NUR 3220 Module 6 Pain Assessment Paper: Self-Report, Patients Who Cannot Self-Report and Bias Example

Believing the Patient: Pain Assessment for Two Patients, and the Bias Research Warns About, on a Newark Surgical Unit

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-3220: Fundamentals of Nursing

Mentor Name

Month Day, Year

Believing the Patient: Pain Assessment for Two Patients, and the Bias Research Warns About, on a Newark Surgical Unit

Two Patients

The patients and the unit are invented. Mr. Jenkins, 45, is a Black man on his first day after an open bowel resection. He reports pain at 8 on a 10-point scale and asks for another dose, though he is talking calmly with his wife and watching television. A staff nurse comments that he does not look like he is in that much pain. Mrs. Ruiz, 86, has advanced dementia and was admitted after a hip fracture repair. She cannot rate her pain, calls out repeatedly, pulls at her dressing and resists turning.

Pain Is What the Patient Says

Pasero and McCaffery (2011) built their approach on McCaffery's definition that pain is whatever the experiencing person says it is, existing whenever they say it does. They argued that the patient's self-report is the most reliable indicator of pain, that behaviors and vital signs are poor substitutes in people who can report and that nurses must accept the report even when the patient does not appear to be in pain. People cope with pain in different ways; some talk, some watch television and some lie still. They also described tools for rating pain, such as numeric scales and faces scales, and the importance of reassessment after treatment.

For Mr. Jenkins, the principle is clear: his rating of 8 is his pain. That he is calm or watching television does not change it.

When Patients Cannot Self-Report

Herr et al. (2011) set out a hierarchy of pain assessment for patients unable to self-report, including people with advanced dementia, unconscious patients and infants. First, attempt self-report, even a simple yes or no. Second, search for potential causes of pain, such as surgery or a fracture, and assume pain is present when a painful condition or procedure exists. Third, observe behaviors, using a validated behavioral tool appropriate to the population. Fourth, ask family or caregivers who know the person what behaviors suggest pain. Fifth, attempt an analgesic trial and watch whether behaviors improve.

For Mrs. Ruiz, the hierarchy calls for assuming pain after hip surgery, observing her behaviors with a tool, asking her daughter and trying an analgesic.

Bias in Pain Assessment

Hoffman et al. (2016) surveyed white medical students and residents about supposed biological differences between races, for example whether Black people's skin is thicker or their nerve endings less sensitive. Roughly half agreed with one or more of the false statements. Participants who held more of these false beliefs judged the Black patient in an identical mock case to be in less pain and made less accurate treatment recommendations. The study helps explain long-documented differences in how pain is treated across racial groups.

The comment that Mr. Jenkins did not look like he was in pain may reflect exactly this kind of bias, whether conscious or not.

Assessing Mr. Jenkins

The student accepted Mr. Jenkins's rating and asked about the pain's location, quality and what helped. He said it was sharp at the incision and worse with coughing. His last dose of opioid had been four hours earlier, and his order allowed a dose every three hours as needed. After discussing with her instructor and the nurse, the student gave the medication, taught him to hug a pillow against the wound when he coughed and reassessed in an hour, when he rated his pain 4. She later spoke with her instructor about the staff nurse's comment, and the instructor discussed it privately with the nurse.

Assessing Mrs. Ruiz

The student tried asking Mrs. Ruiz simple questions, but she could not answer reliably. She scored Mrs. Ruiz on the PAINAD, a dementia pain scale that looks at breathing, distressed sounds, facial expression, body posture and how easily she can be comforted, and Mrs. Ruiz scored 7 out of 10. Her daughter said her mother always called out when she hurt. Assuming pain after hip surgery, the student gave the scheduled acetaminophen and, with the nurse, the as-needed opioid ordered for pain, then repositioned her gently with a pillow between her knees. An hour later, her score was 2, she had stopped calling out and she let the nurse turn her.

Pain Medication Safety

Believing a patient's report does not mean ignoring safety. Before giving Mr. Jenkins's opioid, the student checked his sedation level and breathing rate, since sedation usually comes before dangerous respiratory depression. She used the unit's sedation scale before the dose and an hour after. For Mrs. Ruiz, the student and nurse started with the lowest ordered dose because of her age and watched her closely. Pasero and McCaffery describe monitoring sedation as the key safety step with opioids, which allows nurses to treat pain fully while catching early warning signs.

Non-Drug Measures

The student also used measures that do not depend on medication: splinting for Mr. Jenkins's cough, repositioning and a quiet room for Mrs. Ruiz and asking her daughter to sit with her and hold her hand. Mrs. Ruiz calmed when her daughter spoke to her in Spanish, the language she used at home.

Examining Her Own Judgments

The study by Hoffman and colleagues prompted the student to ask herself whether she had ever doubted a patient's report because of how they looked or who they were. She recognized moments when she had expected a patient to be exaggerating. She now records the patient's own words with the pain score and asks herself, before doubting a report, whether she would doubt it from a different patient.

Limits

Self-report can be influenced by fear, culture and the wish to please, and nurses must still consider safety with opioids. Behavioral tools can be affected by agitation from causes other than pain. The bias study involved medical trainees and mock cases, not nurses with real patients.

Conclusion

Two patients needed two kinds of assessment: belief in a clear self-report and a structured approach when self-report was impossible. Pasero and McCaffery's principle, the position statement on patients unable to self-report and research on racial bias showed the student how to assess accurately and fairly. Both patients' pain improved when it was believed and treated.

References

Herr, K., Coyne, P. J., McCaffery, M., Manworren, R., & Merkel, S. (2011). Pain assessment in the patient unable to self-report: Position statement with clinical practice recommendations. Pain Management Nursing, 12(4), 230-250. https://doi.org/10.1016/j.pmn.2011.10.002

Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296-4301. https://doi.org/10.1073/pnas.1516047113

Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management. Mosby.