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Management of Pain in the Long Term Care Setting

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Title: Management of Pain in the Long Term Care Setting


1
Management of Pain in the Long Term Care Setting
  • Slide Notes
  • The Management of Pain in the Long Term Care
    Setting PowerPoint presentation was developed to
    aid in educating nursing home staff. This
    presentation attempts to merge best practice,
    facility practice, regulatory issues and the
    residents Quality of life into a realistic,
    user-friendly tool aiding in the application of
    Quality Improvement for your facility.

2
Objectives
  • Describe how pain management is different from
    reacting to pain
  • List barriers to pain management
  • Explain myths related to pain management
  • Slide Notes
  • An understanding of the basics of pain management
    within the nursing home environment will be
    helpful to all staff including nurses, nursing
    assistants, dietary aids, Activity coordinators,
    maintenance and housekeeping. Teamwork in
    applying these basics is key to a successful
    program.

3
Understandingpain management
  • instead of reacting to a complaint of pain.
  • Image of Pill bottles lined up in a row
  • Slide Notes
  • Do you want to know if your facility understands
    pain management or are they just reacting to a
    complaint of pain? Here are a few simple
    questions that will determine what is occurring
    in your facility.
  • How many PRN pain medications are given? When are
    they given? Check how many PRN pain medications,
    instead of routinely scheduled pain medications
    on the medication administration record (MAR) are
    documented as being administered. Look for a
    pattern or trend in the administration of these
    PRN medications. This assessment may be a quick
    indicator showing whether Staff are proactive in
    treating pain by assessing and routinely treating
    for pain or only reacting to pain when a resident
    complains of pain. Another check can be done by
    observing if the same residents are getting PRN
    pain medications at the same time almost
    everyday. Does one nurse give out PRN pain
    medications while a different nurse gives no PRN
    pain medications for the same residents? This
    observation may show that nurses may not be
    consistent in their understanding of how to
    assess for pain, behaviors for pain, or
    appropriate reasons for using pain medications.
    Look to see how many PRN pain medications the
    evening charge nurse administers. When the nurse
    reacts to a complaint of pain while attempting to
    do other required nursing duties it interrupts
    the routine which causes a delay and increased
    work. Looking at trends or patterns with the PRN
    pain medications may help save extra work for the
    nurse and increase quality of life for the
    resident.

4
The goal
  • The goal of pain management is the reduction of
    pain and suffering
  • Slide Notes
  • The experiences of hospice nurses show that
    patients worry more about the possible unrelieved
    pain and suffering of their terminal illness than
    the experience of death. Many people can accept
    death but cannot accept pain. If you asked the
    resident whats the worse thing that can
    happen? Would the answer be I could die? For
    most people the answer would be No, I could be
    in pain. Pain is an important issue with
    residents and their families. But, unless the
    resident asks for a pain pill, we often dont
    think about managing pain.
  • Many nurses have stories of how effective pain
    management brought comfort and heartfelt
    thankfulness from the resident and their family
    members. Nurses need to hear these success
    stories in order to understand the importance of
    assisting their residents with pain management.
    Once success is achieved, it will help improve
    the life of the resident and help the nurse feel
    job satisfaction. Staff retention is not a
    problem in a facility where everyone feels that
    they are part of the success. With pain
    management the success is the reduction of pain
    and suffering.

5
Why focus on pain?
  • 45-80 of Nursing Home residents have chronic
    pain
  • Under recognized and under treated
  • Can impact every aspect of a residents life
  • Slide Notes
  • Are we aware of the pain our residents are
    experiencing? If there are up to 80 out of every
    100 residents in pain, are we addressing pain
    through care plans and staff education? Are we
    assessing pain in diagnoses that we know cause
    pain?
  • Whether pain is managed in a hospital or a long
    term facility, research has shown that it is
    generally under-recognized and under-treated. Our
    elderly residents are particularly at risk due to
    their increased incidence of dementia and the
    myths of pain management shared both by staff and
    residents.
  • Focusing on pain may lead us to interventions
    that not only reduce pain and suffering but
    directly affect the ability of a resident to
    walk, sleep, eat, think, socialize and many other
    aspects of their life. If we listen to the night
    staff list which residents could not sleep or the
    day staff list which residents inappropriately
    called out and exhibited behavior problems, we
    may find that pain has been the silent barrier
    for many of these residents trying to achieve a
    higher quality of life.

