Zero-to-10 scales are used to assess pain, enjoyment of life, and general activity. PEG can be self-administered or done by the clinician and is relatively brief. 22 Assessing acute pain Acute pain intensity can be assessed with unidimensional tools such as the VAS and the Wong-Baker FACES Pain Rating Scale (faces depicting increasing levels of pain). While useful for a quick assessment, these scales alone may not appropriately identify patients with pain-related suffering driven by functional limitations, worry, or other factors, and may not detect some patients with clinically significant pain. 23 Although developed for patients with chronic pain, the BPI is also applicable to patients with acute pain. Completed by the patient, the BPI captures ways that pain impacts function and quality of life, although, like most multidimensional
questionnaires, it requires more time (about 10 minutes) and concentration to complete, which may limit its utility in some elderly patients. 21 Pain in patients with dementia Although patients with mild-to-moderate dementia can report their pain and its location, those with severe dementia are often unable to communicate their pain experience or request medication. In these patients, physicians need to observe pain behaviors, including facial expressions, verbal cues, body movements, changes in interpersonal interactions, activity patterns, and mental status. Caregiver observations and reports are critical to appropriate assessment and management of chronic pain conditions. 24
Chronic pain that develops after acute pain A number of factors have been associated with an increased risk for chronic pain following acute pain or surgery including older age, psychological problems, higher levels of pre-procedural pain or pain sensitivity, type and duration of surgery, severity and number of comorbidities, and use of post-procedural radiation or chemotherapy. 25 Some tools have been developed to help clinicians predict the likelihood that a patient will experience chronic pain following acute injury or procedures. The 5-item PICKUP model, for example, showed moderate prognostic performance in a derivation study using data from 2,758 patients with acute low back pain. 26 And Sipila and colleagues developed a 6-item screening instrument for risk factors of persistent pain after breast cancer surgery based on a cohort of 489 women. 27
BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1.
Case Study 1
Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow.
Maurianne is an 85-year-old woman living in a residence facility for people with Alzheimer disease. Her cognition has deteriorated slowly in the seven years she has lived at the facility and now her speech is often a rambling, incoherent stream-of-consciousness, that she only seldom recognizes as such. Maurianne fell and sustained a right femur fracture requiring internal fixation. On the second day after surgery, the hospital nurse noted that Maurianne had an order for acetaminophen every 6 hours as needed. Although Maurianne was lying still and did not appear to be in distress, the nurse contacted the nursing home nurse who reported that Maurianne rarely lies still. The nursing home nurse explained that they assess pain using the Pain Assessment in Advanced Dementia (PAINAD) tool and emailed a copy to the hospital nurse. A review of the medical chart indicated that Maurianne slept intermittently the previous night, and when she conducted a physical examination, Maurianne seemed rigid and exhibited shallow breathing at a rate of about 20 breaths per minute. The nurse used the PAINAD behavioral tool to assess Maurianne’s pain and the result suggested a positive score for possible pain. The nurse immediately called the surgeon and received an order for 1-2 mg morphine every 8 hours over the next 3 days. After the first dose, Maurianne’s body relaxed, and her breathing became regular at a rate of 14 per minute. Later that evening, Maurianne slept 7 hours.
1. Do you think the initial script for acetaminophen was appropriate for this patient? If now, what would you have prescribed?
2. How might Maurianne’s cognitive impairments affect her pain management plan?
3. What other tools or techniques might be used to characterize Maurianne’s level of pain or her response to prescribed analgesics?
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