Patients’ behaviors may provide clues about whether or not they have pain. For example, facial expressions, restlessness, bracing, and changes in activity have been shown to be indicators of pain in patients who are unable to self-report (Gelinas, Fillion, Puntillo, Viens, & Fortier, 2006; Hadjistavropoulos et al., 2007; Herr et al., 2011; McCaffery, Herr, & Pasero, 2011; Pasero, 2009a).
Table 5-1 Hierarchy of Importance of Pain Measures
A number of behavioral pain assessment tools have been tested in patients who cannot report pain; for example, the Critical Care Observation Tool (CCOT) for patients who are critically ill (Gelinas, Fillion, Puntillo, Viens, & Fortier, 2006; Gelinas, Harel, Fillion, Puntillo, & Johnston, 2009; Gelinas & Johnston, 2007). Although behavioral pain assessment tools help to determine whether patients have pain, a limitation of many of them is that they designate specific behaviors, such as body movements and muscle tension, which must be observed and scored depending on the extent to which the behaviors are present. Appropriate use of these tools requires nurses to carefully evaluate each patient’s ability to respond with the requisite behaviors specified by the tool to prevent undertreatment of pain (Pasero, 2009a). For example, tools that require assessment of body movement are not appropriate for use in patients who cannot move, such as those receiving a neuromuscular blocking agent. In such patients, the recommended approach is to assume pain is present (see Table 5-1) and provide recommended doses of analgesics. This assumption can be justified by research that has shown that endotracheal intubation, ventilation, and suctioning-all required in patients receiving a neuromuscular blocking agent-are painful (Puntillo et al., 2001; Stanik-Hutt, Soeken, Belcher, Fontaine, & Gift, 2001).