Pain assessment in the recovery room.
Abstract: The assessment and management of pain in the acute hospital setting is an important issue for practitioners (Layman Young et al 2005). Despite advances in pain management (Fotiadis et al 2004, Powell et al 2004, Wu & Richman 2004) and the use of multimodal analgesic techniques in the theatre/recovery environment (Jin & Chung 2001), for a variety of reasons (Turk & Okifuji 1999, Pasero 2003), patients' reports of pain following surgery suggest that it remains problematic (Rawal 2002, Brown 2004, Coll et al 2004). In the recovery room disorientation, anxiety, fear and nausea may add to and alter patients' perception of pain, making it crucial that recovery room practitioners understand pain and pain assessment. This article outlines and critiques pain assessment tools that may be used to enhance pain management practices in the recovery room.

KEYWORDS Pain / Pain assessment / Recovery room
Author: Brown, Donna N.
Pub Date: 11/01/2008
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2008 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Nov, 2008 Source Volume: 18 Source Issue: 11
Accession Number: 200343274
Full Text: Introduction

The most widely adopted definition of pain describes it as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage' (International Association for the Study of Pain 1979, p250). This definition recognises the subjective, complex and multifaceted nature of pain and encompasses physical, psychological, social, cultural and environmental factors that interconnect and affect how pain is perceived, managed and evaluated (International Association for the Study of Pain 2003).

Kehlet and Dahl (2003) contends that the practical aims of pain relief are to provide subjective comfort and enhance the patient's ability to deep breathe, cough and move easily, thus avoiding postoperative complications (Carr & Goudas 1999, Bertolini et al 2002). However achieving 'subjective comfort' can offer practitioners a challenge, as a report of pain requires that they must try to develop some understanding of the intensity, quality, location and meaning of the pain being described in order to treat it appropriately. Social attitudes and cultural beliefs (of both the person in pain and practitioners) prevail and can limit effective assessment and management of pain (McCaffery & Pasero 1999). Furthermore, researchers have repeatedly highlighted the inconsistencies that exist between nurses' and patients' interpretations of pain (Dahlman et al 1999, Sjostrom et al 2000, Idvall 2004, Carr et al 2005). Arguably discrepancies may be due, in part, to the fact that the parameters being compared by patients and nurses are not necessarily measuring the same pain experience (Sloman et al 2005, Brown et al 2007). Nevertheless pain and pain assessment should be an accepted consideration for all patients undergoing surgery.

Pain assessment tools

Pain assessment tools offer patients an opportunity to make a largely subjective experience objective, by describing pain in a way that is meaningful to them. It is argued that it may also facilitate continuity of care (Bouvette et al 2002). In addition to improving communication, insight into the potential analgesic needs of the individual patient can be developed (particularly for those patients with underlying chronic or palliative pain). While no satisfactory objective measures of pain exist (Joint Commission on the Accreditation of Healthcare Organisations 2001), it is imperative that formal pain assessment tools are utilised not only to facilitate effective communication, but also to reduce the chance of error or bias Carr & Mann 2000).

Practical pain assessment tools for consideration in the recovery room

Choosing the correct pain assessment tool requires practitioners to take into account the patient's age, language, socio-economic, educational and cognitive status (Bucknall et al 2001, Coll et al 2004). Presented below is a selection of the more commonly used pain assessment tools which may be used in the recovery room to promote the patient's self-report of pain and assist teams in managing the patient's pain. A critique of their advantages and disadvantages is also offered to aid decision making for applying the most appropriate tool for individual patients across the age spectrum.

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Unilateral pain rating scales

Single indicators of pain are arguably the most straightforward tools to apply in the recovery environment and are primarily used to determine 'how much a person hurts' (McCaffery & Pasero 1999, p62). The Verbal Rating Scale (VRS), Numerical Rating Scale (NRS), Visual Analogue Scale (VAS), and Faces of Pain Scale (FPS) are suitable for interpreting the intensity of pain and may be easily integrated into documentation processes in acute environments.

