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