difficulty in quantifying their pain. This would include pain intensity on a 0-10 scale. There are pain assessment scales specifically designed for people with dementia. The Abbey Pain Scale is pain assessment tool for measuring pain in people with dementia who can not verbalise.

Pain Assessment

  • Round the clock medication as opposed to ‘as required’.
  • Observe facial expression.
  • Enquire systematically about whether they are in pain.
  • In the case of major surgery it is important to give pain medication on a scheduled basis.
  • Obtain as much information from relatives and carers to assist you in recognising when the person with dementia may be distressed.

The Abbey Pain Scale can be accessed under resources.

Pain assessment in patients who are unable to communicate/express their pain can be particularly challenging. 
For example, patients with dementia or patients with other languages. Observations such as facial expressions, behavioural or vital signs can be useful.
Other pain assessment tools such as verbal rating scale and visual analogue scale can be used.

 At Raigmore Hospital the Acute Pain Team includes:

  • Consultant Anaesthetist - Department of Anaesthesia
  • Clinical Nurse Specialists, Acute Pain Service
  • Senior Pharmacist - Pharmacy Department

Advice can be sought in office hours - 08.00 – 16.00 (page 1003 or 6056)
out of hours please contact the ITU anaesthetist.

  • For information in treating pain in children, see Paediatric Pain Guidelines.
  • For information in other languages, contact the Acute Pain Team

Last reviewed: 31/10/2022

Next review date: 31/10/2025

Author(s): Acute Pain Team.

Version: 3

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Louise Reid, Clinical Nurse Specialist, Claire Wright Acute Pain Nurse Specialist .

Document Id: TAM101

Internal URL: https://nhshighlands.azurewebsites.net/umbraco/#/content/content/edit/14570

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