6
Five easy steps to better pain management
  • 1. Screen for Pain
  • 2. Conduct an Evaluation of Pain
  • 3. Develop a Care Plan
  • 4. Put the Plan into Action. Be Consistent.
  • 5. Re-evaluate regularly
  • Slide Notes
  • Doing an effective job managing pain is possible
    in every facility. Facilities that are successful
    do the five steps listed above CONSISTENTLY. When
    a facility uses Continuous Quality Improvement
    they are helping to ensure that their facility is
    aware of what it takes to keep the five steps
    moving toward better resident care instead of
    stumbling blocks that frustrate staff.
  • Most facilities have an area on their admission
    sheet and periodic assessment sheets that screen
    for pain. Staff educated in pain management
    realize the importance of completing the Screen
    and are more likely to consistently do the
    screening. An EVALUATION of the pain will lead to
    a more effective pain treatment by allowing the
    nurse to communicate to the physician exactly
    what is going on with the resident. This is done
    by describing the pain and how it affects the
    resident. A CARE PLAN allows the sharing of
    specific details for managing pain to be passed
    on to all day, evening, night, weekend, and
    temporary staff for implementation. Since up to
    80 of nursing home residents have chronic pain,
    the CONSISTENT use of these five steps for pain
    management is the hardest barrier most facilities
    face. Without regular RE-EVALUATION, a pain
    management program is unable to identify how the
    resident is actually being managed. Our
    assumptions that appropriate care is being given
    would only be based on guesses.

Screen for PAIN.
Conduct an EVALUATION OF PAIN.
Develop a CARE PLAN.
Put the plan into ACTION. Be CONSISTENT.
RE-EVALUATE regularly.
7
Develop a tracking system
  • You need data to check processes
  • Accurate assessments
  • Prompt and appropriate treatments
  • Repeat evaluations
  • High risk residents identified
  • Pain Coordinator or Pain Committee
  • Slide Notes
  • Quality Improvement continually strives to make
    systems and processes better. Sometimes a barrier
    occurs in a facility that stops the efficiency of
    one or more steps to success. A facility must be
    able to identify which piece of the process needs
    improvement in order to get back on the track to
    good care. A tracking system uses data to check
    processes to isolate problems and verify good
    care. The data can easily tell you whether the
    system is effective or just busy work for the
    staff.
  • A Pain Coordinator or Pain Committee has been
    used by many facilities in coordinating their
    pain management program. The facility is able to
    continue other aspects of resident care while the
    Pain Coordinator or Pain Committee ensure that
    pain is properly addressed. Often times the Pain
    Coordinator will be called by other staff as a
    resource for a pain problem. The Pain Coordinator
    usually maintains a binder of pain information
    that also contains the facilitys policies and
    procedures for pain management.

8
FIVESystemic Barriers
  • To Good
  • Pain
  • Management
  • Slide Notes
  • There are some reoccurring common barriers to
    pain management that can influence how soon your
    facility succeeds in increasing the quality of
    care you give to your residents. We can learn
    from others in our field that have overcome these
    barriers. Their suggestions may help us learn
    without having to experience the negative outcome
    that we might have without this collaboration. We
    can made their successes our own.

9
First systemic barrier
  • Using inappropriate medications to treat pain in
    the elderly.
  • Slide Notes
  • Our population of elderly residents require us to
    know how their bodies react to medications. At
    this stage of their life, drug absorption and the
    length of time the drug is effective will be
    different than when their bodies were younger. As
    part of an interdisciplinary team assigned to
    their care, if we see an inappropriate medication
    ordered, we cannot say but thats what the
    doctor ordered! Communicating with the
    residents physician about the potential for
    side-effects from an inappropriate medication may
    give use the opportunity to establish a working
    relationship with the residents physician. By
    being specific and knowledgeable in our
    assessment of the pain information we present to
    the physician we can become a valuable partner in
    the residents care. If we have PRN pain
    medications routinely ordered for the resident we
    should be able to assess which PRN medication is
    most appropriate for the type of pain the
    resident is experiencing. We can practice Best
    Practice by following the World Health
    Organizations (WHO) analgesic ladder that
    emphasizes the lowest dose of the least potent
    analgesic first. If pain control is not achieved
    then we can increase the dose or switch to a
    stronger analgesic until pain relief is achieved.
    A potential error may occur when the resident is
    admitted into the facility with medications
    prescribed while in the hospital before the
    residents primary physician at the nursing home
    has reviewed the orders. Inappropriate
    medications may be on that admission order.
    Another potential error may occur when the
    residents primary physician is unavailable. A
    physician on-call who is not familiar with the
    resident or may not have experience treating
    geriatric residents may be asked to write an
    order for a pain medication. Our residents are
    relying on us to be their advocates for
    appropriate care.

