Using the PAINAD Scale for Acute Pain Assessment
For patients with significant cognitive impairment, communicating pain verbally can be difficult or impossible, making reliance on traditional numerical pain scales unreliable. An ankle fracture is a known source of acute, nociceptive pain, so the nurse should assume the patient is experiencing pain. The Pain Assessment in Advanced Dementia (PAINAD) scale is a validated and recommended observational tool for this population. It provides a systematic way to monitor behavior for signs of pain, ensuring that it is not overlooked. The nurse should observe the patient for 3–5 minutes, especially during movement like repositioning or transferring, as pain is often more apparent during activity.
The components of the PAINAD scale
The PAINAD scale assesses five key behavioral categories, with each item scored from 0 (normal/no pain) to 2 (most severe pain):
- Breathing, independent of vocalization: The nurse observes the patient's breathing pattern, noting if it is labored, noisy, or hyperventilating.
- Negative vocalization: This includes any moaning, groaning, calling out in a troubled way, or crying.
- Facial expression: Signs include frowning, grimacing, or having a sad or frightened expression.
- Body language: The nurse looks for tense body posture, fidgeting, rigidness, clenched fists, or pulling away from touch.
- Consolability: This evaluates the patient's response to attempts at soothing, noting if they are distracted, reassured, or unable to be consoled.
The total score, ranging from 0 to 10, provides a baseline for pain assessment. A higher score indicates a higher likelihood of pain, guiding the nurse to intervene with pain management strategies.
Comparison of Pain Assessment Scales
While PAINAD is a strong choice, other observational scales exist for similar patient populations. A brief comparison helps to understand the rationale for selecting the most appropriate tool in this specific acute care context.
| Feature | PAINAD | FLACC Scale | Abbey Pain Scale | PACSLAC |
|---|---|---|---|---|
| Target Population | Adults with advanced dementia/cognitive impairment | Originally children; also used for non-communicative adults | People with late-stage dementia, often in residential settings | Seniors with limited ability to communicate |
| Scoring Range | 0 to 10 (0-2 for 5 items) | 0 to 10 (0-2 for 5 items) | 0 to 18 (0-3 for 6 items) | Checklist; not a summative score, uses checkmarks for presence of behaviors |
| Acute vs. Chronic Pain | Effective for both acute (e.g., fracture) and chronic pain | Can be effective for acute pain assessment | Developed for late-stage dementia but validated for some acute pain | Primarily a screening tool for monitoring changes over time |
| Assessment Items | Breathing, negative vocalization, facial expression, body language, consolability | Face, Legs, Activity, Cry, Consolability | Vocalization, facial expression, body language, behavioral changes, physiological changes, physical changes | Includes facial expressions, body movement, social/mood, vocal/physiological |
| Key Limitation | Observer-dependent, can lack a verbal report of intensity | Difficulty distinguishing between pain and non-pain distress | May not be as reliable in acute care environments as it was developed for residential settings | Provides presence/absence of behaviors, not an intensity score |
The PAINAD scale is particularly well-suited for an acute situation like an ankle fracture in a cognitively impaired adult due to its focus on clear, observable behaviors and established use in various care settings, including acute hospitals. It provides a standardized method for assessing pain, which is critical for consistent care.
Best practices for utilizing the PAINAD scale
To ensure the most accurate pain assessment for this patient, the nurse should follow best practices beyond just completing the scale:
- Start with a comprehensive pain assessment approach: Use a hierarchy of assessment techniques, starting with the highest level of patient self-report possible, even if limited. Acknowledge existing painful conditions like the ankle fracture.
- Involve family or caregivers: Ask those familiar with the patient about baseline behaviors and typical pain indicators. They can often provide valuable context for understanding changes.
- Assess frequently and consistently: Use the PAINAD scale consistently over time, and especially after interventions, to track changes and evaluate the effectiveness of pain management.
- Consider a time-limited analgesic trial: If pain is suspected based on behavioral observation, administering a pain medication trial can help confirm if the behaviors are pain-related. Assess the patient's behavior before and after giving the analgesic.
- Contextualize observations: Remember that some behaviors indicating pain, such as agitation, could be caused by other factors like hunger, thirst, or infection. Ankle fractures are clearly painful, but a comprehensive assessment helps rule out other potential causes of distress.
Conclusion
For a patient with cognitive impairment and pain from an ankle fracture, the nurse should utilize the Pain Assessment in Advanced Dementia (PAINAD) scale. This observational tool is highly effective for patients who cannot verbally report pain, allowing nurses to systematically evaluate behavioral indicators like breathing, vocalization, facial expression, body language, and consolability. While other tools exist, PAINAD is a validated choice for this vulnerable population in acute care settings. The nurse should integrate this tool into a comprehensive assessment that includes input from caregivers, frequent observation (especially during movement), and trials of analgesics to ensure proper pain management. This systematic and multi-faceted approach helps to ensure that a patient's pain is identified and treated effectively, improving comfort and overall care. National Institute on Aging: Pain Assessment in Cognitively Impaired Adults is a helpful resource for further reading.
