Pain assessment in the recovery room. (2024)

Introduction

The most widely adopted definition of pain describes it as 'anunpleasant sensory and emotional experience associated with actual orpotential tissue damage, or described in terms of such damage'(International Association for the Study of Pain 1979, p250). Thisdefinition recognises the subjective, complex and multifaceted nature ofpain and encompasses physical, psychological, social, cultural andenvironmental factors that interconnect and affect how pain isperceived, managed and evaluated (International Association for theStudy of Pain 2003).

Kehlet and Dahl (2003) contends that the practical aims of painrelief are to provide subjective comfort and enhance the patient'sability to deep breathe, cough and move easily, thus avoidingpostoperative complications (Carr & Goudas 1999, Bertolini et al2002). However achieving 'subjective comfort' can offerpractitioners a challenge, as a report of pain requires that they musttry to develop some understanding of the intensity, quality, locationand meaning of the pain being described in order to treat itappropriately. Social attitudes and cultural beliefs (of both the personin pain and practitioners) prevail and can limit effective assessmentand management of pain (McCaffery & Pasero 1999). Furthermore,researchers have repeatedly highlighted the inconsistencies that existbetween nurses' and patients' interpretations of pain (Dahlmanet al 1999, Sjostrom et al 2000, Idvall 2004, Carr et al 2005). Arguablydiscrepancies may be due, in part, to the fact that the parameters beingcompared by patients and nurses are not necessarily measuring the samepain experience (Sloman et al 2005, Brown et al 2007). Nevertheless painand pain assessment should be an accepted consideration for all patientsundergoing surgery.

Pain assessment tools

Pain assessment tools offer patients an opportunity to make alargely subjective experience objective, by describing pain in a waythat is meaningful to them. It is argued that it may also facilitatecontinuity of care (Bouvette et al 2002). In addition to improvingcommunication, insight into the potential analgesic needs of theindividual patient can be developed (particularly for those patientswith underlying chronic or palliative pain). While no satisfactoryobjective measures of pain exist (Joint Commission on the Accreditationof Healthcare Organisations 2001), it is imperative that formal painassessment tools are utilised not only to facilitate effectivecommunication, but also to reduce the chance of error or bias Carr &Mann 2000).

Practical pain assessment tools for consideration in the recoveryroom

Choosing the correct pain assessment tool requires practitioners totake into account the patient's age, language, socio-economic,educational and cognitive status (Bucknall et al 2001, Coll et al 2004).Presented below is a selection of the more commonly used pain assessmenttools which may be used in the recovery room to promote thepatient's self-report of pain and assist teams in managing thepatient's pain. A critique of their advantages and disadvantages isalso offered to aid decision making for applying the most appropriatetool for individual patients across the age spectrum.

[ILLUSTRATION OMITTED]

Unilateral pain rating scales

Single indicators of pain are arguably the most straightforwardtools to apply in the recovery environment and are primarily used todetermine 'how much a person hurts' (McCaffery & Pasero1999, p62). The Verbal Rating Scale (VRS), Numerical Rating Scale (NRS),Visual Analogue Scale (VAS), and Faces of Pain Scale (FPS) are suitablefor interpreting the intensity of pain and may be easily integrated intodocumentation processes in acute environments.

Verbal Rating Scale (VRS)

Known also as the Verbal Descriptor Scale (VDS), this tool offers achoice of four adjectives to describe increasing levels of painexperienced by an individual. The scale may be assigned numbers (rangingfrom zero to three) or letters (ranging from A-D) to assist recording(see Table 1).

For acute pain, the VRS provides a quick and simple method of painassessment in the recovery room and can be easily integrated intoroutine observation charts. Additionally, their simplicity may be moreappropriate for older people or those with mild cognitive impairment(Lawler 1997) as VAS or NRS for pain can be conceptually difficult forolder people to use (Closs 1996). While offering a limited choice ofwords may be deemed prescriptive (Schofield 1995), extending the wordchoice makes the VRS time consuming and complicated for patients (Jensen& Karoly 1992). A significant difficulty of employing a VRS is thatit can be difficult to ascertain small changes in pain, as the VRSintervals are less sensitive than those of the NRS and VAS (Williamson& Hoggart 2005). Nevertheless, Lara-Munoz et al (2004) propose thatthe VRS can provide reliable scientific information.

Visual Analogue Scale (VAS)

This tool comprises of a 10cm line with 'no pain' locatedat the point of zero and 'worst imaginable pain' located atthe opposite end. The patient is asked to place or move a marker to thelevel that best indicates the intensity of their pain. The VAS (Figure1) may be administered using a plastic ruler with a sliding marker or bypaper. It is largely presented to the patient horizontally (Ogon et al1996), however as pain may be considered as something that'rises' it can also be used vertically (Aun et al 1986,Stephenson & Herman 2000).

