Contents Previous Next

Attachment B

Pain assessment and management instruments

Pain Assessment Instruments for Adults

B1. Brief Pain Inventory (Short Form)

B2. Initial Pain Assessment Tool

B3. Pain Distress Scales

B4. The Memorial Pain Assessment Card

Pain Assessment Instruments for Children

B5. Pain Experience History

B6. Eland Color Scale Figures

B7. Poker Chip Tool Instructions Sheet

B8. Word-Graphic Rating Scale

B9. Pain Affect Faces Scale

Instruments for Pain Management Documentation

B10. Pain Management Log

B11. Flowsheet for Pain Management Documentation




B1. Brief Pain Inventory (Short Form)

Study ID# ________    Hospital # __________

Do not write above this line

Name. _____________________ _____________________ _____________________
  Last First Middle Initial
1) Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these everyday kinds of pain today? 1. Yes 2. No
2) On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the most.

3) Please rate your pain by circling the one number that best describes your pain at its worst in the past 24 hours.
0 1 2 3 4 5 6 7 8 9 10
No Pain               Pain as bad as you can imagine
4) Please rate your pain by circling the one number that best describes your pain at its least in the past 24 hours.
0 1 2 3 4 5 6 7 8 9 10
No Pain               Pain as bad as you can imagine
5) Please rate your pain by circling the one number that best describes your pain on the average.
0 1 2 3 4 5 6 7 8 9 10
No Pain               Pain as bad as you can imagine
6) Please rate your pain by circling the one number that tells how much pain you have right now.
0 1 2 3 4 5 6 7 8 9 10
No Pain               Pain as bad as you can imagine
7) What treatments or medications are you receiving for your pain?
8) In the past 24 hours, how much relief have pain treatments or medications provided? Please circle the one percentage that most shows how much relief you have received.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No Pain                 Complete relief
9) Circle the one number that describes how, during the past 24 hours, pain has interfered with your:

A. General activity
0 1 2 3 4 5 6 7 8 9 10
Does not interfere               Completely interferes

B. Mood
0 1 2 3 4 5 6 7 8 9 10
Does not interfere               Completely interferes

C. Walking Ability
0 1 2 3 4 5 6 7 8 9 10
Does not interfere               Completely interferes

D. Normal work (includes both work outside the home and housework)
0 1 2 3 4 5 6 7 8 9 10
Does not interfere               Completely interferes

E. Relations with other people
0 1 2 3 4 5 6 7 8 9 10
Does not interfere               Completely interferes

F. Sleep
0 1 2 3 4 5 6 7 8 9 10
Does not interfere               Completely interferes

G. Enjoyment of life
0 1 2 3 4 5 6 7 8 9 10
Does not interfere               Completely interferes

Source: Pain Research Group, Department of Neurology, University of Wisconsin- Madison. Used with permission. May be duplicated and used in clinical practice.

B2. Initial Pain Assessment Tool

Patient's name. ______________ Age__________ Room___________
Diagnosis. _____________________ Pysician___________________
I. Location: Patient or nurse marks drawing.

II. Intensity: Patient rates the pain. Scale used_______________________________________
  Present : _____________________________________________________________
  Worst pain gets:. _______________________________________________________
  Best pain gets:. ________________________________________________________
  Acceptable level of pain:._________________________________________________
III. Quality: (Use patient's own words, e.g., prick, ache, bum, throb, pull, sharp)___________
IV. Onset, duration, variations, rhythms:._________________________________________
V. Manner of expressing pain:__________________________________________________
VI. What relieves the pain?. ___________________________________________________
VII. What causes or Increases the pain?. _________________________________________
VIII. Effects of pain: (Note decreased function, decreased quality of life.)
  Accompanying symptoms (e.g., nausea). __________________________________
  Physical activity._____________________________________________________
  Relationship with others (e.g., irritability).__________________________________
  Emotions (e.g., anger, suicidal, crying).____________________________________
  Other _____________________________________________________________
IX. Other comments:.______________________________________________________
X. Plane.:_______________________________________________________________
Note: May be duplicated and used In clinical practice.
Source: McCaffery and Beebe. 1989. Used with permission.

B3. Pain Distress Scales

1 If used as a graphic rating scale, a 10 cm baseline is recommended.
2 A 10-cm baseline is recommended for VAS scales.
Source: Acute Pain Management Guideline Panel. 1992.

B4. Memorial Pain Assessment Card

B5. Pain Experience History

Child Form Parent Form
Tell me what pain is. What word(s) does your child use in regard to pain?
Tell me about the hurt you have had before. Describe the pain experiences your child has had before.
Do you tell others when you hurt? If yes, who? Does your child tell you or others when he/she is hurting?
What do you do for yourself when you are hurting? How do you know when your child is in pain?
What do you want others to do for you when you hurt? How does your child usually react to pain?
What don't you want others to do for you when you hurt? What do you do for your child when he/she is hurting?
What helps the most to take your hurt away? What does your child do for him/herself when he/she is hurting?
Is there anything special that you want me to know about you when you hurt? (If yes, have child describe.) What works best to decrease or take away your child's pain?
  Is there anything special that you would like me to know about your child and pain? (If yes, describe.)

