Frequently Asked Questions
Frequently Asked Questions
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Which is more effective: To prescribe pain medications on a regular schedule or on demand?
Experts agree: Without question, giving medications on a regular schedule, typically every three to six hours, leads to better pain control for residents (1). Why? Because when there’s an order to take a medication every few hours, the medication gets taken. With PRN, or “on demand,” administration, the medication tends to stay in the bottle.
To improve pain management in their facilities, some nursing homes are now working with their physicians to convert PRN medication orders into routine administration orders for every resident who requests PRN medications three days in a row. Remember, too, that residents are much more likely to request PRN pain medications when licensed nurses ask only two questions during every medication pass: “Do you have pain anywhere right now?” and, if the resident says, “yes” – “Would you like to take something (medication) for your pain?”
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What is the difference between pain screening and pain assessment?
The pain screening recommended in this training module is designed to simply detect the presence of probable chronic pain or acute pain. An assessment delves further to evaluate pain intensity, location, quality, and associated symptoms. This clinical information guides diagnosis and treatment decisions. Our pain interview includes items about presence, frequency, and effect of pain on residents’ daily lives, but does not have enough specific assessment items upon which to base diagnosis and treatment.
Nurses are licensed to conduct clinical assessments, but certified nurse aides are not. Aides can, however, conduct screenings to detect potential clinical problems, including pain, during daily care provision. Both licensed nurses and nurse aides can use our screening interview to identify pain presence – licensed nurses during routine medication passes and nurse aides during daily care provision.
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How often should pain screening be done?
We recommend that pain screening, by a nurse or nurse aide, be done minimally whenever a resident’s vital signs are checked, usually at least once a week, and ideally daily as part of medication pass(es) and ADL care delivery. The American Pain Society (APS) urges health care providers to “consider pain the fifth vital sign and assess (or screen) patients for pain every time you check for pulse, blood pressure, core temperature, and respiration” (2). Observed James Campbell in a presidential address before the APS in 1995: “If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly” (2). Pain should also be assessed whenever a resident’s behavior changes or if he or she is recently diagnosed with depression or shows new symptoms of depression. Chronic pain and depression often go hand in hand.
If your staff does not currently screen or assess pain with vital signs, you may want to implement this change in clinical practice slowly, with a trial run on one hallway for a week or so. Afterwards, ask the nursing staff for feedback so that you can address any concerns going institution-wide with the change. Be wary, though, if nurses claim that they already know which residents have pain and which ones do not because, in our experience, nurses often assume that only those residents who are openly expressing pain complaints and/or requesting pain medications are the only ones experiencing pain. Nurses need to know that many residents, especially those with mild to moderate cognitive impairment, will not express pain complaints unless they are directly asked about their pain experience.
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How often should a comprehensive pain assessment be completed?
We recommend a comprehensive pain assessment by a licensed nurse:
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What is the best way to assess pain?
A pain assessment includes a screening to detect pain, and if present, assesses pain intensity, location, quality, and other symptoms—clinical information that is then used to guide diagnosis and treatment decisions. Your resident’s verbal and cognitive abilities will determine the best assessment strategy. Options include the following:
Should I, as the nurse, share pain assessment findings with nurse aides so that they can help monitor residents for pain presence?
Yes, you should; indeed, nurses should view this task as a key component of the assessment process. As the primary care providers for residents, nurse aides are poised to serve as frontline pain detectors. But to do the job well they need the right tools and information. This includes results from the nurse’s pain assessment.
Let the aides know which residents are in pain, where they hurt, and how bad their pain is. Does Mr. A grimace when he hurts? Does Mrs. B recoil from touch when she aches? What words does the resident use to describe his or her pain (see question below)? Share with the aides any assessment information that will help them detect and alleviate pain among the residents they care for.
You should also teach them how to administer our pain screening interview so that they can confirm or rule out pain presence when they suspect it. This four-item instrument is easy to use (see Step 2), so a short course during an in-service training should cover it. Be sure to alert the nurse aide staff that residents are more likely to experience pain during ADL care provision and daily exercise.
