Completely Interferes

Copyright 1991 Charles S. Cleeland, PhD Pain Research Group All rights resei^ed

Page 2 of 2

Copyright 1991 Charles S. Cleeland, PhD Pain Research Group All rights resei^ed

Source: Used with permission of the author.

Limitations of the BPI include:

■ The patients must be able to answer questions related to their individual chronic pain conditions.

Strengths of the BPI includes:

■ It has a high level of reliability and validity.

Behavioral Pain Scales

As of 2001, The Joint Commission applied pain standards to inpatient care that have been applied to outpatient practice as well. One of the biggest focus areas in The Joint Commission standards was pain assessment for all patients, including individuals who could not self-report their pain. To facilitate the process, a group of pain assessment tools has been developed to assess pain in nonverbal patients.

Thie use of behavioral scales for pain assessment is one of the newest areas of focus for pain assessment, and, as such, the tools that are used are not as refined or completely developed as those that have been used for many years. The current tools are not ideal, but they are the best we have to use at this time. Some of the tools are designed to be used for specific populations, such as demented patients or critically ill, intubated patients. Although this may not seem like it applies to most patients with chronic pain, they do sometimes enter intensive care units through accident or illness, where they may need intubation and may not be able to communicate the extent of their pain.

In order to use a behavioral scale, it is important to identify those behaviors that indicate pain. The original research in this area was to develop a list of behaviors that were indicative of pain, the Checklist of Nonverbal Pain Indicators (CNPI). From the studies comparing pain in cognitively intact patients and similar pain experiences in patients who were cognitively impaired, a list of six behaviors was developed that were determined to indicate the presence of pain (Feldt, 2000; Feldt, Ryden, & Miles, 1998). The six behaviors were identified as the following:

■ Vocalizations

■ Facial grimacing

■ Restlessness

■ Vocal complaints (Feldt, 2000)

Additional behaviors that were determined to be indicative of pain were listed in the American Geriatrics Society's (AGS) guideline for treating persistent pain in older persons. These behaviors include the following:

■ Verbalizations: moaning, calling out, asking for help, groaning

■ Facial expressions: grimacing, frowning, wrinkled forehead, distorted expressions

■ Body movements: rigid tense body posture, guarding, rocking, fidgeting, pacing, massaging the painful area

■ Changes in interpersonal interactions: aggression, combative behavior, resisting care, disruptive, withdrawn

■ Changes in activity patterns or routines: refusing food, appetite changes, increase in rest or sleep, increased wandering

■ Mental status changes: crying, tears, increased confusion, irritability, or distress (AGS, 2002)

When attempting to assess pain in a nonverbal patients, the important elements are the following:

■ Search for the potential causes of pain.

■ Observe patient behaviors.

■ Use surrogate reporting by family or caregivers indicating pain and/or behavior/activity changes.

■ Attempt an analgesic trial (Herr et al., 2006a).

Tools have been developed using behaviors to identify pain, and these assessments have been formatted in several different styles for use in varying patient populations.

Pain Assessment in Advanced Dementia (PAINAD)

Individuals with dementia are some of the most difficult patient to assess for pain. Many are nonverbal. The PAINAD is a pain assessment tool created to assess pain in patients with advanced dementia and Alzheimer's disease.

Thie PAINAD uses five behaviors common to patients with dementia who have pain:

■ Negative vocalizations

■ Facial expression

■ Body language

■ Consolability

Thie five behaviors are rated as follows:

■ 0: Normal, no symptoms or pain behaviors

■ 1: Occasional, slightly affected (e.g., occasional pacing, occasional moans)

■ 2: Positive behaviors (e.g., hyperventilation, body rigidity, repeated moaning, or striking out)

After determination of the extent of the behaviors, they are rated and a score is derived, providing a numeric rating for the pain. Using this tool can provide a more consistent approach to assessing pain in these patients. The tool has been found to be simple and easy to use in the clinical setting. It has also resulted in increased detection of pain.

Limitations include the following:

■ Caregiver assesses for pain.

■ Less comprehensive than needed for assessing pain.

Thiere are other tools that can be used in this patient population to assess pain, but the PAINAD has been used more widely.

Payen Behavioral Pain Scale (BPS)

Critically ill, intubated patients cannot self-report pain. Many of the procedures that are performed on these patients are painful. In a large multisite study, Thunder II, pain ratings for a number of patient procedures were determined. Even so, simple tasks, such as turning a patient in bed, can result in moderate-intensity pain. When these patients have baseline chronic pain, the new pain the patient experiences is more significant and will result in higher-intensity pain.

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