Pain observation and behaviour

Behaviour that may indicate pain are: 

• • facial expressions, such as wincing, grimacing, frowning, blinking rapidly; body movements, such as different ways of walking, protective or slowly walking, staggering, rubbing hands, repetitive movements;
  • verbalizations/vocalisations, such as moaning, grunting, asking for help, yelling, aggressive or offensive language;
  • changes in interactions, such as aggression, withdrawal, rejection of care;
  • changes in activities or routines, such as wandering, different sleep patterns;
  • changes in mental status, such as crying, confusion, irritability;

  In addition, there are also physiological observations that may indicate pain, such as altered breathing patterns and sweating. For patients with dementia, however, there are indications that these observations are unreliable (Scherder et al., 2005).

Everyone reacts differently to pain, and culture influences forms of expression. Pain is a subjective experience.

The healthcare professional must take the patient’s wishes into account. It can be difficult to put one’s own norms and values aside in relation to “oversensitive” people or people who do not show pain emotion. Using pain medication is one way to cope with pain. Pain can be relieved by taking it seriously by paying attention, performing ritual activities and prescribing relaxation exercises and placebos.

Most older people do not tell themselves that they are in pain (they prefer not to “complain”), or they use other words for it, such as “discomfort” or “an unpleasant feeling”. In addition, many older people think that pain is part of ageing.

Neuropathic pain (due to diabetes mellitus) is sometimes palpable and sometimes not. For example, touching the leg/foot is less noticeable, but the pain due to the damaged nerve is noticeable. It is also possible that the older person does not suffer from the neuropathy, but does suffer from the consequences; for example, they walk on a drawing pin and not feel it.

As a nurse or caregiver, you can encourage older people to talk about their pain so that it can be treated. You can help to remove misunderstandings. You can teach people who cannot talk about their pain to recognize their pain, for example when someone spares themselves, shows limitations or indicates fatigue.

Instruments that you can use to score non-verbal expressions of pain in older people include Painaid, PACSLAC and DOLOPLUS-2.

A commonly used model to describe pain is Loeser’s model. This model can help you visualize the pain problem as a structure and describes pain using four circles:

1. Nociception: impending injury in which pain stimuli are converted into nerve signals = physical (no awareness yet).
2. Pain perception: awareness as a result of a pain stimulus that has arrived in the brain and has been converted into awareness.
3. Pain perception: dependent on each person. The experience is determined, among other things, by previous experiences with pain.
4. Pain behaviour: behaviour that the client shows to communicate pain verbally/non-verbally.

 

References: 

Mahdi et al. (2020) Intercultural competence and Health Care. Royal van Gorcum B.V

Verenso 2016. Multidisciplinaire Richtlijn Pijn. Herkenning en behandeling van pijn bij kwetsbare ouderen. Deel 2. VER-003-32-Richtlijn-Pijn-deel2-v5LR.pdf (verenso.nl)

Schim van der Hoeff-van Veen (2017) Geriatrie. BSL

Verenso 2016. VER-003-32-Richtlijn-Pijn-deel2-v5LR.pdf (verenso.nl)  p.40 en p. 23 

Verenso 2016 . VERRichtlijnPijnDeel3web.pdf (verenso.nl) bijlage A

Bleijenberg N. (2019) in: Bakker T. Klinisch redeneren bij ouderen, BSL