Verbal Rating Scale (VRS)

Known also as the Verbal Descriptor Scale (VDS), this tool offers a choice of four adjectives to describe increasing levels of pain experienced by an individual. The scale may be assigned numbers (ranging from zero to three) or letters (ranging from A-D) to assist recording (see Table 1).

For acute pain, the VRS provides a quick and simple method of pain assessment in the recovery room and can be easily integrated into routine observation charts. Additionally, their simplicity may be more appropriate for older people or those with mild cognitive impairment (Lawler 1997) as VAS or NRS for pain can be conceptually difficult for older people to use (Closs 1996). While offering a limited choice of words may be deemed prescriptive (Schofield 1995), extending the word choice makes the VRS time consuming and complicated for patients (Jensen & Karoly 1992). A significant difficulty of employing a VRS is that it can be difficult to ascertain small changes in pain, as the VRS intervals are less sensitive than those of the NRS and VAS (Williamson & Hoggart 2005). Nevertheless, Lara-Munoz et al (2004) propose that the VRS can provide reliable scientific information.

Visual Analogue Scale (VAS)

This tool comprises of a 10cm line with 'no pain' located at the point of zero and 'worst imaginable pain' located at the opposite end. The patient is asked to place or move a marker to the level that best indicates the intensity of their pain. The VAS (Figure 1) may be administered using a plastic ruler with a sliding marker or by paper. It is largely presented to the patient horizontally (Ogon et al 1996), however as pain may be considered as something that 'rises' it can also be used vertically (Aun et al 1986, Stephenson & Herman 2000).

There are variations of the VAS available with numbers (from zero to 10 or zero to 100) or words (no pain, moderate pain, severe pain) being supplemented (see Figure 2).

Williamson and Hoggart (2005) suggest that the more levels a pain tool has the more sensitive it will be to detecting changes in pain. However, Jensen and Karoly (1992) have urged caution in its use due to patients experiencing difficulty in understanding and using the VAS compared to other scales.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Numerical Rating Scale (NRS)

The NRS is an interval level tool that is applied verbally by the practitioner who asks the patient to rate their pain intensity from zero to five or 10. Some studies present the NRS as increasing from zero to five, 10, 20 or 100 (Williamson & Hoggart 2005). As with the VAS, the end point zero signifies no pain and five (10, 20 or 100) represents the worst pain possible.

Since many patients understand the concept of rating their pain from zero to 10, with minimal explanation, this method of pain assessment can be useful when trying to determine the degree of pain an individual is experiencing in situations where they will not or cannot tolerate lengthy questioning. Thus NRS may be useful for patients recovering from anaesthesia, those admitted under stressful or traumatic conditions, the less well educated and the visually impaired (McCaffery & Pasero 1999). Ferrell (1995) suggests that applying a NRS from zero to five may be the most appropriate pain rating scale for cognitively-impaired patients.

The validity of the NRS has been well established (Jensen & Karoly 1992). Additionally, its sensitivity to small changes in pain and its correlation to the VAS are robust (Jensen et al 1986). Its ease of understanding and application makes it a useful tool for daily practice, research and audit purposes. Nevertheless not all patients have the ability to perceive their pain numerically (Carpenter & Brockopp 1995, Bird 2003). A further consideration in applying this tool is that the end point number (5, 10, 20, 100) must be agreed upon and applied consistently in order for meaningful pain assessment to be achieved.

The Faces of Pain Scale (FPS)

The Faces of Pain Scale (FPS) employs six facial expressions that range from a smile through to a grimace. The smiling face at the zero endpoint signifies that the individual has no pain and as they progress through the faces the expressions change indicating that the pain is gaining in intensity. On the reverse or below the faces scale there is a numerical rating scale (NRS) ranging from zero to five (zero to 10 versions are also available). The patient is asked to choose the face that best represents their pain, which in turn corresponds to the appropriate number.

