The Bolton Pain Assessment Tool: Development & Initial Testing - - PowerPoint PPT Presentation

The Bolton Pain Assessment Tool: Development & Initial Testing

Dr Julie Gregory Nurse Lecturer (Acute Pain Nurse) Julie.gregory@manchester.ac.uk

• Pain common symptom
• Management of pain

– improves function, reduces complications and

hospital stay

• need to recognise and assess pain

• Ethical and professional responsibility to

assess and treat pain

• Need to be aware of:
• strategies to assess pain
• Barriers to assessment
• Communication difficulties are a major barrier

Nurses

• “An unpleasant sensory and emotional

experience associated with actual or potential tissue damage or described in terms of such damage.” (IASP, 1994, p210)

• Pain is composed of highly interactive

emotional cognitive and sensory components

• It is Subjective

OR “Pain is whatever the patient says it is”

Pain Perception

• The Gold Standard

Or

• Most reliable indicator of pain intensity and

experience is Self Report

• Use of numerical score, verbal descriptor

score

Pain Assessment

Pain Assessment and Cognitive Impairment

• Self-report of pain should always be attempted & found

to be suitable for many people:

• 68% with moderate to severe impairment (n = 59).

Attempt initially and adopt wording if necessary (instruction s up to 3 times)

(Closs et al. 2004)

• 60% to 70% mild to moderate cognitive impairment Verbal Descriptor

Scale can be used

(Kaasalainen & Crook 2004)

• Moderate dementia 60% NRS and 90% VDS (No repeated instructions)

(Lukas et al 2013)

But ………..

• Communication
• Conscious level
• Understanding of the pain

rating

• Memory of a painful event
• Interpretation of noxious stimuli

(Buffum et al 2007)

Self Report Requires

Problem

• Undetected – misinterpreted – inaccurately

assessed under-treated.

• Hip fracture patients with cognitive

impairment – one third amount of morphine administered compared to cognitively intact.

• 76% - no prescription for post operative

analgesia

(Scherder et al 2009)

Indicators of pain

• What behaviours may indicate pain?

Behaviour Pacing, crying out, aggression, confusion, social withdrawal, apathy

Some Symptoms of Pain

• Difficulties in assessment of pain identified
• 158 indicators of pain
• Identified by 109 nurses
• Variation

(Zwakhalen et al 2004)

Literature

• Vocalisation

– Shout

• Facial grimace
• Body language

– Rubbing, guarding

• Changes in behaviour

– aggression, resists movement

• Physiological change

– Increase HR, BP, sweating

• Physical changes

– Skin damage, fractures,

Behaviours associated with pain

(AGS 2002)

• Various available
• Numerous concerns

– Validity etc

• Not used in practice

– Lacks user friendly

Behavioural pain assessment tools

Pilot survey of the use of Behavioural or Observational Pain Assessment Tools

BEHAVIOURAL SCALE ABBEY PAINAD FLACC ICU ABBEY /ICU NONE Pain meeting 10 1 1 2 5 University 1 1 17 Total 10 2 1 1 2 22

• 58% used an observational pain assessment tool
• Three hospitals use the Abbey pain scale,

(The two nurses indicated they used the PAINAD did not record which hospital they represented.) (Gregory and Richardson 2014)

Assessment Tool Area of practice Type of pain The Abbey Scale Long Term Care (LTC) Acute & Chronic ADD (Assessment of Discomfort in Dementia) LTC Acute & Chronic CNVI ( Checklist of Non Verbal Pain Indicators ) Acute Care LTC Acute &Chronic MOBID ( Mobilization Observation Behaviour Intensity Dementia Pain Scale) LTC Excluded acutely ill PACSLAC ( Pain Assessment Scale for Seniors with Severe Dementia ) LTC Chronic pain PAINAD (Pain Assessment in Advanced Dementia ) LTC Acute & Chronic PADE (Pain Assessment in Dementing Elderly) LTC 24 items PATCOA (Pain Assessment To Confused Older Adults) Acute Care 22 items

DEVELOPMENT OF BEHAVIOURAL PAIN ASSESSMENT SCALES

ABBEY PAINAD CNPI Australia Care Homes 61 residents Staff (n=61) completed the pain scale Development based on the assumption caregivers reliably rate the intensity

• f pain

Nurses’ holistic impression

• f pain severity was used

as the gold standard. USA Long-Term 19, white male residents Good construct reliability and validity PAINAD able to detect differences in pain associated with different medical conditions and analgesic administration. Positive correlation between verbal report and

• bservation with PAINAD in

25 # nof pts (12 cog impaired, 13 intact pts) USA Acute – trauma 88 cognitively impaired (53) and cognitively intact hip fracture (35) Each of the 6 items is scored on a dichotomous two point scale (0= not present; 1=present). Pain present on movement

