Checklist of Nonverbal Pain Indicators

Checklist of Nonverbal Pain Indicators

Date: ______________ Patient Name:___________________________

(Write a 0 if the behavior was not observed, and a 1 if the behavior occurred even briefly during activity or rest.) With Movement Rest

1. Vocal Complaints: Nonverbal (Expression of pain, not in words, moans, groans, grunts, cries, gasps, sighs)

__________

__________

2. Facial Grimaces/Winces (Furrowed brow, narrowed eyes,

tightened lips, dropped jaw, clenched teet, distorted expressions

__________

__________

3. Bracing (Clutching or holding onto siderails, bed, tray table, or affected area during movement

__________

__________

4. Restlessness (Constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still

__________

__________

5. Rubbing: (Massaging affected area) (In addition, record verbal complaints)

__________

__________

6. Vocal Complaints: (Words expressing discomfort of pain—“ouch,” “that hurts”, cursing during movement, or exclamations of protest—“stop,” “that’s enough”)

__________

__________

Subtotal Scores

__________

__________

Total Scores

__________

__________

_________________________________________________________________________________________ Sources: Feldt KS, Treatment of pain in cognitively impaired versus cognitively intact post hip fractured elders (Doctoral diss.) Minneapolis: University of Minnesota, 1996. Dissertation Abstracts International 57, 09B: 5574; Feldt KS, Checklist of Nonverbal Pain Indicators. Pain Management Nursing 2000;1 (1): 13021.

Elaboration and validation of Evendol, a behavioral pain scale for young children attending the Accident and Emergency Department

Elisabeth Fournier-Charrière, MD 1, Christine Ricard, MD 2, Frédérique Lassauge, MD 3,

Barbara Tourniaire, MD 4, Patricia Cimerman, RN 4, Pascale Turquin, RN 1, Bruno Falissard, MD 5, Christelle Descot, MD 1, Alexia Letierce, MD 1, Florence Reiter 1,

Bénédicte Lombart, RN 4, & Ricardo Carbajal, MD 4

1 Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris,

94275 Le Kremlin Bicêtre, France 2 CHU Lapeyronie, Montpellier 3 CHU St Jacques, Besançon

4 Hôpital Trousseau, Paris 5 Hôpital Cochin, Paris

Background In the emergency department, pain has to be assessed quickly, in order to choose appropriate analgesic. A simple behavioral scale, easy to understand, quick to read and easy to fill out was needed for young children under 6. Elaboration EVENDOL, this new scale, was elaborated by five french pediatric pain specialists and emergency staff members. After one year of different feasibility studies, five appropriated items were arrested: vocal or verbal complaint, grimace, movements, postures, interaction with surroundings. Each item is scored from 0 to 3, depending on the intensity and the durability of the sign during the observation time. Total EVENDOL score vary from 0 to 15. Validation The scale was tested at 3 times: before any care, during mobilisation, after analgesic. Construct validity and inter rater reliability were studied. Children were assessed by the nurse and the searcher, with EVENDOL and with Visual Analogue Scale (VAS), and with other scales. Anxiety and asthenia levels were assessed. Self-assessment scores were obtained from children above 4 y-o. Results 297 children (1 month-6 years) were included. Construct validity: -scores before /after nalbuphine varied from 8.14 to 3.62 at rest (p<0.0001), from 11.87 to 6.65 at mobilisation (p=0.0011) -correlations between VAS and EVENDOL: 0.79 to 0.92 at all times (p<0.0001) -correlations between EVENDOL and other behavioral pain scales (EDIN, CHEOPS, FLACC, TPPPS): 0.5 to 0.93 (concurrent validity) -correlations between FPS-R and EVENDOL in 4-6 y-o children varied between 0.64 to 0.93 -correlations between EVENDOL and tiredness, and anxiety were bad (0.15 to 0.34) (discriminant validity).

Presented at the 7th International Forum on Pediatric Pain, White Point, Nova Scotia, Canada, October 2008.

Content validity: excellent Cronbach coefficient (0.83 to 0.92). Inter-rater reliability between nurses and researcher: correlations 0.89 to 0.98, weighted kappa 0.7 to 0.9. Conclusion EVENDOL, a new 5 items’scale to assess young children’s pain in the emergency departments is validated. EVENDOL is simple and well accepted by nurses.

Presented at the 7th International Forum on Pediatric Pain, White Point, Nova Scotia, Canada, October 2008.

Completed 04/04 1

The Assessment of Discomfort in Dementia (ADD) Protocol The Assessment of Discomfort in Dementia (ADD) Protocol is a systematic approach to be used by nurses to make a differential assessment and treatment plan for both physical pain and affective discomfort experienced by people with dementia. Thus, it should be noted that the ADD Protocol is not a typical pain assessment tool. The author currently states the tool is an intervention. However, it is included in this review because of its ability to detect pain in this population. The ADD Protocol focuses on evaluation of persons with difficult behaviors that may represent discomfort. Assessment of pain and discomfort is addressed by the protocol. ADD encompasses physical, affective and social dimensions of pain. In the 2002 version, a checklist of five categories of pain behaviors with dichotomous items specified within each category: Facial expression (8 items), Mood (5 items), Body language (9 items), Voice (9 items), Behavior (11 items). If potential pain behaviors are identified, the protocol consists five steps: (1) Assessment of physical signs and symptoms; (2) Current / past history of pain; (3) If steps 1 and 2 are negative assess environmental press, pacing of activity/stimulation, meaningful human interaction and intervene with non-pharmacological Rx’s; (4) If unsuccessful, medicate with non-narcotic analgesic per written order; (5) If symptoms persist, consult with physician/other health professional or medicate with prn psychotropic per written order. The method of administration is adequately described in articles on the ADD Protocol. Although no documentation of the amount of time involved in using the protocol is currently available, the protocol involves multiple steps and extensive documentation to complete. Thus, use of the ADD would appear to require a considerable amount of time. Moreover, the protocol involves complex clinical decisions, thus its use also requires extensive education. The ADD Protocol was tested (study 1) in 32 long term care facilities in a convenience sample of 104 residents with a mean age 85 years, range 46-100, most of whom had Dementia Alzheimer Type. Subsequent testing (study 2) was conducted in 6 LTC facilities in a convenience sample of 143 subjects, all Caucasian, 81% female, with severe dementia. The average age was 86.65 years (±6.16), range 56-100 years. Reliability • Internal consistency reliability has not been provided and may not be appropriate

considering the nature of the protocol. However, the behavior checklist could and should be evaluated for internal consistency.

• Interrater reliability for the protocol was established in study 1 in a very small sub-sample of 4 residents with percent agreement for total tool 86%; for medication use: 100%; for non-pharmacological interventions: 76%; and discomforting symptomatology: 87%.

• Test-retest reliability has not been established. However, this form of test is appropriate and needed.

Validity • Predictive validity of the ADD Protocol was tested in study 1. Pre-intervention the

sample had an average of 32.85 (±16.78) compared to 23.47 (±16.52) post-

Completed 04/04 2

intervention, a significant decrease in discomfort (t=6.56, p=0.000) and a significant increase in the use of pharmacologic (t=2.56, p=0.012) and non-pharmacologic comfort interventions (t=3.37, p=.001).

The ADD Protocol provides a comprehensive approach to recognition of potential pain conditions through observation and validation procedures that are conceptually sound. The tool addresses diverse potential pain indicators in this population and uses an assessment validation approach that focuses on positive changes in behavior. The behavior checklist is comprehensive. However, data are limited regarding its reliability. Preliminary testing of the protocol suggests its potential usefulness; however, additional testing of reliability and validity is needed, particularly larger samples including minority subjects. The clinical utility is also unclear regarding time for training and time to complete the protocol. Although the protocol is a complete approach to recognition of pain in this population, it may be too complex for routine use and streamlining of the steps may be needed.

Sources of evidence Kovach, C.R., Weissman, D.E., Griffie, J., Matson, S., Muchka, S. (1999). Assessment

and treatment of discomfort for people with late-stage dementia. Journal of Pain and Symptom Management, 18(6), 412- 419.

Kovach, C.R., Noonan, P.E., Griffie, J., Muchka, S., Weissman, D.E. (2001). Use of the

Assessment of Discomfort in Dementia Protocol. Applied Nursing Research, 14(4), 193-200.

Kovach, C.R., Noonan, P.E., Griffie, J., Muchka, S., Weissman, D.E. (2002). The

Assessment of Discomfort in Dementia Protocol. Pain Management Nursing, 3(1), 16-27.

Contact address for tool developer: Christine R. Kovach, PhD, RN, FAAN [email protected] This summary was completed by: K. Herr, S. Decker, K. Bjoro, University of Iowa.

Contact information: [email protected]

Validation of a Behavioral Pain Scale in Critically Ill,Sedated, and Mechanically Ventilated PatientsYounes Aıssaoui, MD*, Amine Ali Zeggwagh, MD, PhD*†, Aıcha Zekraoui, MD*,Khalid Abidi, MD*, and Redouane Abouqal, MD, PhD*†

*Service de Reanimation Medicale et de Toxicologie Clinique, Hopital Ibn Sina; and †Laboratoire de Biostatistiques, deRecherche Clinique et Epidemiologique, Faculte de Medecine et de Pharmacie, Rabat, Morocco

Assessing pain in critically ill patients, particularly innonverbal patients, is a great challenge. In this study,we validated a behavioral pain scale (BPS) in criticallyill, sedated, and mechanically ventilated patients. TheBPS score was the sum of 3 subscales that have a rangescore of 1–4: facial expression, upper limb movements,and compliance with mechanical ventilation. Two as-sessors observed and scored pain simultaneously withthe BPS at rest and during painful procedures. The psy-chometric properties of the BPS that were studied werereliability, validity, and responsiveness. We achieved360 observations in 30 patients. The BPS was internallyreliable (Cronbach � � 0.72). The intraclass correlation

coefficient to evaluate inter-rater reliability was high(0.95). Validity was demonstrated by the change in BPSscores, which were significantly higher during painfulprocedures, with averages of 3.9 � 1.1 at rest and 6.8 �1.9 during procedures (P � 0.001), and by the principalcomponents factor analysis, which revealed a largefirst-factor accounting for 65% of the variance in painexpression. The BPS exhibited excellent responsive-ness, with an effect size ranging from 2.2 to 3.4. Thisstudy demonstrated that the BPS can be valid and reli-able for measuring pain in noncommunicative inten-sive care unit patients.

(Anesth Analg 2005;101:1470–6)

A ssessment and management of pain in criticallyill patients have recently received increased at-tention (1–3). Scientific advances in understand-

ing pain mechanisms, multidimensional methods ofpain assessment, and analgesic pharmacology haveimproved pain management practices. However, painassessment for critically ill patients, especially for non-verbal patients, continues to present a challenge forclinicians and researchers. Critically ill patients areunable to communicate effectively for several reasons,including tracheal intubation, reduced level of con-sciousness, restraints, sedation, and administration ofparalyzing drugs (4–6).

Pain experts agree that a patient’s self-report of painintensity is the most valid measure (4). Unfortunately,most of the existing scales are designed for use withpatients who can respond verbally to assessment com-mands. Consequently, pain management in nonverbalpatients, such as elderly patients with cognitive im-pairment, is often guided by less precise and wholly

untested methods (7). Other methods, such as obser-vational pain tools, must be used in a lieu of patients’self-reports of pain (8). The limited amount of datasuggests that certain observable behaviors may bevalid indicators of pain (9,10). Pain behaviors can bemarkers of the existence, intensity, and causes of pain.Indeed, observing pain behaviors is a commonmethod of assessing pain, especially when patients areunable to verbalize.

Nevertheless, no pain scale comprising behavioralindicators has been validated in the intensive care unit(ICU), except the one developed by Payen et al. (11).The latter consisted of a behavioral pain scale (BPS),which was used to assess pain in patients who hadundergone thoracic or abdominal surgery or who hadbeen admitted for management of multiple trauma.However, its psychometric properties were insuffi-ciently studied, and it has never been validated in amedical ICU. In addition, validation of any pain toolrequires repeated tests of reliability, validity, and re-sponsiveness across samples, settings, and observers.Therefore, the purpose of this prospective study,which sampled from a population of critically ill pa-tients who were sedated and mechanically ventilated,was to validate Payen et al.’s (11) behavioral scale as ameasure of pain using psychometric methods.

Accepted for publication April 6, 2005.Address correspondence and reprint requests to Younes Aissaoui,

MD, Service de Reanimation Medicale et Toxicologie Clinique, BP1005, Hopital Ibn Sina, 10001 Rabat, Morocco. Address e-mail [email protected].

