Presenters 8/26/2011. Task Force on Pain Assessment in Persons Unable to Self Report

Transcription

1 ASPMN Task Force for Pain Assessment in Persons Unable to Self-Report: Position Statement Update and Issue Discussion 1 Presenters Keela Herr, PhD, RN, AGSF, FAAN Professor & Associate Dean for Faculty Co-Director, John A Hartford Center of Geriatric Nursing Excellence College of Nursing, The University of Iowa Renee C.B. Manworren, PhD, RN, BC, APRN,PCNS-BC Nurse Scientist & Assistant Professor Connecticut Children s Medical Center & University of Connecticut School of Medicine Sandra Merkel, MS, RN-BC Clinical Nurse Specialist, C. S. Mott Children s Hospital, University of Michigan Health System 2 Task Force on Pain Assessment in Persons Unable to Self Report Keela Herr, Chair Patrick Coyne, MSN, RN, APRN, FAAN; Virginia Commonwealth University Renee Manworren Margo McCaffery, MS, RN, FAAN; Independent Consultant Sandra Merkel 3 1

2 Objectives Identify general recommendations for pain assessment in individuals who are unable to self report pain. Discuss considerations & strategies to use with persons with advanced dementia, persons at end of life, infants and preverbal toddlers, individuals with intellectual disabilities and those who are intubated and unconscious. Identify issues/challenges with clinical application of pain assessment in those unable to self-report 4 External Reviewers Lynn Breau Margaret L. Campbell Constance Dahlin Celine Gelinas Jo Eland Roxie L. Foster Chris Pasero Terry Voepel-Lewis 5 General Recommendations (ASPMN Task Force Position Statement, 2011) All persons with pain deserve prompt recognition and treatment Pain should be routinely monitored, assessed, reassessed, & documented clearly In patients unable to self-report pain, other approaches must be used No single objective assessment strategy, such as interpretation of behaviors, pathology, or pain estimates by others, is sufficient by itself in this population 6 2

3 General Recommendations (ASPMN Task Force Position Statement, 2011) Utilize the Hierarchy of Pain Assessment Techniques Search for Potential Causes of Pain Observe Patient Behaviors Surrogate Reporting of Pain & Behavior/Activity Chgs Attempt an Analgesic Trial Establish a Procedure for Pain Assessment Utilize behavioral pain assessment tools, as appropriate, to determine presence of pain 7 Position Statement: Updates Updated information for selected populations Incorporated new research & tools Added 2 new populations Individuals with Intellectual Disabilities (ID) Individuals at End-of-Life 8 Considerations & Strategies: Advanced Dementia No evidence that peripheral nociceptor responses or pain transmission impaired in dementia (sensory threshold) CNS changes may influence/diminish interpretation of pain transmission (effective response) ASSUME PAIN PREVALENCE AND SEVERITY SAME AS IN COGNITIVELY INTACT OLDER ADULTS Karp et al, 2008; Kunz et al 2009; Scherder t al, 2009 Puntillo et al,

4 Assessing Cognitively Impaired Older Adults Observe for changes in usual daily activities/interactions/ behaviors Familiarity with Older Adult is KEY Baseline knowledge of usual behavior/activities Surrogate reports of possible pain behaviors Use of Behavioral Pain Tool Analgesic Trial Reassess for changes & responses to treatment 10 Cognitively Impaired Older Adults Self-report: may be possible in mild to moderate CI but ability decreases as dementia progress Search for Potential Causes of Pain: Consider common chronic pain etiologies Observe behavior: during activity if possible; use behavioral pain tool Proxy Report: LTC setting CNA is key provider shown to be effective in recognizing presence of pain Attempt Analgesic Trial: estimate pain intensity based on assessment & select appropriate analgesic Opioid dosing in older adults- initial reduction of 25-50% Kelley, Siegler, & Reid, 2008; Pesonen et al, 2009; AGS Panel on Persistent Pain in Older Persons, 2002; Hadjistavropoulos et al., 2007; Nygaard & Jarland, 2006; Pautex, Herrmann, Michon, Giannakopoulos, & Gold, 2007 Cognitively Impaired Older Adults: Behavioral Pain Assessment Tools 4

