Title: Appendix G: Pain Assessment and Management Training
1Appendix G Pain Assessment and Management
Training Where does it hurt?
- Audience For Registered Staff
- Release Date December 10, 2010
2Objectives
- To improve and maintain a residents 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
3Myths 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
4Research Says
- Approximately 25 of Canadian's suffer from
chronic pain - Chronic pain becomes more common as people get
older - 50 of Canadians take analgesic for chronic pain
- 45-80 of nursing home residents have
substantial pain - 25-26 of residents with daily pain receive no
analgesia
5Definition 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.
6Pain Pathways Pain the Brain
Lewis, Sharon L.. Medical-Surgical Nursing in
Canada, 2nd Edition. Mosby Canada, 072009.).
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7Words Used to Describe Pain
Can You Think of Any ?
Discomfort
Soreness
Pressure
Burning
8Types 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.
9Types of Paincontd
- 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.
10Neuropathic Pain Described
11Types of Paincontd
- 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.
12Sites of Referred Pain
(Lewis, Sharon L.. Medical-Surgical Nursing in
Canada, 2nd Edition. Mosby Canada, 072009.).
ltvbk9781897422014B9781897422014500176_f4
13Components of Effective Treatment of Pain
Pharmacological Non Pharmacological Treatment
Evaluation Of Effectiveness
Assessment
14Pain 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 gt72 hours
- has distress related behaviours (e.g. changes in
anxiety level) or facial grimace - indicates that pain is present through
family/staff/volunteer observation.
15Pain Assessmentcontd
- 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)
16Dimensions 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
17Assessment 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
18Self 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?
19Pain Intensity Rating Scales
- Numeric Rating Scale (NRS)
- Visual Analogue Scale (VAS)
- Verbal Scale
- Facial Grimace Behavioural Flow Chart
20Pain Intensity Rating Scalescontd
21Facial 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 residents facial expression. - Please refer to handout
22Behavioural 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 residents normal behaviour - Observations from family or care givers
23Pharmacological Approach
24Pharmacological 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)
25Non-Pharmacological Approach
- Exercise
- Transcutaneous electrical nerve stimulation
(TENs) - Heat/Cold
- Relaxation Therapy
- Massage
- Acupuncture
- Behaviour Therapy
26Exercise
- Exercise improves your mood
- Exercise combats chronic diseases
- Exercise promotes better sleep
- Exercise boosts your energy level
27Transcutaneous 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.
28Thermal Treatment
29Relaxation Therapy
Distraction and ImageryRedirection on something
and away from pain. Structure technique that
uses the residents 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
residents anxiety and muscle tension. Requires a
quiet environment (guided breathing, meditation).
30Case 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?
31WORKING TOGETHER TO EASE THE PAIN