Appendix G: Pain Assessment and Management Training “Where does it hurt?”

Audience: For Registered StaffRelease Date: December 10, 2010

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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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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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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Definition of Pain“Pain is what the patient say it is, and exists whenever the patients says it does” McCaffery & Pasero (1979)

PainAn 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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Pain Pathways: Pain & the Brain

Lewis, Sharon L.. Medical-Surgical Nursing in Canada, 2nd Edition. Mosby Canada, 072009.). vbk:9781897422014#B9781897422014500176_f2>

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Words Used to Describe Pain

HurtSoreness

PressureBurning

DiscomfortCan You Think of Any ?

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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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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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Neuropathic Pain Described…

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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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Sites of Referred Pain

(Lewis, Sharon L.. Medical-Surgical Nursing in Canada, 2nd Edition. Mosby Canada, 072009.).

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Components of Effective Treatment of Pain

Evaluation Of Effectiveness

Pharmacological &Non

PharmacologicalTreatment

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Pain AssessmentScreening 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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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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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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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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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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Pain Intensity Rating Scales

• Numeric Rating Scale (NRS)

• Visual Analogue Scale (VAS)

• Verbal Scale

• Facial Grimace & Behavioural Flow Chart

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Pain Intensity Rating Scales…cont’d

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Facial Grimace Scale & Behavioural Checklist Flow ChartThe facial grimace scale scores the level of pain (from 1-10) based on the care givers observations for the resident’s facial expression.

Please refer to handout

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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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Pharmacological Approach

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Pharmacological ApproachMild 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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Non-Pharmacological Approach

• Exercise • Transcutaneous electrical nerve stimulation

(TENs)• Heat/Cold• Relaxation Therapy • Massage• Acupuncture• Behaviour Therapy

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Exercise

Exercise improves your mood

Exercise combats chronic diseases

Exercise promotes better sleep

Exercise boosts your energy level

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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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Thermal Treatment

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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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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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WORKING TOGETHER TO EASE THE PAIN

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