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2015: Pain Assessment, the Key to Treating Pain in the Inpatient Setting-Yi

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Pain Assessment, the Key to Treating Pain in the Inpatient Setting

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2015: Pain Assessment, the Key to Treating Pain in the Inpatient Setting-Yi

  1. 1. C A S S I A Y I , A P R N , M S N , C N S , C C R N Pain Assessment, the Key to Treating Pain in the Inpatient Setting Considerations in The Aging And Palliative Populations
  2. 2. Objectives  Apply the Pain Assessment Hierarchy to pain assessment and reassessment in all patient populations  Review importance of sedation assessment  Make the connection between good assessment and good management
  3. 3. Hierarchy Of Pain Assessment Self Report Behavioral assessment Assume or Anticipate pain (APP)
  4. 4. The Numeric Pain Scale  Ask your patient to rate his or her pain on a scale of 0-10, 0 being no pain, and 10 being the worst pain
  5. 5. Some elderly patients may prefer to describe their pain as mild, moderate, or severe
  6. 6. A Reminder About the FACES Tool:  DO NOT choose a face for the patient based on how he/she looks!
  7. 7. Behavioral Assessment Pain Tools CPOT CNPI BPS NVPS NPAT
  8. 8. Behavioral Score Does Not Equal Intensity!!!!  Example= Two people may have the same cut on their finger… Person #1 may be crying, squeezing his finger, and grimacing. Person #2 may be just grimacing This does not mean that Person #1 is experiencing more pain….he just displaying behaviors of pain differently.
  9. 9. Pain and the Dying patient  Pain is not automatic!  Pain must be assessed, just like with any other patient population! • Don’t misinterpret other signs/symptoms of dying with pain! • Restlessness, agitation, moaning, and groaning may accompany terminal delirium • If the diagnosis is unclear, a trial of opioid may be necessary to judge whether pain is driving the observed behaviors
  10. 10. Respiratory Variations in the Dying patient- NOT indicator of pain  Patterns:  Tachypnea, Apnea  Chin-lift, jaw-jerk*  Diminishing tidal volume  Oropharyngeal secretions*  Symptoms: generally comfortable  Distressing to family, not to patient  Management  Family support  Oxygen variably effective  Opioids (rarely)
  11. 11. Palliative Patients are at Increased Risk of Pain  Disease Process  Immobility (who’s driving this??)  Skin break down  Dyspnea
  12. 12. Pain Reassessment  Reassessment times should coincide with peak medication effectiveness, when the patient will feel the greatest effects of analgesia and will also experience the peak of side effects.  5-45 minutes for IV opioids  45-75 min for PO opioids
  13. 13. PlasmaConcentration 0 Time IV Peak 30 min PO / PR/ IM 60 minutes 60 min SQ Peak A little longer than IV 30 min 60 min When should you assess??
  14. 14. Assessing for sedation RASS Ramsey POSS GCS
  15. 15. Why is the Sedation Assessment So Important?  Remember sedation ALWAYS precedes respiratory depression!! If we can catch the patient while they are sedate, we should be able to prevent all opioid related respiratory depression! If left untreated, can lead to This This
  16. 16. Sleep and Assessing Pain  If your patient is asleep when you need to reassess for pain, this could mean 2 things:  Your patient is finally able to sleep! Assess the respiratory status and review previous sedation assessment. If normal, do not wake the patient up! -OR-  The pain medication you gave made your patient sedate. If the respiratory assessment is abnormal, wake the patient up! Further evaluation is required.
  17. 17. What is a Good Respiratory Assessment?  Respiratory Assessment Includes:  Observe for a full minute!  Assess the rate  Assess the rhythm  Assess the depth  Assess respiratory effort. Are they snoring?
  18. 18. Do our Current Assessment Tools work????  Self-report= gold standard  Problem with self-report using a uni-dimensional scale  Pain is a multi-dimensional complex experience- Dynamic!  Numeric scale difficult for some to use  Requires linguistic and social skills  Patients modulate pain behaviors and self-report based on their perception of what’s in their best interest  Providers see verbal and non-verbal signs of pain, but can only respond to reported number Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676
  19. 19. Patients Modulate Pain
  20. 20. Is There Something Better? University of Utah – 2012 Pilot Project  CAPA© developed to replace conventional numeric rating scale (NRS; 0-10 scale)  Press Ganey© scores increased from 18th to 95th percentile  55% patients preferred CAPA ©  Nurses preferred CAPA © 3:1 over NRS
  21. 21. Clinically Aligned Pain Assessment (CAPA) “Pain is More Than Just a Number” ©  Evaluates  intensity of pain  effect of pain on functionality  effect of pain on sleep  efficacy of therapy  progress toward comfort  Engages patient and clinician in a brief conversation about pain resulting in coded evaluation From, Donaldson & Chapman, 2013.
