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Checklist of Nonverbal Pain Indicators

Date: ______________ Patient Name:___________________________

(Write a 0 if the behavior was not observed, and a 1 if the behavior occurred
even briefly during activity or rest.)
With Movement Rest
1. Vocal Complaints: Nonverbal
(Expression of pain, not in words,
moans, groans, grunts, cries, gasps, __________ __________
sighs)
2. Facial Grimaces/Winces
(Furrowed brow, narrowed eyes,
tightened lips, dropped jaw, clenched __________ __________
teet, distorted expressions
3. Bracing
(Clutching or holding onto siderails,
bed, tray table, or affected area __________ __________
during movement
4. Restlessness
(Constant or intermittent shifting of
position, rocking, intermittent or __________ __________
constant hand motions, inability to
keep still
5. Rubbing:
(Massaging affected area)
(In addition, record verbal __________ __________
complaints)

6. Vocal Complaints: (Words
expressing discomfort of pain—
“ouch,” “that hurts”, cursing during __________ __________
movement, or exclamations of
protest—“stop,” “that’s enough”)

Subtotal Scores __________ __________

Total Scores __________ __________

_________________________________________________________________________________________

Sources: Feldt KS, Treatment of pain in cognitively impaired versus cognitively intact post hip fractured elders (Doctoral diss.)
Minneapolis: University of Minnesota, 1996. Dissertation Abstracts International 57, 09B: 5574; Feldt KS, Checklist of
Nonverbal Pain Indicators. Pain Management Nursing 2000;1 (1): 13021.
Elaboration and validation of Evendol, a behavioral pain scale for young children
attending the Accident and Emergency Department

Elisabeth Fournier-Charrière, MD 1, Christine Ricard, MD 2, Frédérique Lassauge, MD 3,
Barbara Tourniaire, MD 4, Patricia Cimerman, RN 4, Pascale Turquin, RN 1, Bruno
Falissard, MD 5, Christelle Descot, MD 1, Alexia Letierce, MD 1, Florence Reiter 1,
Bénédicte Lombart, RN 4, & Ricardo Carbajal, MD 4
1
Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris,
94275 Le Kremlin Bicêtre, France
2
CHU Lapeyronie, Montpellier
3
CHU St Jacques, Besançon
4
Hôpital Trousseau, Paris
5
Hôpital Cochin, Paris

Background
In the emergency department, pain has to be assessed quickly, in order to choose
appropriate analgesic. A simple behavioral scale, easy to understand, quick to read and
easy to fill out was needed for young children under 6.

Elaboration
EVENDOL, this new scale, was elaborated by five french pediatric pain specialists and
emergency staff members. After one year of different feasibility studies, five
appropriated items were arrested: vocal or verbal complaint, grimace, movements,
postures, interaction with surroundings. Each item is scored from 0 to 3, depending on
the intensity and the durability of the sign during the observation time. Total EVENDOL
score vary from 0 to 15.

Validation
The scale was tested at 3 times: before any care, during mobilisation, after analgesic.
Construct validity and inter rater reliability were studied. Children were assessed by the
nurse and the searcher, with EVENDOL and with Visual Analogue Scale (VAS), and
with other scales. Anxiety and asthenia levels were assessed. Self-assessment scores
were obtained from children above 4 y-o.

Results
297 children (1 month-6 years) were included.
Construct validity:
-scores before /after nalbuphine varied from 8.14 to 3.62 at rest (p<0.0001), from 11.87
to 6.65 at mobilisation (p=0.0011)
-correlations between VAS and EVENDOL: 0.79 to 0.92 at all times (p<0.0001)
-correlations between EVENDOL and other behavioral pain scales (EDIN, CHEOPS,
FLACC, TPPPS): 0.5 to 0.93 (concurrent validity)
-correlations between FPS-R and EVENDOL in 4-6 y-o children varied between 0.64 to
0.93
-correlations between EVENDOL and tiredness, and anxiety were bad (0.15 to 0.34)
(discriminant validity).

Presented at the 7th International Forum on Pediatric Pain,
White Point, Nova Scotia, Canada, October 2008.
Content validity: excellent Cronbach coefficient (0.83 to 0.92).
Inter-rater reliability between nurses and researcher: correlations 0.89 to 0.98, weighted
kappa 0.7 to 0.9.

Conclusion
EVENDOL, a new 5 items’scale to assess young children’s pain in the emergency
departments is validated. EVENDOL is simple and well accepted by nurses.

Presented at the 7th International Forum on Pediatric Pain,
White Point, Nova Scotia, Canada, October 2008.
The Assessment of Discomfort in Dementia (ADD) Protocol

The Assessment of Discomfort in Dementia (ADD) Protocol is a systematic
approach to be used by nurses to make a differential assessment and treatment plan for
both physical pain and affective discomfort experienced by people with dementia. Thus,
it should be noted that the ADD Protocol is not a typical pain assessment tool. The author
currently states the tool is an intervention. However, it is included in this review because
of its ability to detect pain in this population.
The ADD Protocol focuses on evaluation of persons with difficult behaviors that
may represent discomfort. Assessment of pain and discomfort is addressed by the
protocol. ADD encompasses physical, affective and social dimensions of pain.
In the 2002 version, a checklist of five categories of pain behaviors with
dichotomous items specified within each category: Facial expression (8 items), Mood (5
items), Body language (9 items), Voice (9 items), Behavior (11 items). If potential pain
behaviors are identified, the protocol consists five steps: (1) Assessment of physical signs
and symptoms; (2) Current / past history of pain; (3) If steps 1 and 2 are negative assess
environmental press, pacing of activity/stimulation, meaningful human interaction and
intervene with non-pharmacological Rx’s; (4) If unsuccessful, medicate with non-
narcotic analgesic per written order; (5) If symptoms persist, consult with physician/other
health professional or medicate with prn psychotropic per written order.
The method of administration is adequately described in articles on the ADD
Protocol. Although no documentation of the amount of time involved in using the
protocol is currently available, the protocol involves multiple steps and extensive
documentation to complete. Thus, use of the ADD would appear to require a considerable
amount of time. Moreover, the protocol involves complex clinical decisions, thus its use
also requires extensive education.
The ADD Protocol was tested (study 1) in 32 long term care facilities in a
convenience sample of 104 residents with a mean age 85 years, range 46-100, most of
whom had Dementia Alzheimer Type. Subsequent testing (study 2) was conducted in 6
LTC facilities in a convenience sample of 143 subjects, all Caucasian, 81% female, with
severe dementia. The average age was 86.65 years (±6.16), range 56-100 years.

Reliability
• Internal consistency reliability has not been provided and may not be appropriate
considering the nature of the protocol. However, the behavior checklist could and
should be evaluated for internal consistency.
• Interrater reliability for the protocol was established in study 1 in a very small sub-
sample of 4 residents with percent agreement for total tool 86%; for medication use:
100%; for non-pharmacological interventions: 76%; and discomforting
symptomatology: 87%.
• Test-retest reliability has not been established. However, this form of test is
appropriate and needed.

Validity
• Predictive validity of the ADD Protocol was tested in study 1. Pre-intervention the
sample had an average of 32.85 (±16.78) compared to 23.47 (±16.52) post-

Completed 04/04 1
intervention, a significant decrease in discomfort (t=6.56, p=0.000) and a significant
increase in the use of pharmacologic (t=2.56, p=0.012) and non-pharmacologic
comfort interventions (t=3.37, p=.001).

The ADD Protocol provides a comprehensive approach to recognition of potential
pain conditions through observation and validation procedures that are conceptually
sound. The tool addresses diverse potential pain indicators in this population and uses an
assessment validation approach that focuses on positive changes in behavior. The
behavior checklist is comprehensive. However, data are limited regarding its reliability.
Preliminary testing of the protocol suggests its potential usefulness; however, additional
testing of reliability and validity is needed, particularly larger samples including minority
subjects. The clinical utility is also unclear regarding time for training and time to
complete the protocol. Although the protocol is a complete approach to recognition of
pain in this population, it may be too complex for routine use and streamlining of the
steps may be needed.

Sources of evidence
Kovach, C.R., Weissman, D.E., Griffie, J., Matson, S., Muchka, S. (1999). Assessment
and treatment of discomfort for people with late-stage dementia. Journal of Pain and
Symptom Management, 18(6), 412- 419.

Kovach, C.R., Noonan, P.E., Griffie, J., Muchka, S., Weissman, D.E. (2001). Use of the
Assessment of Discomfort in Dementia Protocol. Applied Nursing Research, 14(4),
193-200.

Kovach, C.R., Noonan, P.E., Griffie, J., Muchka, S., Weissman, D.E. (2002). The
Assessment of Discomfort in Dementia Protocol. Pain Management Nursing, 3(1),
16-27.

Contact address for tool developer:
Christine R. Kovach, PhD, RN, FAAN ckovach@uwm.edu

This summary was completed by:
K. Herr, S. Decker, K. Bjoro, University of Iowa.
Contact information: keela-herr@uiowa.edu

Completed 04/04 2
Validation of a Behavioral Pain Scale in Critically Ill,
Sedated, and Mechanically Ventilated Patients
Younès Aı̈ssaoui, MD*, Amine Ali Zeggwagh, MD, PhD*†, Aı̈cha Zekraoui, MD*,
Khalid Abidi, MD*, and Redouane Abouqal, MD, PhD*†
*Service de Réanimation Médicale et de Toxicologie Clinique, Hôpital Ibn Sina; and †Laboratoire de Biostatistiques, de
Recherche Clinique et Epidémiologique, Faculté de Médecine et de Pharmacie, Rabat, Morocco

Assessing pain in critically ill patients, particularly in coefficient to evaluate inter-rater reliability was high
nonverbal patients, is a great challenge. In this study, (0.95). Validity was demonstrated by the change in BPS
we validated a behavioral pain scale (BPS) in critically scores, which were significantly higher during painful
ill, sedated, and mechanically ventilated patients. The procedures, with averages of 3.9 ⫾ 1.1 at rest and 6.8 ⫾
BPS score was the sum of 3 subscales that have a range 1.9 during procedures (P ⬍ 0.001), and by the principal
score of 1– 4: facial expression, upper limb movements, components factor analysis, which revealed a large
and compliance with mechanical ventilation. Two as- first-factor accounting for 65% of the variance in pain
sessors observed and scored pain simultaneously with expression. The BPS exhibited excellent responsive-
the BPS at rest and during painful procedures. The psy- ness, with an effect size ranging from 2.2 to 3.4. This
chometric properties of the BPS that were studied were study demonstrated that the BPS can be valid and reli-
reliability, validity, and responsiveness. We achieved able for measuring pain in noncommunicative inten-
360 observations in 30 patients. The BPS was internally sive care unit patients.
reliable (Cronbach ␣ ⫽ 0.72). The intraclass correlation (Anesth Analg 2005;101:1470 –6)