There are variations of the VAS available with numbers (from zeroto 10 or zero to 100) or words (no pain, moderate pain, severe pain)being supplemented (see Figure 2).

Williamson and Hoggart (2005) suggest that the more levels a paintool has the more sensitive it will be to detecting changes in pain.However, Jensen and Karoly (1992) have urged caution in its use due topatients experiencing difficulty in understanding and using the VAScompared to other scales.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Numerical Rating Scale (NRS)

The NRS is an interval level tool that is applied verbally by thepractitioner who asks the patient to rate their pain intensity from zeroto five or 10. Some studies present the NRS as increasing from zero tofive, 10, 20 or 100 (Williamson & Hoggart 2005). As with the VAS,the end point zero signifies no pain and five (10, 20 or 100) representsthe worst pain possible.

Since many patients understand the concept of rating their painfrom zero to 10, with minimal explanation, this method of painassessment can be useful when trying to determine the degree of pain anindividual is experiencing in situations where they will not or cannottolerate lengthy questioning. Thus NRS may be useful for patientsrecovering from anaesthesia, those admitted under stressful or traumaticconditions, the less well educated and the visually impaired (McCaffery& Pasero 1999). Ferrell (1995) suggests that applying a NRS fromzero to five may be the most appropriate pain rating scale forcognitively-impaired patients.

The validity of the NRS has been well established (Jensen &Karoly 1992). Additionally, its sensitivity to small changes in pain andits correlation to the VAS are robust (Jensen et al 1986). Its ease ofunderstanding and application makes it a useful tool for daily practice,research and audit purposes. Nevertheless not all patients have theability to perceive their pain numerically (Carpenter & Brockopp1995, Bird 2003). A further consideration in applying this tool is thatthe end point number (5, 10, 20, 100) must be agreed upon and appliedconsistently in order for meaningful pain assessment to be achieved.

The Faces of Pain Scale (FPS)

The Faces of Pain Scale (FPS) employs six facial expressions thatrange from a smile through to a grimace. The smiling face at the zeroendpoint signifies that the individual has no pain and as they progressthrough the faces the expressions change indicating that the pain isgaining in intensity. On the reverse or below the faces scale there is anumerical rating scale (NRS) ranging from zero to five (zero to 10versions are also available). The patient is asked to choose the facethat best represents their pain, which in turn corresponds to theappropriate number.

The Wong-Baker FACES of pain scale

A popular variation of the FPS, the Wong-Baker FACES of Pain Scale(Figure 3) comprises of a series of six facial expressions (ranging froma smile through neutral to a sad crying face). The smiling face at thezero endpoint signifies that the person feels happy because they have nohurt/pain. Progression through to face five symbolising that the personis experiencing the worst hurt/pain imaginable. The patient is asked tochoose the face that best describes how they are feeling (though theymay not be crying). Hurt, soreness and pain may be used interchangeablydepending on the age of the person who is using the tool.

[FIGURE 3 OMITTED]

In a modification of the Wong-Baker scale, a VAS has been added tothe faces (McCaffery & Pasero 1999). This amended tool has beenrecommended as the choice for most clinical settings due to itspopularity among children from three years (McCaffery & Beebe 1994)through to adult patients. Furthermore it has been translated intoseveral different languages. The FPS and Wong-Baker Scale also have theadvantage of avoiding the bias that can be associated with someinterpretations of the FPS (for example, Oucher scale (Beyer & Wells1989) for children and adolescents), because the faces do not depict oneparticular age, culture or sex. However, a primary drawback of this toolis that it can be a barrier for use with the visually impaired.

Several studies (Herr et al 1998, Kaasalainen & Crook 2004,Jowers Ware et al 2006) have confirmed the validity, reliability andsensitivity of the faces scale. Questions have been raised as to whetherthe FPS may measure overall well-being or fear, as opposed to theconstruct of pain (Stein 1996, Jowers Ware et al 2006). However, JowersWare et al (2006) contend that ease of use and the reliability andvalidity of the FPS make it a useful tool for evaluating pain intensity.

Limitations

Although useful for encouraging practitioners to apply a pain scalein busy recovery room environments, limitations of unilateral RatingScales exist in that they:

* offer a singular approach to pain assessment

* focus primarily on the intensity of pain (Flaherty 1996)

* fail to take account of the context of pain (Williamson &Hoggart 2005).

Other important factors such as location, quality, duration,emotional impact, type of pain and things that may exacerbate or reducepain are omitted. Though recovery room staff may focus primarily onrelieving immediate postoperative pain it is worth noting that the abovefactors might ultimately influence pain management decisions.Furthermore, applying the appropriate pain assessment tool accurately isonly one part of pain management. Of equal importance is thepreoperative preparation of patients (Coll 2004), accepting thepatient's self-report of pain (McCaffrey 1968, JCAHO 2001) andfrequent consultation with patients to determine the adequacy ofanalgesia, in order to plan and provide pain management interventions(Bucknall et al 2001, Dihle 2005).

