27 Oct 2013
Assessment and diagnosis for successful pain management
To provide optimal patient care, nurses require appropriate knowledge, skills and attitudes towards pain, pain assessment and its management. This must be based on the best available evidence to prevent patients from suffering harm (NMC, 2008 ). It is unacceptable for patients to experience unmanaged pain or for nurses to have inadequate knowledge about pain and a poor understanding of their professional accountability in this aspect of care (Dimond, 2002).
Pain - The fifth vital sign
Pain has been identified as the fifth vital signs by Australian and New Zealand College of Anaesthetists and the Chronic pain Coalition in an attempt to facilitate accountability for pain assessment and management (Chronic Pain Policy Coalition, 2007; ANZCA, 2005).
Education
Pre-registration nursing programmes should incorporate pain as a compulsory component, to equip future nurses with the knowledge, skills and attitude to carry out appropriate pain assessment and management from the start of their professional careers. This could result in all patients receiving a higher standard of pain assessment and management in the future and reduce the incidence of unnecessary suffering (Wilson, 2007).
Why is assessment important?
Assessment of a patient’s experience of pain is a crucial component in providing effective pain management. A systematic process of pain assessment, measurement and re-assessment (re-evaluation), enhances the health care teams’ ability to achieve:
a reduced experience of pain;
increased comfort;
improved physiological, psychological and physical function;
increased satisfaction with pain management.
Pain is not a simple sensation that can be easily assessed and measured. Nurses should be aware of the many factors that can influence the patients overall experience and expression of pain, and these should be considered during the assessment process. Fig 1 illustrates the factors involved in the experience of pain.
Pain assessment and measurement
The pain assessment involves:
an overall appraisal of the factors that may influence a patients experience and expression of pain (McCaffery and Pasero 1999)
acomprehensive process of describing pain and its effect on function;
an awareness of the barriers that may affect nurses assessment andmanagement of pain. These include:
- inadequate skills, knowledge, attitudes and beliefs about pain, its assessment and management and the nurses experience (Hall-Lord and Larsson, 2006);
- poor documentation of pain, its assessment, management and re-evaluation;
- patients’ age, type and stage of illness (Hall-Lloyd and Larson, 2006) - older people are less likely to report pain despite evidence showing that they are more likely to experience at least one concurrent problem with pain, for example, musculoskeletal pain or pain associated with peripheral vascular disease (British Pain Society and British Geriatric Society, 2007);
- Myths and misconceptions about pain and its management, for example, fear that patients with acute pain can easily become addicted to their pain medication (McCaffery et al, 2005).
Watch video on Pain Assessment in Older Adults
Measuring pain
Pain should be measured using an assessment tool that identifies the quantity and/or quality of one or more of the dimensions of the patients’ experience of pain. This includes the:
intensity of pain;
Pain - The fifth vital sign
Pain has been identified as the fifth vital signs by Australian and New Zealand College of Anaesthetists and the Chronic pain Coalition in an attempt to facilitate accountability for pain assessment and management (Chronic Pain Policy Coalition, 2007; ANZCA, 2005).
Education
Pre-registration nursing programmes should incorporate pain as a compulsory component, to equip future nurses with the knowledge, skills and attitude to carry out appropriate pain assessment and management from the start of their professional careers. This could result in all patients receiving a higher standard of pain assessment and management in the future and reduce the incidence of unnecessary suffering (Wilson, 2007).
Why is assessment important?
Assessment of a patient’s experience of pain is a crucial component in providing effective pain management. A systematic process of pain assessment, measurement and re-assessment (re-evaluation), enhances the health care teams’ ability to achieve:
a reduced experience of pain;
increased comfort;
improved physiological, psychological and physical function;
increased satisfaction with pain management.
Pain is not a simple sensation that can be easily assessed and measured. Nurses should be aware of the many factors that can influence the patients overall experience and expression of pain, and these should be considered during the assessment process. Fig 1 illustrates the factors involved in the experience of pain.
Pain assessment and measurement
The pain assessment involves:
an overall appraisal of the factors that may influence a patients experience and expression of pain (McCaffery and Pasero 1999)
acomprehensive process of describing pain and its effect on function;
an awareness of the barriers that may affect nurses assessment andmanagement of pain. These include:
- inadequate skills, knowledge, attitudes and beliefs about pain, its assessment and management and the nurses experience (Hall-Lord and Larsson, 2006);
- poor documentation of pain, its assessment, management and re-evaluation;
- patients’ age, type and stage of illness (Hall-Lloyd and Larson, 2006) - older people are less likely to report pain despite evidence showing that they are more likely to experience at least one concurrent problem with pain, for example, musculoskeletal pain or pain associated with peripheral vascular disease (British Pain Society and British Geriatric Society, 2007);
- Myths and misconceptions about pain and its management, for example, fear that patients with acute pain can easily become addicted to their pain medication (McCaffery et al, 2005).
Watch video on Pain Assessment in Older Adults
Measuring pain
Pain should be measured using an assessment tool that identifies the quantity and/or quality of one or more of the dimensions of the patients’ experience of pain. This includes the:
intensity of pain;
Morse Fall Scale
| Item | Item Score | Patient Score |
|---|---|---|
| 1. History of falling (immediate or previous) | No 0 Yes 25 | ______________ |
| 2. Secondary diagnosis (≥ 2 medical diagnoses in chart) | No 0 Yes 15 | ______________ |
| 3. Ambulatory aid None/bedrest/nurse assist Crutches/cane/walker Furniture | 0 15 30 | ______________ |
| 4. Intravenous therapy/heparin lock | No 0 Yes 20 | ______________ |
| 5. Gait Normal/bedrest/wheelchair Weak* Impaired† | 0 10 20 | ______________ |
| 6. Mental status Oriented to own ability Overestimates/forgets limitations | 0 15 | ______________ |
| Total Score‡: Tally the patient score and record. <25: br="" low="" risk="">25-45: Moderate risk >45: High risk | ______________ | |
* Weak gait: Short steps (may shuffle), stooped but able to lift head while walking, may seek support from furniture while walking, but with light touch (for reassurance).
† Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down; significantly impaired balance, requiring furniture, support person, or walking aid to walk.
Also watch Video on Fall Assessment in Seniors
‡ Suggested scoring based on Morse JM, Black C, Oberle K, et al. A prospective study to identify the fall-prone patient. Soc Sci Med 1989; 28(1):81-6. However, note that Morse herself said that the appropriate cut-points to distinguish risk should be determined by each institution based on the risk profile of its patients. For details, see Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging 1989;8;366-7.
† Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down; significantly impaired balance, requiring furniture, support person, or walking aid to walk.
Also watch Video on Fall Assessment in Seniors
‡ Suggested scoring based on Morse JM, Black C, Oberle K, et al. A prospective study to identify the fall-prone patient. Soc Sci Med 1989; 28(1):81-6. However, note that Morse herself said that the appropriate cut-points to distinguish risk should be determined by each institution based on the risk profile of its patients. For details, see Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging 1989;8;366-7.
26 Oct 2013
21 Oct 2013
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