Pain Assessment In The Patient Unable To Self-Report .

2y ago
33 Views
3 Downloads
291.97 KB
21 Pages
Last View : 16d ago
Last Download : 2m ago
Upload by : Helen France
Transcription

PositionStatementPain Assessment in thePatient Unable toSelf-Report: PositionStatement withClinical PracticeRecommendationsKeela Herr, PhD, RN, AGSF, FAAN,*Patrick J. Coyne, MSN, RN, APRN, FAAN,†Margo McCaffery, MS, RN, FAAN,‡Renee Manworren, PhD, RN, CB, APRN, PCNS-BC,§and Sandra Merkel, MS, RN-BC{---From the *University of Iowa Collegeof Nursing, Iowa City, Iowa; †VirginiaCommonwealth University,Richmond, Virginia; ‡IndependentConsultant in the Nursing Care ofPatients with Pain, Los Angeles,California; § Connecticut Children’sMedical Center and University ofConnecticut School of Medicine,Hartford, Connecticut; {C. S. MottChildren’s Hospital, University ofMichigan Health System, Ann Arbor,Michigan.Address correspondence to Dr. KeelaA. Herr, John A. Hartford Center ofGeriatric Nursing Excellence, Collegeof Nursing, University of Iowa, 306CNB, 50 Newton Road, Iowa, IA52242. E-mail: keela-herr@uiowa.eduReceived August 20, 2011;Accepted August 22, 2011.The purpose of this document is toprovide guidance for clinicians caring for populations in which painassessment is difficult. Recommendations provided are based on thebest evidence available at the time ofpreparation.1524-9042/ 36.00Ó 2011 by the American Society forPain Management Nursingdoi:10.1016/j.pmn.2011.10.002POSITION STATEMENTPain is a subjective experience, and no objective tests exist to measure it(American Pain Society, 2009). Whenever possible, the existence and intensityof pain are measured by the patient’s self-report, abiding by the clinical definitionof pain which states, ‘‘Pain is whatever the experiencing person says it is, existingwhenever he/she says it does’’ (McCaffery, 1968). Unfortunately, some patientscannot provide a self-report of pain verbally, in writing, or by other means,such as finger span (Merkel, 2002) or blinking their eyes to answer yes or noquestions (Pasero & McCaffery, 2011).This position statement addresses five populations of patients who may beunable to self-report: older adults with advanced dementia, infants and preverbaltoddlers, critically ill/unconscious patients, persons with intellectual disabilities,and patients at the end of life. Each of these populations may be unable to selfreport pain owing to cognitive, developmental, or physiologic issues, includingmedically induced conditions, creating a major barrier for adequate pain assessment and achieving optimal pain control. Inability to provide a reliable reportabout pain leaves the patient vulnerable to under recognition and under- or overtreatment. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.ETHICAL TENETSThe ethical principles of beneficence (the duty to benefit another) and nonmaleficence (the duty to do no harm) oblige health care professionals to providepain management and comfort to all patients, including those vulnerable individuals who are unable to speak for themselves. Providing quality and comparable care to individuals who cannot report their pain is directed by the principleof justice (the equal or comparative treatment of individuals). Respect forPain Management Nursing, Vol 12, No 4 (December), 2011: pp 230-250

