A brief guide to recognising pain in residentsDeveloped by Dr Clint Douglas, QUT School of Nursing and Dr Judy Wollin, Wesley Mission Brisbane, for staff in aged care settings
Ask Observe ReportIdentify Pain:
Pain is more common than you might think Up to 8 out of every 10 residents have pain that interferes with their daily activities. Older persons are more likely to have persistent pain because of painful diseases such as arthritis or cancer.
Nerve-related pain can occur with diseases such as diabetes or after surgery. New onset or acute pain is commonly caused by recent falls, urinary tract infections, constipation, wounds and skin tears. Leaving home and moving into residential care, the death of a partner, or even missing a pet can also make pain much worse.
Left unrecognised and untreated, pain is a major cause of distress, disability and reduced quality of life among residents. Pain can limit mobility and activities of daily living. It often interferes with sleep, appetite and participation in social activities. Living with pain can also be frightening and frustrating. Residents with pain are almost twice as likely to have symptoms of anxiety and depression. Among residents with dementia, pain is linked to increased inappropriate behaviour and resistance to care.
The bottom line is that pain is common and should always be considered as a possible cause for a change in a resident’s behaviour or condition. Pain needs to be identified and reported.
It’s everyone’s job to identify and act on painAlthough pain is a serious problem for residents, it is often not recognised or treated by staff. Elderly residents with dementia or those who cannot talk are most at risk of being left in pain. It is common for staff not to believe, ignore or do nothing about pain in older people.
Staff looking after residents – especially PCs and AINs – are the eyes and the ears of the Home. You spend the most time with residents. You get to know what is normal for each resident and know when something is wrong. You are in the best position to identify pain. Yet staff often lack the skills or confidence to detect pain and report their concerns to others.
The purpose of this booklet is to help you recognise and report pain using the Identify Pain: Ask, Observe, Report tool with residents.
‘Pain is whatever the experiencing person says it is, existing whenever he or she says it does’ – Margo McCaffery, RN Who is the expert on residents’ pain? Whose pain is it? Staff and family sometimes believe they know more about the resident’s pain than the resident does. But this belief is dangerous. Staff may make comments like ‘She doesn’t have as much pain as she thinks she does,’ or dismiss pain behaviours with comments like ‘Oh, he’s always like that.’ All reports of pain should be taken seriously.
Pain is subjective and your feelings about pain and pain levels may not be the same as the resident. The amount and type of pain each person feels is very different. Pain cannot be proved with a test. Blood tests or X-rays cannot tell us how much someone hurts. What the resident says about their pain is the single most accurate source of pain assessment.
When a resident reports pain, your responsibility is to believe the resident and take action. You may have personal doubts and opinions about the resident’s pain, but this should not stop you from reporting pain or providing care.
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Some attitudes and beliefs about pain are harmfulWe all have attitudes and beliefs about pain. But some beliefs about pain in older persons are major barriers to staff recognising pain and taking action.
MISCONCEPTION CORRECTION
Pain is an expected or natural part of growing old.
Pain is common in older adults, but pain is NOT a normal part of the ageing process. Pain should always be treated.
Pain decreases with age. Pain DOES NOT decrease with age.
If a resident is asleep or busy, he or she does not have pain.
A resident with pain may also sleep well, engage in activities, wash and dress themselves, eat meals, be pleasant with others. Sleep may also indicate exhaustion, not pain relief.
Residents who always complain about pain are attention seeking.
Be careful not to judge and say residents are exaggerating pain for attention, or it’s just a ‘behaviour.’ Believe residents when they say they have pain. Pain needs to be reported, assessed and treated.
A resident’s pain is well controlled if it only occurs on movement (e.g. walking, morning care, transfers).
Pain during movement, activities or repositioning indicates inadequate pain relief – report it.
A resident’s report of pain is unlikely to be true if no physical cause can be found.
All pain is real regardless of whether a physical cause can be found. This does not mean a resident’s pain can be ignored – report it.
Residents with dementia: › don’t feel pain › feel less pain › are unable to indicate pain.
Dementia may make it more difficult for residents to report pain, but it DOES NOT reduce the ability to feel pain. Always ask about pain. Most residents with mild to moderate dementia can use a pain rating scale.
Strategies when the resident’s report of pain is not accepted1 What if the person you tell does not believe you?
1. Accept that everyone is entitled to a personal opinion, but this does not mean we can ignore a resident’s pain.
2. Clarify that pain is what the resident says it is. It cannot be proved or disproved.
3. Quote the Australian Pain Society guidelines2 – ‘The most accurate and reliable source of information about a resident’s pain is the resident’s own report.’
