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.
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 1
 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 ckovach@uwm.edu

This summary was completed by:

K. Herr, S. Decker, K. Bjoro, University of Iowa.
Contact information: keela-herr@uiowa.edu

Completed 04/04 2
Validation of a Behavioral Pain Scale in Critically Ill,
Sedated, and Mechanically Ventilated Patients
Younès Aı̈ssaoui, MD*, Amine Ali Zeggwagh, MD, PhD*†, Aı̈cha Zekraoui,
Khalid Abidi, MD*, and Redouane Abouqal, MD, PhD*†
*Service de Réanimation Médicale et de Toxicologie Clinique, Hôpital Ibn Sina; and †Laboratoire de Biostatistiques, de
Recherche Clinique et Epidémiologique, Faculté de Médecine et de Pharmacie, Rabat, Morocco
Assessing pain in critically ill patients, particularly in
nonverbal patients, is a great challenge. In this study,
we validated a behavioral pain scale (BPS) in critically
ill, sedated, and mechanically ventilated patients. The
BPS score was the sum of 3 subscales that have a range
score of 1– 4: facial expression, upper limb movements,
and compliance with mechanical ventilation. Two as-
sessors observed and scored pain simultaneously with
the BPS at rest and during painful procedures. The psy-
chometric properties of the BPS that were studied were
reliability, validity, and responsiveness. We achieved
360 observations in 30 patients. The BPS was internally
reliable (Cronbach ␣ ⫽ 0.72). The intraclass correlation
A
ssessment and management of pain in critically
ill patients have recently received increased at-
tention (1–3). Scientific advances in understand-
ing pain mechanisms, multidimensional methods of
pain assessment, and analgesic pharmacology have
improved pain management practices. However, pain
assessment for critically ill patients, especially for non-
verbal patients, continues to present a challenge for
clinicians and researchers. Critically ill patients are
unable to communicate effectively for several reasons,
including tracheal intubation, reduced level of con-
sciousness, restraints, sedation, and administration of
paralyzing drugs (4 – 6).
Pain experts agree that a patient’s self-report of pain
intensity is the most valid measure (4). Unfortunately,
most of the existing scales are designed for use with
patients who can respond verbally to assessment com-
mands. Consequently, pain management in nonverbal
patients, such as elderly patients with cognitive im-
pairment, is often guided by less precise and wholly
Accepted for publication April 6, 2005.
Address correspondence and reprint requests to Younès Aissaoui,
MD, Service de Réanimation Médicale et Toxicologie Clinique, BP
1005, Hôpital Ibn Sina, 10001 Rabat, Morocco. Address e-mail to
shadowyounes@hotmail.com.
DOI: 10.1213/01.ANE.0000182331.68722.FF
1470 Anesth Analg 2005;101:1470–6
MD*,
coefficient to evaluate inter-rater reliability was high
(0.95). Validity was demonstrated by the change in BPS
scores, which were significantly higher during painful
procedures, with averages of 3.9 ⫾ 1.1 at rest and 6.8 ⫾
1.9 during procedures (P ⬍ 0.001), and by the principal
components factor analysis, which revealed a large
first-factor accounting for 65% of the variance in pain
expression. The BPS exhibited excellent responsive-
ness, with an effect size ranging from 2.2 to 3.4. This
study 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)
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 data
suggests that certain observable behaviors may be
valid indicators of pain (9,10). Pain behaviors can be
markers of the existence, intensity, and causes of pain.
Indeed, observing pain behaviors is a common
method of assessing pain, especially when patients are
unable to verbalize.
Nevertheless, no pain scale comprising behavioral
indicators 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 had
undergone thoracic or abdominal surgery or who had
been admitted for management of multiple trauma.
However, its psychometric properties were insuffi-
ciently studied, and it has never been validated in a
medical ICU. In addition, validation of any pain tool
requires 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 a
measure of pain using psychometric methods.
©2005 by the International Anesthesia Research Society
0003-2999/05
ANESTH ANALG
2005;101:1470 –6
Methods
The study was performed over a 6-mo period in a 12-bed
ICU of the university teaching hospital Ibn Sina, Rabat,
Morocco. The hospital ethical committee approved the
study protocol, and because this observational study did
not 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 precluded
the use of an auto evaluation pain scale. Patients who
were quadriplegic, receiving neuromuscular blocking
medications, or had a peripheral neuropathy were
excluded. Exclusion criteria were primarily selected to
not include patients whose diseases or medications
might compromise expression of the pain behaviors.
To assess pain intensity, we used the BPS described
by Payen et al. (11). The BPS is based on a sum of three
subscales: facial expression, upper limb movements,
and compliance with mechanical ventilation (Table 1).
Each subscale is scored from 1 (no response) to 4 (full
response). Therefore, possible BPS scores range from 3
(no pain) to 12 (maximum pain).
In addition to the BPS scores, mean arterial blood
pressure and heart rate were also collected, which
were measured by multimodal monitors. These two
hemodynamic variables were collected because previ-
ous studies had shown that increased heart rate and
increased arterial blood pressure are the most frequent
physiological indicators of pain noted by observing
nurses (9).
The patients’ sedation levels were assessed using
the Ramsay scale (12). The Ramsay scale rates sedation
level on a scale from 1 to 6, with higher levels indi-
cating greater degrees of sedation. This instrument
proved satisfactorily reliable and valid (13).
Sample characteristics were also recorded, including
age, 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 by
the various teams of nurses (morning team, afternoon
team, and night team). Each team comprised four
nurses and one nurse’s aide. Assessments were made
by 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 communication
between them. The assessors were not randomized, for
reasons of convenience.
Evaluation of the BPS and the physiological vari-
ables was made at rest and during painful procedures
to appreciate the BPS responsiveness. The two painful
procedures chosen were tracheal suction and periph-
eral venous cannulation. They were selected because
CRITICAL CARE AND TRAUMA AISSAOUI ET AL. 1471
PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS
their painful characters had been demonstrated in sev-
eral previous studies (15–17) and because they were
part of the routine care that was normally planned for
the patients. No additional interventions or proce-
dures were performed on the patients for the benefit
of the study.
The assessments were done in the first 48 h after
admission to the ICU. However, for patients who were
not being ventilated at the time of their admission but
who were ventilated later during their stay, the assess-
ments were made in the first 48 h after mechanical
ventilation began.
Twelve physicians and 16 nurses participated in the
study. Before the beginning of the study, a training ses-
sion was provided to teach assessors how to complete
BPS, followed by a probation period (15 days), during
which 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 BPS
was 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 3
subscales, it was required to include 25–30 patients in
the study.
The validation of an instrument measuring a sub-
jective variable (like pain) requires a comparison with
a “gold standard.” Nevertheless, no pain scale has
been 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, and
responsiveness.
Reliability refers to the lack of measurement error in a
scale and includes internal consistency and inter-rater
reliability. Internal consistency is an indication of how
the items within a scale are interrelated. Cronbach ␣ is
one method of assessing internal consistency (19). A high
Cronbach ␣ 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 the
ability of a new instrument to obtain similar measures
with different assessors. It was assessed using the intra-
class correlation coefficient (ICC) (20). Theoretically, the
ICC can range from 0 (no agreement) to 1.0 (perfect
agreement). Generally, a value larger than 0.8 is re-
garded as satisfactory (20). The ICC was calculated for
the BPS and for each subscale of the BPS separately. A
95% confidence interval (CI) for the coefficient was
derived.
Validity is the degree to which an instrument meas-
ures what it claims to measure (21). Validity was
established in three ways: construct validity, change in
1472 CRITICAL CARE AND TRAUMA AISSAOUI ET AL. ANESTH ANALG
PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS 2005;101:1470 –6

Table 1. The Behavioral Pain Scale (11)

Item Description Score
Facial expression Relaxed 1
Partially tightened (e.g., brow lowering) 2
Fully tightened (e.g., eyelid closing) 3
Grimacing 4
Upper limb movements No movement 1
Partially bent 2
Fully bent with finger flexion 3
Permanently retracted 4
Compliance with mechanical ventilation Tolerating movement 1
Coughing but tolerating ventilation for the most of time 2
Fighting ventilator 3
Unable to control ventilation 4