The Wong-Baker FACES of pain scale

A popular variation of the FPS, the Wong-Baker FACES of Pain Scale (Figure 3) comprises of a series of six facial expressions (ranging from a smile through neutral to a sad crying face). The smiling face at the zero endpoint signifies that the person feels happy because they have no hurt/pain. Progression through to face five symbolising that the person is experiencing the worst hurt/pain imaginable. The patient is asked to choose the face that best describes how they are feeling (though they may not be crying). Hurt, soreness and pain may be used interchangeably depending on the age of the person who is using the tool.

[FIGURE 3 OMITTED]

In a modification of the Wong-Baker scale, a VAS has been added to the faces (McCaffery & Pasero 1999). This amended tool has been recommended as the choice for most clinical settings due to its popularity among children from three years (McCaffery & Beebe 1994) through to adult patients. Furthermore it has been translated into several different languages. The FPS and Wong-Baker Scale also have the advantage of avoiding the bias that can be associated with some interpretations of the FPS (for example, Oucher scale (Beyer & Wells 1989) for children and adolescents), because the faces do not depict one particular age, culture or sex. However, a primary drawback of this tool is that it can be a barrier for use with the visually impaired.

Several studies (Herr et al 1998, Kaasalainen & Crook 2004, Jowers Ware et al 2006) have confirmed the validity, reliability and sensitivity of the faces scale. Questions have been raised as to whether the FPS may measure overall well-being or fear, as opposed to the construct of pain (Stein 1996, Jowers Ware et al 2006). However, Jowers Ware et al (2006) contend that ease of use and the reliability and validity of the FPS make it a useful tool for evaluating pain intensity.

Limitations

Although useful for encouraging practitioners to apply a pain scale in busy recovery room environments, limitations of unilateral Rating Scales exist in that they:

* offer a singular approach to pain assessment

* focus primarily on the intensity of pain (Flaherty 1996)

* fail to take account of the context of pain (Williamson & Hoggart 2005).

Other important factors such as location, quality, duration, emotional impact, type of pain and things that may exacerbate or reduce pain are omitted. Though recovery room staff may focus primarily on relieving immediate postoperative pain it is worth noting that the above factors might ultimately influence pain management decisions. Furthermore, applying the appropriate pain assessment tool accurately is only one part of pain management. Of equal importance is the preoperative preparation of patients (Coll 2004), accepting the patient's self-report of pain (McCaffrey 1968, JCAHO 2001) and frequent consultation with patients to determine the adequacy of analgesia, in order to plan and provide pain management interventions (Bucknall et al 2001, Dihle 2005).

Multidimensional Pain Rating Scales (MPS)

Increasingly patients admitted to hospital have an underlying chronic pain condition for which they are already receiving treatment. For such patients Multidimensional Pain Scales (for example, The McGill Pain Questionnaire (MPQ), (Melzack & Torgerson 1971), The short form McGill Pain Questionnaire (SF-MPQ), (Melzack 1987), Brief Pain Inventory (BPI), (McCaffery & Pasero 1999)) may be more appropriate. These scales assess the location, intensity quality, duration, pattern and/or effects of pain. Arguably multidimensional pain scales are not well suited for application in the recovery environment. However these pain assessment tools may offer valuable information to recovery room practitioners if they are completed prior to surgery. They may be particularly helpful when the analgesic needs of patients, with underlying painful conditions, appear to exceed 'the expected norm'. Possibly this is an area that requires further investigation and input from recovery room practitioners.

Paediatric pain assessment tools

It is essential that pain assessment in children is appropriate for the individual child and his or her family (Twycross et al 1998). As culture, belief, cognitive level (including those with developmental disability), perceptions and the tolerance of pain differs in all children, determining the level of pain experienced can offer a significant challenge. Thus there are a number of pain assessment tools, ranging from assessing pre-verbal to adolescent patients, available. As a rule of thumb pain in paediatric patients can be measured by:

* what children do (behaviour)

* how their bodies react (biological)

* what children say (self-report) (Twycross et al 1998).

