Assessment of Pain in Special Populations

Transcription

1 Assessment of Pain in Special Populations By Ann Schreier, PhD, RN Upon successful completion of this course, continuing education hours will be awarded as follows: Nurses: 2 Contact Hours* *Western Schools is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation.

2 P.O. Box 1930 Brockton, MA ABOUT THE AUTHOR Ann Schreier, PhD, RN, is a professor at East Carolina University (ECU) College of Nursing in Greenville, NC. Dr. Schreier received her BSN degree from Boston University, an MSN from University of California, San Francisco and her PhD from Stanford University. Dr. Schreier has clinical experience in oncology and in hospice. This clinical experience has motivated Dr. Schreier to study and promote best practices in pain management. She is actively engaged in research with studies examining the relationship between pain, fatigue, sleep disturbance, and anxiety of breast cancer survivors and the development of interventions to assist cancer patients cope with pain and co-occurring symptoms. In her 25 years of experience as a faculty member at East Carolina University, she has taught undergraduate and graduate students. By her colleagues, she is considered an expert in the education of nurses in pain management. She has extensively lectured about pain management at a local, regional and national level. In 2017, she received ECU s Distinguished Faculty Mentor Award for her outstanding contributions to mentoring of doctoral students in their research. She is a past president of American Society for Pain Management Nurses.. She serves on the editorial board of Pain Management Nursing. Dr. Schreier is active in advocacy for pain management. Ann Schreier has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. ABOUT THE PEER REVIEWER Angela Starkweather, PhD, ACNP-BC, FAAN, is a tenured professor and serves as the associate dean for academics at University of Connecticut School of Nursing in Storrs, CT. She is a graduate of Seattle Pacific University (BSN) and Loyola University Chicago (MSN and PhD). She has been practicing in acute care settings for the past twenty years, coordinating the pain management of patients across age groups and settings. She directs the P20 Center for Accelerating Precision Pain Self-Management at UConn School of Nursing, where she coordinates interdisciplinary team science and oversees the development and implementation of cutting-edge nursing research. Her program of research focuses on symptom science, gaining a deeper understanding of the biobehavioral mechanisms underlying chronic symptoms and the development and testing of nursing interventions to help relieve suffering and improve quality of life. Angela Starkweather has disclosed that she has no significant financial or other conflicts or interest pertaining to this course book. Nurse Planner: Maryam Mamou, BSN, RN, CRRN, CWOCN The planner who worked on this continuing education activity has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book. Copy Editor: Graphic World, Inc. Western Schools courses are designed to provide healthcare professionals with the educational information they need to enhance their career development as well as to work collaboratively on improving patient care. The information provided within these course materials is the result of research and consultation with prominent healthcare authorities and is, to the best of our knowledge, current and accurate at the time of printing. However, course materials are provided with the understanding that Western Schools is not engaged in offering legal, medical, or other professional advice. Western Schools courses and course materials are not meant to act as a substitute for seeking professional advice or conducting individual research. When the information provided in course materials is applied to individual cases, all recommendations must be considered in light of each case s unique circumstances. Western Schools course materials are intended solely for your use and not for the purpose of providing advice or recommendations to third parties. Western Schools absolves itself of any responsibility for adverse consequences resulting from the failure to seek medical, or other professional advice. Western Schools further absolves itself of any responsibility for updating or revising any programs or publications presented, published, distributed, or sponsored by Western Schools unless otherwise agreed to as part of an individual purchase contract. Products (including brand names) mentioned or pictured in Western Schools courses are not endorsed by Western Schools, any of its accrediting organizations, or any state licensing board. ISBN: COPYRIGHT 2018 S.C. Publishing. All Rights Reserved. No part(s) of this material may be reprinted, reproduced, transmitted, stored in a retrieval system, or otherwise utilized, in any form or by any means electronic or mechanical, including photocopying or recording, now existing or hereinafter invented, nor may any part of this course be used for teaching without written permission from the publisher. FP0518WS ii

3 COURSE INSTRUCTIONS IMPORTANT: Read these instructions BEFORE proceeding! HOW TO EARN CONTINUING EDUCATION CREDIT To successfully complete this course you must: 1) Read the entire course 2) Pass the final exam with a score of 75% or higher* 3) Complete the course evaluation *You have three attempts to pass the exam. If you take the exam online, and fail to receive a passing grade, select Retake Exam. If you submit the exam by mail or fax and you fail to receive a passing grade, you will be notified by mail and receive an additional answer sheet. Final exams must be received at Western Schools before the Complete By date located at the top of the FasTrax answer sheet enclosed with your course. Note: The Complete By date is either 1 year from the date of purchase, or the expiration date assigned to the course, whichever date comes first. HOW TO SUBMIT THE FINAL EXAM AND COURSE EVALUATION ONLINE: BEST OPTION! For instant grading, regardless of course format purchased, submit your exam online at Benefits of submitting exam answers online: Save time and postage Access grade results instantly and retake the exam immediately, if needed Identify and review questions answered incorrectly Access certificate of completion instantly Note: If you have not yet registered on Western Schools website, you will need to register and then call customer service at to request your courses be made available to you online. Mail or Fax: To submit your exam and evaluation answers by mail or fax, fill out the FasTrax answer sheet, which is preprinted with your name, address, and course title. If you are completing more than one course, be sure to record your answers on the correct corresponding answer sheet. Complete the FasTrax Answer Sheet using blue or black ink only. If you make an error use correction fluid. If the exam has fewer than 100 questions, leave any remaining answer circles blank. Respond to the evaluation questions under the heading Evaluation, found on the right-hand side of the FasTrax answer sheet. See the FasTrax Exam Grading & Certificate Issue Options enclosed with your course order for further instructions. CHANGE OF ADDRESS? Contact our customer service department at , or customerservice@westernschools.com, if your postal or address changes prior to completing this course. WESTERN SCHOOLS GUARANTEES YOUR SATISFACTION If any continuing education course fails to meet your expectations, or if you are not satisfied for any reason, you may return the course materials for an exchange or a refund (excluding shipping and handling) within 30 days, provided that you have not already received continuing education credit for the course. Software, video, and audio courses must be returned unopened. Textbooks must not be written in or marked up in any other way. Thank you for using Western Schools to fulfill your continuing education needs! WESTERN SCHOOLS P.O. Box 1930, Brockton, MA iii

