Palliative Care Guidelines - NHS Lanarkshire

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Pain Assessment – Five Key QuestionsAims• Obtain the patient’s owndescription and assessmentof their pain. Most patientshave more than one pain.• Assess each pain separatelyand identify the likelycause(s).• Assess the impact of the painon the patient and family.• Make a diagnosis and explainthis to the patient and family.• Agree a pain managementplan.1. Is the pain severe andoverwhelming2. What is the pain like?3. What is causing thepain?4. Is it a specific type ofpain?5. Are other factorsadding to thedistress?Actions• Record your pain score andassessment. Use a painassessment tool.• Different pains may requiredifferent interventions tocontrol them.(see: Pain management)• Discuss management withpatient / carers. If opioidsare prescribed, discuss anyconcerns about their use(e.g. addiction, side effects,tolerance, hastening death)• Agree goals for pain relief;and a monitoring plan.Reassess regularlyPalliative Care Guidelines: Pain AssessmentImmediate treatment may be requiredbefore further assessment.Adjust the dose according to current analgesic use.Seek adviceAsk about• Site / radiation - body diagrams can help• Character - a list of descriptive words may help• Intensity / severity - a rating scale can help• Timing• Exacerbating factors• Relieving factors (including medication)• Effect on function / sleepUse a structured pain assessment tool to make a fullassessment and record of the patient’s pain.Disease?e.g. direct invasion by cancer; distension of an organ;pressure on surrounding structures.Treatment?e.g. constipation with opioids; chemotherapy neuropathy;mucositis; late onset pain following radiotherapy.Debility?e.g. pressure sores.Other unrelated pathology?e.g. arthritis; cervical spondylitis, osteoporosis,vascular disease, neuropathy.Bone PainWorse on pressure or stressing bone, or weight bearing.Nerve PainBurning / shooting / tingling / jagging, alteredsensation / dermatomal distribution.Liver PainHepatomegaly, right upper quadrant tenderness.Episodic/ incident painSudden onset pain occurring spontaneously or withmovement; can be severe but may be very short lived.Raised intracranial pressureHeadache (and/or nausea) worse with lying down,more often present in the morning.ColicIntermittent, cramping painConsider adjuvant therapies(see: Pain management)• Anxiety / depression.• Other psychological factors e.g. fear, ‘unfinishedbusiness’.• Other physical symptoms e.g. nausea, breathlessness.• Family / carer distress.© NHS Lothian Issue date: January 2009 Review date: March 20121
Palliative Care Guidelines: Pain ManagementSTEP 3: Moderate to Severe PainOPIOID + PARACETAMOL or NSAID +/- OTHER(if not ADJUVANTcontraindicated)Stop any step 2 opioidCodeine or dihydrocodeine 60mg qds ≈ 30mg oral morphine / 24hoursIf titrating with immediate releaseoral morphine prescribe5mg, 4 hourly and as required forbreakthrough pain.If starting with modified releaseoral morphine prescribe10-15mg, 12 hourly andimmediate release morphine 5mgas required for breakthrough pain.Use lower doses and increase dose more slowly if patient is frail,elderly or has renal impairment.See: Choosing & Changing Opioids for second/ third line opioids.Seek advice:♦ Severe pain.♦ Pain notresponding totreatment.♦ Dose of opioid hasincreased rapidlybut patient is stillin pain.♦ Episodes of acutesevere pain.♦ Pain worse onmovement.© NHS Lothian Issue date: January 2009 Review date: March 20121
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Palliative Care Guidelines - NHS Lanarkshire

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