19 - 226Teknik-Assessment Nyeri
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TEKNIK
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Assessment Nyeri Yu Yudiyanta, diyanta, Novita Khoirunnisa, Ratih Wahyu Novitasari Departemen Neurologi, Fakultas Kedokteran Universitas Gadjah Mada, ta, Indonesia Yogyakar ta, Indonesia
ABSTR AK AK ontr ol K ontr ol nyer i tetap merupakan problem signifikan pada pelayanan kesehatan di seluruh dunia. Penanganan nyer i yang efektif ter gantung gantung
pada pemeriksaan dan penilaian nyer i yang seksama berdasarkan informasi subjektif maupun objektif . Anamnesis pasien nyer i sebaiknya menggunakan kombinasi pertanyaan terbuka dan tertutup untuk memperoleh memperoleh informasi masalah pasien. Selain itu , perhatikan juga faktorfaktor seperti tempat wawancara, sikap yang suportif dan tidak menghakimi, tanda-tanda verbal dan nonver bal , dan meluangkan waktu yang cuk up P r up. Penggunaan mnemonik PQRST ( P ro vokatif Quality Region Severity Time) juga akan membantu mengumpulkan informasi vital yang berkaitan dengan proses nyeri pasien.(1) K ata kunci: Assessment nyer i,i, kontrol nyer i
ABSTRACT n health management. An effective management depends on throug through h examination and assessment Pain control is still an important issue iin
based on objective as well as subjective information. Combination Combination of closed and open questions can be utilized in a supportive and noninclined manner manner in relaxed relaxed environment, environment, together with observation on verbal as as well as non verbal clues. Use of PQRST mnemonics can help obtain important information. Yudiyanta, Nov Novita ita Khoirunnisa, Ratih Wahyu Wahyu Novitasari. Pain Assessment. K eywor ds: ds: Pain assessment, pain contr ol ol PENDAHULUAN Sensasi penglihatan, pendengaran, bau, rasa, sentuhan, dan nyer i merupakan hasil stimulasi reseptor sensor ik ik . Nyeri adalah
sensasi yang penting bagi tubuh. Provokasi saraf-saraf sensorik nyer i menghasilkan reaksi ketidaknyamanan, distr ess ess , atau 1 pender itaan. itaan. K ontr ontr ol ol
nyer i tetap merupakan pr oblem oblem signifikan pada pelayanan kesehatan di se-
anak , dewasa, dan pasien tersedasi dengan pemberian obat ataupun tanpa pem pember ber ian ian obat sesuai tingkat nyer i yang dirasakan pasien. 3 Pendekatan untuk memper oleh oleh riwayat detail detail dar i seorang pasien nyer i sebaiknya menggunakan kombinasi perta pertan nyaan terbuka dan tertutup untuk memper oleh oleh inf ormasi o rmasi yang diperlukan untuk mengetahui masalah pasien. Selain itu , per hatik hatik an an juga fakto r-fakto r seper ti menentukan tempat ketika melakukan wawancara,
T Time atau Waktu (frekwensi) (berapa kali dalam sehari)
Tujuan kebijakan penatalaksanaan nyer i di rumah sakit adalah: adalah: a. Semua pasien yang mengalami nyer i mendapat pelayanan sesuai pedoman dan prosedur manajemen nyer i RSUP Dr Sardjito Sardjito b. Menghindar i dampak/risiko nyer i terhadap proses penyembuhan 3
.
luruh dunia. Penanganan nyer i yang efektif tergantung pada pemeriksaan dan penilaian nyer i yang seksama baik ber dasar k k an an informasi subjektif maupun objektif .2 Teknik pemeriksaan /penilaian oleh tenaga kesehatan dan keengganan pasien untuk melaporkan nyer i merupakan dua masalah utama. Masalah-masalah yang berkaitan dengan kesehatan, pasien, dan sistem pelayanan kesehatan secara k eseluruhan eseluruhan diketahui sebagai salah satu peng penghamba hambatt dalam penatalaksaan nyer i yang tepat. epat. Penanganan nyer i adalah upaya mengatasi nyer i yang dilakukan pada pasien ba bayi, yi,
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menunjukkan sik a p yang suportif dan tidak menghakimi, memperhatikan tanda-tanda verbal dan no non nver bal, dan meluangkan waktu yang cukup untuk melakukan wawancara. Penggunaan mnemonik PQRST juga akan membantu untuk mengum mengumpulkan pulkan informasi vital yang berkaitan dengan proses nyer i pasien.1 Mnemonik PQRST untuk Evaluasi Nyeri P Provokatif atau faktor yang mempengaruhi nyeri nyeri Q Quality atau Sensasi nyeri (rasa tajam, tumpul, tersayat) R Region (daerah) lokasi atau penyebaran nyer i S Severity atau intensitas nyeri nyeri
ik an an kenyamanan pada pasien c Member ik
Assessment nyer i awal pada pasien dengan nyer i bisa dibantu menggunakan penilaian nyer i awal (Paser o, Mc Caffery M) (Lampir an an 1). Bila pada pasien anak-anak , assessment awal menggunakan penilaian nyer i awal untuk anak-anak . Untuk pasien nyer i kanker digunakan initial assessment management an 2).). of Cancer Pain (Lampir an Anamnesis nyer i juga perlu menanyak an an riwayat penyakit dahulu tentang nyer i,i, yang meliputi:
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1. Masalah medis yang ber hubungan hubungan 2. Masalah yang mempengaruhi pen pengggunaan terapi nyer i 3. R iwa iwa yat ketergantungan obat PENILAIAN NYERI