A
ssessment and management of pain in critically untested methods (7). Other methods, such as obser-
ill patients have recently received increased at- vational pain tools, must be used in a lieu of patients’
tention (1–3). Scientific advances in understand- self-reports of pain (8). The limited amount of data
ing pain mechanisms, multidimensional methods of suggests that certain observable behaviors may be
pain assessment, and analgesic pharmacology have valid indicators of pain (9,10). Pain behaviors can be
improved pain management practices. However, pain markers of the existence, intensity, and causes of pain.
assessment for critically ill patients, especially for non- Indeed, observing pain behaviors is a common
verbal patients, continues to present a challenge for method of assessing pain, especially when patients are
clinicians and researchers. Critically ill patients are unable to verbalize.
unable to communicate effectively for several reasons, Nevertheless, no pain scale comprising behavioral
including tracheal intubation, reduced level of con- indicators has been validated in the intensive care unit
sciousness, restraints, sedation, and administration of (ICU), except the one developed by Payen et al. (11).
paralyzing drugs (4 – 6). The latter consisted of a behavioral pain scale (BPS),
Pain experts agree that a patient’s self-report of pain which was used to assess pain in patients who had
intensity is the most valid measure (4). Unfortunately, undergone thoracic or abdominal surgery or who had
most of the existing scales are designed for use with been admitted for management of multiple trauma.
patients who can respond verbally to assessment com- However, its psychometric properties were insuffi-
mands. Consequently, pain management in nonverbal ciently studied, and it has never been validated in a
patients, such as elderly patients with cognitive im- medical ICU. In addition, validation of any pain tool
pairment, is often guided by less precise and wholly requires repeated tests of reliability, validity, and re-
sponsiveness across samples, settings, and observers.
Accepted for publication April 6, 2005. Therefore, the purpose of this prospective study,
Address correspondence and reprint requests to Younès Aissaoui,
MD, Service de Réanimation Médicale et Toxicologie Clinique, BP
which sampled from a population of critically ill pa-
1005, Hôpital Ibn Sina, 10001 Rabat, Morocco. Address e-mail to tients who were sedated and mechanically ventilated,
shadowyounes@hotmail.com. was to validate Payen et al.’s (11) behavioral scale as a
DOI: 10.1213/01.ANE.0000182331.68722.FF measure of pain using psychometric methods.

©2005 by the International Anesthesia Research Society
1470 Anesth Analg 2005;101:1470–6 0003-2999/05
ANESTH ANALG CRITICAL CARE AND TRAUMA AISSAOUI ET AL. 1471
2005;101:1470 –6 PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS

Methods their painful characters had been demonstrated in sev-
eral previous studies (15–17) and because they were
The study was performed over a 6-mo period in a 12-bed
part of the routine care that was normally planned for
ICU of the university teaching hospital Ibn Sina, Rabat,
the patients. No additional interventions or proce-
Morocco. The hospital ethical committee approved the
dures were performed on the patients for the benefit
study protocol, and because this observational study did
of the study.
not require any deviation from routine medical practice,
The assessments were done in the first 48 h after
informed consent was not required.
admission to the ICU. However, for patients who were
We included patients who were older than 16 yr,
not being ventilated at the time of their admission but
mechanically ventilated, sedated, and unconscious.
who were ventilated later during their stay, the assess-
Inclusion criteria were chosen because they precluded
ments were made in the first 48 h after mechanical
the use of an auto evaluation pain scale. Patients who
ventilation began.
were quadriplegic, receiving neuromuscular blocking
medications, or had a peripheral neuropathy were Twelve physicians and 16 nurses participated in the
excluded. Exclusion criteria were primarily selected to study. Before the beginning of the study, a training ses-
not include patients whose diseases or medications sion was provided to teach assessors how to complete
might compromise expression of the pain behaviors. BPS, followed by a probation period (15 days), during
To assess pain intensity, we used the BPS described which the BPS was tested on some patients (n ⫽ 4).
by Payen et al. (11). The BPS is based on a sum of three Quantitative variables were expressed as mean ⫾ sd,
subscales: facial expression, upper limb movements, and significance for all statistical tests was set at P ⫽ 0.05.
and compliance with mechanical ventilation (Table 1). The sample size required for validation of the BPS
Each subscale is scored from 1 (no response) to 4 (full was established using the precision of a coefficient,
response). Therefore, possible BPS scores range from 3 such as Cronbach ␣ or Intraclass Correlation Coeffi-
(no pain) to 12 (maximum pain). cient (ICC) (18). Thus, with a precision of Cronbach ␣
In addition to the BPS scores, mean arterial blood of 0.90 ⫾ 0.05 as an objective, and for a scale of 3
pressure and heart rate were also collected, which subscales, it was required to include 25–30 patients in
were measured by multimodal monitors. These two the study.
hemodynamic variables were collected because previ- The validation of an instrument measuring a sub-
ous studies had shown that increased heart rate and jective variable (like pain) requires a comparison with
increased arterial blood pressure are the most frequent a “gold standard.” Nevertheless, no pain scale has
physiological indicators of pain noted by observing been validated in critically ill patients who were un-
nurses (9). able to communicate effectively because of the pres-
The patients’ sedation levels were assessed using ence of artificial airways or underlying pathologies.
the Ramsay scale (12). The Ramsay scale rates sedation Consequently, we had to validate the BPS with indi-
level on a scale from 1 to 6, with higher levels indi- rect arguments, which consisted of checking the psy-
cating greater degrees of sedation. This instrument chometric properties of reliability, validity, and
proved satisfactorily reliable and valid (13). responsiveness.
Sample characteristics were also recorded, including Reliability refers to the lack of measurement error in a
age, sex, Acute Physiology and Chronic Health Evalua- scale and includes internal consistency and inter-rater
tion (APACHE) II score (14), and diagnosis categories. reliability. Internal consistency is an indication of how
APACHE II score was calculated for the first 24 h. the items within a scale are interrelated. Cronbach ␣ is
For each patient, the BPS scores and the two phys- one method of assessing internal consistency (19). A high
iological variables were collected three times a day by Cronbach ␣ value reflects high internal consistency. Gen-
the various teams of nurses (morning team, afternoon erally, a value larger than 0.7 is regarded as satisfactory.
team, and night team). Each team comprised four Inter-rater reliability (or inter-rater agreement) is the
nurses and one nurse’s aide. Assessments were made ability of a new instrument to obtain similar measures
by two evaluators to measure the inter-rater agree- with different assessors. It was assessed using the intra-
ment. The two assessors were the nurse and the phy- class correlation coefficient (ICC) (20). Theoretically, the
sician in charge of the patient. They made their assess- ICC can range from 0 (no agreement) to 1.0 (perfect
ments simultaneously but without any communication agreement). Generally, a value larger than 0.8 is re-
between them. The assessors were not randomized, for garded as satisfactory (20). The ICC was calculated for
reasons of convenience. the BPS and for each subscale of the BPS separately. A
Evaluation of the BPS and the physiological vari- 95% confidence interval (CI) for the coefficient was
ables was made at rest and during painful procedures derived.
to appreciate the BPS responsiveness. The two painful Validity is the degree to which an instrument meas-
procedures chosen were tracheal suction and periph- ures what it claims to measure (21). Validity was
eral venous cannulation. They were selected because established in three ways: construct validity, change in
1472 CRITICAL CARE AND TRAUMA AISSAOUI ET AL. ANESTH ANALG
PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS 2005;101:1470 –6

Table 1. The Behavioral Pain Scale (11)
Item Description Score
Facial expression Relaxed 1
Partially tightened (e.g., brow lowering) 2
Fully tightened (e.g., eyelid closing) 3
Grimacing 4
Upper limb movements No movement 1
Partially bent 2
Fully bent with finger flexion 3
Permanently retracted 4
Compliance with mechanical ventilation Tolerating movement 1
Coughing but tolerating ventilation for the most of time 2
Fighting ventilator 3
Unable to control ventilation 4

BPS scores during pain, and factor structure of the Table 2. Principal Patient Characteristics
BPS.
Age (y) 39 ⫾ 19*
Construct validity is the extent to which scores on a Sex: men/women (n) 18/12
scale correlate with scores of other measures in pre- APACHE II score 17 ⫾ 7.8*
dicted ways (21). We hypothesized that a significant Diagnostic categories (n) Nontraumatic coma (11)
correlation would be found between the BPS scores Acute intoxication (7)
and the two physiological variables that were sup- Respiratory failure (5)
posed to measure the same concept (pain). We also Sepsis (5)
Status epilepticus (2)
tested the correlation between the BPS and the Ram-
say scale. Spearman nonparametric coefficients were * Values expressed as mean ⫾ sd.
APACHE ⫽ Acute Physiology and Chronic Health Evaluation.
used.
Change in BPS scores was assessed by comparing ⫽ 3), and (c) an incomplete or incorrect collection of
the BPS scores at rest and after painful procedures. We data (n ⫽ 3).
hypothesized that if the BPS really measures pain, the Thirty patients were included. The principal patient
BPS scores should be much higher during painful characteristics are presented in Table 2. Each patient
procedures than while the patient is at rest. Wilcoxon was assessed three times a day (morning, afternoon,
paired tests (nonparametric) were used. and night), by two observers (a physician and a
Furthermore, the factor structure of the BPS was nurse), and at two different times (at rest and during
extracted by performing exploratory principal compo- painful procedures). Thus, the various teams achieved
nents factor analysis. This is a statistical procedure 360 observations (30 patients ⫻ 2 observers ⫻ 2 dif-
that enables the underlying dimensions of a scale to be ferent times ⫻ 3 times per day). Realization of a com-
determined (21). plete assessment usually required 3– 4 min.
Responsiveness refers to an instrument’s ability to All patients were sedated with midazolam in con-
detect important changes over time in the concept tinuous infusion except one patient who received thio-
being measured, even if those changes are small (22). pental (status epilepticus). The mean amount of mida-
The magnitude of this property was assessed by the zolam administered was 5.6 ⫾ 2.5 mg/h. The Ramsay
effect size. This coefficient is calculated by dividing scale had an average value of 3.9 ⫾ 1.6. For analgesia,
the difference between the mean BPS scores at rest and the drug frequently used was morphine, also in con-
during painful procedures by the sd of the mean tinuous perfusion. The mean amount of morphine
scores at rest. The effect size is considered small if it is administered was 3 ⫾ 0.7 mg/h.
less than 0.2, moderate if it is near 0.5, and large if it is Change in physiological variables is shown in Table
more than 0.8 (22). 3. There was a significant increase in both hemody-
namic variables during painful procedures. The am-
plitude of this increase was 10.7% for heart rate and
2.6% for mean arterial blood pressure.
Results Cronbach ␣ values indicated that the BPS had good
The various teams assessed 38 patients. However, the internal consistency (Cronbach ␣ ⫽ 0.72). ICC to eval-
assessments of 8 patients could not be included for 3 uate the inter-rater agreement were high for all sub-
major reasons: (a) the patient died before the end of scales of the BPS. For facial expression, ICC was 0.91
the assessments (n ⫽ 2), (b) the presence of exclusion (95% CI, 0.88 – 0.93). For upper limb movements, ICC
criteria (administration of neuromuscular blockade) (n was 0.90 (95% CI, 0.87– 0.92). For compliance with
ANESTH ANALG CRITICAL CARE AND TRAUMA AISSAOUI ET AL. 1473
2005;101:1470 –6 PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS

Table 3. Physiological Variables at Rest and During patients. In particular, the BPS showed a high inter-
Painful Procedures rater reliability (ICC ⫽ 0.95) and a satisfactory internal
Painful consistency (Cronbach ␣ ⫽ 0.72). Validity of the BPS
Rest procedures P-value was demonstrated by a significant increase in BPS
scores during painful procedures and by principal
Heart rate (bpm) 103 ⫾ 22 114 ⫾ 23 ⬍0.001
Mean arterial blood 77 ⫾ 26 79 ⫾ 27 0.042 components factor analysis that identified a large first
pressure (mm Hg) factor, which accounted for 65% of the variance in
pain expression. Furthermore, the BPS exhibited an
Values expressed as mean ⫾ sd.
excellent responsiveness, suggesting that this is a
powerful tool to detect the impact of painful stimula-
mechanical ventilation, ICC was 0.89 (95% CI, 0.85– tion in ICU patients.
0.92). ICC for the total score of the BPS was 0.95 (95% Each of our patients was assessed by three teams of
CI, 0.94 – 0.97). These values showed excellent inter- nurses to remove a possible bias caused by assess-
rater agreement. We also compared the BPS scores ments being made by the same caregivers. Results
obtained by the three teams of caregivers. There was showed that there was no significant difference
no significant difference (Table 4). among the evaluations made by the three teams.
No significant correlation was found between the At rest, theoretically, the BPS scores should be equal
BPS scores and the physiological variables for variabil- to 3, indicating the absence of pain. However, the
ity. The correlation coefficients were r ⫽ 0.16 (P ⫽ mean BPS scores, which were near 4, suggest the
0.13) for heart rate and r ⫽ ⫺0.02 (P ⫽ 0.84) for mean possibility of preexisting background pain before any
arterial blood pressure. When the correlation between procedure was performed. Indeed, our patients, like
the BPS scores and Ramsay scale was investigated, as all ICU patients, are subjected to a multitude of pain-
expected, a significant negative correlation emerged (r ful constraints, including various tubes (nasogastric
⫽ ⫺0.432; P ⬍ 0.001). The higher the sedation level, and endotracheal), central and arterial lines, wrist re-
the lower the BPS scores (Fig. 1). straints, etc. Another explanation could be that the
BPS scores obtained at rest and during painful pro- amount of analgesic infusion was insufficient. This
cedures appear in Table 5. The scores were signifi- fact highlights the need for an instrument that can be
cantly greater during painful procedures than at rest used to titrate and adapt analgesia in critical care.
and did not differ between the two categories of pain- Pain is a stressor that produces a sympathetic stim-
ful procedures (tracheal suction and peripheral ve- ulation (tachycardia, change in arterial blood pressure,
nous cannulation). Moreover, all subscale scores were diaphoresis, and change in pupillary size) (4,23).
significantly higher during painful procedures. These physiological variations can help to detect pain
Using exploratory principal components factor analy- among patients with impaired mental status
sis, we found a large first factor, which accounted for (4,8,23,24). Puntillo et al. (9), in a study of patients
65% of the variance in pain expression, with strong cor- having difficulties with verbal communication (me-
relation of the subscales with this factor, including coef- chanically ventilated or having been tracheally extu-
ficients of 0.90 for facial expression, 0.85 for upper limb bated less than four hours), showed that the most
movements, and 0.64 for compliance with mechanical frequently noted physiological indicators of pain were
ventilation. Table 6 shows the correlation matrix be- increased heart rate and increased arterial blood pres-
tween the subscales of the BPS. The 3 subscales were sure. In our study, heart rate and arterial blood pres-
significantly correlated (all P ⬍ 0.001), with a high cor- sure increased significantly during painful proce-
relation between facial expression and upper limb move- dures, with the increase for heart rate measuring
ments (r ⫽ 0.70) and moderate correlations between approximately 10%. These results coincide with the
compliance with mechanical ventilation and the 2 other observations of clinicians who generally associate pain
subscales (r ⫽ 0.40 with facial expression and r ⫽ 0.29 with a variation of from 10% to 20% in physiological
with upper limb movements). variables (25). However, it is agreed that these physi-
The effect size for responsiveness was large for the ological indicators lack specificity in the ICU and can
three subscale scores and for the total BPS scores be influenced by many medications (vasopressors, ␤
(Table 5). These results showed an excellent respon- adrenergic blockers, antiarrhythmics, sedative drugs,
siveness and, consequently, the excellent ability of the etc.) and pathological conditions (sepsis states, shock,
BPS to quantify change in clinical status and detect hypoxia, and fear) (4). Moreover, no significant corre-
painful procedures. lation was found among the BPS scores and the two
physiological variables in our study. Unfortunately,
the absence of an objective measure of pain in ICU
Discussion patients limited the testing of construct validity. The
This validation study showed that the BPS had good study of Payen et al. (11) had the same results, and no
psychometric properties when used with critically ill published study with a sufficient level of scientific
1474 CRITICAL CARE AND TRAUMA AISSAOUI ET AL. ANESTH ANALG
PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS 2005;101:1470 –6

Table 4. Behavioral Pain Scale Scores as Assessed by Three Nursing Teams
Morning team Afternoon team Night team P-value*
Rest 3.8 ⫾ 1.2 3.7 ⫾ 0.9 3.9 ⫾ 1.2 0.44
Painful procedures 6.6 ⫾ 1.7 6.8 ⫾ 1.7 6.6 ⫾ 2.2 0.46
Values expressed as mean ⫾ sd.
* Friedman test.

BPS subscales contributed to the overall pain assess-
ment rating. The largest contributor was facial expres-
sion (r ⫽ 0.90), followed by upper limb movements (r
⫽ 0.85), and then compliance with mechanical venti-
lation (r ⫽ 0.64). Furthermore, the positive significant
correlation found among the three subscales demon-
strates that they evaluate the same concept, which, in
this case, was pain intensity.
This analysis has shown that behavioral indicators
can be a valid and reliable measure of pain. Few
studies have evaluated pain behaviors in the ICU
(9,10,25). The most recent one (10) identified specific
procedural pain behaviors such as grimacing, rigidity,
wincing, shutting of eyes, verbalization, and clenching
of fists. But in that study, the patients were awake and
could measure their pain with a numeric rating scale.
In fact, facial expression, which contributed most to
the pain rating in our study, is a sign found in various
works measuring both acute and chronic pain
(25,27,28). Prkachin (27) has suggested that four facial
actions carry the bulk of facial information about pain:
Figure 1. Correlations between the behavioral pain scale (BPS) and lowering the brow, tightening and closing of the eye-
the Ramsay scale. lids, wrinkling of the nose, and raising the upper lip.
He has also provided evidence of the existence of a
evidence has found a correlation among these physi- universal facial language of pain. The facial scales,
ological variables and pain (9). which are especially useful for measuring pain in in-
However, the correlation between the BPS and Ram- fants and children, highlight the value of this type of
say scale was negative and significant. The logical direc- signal (4,23,29). Pediatric scales also rely on upper
tion of the association is the higher the sedation level, the limb movements as a measure of pain (23,29). In our
study, upper limb movements contributed as much as
lower the ability to express painful behaviors.
facial expression to the pain rating. Compliance with
In the present study, the BPS yielded a Cronbach ␣
mechanical ventilation, adapted from the Comfort
of 0.72, thus fulfilling Nunnally and Bernstein’s (26)
scale (11), had a moderate but effective contribution to
criterion for satisfactory internal consistency. The
pain assessment. The reason could be that this sub-
inter-rater reliability of the BPS was found to be ex- scale might be affected by some factors unrelated to
cellent (ICC ⫽ 0.95). This indicates that the BPS pro- pain, such as hypoxemia, bronchospasm, and mucous
duces consistent scores from different assessors. Reli- plugging, which can lead to coughing and some fight-
ability is an essential property when caregivers are ing of the ventilator.
numerous, as in the ICU. In addition to these psychometric properties, the
The BPS total and subscale scores were significantly BPS showed good feasibility, in as much as the aver-
higher during the procedures (Table 5). This change in age time of assessment was only four minutes. The
BPS scores testifies to the instrument’s capacity to short time required will make the BPS suitable for
detect and discriminate pain and provides the evi- everyday clinical use.
dence that the BPS is a valid measure of pain. It is also This study has two limitations. First, one aspect of
important that all of the subscales changed, indicating the validation process has not been addressed, namely
that they all have the same ability to discriminate pain. the criterion validity (validity of the BPS in compari-
Principal factor analysis revealed that a large first son with another validated pain scale). We could have
factor was dominant and that the three subscales were compared the BPS to subjective rating of the level pain
strongly related to this factor, which means each of the by an independent rater (a nurse) on a visual analog
ANESTH ANALG CRITICAL CARE AND TRAUMA AISSAOUI ET AL. 1475
2005;101:1470 –6 PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS

Table 5. Behavioral Pain Scale (BPS) Total Scores and BPS Subscale Scores at Rest and During Painful Procedures, with
the Effect Size
Painful
Rest procedure P*-value Effect size
BPS subscales
Facial expression
Morning team 1.2 ⫾ 0.6 2.6 ⫾ 1 ⬍0.0001 2.3
Afternoon team 1.1 ⫾ 0.25 2.8 ⫾ 1.1 ⬍0.0001 6.8
Night team 1.2 ⫾ 0.3 2.7 ⫾ 1.2 ⬍0.0001 5
Upper limb movements
Morning team 1.1 ⫾ 0.2 2 ⫾ 0.7 ⬍0.0001 4.5
Afternoon team 1 ⫾ 0.2 1.9 ⫾ 0.8 ⬍0.0001 4.5
Night team 1.2 ⫾ 0.5 1.9 ⫾ 0.9 ⬍0.0001 1.4
Compliance with mechanical ventilation
Morning team 1.5 ⫾ 0.6 2 ⫾ 0.9 ⬍0.046 0.8
Afternoon team 1.6 ⫾ 0.6 2.1 ⫾ 0.9 ⬍0.005 0.8
Night team 1.5 ⫾ 0.5 2 ⫾ 0.9 ⬍0.006 1
BPS total
Morning team 3.8 ⫾ 1.2 6.6 ⫾ 1.7 ⬍0.0001 2.3
Afternoon team 3.7 ⫾ 0.9 6.8 ⫾ 1.7 ⬍0.0001 3.4
Night team 3.9 ⫾ 1.2 6.6 ⫾ 2.2 ⬍0.0001 2.2
* Wilcoxon paired test.

Table 6. Correlation Matrix Among the Items of the Behavioral Pain Scale
Facial Movements of Compliance with
expression upper limbs mechanical ventilation
Facial expression 1
Movements of upper limbs 0.70 1
Compliance with mechanical ventilation 0.41 0.29 1
Values shown represent Spearman nonparametric correlation coefficients; all correlations were statistically significant at P ⬍ 0.001.

