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Objectivity will reinforce value of pain rating scales
When working with severely burned patients, popular pain assessment tools haven’t always proven adequate in helping nurses accurately gauge pain levels. Researchers are shifting the emphasis from the reliability of assessment tools to the role of the attending nurse in pain assessments.
Based on recent studies, critical care nurses are being advised to shift the focus away from the absolute reliability of conventional pain rating scales. Instead, they are using a balanced assessment involving a patient’s responses to questions and the nurse’s own experience base for evaluations, free of subjective assumptions.
If a patient is intubated or incoherent, nurses can still make a balanced assessment using physiological indicators such as pulse rate, blood pressure readings, and breathing patterns. The key is to rely more on the patient’s responses than on the nurse’s potentially biased assessments, says Mary D. Gordon, RN, a clinical nurse specialist at the U.S. Army Institute of Surgical Research at Fort Sam Houston near San Antonio.
Using standard rating scales such as Visual Analogue and Faces are acceptable. However, nurses can improve the assessment significantly, Gordon says, if they don’t inject their own biases into the process. (For examples of widely used rating scales, see p. 18.)
"Clinicians tend to assess pain in patients and prescribe medications based on their own assumptions of the intensity of pain," Gordon says. "Everyone verbalizes that it’s the patient who describes the pain, but do they really use that as a factor in deciding the medication levels used in relieving that pain?" [Editor’s note: Gordon’s statements in this article are her own and do not necessarily reflect the official views of the Department of the Army or the Department of Defense.]
For years, nurses intuitively have questioned the reliability of tools as the Visual Analogue and Faces rating scales. Now, they have research-based data that help. To get a better gauge of pain levels, nurses can improve their assessments by:
• Departing from age-old beliefs.
Most critical care nurses acknowledge they commonly under-prescribe analgesics out of concern for over-medicating patients or fear the addictive consequences of opioid analgesics. In fact, there is very little risk in the ICU of over-medicating patients, says David Patterson, PhD, a psychologist who specializes in treating burn patients at Harborview Medical Center in Seattle. Gordon concurs.
Even when over-dosing occurs in the burn unit, it is infrequent, and the effects can be blocked or reversed by readjusting dosages or administering such drugs as Narcan, also known as Noloxone, to reverse the opoid’s effects, Patterson says.
• Trusting the patient’s responses.
Don’t assume the patient’s pain level is higher or lower than the patient claims when deciding appropriate medication dosages. Make an assessment based on the patient’s own pain indicators using an agreed-upon rating scale.
The key, according to Gordon, is to agree with the patient on an assessment tool that works and use it consistently. "Leave the preference up to the patient. Ask the patient. The more comfortable the patient feels with assessing the pain, the better he or she will feel with your pain management techniques."1
• Establishing consistency.
Nurses are divided on whether patients should be medicated for pain on a regular schedule or on a PRN basis. Researcher Janet A. Marvin, RN, MN, advocates regular medication.
Past studies with surgery patients suggest those who self-administer pain medication take less over time. This has been one of the arguments in favor of PRN, says Marvin, director of nursing at Shriner’s Hospital for Children in Galveston, TX.
However, "the more consistency you apply across nursing shifts the better," Marvin says. The regimen must be adaptable to changes in the patient’s condition. "The nurse always has the initial responsibility of assessing the patient’s needs."
• Adapting to the patient’s reporting ability.
Obviously heavily sedated, intubated, or incoherent patients present different assessment conditions. With these patients, nurses must rely more on their experience and judgment to gauge pain levels than on rating tools. This isn’t to say that nurses are free to use subjective standards, Marvin warns.
Physiological indicators such as an elevated pulse rate are important pain gauges. Get a second opinion from more experienced nurses or physicians. In the absence of reliable assessment tools, you can safely over-estimate pain levels. In these situations, "take what you think as a nurse and raise the assumed pain level up a notch or two," Gordon advises.
• Recognizing pain’s innate inconsistency.
Pain has a cyclical nature, according to Patterson of Haborview Medical Center. It does provide regular ratings, but the levels can "bounce all over the place." Patients will experience pain at regular intervals, but the levels can vary widely from assessment to assessment. This factor strengthens the notion that regular hourly or half-hourly assessments are a good idea because the patient may not reliably gauge changes in pain levels that require corresponding changes in medication dosages. (See box, p. 17 for more on the nature of pain.)
• Recognizing pain as a subjective experience affected by age and gender.
Patients experience pain on an individual level, Patterson says. The subjective nature of the experiences constantly works against accurate assessments. Studies also show that pain sensations and responses vary widely by age and gender.
Researchers aren’t certain whether these differences are affected by cultural or social factors. They also wonder whether the differences are actually a function of the way patients prefer to report their pain. For example, some studies suggest women prefer the Visual Analog scale while men and children lean toward the Faces scale.
In general, pain assessment tools are flawed and rudimentary, according to Patterson. As a rule, "stick to the simple things. Make the scale you choose to use simple and easy for the patient, and return to it each time," advises Marvin of Shriner’s.
1. Gordon M, Greenfield E, Marvin J, et al. Use of pain assessment tools: Is there a preference? J Burn Care Rehabil 1998; 19:451-454.
Choiniere M, Auger FA, Latarjet J. Visual analogue thermometer: A valid and useful instrument for measuring pain in burned patients. Burns 1994; 20(3):229-235.
Everett JJ, Patterson DR, Marvin JA, et al. Pain assessment from patients with burns and their nurses. J Burn Care Rehabil 1994; 15(2):194-198.
Choiniere M, Melzack R, Girard N, et al. Comparisons between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries. Pain 1990; 40(2):143-152.
For additional information on pain assessment ratings in burn and other acute care cases, contact:
• Mary D. Gordon, RN, MS, Burn Clinical Nurse Specialist, U.S. Army Institute of Surgical Research, 3400 Rawley East Chambers Ave., Fort Sam Houston, TX 78234. E-mail: firstname.lastname@example.org.
• American Burn Association, 625 N. Michigan Ave., Suite 1530, Chicago, IL 60611. Telephone: (312) 642-9260. E-mail: www.ameriburn.org.
Pain tends to be cyclical in nature. In a clinical setting, it falls into two categories:
Procedural pain: This is an acute, shorter-acting source of pain but is also sharper and more intensely felt than chronic pain. This pain is often caused by wound examination, debridement, or invasive treatments such as surgery.
Background pain: This type of pain is chronic, often longer lasting, and less intensely felt than acute pain over time. It can be physically debilitating, and fluctuates in intensity over time.
Source: David Patterson, Harborview Medical Center, Seattle.