10
Drugs to avoid with elders
  • Opioids that are generally contraindicated
  • in the elderly
  • Meperidine (e.g., Demerol confusion from
    metabolites, ceiling effect)
  • Propoxyphene (e.g., Darvocet, no better than
    acetaminophen, has CNS side-effects)
  • Mixed Opioid Antagonists (e.g., Talwin
  • ceiling effect, delirium and hallucinations)
  • Slide Notes
  • The organs of the body that process most
    medications are the kidneys and the liver. These
    organs do not process the medications as well
    when we are elderly. There are individual
    differences with medication effects at any age,
    but generally, as we age we need less of a
    medication and it takes longer for the medication
    to leave our body. Elder residents are usually
    taking more than one medication so they are also
    at risk for a drug interaction. As we progress in
    our facility pain management program we need to
    remain aware of these facts. If we work as a team
    we have excellent help through the scheduled
    monthly visit with our pharmacy consultant. If we
    have a designated Pain Coordinator we can use the
    resources that the Coordinator has collected.
    Certain routine medications are prescribed for
    geriatric residents that we should have
    information on in our pain resource binder. There
    is also a list of inappropriate medications for
    the geriatric population called the Beers List
    that we can reference. It is helpful to have
    information on these inappropriate medications
    available for physicians and family members to
    read. It is possible that the residents
    physician may want to prescribe a medication that
    is on the Beers List because he feels the
    benefits of the medication out-weigh the risks.
    It is then our responsibility to care plan the
    possible adverse effects so that staff will be
    aware of potential problems to watch out for with
    the resident. For example, if the medication
    makes the resident dizzy, then assistance with
    ambulation while on the medication may be
    necessary to add to the care plan.

11
Second systemic barrier
  • Not providing pain treatment or providing
    medications that do not fit the severity of the
    pain.
  • Slide Notes
  • When a resident is in pain we may not be aware of
    the pain because the resident may not let us
    know. One of the more important parts of pain
    management is the screening and assessment of
    pain. The information gathered from the
    assessment of pain is essential to the treatment
    of pain. It may be unnecessary and inappropriate
    to treat a mild pain with a medication that has
    been ordered for the resident but is prescribed
    for a moderate to severe pain.

12
What drugs are used?
  • The WHO analgesic ladder
  • Step 1 Mild to moderate pain Non-opioids
    (acetaminophen, aspirin, NSAIDs)
  • Step 2 Moderate pain unrelieved by Step 1
    Opioids (codeine, dihydrocodeine, hydrocodone,
    oxycodone, tramadol, low dose morphine)
  • Step 3 Moderate to severe pain Opioids such as
    morphine, oxycodone, hydromorphone, fentanyl
  • Slide Notes
  • The Three Step WHO Analgesic Ladder is suggested
    for use based on the premise that health care
    professionals should learn to use a few pain
    relieving drugs well. One can move a step up the
    ladder if there is no relief obtained after a
    drug is used in the recommended dosage and
    frequency. Only one drug from each of the groups
    should be used at the same time. Should a drug
    cease to be effective, a switch should be made to
    one that is definitely stronger if it is
    available. The side effects of both the analgesic
    and the adjuvant should be kept in mind and where
    required, drugs to counteract these efforts
    should be prescribed.
  • Acetaminophen How much is too much. Ask this
    question to your nurses. Post a chart somewhere
    or everywhere.
  • Max dosage is 4000mg/24hr. Dose every 4-6 hours.
    Can be toxic to liver. This drug is found in many
    different medications.
  • Aspirin What effects does aspirin have on the
    individual resident? Causes gastric bleeding and
    abnormal platelet function.
  • NSAIDs What are they? Ibuprofen (Advil, Motrin,
    Nuprin). Can cause gastric bleeding, renal
    impairment, abnormal platelet function,
    constipation, confusion, headaches in older
    residents.
  • Tramadol May precipitate seizures. May cause
    dizziness.
  • Codeine often combined with aspirin or
    acetaminophen. No pain relieve for 10 of
    population
  • Hydrocodone in Lorcet, Lortab, Vicodin
  • Oxycodone in Percocet, Percodan, Tyox, others