DOI: 10.1213/01.ANE.0000182331.68722.FF

©2005 by the International Anesthesia Research Society1470 Anesth Analg 2005;101:1470–6 0003-2999/05

MethodsThe study was performed over a 6-mo period in a 12-bedICU of the university teaching hospital Ibn Sina, Rabat,Morocco. The hospital ethical committee approved thestudy protocol, and because this observational study didnot require any deviation from routine medical practice,informed consent was not required.

We included patients who were older than 16 yr,mechanically ventilated, sedated, and unconscious.Inclusion criteria were chosen because they precludedthe use of an auto evaluation pain scale. Patients whowere quadriplegic, receiving neuromuscular blockingmedications, or had a peripheral neuropathy wereexcluded. Exclusion criteria were primarily selected tonot include patients whose diseases or medicationsmight compromise expression of the pain behaviors.

To assess pain intensity, we used the BPS describedby Payen et al. (11). The BPS is based on a sum of threesubscales: facial expression, upper limb movements,and compliance with mechanical ventilation (Table 1).Each subscale is scored from 1 (no response) to 4 (fullresponse). Therefore, possible BPS scores range from 3(no pain) to 12 (maximum pain).

In addition to the BPS scores, mean arterial bloodpressure and heart rate were also collected, whichwere measured by multimodal monitors. These twohemodynamic variables were collected because previ-ous studies had shown that increased heart rate andincreased arterial blood pressure are the most frequentphysiological indicators of pain noted by observingnurses (9).

The patients’ sedation levels were assessed usingthe Ramsay scale (12). The Ramsay scale rates sedationlevel on a scale from 1 to 6, with higher levels indi-cating greater degrees of sedation. This instrumentproved satisfactorily reliable and valid (13).

Sample characteristics were also recorded, includingage, sex, Acute Physiology and Chronic Health Evalua-tion (APACHE) II score (14), and diagnosis categories.APACHE II score was calculated for the first 24 h.

For each patient, the BPS scores and the two phys-iological variables were collected three times a day bythe various teams of nurses (morning team, afternoonteam, and night team). Each team comprised fournurses and one nurse’s aide. Assessments were madeby two evaluators to measure the inter-rater agree-ment. The two assessors were the nurse and the phy-sician in charge of the patient. They made their assess-ments simultaneously but without any communicationbetween them. The assessors were not randomized, forreasons of convenience.

Evaluation of the BPS and the physiological vari-ables was made at rest and during painful proceduresto appreciate the BPS responsiveness. The two painfulprocedures chosen were tracheal suction and periph-eral venous cannulation. They were selected because

their painful characters had been demonstrated in sev-eral previous studies (15–17) and because they werepart of the routine care that was normally planned forthe patients. No additional interventions or proce-dures were performed on the patients for the benefitof the study.

The assessments were done in the first 48 h afteradmission to the ICU. However, for patients who werenot being ventilated at the time of their admission butwho were ventilated later during their stay, the assess-ments were made in the first 48 h after mechanicalventilation began.

Twelve physicians and 16 nurses participated in thestudy. Before the beginning of the study, a training ses-sion was provided to teach assessors how to completeBPS, followed by a probation period (15 days), duringwhich the BPS was tested on some patients (n � 4).

Quantitative variables were expressed as mean � sd,and significance for all statistical tests was set at P � 0.05.

The sample size required for validation of the BPSwas established using the precision of a coefficient,such as Cronbach � or Intraclass Correlation Coeffi-cient (ICC) (18). Thus, with a precision of Cronbach �of 0.90 � 0.05 as an objective, and for a scale of 3subscales, it was required to include 25–30 patients inthe study.

The validation of an instrument measuring a sub-jective variable (like pain) requires a comparison witha “gold standard.” Nevertheless, no pain scale hasbeen validated in critically ill patients who were un-able to communicate effectively because of the pres-ence of artificial airways or underlying pathologies.Consequently, we had to validate the BPS with indi-rect arguments, which consisted of checking the psy-chometric properties of reliability, validity, andresponsiveness.

Reliability refers to the lack of measurement error in ascale and includes internal consistency and inter-raterreliability. Internal consistency is an indication of howthe items within a scale are interrelated. Cronbach � isone method of assessing internal consistency (19). A highCronbach � value reflects high internal consistency. Gen-erally, a value larger than 0.7 is regarded as satisfactory.Inter-rater reliability (or inter-rater agreement) is theability of a new instrument to obtain similar measureswith different assessors. It was assessed using the intra-class correlation coefficient (ICC) (20). Theoretically, theICC can range from 0 (no agreement) to 1.0 (perfectagreement). Generally, a value larger than 0.8 is re-garded as satisfactory (20). The ICC was calculated forthe BPS and for each subscale of the BPS separately. A95% confidence interval (CI) for the coefficient wasderived.

Validity is the degree to which an instrument meas-ures what it claims to measure (21). Validity wasestablished in three ways: construct validity, change in

ANESTH ANALG CRITICAL CARE AND TRAUMA AISSAOUI ET AL. 14712005;101:1470–6 PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS

BPS scores during pain, and factor structure of theBPS.

Construct validity is the extent to which scores on ascale correlate with scores of other measures in pre-dicted ways (21). We hypothesized that a significantcorrelation would be found between the BPS scoresand the two physiological variables that were sup-posed to measure the same concept (pain). We alsotested the correlation between the BPS and the Ram-say scale. Spearman nonparametric coefficients wereused.

Change in BPS scores was assessed by comparingthe BPS scores at rest and after painful procedures. Wehypothesized that if the BPS really measures pain, theBPS scores should be much higher during painfulprocedures than while the patient is at rest. Wilcoxonpaired tests (nonparametric) were used.

Furthermore, the factor structure of the BPS wasextracted by performing exploratory principal compo-nents factor analysis. This is a statistical procedurethat enables the underlying dimensions of a scale to bedetermined (21).

Responsiveness refers to an instrument’s ability todetect important changes over time in the conceptbeing measured, even if those changes are small (22).The magnitude of this property was assessed by theeffect size. This coefficient is calculated by dividingthe difference between the mean BPS scores at rest andduring painful procedures by the sd of the meanscores at rest. The effect size is considered small if it isless than 0.2, moderate if it is near 0.5, and large if it ismore than 0.8 (22).

ResultsThe various teams assessed 38 patients. However, theassessments of 8 patients could not be included for 3major reasons: (a) the patient died before the end ofthe assessments (n � 2), (b) the presence of exclusioncriteria (administration of neuromuscular blockade) (n

� 3), and (c) an incomplete or incorrect collection ofdata (n � 3).

Thirty patients were included. The principal patientcharacteristics are presented in Table 2. Each patientwas assessed three times a day (morning, afternoon,and night), by two observers (a physician and anurse), and at two different times (at rest and duringpainful procedures). Thus, the various teams achieved360 observations (30 patients � 2 observers � 2 dif-ferent times � 3 times per day). Realization of a com-plete assessment usually required 3–4 min.

All patients were sedated with midazolam in con-tinuous infusion except one patient who received thio-pental (status epilepticus). The mean amount of mida-zolam administered was 5.6 � 2.5 mg/h. The Ramsayscale had an average value of 3.9 � 1.6. For analgesia,the drug frequently used was morphine, also in con-tinuous perfusion. The mean amount of morphineadministered was 3 � 0.7 mg/h.

Change in physiological variables is shown in Table3. There was a significant increase in both hemody-namic variables during painful procedures. The am-plitude of this increase was 10.7% for heart rate and2.6% for mean arterial blood pressure.

Cronbach � values indicated that the BPS had goodinternal consistency (Cronbach � � 0.72). ICC to eval-uate the inter-rater agreement were high for all sub-scales of the BPS. For facial expression, ICC was 0.91(95% CI, 0.88–0.93). For upper limb movements, ICCwas 0.90 (95% CI, 0.87–0.92). For compliance with

Table 1. The Behavioral Pain Scale (11)

Item Description Score

Facial expression Relaxed 1Partially tightened (e.g., brow lowering) 2Fully tightened (e.g., eyelid closing) 3Grimacing 4

Upper limb movements No movement 1Partially bent 2Fully bent with finger flexion 3Permanently retracted 4

Compliance with mechanical ventilation Tolerating movement 1Coughing but tolerating ventilation for the most of time 2Fighting ventilator 3Unable to control ventilation 4

Table 2. Principal Patient Characteristics

Age (y) 39 � 19*Sex: men/women (n) 18/12APACHE II score 17 � 7.8*Diagnostic categories (n) Nontraumatic coma (11)

Acute intoxication (7)Respiratory failure (5)Sepsis (5)Status epilepticus (2)

* Values expressed as mean � sd.APACHE � Acute Physiology and Chronic Health Evaluation.

1472 CRITICAL CARE AND TRAUMA AISSAOUI ET AL. ANESTH ANALGPAIN ASSESSMENT IN CRITICALLY ILL PATIENTS 2005;101:1470–6

mechanical ventilation, ICC was 0.89 (95% CI, 0.85–0.92). ICC for the total score of the BPS was 0.95 (95%CI, 0.94–0.97). These values showed excellent inter-rater agreement. We also compared the BPS scoresobtained by the three teams of caregivers. There wasno significant difference (Table 4).

No significant correlation was found between theBPS scores and the physiological variables for variabil-ity. The correlation coefficients were r � 0.16 (P �0.13) for heart rate and r � �0.02 (P � 0.84) for meanarterial blood pressure. When the correlation betweenthe BPS scores and Ramsay scale was investigated, asexpected, a significant negative correlation emerged (r� �0.432; P � 0.001). The higher the sedation level,the lower the BPS scores (Fig. 1).

BPS scores obtained at rest and during painful pro-cedures appear in Table 5. The scores were signifi-cantly greater during painful procedures than at restand did not differ between the two categories of pain-ful procedures (tracheal suction and peripheral ve-nous cannulation). Moreover, all subscale scores weresignificantly higher during painful procedures.

Using exploratory principal components factor analy-sis, we found a large first factor, which accounted for65% of the variance in pain expression, with strong cor-relation of the subscales with this factor, including coef-ficients of 0.90 for facial expression, 0.85 for upper limbmovements, and 0.64 for compliance with mechanicalventilation. Table 6 shows the correlation matrix be-tween the subscales of the BPS. The 3 subscales weresignificantly correlated (all P � 0.001), with a high cor-relation between facial expression and upper limb move-ments (r � 0.70) and moderate correlations betweencompliance with mechanical ventilation and the 2 othersubscales (r � 0.40 with facial expression and r � 0.29with upper limb movements).

The effect size for responsiveness was large for thethree subscale scores and for the total BPS scores(Table 5). These results showed an excellent respon-siveness and, consequently, the excellent ability of theBPS to quantify change in clinical status and detectpainful procedures.

DiscussionThis validation study showed that the BPS had goodpsychometric properties when used with critically ill

patients. In particular, the BPS showed a high inter-rater reliability (ICC � 0.95) and a satisfactory internalconsistency (Cronbach � � 0.72). Validity of the BPSwas demonstrated by a significant increase in BPSscores during painful procedures and by principalcomponents factor analysis that identified a large firstfactor, which accounted for 65% of the variance inpain expression. Furthermore, the BPS exhibited anexcellent responsiveness, suggesting that this is apowerful tool to detect the impact of painful stimula-tion in ICU patients.

Each of our patients was assessed by three teams ofnurses to remove a possible bias caused by assess-ments being made by the same caregivers. Resultsshowed that there was no significant differenceamong the evaluations made by the three teams.

At rest, theoretically, the BPS scores should be equalto 3, indicating the absence of pain. However, themean BPS scores, which were near 4, suggest thepossibility of preexisting background pain before anyprocedure was performed. Indeed, our patients, likeall ICU patients, are subjected to a multitude of pain-ful constraints, including various tubes (nasogastricand endotracheal), central and arterial lines, wrist re-straints, etc. Another explanation could be that theamount of analgesic infusion was insufficient. Thisfact highlights the need for an instrument that can beused to titrate and adapt analgesia in critical care.

