Anne Madrid, age 80, visits the emergency department complaining of a dry cough and flu-like symptoms. (This case is a composite based on my experience.) Three weeks ago she fell in her home and fractured her pelvis; she was prescribed oxycodone plus acetaminophen (Percocet and others) orally every four hours as needed for pain and placed on bed rest at home for a week. Upon examination, she is found to have pneumonia and admitted to the medical-surgical unit. Her admitting orders include acetaminophen 650 mg every four hours as needed for pain.
Ms. Madrid lives with her 82-year-old husband, who tells Lily Sanders, the floor nurse, that his wife has had a great deal of pain since her fall, spending more time in bed than usual and avoiding movement around the house. Ms. Sanders asks Ms. Madrid to rate her pain: "On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, what is your pain like now?"
Ms. Madrid says that her current pain level is between 2 and 3 while she is in bed, but increases to between 7 and 8 when she tries to move from the bed to walk to the toilet or sit up in a chair. After her pelvic fracture, says Ms. Madrid, she took oxycodone plus acetaminophen every four hours as needed; however, after a few days she tapered herself off the opioid because she didn't want to become addicted. Since stopping the drug, she has been taking acetaminophen 650 mg as needed, usually three times per day.
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Web Video
Watch a video demonstrating the use and interpretation of the numeric rating scale, the verbal descriptor scale, and the Faces Pain Scale-Revised at http://links.lww.com/A251.
A Closer Look
Get more information on why it's important for nurses to assess older patients for the intensity of their pain.
Try This:Pain Assessment for Older Adults
This is the tool in its original form. See page 45.
PAIN ASSESSMENT in OLDER ADULTS
The evaluation of pain intensity using a pain-rating scale provides crucial information to guide treatment plans. This screening will inform the development of an interdisciplinary pain management plan. Because there are no objective measures of pain such as laboratory values or blood pressure, the most reliable measure of pain is the patient's self-report. A quantified pain measurement can be quickly and regularly obtained and used on an ongoing basis to determine the effectiveness of interventions.
The following three simple pain-intensity scales, as shown in Pain Assessment for Older Adults, page 46, are widely used with older adults in acute, long-term, and home care settings: the numeric rating scale (NRS), the verbal descriptor scale, and the Faces Pain Scale-Revised (FPS-R).
The NRS asks a patient to rate her or his pain by assigning it a numeric value, with 0 indicating no pain and 10 representing the worst pain imaginable.
The verbal descriptor scale asks the patient to describe her or his pain using the following descriptors: "no pain," "mild pain," "moderate pain," "severe pain," or "pain as bad as it could be."
The FPS-R is a visual scale on which patients choose the depiction of a facial expression that best corresponds with their pain. The six distinct images range from a smiling face (intensity = 0) to a harsh grimace (intensity = 10).
ADMINISTERING THE SCALES
Choosing a scale
The NRS and the verbal descriptor scale are widely known and frequently used: one or the other may be preferred by specific institutions or nurses. It is important for clinicians to be able to choose from several pain scales. While most clinicians choose the NRS, it may not be the best scale for all patients. For example, a nurse might use the FPS-R with a patient who is hearing impaired so that the patient can visualize the levels of pain. Regardless of the scale used, one of the most important considerations is the consistent use of the same scale with each patient. (To watch the portion of the video discussing use of the scales, go to http://links.lww.com/A252.
Before administering any of the three pain scales, the nurse should tell the patient that she or he is concerned about whether the patient is in any pain. The nurse could begin by saying, "I am curious whether you are bothered by pain right now."
To administer the NRS, which asks patients to rate pain on a numeric scale, the nurse should then continue, "On a scale of 0 to 10, with 0 representing no pain and 10 representing the worst pain you have ever experienced in your life, what is your pain now?"
When using the verbal descriptor scale, which uses words instead of numbers, the nurse could say, "Would you please describe your pain for me, from 'no pain' to 'mild,' 'moderate,' 'severe,' or 'pain as bad as it could be'?"
When using the FPS-R, which depicts a range of faces, the nurse could ask: "Would you please look at this card and point to the face that best represents the level of pain you are experiencing right now?" This tool might be used in patients with some challenges with verbal communication, such as patients who primarily speak another language or those with dementia, as well as those with a hearing impairment.