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BEHAVIORAL PAIN SCALE

Pain Score

Pain A B C D
Behaviors None Mild Moderate Severe

Restless Quiet Slightly Moderate Very
Restless Restless Restless

Tense Relaxed Slight Moderate Extreme
Muscles Tenseness Tenseness Tenseness

Frowning/ No Slight Moderate Constant
Grimacing Frowning/ Frowning/ Frowning/ Frowning/
Grimacing Grimacing Grimacing Grimacing

Patient Talking in Sighs, Groans Groans, Moans Cries out or
Sounds Normal Tone/ Moans Softly Loudly Sobs
No Sound

Instructions: Observe the patient for 10 minutes. Assess the patient on the four
behaviors (none-severe). Obtain a pain score based on the highest behavior observed.

The John Hopkins Hospital PACU Behavioral Pain Rating Scale cited in Mateo, OM., &
Krenzischeck, DA. (1992). A pilot study to assess the relationship between behavioral
manifestations and self-report of pain in post-anesthesia care unit patients. Journal of
Post Anesthesia Nursing. 7(1): 15-21.
NATIONAL INSTITUTES OF HEALTH
WARREN GRANT MAGNUSON CLINICAL CENTER

PAIN INTENSITY INSTRUMENTS
JULY 2003

Checklist of Non-Verbal Indicators (CNVI) (page 1 of 1)

With At Rest
Movement
Vocal Complaints – nonverbal expression of pain
demonstrated by moans, groans, grunts, cries, gasps,
sighs)
Facial Grimaces and Winces – furrowed brow,
narrowed eyes, tightened lips, dropped jaw, clenched teeth,
distorted expression
Bracing – clutching or holding onto siderails, bed, tray
table, or affected area during movement
Restlessness – constant or intermittent shifting of
position, rocking, intermittent or constant hand motions,
inability to keep still
Rubbing – massaging affected area

Vocal complaints – verbal expression of pain using
words, e.g., “ouch” or “that hurts; ” cursing during
movement, or exclamations of protest, e.g., “stop” or “that’s
enough.”
TOTAL SCORE

Indications: Behavioral Health adults who are unable to validate the presence of or quantify
the severity of pain using either the Numerical Rating Scale or the Wong-Baker Faces Pain
Rating Scale.

Instructions:
1. Write a 0 if the behavior was not observed
2. Write a 1 if the behavior even briefly during activity or rest
3. Results in a total score between 0 and 5.
4. The interdisciplinary team in collaboration with the patient (if appropriate), can determine
appropriate interventions in response to CNVI scores.

Reference

Feldt, KS. (2000). The checklist of nonverbal pain indicators (CNPI). Pain Management Nursing,
1(1): 13-21.
FLACC SCALE
(FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY)
0 1 2

No particular Occasional grimace or Frequent to constant
FACE expression or smile frown, withdrawn, frown, clenched jaw,
disinterested quivering chin

0 1 2

Normal position Uneasy, Kicking,
LEGS Or Restless, Or
relaxed Tense Legs drawn up

0 1 2

Lying quietly Squirming Arched
ACTIVITY Normal position Shifting back/forth Rigid
Moves easily Tense Or
Jerking
0 1 2

No Cry Moans or Whimpers Crying Steadily
CRY Occasional Complaint Screams or Sobs
(Awake or Asleep) Frequent Complaints

0 1 2

Content Reassured by Difficult to console
Relaxed occasional touching, or comfort.
CONSOLABILITY hugging, or ‘talking
to.’
Distractible

The FLACC is a behavior pain assessment scale for use in non-verbal patients unable to
provide reports of pain.

Instructions:
1. Rate patient in each of the five measurement categories
2. Add Together
3. Document total pain score
Original articles
Pain Assessment in the
Nonverbal Patient:
Position Statement with
Clinical Practice
Recommendations
yyy Keela Herr, PhD, RN, FAAN,*
Patrick J. Coyne, MSN, RN, CS, FAAN,† Tonya Key, RN, C,‡
Renee Manworren, MS, RN, C, CNS,§
Margo McCaffery, MS, RN, FAAN,¶
Sandra Merkel, MS, RNC,储
Jane Pelosi-Kelly, MSN, RN, C, CS, ANP,# and
Lori Wild, PhD, RN**

y ABSTRACT:
The article presents the position statement and clinical practice rec-
From *Adult and Gerontological
Nursing, The University of Iowa ommendations for pain assessment in the nonverbal patient devel-
College of Nursing, Iowa City, oped by an appointed Task Force and approved by the ASPMN Board
Iowa; †Medical College of Virginia of Directors.
Hospital, Rockville, Virginia;

Washington County Hospital © 2006 by the American Society for Pain Management Nursing
Association, Hagerstown,
Maryland; §Clinical Nurse
Specialist and Manager of Pain
Management, Children’s Medical Pain is a subjective experience, and no objective tests exist to measure it (APS,
Center of Dallas, Dallas, Texas;

Independent Consultant in the 2003). Whenever possible, the existence and intensity of pain are measured by
Nursing Care of Patients with the patient’s self-report, abiding by the clinical definition of pain that states
Pain, Los Angeles, California; 储Mott “Pain is whatever the experiencing person says it is, existing whenever he/she
Children’s Hospital, University of says it does” (McCaffery, 1968). Unfortunately, some patients cannot provide a
Michigan Health System, Ann self-report of pain verbally, in writing, or by other means, such as finger span
Arbor, Michigan; #Alexian Brothers
Hospital Network, Elk Grove (Merkel, 2002) or blinking their eyes to answer yes or no questions (Pasero &
Village, Illinois; and **University McCaffery, 2002).
of Washington Medical Center, This position paper will specifically address three populations of nonverbal
Seattle, Washington. patients: elders with advanced dementia, infants and preverbal toddlers, and
intubated and/or unconscious patients. The inability of these populations to
Address correspondence and reprint
request to Keela Herr, PhD, RN, FAAN,
communicate pain and discomfort because of cognitive, developmental, or
452 NB, College of Nursing, The physiologic issues is a major barrier for them being adequately assessed for pain
University of Iowa, Iowa City, IA and achieving adequate pain management interventions.
52242. E-mail: keela-herr@uiowa.edu

1524-9042/$32.00 ETHICAL TENETS
© 2006 by the American Society
for Pain Management Nursing The ethical principles of beneficence (the duty to benefit another) and nonma-
doi:10.1016/j.pmn.2006.02.003 leficence (the duty to do no harm) oblige health care professionals to provide

Pain Management Nursing, Vol 7, No 2 (June), 2006: pp 44-52
Pain Assessment in the Nonverbal Patient 45

pain management and comfort to all patients, includ- as physiologic distress or emotional distress (Pasero &
ing those challenging individuals who are vulnerable McCaffery, 2005). Potential causes and the context of
and unable to speak for themselves. Providing quality the behavior must be considered when making treat-
and comparable care to individuals who cannot report ment decisions. Awareness of individual baseline be-
haviors and changes that occur with discomfort are
their pain is directed by the principle of justice (the
very useful in differentiating pain from other causes.
equal or comparative treatment of individuals). Re-
d. Surrogate Reporting (family members, parents, care-
spect for human dignity, the first principle in the givers) of Pain and Behavior/Activity Changes.
“Code of Ethics for Nurses” (ANA, 2001), directs Credible information can be obtained from a parent or
nurses to provide and advocate for humane and ap- another person who knows the patient well (e.g.,
propriate care. On the basis of the principle of justice, spouse, child, caregiver). Parents and caregivers
this care is given with compassion and unrestricted by should be encouraged to actively participate in the
consideration of personal attributes, economic status, assessment of pain in their loved one. Familiarity with
or the nature of the health problem. the patient and knowledge of usual and past behaviors
can assist in identifying subtle, less obvious changes in
behavior that may be indicators of pain presence.
GENERAL RECOMMENDATIONS Discrepancies exist between self-report of pain and
external observer judgments of pain severity that oc-
All persons with pain deserve prompt recognition and
cur across varied raters (e.g., physician, nurse, family,
treatment. Pain should be routinely monitored, assessed,
aides) and settings (e.g., inpatient, outpatient, acute
reassessed, and documented clearly to facilitate treat- care, long-term care). Thus, judgments by caregivers
ment and communication among health care clinicians and clinicians may not be accurate reflections of the
(Gordon et al., 2005). In patients who are unable to severity of pain experienced by nonverbal persons
self-report pain, other measures must be used to detect and should be combined with other evidence when
pain and evaluate interventions. No single objective as- possible. A multifaceted approach is recommended
sessment strategy, such as interpretation of behaviors, that combines direct observation, family/caregiver in-
pathology, or estimates of pain by others, is sufficient by put, and evaluation of response to treatment.
itself. Following are recommended considerations: e. Attempt an Analgesic Trial. An empiric analgesic trial
should be initiated if there are pathologic conditions or
1. Use the Hierarchy of Pain Assessment Techniques (Mc- procedures likely to cause pain or if pain behaviors
Caffery & Pasero, 1999): continue after attention to basic needs and comfort mea-
a. Self-report. Attempts should be made to obtain self- sures. Provide an analgesic trial and titration appropriate
report of pain from all patients. A self-report of pain from to the estimated intensity of pain based on the patient’s
a patient with limited verbal and cognitive skills may be pathology and analgesic history. For mild to moderate
a simple yes/no or vocalization. When self-report is ab- pain, a nonopioid analgesic may be given initially (e.g.,
sent or limited, explain why self-report cannot be used acetaminophen every 4 hours for 24 hours). If behaviors
and further investigation and observation are needed. improve, assume pain was the cause and continue the
b. Search for Potential Causes of Pain. Pathologic con- analgesic and add appropriate nonpharmacologic inter-
ditions and common problems or procedures known ventions. If behaviors continue, consider giving a single
to cause pain (e.g., surgery, wound care, rehabilitation low dose, short-acting opioid (e.g., hydrocodone, oxy-
activities, positioning/turning, blood draws, heel codone, or morphine) and observe the effect. If there is
sticks, a history of persistent pain) should trigger an no change in behavior, titrate dose upward by 25% to
intervention, even in the absence of behavioral indi- 50% and observe the effect. Continue to titrate upward
cators. A change in behavior requires careful evalua- until a therapeutic effect is seen, bothersome side effects
tion of the possibility of additional sources of pain.
occur, or no benefit is determined. It may be appropriate
Generally, one may ASSUME PAIN IS PRESENT, and if
to start the analgesic trial with an opioid for conditions in
there is reason to suspect pain, an analgesic trial can
which moderate to severe pain is expected. Explore
be diagnostic as well as therapeutic (APS, 2003). Pain
other potential causes if behaviors continue after a rea-
associated with procedures should be treated before
sonable analgesic trial. The analgesic titration example is
initiation of the procedure. Other problems that may
conservative, and although strategies for safe titration
be causing discomfort should be ruled out (e.g., infec-
should be followed, more aggressive approaches may be
tion, constipation) or treated.
needed (Gordon et al., 2004). No research confirms that
c. Observe Patient Behaviors. In the absence of self-
weight (except in children) should be used to determine
report, observation of behavior is a valid approach to
starting dose (Burns et al., 1989; Macintyre & Jarvis,
pain assessment. Common behaviors that may indi-
1995).
cate discomfort in the selected populations have been
identified in each section below. Pain behaviors are 2. Establish a Procedure for Pain Assessment
not always accurate reflections of pain intensity, and A procedure for evaluating pain presence and response
in some cases indicate another source of distress, such to treatment should be instituted in each health care
46 Herr et al.

