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Pain management 1

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  • 1. Pain Management Purpose: This program is to describe basic pain management principles related to types of pain, how to recognize pain, and how to use pharmacological and non- pharmacological pain treatments.
  • 2. Objectives • Understand how the management of pain affects the quality of life of the LTC resident. • Develop an awareness of misconceptions and consequences of untreated pain. • Recognize different types of pain and identify appropriate analgesics for each type.
  • 3. Objectives, cont. • Utilize pain assessment tools as needed for facility residents. • Understand how to determine correct doses of analgesics, as resident needs change. • Understand that all team members have a role in assessment and treatment of pain.
  • 4. Introduction Responsibility for Effective Pain Relief • Pain is what a patient says it is. • Pain is totally subjective. • In LTC, residents do no always verbalize their pain but express it is other ways. • LTC residents often have more than one source of pain. • LTC residents are at increased risk of drug interactions.
  • 5. Introduction, cont. • Pain is common at end of life as a result of arthritis, circulatory disorders, immobility, neuropathy, cancer and other age-related conditions. • Everyone experiences pain differently. • Older patients report pain differently. • Institutionalized elderly are often stoic about pain.
  • 6. Introduction, cont. • One person’s report of severe pain may seem like almost nothing compared to another. • Caregiver’s challenge is to assess all relevant factors without imposing personal biases. • Resident’s self-report of pain is the single most reliable indicator of pain.
  • 7. Introduction, cont. • All LTC staff and resident’s family share in the role of pain management. • Residents may not have pain when not moving and caregivers report pain when he or she is moving or doing ADLs. • Everyone caring for the resident must know to recognize and report pain.
  • 8. “In any LTC facility, the quality of the pain control will be influenced by the availability of a pain management program and the training, expertise, and experience of its members.”
  • 9. Common Misconceptions about Pain • The caregiver is the best judge of pain. • A person with pain will always have obvious signs such as moaning, abnormal vital signs, or not eating. • Pain is a normal part of aging. • Addiction is common when opioid medications are prescribed.
  • 10. Common Misconceptions about Pain, cont. • Morphine and other strong pain relievers should be reserved for the late stages of dying. • Morphine and other opioids can easily cause lethal respiratory depression. • Pain medication should be given only after the resident develops pain. • Anxiety always makes pain worse.
  • 11. Consequences of Untreated Pain What happens if pain isn’t properly treated? • Poor appetite and weight loss • Disturbed sleep • Withdrawal from talking or social activities • Sadness, anxiety, or depression • Physical and verbal aggression, wandering, acting-out behavior, resists care • Difficulty walking or transferring; may become bed bound
  • 12. Consequences of Untreated Pain, cont. • Skin ulcers • Incontinence • Increased risk for use of chemical and physical restraints • Decreased ability to perform ADL’s • Impaired immune function
  • 13. Descriptions of Pain Categories of Pain by Duration Acute Pain Brief duration, goes away with healing, usually 6 months or less. • Not necessarily more severe than chronic • May be sudden onset or slow in onset • Examples are broken bones, strep throat, and pain after surgery or injury
  • 14. Descriptions of Pain Categories of Pain by Duration Chronic Cancer Pain Pain is expected to have an end, with cure or with death. • Aggressive treatment • Addiction not a concern
  • 15. Categories of Pain by Duration Chronic Non-Malignant Pain Pain has no predictable ending • Difficult to find specific cause • Often can’t be cured • Frequently undertreated
  • 16. Categories of Pain by Type Somatic Source: Skin, muscle, and connective tissue Examples: Sprains, headaches, arthritis Description: Localized, sharp/dull, worse with movement or touch Pain med: Most pain meds will help, if severe, need a stronger medication
  • 17. Categories of Pain by Type Visceral Source: Internal organs Examples: Tumor growth, gastritis, chest pain Description: Not localized, refers, constant and dull, less affected with movement Pain Med: Stronger pain medications
  • 18. Categories of Pain by Type Bone Pain Source: Sensitive nerve fibers on the outer surface of bone Examples: Cancer spread to bone, fx, and severe osteoporosis Description: Tends to be constant, worse with movement Pain Med: Stronger pain meds, opiates with NSAIDS as adjunct
  • 19. Categories of Pain by Type Neuropathic Source: Nerves Examples: Diabetic neuropathy, phantom limb pain, cancer spread to nerve plexis Description: Burning, stabbing, pins and needles, shock-like, shooting Pain Meds: Opioates+tricyclic antidepressants or other adjuvant
  • 20. Pain Assessment Asking about pain is an important part of ALL assessments!! • Everyone caring for the resident is to know to report pain. • Charge nurses must assess all reports of pain. • Assessments to identify and treat pain must be ongoing. • Elderly residents require frequent monitoring for pain.
  • 21. Residents with Dementia or Communication Difficulties Consider the following when assessing residents with dementia or communication problems: • Ask the resident if he or she is having pain. • Consider the disease condition and procedures that may be causing pain, think “if I were that resident, would I want something for pain?”
