Pain Assessment in the Nonverbal Patient
There are a variety of reasons that patients may be unable to verbalize pain, such as sedation, dementia, and delirium.
This can make it difficult to assess, and treat appropriately. When dealing with a patient like this, a first attempt should be made to elicit a self-report from the patient. If this is not possible, discussions with caregivers and family should be used to identify changes in behavior or actions that could be attributed to pain. As a supplement, non-verbal indicators of pain can be used, including:
- Body movements: writhing, restlessness, irritability, agitation
- Compliance with ventilator: coughing, biting endotracheal tube
- Sympathetic activation: Hypertension, tachycardia, diaphoresis
- Facial expressions: grimacing, squinting eyes, tense face, tears
- Reactions to physical exam and movement: combativeness, immobility
Increased vital signs can be used to identify pain, but absence of increased vitals does not indicate absence of pain. If non-verbal indicators are present in the setting of potentially painful conditions (pancreatitis) or procedures (surgery, wound care), then it should be assumed that pain is present and an analgesic trial should be attempted. Response to analgesic trials will help to confirm the presence of pain.
For mechanically ventilated patients, it is important to remember that neither sedatives (propofol, benzodiazepines) nor paralyzing agents (cisatracurium, rocuronium) provide pain control. Most patients on sedation will require adjunctive use of an opioid to maintain comfort while intubated. Opioid use in neuromuscular blockade is highly recommended for every patient due to inability to express physical reactions to pain. If pain is severe and/or chronic, opioid treatment should continue during and after the ventilator weaning process. Untreated and undertreated pain can result in agitation which can make ventilator weaning difficult.
Patients with dementia can be more complex to interpret. With these patients it is imperative that we rely on family member and caregiver interpretations of behavior. If no other source of acute altered behavior is identified (ex: UTI, sepsis, stroke), pain should be considered and an analgesic trial attempted.
Due to the intricacy of the pain assessment in the non-verbal patient, it is recommended that resources are utilized as appropriate. Consults for anesthesia, clinical nursing, and/or clinical pharmacy are available to support your efforts.