setting. The hierarchy of assessment techniques, dis- tient. Assessment approaches and pain indicators should
cussed above, is recommended, and the following can be be documented in a readily visible and consistent manner
used as a template for the initial assessment and treat- that is accessible to all health care providers involved in
ment procedure (Pasero & McCaffery, 2005). the assessment and management of pain (Gordon et al.,
a. Attempt first to elicit a self-report from patient and 2005; Miaskowski et al., 2005).
explain why self-report cannot be used.
b. Identify pathologic conditions or procedures that may
cause pain. PERSONS WITH ADVANCED
c. List patient behaviors that may indicate pain. Behav- DEMENTIA: GUIDING PRINCIPLES
ioral assessment scales may be used. FOR THE ASSESSMENT OF PAIN
d. Identify behaviors that caregivers and others knowl-
edgeable about the patient think may indicate pain. Recommendations for pain assessment in nonverbal
e. Attempt an analgesic trial. older adults with dementia unable to self-report that
3. Use Behavioral Pain Assessment Tools, as Appropriate are unique from the general recommendations include
Use of a behavioral pain assessment tool may assist in the following:
recognition of pain in these challenging populations. It is 1. Self-report. The ravages of dementia seriously impact
incumbent on health care providers to consider the the ability of those with advanced stages of disease to
strength of psychometric evaluation data (e.g., reliability communicate pain. Damage to the central nervous
and validity of the tool), the clinical feasibility of instruments system affects memory, language, and higher order
(e.g., training required, time to complete), and the support cognitive processing necessary to communicate the
for use with the population of interest in the specific setting experience. Yet, despite changes in central nervous
(e.g., acute care, long-term care, home care) when selecting system functioning, persons with dementia still expe-
a specific tool. Use of reliable and valid tools helps ensure rience pain sensation to a degree similar to that of the
that clinicians are using appropriate criteria in their pain cognitively intact older adult (Schuler et al., 2004).
assessments. Standardized tools promote consistency However, dementing illnesses do impact the interpre-
among care providers and care settings and facilitate com- tation of the pain stimulus and the affective response
munication and evaluation of pain management treatment to that sensation (Scherder et al., 2005). Although
decisions. However, the appropriateness of a scale must be self-report of pain is often possible in those with mild
assessed patient by patient, and no one scale should be an to moderate cognitive impairment, as dementia
institutional mandate for all patients in a certain group progresses, the ability to self-report decreases and
(Pasero & McCaffery, 2005). eventually self-report is no longer possible.
When a behavioral tool is scored, that score is not the 2. Searches for Potential Causes of Pain/Discomfort. Con-
same as a pain intensity rating nor can the scores be sider chronic pain causes common in older persons (e.g.,
compared with standard pain intensity ratings or catego- history of arthritis, low back pain, neuropathies). Muscu-
ries of pain severity. Behavioral assessment tools may be loskeletal and neurologic disorders are the most com-
helpful to identify the presence of pain and can be used mon causes of pain and should be given priority in the
to evaluate attempts to relieve pain (Pasero & McCaffery, assessment process. A recent fall or other acute pain-
2005). When selecting a behavioral pain assessment tool, related problem (e.g., urinary tract infection, pneumo-
be sure the patient is able to respond in all categories of nia, skin tear) could be the cause of pain.
behavior. Keys to the use of behavioral pain scales are to 3. Observation of Patient Behaviors. Observe for behav-
focus on the individual’s behavioral presentation and iors recognized as indicators of pain in this popula-
observe for changes in those behaviors with effective tion. Facial expressions, verbalizations/vocalizations,
treatment. Remember that sleep and sedation do not body movements, changes in interpersonal interac-
equate with the absence of pain or with pain relief. tions, changes in activity patterns or routines, and
4. Minimize Emphasis on Physiologic Indicators mental status changes have been identified as catego-
Physiologic indicators (e.g., changes in heart rate, ries of potential pain indicators in older persons with
blood pressure, respiratory rate) are not sensitive for dementia (AGS, 2002). A list of indicators included in
discriminating pain from other sources of distress. Al- these categories and an algorithm for evaluating pain
though physiologic indicators are often used to docu- in persons unable to self-report are available (AGS,
ment pain presence, little research supports the use of 2002). Some behaviors are common and typically con-
vital sign changes for identifying pain. Absence of in- sidered pain related (e.g., facial grimacing, moaning,
creased vital signs does not indicate absence of pain groaning, rubbing a body part), but others are less
(McCaffery & Pasero, 1999). obvious (e.g., agitation, restlessness, irritability, confu-
5. Reassess and Document sion, combativeness, particularly with care activities
After intervention and regularly over time, the patient or treatments, or changes in appetite or usual activi-
should be reassessed with methods of pain assessment ties) and require follow-up evaluation. Typical pain
and specific behavioral indicators that have been identi- behaviors are often not present, and more subtle indi-
fied as significant and appropriate for the individual pa- cators may represent pain. Use the American Geriatric
Pain Assessment in the Nonverbal Patient 47

Society’s indicators of pain (AGS, 2002) or a nonverbal tain data to support their use through Quality Improve-
pain assessment tool that is appropriate, valid, and ment projects.
reliable for use with this population. Behavioral obser-
vation should occur during activity whenever possi- 4. Surrogate Reporting of Pain (e.g., family, caregiver).
ble, because pain may be minimal or absent at rest. In the long-term care setting, the certified nursing
assistant is a key health care provider who has been
Use of Behavioral Pain Assessment Tools shown to be effective in recognizing the presence of
Two critiques of existing nonverbal pain assessment pain (Fisher et al., 2002; Mentes et al., 2004). Educa-
tools indicate that, although there are tools with poten- tion on screening for pain should be a component of
tial, there is no tool that has strong reliability and validity all certified nursing assistant training. Family members
are likely to be the caregiver with the most familiarity
that can be recommended for broad adoption in clinical
with typical pain behaviors or changes in usual activ-
practice for persons with advanced dementia (Herr et al., ities that might suggest pain presence in the acute care
2006; Stolee et al., 2005; Zwakhalen et al., 2006). Exist- setting and in other settings in which the health care
ing tools have limited evaluation that is often narrow in providers do not have a history with the patient (Co-
the samples used and/or the setting in which evaluation hen-Mansfield, 2002; Shega et al., 2004).
was conducted. Behavioral tools with few indicators may 5. Attempt an Analgesic Trial. Estimate the intensity of
be more clinically feasible but may not detect pain in pain based on information obtained from prior assess-
patients who present with less obvious behaviors. ment steps and select an appropriate analgesic. For ex-
Longer and more comprehensive checklists may be more ample, when mild to moderate pain is suspected, acet-
aminophen 500 to 1000 mg every 6 hours may be
sensitive but also identify patients for whom pain may
appropriate initially with titration to stronger analgesics
not be present. Given the current state of high under-
if there is no change in behaviors and pain continues to
recognition of pain in this population, increased sensitiv- be suspect. Low-dose opioids have been effective in
ity may be preferable but will require evaluation to vali- validating agitation as a pain indicator (Manfredi et al.,
date pain as the cause of the suspect behaviors. 2003). Opioid dosing in older adults warrants an initial
A comprehensive review of currently published dose reduction of 25% to 50%. Using an analgesic trial to
tools for assessing pain in nonverbal persons with de- validate the presence of pain before increasing or adding
mentia is available at www.cityofhope/prc/elderly.asp psychotropic medications has several advantages. Com-
and in Herr, Bjoro, and Decker’s article (2006). Tools are pared with psychotropic intervention, response will be
in varying stages of development and validation; how- seen more quickly with an analgesic intervention, the
adverse reactions to analgesics are usually less serious,
ever, those with the strongest conceptual and psycho-
and pain will not be obscured by the sedative properties
metric support at this time, as well as clinical utility, of psychotherapeutic agents. With this approach, pain is
include the following: more likely to be detected and treated. Consider psychi-
● ADD: The Assessment of Discomfort in Dementia Pro- atric approaches, such as adding or changing doses of
tocol (Kovach et al., 1999; 2001; 2002) (tested in long- new psychiatric pharmacologic approaches (e.g., antip-
term care setting; acute/chronic pain) sychotics, sedatives), if behaviors do not improve with
● CNPI: Checklist of Nonverbal Pain Indicators (Feldt, an analgesic trial.
2000a, 2000b; Feldt et al., 1998; Jones et al., 2005)
(tested in acute care setting, long-term care setting;
acute/chronic pain) INFANTS AND PREVERBAL
● Doloplus 2: The Doloplus 2 (Lefebre-Chapiro, 2001; TODDLERS: GUIDING PRINCIPLES
http://www.doloplus.com) (tested in long-term care
FOR THE ASSESSMENT OF PAIN
setting, geriatric centers, palliative care center; chronic
pain) Recommendations for pain assessment in infants/nonver-
● NOPPAIN: Nursing Assistant-Administered Instrument bal children unable to self-report that are unique from
to Assess Pain in Demented Individuals (Snow et al., the general recommendations include the following:
2003) (tested in long-term care; acute and chronic pain)
● PACSLAC: The Pain Assessment Scale for Seniors with 1. Self-report: Infants, toddlers, and developmentally pre-
Severe Dementia (Fuchs-Lacelle, et al., 2004) (tested in verbal children lack the cognitive skills necessary to
long-term care setting; chronic pain) report and describe pain. As children develop verbal
● PAINAD: The Pain Assessment in Advanced Dementia and cognitive skills they are able to report the expe-
Scale ( Lane et al., 2003; Warden et al., 2003) (tested in rience and intensity of pain. The ability to indicate the
long-term care setting; chronic pain; preliminary reports presence of pain emerges at approximately 2 years of
of testing in acute pain not yet published) age. Developmentally appropriate children as young
as 3 years of age may be able to quantify pain using
Clinicians are encouraged to review selected tools for simple validated pain scales (Fanurik et al., 1998; Spa-
appropriateness to the patient’s care setting and ob- grud et al., 2003).
48 Herr et al.

