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Psychological Care 143

TABLE 7.6 Pain scales

Scale Description Comments
Verbal numeric scale ● Self-rating scale ● Patient has to be able to communicate verbally
● Single-item scale ● Needs to understand concept of rating pain
● Scale from 0 (no pain) to 10 (worst pain ever) ● Dependent on prior pain experiences
● Simple, easy to use
Visual Analogue ● Self-rating scale ● Patient can communicate by pointing
Scale (VAS) ● Single-item ● Needs to understand concept of rating pain
● A horizontal line with equal divisions is used for the ● Dependent on patient’s prior pain experiences
patient to rate current pain level (no pain is on far left and ● Simple, easy to use
worst pain is far right)
McGill short pain ● Measures quality of pain ● Gives more information about the patient’s pain 103
questionnaire 102 ● Uses 15 descriptor words to measure sensory effect of pain ● Takes longer to administer
● Can be used in conjunction with a pain intensity scale
Behavioural Pain ● Based on pain related behaviours: the sum of three items ● Patient does not have to communicate
Scale (BPS) (Figure ● Higher scores indicate higher pain intensity (range: 3–12) ● Simple, easy to use
7.6) 97 ● Includes ‘ventilator compliance’ (may no longer be
relevant for pain assessment when using modern
ventilators)
Checklist of ● Developed for cognitively impaired adults ● Patient does not have to communicate
Nonverbal Pain ● Based on the presence/absence of five non-verbal pain ● Simple, easy to use
Indicators (CNPI) 98 behaviours (one is non-verbal vocalisation, e.g. groaning) ● No patient report at all
and verbal complaints ● Not as reliable for immobile patients 98
● Score 0 to 6 (score of 1 allocated for the presence of a pain
behaviour/verbal complaint), higher scores indicate more
pain
Critical Care Pain ● Based on previously developed instruments using pain ● Patient does not have to communicate
Observation Tool related behaviour to assess pain, e.g. BPS ● Simple, easy to use
(CPOT) 99 ● Four items: facial expression, body movements, muscle ● Includes ‘ventilator compliance’ (may no longer be
tension and compliance with ventilator or vocalisation relevant for pain assessment when using modern
● Higher scores indicate more pain (range: 0–8) ventilators) or vocalisation in extubated patients

Item Description Score
Facial expression Relaxed 1
Partially tightened (e.g. brow lowering) 2
Fully tightened (e.g. eyelid closing) 3
Grimacing 4
Upper limbs No movement 1
Partially bent 2
Fully bent with finger flexion 3
Permanently retracted 4
Compliance with ventilation Tolerating movement 1
Coughing but tolerating ventilation for most of the time 2
Fighting ventilator 3
Unable to control ventilation 4
FIGURE 7.6 Behavioural pain scale.
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critical patients, vital signs may be useful if used in con- PAIN MANAGEMENT
junction with other forms of assessment. 95
Although pain management is discussed here indepen-
In addition it is particularly important to regularly dently, in practice pain management is often combined
consider and search for potential sources of pain in with sedative administration to reduce anxiety. However
un responsive patients and those who are unable to com- pain management should always be the first goal for
municate. Nurses are implored to assume pain is present achieving overall patient comfort. Efforts to improve
if there is a reason to suspect pain. If pain is suspected an patient comfort for intubated patients favour the
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analgesic trial may assist in diagnosing sources of pain. concurrent use of both forms of medication. This
As a general rule, analgesia medication should be admin- practice therefore makes it difficult to assess the single
istered to patients who are heavily sedated or receiving effect of each medication on the patient’s pain, and
muscle relaxants as a precaution. highlights its multidimensional properties. In addition to