  • 22. Residents with Dementia or Communication Difficulties, cont. • Use proxy pain reporting-family, staff • Be alert for behaviors that may indicate pain. • Facial expressions • Physical movements • Vocalizations • Social changes • Aggression
  • 23. Treatment of Pain Rules of thumb, common sense rules: • Use the lowest effective dose by the simplest route. • Start with the simplest single agent and maximize it’s potential before adding other drugs. • Use scheduled, long-acting pain medications for constant or frequent pain, with prn, short-acting medication available for breakthrough. • Treat breakthrough pain with one-third the 12 hours scheduled dose.
  • 24. Treatment of Pain, cont. • If three or more prn doses are used in a day, increase the scheduled dose. Increase by ¼ - ½ of the prior dose. Increase the prn dose when you increase the scheduled dose. • Be vigilant at assessing the side effects of medication. Treat or prevent side effects, such as constipation and nausea. Change medication as necessary.
  • 25. Treatment of Pain, cont. • Use the WHO’s step-wise approach, also called WHO Analgesic Ladder, Subsection 2.7 in Manual. • Reevaluate and adjust medications at regular intervals and as necessary. • Do not stop pain medication in terminal patients. Chang the route if needed.
  • 26. Pain Management in the Elderly Elderly present several pain management problems: • Little attention in the literature for physicians or nurses on topic of pain in the elderly. • Elderly report pain differently due to changes in aging-physically, psychologically, culturally. • Institutionalized elderly often stoic about pain. • Cognitive impairment, delirium, and dementia present barriers to pain assessment.
  • 27. Opioid Use in the Elderly Educating staff is essential!! • Opioids produce higher plasma concentrations in older persons • Greater sensitivity in both analgesic properties and side effects • Smaller starting doses required • Consider duration of action, formulation availability, side-effect profile, and resident preference. • Review for drug interactions
  • 28. Opioid Use in the Elderly, cont. • Older persons may have fluctuating pain levels and require rapid titration or frequent breatkthrough medication. • Long-acting are generally suitable once steady pain levels have been achieved. • Once steady pain relief levels are achieved, controlled-released formulas can be used. • Fentanyl patches should not be placed on areas of the body that may receive excessive heat. Patches may be contraindicated with exceptionally low body fat.
  • 29. Pain Management Risk for LTC Residents • Frail elderly at risk for both under and over treatment of pain. • NSAIDS and acetaminophen are effective and appropriate for a variety of pain complaints. • NSAIDS risk gastric and renal toxicity • Unusual drug reactions more common in the elderly. • Staff must be aware of side effects and there must be an effective communication method for staff to know adverse drug reactions.
  • 30. What Everyone Can do to Manage Pain • Show that you care. • Talk to the resident, even if he/she doesn’t understand. Talk to, not around, the resident. • Make the room pleasant. • Take care of the basics-glasses, hearing aides, dry clothes toileting, food, fluids. • Communicate with the team-let others know what works.
  • 31. What Everyone Can do to Manage Pain, cont. • Always report pain. Pain IS NOT a normal part of aging. • Understand the care plan for pain-pain management is a team approach. • Use relaxation methods to decrease anxiety and muscle tension. • Use tactile strategies like stroking and massage. • Music, art and meditation can be very helpful. • Don’t forget the team. Pt for mobility and safety, OT for positioning and splints.
  • 32. MDS and Regulatory Requirements The following MDS items could be primary or secondary triggers for recognizing pain: • Section E.1 Mood and Behavior Patterns For example, repetitive verbalization, persistent anger, repetitive health complaints; sad, worried, facial expression, crying, tearfulness, repetitive movements, reduced social interaction.
  • 33. MDS and Regulatory Requirements, cont. • Section E.4. Mood and Behavior Patterns For example, wandering, verbally abusive, physically abusive, socially inappropriate, resists care. • Section F.2. Psychosocial Well-being For example, covert/open conflict or repeated criticism of staff, unhappy with roommate, unhappy with other residents.
  • 34. MDS and Regulatory Requirements, cont. • Section I.1. Disease Diagnoses For example, deep vein thrombosis, arthritis, hip fracture, missing limb, osteoporosis, pathological bone fracture, cancer. • Section I.2. Infections For example, wound infection • Section J.2. Pain Symptoms
  • 35. MDS and Regulatory Requirements, cont. • Section K. Oral/nutritional status For example, mouth pain. • Section L. Oral/Dental Status For example, inflamed, swollen, bleeding gums, abscesses, ulcers or rashes. • Section M. Skin conditions For example, skin ulcers, abrasions, bruises, rashes, skin tears, cuts, surgical wounds, skin treatments; foot problems.
  • 36. MDS and Regulatory Requirements, cont. State Licensure 19 CSR 30-85.042 (67) Requires the facility to address the resident’s pain: “Each resident shall receive personal attention and nursing care in accordance with his/her condition and consistent with current acceptable nursing practice.”
  • 37. MDS and Regulatory Requirements, cont. Federal Regulation 42 CFR Section 483.20 (b), F272 Requires facility to make a comprehensive assessment: “A facility must make a comprehensive assessment of resident’s needs, using the RAI specified by the state.”
  • 38. MDS and Regulatory Requirements, cont. 42 CFR 483.20 (k) F279 Requires facility staff to develop a comprehensive care plan to address pain: “The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.”
  • 39. MDS and Regulatory Requirements, cont. 42 CFR Section 483.25, F309 Requires facility staff to meet the pain needs of the resident: “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.”

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