2. Search for Potential Causes of Pain/Discomfort: In- Use of Behavioral Pain Assessment Tools
fections, injuries, diagnostic tests, surgical procedures, Although no single behavioral scale has been shown to
and disease progression are possible causes for pain in be superior to others, clinicians should select a scale
infants and young children and should be treated with that is appropriate to the patient and types of pain on
the presumption that pain is present. Developmentally
which it has been tested. Behavioral pain tools should
nonverbal children have a higher burden of pain from
frequent medical/surgical procedures and illness, and
be used for initial and ongoing assessments.
suspicion of pain should be high (Stevens et al., 2003). ● CHEOPS: Children’s Hospital of Eastern Ontario Pain
3. Observation of Patient Behaviors. Infants and chil- Scale (McGrath et al., 1985) (tested in 1 to 5 years of
dren react to pain by exhibiting specific behaviors. age; Post Anesthesia Care Unit, surgical pain)
The primary behavioral categories used to help iden- ● CHIPPS: (Buttner & Finke, 2000) (tested in birth to 5
tify pain in this population include facial expression, years of age: clinic and acute care setting; surgical pain)
body activity/motor movement, and crying/verbaliza- ● COMFORT Behavior Scale (van Dijk et al., 2000, 2005)
tion. Body posture, changes in muscle tone, and re- (tested in neonate to 3 years of age; intensive care
sponse to the environment are also indicators of pain. setting, surgical pain. Revised scale of COMFORT (Am-
Facial expressions of an infant experiencing acute buel et al., 1992; Canenvale, & Razack, 2002) measures
pain include eyebrows lowered and drawn together to other constructs than pain (tested in newborn to 9 years
form a vertical furrow, a bulge between the brows of age, intensive care setting, mechanically ventilated).
with the eyes tightly closed, cheeks raised with a ● CRIES: (Krechel & Bildner, 1995) (tested in neonates;
furrow between the nose and upper lip, and the neonatal and pediatric intensive care setting, procedural
mouth open and stretched in the shape of square and surgical pain)
(Grunau & Craig, 1990). In addition, high-pitched, ● DSVNI: Distress Scale for Ventilated Newborn Infants
tense, and harsh cries have been indicated as a behav- (Sparshott 1996) (tested in ventilated newborns, inten-
ioral measure of infant pain (Fuller & Conner, 1995). sive care setting; procedural pain)
However, infant behaviors such as crying and facial ● FLACC: Faces, Legs, Activity, Cry, Consolability Obser-
expressions that accompany crying are not indepen- vational Tool (Manworren & Hynan, 2003; Merkel et al.,
dent indicators of acute pain (Fuller, 2001). 1997; Willis et al., 2003) (tested in 2 months to 7 years
The primary behavioral signs of pain are often more of age; Post Anesthesia Care, intensive care, acute care
apparent and consistent for procedural pain and post- settings, surgical pain and acute pain)
operative pain than for chronic pain. As a child gains ● DEGR Scale: Douleur Enfant Gustave Roussy (Gauvin-
control over body movement there will be greater Piguard, 1999) (tested in 2 to 6 years; acute care, cancer
differences in observed behavioral responses to pain. pain)
Sleeping and withdrawn behavior may be the child’s ● PIPP: Premature Infant Pain Profile (Stevens, 1996)
attempts to control pain by limiting activity and inter- (tested in premature and term neonates; neonatal set-
actions. There may be a dampening of the primary tings, procedural pain)
pain behaviors in children who experience prolonged ● RIPS: Riley Infant Pain Scale (Schade et al., 1996) (tested
pain or chronic pain. Behaviors seen in children with in newborn to 3 years of age; acute care setting; surgical
chronic cancer pain include posturing, wariness of pain)
being moved, and psychomotor inertia that has been ● UWCH (University of Wisconsin Children’s Hospital)
described as withdrawal, lack of expression, and lack Pain Scale for Preverbal and Nonverbal Children
of interest in surroundings (Gauvin-Piquard et al., (Soetenga et al., 1999) (tested in less than 3 years old;
1999). Distress behaviors, such as irritability, agitation, acute care setting, surgical and procedural pain)
and restlessness, may or may not be related to pain
and, in many cases, may indicate physiologic distress, 4. Surrogate Reporting of Pain. Include evaluation of
such as respiratory compromise or drug reactions. the response of the infant, toddler, and developmen-
Therefore, consider the context of the behaviors, med- tally nonverbal child to parents and the environment
ical history, and caregiver opinions when using behav- in the assessment of pain. Responsiveness to interven-
ioral pain assessment tools and making treatment de- tions by a trusted caregiver to console the child, such
cisions. as rocking, touch, and verbal reassurance, must be
Physiologic indicators, such as heart rate, respira- considered when observing distressed behaviors. Par-
tory rate, and oxygen saturation, have been reported ents usually know their child’s typical behavioral re-
as providing information about the neonatal response sponse to pain and can identify behaviors unique to
to noxious stimuli and are associated with acute pain the child that can be included in the assessment of
(Stevens, Johnston, Petyshen & Taddio, 1996). Physi- pain. However, the nursing staff may be most familiar
ologic indicators, however, are also affected by dis- with the infant or young child’s pain behavior if the
ease, medications, and changes in physiologic status child has not been home since birth.
and, therefore, are not good predictors of pain or the Explain behavioral scales to parents and encourage
absence of pain (Foster et al., 2003). them to actively participate in identifying pain and
Pain Assessment in the Nonverbal Patient 49

evaluating their child’s response to interventions procedures thought to be painful. Patients may exhibit
(NANN position statement, 1999). distress behaviors as a result of the fear and anxiety
5. Analgesic Trial. Initiate an analgesic trial with a non- associated with being in the intensive care unit. An
opioid or low-dose opioid if pain is suspected and analgesic trial (see no. 5 below) may be helpful in
comfort measures, such as parental presence, security distinguishing distress behaviors from pain behaviors.
items, sucking, and distraction, are not effective in Relying on changes in vital signs as a primary indi-
easing behaviors that may suggest pain. Base initial cator of pain can be misleading because these may also
opioid dose on weight and titrate as appropriate. Ex- be attributed to underlying physiologic conditions,
plore other potential causes of distress if behaviors homeostatic changes, and medications. There is lim-
continue after a reasonable analgesic trial. ited evidence that supports the use of vital signs as a
single indicator of pain; however, both physiologic
and behavioral responses often increase temporarily
INTUBATED AND/OR UNCONSCIOUS with a sudden onset of pain (Foster et al., 2003).
PERSONS: GUIDING PRINCIPLES FOR Changes in physiologic measures should be consid-
ered a cue to begin further assessment for pain or
THE ASSESSMENT OF PAIN
other stressors (Foster, 2001). Absence of increased
Recommendations for pain assessment in intubated vital signs does not indicate absence of pain (McCaf-
and/or unconscious persons unable to self-report that fery & Pasero, 1999).
are unique from the general recommendations include Use of Behavioral Pain Assessment Tools
the following: Although no single behavioral scale has been shown to
1. Self-report. Self-report of pain should be attempted; be superior for use with this population, tools tested in
however, obtaining a report of pain from a critically ill other settings may be useful if appropriate to the
patient may be hampered by delirium, cognitive and population and pain problem. Tools should be tested
communication limitations, level of consciousness, to ensure they are reliable and valid if used with a
presence of an endotracheal tube, sedatives, and neu- population in whom they have not been studied.
romuscular blocking agents. Because of delirium that
can wax and wane and impact ability to self-report, Pediatrics
serial assessment for the ability to self-report should be
● FLACC: Faces, Legs, Activity, Cry, Consolability Obser-
conducted.
2. Potential Causes of Pain/Discomfort. Sources of pain vational Tool (Manworren & Hynan, 1995; Merkel et al.,
in critically ill patients include the existing medical 1997; Willis et al., 2003) (tested in 2 months to 7 years
condition, traumatic injuries, surgical/medical proce- of age; Post Anesthesia Care, intensive care, acute care
dures, invasive instrumentation, blood draws, and settings, surgical pain and acute pain)
● DSVNI: Distress Scale for Ventilated Newborn Infant
other routine care such as suctioning, turning, posi-
tioning, drain and catheter removal, and wound care (Sparshott, 1966) (tested in ventilated newborns; inten-
(Jacob & Puntillo, 1999; Puntillo et al., 2001, 2004; sive care setting; procedural pain)
● COMFORT Behavior Scale (van Dijk et al., 2005) (tested
Simons et al., 2003; Stanik-Hutt et al., 2001). Verbal
adult patients describe a constant baseline aching pain in neonate to 3 years of age; intensive care setting,
with intermittent procedure-related pain descriptors surgical pain. Revised scale of COMFORT (Ambuel et al.,
such as sharp, stinging, stabbing, shooting, and awful 1992; Canenvale, & Razack, 2002) Measures other con-
pain; thus it should be assumed that those unable to structs than pain. (tested in newborn to 9 years of age;
report pain also experience these sensations (Puntillo intensive care setting, mechanically ventilated)
et al., 2001). In addition, immobility, hidden infection, Adults
and early decubiti can cause pain and discomfort.
● BPS: Behavioral Pain Scale (Payen, 2001) (tested in
3. Observation of Patient Behavior. Facial tension and
adults; intensive care; procedural pain age)
expressions such as grimacing, frowning, and wincing
● CPOT: Critical-Care Pain Observation Tool (Gelinas et
are often seen in critically ill patients experiencing
al., in press) (tested in adults; intensive care setting;
pain. Physical movement, immobility, and increased
nociceptive procedures)
muscle tone may indicate the presence of pain. Tear-
ing and diaphoresis in the sedated paralyzed and ven- 4. Surrogate Reporting of Pain. Parents of children,
tilated patient represents autonomic responses to dis- caregivers, family members, and surrogates can help
comfort (Hamil-Ruth & Marohn, 1999). Behavioral identify specific pain indicators for critically ill individ-
pain scales are not appropriate for pharmacologically uals. A family member’s report of their impression of
paralyzed infants, children, adults, or those who are a patient’s pain and response to an intervention
flaccid and cannot respond behaviorally to pain. As- should be included as one aspect of a pain assessment
sume pain is present and administer analgesics appro- in the critically ill patient.
priately to patients who are given muscle relaxants 5. Analgesic Trial. Initiate an analgesic trial if pain is
and/or deep sedation and experience conditions and suspected. The priority of the analgesic trial is to verify
50 Herr et al.

the presence of pain. Ongoing treatment should con- This position paper describes the severity of this issue,
sider the unique issues of this population. The ongo- defines populations at risk, and offers strategies, tools,
ing use of analgesics, sedatives, and comfort measures and resources for appropriate pain assessment. Nurses
can provide pain relief and reduce the effect of the have a moral, ethical, and professional obligation to
stress response. Paralyzing agents and sedatives are
advocate for all individuals in their care. Just like all
not substitutes for analgesics. This population is often
being weaned from opioids to support a successful
other patients, these special populations require con-
extubation; however, suspected pain should be sistent, ongoing assessment, appropriate treatment,
treated. Less sedating agents and approaches should and evaluation of interventions to ensure the best
be considered as appropriate, such as nonsteroidal possible pain relief. Clinicians are encouraged to mon-
anti-inflammatory drugs, patient-controlled analgesia, itor current research regarding new developments in
and epidural analgesia. In patients with head injury, strategies and tools for assessing pain in these popu-
opioids should be used as appropriate for pain but lations.
weighed against the risk of sedation. Short-acting opi-
oids such as fentanyl may allow for appropriate titra-
Acknowledgments
tion yet allow quick retreat if needed.
The authors sincerely thank the following expert reviewers:
Margaret L. Campbell, RN, PhD(c), FAAN, Constance Dahlin,
SUMMARY APRN, BC, PCM, Joann Eland, PhD, RN, FNAP, FAAN, Jill
Loeb, BSN, MSN, RN, Chris Pasero, RN, C, MS, FAAN, Kath-
Individuals who are unable to communicate their dis- leen Puntillo, RN, DNSc, FAAN, and Roxie L. Foster, PhD,
comfort are at greater risk for inadequate analgesia. RN, FAAN.