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5 WESTERN SCHOOLS COURSE EVALUATION ASSESSMENT OF PAIN IN SPECIAL POPULATIONS INSTRUCTIONS: Using the scale below, please respond to the following evaluation statements. All responses should be recorded in the right-hand column of the FasTrax answer sheet, in the section marked Evaluation. Be sure to fill in each corresponding answer circle completely using blue or black ink. Leave any remaining answer circles blank. A B C D Agree Agree Disagree Disagree Strongly Somewhat Somewhat Strongly OUTCOMES: After completing this course, I am able to: 1. Identify an appropriate pain assessment measure for premature infants or neonates. 2. Identify an appropriate measure of pain for the person with a developmental delay. 3. List common painful conditions experienced by older adults. 4. Identify an instrument to assess pain in the older adult with a cognitive impairment. COURSE CONTENT 5. The course content was presented in a well-organized and clearly written manner. 6. The course content was presented in a fair, unbiased and balanced manner. 7. The course content presented current developments in the field. 8. The course was relevant to my professional practice or interests. 9. The final examination was at an appropriate level for the content of the course. 10. The course expanded my knowledge and enhanced my skills related to the subject matter. 11. I intend to apply the knowledge and skills I ve learned to my practice. A. Yes B. Unsure C. No D. Not Applicable CUSTOMER SERVICE The following section addresses your experience in interacting with Western Schools. Use the scale below to respond to the statements in this section. A. Yes B. No C. Not Applicable 12. Western Schools staff was responsive to my request for disability accommodations. 13. The Western Schools website was informative and easy to navigate. 14. The process of ordering was easy and efficient. 15. Western Schools staff was knowledgeable and helpful in addressing my questions or problems. ATTESTATION 16. I certify that I have read the course materials and personally completed the final examination based on the material presented. Mark A for Agree and B for Disagree. v continued on next page

6 vi Course Evaluation Assessment of Pain in Special Populations COURSE RATING 17. My overall rating for this course is A. Poor B. Below Average C. Average D. Good E. Excellent You may be contacted within 3 to 6 months of completing this course to participate in a brief survey to evaluate the impact of this course on your clinical practice and patient/client outcomes. Note: To provide additional feedback regarding this course and Western Schools services, or to suggest new course topics, use the space provided on the Important Information form found on the back of the FasTrax instruction sheet included with your course.

7 CONTENTS Course Evaluation...v Figures and Tables...ix Pretest...xi Introduction...xv Learning Outcomes...xv Assessment of Pain in Special Populations...1 Learning Outcome...1 Chapter Objectives...1 Introduction...1 Pediatric Pain...1 Development and Pain Assessment...2 Pain Assessment in Infants...2 Pain Assessment in Children...4 General Assessment Principles...6 Patients With Developmental Disabilities...6 Geriatric Patients...7 Barriers to Pain Management...7 Pain Assessment in the Older Adult...8 Pain Assessment in the Cognitively Impaired Older Adult...9 Case Study Questions...11 Responses...11 Case Study Questions...12 Responses...13 Summary...13 Exam Questions...15 Glossary...17 References...19 vii

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9 FIGURES AND TABLES Table 1: Preverbal, Early Verbal Pediatric Pain Scale (PEPPS) Modified for Emergency Room Use...4 Table 2: Instruments for Assessing Pain in Infants and Children...5 Figure 1: Wong-Baker FACES Pain Rating Scale...6 Table 3: Instruments to Assess Pain in Nonverbal Adults and in Severe Dementia...10 ix

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11 PRETEST 1. Begin this course by taking the pretest. Circle the answers to the questions on this page, or write the answers on a separate sheet of paper. Do not log answers to the pretest questions on the FasTrax test sheet included with the course. 2. Compare your answers to the pretest key located at the end of the pretest. The pretest key indicates the chapter where the content of that question is discussed. Make note of the questions you missed, so that you can focus on those areas as you complete the course. 3. Complete the course by reading the chapters and completing the exam questions at the end of each chapter. Answers to the exam questions should be logged on the FasTrax test sheet included with the course. Note: Choose the one option that BEST answers each question. 1. To assess a patient in the neonatal intensive care unit for pain, the nurse uses a. the Wong-Baker FACES Scale. b. the oxygen saturation reading. c. the Premature Infant Pain Profile. d. the Numerical Rating Scale (NRS). 2. Children can accurately self-report pain at which age? a. 3 b. 5 c. 7 d. It is unclear. 3. The illnesses that are frequently the source of pain in older adults are a. acute lymphoblastic leukemia and asthma. b. chronic obstructive lung disease and cancer. c. diabetes and pneumonia. d. osteoarthritis and malignancies. xi 4. To more accurately assess pain in the older adult with severe dementia, the nurse uses a. vital sign changes. b. the Faces, Legs, Activity, Cry Consolability Scale. c. the Pain Assessment in Advanced Dementia Scale. d. the Numerical Rating Scale with verbal descriptors. 5. The Abbey Pain Scale contains both a. behavioral and physiological measures. b. psychological and emotional measures. c. emotional and behavioral measures. d. physiological and psychological measures. PRETEST KEY 1. C page 2 2. D page 4 3. D page 7 4. C page 9 5. A page 11