In addition Twycross et al (1998) have offered some guidance to clinicians in terms of which pain assessment tool should be used when (Table 2).

Older people (65 years and over)

While the prevalence of pain in older people varies throughout the literature, what is consistent is that pain, in this patient group, remains problematic (NCEPOD 1999, Kaasakainen & Crook 2004, Lovheim et al 2006). As the admission of older people to hospital increases (DH 2000), and inadequately managed pain is associated with many adverse consequences (JCAHO 2001, Kemp et al 2005) the need for appropriate pain management is crucial (Brown 2004). However, as older people present practitioners with unique challenges (Table 3) it is necessary to develop some understanding of what these challenges are, if practitioners are to enhance their practice.

Table 3 was compiled following a review of the literature relating to older people undergoing surgery (Brown 2004) and an in-depth ethnographic study of older people undergoing colorectal surgery (Brown & McCormack 2005, 2006).

Pain assessment with older people

None to mild cognitive impairment The principles for assessing pain in older patients with no or mild/early cognitive impairment (including dementia) are the same as those for a person with no memory problems (McClean & Cunningham 2007). McClean (2003) suggests older people can report pain as accurately as their younger counterparts, using the pain rating scales outlined previously. However, it may be necessary to consider adopting words other than pain in order to elicit a forthright response (for example, ache, discomfort, sore). For those patients with mild cognitive impairment it is also helpful to clearly ask if they have pain at present, how big a problem it is and to give them sufficient time to answer (McCaffery & Pasero 1999, McClean & Cunningham 2007). Pain rating scales should be used until patients are no longer considered able to respond to the scale for themselves. They may well be significantly cognitively impaired before this occurs (McClean & Cunningham 2007).

Moderate to severe cognitive impairment

As cognitive impairment progresses it becomes more difficult for patients to accurately describe their pain and recovery room practitioners become reliant on other sources of information concerning the patient's pain. Assessing pain using behavioural indicators may assist recovery room practitioners at this stage (American Geriatrics Society 2002, Zwakhalen et al 2006). Behavioural indicator pain scales place the practitioner's observation of the patient into a framework that usually consists of:

* physiological changes--such as colour, vital signs, sleep pattern, guarding, sweating, loss of appetite

* body language changes--such as agitation, aggression, weeping, reaction to touch, increased or decreased movement

* behavioural changes--such as facial expression, withdrawal, assuming a foetal position.

There are a number of behavioural indicator pain assessment scales available (for example, Hurley et al 1992, Kovach et al 1999, Feldt 2000, Warden 2003, Abbey et al 2004) that include observation of some or all of the behaviours mentioned above. Debate concerning the reliability and validity of observational pain scales led the American Geriatrics Society (AGS 2002) to examine the reliability of practitioners utilising observations to make a diagnosis of pain in patients with severe cognitive impairment. Consequently they suggested six areas that should be incorporated into behavioural pain assessment charts (facial expression, negative vocalisation, body language, changes in activity patterns or routine, changes in interpersonal interactions, mental status changes).

Currently the only two behavioural pain assessment scales that take account of all six areas are:

* The Assessment of Discomfort in Dementia Protocol (ADD) (Kovach et al 1999)

* The Abbey Pain Scale (Abbey 2004).

However, changes in activity patterns or routine, changes in interpersonal interactions and mental status changes may be difficult for recovery room practitioners to ascertain as they care for patients for relatively short periods of time. Nevertheless if ward nursing staff have initiated behavioural assessment scales prior to surgery they may assist recovery room practitioners in assessing pain in older patients with cognitive impairment. This is an area that requires further research.

Summary

Pain assessment tools enhance communication between patients and practitioners by making a subjective experience measurable. Field (1996) suggests that recovery ward nurses have a special and significant role in assessing and relieving postoperative pain. Postoperative pain assessment should focus on the needs of the individual patient rather than on preconceived ideas of how much pain a certain type of surgery may elicit (Sjostrom et al 2000). To achieve this, a valid pain assessment tool should be consistently utilised.