13
Third systemic barrier
  • Not assessing with the right tools at the right
    time.
  • Slide Notes
  • Does your staff understand YOUR pain management
    policy? Is the right pain scale is used on the
    right resident at the right time? There are many
    different pain scales used to accommodate the
    different needs of the residents in you facility.
    Using the right scale instead of a one size fits
    all will ensure that the individual needs of
    your residents will be met. Not fitting the
    correct pain scale to your resident may result in
    the wrong type of medication or no medication
    being given for pain relief.

14
Validated pain scales for the cognitively
intact residents
  • Wong-Baker Face Scale
  • Numeric Rating Scale
  • Visual Analog Scale
  • Pain Map
  • Memorial Pain Assessment Card
  • McGill Pain Inventory
  • Brief Pain Inventory
  • Multidimensional Pain Inventory
  • Wisconsin Brief Pain Questionnaire
  • Slide Notes
  • What is a validated pain scale? Validated can be
    defined as a pain scale that has data from at
    least one study to prove that it does what it is
    suppose to do. If you use a pain scale that is a
    combination of several pain scales or a pain
    scale that you have put together with the help of
    you staff, you can not be ASSURED that it will
    give you the correct information you need from
    your assessment. A good example of this point can
    be found when using the Wong-Baker Face Scale on
    cognitively impaired residents. Studies using the
    scale on cognitively impaired residents have
    found that as the cognition declines, the
    resident will pick the happiest face on the
    scale whether the resident has pain or not.

15
Validated pain scales for the cognitively
impaired residents
  • Pain Assessment in Advanced Dementia (PAINAD)
  • Abby Pain Scale
  • Doloplus Scale
  • Discomfort Scale for Dementia of the Alzheimers
    type
  • Checklist of Nonverbal Pain Indicators
  • Non-Communicative Patients Pain Assessment
    Instrument (NOPPAIN)
  • Slide Notes
  • All of these pain scales have been validated and
    are used to make assessments on the residents you
    have that may not be able to verbally express
    their pain.

16
Cognitively Impaired Residents
  • At higher risk for under treatment
  • Often able to report feeling pain
  • Assessment tools suited to the resident should
    be used
  • Even in cognitively impaired
  • individuals, self reports of pain should be
  • considered reliable
  • Slide Notes
  • Ask yourself and those in your facility who
    assess pain, if these statements are true or
    false. This slide can be used as a quick
    assessment of whether your cognitively impaired
    residents are accurately being assessed for pain.
    If any of these statements are believed by staff
    to be false, then the measure for pain management
    used in your facility may be falsely low. Pain
    may not be recognized in residents that can not
    respond to the pain scale you are using. ALL THE
    STATEMENTS ON THIS SLIDE ARE TRUE.

17
Reassessment Times
  • Done at the time of peak pain relieving effect.
    This time depends on the medication half-life,
    based on its form and route of delivery.
  • At the mid-point between doses
  • Immediately before a scheduled dose
  • Slide Notes
  • An assessment for pain relief done at a time that
    is inappropriate will alert you to the problem of
    treating pain control in residents by reacting to
    pain versus having a pain management program.
    Knowing when to expect pain relief will allow
    staff to plan reassessment times. The decision to
    continue the pain medication as ordered or to
    alert the physician that the resident is not
    receiving pain relief can only be obtained if
    reassessment is timed to reflect the pain
    medications real effect on the resident. Making
    an assessment before the medication has had a
    chance to work with the residents body does not
    give an assessment of the medication. Nursing
    staff in services can contain the information
    needed for pain management. A periodic check of
    reassessment times in the nurses notes or in the
    medication administration record is a good way to
    monitor if more in services are needed.

