ASSESSING PAIN WITH COGNITIVE IMPAIRED PATIENTS: A PILOT STUDY TO TEST AN ASSESSMENT TOOL ON TRAUMA WARDS

The assessment of pain in patients with cognitive impairment has been recognised as a challenge by many clinicians. As people live longer their risk of falls increases as does the incidence of dementia and acute delirium during hospitalisation (Ouldred and Bryant 2012). As a result many patients on trauma and orthopaedic units are older and experience some degree of cognitive impairment, for example between 10% and 50% of fractured neck of femur patients experience acute delirium following surgery (Ouldred and Bryant 2012). This means that they may have difficulties using a pain scale and communicating their pain. Herr (2011) recommends the use of behavioural pain assessment tools when patients are unable to express their pain using a verbal rating scale.There are many behavioural pain assessment tools available that tend not to be used routinely in everyday practice (Manias 2012). Many of the tools were devised for use in long-term care, such as the Abbey Pain scale (Abbey et al 2000) and the Pain assessment IN Advanced Dementia (Warden et al 2004). These rely to some extent on knowledge of the individual to identify a change from normal behaviour and nurses in acute care do not have this knowledge of the individual. There are fewer behavioural pain assessment tools for use in acute care. The Checklist for Nonverbal Pain Indicator (CNPI) (Feldt 2000) was devised on trauma wards in the USA. It consists of six observations, at rest and on movement. When the CNPI was trialled on a trauma unit in the UK it was found to have practical problems in its use, it was simplistic and not consistently effective in assessing pain when evaluated by the staff on the unit and when compared to other behavioural pain assessments (Gregory 2012). Although using a behavioural pain assessment tool did help assess pain it was observed that in some instances the family of individual patients identified pain and were able to describe behaviour indicting pain based on their knowledge of the patient’s normal behaviour.A new behavioural pain assessment tool was devised as a result of trialling established behavioural pain assessment tools the projects findings. A combination of the Abbey pain scale with the format of the PAINAD has been produced with the inclusion of a description of specific pain behaviours by members of a patient’s family. This is a unique addition to a behavioural pain assessment tool and it is felt that involvement by the family is important and that they should be included in the assessment process. The assessment tool produced has been named the Bolton Pain assessment Scale (BPAT) (Gregory 2012).When behavioural pain assessment tools have been validated there has been limited involvement of the clinical teams who will use them in everyday practice. To ensure that the BPAT will be acceptable and used in everyday practice clinicians have been involved in its production and small pilot studies have been undertaken as ‘proof of concept’ project within trauma units in NHS hospitals within the UK.