5.8 Subjective Assessment Overview
A subjective assessment is an important component of evaluating a client’s pain. It is often referred to as a self-report because the client is reporting and describing their own pain as opposed to your observations as a nurse (objective assessment).
A cultural humility approach can help you better understand the meaning of a client’s pain. This kind of approach involves having an authentic conversation with the client. How do they understand pain? Some people reserve the word “pain” to describe severe sensations, so they might not refer to a mild symptom as pain. Others may associate pain with vulnerability and use alternative words to describe it. Therefore, if they initially tell you they are not in pain, try rephrasing your question using words such as discomfort, hurt, tenderness, and sensations. When probing further about their pain, it is also a best practice to use the words the client uses.
Another issue is that some clients believe “good” clients do not “complain” about pain. Thus, it is important to show that you care when you ask about the client’s pain and use a professional and serious tone. It may be helpful to use permission statements depending on the situation. For example, you may say “pain is common after this procedure, do you have any pain?”
Contextualizing Inclusivity
Although subjective assessment is an important way to evaluate pain, be aware that not everyone can verbally communicate their pain (e.g., clients who are pre-verbal or nonverbal). Therefore, you should use other types of assessment that focus on behavioral and physiological cues.
Always remember: Pain is what the client tells you it is. This important adage is worth repeating, because unconscious bias and/or long-held myths that have no evidence to support them still influence practice. In addition to institutional racism, there are outdated beliefs that newborns and elderly do not feel as much pain as others, and that people who use illegal substances do not require pain management.
It’s your job to advocate and ensure that decisions are made based on evidence. The client’s subjective experience is as important as your objective assessment, because you can’t always observe pain.
The main components of a subjective assessment include:
- Presence of pain: do they have pain? If so, how long have they had it?
- Location of pain: where is it located?
- Severity/quantity of pain: how bad is the pain?
- Descriptors of pain: how do they describe the pain? Is it constant or intermittent?
- Associated factors and triggers of pain: are there any associated signs or symptoms with the pain? Is there anything that triggers their pain or makes it worse? What were they doing when the pain started?
- Impact of pain: how is it affecting them?
- Management of pain: have they tried to manage or treat it?
Priorities of Care
Certain cues require prompt and urgent action. New onset and severe pain are critical findings that require prompt action. This is especially true for chest pain, which could be angina, and is considered a first-level priority of care. In this case, ask a colleague to notify the physician or nurse practitioner while you keep the client at rest and assess pulse, blood pressure, and oxygen saturations. Depending on the setting and if appropriate, adhere to existing directives, such as order an electrocardiogram and blood work, administer oxygen, initiate intravenous access, and give nitroglycerin and morphine. If you are in a home setting and/or do not have access to these treatments, call 911 if this is new onset angina for the client as they may be having a myocardial infarction. The client can chew and swallow acetylsalicylic acid (usually low-dose ASA, 81 mg) as long as there are no contraindications; this can be helpful to prevent the clot from getting bigger.
Clinical Tip: Opioid Use, Stigma, and Language Examples
Opioid misuse is a serious issue across the United States. Although opioids are beneficial when treating certain types of pain when used as prescribed, the risk for misuse has been described as a crisis in the United States as well as in other countries. Opioid misuse is also a stigmatizing condition and as a result can influence individuals to avoid treatment or not discuss their opioid use.
Try to use a cultural humility and harm reduction approach during your subjective health assessment, with nonjudgmental and supporting language and an open interviewing approach.
The Substance Abuse and Mental Health Services Administration (SAMHSA) details the following strategies:
- Respect autonomy: Each individual is different. It is important to meet people where they are, and for people to lead their own individual journeys. Harm reduction approaches, initiatives, programs, and services value and support the dignity, personal freedom, autonomy, self-determination, voice, and decision-making of PWUD (people who use drugs).
- Practice acceptance and hospitality: Love, trust, and connection are important in harm reduction work. Harm reduction approaches, initiatives, programs, and services hold space for people who are at greatest risk for marginalization and discrimination. These elements emphasize trusting relationships and meaningful connections and understand that this is an important way to motivate people to find personal success and to feel less isolated.
- Provide support: Harm reduction approaches, initiatives, programs, and services provide information and support without judgment, in a manner that is non-punitive, compassionate, humanistic, and empathetic. Peer-led services enhance and support individual positive change and recovery, and peer-led leadership leads to better outcomes.
- Connect with community: Positive connections with community, including family members (biological or chosen), are an important part of well-being. Community members often assist loved ones with safety, risk reduction, or overdose response. When possible, harm reduction initiatives, programs, and services support families in expanding and deepening their strategies for love and support, and include families in services, with the explicit permission of the individual.
- Provide many pathways to well-being across the continuum of health and social care: Harm reduction can and should happen across the full continuum of health and social care, meeting whole-person health and social needs. In networking with other providers, harm reduction initiatives, programs, and services work to build relationships and trust with health and social care partners that embrace supporting principles. To help achieve this, organizations practicing harm reduction utilize education and encourage policies that facilitate interconnectedness between all parties.
Some clients may refuse opioid medications for fear of addiction or because of a history of opioid misuse. Thus, a client-centered and interprofessional approach to pain management is important.
Check out the video Language. How do you talk about addiction? [7:37] to support your learning.
Activity: Check Your Understanding
References
Greene-Moton, E., & Minkler, M. (2020). Cultural competence or cultural humility? Moving beyond the debate. Health Promotion Practice, 21(1), 1-4. https://doi.org/10.1177/1524839919884912
Substance Abuse and Mental Health Services Administration. (2023). SAMHA Harm Reduction Framework. https://www.samhsa.gov/find-help/harm-reduction/framework.