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chier, J., & Duivenvoorden, H. J. (2000). The reliability Other Position papers/statements/guidelines
and validity of the COMFORT scale as a postoperative pain American Medical Directors Association. (2003).
instrument in 0 to 3-year-old infants. Pain, 84, 367-377. Chronic pain management in the long-term care setting.
van Dijk, M., Peters, W. B., van Deventer, P., & Tibboel, Columbia, MD: Author.
D. (2005). The COMFORT behavior scale. American Jour- American Pain Society. (2003). Principles of analgesic
nal of Nursing, 105(1), 33-35, 37. Free CD ROM and algo-
use in the treatment of acute pain and cancer pain (5th
rithm on assessment and treatment can be obtained by
ed). Glenview, IL, Author.
writing Dr. Monique van Dijk at m.vandijk.3@
Anand, K. J. S., & International Evidence-Based Group
erasmusmc.nl.
for Neonatal Pain. (2001). Consensus statement for the
Willis, M. H., Merkel, S. I., Voepel-Lewis, T., & Malviya,
prevention and management of pain in the newborn. Ar-
S. (2003). FLACC Behavioral Pain Assessment Scale: a com-
chives of Pediatric Adolescent Medicine, 155, 173-180.
parison with the child’s self-report. Pediatric Nursing,
National Association of Neonatal Nurses. (1999). Posi-
29(3), 195-8.
tion statement #3019. Pain management in infants. Re-
Intubated and/or unconscious patient trieved January 10, 2005 from http.www.nann.org/files/
references (not cited earlier) public/3019.doc.
Ambuel B., Hamlett, K. W., Marx, C. M., & Blumer, J. L. American Pain Society & American Academy of Pediat-
(1992). Assessing distress in pediatric intensive care rics. (2001). The assessment and management of acute
environments: the COMFORT scale. Journal of Pediatric pain in infants, children, and adolescents. [Position state-
Psychology, 17(1), 95-109. ment]. Retrieved January 10, 2005 from http.www.
Buttner, W., & Finke, W. (2000). Analysis of behavioural ampainsoc.org/advocacy/pediatric2.htm.
and physiological parameters for the assessment of postop- American Academy of Pediatrics & Canadian Paediatric
erative analgesic demand in newborns, infants and young Society. (2000). Prevention and management of pain and
children: A comprehensive report on seven consecutive stress in the neonate. [Policy statement]. Pediatrics,
studies. Paediatric Anaesthesia, 10(3), 303-318. 105(2), 454-461.
Pain Management
Nursing Role/Core Competency
A Guide for Nurses

______________________________________________________________________________

THE GUIDE MUST BE READ IN CONJUNCTION WITH THE NURSE PRACTICE ACT (MD. CODE ANN., HEALTH
OCC., TITLE 8), BOARD REGULATIONS (COMAR 10.27.01 et. seq.), AND EMPLOYER POLICIES.
THE GUIDE IS NOT INTENDED TO REPLACE OR MODIFY THE ACT OR THE REGULATIONS, OR
EMPLOYER POLICIES. IN THE EVENT OF AMBIGUITY OR INCONSISTENCY, THE NURSE
PRACTICE ACT AND THE BOARD’S REGULATIONS TAKE PRECEDENCE.
Pain Management
Nursing Role/Core Competency
A Guide for Nurses

PURPOSE OF THIS EDUCATIONAL GUIDE

The purpose of this document is to assist the Pain management is only one aspect of the
licensed nurse in recognizing his/her complex process of providing palliative care.
accountability in effectively managing It is beyond the scope of this document to
patients’ pain through assessment, address other issues involved in palliative
intervention and advocacy. care.

BACKGROUND

Pain management encompasses various types response can provide maximum pain relief
of pain experiences throughout an individual’s without adversely affecting respiratory status.
life cycle from birth to the end of life. Pain expe- Therefore, it is unwarranted to under-utilize or
riences may include acute and chronic pain, pain withhold opioids from a patient who is
from a chronic deteriorating condition, or pain as experiencing pain based on fear of causing
one of many symptoms of the patient receiving respiratory depression.
palliative care. Pain is not exclusively physiologi - Due to multiple advances in the field of pain
cal but also includes spiritual, emotional and psy- management (i.e. pain assessment, pharmacolog-
chosocial dimensions. The goal of pain manage- ical and non-pharmacological interventions),
ment throughout the life cycle is the same - to licensed nurses may have incomplete or inaccu-
address the dimensions of pain and to provide rate information about the following variables
maximum pain relief with minimal side effects. which contribute to ineffective pain management:
Review of the literature, anecdotal reports and 1. What is pain and how do patients
dialogue with colleagues reveals that the majority demonstrate their pain?
of patients do not receive adequate pain manage- 2. How is pain assessed and managed?
ment. A wide variety of factors including inaccu- 3. Is there a difference between
rate information, myths, rumors, fear and cultural psychological dependence, addiction
issues contribute to inadequate pain management. and physical dependence?
For example, a prevailing rumor in the nursing 4. Does aggressive use of opioids cause
profession is that a nurse can lose his/her nursing addiction?
license for causing a patient’s respiratory depress- 5. How does the patient’s cultural back-
ion by frequent administration or by giving high ground effect pain expression and
doses of opioids, even though there is no documen- management?
ted evidence to substantiate this fear. The Myths and misinformation also contribute
literature shows that adequate assessment in to ineffective pain management. Some common
conjunction with opioid titration based on patient myths include:

2
Pain Management Nursing Role/Core Competency

1. Too much pain medication too frequently Populations identified by the literature as being at
constitutes substance abuse, causes greater risk include: infants and children, women,
addiction, will result in respiratory the elderly, patients with cognitive dysfunction,
depression or will hasten death; patients with emotional or mental illness, patients
2. Pain should be treated, not prevented; with chronic pain, patients with neuropathic pain,
3. People in pain always report their pain to substance abusers, minority populations, the
their health care provider; homeless, and patients with terminal illnesses.
4. People in pain demonstrate or show that In
they have pain - pain can be seen in the addition, patients who speak a different language
patient’s behavior; or who are from a cultural tradition different from
5. The level of pain is often exaggerated by that of the clinician pose a special challenge. In
the patient; effect, any patient, regard- less of age, is at risk of
6. Generally a patient cannot be relieved of all being under-treated for pain. All populations can
pain; be placed at greater risk because of the health care
7. Some pain is good so that the patient’s provider’s own belief system which may include
symptoms are not masked; the previously discussed myths and
8. Newborn infants do not have pain; and, misinformation.
9. It is expected that the elderly, especially the These factors and others have prompted the
frail elderly, always have some pain. Board to develop this educational guide for the
Maryland licensed nurse. The intent is to provide
Patient Populations at Risk of Under factual information and assist the licensed nurse in
Management developing core nursing competencies in pain
management. The licensed nurse must become
Because of multiple barriers to adequate pain familiar with standards, guidelines and definitions
management, all patients are at risk for under- regarding pain and its management, including but
treatment of pain. Since pain is identified and not limited to those listed in the definition of
reported primarily through patient self- reporting, terms and bibliography and to refer to these
difficulty in communicating increases the patient’s documents when advocating for the patient in
risk for under-treatment. pain.

3
Licensed Nurse Role:
Knowledge Based Practice

The licensed nurse is responsible and account- Pain is subjective. It is whatever the patient
able to ensure that a patient receives appropriate says it is. The nurse utilizes the nursing process in
evidence-based nursing assessment and interven- the management of pain. Adequate measurement
tion which effectively treats the patient’s pain and and management of pain includes knowledge in
meets the recognized standard of care. In order to the following areas:
advocate for the patient, the licensed nurse must 1. Pain assessment:
possess the following: a) The nurse utilizes a developmentally
appropriate, standardized pain assessment tool
A) Knowledge of Self which includes: a pain measurement tool
which has demonstrated reliability and validity
The practice of nursing includes the knowledge and patient participation, which is essential in
of one’s self through assessment of attitudes, the assessment process. For those incapable of
values, beliefs, and cultural background and influ- self-reporting, standardized pain assessment
ences that have formed each of us as individuals. tools should include behavioral observations
These factors affect the nurse when assessing, with or without physiologic measures.
evaluating, and interpreting the patient’s state- i. Physiologic signs such as tachy-
ments, behavior, physical response, and appear- cardia, hypertension, diaphoresis and pallor
ance. The greatest barrier to the patient achieving are non-specific to pain and may be an
effective pain management may be the nurse’s: indicator of another, unrelated physiologic
1. Individual experiences with pain; problem. For patients in pain, these
2. Personal use of medications or non- physiologic signs may be present for a
pharmacological methods to manage short period of time or not at all.
pain; and, ii. Sole reliance on these physiologic
3. Family’s or significant others’ history or signs to assess pain may be inappropriate.
experience with substances for pain control or b) The nurse is knowledgeable regarding the
mood altering effect. difference in categories of pain (i.e. acute,
chronic, breakthrough);
When the licensed nurse is influenced or con- c) The nurse is knowledgeable regarding the
strained by personal factors, the nurse may not most likely potential sources of pain (i.e.
assess, evaluate or communicate the patient’s pain neurological, muscular, skeletal, visceral);
level effectively or objectively. This can be further d)The nurse assesses the patient’s individual
compounded if the nurse does not have adequate pain pattern, including the individual patient’s
knowledge regarding pain management and, as a pain experiences, methods of expressing pain,
result, can not recognize the need to seek out cultural influences, and how the individual
additional information to assess and manage the manages their pain.
patient’s pain appropriately. For instance, a nurse 2. Pharmacologic and Non-Pharmacologic
who believes or states, “You can tell by looking at Intervention:
the patient if they are in pain” is demonstrating an a) The nurse is knowledgeable about the
inadequate knowledge base. pharmacological interventions of opioid,
non-opioid, and adjuvant drug therapies
B) Knowledge of Pain

4
Pain Management Nursing Role/Core Competency

(including dosages, side effects, drug b) Barriers to effective pain management,
interactions, etc.) which are most effective which may include personal, cultural and
for the most likely source of an individual Institutional barriers. Sources of these
patient’s pain. barriers may include but are not limited to
b) The nurse is knowledgeable that placebos patient, family, significant other, physician,
should not be utilized to assess if pain exists or nurse and institutional constraints;
to treat pain. 3. Reporting the patient’s level of pain;
c) The nurse is knowledgeable regarding non- 5. Developing the patient’s plan of care that
pharmacologic strategies for pain management includes an interdisciplinary plan for
(i.e. acupuncture, application of hot and cold, effective pain management involving the
massage, breathing techniques, etc.). patient, family and significant other;
3. Current pain management standards and 6. Implementing pain management strategies
guidelines. and indicated nursing interventions
4. The difference between tolerance, physical and including:
psychological dependence, withdrawal and a) Aggressive treatment of side effects
pseudoaddiction. (i.e. nausea, vomiting, constipation,
pruritus etc),
C) Knowledge of the Standard of Care b. Educating the patient, family and
significant other(s) regarding,
The standard of care is effective ongoing pain (i) Their role in pain management,
assessment and pain management. This includes (ii) The detrimental effects of
but is not limited to: unrelieved pain,
1. Acknowledging and accepting the patient’s (iii) Overcoming barriers to effective
pain; pain management,
2. Identifying the most likely source of the (iv) The pain management plan
patient’s pain; and expected outcome of the plan;.
3. Assessing pain at regular intervals, with 7. Evaluating the effectiveness of the
each new report of pain or when pain is strategies and the nursing interventions;
expected to occur or reoccur. 8. Documenting and reporting the interven-
Assessment includes but is not limited tions, patient’s response, outcomes; and
to: 9. Advocating for the patient and family for
a) The patient’s level of pain utilizing a effective pain management.
pain assessment tool;

5
PATIENT ADVOCACY

The nurse’s primary commitment is to the The nurse also has an obligation to advocate
health, welfare, comfort and safety of the for all patients in the aggregate. When an
patient. Self-awareness, knowledge of pain and organization’s policies, procedures and practices
pain assessment, and knowledge of the standard are insufficient to provide consistent effective
of care for pain management enhances the pain management, the nurse works through
nurse’s ability to advocate for and assure appropriate committees and channels to insure
effective pain management for each patient. that patients’ pain management needs are
When advocating for the patient, it is crucial addressed. This advocacy role is particularly
that the nurse utilize and reference current critical for populations known to be at risk for
evidence-based pain management standards and under-management of their pain.
guidelines.
As a patient advocate, the nurse takes all SUMMARY
reasonable means to alleviate the patient’s pain
and suffering. In addition, the nurse consults This educational guide is intended to assist
and collaborates with specially trained experts in the licensed nurse to act in an accountable
pain management, such as registered nurses, manner to effectively manage a patient’s pain.
licensed physicians, pharmacists, massage This document emphasizes that the licensed
therapists, acupuncturists and others to assure an nurse must continue to develop self-awareness
effective interdisciplinary treatment plan to and enhance his/her learning in order to remain
address each patient’s pain. When the patient’s current in nursing knowledge and skill relative
pain needs are not being adequately addressed, to attempt to pain management. The licensed
the nurse continues to advocate for the patient nurse is responsible and accountable to work
through other means, such as referral to the toward effectively managing the patient’s pain
organization’s joint practice committee, the through assessment, intervention and patient
ethics committee, and/or the organization’s advocacy.
chain of command.

6
DEFINITION OF TERMS

1. Pain management: The use of pharmaco- c) Breakthrough Pain: An acute
logical and non-pharmacological interven- exacerbation of pain that breaks through
tions to control the patient’s identified pain. an existing analgesic regime.
Pain management extends beyond pain 2. Palliative Care: The active total care of
relief, encompassing the patient’s quality of patients focusing on symptom manage-
life, ability to work productively, to enjoy ment, of which pain is only one of many
recreation, to function normally in the symptoms. The goal of palliative care is
family and society, and to die with dignity. achievement of the best quality of life for
2. Pain: An unpleasant sensory and emotional patients, families and significant others by
experience associated with actual or addressing psychological, social and
potential tissue damage or described in spiritual problems, in addition to
terms of such damage. Pain is always controlling the patient’s pain and other
subjective and is whatever the person says symptoms.
it is, existing whenever the person says it 4. Suffering: The state of severe distress
does. The clinician must accept the associated with events that threaten the well
patient’s report of pain. Categories of pain being of the person. Suffering often occurs
include but are not limited to: in the presence of pain, shortness of breath,
a) Acute Pain: A normal, predicated or other bodily symptoms. Suffering
physiologic response to an adverse clinical, extends beyond the physical domain. For
thermal or mechanical stimulus. It is example, a woman awaiting breast biopsy
generally time-limited and responsive to may “suffer” because of anticipated loss of
opioid and non-opioid therapy. Acute pain her breast, while after the biopsy the
responses may vary between patients and woman may have “pain” from the
between pain episodes within an individual procedure.
patient. Acute pain episodes may be 5. Tolerance: The process by which the body
present in patients with chronic pain. requires a progressively greater amount of a
b) Chronic Pain: Malignant or non- drug, over time, to achieve the same results.
malignant pain that exists beyond its As it relates to pain relief, tolerance is
expected time frame for healing or where decreasing pain relief over time with the
healing may not have occurred. It is same dosage. Patient can become tolerant
persistent pain that is not amenable to to the analgesic effect of opioid therapy,
routine pain control methods. Chronic pain requiring an increase in dose. For many
is often present with no physiologic signs, opioids there is no known ceiling to the
which may lull the clinician into falsely amount that can be given, meaning that
believing the patient is not in pain. Chronic pain relief can increase with an increase in
pain may result in a look of sadness, the dose of the opioid. In addition, patients
depression, or fatigue causing the clinician can become tolerant to some adverse effects
to misinterpret the picture and not identify (respiratory depression, somnolence, and
that the patient may also be experiencing nausea) related to opioid therapy.
pain. Patients with chronic pain may have 6. Substance abuse: The use of any chemical
episodes of acute pain related to treatment, substance for other than its medically
procedures, disease progression or re- intended purpose.
occurrence.

7
Pain Management Nursing Role/Core Competency

7. Pseudoaddiction: The pattern of drug- 13. Adjuvant Medications: Medications that
seeking behavior among pain patients are used to a) enhance the pain relieving
because of inadequate management of their effects of opioids and non-opioids, b) treat
pain problem which can be mistaken for concurrent symptoms that exacerbate pain
addiction. such as utilization of anxiolytics, or c)
8. Physical dependence: A physical response provide independent analgesia for specific
of the body to a substance characterized by sources of pain (i.e. neurologic pain), such
signs of withdrawal if the substance is as utilization of tricylic anti-depressants and
stopped without tapering, markedly reduced anti-convulsants.
after prolonged use, or if an antagonist is 14. Opiate: A drug whose origin is the opium
administered. Physical dependence is an poppy, including codeine and morphine.
expected result of opioid use. Physical 15. Pain Assessment: The comprehensive
dependence, by itself, does not equate with evaluation of the patient’s pain including
addiction. but not limited to: location, intensity,
9. Abstinence (withdrawal) Syndrome: duration of the pain; aggravating and
Physical symptoms that can occur after relieving factors; effects on activities of
abrupt discontinuation or dose reduction of daily living, sleep pattern and psychosocial
an opioid or administration of an antagonist. aspects of the patient’s life, and effective-
The syndrome is characterized by any or all ness of current management strategies. Pain
of the following: anxiety, irritability, chills, assessment includes the use of a
hot flashes, salivation, lacrimation, standardized pain measurement tool.
rhinorrhea, diaphoresis, piloerection, nausea, 16. Pain Measurement Tool: The quantitative
vomiting, abdominal cramps, and insomnia. examination of the intensity of the pain as
Withdrawal should be avoided by gradual reported by the patient utilizing a standard-
reduction of dose rather than abrupt ized instrument which has demonstrated
discontinuation. reliability and validity.
10. Addiction: A neurobehavioral disorder 17. Titration: Adjustment of medication levels
characterized by compulsive seeking of within the dosage and frequency ranges
mood-altering substances and continued use stipulated by the authorized prescriber in
despite harm. Addiction may also be refer- accordance with an agency’s established
red to by terms such as “drug dependence” protocols, guidelines or policies.
and “psychological dependence.” Addiction 18. Evidence-Based Practice: The conscien-
is not the same as physical dependence. tious and judicious use of current best
11. Opioid: Denotes both natural (codeine, evidence for making clinical decisions
morphine) and synthetic (methadone, about the care of patients. Evidence may
fentanyl) drugs whose pharmacologic effects include but is not limited to: research
are mediated by specific receptors in the findings, literature, bench-marking data,
nervous system. clinical experts, quality improvement, risk
12. Non-Opioid: A medication that provides management data, and standards and
pain relief, but that is not an opiate or a guidelines.
nonsteroid anti-inflammatory drugs
(NSAIDS), acetaminophen). synthetic
analog of an opiate (i.e.

8
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medresin.htm

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1. Karen Kaiser, RN, MS, Clinical Practice 14. Bernadette Greene, RN, MS, Nursing
Coordinator, University of Maryland Medical Practice Issues Committee, Maryland
System, Baltimore, MD. Board of Nursing, Baltimore, MD.
2. Margaret Perrone, RN, CRNH, Program 15. Ann Triantafillos, RN, MSN, Nursing
Coordinator, Palliative Care Program, Practice Issues Committee, Maryland
University of Maryland Medical System, Board of Nursing, Baltimore, MD.
Baltimore, MD. 16. Sandra L. Dearholt, RN, MS, Nursing
3. Anita Tarzian, RN, PhD., Maryland Health Practice Issues Committee, Maryland
Care Ethics Committee Network, University Board of Nursing, Baltimore, MD.
of Maryland School of Law, Baltimore, MD. 17. Charlene A. Hall, LPN, Nursing Practice
4. Chris Clyde, RN, Nursing Coordinator, Issues Committee, Maryland Board of
University of Maryland Medical Systems Pain Nursing, Baltimore, MD.
Center, Baltimore, MD. 18. Carol F. Wynne, RN, MS, Nursing
5. Marilyn McCord, RN, Pulmonary Clinical Practice Issues Committee, Maryland
Specialist, Sinai Hospital, Baltimore, MD. Board of Nursing, Baltimore, MD.
6. Donna Hale, RN, MS, Consultant in 19. Marsha Hopkins, LPN, Nursing Practice
Perioperative/Pain Service/Sinai Joint Center, Issues Committee, Maryland Board of
Life Bridge Health Center, Baltimore, MD. Nursing, Baltimore, MD.
7. Veronica Noah, RN, IV Therapy-Pain 20. Laurie Miller, RN, BS, Nursing Practice
Management Team. Frederick Memorial Issues Committee, Maryland Board of
Hospital, Frederick, MD. Nursing, Baltimore, MD.
8. Mary Lou Perin, RN, MSN, Pain Management 21. Lou Williams, RN, Nursing Practice
Consultant. Pain Relief/USA. Middletown, Issues Committee, Maryland Board of
MD. Nursing, Baltimore, MD.
9. Lori KozlowskI, CRNP-P, Acute Pain 22. Susan Niewenhous, RN, MS, Nursing
Management Team. Johns Hopkins Hospital, Practice Issues Committee, Maryland
Baltimore, MD. Board of Nursing, Baltimore, MD.
10. Kathleen White, RN, PhD, Nursing Practice 23. Kathryn Offenbacher, RN, BSN,
Issues Committee, Maryland Board of Nursing Practice Issues Committee,
Nursing, Baltimore, MD. Maryland Board of Nursing, Baltimore,
11. Ann K. Sober, RN, BS, Nursing Practice MD.
Issues Committee, Maryland Board of 24. Chris Murphy, RN, BSN, Nursing
Nursing, Baltimore, MD. Practice Issues Committee, Maryland
12. Voncelia S. Brown RN, MS, Nursing Practice Board of Nursing, Baltimore, MD.
Issues Committee, Maryland Board of 25. Debbie Somerville, RN, MPH, Nursing
Nursing, Baltimore, MD. Practice Issues Committee, Maryland
13. Ralph Washington, RN, Nursing Practice Board of Nursing, Baltimore, MD.
Issues Committee, Maryland Board of
Nursing, Baltimore, MD.

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