18
Fourth systemic barrier
  • Not communicating the findings of the
    reassessment to the physician so the treatment
    can be revised and goals met.
  • Slide Notes
  • Many physicians who prescribe a treatment plan
    for their nursing home residents pain rely
    solely on the information the nurse provides in
    the pain assessment or telephone conversation.
    If an inaccurate pain assessment is done then an
    inaccurate treatment for pain may be done.

19
Effectiveness of pain treatment
  • Function
  • Mood
  • Activity Level
  • Does the pain treatment meet the residents
    acceptable level of discomfort?
  • Slide Notes
  • An important question to ask the resident who has
    pain is what level of pain is acceptable to
    you?. There may be a different answer to this
    question from each resident. Nurses need to be
    aware of each individual answer to have an
    effective pain management program. Goals set for
    the resident should be contained in the care plan
    for pain. Using the information from the care
    plan will help ensure that the NEEDS OF THE
    RESIDENT ARE BEING MET.
  • FUNCTION Has the residents physical or
    cognitive function improved since the initiation
    of pain medication?
  • MOOD Has the residents mood or behavior
    improved?
  • ACTIVITY LEVEL Has the residents physical
    activity level increased? Improved ADLs?

20
Fifth systemic barrier
  • Not addressing pain myths in residents, family or
    staff.
  • Slide Notes
  • We assume we all know the facts about pain
    management. In reality we all have different
    levels of knowledge. Pain myths can stop
    residents from letting Staff know if a resident
    has pain. Pain myths can stop nurses from
    screening and assessing for pain so that pain is
    not recognized or addressed.

21
Common myths about chronic pain
  • It is a signal of weakness to acknowledge pain
  • Pain is an inevitable part of aging
  • Pain is a punishment for past actions
  • Pain means death is near
  • Pain meds should only be taken for severe pain
  • Slide Notes
  • Myths are not questioned by those residents or
    staff that believe they are true. It is hard to
    know if a myth is the problem leading to no pain
    complaints or lack of pain assessments. You will
    know if myths are a problem in your facility only
    if you discuss the myth with residents and staff.

22
Common myths about chronic pain
  • Acknowledging pain means undergoing painful tests
  • The elderly have a higher tolerance for pain
  • Cognitively impaired residents cant feel pain
  • Residents complain about pain just to get
    attention
  • Taking pain medication leads to addiction
  • Slide Notes
  • The greatest solution to the problem of myths
    being a barrier to pain management is to just
    TALK about pain.

23
Pain managementinterdisciplinary team effort
  • Administrator
  • Medical director
  • Director of nursing
  • Attending physician
  • Consultant pharmacist
  • Therapists (PT, OT)
  • Social Workers
  • Resident and family
  • Nursing staff
  • Environmental Services
  • Dietary staff
  • Activities staff
  • Slide Notes
  • Reacting to pain is usually the solitary duty of
    the residents charge nurse. Pain Management is
    the duty of all the staff in the facility who
    care for the resident.

24
Frontline caregivers play a vital role
  • Ask the resident
  • Are you having pain right now?
  • Is your backside sore?
  • Does your arm hurt?
  • Are you uncomfortable?
  • Give staff permission to.. Observe for signs of
    discomfort
  • Slide Notes
  • Some residents will not acknowledge their pain by
    telling staff that they have pain. But, listening
    to the resident may reveal that the resident is
    not up to par, or a little under the weather or
    just not comfortable. Many other phases may tell
    staff that the resident is in pain. There are
    some residents who have a closer relationship
    with the nursing assistant, maintenance person or
    housekeeping person than their charge nurse. The
    resident may be more willing to say how they feel
    to them. If the nursing staff responds to
    information about the resident from other staff,
    a team approach to managing pain can help improve
    the care of the resident.

25
What is pain?
  • An unpleasant sensory and emotional experience
  • Highly subjective with no objective biological
    markers
  • Chronic pain is an abnormal condition
  • Pain is what the resident says it is.
  • Slide Notes
  • Pain is not meant by the body to be tolerated.
    The body uses pain to let us know something is
    not right and needs our attention.