Multidimensional Pain Rating Scales (MPS)

Increasingly patients admitted to hospital have an underlyingchronic pain condition for which they are already receiving treatment.For such patients Multidimensional Pain Scales (for example, The McGillPain Questionnaire (MPQ), (Melzack & Torgerson 1971), The short formMcGill Pain Questionnaire (SF-MPQ), (Melzack 1987), Brief Pain Inventory(BPI), (McCaffery & Pasero 1999)) may be more appropriate. Thesescales assess the location, intensity quality, duration, pattern and/oreffects of pain. Arguably multidimensional pain scales are not wellsuited for application in the recovery environment. However these painassessment tools may offer valuable information to recovery roompractitioners if they are completed prior to surgery. They may beparticularly helpful when the analgesic needs of patients, withunderlying painful conditions, appear to exceed 'the expectednorm'. Possibly this is an area that requires further investigationand input from recovery room practitioners.

Paediatric pain assessment tools

It is essential that pain assessment in children is appropriate forthe individual child and his or her family (Twycross et al 1998). Asculture, belief, cognitive level (including those with developmentaldisability), perceptions and the tolerance of pain differs in allchildren, determining the level of pain experienced can offer asignificant challenge. Thus there are a number of pain assessment tools,ranging from assessing pre-verbal to adolescent patients, available. Asa rule of thumb pain in paediatric patients can be measured by:

* what children do (behaviour)

* how their bodies react (biological)

* what children say (self-report) (Twycross et al 1998).

In addition Twycross et al (1998) have offered some guidance toclinicians in terms of which pain assessment tool should be used when(Table 2).

Older people (65 years and over)

While the prevalence of pain in older people varies throughout theliterature, what is consistent is that pain, in this patient group,remains problematic (NCEPOD 1999, Kaasakainen & Crook 2004, Lovheimet al 2006). As the admission of older people to hospital increases (DH2000), and inadequately managed pain is associated with many adverseconsequences (JCAHO 2001, Kemp et al 2005) the need for appropriate painmanagement is crucial (Brown 2004). However, as older people presentpractitioners with unique challenges (Table 3) it is necessary todevelop some understanding of what these challenges are, ifpractitioners are to enhance their practice.

Table 3 was compiled following a review of the literature relatingto older people undergoing surgery (Brown 2004) and an in-depthethnographic study of older people undergoing colorectal surgery (Brown& McCormack 2005, 2006).

Pain assessment with older people

None to mild cognitive impairment The principles for assessing painin older patients with no or mild/early cognitive impairment (includingdementia) are the same as those for a person with no memory problems(McClean & Cunningham 2007). McClean (2003) suggests older peoplecan report pain as accurately as their younger counterparts, using thepain rating scales outlined previously. However, it may be necessary toconsider adopting words other than pain in order to elicit a forthrightresponse (for example, ache, discomfort, sore). For those patients withmild cognitive impairment it is also helpful to clearly ask if they havepain at present, how big a problem it is and to give them sufficienttime to answer (McCaffery & Pasero 1999, McClean & Cunningham2007). Pain rating scales should be used until patients are no longerconsidered able to respond to the scale for themselves. They may well besignificantly cognitively impaired before this occurs (McClean &Cunningham 2007).

Moderate to severe cognitive impairment

As cognitive impairment progresses it becomes more difficult forpatients to accurately describe their pain and recovery roompractitioners become reliant on other sources of information concerningthe patient's pain. Assessing pain using behavioural indicators mayassist recovery room practitioners at this stage (American GeriatricsSociety 2002, Zwakhalen et al 2006). Behavioural indicator pain scalesplace the practitioner's observation of the patient into aframework that usually consists of:

* physiological changes--such as colour, vital signs, sleeppattern, guarding, sweating, loss of appetite

* body language changes--such as agitation, aggression, weeping,reaction to touch, increased or decreased movement

* behavioural changes--such as facial expression, withdrawal,assuming a foetal position.

There are a number of behavioural indicator pain assessment scalesavailable (for example, Hurley et al 1992, Kovach et al 1999, Feldt2000, Warden 2003, Abbey et al 2004) that include observation of some orall of the behaviours mentioned above. Debate concerning the reliabilityand validity of observational pain scales led the American GeriatricsSociety (AGS 2002) to examine the reliability of practitioners utilisingobservations to make a diagnosis of pain in patients with severecognitive impairment. Consequently they suggested six areas that shouldbe incorporated into behavioural pain assessment charts (facialexpression, negative vocalisation, body language, changes in activitypatterns or routine, changes in interpersonal interactions, mentalstatus changes).

