EVIDENCE-BASEDCARE SHEET

ICD-9780.96

ICD-10R52

AuthorsDana N. Rutledge, RN, PhD

Cinahl Information Systems, Glendale, CACarita Caple, RN, BSN, MSHS

Cinahl Information Systems, Glendale, CA

ReviewersKathleen Walsh, RN, MSN, CCRN

Cinahl Information Systems, Glendale, CANursing Practice Council

Glendale Adventist Medical Center,Glendale, CA

EditorDiane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

August 2, 2013

Published by Cinahl Information Systems, a division of EBSCO Publishing. Copyright2013, Cinahl Information Systems. All rights reserved. Nopart of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any informationstorage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or informationgiven herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Pain Assessment in Special Populations

What We Know Sensitivity to pain can vary widely between patient populations (e.g., older adults, children, people of various

cultural backgrounds, and patients with sensory alterations or chronic pain)(1,2,3,4,5,6,7,8,9,10,11,12)

Older patients: Pain syndromes are common in older adulthood, yet older adults are less likely than youngerpatients to have their pain effectively managed because of clinician fear of drug-drug interactions and reluctanceto prescribe opiates, or because of difficulties in assessing pain in this population(1,2,9)

Studies have shown that older adults with dementia often experience unrelieved pain in part because theyhave difficulty reporting pain with standard pain assessment tools due to their cognitive impairment orcommunication deficit(9)

- Alternatives for these patients include use of pain scales developed for children (e.g., Faces Pain Scale), ordeveloped specifically for older adults with cognitive impairment (e.g., Doloplus-2 Scale)(2)

- Observational pain assessment tools such as the Checklist of Nonverbal Pain Behaviors (CNPI) and the PainAssessment in Advanced Dementia (PAIN-AD) can be used as a part of a comprehensive pain assessmentapproach in order to detect unrelieved pain in older adults(3)

Patients with cognitive deficits might be able to use self-report tools (e.g., 0 to 10 rating scale) for painintensity. When self-report is not reliable or possible, behavioral cues such as changes in behavior (e.g.,grimacing, vocalizations, postural changes) and sympathetic responses (e.g., pallor, elevated blood pressure,dilated pupils, tachycardia) can alert the clinician to the presence of pain;(2,12) pain assessment tools, such asthe Behavioral Pain Scale can be used(11)

- Older adults in pain can become agitated, experience difficulty concentrating, or be reluctant to eat orengage in physical activity(1,2)

The decline in function typical of older adults is exacerbated when they experience pain. When in pain, olderadults can require global assistance with ADLs and experience substantial decline in quality of life(1)

Patients with cancer: Severe pain is a common component of cancer and related treatments. Multiple studieshave shown that clinicians commonly underestimate the severity of pain experienced by cancer patients(4)

The patients self-reported rating of their cancer-related pain is more important than clinician assessment indetermining optimal pain management strategies(4)

Frequent assessment of cancer pain, coupled with evaluation of the effectiveness of pain managementstrategies, is crucial to optimizing pain control for patients with cancer(4)

Children and adolescents: Children and adolescents with chronic pain can experience emotional difficulties,disruption in school attendance, impaired social skills, and catastrophic thinking; the impact of pain in thispopulation is significantly affected by the level of family cohesion and support(8)

Questionnaires such as the Bath Adolescent Pain Questionnaire or electronic pain diaries (i.e., typically ahandheld computer that permits the operator to record instances of pain with an automatic date and timestamp) can be used to assess pain in children and adolescent patients(5,8)

Patients of various cultural backgrounds Depending on cultural norms, some ethnic groups tend to be more verbally expressive (e.g., Hispanics) than

others (e.g., Chinese) about communicating pain to clinicians. Therefore, pain assessment requires monitoringfor changes in behavior, expression, and posture, as well as listening for verbal cues(4,10)

Differences in language and misinterpreted visual or verbal expressions between clinicians and patients canlead to errors in pain assessment(10)

- Pain assessment tools might require special adaptation to be correctly interpreted by individuals of otherbackgrounds and languages(2,7)

Critically ill patients: Critically ill patients often experience procedural pain (e.g., chest tube removal,endotracheal suctioning) in addition to the pain directly related to their underlying medical condition(6)

Assessing critically ill patients for pain can speed their recovery. Patients in the intensive care unit whoundergo early pain assessment and treatment require less sedation and shorter duration of mechanicalventilation(6)

Patients without cognitive impairment but who are unable to talk (e.g., those who are intubated) can indicatepain intensity with a corresponding number of fingers or by pointing to a number on a pain scale(6)