ujung ekstrem juga digunakan pada skala ini, sama seperti pada VAS atau skala r eda eda nyer i (Gambar 2). Skala numer ik ik verbal ini lebih bermanfaat pada periode pascabedah, karena secara alami verbal/kata-kata tidak terlalu mengandalkan koordinasi visual dan
B. Multi-dimensional Mengukur intensitas dan afektif (un pleasantness) nyer i kronis - Diaplikasikan untuk nyer i kronis - Dapat dipakai untuk outcome assessment klinis klinis
Ada beberapa cara untuk membantu mengetahui akibat nyer i menggunakan skala multidimensi. i. assessment nyer i tunggal atau multidimens
motor ik ik . Skala verbal menggunakan katakata dan bukan garis atau angka untuk menggambarkan tingkat nyer i.i. Skala yang
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Skala assessment nyeri A. Uni- dimensional: - Hanya mengukur intensitas nyer i - Cocok (appropriate ) untuk nyer i akut akut - Skala yang biasa digunakan untuk evaluasi outcome outcome pemberian pemberian analgetik - Skala assessment nyer i uni-dimensional ini meliputi 4:
• Visual Analog Scale ( VAS) VAS) Skala analog visual (VAS) adalah cara yang paling banyak digunakan untuk menilai nyer i.i. Skala linier ini menggambarkan secara visual gradasi tingkat nyer i yang mungkin dialami seorang pasien. Rentang nyer i diwak ili ili sebagai garis sepanjang 10 cm, dengan dengan atau tanpa tanda pada tiap sentimeter (Gambar 1). Tanda pada kedua ujung garis ini dapat berupa angka atau pernyataan desk r r iptif iptif . Ujung yang satu mewak ili ili tidak ada nyer i,i, sedangkan ujung yang lain mewak ili ili rasa nyer i terparah yang mungkin terjadi. Skala dapat dibuat vertikal atau hor iz izontal. VAS juga dapat diadaptasi menjadi skala hilangnya/ reda rasa nyer i.i. Digunakan pada pasien anak >8 tahun tahun dan dewasa. Manfaat utama VAS adalah pen penggu ggunaan naannya nya sangat mudah dan sederhana. Namun, untuk per iode iode pascabedah, VAS tidak banyak ber manfaat manfaat
digunakan dapat berupa tidak ada nyer i,i, sedang, parah. Hilang/redanya nyer i dapat dinyatakan sebagai sama sekali tidak hilang, sedikit ber k k urang urang, cukup ber k k urang u rang, baik/ nyer i hilang sama sekali. K ar ar ena ena skala ini membatasi pili pilihan han kata pasien, skala ini tidak dapat membedakan berbagai tipe nyer i.i. • Numeric Rating Scale (NRS) (Gambar 3) Dianggap sederhana dan mudah dimenger ti, sensitif terhadap dosis, jenis kelamin, dan perbedaan perbeda an etnis. Lebih baik daripada VAS terutama untuk menilai nyer i akut. Namun, kekurangannya adalah keterbatasan pilihan kata untuk menggambarkan menggambarkan rasa nyer i,i, tidak memungkinkan untuk membedakan tingkat nyer i dengan lebih teliti dan dianggap terdapat jarak yang sama antar kata yang menggambarkan efek analgesik . Wong Baker Baker Pain Rating Scale Scale • Wong Digunakan pada pasien dewasa dan anak >3 tahun yang tidak dapat menggambar k k an an intensitas nyerinya nyerinya dengan angka (Gambar 4).).
karena VAS memerlukan koordinasi visual dan motorik serta kemampuan konsentrasi. konsentrasi. • Verbal Rating Scale ( VRS) VRS) ini menggunakan angk a-angk Sk ala sampai ala ini a-angk a 0 sampai 10 untuk menggambarkan tingkat nyer i.i. Dua Dua
Gambar 2. Verbal
Gambar 1. Visual
Gambar 3. Numeric
Rating Scale ( VRS) VRS)
4
Skala multi-dimensional ini meliputi :
McGill ill P P ain ain Questionnaire uestionnaire (MPQ) (lampir an an 3) • McG Terdiri dar i empat bagian: (1) gambar nyer i,i, (2) indeks nyer i (PRI), (3) pertanyaan pertanyaan mengenai nyer i terdahulu dan lokasinya; dan (4) indeks intensitas nyer i yang dialami saat ini. PRI ter dir dir i dar i 78 kata sifat/ajektif , yang dibagi dibagi ke dalam 20 k elompok elompok . Setiap set mengandung sekitar 6 kata yang menggambarka n kualitas nyer i yang makin meningkat. K elompok elompok 1 sampai 10 menggambarkan kualitas al , sensorik nyer i (misalnya, waktu/tempor al lok asi/ asi/ spatial spatial , suhu/thermal ). ). K elompok elompok kualitas 11 sampai 15 menggambarkan efektif nyer i (misalnya str es es, takut, sifat-sifat otonom). K elompok elompok 16 menggambar k k an an dimensi evaluasi dan kelompok 17 sampai sampai 20 untuk keterangan lain-lain dan mencak up up kata-kata spesifik untuk kondisi ter tentu. Penilaian menggunakan angka diber ik ik an an untuk setiap kata sifat dan kemudian dengan menjumlahkan semua angka ber dasar k k an an pilihan kata pasien maka akan diperoleh angka total (PRI( T )). )). The Brief Pain Inventory (BPI) (lampir an an 4) Adalah kuesioner medis yang digunak an an untuk menilai nyer i.i. Awalnya digunak an an untuk mengassess mengassess nyer i k ank er , namun ank er sudah divalidasi juga untuk assessment nyer i k r ronik o nik .