CHALLENGES
Many other factors besides those mentioned above could influence a nurse's choice of a pain scale. For example, patients with a visual deficit won't be able to use the FPS-R, while language barriers might interfere with a patient's comprehension of questions.
Cognitive impairment
Some evidence suggests that the three scales discussed in this article are ineffective with a significant proportion of cognitively impaired older adults. Ferrell and colleagues studied pain assessment in a skilled nursing home with a "very high prevalence of cognitive impairment."1 (The mean Folstein Mini-Mental State Examination [MMSE] score was 12 +/- 7.9 out of 30; scores of 23 or less indicate cognitive impairment.) They found that 83% of residents could complete at least one of the five pain-rating scales used during the study. Most residents (65%) could complete the Present Pain Intensity Scale of the McGill Pain Questionnaire (choosing words to describe the pain), which is similar to the verbal descriptor scale. Residents were least likely to complete the NRS (called the "verbal scale" in the study) or a "visual analog scale" that required patients to mark their pain level along a line using a pencil.
Wynne and colleagues studied the effectiveness of the NRS (referred to in the study as the "verbal rating scale"), a "visual analog scale," an earlier version of the FPS-R ("Wong-Baker Pain Scale"), and the "McGill Word Scale" in 37 nursing home residents, 64% of whom were cognitively impaired.2 Making monthly pain assessments for a year, the authors found that participants couldn't complete the NRS 49% of the time, the visual analog scale 43% of the time, the Wong-Baker scale 39% of the time, and the McGill Word Scale 27% of the time. In addition, "residents with an MMSE [score] of less than 15 demonstrated significantly lower response rates to all the severity instruments than residents with higher MMSE scores," with the NRS, visual analog scale, and faces scale eliciting the lowest response rates in this population. The authors stress that more research is needed. They suggest that no single method of pain assessment has been established for use with this population and that the choice of a scale must reflect the needs of individual patients. (To view the segment of the online video discussing the assessment of pain in patients with dementia, go to http://links.lww.com/A253. Also, AJN will feature an article on this topic next month.)
Ethnic and racial minorities
A descriptive study by Ware and colleagues-in which participants were 74% black, 16% Hispanic, and 10% Asian-found that all three of these scales were easily used by over 90% of the study participants.3 However, more research is needed into the disparities of pain management across racial and ethnic populations, and it is important to consider the possible influence of culture on the expression of pain.
INTERPRETING AND USING THE RESULTS
Scoring the NRS
The numerical scores of the NRS are interpreted as follows: 1 to 3 represents mild pain; 4 to 6, moderate pain; and 7 to 10, severe pain. When any confusion exists about the intensity of the patient's pain (such as when the nurse suspects that the patient has underestimated her or his pain), the nurse can confirm the results of the NRS by using verbal descriptors, as in the following exchange between Ms. Sanders and Ms. Madrid:
"Ms. Madrid," says Ms. Sanders, "would I be correct in describing your pain as mild when you are resting and severe when you try to move?"
"Yes," says Ms. Madrid. "I think this is why I have spent so much time in bed. My pain is just so severe when I move around."
Scoring the verbal descriptor scale
Interpreting the results of the verbal descriptor scale should focus on the words used to describe the pain. The nurse should record the words used by the patient and compare them with words she or he used previously. This can be complicated if patients choose to use different descriptors than those specified by the scale. For example, if the patient describes her or his pain as "excruciating," the nurse would need to clarify the patient's meaning by asking whether the best descriptor would be "severe" or "pain as bad as it could be."
Scoring the FPS-R
This scale is interpreted by applying a numeric scale with values assigned to each of the six facial expressions. The face that depicts a slight smile would be scored 0 points. The remaining faces are scored from 2 to 10 points depending upon the severity of the pain depicted by the face. The numeric notation for the faces on the scale is not displayed to the patient.
Using the results
The following dialogue describes how Ms. Sanders uses the results of the NRS to help Ms. Madrid think more objectively about her own pain and whether her treatment should be modified. The results of the verbal descriptor scale and the FPS-R could be used in similar ways.