5 Considerations & Strategies: End of Life Pain is a common symptom in most lifethreatening or progressive illnesses Untreated pain may actually accelerate death by limiting mobility, increasing physiological stress and impacting factors such as pneumonia and thromboembolism As nurses advocate for effective pain management in this population, a major emphasis is appropriate pain assessment Hospice and Palliative Nurses Association (HPNA), 2008; Paice, End of Life Self-report Cognitive abilities to verbalize pain often fail as disease progresses Absence of reported pain does not mean patient is not experiencing pain or pain has resolved Search for Potential Causes of Pain Pain assessment critical at end-of-liferequirements skilled pain & physical assessments Causes of pain are typically very complex, numerous sites and etiologies of pain Agar & Lawlor, 2008; Del Fabbro, Dalal, & Bruera, 2006; Fink & Gates, 2010; Lester et al, 2011) 14 End of Life Observation of Patient Behaviors Delirium & agitation frequent as death approaches May be due to intractable pain but many other etiologies as well Use of Behavioral Pain Assessment Tools Limited tools developed & validated for EOL Multidimensional Objective Pain Assessment Tool (MOPAT):recently developed to assess acute pain in patients who are unable to self-report in hospice and palliative care settings McGuire, Reifsnyder, Soeken, Kaiser, & Yeager,

6 Patients at End-of-Life: Behavioral Pain Assessment Tools End of Life Proxy Reporting of Pain Family and/or caregivers Attempt an Analgesic Trial Determining presence of pain based on response to analgesia is very challenging in this population, as intentional sedation may obscure behaviors often used to detect pain Prudent to assume pain present and continue analgesic treatment in the sedated patient Fink & Gates, 2010; Paice, Considerations & Strategies: Infants and Preverbal Toddlers Recommendations for pain assessment in infants/ nonverbal children unable to self-report that are unique from the general recommendations include: 1. Self-report 2. Search for Potential Causes of Pain 3. Observation of Patient Behaviors 4. Proxy Reporting of Pain 5. Analgesic Trial 18 6

7 1. Self-report: Lack cognitive skills necessary to report and describe pain Able to express the presence of pain at 2 years Developmentally appropriate children as young as 3 may be able to quantify pain using simple validated pain tools Report bias is very common in children 3-5 years Difficulty discriminating between the sensory experience of pain & distress or fear of pain, as well as distressing symptoms such as nausea The majority of children over 8 are able to reliably use a self-report numeric rating tool Fanuriket al,1998; McGrathet al PedIMMPACT, 2008; Spagrud, Piira, & Von Baeyer, 2003; Stanford, Chambers, & Craig, 2006; von Baeyer et al, 1999; Wennstrom & Bergh, Search for Potential Causes of Pain: Infections Injuries Diagnostic tests Surgical procedures Disease progression Treat with the presumption that pain is present. McGrath et al, 2008; Stevens et al, 2003 Observation of Patient Behaviors The primary behavioral signs of pain are often more apparent & consistent for procedural pain and postoperative pain than for chronic pain. Facial expression Body activity/motor movement Crying/verbalization Body posture Changes in muscle tone Changes to response to the environment High pitched, tense, and harsh cry Grunau & Craig, 1990 ; McGrath et al,

8 3. Observation of Patient Behaviors Neonates who are experiencing persistent pain may exhibit signs of energy conservation Observed behavioral responses to pain change, as a child gains control over body There may be a dampening of pain behaviors in children experiencing prolonged or chronic pain Distress behaviors may or may not be related to pain Physiologic indicators are associated with acute pain in neonates, however, they are also affected by changes in physiologic status American Academy of Pediatrics Committee on Fetus and Newborn, American Academy of Pediatrics Section on Surgery, & Canadian Paediatric Society Fetus and Newborn Committee, 2006; Anand, 2007; Busoni, 2007; Eccleston, Bruce, & Carter, Use of Behavioral Pain Assessment Tools No single behavioral tool has been shown to be superior to others. Clinicians should select a tool that is appropriate to the patient and types of pain on which it has been tested. Behavioral pain tools should be used for initial and ongoing assessments. Crellin, Sullivan, Babl, O'Sullivan, & Hutchinson, 2007; von Baeyer & Spagrud, 2007 Use of Behavioral Pain Assessment Tools Tool Tested In: Sample Tested in: Setting CHEOPS: Children s Hospital of Eastern Ontario Pain Scale CHIPPS: Children's and Infants' Postoperative Pain COMFORT Behavior Scale CRIES Children 4 months to 17 years of age; Procedural pain and brief post-surgical Children birth to 5 years of age; Surgical pain Neonate to 3 years of age; Surgical pain Neonates; Procedural and surgical pain Post Anesthesia Care Unit Acute care Intensive care Neonatal & pediatric intensive care FLACC: Faces, Legs, Activity, Cry, Consolability Observational Tool Children 0 months to 18 years of age; Post-operative hospital and procedural pain, surgical pain and acute pain Post Anesthesia Care, intensive care, acute care N-PASS: Neonatal Pain, Agitation, and Sedation Scale PIPP: Premature Infant Pain Profile Toddler-Preschooler Postoperative Pain Measure Premature neonates 23 to 40 weeks gestation; procedural and postoperative Premature and term neonates; procedural pain Children 1 to 5 years of age; shortterm post-surgical pain Neonatal Intensive Care Unit Neonatal Intensive Care Unit Post Anesthesia Care, Acute Care 8

