Transcript Slide 1

E L N E C
Geriatric Curriculum
End-of-Life Nursing Education Consortium
Module 2:
Pain Assessment and
Management
ELNEC Attribution Statement
The End-of-Life Nursing Education Consortium (ELNEC)
Project is a national end-of-life educational program
administered by City of Hope National Medical Center
(COH) and the American Association of Colleges of
Nursing (AACN) designed to enhance palliative care in
nursing. The ELNEC Project was originally funded by a
grant from the Robert Wood Johnson Foundation with
additional support from other funding organizations
(Oncology Nursing, Aetna, Archstone, and California
HealthCare Foundations; National Cancer, and Open
Society Institutes). Materials are copyrighted by COH
and AACN and are used with permission.
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Module 2 Parts
Part I:
A. General pain assessment
B. Assessment of pain in nonverbal residents
Part II:
A. Nonopioid medications for pain management
B. Opioid medications
C. Management of analgesic side effects
Part III:
A. Nursing assistant role in observing and relieving
pain
B. Nondrug interventions for pain and other
symptoms
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Part I A: General Pain
Assessment
Objectives
• Define pain
• Describe categories of pain
• Describe the prevalence of pain among
older adults
• List challenges in assessing pain in older
adults
• Discuss the primary components of a
nursing pain assessment
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Definitions of Pain
• “An unpleasant sensory and
emotional experience associated with
actual or potential tissue damage”
IASP, 1979
• “Pain is whatever the person says it
is…”
McCaffery & Pasero, 1999
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Pain in Older Adults
• 25 – 56% community-dwelling elders
Helme & Gibson, 2001; Shega et al., 2004
• 45 – 85% nursing home residents
AGS, 2002; Won et al., 2004
• 1/3 cancer pts receiving treatment and
2/3 with advanced cancer
APS, 2003
• 50% of hospitalized pts in last 3 days of
life
SUPPORT, 1995
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Acute and Chronic Pain
Acute
• Sudden onset, in response
to illness or injury
• Usually decreases over
time as healing occurs;
self-limiting
• Goal: eliminate pain by
treating cause
• Physical signs: “fight or
flight”
• Behavioral signs
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Chronic (Persistent)
• Insidious onset, or follows
acute
• Lasts beyond expected
healing period or
associated with a chronic
condition
• Goal: maintain function &
quality of life
• Behavioral signs
Major Categories of Pain
Nociceptive
• Sources: organs, bone,
joint, muscle, skin,
connective tissue
• Examples: arthritis,
tumors, gall stones, muscle
strain
• Character: dull, aching,
pressure, tender
• Responds to traditional
pain medicines & therapies
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Neuropathic
• Source: peripheral nerve
or CNS pathology
• Examples: postherpetic
neuralgia, diabetic
neuropathy, spinal stenosis
• Character: shooting,
burning, electric shock,
tingling
• Requires different types of
medications than
nociceptive pain
Most Common Types of Persistent
Pain in Older Adults
• Musculoskeletal (e.g., low back pain,
osteoarthritis)
• Neuropathies (e.g., diabetic
neuropathy, post-herpetic neuralgia)
• Cancer
AGS, 2002
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Challenges to Assessing Pain
• Stoicism, not wanting
to be a “complainer”
• Concerns about taking
pain medicines
• Belief that pain is part
of growing old
• Fear of the meaning of
the pain
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Conditions that Influence Pain
Experience and Reporting
• Depression
• Sensory impairment
• Cognitive impairment
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“I don’t have
any pain, but I
sure am sore!”
No c/o ≠ no pain
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Pain Evaluation
• Pain history
• Physical examination
• Laboratory/diagnostic
evaluation
Paice & Fine, 2006
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Analgesic History
• Previous experience with pain
medication
• What medications?
• What doses?
• Efficacy?
• Side effects?
• Attitudes?
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Pain Assessment
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Etiology
Location
Pain Intensity
Character
Pattern
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Functional Status
Side Effects
Goals of Care
Cultural factors,
meaning of the pain
Etiology
• Is the pain location and
quality consistent with
known diagnosis or is
this a new pain?
• Is it a treatable
etiology?
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Pain Location
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Pain Location
Sites of
Referred Pain
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Pain Intensity Tools
Herr, 2002; Hicks et al., 2001
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Pain Intensity
• Setting goals for pain relief
– will have < 4/10 pain
• Incorporating pain relief goals into the
treatment plan
– Oxycontin 20 mg – i tab q12h for pain >
4/10
– Morphine sl, 10 mg, q4h prn for moderate
to severe pain
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Pain Character
Somatic/Nociceptive
• Aching
• Dull
• Sore
• Throbbing/cramping
• Deep
Neuropathic
• Shooting
• Burning
• Sharp
• Electric shock/tingling
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Temporal Patterns
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What Makes the Pain Worse?
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Movement
Feeling blue or depressed
Fatigue
Nausea
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What Makes the Pain Better?
