EV I DE NCE - BA S E D

CARE SHEET

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 younger patients to have their pain effectively managed because of clinician fear of drug-drug interactions and reluctance to 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 they have difficulty reporting pain with standard pain assessment tools due to their cognitive impairment or communication deficit(9) - Alternatives for these patients include use of pain scales developed for children (e.g., Faces Pain Scale), or developed 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 Pain Assessment in Advanced Dementia (PAIN-AD) can be used as a part of a comprehensive pain assessment approach 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 pain intensity. 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 as the Behavioral Pain Scale can be used(11) - Older adults in pain can become agitated, experience difficulty concentrating, or be reluctant to eat or engage in physical activity(1,2) The decline in function typical of older adults is exacerbated when they experience pain. When in pain, older adults 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 studies have 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 in determining optimal pain management strategies(4) Frequent assessment of cancer pain, coupled with evaluation of the effectiveness of pain management strategies, 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 this population 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 a handheld computer that permits the operator to record instances of pain with an automatic date and time stamp) 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 monitoring for 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 can lead to errors in pain assessment(10) - Pain assessment tools might require special adaptation to be correctly interpreted by individuals of other backgrounds 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 who undergo early pain assessment and treatment require less sedation and shorter duration of mechanical ventilation(6) Patients without cognitive impairment but who are unable to talk (e.g., those who are intubated) can indicate pain intensity with a corresponding number of fingers or by pointing to a number on a pain scale(6)

ICD-9
780.96

ICD-10
R52

Authors
Dana N. Rutledge, RN, PhD Cinahl Information Systems, Glendale, CA Carita Caple, RN, BSN, MSHS Cinahl Information Systems, Glendale, CA

Reviewers
Kathleen Walsh, RN, MSN, CCRN Cinahl Information Systems, Glendale, CA Nursing Practice Council Glendale Adventist Medical Center, Glendale, CA

Editor
Diane 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. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given 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

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

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

Coding Matrix
References are rated using the following codes, listed in order of strength: M Published meta-analysis SR Published systematic or integrative literature review RCT Published research (randomized controlled trial) R Published research (not randomized controlled trial) C Case histories, case studies G Published guidelines RV Published review of the literature RU Published research utilization report QI Published quality improvement report L Legislation PGR Published government report PFR Published funded report PP Policies, procedures, protocols X Practice exemplars, stories, opinions GI General or background information/texts/reports U Unpublished research, reviews, poster presentations or other such materials CP Conference proceedings, abstracts, presentation

References
1. 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)