9 4. Proxy Reporting of Pain Observe & evaluate the child s response to a trusted caregiver and the environment Parents usually know child s typical response to pain & can identify behaviors unique to their child Nursing staff may be most familiar with children s first experiences with surgical or procedural pain Explain behavioral tools to parents to encourage active participation in identifying pain and evaluating responses to interventions 5. Analgesic Trial Initiate analgesic trial with non-opioid or low-dose opioid if pain is suspected & comfort measures not effective in easing behaviors that suggest pain Base initial dose on weight in children up to 50 kg Oral sucrose can be an effective analgesic for infants 3 months & younger who are undergoing minor pain procedures Explore other potential causes of distress if behaviors continue Gusic, Dyer, & Polomano, 2008; Johnston, Fernandes, & Campbell-Yeo, 2011 Considerations & Strategies: Persons with Intellectual Disabilities (ID) Persons with ID cognitively impaired since birth & this ID continues throughout life; whereas cognitive impairment can be acquired at any age ID may or may not be accompanied by physical disability IQ scores below 50 indicate moderate, severe, or profound impairment American Psychiatric Association, 1994 ; Bottos & Chambers, 2006; Goodenough et al,

10 Intellectual Disabilities 1. Self-report: The majority of individuals with ID are verbal and can self-report pain using a developmentally appropriate self-report pain assessment tool. Thus, seeking self-report and establishing reliability of self-report should be a first step Search for Potential Causes of Pain: Higher burden of pain compared to healthy individuals, which may be related to challenges in recognizing & communicating presence of pain Imperative that providers carefully assess for presence, location, & severity of pain, particularly when a potential source of pain is present Treating these potential sources on the assumption that pain is present may be appropriate 3. Observation of Patient Behaviors: Individual behavioral response to painful stimuli varies Some data demonstrated differences in pain responses based on diagnosis, however, majority of children appear to have intact sensory function Researchers also noted that self-injurious behaviors may be indicative of pain Individual differences in response to pain may contribute to under- or over-estimation of pain Symons, Shinde, & Gilles, 2008; Bosch, 2002; Carr & Owen-Deschryver, 2007; Davies, 2010; Dubois, Capdevila, Bringuier, & Pry, 2010; Hunt, Goldman et al,

11 Use of Behavioral Pain Assessment Tools Considerable research has focused on creating assessment tools for children with IDs, few studies included adults with IDs Clinicians should select tool that is appropriate to the patient & types of pain on which it has been tested weighing psychometrics with tools having repeated supporting research by multiple authors being the strongest Table 6: Persons with Intellectual Disabilities (ID): Behavioral Pain Assessment Tools Tool Tested In: Sample Tested in: Setting rflacc: Revised Faces, Legs, Activity, Cry, Consolability Observational Tool NCCPC: Noncommunicating Children s Pain Checklist Individualized Numeric Rating Scale (INRS) Children 4-19 years of age, mild to severe impairment; postoperative pain Children with ID; chronic pain Children 6 to 18 years of age, severe intellectual disability Acute care Post operative, rehabilitation hospital; NCCPC-R tested in children and adults in home/residential settings Acute care Paediatric Pain Profile NCAPC: The Non- Communicating Adult Pain Checklist Children 1 18 yrs of age, severe neurological disability & unable to communicate through speech or augmentative communication; chronic and postoperative pain Adult population, all levels of Intellectual and Developmental Disabilities (IDD) Home, hospice, acute care Residential or community setting 4. Proxy Reporting of Pain. Caregivers of children with IDs relatively sensitive pain detectors, but frequently underestimated pain intensity compared to their children s estimates (in those who could communicate), & pain may be undertreated Parents estimations of their child s pain improved when provided with information and a structured observational tool Many of the issues raised in these studies may be relevant to the care of adults with IDs 11

