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
Nurses • 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
Pain Perception • “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 Assessment • The Gold Standard Or • Most reliable indicator of pain intensity and experience is Self Report • Use of numerical score, verbal descriptor score
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 ………..
Self Report Requires • Communication • Conscious level • Understanding of the pain rating • Memory of a painful event • Interpretation of noxious stimuli (Buffum et al 2007)
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?
Some Symptoms of Pain Behaviour Pacing, crying out, aggression, confusion, social withdrawal, apathy
Literature • Difficulties in assessment of pain identified • 158 indicators of pain • Identified by 109 nurses • Variation (Zwakhalen et al 2004)
Behaviours associated with pain (AGS 2002) • 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,
Behavioural pain assessment tools • Various available • Numerous concerns – Validity etc • Not used in practice – Lacks user friendly
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 Acute & Chronic Discomfort in Dementia) LTC CNVI ( Checklist of Non Verbal Acute Care Acute &Chronic Pain Indicators ) LTC MOBID ( Mobilization LTC Excluded acutely ill Observation Behaviour Intensity Dementia Pain Scale) PACSLAC ( Pain Assessment LTC Chronic pain Scale for Seniors with Severe Dementia ) PAINAD (Pain Assessment in LTC Acute & Chronic Advanced Dementia ) PADE (Pain Assessment in LTC 24 items Dementing Elderly) PATCOA (Pain Assessment To Acute Care 22 items Confused Older Adults)
DEVELOPMENT OF BEHAVIOURAL PAIN ASSESSMENT SCALES ABBEY PAINAD CNPI Australia USA USA Care Homes Long-Term Acute – trauma 61 residents 19, white male residents 88 cognitively impaired (53) and Staff (n=61) completed the Good construct reliability cognitively intact hip pain scale and validity fracture (35) Development based on the PAINAD able to detect Each of the 6 items is assumption caregivers differences in pain scored on a dichotomous reliably rate the intensity associated with different two point scale (0= not of pain medical conditions and present; 1=present). analgesic administration. Nurses’ holistic impression Positive correlation Pain present on movement of pain severity was used between verbal report and as the gold standard. observation with PAINAD in 25 # nof pts (12 cog impaired, 13 intact pts)
The Abbey Pain tool Scale 17
Problems with behavioural assessment 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
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 )
Comparison of scales content Vocalisation Facial Body Behaviour Physiological Physical change Scale grimace change change language Abbey × × Restless Rubbing CNVI × Breathing PAINAD (consolability)
Evaluation by nurses following use in acute care ABBEY PAINAD CNPI • • • Easy to use and Easy to use and 44% easy to use and understandable understandable understandable • 1-5 mins to complete • • 1-5 mins to complete 1-5 mins to complete ‘ gives prompts’, • • ‘easy to follow’ ‘ not clear what the • ‘effective’ • ‘good to use especially numerical scores should • justifies analgesia’ in those who cannot action’ • ‘like the communicate’ • documentation ’ ‘ a very good pain ‘nowhere to document • ‘Subjective ‘ assessment tool’ findings’ • RATED • Mean = 8.0 Mean = 8.6 Mean = 4.5
Evaluation of 3 scales • 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
Bolton Pain Assessment Tool • 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 (For patients with communication problems) NAME OF PATIENT………………………………………………………………. NAME AND DESIGNATION OF PERSON COMPLETING SCORE:…………………………………. DATE AND TIME …………….. SCORE ABSENT MILD 1 MODERATE 2 SEVERE 3 SCORE 0 Occasional moan or groan Low level speech with a Repeatedly crying out, loud VOCALISATION none negative or disapproving moaning or crying quality Smiling Looking tense, Sad Grimacing and looks frightened FACIAL EXPRESSION or relaxed Frowning, CHANGE IN BODY None Tense, fidgeting Guarding part of the body, Withdrawn, rigid, fists clenched. LANGUAGE Knees pulled up Refusing to eat, alterations Pulling or pushing away, striking BEHA VIOURAL None Increased confusion in usual pattern out CHANGE Occasional laboured Hyperventilation, increased Change in pulse BP, respiratory rate PHYSIOLOGICAL Normal breath, increased heart heart rate and BP and perspiring, flushed or pallor CHANGE rate 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 3-7 9-13 14+ NO PAIN MILD PAIN MODERATE PAIN SEVERE PAIN
Proof of concept at UHSM • 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
Evaluation • 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
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