Pain is a stressor that produces a sympathetic stim-ulation (tachycardia, change in arterial blood pressure,diaphoresis, and change in pupillary size) (4,23).These physiological variations can help to detect painamong patients with impaired mental status(4,8,23,24). Puntillo et al. (9), in a study of patientshaving difficulties with verbal communication (me-chanically ventilated or having been tracheally extu-bated less than four hours), showed that the mostfrequently noted physiological indicators of pain wereincreased heart rate and increased arterial blood pres-sure. In our study, heart rate and arterial blood pres-sure increased significantly during painful proce-dures, with the increase for heart rate measuringapproximately 10%. These results coincide with theobservations of clinicians who generally associate painwith a variation of from 10% to 20% in physiologicalvariables (25). However, it is agreed that these physi-ological indicators lack specificity in the ICU and canbe influenced by many medications (vasopressors, �adrenergic blockers, antiarrhythmics, sedative drugs,etc.) and pathological conditions (sepsis states, shock,hypoxia, and fear) (4). Moreover, no significant corre-lation was found among the BPS scores and the twophysiological variables in our study. Unfortunately,the absence of an objective measure of pain in ICUpatients limited the testing of construct validity. Thestudy of Payen et al. (11) had the same results, and nopublished study with a sufficient level of scientific

Table 3. Physiological Variables at Rest and DuringPainful Procedures

RestPainful

procedures P-value

Heart rate (bpm) 103 � 22 114 � 23 �0.001Mean arterial blood

pressure (mm Hg)77 � 26 79 � 27 0.042

Values expressed as mean � sd.


evidence has found a correlation among these physi-ological variables and pain (9).

However, the correlation between the BPS and Ram-say scale was negative and significant. The logical direc-tion of the association is the higher the sedation level, thelower the ability to express painful behaviors.

In the present study, the BPS yielded a Cronbach �of 0.72, thus fulfilling Nunnally and Bernstein’s (26)criterion for satisfactory internal consistency. Theinter-rater reliability of the BPS was found to be ex-cellent (ICC � 0.95). This indicates that the BPS pro-duces consistent scores from different assessors. Reli-ability is an essential property when caregivers arenumerous, as in the ICU.

The BPS total and subscale scores were significantlyhigher during the procedures (Table 5). This change inBPS scores testifies to the instrument’s capacity todetect and discriminate pain and provides the evi-dence that the BPS is a valid measure of pain. It is alsoimportant that all of the subscales changed, indicatingthat they all have the same ability to discriminate pain.

Principal factor analysis revealed that a large firstfactor was dominant and that the three subscales werestrongly related to this factor, which means each of the

BPS subscales contributed to the overall pain assess-ment rating. The largest contributor was facial expres-sion (r � 0.90), followed by upper limb movements (r� 0.85), and then compliance with mechanical venti-lation (r � 0.64). Furthermore, the positive significantcorrelation found among the three subscales demon-strates that they evaluate the same concept, which, inthis case, was pain intensity.

This analysis has shown that behavioral indicatorscan be a valid and reliable measure of pain. Fewstudies have evaluated pain behaviors in the ICU(9,10,25). The most recent one (10) identified specificprocedural pain behaviors such as grimacing, rigidity,wincing, shutting of eyes, verbalization, and clenchingof fists. But in that study, the patients were awake andcould measure their pain with a numeric rating scale.In fact, facial expression, which contributed most tothe pain rating in our study, is a sign found in variousworks measuring both acute and chronic pain(25,27,28). Prkachin (27) has suggested that four facialactions carry the bulk of facial information about pain:lowering the brow, tightening and closing of the eye-lids, wrinkling of the nose, and raising the upper lip.He has also provided evidence of the existence of auniversal facial language of pain. The facial scales,which are especially useful for measuring pain in in-fants and children, highlight the value of this type ofsignal (4,23,29). Pediatric scales also rely on upperlimb movements as a measure of pain (23,29). In ourstudy, upper limb movements contributed as much asfacial expression to the pain rating. Compliance withmechanical ventilation, adapted from the Comfortscale (11), had a moderate but effective contribution topain assessment. The reason could be that this sub-scale might be affected by some factors unrelated topain, such as hypoxemia, bronchospasm, and mucousplugging, which can lead to coughing and some fight-ing of the ventilator.

In addition to these psychometric properties, theBPS showed good feasibility, in as much as the aver-age time of assessment was only four minutes. Theshort time required will make the BPS suitable foreveryday clinical use.

This study has two limitations. First, one aspect ofthe validation process has not been addressed, namelythe criterion validity (validity of the BPS in compari-son with another validated pain scale). We could havecompared the BPS to subjective rating of the level painby an independent rater (a nurse) on a visual analog

Figure 1. Correlations between the behavioral pain scale (BPS) andthe Ramsay scale.

Table 4. Behavioral Pain Scale Scores as Assessed by Three Nursing Teams

Morning team Afternoon team Night team P-value*

Rest 3.8 � 1.2 3.7 � 0.9 3.9 � 1.2 0.44Painful procedures 6.6 � 1.7 6.8 � 1.7 6.6 � 2.2 0.46

Values expressed as mean � sd.* Friedman test.


scale (VAS). However, apart from the BPS, no othervalidated instrument has been developed to measurethe level of pain in mechanically ventilated ICU pa-tients, and the VAS has never been validated in suchpatients. In addition, a number of studies have foundthat from 35% to 55% of nurses under-rate patient painwhen using the VAS (4). This precludes any analysisof criterion validity in which the new instrumentwould be compared to a reference instrument.

The second limitation of our study is that the sam-ple of critical care patients observed was small. Futurestudies will have to include more patients.

We conclude that the present study provides evi-dence that the BPS has good psychometric properties.This instrument might prove useful to measure pain inuncommunicative critically ill patients and to evaluatethe effectiveness of analgesic treatment and adapt it.Further studies are required to determine whether theuse of this scale can really improve management ofpain in the critical care setting.

The authors gratefully acknowledge all the nurses and physicianswho participated in this study, Dounia Benzarouel for her assistancewith data collection, and Younes Lahrech and Khalil Zakari for theirhelp during the writing of this manuscript.

References1. Carroll KC, Atkins PJ, Herold GR, et al. Pain assessment and

management in critically ill postoperative and trauma patients.Am J Crit Care 1999;8:105–17.

2. Puntillo KA. Pain assessment and management in the criticallyill: wizardry or science? Am J Crit Care 2003;12:310–6.

3. Edrek MA, Pronovost J. Improving assessment and treatment ofpain in the critically ill. Int J Qual Health Care 2004;16:59–64.

4. Hamill-Ruth RJ, Marohn ML. Evaluation of pain in the criticallyill patient. Crit Care Clin 1999;15:35–54.

5. Puntillo KA. The phenomenon of pain and critical care nursing.Heart Lung 1988;17:262–70.

6. Shannon K, Bucknall T. Pain assessment in critical care: what havewe learnt from research. Intensive Crit Care Nurs 2003;19:154–62.

7. Taylor LJ, Herr K. Pain intensity assessment: a comparison ofselected pain intensity scales for use in cognitively intact andcognitively impaired African American older adults. PainManag Nurs 2003;4:87–95.

8. Puntillo KA, Stannard D, Miakowski C, et al. Use of painassessment and intervention notation (P.A.I.N) tool in criticalcare nursing: nurses’ evaluations. Heart Lung 2002;31:303–13.

9. Puntillo KA, Miakowski C, Kehrle K, et al. Relationship betweenbehavioral and physiological indicators of pain, critical carepatients’ self reports of pain, and opioid administration. CritCare Med 1997;25:1159–66.

10. Puntillo KA, Morris AB, Thompson CL, et al. Pain behaviorsobserved during six common procedures: results from ThunderProject II. Crit Care Med 2004;32:421–7.

11. Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically illsedated patients by using a behavioral pain scale. Crit Care Med2001;29:2258–63.

Table 5. Behavioral Pain Scale (BPS) Total Scores and BPS Subscale Scores at Rest and During Painful Procedures, withthe Effect Size

RestPainful

procedure P*-value Effect size

BPS subscalesFacial expression

Morning team 1.2 � 0.6 2.6 � 1 �0.0001 2.3Afternoon team 1.1 � 0.25 2.8 � 1.1 �0.0001 6.8Night team 1.2 � 0.3 2.7 � 1.2 �0.0001 5

Upper limb movementsMorning team 1.1 � 0.2 2 � 0.7 �0.0001 4.5Afternoon team 1 � 0.2 1.9 � 0.8 �0.0001 4.5Night team 1.2 � 0.5 1.9 � 0.9 �0.0001 1.4

Compliance with mechanical ventilationMorning team 1.5 � 0.6 2 � 0.9 �0.046 0.8Afternoon team 1.6 � 0.6 2.1 � 0.9 �0.005 0.8Night team 1.5 � 0.5 2 � 0.9 �0.006 1

BPS totalMorning team 3.8 � 1.2 6.6 � 1.7 �0.0001 2.3Afternoon team 3.7 � 0.9 6.8 � 1.7 �0.0001 3.4Night team 3.9 � 1.2 6.6 � 2.2 �0.0001 2.2

* Wilcoxon paired test.

Table 6. Correlation Matrix Among the Items of the Behavioral Pain Scale

Facialexpression

Movements ofupper limbs

Compliance withmechanical ventilation

Facial expression 1Movements of upper limbs 0.70 1Compliance with mechanical ventilation 0.41 0.29 1

Values shown represent Spearman nonparametric correlation coefficients; all correlations were statistically significant at P � 0.001.


12. Ramsay MAE, Savege TM, Simpson BRJ, Goodwin R. Con-trolled sedation with alphaxolone-alphadolone. Br Med J 1974;2:656–9.

13. Riker RR, Picard JT, Fraser GL. Prospective evaluation of theSedation-Agitation Scale for adult critically ill patients. CritCare Med 1999;27:1325–9.

14. Knaus W, Draper EA, Wagner DP, Zimmerman JE. APACHE II:a severity of disease classification system. Crit Care Med 1985;13:818–29.

15. Puntillo KA. Dimensions of procedural pain and its analgesicmanagement in critically ill surgical patients. Am J Crit Care1994;3:116–22.

16. Puntillo KA, White C, Morris AB, et al. Patients’ perceptionsand responses to procedural pain: results from Thunder ProjectII. Am J Crit Care 2001;10:238–51.

17. Vaghadia H, al-Ahdal OH, Nevin K. EMLA patch for venouscannulation in adult surgical outpatients. Can J Anaesth 1997;44:798–802.

18. Feldt LS. The approximate sampling distribution of Kuder-Richardson reliability coefficient twenty. Psychometrika 1965;30:357–370.

19. Cronbach LJ. Coefficient alpha and the internal structure oftests. Psychometrika 1951;16:297–334.

20. Shrout PE, Fleiss JL. Intraclass correlation: uses in assess raterreliability. Psychol Bull 1979;86:420–8.

21. Kline P. A psychometrics primer. London: Free AssociationBooks, 2000.

22. Wright JG, Young NL. A comparison of different indices ofresponsiveness. J Clin Epidemiol 1997;50:239–47.

23. Franck LS, Greenberg CS, Stevens B. Pain assessment in infantsand children. Pediatr Clin North Am 2000;47:487–512.

24. Leisifer D. Monitoring pain control and charting. Crit Care Clin1990;6:283–94.

25. Terai T, Yukioka H, Asada A. Pain evaluation in the intensive careunit: observer-reported faces scale compared with self-reportedvisual analog scale. Reg Anesth Pain Med 1998;23:147–51.

26. Nunnally JC, Bernstein IH. Psychometric theory. 3rd ed. NewYork: McGraw-Hill, 1994:83–113.

27. Prkachin KM. The consistency of facial expression of pain: acomparison across modalities. Pain 1992;51:297–306.

28. LeResche L, Dworkin SF. Facial expressions of pain and emo-tions in chronic TMD patients. Pain 1988;35:71–8.

29. Mathew PJ, Mathew JL. Assessment and management of pain ininfants. Postgrad Med J 2003;79:438–43.


BEHAVIORAL PAIN SCALE

Pain Score Pain A B C D Behaviors None Mild Moderate Severe Restless Quiet Slightly Moderate Very Restless Restless Restless Tense Relaxed Slight Moderate Extreme Muscles Tenseness Tenseness Tenseness Frowning/ No Slight Moderate Constant Grimacing Frowning/ Frowning/ Frowning/ Frowning/ Grimacing Grimacing Grimacing Grimacing Patient Talking in Sighs, Groans Groans, Moans Cries out or Sounds Normal Tone/ Moans Softly Loudly Sobs No Sound Instructions: Observe the patient for 10 minutes. Assess the patient on the four behaviors (none-severe). Obtain a pain score based on the highest behavior observed. The John Hopkins Hospital PACU Behavioral Pain Rating Scale cited in Mateo, OM., & Krenzischeck, DA. (1992). A pilot study to assess the relationship between behavioral manifestations and self-report of pain in post-anesthesia care unit patients. Journal of Post Anesthesia Nursing. 7(1): 15-21.

