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Advancing Excellence in Pain Assessment (Part 2)

December 10, 2008
by Steven B. Littlehale, MS, GCNS-BC, Jane M. Niemi, MSN, RN, LHNA, and Sheila G. Capitosti, MHSA, RNC, NHA
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Elements for an effective pain management program

Screening all residents for pain is the baseline step in the management of pain. Due to the barriers previously mentioned, the nursing home needs to create a setting where the “Identification of Pain” is an organization-wide commitment. How questions are asked or phrased and which screening tools are used needs consideration and will influence the perceived response from the resident. Each resident should be screened for pain on a periodic basis, but at least at admission, readmission, and with each MDS assessment and each change in condition.

Best practice incorporates the identification of pain into daily practice. Nursing home policy and procedures should identify the options for pain screening tools, plus when and how the staff will screen for pain. A thorough screening process recognizes the importance of the participation of both clinical and non-clinical staff members. Staff in all departments can assist in identifying pain—CNAs, dietary, activities, etc. Communicating the importance of identifying pain and bringing it to the attention of the Unit Manager/Licensed Nursing is vital. Education regarding the identification of pain should include all staff. The screening process utilizes pain screening tools or pain scales. There are several different types of pain scales available for the cognitively intact or impaired resident.


Cognitively impaired residents

Tools that capture nonverbal expressions of pain are needed for the severely cognitively impaired resident. Residents may have difficulty expressing when they have pain or are unable to participate in the verbal pain assessment. Pain may be assessed by staff observation of behaviors such as restlessness, vocalizations, facial expressions, and breathing patterns.


Several different pain scales suitable for capturing pain in this group of elders are available. Two such scales are the PAINAD (Pain Assessment in Advanced Dementia) and the PADE (Pain Assessment for the Dementing Elderly).

The Pain Assessment in Advanced Dementia (PAINAD) scale refers to five behavior domains that can be scored from 0 through 2. These domain scores are then added to get a total score up to 10. Staff should be aware that these non-verbal behavioral symptoms may indicate something other than pain (e.g., delirium) and a thorough pain assessment and examination should be completed. For more information, refer to


Cognitively intact residents

Various types of pain scales are available for screening the cognitively intact elder:

  • Visual Analogue Scale (VAS)
  • Verbal Numeric Rating Scale
  • Faces Scales (Wong-Baker FACES Pain Rating Scale and others)
  • Verbal Descriptor Scale (can be customized to resident)
  • MDS—Pain Scale
  • Other scales, such as a pain thermometer or color scales

Ensure that pain screening is incorporated into the admission process. At this time, determine which tool to use for the resident and ensure that this decision is relayed to staff for consistency of use. Remember, even though a pain scale is selected and explained to the resident, the resident may need the scale and range to be defined frequently to maintain full understanding of the rating.

There may be other identifiers that should trigger a pain screening, such as certain diagnoses and conditions, decreasing ADLs, decreasing ROM and mobility, and behaviors. Take the time to consider if pain is a factor in either the condition or clinical finding.


Pain assessment

A comprehensive pain assessment is completed once pain has been identified. Pain may have several different causes, such as acute illness or injury, ADL shortfalls, repositioning, or aggravating treatment or therapy. Persistent pain can be a symptom of many diseases such as cancer, arthritis, and neuropathy or end-stage disease. Identifying the underlying cause and fully understanding the pain symptoms is necessary to adequately treat the pain.

At a minimum, an initial pain assessment should include: