E L N E C Geriatric Curriculum

E L N E C Geriatric CurriculumEnd-of-Life Nursing Education Consortium

Session 4:Pain Management

Fairfield UniversityQuinnipiac University

School of Nursing ELDER Project

E L N E C Geriatric Curriculum

Objectives: Upon completion of this session, the participant will be able to…

1. Define pain.

2. Discuss the importance of a thorough and continual pain assessment.

3. Identify barriers to adequate pain relief.

E L N E C Geriatric Curriculum

Activity…

E L N E C Geriatric Curriculum

MYTHS ABOUT PAIN MANAGEMENT

1. It is easy to get addicted to pain medicines.

2. If the patient dies soon after an injection, the last person

who gave the medication has contributed to the death.

3. Patients who talk a lot about their pain are complainers

and want attention.

4. A sleeping person can not be in pain.

5. A person smiling, talking, joking or watching TV can not

be in pain.

• ©2001 D.J. Wilkie & TNEEL Investigators

E L N E C Geriatric Curriculum

“Pain is …

Whatever the person says it is…”

Pasero & McCaffery, 2010

E L N E C Geriatric Curriculum

Ms. P is a 55-year old woman with cancer. She got pain medication less than two hours ago after which she said she felt much better. A coworker said that Mrs. P is complaining of pain again. The co-worker says “She can’t be hurting as much as she says she is.” What is the health care worker’s best response?

 

1. “Pain is whatever she says it is. Let’s assess her further.”2. “We need to explore the cultural meaning pain has for

her.”3. “I will tell her gently that she must wait four hours

between doses.” 4. “I’ll wait to give the next dose and re-assess her a little

early, in an hour.”

E L N E C Geriatric Curriculum

Most Common Types of Persistent Pain in Older Adults • Musculoskeletal • Osteoporosis/compression fractures/degenerative disc disease• Neuropathies• Cancer • Spinal Stenosis• Pressure ulcers / wounds AGS, 2009; Ferrell, 1990; Weiner & Herr, 2002

E L N E C Geriatric Curriculum

Challenges to Assessing Pain–Stoicism, not

wanting to be a complainer

–Fears: procedures, side effects, addiction

–Fatalism: Pain is part of aging

–Culture–Cognitive or

sensory impairment, depression, etc.

–Concurrent illnesses

• Why have some of your patients been reluctant to report pain?

-Use of different words to describe pain

E L N E C Geriatric Curriculum

What are the barriers to Pain Relief?

• Healthcare Professionals• Healthcare Systems• Patients/Families

Davis et al., 2002; Gunnarsdottir et al., 2002; Pasero & McCaffery, 2010; Miaskowski et al, 2005;

Paice, 2010

ACTIVITY

E L N E C Geriatric Curriculum

Pain Evaluation

• Pain history• Physical examination• Laboratory/diagnostic

evaluation• How can different members of the palliative care

team (and family) assist in the assessment of pain management?

Fink & Gates, 2010

E L N E C Geriatric Curriculum

Pain Assessment

• Etiology• Location • Pain Intensity• Character• Pattern

• Functional Status• Goals of Care

E L N E C Geriatric Curriculum

Pain Intensity Tools

Fink & Gates, 2010; Herr et al., 2006

E L N E C Geriatric Curriculum

Patients at Risk for Undertreatment

•Children and older adults•Non-verbal or cognitively impaired•Patients who deny pain•Non-English speaking•Different cultures•History of addictive disease

E L N E C Geriatric Curriculum

Reference:Warden, V., Hurley, A.C. & Volicer, L. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Demetia (PAINAD) scale. Journal of the American Medical Director Association, 4(1), 9-15.

E L N E C Geriatric Curriculum

The healthcare worker is talking with the parents of a 2-year-old boy diagnosed with leukemia about pain management. Which of the following statements indicates understanding about pain management in children? •  

1. “He needs to be assessed carefully so that he gets enough pain medication.”

2. “He may need less pain medication since he has limited memory of the pain.”

3. “He may become addicted because he is so young and getting pain medicine.”

4. “He doesn’t feel that much pain because his nervous system is still maturing.”

E L N E C Geriatric Curriculum

Impact of Pain on QOL

• ADLs• Mobility/transfers• Participation in meals, social

activities• Mood interference• Sleep interference

How does being in pain affect QOL?

E L N E C Geriatric Curriculum

The healthcare team is caring for a woman with advanced cancer. The client reports ongoing fatigue. Which of the following statements by the husband shows he understands the wife’s fatigue? 

1. “She sleeps quite a bit, so she shouldn’t be as tired as she is.”

2. “She’s lost some weight. I know she’ll feel better if she eats more.”

3. “She’s been in pain. If we control that maybe she’ll have more energy.”

4. “She seems moody, so we need to cheer her up and make her laugh.”