Ms. Sanders tells Ms. Madrid, "I am concerned that your level of pain is as high as 7 or 8 when you start moving around. Reducing your pain level will certainly help you to feel better but will also allow you to move around more and speed your recovery from pneumonia. I think it would be helpful if I call Dr. Stevens to discuss how we can work to increase your comfort. At what level would you like your pain to be when you're moving around?" Ms. Madrid: "I would feel much better if my pain was less than 5 when I'm moving around." (The pain rating that allows the patient to perform a range of activities with relative ease is sometimes called the comfort-function goal. For more, see "Comfort-Function Goals," Pain Control, September 2004.)
Dr. Stevens agrees that Ms. Madrid's pain should be better controlled. He changes her acetaminophen prescription to 650 mg orally three times per day (rather than "as needed") and recommends that Ms. Madrid take one tablet of oxycodone plus acetaminophen orally every morning one hour before she engages in activity such as rehabilitation. Ms. Sanders also implements a fall-risk care plan for her because of the increased risk of falls when a patient is taking opioid analgesics.
COMMUNICATING THE RESULTS
Managing pain in older adults with multiple medical problems is best accomplished by an interdisciplinary team. Communication around the issue of pain should include team members, the patient, caregivers, and others. (For more information about the prevalence and perceptions of pain in older adults, see "Why Assess Older Adults' Pain?" on page 42.)
A sense of control
Teaching patients to use quantitative or descriptive reports of pain will help them to communicate their concerns about pain to nurses, physicians, and physical therapists and can also increase their sense of control. Ms. Sanders teaches Ms. Madrid how to keep a pain diary in which she can document her pain and her responses to analgesics and other interventions. This simple tool can help patients determine the effectiveness of their pain management plans and share their findings with the team members. (For more on pain diaries, see "Pain Diaries," Pain Control, page 36.)
Patient education
Nurses need to provide patients with information on the importance of pain management to maintain mobility and safety. They should also address patients' fears of addiction, letting them know that fear of addiction is common but that the percentage of patients who become addicted to pain medications has been shown to be quite low.4 Patient education that focuses on the benefits of effective pain management is important.
CONSIDER THIS
What evidence supports the use of the scales?
A literature review found that all three scales presented in this article (and variations of these scales) have demonstrated solid psychometric properties across health care settings.5 A study measuring "experimentally induced thermal stimuli" conducted by Herr and colleagues found strong reliability and validity for all three scales when they are used in adults of all ages, including older adults with mild cognitive impairment. Overall, the study found the verbal descriptor scale to have the "strongest psychometric support," followed by the FPS-R and the NRS or its equivalent.6 And the participants in the study said they most preferred a version of the NRS with 21 gradations (from 0 to 20), then the verbal descriptor scale, the 11-point NRS (from 0 to 10), and the FPS-R.
* Reliability. All of the scales have demonstrated good internal consistency, with Cronbach's [alpha] coefficients of 0.86 to 0.88 for the NRS, 0.85 to 0.86 for the verbal descriptor scale, and 0.88 to 0.89 for the FPS-R.5,6 Test-retest reliability for each ranged from 0.57 to 0.83 for the NRS, from 0.52 to 0.83 for the verbal descriptor scale, and from 0.44 to 0.94 for the FPS-R.5,6
* Validity. Herr and colleagues also reported that a factor analysis showed that all three scales were valid, although the FPS-R was the weakest.6
* Sensitivity. Herr and colleagues found that all three scales were sensitive to the discomfort reported by older adults with exposure to various temperatures.
Watch It!!
Go to http://links.lww.com/A251 to watch a nurse use pain-intensity scales to assess pain in a patient and discuss how to administer them and interpret results. Then watch the health care team plan intervention strategies.
View this video in its entirety and then apply for CE credit at http://www.nursingcenter.com/AJNolderadults; click on the How to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player.
Online Resources
For more information on this and other geriatric assessment tools and best practices go to http://www.ConsultGeriRN.org-the clinical Web site of the Hartford Institute for Geriatric Nursing, New York University College of Nursing, and the Nurses Improving Care for Healthsystem Elders (NICHE) program. The site presents authoritative clinical products, resources, and continuing education opportunities that support individual nurses and practice settings.
Visit the Hartford Institute site, http://www.hartfordign.org, and the NICHE site, http://www.nicheprogram.org, for additional products and resources.
Visit http://www.nursingcenter.com/AJNolderadults and click on the How to Try This link to access all articles and videos in this series.
REFERENCES