A veterinary nurse’s guide to pain recognition and management in companion animals

Hopefully, the days are long gone of giving an animal in pain a shot of non-steroidal and hoping it was enough or otherwise reaching for the securely locked bottle of pethidine to give a painful intramuscular injection. Nowadays, we have many strings to our veterinary bow when it comes to pain control and management. Although veterinary nurses cannot prescribe or administer pain medication without direction from the veterinary surgeon, there are things they can do to help patients during their stays to ensure they are as pain-free as possible.

Analgesia and pain management are some of the most common areas nurses need to manage within the veterinary practice, and the definition is broad; it can mean acute pain, say, a road traffic accident with a broken limb, or it can mean more chronic pain, such as that seen with osteoarthritic patients. Furthermore, how one animal responds to pain differs from how another may react – this is no different than my pain threshold being quite high compared to that of some of my friends!

So, it is important that, as veterinary nurses, we recognise signs of pain and discomfort, report them to the veterinary surgeon, implement any changes needed or prescribed and, most importantly, monitor their response to those changes to see if they have a positive effect or if more needs to be done.

Common signs of pain and discomfort to look out for

Signs of pain and/or discomfort you should look out for include:

• Vocalisation – this is especially important if the patient was previously quiet or if the vocalisation has changed from an “annoyed I’m in a kennel” noise to a more painful/unsettled one
• Panting – often accompanied by drooling
• Shivering/shaking
• Pacing and general unsettled appearance – are they trying to lie down but can’t get comfortable? Can they bend down to the water and food bowls?
• Refusal to eat – obviously some patients refuse food in hospital because they are fussy eaters or have a special diet, or purely due to stress, but if you have checked with the parents what the patient eats and they are still refusing it, don’t discount the fact they may be experiencing pain when eating
• Aversion to handling – shying away, hissing/growling and hiding may all be signs that the patient is scared of being handled as they associate it with pain. Is the patient always like this in the clinic? Were they like this prior to the illness/procedure?
• Increased body temperature – patients in pain often have a raised core temperature due to a combination of the above features
• Toileting issues – has the patient not passed urine or faeces while staying in the hospital as they are stressed due to a different litter substrate or because they are not used to going to the toilet on a lead? Or have they not toileted because it is painful to do so? Sometimes the use of stool softeners may be indicated, and modifications like shallow litter trays need to be considered for cats who have skeletal pain, such as pelvic fractures – I often use the cardboard trays or tins the food comes in
• Grooming – this can be noted in one of two ways: areas of matted hair along the back and hips as seen on elderly cats, which may indicate discomfort in trying to reach that area to groom, or over-grooming an area. Both of these can be an indicator of pain or discomfort. Think of that old yellow Labrador with brown saliva staining all over the toes and carpus of its arthritic forelimb, or the chronic bladder cats with a bald belly from over-grooming
• Decreased exercise – the refusal to mobilise either as normal or at all is often a sign of discomfort

Pain scoring

The use of pain scoring in the practice setting is now becoming more commonplace, with various formats available for use in the veterinary world. The most commonly used scales are the Glasgow composite measured pain scale and  the Colorado acute pain scale.

Pain scoring evaluates different responses to specific actions, including:

• What the patient is doing while in the kennel – are they resting, unsettled, vocalising or bothering the wound/painful region, etc?
• What happens if you make the patient move – do they refuse to move, move happily or vocalise?
• How the patient reacts if you gently touch the perimeter of the wound/painful area – do they ignore you, growl, guard or cry?
• How the patient seems overall – are they their normal character and acting in a way you recognise? Are they interacting or huddled at the back of the kennel whimpering? Are they vocalising?

As the use of pain scoring in practice has become more common, there have been additions and modifications made to the traditional pain scoring methods. The development of the facial grimace scales for cats and rabbits, which look at the key facial position of the eyes, nose and whiskers on the patient to detect discomfort, is a significant addition.