•
Memoriall Pain Assessme Assessment nt C ar ar d d • Memoria Merupakan instrumen yang cukup valid untuk evaluasi efektivitas efektivitas dan peng pengobatan obatan nyer i kronis secara subjektif . Terdiri atas 4 komponen penilaian tentang nyer i meliputi intensitas nyer i,i, deskripsi nyer i,i, pengurangan pengurangan nyer i dan mood . ( Gambar 5)
Analog Scale ( VAS) VAS)
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Rating Scale (NRS)
Gambar 4. Wong Wong Baker Baker
Pain Rating Rating Scale
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• Catatan harian nyer i ( Pain Pain diar y) Adalah catatan tertulis atau lisan mengenai pengalaman pengal aman pasie pasien n dan perila perilakunya kunya.. Jenis laporan ini sangat membantu membantu untuk memantau variasi status penyakit sehar i-har i-har i dan respons pasien terhadap terapi. Pasien mencatat intensitas nyerinya dan kaitan dengan perilakunya, misalnya aktivitas harian, harian, tidur , aktivitas seksual, kapan menggunakan obat, makan, merawat rumah dan aktivitas lainnya. rekreasi lainnya. Pengkajian nyer i pada ger iatr i membutuhkan kekhususan disebabkan hilangnya neuron otak dan korda spinalis mengakibatk an perubahan yang sering diinterpretasikan sebagai abnormal pada individu lebih muda. K ecepatan ecepatan konduksi saraf menurun antara 5-10% akibat proses menua, hal ini akan menurunkan waktu respons dan memperlambat transmisi impuls , sehingga menurunkan persepsi sensor i sentuh dan nyer i.i.
Tabel. Perbedaan karakteristik nyer i nosiseptik dan nyer i neur opatik opatik Nyeri Nosisep Nosiseptik tik -
Terlokalisasi pada tempat cedera cedera stimulus Sensasi sesuai stimulus Akut, mempunyai batas waktu waktu Memiliki fungsi protektif
digunakan: Pengkajian nyer i yang digunakan: • Untuk pasien bayi 0-1 tahun, digunak an an skala NIPS ( Neonatal Neona tal Infant Pain S cale cale ) ( Lampir an an 7).).
Pengkajian awal nyer i pada ger iatr iatr i dapat menggunakan instrumen Nonverbal P ain ain 5 Indicators (CNPI) (Lampir an an 5). Bila pada pasien tersebut terdapat demensia digunakan Pain Assessment in Advanced Dementia Scale (PAINAD) 6 (Lampir an an 6).).
neurologi belum ber kk embang Sistem neurologi embang sempurna saat bayi dilahirkan. Sebagian besarr perke besa perkemba mbangan ngan otak , mielinisasi sistem saraf pusat dan per if if er er , terjadi selama tahun pertama kehidupan. Beberapa refleks refleks primitif primitif sudah ada pada saat dilahirkan, ter masuk masuk diri ketika mendapat refleks menarik stimulus nyer i.i. Bayi baru lahir ser ingk ali ali memerlukan stimulus yang kuat untuk menghasilkan respons – dan kemudian dia akan merespons merespons dengan cara menangis menangis dan menggerakan seluruh tubuh. K emampuan emampuan melokalisasi tempat stimulus dan untuk menghasilkan respons spesifik motor ik ik anakanak berkembang seiring dengan tingkat mielinisasi.7
Pengkajian di RSUP Dr. Sardjito Semua pasien yang dilayani di RSUP Dr Sardjito menjalani pengkajian nyer i.i.
Untuk pasien anak >8 tahun dan dewasa • digunakan VAS (Visual Analog Scale) (Gambar 3)
Nyeri Neur opatik
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Nyeri di bagian distal dar i lesi atau disfungsi saraf Sensasi tidak selalu sesuai dengan stimulus, rasa panas, berdenyut, ngilu ngilu r onis K r onis, persisten setelah cedera menyembuh
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Tidak memilik i fungsi protektif
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• Pada pasien dewasa dan anak >3 tahun yang tidak dapat menggambarkan intensitas nyerinya dengan angka, digunakan Wong Baker FACES Pain FACES Pain Scale (Gambar 4) • Pada anak usia 2 mungkin ter dapat dapat nyer i neur opatik opatik . 2. LANNS ( The The Leeds eeds Assessment of Neuropathic Symptoms and Signs Pain Signs Pain Scale) (Lampir an an 11) Untuk membedakan nyer i neuropatik atau Gambar 5. Memorial
Pain Asses Assessment sment C ar ar d d
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nosiseptik juga dapat digunakan instrumen instru men
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TEKNIK eter gantungan mengindikasikan terjadinya k et gantungan opioid dan dibutuhkan untuk evaluasi terapi dan foll follow ow up ketat terhadap k emungkinan emungkinan 9 kerusakan organ tubuh.
mungkin pasien menderita nyeri neur opatik opatik . Di RS Dr Sar djit djito, assessment ulang nyer i diEVALUASI
Evaluasi pengo pengobatan batan meliputi: meliputi: 1. Dosis dan pola peng penggunaa gunaan n 2. Ef ektifitas ektifitas 3. Toleransi obat
Efek samping obat sebaiknya dicatat menggunakan List of Medicines for for Pain Pain and S ide Effects (Lampir an an 12) yang dilihat setiap kali pasien hendak mengkonsumsi obat, dan untuk menilai keberhasilan pengobatan dapat juga menggunakan instrumen P ain ain 8 and Pain Relief Rec Reco or d d (Lampir an an 13).).
