The Challenge Of Assessing Pain

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In a recent survey of 3,000 nurses and another survey of 400 nurse practitioners, pain assessment was cited as a major source of concern and knowledge deficit (D'Arcy, 2008; 2009). Many of the nurses who responded to the survey felt that they were not getting a pain assessment that was accurate. In the nurse practitioner survey, the respondents indicated that they felt that their nurse practitioner education had not prepared them to assess or treat pain in patients with chronic pain. There were repeated requests in the comment sections of the surveys about learning to perform an accurate pain assessment and how to assess pain in patients with chronic pain and/ or a history of substance abuse. Despite the years of education on pain assessment that has been provided to nurses and other health care professionals, pain assessment still remains difficult. Pain assessment is problematic because of the following:

■ It relies on patient self-report.

■ Health care providers have difficulty trusting the patient's report of pain.

■ The assessment process uses an objective scale to convey a subjective experience.

■ The health care provider comes to the patient interaction with bias as a result of family and personal values and beliefs about pain (D'Arcy, 2007).

Pain assessment is the core component to developing and implementing care and providing adequate pain management for patients. Choosing a medication to treat pain is driven by the assessment process. Additionally, adjustments to the patient's plan of care are based on the patient's response to the intervention as determined by pain assessment and reassessment (Ackley, Ladwig, Swan, & Tucker, 2008; Berry, Covington, Dahl, Katz, & Miaskowski, 2006). If pain is not assessed well, it can result in undertreatment or nontreatment that can have significant effect on the patient.

— For acute pain, untreated or undertreated pain can limit mobility and result in a serious complication, such as pneumonia or deep vein thrombosis. It can also delay discharge or impair recovery and it may, in some cases, result in a difficult-to-treat chronic pain condition, such as complex regional pain syndrome (American Pain Society [APS], 2008; D'Arcy, 2007). —Forchronicpain, untreated or undertreated pain can limit functionality, increase the potential for disability, cause suffering, and decrease the patient's quality of life by causing anxiety, fear, depression, and uncertainty (Berry et al., 2006).

For chronic pain patients, pain assessment is more difficult because of the multifaceted nature of the pain. The patient comes to the experience not only with high pain intensity but also with depression, changes in relationships, potential impact on lifestyle related to the inability to work, and emotional needs. Conveying those varied elements of the pain experience in a single number is not reasonable. Therefore, multidimensional pain assessment scales are needed to assess all aspects of the pain experience. For chronic pain patients, functionality may be a better indicator of pain relief than a change in numeric-intensity pain ratings (Ackley et al., 2008; D'Arcy, 2007; Jensen, 2011).

Some patients do not understand the term "functionality." The term "impact on daily activity" might be better understood. Questions that can give good insight into the ability of the patient to perform the needed tasks of daily living include the following:

■ How far can you walk independently, with assistance?

■ Who does the cooking/washing/cleaning at your house?

■ How many stairs can you climb before you need to stop?

■ Do you go to the movies/church/visit family?

■ Can you go grocery shopping?

If possible, it is always good to observe the patients while they are moving from one position to another. For example, if sitting patients are called into the health care provider's office, do they need several attempts to get into a standing position, do they use the arms of the chair to push themselves up, or do they need assistive devices to move? Does a patient limp or favor one extremity over another? All of these examples can indicate that pain is significantly limiting the patient's ability to move or function freely.

Clinical When assessing a patient with chronic pain, always ask what the Pearl patient's worst daily pain level is and best daily pain level is. Set a pain goal that reflects a pain level that is achievable in comparison to the best and worst pain ratings provided by the patient.

Many of the original pain assessment tools were designed for research and were one dimensional, only measuring the intensity of the pain. Because of the complexity of chronic pain, multidimensional pain assessment tools are needed to assess pain. These more comprehensive tools not only include a pain intensity rating but also include questions about how effective pain medications are, the patient's mood, quality of the pain, and impact on activity (functionality). For patients who cannot self-report, such as intubated critically ill patients or demented or cognitively impaired elderly, behavioral scales have been developed to help assess pain. The following sections of the chapter will discuss specific pain assessment tools and techniques.

Assessment

Assessing pain is a subjective process; it is more an art than a science. For verbal patients, the self-report is the standard for assessing pain. To perform a standard pain assessment, the nurse asks the patient to rate pain intensity using a simple one-dimensional scale, such as the

Numeric Rating Scale (NRS). The NRS is an 11-point Likert-type scale with 11 numbers ranked from 0 (no pain) through 10 (worst possible pain) to indicate pain severity. The higher the number selected by the patient, the more severe the pain. This type of assessment is most useful for assessing pain intensity and medication efficacy.