Position Statement: Pain Assessment Without Self-Reporthuman dignity, the first principle in the ‘‘Code ofEthics for Nurses’’ (American Nurses Association,2001), directs nurses to provide and advocate for humane and appropriate care. Based on the principleof justice, this care is given with compassion and unrestricted by consideration of personal attributes, economic status, or the nature of the health problem. Inalignment with these ethical tenets, the InternationalAssociation for the Study of Pain (IASP) initiated theDeclaration of Montreal at the International Pain Summit, a statement acknowledging access to pain management as a fundamental human right endorsed by64 IASP Chapters and many other organizations and individuals (International Association for the Study ofPain, 2011).The American Society for Pain Management Nursing positions that all persons with pain deserve promptrecognition and treatment. Pain should be routinely assessed, reassessed, and documented to facilitate treatment and communication among health careclinicians (Gordon, Dahl, Miaskowski, McCarberg,Todd, Paice, et al., 2005). In patients who are unableto self-report pain, other strategies must be used to infer pain and evaluate interventions. No single objectiveassessment strategy, such as interpretation of behaviors, pathology or estimates of pain by others, is sufficient by itself.GENERAL RECOMMENTATIONS FORCLINICAL PRACTICEA Hierarchy of Pain Assessment Techniques (Pasero &McCaffery, 2011; Hadjistavropoulos, Herr, Turk, Fine,Dworkin, Helme, et al., 2007) has been recommendedas a framework to guide assessment approaches and isrelevant for patients unable to self-report. Table 1 provides a summary of the key tenets as they relate to specific subpopulations. General recommendations forassessing pain in those unable to self-report follow.Use the Hierarchy of Pain AssessmentTechniquesSelf-Report. Attempts should be made to obtain selfreport of pain from all patients. A self-report of painfrom a patient with limited verbal and cognitive skillsmay be a simple yes/no or other vocalizations orgestures, such as hand grasp or eye blink. When selfreport is absent or limited, explain why self-report cannot be used and further investigation and observationare needed.Search for Potential Causes of Pain. Pathologicconditions (e.g., surgery, trauma, osteoarthritis,wounds, history of persistent pain) and common procedures known to cause iatrogenic pain (e.g., wound231care, rehabilitation activities, positioning/turning,blood draws, heel sticks), should trigger an intervention, even in the absence of behavioral indicators. Iatrogenic pain associated with procedures should betreated before initiation of the procedure. A changein behavior requires careful evaluation of pain or othersources of distress, including physiologic compromise(e.g., respiratory distress, cardiac failure, hypotension). Generally, one may assume that pain is present,and if there is reason to suspect pain, an analgesic trialcan be diagnostic as well as therapeutic (American PainSociety, 2008). Other problems that may be causingdiscomfort should be ruled out (e.g., infection, constipation) or treated.Observe Patient Behaviors. In the absence of selfreport, observation of behavior is a valid approach topain assessment. Common behaviors that may indicatepain, as well as evidence-based valid and reliable behavioral pain tools for the selected populations, havebeen identified for each subpopulation. Althoughweak to moderate correlations have been found between behavioral pain scores and the self-report ofpain intensity, these two means of pain assessmentmeasure different components of pain (sensory and behavioral) and should be considered to provide complementary information about the pain experience.Therefore, a behavioral pain score should not be considered to be equivalent to a self-report of pain intensity (e.g., a behavioral pain score of 4/10 does notequal a self-report of pain intensity of 4/10).Moreover, pain behaviors are not specific reflections of pain intensity, and in some cases indicate another source of distress, such as physiologic oremotional distress (Pasero & McCaffery, 2005). It is difficult to discriminate pain intensity from pain unpleasantness and emotions such as fear. Potential causes andthe context of the behavior must be considered whenmaking treatment decisions. Remember that sleep andsedation do not equate with the absence of pain orwith pain relief. Awareness of individual baseline behaviors and changes that occur during proceduresknown to be painful or other potential sources ofpain are useful in differentiating pain from othercauses.Proxy Reporting (family members, parents,unlicensed caregivers, professional caregivers)of Pain and Behavior/Activity Changes. Credibleinformation can be obtained from a family memberor another person who knows the patient well (e.g.,spouse, parent, child, caregiver). Parents and consistent caregivers should be encouraged to actively participate in the assessment of pain. Familiarity with thepatient and knowledge of usual and past behaviorscan assist in identifying subtle less obvious changes