4. Ask, ‘Why is it so difficult to believe that this person hurts?’
1 Based on: Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management. St Louis: Mosby, p. 22.
2 Available at http://www.apsoc.org.au/publications
What residents may not tell you ...Another dangerous belief is that a quiet resident is a pain-free resident. You need to be proactive in asking about pain because residents often deny or under-report pain. Residents often believe many of the same myths about pain just discussed, such as pain is part of growing old.
Residents may also say they don’t have pain or refuse pain relief for other reasons, for example:
› Older residents often believe it’s important to be strong and not complain about pain.
› They may believe that there’s not much that can be done to relieve pain.
› Some fear the need for treatment or addiction to pain medication.
› Residents may be concerned about bothering staff or being seen by staff as a complainer or whinger.
› Nonverbal residents may not be able to report pain.
Teach residents that reporting pain is the only way to identify the problem and treat it. Encourage residents to report pain to staff and reassure them this is not complaining.
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Identify Pain: AskThe first step to identify pain is to regularly ask the resident. Remember that the resident is the expert on their pain. Always attempt to ask all residents, including those with mild to moderate dementia or those who have difficulty talking. A self-report of pain may be a simple yes/no or vocalisation, or gestures, such as hand grasp or eye blink.
Using the tool: Make sure hearing aids and glasses are in place and that you give enough time for the resident to respond.
First, use the tool to ask if the resident has pain in different ways because residents often use words other than pain to identify pain problems (e.g., Does it hurt anywhere? Do you have any aching or soreness?).
Next, show the faces pain scale to the resident. Explain that these faces show how much something can hurt. The first face on the left shows no pain. The faces show more and more pain, up to the last face on the right – it shows the worst possible pain. Ask the resident to ‘Point to the face that shows how much you hurt right now.’
If the resident indicates pain then believe them. If you doubt that the resident can reliably report pain using the faces scale, ask the resident to show you where very bad pain would be located on the scale. Then ask them to show you where a mild pain would be located. If the resident points to the correct faces based on the severity of pain, they can reliably use the scale.
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Identify Pain: ObservePain is what the person says it is – but what if they can’t tell us? People who cannot talk or who have advanced dementia may not be able to tell you about their pain. Another key step to identify pain among residents is to observe for changes in behaviour.
A common clue to the presence of pain is a change in the resident’s ‘normal’ behaviour. Residents who are normally quiet may become agitated, cranky, and/or aggressive. They may yell out, scream, hit and pace. They may groan, moan, pant, or exhibit facial grimacing or frowning, particularly with movement or activity. They may have changes in appetite or usual activity level, or they may rock, rub, or protect a body part. Residents who normally are restless or agitated may become withdrawn, quiet and sad.
Any changes in the resident’s behaviour or condition should be treated as suspicious and prompt staff to ask: Could it be pain?
Using the tool:The tool reminds you what common pain behaviours to observe for. Make sure you look for any signs of pain during movement and activities.
Look for pain behaviours during personal and hygiene care, when repositioning or walking with residents, and following activities or treatments.
Watch for facial expressions of pain during any activities. The photographs of a resident’s face on the tool also show an example of a face in pain. If you see any of these behaviours, pain needs to be reported.
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Identify Pain: ReportIf you hear or see any of the indicators of pain on the tool, then it might be pain – report it. You can use the tool to communicate your findings to the RN.
Checklist for Reporting Residents’ Pain1. What has changed?
e.g., ‘She is reporting knee pain which is limiting her ability to walk.’
2. What is worrying you? e.g., ‘I’ve noticed she is a lot more sad and withdrawn, which is unusual for her – it might be pain.’
3. What do you want the RN to do? e.g., ‘I’d like you to assess her pain and review her care plan with me.’
Pain is invisible to others and may go unnoticed unless it’s reported. That’s why speaking up and getting the resident’s pain assessed is so important.
Don’t dismiss it – Report itYour role is critical in detecting pain in residents, especially those who have trouble communicating. You know the residents well. You recognise changes in the residents’ behaviour. You learn what makes residents feel better and what makes them hurt more.
› Report all pain residents tell you about.
› Report all pain behaviours you see or hear.
› Report all pain you ‘just want checked.’
Using the Identify Pain: Ask, Observe, Report tool in your everyday work will assist you to support and get help for residents in pain.
Ask the resident › Do you have any pain? › Does it hurt anywhere? › Do you have any aching
or soreness? › Do you have any ache, pain or discomfort?
Ask the residentPoint to the face that shows how much you hurt right now.
No pain Moderate pain Worst possible pain
Ask Observe ReportIdentify Pain:
For further information please contact
Clint Douglas RN PhD
School of NursingQueensland University of TechnologyVictoria Park RoadKelvin GroveQLD 4059
Email [email protected]
CRICOS No. 00213J
© 2014 QUT 20313
AcknowledgementThis project was funded by an Early Career Researcher Fellowship, Nursing and Midwifery Research Fellowships (HMR), Queensland Government, Department of Health.