E L N E C Geriatric Curriculum

When to Assess and Document

• Admission• Regular intervals• New pain• Exacerbations• Uncontrolled pain• New therapy (new

meds, increased doses)

E L N E C Geriatric Curriculum

Good Pain Management

There are many challenges to assessing pain in older adults —

nonetheless, there is no pain relief when there is no pain assessment

E L N E C Geriatric Curriculum

What do you think?• Mr. F has advanced prostate cancer with spread to the

bone (bone metastasis). He is in a coma, and is being cared for at home by his daughter. The home health worker is teaching the daughter about assessing her father’s pain. Which of the following statements by the daughter shows she understands her father’s pain level?

1. “If he is not moaning, he’s probably not in pain.” 2. “I’ll have to guess when he is in pain since he can’t tell

me.”3. “Now that he’s unable to tell me, we can stop his pain

medication.”4. “Since he was in pain when he could talk, I assume he’s

still in pain.”

E L N E C Geriatric Curriculum

NSAIDS Side Effects

• Risk of adverse events( GI bleeding) increases with age

AGS, 2009; Paice, 2010

E L N E C Geriatric Curriculum

Opioid Side Effects

• Sedation • Nausea and vomiting • Constipation• Urinary retention• Confusion• Hallucinations• Respiratory depression (rare)

E L N E C Geriatric Curriculum

Addressing Barriers to Opioid Use

E L N E C Geriatric Curriculum

Definitions

• Addiction • Tolerance • Physical Dependence

activity

E L N E C Geriatric Curriculum

Definitions

activity

What is it?1. Dependence2. Tolerance3. Addiction

caused by a withdrawal syndrome that can be produced by abruptly stopping or a rapid dose reduction in a drug

1. unable to control drug use2. compulsive drug use3. continued use despite harm4. craving the drug .

a state of adaptation in which exposure to a drug causes changes that result in a decrease in the drug's effects.

E L N E C Geriatric Curriculum

Which of the following statements shows a correct understanding of pain management for clients with a history of substance abuse?   1. "They should not be given pain medicine for pain because

they become addicted.”2. "They will need smaller doses of pain medicine to prevent

an overdose.” 3. "They may require higher dose of pain medicine to relieve

their pain."4. "They need to withdraw from the drugs they are on

before getting pain medicine.”

E L N E C Geriatric Curriculum

The principle of double effect…

• …differentiates between giving medication with the intent to relieve pain that might inadvertently hasten death versus giving medication to intentionally cause death.

• There will always be a last dose of opioid !• (Prince-Paul & Daly, 2010; Sykes & Thorns, 2003).

• Have you ever hesitated to medicate a patient because you felt it may hasten the patient’s death?

E L N E C Geriatric Curriculum

 Which of the following clients is at the highest risk for developing constipation?

•   

1. A 48-year-old with metastatic cancer of the spine on high doses of opioids who has dehydration.

2. A 76-year-old with cancer of the bowel who has begun treatment for Clostridium difficile.

3. An 85-year old with hepatic encephalopathy who is receiving prescribed neomycin (Mycifradin) and lactulose.

4. A 90-year-old with uterine cancer and laboratory evidence of hypocalcemia and hyperkalemia.

E L N E C Geriatric Curriculum

Case Example: Mr. Rosena• Mr. Rosena’s story and your connection:

– He is told by you that his cancer is progressing.– You learn that Mr. Rosena is afraid of pain more than death. – You reassure him that you’re committed to relieving any pain– You assess him frequently for pain / Offer round-the-clock pain service

• Positive result based on visit:– A major concern is alleviated for Mr. Rosena.

Wong-Baker FACES Pain Rating Scale

NO HURT HURTS LITTLE BIT

HURTS LITTLE MORE

HURTS EVEN MORE

HURTS WHOLE LOT

HURTS WORST

E L N E C Geriatric Curriculum

The 68 year old patient is in the last hours of life after a lengthy illness. The patient has been receiving – pain medicine. In assessing the patient as death approaches, the pain medication may need to be:

1. increased or decreased to maintain pain control2. given only if the patient asks for it3. monitored because different types of pain

increase as death approaches4. stopped because of decreased consciousness and

altered mental state

E L N E C Geriatric Curriculum

Summary

• Pain is whatever the person says it is.• Pain assessment should on ongoing.• Identify and overcome barriers to pain

relief.

E L N E C Geriatric Curriculum

Last question…

• What one practice improvement can you begin as a result of attending this session?

E L N E C Geriatric Curriculum

References

City of Hope & the American Association of Colleges of Nursing, 2007; Revised, 2010. The End-of-Life Nursing Education Consortium (ELNEC)- Geriatric Training Program and Curriculum is a project of the City of Hope (Betty R. Ferrell, PhD, FAAN, Principal Investigator) in collaboration with the American Association of Colleges of Nursing (Pam Malloy, RN, MN, OCN, Co-Investigator).

D.J. Wilkie & TNEEL Investigators, 2001. Toolkit for Nursing Excellence at End of Life Transition, version 1.0. Cancer Pain & Symptom Management Nursing Research Group; University of Washington.

Supported by DHHS/HRSA/BHPR/Division of Nursing Grant # D62HP06858