Pain assessment tools for renal patients

5.1 Pain assessment tools

5.1.3 Pain assessment tools for renal patients

For patients unable to self-report pain, such as patients with cognitive impairment or impaired consciousness, or for others unwilling to cooperate or unable to understand the assessment tool, other methods need to be in place to detect pain and evaluate interventions.

Behavioural pain assessment tools (Pasero & McCaffery 2002), facial expressions, functional impairment (ambulation or coughing), or physiological responses, such as heart rate variations, can provide additional information and be useful in assessment process (Macintyre et al. 2010).

Finally, in assessing pain in renal patients all the above pain assessment scales and questionnaires could be used. The following questionnaires have been already used in renal patients with remarkable findings:

• the Brief Pain Inventory (BPI) (Davison 2003, Golan et al. 2009, Gamondi et al. 2013),

• the McGill Pain Questionnaire (MPQ) (Binik et al. 1982, Davison 2003, Barakzoy &

Moss 2006, Masajtis-Zagajewska et al. 2011, Harris et al. 2012) and its short form (SFMPQ) (Melzack 1975),

• the Pain Management Index (PMI) (Cleeland et al. 1994, Davison 2003, Barkzoy &

Moss 2006),

• the Edmonton Symptom Assessment System (ESAS) (Weisbord et al. 2005, Davison &

Jhangri 2005, Davison et al. 2006).

Some other assessment tools, such the ones mentioned below, can be used in measuring pain in renal patients, eventhough they are mainly for assessing kidney disease symptoms and their impact on the patients’ daily life.

• the Palliative Care Outcome Scale-Renal (POS-renal) (Hearn & Higginson 1999, Murphy et al. 2009),

• the Physical Symptom Distress Scale (PSDS) (Chiou 1998),

• the Dialysis Symptom Index (DSI) (Weisbord et al. 2004).

Of the previous mentioned questionnaires the Visual Analogue Scales and Wong-Baker Pain Rating Scales are useful tools but they are only assessing pain intensity and not other pain characteristics (duration or quality) and pain treatments administered. On the other hand, the Brief Pain Inventory and the McGill Pain Questionnaire eventhough they are multidimensional tools they are time consuming. In the BPI means of pain management can also be recorded.

In conclusion, while choosing the tool that will help a healthcare professional in assessing a renal patient’s pain level, the American Agency for Health Care Policy and Research Clinical Practice (AHCPRCP) guidelines should be in mind. According to these healthcare professionals should follow the ABCDE process:

• ASK regularly about pain and systematically ASSESS it

• BELIEVE the patient and family when they report pain and what relieves it

• CHOOSE pain control options according to the patient’s and family’s needs and setting

• DELIVER planned, logical and coordinated interventions

• EMPOWER patients and families. ENABLE them to control their course to the greatest extent possible (Moss et al. 2004).

44mm “mild pain” and 45 to 74 as “moderate pain” (Miller & Ferris 1993, Jensen et al.

2003).

- In Categorical Scales patients are asked to rate pain intensity using pictures or sketches with different facial expressions symbolising increasing levels of pain intensity, starting from happy smiley face and moving towards a face in agony. Underneath each facial expression there is a number starting from “0” to “10”, the total pain level is the added score of each expression chosen. Faces Pain Scale for Adults and Children and Wong-Baker Pain Rating Scales are the most popular (Wong & Wong-Baker 1995).

- Coloured Analogue Pain Scales are using different colours to choose, for representing the individual’s pain perception. Usually, small coloured cards, pencils and markers are used. This scale is used, mainly, with children even of preschool age.

- Segmentation Scales are using the exact same objects, such as coins or marks, which represent a part of a total. The patient chooses the number of objects representing the pain experienced at the particular moment.

5.1.2 Multi-dimensional pain assessment tools

Multi-dimensional assessment tools are designed for self-report also, but healthcare professionals can help the patient to fill it in. They provide information about pain characteristics and its impact on the individual. The most popular multidimensional assessment tools are the following:

- Initial Pain Assessment Tool which gives information about pain characteristics and the effects of pain in everyday life (appetite, emotions, relationships, sleep). It includes a body diagram in order to pinpoint the exact pain location, a scale for pain intensity and space to write comments (McCaffery & Pasero 1999).

- Brief Pain Inventory (BPI) is quick (5-15 minutes), easy to use and records both pain intensity as well as disability caused by pain. It consists of questions on pain experienced over the past 24 hours (intensity, location, impact on every-day life, effectiveness of treatment). It can be used for a variety of patient populations (Cleeland & Ryan 1994).

- McGill Pain Questionnaire (MPQ) assesses pain in three dimensions (affective, evaluative and sensory) using words describing pain (Melzack 1975, Pham et al. 2009).

