This document outlines a training program aimed at improving pain assessment and management for elderly residents in care facilities. It discusses myths about pain in the elderly, the types and pathways of pain, and provides guidelines for effective pain assessment and treatment strategies, both pharmacological and non-pharmacological. The document emphasizes the importance of monitoring pain in seniors, highlights indicators for assessment, and includes case studies for practical application.

1. Appendix G:
Pain Assessment and
Management Training
“Where does it hurt?”
Audience: For Registered Staff
Release Date: December 10, 2010

2. Objectives
• To improve and maintain a resident’s
optimal functional level and quality of life
• To optimally control pain for all residents
• To reduce incidence of unmanaged pain
• To ensure best practice interventions for
residents with pain
• To monitor and track trends related to pain
management
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3. Myths About Pain and the Elderly
• Pain is a normal part of aging
• The elderly perceive pain to a lesser degree
or sensitivity than young people
• If an elderly person does not complain then
they are not in pain
• Elderly patients should receive lower
morphine doses than younger patients
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4. Research Says
• Approximately 25% of Canadian's suffer from
chronic pain
• Chronic pain becomes more common as people get
older
• 50% of Canadian’s take analgesic for chronic pain
• 45-80% of nursing home residents have substantial
pain
• 25-26% of residents with daily pain receive no
analgesia
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5. Definition of Pain
“Pain is what the patient say it is, and exists whenever the
patients says it does” McCaffery & Pasero (1979)
Pain
An unpleasant subjective sensory and
emotional experience that is associated
with actual or potential tissue damage,
or described in terms of such damage.
RAI-MDS Definition: Pain that is
reported is unrelieved pain. If the
resident does not have any pain due to
pain management, then it is coded as
“0” for no pain.
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6. Pain Pathways:
Pain & the Brain
Lewis, Sharon L.. Medical-Surgical Nursing in Canada, 2nd Edition. Mosby Canada, 072009.).
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7. Words Used to Describe Pain
Hurt
Soreness
Pressure
Burning
Discomfort
Can You Think of Any ?
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8. Types of Pain
1) Acute Pain: sudden onset, lasts less
than 3 months or usual time of healing.
Can range from mild to severe.
Decreases with time.
2) Chronic Pain: persist after healing
occurs. Pain can be disabling and
accompanied with depression and
anxiety.
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9. 3) Neuropathic Pain: Pain that is initiated or
caused by a primary lesion or dysfunction in the
nervous system (Central Nervous System &
Peripheral Nervous System)-stimuli abnormally
processed by the nervous system.
Neuropathic pain is usually described as sharp,
burning, or shooting and is often associated
with other symptoms such as numbness or
tingling in the affected area.
Types of Pain…cont`d
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10. Neuropathic Pain Described…
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11. Types of Pain…cont`d
4) Referred Pain: is a term used to describe the
phenomenon of pain perceived at a site
adjacent to or at a distance from the site of an
injury's origin.
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12. Sites of Referred Pain
(Lewis, Sharon L.. Medical-Surgical Nursing in Canada, 2nd Edition. Mosby Canada, 072009.).
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13. Components of Effective Treatment
of Pain
Evaluation Of
Effectiveness
Pharmacological &
Non Pharmacological
Treatment
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14. Pain Assessment
Screening should done daily (can be done during routine assessments by
asking residents/ SDM about the presence of pain, ache or discomfort
Full assessment using a Pain Assessment Tool:
• within 24 hours of admission
• quarterly (according to the RAI-MDS 2.0 schedule)
• when a the resident exhibits a change in health status or pain is not relieved
by initial interventions (e.g. is diagnosed with a chronic disease)
For example:
• states he/she has pain;
• diagnosed with chronic painful disease;
• has history of chronic unexpressed pain;
• taking pain-related medication for >72 hours;
• has distress related behaviours (e.g. changes in anxiety level) or facial grimace
• indicates that pain is present through family/staff/volunteer observation.
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15. Pain Assessment…cont’d
Behavioural Indicators:
• Facial Expression (frowning, tightly closed eyes,
grimacing)
• Body Language and Movement ( fidgeting, rocking,
rigid posture)
• Behaviour ( sleeplessness, decreased appetite, mood
swings, wanting to sleep all day)
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16. Dimensions of Pain Assessment
• Type of pain
• Onset of pain
• Location of pain
• Intensity
• Quality
• Frequency
• Factors that precipitate and relieve pain
• Treatments used and the effectiveness
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17. Assessment Techniques
Self-report Measures
• “Gold Standard” of pain assessment for residents that are
cognitively intact. When the self-report option is not available,
observation of the resident behaviours and reports from family
and caregivers are used.
