Post on 27-Mar-2015
Chronic Pain in Primary Chronic Pain in Primary Care: Assessment Across Care: Assessment Across the Lifespanthe Lifespan
Module 2Module 2Stephanie Key, MSN, RN, CPNP-PCMary Lou Adams, PhD, RN, FNP-BC, FAANFrances Sonstein, MSN, RN, FNP, CNSDiane Tyler, PhD, RN, FNP-BC, FNP-C, FAANPaula Worley, MSN, RN, FNP-BC The University of Texas at Austin School of Nursing
Consultants: Yvonne D’Arcy, MSN, RN and JoEllen Wynne, MSN, RN, FNP-BC, FAANP
Objectives:Objectives:Discuss factors that affect the
assessment of chronic pain.Describe components of the
comprehensive assessment of chronic pain.
Identify valid and reliable pain assessment tools appropriate for primary care.
Goal: provide NPs with a concise overview of standardized pain assessment methods.
Factors that affect Pain Factors that affect Pain AssessmentAssessmentPersonal meaning of pain
◦Quality of life◦Financial burden◦Social isolation
Cultural aspects◦Race/ethnicity◦Language
CognitionExtraneous factors
Comprehensive Comprehensive AssessmentAssessment
History◦Present Illness (OLDCARTS)
Onset Location Duration Characteristics Aggravating and Alleviating factors Radiate Timing Severity/Intensity
◦Past medical (co-morbidities)◦ Any past issues with pain management
Comprehensive Comprehensive AssessmentAssessment
Physical Examination◦Vital Signs◦General survey◦Neurological exam◦Musculoskeletal exam◦Pain evaluation & descriptors
Nociceptive Sharp & stabbing; Dull, aching & throbbing
Neuropathic Burning, electric & tingling
Comprehensive Comprehensive AssessmentAssessment
Psychosocial factors◦Impact on lifestyle
Family dynamics Social isolation Sleep Work productivity
◦Fear of addiction◦Mental health
Suicide risk Depression
Comprehensive Comprehensive AssessmentAssessmentMedication review
◦ Current medicines◦ Past medicines for pain control and effect
Behavioral measures◦ Checklist of Nonverbal Pain Indicators(CNPI)
Vocal complaints: nonverbal (sighs, gasps, groans, moans, cries)
Facial grimaces (furrowed brow, clenched teeth, tightened lips, distorted expressions, narrowed eyes)
Bracing (clutching or holding onto something or affected area during movement)
Restlessness (constant or intermittent shifting, rocking, hand motions, inability to sit still)
Rubbing (massaging of affected area) Vocal complaints (words expressing pain or
discomfort, cursing during movement, exclamations of protest) Feldt, K.S. (2000). The checklist
of nonverbal pain indicators (CNPI). Pain Management Nursing.3(1): 13-21.
Comprehensive Comprehensive AssessmentAssessment
Diagnostic Studies◦Individualized to the patient and history◦Low back pain national guidelines
“Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic impairments or signs or symptoms indicating a serious or specific underlying condition, or if they are candidates for invasive interventions. Routine imaging is not associated with clinically meaningful benefits in other patients and can lead to harms.”
Roger Chou, Amir Qaseem, Douglas K. Owens, Paul Shekelle, ; Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Annals of Internal Medicine. 2011 Feb;154(3):181-189.
Pain Assessment ToolsPain Assessment ToolsTypes of Pain Scales
◦Uni-dimensional◦Multi-dimensional
Tools for AdultsTools for Children
Tools for AdultsTools for AdultsAdult faces toolMultiple-Language Pain Assessment
ScaleBrief Pain Inventory (BPI)- Short
formMcGill Pain Questionnaire (MPQ)Short-form MPQPain Quality Assessment Scale
(PQAS)Depression scale
Tools for Children and Tools for Children and InfantsInfants
Wong/Baker Faces Rating ScaleBody Outline ToolNeonatal Infant Pain Scale (NIPS)Depression scale
Tool for Dementia PatientsTool for Dementia Patients Pain Assessment in Advanced
Dementia Scale (PAINAD)◦Breathing◦Negative vocalizations◦Facial expression◦Body language◦Consolability ◦Scores range 0-10
Screen for AddictionScreen for Addiction Screening Instrument for Substance Abuse Potential
(SISAP)®
◦ a 5-item, clinician-administered test that asks pointed questions concerning alcohol, marijuana, and cigarette abuse
Screener and Opioid Assessment for Patients in Pain (SOAPP)®
◦ a self-report questionnaire available in 5-, 14-, and 24-item versions, which has recently undergone revisions and which is considered less susceptible to patient deception
Opioid Risk Tool (ORT) ®
◦ a 5-item, yes-or-no, self-report for measuring and predicting the probability that a patient taking opioids will display aberrant behaviors
Current Opioid Misuse Measure (COMM)®
◦ a 40-item patient directed questionnaire that assesses how patient is currently using their medications
ImplicationsImplicationsAssessment is the basis for
appropriate management.Assessment is a multifactorial process.The patient is part of the team in
managing chronic pain.As a health care provider, it is
pertinent to trust your patients and verify the information.