BPS scores during pain, and factor structure of the
BPS.
Construct validity is the extent to which scores on a
scale correlate with scores of other measures in pre-
dicted ways (21). We hypothesized that a significant
correlation would be found between the BPS scores
and the two physiological variables that were sup-
posed to measure the same concept (pain). We also
tested the correlation between the BPS and the Ram-
say scale. Spearman nonparametric coefficients were
used.
Change in BPS scores was assessed by comparing
the BPS scores at rest and after painful procedures. We
hypothesized that if the BPS really measures pain, the
BPS scores should be much higher during painful
procedures than while the patient is at rest. Wilcoxon
paired tests (nonparametric) were used.
Furthermore, the factor structure of the BPS was
extracted by performing exploratory principal compo-
nents factor analysis. This is a statistical procedure
that enables the underlying dimensions of a scale to be
determined (21).
Responsiveness refers to an instrument’s ability to
detect important changes over time in the concept
being measured, even if those changes are small (22).
The magnitude of this property was assessed by the
effect size. This coefficient is calculated by dividing
the difference between the mean BPS scores at rest and
during painful procedures by the sd of the mean
scores at rest. The effect size is considered small if it is
less than 0.2, moderate if it is near 0.5, and large if it is
more than 0.8 (22).
Results
The various teams assessed 38 patients. However, the
assessments of 8 patients could not be included for 3
major reasons: (a) the patient died before the end of
the assessments (n ⫽ 2), (b) the presence of exclusion
criteria (administration of neuromuscular blockade) (n
Table 2. Principal Patient Characteristics
Age (y) 39 ⫾ 19*
Sex: men/women (n) 18/12
APACHE 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.
⫽ 3), and (c) an incomplete or incorrect collection of
data (n ⫽ 3).
Thirty patients were included. The principal patient
characteristics are presented in Table 2. Each patient
was assessed three times a day (morning, afternoon,
and night), by two observers (a physician and a
nurse), and at two different times (at rest and during
painful procedures). Thus, the various teams achieved
360 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 Ramsay
scale 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 morphine
administered was 3 ⫾ 0.7 mg/h.
Change in physiological variables is shown in Table
3. 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 and
2.6% for mean arterial blood pressure.
Cronbach ␣ values indicated that the BPS had good
internal 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, ICC
was 0.90 (95% CI, 0.87– 0.92). For compliance with
ANESTH ANALG
2005;101:1470 –6
Table 3. Physiological Variables at Rest and During
Painful Procedures
Painful
Rest procedures P-value
Heart rate (bpm) 103 ⫾ 22 114 ⫾ 23 ⬍0.001
Mean arterial blood 77 ⫾ 26 79 ⫾ 27 0.042
pressure (mm Hg)
Values expressed as mean ⫾ sd.
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 scores
obtained by the three teams of caregivers. There was
no significant difference (Table 4).
No significant correlation was found between the
BPS 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 mean
arterial blood pressure. When the correlation between
the BPS scores and Ramsay scale was investigated, as
expected, 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 rest
and did not differ between the two categories of pain-
ful procedures (tracheal suction and peripheral ve-
nous cannulation). Moreover, all subscale scores were
significantly higher during painful procedures.
Using exploratory principal components factor analy-
sis, we found a large first factor, which accounted for
65% 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 limb
movements, and 0.64 for compliance with mechanical
ventilation. Table 6 shows the correlation matrix be-
tween the subscales of the BPS. The 3 subscales were
significantly correlated (all P ⬍ 0.001), with a high cor-
relation between facial expression and upper limb move-
ments (r ⫽ 0.70) and moderate correlations between
compliance with mechanical ventilation and the 2 other
subscales (r ⫽ 0.40 with facial expression and r ⫽ 0.29
with upper limb movements).
The effect size for responsiveness was large for the
three subscale scores and for the total BPS scores
(Table 5). These results showed an excellent respon-
siveness and, consequently, the excellent ability of the
BPS to quantify change in clinical status and detect
painful procedures.
Discussion
This validation study showed that the BPS had good
psychometric properties when used with critically ill
CRITICAL CARE AND TRAUMA AISSAOUI ET AL. 1473
PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS
patients. In particular, the BPS showed a high inter-
rater reliability (ICC ⫽ 0.95) and a satisfactory internal
consistency (Cronbach ␣ ⫽ 0.72). Validity of the BPS
was demonstrated by a significant increase in BPS
scores during painful procedures and by principal
components factor analysis that identified a large first
factor, which accounted for 65% of the variance in
pain expression. Furthermore, the BPS exhibited an
excellent responsiveness, suggesting that this is a
powerful tool to detect the impact of painful stimula-
tion in ICU patients.
Each of our patients was assessed by three teams of
nurses to remove a possible bias caused by assess-
ments being made by the same caregivers. Results
showed that there was no significant difference
among the evaluations made by the three teams.
At rest, theoretically, the BPS scores should be equal
to 3, indicating the absence of pain. However, the
mean BPS scores, which were near 4, suggest the
possibility of preexisting background pain before any
procedure was performed. Indeed, our patients, like
all ICU patients, are subjected to a multitude of pain-
ful constraints, including various tubes (nasogastric
and endotracheal), central and arterial lines, wrist re-
straints, etc. Another explanation could be that the
amount of analgesic infusion was insufficient. This
fact highlights the need for an instrument that can be
used 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 pain
among patients with impaired mental status
(4,8,23,24). Puntillo et al. (9), in a study of patients
having difficulties with verbal communication (me-
chanically ventilated or having been tracheally extu-
bated less than four hours), showed that the most
frequently noted physiological indicators of pain were
increased 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 measuring
approximately 10%. These results coincide with the
observations of clinicians who generally associate pain
with a variation of from 10% to 20% in physiological
variables (25). However, it is agreed that these physi-
ological indicators lack specificity in the ICU and can
be 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 two
physiological variables in our study. Unfortunately,
the absence of an objective measure of pain in ICU
patients limited the testing of construct validity. The
study of Payen et al. (11) had the same results, and no
published study with a sufficient level of scientific
1474 CRITICAL CARE AND TRAUMA AISSAOUI ET AL.
PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS
Table 4. Behavioral Pain Scale Scores as Assessed by Three Nursing Teams
Morning team
Rest 3.8 ⫾ 1.2
Painful procedures 6.6 ⫾ 1.7
Values expressed as mean ⫾ sd.
* Friedman test.
Figure 1. Correlations between the behavioral pain scale (BPS) and
the Ramsay scale.
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, the
lower 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. The
inter-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 are
numerous, as in the ICU.
The BPS total and subscale scores were significantly
higher during the procedures (Table 5). This change in
BPS scores testifies to the instrument’s capacity to
detect and discriminate pain and provides the evi-
dence that the BPS is a valid measure of pain. It is also
important that all of the subscales changed, indicating
that they all have the same ability to discriminate pain.
Principal factor analysis revealed that a large first
factor was dominant and that the three subscales were
strongly related to this factor, which means each of the
ANESTH ANALG
2005;101:1470 –6
Afternoon team Night team P-value*
3.7 ⫾ 0.9 3.9 ⫾ 1.2 0.44
6.8 ⫾ 1.7 6.6 ⫾ 2.2 0.46
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 significant
correlation found among the three subscales demon-
strates that they evaluate the same concept, which, in
this case, was pain intensity.
This analysis has shown that behavioral indicators
can be a valid and reliable measure of pain. Few
studies have evaluated pain behaviors in the ICU
(9,10,25). The most recent one (10) identified specific
procedural pain behaviors such as grimacing, rigidity,
wincing, shutting of eyes, verbalization, and clenching
of fists. But in that study, the patients were awake and
could measure their pain with a numeric rating scale.
In fact, facial expression, which contributed most to
the pain rating in our study, is a sign found in various
works measuring both acute and chronic pain
(25,27,28). Prkachin (27) has suggested that four facial
actions 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 a
universal 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 of
signal (4,23,29). Pediatric scales also rely on upper
limb movements as a measure of pain (23,29). In our
study, upper limb movements contributed as much as
facial expression to the pain rating. Compliance with
mechanical ventilation, adapted from the Comfort
scale (11), had a moderate but effective contribution to
pain assessment. The reason could be that this sub-
scale might be affected by some factors unrelated to
pain, such as hypoxemia, bronchospasm, and mucous
plugging, which can lead to coughing and some fight-
ing of the ventilator.
In addition to these psychometric properties, the
BPS showed good feasibility, in as much as the aver-
age time of assessment was only four minutes. The
short time required will make the BPS suitable for
everyday clinical use.
This study has two limitations. First, one aspect of
the validation process has not been addressed, namely
the criterion validity (validity of the BPS in compari-
son with another validated pain scale). We could have
compared the BPS to subjective rating of the level pain
by an independent rater (a nurse) on a visual analog
ANESTH ANALG CRITICAL CARE AND TRAUMA AISSAOUI ET AL. 1475
2005;101:1470 –6 PAIN ASSESSMENT IN CRITICALLY ILL PATIENTS

Table 5. Behavioral Pain Scale (BPS) Total Scores and BPS Subscale Scores at Rest and During Painful Procedures, with
the Effect Size
Painful
Rest procedure P*-value Effect size
BPS subscales
Facial expression
Morning team 1.2 ⫾ 0.6 2.6 ⫾ 1 ⬍0.0001 2.3
Afternoon team 1.1 ⫾ 0.25 2.8 ⫾ 1.1 ⬍0.0001 6.8
Night team 1.2 ⫾ 0.3 2.7 ⫾ 1.2 ⬍0.0001 5
Upper limb movements
Morning team 1.1 ⫾ 0.2 2 ⫾ 0.7 ⬍0.0001 4.5
Afternoon team 1 ⫾ 0.2 1.9 ⫾ 0.8 ⬍0.0001 4.5
Night team 1.2 ⫾ 0.5 1.9 ⫾ 0.9 ⬍0.0001 1.4
Compliance with mechanical ventilation
Morning team 1.5 ⫾ 0.6 2 ⫾ 0.9 ⬍0.046 0.8
Afternoon team 1.6 ⫾ 0.6 2.1 ⫾ 0.9 ⬍0.005 0.8
Night team 1.5 ⫾ 0.5 2 ⫾ 0.9 ⬍0.006 1
BPS total
Morning team 3.8 ⫾ 1.2 6.6 ⫾ 1.7 ⬍0.0001 2.3
Afternoon team 3.7 ⫾ 0.9 6.8 ⫾ 1.7 ⬍0.0001 3.4
Night 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
Facial Movements of Compliance with
expression upper limbs mechanical ventilation
Facial expression 1
Movements of upper limbs 0.70 1
Compliance with mechanical ventilation 0.41 0.29 1
Values shown represent Spearman nonparametric correlation coefficients; all correlations were statistically significant at P ⬍ 0.001.