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I’ve noticed that some residents speak not of “pain” but of “aches” and areas that “hurt.” Should I use these same words to refer to pain when I assess these residents?
Yes, by all means adopt the resident’s vocabulary, and instruct the nurse aides who care for these residents to do the same. Pain is subjective, so it’s not surprising that individuals refer to it in a variety of ways. Aches. Hurts. A stab. A burning sensation. A pinched feeling. A pounding. “Pain,” writes McCaffery and Pasero, “is whatever the person says it is, existing whenever (the person) say it does” (3).
Note the resident’s description of his or her pain in the medical chart so that other care providers also can speak the resident’s language when assessing, treating, and managing pain.
Even if a resident responds to your questions in terms of “pain,” you may want to try using other words like “hurt” and “ache” when conducting pain screenings and assessments to see whether the resident gives a different response. Then use the most appropriate term in subsequent screenings and assessments. This may be especially helpful when screening communicative residents with mild to moderate cognitive impairment.
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Does the Minimum Data Set (MDS) pain quality indicator show that some nursing homes provide better pain management?
In a recent study conducted in 16 nursing homes, we collected independent data that showed that the MDS quality indicator (QI) for “prevalence of pain” does indeed accurately discriminate between facilities (4). Interpretation of the pain indicator requires caution, however. Rather than reflecting poor quality, a high prevalence of pain according to the MDS was associated with better pain assessment and treatment care processes.
For our study, we compared eight nursing homes that scored in the upper 75th percentile on the prevalence of pain QI and eight nursing homes that scored in the lower 25th percentile for the same QI. Our research staff collected data through interviews with 255 residents and medical record reviews.
In high prevalence homes, 47% of the participating residents had pain documented on their most recent MDS and the same percentage reported symptoms of chronic pain during interviews with research staff. By contrast, in low prevalence homes, 9% of the participating residents had pain documented on their most recent MDS, but 27% reported chronic pain symptoms in interviews.
On every measure of pain-related care quality independently evaluated in this study (see our quality indicators for pain care), nursing homes with a high reported prevalence of pain on the MDS performed better than nursing homes with low MDS pain prevalence. One explanation is that a higher prevalence of pain among residents sensitizes nursing home staff to the need for better overall care for pain.
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Will providing more exercise for residents in pain help alleviate their pain?
Perhaps not, and in fact, more exercise may tend to increase pain in this frail population. In a recent study, we found that exercise alone may be ineffective for pain management among nursing home residents (5). This does not mean that residents should not exercise; on the contrary, residents stand to benefit from more exercise, especially in maintaining functional abilities. But nursing home staff should consider that exercise to improve residents’ physical function may increase pain complaints, thereby requiring pre-emptive analgesia, other pain control strategies, or modified exercise techniques. Staff who provide exercise care should inquire about the resident’s pain during exercise (“Do you have pain anywhere right now?”) and be sensitive to other pain symptoms exhibited by the resident during exercise (e.g., facial grimacing, moaning or groaning).
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- Which is more effective: To prescribe pain medications on a regular schedule or on demand?
- What is the difference between pain screening and pain assessment?
- How often should pain screening be done?
- How often should a comprehensive pain assessment be completed?
- What is the best way to assess pain?
- Should I, as the nurse, share pain assessment findings with nurse aides so that they can help monitor residents for pain presence?
- I've noticed that some residents speak not of "pain" but of "aches" and areas that "hurt." Should I use these same words to refer to pain when I assess these residents?
- Does the Minimum Data Set (MDS) pain quality indicator show that some nursing homes provide better pain management?
- Will providing more exercise for residents in pain help alleviate their pain?
Which is more effective: To prescribe pain medications on a regular schedule or on demand?
Experts agree: Without question, giving medications on a regular schedule, typically every three to six hours, leads to better pain control for residents (1). Why? Because when there’s an order to take a medication every few hours, the medication gets taken. With PRN, or “on demand,” administration, the medication tends to stay in the bottle.
