Assessment of Pain

1
Assessment of Pain

• Evelyn Duffy, ND, APRN, BC

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Long Term Care

• Studies have noted that pain is present in 26-83
  of residents in LTC
• More than one fourth of those (26) received no
  analgesia, with those over 85 years of age and
  those with cognitive impairment the least likely
  to be treated
• An additional number are under treated for pain

3
Community Dwelling

• A study of community dwelling elders noted an
  incidence of daily pain of up to 49 in those age
  65 and older
• Those over 85 years of age and those with
  cognitive impairment were least likely to be
  treated

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PAIN IS . . .

• Pain is whatever you say it is and it exists
  wherever you say it does!
• Margo McCafferty

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Pain is

• not there if they dont say it is there?

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Why Not Report Pain?

• Normal part of aging
• Fear of possible diagnosis
• Cohort barriers
• Fear of addiction
• Cultural barriers

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Why Not Report Pain?

• Dont Ask/Dont Tell

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The Fifth Vital Sign

• How do you take this vital sign?
• You Ask!
• Ask, ask, and ask again

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JCAHO 7 Commandments

• Recognize the right of patients to appropriate
  assessment and management of pain
• Assess the existence and, if present, the nature
  and intensity of pain in all patients

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JCAHO 7 Commandments

• Record the results of the assessment in a way
  that facilitates regular reassessment and
  follow-up
• Determine and assure staff competency in pain
  assessment and management, and address pain
  assessment and management in the orientation of
  all new staff

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JCAHO 7 Commandments

• Establish policies and procedures that support
  the appropriate prescription or ordering of
  effective pain medications
• Educate patients and their families about
  effective pain management
• Address patient needs for symptom management in
  the discharge planning process.

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Pain Care Bill of Rights

• Developed by the American Pain Foundation
• The Patients rights
• Pain assessment , treatment, reassessment, and
  referral if necessary
• Right to involvement in decision making
• Right to refuse treatment

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CAUSES OF CHRONIC PAIN IN ELDERS

• Arthritis
• Ischemic disorders
• Neuralgia
• Post-stroke
• Spinal stenosis
• Peripheral vascular disease
• Diabetic neuropathy
• Osteoporosis
• Temporal arteritis
• Cancer

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Causes of Acute Pain

• Arthritis flare ups
• Trauma from falls
• Skin problems
• Infections
• Constipation
• Angina

Acute on Chronic Pain
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Morbidity of Untreated Pain

• Depression
• Inactivity
• Withdrawal
• Fatigue
• Sleep disturbance
• Irritability
• Physical deconditioning

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Assessing the Pain

• Timing
• Onset
• Duration
• Frequency
• Location
• Quality
• Quantity/severity (Pain Scale)
• Aggravating/alleviating
• Associated symptoms
• Patient perspective/self treatment

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Tools to Quantify Pain
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Tools to Quantify Pain
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Ask, Ask, and Ask Again

• Upon awakening
• Before activity
• After treatment
• Before discharge

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Dementia

• 50 of those over 85 years of age living in the
  community have some dementia
• At least half of all Long Term Care residents
  have dementia

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Pain in Dementia

• No evidence that sensitivity to pain is dulled in
  demented patients
• In early dementia visual analog scales are still
  affective tools for assessment

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Pain in Dementia

• In mid stage dementia abstract reasoning is lost
  so that scales are not understood
• May be able to acknowledge pain present at the
  time you ask, but cannot rate or give duration
• In advanced dementia patients are not verbal and
  are not able to report pain

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Tools to Assess Pain in Dementia

• Use both self report and nonverbal measures
• Talk to the family or significant other
• Observation
• Facial cues
• Increase or decrease in movement
• Restlessness
• Vocalizations

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Lessons from Pediatrics
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http//www.hartfordign.org/publications/trythis/as
sessingPain.pdf
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PAINAD
Warden, V, Hurley, A.C., Volicer, L. (2003).
JAMDA. Jan/Feb Pp 9-15
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Breathing
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Negative Vocalization
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Facial Expression
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Body Language
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Consolability
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Who Needs to Ask?

• Nurses
• Assistants
• Facility Staff
• Families

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Additional Questions

• Location
• Description
• How often?

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Pain Record

• Self record
• Nursing record
• Fifth vital sign

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Web Resources

• http//www.cityofhope.org/prc/elderly.asp
• American Geriatric Society Guidelines
• http//www.americangeriatrics.org/products/positio
  npapers/JGS5071.pdf

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Web Resources

• American Medical Directors Association Guidelines
• http//www.amda.com/tools/cpg/chronicpain.cfm
• University of Wisconsin
• http//www2.edc.org/lastacts/archives/archivesJan0
  1/featureinn.asp

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Communicating Recommendations

• SBAR
• Developed for communication on submarines
• Similar to SOAP
• Clear, concise, and to the point
• Whats your problem?
• What do you need?
• Nurses want to tell a story
• Physicians want the bottom line

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SBAR

• Situation
• I just admitted your patient, Mr. J. He needs
  something for pain
• Background
• He is 78 years old and had a R TKA three days
  ago. He became confused while using his
  hydromorphone PCA, so the hospital has only been
  giving him Tylenol, 500mg 2 tablets every 4
  hours. He rates his pain as an 8-9 on a scale of
  1-10 with little relief from the Tylenol. He
  cant participate in therapy as he should because
  of the pain.
• Assessment
• He is no longer confused and he had no prior
  history of dementia. He just had his knee
  replaced, he needs something more for pain.
• Recommendation
• I think he could benefit from gtgtgtgtgtgtgtmake a
  suggestion!

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Using Medication

• You are responsible for the med given
• Know your patient
• Know their diagnoses
• Know their labs
• Serum creatinine
• Liver functions
• Nutritional status

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Treating Older Adults

• Older Adults suffer from multiple chronic
  diseases and are more likely to be on multiple
  medications
• Older adults experience an increased incidence of
  adverse drug effects
• There is an increased likelihood that they will
  respond atypically to a given drug

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Medication Rule

• Start low go slow
• Lower initial dose
• Allow longer interval at each dose
• Increase dose in smaller increments
• Assess, assess, assess, assess

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Nonpharmacologic Treatments

• Music
• Exercise
• Heat/cold
• Diet modifications
• Warm milk
• Naps
• Light

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The Fifth Vital Sign

• Dont miss out
• Seek and you will find
• Communication is the key
• Know your residents
• Use your resources