Monitoring pain in aged care residents is crucial to ensure their comfort and quality of life.
To improve the management of pain and to create pain vigilant aged care facilities it has been proposed that pain is considered the fifth vital sign, after temperature, pulse, blood pressure and respiration rate.
Pain needs to be assessed regularly and the presence of pain – or inadequately controlled pain – should be investigated at admission, whenever there are significant changes in the resident’s condition or behaviour, and routinely.
The best indicator of pain is the resident’s own report. Therefore, residents who are able to report pain, including those with mild to moderate dementia, need to be asked regularly about the presence of pain.
So what are the key components needed in the assessment of pain?
1. Direct questioning
Direct questioning about the presence of pain and this should include the use of alternative descriptors for pain, such as hurt or discomfort.
When asking residents about pain, use a quiet area with minimal distraction as this may elicit the best response.
Make eye contact with the resident and carefully phrase questions in a broad and open ended way.
Focus on asking about any current pain, right at this moment, as responses about past pain or discomfort may be less reliable. Allow sufficient time for the resident to process the question and respond. Use at least two different questions phrased differently to assess pain.
2. Observation for Signs of Pain
This needs to be done for all residents, but it is more important for residents with cognitive and/or communication impairment.
- Verbalisations/vocalisations: e.g. whimpering, groaning, calling out
- Facial expressions: e.g. frowning, looking tense, grimacing
- Body movements: e.g. fidgeting, rocking, guarding of a body part, changes in mobility or restricted movements
- Changes in interpersonal interactions: e.g. aggressive, combative, withdrawn, socially inappropriate
- Changes in activity patterns or routines: e.g. refusing food, appetite change, increased rest periods or wandering, sudden cessation of common routines
- Mental status changes: e.g. crying, increased confusion, distress, irritability.
For residents with dementia or impaired verbal communication skills the need to rely upon non‐verbal signs to identify and assess pain increases.
It is important to understand that some residents with dementia demonstrate little or no specific behaviour associated with severe pain.
Expressions of pain may not be apparent in chronic pain states when a person is at rest. In many cases movement‐induced exacerbation of the underlying pain condition will result in overt behavioural expressions similar to those seen in acute pain conditions.
It should be noted that some of these behaviours can indicate that the resident is distressed for reasons other than pain.
3. Descriptions of Pain
Thorough description of the pain, including the impact of pain on the ability to do daily activities, undertake social activities and the impact on relationships.
Affective dimensions include fear, anxiety and depression, while there are sensory dimensions, such as the severity and location of pain.
A component of assessing pain is to assist the resident describe their pain and take a pain history.
The PQRST list can assist obtaining this information where:
- P relates to Provoking factors. What makes the pain better and what makes it worse?
- Q relates to the Quality of the pain. What is the pain like? Describe the pain, is it aching, sharp, deep, shooting?
- R relates to Region and Radiation. Where is the pain and does it go anywhere else? Note this may be assisted by asking the resident to point to the pain?
- S relates to the Severity of the pain. Ask the resident about their worst pain, average pain, pain right now, pain with movement. Use pain scales to assist the resident rate pain severity and continue using the same scale in future assessments.
- T relates to Timing. How does the pain experience vary over time?
4. Measurement of Pain using Scales and Assessment Tools
Once a comprehensive pain assessment is completed, a unidimensional pain assessment scale can be used for ongoing evaluation of pain intensity and to monitor the response to treatment.
It is important to find a tool that is sensitive to the cognitive, language and sensory impairments of each individual resident. It may require carers/nurses to trial several tools to find the one that works best with that resident.
Verbal categorical scales (e.g. None, Mild, Moderate and Severe) are often preferred by older people and have the greatest reliability and validity.
Most importantly, the same tool should be used for ongoing assessment of the resident’s pain and their response to therapy.
5. Physical Examinations
The underlying cause of the resident’s pain needs to be investigated by conducting a physical examination and other relevant investigations.
It is from there that a pain management regime can be developed.
What Carers and Aged Care Staff Can Do
Registered nurses are primarily responsible for pain assessment, however personal care workers or assistants in nursing who provide daily care to residents are often the ones assisting more closely throughout the day. Some ways staff can help include:
- Familiarising themselves with common pain behaviours. In addition, the nurse can provide specific direction for particular residents such as those newly admitted to the facility. At handover the staff may be asked to report if the resident has any difficulties – for example, if the resident has painful feet or discomfort when walking, as a side effect to their diabetic neuropathy affecting their feet.
- Ensuring the resident’s basic needs are met, e.g. are they hungry, thirsty, hot or cold, lonely, fearful or needing the toilet?
- Reassuring the resident, by word and by action, that they are safe.
- Providing comfort measures e.g. massage (as advised) or repositioning the resident.
- Monitoring resident’s response to prescribed pain treatments for continued pain behaviours.
- Notifying a nurse if basic needs and comfort measures have been tried and are ineffective.
ORBIS AU-4394 Feb18