Pain Assessment. Cathy Murray MSN RN OCNS-C Clinical Nurse Specialist December /21/2014 1

Transcription

1 Pain Assessment Cathy Murray MSN RN OCNS-C Clinical Nurse Specialist December /21/2014 1

2 Objectives Articulate pain assessment strategies. Identify appropriate assessment tools for patients. Describe pain assessment in non-verbal patients.

3 Careful Assessment is the Key Our failure to assess is thought to be the most common cause of unrelieved pain and unnecessary suffering American Pain Society 2003; McCaffery, Pasero 1999

4 Complexity of Pain Assessment Failure to make a good pain assessment Underestimation of pain Failure to accept patient s report of pain Failure to act on the patient s report of pain Multiple misconceptions about pain 3/21/2014 4

5 Principles of Assessment Assessment should be routine and consistent Accept patient self-report Use self-report with a rating scale Document and track scores over time Assess when pain is reported and suspected Re-assess routinely to determine efficacy & identify changes Consider individual, cultural, ethnic differences

6 Principles of Assessment Self-report is the single most reliable indicator of pain.

7 Pain Assessment Strategies 3/21/2014 7

8 Components of Assessment Description Temporal Location Alleviating or aggravating factors Intensity Associated signs/symptoms of the pain

9 Description Explains the quality of the pain What does the pain feel like? Sore? Sharp? Stabbing? Aching? Quality can determine type of treatment Nociceptive vs. neuropathic

10 Temporal Components Includes duration and onset of pain Is the pain continuous, intermittent, breakthrough or end of dose? How long does the pain last? How often does it come?

11 Location Includes areas of the body where pain exists Does the pain radiate to other body parts? Pain diagram may be useful

12 Alleviating/Aggravating Factors Determine circumstances that affect the pain Determine if there are activities, emotions, or environmental conditions that contribute to pain What makes the pain worse? What makes the pain better?

13 Intensity Pain rating scales can be used to quantify the pain experience The appropriate scale should be chosen based on patient characteristics Cognitive function Culture Language Developmental age

14 Associated Signs and Symptoms Pain can affect other facets of the patient Is the patient experiencing any of the following: Anxiety Sleep disturbance Fatigue Stress Sexual dysfunction Depression Immobility Anorexia

15 The Interview Review patient s pain and record Use open ended questions Be aware of non-verbals Observe patient/family/caregiver interactions Identify expectations Education written and verbal

16 Establish Comfort-Function Goal Discussion between nurse and the patient to mutually establish a goal. Explain that the goal is comfort in the presence of function. What level of pain can you tolerate to perform activities of daily living; ambulation? No Pain is unrealistic Pasero & McCaffery, 2011, p

17 Hierarchy of Pain Assessment 1. Self report: Single most reliable. 2. Assume Pain Present: Presence of a pathologic condition or procedure that usually causes pain. 3. Behaviors: cry, grimace, moaning, guarding, change in activity. 4. Surrogate Report: family and caregivers. 5. Analgesic Trial: low dose of pain medication, slowly increase based on response. Self Report Assume Pain Present Pasero & McCaffery, 2011, p. 123 Behavior Surrogate Report Analgesic Trial

18 Self-Report Pain Scales The patient s self-report of pain is the best measure whenever possible. If the patient can tell you about his/her pain, use an intensity scale Numeric Rating Scale (NRS) (0-10) Faces Pain Scale Revised (0-10)

19 Assume Pain Present The patient cannot self-report, think about these things: Is a diagnosis or situation present that is known to cause pain? Is there underlying pathology and potential for pain? Is pain commonly associated with the patient s condition? Make appropriate assumptions and proceed with treatment - Assume Pain Present Pasero & McCaffery, 2011 p. 123

20 Pain Behaviors Observe the patient for the following behaviors that have been associated with a painful condition: Crying, grimacing, moaning, aggressiveness, restless, being uncooperative, rubbing or massaging, guarding. Changes in sleeping and eating patterns. Pasero & McCaffery, 2011, p

21 Surrogate Report When present, solicit information from family and/or caregivers Presence of a painful condition Patterns of behavior that suggest pain. When your mother has pain how does she act, behave? Pasero & McCaffery, 2011, p. 124

22 Analgesic Trial Use a trial administration of pain medication and increase the dose based on the patient s response. Start with a low dose of pain medication Start low, go slow. Slowly increase dose until you see: Changes in behaviors. Improved sleeping and eating patterns. Improved participation in daily activities. Watch for sedation. Pasero & McCaffery, 2011, p. 125

23 IU Health Approved Pain Rating Scales 3/21/

24 Assessment Tools Assessment Tool Method Criteria for Use Numeric Rating Scale Self-report 8 y.o. if developmentally appropriate Faces Pain Scale-Revised Self-report 4 y.o. if developmentally appropriate N-PASS Observational 37 weeks gestation FLACC Observational 38 weeks gestation to 7 y.o. (now approved in adults per IUH policy) Non-verbal Pain Scale Observational Nonverbal or intubated patients 7 y.o. (ICU, PACU, ED)

25 Assessment Tools Numeric Rating Scale

26 Assessment Tools Faces Pain Scales

27 Assessment Tools

28 Assessment Tools FLACC

29 Assessment Tools Non-Verbal Pain Scale

30 Observational Pain Scales Remember! Observational Pain Scale results do not measure intensity and cannot be compared to the NRS or FACES-Revised. Observational pain scales estimate the presence of pain. Pasero & McCaffery, 2011, p. 127

31 Use of Sedation Scales Enhances accuracy and consistency of assessment and interventions Allows for monitoring of trends Sedation is an early warning sign for respiratory depression Easier to communicate effectively between members of healthcare team

32 Sedation Scales Aldrete s Scale Used to determine readiness for discharge from the PACU Richmond Agitation and Sedation Scale (RASS) Used for goal directed (purposeful) sedation during procedures or in ventilated critically ill patients Not recommended for use during opioid administration for pain management Pasero Opioid Sedation Scale (POSS) Sedation assessment during opioid administration for pain management

33 Pasero Opioid-Induced Sedation Scale (POSS) Rating Action Needed Recommendations S = sleep, easy to arouse Acceptable; no action necessary 1 = Awake & alert Acceptable; no action necessary 2 = Slightly drowsy, easily aroused 3 = Frequently drowsy, drifts off to sleep during conversation 4 = Somnolent, minimal or no response to verbal and physical stimulation Acceptable; no action necessary Unacceptable; monitor respiratory and sedation status Unacceptable; monitor respiratory and sedation level; do not leave the patient May increase opioid dose if needed May increase opioid dose if needed May increase opioid dose if needed Decrease opioid dose 25% to 50%; consider administering non-opioid; notify provider Stop opioid; consider naloxone; call RR team

34 Review of Objectives Articulate pain assessment strategies. Identify appropriate assessment tools for patients. Describe pain assessment in nonverbal patients. 3/21/

35 References American Society of Pain Management Nursing (2005). Study guide for pain management nursing certification preparation. Pasero, C. & McCaffery, M. (2011). Pain Assessment and Pharmacologic Management. St. Louis: Mosby. St. Marie, B. (2010). Core Curriculum for Pain Management Nursing (2nd ed.). Atlanta: Kendall Hunt Publishing Company.