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13 INTRODUCTION LEARNING OUTCOMES After completing this course, the learner will be able to: 1. Identify an appropriate pain assessment measure for premature infants or neonates. 2. Identify an appropriate measure of pain for the person with a developmental delay. 3. List common painful conditions experienced by older adults. 4. Identify an instrument to assess pain in the older adult with a cognitive impairment. Licensed practical nurses and registered nurses care for patients who experience pain in acute care, long-term care, and community settings. When caring for the person in pain, nurses and other healthcare professionals need to consider how pain affects the physical, psychological, social, and spiritual well-being of individuals. An important role of the nurse in providing quality patient care is advocating for effective pain treatment while reducing potential harm. Because pain is a universal experience, nurses need to be knowledgeable regarding the assessment and treatment of pain across healthcare settings and for diverse populations. In initial educational programs, nurses, and other healthcare professionals receive limited education regarding pain and effective pain management. The purpose of this course is to provide the learner with current knowledge about pain and nursing care for premature infants, older adults, and patients with developmental delays. Upon completion of this course, the learner will be able to demonstrate an understanding of pain assessment for patients in these populations and identify evidence-based assessment for patients whose cognitive impairment, age, or level of consciousness makes them incapable of reporting their pain. The learner will also be able to demonstrate an understanding of the pharmacologic and nonpharmacologic treatment of acute and chronic pain as well as treatment of pain for patients in these special populations. With this knowledge, the learner will be able to educate diverse patient groups about pain and advocate for safe and effective pain treatment based upon scientific evidence. xiii

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15 ASSESSMENT OF PAIN IN SPECIAL POPULATIONS LEARNING OUTCOME After completing this chapter, the learner will be able to discuss factors that affect assessment of pain in infants, children, older adults, and those with cognitive or verbal deficits or developmental delays, along with appropriate assessment measurements for each population. CHAPTER OBJECTIVES After completing this chapter, the learner will be able to: 1. Identify an appropriate pain assessment measure for premature infants or neonates. 2. Identify an appropriate measure of pain for the person with a developmental delay. 3. List common painful conditions experienced by older adults. 4. Identify an instrument to assess pain in the older adult with a cognitive impairment. INTRODUCTION Current standards of practice in the United States place a priority on pain management and emphasize the need for organizations to follow standards for assessment and management of pain. The Joint Commission (2017) Prepublication Standards Standards Revisions 1 Related to Pain Assessment and Management outline the standards of pain management that organizations are expected to follow. In certain populations, there are difficulties with meeting these standards. The very young and the elderly, who frequently have cognitive and verbal deficits or developmental disabilities, are at great risk for poor management of their pain. It is especially challenging to assess pain in people with developmental or neurocognitive disabilities. PEDIATRIC PAIN Children often suffer needlessly due to their inability to verbally communicate pain and the failure of healthcare professionals to approach the management of pain in children through developmental paradigms. Children and adolescents experience pain from a variety of conditions: acute pain from injuries and surgeries, recurrent pain (e.g., headache and stomach ache), and diseases associated with pain, such as juvenile arthritis and sickle cell disease (Baumbauer et al., 2016). Evidence suggests that children s pain is undertreated (Birnie et al., 2014). Children with chronic health conditions, such as sickle cell disease, report severe pain during hospitalizations (Solodiuk et al., 2014). One study found that the prevalence of moderate to severe pain is 27% in hospitalized children, with more infants and

16 2 Assessment of Pain in Special Populations adolescents experiencing moderate to severe pain (Groenewald, Rabbitts, Schroeder, & Harrison, 2012). The first step to effective pain management is assessment, and there are a number of pain intensity instruments available specifically devised for infants and children unable to report pain and for children who can report pain. Yet, research suggests that many nurses do not use these tools (O Neal & Olds, 2016; Twycross, Forgeron, & Williams, 2015). When caring for infants and children, the healthcare professional needs to understand how pain is expressed depending upon the developmental age of the child. In addition, the healthcare professional needs to develop a trusting relationship with the child and the parents. This chapter discusses what tools, skills, and factors must be considered for assessment of pain in children. Development and Pain Assessment As with adults, self-report is considered the best way to assess pain in children. However, infants and neonates cannot verbally communicate pain. Neonates and infants communicate through crying and nonverbal expression. Therefore, the healthcare provider and parents must infer the presence and severity of pain by behavioral and physiological responses. Initially, infants have a generalized motor response to pain, which is a generalized withdrawal flexion of limbs (Fitzgerald, 2015). The toddler can begin to make verbal expressions of pain (such as ouch), but self-report is considered unreliable (von Baeyer et al., 2017) because the toddler lacks the vocabulary to accurately self-report. Although children as young as age 3 are able to report pain, they do not necessarily have the conceptual development to quantify their pain (Tsze, Hirschfeld, Dayan, Bulloch, & von Baeyer, 2016). In an attempt to determine what developmental characteristics predicted the ability to self-report pain in children ages 3 to 4, von Baeyer and colleagues (2017) found that there is no evidence that 3-year-olds are able to use standardized pain intensity scales and it is unclear if 4-year-olds are able to use an instrument. For the younger child, a simple method of self-report should be used. For instance, 3-yearolds are often able to respond to Do you have pain? Or do you hurt? Generally, children older than age 8 can self-report but may experience difficulty in describing pain due to lack of experience. However, they can be taught how to use a standardized scale (Manworren & Stinson, 2016). The school-age child with chronic, painful conditions may exhibit pain by withdrawing from activities (Baumbauer et al., 2016). Pain Assessment in Infants Healthcare professionals rely on behavioral responses and physiological responses to assess pain in infants. There are many behavioral assessment tools developed for this age group. None of these tools has been shown to be the most accurate in detecting pain, and no tool is preferred over any other tool (Badr, 2013). There is wide variability in infants responses to pain. A key consideration is gestational age (Badr, 2013). Preterm infants are subjected to many painful procedures, and neonatal intensive care unit nurses observe both behavioral and physiological responses. Variability in heart rate and oxygen saturation occur in response to noxious stimuli. A tool that is commonly used for premature infants is the Premature Infant Pain Profile (PIPP), which measures behavioral state, heart rate, oxygen saturation, brow bulge, eye squeeze, and nasolabial furrow in response to stimuli (Stevens, Johnston, Petryshen, & Taddio, 1996; Stoddard et al., 2002). In a study of premature infants, Boyle, Freer, Wong, McIntosh, and Anand (2006) found that nurses were able

