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Pain Management in the Non-Verbal Patient

L. Donnelly 2010

Gaylord Hospital


Pain Assessment 

Pain is whatever the person says it is, existing whenever he or she says it does (McCaffery, 1968). Pain is a subjective experience with no objective test available to measure it (APS, 2003). The best measure of pain comes directly from the patient using self-report.


Pain Assessment ď Ž

When patients are unable to self-report due to communication issues or level of consciousness, the nurse must provide routine assessments to ensure appropriate interventions are provided for pain relief.


Assessment ď Ž

ď Ž

No single measure exists to definitively assess pain in the non-verbal patient. The nurse must use a strategy of observing behaviors and body language, reviewing potential causes of pain and estimates of pain by others.


Assessment ď Ž

ď Ž

Assessment should include observing the patient for indicators of pain including: Noisy breathing, negative vocalization, sad or frightened facial expression, tense body language, fidgeting, aggressive or irritable behaviors (Gaylord Hospital policy P-P12).


Observe Behaviors ď Ž

ď Ž

Common behaviors may be identified in selected populations and may serve as a guide to pain assessment. Unfortunately, pain behaviors do not always provide accurate reflections of pain intensity and may actually reflect another source of distress, either physiological or emotional (Herr et al., 2006).


Observe Behaviors 

It is helpful to be aware of an individual’s baseline behaviors in order to accurately assess behaviors which deviate from the norm and may be indicative of pain (Herr et al., 2006). Family can be helpful in identifying baseline behaviors for non-verbal patients.


Review Potential Causes of Pain 

In addition to observing a patient’s behavior, all patients should be evaluated for potential causes of pain. This should include an assessment before and after any procedures, tests and activities such as positioning, transfers, ADLs.


Review Potential Causes of Pain ď Ž

Activities such as dressing changes, wound care, positioning and turning, blood draws, finger sticks and invasive procedures should be identified as potentially pain provoking and treated with appropriate pain relieving interventions, even in the absence of behavioral indicators (Herr et al., 2006).


Review Potential Causes of Pain ď Ž

Patients should also be evaluated for potential causes of pain based on physiological indicators and data such as vital signs, infections, laboratory results, assessment of skin integrity, etc.


Review Potential Causes of Pain ď Ž

ď Ž

Procedures known to create pain should not be undertaken until pain alleviating measures are taken. Observe behaviors closely during procedures and evaluate carefully for the possibility of sources of pain (Herr et al., 2006).


Surrogate Reporting 

Surrogate reporting may be necessary when patients are unable to self-report pain. Individuals with knowledge of the patient’s baseline behaviors may be helpful in identifying those behaviors which are indicative of pain.


Surrogate Reporting ď Ž

ď Ž

Parents and caregivers should be encouraged to actively participate in the assessment of pain in their loved one (Herr et al., 2006). Familiarity with the patient and knowledge of past behaviors can identify subtle changes that may be indicators of the presence of pain (Herr et al., 2006).


Assessment ď Ž

The nurse should use a combination of behavior observation, assessment of physiological indicators and surrogate reporting when determining the level of pain a patient may be experiencing.


Special Populations: Intubated or Unconscious  

Self-report of pain should always be attempted. If a patient is confused or having mental status changes, serial assessment for the ability to selfreport should be done (Herr et al., 2006). Conscious patients, even those experiencing confusion, should be given the opportunity to self-report their pain.


Special Populations: Intubated or Unconscious ď Ž

ď Ž

If patient is unconscious or unable to report, procedures and care should be evaluated for the potential of provoking pain. Pain medication should be given prior to procedures and care assumed to cause pain.


Special Populations: Intubated or Unconscious ď Ž

Sources of pain in critically ill patients include: their existing medical condition, traumatic injuries, medical procedures, invasive instrumentation and routine care such as suctioning, turning, positioning, catheter removal and wound care (Jacob & Puntillo in Herr et al., 2006).


Special Populations: Intubated or Unconscious ď Ž

ď Ž

In addition to these pain causing stimuli, consider immobility, infection and decubiti to be a source of pain. It should always be assumed that those unable to report pain are feeling pain during these procedures (Herr et al., 2006).


Vital Signs as Pain Indicator 

Using vital sign changes as a primary indicator of pain is not reliable. There is limited evidence that supports the use of vital signs as a single indicator of pain (Herr et al., 2006). Absence of increased vital signs does not indicate absence of pain (McCaffery & Passero, 1999).


Vital Signs as Pain Indicator 

The underlying condition of the patient, medications, stress, and patient positioning can all influence vital signs. A fluctuation in vital signs may indicate a change in condition unrelated to pain. A complete assessment should be done to identify potential sources of pain.


References 

American Pain Society (APS) (2003). Principles of analgesic use in the treatment of acute pain and cancer pain. (5th ed). Glenville, IL: Author. Gaylord Hospital Department of Nursing. Pain Management PolicyPP-12. Herr et al., (2006). Pain assessment in the non-verbal patient: Position statement with clinical practice recommendations. American Society for Pain Management Nursing, 7, 44-52. McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man environment interactions. Pasero, C., & McCaffery, M. (2002). Pain in the critically ill. The American Journal of Nursing, 102 (1), 59-60.

Pain Management in the non-verbal patient  

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