Identifying Pain in Those Who Can’t Communicate it
Published: 09 June 2020
Published: 09 June 2020
For patients who do not have the capacity to communicate, pain can be overlooked, causing significant but unnecessary discomfort and distress.
Pain is complex, subjective and varying. The International Association for the Study of Pain (IASP) (2017) defines pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’.
Pain can range from mild to severe, affecting a localised area or several parts of the body. It is a highly personal experience that varies in intensity depending on the individual, even if caused by the same stimulus (Shiel 2017, 2018).
Rather than purely causing physical discomfort, pain may also have implications on an individual’s emotional or mental wellbeing (Painaustralia 2016).
There are three types of pain:
(Painaustralia 2016; Shiel 2017)
Pain is prevalent, especially in older adults and people with medical conditions.
(Painaustralia 2017; Deldar, Froutan & Ebadi 2018)
The highly subjective nature of pain means that the best person to measure and describe the pain is the individual experiencing it. Patient self-reports are the most reliable gauge (Shiel 2017; Gélinas 2016).
Furthermore, adequate communication is one of the most important components of caring for patients (Marie Curie 2019).
However, some patients may not have the capacity to self-report their pain. The process of discussing and assessing pain is a complicated social transaction between patient and healthcare professional, and if the patient is unable to communicate their pain, it becomes difficult to appropriately respond to and treat their discomfort (Boekel et al. 2017).
A study found that 1 in 10 patients self-report a low level of pain even if the pain is considered unacceptable. This poses serious questions and concerns about those who cannot communicate their pain at all (Boekel et al. 2017).
In addition to being a physically uncomfortable experience, untreated pain may also:
(Booker & Haedtke 2016; McGuire et al. 2016; Gan 2017)
When a patient is unable to verbally express their discomfort, you should use assessment tools and observe for any pain behaviours. This is imperative to ensure all patients are comfortable and nobody is unknowingly suffering (Booker & Haedtke 2016).
(Booker & Haedtke 2016; McGuire et al. 2016; Marie Curie 2019; VIC DoH n.d.)
There many tools that may be used to assess non-verbal patients. The following are some widely-used examples - please note that this is not a comprehensive list of every tool available.
An extended list of tools can be found here.
Note: Always refer to your facility’s policies and procedures when selecting and using pain assessment tools.
The following behaviours may suggest the presence of pain in adults who are unable to communicate:
|Facial expressions||Facial expressions Rapid blinking, fear, brow lowering, clenched teeth, narrowing or closure of eyes, upper lip raising, nose wrinkling.|
|Verbalisations||Screaming, swearing, crying, moaning, sighing, making fewer sounds than is typical.|
|Body movements||Gaiting, limping, rubbing a body area, muscle rigidity, decreased movement, guarding, pacing, rocking, fidgeting, repetitive movements, reluctance to move, decreased range of movement.|
|Interpersonal interactions||Resisting care, aggression, withdrawal, isolation.|
|Mood and mental state||Delirium, depressive state, agitation, anxiety, irritability, crying, impaired executive function, declining cognition, worsening of cognitive impairment, confusion, restlessness.|
|Activity||Wandering, sleep disturbances, increased sleep, social disengagement, change of routine, staying in bed, low appetite.|
|Function||Decreased ability to function in daily life, falls.|
|Autonomic signs||Pallor, altered breathing, change in vital signs, sweating.|
(Adapted from Booker & Haedtke 2016; Dementia Australia 2015)
Note: These signs may be unrelated to pain and caused by another condition. Some patients experiencing pain may display few or none of these signs (Dementia Australia 2015).
A study identified the following challenges experienced by nurses that may inhibit the assessment of pain in non-verbal patients:
(Deldar, Froutan & Ebadi 2018)
Identifying and remedying these barriers to effective pain assessment will help improve the quality of care delivered to non-verbal patients (Deldar, Froutan & Ebadi 2018).
Sourcing and using appropriate assessment tools for patients who are unable to communicate their pain is crucial. Poorly-managed pain can lead to other health complications and unnecessary discomfort and distress.
Thorough assessments should be performed to identify and manage pain experienced by non-verbal patients - being unable to verbalise their discomfort means they are relying on healthcare professionals to ensure they are comfortable and not quietly suffering.
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