scale (VAS). However, apart from the BPS, no other References

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The second limitation of our study is that the sam-
ple of critical care patients observed was small. Future
studies 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 in
uncommunicative critically ill patients and to evaluate
the effectiveness of analgesic treatment and adapt it.
Further studies are required to determine whether the
use of this scale can really improve management of
pain in the critical care setting.
The authors gratefully acknowledge all the nurses and physicians
who participated in this study, Dounia Benzarouel for her assistance
with data collection, and Younès Lahrech and Khalil Zakari for their
help during the writing of this manuscript.
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 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 At Rest
Movement
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)
0 1 2

No particular Occasional grimace or Frequent to constant

FACE expression or smile frown, withdrawn, frown, clenched jaw,
disinterested quivering chin

0 1 2

Normal position Uneasy, Kicking,

LEGS Or Restless, Or
relaxed Tense Legs drawn up

0 1 2

Lying quietly Squirming Arched

ACTIVITY Normal position Shifting back/forth Rigid
Moves easily Tense Or
Jerking
0 1 2

No Cry Moans or Whimpers Crying Steadily

CRY Occasional Complaint Screams or Sobs
(Awake or Asleep) Frequent Complaints

0 1 2

Content Reassured by Difficult to console

Relaxed occasional touching, or comfort.
CONSOLABILITY hugging, or ‘talking
to.’
Distractible

