We all want the best for our patients, that’s why we do the job we do. As Veterinary Nurses we are advocates for our patients which means we have an ethical obligation to speak up for, defend, and act on behalf of animals in our care. One way we can do this is to minimise pain and alleviate suffering through appropriate pain management protocols. A key component of this is pain scoring.
How Pain effects our patients
Pain is an unpleasant physical sensation caused by injury or illness. All animals have the ability to feel pain and I’m sure at some stage in your life you have experienced this feeling yourself! It is our duty as vet nurses to work alongside the vets to assess pain and administer appropriate analgesia to our patients as required.
Pain plays a very important role in the overall health and wellbeing of animals. Not only can pain have negative emotional effects on our patients causing an increase in fear, anxiety and stress, it can have physical effects on the body systems too which can delay the recovery period.
The Difficulties in Assessing Pain
Cats and dogs are good at hiding pain, it’s their protective mechanism. They may seem a bit quiet or off their food and this is often put down to them being stressed about being in a different environment. It is easy to believe that they are tolerating the pain. Many old or severely ill animals and are too weak to display excessive behaviours, such as howling, whereas patients that show extreme behavioural signs or those that have severe obvious injuries, such as a fractured bone, are given analgesic relief. Patients that are showing these signs are often in severe pain by this point. It is important that we don’t allow animals to get to that stage before giving analgesics, they should not have to prove that they are in pain to get appropriate pain relief.
Unlike in human medicine where patients are able to tell us about the pain they are experiencing we have to be able to recognise the signs of pain in non-verbal patients. We use both physiological and behavioural signs along with our knowledge of likely causes of pain to guide its management.
Even though pain is experienced by all animals it is very much an individual experience. Behavioural expression of pain varies between each patient and is dependent on the species, age, gender, current health status, temperament and environment. These factors should be taken into consideration when assessing patients.
When should we assess our patients pain levels?
Assessment of pain is the first important step in its successful management. The WSAVA states that pain assessments should be considered as the 4th vital sign after temperature, pulse and respiration and that pain assessments should be carried out at each patient examination.
The frequency of pain assessments will be determined on an case by case basis and will depend on hospital protocols and the types of analgesia being used. Patients in the immediate post-operative recovery period or in a critical condition will generally be monitored more frequently than those in the general wards. It is recommended that post-operative pain assessments are performed every 30 minutes, whereas general day stay patients should be assessed every 4 hours or a minimum of 4 times per day.
Why use Pain Scoring Systems
Pain scales are frequently used in human medicine but are still fairly new to Veterinary Practice. As our patients cannot tell us about the pain they are experiencing it is important that we learn to recognise the signs of pain.
As individual people and animals experience pain differently, we can also interpret another individuals pain how we ourselves would experience it. What I might think is something that would be extremely painful, someone else may think it’s not quite as bad. It is very easy to allow our personal emotions to affect this assessment. Because of this, often vet nurses find their requests to give pain relief are often denied.
When we do pain scoring via pain scales, we get a set of ‘rules’ to follow so that a more uniform score on a patients pain level can be given. This eliminates the ‘variables’ that can occur through different staff members performing assessments and provides a more accurate picture of the patients status. We can then interpret the information from the pain scale and communicate with our vets about a patients requirement for pain relief.
The CSU Pain Scale
The Colorado State University (CSU) has developed a pain scale that is easy to use and uses a combination of pictures and descriptions to evaluate an animals pain level. It starts with a quiet distance observation of the patient and then a more hands on physical examination. It encourages the observer to focus on the overall pain of the patient in addition to the primary lesion. There is minimum room for interpretation required which decreases the variables through having multiple observers. There are CSU pain scales available for dogs, cats and horses and each depicts the specific behaviours observed by each species.
Introducing Pain Scales into your clinic
There are a variety of pain scales available to use and some clinics have their own. If the pain scales are too complicated then they are likely to not be used correctly and cause inconsistencies. This is an important factor to remember when deciding on which one to use. We want to ensure that all our team in actively involved in pain scoring and use the same system for consistency.
Introducing new protocols into a clinic can be challenging as I’m sure we will all agree. It is not something to be rushed and all staff need to be on board and receive training on how to use the charts to ensure that new protocols are followed and adhered to.
Shaffran, N and Grubb, T, ‘Pain Management’ In Clinical Textbook for Vet Technicians 7th ed.
Phillips, H 2012, Pain Management Learners Guide. Melbourne: Veterinary Nurse Solutions
Mathews, K Kronen, P Lascelles D, Nolan, A Robertson, S Steagall, P Wright, B Yamashita, K 2014, ‘Guidelines for the Recognition, Assessment and Treatment of Pain’ WSAVA