17 Assessment of Pain in Special Populations 3 to assess pain in infants on mechanical ventilation using infants facial expressions, activity levels, response to handling, and lack of synchrony with the ventilator. The PIPP consists of six behavioral responses (alertness, calmness, muscle tone, movement, facial tension, and respiratory response/crying) and two physiological measures (heart rate and mean arterial pressure). The PIPP also includes scoring of contextual variables of gestational age and behavioral state before scoring of facial actions, heart rate, and oxygen saturation. Stevens and colleagues (2014) revised the scale for ease of use. The main change was in the scoring procedure, with gestational age and behavioral state measured after physiological and behavioral measures. The revised instrument was found to be valid and feasible for use in neonatal intensive care units for gestational ages of 26 weeks to greater than 37 weeks (Gibbins et al., 2014). Scores were statistically significantly different for painful procedures and nonpainful procedures. This instrument can be used to evaluate the efficacy of pain treatment. The COMFORT scale is a reliable measure of pain in the newborn undergoing surgery (Franck, Ridout, Howard, Peters, & Honour, 2011). An alternative to the COMFORT scale is the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale. Krechel and Bildner (1995) developed and tested this tool. It is an appropriate measurement for infants between the ages of 0 and 6 months. A behavioral scale that is widely used to assess pain in infants, toddlers, and young children is the Face, Legs, Activity, Cry, Consolability (FLACC) scale. This scale was initially developed to measure postoperative pain in young children (Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997). For this observational scale, the healthcare professional observes the patient for facial expression, movement of legs, general activity, crying behavior, and the ease with which he or she is consoled (Melby, McBride, & McAfee, 2011). It is important for the nurse to consider the situation and patient s age when using any instrument. Crellin, Harrison, Santamaria, and Babl (2015) conducted an analysis of studies that measured pain with the FLACC scale. They concluded the FLACC is reliable and valid for use with the originally intended subjects (2 months to 7 years) for postoperative pain but there is insufficient evidence that it is appropriate to assess procedural pain. Nurses and other healthcare providers should keep in mind that this scale is based on behaviors in response to pain. Developmentally, premature infants and those under 2 months of age may not exhibit the same pain behaviors. Likewise, evidence suggests that those over 7 years of age can self-report. Kochman and colleagues (2017) demonstrated that the FLACC scale is a reliable measure of acute pain in the emergency room for pediatric patients between the ages of 6 months and 5 years. These instruments are also useful for documentation and for assessment of the effectiveness of interventions. Another tool to assess pain in this population is the Preverbal, Early Verbal Pediatric Pain Scale (PEPPS), which assesses seven categories: heart rate, cry, facial expression, consolability/restlessness, body posture, sociability, and sucking/feeding (Schultz et al., 1999). For use in the emergency room, the PEPPS was modified by removing the sucking/ feeding and heart rate categories (Strout & Baumann, 2011). The authors removed those categories because in the emergency room, heart rate is often elevated because of illness and feedings are restricted (see Table 1). There are similarities among the instruments in behaviors measured. Nurses can select any of these instruments to use with this population,

18 4 Assessment of Pain in Special Populations TABLE 1: PREVERBAL, EARLY VERBAL PEDIATRIC PAIN SCALE (PEPPS) MODIFIED FOR EMERGENCY ROOM USE Parameter Facial Cry (audible/ visual) Consolability/ state of restfulness Body Posture Sociability Relaxed facial expression No cry Pleasant, well integrated Body at rest, relaxed positioning Responds to voice and/or touch; makes eye contact and/or smiles; easy to obtain or maintain; sleeping Whimpering, groaning Distractible, easy to console, intermittent fussiness Clenched fists, curled toes and/ or reaching for, touching wound or area Grimace, brows drawn together; eyes partially closed, squinting Intermittent crying Able to console, distract with difficulty; intermittent restlessness; irritability Localization with extension or flexion or stiff and nonmoving With effort, responds to voice and/or touch; makes eye contact but difficulty to obtain or maintain Sustained crying Intermittent or sustained movement with or without rigidity Severe grimace; brows lowered, tightly drawn together; eyes tightly closed Screaming Unable to console, restlessness, sustained movement Sustained arching, flailing, thrashing, and/or kicking Absent eye contact, no response to voice and/or touch Note. Adapted from Schultz, A. A., Strout, T. D., Jordan, P., & Worthing, B. (2002). Safety, tolerability, and efficacy of iontophoresis with lidocaine for dermal anesthesia in ED pediatric patients. Journal of Emergency Nursing, 28(4), but it is best that a single instrument be used by the institution so that all the staff become familiar with it and use the same scale to measure pain (see Table 2). Pain Assessment in Children It is unclear at what age children can accurately self-report. For children who are older than 3, self-report measures can be used with the understanding that they may or may not be accurate. Emmott and colleagues (2017) tested a simplified method to assess pain intensity in 3- and 4-year-old children. They used a two-step process. First, they asked the child if he or she had pain and if the child said yes then used a 3-face scale and an image of 1, 2, and 3 colored blocks. The 4-year-olds were able to quantify their pain with the 3 faces and the 3 blocks, but the 3-year-olds were not. Some authors suggest that by age 4, some children with acute pain are cognitively capable of accurate self-report with tools such as the FACES Pain Scale-Revised (Tsze et al., 2016). Others suggest that age 7 is the age at which most children possess the capacity to self-report. Healthcare providers need to use their judgment and the most appropriate tool for the individual child. Children may not want to report pain because of fear of