Currently the only two behavioural pain assessment scales that takeaccount of all six areas are:

* The Assessment of Discomfort in Dementia Protocol (ADD) (Kovachet al 1999)

* The Abbey Pain Scale (Abbey 2004).

However, changes in activity patterns or routine, changes ininterpersonal interactions and mental status changes may be difficultfor recovery room practitioners to ascertain as they care for patientsfor relatively short periods of time. Nevertheless if ward nursing staffhave initiated behavioural assessment scales prior to surgery they mayassist recovery room practitioners in assessing pain in older patientswith cognitive impairment. This is an area that requires furtherresearch.

Summary

Pain assessment tools enhance communication between patients andpractitioners by making a subjective experience measurable. Field (1996)suggests that recovery ward nurses have a special and significant rolein assessing and relieving postoperative pain. Postoperative painassessment should focus on the needs of the individual patient ratherthan on preconceived ideas of how much pain a certain type of surgerymay elicit (Sjostrom et al 2000). To achieve this, a valid painassessment tool should be consistently utilised.

As highlighted earlier, a unilateral pain assessment tool may bebest applied in the initial postoperative period, with the recovery roomnurse taking an active part in asking the patient to rate their pain anddocumenting the reported pain for the patient. However, unilateral painassessment scales are not without their limitations. For those patientswho are anxious or not responding to pain management interventions,recovery room practitioners may need to consider the broader context ofpain (Botti et al 2004). In addition, MPSs (for patients with underlyingpain conditions) and behavioural pain assessment tools (for patientswith cognitive impairment) may offer recovery room practitioners theadditional information they require for enhancing pain managementpractices. However, this is an area that requires collaborative workingand further research (Table 4).

References

Abbey JA, Piller N, DeBellis A et al 2004 The Abbey Pain Scale. A1-minute numerical indicator for people with late-stage dementiaInternational Journal of Palliative Nursing 10 (1) 6-13

American Geriatrics Society (AGS) Panel on Persistent Pain in OlderPersons 2002 The management of persistent Pain in older persons Journalof the American Geriatrics Society 50 (Supplement) 205-224

Aun C, Lam YM, Collett B 1986 Evaluation of the use of visualanalogues scale in Chinese patients Pain 25 (2) 215-221

Bertolini G, Minelli C, Latronico N et al 2002 The use of analgesicdrugs in postoperative patients: The neglected problem of pain controlin intensive care units. An observational, prospective, multicentrestudy in 128 Italian Intensive Care Units European Journal ClinicalPharmacology 58 (1) 73-77

Beyer JE, Wells N 1989 The assessment of pain in children PediatricClinics of North America 36 (4) 837-854

Bird J 2003 Selection of pain measurement tools Nursing Standard 18(13) 33-39

Botti M, Bucknall T, Manias E 2004 The problem of postoperativepain: Issues for future research Journal of Nursing Practice 10 (6)257-263

Bouvette M, Fothergill-Bourbonnais F, Perreault A 2002Implementation of the pain and symptom assessment record (PSAR) Journalof Advanced Nursing 40 (6) 685-700

Brockopp DY, Warden S, Colclough G, Brockopp G 1996 Elderlypeople's knowledge of and attitudes to pain management BritishJournal of Nursing 5 (9) 556-562

Brown D, McCormack B 2006 Determining factors that impact uponeffective evidence based pain management with older people, followingcolorectal surgery: An ethnographic study Journal of Clinical Nursing 15(10) 1287-1298

Brown D, McCormack B 2005 Determining factors that impact uponeffective evidence based pain management with older people, followingcolorectal surgery: An ethnographic study Report Belfast, The RoyalHospitals

Brown D 2004 A literature review exploring how healthcareprofessionals contribute to the assessment and control of pain in olderpatients International Journal of Older People Nursing in associationwith Journal of Clinical Nursing 13 (6b) 74-90

Brown D, O'Neill O, Beck A 2007 Transition from epidural tooral analgesia Nursing Standard 21 (21) 35-40

Bruce A, Kopp P 2001 Pain experienced by older people ProfessionalNurse 16 (11) 1481-1485

Bucknall T, Manias E, Botti M 2001 Acute Pain Management:Implications of scientific evidence for nursing practice in thepostoperative context International Journal of Nursing Practice 7 (4)266-273

Carpenter J, Brockopp D 1995 Comparison of patients' ratingsand examination of nurses' responses to pain Cancer Nursing 18 (4)292-298

Carr DB, Goudas LC, 1999 Acute Pain Lancet 353 (June) 2051-2058

Carr ECJ, Mann EM 2000 Pain: Creative Approaches to EffectiveManagement London, Palgrave Macmillan