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

From *Adult and Gerontological
Nursing, The University of Iowa
College of Nursing, Iowa City,
Iowa; †Medical College of Virginia
Hospital, Rockville, Virginia;
‡
Washington County Hospital
Association, Hagerstown,
Maryland; §Clinical Nurse
Specialist and Manager of Pain
Management, Children’s Medical
Center of Dallas, Dallas, Texas;
¶
Independent Consultant in the
Nursing Care of Patients with
Pain, Los Angeles, California; 储Mott
Children’s Hospital, University of
Michigan Health System, Ann
Arbor, Michigan; #Alexian Brothers
Hospital Network, Elk Grove
Village, Illinois; and **University
of Washington Medical Center,
Seattle, Washington.
Address correspondence and reprint
request to Keela Herr, PhD, RN, FAAN,
452 NB, College of Nursing, The
University of Iowa, Iowa City, IA
52242. E-mail: keela-herr@uiowa.edu
1524-9042/$32.00
© 2006 by the American Society
for Pain Management Nursing
doi:10.1016/j.pmn.2006.02.003
Original articles
Pain Assessment in the
Nonverbal Patient:
Position Statement with
Clinical Practice
Recommendations
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,储
Jane Pelosi-Kelly, MSN, RN, C, CS, ANP,# and
Lori Wild, PhD, RN**
y ABSTRACT:
The article presents the position statement and clinical practice rec-
ommendations for pain assessment in the nonverbal patient devel-
oped by an appointed Task Force and approved by the ASPMN Board
of Directors.
© 2006 by the American Society for Pain Management Nursing
Pain is a subjective experience, and no objective tests exist to measure it (APS,
2003). Whenever possible, the existence and intensity of pain are measured by
the patient’s self-report, abiding by the clinical definition of pain that states
“Pain is whatever the experiencing person says it is, existing whenever he/she
says it does” (McCaffery, 1968). Unfortunately, some patients cannot provide a
self-report of pain verbally, in writing, or by other means, such as finger span
(Merkel, 2002) or blinking their eyes to answer yes or no questions (Pasero &
McCaffery, 2002).
This position paper will specifically address three populations of nonverbal
patients: elders with advanced dementia, infants and preverbal toddlers, and
intubated and/or unconscious patients. The inability of these populations to
communicate pain and discomfort because of cognitive, developmental, or
physiologic issues is a major barrier for them being adequately assessed for pain
and achieving adequate pain management interventions.
ETHICAL TENETS
The ethical principles of beneficence (the duty to benefit another) and nonma-
leficence (the duty to do no harm) oblige health care professionals to provide
Pain Management Nursing, Vol 7, No 2 (June), 2006: pp 44-52
 Pain Assessment in the Nonverbal Patient
pain management and comfort to all patients, includ-
ing those challenging individuals who are vulnerable
and unable to speak for themselves. Providing quality
and comparable care to individuals who cannot report
their pain is directed by the principle of justice (the
equal or comparative treatment of individuals). Re-
spect for human dignity, the first principle in the
“Code of Ethics for Nurses” (ANA, 2001), directs
nurses to provide and advocate for humane and ap-
propriate care. On the basis of the principle of justice,
this care is given with compassion and unrestricted by
consideration of personal attributes, economic status,
or the nature of the health problem.
GENERAL RECOMMENDATIONS
All persons with pain deserve prompt recognition and
treatment. Pain should be routinely monitored, assessed,
reassessed, and documented clearly to facilitate treat-
ment and communication among health care clinicians
(Gordon et al., 2005). In patients who are unable to
self-report pain, other measures must be used to detect
pain and evaluate interventions. No single objective as-
sessment strategy, such as interpretation of behaviors,
pathology, or estimates of pain by others, is sufficient by
itself. 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 from
a patient with limited verbal and cognitive skills may be
a simple yes/no or vocalization. When self-report is ab-
sent or limited, explain why self-report cannot be used
and further investigation and observation are needed.
b. Search for Potential Causes of Pain. Pathologic con-
ditions and common problems or procedures known
to cause pain (e.g., surgery, wound care, rehabilitation
activities, positioning/turning, blood draws, heel
sticks, a history of persistent pain) should trigger an
intervention, 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 if
there is reason to suspect pain, an analgesic trial can
be diagnostic as well as therapeutic (APS, 2003). Pain
associated with procedures should be treated before
initiation of the procedure. Other problems that may
be 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 to
pain assessment. Common behaviors that may indi-
cate discomfort in the selected populations have been
identified in each section below. Pain behaviors are
not always accurate reflections of pain intensity, and
in some cases indicate another source of distress, such
45
as physiologic distress or emotional distress (Pasero &
McCaffery, 2005). Potential causes and the context of
the behavior must be considered when making treat-
ment decisions. Awareness of individual baseline be-
haviors and changes that occur with discomfort are
very 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 or
another person who knows the patient well (e.g.,
spouse, child, caregiver). Parents and caregivers
should be encouraged to actively participate in the
assessment of pain in their loved one. Familiarity with
the patient and knowledge of usual and past behaviors
can assist in identifying subtle, less obvious changes in
behavior that may be indicators of pain presence.
Discrepancies exist between self-report of pain and
external observer judgments of pain severity that oc-
cur across varied raters (e.g., physician, nurse, family,
aides) and settings (e.g., inpatient, outpatient, acute
care, long-term care). Thus, judgments by caregivers
and clinicians may not be accurate reflections of the
severity of pain experienced by nonverbal persons
and should be combined with other evidence when
possible. A multifaceted approach is recommended
that combines direct observation, family/caregiver in-
put, and evaluation of response to treatment.
e. Attempt an Analgesic Trial. An empiric analgesic trial
should be initiated if there are pathologic conditions or
procedures likely to cause pain or if pain behaviors
continue after attention to basic needs and comfort mea-
sures. Provide an analgesic trial and titration appropriate
to the estimated intensity of pain based on the patient’s
pathology and analgesic history. For mild to moderate
pain, a nonopioid analgesic may be given initially (e.g.,
acetaminophen every 4 hours for 24 hours). If behaviors
improve, assume pain was the cause and continue the
analgesic and add appropriate nonpharmacologic inter-
ventions. If behaviors continue, consider giving a single
low dose, short-acting opioid (e.g., hydrocodone, oxy-
codone, or morphine) and observe the effect. If there is
no change in behavior, titrate dose upward by 25% to
50% and observe the effect. Continue to titrate upward
until a therapeutic effect is seen, bothersome side effects
occur, or no benefit is determined. It may be appropriate
to start the analgesic trial with an opioid for conditions in
which moderate to severe pain is expected. Explore
other potential causes if behaviors continue after a rea-
sonable analgesic trial. The analgesic titration example is
conservative, and although strategies for safe titration
should be followed, more aggressive approaches may be
needed (Gordon et al., 2004). No research confirms that
weight (except in children) should be used to determine
starting dose (Burns et al., 1989; Macintyre & Jarvis,
1995).
2. Establish a Procedure for Pain Assessment
A procedure for evaluating pain presence and response
to treatment should be instituted in each health care
46
setting. The hierarchy of assessment techniques, dis-
cussed above, is recommended, and the following can be
used 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 Appropriate
Use of a behavioral pain assessment tool may assist in
recognition of pain in these challenging populations. It is
incumbent on health care providers to consider the
strength of psychometric evaluation data (e.g., reliability
and validity of the tool), the clinical feasibility of instruments
(e.g., training required, time to complete), and the support
for use with the population of interest in the specific setting
(e.g., acute care, long-term care, home care) when selecting
a specific tool. Use of reliable and valid tools helps ensure
that clinicians are using appropriate criteria in their pain
assessments. Standardized tools promote consistency
among care providers and care settings and facilitate com-
munication and evaluation of pain management treatment
decisions. However, the appropriateness of a scale must be
assessed patient by patient, and no one scale should be an
institutional mandate for all patients in a certain group
(Pasero & McCaffery, 2005).
When a behavioral tool is scored, that score is not the
same as a pain intensity rating nor can the scores be
compared with standard pain intensity ratings or catego-
ries of pain severity. Behavioral assessment tools may be
helpful to identify the presence of pain and can be used
to 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 of
behavior. Keys to the use of behavioral pain scales are to
focus on the individual’s behavioral presentation and
observe for changes in those behaviors with effective
treatment. Remember that sleep and sedation do not
equate with the absence of pain or with pain relief.
4. Minimize Emphasis on Physiologic Indicators
Physiologic indicators (e.g., changes in heart rate,
blood pressure, respiratory rate) are not sensitive for
discriminating pain from other sources of distress. Al-
though physiologic indicators are often used to docu-
ment pain presence, little research supports the use of
vital sign changes for identifying pain. Absence of in-
creased vital signs does not indicate absence of pain
(McCaffery & Pasero, 1999).
5. Reassess and Document
After intervention and regularly over time, the patient
should be reassessed with methods of pain assessment
and specific behavioral indicators that have been identi-
fied as significant and appropriate for the individual pa-
Herr et al.
tient. Assessment approaches and pain indicators should
be documented in a readily visible and consistent manner
that is accessible to all health care providers involved in
the assessment and management of pain (Gordon et al.,
2005; Miaskowski et al., 2005).
PERSONS WITH ADVANCED
DEMENTIA: GUIDING PRINCIPLES
FOR THE ASSESSMENT OF PAIN
Recommendations for pain assessment in nonverbal
older adults with dementia unable to self-report that