19 Assessment of Pain in Special Populations 5 TABLE 2: INSTRUMENTS FOR ASSESSING PAIN IN INFANTS AND CHILDREN Age Instrument Source Premature/Infant Premature Infant Pain Profile (PIPP) Stevens et al., 1996 COMFORT Franck et al., 2011 Crying, Requires Oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) Krechel & Bildner, 1995 Face, Legs, Activity, Cry, Consolability (FLACC) Merkel et al., 1997 Preverbal, Early Verbal Pediatric Pain Scale (PEPPS) Schultz et al., 2002 Toddler/Preschool Face, Legs, Activity, Cry, Consolability (FLACC) Merkel et al., 1997 Two-step process: Pain (yes or no); 3 faces or 3 cubes Tsze et al., 2016 School Age FACES Pain Scale-Revised Hicks et al., 2001 Numerical Rating Scale (NRS) Miró et al., 2016 Verbal Descriptor Scale (VDS) Miró et al., 2016 Adolescent Adolescent Pediatric Pain Tool (APPT) Jacob et al., 2014 Note. From Western Schools, needles or other procedures that might be used to treat their pain. In addition, parents influence the child s expression and reporting of pain. When a parent is very anxious, the child may report or behave in a manner that suggests a high pain rating. Education and interventions to reduce parent anxiety may improve the child s ability to cope with painful procedures. The most common rating scale is the FACES Pain Scale, first developed by Wong and Baker (Garra et al., 2010; Wong-Baker FACES Foundation, 2016). The scale uses several facial expressions that go from smiling to crying and several in between (see Figure 1). The child is to choose the face that most closely shows the level of pain being experienced. A review suggested that children younger than 7 are able to distinguish only 3 categories of pain (Quinn, Sheldon, & Cooley, 2014). In addition, the smiling face often results in an overestimation of pain. In a study comparing the FACES tool to the Numerical Rating Scale (NRS) and the Verbal Descriptor Scale, Miró and colleagues (2016) found that children with physical disabilities between the ages of 8 and 11 were unable to differentiate between the first 3 faces. For this sample, the NRS (11-point scale) was found to be the most valid pain intensity scale. The revised FACES Pain Scale uses a neutral face rather than a smiling face (Hicks, von Baeyer, Spafford, van Korlaar, & Goodenough, 2001). The Oucher scale uses actual photographs of children in place of the cartoons or the neutral revised FACES Pain Scale. There are three versions: Caucasian, African American, and Hispanic (Beyer & Aradine, 1986). As children mature, intensity scales, such as the NRS and the Visual Analogue Scale, can be used. Adolescents are able to self-report because they can think abstractly. However, adolescents sometimes hesitate to report pain because of fear that their activities will be restricted (Ameringer, 2010). In the presence of others, such as parents or peers, adolescents sometimes deny pain (Srouji, Ratnapalan, & Schneeweiss, 2010). These tools measure only a single dimension of pain intensity. The pain experience is multidimensional, so to fully assess pain, a multidimensional tool is needed. One such instrument is the Adolescent Pediatric Pain Tool. This tool includes a body diagram, a pain intensity measure, pain descriptors, and

20 6 Assessment of Pain in Special Populations FIGURE 1: WONG-BAKER FACES PAIN RATING SCALE Note. From Wong, D. L., Hackenberry-Eaton, M., Wilson, D., Winkelstein, M. L., & Schwartz, P. (2001). Wong s essentials of pediatric nursing (6th ed.). St. Louis, MO: Mosby. temporal patterns of pain ( toolkit.org/index.php?pagelink=browse. protocoldetails&id=190902).. The tool has been validated for a wide range of settings (schools, outpatient clinics, and hospitals) as well as for acute and chronic pain conditions (Jacob, Mack, Savedra, Van Cleve, & Wilkie, 2014). It is appropriate for use with children greater than 8 years of age. General Assessment Principles Despite the age of the child, pain can be assessed. Children have fully developed nervous systems with respect to pain, its transmission, and its modulation. Developmentally appropriate tools should be used to assess pain and treatment efficacy. Chronological age is the best determinant of ability to self-report. PATIENTS WITH DEVELOPMENTAL DISABILITIES Assessing pain in individuals with intellectual or developmental disabilities (such as Down syndrome) is challenging. These individuals often suffer from chronic illnesses that result in pain (McGuire & Defrin, 2015). Individuals with profound intellectual and motor disabilities have many medical illnesses that increase the risk for pain (McGuire & Defrin, 2015; van Timmeren et al., 2017). These adults and children may not recognize pain as readily as others, and it is important for the nurse to be alert to physiological changes. If these individuals are verbal, self-report may be possible. Depending on the intellectual ability and developmental age, many individuals with intellectual disabilities are able to self-report (McGuire & Defrin, 2015). The nurse can use similar instruments as described for pediatric patients. Many children with special needs attend public school, and school nurses are responsible for pain assessment and management. Quinn (2016) surveyed school nurses and found that the majority used standardized assessment instruments and varied these depending on the cognitive ability of the child. These nurses relied on teacher assessment and physical assessment for those with profound special needs. A good tool to use with profoundly intellectually disabled children is the Checklist Pain Behavior. Dutch researchers initially developed a 23-item checklist to detect pain in children with profound intellectual and severe or profound motor disabilities