17

The Abbey Pain tool Scale

No behaviour is unique to pain

• Behaviour is unique to individuals
• Do carers pick up on behaviour?
• Suggestion - Need to ‘know the person’.
• Other reasons for distress

– Fear and anxiety, anger and frustration – Distress from environment, others, change – Low mood, boredom, hallucinations

Problems with behavioural assessment

Trial of 3 tools in acute care

Practice development project

• Examined some of the pain assessment tools

available

• Decided to use:

– Abbey pain assessment – PAINAD (Pain Assessment in Advanced Dementia) – CNPI (Checklist of Non Verbal Pain Indicators )

Scale

Vocalisation Facial grimace Body language Behaviour change Physiological change Physical change

Abbey       CNVI   

Restless Rubbing

× ×

PAINAD    

Breathing

×

(consolability)

Comparison of scales content

ABBEY

PAINAD CNPI

• Easy to use and

understandable

• 1-5 mins to complete
• ‘gives prompts’,
• ‘effective’
• justifies analgesia’
• ‘like the

documentation’

• ‘Subjective ‘
• Easy to use and

understandable

• 1-5 mins to complete
• ‘easy to follow’
• ‘good to use especially

in those who cannot communicate’

• ‘ a very good pain

assessment tool’

• 44% easy to use and

understandable

• 1-5 mins to complete

‘ not clear what the numerical scores should action’ ‘nowhere to document findings’

• RATED
• Mean = 8.0

Mean = 8.6 Mean = 4.5

Evaluation by nurses following use in acute care

• From literature CNPI appears to be suitable for

acute care – trauma

• In practice and when compared to other tools

not useful

• During the trials some patients had pain

identified by relatives.

• Tools did not always capture pain.
• Need to be included in an assessment tool

Evaluation of 3 scales

• Combined the Abbey scale with PAINAD
• Included a section for relatives and / or carers

to comment or rate an individuals pain

• Physiotherapy comments for pain on

movement.

Bolton Pain Assessment Tool

SCORE ABSENT MILD 1 MODERATE 2 SEVERE 3

SCORE

VOCALISATION none Occasional moan or groan Low level speech with a negative or disapproving quality Repeatedly crying out, loud moaning or crying FACIAL EXPRESSION Smiling

• r relaxed

Looking tense, Sad Frowning, Grimacing and looks frightened CHANGE IN BODY LANGUAGE None Tense, fidgeting Guarding part of the body, Withdrawn, rigid, fists clenched. Knees pulled up BEHA VIOURAL CHANGE None Increased confusion Refusing to eat, alterations in usual pattern Pulling or pushing away, striking

• ut

PHYSIOLOGICAL CHANGE

Normal Occasional laboured breath, increased heart rate Hyperventilation, increased heart rate and BP Change in pulse BP, respiratory rate and perspiring, flushed or pallor PHYSICAL CHANGES None Skin tears Pressure sores, arthritis Post surgery, trauma, TOTAL SCORE:

Comments by family or usual care givers Pain on movement/ physiotherapy 0-2 NO PAIN 3-7 MILD PAIN 9-13 MODERATE PAIN 14+ SEVERE PAIN

BOLTON PAIN ASSESSMENT TOOL (For patients with communication problems) NAME OF PATIENT………………………………………………………………. NAME AND DESIGNATION OF PERSON COMPLETING SCORE:…………………………………. DATE AND TIME ……………..

• Audit identified no observational tool used
• 4 wards involved
• Trauma, medical, stroke unit and long term care
• Meeting held with senior staff
• Assessment tool adjusted
• Information file produced and some educational

input

• Used BPAT for 6 weeks
• Completed an evaluation sheet

Proof of concept at UHSM

• Easy to use
• 1-5 mins
• Useful – identified pain
• Led to analgesia administration
• Request for analgesic review
• Average rating of scale = 8/10
• Low involvement of family
• Not as positive in long term unit
• Appeared to resent use of a formal assessment

tool

Evaluation

Cognitive Impairment Pain Assessment Scale

(For patients with communication difficulties i.e. Dementia, Stroke, Learning Disability, Acute confusion)

Date

Time

Score

Absent 0 Mild 1 Moderate 2 Severe 3

Score Vocalisation

None Occasional moan / groan Low level speech with a negative

• r disapproving

quality Repeatedly crying

• ut loud, moaning
• r crying

Facial Expression

Smiling / relaxed Looking tense Sad, frowning Grimacing & looks frightened

Change to body language

None Tense, fidgeting Guarding part of the body Withdrawn, rigid, fists clenched, knees pulled up

Behavioural change

None Increased confusion Refusing to eat, alterations in usual pattern Pulling or pushing away, striking out.