All pain scoring is subjective, and I feel it is always recommended that the same person carries out pain scoring for a particular patient all day where possible because they will notice changes that may appear normal to someone else. This is especially true if you are using any kind of grimace scale scoring.

Pain scoring for chronic pain

The types of pain scoring discussed above are great for acute or hospital admission pain assessments, but as a nurse, I feel that pain management for chronic pain cases (eg osteoarthritis) is something nurses can really help with.

Why not consider using a mobility and pain assessment checklist for chronic pain cases, or even when you suspect an issue but the owner does not fully see the degree of the problem? In these questionnaires, you can use subjective questions about their pets’ day-to-day activities, getting them to rate how well/easily they do the task. To do this, you might ask about:

• Climbing stairs – is this normal or slowly, with difficulty?
• Playing with toys – does the pet still play with toys, avoid toy play or only lie down to chew toys now?
• Getting in and out of the car – does the pet still jump in and out with ease or is it slower than normal? Do they need to be lifted in and out?
• Grooming – does the pet groom as it used to or do they groom more or less than usual?

These are just a few examples of the questions you can use.

Lots of pharmaceutical companies now provide charts with these types of questions, and I have made two for my practice: one for cats and one for dogs.

I find the best way to use these checklists is not only for chronic arthritis patients for monitoring of the condition but also for newly diagnosed chronic pain patients, who you are trialling a new regime with, be it medications or alternative adjuncts. I get owners to fill the chart in on the day of presentation/diagnosis then I give them a second chart to complete one to two weeks later. This allows you to compare them to see any areas of improvement (hopefully not deterioration), which can be used to highlight the benefit of what they are doing to manage their pet’s pain.

How else can nurses help with pain management in practice?

Aside from pain scoring and monitoring the patient, there are certain things we can do or consider as veterinary nurses to reduce the potential discomfort and lower the pain response of any of our patients during their stay.

Recumbent patients

We all know about the prevention of bed sores in recumbent patients, but there are other modifications you can consider to help alleviate the discomfort of these patients. Remember the comfort of recumbent patients is not just about the correct bedding – do they need a pillow or rolled-up blanket to raise their head a little? Could you pop foam wedges or folded blankets between their knees to hold their legs in a more comfortable position so they aren’t resting straight on top of each other? I would also consider the use of vacuum-type cushions for long-term recumbent patients as they make it easier to position them sternally (if safe with their condition); they also help dissipate pressure.

Feeding

Some patients may find it uncomfortable to bend down to reach food and water bowls, so it is worth considering if you need to raise them. You don’t have to use anything fancy – just pop them on another food bowl covered with a towel or use a cardboard box or upturned bucket for bigger patients.

Does your patient’s condition allow them to eat hard food or large chunks? Some oral and even cervical conditions can cause the process of chewing and swallowing food to become painful, so consider soaking kibble and blending food to a looser consistency.

Toileting

For dogs who need to go outside to toilet, observe if they find a collar or harness more comfortable, and consider if they need help mobilising – you may need to use a “help-me-up”-type harness.

Consider if cats suffering painful conditions that make mobilisation difficult require a low-sided litter tray so they don’t have to climb into it. A great trick I often use is making low-walled litter trays from the cardboard trays that pet food tins come in – simply line them with a cut out kennel liner and pop in a bit of cat litter!

Also, consider whether patients may benefit from stool softeners to prevent them from straining to pass rock-hard faeces, especially if they are finding it difficult to assume the correct position to toilet.

Bladder care is super important, and a full bladder can be uncomfortable and painful in itself, so don’t forget to monitor the production of urine closely in painful patients and remember they may need their bladder to be emptied to make them more comfortable.

Conclusion

So, as you can see, there are lots of ways veterinary nurses can be involved in the pain management of our furry friends! Don’t be afraid to try something different to see if it helps; sometimes we need to think outside the box to help our patients and as vet nurses, we are great at that.