Carr ECJ, Thomas VJ 1997 Anticipating and experiencingpostoperative pain: the patients' perspective Journal of ClinicalNursing 6 (3) 191-201

Carr ECJ, Thomas VJ, Wilson-Barnet J 2005 Patient experiences ofanxiety and depression and acute pain after surgery: a longitudinalperspective International Journal of Nursing Studies 42 (5) 521-530

Closs SJ 1996 Pain and elderly patients: a survey of nurses'knowledge and experiences Journal of Advanced Nursing 23 (2) 237-242

Closs SJ 1994 Pain in elderly patients: a neglected phenomenonJournal of Advanced Nursing 19 (6) 1072-1081

Coll AM, Ameen JM, Mead D 2004 Postoperative pain assessment toolsin day surgery: literature review Journal of Advanced Nursing 46 (2)124-133

Dahlman GB, Dykes AK, Elander G 1999 Patients' evaluation ofpain and nurses' management of analgesics after surgery. The effectof a study day on the subject of pain for nurses working at the thoraxsurgery department Journal of Advanced Nursing 30 (4) 866-874

Department of Health 2000 The National Health Service Plan: A Planfor Investment, A Plan for Reform London, The Stationery Office

Dihle A, Bjolseth G, Helseth S 2006 The gap between saying anddoing in postoperative pain management Journal of Clinical Nursing 15(4) 469-479

Epps C 2001 Recognising pain in the institutionalised elder withdementia Geriatric Nursing 22 (2) 71-79

Feldt KS 2000 The Checklist of Nonverbal Pain Indicators (CNPI)Pain Management Nursing 1 (1) 13-21

Feldt KS, Ryden MB, Miles S 1998 Treatment of pain in cognitivelyimpaired compared with cognitively intact older patients with hipfracture Journal of American Geriatrics Society 46 1079-1085

Ferrell BA 1995 Pain Evaluation and management in the nursing homeAnnals of Internal Medicine 123 (9) 681-687

Ferrell B, Ferrell B 1992 Pain in the Elderly In: Watt-Watson J,Donovan M (Eds) Pain Management: Nursing Perspective Philadelphia PA,Mosby

Field L 1996 Factors influencing nurses analgesia decisions BritishJournal of Nursing 5 (14) 838-844

Fine PG 2001 Opioid analgesic drugs in older people Clinics inGeriatric Medicine 17 (3) 479-487

Flaherty S 1996 Pain measurement tools for clinical practice andresearch Journal of the American Association of Nurse Anesthetists 64(2) 133-140

Fotiadis RJ, Badvie S, Weston MD, Allen-Mersh TG1 2004 Epiduralanalgesia in gastrointestinal surgery British Journal of Surgery 91 (7)828-841

Gloth FM 2000 Geriatric Pain: factors that limit pain relief andincrease complications Geriatrics 55 46-54

Harkins SW, Kwentus J, Price DD 1990 Pain and Suffering in theElderly In: Bonica JJ (Ed) The Management of Pain Philadelphia, Lea andFebiger

Helme RD, Gibson SJ 2001 The epidemiology of pain in elderly peopleClinics in Geriatric Medicine 17 (3) 417-431

Herr KA, Mobily PR, Kohort FJ, Wagenaar D 1998 Evaluation of theFaces of Pain Scale for use with the elderly Clinical Journal of Pain 14(1) 29-38

Herr K. & Mobily P. 1991 Complexities of pain assessment in theelderly: clinical considerations. Journal of Gerontological Nursing 17(4) 12-19

Hockenberry MJ, Wilson D, Winkelstein ML 2005 Wong'sEssentials of Pediatric Nursing (7th Ed) St Louis, Mosby

Horgas AL 2003 Pain management in elderly adults Journal ofInfusion Nursing 26 161-165

Hurley AC, Volicer BJ, Hanrahan PA, Houde S, Volicer L 1992Assessment of discomfort in advanced Alzheimer patients Research inNursing and Health 15 (5) 369-377

Idvall E 2004 Quality of care in postoperative pain management:what is realistic in clinical practice? Journal of Nursing Management 12(3) 162-166

International Association for the Study of Pain 2003 PainTerminology Available from: www.iasppain.org/terms-p.html [Accessed 18September 2008]

International Association for the Study of Pain 1979 InternationalAssociation for the Study of Pain sub-committee on taxonomy, pain terms:a list of definitions and notes on usage Pain 6 (3) 249-252

Jensen MP, Karoly P, Braver S 1986 The measurement of clinical painintensity: a comparison of six methods Pain 27 (1) 117-126

Jensen TS, Karoly P 1992 Self-report scales and procedures forassessing pain in adults In: The Handbook of Pain Assessment (Turk DC,Melzack R eds) New York, The Guildford Press

