A New Approach to the 0 to 10 Pain Scale
Having a consistent and reliable pain rating scale is extremely valuable for EMS providers in the treatment of pain and for continued patient assessment.3 The 0 to 10 pain scale has become the most widely utilized and accepted measure of pain in all settings.5 Assessment terms like mild, moderate and severe have previously been used to assess pain prior to the numeric pain scale.
The 0 to 10 pain scale originally appeared after World War II, not as a patient assessment tool, but as a research survey method. The 0 to 10 pain scale has since emerged as the required tool in pain assessment and documentation in all areas of healthcare. But how the pain scale is used can make a world of difference in the patient’s experience of pain relief, comfort and healing.
The problem with the 0 to 10 pain scale is that clinicians don’t always want to believe it and they may not understand how to apply it well. When a medic asks a patient to rate their pain on the 0 to 10 scale and the patient replies “15,” the medic may be skeptical. This is also true when the patient rates the pain as an “8” but the medic doesn’t think the patient looks that uncomfortable. Is the problem the patient or the way the assessment tool being is used?
We all know that people have their own individual pain tolerance. Pain, in fact, is a perception.2 Because pain is perceived differently from one person to another and under different circumstances, this provides us an opportunity to modify the experience. The goal is to always do your best to modify the perception of pain to bring the most comfort. So, when you use the 1 to 10 pain scale, what is your goal? Are you asking for what you want? Repeatedly asking the patient for their pain rating may be counterproductive. Are you seeking a pain rating or do you really want to assess the patient’s comfort?
Most EMS providers have never really been instructed on how to use the 0 to 10 pain scale. There is no formal training. People just expect you to know it. It’s simple; just rate the pain with a number from 0 to 10. However, it’s common practice to hear healthcare providers say: Rate your pain on a zero to ten scale with ten being the worst possible pain you ever experienced.4 Is this really the best way to utilize this scale? You’ve just asked the patient to recall previous painful experiences; on top of the pain they are actually experiencing now.
Here are some simple and effective ways to enhance your use of the 0 to 10 pain scale to provide a consistent and effective approach with every patient that will promote greater comfort, improved clinical outcome and also express compassion.
Initial Pain Assessment
This is the new approach to communicating the use of the 0 to 10 pain scale.
The clinician says: Please rate the pain on a zero to ten scale with “0” being no pain and “10” being the highest.
When you say 10 is the highest, this caps the scale and avoids the patient going over 10. Remember pain is a perception that you must capture on a numeric scale. Putting feelings into numbers is not always easy for people. You must be clear and specific. It’s important for you to provide an accurate reassessment of pain, and to do that, you must provide a good starting point.
Notice the choice of words: “0” being no pain. It is critical that you provide a qualifier for both ends of the scale. Why only emphasize the “10” with a descriptor of severe pain? Don’t describe it “as the worst possible pain you ever experienced”. The reason for this is that you may be unwittingly leading the patient to recall or imagine previous severely painful experiences. Simply use the phrase; and 10 is the “highest”. Notice the subtle but profound difference. This is a neutral and more accurate descriptor for the numeric scale that does not have any mental or emotional associations with previous painful experiences.
Why is This Important?
The Power of Association. Recalling past painful experiences may enhance the current experience of pain. All sensory information, including painful sensations, are processed in the outside layer of the brain, the primary somatosensory (S1) cortex. These pain memories manifest themselves in alterations in the S1 cortex and may contribute to hypersensitivity even in the absence of peripheral stimulation.2
The Stress Response. Recalling past painful experiences can trigger the stress response. The pain experience may be worsened with increased stress, which results in tight muscles, increased pulse rate and blood pressure and the release of stress hormones.1
Your Goal. You always want to bring comfort and reduce discomfort. Begin thinking of the pain scale as a tool to measure comfort as well.
This is the new approach to reassessment using the 0 to 10 pain scale.
The clinician says: Feeling Better? or How are you feeling?
A common reassessment practice is to reassess the patients’ pain by asking How’s your pain? In this case you’ve assumed that the patient has pain.Is this really what you want?The patient may comply with the request and search for pain. A better approach is to ask a more neutral and open question such as: How are you feeling?
Another good reassessment phrase is “ Feeling Better.” If the patient appears to look good, this is a great way to express caring and expectation for comfort. If the patient’s reply is “Yes,” they have just verbally reaffirmed their feeling. This provides an uplifting feeling of confidence in their healing experience.
When the patient replies that they’re feeling better, you should say things like “Great, I’m so happy you’re feeling better” or give the patient credit by saying “good job!” It’s important to also reassess how much better they are feeling on the pain scale. Ask the patient: “How much better do you feel?” You may even say, the pain was an “8,” how much lower is it now? ”
If the patient says “No,” “It’s the same,” or “It’s worse,” then reassess the patient’s discomfort by asking “What number is it now?” Don’t ask “how’s your pain?” Then express to the patient “I’m sorry this has been uncomfortable for you, let’s see what we can do to get you feeling better.” Always point the way to comfort and caring. Even when you can’t reduce the pain, you will be acting with compassion and the patient will feel how much you care.
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