21 Assessment of Pain in Special Populations 7 (Terstegen, 2004). Subsequently, a shortened checklist consisting of 10 behaviors was tested and found reliable and valid with a sample of children with profound intellectual and motor disabilities (van der Putten & Vlaskamp, 2011). The 10 items are used to indicate whether pain is present. The behaviors include tense face, deeper nasolabial furrow, grimace, looking sad, eyes squeezed, panic or panic attack, moaning, crying, sounds of restlessness, and tears. Alternatively, the FLACC scale has been modified for use with children between 4 and 19 years of age with cognitive impairment (Crellin et al., 2015). Also, the revised FLACC can be used with nonverbal children with cerebral palsy (Pedersen, Rahbek, Nikolajsen, & Moller-Madsen, 2015). Some nonverbal individuals with intellectual disabilities respond to pain with different behaviors, such as freezing in place. The healthcare professional should engage the parent, guardian, or significant person in the assessment process. Davies (2010) found that parents were able to recognize pain in their children with Down syndrome. Pain indicators to these parents were changes in social and emotional state as well as verbal responses. These individuals are familiar with the usual behavior of the patient and are able to relay aberrant behavior. Some nonverbal individuals with developmental disabilities demonstrate self-injury behaviors and other problem behaviors, such as aggression. In a sample of children with an average age of 4, those with problem behaviors had higher pain scores (Courtemanche, Black, & Reese, 2016). It is unclear whether these behaviors are in response to pain. Additional research is needed to understand this phenomenon. GERIATRIC PATIENTS The older adult is at risk for both underreporting and undertreatment of pain (Ware et al., 2015). The risk of pain from a variety of medical disorders (including osteoarthritis, injury from falls, diabetes, and malignancies) increases with age (Patel, Guralnik, Dansie, & Turk, 2013; Patel et al., 2014). Evidence suggests that as individuals age, their tolerance for pain decreases (Hadjistavropoulos et al., 2014). Some common causes of pain in older adults are musculoskeletal pain, peripheral neuropathies, and neurologic disorders (Molton & Terrill, 2014; Reid, Eccleston, & Pillemer, 2015). The treatment of persistent pain in the older adult is important because those with pain reduce physical and social activities, leading to increasing pain, obesity, and social isolation (Molton & Terrill, 2014). In a national survey of nursing home Medicare beneficiaries, 60% experienced persistent moderate to severe pain (Shen, Zuckerman, Palmer, & Stuart, 2015). The incidence of herpes zoster, or shingles, increases with age, with between 6 and 8 per 1,000 people over the age of 60 experiencing shingles (Kawai, Gebremeskel, & Acosta, 2014). An estimated 5% to 30% of those contracting shingles developed pain afterward (Kawai et al., 2014). This pain is called postherpetic neuralgia. Barriers to Pain Management In a study of older adults who were admitted to an emergency department for a long bone fracture, Fry, Arendts, Chenoweth, and MacGregor (2015) reported that 80% of the 255 older adults received pain medication. However, the average wait time for analgesia was 83 min, with cognitively impaired individuals waiting an average of 149 min. Several specific barriers have been identified that result in the underreporting and undertreatment of pain in older adults. Some older adults underreport their pain in the belief that pain is a natural part of the aging process and should be expected and that other comorbid conditions are more important and hold negative attitudes to pain treatment options (Makris et al., 2015; Savvas & Gibson, 2016). Communication gaps can occur when older adults use different words

22 8 Assessment of Pain in Special Populations to describe pain (such as ache or soreness) and may respond that they do not have pain when asked to rate it. Also, some older adults avoid activities that produce pain and therefore report no pain. The elderly are often fearful of addiction, overdose, and side effects and may refuse medications because they are afraid to use anything unfamiliar (Molton & Terrill, 2014). Older adults with financial concerns or constraints may choose to refuse some treatments. In addition, the older adult is more likely to have cognitive impairments, discussed later in the chapter, that make pain assessment more difficult. Jones and colleagues (2006) conducted a prospective descriptive study in 12 Colorado nursing homes. Residents were interviewed every 3 months about their pain to ascertain barriers to effective pain management. The researchers found that of those reporting pain, one half did not request pain medications. The most common reasons for not requesting pain medicine were stoicism and medication concerns (Jones et al., 2006). Herr and Titler (2009) conducted a retrospective longitudinal review of pain assessment and pharmacologic interventions for older adults with hip fractures in 12 Midwestern emergency departments. They were interested in examining whether The Joint Commission s pain assessment standards had made an impact on pain assessment and management for older adults with hip fractures. A total of 1,454 records were reviewed. The average age of the patients was 84 years, and these patients were predominantly White females. The percentage of patients who were assessed using an NRS increased from 16.5% to 54.4% over the 33 months of the study. At the end of the study, 34% of the patients had not been assessed for pain with any objective measure. In addition, although pain was documented in almost all records, only 60% of the patients received any analgesia (Herr & Titler, 2009). Pain Assessment in the Older Adult There are many unidimensional pain intensity rating scales. The selection of the most appropriate rating scale depends on many factors, such as the patient s cognition, physiological state, sensory alterations (such as hearing and vision impairment), education level, culture, and personal preference. When selecting an intensity rating scale, the nurse needs to pay attention to these factors. The Visual Ana logue Scale involves the patient marking where the pain falls from 0 to 10 on a linear continuum, with 0 meaning no pain, and 10 indicating the worst pain possible. The NRS provides a numerical pain score and a verbal report by the patient of a number on a continuum of 0 to 10. The patient is cued to remember the worst pain he or she has ever felt or the worst that the current pain level has been and to rate it from 0 to 10. The patient then verbalizes the pain score that reflects his or her current pain level. With the Verbal Descriptor Scale, the nurse asks the patient to rate his or her pain as none, slight, mild, moderate, severe, extreme, or most intense possible. Older adults often prefer this scale (Taylor & Herr, 2003). The Iowa Pain Thermometer combines the verbal descriptors with the visual aid of a thermometer, and some older adults prefer this tool. The revised FACES Pain Scale is appropriate for cognitively intact and cognitively impaired adults of various cultures (McCaffery, Herr, & Pasero, 2011). Because older adults with mild to moderate cognitive impairment can often self-report, the nurse should try a self-report measure before resorting to a behavioral scale (Hadjistavropoulos et al., 2014). Instruments that measure the multidimensional nature of pain can be used to determine the intensity of pain as well as how the pain affects the patient s function and quality of life and what pain relief measures have or have