B6. Eland Color Scale: Directions for Use

After discussing with the child several things that have hurt the child in the past:

  1. Present eight crayons or markers to the child. Suggested colors are yellow, orange, red, green, blue, purple, brown, and black.
  2. Ask the following questions, and after the child has answered, mark the appropriate square on the tool (e.g., severe pain, worst hurt), and put that color away from the others. For convenience, the word hurt is used here, but whatever term the child uses should be substituted. Ask the child these questions:
    • "Of these colors, which color is most like the worst hurt you have ever had (using whatever example the child has given) or the worst hurt anybody could ever have?" Which phrase is chosen will depend on the child's experience and what the child is able to understand. Some children may be able to imagine much worse pain than they have ever had, white other children can only understand what they have experienced. Of course, some children may have experienced the worst pain they can imagine.
    • "Which color is almost as much hurt as the worst hurt (or use example given above, if any), but not quite as bad?"
    • "Which color is like something that hurts just a little?"
    • "Which color is like no hurt at all?"
  3. Show the four colors (marked boxes, crayons, or markers) to the child in the order he has chosen them, from the color chosen for the worst hurt to the color chosen for no hurt.
  4. Ask the child to color the body outlines where he hurts, using the colors he has chosen to show how much it hurts.
  5. When the child finishes, ask the child if this is a picture of how he hurts now or how he hurt earlier. Be specific about what earlier means by relating the time to an event, e.g., at lunch or in the playroom.

Reprinted with permission of J.M. Eland from McCaffery and Beebe, 1989. May be duplicated for use in practice.

B7. Poker Chip Tool Instruction Sheet1

English Instructions:
  1. Say to the child: "I want to talk with you about the hurt you may be having right now.
  2. Align the chips horizontally in front of the child on the bedside table, a dip-board, or other firm surface.
  3. Tell the child. "These are pieces of hurt." Beginning at the chip nearest the child's left side and ending at the one nearest the right side, point to the chips and say, This (first chip) is a little bit of hurt and this (fourth chip) Is the most hurt you could ever have."

    For a young child or for any child who may not fully comprehend the instructions, clarify by saying, "That means this (one) is just a little hurt, this (two) is a little more hurt. this (three) is more yet, and this (tour) is the most hurt you could ever have."

    • Do not give children an option for zero hurt Research with the Poker Chip Tool has verified that children without pain will so indicate by responses such as, "I don't have any."
  4. Ask the child. "How many pieces of hurt do you have right now?"
    • After initial use of the Poker Chip Tool, some children internalize the concept "pieces of hurt." If a child gives a response such as "I have one right now," before you ask or before you lay out the poker chips, proceed with instruction #5.
  5. Record the number of chips on the Pain Flow Sheet
  6. Clarify the child's answer by words such as, "Oh, you have a little hurt? Tell me about the hurt."
Spanish Instructions2:
  1. Tell the parent: "Esras fichas de poker son una manera de medir dolor. Usamos cuatro fichas rojas."
  2. Say to the child: "Las fichas son como pedazos de dolor, una ticha (pedazo) es un poquito de dolor, mientras cuatro fichas (pedazos) signifies el dolor maximo que tu puedes sentir. Cuantos pedazos de dolor tienes?"
1 Developed in 1975 by Nancy 0. Hester, University of Colorado Health Sciences Center. Denver. CO.

2 Spanish instructions by Jordan-Marsh. M., Hall. 0.. Yoder. L. Watson. R., McFartane-Sosa. G.. & Qarcia, M. (1990). The Harbor-UCLA Medical Center Humor Project tor Children. Los Angeles: Harbor-UCLA Medical Center. 

B8. Word Graphic Rating Scale1


"This is a line with words to describe how much pain you may have. This side of the line means no pain and over here the line means worst possible pain." (Point with your finger where "no pain" is, and run your finger along the line to "worst possible pain." as you say it.) "If you have no pain, you would mark like this." (Show example.) "If you have some pain, you would mark somewhere along the line, depending on how much pain you have." (Show example.) "The more pain you have, the closer to worst pain you would mark. The worst pain possible is marked like this." (Show example.)

"Show me how much pain you have right now by marking with a straight, up and down line anywhere along the line to show how much pain you have right now."

Reprinted with permission from Savedra, Tester, Holzemer, et al., 1989. [updated 1992]

B9. Pain Affect Faces Scale

Children are presented with one of three different randomly ordered face sheets. They select the face that best represents how they feel in relation to their pain conditions from "the happiest feeling possible" to the "saddest feeling possible." This figure is actually the scoring card used to quantify children's responses. The numbers represent the magnitude of pain affect (between 0 and 1) shown in each face, based on previous research on children.

Reprinted with permission of McGrath from Patt, 1993

B10. Pain management log

Pain management log for _______________________________

Please use this pain assessment scale to fill out your pain control log:

Date Time How severe is the pain Medicine or non-drug pain control method How severe is the pain after one hour? Activity at time of pain

B11. Flowsheet for pain management documentation

Patient_____________________________________________ Date_________________
Pain rating scale used1_____________________________________________________
Purpose: To evaluate the safety and effectiveness of the analgesic(s)
Analgesics(s) prescribed:.___________________________________________________
Time Pain Rating Analgesic R P BP Level of arousal Other Plan and Comments

Source: McCaffery & Beebe, 1989. Used with permission

Note: Maybe duplicated for use in clinical practice.
1 Pain rating: A number of different scales may be used. Indicate which scale is used and use the same scale each time
2 Possibilities for other columns: bowel function, activities, nausea and vomiting, an other pain relief measure. Identify the side effects of greatest concern to patient, family, physician, and nurse.