NATIONAL INSTITUTES OF HEALTH WARREN GRANT MAGNUSON CLINICAL CENTER

PAIN INTENSITY INSTRUMENTS

JULY 2003 Checklist of Non-Verbal Indicators (CNVI) (page 1 of 1) With

Movement At Rest

Vocal Complaints – nonverbal expression of pain demonstrated by moans, groans, grunts, cries, gasps, sighs)

Facial Grimaces and Winces – furrowed brow, narrowed eyes, tightened lips, dropped jaw, clenched teeth, distorted expression

Bracing – clutching or holding onto siderails, bed, tray table, or affected area during movement

Restlessness – constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still

Rubbing – massaging affected area

Vocal complaints – verbal expression of pain using words, e.g., “ouch” or “that hurts; ” cursing during movement, or exclamations of protest, e.g., “stop” or “that’s enough.”

TOTAL SCORE Indications: Behavioral Health adults who are unable to validate the presence of or quantify the severity of pain using either the Numerical Rating Scale or the Wong-Baker Faces Pain Rating Scale. Instructions: 1. Write a 0 if the behavior was not observed 2. Write a 1 if the behavior even briefly during activity or rest 3. Results in a total score between 0 and 5. 4. The interdisciplinary team in collaboration with the patient (if appropriate), can determine

appropriate interventions in response to CNVI scores. Reference Feldt, KS. (2000). The checklist of nonverbal pain indicators (CNPI). Pain Management Nursing, 1(1): 13-21.

FLACC SCALE (FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY)

FACE

0

No particular expression or smile

1

Occasional grimace or frown, withdrawn,

disinterested

2

Frequent to constant frown, clenched jaw,

quivering chin

LEGS

0

Normal position Or

relaxed

1

Uneasy, Restless,

Tense

2

Kicking, Or

Legs drawn up

ACTIVITY

0

Lying quietly Normal position

Moves easily

1

Squirming Shifting back/forth

Tense

2

Arched Rigid

Or Jerking

CRY

0

No Cry

(Awake or Asleep)

1

Moans or Whimpers Occasional Complaint

2

Crying Steadily Screams or Sobs

Frequent Complaints

CONSOLABILITY

0

Content Relaxed

1

Reassured by occasional touching, hugging, or ‘talking

to.’ Distractible

2

Difficult to console or comfort.

The FLACC is a behavior pain assessment scale for use in non-verbal patients unable to provide reports of pain. Instructions: 1. Rate patient in each of the five measurement categories 2. Add Together 3. Document total pain score

Lori Wild, PhD, RN**

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Original articles

rom *Adult and Gerontologicalursing, The University of Iowaollege of Nursing, Iowa City,owa; †Medical College of Virginiaospital, Rockville, Virginia;

Washington County Hospitalssociation, Hagerstown,aryland; §Clinical Nurse

pecialist and Manager of Painanagement, Children’s Medicalenter of Dallas, Dallas, Texas;Independent Consultant in theursing Care of Patients withain, Los Angeles, California; �Motthildren’s Hospital, University ofichigan Health System, Annrbor, Michigan; #Alexian Brothersospital Network, Elk Groveillage, Illinois; and **Universityf Washington Medical Center,eattle, Washington.

ddress correspondence and reprintequest to Keela Herr, PhD, RN, FAAN,52 NB, College of Nursing, Theniversity of Iowa, Iowa City, IA2242. E-mail: [email protected]

524-9042/$32.002006 by the American Society

or Pain Management Nursing
loi:10.1016/j.pmn.2006.02.003
Pain Assessment in theNonverbal Patient:Position Statement withClinical PracticeRecommendations

yyy Keela Herr, PhD, RN, FAAN,*Patrick J. Coyne, MSN, RN, CS, FAAN,† Tonya Key, RN, C,‡

Renee Manworren, MS, RN, C, CNS,§

Margo McCaffery, MS, RN, FAAN,¶

Sandra Merkel, MS, RNC,�

Jane Pelosi-Kelly, MSN, RN, C, CS, ANP,# and

ABSTRACT:he article presents the position statement and clinical practice rec-mmendations for pain assessment in the nonverbal patient devel-ped by an appointed Task Force and approved by the ASPMN Boardf Directors.2006 by the American Society for Pain Management Nursing

ain is a subjective experience, and no objective tests exist to measure it (APS,003). Whenever possible, the existence and intensity of pain are measured byhe patient’s self-report, abiding by the clinical definition of pain that statesPain is whatever the experiencing person says it is, existing whenever he/sheays it does” (McCaffery, 1968). Unfortunately, some patients cannot provide aelf-report of pain verbally, in writing, or by other means, such as finger spanMerkel, 2002) or blinking their eyes to answer yes or no questions (Pasero &cCaffery, 2002).

This position paper will specifically address three populations of nonverbalatients: elders with advanced dementia, infants and preverbal toddlers, and

ntubated and/or unconscious patients. The inability of these populations toommunicate pain and discomfort because of cognitive, developmental, orhysiologic issues is a major barrier for them being adequately assessed for painnd achieving adequate pain management interventions.

THICAL TENETShe ethical principles of beneficence (the duty to benefit another) and nonma-

eficence (the duty to do no harm) oblige health care professionals to provide

Pain Management Nursing, Vol 7, No 2 (June), 2006: pp 44-52

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45Pain Assessment in the Nonverbal Patient

ain management and comfort to all patients, includ-ng those challenging individuals who are vulnerablend unable to speak for themselves. Providing qualitynd comparable care to individuals who cannot reportheir pain is directed by the principle of justice (thequal or comparative treatment of individuals). Re-pect for human dignity, the first principle in theCode of Ethics for Nurses” (ANA, 2001), directsurses to provide and advocate for humane and ap-ropriate care. On the basis of the principle of justice,his care is given with compassion and unrestricted byonsideration of personal attributes, economic status,r the nature of the health problem.

ENERAL RECOMMENDATIONSll persons with pain deserve prompt recognition and

reatment. Pain should be routinely monitored, assessed,eassessed, and documented clearly to facilitate treat-ent and communication among health care clinicians

Gordon et al., 2005). In patients who are unable toelf-report pain, other measures must be used to detectain and evaluate interventions. No single objective as-essment strategy, such as interpretation of behaviors,athology, or estimates of pain by others, is sufficient by

tself. Following are recommended considerations:

1. Use the Hierarchy of Pain Assessment Techniques (Mc-Caffery & Pasero, 1999):a. Self-report. Attempts should be made to obtain self-

report of pain from all patients. A self-report of pain froma patient with limited verbal and cognitive skills may bea simple yes/no or vocalization. When self-report is ab-sent or limited, explain why self-report cannot be usedand further investigation and observation are needed.

b. Search for Potential Causes of Pain. Pathologic con-ditions and common problems or procedures knownto cause pain (e.g., surgery, wound care, rehabilitationactivities, positioning/turning, blood draws, heelsticks, a history of persistent pain) should trigger anintervention, even in the absence of behavioral indi-cators. A change in behavior requires careful evalua-tion of the possibility of additional sources of pain.Generally, one may ASSUME PAIN IS PRESENT, and ifthere is reason to suspect pain, an analgesic trial canbe diagnostic as well as therapeutic (APS, 2003). Painassociated with procedures should be treated beforeinitiation of the procedure. Other problems that maybe causing discomfort should be ruled out (e.g., infec-tion, constipation) or treated.

c. Observe Patient Behaviors. In the absence of self-report, observation of behavior is a valid approach topain assessment. Common behaviors that may indi-cate discomfort in the selected populations have beenidentified in each section below. Pain behaviors arenot always accurate reflections of pain intensity, and
in some cases indicate another source of distress, such
as physiologic distress or emotional distress (Pasero &McCaffery, 2005). Potential causes and the context ofthe behavior must be considered when making treat-ment decisions. Awareness of individual baseline be-haviors and changes that occur with discomfort arevery useful in differentiating pain from other causes.

d. Surrogate Reporting (family members, parents, care-givers) of Pain and Behavior/Activity Changes.Credible information can be obtained from a parent oranother person who knows the patient well (e.g.,spouse, child, caregiver). Parents and caregiversshould be encouraged to actively participate in theassessment of pain in their loved one. Familiarity withthe patient and knowledge of usual and past behaviorscan assist in identifying subtle, less obvious changes inbehavior that may be indicators of pain presence.

Discrepancies exist between self-report of pain andexternal observer judgments of pain severity that oc-cur across varied raters (e.g., physician, nurse, family,aides) and settings (e.g., inpatient, outpatient, acutecare, long-term care). Thus, judgments by caregiversand clinicians may not be accurate reflections of theseverity of pain experienced by nonverbal personsand should be combined with other evidence whenpossible. A multifaceted approach is recommendedthat combines direct observation, family/caregiver in-put, and evaluation of response to treatment.

e. Attempt an Analgesic Trial. An empiric analgesic trialshould be initiated if there are pathologic conditions orprocedures likely to cause pain or if pain behaviorscontinue after attention to basic needs and comfort mea-sures. Provide an analgesic trial and titration appropriateto the estimated intensity of pain based on the patient’spathology and analgesic history. For mild to moderatepain, a nonopioid analgesic may be given initially (e.g.,acetaminophen every 4 hours for 24 hours). If behaviorsimprove, assume pain was the cause and continue theanalgesic and add appropriate nonpharmacologic inter-ventions. If behaviors continue, consider giving a singlelow dose, short-acting opioid (e.g., hydrocodone, oxy-codone, or morphine) and observe the effect. If there isno change in behavior, titrate dose upward by 25% to50% and observe the effect. Continue to titrate upwarduntil a therapeutic effect is seen, bothersome side effectsoccur, or no benefit is determined. It may be appropriateto start the analgesic trial with an opioid for conditions inwhich moderate to severe pain is expected. Exploreother potential causes if behaviors continue after a rea-sonable analgesic trial. The analgesic titration example isconservative, and although strategies for safe titrationshould be followed, more aggressive approaches may beneeded (Gordon et al., 2004). No research confirms thatweight (except in children) should be used to determinestarting dose (Burns et al., 1989; Macintyre & Jarvis,1995).

2. Establish a Procedure for Pain AssessmentA procedure for evaluating pain presence and response

to treatment should be instituted in each health care

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46 Herr et al.

setting. The hierarchy of assessment techniques, dis-cussed above, is recommended, and the following can beused as a template for the initial assessment and treat-ment procedure (Pasero & McCaffery, 2005).a. Attempt first to elicit a self-report from patient and

explain why self-report cannot be used.b. Identify pathologic conditions or procedures that may

cause pain.c. List patient behaviors that may indicate pain. Behav-

ioral assessment scales may be used.d. Identify behaviors that caregivers and others knowl-

edgeable about the patient think may indicate pain.e. Attempt an analgesic trial.

3. Use Behavioral Pain Assessment Tools, as AppropriateUse of a behavioral pain assessment tool may assist in

recognition of pain in these challenging populations. It isincumbent on health care providers to consider thestrength of psychometric evaluation data (e.g., reliabilityand validity of the tool), the clinical feasibility of instruments(e.g., training required, time to complete), and the supportfor use with the population of interest in the specific setting(e.g., acute care, long-term care, home care) when selectinga specific tool. Use of reliable and valid tools helps ensurethat clinicians are using appropriate criteria in their painassessments. Standardized tools promote consistencyamong care providers and care settings and facilitate com-munication and evaluation of pain management treatmentdecisions. However, the appropriateness of a scale must beassessed patient by patient, and no one scale should be aninstitutional mandate for all patients in a certain group(Pasero & McCaffery, 2005).

When a behavioral tool is scored, that score is not thesame as a pain intensity rating nor can the scores becompared with standard pain intensity ratings or catego-ries of pain severity. Behavioral assessment tools may behelpful to identify the presence of pain and can be usedto evaluate attempts to relieve pain (Pasero & McCaffery,2005). When selecting a behavioral pain assessment tool,be sure the patient is able to respond in all categories ofbehavior. Keys to the use of behavioral pain scales are tofocus on the individual’s behavioral presentation andobserve for changes in those behaviors with effectivetreatment. Remember that sleep and sedation do notequate with the absence of pain or with pain relief.

4. Minimize Emphasis on Physiologic IndicatorsPhysiologic indicators (e.g., changes in heart rate,

blood pressure, respiratory rate) are not sensitive fordiscriminating pain from other sources of distress. Al-though physiologic indicators are often used to docu-ment pain presence, little research supports the use ofvital sign changes for identifying pain. Absence of in-creased vital signs does not indicate absence of pain(McCaffery & Pasero, 1999).

