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Appendix G: Pain Assessment and Management Training


Pain Assessment and Management Training ... Indicate how you would assess her pain and what tools and observational skills you would use. – PowerPoint PPT presentation

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Title: Appendix G: Pain Assessment and Management Training

Appendix G Pain Assessment and Management
Training Where does it hurt?
  • Audience For Registered Staff
  • Release Date December 10, 2010

  • 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

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

Research Says
  • Approximately 25 of Canadian's suffer from
    chronic pain
  • Chronic pain becomes more common as people get
  • 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

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.
Pain Pathways Pain the Brain

Lewis, Sharon L.. Medical-Surgical Nursing in
Canada, 2nd Edition. Mosby Canada, 072009.).
Words Used to Describe Pain
Can You Think of Any ?
  • Hurt

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.

Types 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.

Neuropathic Pain Described
Types 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.

Sites of Referred Pain
(Lewis, Sharon L.. Medical-Surgical Nursing in
Canada, 2nd Edition. Mosby Canada, 072009.).
Components of Effective Treatment of Pain
Pharmacological Non Pharmacological Treatment
Evaluation Of Effectiveness
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
  • 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.

Pain 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)

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

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
  • 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

Self Report Tools
  • Descriptive Tools
  • Where is the pain ?
  • 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?

Pain Intensity Rating Scales
  • Numeric Rating Scale (NRS)
  • Visual Analogue Scale (VAS)
  • Verbal Scale
  • Facial Grimace Behavioural Flow Chart

Pain Intensity Rating Scalescontd
Facial Grimace Scale Behavioural Checklist Flow
  • 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

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 residents normal behaviour
  • Observations from family or care givers

Pharmacological Approach
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)

Non-Pharmacological Approach
  • Exercise
  • Transcutaneous electrical nerve stimulation
  • Heat/Cold
  • Relaxation Therapy
  • Massage
  • Acupuncture
  • Behaviour Therapy

  • Exercise improves your mood
  • Exercise combats chronic diseases
  • Exercise promotes better sleep
  • Exercise boosts your energy level

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
Thermal Treatment
Relaxation 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).
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?