Assessment and Reassessment of Pain

Pain assessment in the ED involves determining its location, quality, and severity. Since pain is dynamic and changes with time, its severity requires assessment and reassessment, ideally involving the use of validated objective and subjective pain assessment instruments.

The awake, cooperative, competent patient can describe and locate pain and be assessed easily and reliably. 1 Patients who have difficulty communicating are at risk of inadequate pain management. Patients who are cognitively impaired, psychotic, or severely emotionally disturbed as well as children, the elderly, patients who do not speak the language of their health care team, and patients whose level of education or cultural background differs significantly from that of their health care team are at particular risk.4 These scenarios require a more objective than subjective approach. Involvement of family members is often valuable.

For comprehensive assessment of pediatric pain, age-appropriate, developmentally specific techniques are essential, and assessment is enhanced by the involvement of the parents or caregiver. (See Chap 130.)

The elderly often report pain very differently from younger patients because of physiologic as well as psychological and cultural changes associated with aging. The high prevalence of visual, hearing, motor, and cognitive impairments among the elderly can be barriers to effective pain assessment, affecting the reliability of traditional pain assessment instruments.

Ethnicity has bearing on different cultural concepts of pain and on the characteristics of culturally appropriate pain-related behaviors. There is also interplay between the ethnicity of patient and physician. Most pain instruments are to some extent language-dependent. In practical consideration of language difficulties and cross-cultural measurement, visual analogue scales have been preferred. Confounding issues are the interplay of socioeconomic status and also the degree of accommodation to the dominant culture.5

Gender-related differences in reporting of pain intensity are equivocal, but women are more likely to express pain and to actively seek treatment. Physicians have a tendency to underestimate and undertreat pain in female patients.6

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