5. Reassess and DocumentAfter intervention and regularly over time, the patient

should be reassessed with methods of pain assessmentand specific behavioral indicators that have been identi-
fied as significant and appropriate for the individual pa-
tient. Assessment approaches and pain indicators shouldbe documented in a readily visible and consistent mannerthat is accessible to all health care providers involved inthe assessment and management of pain (Gordon et al.,2005; Miaskowski et al., 2005).

ERSONS WITH ADVANCEDEMENTIA: GUIDING PRINCIPLESOR THE ASSESSMENT OF PAIN

ecommendations for pain assessment in nonverballder adults with dementia unable to self-report thatre unique from the general recommendations includehe following:

1. Self-report. The ravages of dementia seriously impactthe ability of those with advanced stages of disease tocommunicate pain. Damage to the central nervoussystem affects memory, language, and higher ordercognitive processing necessary to communicate theexperience. Yet, despite changes in central nervoussystem functioning, persons with dementia still expe-rience pain sensation to a degree similar to that of thecognitively intact older adult (Schuler et al., 2004).However, dementing illnesses do impact the interpre-tation of the pain stimulus and the affective responseto that sensation (Scherder et al., 2005). Althoughself-report of pain is often possible in those with mildto moderate cognitive impairment, as dementiaprogresses, the ability to self-report decreases andeventually self-report is no longer possible.

2. Searches for Potential Causes of Pain/Discomfort. Con-sider chronic pain causes common in older persons (e.g.,history of arthritis, low back pain, neuropathies). Muscu-loskeletal and neurologic disorders are the most com-mon causes of pain and should be given priority in theassessment process. A recent fall or other acute pain-related problem (e.g., urinary tract infection, pneumo-nia, skin tear) could be the cause of pain.

3. Observation of Patient Behaviors. Observe for behav-iors recognized as indicators of pain in this popula-tion. Facial expressions, verbalizations/vocalizations,body movements, changes in interpersonal interac-tions, changes in activity patterns or routines, andmental status changes have been identified as catego-ries of potential pain indicators in older persons withdementia (AGS, 2002). A list of indicators included inthese categories and an algorithm for evaluating painin persons unable to self-report are available (AGS,2002). Some behaviors are common and typically con-sidered pain related (e.g., facial grimacing, moaning,groaning, rubbing a body part), but others are lessobvious (e.g., agitation, restlessness, irritability, confu-sion, combativeness, particularly with care activitiesor treatments, or changes in appetite or usual activi-ties) and require follow-up evaluation. Typical painbehaviors are often not present, and more subtle indi-
cators may represent pain. Use the American Geriatric

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Society’s indicators of pain (AGS, 2002) or a nonverbalpain assessment tool that is appropriate, valid, andreliable for use with this population. Behavioral obser-vation should occur during activity whenever possi-ble, because pain may be minimal or absent at rest.

se of Behavioral Pain Assessment Toolswo critiques of existing nonverbal pain assessment

ools indicate that, although there are tools with poten-ial, there is no tool that has strong reliability and validityhat can be recommended for broad adoption in clinicalractice for persons with advanced dementia (Herr et al.,006; Stolee et al., 2005; Zwakhalen et al., 2006). Exist-

ng tools have limited evaluation that is often narrow inhe samples used and/or the setting in which evaluationas conducted. Behavioral tools with few indicators maye more clinically feasible but may not detect pain inatients who present with less obvious behaviors.onger and more comprehensive checklists may be moreensitive but also identify patients for whom pain mayot be present. Given the current state of high under-ecognition of pain in this population, increased sensitiv-ty may be preferable but will require evaluation to vali-ate pain as the cause of the suspect behaviors.

A comprehensive review of currently publishedools for assessing pain in nonverbal persons with de-entia is available at www.cityofhope/prc/elderly.asp

nd in Herr, Bjoro, and Decker’s article (2006). Tools aren varying stages of development and validation; how-ver, those with the strongest conceptual and psycho-etric support at this time, as well as clinical utility,

nclude the following:

● ADD: The Assessment of Discomfort in Dementia Pro-tocol (Kovach et al., 1999; 2001; 2002) (tested in long-term care setting; acute/chronic pain)

● CNPI: Checklist of Nonverbal Pain Indicators (Feldt,2000a, 2000b; Feldt et al., 1998; Jones et al., 2005)(tested in acute care setting, long-term care setting;acute/chronic pain)

● Doloplus 2: The Doloplus 2 (Lefebre-Chapiro, 2001;http://www.doloplus.com) (tested in long-term caresetting, geriatric centers, palliative care center; chronicpain)

● NOPPAIN: Nursing Assistant-Administered Instrumentto Assess Pain in Demented Individuals (Snow et al.,2003) (tested in long-term care; acute and chronic pain)

● PACSLAC: The Pain Assessment Scale for Seniors withSevere Dementia (Fuchs-Lacelle, et al., 2004) (tested inlong-term care setting; chronic pain)

● PAINAD: The Pain Assessment in Advanced DementiaScale ( Lane et al., 2003; Warden et al., 2003) (tested inlong-term care setting; chronic pain; preliminary reportsof testing in acute pain not yet published)

linicians are encouraged to review selected tools for
ppropriateness to the patient’s care setting and ob-
ain data to support their use through Quality Improve-ent projects.

4. Surrogate Reporting of Pain (e.g., family, caregiver).In the long-term care setting, the certified nursingassistant is a key health care provider who has beenshown to be effective in recognizing the presence ofpain (Fisher et al., 2002; Mentes et al., 2004). Educa-tion on screening for pain should be a component ofall certified nursing assistant training. Family membersare likely to be the caregiver with the most familiaritywith typical pain behaviors or changes in usual activ-ities that might suggest pain presence in the acute caresetting and in other settings in which the health careproviders do not have a history with the patient (Co-hen-Mansfield, 2002; Shega et al., 2004).

5. Attempt an Analgesic Trial. Estimate the intensity ofpain based on information obtained from prior assess-ment steps and select an appropriate analgesic. For ex-ample, when mild to moderate pain is suspected, acet-aminophen 500 to 1000 mg every 6 hours may beappropriate initially with titration to stronger analgesicsif there is no change in behaviors and pain continues tobe suspect. Low-dose opioids have been effective invalidating agitation as a pain indicator (Manfredi et al.,2003). Opioid dosing in older adults warrants an initialdose reduction of 25% to 50%. Using an analgesic trial tovalidate the presence of pain before increasing or addingpsychotropic medications has several advantages. Com-pared with psychotropic intervention, response will beseen more quickly with an analgesic intervention, theadverse reactions to analgesics are usually less serious,and pain will not be obscured by the sedative propertiesof psychotherapeutic agents. With this approach, pain ismore likely to be detected and treated. Consider psychi-atric approaches, such as adding or changing doses ofnew psychiatric pharmacologic approaches (e.g., antip-sychotics, sedatives), if behaviors do not improve withan analgesic trial.

NFANTS AND PREVERBALODDLERS: GUIDING PRINCIPLESOR THE ASSESSMENT OF PAIN

ecommendations for pain assessment in infants/nonver-al children unable to self-report that are unique fromhe general recommendations include the following:

1. Self-report: Infants, toddlers, and developmentally pre-verbal children lack the cognitive skills necessary toreport and describe pain. As children develop verbaland cognitive skills they are able to report the expe-rience and intensity of pain. The ability to indicate thepresence of pain emerges at approximately 2 years ofage. Developmentally appropriate children as youngas 3 years of age may be able to quantify pain usingsimple validated pain scales (Fanurik et al., 1998; Spa-
grud et al., 2003).
http://www.cityofhope/prc/elderly.asp

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48 Herr et al.

2. Search for Potential Causes of Pain/Discomfort: In-fections, injuries, diagnostic tests, surgical procedures,and disease progression are possible causes for pain ininfants and young children and should be treated withthe presumption that pain is present. Developmentallynonverbal children have a higher burden of pain fromfrequent medical/surgical procedures and illness, andsuspicion of pain should be high (Stevens et al., 2003).

3. Observation of Patient Behaviors. Infants and chil-dren react to pain by exhibiting specific behaviors.The primary behavioral categories used to help iden-tify pain in this population include facial expression,body activity/motor movement, and crying/verbaliza-tion. Body posture, changes in muscle tone, and re-sponse to the environment are also indicators of pain.Facial expressions of an infant experiencing acutepain include eyebrows lowered and drawn together toform a vertical furrow, a bulge between the browswith the eyes tightly closed, cheeks raised with afurrow between the nose and upper lip, and themouth open and stretched in the shape of square(Grunau & Craig, 1990). In addition, high-pitched,tense, and harsh cries have been indicated as a behav-ioral measure of infant pain (Fuller & Conner, 1995).However, infant behaviors such as crying and facialexpressions that accompany crying are not indepen-dent indicators of acute pain (Fuller, 2001).

The primary behavioral signs of pain are often moreapparent and consistent for procedural pain and post-operative pain than for chronic pain. As a child gainscontrol over body movement there will be greaterdifferences in observed behavioral responses to pain.Sleeping and withdrawn behavior may be the child’sattempts to control pain by limiting activity and inter-actions. There may be a dampening of the primarypain behaviors in children who experience prolongedpain or chronic pain. Behaviors seen in children withchronic cancer pain include posturing, wariness ofbeing moved, and psychomotor inertia that has beendescribed as withdrawal, lack of expression, and lackof interest in surroundings (Gauvin-Piquard et al.,1999). Distress behaviors, such as irritability, agitation,and restlessness, may or may not be related to painand, in many cases, may indicate physiologic distress,such as respiratory compromise or drug reactions.Therefore, consider the context of the behaviors, med-ical history, and caregiver opinions when using behav-ioral pain assessment tools and making treatment de-cisions.

Physiologic indicators, such as heart rate, respira-tory rate, and oxygen saturation, have been reportedas providing information about the neonatal responseto noxious stimuli and are associated with acute pain(Stevens, Johnston, Petyshen & Taddio, 1996). Physi-ologic indicators, however, are also affected by dis-ease, medications, and changes in physiologic statusand, therefore, are not good predictors of pain or the
absence of pain (Foster et al., 2003).
se of Behavioral Pain Assessment Toolslthough no single behavioral scale has been shown toe superior to others, clinicians should select a scalehat is appropriate to the patient and types of pain onhich it has been tested. Behavioral pain tools shoulde used for initial and ongoing assessments.

● CHEOPS: Children’s Hospital of Eastern Ontario PainScale (McGrath et al., 1985) (tested in 1 to 5 years ofage; Post Anesthesia Care Unit, surgical pain)

● CHIPPS: (Buttner & Finke, 2000) (tested in birth to 5years of age: clinic and acute care setting; surgical pain)

● COMFORT Behavior Scale (van Dijk et al., 2000, 2005)(tested in neonate to 3 years of age; intensive caresetting, surgical pain. Revised scale of COMFORT (Am-buel et al., 1992; Canenvale, & Razack, 2002) measuresother constructs than pain (tested in newborn to 9 yearsof age, intensive care setting, mechanically ventilated).

● CRIES: (Krechel & Bildner, 1995) (tested in neonates;neonatal and pediatric intensive care setting, proceduraland surgical pain)

● DSVNI: Distress Scale for Ventilated Newborn Infants(Sparshott 1996) (tested in ventilated newborns, inten-sive care setting; procedural pain)

● FLACC: Faces, Legs, Activity, Cry, Consolability Obser-vational Tool (Manworren & Hynan, 2003; Merkel et al.,1997; Willis et al., 2003) (tested in 2 months to 7 yearsof age; Post Anesthesia Care, intensive care, acute caresettings, surgical pain and acute pain)

● DEGR Scale: Douleur Enfant Gustave Roussy (Gauvin-Piguard, 1999) (tested in 2 to 6 years; acute care, cancerpain)

● PIPP: Premature Infant Pain Profile (Stevens, 1996)(tested in premature and term neonates; neonatal set-tings, procedural pain)

● RIPS: Riley Infant Pain Scale (Schade et al., 1996) (testedin newborn to 3 years of age; acute care setting; surgicalpain)

● UWCH (University of Wisconsin Children’s Hospital)Pain Scale for Preverbal and Nonverbal Children(Soetenga et al., 1999) (tested in less than 3 years old;acute care setting, surgical and procedural pain)

4. Surrogate Reporting of Pain. Include evaluation ofthe response of the infant, toddler, and developmen-tally nonverbal child to parents and the environmentin the assessment of pain. Responsiveness to interven-tions by a trusted caregiver to console the child, suchas rocking, touch, and verbal reassurance, must beconsidered when observing distressed behaviors. Par-ents usually know their child’s typical behavioral re-sponse to pain and can identify behaviors unique tothe child that can be included in the assessment ofpain. However, the nursing staff may be most familiarwith the infant or young child’s pain behavior if thechild has not been home since birth.