232TABLE 1.Hierarchy of Pain Assessment Techniques (Pasero & McCaffery, 2011) and Specific Considerations by SubpopulationCritically Ill/Unconscious1. Obtainself-reportInfants, toddlers, &developmentallypreverbal children lackcognitive skillsnecessary to report &describe pain.2. Search forpotential causesof painInfections, injuries,diagnostic tests,surgical procedures, &disease progressionpossible causes.3. Observe patientbehaviorPrimary behavioralcategories used to helpidentify pain in infantsinclude facialexpression, bodyactivity/motormovement, & crying/verbalization.As cognitive abilitiesincrease, toddlers &children demonstratefewer overt painbehaviors. Evaluateresponse to painfulstimuli and use ofeffective consolingtechniquesSelf-report should beattempted; however,may be hampered bydelirium, cognitive &communicationlimitations, level ofconsciousness,presence ofendotracheal tube,sedatives, &neuromuscularblocking agents.Sources of pain includeexisting medicalcondition, traumaticinjuries, surgical/medical procedures,invasiveinstrumentation,drawing blood, & otherroutine care:suctioning, turning,positioning, drain &catheter removal, &wound care.Facial tension &expressions, such asgrimacing, frowning, &wincing, often seen incritically ill patientsexperiencing pain.DementiaIntellectualDisability (ID)End of LifeSelf-report of pain oftenpossible in mild tomoderate cognitiveimpairment, but abilityto self-reportdecreases as dementiaprogresses.Majority of individualswith ID are verbal & canself-report pain usingappropriate self-reportpain assessment tool.Cognitive abilities oftenfail as diseaseprogresses. Painassessment mustinclude assuming thatpain is present if painwas previouslya complaint.Consider commonchronic pain etiologies.Musculoskeletal, &neurologic disordersmost common causesof pain in older adults.Prevalence & burden ofpain higher than inhealthy children, &prevalence of pain inadults with ID higherthan in adultswithout ID.Causes of pain in thispopulation typicallyvery complex;numerous sites &etiologies of pain notuncommon.Observe facialexpressions,verbalizations/vocalizations, bodymovements, changesin interactions,changes in activitypatterns or routines, &mental status.Behavioral observationshould occur duringactivity wheneverpossibleBehavioral pain toolsshould be used forinitial & ongoingassessments.Use indicators shown tobe relevant to specificpatient. Intensiveassessment required.Herr et al.Infants/PreverbalToddlersHierarchy

Assuring adequateanalgesia whilemonitoring forpresence of painrequires diligence andconsideration ofpathology, conditionsknown to be painrelated, and estimatesof pain by others.Estimate the intensity ofpain based oninformation obtainedfrom prior assessmentsteps & selectappropriate analgesic.Opioid dosing in olderadults warrants initialdose reduction to25%-50% of adultdose.Base initial opioid doseon weight and titrate asappropriate.5. Attempt ananalgesic trialInitiate analgesic trial ifpain is suspected toverify presence of pain.Parents usually knowtheir child’s typicalbehavioral response topain and can identifybehaviors unique to thechild to include in theassessment of pain.4. Proxy reportingParents, caregivers, &family members canhelp identify specificpain indicators forcritically ill/unconsciousindividuals.In long-term care setting,the certified nursingassistant is a key healthcare provider shown tobe effective inrecognizing presenceof pain.Family helpful if visitregularly.Parents & caregivers mayknow individual’stypical behavioralresponse to pain & canidentify unique painbehaviors. However,caregivers of childrenwith ID frequentlyunderestimate painintensity.Initiate analgesic trial ifpain is suspected.Family and/or caregiversplay an essential role inrecognizing pain andevaluating comfort asthe person transitionstoward death.Position Statement: Pain Assessment Without Self-Report233in behavior that may be indicators of pain presence.Discrepancies exist between self-report of pain and external observer judgments of pain intensity that occuracross varied raters (e.g., physician, nurse, family,aides) and settings (e.g., inpatient, outpatient, acutecare, long-term care), with family members overestimating and providers underestimating the intensityof pain experienced (Kappesser, Williams, &Prkachin, 2006). Therefore, judgments by caregiversand clinicians are considered to be proxy assessmentsof pain intensity and should be combined with otherevidence when possible. A multifaceted approach isrecommended that combines direct observation, family/caregiver input, consideration of known painproducing conditions, and evaluation of response totreatment.Attempt an Analgesic Trial. An empiric analgesictrial should be initiated if there are pathologic conditions or procedures likely to cause pain or if pain behaviors continue after attention to basic needs andcomfort measures. Provide an analgesic trial and titration appropriate to the estimated intensity of painbased on the patient’s pathology and analgesic history.In general, if mild to moderate pain is suspected, nonpharmacologic approaches and nonopioid analgesicsmay be given initially (e.g., adult dose: 500 to 1,000mg acetaminophen every 6 hours for 24 hours). If behaviors improve, assume pain was the cause, continuethe analgesic, and add appropriate nonpharmacologicinterventions. Consider giving a single low-dose shortacting opioid (e.g., hydrocodone, oxycodone, morphine) and observe the effect if behaviors that suggestpain continue. If there is no change in behavior, ruleout other potential sources of pain or discomfort.Doses may then be carefully adjusted until a therapeutic effect is seen, bothersome or worrisome side effects occur, or lack of benefit is determined. In thecase of neuropathic pain, it is not uncommon for analgesic trials to fail and therefore health care providersto assume there is no pain. It is important to considermedications to treat neuropathic pain if there is a history of conditions that might suggest a neuropathicetiology. It may be appropriate to start the analgesictrial with an opioid for conditions in which moderateto severe pain is expected. Reassess for other potentialcauses if behaviors continue after a reasonable analgesic trial.The analgesic titration recommendation above isconservative and, although strategies for safe titrationshould be followed, more aggressive approaches maybe needed (Gordon, Dahl, Phillips, Franderson,Crowley, Foster, et al., 2004). Titration doses shouldconsider the patient’s underlying comorbidities, because certain populations (e.g., obstructive sleep

