5.7 Timing and Frequency of Screening for and Assessment of Pain
All clients should be screened for the presence of pain. If pain is present, then you should assess the pain.
Timing and frequency of screening for and assessment of pain depends on several factors. It can be useful to check with the unit/institution where you work about pain assessment frequency. You should perform routine screening for and assessment of pain at specific times and during certain situations such as:
- Admission to a health care setting.
- Primary health care visit.
- Start of shift when first assessing a client.
- Change in the client’s condition (e.g., change in vital signs) or other potential physiological or behavioral signs of pain. Oftentimes, pain is assessed with each set of vital signs.
- Prior to a procedure or activity to establish a baseline (e.g., walking for the first time postoperatively) as well as during and after a procedure or activity.
- After treatment (e.g., after the provision of pain medication such as analgesics) and continued reassessment until treatment takes effect. Reassessment is often based on the medication’s onset of action (how long the medication takes to begin taking effect), peak effectiveness (how long it takes for the medication to be at its maximum concentration in the body, thus its greatest therapeutic effect) and duration (length of time that a medication produces a therapeutic effect) (Chippewa Valley Technical College, n.d.). Continued reassessment of pain may be needed so that you can determine whether additional treatment is required.
- When there is a written order for pain assessment. For example, physicians and nurse practitioners sometimes provide written orders for pain assessments (e.g., pain assessment every four hours or pain assessment every eight hours).
Pain assessments are often repeated to evaluate the effectiveness of treatment and medication. First, you should assess the client’s baseline and review the client’s chart to get a full picture of the client’s pain. The timing of repeat pain assessments will depend on several factors (see Table 5.2). Always compare your findings to the client’s baseline.
| Factor | Consideration |
| Time for the medication to take effect | Some over-the-counter oral pain medications can start taking effect in 15–30 minutes, but peak effectiveness usually takes one hour and up to two hours. Typically, pain is reassessed 30–60 minutes after oral medication is given.
Intravenous quick-acting opioid pain relievers (e.g., morphine) can take effect within 1–2 minutes with peak effects between 5–15 minutes. Opioids may have even quicker peak effects, e.g., 2–5 minutes for fentanyl (Vahedi et al., 2019). |
| Specific situation | In acute situations where you are attempting to control the pain quickly with an intravenous medication, you may reassess within 2–5 minutes. Additionally, you should assess for adverse effects such as respiratory depression with opioid administration. Do not assume that a client is not in pain because their eyes are closed, or because they are smiling or talking.
In other situations, a client may be given an oral pain medication at bedtime; thus, you may not reassess until they wake up or in the morning. You might ask the client to ring their call bell if the pain has not subsided in an hour. |
Contextualizing Inclusivity
Consider forms of pain management other than traditional Western medications when making decisions regarding pain reassessment. Currently cannabis is used for pain management and nurses need to review the legal aspects within their state. As a nurse, you will need to assess the many other forms of pain management that a client may choose to use (e.g., mindfulness meditation, acupuncture, play for children) and assess effectiveness as needed.
An open-ended and inclusive question to ask clients is: Tell me about the ways you manage your pain.
Some Indigenous clients may choose to utilize traditional medicines instead of, or along with, Western medications. To learn more about treating Indigenous clients using traditional medicines, see Pain, Pain Killers and Indigenous Peoples: Choose the right medicine for you in partnership with your physician.
Activity: Check Your Understanding
References
Chippewa Valley Technical College (n.d.). Nursing pharmacology. https://wtcs.pressbooks.pub/pharmacology/
Vahedi, H., Hajebi, H., Vahidi, E., Nejati, A., & Saeedi, M. (2019). Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury. World J Emerg Med, 10(1), 27-32. https://doi.org/10.5847/wjem.j.1920-8642.2019.01.004
This section presents a brief description of assessment of the spinal accessory nerves; more information can be found in the musculoskeletal resource. The following tests are usually performed with the client in a sitting or standing position.
- Inspect the neck and shoulders anteriorly and posteriorly and inspect the head position.
- Normally the neck and muscles (sternocleidomastoid and trapezius) are symmetrical and shoulders are at the same level. The head is midline and upright.
- Abnormal findings are asymmetry of neck and muscles with a drooping shoulder or if the head droops forward, backward, or off to one side.
- Ask the client to shrug their shoulders.
- Normally, the client should be able to lift up/shrug shoulders.
- Abnormal findings are limited to no ROM and inability to shrug shoulders.
- Place hand on client's cheek and have them turn their neck against resistance.
- Normally, the client should have full resistance bilaterally.
- Abnormal findings are partial or no resistance on one or both sides.
- Note the findings.
- Normal findings might be documented as: “Spinal accessory nerve testing: Symmetrical neck and muscles with shoulders at same level. Shoulders and neck full resistance bilaterally.”
- Abnormal findings might be documented as: “Right shoulder lower than left. Client unable to shrug right shoulder fully with decreased resistance.”
- Ask the client to open their mouth and stick their tongue out as far as they can. Ask them to move it to one side and then the other side.
- Normally, the tongue should be midline with no tremors and ease of movement.
- Abnormal findings would be a tongue that deviates to one side, with tremors and/or decreased or absent movement.
- Next, place your fingertips on one side of the client’s cheeks. Ask the client to move the tip of their tongue against the buccal mucosa inside their mouth so that they can feel your fingers. Tell them that you are going to apply pressure with your fingers and they should attempt to resist the pressure. Repeat on the other side.
- Normally, the client should be able to resist your pressure.
- Abnormal findings would be a client who is unable to resist your pressure.
See Video 14.
Video 14: Hypoglossal nerve testing (CN XII).
- Note the findings.
- Normal findings might be documented as: “Hypoglossal testing: Tongue midline, no deviation, able to move tongue from side to side and resist examiner’s pressure.”
- Abnormal findings might be documented as: “Hypoglossal testing: Tongue deviates to left side with tremors. Absent muscle resistance of tongue bilaterally.”
Contextualizing Inclusivity
- Your findings may be affected by the client’s age. As individuals age, they often experience a diminished ability to smell and taste bilaterally, as well as reduced peripheral vision.
- Some clients may feel vulnerable when a nurse is behind them; recall the steps of a trauma-informed approach.
