5.18 Objective Assessment
It is always important to perform an objective assessment following a subjective assessment, but this is particularly the case for infants, young children, and nonverbal clients who may have difficulties with self-reporting.
The type of objective assessment used will depend on the location of the pain, the related body systems, and the acuity of the situation. Specific focused assessments on a body system may be necessary. For example, if a client describes knee pain, you should do a focused assessment on the musculoskeletal system. If a client describes chest pain, you should do a focused assessment on the cardiovascular and the respiratory system and possibly the musculoskeletal system.
The objective assessment does not follow a specific order; it depends on the acuity of the situation and the stability of the client. Common components of an objective assessment of pain include:
- Full set of vital signs.
Vital signs can be affected by pain, particularly acute pain. Collection and assessment of vital sign data may provide important information related to the client’s stability and the potential for clinical deterioration. Vital signs are also an important component of pain tools that include physiological measures; these can be particularly helpful in clients who are pre-verbal or nonverbal such as newborns, young children, clients that may have a developmental challenge, and clients who are unconscious. However, vital sign changes cannot help you differentiate between pain and other forms of distress such as fear and anxiety. You should always consider the context when interpreting vital signs, because they can be affected by level of consciousness, medications, and sedation. Therefore, your clinical judgment will be based on a comprehensive subjective and objective assessment, along with critical thinking.
- Inspection of the area.
Typically, you will inspect the area on the body where a client indicates they are having pain. Inspection is performed bilaterally, in which you compare the left side to the right side. For example, if a client is having eye pain, you should compare the left eye to the right eye. Inspect for and note any abnormalities such as discoloration (e.g., redness), bruising, swelling, scarring, incisions, masses, deformities, asymmetry, lesions, non-intact skin, and pressure injuries. With chest pain, you should also inspect for cardiac heaves (forceful movements observed on the skin over the chest wall) and epigastric pulsations. With abdominal pain, you should also inspect for abdominal contour and peristaltic movements.
- Palpation of the area.
After conducting a subjective assessment, you should palpate the area (and related areas) in which the client is having pain. Palpation is performed bilaterally: compare the left side to the right side. For example, if a client is having left shoulder pain, you should palpate the right shoulder first and then the painful left shoulder. Similarly, if a client is having abdominal pain, you should palpate the painful area last. During palpation, you should assess skin temperature, swelling, masses, deformities, and crepitation if associated with a joint. You should also observe any signs of pain during palpation, such as a change in respiration (e.g., holding their breath), facial grimacing, withdrawing their body/limb, and guarding.
- Auscultation and percussion.
Perform auscultation and percussion when a client is describing chest or abdominal pain. For example, with chest pain, you should auscultate the lungs, and the apical pulse and cardiac valves. With abdominal pain, you should auscultate the abdomen for bowel sounds and percuss the abdominal area.
Clinical Tip
Always compare the right and left side of the body when inspecting and palpating, because the best standard of comparison is the client’s own anatomy. The presence of a bilateral versus a unilateral finding is often of clinical significance. For example, the left ankle should be symmetrical with the right ankle. The presence of edema in one ankle versus both ankles is meaningful when making judgments about the underlying pathology.
When palpating an area, be aware of responses that may be categorized as allodynia or hyperalgesia. For example, if you press gently on an area (a stimulus that does not normally result in pain) and the client communicates pain, this is considered allodynia. Additionally, if you press firmly on an area (a stimulus that would normally result in pain) and the client communicates an exaggerated response to the pain, this is considered hyperalgesia. These conditions are different, but may coexist in the presence of diseases such as migraines and diabetes.
The Glasgow Coma Scale (GCS) is a common neurological tool to assess level of consciousness and detect and track clinical changes in consciousness when clients have had a traumatic brain injury or any condition that causes an impairment in consciousness (Teasdale et al., 2014).
GCS is used in the context of head injuries, cerebral hemorrhage or lesions, stroke, and general trauma. It is commonly used in acute and emergency care, critical care, post-operative care, and in neurological settings. It is important to elicit a baseline and then monitor trends, particularly with an altered GCS or during the acute phase of a neurological condition.