Finally document, document, document!
Website References Website References http://www.painedu.org/tools.aspwww.wongbakerfaces.orgwww.emergingsolutionsinpain.co
m
http://www.inflexxion.com/COMM
ReferencesReferences Bouhassira, D. & Attal, N. (2011). Diagnosis and assessment of
neuropathic pain: The saga of clinical tools. PAIN, 152, S74-S83. Feldt, K.S. (2000). The checklist of nonverbal pain indicators
(CNPI). Pain Management Nursing.3(1): 13-21. Chou, R., Qaseem, A., Owens, D.K., & Shekelle, P. (2011).
Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Annals of Internal Medicine 54(3):181-189.
Loretz, L. (2005). Primary care tools for clinicians. St. Louis, MO: Mosby.
Herr, K, Bursch, H., Miller, L.L. , & Seafford, K. (2010). Use of pain-behavioral assessment tools in the nursing home. Journal of Gerontological Nursing, 36, 18-29.
Narayan, M.C. (2010). Culture’s effects on pain assessment and management. American Journal of Nursing, 110(4), 38-47.
Post-Test QuestionsPost-Test Questions1. Pain is highly complex and personal.
a) Trueb) False
2. Which of the following are factors that affect pain assessment?
a) Race/ethnicityb) Cognitionc) Language barriersd) All of the above
Post-Test QuestionsPost-Test Questions
3. What does the “A” stand for in the acronym OLDCARTS in the history of present illness?
a) Adverse reactionsb) Alcohol usec) Aggravating and Alleviating factorsd) All of the above
Post-Test QuestionsPost-Test Questions4. Listening to a patient’s description of his pain can provide insight into the type of pain such as nociceptive or neuropathic.
a) True b) False
Post-Test QuestionsPost-Test Questions
5. There is a lower suicide risk in patients with chronic pain than in the average population.
a) Trueb) False
Post-Test QuestionsPost-Test Questions6. During an examination of a 82-
year old male who is non-verbal, you observe that the patient has tightened lips and clenched teeth when you palpate his shoulder. This is an example of which behavior on the Checklist of Nonverbal Pain Indicators(CNPI)?
a) Restlessnessb) Facial grimaces/Wincesc) Bracingd) Rubbing
Post-Test QuestionsPost-Test Questions7. Basic X-ray films should be ordered on all patients that complain of chronic pain.
a) Trueb) False
Post-Test QuestionsPost-Test Questions
8. A screening tool that allows the provider to assess only the intensity of pain is called a:
a) Uni-dimensional scaleb) Multi-dimensional scalec) Bi-modal scaled) Multi-factorial scale
Post-Test QuestionsPost-Test Questions
9. All of the following chronic pain tools are reliable and valid to use with adults except:
a) Brief Pain Inventory(BPI)-Short formb) McGIll Pain Questionnaire(MPQ)c) Pain Quality Assessment Scale(PQAS)d) Neonatal Infant Pain Scale(NIPS)
Post-Test QuestionsPost-Test Questions10. Which of the following screening
tools for opioid use measures and predicts the probability that a patient taking opioids will display aberrant behaviors?
a) Current Opioid Misuse Measure(COMM)
b) Opioid Risk Tool(ORT)
c) Screening Instrument for Substance Abuse Potential (SISAP)
d) Screener and Opioid Assessment for Patients in Pain (SOAPP)®