terapi obat opioid, sebelumnya dinilai terlebih dahulu Opioid Risk Tool (Lampir an an 14). Dengan instrumen ini pasien dapat dik ategor ategor ik ik an an risiko r endah, endah, eter gantungan sedang atau tinggi untuk k et gantungan terapi opioid. K emudian emudian setelah pasien menerima terapi opioid, dinilai pula Addi Addicti ction on Behaviors Beha viors Checkli Checklist st guna mengetahui apak ah ah sudah terjadi ketergantungan ter hadap hadap an 15).). Skor ABC >3 terapi opioid (Lampir an Bila pasien menda mendapat pat
lakukan pada pasien yang dirawat lebih dar i beberapa jam dan menun beberapa menunjukkan jukkan rasa nyer i,i, 3 sebagai ber ik ik ut: ut: • Lakukan assessment nyer i yang k ompr ompr ehensif setiap kali melakukan pemeriksaan fisik pada pasien Dilakukan pada: pasien yang mengeluh • nyer i,i, 1 jam setelah tatalaksana nyer i,i, setiap setiap 4 jam (pada pasien yang sadar/bangun) atau sesuai jenis dan onset masing-masing jenis obat, pasien yang menjalani prosedur menyakitkan, sebelum transfer pasien, pasien, dan sebelum pasien pulang dar i rumah sakit. sakit. Pada pasien nyer i kardiak ( jantu • jantu ng), lak uk uk an an assessment ulang setiap 5 menit setelah pemberian nitrat atau obat-obatan intravena. intravena. ak ut/k • Pada nyer i ut/k r r onik lakukan onik , assessment ulang tiap 30 menit-1 jam setelah pemberian obat anti-n anti-nyyer i.i. Semua tindakan assessment dan pe pena nanga ngana nan n nyer i didokumentasikan dalam catatan rencana pengelolaan, implementasi, catatan
perkembanga perkembangan n terintegrasi dan lembar monitoring terpadu rawat inap, rawat jalan, maupun rawat khusus rekam medis. Staf yang terlibat dalam penanganan nyer i semuanya kompeten. Rumah sakit memilik i proses untuk mendidik staf mengenai manajemen nyer i dengan pelatihan manajemen nyer i.i.3
melaksanakan
Evaluasi nyer i secara psiko psikologik logik terutama pada nyer i k r r onis meliputi: o nis, meliputi: kronis) 1. Gangguan mood (pada 50% nyer i kronis) somatis 2. Gejala somatis 3. Gangguan tidur dan nafsu mak an an Libido 4. Libido 5. Ide bunuh dir i 6. Pengaruh nyer i dalam kehidupan sehar i har i:i: aktifitas sehar i-har i-har i,i, pekerjaan dan keuangan, hubungan personal, k ebutuhan ebutuhan akan rekreasi. rekreasi. eseluruhan Evaluasi pasien nyer i secara k eseluruhan dapat menggunakan instrumen P atient atient Comfort Assessment Guide (Lampir an an 16) yang ter dir dir i atas 11 pertanyaan tentang status nyer i,i, penguranga pengurangan n nyer i,i, gejala lain, dan efek samping sebagai tolok ukur status fungsional pasien. Assessment ini membantu monitor dan dokumentasi status pasien dan respons pasien terhadap pen pengoba gobatan. tan.
DAFTAR PUSTAKA
1.
R aylene MR. 2008; terj. D. Lyrawati, 2009. Penilaian Ny Nyer er i.i. Cited. AHRQ Publication No. 02-E032. Rockville: Agency for Healthcare Research and Qualit y, July 2002. 2002.
2.
1987:32. Fields H L. Pain. New Yor k k : McGraw-H ill, 1987:32.
3.
Tim Nyeri RSUP Dr Sar djit djito. Yogyakar ta: ta: Protap nyer i RSUP Dr Sarjito. 2012. 2012.
4.
Bieri D, Reeve RA, Champion CD, Addicoat L, Ziegler JB. The faces pain scale for the self-assessment of the the severity of pain experienced by children: Development, initial validation, and
1990;41:139-150. preliminar y investigation for ratio scale proper ties ties. Pain 1990;41:139-150. 5.
Pain assessment in the the cognitively impaired and unimpaired elder ly 2000;1(4):106-115. Manz BD, Mosier R, Nusser-G erlach MA, Bergstrom M, Agrawal S. Pain ly. Pain Manag Nurs . 2000;1(4):106-115.
6.
2003:4(1):50-51. Villanueva MR, Smith TL, Erickson JS, Lee AC, Singer CM. Pain assessment for the dementing elderly (PADE): reliability and validity of a new measur e. J Am Med Dir Assoc. 2003:4(1):50-51.
7.
and children. Pediatr Clin. North Am 2000;47(3):487-512. 2000;47(3):487-512. Franck LS, Greenberg CS, Stevens B. Pain assessment in infants and
8.
K oo oo PJS. Pain. I n: n: Young LY, K oda-K oda-K imble imble MA. Applied Therapeutics: the Clinical Use of Drugs, 9th ed. Vancouver : Applied Therapeutics; 2004. 2004.
9.
Morley-Forster PK, Clark AJ, Speechley M, Moulia DE. Attitudes toward opioid use for chronic pain: a Canadian physician sur vey. Pain Res Manag 2003;8:189-194. 2003;8:189-194.
10. K elompok elompok Studi Ny Studi Nyer er i.i. K onsensus onsensus Nasion al 1 : Penatalaksanaaan nyer i neur opatik opatik . Perdossi: 2011.
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Lampiran 1. Initial pain assessment (Pasero C, Mc Caffery) Caffery)
Form 1.1 Initial Pain Assessment Tool Date Patient’s atient’s Name Name
Age
Diagnosis
Room
Physician Physician Nurse
1. LOCATION: Patient or nurse mark drawing.
2. INTENSITY: Patient rates the pain. Scale used Present pain: Present pain:
Worst pain pain gets:
AIN CONSTANT? 3. IS THIS PAIN
YES;
Best pain pain gets:
Acceptable level of pain:
NO IF NO NOT, HOW OFTEN DOES IT IT OCCUR?
4. QU QUALITY ALITY: (For example: ache, deep, sharp, sharp, hot, cold, like sensitive skin, sharp, sharp, itchy) 5. ONSET, DURATION, VARIA ARIATIONS, TIONS, RHYTHMS:
6. MANNER OF EXPRESSING PAIN: PAIN: 7. WHAT RELIEVES PAIN?
8. WHAT CAUSES OR INCREASES THE PAIN?
life.) 9. EFFECTS OF PAIN: (Note decreased function, decreased quality of life.) Accompanying symptoms (e.g., nausea)
Sleep Sleep Appetite Physical activity Relationship with others (e.g., irritability) Emotions (e.g., anger, suicidal, crying) Concentration Other 10. OTHER COMMENTS:
11. PLAN: PLAN: May be duplicated for use in clinical practice. Copyright Pasero C, McCaffery McCaffery M, 2008. As appears in Pasero C, McCaffery M. Pain: Assessment and pharmaco pharmacologic logic management , 2011, Mosby, Inc.
