Pain Assessment Across the Life Span

Transcription

1 Pain Assessment Across the Life Span What is the Evidence? Kim Litwack PhD RN FAAN University of Wisconsin-Milwaukee

2 Pain Definition Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage Major complaint in primary care and in hospitalized patients. It is the #1 concern of patients facing surgery.

3 Importance of Pain Assessment Beyond code of ethics and beyond regulatory requirements Essential for optimal care Patients for care to ensure rapid titration of therapy and pre-emptive intervention

4 Why Assess? The 5 th vital sign Assessment leads to nursing diagnosis Nursing diagnosis leads to intervention Intervention leads to improved patient outcomes and improved patient satisfaction All patients can be assessed.

5 Hierarchy of Assessment Patient self-report Known painful procedures/pathology Surrogate/proxy reporting Behavior Physiologic indicators

6 Self Reporting Scales Simple Useful Valid as a subjective measure Sensitive to small changes in intensity Common and well understood by patients and PACU nurses That said, scales were designed for research and, as such, have limitations

7 Accepted Tools for Verbal Patients

8 Easily Translated Please point to the number that best describes your pain No pain Terrible pain provides access to the faces and 1-10 scale translation for over 30 languages

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10 Second level: Consider pathology Type of surgery Procedures

11 Third Level: Surrogate/Proxy Reporting

12 Fourth and Fifth Level: Behavior and Physiologic Responses

13 Little knowledge about tools for those unable to communicate

14 Objective Assessment Tools We look for data We need data But is the tool giving us the data that we need? We are trying to make a judgment about behavior and data as an interpretation of a personal experience

15 What is the reliability and validity of our assessment tools? Reliability: precision and consistency of a measure- Validity: accuracy in measuring what we want to measure-

16 Pediatric pain Neonates and infants do experience pain Neonates experience as much pain as older children and experience long-term consequences from exposure to repeated painful stimuli

17 Premature Infant Pain Profile (PIPP) Useful for premature infants less than 36 weeks Uses physiologic indicators as evidence, including behavioral state, heart rate, O 2 sat, brow bulge, eye squeeze and nasolabial furrow

18 PIPP: Premature Infants

19 CRIES: 32 weeks pre-term to 20 weeks post-delivery

20 CRIES Excellent inter-rater reliability (>0.9) Excellent construct reliability (p<0.001) Good concurrent validity with other scales Good predictive validity

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22 N-PASS Inter-rater reliability for pain (0.95 for pain and 0.90 for sedation-p<0.001 to ) Variable internal consistency (Cronbach a 0.82 for high pain scores and 0.31 at low pain scores) Concurrent reliability with PIPP scale (0.83) Good discriminate validity (p<0.0001) High construct validity (p<0.0001) pre and post pain intervention

23 Neonatal Infant Pain Scale (NIPS) Premature and full term infants

24 Sometimes it is easier than others

25 Riley: Children < 36 months

26 FLACC- 2 months to 7 years and Cognitively Impaired

27 FLACC Criterion validity is high (p=0.963) Inter-rater reliability is high (r > ) Internal consistency is high (Cronbach a 0.882) Construct validity high (p<.001) as scores dropped after pain medication was administered

28 Comfort Scale Children, cognitive impairment, intubated patients

29 Others CHEOPS: Children s Hospital of Eastern Ontario (Canada) Pain Scale Children 1-7 years old Cry, facial, verbalizations, torso, touch, legs Does include verbalizations for those old enough, but relies on behavior as well

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31 PAINAD Internal consistency reliability ranging from.50 (behavior at rest) to.67 (for behaviors during unpleasant caregiver activities Inter-rater reliability high (r ) Lin P.C., Lin L.C., Shyu Y.I.L. & Hua M.S. (2010) Chinese version of the Pain Assessment in Advanced Dementia Scale: initial psychometric evaluation. Journal of Advanced Nursing 66(10),

32 Chronic Pain Scale for Nonverbal Adults with Intellectual Disabilities (CPS- NAID) Burkitt, Breau, Salsman, Sarsfield-Turner & Mullen (2009) Needs more research but offers cut-off scores and early psychometrics are good. Based on items that are highly valid and reliable in children Non-communicating Adult Pain Scale (NCAPS) Lotan, Ljunggren, Johnsen, Defrin, Pick, & Strand (2009) Lotan, Moe-Nilssen, Ljunggren& Strand (2009) Pain and Discomfort Scale (PADS) Bodfish, Harper, Deacon, Symons (Report; 2001) Phan, Edwards, Robinson (2005) Oberlander, T. & Symons, F. (2006). Pain in children and adults with developmental disabilities. Baltimore, MD: Brookes Publishing Co.

33 More Pain Measures (Breauet) for nonverbal children and adults Non-communicating children's pain checklist-revised (NCCPC-R) Non-communicating children's pain checklist-post-operative version (NCCPC-PV) Chronic Pain Scale for Nonverbal Adults with intellectual Disabilities (CPS-NAID) Available for free download to use in practice

34 Caveats with assessment tools Selection of developmentally appropriate pain scale Selection of appropriate intervention, which may be non-pharmacologic Assessment is a process not an end-point No empirical evidence demonstrating the superiority of one assessment tool over another, but research does suggest that the same scale(s) should be used within an institution

35 Despite the numbers It is particularly important for nurses to KNOW THE PATIENT and to know the USUAL CARE- GIVERS as YOU and their caregivers are better than any tool in assessing pain and the response to interventions. Consideration of self-report, pathology and proxy as more reliable and valid

36 Does not require a tool to assess.. Facial expression and vocalizations, body posture and movement patterns These are accurate means for assessing the Scores can mislead. A low, medium or high score does not indicate the patient s level of distress

37 Nursing Process Use of the nursing process can guide pain management in any setting ASSESS using all data available DETERMINE need for action PLAN your intervention INITIATE intervention RE-ASSESS patient response and modify as needed

38 Patient satisfaction is highest with Patient experiences with the nursing staff To include:, skill, friendliness, sensitivity Fulfillment of expectations To include response to complaints, especially of pain

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40 So what is the best pain assessment tool?

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42 Thank you