26
Causes of chronic pain in elders
  • DJD
  • Rheumatoid arthritis
  • Low back disorders
  • Osteoporosis with compression fractures
  • Diabetic neuropathy
  • Headaches
  • Oral or dental pathology
  • PVD
  • Improper positioning, use of restraints
  • Pressure Ulcers
  • Immobility, contractures

27
How do I know when a resident has pain?
28
Signs and symptoms suggestive of pain
  • Frowning, grimacing, fearful facial expressions,
    grinding of teeth, calling out
  • Bracing, guarding, rubbing, rocking
  • Fidgeting, increasing or recurring restlessness
  • Striking out, increasing or recurring agitation
  • Eating or sleeping poorly
  • Decreasing activity level
  • Loss of function

29
Pain may impact other issues
  • Mobility (gait disturbances, falls)

30
Pain may impact other issues
  • Sleep (increased, decreased)

31
Pain may impact other issues
  • Appetite (malnutrition)

32
Pain may impact other issues
  • Bowel / Bladder

33
Pain may impact other issues
  • Cognition (confusion, depression, anxiety)

34
Pain may impact other issues
  • Socialization (decreased)

35
Pain may impact other issues
  • Multiple Med Use(psychotropic misuse)

36
Staff play a vital role
  • Use the same pain assessment tools
  • Appoint a pain coordinator
  • Education program for all staff
  • Communication information
  • must be conveyed to and acted on
  • by the appropriate staff.

37
Screen for the presence of pain
38
Screeningschedule
  • On admission
  • Quarterly MDS review
  • On significant change in condition
  • During annual MDS
  • During routine daily care
  • Any time pain is suspected
  • DRIP, DRIP, DRIP, DRIP
  • Data Rich Information Poor (DRIP)

39
Tools for Pain Management
  • Nurses use MARs to manage pain.
  • QI/QM Reports generated from MDS data can be used
    to monitor pain program
  • Slide Notes
  • These tools provide us with data to manage the
    process.

40
How to do a pain evaluation
  • How does the pain
  • affect the resident?
  • 1. Location of pain (where)
  • 2. Time of onset (first started)
  • 3. Frequency of pain (how often am/pm)
  • 4. Quality of pain (description)
  • Intensity of pain (validated pain scale)
  • Slide Notes
  • Does your facilitys policy and procedures cover
    these important areas in a pain evaluation?

41
Assessing PainQuality
  • Nociceptive pain (somatic) aching, deep, dull,
    gnawing, throbbing, sharp
  • Nociceptive pain (visceral) cramping,
    squeezing, pressure
  • Neuropathic pain burning, numb, radiating,
    shooting, stabbing, tingling
  • Slide Notes
  • This information is important for the nurse to
    convey to the physician as a result of the pain
    evaluation.

42
Conduct an in-depth evaluation
  • Review diagnoses contributing to the pain.
  • Note all current treatments
  • Note dosage and frequency of all pain med
  • Ask about frequency and location of pain
  • How is pain affecting mood, activities, sleep,
    etc
  • Review effectiveness of drugs and tx used in
    past
  • Slide Notes
  • Diagnoses or conditions that may be causing or
    contributing to the pain.
  • Treatments
  • Dosage and frequency of all pain medications
  • Frequency and location of pain and words used to
    describe pain. What makes pain better or worse?
  • Pain affecting mood, activities, sleep, etc
  • Effectiveness of drugs and treatment used in past

43
Review the residents med record
  • With each change in pain medication
  • With a sudden change in status of the resident
  • With the Consultant Pharmacist
  • Any med changes if recently admitted
  • Any recently discontinued pain meds
  • Drugs poorly tolerated OR giving less than
    optimal control
  • Any increase in pain related to worsening
    disease
  • When drug toxicity could be a problem

44
Repeat evaluation with each new complaint of pain
  • Dont assume a change in the nature of a
    residents pain, or a new pain, is related to the
    original underlying cause.
  • Sometimes it is caused by an acute condition
    requiring immediate attention!

45
How do we select individualized care plan
interventions?
46
Identify preferences for treatment
  • Ask about preferences and expectations
  • Slide Notes
  • Preferences and expectations individualizes the
    residents PLAN OF CARE and facilitates adherence
    to treatment regimen and achievement of
    therapeutic goals.

