Use these tips to improve assessment of pain
Use these tips to improve assessment of pain
Experts give you the questions to ask
Case managers have a new incentive to develop and implement good pain management policies and a new framework for what those policies should include, thanks to the pain management standards the Joint Commis sion on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, added to its 2000-2001 accreditation manuals for health care organizations and health plans. As an added bonus, proper pain management reduces health care costs — and that’s a benefit case managers are always quick to embrace.
Hospital admissions for uncontrolled pain cost one California hospital $5 million in a single year, and a good pain management program cut those costs by $2 million. "The savings come as a by-product of good pain management," explains Maureen Carling, RN, SCM, NDN, HV, a pain specialist and educator with Chatsworth Pain and Symptom Management in Williamsburg, VA. "Training nurses and case managers to properly manage pain relieves suffering and makes operations more efficient."
The first step in any pain management effort is a proper pain assessment. The most-favored manner of determining a patient’s pain level is to ask patients to rate pain on a scale, notes Carling. "Pain scales are not so much a good pain assessment tool as a measure of the effectiveness of pain medication. Imagine I come to you with a pain in my chest. Does telling you I have a pain level of six on a scale of zero to 10 tell you what medication I need?"
Carling developed a pain assessment tool and algorithm to help nurses and case managers identify, describe, and adequately manage pain in their patients. "To develop a proper pain regimen, you have to accurately identify the pain," she says. "You wouldn’t offer a patient an antacid for a headache. You have to properly identify the type and position of the pain to properly treat it."
The assessment tool includes a body chart to help locate the exact site of pain. The chart allows case managers to write detailed notes on the patients’ responses to questions about their pain. Case managers can map out the location of the pain on the chart, then provide detailed observations about the level and type of pain the patient is experiencing at each site.
"There are eight different types of pain, and they respond to different medications. You may find that a patient has six different types of pain, and only four of them are relieved by the current pain management plan. The tool and the assessment work together to develop a plan for managing the patient’s unique needs," she says, adding that physicians report that they like the tool because it offers more information than the more common zero to 10 pain scales. The eight types of pain Carling identifies on her algorithm are visceral, soft tissue, bone, nerve compression, pleuritic, colic, muscle spasm, and nerve destruction.
Of those, only visceral and soft tissue pain are completely responsive to opioids, which remain the most commonly prescribed painkillers in the United States, notes Carling. Bone pain, nerve compression, and pleuritic pain are only semi-responsive to opioids, and colic, muscle spasm, and nerve destruction pain are resistant to opioids, she adds. "If a pain reliever is ineffective, then discontinue it. You’ll save thousands of dollars. By accurately identifying the type of pain, you will do a much better job of relieving it."
Get the details
The assessment tool and algorithm also provide useful information on the duration and description of pain. Case managers must ask detailed questions to get a complete picture of a patients’ pain. Those questions include:
• Is the pain continuous or variable?
• Does it ache all the time?
• Is the pain worse on movement?
• Is the pain a dull, steady ache?
• Is it a burning or stabbing pain?
• Is the pain a deep ache?
• Is it worse on breathing?
• Does it come and go?
• Is it a cramp-like or spasm pain that feels like a pulling or tightening?
• Is it a stinging discomfort or numbness?
"Only when the pain has been examined from many angles [can] the road to dulling that pain can be determined," says Carling.
The same tools can be used to track the effectiveness of pain medications, she notes. "Good pain relief falls inside a therapeutic window where the patient feels little or no pain yet remains with no mental clouding. If the prescribed medication makes the patient drowsy, that should tell you the body is not using the medication for pain relief and it’s the wrong medication. Often, you’re observing a patient who has been prescribed an opioid for an opioid-resistant pain," she says, adding that the algorithm provides treatment choices for each type of pain described on the pain assessment tool.
Of course, many case managers never directly observe their patients, which can make a thorough pain assessment more challenging but not impossible, says Carol P. Curtiss, RN, MSN, clinical nurse specialist consultant in Greenfield, MA. She notes that telephonic case managers should reassess their patient’s pain relief regimen during every telephone interaction. "I think telephonic case managers have to be slightly better skilled to do a proper pain assessment. They don’t have some of the advantages [of] case managers who are able to actually observe the patient," she says. "However, telephonic case managers can do a good pain assessment over the telephone by asking some carefully worded questions designed to solicit answers that help them develop a clear sense of their patient’s level of pain relief."
Those questions include:
• When did the pain start?
• How long does it last?
• What makes the pain better?
• What makes the pain worse?
• Where does your pain fall on a scale of zero to 10?
• How much pain relief do you get on a scale of zero to 10 from pain medication?
• How long does the pain relief last?
• Does the pain come back before you next scheduled dose of pain medication?
• How does the pain affect your ability to sleep?
• How does the pain affect your ability to work?
• How does the pain affect your social life?
• How does the pain affect your sexuality?
"The key is to ask the same questions and to use the same pain scale every time so that you can compare pain symptoms over time and track them," she says. "Of course, it’s best every one along the continuum of care uses the same scale or pain assessment tool, but that’s not always possible. The goal is to use an assessment tool that makes pain visible and to use it to change the pain management pain whenever pain is inadequately relieved."
The problem of undertreated pain in the United States is almost entirely caused by an education gap, says Carling. "In 1996, only six medical schools in the United States offered courses dedicated to pain management. This issue of uncontrolled pain is not one of needing bigger and better narcotics, it’s that pain did not have a high priority in medical education. The Joint Com mission has raised the priority the health care system places on pain management. Now, we have educate physicians and nurses to meet this new challenge."
[Editor’s note: Carling’s algorithm is available on a wallet-size laminated card for $3. In addition, Carling recently made her four-hour pain education seminar available in an audiotape set that comes with a pain management manual for $99.95. For more information, contact Chatsworth Pain and Symptom Management at (757) 220-6640.]
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