Page 106 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Management of Cancer Pain (Second Edition)
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Breathing Normal Occasional laboured Noisy laboured
independent of breathing. breathing. Long period
vocalisation Short period of of hyperventilation.
hyperventilation. Cheyne-Stokes
respirations.
Negative None Occasional moan or Repeated troubled
vocalization groan. Low-level calling out.
speech with a Loud moaning or
negative or groaning.
disapproving quality. Crying.

Facial Smiling or Sad. Frightened. Facial grimacing.
expression inexpressive Frown.
Body Relaxed Tense. Distressed Rigid. Fists clenched.
language pacing. Fidgeting. Knees pulled up.
Pulling or pushing away.
Striking out.
Consolability No need to Distracted or Unable to console,
console reassured by voice distract or reassure.
or touch.
Total**
*Five-item observational tool (see the description of each item below).

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The PAINAD scale is a reliable pain assessment tool for patients with advanced
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is scored on a range from 0 (not present) to 2 (completely present) based on direct
observation for a total score that ranges from 0 to 10.

Reference: Warden V, Hurley AC, Volicer L. Development and psychometric
evaluation of the Pain Assessment in Advanced Dementia (PAINAD)
scale. J Am Med Dir Assoc. 2003;4(1):9-15.

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