47
Comfort measures
  • Environment
  • Positioning
  • Backrubs / Massage
  • Reassuring words and touch
  • Topical analgesic
  • Chaplain or counselor
  • Education
  • Slide Notes
  • Environment temperature and noisemove resident
    to a quieter part of the facility
  • Positioning restraints and wheelchairs can
    increase the feeling of discomfort if left in
    place
  • Backrubs/Massage try a foot massage
  • Topical analgesic like aspercreme or something
    they had successfully used at home
  • Chaplain or counselor should be invited to visit.
    Can help with some of the myths of pain
  • Education of staff, residents and family members
    can be very beneficial without additional
    medications or cost

48
Relaxation and diversion techniques
  • Books on tape
  • Conversation
  • Activity
  • Visitors
  • Pet Therapy
  • Music
  • Aromatherapy

49
Non pharmacological
  • Physical/Occupational Therapy
  • Hot packs or ice, Transcutaneous Electrical Nerve
    Stimulation (TENS) unit, or Ultrasound
    treatments, evaluate for positioning, high-backed
    wheelchair, soft neck collar, wedge, braces,
    walking program, stretching exercises

50
Non pharmacological
  • Psychiatry
  • Psychology or Social Work
  • Chaplain consult
  • Slide Notes
  • Psychiatry for depression, anxiety, behavior
    management
  • Psychology or Social Work support and
    counseling for coping through difficult
    situations
  • Chaplain consult for concerns about suffering,
    finding meaning, end-of-life concerns, prayer

51
Starting drug therapy
  • Single analgesic
  • Least invasive
  • Individualized
  • Lowest dose
  • Re-assessment
  • Routine medications
  • Slide Notes
  • Generally use best single analgesic
  • Least invasive route injections not recommended
    on geriatric residents
  • Individualized to the specific characteristics of
    the resident
  • Need frequent re-assessment to titrate dose
  • Administer medications routinely (not PRN)

52
Medicating to relieve pain
  • Around the clock
  • As needed
  • Adjuvant meds
  • Side effects
  • Slide Notes
  • Use around the clock administration of meds
  • Use as needed doses for breakthrough pain or
    before therapy, dressing changes, etc
  • Use adjuvant meds to enhance effect of pain
    meds
  • Prevent and treat side effects of analgesics
    change drugs if necessary

53
Managing side effects of medications
  • Constipation
  • Sedation
  • Nausea with/without vomiting
  • Delirium
  • Slide Notes
  • Constipation -A laxative (e.g., sorbitol) needs
    to be started at same time opioids are
    prescribed.
  • Sedation - Some meds may make residents a little
    drowsy should disappear in a few days.
  • Nausea with/without vomiting -Check for impaction
    but be careful if resident has heart problems
    offer small, frequent meals.
  • Delirium -Properly prescribed meds should not
    result in much confusion. If delirium is
    present, notify physician immediately.

54
Evaluate treatment
  • Response
  • Side effects
  • Slide notes
  • EVALUATE THE RESPONSE TO TREATMENT
  • Evaluate and document the residents response to
    drug and complementary therapies
  • Track SIDE EFFECTS associated with each
    intervention

55
Points to remember
  • Investigate all residents who trigger for pain
  • Assess nature and intensity of pain
  • Evaluate new complaint of pain
  • WHO Analgesic Ladder
  • Treat side affects
  • Consider hospice
  • Slide Notes
  • Communicate residents who trigger for pain on
    MDS, or you suspect has pain
  • Concentrate on evaluating the nature and
    intensity of pain
  • Evaluate each new complaint/suspicion of pain
  • Medicating by WHO Analgesic Ladder ensures that
    pain can always be treated
  • Treat side effects aggressively (anticipate
    constipation)
  • Consider hospice as a resource for difficult to
    manage end-of-life pain or symptoms

56
THE END
  • This material was prepared by TMF Health Quality
    Institute, the Medicare Quality Improvement
    Organization for Texas, under contract with the
    Centers for Medicare Medicaid Services (CMS),
    an agency of the U.S. Department of Health and
    Human Services. The contents presented do not
    necessarily reflect CMS policy.
    8SOW-TX-NHQI-06-04

This material was prepared by TMF Health Quality
Institute, the Medicare Quality Improvement
Organization for Texas, under contract with the
Centers for Medicare Medicaid Services (CMS),
an agency of the U.S. Department of Health and
Human Services. The contents presented do not
necessarily reflect CMS policy. 8SOW-TX-NHQI-06-04
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