Behavioural Measure (e.g. for the cognitively
impaired)
• Used in conjunction with self-report
• Used to assess pain in resident that are unable to speak or not
cognitively intact
• Refer to Pain Indicator list for the Cognitively Impaired
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18. Self Report Tools
Descriptive Tools
• Where is the pain ?
• PQRST
– Provocation – what causes that pain? What makes is worse?
What makes it better?
– Quality- what does your pain feel like? What words would
you use to describe your pain?
– Radiating – Does the pain move anywhere?
– Severity- How much does it hurt on a scale of 0 (no pain)-10(
the worst pain)
– Timing/ Treatment- when did your pain start? How often does
it occur? How long does it last?
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19. Pain Intensity Rating Scales
• Numeric Rating Scale (NRS)
• Visual Analogue Scale (VAS)
• Verbal Scale
• Facial Grimace & Behavioural Flow Chart
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20. Pain Intensity Rating Scales
…cont’d
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21. Facial Grimace Scale & Behavioural
Checklist Flow Chart
The facial grimace scale scores the level of pain
(from 1-10) based on the care givers
observations for the resident’s facial expression.
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22. Behavioural Observation
• Mild to moderately cognitively impaired older adults
can report pain so ASK for self-report
• Pain in cognitively impaired resident is measure
through behavioural signs
• This involves:
 Observation of specific, discrete behaviours that
vary from the resident’s normal behaviour
 Observations from family or care givers
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23. Pharmacological Approach
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24. Pharmacological Approach
Mild Pain
• Non-Opioids
• Acetaminophen
• Aspirin
• Non-Steriodal Anti-inflammatory Drugs (NSAIDS)
Mild to Moderate Pain
• Opioids
• Morphine
• Hydromorphone
• Oxycodone
Moderate to Severe
• Adjuvant Drugs
• Anticonvulsants (neurotin, tegretorl, clonazepam)
• Antidepressant (tricyclic, Prozac)
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25. Non-Pharmacological Approach
• Exercise
• Transcutaneous electrical nerve stimulation
(TENs)
• Heat/Cold
• Relaxation Therapy
• Massage
• Acupuncture
• Behaviour Therapy
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26. Exercise
 Exercise improves your mood
 Exercise combats chronic diseases
 Exercise promotes better sleep
 Exercise boosts your energy level
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27. Transcutaneous Electrical
Nerve Stimulation
(Acronym TENS) is the use of electric
current produced by a device to
stimulate the nerves for therapeutic
purposes. TENS by definition covers
the complete range of
transcutaneously applied currents
used for nerve excitation, although the
term is often used with a more
restrictive intent, namely to describe
the kind of pulses produced by
portable stimulators used to treat
pain.
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28. Thermal Treatment
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29. Relaxation Therapy
Distraction and Imagery:
Redirection on something and
away from pain.
Structure technique that uses the
resident’s own imagination to develop
sensory images that divert focus away from
the pain sensation and emphasize other
experiences and pleasant memories.
Relaxation: Aim is to free resident’s
anxiety and muscle tension. Requires a
quiet environment (guided breathing,
meditation).
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30. Case Study
Mrs. V is a 85 year old woman who has just been re-admitted to your LTC
home following a brief stay in an acute care hospital. Mrs. V has a diagnosis of
dementia. Prior to admission to the hospital she was mobile but because of
the dementia was unable to participate in her care and other activities of
daily living. She was sent to hospital because of a fall which resulted in a
fracture to her left (L) hip.
When you receive the resident, she is moaning loudly and her eyes are
tightly closed. She is very rigid and grimaces when you attempt to move her
in bed. Placing the resident on her Right side and supporting her Left leg
appears to relax her and the moaning is less intensive.
Several of her children are at her bedside and look to you to help their
mother.
Indicate how you would assess her pain and what tools and observational
skills you would use. How would you determine if the interventions you tried
were effective?
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31. WORKING TOGETHER TO
EASE THE PAIN
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