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Medications
Moderating physical activity
Distraction
Heat and cold
Home remedies
Complementary therapies
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Effect on Function and QOL
• ADLs
• Mobility/transfers
• Participation in meals, social
activities
• Mood interference
• Sleep interference
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Examples of Functional Goals
– Able to attend bingo
– Reports enhanced mood as a result of
decreased pain
– Can transfer from bed to chair without
crying out
– Will not strike CNAs during am care
– Attends all PT sessions
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Functional Status
• Incorporating functional status
improvement into the treatment plan
– Hydrocodone 5 mg/APAP 500 mg – i tab at 2
PM on Tuesdays and Fridays (one hour prior
to bingo)
– Hydrocodone 5 mg/APAP 500 mg – ii tabs at
7AM on Wednesday mornings (one hour prior
to bath)
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Communicating with Physicians:
Key Strategies
• Diagnosis, pre-existing
pain, recent med changes
• Summarize your
assessment data
(intensity, character, location, side effects,
pattern)
• Report resident’s/family’s concerns
• Your recommendations for changes
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When to Assess and Document
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Admission
Regular intervals
New pain
Exacerbations
Uncontrolled pain
New therapy (new
meds, increased
doses)
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Summary
There are many challenges to
assessing pain in older adults —
nonetheless, there is no pain relief
when there is no pain assessment
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Part I B: Assessment of Pain in
Nonverbal Older Adults
Objectives:
• List older adults who may be unable to
reliably report pain
• Describe behaviors associated with pain
• Describe approaches to assessing and
treating pain in nonverbal older adults
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Nonverbal Patients
• Advanced dementia
• Progressive neurological
disease
• Post CVA
• Imminently dying
• Developmentally
disabled
• Delirium
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What is Different about the Pain
Experience of Demented Older Adults?
• Tolerance to acute pain possibly increases
but pain threshold does not appear to
change
• Dementia may blunt response to acute pain
• Cognitive impairment may decrease the
perceived analgesic effectiveness
• Pain can negatively affect cognitive function
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Can Older Adults with Cognitive
Impairment (CI) Give Reliable Pain
Reports?
• CI residents slightly underreport pain, but
their reports are valid (Parmelee et al., 1993)
• 83% of residents with mild to moderate CI
could reliably complete at least one pain
scale (Ferrell et al., 1995)
• 73% of post-op patients with moderate CI
were able to complete a 4-point verbal
descriptor scale (Closs et al., 2004; Feldt et al., 2000)
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Cognitive Impairment & Pain
Management
• Pain is documented less frequently for CI elders,
despite having similar numbers of painful
diagnoses as less impaired elders
(Sengstaken & King, 1993)
• Less analgesic is prescribed and administered for
CI elders, despite similar numbers of painful
diagnoses
(Horgas & Tsai, 1998)
• Among NH residents, those who are CI are at
increased risk for undertreatment of pain
compared with cognitively intact residents
(Bernabei et al, 1998)
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ASPMN Position
Statement/Guideline
• All persons deserve prompt recognition and
treatment of pain even when they cannot
express their pain verbally
• Establish a pain assessment procedure
• Use Hierarchy of Pain Assessment Techniques
• “Assume pain is present”
• Use empirical trials
• Re-assess and document (Herr et al., 2006)
www.aspmn.org/Organization/position_papers.htm
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Hierarchy of Data Sources
• Older adult’s report (if
possible)
• Prior pain history
• Painful diagnoses
• Behavioral indicators
• Observer assessment
• Response to empirical
therapy
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Painful Diagnoses
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Degenerative Joint Disease
Degenerative Disc Disease
Spinal Stenosis
Osteoporosis/Compression Fractures
Diabetes
Cancer
Herpes Zoster
Pressure Ulcers/wounds
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Behavioral/Observational Cues
Obvious:
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Grimacing or wincing
Bracing
Guarding
Rubbing
Less Obvious:
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Changes in activity level
Sleeplessness, restlessness
Resistance to movement
Withdrawal/apathy
Increased agitation, anger, etc.
Decreased appetite
Vocalizations
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Pay particular
attention to
changes from
normal
behaviors
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Pain Behavior Assessment Tools
• Checklist for Nonverbal Pain Indicators
(CNPI) (Feldt, 2000)
• NOPAIN (Snow et al., 2004)
• PAIN-AD (Warden et al., 2003)
Available at:
http://prc.coh.org/elderly.asp
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Causes of Physical Pain in
Individual’s Dementia
• Constipation or diarrhea
• Lodged food
particles
• Contractures
• Pressure ulcers
• UTI
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Volicer & Hurley, 1999
Empirical Trials in Nonverbal
Residents
Try pain medicine
Behaviors suggest it
could be pain
Behaviors decrease
It’s probably pain!
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Communication and
documentation is
critical in successful
assessment and
treatment of pain in
nonverbal older
adults
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