Jin F, Chung F 2001 Multimodal analgesia for postoperative painJournal of Clinical Anaesthesia 13 (7) 524-539

Joint Commission on the Accreditation of Healthcare Organisations2001 Implementing the New Pain Management Standards Oakbrook, Illinois,JCAHO

Jowers Ware L, Epps CD, Herr K, Packard A 2006 Evaluation of theRevised Faces of Pain Scale, Verbal Descriptor Scale, Numeric RatingScale, and Iowa Pain Thermometer in Older Minority Adults PainManagement

Nursing 7 (3) 117-125

Kaasalainen S, Crook J 2004 An exploration of seniors' abilityto report pain Clinical Nursing Research 13 (3) 199-215

Kehlet H, Dahl J 2003 Anaesthesia, surgery and challenges inpostoperative recovery The Lancet 362 (9399) 1921-1928

Kemp CA, Ersek M, Turner JA. 2005 A descriptive study of olderadults with persistent pain: Use and perceived effectiveness of painmanagement strategies BioMedical Central Geriatrics 5 (12) 1-10

Kovach CR, Weissman DE, Griffie J, Matson S, Muchka S 1999Assessment and treatment of discomfort for people with late-stagedementia. Journal of Pain and Symptom Management 18 (6) 412-419

Lara-Munoz C, De Leon SP, Feinstein AR, Puente A, Wells CK 2004Comparison of three rating scales for measuring subjective phenomena inclinical research. I. Use of experimentally controlled auditory stimuliArchives of Medical Research 35 (1) 43-48

Lawler K 1997 Pain assessment (Supplement) Professional Nurse 13(1) 55-58

Layman Young J, Horton FM, Davidhizar R 2005 Nursing attitudes andbeliefs in pain assessment and management Journal Advanced Nursing 53(4) 412-421

Lovheim H, Sandman PO, Kallin K, Karlsson S, Gustafson Y 2006 Poorstaff awareness of analgesic treatment jeopardises adequate pain controlin the care of older people Age and Aging 35 (3) 257-261

McCaffery M, Beebe A 1994 Assessment In: Latham J (Ed) PainManagement and Nursing Care London, Mosby

McCaffery M, Pasero C 1999 Pain: Clinical Manual (2nd Edn)Missouri, Mosby Inc.

McCaffery M 1968 Nursing practice theories related to cognition,bodily pain and man-environment interactions Los Angeles, University ofCalifornia at Los Angeles Students' Store

McClean W, Cunningham C 2007 Pain in Older People and People withDementia: A Practical Guide University of Sterling, The DementiaServices Development Centre Publications

McClean W 2003 Identifying and managing pain in people withdementia Nursing and Residential Care 5 (9) 428-430

McClean W, Higginbotham N 2002 Prevalence of pain among nursinghome residents in rural New South Wales Medical Journal Australia 177(1) 17-20

McCormack B 2003 A Conceptual framework for person-centred practicewith older people International Journal of Nursing Practice 9 (3)202-209

Melzack R 1987 The Short-Form McGill Pain Questionnaire Pain 30191-197

Melzack R, Torgerson WS 1971 On the language of pain Anesthesiology34 (1) 50-59

Melzack R, Wall PD 1982 The Challenge of Pain London, Penguin

Morrison R, Sui A 2000 A comparison of pain and its treatment inadvanced dementia and cognitively intact patients with hip fractureJournal of Pain and Symptom Management 19 (4) 240-248

National Confidential Enquiry into Perioperative Deaths 1999Extremes of Age London, NCEPOD

Ogon M, Krismer M, Sollner W, Kantner-Rumplmair W, Lampe A 1996Chronic low back pain measurement with visual analogue scales indifferent settings Pain 64 (3) 425-428

Owen H, Szekely J, Plummer J, Cushnie J, Mather L 1989 Variables ofpatient controlled analgesia 2: concurrent infusion Anaesthesia 44 (1)11-13

Pasero C 2003 Pain in the emergency department. American Journal ofNursing 103 (7) 73-74

Powell AE, Davies HTO, Bannister J, Macrae WA 2004 Rhetoric andreality on acute pain services in the UK: a national postalquestionnaire survey British Journal of Anaesthesia 92 (5) 689-693

Rawal N 2002 Acute pain services revisited: good from far, far fromgood? Regional Anaesthesia and Pain Medicine 27 (2) 117-121

Schofield P 1995 Using assessment tools to help patients in painProfessional Nurse 10 (11) 703-706

Sengstaken EA, King SA 1993 The problems of pain and its detectionamong geriatric nursing home residents Journal of the American GeriatricSociety 41 (5) 541-544

Simons W, Malabar R 1995 Assessing pain in elderly patients whocannot respond verbally Journal of Advanced Nursing 22 (4) 663-669

