Tailor pain tools to patient

Understand beliefs that affect assessment

Language and cultural beliefs can affect the accuracy of pain assessment tools regularly used by hospice staff members, says Hank Willner, MD, medical consultant for Hospice Foundation of America and hospice medical director and palliative care consultant for Capital Caring in Falls Church, VA. Interpretation of visual and numeric scales may differ according to culture, he explains.

Even though a smiling face may mean no pain to the clinician, a smiling face may indicate embarrassment to some people, says Willner. Before relying upon a scale that uses faces, first show the faces to patients and then ask what the facial expression means to them, he suggests. "This will give you more information about how the patient interprets the scale," he says.

When using a numeric scale, find a way to define the numbers to which patients can relate, suggests Willner. "For example, say that a particular number is pain like a toothache, a stabbing knife or a needle," he says. For women who have had children, describe the highest number as labor or if the person has had kidney stones, use that pain as the highest level, he says. "Converting pain into a number is a conceptual challenge for most people, so using definitions that both patient and clinician can understand improves communication," he says.

Nurses should also talk to patients about their views of pain to better understand how the patient expresses pain, says Willner. Ask patients what they think causes their pain, how the pain affects their lives, and what they hope for in terms of relief from the clinician, he says. Ask the patient what has already been done to control pain, how well it worked, and why the patient does not think it worked, he says. "This information will help the nurse not only determine the best way to approach pain control, but also to evaluate which approaches the patient is most likely to accept," he adds.

"Many cultures believe in the healing or comforting effects of teas, herbs, touch therapy or acupressure," points out Mary Curry Narayan, MSN, RN, HHCNS-BC, a clinical education and transcultural nurse specialist and owner, Narayan Associates in Vienna, VA. If the patient believes these treatments will work, they may be an effective addition to more traditional medicine, she says. "If the non-traditional treatment is not medically contraindicated, I encourage them to do what makes them comfortable."

If medication is prescribed, be sure you prescribe it in a way that enables the patient to take it as prescribed, suggests Narayan. "Some cultures associate different colors with different meanings such as bad or good," she says. "If blue is a negative color for my patient, I prescribe the medication in a different dose that results in a different color pill," she says. One blue pill versus two yellow pills that equal the same dose can improve compliance and improve pain management, she points out.

If the patient's upbringing has taught stoicism or refusal to take pain medicine until pain is excruciating, you can help the patient by instructing patient and family to take the pain medication on schedule, says Jennifer Carlson, director of operations for Amedisys Hospice of Sweetwater in Sweetwater, TN. "If you know the patient is in pain but doesn't want to have to ask family members for pain medication, you can make it routine." She adds, "This means the patient doesn't have to explain himself to family members because 'the nurse said it has to be taken this way.'"