Pain Evaluation in Verbal Communicating Patients

1. The PQRST Framework (Structured Pain History)

2. Self-Report Pain Scales

A. Numeric Rating Scale (NRS)

• Format: Patient selects a whole number from 0 to 10
  • 0 = No pain
  • 1–3 = Mild pain
  • 4–6 = Moderate pain
  • 7–10 = Severe pain
• Modified NRS: Can include half-numbers (0–10 in 0.5 increments), offering 21 points — the maximum levels most humans can discriminate (Local Anesthesia and Minimal Sedation, p. 2)
• Use: Most widely used in clinical and research settings; quick, reliable, easy to administer verbally
• Clinically significant change: A difference of 1.5–2.0 points is considered clinically meaningful (Local Anesthesia and Minimal Sedation, p. 2)

B. Visual Analog Scale (VAS)

• Format: A 10-cm (100-mm) horizontal line anchored by:
  • Left end: "No pain"
  • Right end: "Worst pain imaginable"
• Patient draws a perpendicular mark on the line; the distance from the left end is measured in mm or cm
• Clinically significant change: A difference of 1.5–2.0 cm is considered meaningful (Local Anesthesia and Minimal Sedation, p. 2)
• Use: Common in research; can be used in clinical settings with literate, cooperative patients

C. Verbal Rating Scale (VRS)

• Format: Categorical descriptors — typically:
  • None = 0
  • Mild = 1–3
  • Moderate = 4–6
  • Severe = 7–10
• Use: Useful for patients who have difficulty with numbers; maps directly onto NRS values (Local Anesthesia and Minimal Sedation, p. 2)

D. Wong-Baker FACES Pain Scale

• Format: Six cartoon faces ranging from a smiling face (no pain) to a crying face (worst pain)
• Patient points to the face that best describes their pain
• Use: Validated for children ≥3 years and adults; particularly useful for patients with limited numerical literacy
• Recommended in pediatric patients ≥6 years capable of communicating (PICU Pain & Agitation Guidelines, p. 8)

E. Oucher Scale

• Combines a numerical scale (0–100) with photographs of children's faces showing varying levels of distress
• Available in multiple ethnicities
• Use: Children ages 3–13; also useful in adults with developmental concerns

3. Multidimensional Pain Assessment

Brief Pain Inventory (BPI)

• Assesses pain intensity (worst, least, average, current) and interference with daily activities (walking, sleep, mood, work, enjoyment of life)
• Widely used in oncology and chronic pain

McGill Pain Questionnaire (MPQ)

• Patients select words from categories: sensory (throbbing, stabbing), affective (exhausting, fearful), and evaluative (unbearable)
• Generates a Pain Rating Index (PRI) and Present Pain Intensity (PPI)
• Useful for characterizing pain quality in addition to intensity

4. Functional and Behavioral Context

• Effect on function: Sleep, mobility, appetite, concentration, activities of daily living
• Psychological impact: Anxiety, depression, catastrophizing (consider screening tools like PHQ-9 or Pain Catastrophizing Scale in chronic pain)
• Analgesic history: Current medications, prior treatments, allergies, substance use history
• Patient goals: Desired pain level vs. functional goals (e.g., "I want to be able to walk to the bathroom")

5. Documentation and Reassessment

• Record the scale used, score, time of assessment, and intervention given
• Reassess pain 30–60 minutes after pharmacological intervention (or sooner for IV medications)
• Track trends over time, not just single scores
• Set a comfort-function goal with the patient (e.g., pain ≤3/10 to allow ambulation)

Summary Table