To improve pain management in their facilities, some nursing homes are now working with their physicians to convert PRN medication orders into routine administration orders for every resident who requests PRN medications three days in a row. Remember, too, that residents are much more likely to request PRN pain medications when licensed nurses ask only two questions during every medication pass: “Do you have pain anywhere right now?” and, if the resident says, “yes” – “Would you like to take something (medication) for your pain?”
Back to Top
What is the difference between pain screening and pain assessment?
The pain screening recommended in this training module is designed to simply detect the presence of probable chronic pain or acute pain. An assessment delves further to evaluate pain intensity, location, quality, and associated symptoms. This clinical information guides diagnosis and treatment decisions. Our pain interview includes items about presence, frequency, and effect of pain on residents’ daily lives, but does not have enough specific assessment items upon which to base diagnosis and treatment.
Nurses are licensed to conduct clinical assessments, but certified nurse aides are not. Aides can, however, conduct screenings to detect potential clinical problems, including pain, during daily care provision. Both licensed nurses and nurse aides can use our screening interview to identify pain presence – licensed nurses during routine medication passes and nurse aides during daily care provision.
Back to Top
How often should pain screening be done?
We recommend that pain screening, by a nurse or nurse aide, be done minimally whenever a resident’s vital signs are checked, usually at least once a week, and ideally daily as part of medication pass(es) and ADL care delivery. The American Pain Society (APS) urges health care providers to “consider pain the fifth vital sign and assess (or screen) patients for pain every time you check for pulse, blood pressure, core temperature, and respiration” (2). Observed James Campbell in a presidential address before the APS in 1995: “If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly” (2). Pain should also be assessed whenever a resident’s behavior changes or if he or she is recently diagnosed with depression or shows new symptoms of depression. Chronic pain and depression often go hand in hand.
If your staff does not currently screen or assess pain with vital signs, you may want to implement this change in clinical practice slowly, with a trial run on one hallway for a week or so. Afterwards, ask the nursing staff for feedback so that you can address any concerns going institution-wide with the change. Be wary, though, if nurses claim that they already know which residents have pain and which ones do not because, in our experience, nurses often assume that only those residents who are openly expressing pain complaints and/or requesting pain medications are the only ones experiencing pain. Nurses need to know that many residents, especially those with mild to moderate cognitive impairment, will not express pain complaints unless they are directly asked about their pain experience.
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How often should a comprehensive pain assessment be completed?
We recommend a comprehensive pain assessment by a licensed nurse:
- at admission,
- with every quarterly MDS assessment, and
- when routinely assessing for pain as a 5th vital sign.
Back to Top
What is the best way to assess pain?
A pain assessment includes a screening to detect pain, and if present, assesses pain intensity, location, quality, and other symptoms—clinical information that is then used to guide diagnosis and treatment decisions. Your resident’s verbal and cognitive abilities will determine the best assessment strategy. Options include the following:
- Pain intensity can be assessed with the verbally administered zero-to-ten pain scale (where 0 represents “no pain at all” and 10 signifies “the worst pain I have ever experienced”), or, for residents with mild to moderate cognitive impairment, a word descriptor scale, faces scale, or pain thermometer.
- For uncommunicative residents, use an observational tool such as the five-item Pain Assessment in Advanced Dementia, also known as PAINAD.
- For an observational assessment, be sure to observe the resident while he or she is moving; most pain in nursing home residents is musculoskeletal and at its worst when the resident is in motion. Some of the best times for these observations are during morning or evening ADL care, physical therapy appointments, and range of motion exercises.
- For residents with more severe cognitive impairment, an assessment of behaviors and family or caregiver's observations are essential, especially observations of pain symptoms during ADL care delivery (e.g., facial grimacing or groaning when being transferred out of bed). Consider also, the resident’s history of pain and current pain-related diagnoses.