are unique from the general recommendations include
the following:
1. Self-report. The ravages of dementia seriously impact
the ability of those with advanced stages of disease to
communicate pain. Damage to the central nervous
system affects memory, language, and higher order
cognitive processing necessary to communicate the
experience. Yet, despite changes in central nervous
system functioning, persons with dementia still expe-
rience pain sensation to a degree similar to that of the
cognitively intact older adult (Schuler et al., 2004).
However, dementing illnesses do impact the interpre-
tation of the pain stimulus and the affective response
to that sensation (Scherder et al., 2005). Although
self-report of pain is often possible in those with mild
to moderate cognitive impairment, as dementia
progresses, the ability to self-report decreases and
eventually 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 the
assessment 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, and
mental status changes have been identified as catego-
ries of potential pain indicators in older persons with
dementia (AGS, 2002). A list of indicators included in
these categories and an algorithm for evaluating pain
in 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 less
obvious (e.g., agitation, restlessness, irritability, confu-
sion, combativeness, particularly with care activities
or treatments, or changes in appetite or usual activi-
ties) and require follow-up evaluation. Typical pain
behaviors are often not present, and more subtle indi-
cators may represent pain. Use the American Geriatric
 Pain Assessment in the Nonverbal Patient
Society’s indicators of pain (AGS, 2002) or a nonverbal
pain assessment tool that is appropriate, valid, and
reliable for use with this population. Behavioral obser-
vation should occur during activity whenever possi-
ble, because pain may be minimal or absent at rest.
Use of Behavioral Pain Assessment Tools
Two critiques of existing nonverbal pain assessment
tools indicate that, although there are tools with poten-
tial, there is no tool that has strong reliability and validity
that can be recommended for broad adoption in clinical
practice for persons with advanced dementia (Herr et al.,
2006; Stolee et al., 2005; Zwakhalen et al., 2006). Exist-
ing tools have limited evaluation that is often narrow in
the samples used and/or the setting in which evaluation
was conducted. Behavioral tools with few indicators may
be more clinically feasible but may not detect pain in
patients who present with less obvious behaviors.
Longer and more comprehensive checklists may be more
sensitive but also identify patients for whom pain may
not be present. Given the current state of high under-
recognition of pain in this population, increased sensitiv-
ity may be preferable but will require evaluation to vali-
date pain as the cause of the suspect behaviors.
A comprehensive review of currently published
tools for assessing pain in nonverbal persons with de-
mentia is available at www.cityofhope/prc/elderly.asp
and in Herr, Bjoro, and Decker’s article (2006). Tools are
in varying stages of development and validation; how-
ever, those with the strongest conceptual and psycho-
metric support at this time, as well as clinical utility,
include 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 care
setting, geriatric centers, palliative care center; chronic
pain)
● NOPPAIN: Nursing Assistant-Administered Instrument
to 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 with
Severe Dementia (Fuchs-Lacelle, et al., 2004) (tested in
long-term care setting; chronic pain)
● PAINAD: The Pain Assessment in Advanced Dementia
Scale ( Lane et al., 2003; Warden et al., 2003) (tested in
long-term care setting; chronic pain; preliminary reports
of testing in acute pain not yet published)
Clinicians are encouraged to review selected tools for
appropriateness to the patient’s care setting and ob-
47
tain data to support their use through Quality Improve-
ment projects.
4. Surrogate Reporting of Pain (e.g., family, caregiver).
In the long-term care setting, the certified nursing
assistant is a key health care provider who has been
shown to be effective in recognizing the presence of
pain (Fisher et al., 2002; Mentes et al., 2004). Educa-
tion on screening for pain should be a component of
all certified nursing assistant training. Family members
are likely to be the caregiver with the most familiarity
with typical pain behaviors or changes in usual activ-
ities that might suggest pain presence in the acute care
setting and in other settings in which the health care
providers do not have a history with the patient (Co-
hen-Mansfield, 2002; Shega et al., 2004).
5. Attempt an Analgesic Trial. Estimate the intensity of
pain 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 be
appropriate initially with titration to stronger analgesics
if there is no change in behaviors and pain continues to
be suspect. Low-dose opioids have been effective in
validating agitation as a pain indicator (Manfredi et al.,
2003). Opioid dosing in older adults warrants an initial
dose reduction of 25% to 50%. Using an analgesic trial to
validate the presence of pain before increasing or adding
psychotropic medications has several advantages. Com-
pared with psychotropic intervention, response will be
seen more quickly with an analgesic intervention, the
adverse reactions to analgesics are usually less serious,
and pain will not be obscured by the sedative properties
of psychotherapeutic agents. With this approach, pain is
more likely to be detected and treated. Consider psychi-
atric approaches, such as adding or changing doses of
new psychiatric pharmacologic approaches (e.g., antip-
sychotics, sedatives), if behaviors do not improve with
an analgesic trial.
INFANTS AND PREVERBAL
TODDLERS: GUIDING PRINCIPLES
FOR THE ASSESSMENT OF PAIN
Recommendations for pain assessment in infants/nonver-
bal children unable to self-report that are unique from
the general recommendations include the following:
1. Self-report: Infants, toddlers, and developmentally pre-
verbal children lack the cognitive skills necessary to
report and describe pain. As children develop verbal
and cognitive skills they are able to report the expe-
rience and intensity of pain. The ability to indicate the
presence of pain emerges at approximately 2 years of
age. Developmentally appropriate children as young
as 3 years of age may be able to quantify pain using
simple validated pain scales (Fanurik et al., 1998; Spa-
grud et al., 2003).
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 in
infants and young children and should be treated with
the presumption that pain is present. Developmentally
nonverbal children have a higher burden of pain from
frequent medical/surgical procedures and illness, and
suspicion 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 acute
pain include eyebrows lowered and drawn together to
form a vertical furrow, a bulge between the brows
with the eyes tightly closed, cheeks raised with a
furrow between the nose and upper lip, and the
mouth 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 facial
expressions that accompany crying are not indepen-
dent indicators of acute pain (Fuller, 2001).
The primary behavioral signs of pain are often more
apparent and consistent for procedural pain and post-
operative pain than for chronic pain. As a child gains
control over body movement there will be greater
differences in observed behavioral responses to pain.
Sleeping and withdrawn behavior may be the child’s
attempts to control pain by limiting activity and inter-
actions. There may be a dampening of the primary
pain behaviors in children who experience prolonged
pain or chronic pain. Behaviors seen in children with
chronic cancer pain include posturing, wariness of
being moved, and psychomotor inertia that has been
described as withdrawal, lack of expression, and lack
of interest in surroundings (Gauvin-Piquard et al.,
1999). Distress behaviors, such as irritability, agitation,
and restlessness, may or may not be related to pain
and, 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 reported
as providing information about the neonatal response
to 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 status
and, therefore, are not good predictors of pain or the
absence of pain (Foster et al., 2003).
Use of Behavioral Pain Assessment Tools
Although no single behavioral scale has been shown to
be superior to others, clinicians should select a scale
that is appropriate to the patient and types of pain on
which it has been tested. Behavioral pain tools should
be used for initial and ongoing assessments.
● CHEOPS: Children’s Hospital of Eastern Ontario Pain
Scale (McGrath et al., 1985) (tested in 1 to 5 years of
age; Post Anesthesia Care Unit, surgical pain)
● CHIPPS: (Buttner & Finke, 2000) (tested in birth to 5
years 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 care
setting, surgical pain. Revised scale of COMFORT (Am-
buel et al., 1992; Canenvale, & Razack, 2002) measures
other constructs than pain (tested in newborn to 9 years
of age, intensive care setting, mechanically ventilated).
● CRIES: (Krechel & Bildner, 1995) (tested in neonates;
neonatal and pediatric intensive care setting, procedural
and 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 years
of age; Post Anesthesia Care, intensive care, acute care
settings, surgical pain and acute pain)
● DEGR Scale: Douleur Enfant Gustave Roussy (Gauvin-
Piguard, 1999) (tested in 2 to 6 years; acute care, cancer
pain)
● 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) (tested
in newborn to 3 years of age; acute care setting; surgical
pain)
● 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 of
the response of the infant, toddler, and developmen-
tally nonverbal child to parents and the environment
in the assessment of pain. Responsiveness to interven-
tions by a trusted caregiver to console the child, such
as rocking, touch, and verbal reassurance, must be
considered when observing distressed behaviors. Par-
ents usually know their child’s typical behavioral re-
sponse to pain and can identify behaviors unique to
the child that can be included in the assessment of
pain. However, the nursing staff may be most familiar
with the infant or young child’s pain behavior if the
child has not been home since birth.
Explain behavioral scales to parents and encourage
them to actively participate in identifying pain and
 Pain Assessment in the Nonverbal Patient
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 and
comfort measures, such as parental presence, security
items, sucking, and distraction, are not effective in
easing behaviors that may suggest pain. Base initial
opioid dose on weight and titrate as appropriate. Ex-
plore other potential causes of distress if behaviors
continue after a reasonable analgesic trial.
INTUBATED AND/OR UNCONSCIOUS
PERSONS: GUIDING PRINCIPLES FOR
THE ASSESSMENT OF PAIN
Recommendations for pain assessment in intubated