Patients with syndromes such as complex regional pain syndrome (CRPS), sickle cell disease (SCD), and fibromyalgia can experience unusually severe pain(9)

Patients in this population can experience severe pain that worsens with movement, and can face inadequate pain control that leads to drug-seekingbehavior

Patients with chronic pain syndromes will often require multiple pain-relief strategies (e.g., repositioning, opiates, relaxation techniques) before pain reliefis achieved

What We Can Do Learn about pain assessment in special populations; share this knowledge with your colleagues Be cognizant that patients of different ages, ethnic backgrounds, or with various types of illness might express pain differently, and that alternative pain

assessment tools might be required to accurately assess for pain among various patient populations(1,9,10,11,12)

Note that caregiver continuity enhances the ability to detect subtle changes in behaviors of older adults, children, and patients with cognitive impairment Be aware of behavioral indications of pain among various patient groups (e.g., irritability in children, agitation in older adults, drug-seeking behavior in

patients with inadequately managed pain) Act as an advocate for patients by frequently assessing for pain, evaluating the efficacy of current pain management strategies, reporting unrelieved pain to

the treating clinician, and requesting a referral to a pain management specialist, if indicated

NoteRecent review of the literature has found no updated research evidence on this topic since previous publication on June 10, 2011.

Coding MatrixReferences are rated using the following codes, listed in order of strength:

M Published meta-analysisSR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)R Published research (not randomized controlled trial)C Case histories, case studiesG Published guidelines

RV Published review of the literatureRU Published research utilization reportQI Published quality improvement reportL Legislation

PGR Published government reportPFR Published funded report

PP Policies, procedures, protocolsX Practice exemplars, stories, opinions

GI General or background information/texts/reportsU Unpublished research, reviews, poster presentations or

other such materialsCP Conference proceedings, abstracts, presentation

References1. Bruckenthal, P., Reid, M. C., & Reisner, L. (2009). Special issues in the management of chronic pain in older adults. Pain Medicine, 10(Suppl 2), S67-S78. (RV)2. Chen, Y. -H., Lin, L. -C., & Watson, R. (2010). Evaluation of the psychometric properties and the clinical feasibility of a Chinese version of the Doloplus-2 scale among

cognitively impaired older people with communication difficulty. International Journal of Nursing Studies, 47(1), 78-88. (R)3. Ersek, M., Herr, K., Neradilek, M. B., Buck, H. G., & Black, B. (2010). Comparing the psychometric properties of the Checklist of Nonverbal Pain Behaviors (CNPI) and the Pain

Assessment in Advanced Dementia (PAIN-AD) instruments. Pain Medicine, 11(3), 395-404. (R)4. Gotay, C. (2009). Patient symptoms and clinician toxicity ratings: Both have a role in cancer care. Journal of the National Cancer Institute, 101(23), 1602-1603. (X)5. Palermo, T. M. (2009). Assessment of chronic pain in children: Current status and emerging topics. Pain Research & Management: The Journal of the Canadian Pain Society,

14(1), 21-26. (RV)6. Payen, J. -F., Bosson, J. -L., Chanques, G., Mantz, J., & Labarere, J. (2009). Pain assessment is associated with decreased duration of mechanical ventilation in the intensive

care unit. Anesthesiology, 111(6), 1308-1316. (R)7. Takai, Y., Yamamoto-Mitani, N., Chiba, Y., Nishikawa, Y., Hayashi, K., & Sugai, Y. (2010). Abbey Pain Scale: Development and validation of the Japanese version. Geriatrics &

Gerontology International, 10(2), 145-153. (R)8. Vowles, K. E., Jordan, A., & Eccleston, C. (2010). Toward a taxonomy of adolescents with chronic pain: Exploratory cluster and discriminant analyses of the Bath Adolescent

Pain Questionnaire. European Journal of Pain, 14(2), 214-221. (R)9. Willens, J. S. (2010). Pain management. In S. C. Smeltzer, B. G. Bare, J. L. Hinkle, & K. H. Cheever (Eds.), Brunner & Suddarth's textbook of medical-surgical nursing (12th

ed., Vol. 1, pp. 231-233). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. (GI)10. Zinke, J. L., Lam, C. S., Harden, R. N., & Fogg, L. (2010). Examining the cross-cultural validity of the English short-form McGill Pain Questionnaire using the matched

moderated regression methodology. Clinical Journal of Pain, 26(2), 153-162. (R)11. Pain assessment. (2012). Lippincotts nursing procedures and skills. Retrieved from http://procedures.lww.com/lnp.view.do?pId=1567737&s=p (GI)12. Pain management. (2013). In Lippincotts nursing procedures (6th ed., pp. 542-546). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. (GI)