Explain behavioral scales to parents and encourage
them to actively participate in identifying pain and

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evaluating their child’s response to interventions(NANN position statement, 1999).

5. Analgesic Trial. Initiate an analgesic trial with a non-opioid or low-dose opioid if pain is suspected andcomfort measures, such as parental presence, securityitems, sucking, and distraction, are not effective ineasing behaviors that may suggest pain. Base initialopioid dose on weight and titrate as appropriate. Ex-plore other potential causes of distress if behaviorscontinue after a reasonable analgesic trial.

NTUBATED AND/OR UNCONSCIOUSERSONS: GUIDING PRINCIPLES FORHE ASSESSMENT OF PAIN

ecommendations for pain assessment in intubatednd/or unconscious persons unable to self-report thatre unique from the general recommendations includehe following:

1. Self-report. Self-report of pain should be attempted;however, obtaining a report of pain from a critically illpatient may be hampered by delirium, cognitive andcommunication limitations, level of consciousness,presence of an endotracheal tube, sedatives, and neu-romuscular blocking agents. Because of delirium thatcan wax and wane and impact ability to self-report,serial assessment for the ability to self-report should beconducted.

2. Potential Causes of Pain/Discomfort. Sources of painin critically ill patients include the existing medicalcondition, traumatic injuries, surgical/medical proce-dures, invasive instrumentation, blood draws, andother routine care such as suctioning, turning, posi-tioning, drain and catheter removal, and wound care(Jacob & Puntillo, 1999; Puntillo et al., 2001, 2004;Simons et al., 2003; Stanik-Hutt et al., 2001). Verbaladult patients describe a constant baseline aching painwith intermittent procedure-related pain descriptorssuch as sharp, stinging, stabbing, shooting, and awfulpain; thus it should be assumed that those unable toreport pain also experience these sensations (Puntilloet al., 2001). In addition, immobility, hidden infection,and early decubiti can cause pain and discomfort.

3. Observation of Patient Behavior. Facial tension andexpressions such as grimacing, frowning, and wincingare often seen in critically ill patients experiencingpain. Physical movement, immobility, and increasedmuscle tone may indicate the presence of pain. Tear-ing and diaphoresis in the sedated paralyzed and ven-tilated patient represents autonomic responses to dis-comfort (Hamil-Ruth & Marohn, 1999). Behavioralpain scales are not appropriate for pharmacologicallyparalyzed infants, children, adults, or those who areflaccid and cannot respond behaviorally to pain. As-sume pain is present and administer analgesics appro-priately to patients who are given muscle relaxants
and/or deep sedation and experience conditions and
procedures thought to be painful. Patients may exhibitdistress behaviors as a result of the fear and anxietyassociated with being in the intensive care unit. Ananalgesic trial (see no. 5 below) may be helpful indistinguishing distress behaviors from pain behaviors.

Relying on changes in vital signs as a primary indi-cator of pain can be misleading because these may alsobe attributed to underlying physiologic conditions,homeostatic changes, and medications. There is lim-ited evidence that supports the use of vital signs as asingle indicator of pain; however, both physiologicand behavioral responses often increase temporarilywith a sudden onset of pain (Foster et al., 2003).Changes in physiologic measures should be consid-ered a cue to begin further assessment for pain orother stressors (Foster, 2001). Absence of increasedvital signs does not indicate absence of pain (McCaf-fery & Pasero, 1999).

se of Behavioral Pain Assessment Toolslthough no single behavioral scale has been shown toe superior for use with this population, tools tested inther settings may be useful if appropriate to theopulation and pain problem. Tools should be testedo ensure they are reliable and valid if used with aopulation in whom they have not been studied.

ediatrics

● FLACC: Faces, Legs, Activity, Cry, Consolability Obser-vational Tool (Manworren & Hynan, 1995; Merkel et al.,1997; Willis et al., 2003) (tested in 2 months to 7 yearsof age; Post Anesthesia Care, intensive care, acute caresettings, surgical pain and acute pain)

● DSVNI: Distress Scale for Ventilated Newborn Infant(Sparshott, 1966) (tested in ventilated newborns; inten-sive care setting; procedural pain)

● COMFORT Behavior Scale (van Dijk et al., 2005) (testedin neonate to 3 years of age; intensive care setting,surgical pain. Revised scale of COMFORT (Ambuel et al.,1992; Canenvale, & Razack, 2002) Measures other con-structs than pain. (tested in newborn to 9 years of age;intensive care setting, mechanically ventilated)

dults

● BPS: Behavioral Pain Scale (Payen, 2001) (tested inadults; intensive care; procedural pain age)

● CPOT: Critical-Care Pain Observation Tool (Gelinas etal., in press) (tested in adults; intensive care setting;nociceptive procedures)

4. Surrogate Reporting of Pain. Parents of children,caregivers, family members, and surrogates can helpidentify specific pain indicators for critically ill individ-uals. A family member’s report of their impression ofa patient’s pain and response to an interventionshould be included as one aspect of a pain assessmentin the critically ill patient.

5. Analgesic Trial. Initiate an analgesic trial if pain is
suspected. The priority of the analgesic trial is to verify

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the presence of pain. Ongoing treatment should con-sider the unique issues of this population. The ongo-ing use of analgesics, sedatives, and comfort measurescan provide pain relief and reduce the effect of thestress response. Paralyzing agents and sedatives arenot substitutes for analgesics. This population is oftenbeing weaned from opioids to support a successfulextubation; however, suspected pain should betreated. Less sedating agents and approaches shouldbe considered as appropriate, such as nonsteroidalanti-inflammatory drugs, patient-controlled analgesia,and epidural analgesia. In patients with head injury,opioids should be used as appropriate for pain butweighed against the risk of sedation. Short-acting opi-oids such as fentanyl may allow for appropriate titra-tion yet allow quick retreat if needed.

UMMARY

ndividuals who are unable to communicate their dis-
omfort are at greater risk for inadequate analgesia. R
ain, 102(3), 289-296.

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his position paper describes the severity of this issue,efines populations at risk, and offers strategies, tools,nd resources for appropriate pain assessment. Nursesave a moral, ethical, and professional obligation todvocate for all individuals in their care. Just like allther patients, these special populations require con-istent, ongoing assessment, appropriate treatment,nd evaluation of interventions to ensure the bestossible pain relief. Clinicians are encouraged to mon-

tor current research regarding new developments intrategies and tools for assessing pain in these popu-ations.

cknowledgments

he authors sincerely thank the following expert reviewers:argaret L. Campbell, RN, PhD(c), FAAN, Constance Dahlin,PRN, BC, PCM, Joann Eland, PhD, RN, FNAP, FAAN, Jilloeb, BSN, MSN, RN, Chris Pasero, RN, C, MS, FAAN, Kath-een Puntillo, RN, DNSc, FAAN, and Roxie L. Foster, PhD,
N, FAAN.
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Pain ManagementNursing Role/Core Competency

A Guide for Nurses

______________________________________________________________________________

THE GUIDE MUST BE READ IN CONJUNCTION WITH THE NURSE PRACTICE ACT (MD. CODE ANN., HEALTHOCC., TITLE 8), BOARD REGULATIONS (COMAR 10.27.01 et. seq.), AND EMPLOYER POLICIES.

THE GUIDE IS NOT INTENDED TO REPLACE OR MODIFY THE ACT OR THE REGULATIONS, OR EMPLOYER POLICIES. IN THE EVENT OF AMBIGUITY OR INCONSISTENCY, THE NURSE

PRACTICE ACT AND THE BOARD’S REGULATIONS TAKE PRECEDENCE.

2

Pain ManagementNursing Role/Core Competency

A Guide for Nurses

PURPOSE OF THIS EDUCATIONAL GUIDE

The purpose of this document is to assist thelicensed nurse in recognizing his/her accountability in effectively managingpatients’ pain through assessment,intervention and advocacy.

Pain management is only one aspect of thecomplex process of providing palliative care. It is beyond the scope of this document toaddress other issues involved in palliativecare.

BACKGROUND

Pain management encompasses various typesof pain experiences throughout an individual’slife cycle from birth to the end of life. Pain expe-riences may include acute and chronic pain, painfrom a chronic deteriorating condition, or pain asone of many symptoms of the patient receivingpalliative care. Pain is not exclusively physiologi -cal but also includes spiritual, emotional and psy-chosocial dimensions. The goal of pain manage-ment throughout the life cycle is the same - toaddress the dimensions of pain and to providemaximum pain relief with minimal side effects. Review of the literature, anecdotal reports anddialogue with colleagues reveals that the majorityof patients do not receive adequate pain manage-ment. A wide variety of factors including inaccu- rate information, myths, rumors, fear and culturalissues contribute to inadequate pain management. For example, a prevailing rumor in the nursing profession is that a nurse can lose his/her nursinglicense for causing a patient’s respiratory depress-ion by frequent administration or by giving highdoses of opioids, even though there is no documen-ted evidence to substantiate this fear. Theliterature shows that adequate assessment inconjunction with opioid titration based on patient

response can provide maximum pain reliefwithout adversely affecting respiratory status. Therefore, it is unwarranted to under-utilize orwithhold opioids from a patient who isexperiencing pain based on fear of causingrespiratory depression. Due to multiple advances in the field of painmanagement (i.e. pain assessment, pharmacolog-ical and non-pharmacological interventions),licensed nurses may have incomplete or inaccu-rate information about the following variables which contribute to ineffective pain management:

1. What is pain and how do patients demonstrate their pain?

2. How is pain assessed and managed? 3. Is there a difference between

psychological dependence, addictionand physical dependence?

4. Does aggressive use of opioids cause addiction?

5. How does the patient’s cultural back-ground effect pain expression andmanagement?

Myths and misinformation also contribute to ineffective pain management. Some commonmyths include:

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1. Too much pain medication too frequentlyconstitutes substance abuse, causes addiction, will result in respiratorydepression or will hasten death;

2. Pain should be treated, not prevented;3. People in pain always report their pain to

their health care provider;4. People in pain demonstrate or show that

they have pain - pain can be seen in thepatient’s behavior;

5. The level of pain is often exaggerated bythe patient;

6. Generally a patient cannot be relieved of all pain;

7. Some pain is good so that the patient’s symptoms are not masked;

8. Newborn infants do not have pain; and, 9. It is expected that the elderly, especially the

frail elderly, always have some pain.

Patient Populations at Risk of UnderManagement

Because of multiple barriers to adequate painmanagement, all patients are at risk for under-treatment of pain. Since pain is identified andreported primarily through patient self- reporting,difficulty in communicating increases the patient’srisk for under-treatment.

Populations identified by the literature as being atgreater risk include: infants and children, women,the elderly, patients with cognitive dysfunction,patients with emotional or mental illness, patients with chronic pain, patients with neuropathic pain,substance abusers, minority populations, thehomeless, and patients with terminal illnesses. Inaddition, patients who speak a different languageor who are from a cultural tradition different fromthat of the clinician pose a special challenge. Ineffect, any patient, regard- less of age, is at risk ofbeing under-treated for pain. All populations canbe placed at greater risk because of the health careprovider’s own belief system which may includethe previously discussed myths andmisinformation.

These factors and others have prompted theBoard to develop this educational guide for theMaryland licensed nurse. The intent is to providefactual information and assist the licensed nurse indeveloping core nursing competencies in painmanagement. The licensed nurse must becomefamiliar with standards, guidelines and definitionsregarding pain and its management, including butnot limited to those listed in the definition ofterms and bibliography and to refer to thesedocuments when advocating for the patient inpain.

Pain Management Nursing Role/Core Competency

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Licensed Nurse Role: Knowledge Based Practice

The licensed nurse is responsible and account-able to ensure that a patient receives appropriateevidence-based nursing assessment and interven-tion which effectively treats the patient’s pain andmeets the recognized standard of care. In order toadvocate for the patient, the licensed nurse mustpossess the following:

A) Knowledge of Self

The practice of nursing includes the knowledge of one’s self through assessment of attitudes,values, beliefs, and cultural background and influ-ences that have formed each of us as individuals. These factors affect the nurse when assessing,evaluating, and interpreting the patient’s state-ments, behavior, physical response, and appear-ance. The greatest barrier to the patient achievingeffective pain management may be the nurse’s:

1. Individual experiences with pain; 2. Personal use of medications or non-

pharmacological methods to managepain; and,

3. Family’s or significant others’ history or experience with substances for pain control ormood altering effect.

When the licensed nurse is influenced or con-strained by personal factors, the nurse may not assess, evaluate or communicate the patient’s painlevel effectively or objectively. This can be furthercompounded if the nurse does not have adequateknowledge regarding pain management and, as aresult, can not recognize the need to seek outadditional information to assess and manage thepatient’s pain appropriately. For instance, a nursewho believes or states, “You can tell by looking atthe patient if they are in pain” is demonstrating aninadequate knowledge base.