It is time consuming and a short-form of it was produced later (Melzack 1987).

- Pain Attitude Scales, such as Face Legs Arms Cry Consolability Scale (FLACC), ared used for unconscious or developmentally delayed patients (Erdek & Pronovost 2004). Nurse is assessing facial expressions, extremities mobility, spasticity, cry, response to consolidating interventions or response to mechanical breathing support (Behavioral Pain Scale, BPS). The higher the score, the more the pain experienced by the patient.

- Neuropathic Pain Scales evaluate eight common qualities of neuropathic pain, such as cold, dull, hot, itchy, sharp, sensitive, deep and surface, are easy to use and sensitive to treatment effects. The patient rates the above items using a scale from “0” (none) to “10”

(most imaginable) (Galer & Jensen 1997, Bennett 2001).

- The Pain Management Index (PMI) is assessing the adequacy of pain control according to the patients’s reported level of pain and it was primarily developed for cancer patients (Cleeland et al. 1994). It consists of two parts, on the first part the patient is asked to record the worst pain score on the Brief Pain Inventory (BFI) and on the second part to choose from four levels of analgesic therapy based on the WHO guidelines (0-no analgesic, 1-a non-opioid, 2-weak opioid, 3-a strong opioid) the one that he/she used.

PMI ranges from -3 (a patient with severe pain receiving no analgesics) to +3 (a patient on opioids and reporting no pain).

- The Edmonton Symptom Assessment System (ESAS) has been widely used in palliative care (Chang et al. 2000). In the last ten years it has been used in the Chronic Kidney Disease population (Weisbord et al. 2005, Davison & Jhangri 2005, Davison et al. 2006) with good results. It is simple, short and self-completed with ten visual analogue scales

ranging from 0 (no) to 10 (severe) assessing pain, activity, anxiety, appetite, depression, drowsiness, nausea, pruritus, well-being and shortness of breath.

5.1.3 Pain assessment tools for renal patients

• the Brief Pain Inventory (BPI) (Davison 2003, Golan et al. 2009, Gamondi et al. 2013),

• the McGill Pain Questionnaire (MPQ) (Binik et al. 1982, Davison 2003, Barakzoy &

Moss 2006, Masajtis-Zagajewska et al. 2011, Harris et al. 2012) and its short form (SFMPQ) (Melzack 1975),

• the Pain Management Index (PMI) (Cleeland et al. 1994, Davison 2003, Barkzoy &

Moss 2006),

• the Edmonton Symptom Assessment System (ESAS) (Weisbord et al. 2005, Davison &

Jhangri 2005, Davison et al. 2006).

• the Palliative Care Outcome Scale-Renal (POS-renal) (Hearn & Higginson 1999, Murphy et al. 2009),

• the Physical Symptom Distress Scale (PSDS) (Chiou 1998),

• the Dialysis Symptom Index (DSI) (Weisbord et al. 2004).

• ASK regularly about pain and systematically ASSESS it

• BELIEVE the patient and family when they report pain and what relieves it

• CHOOSE pain control options according to the patient’s and family’s needs and setting

• DELIVER planned, logical and coordinated interventions

• EMPOWER patients and families. ENABLE them to control their course to the greatest extent possible (Moss et al. 2004).

Table 1. Pain assessment tools.

Uni-dimensional pain assessment tools Verbal Descriptor

Scales (VDS) List of words or phrases which describe pain intensity and response to analgesics, ranging from 0 (no pain at all) to 5 (unbearable pain).

Numerical Rating.

Scales (NRS) Numbers ranging from 0 (no pain) to 10 or 100 (worst pain imaginable). The scale can be in printed or verbal form.

Visual Analogue .

Scales (VAS) An horizontal or vertical line of 100mm, with ”no pain” on the left side and

”worst imaginable pain” on the right side. Pain intensity is marked on the line and measured the exact distance from the left side of the line.

Categorical Scales (Wong- . Baker Pain Rating Scales)

Pictures or sketches of facial expressions are used. The scales start from happy smiley face (0) moving towards a face in agony (10).

Coloured Analogue

Pain . Scales Different coloured cards, pencils or marks are used to measure pain intensity.

Segmentation Scales Objects, such as coins or marks, are used. The patient chooses the number of objects that best describe his/hers pain intensity.

Multi-dimensional pain assessment tools Initial Pain .

Assessment Tool It consists of a dody diagram to pinpoint the exact pain location, a scale for pain intensity and space to write comments. It presents pain characteristics and effects of pain in everyday life.

Brief Pain .

