PAINAD

ASSESSING PAIN IN PATIENTS WITH ADVANCED DEMENTIA

OBJECTIVES

Discuss the definition of pain Review the various ways pain is

assessed at LHS Review the five components of pain Explain the use of the PAINAD Scale Apply the concept of PAINAD to

situations.

HISTORICAL FACTS

Self report of pain most reliable measure of pain intensity

Many patients unable to rate their pain using the Wong-Baker rating scale

These include: infants, young children, pts with advanced dementia, sedated or intubated patients

Pain Assessment Tools at LHS

Wong-Baker Scale (1-10 scale) – used for responsive adult patients

FLACC Scale developed to measure pain in infants and young children

FLACC used at LHS for other types of non-verbal patients

Research indicates FLACC is not useful in assessing pain of the cognitively impaired elderly population

PAIN

Pain can be defined in two ways. Clinically-based Scientifically-based

PAIN

Clinically-based Pain: Whatever the experiencing person says it is,

existing wherever the person says it does (McCaffery,

1997)Scientifically-based Pain “an unpleasant sensory and emotional

experience associated with actual or potential tissue damage or described in terms of such damage” (Mersey, 1994)

These components are interrelated and connected to the understanding of pain and pain management.

Pain as a Multidimensional Phenomenon

As a phenomenon pain is multidimensional and consists of five components:

affective behavioral cognitive sensory physiological.

Factors that are Influenced by the Perception of Pain

Emotional Pain

(Affective)

Social Pain(Behavioral)

Physical Pain(Physiological)

Spiritual Pain(Cognitive)

Social IsolationFear Depression Anger Sadness

Financial Worries Family Distress Inability to Work

Illness(cancer)Treatment Unrelated to Cancer

GuiltRegret Fear of Dying

Literature Review

Literature on use of FLACC scale in the adult is negligible.

FLACC scale developed to measure pain in infants and children who could not report pain.

Ten pain assessment tools evaluated in nonverbal older adults with dementia.

FLACC scale scored the lowest overall.

Reliability and Validity of FLACC

FLACC scale appropriate for infants and young children

Validity and Reliability in the adult population has not been established

Conclusion: A more suitable behavioral pain scale needed for the non-verbal adult population with dementia

PAINAD

Found to be valuable in assessing pain behaviors in patients with advanced dementia.

Not recommended for assessing pain in the intubated/sedated population.

PAINAD

Scale consists of five items Each recorded on a scale of 0-2 Patient’s score can range from 0-10 Scale requires little training Is easy to use Can be used by nurses

Pain Assessment in Advanced Dementia (PAINAD)Scale

PAINAD

BREATHING Normal breathing –effortless, quiet,

rhythmic (smooth) respirations. Occasional Labored Breathing –

episodic bursts of harsh, difficult or wearing respirations

PAINADBreathing Cont.

Short Period of Hyperventilation - Intervals of rapid, deep breaths lasting a short period of time

Noisy Labored Breathing –Loud, gurgling, wheezing that appear strenuous or wearing

Long Period Of Hyperventilation – Excessive rate and depth of respirations lasting a considerable time.

PAINADBreathing Cont.

Cheyne-Stokes respirations – rhythmic waxing and waning of breathing from very deep to shallow respirations with periods of apnea (cessation of breathing)

PAINADNEGATIVE VOCALIZATION

None- speech or vocalization that has a neutral or pleasant quality.

Occasional moan or groan – Mournful or murmuring sounds, wails or laments. Groaning is characterized by louder thabn usual inarticulate involuntary sounds, often abruptly beginning and ending

PAINADNEGATIVE VOCALIZATION

Low Level Speech with a Negative or Disapproving Quality – Muttering, mumbling, whining, grumbling, or swearing in a low volume with a complaining sarcastic or caustic tone

Repeated Troubled Calling Out – phases or words being used over and over in a tone that suggests anxiety, uneasiness, or distress

PAINADNEGATIVE VOCALIZATION

Loud Moaning or Groaning – Mournful or murmuring sounds, wails or laments in much louder than usual volume. Louder than usual inarticulate involuntary sounds, of abruptly beginning and ending

Crying – Utterance of emotion accompanied by tears. There may be sobbing or quiet weeping.