23 Assessment of Pain in Special Populations 9 not alleviated the pain. One example is the McGill Pain Questionnaire. This widely used questionnaire is a 78-item instrument that uses verbal descriptors to report pain in the sensory, evaluative, and affective dimensions. It is available as a short form, which has been demonstrated to have more utility in the cancer pain setting, in which patients tire easily (Melzack, 1987). Another widely used instrument is the Brief Pain Inventory (Daut, Cleeland, & Flanery, 1983). Using the Brief Pain Inventory, the patient indicates intensity of pain at worst, usual, and least and the degree of interference with functioning. The Brief Pain Inventory short form is a reliable and valid tool for measuring all types of pain (McCaffery et al., 2011). Pain Assessment in the Cognitively Impaired Older Adult The assessment of pain in the patient with cognitive impairment is complex (Booker & Herr, 2016). Dementia and delirium are two common conditions that can occur in the older adult. Dementia is a serious degenerative brain disorder that primarily affects those over 65 years of age and affects millions of older adults. Alzheimer s disease is the most common cause of dementia and is the sixth leading cause of death in the United States (Alzheimer s Association, 2017). Some suggest that the experience of pain may be perceived differently in dementia due to pathologic changes in the neurologic system with some variance in tolerance and pain thresholds (Hadjistavropoulos et al., 2014). Further complicating assessment, researchers suggest that the nonverbal expression of pain is altered in dementia patients (Scherder et al., 2005). However, in a study of nursing home residents with dementia, Barry, Parsons, Passmore, and Hughes (2015) found that the majority of residents (83%) were able to self-report their pain with the 7-point Verbal Descriptor Scale. Because individuals with dementia become increasingly unable to verbalize their experiences, assessment measures such as the Pain Assessment in Advanced Dementia Scale (PAINAD), which is discussed later in the chapter, are indicated. In a study of nursing homes, residents with cognitive impairments were less likely than other patients to receive treatment for pain (Reynolds, Hanson, DeVellis, Henderson, & Steinhauser, 2008). Delirium, or acute confusion, often occurs during hospitalization. The older adult is at an increased risk for altered mental status during an acute illness (Inouye, Westendorp, & Saczynski, 2014). Although the etiology of delirium is multifactorial, a disruption of neuro transmitters and neurologic pathways in the brain occurs with environmental and physiological alterations (Inouye et al., 2014). The causes of delirium are complex. Delirium risk increases with age and for those with cognitive impairments, such as dementia. The reported incidence of delirium is variable across healthcare settings, with the highest rates in intensive care units and palliative care (Inouye et al., 2014). Recent guidelines emphasize the need to assess for pain in intensive care unit patients with delirium and strongly support use of selfreport with an NRS (Barr & Pandharipande, 2013). If patients are unable to self-report, these guidelines recommend use of the Behavioral Pain Scale or the Critical Care Pain Observation Tool. Others suggest that the PAINAD may be used for patients experiencing delirium (Paulson, Monroe, & Mion, 2014). Well-managed pain decreases the need for sedation and the prevalence of delirium in intensive care unit patients (Barr & Pandharipande, 2013) as well as the development of delirium (Paulson et al., 2014). Nurses assess pain through their knowledge of the usual behavior of patients, observing subtle behavior changes, and providing pain treatment (pharmacologic and nonpharmacologic) and then assessing for the response (Chang, Oh, Park, Kim, & Kil, 2011). The dynamic process of effectively assessing pain

