WEIGHING IN ON HOW MUCH IT HURTS. Janet Jones, RN, BSN, PHN, ET, CWOCN, DAPWCA 64 HEALTHY SKIN

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1 WEIGHING IN ON HOW MUCH IT HURTS Janet Jones, RN, BSN, PHN, ET, CWOCN, DAPWCA 64 HEALTHY SKIN

2 SURVEY READINESS The Problem with Pain Aside from causing discomfort for residents and making daily living difficult, pain is also hard to assess and measure. So it s not uncommon for nursing home residents to have pain that s undertreated or untreated. To provide the best care possible, we must make every attempt to treat residents pain. This means finding the right measurement tools and procedures, and consistently following them. Common Measures in Daily Care Though a variety of methods can be used to measure pain, it s been found that scales are an especially helpful assessment tool. Using verbal, visual, or numeric measures, pain intensity scales objectively measure the sensory aspect of a resident s pain. Based on the resident s response, the scale helps you choose the most appropriate pain medication and determine the effectiveness of any other medication they re currently taking. Of course, how well a scale works depends on using the right one. Not All Scales are Effective The most commonly used scales aren t necessarily ideal. They measure pain using categorical descriptors, either verbal (none, mild, moderate, severe) or numerical (0 through 3). Residents are asked to choose the category that describes their pain. The problem is that these types of scales have inherent limitations. Healthcare professionals tend to receive varying descriptions for the same pain level from different residents, and find that their own category descriptions inadvertently influence a resident s response. The result? Inadequate or excessive treatment, which at best does nothing to address residents pain and at worst may put their lives at risk. Plus, resident records are inaccurate from both a medical treatment and insurance provider perspective. Better Scales for Best Results Knowing that pain scales are still the most effective option, caregivers look for new and better methods to properly measure the amount and intensity of residents pain. A few of the best pain assessment scales are outlined below you may want to consider using one or more of them at your facility: Numeric Pain Intensity Scale: Translated into many languages, this is a ten centimeter line with the words no pain at one end and worst possible pain at the other end, and numbers zero through ten running along the line from left to right. How do you use it? Ask residents to choose a number that represents the pain they re experiencing (0 = no pain; 5 = moderate pain; 10 = worst possible pain). While it can be presented verbally, visual viewing may help in standardizing the pain assessment process. Improving Quality of Care Based on CMS Guidelines 65

3 When can you use it? Considered the gold standard for pain assessment, it can be used for adults and children over age seven. It s also useful with hearingimpaired residents. FACES Pain Rating Scale (FPRS): This consists of six faces ranging from a happy, smiling face to a crying, frowning face. How do you use it? Ask residents to choose the face that most closely reflects their own pain at the time (face 0 = no pain; face 1= minor pain; up to face 5 = extreme pain). When can you use it? It s preferred for use with children age three and older. And can be used for cognitively impaired residents or those who speak English as a second language. (Note that validity and reliability for adult patients has yet to be established, though it s been used in geriatric population studies and found comparable to Visual Analog Scale.) Visual Analog Scale (VAS): The most frequently used measurement scale in healthcare research; it s a ten centimeter line with verbal descriptors on each end. How do you use it? Ask residents to mark the location on the line that corresponds to the amount of pain they re currently experiencing (low end = no pain at all; high end = worst possible pain), which allows them to indicate exact intensity using a personal response style. Score it by measuring the millimeters between the low end and the resident s mark (this is interval-level data). When can you use it? Good for young children, adults and non-english speaking residents, as long as no visual or motor impairments are present. No special training is needed and there s little margin for error. (It s also reliable for measuring pain relief, with responses ranging from no pain relief to complete pain relief. ) 66 HEALTHY SKIN

4 SURVEY READINESS Additional information Repeat assessments should be done within a short time interval. Do not ask residents to recall previous pain levels. Reliability of results may vary if scoring is done by more than one person. Validity can be examined by using a different established and valid instrument, such as a numeric pain intensity scale, to measure a resident s pain at the same time as VAS. Use a computer-generated line or have the VAS printed. Using scale gradations may reduce its sensitivity. If more than one ruler is used for manual scoring, make sure they re identical. Meets current insurance industry standards for describing levels of pain; permits greater efficiency in recording and tracking resident information, and processing and submitting bills for payment. Can be used to measure other variables such as emotional distress, nausea, or recall and recognition of material in an educational presentation. Special Consideration for Wounds Wounds, and wound treatment, can be especially painful. And the pain can change over time. So when caring for residents with wounds, pay special attention to what they tell you about their pain, and follow these guidelines for effective healing and successful pain reduction. Remember, residents may have pain even though they don t express it. Quantify pain using a validated pain assessment scale, like the ones described above. Implement measures to eliminate or control the source of pain. Reposition residents off of wound(s). Use products that create and maintain an optimal amount of moisture. Consider the use of atraumatic wound dressings. Use support surfaces and other appropriate positioning devices. Use analgesics to treat procedure-related pain, as well as chronic pain. Initiate referrals to pain clinics for residents with chronic pain. Improving Quality of Care Based on CMS Guidelines 67

