VOL: 97, ISSUE: 17, PAGE NO: 38
Fiona Bett, BA, RGN, is staff nurse, cardiology, Royal Infirmary of Edinburgh NHS TrustPain is a complex and subjective experience that is difficult to assess. Many factors influence how it is communicated, including age, culture, gender and personality. The meaning patients attach to pain can also have a profound effect on how they may react to and express their pain (East, 1992).
Pain is a complex and subjective experience that is difficult to assess. Many factors influence how it is communicated, including age, culture, gender and personality. The meaning patients attach to pain can also have a profound effect on how they may react to and express their pain (East, 1992).
Effective pain control is crucial to patient recovery, particularly for those being treated for a myocardial infarction (MI) (Willetts, 1989). However, nurses can fail to assess the intensity of patients' pain accurately and often underestimate it by judging it on their own values or experiences (Browne, 1996; East, 1992).
Pain assessment tools
Pain assessment tools are designed to help patients communicate their pain and encourage nurses to promote a systematic approach towards managing it. They generally take the form of a pain chart that incorporates a measurement tool (Briggs, 1995). Pain tools aim to eliminate subjectivity, enabling an individual, objective and measurable assessment.
The pain tool introduced to our coronary care unit (CCU) consists of a visual scale, with graduations from 0 (no pain) to 10 (worst pain ever). The nurse explains the scale to the patient, who is then asked to indicate where on the chart he or she rates the severity of their pain. This is then recorded on the pain chart, with the date and time and a description of the character and site of it.
There is also space to evaluate any treatment, recording the time and related pain score. The nurse evaluates the effectiveness of analgesia and assesses the need for further treatment. This is a joint activity with the patient.
The pain tool is stored in the care plan folder, along with the observation and drug prescription charts, all of which are accessible to both medical and nursing staff. The written record of the assessment and consequent management is, potentially, a very effective form of communication pathway between staff.
Some months after its introduction, the cardiology quality group decided to carry out a retrospective review of the use of the pain tool in CCU during the first 24 hours after admission. Information was collected from the pain chart and visual analogue tool, the drug prescription sheet, the nursing records and a staff questionnaire.
The audit included 69 patients admitted to CCU over a three-month period with a diagnosis of MI. The following information was gathered from the nursing record:
- The patient's name, date of birth, sex and diagnosis;
- The pain control, if any, given in A&E (type and dose);
- The patient's pain score on admission to CCU;
- The analgesia given in the first two hours in CCU, two to six hours and six to 12 hours (type and dose);
- Whether each episode of pain was documented during the first 24 hours;
- Whether each dose of analgesia given was evaluated;
- Whether all the columns on the pain evaluation chart were used.
To allow comparison with other data, all CCU staff were asked to fill in a questionnaire. They had two weeks to complete it, allowing for shift patterns and annual leave. The completed forms were collected from a pick-up point and analysed.
Sixty-nine patients were audited: 42 men and 27 women. Only 14 received analgesia in A&E. On admission to CCU, the average pain score was 3.7 out of 10. Patients who were given analgesia in A&E had an average score of 3.6 out of 10 on admission to CCU. The rest had an average of 4. Not all patients had their pain scores documented.
The study revealed that pain control was fully documented in only 23 cases. It was partially documented in the rest. Three patients had nothing recorded on their pain charts. It was common for patients whose pain was not documented in terms of type, location and score to have nothing else written on their charts. Of those whose pain was recorded, it was also fully evaluated on the charts of all but five of them.
The type of treatment given should be documented on the pain chart. But when checked against the drug chart to determine what drugs were given and when, the two records did not to correlate.
When patients receive glyceryl trinitrate, the pain chart should record when it was started, when it was titrated in response to pain and an evaluation of its effectiveness. However, all drugs are prescribed on the drug chart, which is stored with other patient records for use by both medical and nursing staff. Consequently, they are often difficult to obtain at the time of pain assessment.
Glyceryl trinitrate was not recorded on the pain chart as it was not considered a specific analgesic: its primary function is in cardiac management but its action relieves pain.
A total of 36 questionnaires were sent out. The 26 respondents had a mean 3.4 years of experience in CCU.
The respondents were asked what factors they considered when assessing pain. All said they considered the site of the pain and the effectiveness of analgesia. In addition, most said they considered the score and type of pain. Autonomic disturbance, such as sweating and restlessness, and assessment and duration of pain-free state were also considerations for 18 staff members.
Other factors included non-verbal and verbal cues. Patients were asked whether they had previous experience of this type of pain and whether any action may have initiated the pain, for example, washing, walking or straining. However, there were interesting differences when what staff claimed to assess was compared with what was actually documented. All respondents claimed to assess the site of the pain, but this was documented on the pain charts for only three patients.
Twenty-one respondents found the visual tool straightforward to use but encountered common difficulties: the pain tool was cumbersome and not always accessible; staff lacked the time to use it; there were too many descriptions of pain for patients to look at; patients had a poor understanding of the concept of the tool and their perceptions of the scoring differed from those of the nurses. Some patients found it difficult to describe their pain or to cooperate, and those with poor eyesight struggled to use the tool.
Only 10 staff used the tool on patient admission to CCU and only four used it during every assessment. Staff felt it was often difficult for patients to rate their pain, particularly if they were distressed or sleepy. Other admission priorities, such as a shocked patient or complications, often overrode the use of the pain tool. If patients were too ill to respond to the tool, analgesia would be given as per prescription on the assumption that the pain was at its worst.
The main reasons for not using the pain tool/chart during every assessment included the patient's failure to grasp the concept of the tool, the inaccessibility of the visual analogue and the patients' general condition dictating otherwise.
All the respondents said they used a verbal score independently of the visual tool. Generally, they felt that if adequate explanation was given there was no need for a visual tool. Many thought the visual tool was inappropriate during acute MI, where nurses often have to assess pain in patients who are unable to cooperate.
Pearson's correlation coefficient, which was cited by Morris (1989), was used to establish whether there was a link between the respondents' years of experience in CCU and the use of the pain tool on admission and during every pain assessment. In both cases it was not significant.
Seventeen respondents suggested improvements, the main ones being to simplify the documentation, keep the tool at the bedside and, where possible, for patients to document their own pain. Two respondents thought the visual aid was unnecessary. Other suggestions included the use of alternative therapies, glyceryl trinitrate as a standard prescription, intravenous morphine in all cases during the first 12 hours in CCU and more space for documentation.
The outcome of this audit yielded eight main recommendations (See Box 1).
Since the completion of the audit, a pain standard specific to CCU has been compiled (see Box 2). The visual tool has been revamped to be more user-friendly, using a colour-coded curved chart (Fig 1) that is placed at the bedside. A separate prescription chart has been formulated for glyceryl trinitrate. The pain chart has been simplified, with fewer categories and codes, and is now on the reverse of the glyceryl trinitrate chart. Implementation of the recommendations is to be gradual, in step with an overall review and changes in the nursing documentation currently in use.