and/or unconscious persons unable to self-report that
are unique from the general recommendations include
the following:
1. Self-report. Self-report of pain should be attempted;
however, obtaining a report of pain from a critically ill
patient may be hampered by delirium, cognitive and
communication limitations, level of consciousness,
presence of an endotracheal tube, sedatives, and neu-
romuscular blocking agents. Because of delirium that
can wax and wane and impact ability to self-report,
serial assessment for the ability to self-report should be
conducted.
2. Potential Causes of Pain/Discomfort. Sources of pain
in critically ill patients include the existing medical
condition, traumatic injuries, surgical/medical proce-
dures, invasive instrumentation, blood draws, and
other 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). Verbal
adult patients describe a constant baseline aching pain
with intermittent procedure-related pain descriptors
such as sharp, stinging, stabbing, shooting, and awful
pain; thus it should be assumed that those unable to
report pain also experience these sensations (Puntillo
et al., 2001). In addition, immobility, hidden infection,
and early decubiti can cause pain and discomfort.
3. Observation of Patient Behavior. Facial tension and
expressions such as grimacing, frowning, and wincing
are often seen in critically ill patients experiencing
pain. Physical movement, immobility, and increased
muscle 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). Behavioral
pain scales are not appropriate for pharmacologically
paralyzed infants, children, adults, or those who are
flaccid 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
49
procedures thought to be painful. Patients may exhibit
distress behaviors as a result of the fear and anxiety
associated with being in the intensive care unit. An
analgesic trial (see no. 5 below) may be helpful in
distinguishing distress behaviors from pain behaviors.
Relying on changes in vital signs as a primary indi-
cator of pain can be misleading because these may also
be attributed to underlying physiologic conditions,
homeostatic changes, and medications. There is lim-
ited evidence that supports the use of vital signs as a
single indicator of pain; however, both physiologic
and behavioral responses often increase temporarily
with 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 or
other stressors (Foster, 2001). Absence of increased
vital signs does not indicate absence of pain (McCaf-
fery & Pasero, 1999).
Use of Behavioral Pain Assessment Tools
Although no single behavioral scale has been shown to
be superior for use with this population, tools tested in
other settings may be useful if appropriate to the
population and pain problem. Tools should be tested
to ensure they are reliable and valid if used with a
population in whom they have not been studied.
Pediatrics
● 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 years
of age; Post Anesthesia Care, intensive care, acute care
settings, 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) (tested
in 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)
Adults
● BPS: Behavioral Pain Scale (Payen, 2001) (tested in
adults; intensive care; procedural pain age)
● CPOT: Critical-Care Pain Observation Tool (Gelinas et
al., in press) (tested in adults; intensive care setting;
nociceptive procedures)
4. Surrogate Reporting of Pain. Parents of children,
caregivers, family members, and surrogates can help
identify specific pain indicators for critically ill individ-
uals. A family member’s report of their impression of
a patient’s pain and response to an intervention
should be included as one aspect of a pain assessment
in the critically ill patient.
5. Analgesic Trial. Initiate an analgesic trial if pain is
suspected. The priority of the analgesic trial is to verify
50
the presence of pain. Ongoing treatment should con-
sider the unique issues of this population. The ongo-
ing use of analgesics, sedatives, and comfort measures
can provide pain relief and reduce the effect of the
stress response. Paralyzing agents and sedatives are
not substitutes for analgesics. This population is often
being weaned from opioids to support a successful
extubation; however, suspected pain should be
treated. Less sedating agents and approaches should
be considered as appropriate, such as nonsteroidal
anti-inflammatory drugs, patient-controlled analgesia,
and epidural analgesia. In patients with head injury,
opioids should be used as appropriate for pain but
weighed against the risk of sedation. Short-acting opi-
oids such as fentanyl may allow for appropriate titra-
tion yet allow quick retreat if needed.
SUMMARY
Individuals who are unable to communicate their dis-
comfort are at greater risk for inadequate analgesia.
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The authors sincerely thank the following expert reviewers:
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dation of FLACC: preverbal patient pain scale. Pediatric
Nursing, 29(2), 140-146.
McGrath, P. J., Johnson, G. I., Goodman, J. T., Schill-
inger, J., Dunn, J., & Chapman, J. (1985). CHEOPS: a be-
havioral scale for rating postoperative pain in children. In
H. L. Fields (Ed.), Advances in Pain Research, 9, 395-402,
New York, NY: Raven.
Merkel, S., Voepel-Lewis, T, Shayevitz, J., & Malviya, S.
(1997). The FLACC: a behavioral scale for scoring postop-
erative pain in young children. Pediatric Nursing, 23(3),
293-297.
Schade, J. G., Joyce, B.A., Gerkensmeyer, J., & Keck, J. F.
(1996). Comparison of three preverbal scales for postopera-
tive pain assessment in a diverse pediatric sample. Journal of
Pain & Symptom Management, 12(6), 670-676.
Soetenga, D., Frank, J., & Pellino, T. A. (1999). Assess-
ment of the validity and reliability of the University of Wis-
consin Children’s Hospital pain scale for preverbal and
nonverbal children. Pediatric Nursing, 25(6), 670-676.
Spagrud, L. J., Piira, T, & von Baeyer, C. L. (2003). Chil-
dren’s self report of pain intensity. American Journal of
Nursing, 103(12), 62-64.
Sparshott, M. (1996). The development of a clinical dis-
tress scale for ventilated newborn infants: Identification of
pain and distress based on validated scores. Journal of
Neonatal Nursing, 2, 5-11.
Stevens, B., Johnston, C., Petryshen, R., & Taddio, A.
(1996). Premature Infant Pain Profile: development and
initial validation. Clinical Journal of Pain, 12, 13-22.
Stevens, B., McGrath, P., Gibbins, S., Beyene, J., Breau,
L., Camfield, C., et al. (2003). Procedural pain in newborns
at risk for neurologic impairment. Pain, 105, 27-35.
van Dijk, M., Boer, J. B., Koot, H. M., Tibboel, D., Pass-
chier, J., & Duivenvoorden, H. J. (2000). The reliability
and validity of the COMFORT scale as a postoperative pain
instrument in 0 to 3-year-old infants. Pain, 84, 367-377.
van Dijk, M., Peters, W. B., van Deventer, P., & Tibboel,
D. (2005). The COMFORT behavior scale. American Jour-
nal of Nursing, 105(1), 33-35, 37. Free CD ROM and algo-
rithm on assessment and treatment can be obtained by
writing Dr. Monique van Dijk at m.vandijk.3@
erasmusmc.nl.
Willis, M. H., Merkel, S. I., Voepel-Lewis, T., & Malviya,
S. (2003). FLACC Behavioral Pain Assessment Scale: a com-
parison with the child’s self-report. Pediatric Nursing,
29(3), 195-8.
Intubated and/or unconscious patient
references (not cited earlier)
Ambuel B., Hamlett, K. W., Marx, C. M., & Blumer, J. L.
(1992). Assessing distress in pediatric intensive care
environments: the COMFORT scale. Journal of Pediatric
Psychology, 17(1), 95-109.
Buttner, W., & Finke, W. (2000). Analysis of behavioural
and physiological parameters for the assessment of postop-
erative analgesic demand in newborns, infants and young
children: A comprehensive report on seven consecutive
studies. Paediatric Anaesthesia, 10(3), 303-318.
Canenvale, F. A., & Razack, S. (2002). An item analysis
of the COMFORT scale in a pediatric intensive care unit.
Pediatric Critical Care Medicine, 3(2), 177-180.
Foster, R. L., Yucha, C. B., Zuck, J. & Vojir, C. P. (2003).
Physiologic correlates of comfort in healthy children. Pain
Management Nursing, 4(10), 23-30.
Foster, R. L. (2001). Nursing judgment: the key to pain
assessment in critically ill children. Journal of the Society
of Pediatric Nurses, 6(2), 90-96.
Gelinas, C., Fillion, L., Puntillo, K. A., Bertrand, R. & Du-
puis, F. A. (in press). Validation of the Critical-Care Pain
Observation Tool (CPOT) in adult patients. Presented at
the IASP 11th World Congress on Pain, Sydney, Australia,
August 212, 2005.
Jacob, E., & Puntillo, K. A. (1999). A survey of nursing
practice in the assessment and management of pain in
children. Pediatric Nursing, 25(3), 278-286.
Jacobi, J., Fraser, G. L., Coursin, D. B., Riker, R. R., Fon-
taine, D., Wittbrodt, E. T., et al. (2002). Clinical practice
guidelines for the sustained use of sedatives and analgesics
in the critically ill adult. Critical Care Medicine, 30(1),
119-141.
Payen, J. F., Bru, O., Bosson, J. L., Lagrasta, A., Novel, E.,
Deschaux, L., et al. (2001). Assessing pain in critically ill
sedated patients using a behavioral pain scale. Critical
Care Medicine, 29(12), 2258-2263.
Puntillo, K. A., Morris, A. B., Thompson, C. L., Stanik-
Hutt, J. A., White, L., & Wild, L. J. (2004). Pain behaviors
observed during six common procedures: results from
Thunder Project II. Critical Care Medicine, 32(2), 412-
427.
Simons, S. H. P., van Dijk, M., Anand, K. S., & Rooft-
hooft, D. (2003). Do we still hurt newborn babies? A pro-
spective study of procedural pain and analgesia in neo-
nates. Arch Pediatr Adolesc Med 157(11), 1058-1064.
Stanik-Hutt, J. A., Soeken, K. L., Belcher, A. E., Fontaine,
D. K., & Gift, A. G. (2001). Pain experiences of traumati-
cally injured patients in a critical care setting. American
Journal of Critical Care, 10(4), 252-259.
Other Position papers/statements/guidelines
American Medical Directors Association. (2003).
Chronic pain management in the long-term care setting.
Columbia, MD: Author.
American Pain Society. (2003). Principles of analgesic
use in the treatment of acute pain and cancer pain (5th
ed). Glenview, IL, Author.
Anand, K. J. S., & International Evidence-Based Group
for Neonatal Pain. (2001). Consensus statement for the
prevention and management of pain in the newborn. Ar-
chives of Pediatric Adolescent Medicine, 155, 173-180.
National Association of Neonatal Nurses. (1999). Posi-
tion statement #3019. Pain management in infants. Re-
trieved January 10, 2005 from http.www.nann.org/files/
public/3019.doc.
American Pain Society & American Academy of Pediat-
rics. (2001). The assessment and management of acute
pain in infants, children, and adolescents. [Position state-
ment]. Retrieved January 10, 2005 from http.www.
ampainsoc.org/advocacy/pediatric2.htm.
American Academy of Pediatrics & Canadian Paediatric
Society. (2000). Prevention and management of pain and
stress in the neonate. [Policy statement]. Pediatrics,
105(2), 454-461.
 Pain Management
Nursing Role/Core Competency
A Guide for Nurses

