Evaluating Pain in a Non-Verbal Patient
Dear OncoLink "Ask The Experts,"
Erin McMenamin, MSN, CRNP, AOCN, Pain Medicine Nurse Practitioner and Program Manager at the Abramson Cancer Center of the University of Pennsylvania, responds:If a patient is nonresponsive, we generally assume that he or she is not responding to pain. As for nonverbal patients, we use a rating of nonverbal indicators and assess if these indicators are present at rest and/or with movement (see below). One point is given for each "yes" response, resulting in a score on a 0-12 scale.
In ICU patients, the RASS scale is used, which evaluates agitation and sedation.
A good reference is:
Herr, K et al. (2006) Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations. Pain Management Nursing, Vol 7, No 2 (June): pp 44-52.