24 10 Assessment of Pain in Special Populations relies on daily contact with patients. To promote comfort in patients with dementia, nurses can provide an individualized treatment process. As with the cognitively intact older adult, self-report is the preferable measurement of pain. Researchers have studied whether and how reliably individuals with cognitive impairments can report pain intensity and which is the most effective tool to use. Adults with mild to moderately severe cognitive impairment can rate their pain intensity with simple verbal tools (Booker & Herr, 2016). Because patients with cognitive impairment have difficulty with memory, test-retest reliability is poor (Feldt, Ryden, & Miles, 1998). Snow and colleagues (2009) studied community-dwelling adults with dementia using three simple pain intensity questions to predict decrease in psychosocial function: What is the pain now? What is the worst pain in the past week? How much does the pain interfere with usual activity? They reported no difficulty in obtaining responses from the subjects. As dementia symptoms increase, a person s declining abilities to remember, think abstractly, and verbally respond make self-report problematic. Cohen-Mansfield (2005) studied the reliability and validity of pain ratings by nursing staff members in a sample of 57 cognitively impaired nursing home residents. The level of familiarity with the patient increased reliability. When cognitive impairment was severe, pain rating scores were less reliable. A variety of behavioral assessment tools have been developed to assess pain in older adults with moderate to severe cognitive impairments. In this chapter, a few of the most commonly reported behavioral assessment tools, the Critical Care Pain Observation Scale, the PAINAD, the Pain Assessment Checklist for Seniors with Limited Ability to Communicate-II, the Abbey Pain Scale, and the Doloplus-2, are discussed (see Table 3). It is important that the nurse use a validated tool rather than rely on physiological measures. These behavioral assessment instruments commonly include facial expressions, vocalizations, body movement, and changes in activity or mood. The nurse should also keep in mind the context and illness experienced. For instance, certain medical events, such as a fracture, cause pain, and certain interventions, such as suctioning, are noxious. Kanji and colleagues (2016) confirmed that the Critical Care Pain Observation Scale was useful for assessing pain in noncomatose, critically ill adults experiencing delirium and demonstrated high inter-rater reliability. The PAINAD consists of 5 behaviors (breathing, negative vocalization, facial expression, body language, and consolability) to observe and rate with a score TABLE 3: INSTRUMENTS TO ASSESS PAIN IN NONVERBAL ADULTS AND IN SEVERE DEMENTIA Instrument Source Context/Situation CPOT Kanji et al., 2016 Critical Care/delirium PAINAD Warden, Hurley, & Volicer, 2003 Moderate to severe dementia PASLAC-II Chan, Hadjistavropoulos, Williams, & Lints-Martindale, 2013 Long-term care/dementia or nonverbal Abbey Pain Scale Abbey et al., 2004 Moderate to severe dementia Doloplus-2 Pautex, Herrmann, Michon, Giannakopoulos, & Gold, 2007 Moderate to severe dementia CPOT = Critical Care Pain Observation Tool; PAINAD = Pain Assessment in Advanced Dementia Scale; PASLAC-II = Pain Assessment Checklist for Seniors with Limited Ability to Communicate. Note. From Western Schools, 2018.

25 Assessment of Pain in Special Populations 11 from 0 to 2 (Warden, Hurley, & Volicer, 2003). A higher score indicates greater intensity of pain. The scale takes 5 min to administer and has been shown to be a valid measure (Lukas, Barber, Johnson, & Gibson, 2013). The Pain Assessment Checklist for Seniors with Limited Ability to Communicate-II is composed of 31 items grouped in the following categories: facial expressions, verbalizations, body movements, changes in interpersonal interactions, changes in activity patterns, and mental status changes (Chan, Hadjistavropoulos, Williams, & Lints- Martindale, 2014). This instrument has been tested in long-term care facilities and is simple enough to be used by care partners as well as registered nurses with appropriate training and can reliably distinguish presence of pain from no pain (Hadjistavropoulos et al., 2014). Each item is scored 0 (not present) or 1 (present). The Abbey Pain Scale contains both behavioral and physiological measures (Abbey et al., 2004). Vocalization, facial expression, change in body language, behavior change (alteration in usual patterns), physiological change (temperature, pulse, or blood pressure), and physical changes (such as skin tears, pressure areas, and other injuries) are rated on a Likert scale from absent (0) to severe (3). Scores can range from 0 to 18. The Abbey Pain Scale can measure both presence and intensity of pain (Lukas et al., 2013) and is a good instrument for nurses who assess pain in nonverbal patients less frequently (Neville & Ostini, 2014). The Doloplus-2 is composed of 10 assessment items in 3 groups: somatic, psycho motor, and psychosocial reactions. There are five observations for somatic reactions (somatic complaints, protective body postures, protection of sore areas, expression, and sleep pattern). Psychomotor reactions include two observations (washing/dressing and mobility), and psycho social reactions include three observations (communication, social life, and problems of behavior). Observations are rated on a Likert scale from 0 to 3. A score of 5 or more indicates the presence of pain (Pautex, Herrmann, Michon, Giannakopoulos, & Gold, 2007). When used to assess pain in nursing home patients with severe dementia, the Doloplus-2 identified the presence of pain in a greater number of patients than judgments of nurses not using a tool. Neville and Ostini (2014) found the Doloplus-2 to have good inter-rater reliability and very good validity, but it is more suitable for nurses with greater experience. The caregiver s familiarity with the patient may assist the nurse in assessing the nonverbal older adult, and nurses are encouraged to use these individuals to validate presence of pain (Booker & Herr, 2016). CASE STUDY 1 A 4-year-old boy is brought to the emergency room by his mother after a fall off a slide at a local park. His mother reports that he did not hit his head but landed hard on his right arm. The boy is crying and is clinging to his mother. The mother is talking gently to her son. She tells her son that the nurse will help him. The triage nurse notes that there is an obvious deformity of his right arm. When the nurse tries to examine the boy, he guards his arm and cries loudly when the arm is touched. The boy does not respond to the nurse verbally and continues to cling to his mother. The nurse records in the chart that his pain is severe. Questions 1. Can the nurse perform an objective measure of pain? 2. How should the mother be included in the pain assessment? 3. Because it is obvious that the child is in pain, is it necessary to use a rating scale? Responses 1. As previously stated, a 4-year-old may or may not be able to accurately report pain