B) Knowledge of Pain

Pain is subjective. It is whatever the patientsays it is. The nurse utilizes the nursing process inthe management of pain. Adequate measurementand management of pain includes knowledge inthe following areas:1. Pain assessment:

a) The nurse utilizes a developmentally appropriate, standardized pain assessment toolwhich includes: a pain measurement toolwhich has demonstrated reliability and validityand patient participation, which is essential inthe assessment process. For those incapable ofself-reporting, standardized pain assessmenttools should include behavioral observationswith or without physiologic measures.

i. Physiologic signs such as tachycardia, hypertension, diaphoresis and pallorare non-specific to pain and may be anindicator of another, unrelated physiologicproblem. For patients in pain, thesephysiologic signs may be present for ashort period of time or not at all.ii. Sole reliance on these physiologic signs to assess pain may be inappropriate.

b) The nurse is knowledgeable regarding the difference in categories of pain (i.e. acute,chronic, breakthrough); c) The nurse is knowledgeable regarding the most likely potential sources of pain (i.e.neurological, muscular, skeletal, visceral);d)The nurse assesses the patient’s individual pain pattern, including the individual patient’spain experiences, methods of expressing pain,cultural influences, and how the individualmanages their pain.

2. Pharmacologic and Non-PharmacologicIntervention:a) The nurse is knowledgeable about the pharmacological interventions of opioid, non-opioid, and adjuvant drug therapies

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(including dosages, side effects, druginteractions, etc.) which are most effectivefor the most likely source of an individualpatient’s pain. b) The nurse is knowledgeable that placebos should not be utilized to assess if pain exists orto treat pain.c) The nurse is knowledgeable regarding non-pharmacologic strategies for pain management(i.e. acupuncture, application of hot and cold,massage, breathing techniques, etc.).

3. Current pain management standards and guidelines.

4. The difference between tolerance, physical andpsychological dependence, withdrawal andpseudoaddiction.

C) Knowledge of the Standard of Care

The standard of care is effective ongoing painassessment and pain management. This includesbut is not limited to:

1. Acknowledging and accepting the patient’spain;

2. Identifying the most likely source of thepatient’s pain;

3. Assessing pain at regular intervals, witheach new report of pain or when pain is

expected to occur or reoccur. Assessment includes but is not limitedto:

a) The patient’s level of pain utilizing apain assessment tool;

b) Barriers to effective pain management,which may include personal, cultural andInstitutional barriers. Sources of thesebarriers may include but are not limited topatient, family, significant other, physician,

nurse and institutional constraints;3. Reporting the patient’s level of pain;5. Developing the patient’s plan of care that

includes an interdisciplinary plan foreffective pain management involving thepatient, family and significant other;

6. Implementing pain management strategiesand indicated nursing interventionsincluding: a) Aggressive treatment of side effects (i.e. nausea, vomiting, constipation,pruritus etc),b. Educating the patient, family andsignificant other(s) regarding, (i) Their role in pain management, (ii) The detrimental effects of

unrelieved pain, (iii) Overcoming barriers to effective pain management, (iv) The pain management plan

and expected outcome of the plan;.7. Evaluating the effectiveness of the

strategies and the nursing interventions;8. Documenting and reporting the interven-

tions, patient’s response, outcomes; and9. Advocating for the patient and family for

effective pain management.


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PATIENT ADVOCACY

The nurse’s primary commitment is to the health, welfare, comfort and safety of thepatient. Self-awareness, knowledge of pain andpain assessment, and knowledge of the standardof care for pain management enhances thenurse’s ability to advocate for and assureeffective pain management for each patient. When advocating for the patient, it is crucialthat the nurse utilize and reference currentevidence-based pain management standards andguidelines.

As a patient advocate, the nurse takes allreasonable means to alleviate the patient’s painand suffering. In addition, the nurse consultsand collaborates with specially trained experts inpain management, such as registered nurses,licensed physicians, pharmacists, massagetherapists, acupuncturists and others to assure aneffective interdisciplinary treatment plan toaddress each patient’s pain. When the patient’spain needs are not being adequately addressed,the nurse continues to advocate for the patientthrough other means, such as referral to theorganization’s joint practice committee, theethics committee, and/or the organization’s chain of command.

The nurse also has an obligation to advocatefor all patients in the aggregate. When anorganization’s policies, procedures and practicesare insufficient to provide consistent effectivepain management, the nurse works throughappropriate committees and channels to insurethat patients’ pain management needs areaddressed. This advocacy role is particularlycritical for populations known to be at risk forunder-management of their pain.

SUMMARY

This educational guide is intended to assistthe licensed nurse to act in an accountable manner to effectively manage a patient’s pain. This document emphasizes that the licensednurse must continue to develop self-awarenessand enhance his/her learning in order to remaincurrent in nursing knowledge and skill relativeto attempt to pain management. The licensednurse is responsible and accountable to worktoward effectively managing the patient’s painthrough assessment, intervention and patientadvocacy.

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DEFINITION OF TERMS

1. Pain management: The use of pharmaco-logical and non-pharmacological interven-tions to control the patient’s identified pain. Pain management extends beyond painrelief, encompassing the patient’s quality oflife, ability to work productively, to enjoyrecreation, to function normally in thefamily and society, and to die with dignity.

2. Pain: An unpleasant sensory and emotionalexperience associated with actual orpotential tissue damage or described interms of such damage. Pain is alwayssubjective and is whatever the person saysit is, existing whenever the person says itdoes. The clinician must accept thepatient’s report of pain. Categories of paininclude but are not limited to:a) Acute Pain: A normal, predicated physiologic response to an adverse clinical,thermal or mechanical stimulus. It isgenerally time-limited and responsive toopioid and non-opioid therapy. Acute painresponses may vary between patients andbetween pain episodes within an individualpatient. Acute pain episodes may bepresent in patients with chronic pain.b) Chronic Pain: Malignant or non- malignant pain that exists beyond itsexpected time frame for healing or wherehealing may not have occurred. It ispersistent pain that is not amenable toroutine pain control methods. Chronic painis often present with no physiologic signs,which may lull the clinician into falselybelieving the patient is not in pain. Chronicpain may result in a look of sadness,depression, or fatigue causing the clinicianto misinterpret the picture and not identifythat the patient may also be experiencingpain. Patients with chronic pain may haveepisodes of acute pain related to treatment,procedures, disease progression or re-occurrence.

c) Breakthrough Pain: An acuteexacerbation of pain that breaks through an existing analgesic regime.

2. Palliative Care: The active total care ofpatients focusing on symptom manage-ment, of which pain is only one of manysymptoms. The goal of palliative care isachievement of the best quality of life forpatients, families and significant others byaddressing psychological, social andspiritual problems, in addition tocontrolling the patient’s pain and othersymptoms.

4. Suffering: The state of severe distressassociated with events that threaten the wellbeing of the person. Suffering often occursin the presence of pain, shortness of breath,or other bodily symptoms. Sufferingextends beyond the physical domain. Forexample, a woman awaiting breast biopsymay “suffer” because of anticipated loss ofher breast, while after the biopsy thewoman may have “pain” from theprocedure.

5. Tolerance: The process by which the bodyrequires a progressively greater amount of adrug, over time, to achieve the same results. As it relates to pain relief, tolerance isdecreasing pain relief over time with thesame dosage. Patient can become tolerantto the analgesic effect of opioid therapy,requiring an increase in dose. For manyopioids there is no known ceiling to theamount that can be given, meaning thatpain relief can increase with an increase inthe dose of the opioid. In addition, patientscan become tolerant to some adverse effects(respiratory depression, somnolence, andnausea) related to opioid therapy.

6. Substance abuse: The use of any chemicalsubstance for other than its medicallyintended purpose.

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7. Pseudoaddiction: The pattern of drug-seeking behavior among pain patientsbecause of inadequate management of theirpain problem which can be mistaken foraddiction.

8. Physical dependence: A physical responseof the body to a substance characterized bysigns of withdrawal if the substance isstopped without tapering, markedly reducedafter prolonged use, or if an antagonist isadministered. Physical dependence is anexpected result of opioid use. Physicaldependence, by itself, does not equate withaddiction.

9. Abstinence (withdrawal) Syndrome:Physical symptoms that can occur afterabrupt discontinuation or dose reduction ofan opioid or administration of an antagonist. The syndrome is characterized by any or allof the following: anxiety, irritability, chills,hot flashes, salivation, lacrimation,rhinorrhea, diaphoresis, piloerection, nausea,vomiting, abdominal cramps, and insomnia. Withdrawal should be avoided by gradualreduction of dose rather than abruptdiscontinuation.

10. Addiction: A neurobehavioral disordercharacterized by compulsive seeking ofmood-altering substances and continued usedespite harm. Addiction may also be refer-red to by terms such as “drug dependence”and “psychological dependence.” Addictionis not the same as physical dependence.

11. Opioid: Denotes both natural (codeine,morphine) and synthetic (methadone,fentanyl) drugs whose pharmacologic effectsare mediated by specific receptors in thenervous system.

12. Non-Opioid: A medication that providespain relief, but that is not an opiate or anonsteroid anti-inflammatory drugs(NSAIDS), acetaminophen). syntheticanalog of an opiate (i.e.

13. Adjuvant Medications: Medications thatare used to a) enhance the pain relieving effects of opioids and non-opioids, b) treatconcurrent symptoms that exacerbate painsuch as utilization of anxiolytics, or c)provide independent analgesia for specificsources of pain (i.e. neurologic pain), suchas utilization of tricylic anti-depressants andanti-convulsants.

14. Opiate: A drug whose origin is the opiumpoppy, including codeine and morphine.

15. Pain Assessment: The comprehensiveevaluation of the patient’s pain includingbut not limited to: location, intensity,duration of the pain; aggravating andrelieving factors; effects on activities ofdaily living, sleep pattern and psychosocialaspects of the patient’s life, and effective-ness of current management strategies. Painassessment includes the use of astandardized pain measurement tool.

16. Pain Measurement Tool: The quantitativeexamination of the intensity of the pain asreported by the patient utilizing a standard-ized instrument which has demonstratedreliability and validity.

17. Titration: Adjustment of medication levelswithin the dosage and frequency rangesstipulated by the authorized prescriber inaccordance with an agency’s establishedprotocols, guidelines or policies.

18. Evidence-Based Practice: The conscien-tious and judicious use of current bestevidence for making clinical decisionsabout the care of patients. Evidence mayinclude but is not limited to: researchfindings, literature, bench-marking data,clinical experts, quality improvement, riskmanagement data, and standards andguidelines.


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REFERENCES

Written Resources1. Kaiser, Karen, RN, MS. “Personal Strate-

gies to Overcome Barriers to InadequatePain Manage-ment.” Presented to NursingPractice Issues Committee, Maryland Boardof Nursing, September 1999.

2. Kaiser, Karen, RN, MS, Clyde, Chris, RN,MS, Perrone, Margaret RN, BS, andTarzian, Anita RN, Ph.D. “OvercomingBarriers to Adequate Pain Management.” Presented to the Nursing Practice IssuesCommittee, Maryland Board of Nursing,September, 1999.

3. English, Nancy RN, Ph.D., Yocum, CindyRN, CRNH. “Guidelines for CurriculumDevelopment on End-of-Life and PalliativeCare In Nursing.” Presented to NationalCouncil of Hospice Professionals, NationalHospice Organizations, April 1997.

4. Singer, Peter A., MD, MPH, FRCPC,Martin, Douglas K., and Merrijoy, Kelner,Ph.D. “Quality End-of-Life Care: Patients’Perspective.” JAMA. Vol. 281 No. 2. Jan.13, 1999. pp. 162-168.

5. Conant, Loring and Lowney, Arlene. “TheRole of Hospice Philosophy of Care in NonHospice Settings.” Journal of Law,Medicine and Ethics. Vol 24, #4. Winter1996. pp 365-368.