As highlighted earlier, a unilateral pain assessment tool may be best applied in the initial postoperative period, with the recovery room nurse taking an active part in asking the patient to rate their pain and documenting the reported pain for the patient. However, unilateral pain assessment scales are not without their limitations. For those patients who are anxious or not responding to pain management interventions, recovery room practitioners may need to consider the broader context of pain (Botti et al 2004). In addition, MPSs (for patients with underlying pain conditions) and behavioural pain assessment tools (for patients with cognitive impairment) may offer recovery room practitioners the additional information they require for enhancing pain management practices. However, this is an area that requires collaborative working and further research (Table 4).

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About the author

Donna Brown

PhD, MA, PGDipHP,

PGC(LLL), RGN

Senior Acute Pain Control

Sister, Belfast Trust, Royal

Hosptials, Belfast

Task 1

Review

Reflect

Review this article in relation to your experience of pain assessment in the recovery room.

Reflect on your approaches to pain assessment, across the age spectrum.

Notional Learning Hours 1 hour for each task

Knowledge and Skills Dimension

Core 2: Personal and people development

Task 2

Reflect

Scheme of work

Arrange to spend some time with the Acute Pain Service observing how they assess pain in different patient groups. Reflect on your experience and consider how you could use your new knowledge to improve your practice and patient care

Notional Learning Hours 1 hour for each task

Knowledge and Skills Dimension

Core 2: Personal and people development

Task 3

Reflect

Identify patients in the recovery room with complex pain assessment and management needs. Reflect on what knowledge and skills recovery wards nurses used to assess and manage their pain.

Notional Learning Hours 1 hour for reflection

Knowledge and Skills Dimension

Core 4: Service improvement Core 5: Quality

Task 4

Case study

Reflect

Complete a case study on a patient with complex pain management needs (e.g. underlying chronic or palliative pain).

Reflect on your how you assessed and managed their pain and what knowledge you could bring to your role.

Notional Learning Hours 1 hour for each task

Knowledge and Skills Dimension

Core 2: Personal and people development

Core 3: Health, safety and security

Core 4: Service improvement

Core 5: Quality

HWB6: Assesment and treatment planning

HWB7: Interventions and treatments

Task 5

Project

Identify members of the multidisciplinary team who could assist you to develop preoperative pain assessment guidelines for patients with complex pain assessment needs. Consider what steps you may need to take to promote enhanced pain assessment practices for these patients.

Notional Learning Hours 1 hour

Knowledge and Skills Dimension

Core 2: Personal and people development

Core 3: Health, safety and security

Core 4: Service improvement

Core 5: Quality

by Dr Donna N Brown Correspondence address: Acute Pain Service, Level 3, New Building, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA. Email: donna.brown@belfasttrust.hscni.net

Additional Learning Resources

Associated AfPP online modules:

* Additional Learning Resources

* Associated AfPP on line modules:

* Airway Management

* Breathing Management

* Breathing Circuits and Their Uses

* Anaesthetic Drugs

* Supportive Pharmacology

* Circulation and Invasive Monitoring

* Patient Care: Knowing and Doing

* The Multi-disciplinary Team in the Operating Theatre

* Communication Skills

* Patient Care in the Operating Department

* Organisational Skills and Tools

* Patient Assessment in Recovery

* Pain Management in Recovery

* Health and Safety

* Infection Control

* Universal / Standard Precautions

* Managing Sharps and Waste

* Control and Scavenging of Waste Anaesthetic Gases

* Liability and Accountability

* Care and Responsibility

* Consent

* The Human Rights Act

Web links and key documents

International Association for the Study of Pain 2003 International Association for the Study of Pain (IASP) pain terminology, available from http://www.iasp-pain.org/terms-p.html. [Accessed 12/07/07]

British Association of Anaesthetic and Recovery Nurses http://www.barna.co.uk/

Reflective model

You will find this reflective model template and many others under the career development tab on the AfPP website.
Table 1 Verbal Rating Scale

0   Or   A   No pain
1   Or   B   Mild Pain
2   Or   C   Moderate Pain
3   Or   D   Severe Pain

Table 2 Paediatric pain assessment tools and age suitability

Which tool should be used when?

