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It is imperative to ascertain the patient’s current level of anxiety and depression and to understand each patient’s own understanding of the meaning of pain (Foley 2004). The cause of each pain should therefore be identified carefully; many pains unrelated to the cancer will respond to specific treatment. If the pain is due to the cancer, then it is important to determine the precise mechanism of pain because treatment will vary accordingly. Patients with cancer may experience a range of psychological and spiritual problems that extend far beyond the experience of physical pain (Paz and Seymour 2008).

The concept of total pain reminds practitioners that pain is a deeply personal experience and that one of the greatest challenges is for nurses to be able to facilitate the expression for each individual of that particular pain (Krishnasamy 2008). Pain assessment needs to acknowledge these facts and particular attention must be paid to factors that will modulate pain sensitivity (Table 9.1).

Table 9.1 Factors affecting pain sensitivity

Sensitivity increased Sensitivity lowered

Discomfort Relief of symptoms

Insomnia Sleep

Fatigue Rest

Anxiety Sympathy

Fear Understanding

Anger Companionship

Sadness Diversional activity

Depression Reduction in anxiety

Boredom Elevation of mood

Assessment in vulnerable and older adults

Pain assessment in vulnerable adults, for example those with cognitive impairment or dementia, and older adults may require careful consideration. Older adult patients may be reluctant to report pain due to previous bad experiences with healthcare services, anxieties about the potential cause of the pain, stoic attitudes (‘put up with pain’, ‘don’t make a fuss’) and also have concerns about side-effects of analgesic medications. These issues create barriers to effective assessment and management of pain and need to be explored and strategies developed to overcome them.

Preprocedural considerations

Assessment and recording tools

Accurate pain assessment is a prerequisite of effective control and is an essential component of nursing care. In the assessment process, the nurse gathers information from the patient that allows an understanding of the patient’s experience and its effect on their life. The information obtained guides the nurse in planning and evaluating strategies for care. Pain is rarely static; therefore, its assessment is not a one-time process but is ongoing.

Pain assessment can be difficult to achieve. For example, the tendency suggested by both research and clinical practice is for the patient not to report any pain or to do so inadequately or inaccurately, minimizing the pain experience (McCaffery and Beebe 1989). Nurses are influenced by a number of variables when assessing the amount of pain a patient is suffering (Kitson 1994). Pargeon and Hailey (1999) demonstrated that healthcare providers usually over- or underestimate a patient’s pain. It has also been suggested that nurses do not possess sufficient knowledge to care for patients in pain (Drayer et al. 1999, McCaffery and Ferrell 1997). A survey of over 3000 nurses (McCaffery and Robinson 2002) demonstrated that nurse education has improved confidence in the pain assessment process but that further education continues to be required in the pharmacology of pain medications and addressing nurses’ fears of opioid addiction and respiratory depression, which continue to contribute to the undertreatment of pain.

A variety of pain assessment tools exist which can be used to assist nurses to assess pain and plan nursing care. They enable pain to be successfully assessed and monitored (McCaffery and Beebe 1989, Twycross et al. 1996, Walker et al. 1987) and improve communication between staff and patients (Raiman 1986). Higginson (1998), p.150) notes that: ‘Taking assessments directly from the patient is the most valid way of collecting information on their quality of life’. Encouraging patients to take an active role in their pain assessment by using pain tools helps to increase their confidence and makes them feel part of