Steps in the GCS assessment include:
- Assess for any factors that could influence your assessment (see Contextualizing Inclusivity textbox below).
- Observe behaviours as per Table 3 and apply verbal and physical stimuli as needed (e.g., if spontaneous behaviours are absent).
- Judge criteria with rating and score.
- Evaluate the score for each component (eye opening, verbal response, best motor response).
- Evaluate the total GCS score by adding up scores for the three components of the GCS
- If any components are “non-testable,” note this and do not provide a total score. For example, verbal responses may not be testable if a client has a breathing tube, and eye opening may not be testable if a client has periorbital edema that prevents eye opening.
See Video 2 on how to use the Glasgow Coma Scale with a demonstration.
Table 3: Components of the Glasgow Coma Scale. (copyright Teasdale, 2015, permission to use in this resource).
|
Eye opening
Verbal response
Best motor response
|
Clinical Tips: Physical Stimuli and Flexion Responses
If no response is elicited when using the GCS, you may need to apply physical stimuli (see Figure 5), which are usually applied in the following order to:
- Finger nail bed.
- Trapezius muscle.
- Supraorbital notch.
Figure 5: Physical stimulus.
Copyright Teasdale, 2015 (used with permission), https://www.glasgowcomascale.org/downloads/GCS-Assessment-Aid-English.pdf?v=3.
Contextualizing Inclusivity
Before using the GCS, assess for factors that could influence the validity of the tool.
For example, children under five may not be able to obey commands and answer questions. The GCS components provided in Table 3 are considered reliable for those over the age of 5 (Royal College of Physicians and Surgeons of Glasgow, n.d.). When working with children, it is best to check with your institution about whether they use a specific scale, e.g., the Paediatric Glasgow Coma Scale or other tools to evaluate level of consciousness.
Another issue is that a hearing impairment can influence a client’s ability to respond to verbal stimuli. You may need to employ alternative options such as gently touching the client’s arm to observe if their eyes are open, using sign language, or writing on a piece of paper.
Other factors could include language discordance or barriers that inhibit clients from speaking, such as a breathing tube. Many pathologies and conditions can affect the validity of the GCS such as the presence of hypoxemia, intellectual and neurological deficits, and movement disorders, pharmacological agents such as sedation, and use of alcohol, cannabis, or other substances that affect cognition.
Prioritizing Care
GCS scores can range from 3 (unresponsiveness in all three components of the GCS tool) to 15 (no deficits in responsiveness in all three components of the GCS tool) (National Institute for Health and Care Excellence [NICE], 2023). With acute traumatic brain injury, GCS scores are classified as:
- Severe injury: GCS 8 or less (suggestive of coma state).
- Moderate injury: GCS 9 to 12.
- Mild injury: GCS 13 to 15.
(NICE, 2023).
Anyone presenting in a community or emergency setting with decreased consciousness or a score of less than 15 should be assessed immediately. At first, clients with GCS scores below 15 should be monitored regularly. The frequency of GCS assessment varies significantly: it is contingent on timing since the injury/trauma as well as trends in improvement or deterioration. Until a stable pattern is observed, all changes should be reported to the physician/nurse practitioner. NICE (2023) recommends the following frequency of observation:
- Every 30 minutes until GCS is 15 or every 30 minutes if there is a decrease in the GCS.
- If GCS is 15: observe every 30 minutes for 2 hours, then hourly for 4 hours, then every 2 hours.
These frequencies may vary depending on the client’s situation, the acuity of symptoms, and the institution/unit.
NICE (2023). Head injury: Assessment and early management. https://www.nice.org.uk/guidance/ng232/resources/head-injury-assessment-and-early-management-pdf-66143892774085
Royal College of Physicians and Surgeons of Glasgow. (n.d.). The Glasgow structured approach to assessment of the Glasgow Coma Scale. https://www.glasgowcomascale.org/faq/
Teasdale, G., Maas, A., Lecky, F., Manley, G., Stocchetti, N., & Murray, G. (2024). The Glasgow Coma Scale at 40 years: Standing the test of time. The Lancet Neurology, 13(8), 844-854.