PAINADFACIAL EXPRESSION

Smiling or Inexpressive – Upturned corners of the mouth, brightening of the eyes and a look of pleasure or contentment. Inexpressive refers to a neutral, at ease, relaxed or blank look

SAD – Unhappy, Lonesome, sorrowful, or dejected look. There maybe tears in the eyes.

PAINADFACIAL EXPRESSION

Frightened- a look of fear, alarm, heightened anxiety. Eyes appear wide open

Frown – Downward turn of the corners of the mouth. Increased facial wrinkling in the forehead and around the mouth

Facial Grimacing- distorted, distressed look. More wrinkled brow and around the mouth. Eyes may be squeezed shut.

PAINADBODY LANGUAGE

Relaxed – calm, restful, mellow appearance. Taking it easy.

Tense – Strained, apprehensive or worried appearance. Jaw maybe clenched

Distressed Pacing- activity that seems unsettled, fearful, worried or disturbed

PAINADBODY LANGUAGE

Fidgeting – restless movement, squirming or wiggling, repetitive touch, tugging or rubbing body parts

Rigid – stiffening of the body. Arms and legs are tight and inflexible. Trunk straight and unyielding.

PAINADBODY LANGUAGE

Fists clenched – tightly close hand. Maybe opened and closed repeatedly or held tightly shut.

Knees Pulled Up – Flexing legs and drawing knees up toward chest

Pulling or pushing away- Restiveness upon approach; yanking or wrenching him /herself free or shoving you away

PAINADBODY LANGUAGE

Striking Out – Hitting, kicking, grabbing, punching, biting or other form of personal assault.

PAINADCONSOLABILITY

No Need To Console – a sense of well being, appears content

Distracted or Reassured by Voice or Touch – Disruption in the behavior when the person is spoken to or touched. Behavior stops during the period of interaction; no indication of distress

Unable to Console, Distract or Reassure-No amount of comforting, verbal or physical will stop a behavior

CONCLUSION Wong Baker Pain Scale will continue

to be used for patients who can respond to the 0-10 scale

FLACC pain scale will continue to be used for children and infants

PAINAD scale will be used to assess non-verbal dementia patients

PAINAD scale has not been proven useful in comatose patients

CONCLUSION PAINAD should not be used by the

PCAs/Student Techs/ED Techs Patients who are unresponsive must

be assessed for pain by the RN or LPN

PAINAD will be an available choice in Soarian

COMPUTER BASED LEARNING TEST FOR PAINAD SCALE

1. The PAINAD scale is appropriate for use with which of the following patients?

A. A 24 year old alert and oriented patient admitted for post-operative appendectomy

B. An 86 year old female with late stage dementia who only moans when you ask her to rate her pain level

C. A 72 year old male with early dementia who is answers appropriately to questions but is occasionally confused to time.

D. A 60 year old female intubated for pulmonary edema.

Ans: (B) Patients with advanced dementia cannot report pain because of verbal and cognitive deficits. The PAINAD scale was specifically developed for this type of patient.)

2. True or False – The PAINAD scale uses a 0-10 rating.

Ans: (True – The PAINAD scale rates each of the 5 behaviors {breathing, negative vocalization, facial expression, body language and consolability} on a 0-2 rating for a total possible pain rating of 0-10)

TEST Cont.

3. True or False – The PAINAD scale is replacing the FLACC scale to assess pain in nonverbal dementia patients.

Ans: (True – The PAINAD scale was developed specifically for assessing pain in patients with advanced dementia, whereas the FLACC scale was designed for assessing pain in infants and children.)

TEST

Mr. Brown is a 70 year old patient admitted with cellulitis. He is in advanced stage of dementia, nonverbal with contracted arms and legs. When turning him, Mr. Brown moans loudly and pushes away striking at the nurses. He has short periods of hyperventilation during care. He appears frightened but stops moaning when distracted by the nurses voice of reassurance. What is this patient’s pain level?

0/10 5/10 7/10 10/10

Ans: C Assessing each of the 5 behaviors: Breathing – score of 1, Negative Vocalization- score of 2, Facial expression- score of 1, Body Language- score of 2, Consolability- score of 1---for a total pain score of 7/10)