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Lampiran 2. Initial assessment management of Cancer Pain Pain
Initial Pain Assessment 1. Onset and temporal pattern — When When did your pain start? How often does it occur? Has its intensity changed? changed? 2. Location — Where Where is your pain? Is there more than one site? site? 3. Description — What What does your pain feel like? What words would you use to describe your pain? pain? A. Assessment of pain intensity and character
4. Intensity — On On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine, how much does it hurt right now? How much does it hurt at its worst? How much does it hurt at its best? best? 5. Aggravating and relieving factors — What What makes your pain better? What makes your pain worse? worse? 6. Previous treatment — What What types of treatment have you tried to relieve your pain? Were they and are they effective? effective? 7. Effect — How does the pain affect physical and social function? function? 1. Effect and understanding of the cancer diagnosis
and cancer treatment on the patient and the caregiver. caregiver. 2. The meaning of the pain to the patient and the family. family. 3. Significant past instances of pain and their effect on the patient. patient.
B. Psychosocial assessment
Psychosocial assessment should include the following:
4. The patient's typical coping responses to stress or pain. pain. 5. The patient's knowledge of, curiosity about, preferences for, and expectations about pain management methods. methods. 6. The patient's concerns about using controlled substances such as opioids, anxiolytics, or stimulants. 7. The economic effect of the pain and its treatment. treatment. 8. Changes in mood that have occurred as a result of the pain (e.g., depression, anxiety). anxiety).
1. Examine site of pain and evaluate common referral patterns. C. Physical and neurologic examination
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2. Perform pertinent neurologic evaluation. evaluation.
Head and neck pain — cranial nerve and fundoscopic evaluation. evaluation. Back and neck pain — motor and sensory function in limbs; rectal and urinary sphincter function. function.
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1. Evaluate recurrence or progression of disease or tissue injury related to cancer treatment. treatment.
Tumor markers and other blood tests. tests. Radiologic studies. studies. Neurophysiologic (e.g., electromyography) testing. testing.
2. Perform appropriate radiologic studies and correlate normal and abnormal findings with physical and neurologic examination. examination. D. Diagnostic evaluation
Bone scan — false negatives in myeloma, lym phoma, previous radiotherapy sites. sites. 3. Recognize limitations of diagnostic studies. studies.
CT scan — good definition of bone and soft tissue but difficult to image entire spine. spine. MRI scan — bone bone definition not as good as CT; better images of spine and brain br ain
*) Reference: Adapted from Management of Cancer Pain, Clinical Guideline Number 9. AHCPR Publication No. 94-0592: March 1994. Agency f or or ville, MD. Healthcare Research & Quality, Rock ville
orm ) Lampiran 3. Mc Gill Questionnaire (Short F orm
Tanggal:
Nama Pasien:
Tidak Ada da
R ingan ingan
Sedang edang
Ber at
Cekot-cekot Cekot-cekot
0) 0)
1) 1)
2) 2)
3) 3)
Menyentak
0) 0)
1) 1)
2) 2)
3) 3)
pisau) Menikam (seperti pisau)
0) 0)
1) 1)
2) 2)
3) 3)
Tajam (seperti silet) silet)
0) 0)
1) 1)
2) 2)
3) 3)
K eram eram
0) 0)
1) 1)
2) 2)
3) 3)
Menggigit Menggigit
0) 0)
1) 1)
2) 2)
3) 3)
Ter baka r
0) 0)
1) 1)
2) 2)
3) 3)
Ngilu Ngilu
0) 0)
1) 1)
2) 2)
3) 3)
Berat/pegal Berat/pegal
0) 0)
1) 1)
2) 2)
3) 3)
Nyeri sentuh
0) 0)
1) 1)
2) 2)
3) 3)
Mencabik-cabik
0) 0)
1) 1)
2) 2)
3) 3)
Melelahkan Melelahkan
0) 0)
1) 1)
2) 2)
3) 3)
Memualkan Memualkan
0) 0)
1) 1)
2) 2)
3) 3)
Menghukum-kejam Menghukum-kejam
0) 0)
1) 1)
2) 2)
3) 3)
R asa asa
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Lampiran 4. Brief Pain I nventor y ( short form short form )
Brief Pain Inventory (Short (Short Form) Study ID#
Hospital#
Do not write above this line
Date:
Time:
Name: Last 1)
First
Throughout our lives, lives, most of us have had pain from time to time time (such as minor headaches, headaches, sprains, and toothaches). toothaches). Have you had pain other than these everyday kinds of pain today? today? 1. Yes
2)
Middle Initial Initial
2. No No
On the diagram, diagram, shade in the areas where where you feel pain. Put an X on on the area that hurts hurts the most. most.
Right
Right
Left Left
Left Left
3)
Please rate your your pain by circling circling the one number number that best describes your pain at its WORST in the past 24 hours. hours. 0
1
2
3
4
5
6
7
8
No pain
4)
9
10 10
Pain as bad as you can imagine imagine
Please rate your your pain by circling circling the one number number that best describes your pain at its LEAST in the past 24 hours. hours. 0
1
No pain
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3
4
5
6
7
8
9
10 10
Pain as bad as you can imagine
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5)
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Please rate your pain by circling the the one number that best describes your pain on the the AVERAGE. VERAGE. 0
1
2
3
4
5
6
7
8
No pain
6)
10 10
Pain as bad as you can imagine imagine
Please rate your pain by circling the the one number that tells tells how much pain you have RIGHT NOW NOW.. 0
1
2
3
4
5
6
7
8
No pain
7)
9
9
10 10
Pain as bad as you can imagine imagine
What treatments treatments or medications medications are you receiving receiving for your your pain? pain?
