It has been labeled and promoted as the “5th Vital Sign”. Still, pain continues to be unassessed and inadequately treated.

Studies have found many barriers to the management of pain.  Due to the highly subjective and personal nature of pain patients may inadvertently sabotage attempts to obtain a full pain assessment and provide subsequent treatment.  The patient may be unwilling to communicate the extent of his pain, or fear that he will be seen as a “bother” or drug seeker.  Commonly, patients also fear addiction, tolerance, and possible side effects of the medications they may be given.  The patient’s overall attitude may be depressed and fatalistic causing him to feel that the pain is inevitable and must be tolerated.  He may also feel that treatments will be ineffective or lack understanding about effective treatment methods.  He may be trying to maintain independence and control over his situation.  Cultural, religious, and age related factors create additional barriers.

Nurses also provide barriers. Some nurses still fail to recognize the importance of a full pain assessment.  Nurses can also adopt the attitude of inevitability of pain.  This may be the result of inadequate knowledge, or a perceived lack of time necessary to conduct a pain assessment.  It is often given a low priority in the nursing care plan.  Personal prejudice and bias when dealing with certain patients may also interfere with overall care.

The healthcare system can also fail to place a level of importance on full pain assessments by a lack of provider accountability, policies, criteria or availability of pain assessment tools.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has outlined several core principles of pain assessment.  JCAHO states that:

• All patients have the right to appropriate assessment and management of pain.
• Assessments for pain must be appropriate for the individual patient and address all aspects of their pain.  Both the patient and family should be included in the assessment process.
• The most accurate indicator of pain is the patient’s own description.  It is always subjective- the clinician should accept and respect the patient’s report of pain.  Each person’s pain experience is unique and dependent on many contributing factors including:  heredity, energy level, coping skills, and prior experiences.  Physiological and behavioral observations should not replace information obtained directly from the patient when it can be communicated.
• Pain can be present without physiological evidence or cause, pain in such cases should not be immediately assigned to a psychological causes.
• Chronic pain can create an overall lower threshold of tolerance for pain and other stimuli.  Unrelieved pain has adverse affects on all aspects of the patient’s life. 

It becomes the responsibility of the nurse to be familiar with the pain assessment tools available to them and utilize them appropriately.  The Agency for Health Care Policy and Research (AHCPR) recommends that no matter which tool is used the health care provider should follow the “ABCDE” mnemonic as a guide to pain assessment and management.

A:  Ask regularly and consistently.  Use the same systematic approach every time pain is assessed.

B:  Believe the patient’s report of pain and how it is best relieved.

C:  Choose appropriate pain control options according to the needs of the patient, family and setting.

D:  Deliver pain relief in a timely, consistent and coordinated manner.

E:  Empower the patient and family with information and an active voice in their care plan.

The final aspect of the pain assessment is documentation.  Complete pain documentation in the medical record should include an initial comprehensive pain assessment with the current pain management regime and the patient’s past experience with pain and its control.  Patient goals and expectations for pain management should also be addressed.

Progress notes should include recurrent pain assessments with baseline pain scores, breakthrough pain episodes, noting timing, severity and related causes, and how they were treated.  Any pain treatments provided, including nonpharmacological, their timing and results are documented.  Related pain factors such as sleep, activity levels, social interaction and mood are also important to note.  Patient teaching interventions should be described and evaluated for effectiveness.  Lastly, adverse effects such as changes in bowel function, sedation, and nausea and vomiting should be anticipated in the care plan, frequently assessed for and treated with accompanying documentation.

Pain is treatable; no patient should have to hurt.  Through effect pain assessments we as nurses can provide the needed relief.

Reference:

• Ferrell, BR. Coyle, N.  Textbook of Palliative Nursing. Second Edition.  New York:  Oxford University Press, Inc. 2006. 97-109.

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