______________________________________________________________________________

THE GUIDE MUST BE READ IN CONJUNCTION WITH THE NURSE PRACTICE ACT (MD. CODE ANN., HEALTH
OCC., 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.
 Pain Management
Nursing Role/Core Competency
A Guide for Nurses
PURPOSE OF THIS EDUCATIONAL GUIDE
The purpose of this document is to assist the
licensed nurse in recognizing his/her
accountability in effectively managing
patients’ pain through assessment,
intervention and advocacy.
BACKGROUND
Pain management encompasses various types
of pain experiences throughout an individual’s
life cycle from birth to the end of life. Pain expe-
riences may include acute and chronic pain, pain
from a chronic deteriorating condition, or pain as
one of many symptoms of the patient receiving
palliative 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 - to
address the dimensions of pain and to provide
maximum pain relief with minimal side effects.
Review of the literature, anecdotal reports and
dialogue with colleagues reveals that the majority
of patients do not receive adequate pain manage-
ment. A wide variety of factors including inaccu-
rate information, myths, rumors, fear and cultural
issues contribute to inadequate pain management.
For example, a prevailing rumor in the nursing
profession is that a nurse can lose his/her nursing
license for causing a patient’s respiratory depress-
ion by frequent administration or by giving high
doses of opioids, even though there is no documen-
ted evidence to substantiate this fear. The
literature shows that adequate assessment in
conjunction with opioid titration based on patient
2
Pain management is only one aspect of the
complex process of providing palliative care.
It is beyond the scope of this document to
address other issues involved in palliative
care.
response can provide maximum pain relief
without adversely affecting respiratory status.
Therefore, it is unwarranted to under-utilize or
withhold opioids from a patient who is
experiencing pain based on fear of causing
respiratory depression.
Due to multiple advances in the field of pain
management (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, addiction
and physical dependence?
4. Does aggressive use of opioids cause
addiction?
5. How does the patient’s cultural back-
ground effect pain expression and
management?
Myths and misinformation also contribute
to ineffective pain management. Some common
myths include:
 Pain Management Nursing Role/Core Competency
1. Too much pain medication too frequently
constitutes substance abuse, causes
addiction, will result in respiratory
depression 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 the
patient’s behavior;
5. The level of pain is often exaggerated by
the 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 Under
Management
Because of multiple barriers to adequate pain
management, all patients are at risk for under-
treatment of pain. Since pain is identified and
reported primarily through patient self- reporting,
difficulty in communicating increases the patient’s
risk for under-treatment.
3
Populations identified by the literature as being at
greater 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, the
homeless, and patients with terminal illnesses.
In
addition, patients who speak a different language
or who are from a cultural tradition different from
that of the clinician pose a special challenge. In
effect, any patient, regard- less of age, is at risk of
being under-treated for pain. All populations can
be placed at greater risk because of the health care
provider’s own belief system which may include
the previously discussed myths and
misinformation.
These factors and others have prompted the
Board to develop this educational guide for the
Maryland licensed nurse. The intent is to provide
factual information and assist the licensed nurse in
developing core nursing competencies in pain
management. The licensed nurse must become
familiar with standards, guidelines and definitions
regarding pain and its management, including but
not limited to those listed in the definition of
terms and bibliography and to refer to these
documents when advocating for the patient in
pain.
 Licensed Nurse Role:
Knowledge Based Practice
The licensed nurse is responsible and account-
able to ensure that a patient receives appropriate
evidence-based nursing assessment and interven-
tion which effectively treats the patient’s pain and
meets the recognized standard of care. In order to
advocate for the patient, the licensed nurse must
possess 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 achieving
effective pain management may be the nurse’s:
1. Individual experiences with pain;
2. Personal use of medications or non-
pharmacological methods to manage
pain; and,
3. Family’s or significant others’ history or
experience with substances for pain control or
mood 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 pain
level effectively or objectively. This can be further
compounded if the nurse does not have adequate
knowledge regarding pain management and, as a
result, can not recognize the need to seek out
additional information to assess and manage the
patient’s pain appropriately. For instance, a nurse
who believes or states, “You can tell by looking at
the patient if they are in pain” is demonstrating an
inadequate knowledge base.
B) Knowledge of Pain
4
Pain is subjective. It is whatever the patient
says it is. The nurse utilizes the nursing process in
the management of pain. Adequate measurement
and management of pain includes knowledge in
the following areas:
1. Pain assessment:
a) The nurse utilizes a developmentally
appropriate, standardized pain assessment tool
which includes: a pain measurement tool
which has demonstrated reliability and validity
and patient participation, which is essential in
the assessment process. For those incapable of
self-reporting, standardized pain assessment
tools should include behavioral observations
with or without physiologic measures.
i. Physiologic signs such as tachy-
cardia, hypertension, diaphoresis and pallor
are non-specific to pain and may be an
indicator of another, unrelated physiologic
problem. For patients in pain, these
physiologic signs may be present for a
short 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’s
pain experiences, methods of expressing pain,
cultural influences, and how the individual
manages their pain.
2. Pharmacologic and Non-Pharmacologic
Intervention:
a) The nurse is knowledgeable about the
pharmacological interventions of opioid,
non-opioid, and adjuvant drug therapies
 Pain Management Nursing Role/Core Competency
(including dosages, side effects, drug
interactions, etc.) which are most effective
for the most likely source of an individual
patient’s pain.
b) The nurse is knowledgeable that placebos
should not be utilized to assess if pain exists or
to 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 and
psychological dependence, withdrawal and
pseudoaddiction.
C) Knowledge of the Standard of Care
The standard of care is effective ongoing pain
assessment and pain management. This includes
but is not limited to:
1. Acknowledging and accepting the patient’s
pain;
2. Identifying the most likely source of the
patient’s pain;
3. Assessing pain at regular intervals, with
each new report of pain or when pain is
expected to occur or reoccur.
Assessment includes but is not limited
to:
a) The patient’s level of pain utilizing a
pain assessment tool;
5
b) Barriers to effective pain management,
which may include personal, cultural and
Institutional barriers. Sources of these
barriers may include but are not limited to
patient, 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 for
effective pain management involving the
patient, family and significant other;
6. Implementing pain management strategies
and indicated nursing interventions
including:
a) Aggressive treatment of side effects
(i.e. nausea, vomiting, constipation,
pruritus etc),
b. Educating the patient, family and
significant 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; and
9. Advocating for the patient and family for
effective pain management.
 PATIENT ADVOCACY
The nurse’s primary commitment is to the
health, welfare, comfort and safety of the
patient. Self-awareness, knowledge of pain and
pain assessment, and knowledge of the standard
of care for pain management enhances the
nurse’s ability to advocate for and assure
effective pain management for each patient.
When advocating for the patient, it is crucial
that the nurse utilize and reference current
evidence-based pain management standards and
guidelines.
As a patient advocate, the nurse takes all
reasonable means to alleviate the patient’s pain
and suffering. In addition, the nurse consults
and collaborates with specially trained experts in
pain management, such as registered nurses,
licensed physicians, pharmacists, massage
therapists, acupuncturists and others to assure an
effective interdisciplinary treatment plan to
address each patient’s pain. When the patient’s
pain needs are not being adequately addressed,
the nurse continues to advocate for the patient
through other means, such as referral to the
organization’s joint practice committee, the
ethics committee, and/or the organization’s
chain of command.
6
The nurse also has an obligation to advocate
for all patients in the aggregate. When an
organization’s policies, procedures and practices
are insufficient to provide consistent effective
pain management, the nurse works through
appropriate committees and channels to insure
that patients’ pain management needs are
addressed. This advocacy role is particularly
critical for populations known to be at risk for
under-management of their pain.
SUMMARY
This educational guide is intended to assist
the licensed nurse to act in an accountable
manner to effectively manage a patient’s pain.
This document emphasizes that the licensed
nurse must continue to develop self-awareness
and enhance his/her learning in order to remain
current in nursing knowledge and skill relative
to attempt to pain management. The licensed
nurse is responsible and accountable to work
toward effectively managing the patient’s pain
through assessment, intervention and patient
advocacy.
 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 pain
relief, encompassing the patient’s quality of
life, ability to work productively, to enjoy
recreation, to function normally in the
family and society, and to die with dignity.
2. Pain: An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage or described in
terms of such damage. Pain is always
subjective and is whatever the person says
it is, existing whenever the person says it
does. The clinician must accept the
patient’s report of pain. Categories of pain
include but are not limited to:
a) Acute Pain: A normal, predicated
physiologic response to an adverse clinical,
thermal or mechanical stimulus. It is
generally time-limited and responsive to
opioid and non-opioid therapy. Acute pain
responses may vary between patients and
between pain episodes within an individual
patient. Acute pain episodes may be
present in patients with chronic pain.
b) Chronic Pain: Malignant or non-
malignant pain that exists beyond its
expected time frame for healing or where
healing may not have occurred. It is
persistent pain that is not amenable to
routine pain control methods. Chronic pain
is often present with no physiologic signs,
which may lull the clinician into falsely
believing the patient is not in pain. Chronic
pain may result in a look of sadness,
depression, or fatigue causing the clinician
to misinterpret the picture and not identify
that the patient may also be experiencing
pain. Patients with chronic pain may have
episodes of acute pain related to treatment,
procedures, disease progression or re-
occurrence.
7
c) Breakthrough Pain: An acute
exacerbation of pain that breaks through
an existing analgesic regime.
2. Palliative Care: The active total care of
patients focusing on symptom manage-
ment, of which pain is only one of many
symptoms. The goal of palliative care is
achievement of the best quality of life for
patients, families and significant others by
addressing psychological, social and
spiritual problems, in addition to
controlling the patient’s pain and other
symptoms.
4. Suffering: The state of severe distress
associated with events that threaten the well
being of the person. Suffering often occurs
in the presence of pain, shortness of breath,
or other bodily symptoms. Suffering
extends beyond the physical domain. For
example, a woman awaiting breast biopsy
may “suffer” because of anticipated loss of
her breast, while after the biopsy the
woman may have “pain” from the
procedure.
5. Tolerance: The process by which the body
requires a progressively greater amount of a
drug, over time, to achieve the same results.
As it relates to pain relief, tolerance is
decreasing pain relief over time with the
same dosage. Patient can become tolerant
to the analgesic effect of opioid therapy,
requiring an increase in dose. For many
opioids there is no known ceiling to the
amount that can be given, meaning that
pain relief can increase with an increase in
the dose of the opioid. In addition, patients
can become tolerant to some adverse effects
(respiratory depression, somnolence, and
nausea) related to opioid therapy.
6. Substance abuse: The use of any chemical
substance for other than its medically
intended purpose.
 Pain Management Nursing Role/Core Competency
7. Pseudoaddiction: The pattern of drug-
seeking behavior among pain patients