8) In the past 24 hours, hours, how much relief relief have pain treatments treatments or medications provided? provided? Please circle the one percentage that most shows how much RELIEF you have received. received. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
No relief 9)
100% 100%
Complete relief
Circle the one number that describes how, how, during the past 24 hours, pain pain has interfered with your: your: A. General activity: activity: 0
1
2
3
4
5
6
7
8
9
Does not interfere
10 10 Completely interferes interferes
B. Mood: Mood: 0
1
2
3
4
5
6
7
8
9
Does not interfere
C.
10 10 Completely interferes interferes
Walking ability: ability:
0
1
Does not interfere
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3
4
5
6
7
8
9
10 10 Completely interferes
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D. Normal work work (includes both work outside outside the home home and housework): housework): 0
1
2
3
4
5
6
7
8
9
Does not interfere
E.
Completely interferes interferes
Relations with other people: people:
0
1
2
3
4
5
6
7
8
9
Does not interfere
F.
10 10
10 10 Completely interferes interferes
Sleep: Sleep:
0
1
2
3
4
5
6
7
8
9
Does not interfere
10 10 Completely interferes interferes
life: G. Enjoyment of life: 0
1
2
3
4
5
6
7
8
Does not interfere
10 10 Completely interferes interferes
!
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Lampiran 5.
Checklist of Nonverbal Pain Indicators (CNPI) (CNPI)
Instructions: Observe the patient for the following behaviors both at rest and during movement. movement.
Checklist of Nonverbal Pain Indicators (CNPI) (CNPI) Behavior
With With Movement Movement
At At Rest Rest
1. Vocal complaints: nonverbal nonverbal cries) (Sighs, gasps, moans, groans, cries) 2. Facial Grimaces/Winces Grimaces/Winces (Furrowed brow, narrowed eyes, clenched teeth, tightened lips, jaw drop, distorted expressions) expressions) Bracing 3. Bracing (Clutching or holding onto furniture, equipment, or affected area during movement) movement) Restlessness 4. Restlessness (Constant or intermittent shifting of position, rocking, intermittent or constant hand motions, motions, inability to keep still) still) Rubbing affected area) 5. Rubbing area) (Massaging verbal 6. Vocal complaints: verbal (Words expressing discomfort or pain [e.g., "ouch," "that hurts"]; cursing during movement; exclamations of protest [e.g., "stop," "that's enough"] ) ) Subtotall Scores Scores Subtota Total Score Score
S cor in g : Score a 0 if the behavior was not observed. Score a 1 if the behavior occurred even briefly during activity or at rest. The total number of indicators is summed for the behaviors observed at rest, with movement, and overall. There are no clear cutoff scores to indicate severity of pain; instead, the presence of any of the behaviors may be indicative of pain, warranting further investigation, treatment, and monitoring by the practitioner. practitioner.
S our ces : Nurs. 2000 Mar;1(1):13-21. Mar;1(1):13-21. Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Manag Nurs. Horgas AL. Assessing pain in persons with dementia. In: Boltz M, series ed. Try This: Best Practices in Nursing Care for Hospitalized Older Adults with Dementia. 2003 Fall;1(2). The Hartford Institute for Geriatric Nursing. www.hartfordign.org
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Lampiran 6.
Pain Assessment in Advanced Dementia Scale (PAINAD) (PAINAD)
Instructions: Observe the patient for five minutes before scoring his or her behaviors. Score the behaviors according to the following chart. Definitions of each item are provided on the following page. The patient can be observed under different conditions (e.g., at rest, during a pleasant activity, during caregiving, after the administration of pain medication). medication).
Behavior
0
1
Breathing Breathing Independent of vocalization Independent vocalization
Normal Normal
Occasional labored breathing breathing Short period of hyperventilation hyperventilation
Negative vocalization vocalization
None None
expression Facial expression
Smiling or inexpressive inexpressive
language Body language
Relaxed Relaxed
Occasional moan or groan groan Low-level speech with a negative or disapproving disapprovin g quality quality Sad Sad Frightened Frightened Frown Frown Tense Tense pacing Distressed pacing Fidgeting Fidgeting
Consolability Consolability
No need to console console
Distracted or reassured by voice or touch touch
2
Score Score
Noisy labored breathing breathing Long period of hyperventilation hyperventilation Cheyne-Stokes respirations respirations Repeated troubled calling out out Loud moaning or groaning groaning Crying Crying Facial grimacing grimacing
Rigid Rigid clenched Fists clenched up Knees pulled up Pulling or pushing away away Striking out out Unable to console, distract, or reassure reassure
TOTAL SCORE (Warden et al., 2003) 2003)
S cor ing : The total score ranges from 0-10 points. A possible interpretation of the scores is: 1-3=mild pain; 4-6=moderate pain; 7-10=severe pain. These ranges are based on a standard 0-10 scale of pain, but have not been substantiated in the literature for this tool. tool. S our ce: 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 2003;4(1):9-15. -15.