Thie other basic elements of a pain assessment for verbal patients include the following:

Location—Have the patient point to the area on the body that is painful. For multiple painful areas, have the patient locate each one individually. If one area is more painful than the next, make sure the most painful area is clearly identified. If there is a radiation of pain, for example, down a leg or arm, make sure the area is clearly defined so that the correct treatment options can be determined. A body diagram can be helpful when the patient is trying to locate the pain. Using colors for pain in different parts of the body can also help determine any differences in pain intensity. Red can indicate a more severe level of pain, whereas blue can indicate pain that is less intense. Patients like to use different ways to communicate the exact location of their pain and intensity of pain they are experiencing. Duration—Ask the patient, "When did you first feel this pain?" and "How long does the pain last?" Explore any potential sources or causes of the pain. Ask if the pain intensity varies during different times of the day and how long the periods of higher intensity pain last. Intensity—Use the NRS to have the patient rate the intensity of the pain. If the patient has any times of the day or night when the pain intensity is more or less severe, ask if the prescribed medication reduces the intensity of the pain. If the patient is taking pain medication, determine how effective the patient feels it is in decreasing the pain intensity. Another option for determining pain intensity if the patient cannot use the NRS is the use of terms mild, moderate, or severe to see if a range for pain intensity can be determined. Quality/Description—Have the patient describe the quality of the pain. This may be one of the most important items in the assessment process. If the patient uses words like burning, tingling, or painful numbness, it may indicate a neuropathic source for the pain. It is important to allow patients to describe the pain in their own words so it is most accurately represented.

Alleviating/Aggravating Factors—All patients have some form of home remedy for pain, and they most often will attempt to treat their pain before they seek health care. If the patient has tried some form of pain relief, ask if it helped or if it made the pain better or worse. Ask the patient if activity made the pain worse or if rest improved the pain. Ask the patient if there is any position better than another for relieving the pain. Pain Management Goal—For most patients with chronic pain, the concept of being pain free is not a valid goal. Because of injury or continued pain from physiologic causes, the potential of removing all of the pain is very low. Work with the patient to set a goal that is reasonable and achievable. Most patients with chronic pain have a pain intensity rating that will allow them to function at their highest level. Ask the patient what pain intensity they think is acceptable and then tailor pain interventions to achieve the patient's expectations. Consistent pain reassessment will track progress toward the goal that has been set. Function Goal—Pain is dynamic and increases with activity (Dahl & Kehlet, 2006). Ask the patient how the pain interferes with his or her activities of daily living. Assess the patient for sleep disturbances that can affect the patient's ability to function. By setting a functionality goal, progress can be tracked at each subsequent visit. (D'Arcy, 2007; 2010)

Including the patient with chronic pain in the assessment process gives the patient a feeling of validation and encourages them to work toward the pain and functional goal. Providing maximum pain relief and functionality is the goal of any pain relief treatment for a chronic pain patient (Ackley et al., 2008; American Society for Pain Management Nursing [ASPMN], 2010; D'Arcy, 2007; The Joint Commission, 2000).

The previous elements work well for patients who are able to self-report their pain. Using the hierarchy of pain assessment can help delineate the assessment process for patients who are not able to report pain.

Hierarchy of Pain Assessment

■ Attempt a self-report of pain. The patient's self-report is the best way to assess for pain.

■ Search for potential causes of the pain.

■ Observe patient behaviors.

■ Use surrogate reporting.

■ Attempt an analgesic trial (Herr, Coyne, Key, Manworren, McCaf-fery, Merkel, et al., 2006)

In addition to the hierarchy of pain assessment, using the following basic elements in practice can help standardize the assessment process for these patients:

■ Use the hierarchy of pain assessment techniques.

■ Establish a procedure for pain assessment.

■ Use behavioral pain assessment tools when appropriate.

■ Minimize emphasis on physiologic indicators.

■ Reassess and document (Herr et al., 2006; Herr, Bjoro, & Decker, 2006).

The most critical aspect of the pain assessment process for the nurse and other members of the health care team is to believe the patient's report of pain. Patients are doing the very best they can to provide you with an accurate picture of the complex pain they are experiencing. It is extremely important for the nurse to respect the patient's report of pain as presented and then, in good faith, act to help relieve the pain. If the health care provider doubts or diminishes the patient's report of pain, trust will be lost and the patient will not be open to believing that the health care provider is interested in treating and managing the pain. This lack of trust can sabotage even the best plan of care.

Most patients with chronic pain are relief seeking, not drug seeking. Approach the assessment process with a nonjudgmental attitude and a willingness to believe and invest time in helping the patient with his or her pain. The use of in-depth questions to collect all of the salient information during the assessment process will help to determine the kind of interventions that will be most helpful in providing the best possible pain relief for the patient. Using a reliable and valid pain assessment tool will provide objective criteria for pain assessment and provide a means of tracking progress toward patient goals.

Clinical Pearl

Failure to believe the patient's report of pain will ensure that the assessment process will be faulty and it will not produce positive outcomes.

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