Sjostrom B, Dahlgren LO, Halijamae H 2000 Strategies used inpostoperative pain assessment and their clinical accuracy Journal ofClinical Nursing 9 (1) 111-118

Sloman R, Rosen G, Rom M, Shir Y 2005 Nurses' assessment ofpain in surgical patients Journal of Advanced Nursing 52 (2) 125-132

Stein WM 1996 Cancer Pain in the Elderly In: Ferrell BR, Farrell BAPain in the Elderly: Taskforce on Pain in the Elderly Seattle, IASPPress

Stephenson NL, Herman JA 2000 Pain Measurement: a comparison usinghorizontal and vertical analogue scales Applied Nursing Research 13157-158

Turk D, Okifuji A 1999 Assessment of patients' reporting ofpain: an integrated perspective Lancet 353 (9166) 1784-1788

Twycross A, Moriarty A, Betts T 1998 Paediatric Pain ManagementOxon, Radcliffe Medical Press Ltd

Walding MF, 1991 Pain, anxiety and powerlessness Journal ofAdvanced Nursing 16 (4) 388-397

Warden V, Hurley AC, Volicer L 2003 Development and psychometricevaluation of the Pain Assessment in Advanced Dementia (PAINAD) scaleJournal of the American Medical Directors Association 4 (1) 9-15

Watt-Watson J, Stevens B, Garfinkel P, Streiner D, Gallop R 2001Relationship between nurses' pain knowledge and pain managementoutcomes for their postoperative cardiac patients Journal of AdvancedNursing 36 (4) 535-545

Williamson A, Hoggart B 2005 Pain: A review of three commonly usedpain rating scales Journal of Clinical Nursing 14 (7) 798-804

Wu CL, Richman J 2004 M. Postoperative pain and quality of recoveryCurrent Opinion in Anesthesiology 17 (5) 455-460

Yates P, Dewar A, Fentiman B 1995 Pain: the views of elderly peopleliving in long-term residential care settings Journal of AdvancedNursing 21 (4) 667-674

Zwakhalen SMG, Hamers JPH, Adu-Saad HH, Berger MPF 2006 Pain inelderly people with severe dementia: A systematic review of behaviouralpain assessment tools Biomedcentral Geriatrics 6 (3) Available from:www.biomedcentral.com/1471-2318/6/3 [Accessed 30 September 2008]

About the author

Donna Brown

PhD, MA, PGDipHP,

PGC(LLL), RGN

Senior Acute Pain Control

Sister, Belfast Trust, Royal

Hosptials, Belfast

Task 1

Review

Reflect

Review this article in relation to your experience of painassessment in the recovery room.

Reflect on your approaches to pain assessment, across the agespectrum.

Notional Learning Hours 1 hour for each task

Knowledge and Skills Dimension

Core 2: Personal and people development

Task 2

Reflect

Scheme of work

Arrange to spend some time with the Acute Pain Service observinghow they assess pain in different patient groups. Reflect on yourexperience and consider how you could use your new knowledge to improveyour practice and patient care

Notional Learning Hours 1 hour for each task

Knowledge and Skills Dimension

Core 2: Personal and people development

Task 3

Reflect

Identify patients in the recovery room with complex pain assessmentand management needs. Reflect on what knowledge and skills recoverywards nurses used to assess and manage their pain.

Notional Learning Hours 1 hour for reflection

Knowledge and Skills Dimension

Core 4: Service improvement Core 5: Quality

Task 4

Case study

Reflect

Complete a case study on a patient with complex pain managementneeds (e.g. underlying chronic or palliative pain).

Reflect on your how you assessed and managed their pain and whatknowledge you could bring to your role.

Notional Learning Hours 1 hour for each task

Knowledge and Skills Dimension

Core 2: Personal and people development

Core 3: Health, safety and security

Core 4: Service improvement

Core 5: Quality

HWB6: Assesment and treatment planning

HWB7: Interventions and treatments

Task 5

Project

Identify members of the multidisciplinary team who could assist youto develop preoperative pain assessment guidelines for patients withcomplex pain assessment needs. Consider what steps you may need to taketo promote enhanced pain assessment practices for these patients.

