72 yr old female admitted to facility late Friday afternoon from acute hospital after fall at home. In hospital she had Rt. hip surgery 2 days ago. Other pertinent diagnoses include diabetes, COPD, CAD, CHF, HTN, anemia, osteoporosis, depression, peripheral vascular disease, osteoarthritis, & dementia.

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Pain is likely to be an issue

 Different types of pain are likely  Acute post operative bone & muscle pain (rt. hip fx.)  Potential chronic muscle & joint pain from osteoarthritis, osteoporosis  Potential cardiac pain (CAD, CHF)  Potential neuropathic pain (DM)  Communication may be an issue (Dementia)

 When you enter the room to perform the pain assessment you observe:  Hazel in bed, grimacing & seems tense  She is verbal, responds to her name, but confused  When you ask if she has pain she says “Yes”  When you ask where she says “all over”  What is the next step?

 You correctly decide to use a tool for residents with dementia  Choices – PACSLAC or PAINAD  Hazel scores a 6 on the PAINAD indicating that she does have pain

 During your physical exam of Hazel, you notice she resists against movement of her upper extremities saying “that hurts”  She also c/o pain when you touch her lower legs  You start to turn her to observe her surgical site but she also cries out that it hurts  What should you do at that point?

 After medicating Hazel for pain, you complete your exam, you ask the CNA to get Hazel her dinner & assist her to eat  A few minutes later the CNA returns & reports that Hazel did not want to eat stating she wasn’t hungry  What is a potential cause?

 Comprehensive assessments cannot always be completed in a single shift  In cognitively impaired residents, additional information may be needed  Nurses must take the time to observe behaviors, response to pain medication, etc.

 Family members can be great sources of information  Surrogates such as children, spouses or close friends  If not present during admission, call within the first 24 hrs  CNAs can also help complete assessment based on their observations during care

 Hazel has frequent moderate to severe pain in her joints & her legs hurt, burn almost all the time  Hazel’s pain is worse with movement  Hazel can report pain but not how bad it is  Hazel cries out when pain gets really bad but otherwise will not say anything unless moved  Pain improves with analgesics & correct positioning  Her daughter emphasizes that she wants her mom to be comfortable at all times

 Is Hazel able to self report?

 Surrogate report on average & worst pain?

 PAINAD Score  Behavioral Pain Indicators  Pain Location  Pain Pattern

 Acute painful conditions  Diagnosis (es)  Impact on function & quality of life  Current therapeutic regimen from physician orders  Recommended changes to treatment plan – plan not yet developed

 History of pain & its treatment  Characteristics of pain  Impact of pain on quality of life  Factors that precipitate pain  Strategies or factors that reduce pain  Associated pain symptoms  Physical Examination  Current medical condition & medications  Resident goals for pain management

 Facilities & staff are responsible for ensuring residents obtain their highest practicable level  Residents must be involved in their pain management & their individual needs & goals should be basis of care plan  Care must be individualized based on a comprehensive assessment &MUST meet clinical standards of quality  Staff must monitor continuously & revise when necessary in a timely manner  Staff must communicate resident status or change of condition with health care practitioners, resident, & family  Staff must document accurately

Adapted and used with permission of D. Bakerjian, PhD, MSN, APRN, University of CA, San Francisco, 2009.