Physiological change

Normal Occasional laboured breaths, increased heart rate Hyperventilation increased heart rate & BP Changes in pulse, BP, respiratory rate & perspiring, flushed or pallor

Physical changes

None Skin tears Pressure sores, arthritis Pre-op trauma & post surgery < day 4

Pain on movement or physiotherapy

None Mild Moderate Severe

Ask family or usual care giver about normal behaviours. Use ‘My Traffic Light’ / ‘Forget me Not’ these may change the scoring:

Patient Name RM2 DOB

Total score

0 – 2 = no pain 3 – 8 = mild pain 9 – 14 = moderate 15+ = severe pain Guidance overleaf

Analgesia given ( Y / N ) Signature

• Communication affects how people express

pain

• Behaviour and changes to behaviour suggests

pain or other problem

• Use self report- verbal descriptor initially
• Observation of behaviour when unable to
• btain score
• Many tools available –need to choose one

suitable for specific context

Discussion

• There are a large number of behavioural pain

assessment tools available

• Not used in everyday practice
• Behaviour may indicate other causes for

distress

• Should be used with other information
• Ideally with someone who knows the

individual well

Discussion

Further Development

• Testing of BPAT required
• Inter-rater reliability

– Two nurses (HCP) observe and score pain independently but at same time – Compare scores

• Concurrent Validity

– Observe behaviour in cognitively intact patients and score pain – Ask for a pain score and compare

Let me know if interested

• Julie.gregory@manchester.ac.uk
• Happy to talk over lunch
• Any questions or comments???

• American Geriatric Society (2002) the management of persistent pain in older people. American Geriatric

Society , 50 (6) supplement.

• Chen Y-H, Lin L-C and Watson R(2010) Validating nurses’ and nursing assistants report of assessing pain in older

people with dementia. Journal of Clinical Nursing 19, 42-52 doi :10.1111/j.1365-2702.2009.02950.x

• Closs SJ, Barr B, Briggs M, cash K, Seers K (2004) A comparison of four pain assessment scales for Nursing

home residents with varying degrees of cognitive impairment. Journal of Pain and Symptom management 27 (3) 196-205

• de Souto Barreto P.Lapeyre-Mestre M, Vellas B Rolland Y (2013) Potential underuse of analgesia for recognised

pain in a nursing home residents with dementia: A cross- sectional study. PAIN 154, 2427-2431

• Gregory J (2012) How can we assess pain in people who have difficulty communicating? A Practice

development project identifying a pain assessment tools for acute care. International Practice Development Journal 2 (2) 6-20

• Herr K (2011) Pain assessment strategies in older patients. The Journal of Pain 12 (3) s3-s13
• Lukas A, Nierecker T, Gunther I Mayer B Nikolaus T(2013) Self and proxy report from the assessment of pain in

patients with and without cognitive impairment. Experiences gained in a geriatric hospital. Z Gerontolicie and Geriatrie 3, 214-221.

• Schofield P (2008) assessment and management of pain in older adults with dementia: a review of current

practice and future directions. Current Opinions in Supportive and Palliative Care. 2: 128-132

• Williamson A and Hoggart B (2005) Pain: a review of three commonly used pain rating scales. Journal of Clinical

Nursing: 14, 798 – 804.

• Zwakhalen SMG, Dongen KAJ, Hamers JPH, ABU-Saad HH (2004) Pain assessment in intellectually disabled

people: non-verbal indicators. Journal of Advanced Nursing 45 (3) 236-245.

References

• Alzheimer’s Society (2007) Dementia UK
• Buffum MD, Hutt E, Chang V T Craine MH Snow AL (2007) Cognitive impairment and pain

management: review of issues and challenges. Journal of Rehabilitation Research and Development 44 (2) 315-330

• Department of Health (2010) Quality outcomes for people with dementia: Building on the

work of the National Dementia Strategy

• Department of Health (2009) Living well with dementia: A National Dementia Strategy
• Fuchs-Lacelle S, Hadjistavropoulos T (2004), Development and preliminary validation of the

pain assessment checklist for seniors with limited ability to communicate (PACSLAC) Pain Management Nursing. Vol.5: pp37–49.

• Kaasalainen S and Crook J (2004) An exploration of seniors’ ability to report pain. Clinical

Nursing Research 13, 2, 199-215.

• NICE/SCIE Dementia Guidelines (2006)
• NHS Confederation 2010 Acute awareness: improving hospital care
• Roherer, J & Warren, J. Fronto-temporal dementia (on-line)

http://pdsg.org.uk/clinical_information (Accessed on 22 March 2011)

References