  22. 22. CAPA© Tool (modified; original in blue) The conversation leads to documentation- not the other way around. Question Response Comfort •Intolerable •Tolerable with discomfort •Comfortably manageable •Negligible pain Change in Pain •Getting worse •About the same •Getting better Pain Control •Inadequate pain control Inadequate pain control •Partially effective Effective, just about right •Fully effective Would like to reduce medication (why?) Functioning •Can’t do anything because of pain •Pain keeps me from doing most of what I need to do •Can do most things, but pain gets in the way of some •Can do everything I need to Sleep •Awake with pain most of night •Awake with occasional pain •Normal Sleep From, Donaldson & Chapman, 2013.
  23. 23. Good Assessment is what Makes Good Management Possible!
  24. 24. PlasmaConcentration 0 Time IV Peak 20 min PO / PR/ IM 60 minutes 60 min SQ Peak A little longer than IV 30 min 60 min Morphine IV Peak effect: 20 minutes Half-life: 2-4 hours Continuous morphine infusion : Time to steady state: 10-20 hours
  25. 25. PlasmaConcentration 0 Time to Drip Steady State 164 8 12 Time ( hours ) 20 24 50% 75% 87.5% 93.75% 97% 100% Pain Control Change GTT Steady State
  26. 26. Pain Management with Geriatric Patients Analgesic therapy issues  Physiologic changes  Absorption  Distribution  Metabolism  Elimination  Opioids  Recommend reducing initial opioid dosing by 25-50% in elderly patient
  27. 27. • Retrospective study at UC San Diego • Patients who died while receiving Continuous Morphine Infusion (CMI) from 2012-2013 N=190 • Mean age was 66.4 years (range: 19-99 years) • 109 males and 81 females • At initiation of CMI, 25.8% (n=49) had an oncologic diagnosis and 73.2% (n=139) were in the ICU. Morphine Study at UCSDH Internal data: Lin KJ, Chang A, Edmonds KP, Roeland EJ, Revta C, Ma JD, Atayee RS. Variable Patterns of Continuous Morphine Infusions at End of Life. Submitted to Journal of Palliative Medicine January 2015
  28. 28. • Prior to CMI initiation, 40.5% (n=77) were opioid naïve • 85% (n=160) had documented indication for CMI (e.g. compassionate extubation or comfort care with pain/dyspnea) • 60% (n=120) did not receive any bolus doses prior to CMI initiation and of these 23% were opioid naïve (n=44) • Between start and end of CMI +130% in rate of CMI +442% morphine IV dose Patients on CMI: 24.2% (n=46) had a GFR < 30 mL/min 73.1% (n=139) a GFR >30 mL/min 2% (n=5) were not recorded A Few Key Findings from Morphine Study Internal data: Lin KJ, Chang A, Edmonds KP, Roeland EJ, Revta C, Ma JD, Atayee RS. Variable Patterns of Continuous Morphine Infusions at End of Life. Submitted to Journal of Palliative Medicine January 2015
  29. 29. What is the Goal? Continuous Infusion Bolus • Achieve continuous pain/agitation control by administering a continuous infusion (at the lowest possible dose to minimize accumulation) • Assess the effect of the continuous drip rate when steady state is reached (5-72 hours with pain meds) • Should not be used for patients with anuria or oliguria There are 2 goals of IV boluses for patients who are already on a continuous drip: 1. To treat a pain score or agitation level that is above/beyond the patient’s consistent level. 2. Indicates if the continuous IV infusion needs to be increased
  30. 30. Continuous Infusions- Back to Basics! Bolus 1st! Bolus Re-Assess Still have pain? Re- Bolus! No more pain? If painful stimuli is constant, titrate up! Assess Start Here!
  31. 31. In Conclusion….  Assess, Assess, Assess before you treat!  Assess for sedation, not just pain!  Pain and sedation assessment will help you decide HOW to treat.  Pain assessment is still important in the palliative population! Don’t make assumptions!  Consider lower doses in the aging population  Bolus before you titrate!
  32. 32. References  Vila Jr H, Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesthesia & Analgesia. 2005;101(2):474-480.  Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Management Nursing. 2011;12(3):118-145. e110.  Gupta A, Daigle S, Mojica J, Hurley RW. Patient perception of pain care in hospitals in the United States. J Pain Research. 2009;2:157.  Ahlers A, Gulik L, Veen A, et al. D. Comparison of different pain scoring systems in critically ill patients in a general ICU. Critical Care. 2008; 12:R15.  Drew D, Gordan D, Renner L, et al. The use of "as needed" range orders for opioid analgesics in the management of pain: a consensus statemetns of the american society of pian management nurses and the american pain society. Pain Mangement Nursing. 2014; 15(2) 551-554.  The joint commission sentinel event alert. A Complementary Publication of the Joint Commission. 2012; 49.  Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine. 2013;41(1):263-306.  Schilling A, Corey R, Leonard M, et al. Acetaminophen: old drug, new warnings.Cleavelant Clinical Journal of Medicine. 2010; 7(1) 19-27.

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