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PAINAD Item Definitions 2003) (Warden et al., 2003)
Breathing Breathing 1. Normal breathing is characterized by effortless, quiet, rhythmic (smooth) respirations. respirations. 2. Occasional labored breathing is characterized by episodic bursts of harsh, difficult, or wearing respirations. respirations. 3. Short period of hyperventilation is characterized by intervals of rapid, deep breaths lasting a short period of time. 4. Noisy labored breathing is characterized by negative-sounding respirations on inspiration or expiration. They may be loud, gurgling, wheezing. They appear strenuous or wearing. 5. Long period of hyperventilation is characterized by an excessive rate and depth of respirations lasting a considerable considerab le time. time. 6. Cheyne-Stokes respirations are characterized by rhythmic waxing and waning of breathing from very deep to shallow respirations with periods of apnea (cessation of breathing). Negative Vocalization Vocalization 1. None is characterized by speech or vocalization that has a neutral or pleasant quality. 2. Occasional moan or groan is characterized by mournful or murmuring sounds, wails, or laments. Groaning is characterized by louder than usual inarticulate involuntary sounds, often abruptly beginning and ending. 3. Low level speech with a negative or disapproving quality is characterized by muttering, mumbling, whining, grumbling, or swearing in a low volume with a complaining, sarcastic, or caustic tone. 4. Repeated troubled calling out is characterized by phrases or words being used over and over in a tone that suggests anxiety, uneasiness, or distress. distress. 5. Loud moaning or groaning is characterized by mournful or murmuring sounds, wails, or laments in much louder than usual volume. Loud groaning is characterized by louder than usual inarticulate involuntary sounds, often abruptly abruptly ending. beginning and ending. 6. Crying is characterized by an utterance of emotion accompanied by tears. There may be sobbing or quiet weeping. weeping. Facial Expression Expression 1. Smiling or inexpressive. inexpressive. Smiling is characterized by upturned corners of the mouth, brightening of the eyes, and a look of pleasure or contentment. Inexpressive refers to a neutral, at ease, relaxed, or blank look. 2. Sad is characterized by an unhappy, lonesome, sorrowful, or dejected look. There may be tears in the eyes. 3. Frightened is characterized by a look of fear, alarm, or heightened anxiety. Eyes appear wide open. open. 4. Frown is characterized by a downward turn of the corners of the mouth. Increased facial wrinkling in the forehead and around the mouth may appear. appear. 5. Facial grimacing is characterized by a distorted, distressed look. The brow is more wrinkled, as is the area around the mouth. Eyes may be squeezed shut. shut. Language Body Language easy. 1. Relaxed is characterized by a calm, restful, mellow appearance. The person seems to be taking it easy. 2. Tense is characterized by a strained, apprehensive, or worried appearance. The jaw may be clenched. (Exclude any contractures.) contractures.) 3. Distressed pacing is characterized by activity that seems unsettled. There may be a fearful, worried, or disturbed element present. The rate may be faster or slower. 4. Fidgeting is characterized by restless movement. Squirming about or wiggling in the chair may occur. The person might be hitching a chair across the room. Repetitive touching, tugging, or rubbing body parts can also be observed. 5. Rigid is characterized by stiffening of the body. The arms and/or legs are tight and inflexible. The trunk may appear straight and unyielding. (Exclude any contractures.) contractures.) 6. Fists clenched cl enched is characterized by tightly closed hands. They may be opened and closed repeatedly or held tightly shut. shut. 7. Knees pulled up is characterized by flexing the legs and drawing the knees up toward the chest. An overall troubled appearance. (Exclude any contractures.) contractures.) 8. Pulling or pushing away is characterized by resistiveness upon approach or to care. The person is trying to escape by yanking or wrenching him- or herself free or shoving you away. away. 9. Striking out is characterized by hitting, kicking, grabbing, punching, biting, or other form of personal assault. Consolability Consolability 1. No need to console is characterized by a sense of well-being. The person appears content. content. 2. Distracted or reassured by voice or touch is characterized by a disruption in the behavior when the person is spoken to or touched. The behavior stops during the period of interaction, with no indication that the person is at all distressed. distressed. 3. Unable to console, distract, or reassure is characterized by the inability to soothe the person or stop a behavior with words or actions. No amount of comforting, verbal or physical, will alleviate the behavior.
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Neonatal Infant Lampiran 7. NIPS ( Neonatal Infant Pain S cale cale)
Assessment nyeri Ekspresi wajah wajah 0- Otot relaks relaks Meringis 1- Meringis
netral Wajah tenang, ekspresi netral Otot wajah tegang , alis berkerut (ekspresi wajah negatif )
Tangisan is 0- Tidak menangis 1- Merengek keras 2- Menangis keras
Tenang, tidak menangis is Mengerang lemah intermiten encang, melengking terus menerus menerus Menangis k encang (catatan: m menangis enangis tanpa suara diber i skor bila bayi diintubasi) diintubasi)
Pola napas napas Relaks 0- Relaks nafas 1- Perubahan nafas
biasa Bernapas biasa Tarikan ir eguler eguler , lebih cepat dibanding biasa, menahan napas, tersedak
Tungk ai ai Relaks 0- Relaks 1- Fleksi/ ekstensi ekstensi
biasa Tidak ada kekakuan otot, gerakan tungkai biasa kaku Tegang kaku
Tingkat kesadaran kesadaran 0- Tidur/ bangun 1- Gelisah Gelisah
Tenang tidur lelap atau bangun gelisah Sadar atau gelisah
Interpr etasi: etasi: Skor 0 tidak perlu intervensi intervensi Skor 1-3 intervensi non-farmakologis Skor 4- 5 terapi analgetik non-opioid Skor 6-7
terapi opioid opioid
Lampiran 8. FLACC Behavioral FLACC Behavioral Tool (Face, Legs, Legs, Activity , Cry and C onsolabilit onsolabilit y)
Indik asi: asi: anak usia 8 !"#$#% &' &&
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Lampiran 15. Addiction Behavior Checklist Checklist
Addiction Behaviors Checklist (ABC) Designed to track behaviors characteristic of addiction related to prescription opioid medications in chronic pain patients. Items are focused on observable behaviors noted both during and between visits. ABC is focused on longitudinal assessment and tracking of problematic behaviors.