Tool                  Age group

Faces                 From 3 years
Poker chips           4-8 years
Eland Colour Scale    4-10 years
Numerical From        9-10 years
Verbal Rating Scale   9-15
Oucher                3-12 years
                      Useful for young children and
                      those with language difficulties

Reproduced with permission of Twycross et al (1998) Paediatric
Pain Management: a multi-disciplinary approach Oxford,
Radcliffe Medical Press p57

Table 3 The challenges of assessing and managing pain in the
older person

Research findings suggest that:

Pain sensitivity: threshold/tolerance

May differ in people of advanced age (Helme & Gibson 2001, Fine
2001) with subsequent management of pain being complicated by
multiple, non-concomitant causes and locations of pain (Herr &
Mobily 1991, Closs 1994, Epps 2001, Horgas 2003). However, it is
incorrect to assume that 'differ' means that pain reduces or
becomes absent. Rather it implies there is a variation in the
experience of pain, with some possible increase in patients' pain
tolerance (McClean & Cunningham 2007).

Analgesic intake

Older people receive less analgesia than their younger counterparts
with the same degree of pain (Morrison & Sui 2000). This may be due
in part to psychological or physical changes associated with age or
the dominant ageist belief that it is usual for older people to
experience pain daily and they 'simply have to put up with it'
(Harkins et al 1990, Yates et al 1995, Gloth 2000). However, Owen
et al (1989) argued that older patients, using Patient Controlled
Analgesia as a form of postoperative pain relief, did not
self-administer less medication.

Cognitive impairment

Cognitively impaired people receive much less analgesia than their
cognitively intact peers (Feldt et al 1998, Morrison & Sui 2000).
Ferrell and Ferrell (1992) argue that it is dangerous to assume
older people with cognitive impairment perceive pain differently,
as there is no available evidence to suggest that individuals with
cognitive impairment overstate or invent the pain they report
(Bruce & Kopp 2001).

Perceptions

The older persons' perception of staff being 'too busy' (Yates et
al 1995) or fear of being regarded as a nuisance influence the
older patients' willingness to communicate their pain concerns
(Herr & Mobily 1991, Carr & Thomas 1997, Brown & McCormack 2006).
Older people may further be disempowered because of negative
stereotypical attitudes which assume that growing older inevitably
results in reduced capacity for involvement (McCormack 2003). Thus
complex pain management needs remain unaddressed (Helme & Gibson
2001, Horgas 2003) or discussed with family members, who may
themselves not be sufficiently knowledgeable to best advise the
older person (Brown & McCormack 2006).

Practices

Task orientated practices in the hospital setting, a lack of
awareness of older peoples' needs and wishes and inadequate
communication affect pain assessment and management with older
people (Brown & McCormack 2006).

Communication

It has been well recognised that older people may experience
difficulties in communicating their analgesic needs to others
(Sengstaken & King 1993, Simons & Malabar 1995). Brockopp et al
(1996) found that although 92% of 125 older people understood that
the person who is experiencing pain is the authority on their pain,
only 66% believed that their pain would not be taken seriously when
discussed with others. Ferrell (1995) highlights that poor memory,
depression and sensory impairment may contribute to the challenges
of achieving accurate pain assessment. The practicalities of older
people experiencing hearing difficulties make it possible that
patients do not respond to questions concerning their pain because
they misunderstand or simply did not hear what they were being
asked (Brown & McCormack 2006).

Table 4 Key points for pain assessment tools

Key points

Pain assessment tools and charts must be:

* Easily understood by patients and staff

* Appropriate for the patient population they are to be used with

* Quick to apply

* Consistently applied and evaluated with patient input

* Used with consideration to context and behavioural signs

* Offer a sensitive, reliable and valid measure.
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