234Herr et al.apena, neurologic impairment, older adults) are at riskfor opioid adverse effects (Brown, Laferriere, & Moss,2004; Overdyk, Carter, Maddox, Callura, Herrin, &Henriquez,2007;Voepel-Lewis,Marinkovic,Kostrzewa, Tait, & Malviya, 2008). No researchconfirms that weight (except in children) should beused to determine starting dose (Burns, Hodsman,McLintock, Gillies, Kenny, & McArdle, 1989;Macintyre & Jarvis, 1996).Establish a Procedure for Pain AssessmentA procedure for evaluating pain presence and response to treatment should be instituted in eachhealth care setting. The hierarchy of assessment techniques discussed above is recommended, and the following can be used as a template for the initialassessment and treatment procedure (Pasero &McCaffery, 2011).a. Attempt first to elicit a self-report from patient and, ifunable, document why self-report cannot be used.b. Identify pathologic conditions or procedures that maycause pain.c. List patient behaviors that may indicate pain. A behavioral assessment tool may be used.d. Identify behaviors that caregivers and others knowledgeable about the patient think may indicate pain.e. Attempt an analgesic trial.Use Behavioral Pain Assessment Tools asAppropriateUse of a behavioral pain assessment tool may assist inrecognition of pain in these vulnerable populations.It is incumbent on health care providers to considerthe strength of psychometric evaluation data (e.g., reliability and validity of the tool in a specific patient population and a given context) and the clinical feasibilityof instruments (e.g., training required, time to complete). Clinicians should select a tool that has beenevaluated in the population and setting of interest.Tools with repeated supporting research by multipleauthors are considered to be stronger. Use of a reliableand valid tool helps to ensure that clinicians are usingappropriate criteria in their pain assessments. Standardized tools promote consistency among care providers and care settings and facilitate communicationand evaluation of pain management treatment decisions. However, the appropriateness of a tool mustbe assessed patient by patient, and no one tool shouldbe an institutional mandate for all patients (Pasero &McCaffery, 2005). For example, a behavior pain tooldeveloped for persons with dementia may not be appropriate for patients in the intensive care unit whoare unable to communicate, and tools for childrenare not generalizable to adults.For some behavioral tools that are scored, the intensity of the pain may be assumed to be reflected inthe sum of the score. However, a behavioral pain scoreis not the same as a self-reported pain intensity rating,nor can the scores be compared with standard pain intensity ratings or categories of pain intensity. Behavioral assessment tools can be helpful to identify thepresence of pain and to evaluate treatment effects(Pasero & McCaffery, 2011). When selecting a behavioral pain assessment tool, if the score and determination of pain depend on a response in each category ofbehavior, it is important that the patient is able to respond in all categories. For example, a tool that includes bracing/rubbing or restlessness would not beappropriate for a patient who is intentionally sedated.Keys to the use of behavioral pain tools are to focuson the individual’s behavioral presentation (atboth rest and on movement or during proceduresknown to be painful) and to observe for changes inthose behaviors with effective treatment. Increasesor decreases in the number or intensity of behaviorssuggest increasing or decreasing pain.Minimize Emphasis on Physiologic IndicatorsPhysiologic indicators (e.g., changes in heart rate, bloodpressure, respiratory rate), though important for assessing for potential side effects, are not sensitive for discriminating pain from other sources of distress.Although physiologic indicators are often used to document pain presence, the correlation of vital signchanges with behaviors and self-reports of pain hasbeen weak or absent (Aissaoui, Zeggwagh, Zekraoui,Abidi, & Abouqal, 2005; Arbour & Gelinas, 2010;Foster, Yucha, Zuk, & Vojir, 2003; Gelinas & Johnston,2007; Gelinas & Arbour, 2009; Walco, Conte, Labay,Engel, & Zeltzer, 2005). Absence of a change in vitalsigns does not indicate absence of pain.Reassess and DocumentAfter intervention and regularly over time, the patientshould be reassessed with methods of pain assessment and specific behavioral indicators that havebeen identified as significant and appropriate for theindividual patient. Assessment approaches and painindicators should be documented in a readily visibleand consistent manner that is accessible to all healthcare providers involved in the assessment and management of pain (Gordon et al., 2005; Miaskowski,Cleary, Burney, Coyne, Finley, et al., 2005). Inthe case of temporary inability to self-report, patientcapacity to self-report should be reevaluatedperiodically.

