When patients can’t participate, staff intercede

Special groups get special approach

To make sure that all patients have their pain effectively controlled, it is important to address the needs of special populations. When patients are unable to provide self reports of pain because they are confused or have decreased levels of consciousness, nurses at Grant/Riverside Methodist Hospitals in Columbus, OH, follow special guidelines for the assessment and documentation of pain, says Lisa Hartkopf Smith, RN, MS, AOCN, clinical nurse specialist, pain management at the Riverside Methodist campus.

The guidelines include the following:

• Pathological conditions or procedures that usually cause pain are strong indicators that pain may be present, despite the patient’s inability to report.

• Assess behaviors indicating pain such as crying or grimacing. However, patients with chronic pain or who have adapted to their pain may not demonstrate these behaviors.

• Proxy pain ratings, or pain ratings provided by family members or significant others, may be used. Document who provides the pain rating.

In addition to guidelines that address special cases several types of pain scales are available in case the 0-10 pain scale is not suitable for the patient. Other choices include the faces pain scale, verbal descriptor scale, and visual analogue scale. Pain scales are available in 30 languages.

At the University of Washington Medical Center in Seattle, about 90% of the patients use the numeric pain scale, but nurses are told that they can’t just intervene on the basis of a pain score, says Joan Ching, RN, MN, pain management clinical nurse specialist. "Nurses know not to just use the numbers, but to look at what the patient is able to do or not able to do," she says. For example, are they able to get out of bed and walk around to speed their recovery?

A patient may say that he or she is a 3 or 4 on the pain scale but then refuses to get out of bed because he or she is in too much pain, explains Ching. In that case, a pain intervention should be implemented.