Addiction Behaviors Checklist I nstructions: Code only for patients prescribed opioid or sedative analgesics on behaviors exhibited ‘‘since
last
visit’’ and ‘‘within the current visit’’ (NA
=
not assessed)
Addiction behaviors — since since last visit 1. Patient used illicit drugs or evidences problem drinking*
Y
N N
NA NA
2. Patient has hoarded meds
Y
N N
NA NA
prescribed 3. Patient used more narcotic than prescribed
Y
N N
NA NA
4. Patient ran out of meds early
Y
N N
NA NA
5. Patient has increased use of narcotics
Y
N N
NA NA
6. Patient used analgesics PRN when prescription is for time contingent use Y
N N
NA NA
7. Patient received narcotics from more than one provide provider r
Y
N N
NA NA
streets 8. Patient bought meds on the streets
Y
N N
NA NA
1. Patient appears sedated or confused (e.g., slurred speech, speech, unresponsive unresponsive)) Y
N N
NA NA
2. Patient expresses worries about addiction
Y
N N
NA NA
3. Patient expressed a strong preference for a specific type of analgesic or a specific route of administration
Y
N N
NA NA
4. Patient expresses concern about future availability of narcotic
Y
N N
NA NA
5. Patient reports worsened relationships with family family
Y
N N
NA NA
6. Patient misrepresented analgesic prescription or use
Y
N N
NA NA
7. Patient indicated she or he ‘‘needs’’ ‘‘needs’’ or ‘‘must ‘‘must have’’ have’’ analgesic meds
Y
N N
NA NA
predominant ant issue of visit visit 8. Discussion of analgesic meds was the predomin
Y
N N
NA NA
-management 9. Patient exhibited lack of interest in rehab or self -management
Y
N N
NA NA
10. Patie Patient nt reports minimal/inadequate relief from narcotic analgesic analgesic
Y
N N
NA NA
agreement 11. Patient indicated difficulty with difficulty with using medication agreement
Y
N N
NA NA
Y
N
NA NA
Addiction behaviors — within within current visit
Other
1. Significant others express expres s concern over patient’s use of analgesics *
Item 1 original phrasing: (‘‘ Patient used ETOH or illicit drugs’’), drugs’’), had had a low correlation with global clinical judgment. This is possibly is possibly associated with difficulty difficulty in content interpretation, in that if a patient endorsed highly infrequent alcohol use, he or she would receive a positive rating on prescription tion opioid medications medications inappropriately. Therefore, we include in this version of the AB C this item, but not be considered as using the prescrip specifies problem drinking as the criterion for alcohol use. a suggested wording change for this item that specifies
AB C Score: Score of r 3 indicates possible inappropriate opioid use and should flag flag for for further examination of specific signs of misuse and more careful patient monitoring screening, pill pill counts, removal of opioid). monitoring (i.e., urine screening,
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Lampiran 16.Patient Comfort Assessment Guide Guide
Patient Comfort Assessment Guide Date: Name: –––––––––– ––––– ––––––––––– –––––– ––––– ––––––––––– –––––––––––– ––––––––––– ––––––––––– –––––– –––––– ––––––– – ––––––––––––– ––––––––– –––– 1. Where is your pain? 2. Circle the words that describe your pain.
Circle
aching
sharp sharp
throbbing
tender
shooting
burning
numb
stabbing stabbing
exhausting
miserable
gnawing
tiring tiring
unbearable unbearable
ne
penetrating
nagging nagging
continuous
occasional
What time of day is your pain the worst? Circle one. 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 Relief Treatment or Medicine (include dose) 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) Relie Relief d) –––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––– ––––––––– No 0 1 2 3 4 5 6 7 8 9 10 Complete Treatment or Medicine (include dose) Relief Relief
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10. What side effects or symptoms are you having? Circle the number that best describes your experience during the past week. week.
a. Nausea a. Nausea
Barely Noticeable
0 1 2 3 4 5 6 7 8 9 10
Severe Enough to Stop Medicine
b. Vomiting
Barely Noticeable
0 1 2 3 4 5 6 7 8 9 10
Severe Enough to Stop Medicine
c. Constipation
Barely Noticeable
0 1 2 3 4 5 6 7 8 9 10
Severe Enough to Stop Medicine
d. Lack of Appetite
Barely Noticeable
0 1 2 3 4 5 6 7 8 9 10
Severe Enough to Stop Medicine
e. Tired
Barely Noticeable
0 1 2 3 4 5 6 7 8 9 10
Severe Enough to Stop Medicine
Barely Noticeable
0 1 2 3 4 5 6 7 8 9 10
Severe Enough to Stop Medicine
g. Nightmares
Barely Noticeable
0 1 2 3 4 5 6 7 8 9 10
Severe Enough to Stop Medicine
h. Sweating
Barely Noticeable
0 1 2 3 4 5 6 7 8 9 10
Severe Enough to Stop Medicine
i. Difficulty Thinking Barely Noticeable
0 1 2 3 4 5 6 7 8 9 10
Severe Enough to Stop Medicine
j. Insomnia
0 1 2 3 4 5 6 7 8 9 10
Severe Enough to Stop Medicine
f. Itching
Barely Noticeable
11. Circle the one number that describes how during the past week pain has interfered with your:
a. General Activity Activity
Does Not Interfere
0 1 2 3 4 5 6 7 8 9 10
Completely Interferes
Does Not Interfere
0 1 2 3 4 5 6 7 8 9 10
Completely Interferes
c. Normal Work
Does Not Interfere
0 1 2 3 4 5 6 7 8 9 10
Completely Interferes
Sleep d. Sleep
Does Not
0 1 2 3 4 5 6 7 8 9 10
Completely
b. Mood
Interfere
e. Enjoyment of Life Life Does Not Interfere
f.
g. Relations with Other People People
Interferes 0 1 2 3 4 5 6 7 8 9 10
Completely Interferes
Does Not
0 1 2 3 4 5 6 7 8 9 10
Completely Interferes
Does Not Interfere
0 1 2 3 4 5 6 7 8 9 10
Completely Interferes
Prepared Prepared by by Elizabeth J. Narcessian, Narcessian, MD, Clinical Chief of Pain Management, Kessler Institute for Rehabilitation, Inc.
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