Position Statement: Pain Assessment Without Self-ReportPERSONS WITH ADVA

assessing pain in those unable to self-report follow. Use the Hierarchy of Pain Assessment Techniques Self-Report. Attempts should be made to obtain self-report of pain from all patients. A self-report of pain from a patient with limited verbal and cognitive skills may be a simple yes/no or o

Related Documents:

May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)

Silat is a combative art of self-defense and survival rooted from Matay archipelago. It was traced at thé early of Langkasuka Kingdom (2nd century CE) till thé reign of Melaka (Malaysia) Sultanate era (13th century). Silat has now evolved to become part of social culture and tradition with thé appearance of a fine physical and spiritual .

On an exceptional basis, Member States may request UNESCO to provide thé candidates with access to thé platform so they can complète thé form by themselves. Thèse requests must be addressed to esd rize unesco. or by 15 A ril 2021 UNESCO will provide thé nomineewith accessto thé platform via their émail address.

̶The leading indicator of employee engagement is based on the quality of the relationship between employee and supervisor Empower your managers! ̶Help them understand the impact on the organization ̶Share important changes, plan options, tasks, and deadlines ̶Provide key messages and talking points ̶Prepare them to answer employee questions

Dr. Sunita Bharatwal** Dr. Pawan Garga*** Abstract Customer satisfaction is derived from thè functionalities and values, a product or Service can provide. The current study aims to segregate thè dimensions of ordine Service quality and gather insights on its impact on web shopping. The trends of purchases have

pain”, “more pain” and “the most pain possible”. Slightly older children can also say how much they are hurting by rating their pain on a 0-10 (or 0-100) scale. Zero is no pain and 10 (or 100) is the worst possible pain. What a child is doing Often children show their pain by crying, making a “pain” face, or by holding or rubbing .

Chính Văn.- Còn đức Thế tôn thì tuệ giác cực kỳ trong sạch 8: hiện hành bất nhị 9, đạt đến vô tướng 10, đứng vào chỗ đứng của các đức Thế tôn 11, thể hiện tính bình đẳng của các Ngài, đến chỗ không còn chướng ngại 12, giáo pháp không thể khuynh đảo, tâm thức không bị cản trở, cái được

severe pain. Treatment of acute pain When assessing a patient with acute pain, the nurse should consider: The patient's report of pain or observation of pain (such as the number on a 1 to 10 scale). The patient's functional ability. The patient's level of consciousness. The site of pain and the cause.