6. Keay, Timothy, MD, M.A.-TH andSchonwetter, Ronald, MD. “Hospice Carein the Nursing Home.” American FamilyPhysician. Vol. 57, No. 3. February 1,1998. pp. 491-494.

7. Cameron, Miriam E. “Completing Life andDying Triumphantly.” Journal of NursingLaw. Vol. 6, Issue 1. 1999. pp. 27-32.

8. Arnstein, Paul, P.D., ARNP “PolicyStatement: The Ordering and Administrationof Placebos.” Distributed by the MaydayPain Resource Center. 1998.

9. McCaffery, Margo, Ferrell, Betty R., andTurner, Martha. “Ethical Issues in the Useof Placebos in Cancer Pain Management.” ONF (Ethical Issues). Vol. 23, No. 10.1996. pp. 1587-1593.

10. Fohr, Susan Anderson J.D., MA. “TheDouble Effect of Pain Medication:Separating Myth from Reality.” Journal ofPalliative Medicine. Vol. 1, No. 4. 1998. pp. 315-328.

11. Promotion of Comfort and Relief of Pain inDying. Position Statement - AmericanNurses Association. Sept. 5, 1991.

12. Forgoing Nutrition and Hydration. PositionStatement-American Nurses Association. April 2, 1992.

13. Active Euthanasia. Position Statement-American Nurses Association. December8, 1994.

14. Assisted Suicide. Position Statement-American Nurses Association. December8, 1994.

15. Portnoy, Russell. “Morphine Infusions atthe End of Life: The Pitfalls in Reasoningfrom Anecdote.” Journal of PalliativeCare. Vol. 12, No. 4. 1996. pp. 44-46.

16. Mount Balfour. “Morphine Drips, TerminalSedation, and Slow Euthanasia: Definitionsand Facts, Not Anecdotes.” Journal ofPalliative Care. Vol. 112, No. 4 1996. pp.31-37.

17. “Peaceful Death: Recommended Compet-encies and Curricular Guidelines for End-of-LifeNursing Care.” AmericanAssociation of Colleges of Nursing, RobertWood Johnson Foundation, End-of-Life-Care Roundtable. Nov. 11-12, 1997.

18. Joranson, David E. and Gilson, Aaron M.“Regulatory Barriers to Pain Management.” Seminars in Oncology Nursing. Vol. 14,No 2. May 1998.

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19. “Controlled Substances and PainManagement: A New Focus for State Medical Boards.” Federation of State Medical Board Bulletin. Vol. 85, No. 2.1998. pp. 78-83.

20. Pain Management Policy - California Boardof Registered Nursing, Approved 4/94,Revised 3/99.

21. Pain Management Content CurriculumGuidelines. California Board of RegisteredNursing. Approved 6/99.

22. Standards of Competent Performance. California Board of Registered Nursing,Approved 4/97.

23. _____ “Strengthening Nursing Education inPain Management and End-of-Life Care.”Supported by a grant from the Robert WoodJohnson Foundation. Completed December3, 1998, updated edition February 10, 1999.

24. Model Guidelines for The Use of ControlledSubstances For the Treatment of Pain.Federation of State Medical Boards of theUnited States, Inc. May, 1998.

25. Byock, Ira M.D. Ethics of End of Life Care:Keynote Address. Care at the End of Life. Baltimore, MD., March 22, 1999.

26. Portenoy, Russell. “ContemporaryDiagnosis and Management of Pain inOncologic and AIDS Patients.” Handbooksin Health Care. Newton, PA. 1998.

27. _____”State in End of Life Care.” Focus:Pain Management. Issue 4. April 1999, pp.1-8.

28. Annotated Code of Maryland, HealthOccupations Article, Title 8,§§ 8:101(e) and(f).

29. Maryland Board of Nursing DR 97-6 Re:The Role of the Registered Nurse (RN) inThe Management of Analgesia by CatheterTechniques (Epidural, Intrathecal,Intrapleural, or Peripheral Nerve Catheters),issued by the Board June 24, 1997.

30. Resource Guide: Information aboutRegulatory Issues in Pain Management. Pain& Policy Studies Group, WHOCollaborating Center for Policy andCommunications in Cancer Pain. University

of Wisconsin Comprehensive CancerCenter, Madison, Wisconsin. July 1998.

31. Spross, J., McGuire, D., and Schmitt, R. (1990). ONS position paper on cancerpain. Part I. ONF, 17(4):585-614.

32. Spross, J., MCGuire, D., and Schmitt, R.(1990). ONS position paper on cancerpain. Part II. ONF, 17 (5):751-760.

33. Spross, J., McGuire, D., and Schmitt, R.(1990). ONS position paper on cancerpain. Part III. ONF, 17(6):943-955.

34. Bieri, D., Reeve, R.A., Champion, G.D., Addicoat, L. and Ziegler, J.B. “The FaciesPain Scale for the Self-Assessment of theSeverity of Pain Experienced by Children:Development, Initial Validation, andPreliminary Investigations for RatioProperties.” Pain. 1990. 41:139-50.

35. Cassel, Eric J., MD. “The Nature ofSuffering and The Goals of Medicine.” The New England Journal of Medicine. Vol. 306, No. 11. March 18, 1982. pp.639-645.

36. Joranson DE, Gilson Am, Ryan MA,Nelson, JM. Achieving Balance in StatePain Policy: A Guide to Evaluation Part I. The Pain and Policy Studies Group,University of Wisconsin ComprehensiveCancer Center. Madison, Wisconsin 1999.

37. North Carolina Joint Statement on PainManagement in End of Life Care, Adoptedby the North Carolina Medical, Nursingand Pharmacy Board, October 21, 1999.

38. California Board of Registered Nursing:A. Pain Management Policy, 4/94.B. Curriculum Guidelines for Pain Management Content, 6/94.C. Testimony before the California Senate Subcommittee on Prescription Drugs, 7/18/95.

39. State of Washington, Medical QualityAssurance Commission, Guidelines forManagement of Pain. 4/18/96.

40. Gebbie, Kristine M., Wakefield, Mary, andKerfoot, Karlene. “Nursing and HealthPolicy.” Journal of Nursing Scholarship. Third Quarter, 2000. pp 307-314.


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41. McPheeters, M., MPH and Lohr, K.N.,PhD., “Evidenced-Based Practice andNursing: Commentary.” Outcomes Management for Nursing Practice. Vol. 13, No 2. July-September, 1999. p. 99.

42. Goode, Colleen J. “What Constitutes the“Evidence in Evidence-Based Practice?”. Applied Nursing Research. Vol. 13, No. 4. November 2000, p. 222-225.

43. “Why Should Perioperative RNs Care AboutEvidence-Based Practice?” (ResearchCorner). AORN Journal. Vol. 72, No1. July 2000 pp. 109-111.

44. Stetler, Cheryl B. Ph.D, RN, FAAN, et al“Evidence-Based Practice and the Role ofNursing Leadership.” JONA. Vol 28, No.7/8. July/August, 1998. pp. 45-53.

45. Web site addresses:a) National Guidelines Clearing House -

www.mzch.govb) Americans for Better Care of the Dying -

www.abcd-caring.comc) American Pain Society-

www.ampainsoc.orgd) American Society for Biothics and

Humanities -www.asbh.orge) Center for Ethics in Health Care -

www.ohsu.edu.ethicsf) Oncology Nursing Society -

www.ons.orgg) Pain Link Home, A Pain Management

Resource - www.edc.org/painlinkh) The American Alliance of Cancer Pain

Initiative -www.wisc.edu/trc/steony/steint/html

i) Hospice Association of America-www.hospice.america.org

j) Memorial Sloan - Kiltering CancerCenter-www.mskcc.org

k) May Day Pain Link-City of Hope-www.city of hope.org/medinfo/medresin.htm

l) Growth House News--www.growthouseorg or www.pallcare.org/growth.htm

m) Wisconsin Educational Consortium onPainPolicy--www.medsch.wisc.edu/pain policy/ncjoint.htm.

46. Standards and guidelines for painmanagement:a)____, Management of Cancer Pain:Adults. Clinical Practice Guidelines #9. Quick Reference Guide for Clinicians. U.S. Department of Health and HumanServices, Public Health Service, Agencyfor Health Care Policy and Research. March, 1994.b) ____, Principles of Analgesic Use in theTreatment of Acute Pain and Cancer Pain,3rd Ed. American Pain Society. Skokie, Ill.c) ____, The Use of Opioids for theTreatment of Chronic Pain. © 1997AmericanAcademy of Pain Medicine andAmerican Pain Society. Glenview, Ill.d) Ferrell, Betty Rolling P.d., FAAN and McCaffery, Margo, RN, MS, FAAN.“Current Placebo Practice and Policy.”American Society of Pain ManagementNurses Pathways, Winter 1996. pp. 12-14.e) New JCAHO Standards: Intents,Examples, and Scoring Questions for PainAssessment and Management in Hospitals. May 1999.f) ____, Acute Pain Management in Adults:Operative Procedures. A Quick ReferenceGuide for Clinicians. U.S. Department ofHealth and Human Services, Public HealthService, Agency for Health Care Policy andResearch.g) ____, “The Management of Chronic Painin Older Adults.” American GeriatricSociety’s Panel on Chronic Pain in OlderAdults. Journal of The American GeriatricSociety. Vol.46. 1998. pp. 635-651.


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Resources

Personal1. Karen Kaiser, RN, MS, Clinical Practice

Coordinator, University of Maryland Medical System, Baltimore, MD.

2. Margaret Perrone, RN, CRNH, ProgramCoordinator, Palliative Care Program,University of Maryland Medical System,Baltimore, MD.

3. Anita Tarzian, RN, PhD., Maryland HealthCare Ethics Committee Network, Universityof Maryland School of Law, Baltimore, MD.

4. Chris Clyde, RN, Nursing Coordinator,University of Maryland Medical Systems PainCenter, Baltimore, MD.

5. Marilyn McCord, RN, Pulmonary Clinical Specialist, Sinai Hospital, Baltimore, MD.

6. Donna Hale, RN, MS, Consultant inPerioperative/Pain Service/Sinai Joint Center,Life Bridge Health Center, Baltimore, MD.

7. Veronica Noah, RN, IV Therapy-PainManagement Team. Frederick MemorialHospital, Frederick, MD.

8. Mary Lou Perin, RN, MSN, Pain ManagementConsultant. Pain Relief/USA. Middletown,MD.

9. Lori KozlowskI, CRNP-P, Acute PainManagement Team. Johns Hopkins Hospital,Baltimore, MD.

10. Kathleen White, RN, PhD, Nursing PracticeIssues Committee, Maryland Board ofNursing, Baltimore, MD.

11. Ann K. Sober, RN, BS, Nursing PracticeIssues Committee, Maryland Board ofNursing, Baltimore, MD.

12. Voncelia S. Brown RN, MS, Nursing PracticeIssues Committee, Maryland Board ofNursing, Baltimore, MD.

13. Ralph Washington, RN, Nursing PracticeIssues Committee, Maryland Board ofNursing, Baltimore, MD.

14. Bernadette Greene, RN, MS, NursingPractice Issues Committee, MarylandBoard of Nursing, Baltimore, MD.

15. Ann Triantafillos, RN, MSN, NursingPractice Issues Committee, MarylandBoard of Nursing, Baltimore, MD.

16. Sandra L. Dearholt, RN, MS, NursingPractice Issues Committee, MarylandBoard of Nursing, Baltimore, MD.

17. Charlene A. Hall, LPN, Nursing PracticeIssues Committee, Maryland Board ofNursing, Baltimore, MD.

18. Carol F. Wynne, RN, MS, NursingPractice Issues Committee, MarylandBoard of Nursing, Baltimore, MD.

19. Marsha Hopkins, LPN, Nursing PracticeIssues Committee, Maryland Board ofNursing, Baltimore, MD.

20. Laurie Miller, RN, BS, Nursing PracticeIssues Committee, Maryland Board ofNursing, Baltimore, MD.

21. Lou Williams, RN, Nursing PracticeIssues Committee, Maryland Board ofNursing, Baltimore, MD.

22. Susan Niewenhous, RN, MS, NursingPractice Issues Committee, MarylandBoard of Nursing, Baltimore, MD.

23. Kathryn Offenbacher, RN, BSN, Nursing Practice Issues Committee,Maryland Board of Nursing, Baltimore,MD.

24. Chris Murphy, RN, BSN, NursingPractice Issues Committee, MarylandBoard of Nursing, Baltimore, MD.

25. Debbie Somerville, RN, MPH, NursingPractice Issues Committee, MarylandBoard of Nursing, Baltimore, MD.

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Documents

Checklist of Nonverbal Pain Indicators