Patient
Comfort
Assessment
Guide
To facilitate your
assessment of your
patients’ pain and its
effect on their daily
activities
Partners Against Pain®
is a service brought to you by
Purdue Pharma L.P.
Sources: Brief Pain Inventory, Charles Cleeland, Copyright 1991. McCorkle R, Young K. Development of a symptom distress scale. Cancer Nursing. 1978;1:373-378.
®
© 2004, 2011 Purdue Pharma L.P., Stamford, CT 06901 G5375 PAP023 11/11
Patient Comfort Assessment Guide
Pharmacologic management of pain, as a component of
the total management of the patient with persistent pain, is
increasingly utilized among healthcare professionals.
Although healthcare professionals want to provide optimal
care for their patients, time constraints often impose barriers
that may interfere with the goals of care. Applying phar-
macologic protocols for pain management requires proper
evaluation, implementation, and monitoring.
To assist in this challenge, Purdue has supported the
development of a concise documentation tool to help the
clinician with the assessment of pain and implementation
of pain treatment regimens. This PATIENT COMFORT
ASSESSMENT GUIDE encompasses pain status, pain relief,
other symptoms and side effects, as well as the impact of
pain on the patient’s functional status. For clinical pur-
poses, these components have proven helpful in monitoring
and documenting the status of patients and their response
to treatment interventions.
This guide was prepared by the late Elizabeth J. Narcessian,
MD, clinical chief of pain management at the Kessler
Institute for Rehabilitation. Her deep concern for patient
comfort led Dr. Narcessian to compile this assessment
guide from components of other survey instruments that
have been developed and validated in their entirety.
In her introduction to the first edition, Dr. Narcessian
observed: “As we strive to optimize the quality of life of our
patients by decreasing their pain, it is imperative that we
maintain proper documentation both to monitor effective-
ness of the treatment protocol, as well as provide data to
track the patient’s status. This task can be simplified by
using the PATIENT COMFORT ASSESSMENT GUIDE.”
®
Patient Comfort Assessment Guide
Name:–––––––––––––––––––––––––––––––––––––––––––––––––––– Date:––––––––––––––
1. Where is your pain?______________________________________________________________________
2. Circle the words that describe your pain.
aching sharp penetrating
throbbing tender nagging
shooting burning numb
stabbing exhausting miserable
gnawing tiring unbearable
Circle One occasional continuous
What time of day is your pain the worst? Circle one.
morning afternoon evening nighttime
3. Rate your pain by circling the number that best describes your pain at its worst in the last month.
No Pain 0 1 2 3 4 5 6 7 8 9 10 Pain as bad as you can imagine
4. Rate your pain by circling the number that best describes your pain at its least in the last month.
No Pain 0 1 2 3 4 5 6 7 8 9 10 Pain as bad as you can imagine
5. Rate your pain by circling the number that best describes your pain on average in the last month.
No Pain 0 1 2 3 4 5 6 7 8 9 10 Pain as bad as you can imagine
6. Rate your pain by circling the number that best describes your pain right now.
No Pain 0 1 2 3 4 5 6 7 8 9 10 Pain as bad as you can imagine
7. What makes your pain better?–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
8. What makes your pain worse?––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
9. What treatments or medicines are you receiving for your pain? Circle the number to describe the
amount of relief the treatment or medicine provide(s) you.
a)–––––––––––––––––––––––––––––––––––– No 0 1 2 3 4 5 6 7 8 9 10 Complete
Treatment or Medicine (include dose) Relief Relief
b)–––––––––––––––––––––––––––––––––––– No 0 1 2 3 4 5 6 7 8 9 10 Complete
Treatment or Medicine (include dose) Relief Relief
c)––––––––––––––––––––––––––––––––––––– No 0 1 2 3 4 5 6 7 8 9 10 Complete
Treatment or Medicine (include dose) Relief Relief
d)–––––––––––––––––––––––––––––––––––– No 0 1 2 3 4 5 6 7 8 9 10 Complete
Treatment or Medicine (include dose) Relief Relief
10. What side effects or symptoms are you having? Circle the number that best describes your
experience during the past week.