12 Three tools that identify unique behaviors to the individual patient s response to pain The Individualized Numeric Rating Scale (INRS) is based on proxy ratings by parents The rflacc provides descriptors unique to this population & suggests clinicians seek input about person s baseline & pain behaviors The Paediatric Pain Profile includes section for caregivers to complete about child s pain history 5. Analgesic Trial. Initiate analgesic trial if pain is suspected Trial should be tailored to the age of the patient or weight in those under 50kg. Considerations & Strategies: Critically Ill/Unconscious Recommendations for pain assessment in critically ill /unconscious persons unique from the general recommendations include: 1. Self-report 2. Search for Potential Causes of Pain 3. Observation of Patient Behaviors 4. Proxy Reporting of Pain 5. Analgesic Trial 36 12

13 Self Report Self-report is hampered Inability to speak, ET tube Level of consciousness, delirium Medications: sedatives and neuromuscular blocking agents Self-report should be attempted Simple yes no; nod of the head Serial assessment to determine ability to self report Causes of Pain Pain from varied causes Medical conditions Surgical procedures Injuries Pre-existing conditions Procedures: invasive instrumentation, blood draws, chest tube removal Routine Care: suctioning, turning Decreased mobility and infection: wound care and positioning Puntillo, 2001; Puntillo, 2004; Simons, 2003; Stanik-Hutt, 2001 Patient Behaviors Common behaviors Facial expression Physical movements, immobility, change in tone Compliance with ventilator Autonomic Responses (tearing, diaphoresis) Limited behaviors in some patients Pharmacologically paralyzed persons Brain-injured patients Assume Pain Present (APP) 13

14 Patient Behaviors Do not rely on vital signs as a primary indicator of pain Physiological changes and medications Cue for further assessment Other behaviors that may indicate discomfort/pain Poor quality of sleep; restlessness Slow movement Other behaviors that may confuse the picture Breath holding Crying Agitation Depression Behavioral Pain Assessment Tools Pain is multidimensional Consolability not a pain behavior but a dimension of the pain experience Pain is subjective Nonverbal populations at risk for poor assessment No one tool is superior Validated tools are useful Apply to the population or test in new population Pilot and implement in new settings Critically Ill/Unconscious Persons: Behavioral Pain Assessment Tools 14

15 Proxy Report Family member s report of their impression of pain and response to intervention is one aspect of the pain assessment Ask family members to help identify specific pain indicators Clinical Judgment Foundations of clinical judgment Knowledge and experience Assessment and monitoring Patient interaction Collaboration and communication Clinical judgment guides decision making Pain vs. physiological changes Pain vs. anxiety or emotional changes Medication choice Comfort measures Analgesic Trial Initiate analgesic is pain is suspected: ongoing treatment adjusted based on response Analgesics, sedatives and non-drug therapies Tapering of opioids and sedatives Extubation Drug withdrawal Unique needs of the person Head injury Agitation: delirium, hyperalgesia NSAIDs 15

16 Pain Assessment in the Patient Unable to Self- Report: Challenges Populations at risk for poor assessment and pain control Challenges for the clinician Develop an approach for assessment and treatment Select and use available tools Application of tools and evidence into the practice setting Pitfall of a Pain Observation Tool Differentiating pain from other sources of behavioral distress Agitation Physiologic Cause History and Risks Context and Caregiver No Yes Anxiety Pain Delirium Challenge: Refine the approach Define and standardize the process for assessment Frequency of assessment Responsibility of staff Caregiver input Standardize the process for treatment Analgesic trial Titration and assessment 16

17 Challenge: Select and refine the tool Framework for observed behaviors Main behaviors: face, verbalization, body movements Framework based on review of literature American Geriatrics Society Pediatric tool comparison Select the behavioral tool Comprehensive vs. limited list of behaviors Complexity, time requirement and scoring Teach staff and caregivers how to use the tool Challenges: Application to practice No standard tool is available Unable to classify into a number- pain score Teach clinicians to recognize pain Clinical judgment is required Populations and settings Acute vs. chronic pain Pilot tools and processes QI and research: share the results Cultures and Language Testing and validating Translation of words and behaviors Questions 51 17