Notional Learning Hours 1 hour

Knowledge and Skills Dimension

Core 2: Personal and people development

Core 3: Health, safety and security

Core 4: Service improvement

Core 5: Quality

by Dr Donna N Brown Correspondence address: Acute Pain Service,Level 3, New Building, Royal Victoria Hospital, Grosvenor Road, Belfast,BT12 6BA. Email: [emailprotected]

Additional Learning Resources

Associated AfPP online modules:

* Additional Learning Resources

* Associated AfPP on line modules:

* Airway Management

* Breathing Management

* Breathing Circuits and Their Uses

* Anaesthetic Drugs

* Supportive Pharmacology

* Circulation and Invasive Monitoring

* Patient Care: Knowing and Doing

* The Multi-disciplinary Team in the Operating Theatre

* Communication Skills

* Patient Care in the Operating Department

* Organisational Skills and Tools

* Patient Assessment in Recovery

* Pain Management in Recovery

* Health and Safety

* Infection Control

* Universal / Standard Precautions

* Managing Sharps and Waste

* Control and Scavenging of Waste Anaesthetic Gases

* Liability and Accountability

* Care and Responsibility

* Consent

* The Human Rights Act

Web links and key documents

International Association for the Study of Pain 2003 InternationalAssociation for the Study of Pain (IASP) pain terminology, availablefrom http://www.iasp-pain.org/terms-p.html. [Accessed 12/07/07]

British Association of Anaesthetic and Recovery Nurseshttp://www.barna.co.uk/

Reflective model

You will find this reflective model template and many others underthe career development tab on the AfPP website.

Table 1 Verbal Rating Scale0 Or A No pain1 Or B Mild Pain2 Or C Moderate Pain3 Or D Severe PainTable 2 Paediatric pain assessment tools and age suitabilityWhich tool should be used when?Tool Age groupFaces From 3 yearsPoker chips 4-8 yearsEland Colour Scale 4-10 yearsNumerical From 9-10 yearsVerbal Rating Scale 9-15Oucher 3-12 years Useful for young children and those with language difficultiesReproduced with permission of Twycross et al (1998) PaediatricPain Management: a multi-disciplinary approach Oxford,Radcliffe Medical Press p57Table 3 The challenges of assessing and managing pain in theolder personResearch findings suggest that:Pain sensitivity: threshold/toleranceMay differ in people of advanced age (Helme & Gibson 2001, Fine2001) with subsequent management of pain being complicated bymultiple, non-concomitant causes and locations of pain (Herr &Mobily 1991, Closs 1994, Epps 2001, Horgas 2003). However, it isincorrect to assume that 'differ' means that pain reduces orbecomes absent. Rather it implies there is a variation in theexperience of pain, with some possible increase in patients' paintolerance (McClean & Cunningham 2007).Analgesic intakeOlder people receive less analgesia than their younger counterpartswith the same degree of pain (Morrison & Sui 2000). This may be duein part to psychological or physical changes associated with age orthe dominant ageist belief that it is usual for older people toexperience pain daily and they 'simply have to put up with it'(Harkins et al 1990, Yates et al 1995, Gloth 2000). However, Owenet al (1989) argued that older patients, using Patient ControlledAnalgesia as a form of postoperative pain relief, did notself-administer less medication.Cognitive impairmentCognitively impaired people receive much less analgesia than theircognitively intact peers (Feldt et al 1998, Morrison & Sui 2000).Ferrell and Ferrell (1992) argue that it is dangerous to assumeolder people with cognitive impairment perceive pain differently,as there is no available evidence to suggest that individuals withcognitive impairment overstate or invent the pain they report(Bruce & Kopp 2001).PerceptionsThe older persons' perception of staff being 'too busy' (Yates etal 1995) or fear of being regarded as a nuisance influence theolder patients' willingness to communicate their pain concerns(Herr & Mobily 1991, Carr & Thomas 1997, Brown & McCormack 2006).Older people may further be disempowered because of negativestereotypical attitudes which assume that growing older inevitablyresults in reduced capacity for involvement (McCormack 2003). Thuscomplex pain management needs remain unaddressed (Helme & Gibson2001, Horgas 2003) or discussed with family members, who maythemselves not be sufficiently knowledgeable to best advise theolder person (Brown & McCormack 2006).PracticesTask orientated practices in the hospital setting, a lack ofawareness of older peoples' needs and wishes and inadequatecommunication affect pain assessment and management with olderpeople (Brown & McCormack 2006).CommunicationIt has been well recognised that older people may experiencedifficulties in communicating their analgesic needs to others(Sengstaken & King 1993, Simons & Malabar 1995). Brockopp et al(1996) found that although 92% of 125 older people understood thatthe person who is experiencing pain is the authority on their pain,only 66% believed that their pain would not be taken seriously whendiscussed with others. Ferrell (1995) highlights that poor memory,depression and sensory impairment may contribute to the challengesof achieving accurate pain assessment. The practicalities of olderpeople experiencing hearing difficulties make it possible thatpatients do not respond to questions concerning their pain becausethey misunderstand or simply did not hear what they were beingasked (Brown & McCormack 2006).Table 4 Key points for pain assessment toolsKey pointsPain assessment tools and charts must be:* Easily understood by patients and staff* Appropriate for the patient population they are to be used with* Quick to apply* Consistently applied and evaluated with patient input* Used with consideration to context and behavioural signs* Offer a sensitive, reliable and valid measure.