a. Nausea Barely 0 1 2 3 4 5 6 7 8 9 10 Severe Enough
Noticeable to Stop Medicine
b. Vomiting Barely 0 1 2 3 4 5 6 7 8 9 10 Severe Enough
Noticeable to Stop Medicine
c. Constipation Barely 0 1 2 3 4 5 6 7 8 9 10 Severe Enough
Noticeable to Stop Medicine
d. Lack of Appetite Barely 0 1 2 3 4 5 6 7 8 9 10 Severe Enough
Noticeable to Stop Medicine
e. Tired Barely 0 1 2 3 4 5 6 7 8 9 10 Severe Enough
Noticeable to Stop Medicine
f. Itching Barely 0 1 2 3 4 5 6 7 8 9 10 Severe Enough
Noticeable to Stop Medicine
g. Nightmares Barely 0 1 2 3 4 5 6 7 8 9 10 Severe Enough
Noticeable to Stop Medicine
h. Sweating Barely 0 1 2 3 4 5 6 7 8 9 10 Severe Enough
Noticeable to Stop Medicine
i. Difficulty Thinking Barely 0 1 2 3 4 5 6 7 8 9 10 Severe Enough
Noticeable to Stop Medicine
j. Insomnia Barely 0 1 2 3 4 5 6 7 8 9 10 Severe Enough
Noticeable to Stop Medicine
11. Circle the one number that describes how during the past week pain has interfered with your:
a. General Activity Does Not 0 1 2 3 4 5 6 7 8 9 10 Completely
Interfere Interferes
b. Mood Does Not 0 1 2 3 4 5 6 7 8 9 10 Completely
Interfere Interferes
c. Normal Work Does Not 0 1 2 3 4 5 6 7 8 9 10 Completely
Interfere Interferes
d. Sleep Does Not 0 1 2 3 4 5 6 7 8 9 10 Completely
Interfere Interferes
e. Enjoyment of Life Does Not 0 1 2 3 4 5 6 7 8 9 10 Completely
Interfere Interferes
f. Ability to Concentrate Does Not 0 1 2 3 4 5 6 7 8 9 10 Completely
Interfere Interferes
g. Relations with Does Not 0 1 2 3 4 5 6 7 8 9 10 Completely
Other People Interfere Interferes
Prepared by Elizabeth J. Narcessian, MD, Clinical Chief of Pain Management, Kessler Institute for Rehabilitation, Inc. G5375 PAP023 11/11
Patient Comfort Assessment Guide
Pharmacologic management of pain, as a component of
the total management of the patient with persistent pain, is
increasingly utilized among healthcare professionals.
Although healthcare professionals want to provide optimal
care for their patients, time constraints often impose barriers
that may interfere with the goals of care. Applying phar-
macologic protocols for pain management requires proper
evaluation, implementation, and monitoring.
To assist in this challenge, Purdue has supported the
development of a concise documentation tool to help the
clinician with the assessment of pain and implementation
of pain treatment regimens. This PATIENT COMFORT
ASSESSMENT GUIDE encompasses pain status, pain relief,
other symptoms and side effects, as well as the impact of
pain on the patient’s functional status. For clinical pur-
poses, these components have proven helpful in monitoring
and documenting the status of patients and their response
to treatment interventions.
This guide was prepared by the late Elizabeth J. Narcessian,
MD, clinical chief of pain management at the Kessler
Institute for Rehabilitation. Her deep concern for patient
comfort led Dr. Narcessian to compile this assessment
guide from components of other survey instruments that
have been developed and validated in their entirety.
In her introduction to the first edition, Dr. Narcessian
observed: “As we strive to optimize the quality of life of our
patients by decreasing their pain, it is imperative that we
maintain proper documentation both to monitor effective-
ness of the treatment protocol, as well as provide data to
track the patient’s status. This task can be simplified by
using the PATIENT COMFORT ASSESSMENT GUIDE.”
®
Patient
Comfort
Assessment
Guide
To facilitate your
assessment of your
patients’ pain and its
effect on their daily
activities
Partners Against Pain®
is a service brought to you by
Purdue Pharma L.P.
Sources: Brief Pain Inventory, Charles Cleeland, Copyright 1991. McCorkle R, Young K. Development of a symptom distress scale. Cancer Nursing. 1978;1:373-378.
®
© 2004, 2011 Purdue Pharma L.P., Stamford, CT 06901 G5375 PAP023 11/11