because of inadequate management of their
pain problem which can be mistaken for
addiction.
8. Physical dependence: A physical response
of the body to a substance characterized by
signs of withdrawal if the substance is
stopped without tapering, markedly reduced
after prolonged use, or if an antagonist is
administered. Physical dependence is an
expected result of opioid use. Physical
dependence, by itself, does not equate with
addiction.
9. Abstinence (withdrawal) Syndrome:
Physical symptoms that can occur after
abrupt discontinuation or dose reduction of
an opioid or administration of an antagonist.
The syndrome is characterized by any or all
of the following: anxiety, irritability, chills,
hot flashes, salivation, lacrimation,
rhinorrhea, diaphoresis, piloerection, nausea,
vomiting, abdominal cramps, and insomnia.
Withdrawal should be avoided by gradual
reduction of dose rather than abrupt
discontinuation.
10. Addiction: A neurobehavioral disorder
characterized by compulsive seeking of
mood-altering substances and continued use
despite harm. Addiction may also be refer-
red to by terms such as “drug dependence”
and “psychological dependence.” Addiction
is not the same as physical dependence.
11. Opioid: Denotes both natural (codeine,
morphine) and synthetic (methadone,
fentanyl) drugs whose pharmacologic effects
are mediated by specific receptors in the
nervous system.
12. Non-Opioid: A medication that provides
pain relief, but that is not an opiate or a
nonsteroid anti-inflammatory drugs
(NSAIDS), acetaminophen). synthetic
analog of an opiate (i.e.
8
13. Adjuvant Medications: Medications that
are used to a) enhance the pain relieving
effects of opioids and non-opioids, b) treat
concurrent symptoms that exacerbate pain
such as utilization of anxiolytics, or c)
provide independent analgesia for specific
sources of pain (i.e. neurologic pain), such
as utilization of tricylic anti-depressants and
anti-convulsants.
14. Opiate: A drug whose origin is the opium
poppy, including codeine and morphine.
15. Pain Assessment: The comprehensive
evaluation of the patient’s pain including
but not limited to: location, intensity,
duration of the pain; aggravating and
relieving factors; effects on activities of
daily living, sleep pattern and psychosocial
aspects of the patient’s life, and effective-
ness of current management strategies. Pain
assessment includes the use of a
standardized pain measurement tool.
16. Pain Measurement Tool: The quantitative
examination of the intensity of the pain as
reported by the patient utilizing a standard-
ized instrument which has demonstrated
reliability and validity.
17. Titration: Adjustment of medication levels
within the dosage and frequency ranges
stipulated by the authorized prescriber in
accordance with an agency’s established
protocols, guidelines or policies.
18. Evidence-Based Practice: The conscien-
tious and judicious use of current best
evidence for making clinical decisions
about the care of patients. Evidence may
include but is not limited to: research
findings, literature, bench-marking data,
clinical experts, quality improvement, risk
management data, and standards and
guidelines.
 REFERENCES
Written Resources
1. Kaiser, Karen, RN, MS. “Personal Strate-
gies to Overcome Barriers to Inadequate
Pain Manage-ment.” Presented to Nursing
Practice Issues Committee, Maryland Board
of Nursing, September 1999.
2. Kaiser, Karen, RN, MS, Clyde, Chris, RN,
MS, Perrone, Margaret RN, BS, and
Tarzian, Anita RN, Ph.D. “Overcoming
Barriers to Adequate Pain Management.”
Presented to the Nursing Practice Issues
Committee, Maryland Board of Nursing,
September, 1999.
3. English, Nancy RN, Ph.D., Yocum, Cindy
RN, CRNH. “Guidelines for Curriculum
Development on End-of-Life and Palliative
Care In Nursing.” Presented to National
Council of Hospice Professionals, National
Hospice 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. “The
Role of Hospice Philosophy of Care in Non
Hospice Settings.” Journal of Law,
Medicine and Ethics. Vol 24, #4. Winter
1996. pp 365-368.
6. Keay, Timothy, MD, M.A.-TH and
Schonwetter, Ronald, MD. “Hospice Care
in the Nursing Home.” American Family
Physician. Vol. 57, No. 3. February 1,
1998. pp. 491-494.
7. Cameron, Miriam E. “Completing Life and
Dying Triumphantly.” Journal of Nursing
Law. Vol. 6, Issue 1. 1999. pp. 27-32.
8. Arnstein, Paul, P.D., ARNP “Policy
Statement: The Ordering and Administration
of Placebos.” Distributed by the Mayday
Pain Resource Center. 1998.
9
9. McCaffery, Margo, Ferrell, Betty R., and
Turner, Martha. “Ethical Issues in the Use
of Placebos in Cancer Pain Management.”
ONF (Ethical Issues). Vol. 23, No. 10.
1996. pp. 1587-1593.
10. Fohr, Susan Anderson J.D., MA. “The
Double Effect of Pain Medication:
Separating Myth from Reality.” Journal of
Palliative Medicine. Vol. 1, No. 4. 1998.
pp. 315-328.
11. Promotion of Comfort and Relief of Pain in
Dying. Position Statement - American
Nurses Association. Sept. 5, 1991.
12. Forgoing Nutrition and Hydration. Position
Statement-American Nurses Association.
April 2, 1992.
13. Active Euthanasia. Position Statement-
American Nurses Association. December
8, 1994.
14. Assisted Suicide. Position Statement-
American Nurses Association. December
8, 1994.
15. Portnoy, Russell. “Morphine Infusions at
the End of Life: The Pitfalls in Reasoning
from Anecdote.” Journal of Palliative
Care. Vol. 12, No. 4. 1996. pp. 44-46.
16. Mount Balfour. “Morphine Drips, Terminal
Sedation, and Slow Euthanasia: Definitions
and Facts, Not Anecdotes.” Journal of
Palliative Care. Vol. 112, No. 4 1996. pp.
31-37.
17. “Peaceful Death: Recommended Compet-
encies and Curricular Guidelines for End-
of-LifeNursing Care.” American
Association of Colleges of Nursing, Robert
Wood 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.
 Pain Management Nursing Role/Core Competency
19. “Controlled Substances and Pain
Management: 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 Board
of Registered Nursing, Approved 4/94,
Revised 3/99.
21. Pain Management Content Curriculum
Guidelines. California Board of Registered
Nursing. Approved 6/99.
22. Standards of Competent Performance.
California Board of Registered Nursing,
Approved 4/97.
23. _____ “Strengthening Nursing Education in
Pain Management and End-of-Life Care.”
Supported by a grant from the Robert Wood
Johnson Foundation. Completed December
3, 1998, updated edition February 10, 1999.
24. Model Guidelines for The Use of Controlled
Substances For the Treatment of Pain.
Federation of State Medical Boards of the
United 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. “Contemporary
Diagnosis and Management of Pain in
Oncologic and AIDS Patients.” Handbooks
in 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, Health
Occupations Article, Title 8,§§ 8:101(e) and
(f).
29. Maryland Board of Nursing DR 97-6 Re:
The Role of the Registered Nurse (RN) in
The Management of Analgesia by Catheter
Techniques (Epidural, Intrathecal,
Intrapleural, or Peripheral Nerve Catheters),
issued by the Board June 24, 1997.
30. Resource Guide: Information about
Regulatory Issues in Pain Management. Pain
& Policy Studies Group, WHO
Collaborating Center for Policy and
Communications in Cancer Pain. University
10
of Wisconsin Comprehensive Cancer
Center, Madison, Wisconsin. July 1998.
31. Spross, J., McGuire, D., and Schmitt, R.
(1990). ONS position paper on cancer
pain. Part I. ONF, 17(4):585-614.
32. Spross, J., MCGuire, D., and Schmitt, R.
(1990). ONS position paper on cancer
pain. Part II. ONF, 17 (5):751-760.
33. Spross, J., McGuire, D., and Schmitt, R.
(1990). ONS position paper on cancer
pain. Part III. ONF, 17(6):943-955.
34. Bieri, D., Reeve, R.A., Champion, G.D.,
Addicoat, L. and Ziegler, J.B. “The Facies
Pain Scale for the Self-Assessment of the
Severity of Pain Experienced by Children:
Development, Initial Validation, and
Preliminary Investigations for Ratio
Properties.” Pain. 1990. 41:139-50.
35. Cassel, Eric J., MD. “The Nature of
Suffering 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 State
Pain Policy: A Guide to Evaluation Part I.
The Pain and Policy Studies Group,
University of Wisconsin Comprehensive
Cancer Center. Madison, Wisconsin 1999.
37. North Carolina Joint Statement on Pain
Management in End of Life Care, Adopted
by the North Carolina Medical, Nursing
and 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 Quality
Assurance Commission, Guidelines for
Management of Pain. 4/18/96.
40. Gebbie, Kristine M., Wakefield, Mary, and
Kerfoot, Karlene. “Nursing and Health
Policy.” Journal of Nursing Scholarship.
Third Quarter, 2000. pp 307-314.
 Pain Management Nursing Role/Core Competency
41. McPheeters, M., MPH and Lohr, K.N.,
PhD., “Evidenced-Based Practice and
Nursing: 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 About
Evidence-Based Practice?” (Research
Corner). AORN Journal. Vol. 72, No
1. July 2000 pp. 109-111.
44. Stetler, Cheryl B. Ph.D, RN, FAAN, et al
“Evidence-Based Practice and the Role of
Nursing Leadership.” JONA. Vol 28, No.
7/8. July/August, 1998. pp. 45-53.
45. Web site addresses:
a) National Guidelines Clearing House -
www.mzch.gov
b) Americans for Better Care of the Dying -
www.abcd-caring.com
c) American Pain Society-
www.ampainsoc.org
d) American Society for Biothics and
Humanities -www.asbh.org
e) Center for Ethics in Health Care -
www.ohsu.edu.ethics
f) Oncology Nursing Society -
www.ons.org
g) Pain Link Home, A Pain Management
Resource - www.edc.org/painlink
h) 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 Cancer
Center-www.mskcc.org
k) May Day Pain Link-City of Hope-
www.city of hope.org/medinfo/
medresin.htm
11
l) Growth House News--www.growthouse
org or www.pallcare.org/growth.htm
m) Wisconsin Educational Consortium on
PainPolicy--www.medsch.wisc.edu/
pain policy/ncjoint.htm.
46. Standards and guidelines for pain
management:
a)____, Management of Cancer Pain:
Adults. Clinical Practice Guidelines #9.
Quick Reference Guide for Clinicians.
U.S. Department of Health and Human
Services, Public Health Service, Agency
for Health Care Policy and Research.
March, 1994.
b) ____, Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain,
3rd Ed. American Pain Society. Skokie, Ill.
c) ____, The Use of Opioids for the
Treatment of Chronic Pain. © 1997
AmericanAcademy of Pain Medicine and
American 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 Management
Nurses Pathways, Winter 1996. pp. 12-14.
e) New JCAHO Standards: Intents,
Examples, and Scoring Questions for Pain
Assessment and Management in Hospitals.
May 1999.
f) ____, Acute Pain Management in Adults:
Operative Procedures. A Quick Reference
Guide for Clinicians. U.S. Department of
Health and Human Services, Public Health
Service, Agency for Health Care Policy and
Research.
g) ____, “The Management of Chronic Pain
in Older Adults.” American Geriatric
Society’s Panel on Chronic Pain in Older
Adults. Journal of The American Geriatric
Society. Vol.46. 1998. pp. 635-651.
 Resources
Personal
1. Karen Kaiser, RN, MS, Clinical Practice
Coordinator, University of Maryland Medical
System, Baltimore, MD.
2. Margaret Perrone, RN, CRNH, Program
Coordinator, Palliative Care Program,
University of Maryland Medical System,
Baltimore, MD.
3. Anita Tarzian, RN, PhD., Maryland Health
Care Ethics Committee Network, University
of Maryland School of Law, Baltimore, MD.
4. Chris Clyde, RN, Nursing Coordinator,
University of Maryland Medical Systems Pain
Center, Baltimore, MD.
5. Marilyn McCord, RN, Pulmonary Clinical
Specialist, Sinai Hospital, Baltimore, MD.
6. Donna Hale, RN, MS, Consultant in
Perioperative/Pain Service/Sinai Joint Center,
Life Bridge Health Center, Baltimore, MD.
7. Veronica Noah, RN, IV Therapy-Pain
Management Team. Frederick Memorial
Hospital, Frederick, MD.
8. Mary Lou Perin, RN, MSN, Pain Management
Consultant. Pain Relief/USA. Middletown,
MD.
9. Lori KozlowskI, CRNP-P, Acute Pain
Management Team. Johns Hopkins Hospital,
Baltimore, MD.
10. Kathleen White, RN, PhD, Nursing Practice
Issues Committee, Maryland Board of
Nursing, Baltimore, MD.
11. Ann K. Sober, RN, BS, Nursing Practice
Issues Committee, Maryland Board of
Nursing, Baltimore, MD.
12. Voncelia S. Brown RN, MS, Nursing Practice
Issues Committee, Maryland Board of
Nursing, Baltimore, MD.
13. Ralph Washington, RN, Nursing Practice
Issues Committee, Maryland Board of
Nursing, Baltimore, MD.
12
14. Bernadette Greene, RN, MS, Nursing
Practice Issues Committee, Maryland
Board of Nursing, Baltimore, MD.
15. Ann Triantafillos, RN, MSN, Nursing
Practice Issues Committee, Maryland
Board of Nursing, Baltimore, MD.
16. Sandra L. Dearholt, RN, MS, Nursing
Practice Issues Committee, Maryland
Board of Nursing, Baltimore, MD.
17. Charlene A. Hall, LPN, Nursing Practice
Issues Committee, Maryland Board of
Nursing, Baltimore, MD.
18. Carol F. Wynne, RN, MS, Nursing
Practice Issues Committee, Maryland
Board of Nursing, Baltimore, MD.
19. Marsha Hopkins, LPN, Nursing Practice
Issues Committee, Maryland Board of
Nursing, Baltimore, MD.
20. Laurie Miller, RN, BS, Nursing Practice
Issues Committee, Maryland Board of
Nursing, Baltimore, MD.
21. Lou Williams, RN, Nursing Practice
Issues Committee, Maryland Board of
Nursing, Baltimore, MD.
22. Susan Niewenhous, RN, MS, Nursing
Practice Issues Committee, Maryland
Board of Nursing, Baltimore, MD.
23. Kathryn Offenbacher, RN, BSN,
Nursing Practice Issues Committee,
Maryland Board of Nursing, Baltimore,
MD.
24. Chris Murphy, RN, BSN, Nursing
Practice Issues Committee, Maryland
Board of Nursing, Baltimore, MD.
25. Debbie Somerville, RN, MPH, Nursing
Practice Issues Committee, Maryland
Board of Nursing, Baltimore, MD.
13