Should I, as the nurse, share pain assessment findings with nurse aides so that they can help monitor residents for pain presence?
Yes, you should; indeed, nurses should view this task as a key component of the assessment process. As the primary care providers for residents, nurse aides are poised to serve as frontline pain detectors. But to do the job well they need the right tools and information. This includes results from the nurse’s pain assessment.
Let the aides know which residents are in pain, where they hurt, and how bad their pain is. Does Mr. A grimace when he hurts? Does Mrs. B recoil from touch when she aches? What words does the resident use to describe his or her pain (see question below)? Share with the aides any assessment information that will help them detect and alleviate pain among the residents they care for.
You should also teach them how to administer our pain screening interview so that they can confirm or rule out pain presence when they suspect it. This four-item instrument is easy to use (see Step 2), so a short course during an in-service training should cover it. Be sure to alert the nurse aide staff that residents are more likely to experience pain during ADL care provision and daily exercise.
Back to Top
I’ve noticed that some residents speak not of “pain” but of “aches” and areas that “hurt.” Should I use these same words to refer to pain when I assess these residents?
Yes, by all means adopt the resident’s vocabulary, and instruct the nurse aides who care for these residents to do the same. Pain is subjective, so it’s not surprising that individuals refer to it in a variety of ways. Aches. Hurts. A stab. A burning sensation. A pinched feeling. A pounding. “Pain,” writes McCaffery and Pasero, “is whatever the person says it is, existing whenever (the person) say it does” (3).
Note the resident’s description of his or her pain in the medical chart so that other care providers also can speak the resident’s language when assessing, treating, and managing pain.
Even if a resident responds to your questions in terms of “pain,” you may want to try using other words like “hurt” and “ache” when conducting pain screenings and assessments to see whether the resident gives a different response. Then use the most appropriate term in subsequent screenings and assessments. This may be especially helpful when screening communicative residents with mild to moderate cognitive impairment.
Back to Top
Does the Minimum Data Set (MDS) pain quality indicator show that some nursing homes provide better pain management?
In a recent study conducted in 16 nursing homes, we collected independent data that showed that the MDS quality indicator (QI) for “prevalence of pain” does indeed accurately discriminate between facilities (4). Interpretation of the pain indicator requires caution, however. Rather than reflecting poor quality, a high prevalence of pain according to the MDS was associated with better pain assessment and treatment care processes.
For our study, we compared eight nursing homes that scored in the upper 75th percentile on the prevalence of pain QI and eight nursing homes that scored in the lower 25th percentile for the same QI. Our research staff collected data through interviews with 255 residents and medical record reviews.
In high prevalence homes, 47% of the participating residents had pain documented on their most recent MDS and the same percentage reported symptoms of chronic pain during interviews with research staff. By contrast, in low prevalence homes, 9% of the participating residents had pain documented on their most recent MDS, but 27% reported chronic pain symptoms in interviews.
On every measure of pain-related care quality independently evaluated in this study (see our quality indicators for pain care), nursing homes with a high reported prevalence of pain on the MDS performed better than nursing homes with low MDS pain prevalence. One explanation is that a higher prevalence of pain among residents sensitizes nursing home staff to the need for better overall care for pain.
Back to Top
Will providing more exercise for residents in pain help alleviate their pain?
Perhaps not, and in fact, more exercise may tend to increase pain in this frail population. In a recent study, we found that exercise alone may be ineffective for pain management among nursing home residents (5). This does not mean that residents should not exercise; on the contrary, residents stand to benefit from more exercise, especially in maintaining functional abilities. But nursing home staff should consider that exercise to improve residents’ physical function may increase pain complaints, thereby requiring pre-emptive analgesia, other pain control strategies, or modified exercise techniques. Staff who provide exercise care should inquire about the resident’s pain during exercise (“Do you have pain anywhere right now?”) and be sensitive to other pain symptoms exhibited by the resident during exercise (e.g., facial grimacing, moaning or groaning).
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