5 Pain Relief No Matter the Scale Depending on the scale you choose to use, if a drug is working well there should be a downward trend in the numbers, facial expressions should become more positive, or the mark on the line should be shorter upon repeated assessments. Reassessments should be done at regular intervals, after administration of pain medication or nondrug pain-relieving interventions, to ensure that optimal pain relief has been achieved. Staying on top of residents pain levels, and really listening to what they have to say about their pain, not only shows that you care and respect them it shows you re ultimately concerned with improving the state of their well-being. See examples of these pain scales in the Forms and Tools section, page 85. References Duggleby W, Lander J. Cognitive status and postoperative pain: Older adults. J of Pain and Symptom Management. 1994;9(1): Williams J, Holleman D, Simel D. Measuring shoulder pain with the shoulder pain and disability index. J of Rheumatology. 1995;22(4): Valvano M, Leffler S. Comparison of bupivacaine and lidocaine/bupivacaine for local anesthesia/digital nerve block. Annals of Emergency Medicine. 1996;27(4): Jacobson P, Bovbjerg D, Schwartz M, et al. Conditioned emotional distress in women receiving chemotherapy for breast cancer. J of Consulting and Clinical Psychology. 1995;63(1): Rabinov C, Kreiman J, Gerratt B, Bielamowicz S. Comparing reliability of perceptual ratings of roughness and acoustic measure of jitter. J of Speech & Hearing Research. 1995;38(1): Goldstein M, Clarke A, Michelson D, et al. Developing and testing a multimedia presentation of a health-state description. Medical Decision Making. 1994;14(4): Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guideline, No.3. Rockville, Md: AHCPR; Dahl JL, Gordon DB. Joint Commission Pain Standards: A Progress Report. APS Bulletin. 2002;12(6). McCaffery M, Passero C. Pain: Clinical Manual. 2nd ed. St. Louis, Mo: Mosby-Year Book, Inc; National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevalence, Cost, and Risk Assessment: Consensus Development Conference Statement. Decubitus. 1989;2(2): Fink R, Gates R. Pain Assessment. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. Oxford University Press; Keele KD. The Pain Chart. Lancet. 1948;2:6-8. Wong DL, Baker CM. Pain in Children: Comparison of Assessment Scales. Pediatric Nursing. 1988;14(1):9-17. Flaherty SA. Pain Measurement Tools for Clinical Practice and Research. Journal of the American Association of Nurse Anesthetists. 1996;64(2): Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Schwartz P. Wong s Essentials of Pediatric Nursing. 6th ed. St. Louis, Mo: Mosby; Dallam LE, Barkauskas C, Ayello EA, Baranoski S. Pain management and wounds. In: Baranoski S, Ayello EA. Wound Care Essentials Practice and Principles. Springhouse, Pa: Lippincott Williams & Wilkins; 2004: Cowles J. Pain Relief. Bloomington, Mn: MasterMedia; HEALTHY SKIN

6 SURVEY READINESS Pain Patient s Bill of Rights You have the right to: Have your pain prevented or controlled adequately. Have your pain and pain medication history taken. Have your pain questions answered freely. Develop a pain plan with your doctor. Know what medication, treatment or anesthesia will be given. Know the risks, benefits and side effects of treatment. Know what alternative pain treatments may be available. Sign a statement of informed consent before any treatment. Be believed when you say you have pain. Have your pain assessed on an individual basis. Have your pain assessed using the 0 = no pain, 10 = worst pain scale. Ask for changes in treatments if your pain persists. Receive compassionate and sympathetic care. Receive pain medication on a timely basis. Refuse treatment without prejudice from your doctor. Seek a second opinion or request a pain-care specialist. Be given your records on request. Include your family in decision-making. Remind those who care for you that your pain management is part of your diagnostic, medical or surgical care. by Jane Cowles, PhD Improving Quality of Care Based on CMS Guidelines 69