Inventory (BPI) Questions on pain experienced (location, intensity, impact on life, effectiveness of treatment) over the past 24 hours.

McGill Pain .

Questionnaire (MPQ) Groups of words describing and assessing pain in three dimensions (sensory, affective, evaluative).

Pain Attitude .

Scales Recording and assessing facial expressions, extremities mobility, spasticity, cry, response to interventions or response to mechanical breathing support.

Neuropathic Pain .

Scales Assesses, from 0 (none) to 10 (most imaginable), qualities of neuropathic pain, such as sharp, dull, hot, cold, sensitive, itchy, deep and surface.

Pain Management .

Index (PMI) Assess, in two parts, the worst pain score with the use of the BPI and the used of analgesic therapy based on the WHO guidelines (0-no analgesic, 1-a non-opioid, 2-weak opioid, 3-a strong opioid). PMI ranges from -3 (severe pain receiving no analgesics) to +3 (use of opioids and no pain).

Edmonton Symptom Assessment System (ESAS)

A simple, short and self-completed questionnaire with ten visual analogue scales ranging from 0 (no) to 10 (severe) assessing pain, activity, anxiety, appetite, depression, drowsiness, nausea, pruritus, well-being and shortness of breath.

6 Management of pain in renal patients

Renal patients suffering from pain have to be prepared not to set their expectations, regarding pain management, too high. If the patient is lead to believe that he/she will be permanently cured from pain and this does not happen, disappointment and disbelief in healthcare professionals is installed (Bajwa et al. 2001). As it was already argued, pain is a subjective feeling and is difficult to be measured directly. In trying to manage pain, it is essential for the healthcare professionals to be open-minded and to be able to listen to what the patient says describing his/her pain experience. After assessing, a planned nursing approach for pain management has to be implemented. The goal of the nursing plan is to have the patient as comfortable as possible and to have him/her adapt to the new, painful, way of life. Unfortunately, even the best designed nursing care plan cannot meet its goals unless the patient and healthcare professional collaborate and work together.

Pain management in renal patients has to overcome, on the one hand, the subjective nature of pain and, on the other, the fact that there are no specific guidelines for pain management.

In regards to the first, nurses’ knowledge, judgement and, unfortunately, biases shape the care planned (Manias & Williams 2007, Meechan et al. 2011). A patient’s pain experience is a complex situation that requires analytic and synthetic skills in order for the healthcare professional to collect, assess and use any information given. Decision-making can be affected by preconceived notions about the patient’s behaviour, diagnosis, personality and thus preventing them from receiving effective pain treatment (Manias & Williams 2008).

Furthermore, nurses may be influenced by factors such as culture, ethnicity, age, cognitive performance and sociodemographic background (Brockopp et al. 2004, Kourakos & Kafkia 2007).

As technology advances and new medications are developed, it is important for caregivers to stay current and to be willing to incorporate new ways to better assess and manage pain (Young et al. 2006). Patients with Chronic Kidney Disease are at risk of ineffective pain control either at home modalities (PD or home HD) or at hospital settings (HD) due to the complexity of their medical condition and co-morbidities, such as Diabetes Mellitus, peripheral vascular or cardiovascular disease and renal osteodystrophy (Salisbury et al. 2009, Ponticelli et al. 2015). Altered medication clearance and affected renal function can cause side effects or complications with specific medications, making challenging the attempt to control pain (Kurella et al. 2003, Rehm 2003, Davison 2005, Plantinga et al. 2011, St. Peter et al. 2013, Davison et al. 2014).

Understanding the pathophysiology of pain is essential in order to implement a pain management strategy. A wide variety of methods can be used by the healthcare professionals, such as physical measures, psychobehavioral modification techniques, medications or physical interventions (Bajwa et al. 2001, Dysvik et al. 2004). When non-pharmacological methods are implemented, health-care personnel should have in mind that the methods have to be simple, easy to learn and use, with minimal effort and expenditure of time (Grantham & Brown 2012). Chronic patients, such as Chronic Kidney Disease patients, are often too tired and ill to learn complex techniques. Both pharmacological and non-pharmacological interventions should be used with regular assessment and recording of pain intensity, adverse effects, and implication on quality of life. However, a number of research studies in a variety of settings show that pain is undertreated (Gordon et al. 2005, McMillan et al. 2005). Acute unrelieved pain can cause serious side-effects, such as pneumonia and deep vein thrombosis, delayed recovery and can evolve to chronic pain.

Unrelieved chronic pain affects everyday functionality, decreases quality of life, causes anxiety, fear, anger and depression. Furthermore, it can lead to absenteeism or inability to work (Lame et al. 2005, Breivik et al. 2006, Oosterhof et al. 2014). Chronic illness is an area to