CENLE End-of-Life Nursing Education Consortium Module 2: Pain Assessment and Management Geriatric Curriculum.

CCEENNLLEEEnd-of-Life Nursing Education ConsortiumEnd-of-Life Nursing Education Consortium

Module 2:Module 2:Pain Assessment and Pain Assessment and ManagementManagement

Geriatric CurriculumGeriatric Curriculum

EE LL NN EE CC Geriatric CurriculumGeriatric Curriculum

ELNEC Attribution StatementELNEC Attribution Statement

The End-of-Life Nursing Education Consortium (ELNEC) The End-of-Life Nursing Education Consortium (ELNEC) Project is a national end-of-life educational program Project is a national end-of-life educational program administered by City of Hope National Medical Center administered by City of Hope National Medical Center (COH) and the American Association of Colleges of (COH) and the American Association of Colleges of Nursing (AACN) designed to enhance palliative care in Nursing (AACN) designed to enhance palliative care in nursing. The ELNEC Project was originally funded by a nursing. The ELNEC Project was originally funded by a grant from the Robert Wood Johnson Foundation with grant from the Robert Wood Johnson Foundation with additional support from other funding organizations additional support from other funding organizations (Oncology Nursing, Aetna, Archstone, and California (Oncology Nursing, Aetna, Archstone, and California HealthCare Foundations; National Cancer, and Open HealthCare Foundations; National Cancer, and Open Society Institutes). Materials are copyrighted by COH Society Institutes). Materials are copyrighted by COH and AACN and are used with permission. and AACN and are used with permission.


Module 2 PartsModule 2 PartsPart I:Part I:A.A. General pain assessmentGeneral pain assessmentB.B. Assessment of pain in nonverbal residentsAssessment of pain in nonverbal residentsPart II:Part II:A.A. Nonopioid medications for pain managementNonopioid medications for pain managementB.B. Opioid medicationsOpioid medicationsC.C. Management of analgesic side effectsManagement of analgesic side effectsPart III:Part III:A.A. Nursing assistant role in observing and relieving Nursing assistant role in observing and relieving

painpainB.B. Nondrug interventions for pain and other Nondrug interventions for pain and other

symptomssymptoms


Part I A: General Pain Part I A: General Pain AssessmentAssessmentObjectivesObjectives• Define pain Define pain • Describe categories of painDescribe categories of pain• Describe the prevalence of pain among older Describe the prevalence of pain among older

adultsadults• List challenges in assessing pain in older List challenges in assessing pain in older

adultsadults• Discuss the primary components of a Discuss the primary components of a

nursing pain assessmentnursing pain assessment


Definitions of PainDefinitions of Pain

• ““An unpleasant sensory and An unpleasant sensory and emotional experience associated with emotional experience associated with actual or potential tissue damage” actual or potential tissue damage” IASP, 1979IASP, 1979• ““Pain is whatever the person says it Pain is whatever the person says it

is…” is…” McCaffery & Pasero, 1999McCaffery & Pasero, 1999


Pain in Older AdultsPain in Older Adults

• 25 – 56% community-dwelling elders 25 – 56% community-dwelling elders Helme & Gibson, 2001; Shega et al., 2004Helme & Gibson, 2001; Shega et al., 2004

• 45 – 85% nursing home residents45 – 85% nursing home residents

AGS, 2002; Won et al., 2004 AGS, 2002; Won et al., 2004

• 1/3 cancer pts receiving treatment and 2/3 1/3 cancer pts receiving treatment and 2/3 with advanced cancer with advanced cancer

APS, 2003APS, 2003

• 50% of hospitalized pts in last 3 days of life 50% of hospitalized pts in last 3 days of life SUPPORT, 1995SUPPORT, 1995


AcuteAcute• Sudden onset, in response Sudden onset, in response

to illness or injuryto illness or injury• Usually decreases over Usually decreases over

time as healing occurs; time as healing occurs; self-limitingself-limiting

• Goal: eliminate pain by Goal: eliminate pain by treating causetreating cause

• Physical signs: “fight or Physical signs: “fight or flight”flight”

• Behavioral signsBehavioral signs

Chronic (Persistent)Chronic (Persistent)

• Insidious onset, or follows Insidious onset, or follows acuteacute

• Lasts beyond expected Lasts beyond expected healing period or healing period or associated with a chronic associated with a chronic conditioncondition

• Goal: maintain function & Goal: maintain function & quality of lifequality of life

• Behavioral signsBehavioral signs

Acute and Chronic PainAcute and Chronic Pain


Major Categories of PainMajor Categories of PainNociceptiveNociceptive• Sources: organs, bone, joint, Sources: organs, bone, joint,

muscle, skin, connective muscle, skin, connective tissuetissue

• Examples: arthritis, tumors, Examples: arthritis, tumors, gall stones, muscle straingall stones, muscle strain

• Character: dull, aching, Character: dull, aching, pressure, tenderpressure, tender

• Responds to traditional pain Responds to traditional pain medicines & therapiesmedicines & therapies

NeuropathicNeuropathic• Source: peripheral nerve or Source: peripheral nerve or

CNS pathologyCNS pathology• Examples: postherpetic Examples: postherpetic

neuralgia, diabetic neuralgia, diabetic neuropathy, spinal stenosisneuropathy, spinal stenosis

• Character: shooting, Character: shooting, burning, electric shock, burning, electric shock, tinglingtingling

• Requires different types of Requires different types of medications than nociceptive medications than nociceptive painpain


Most Common Types of Persistent Most Common Types of Persistent Pain in Older AdultsPain in Older Adults

• Musculoskeletal (e.g., low back pain, Musculoskeletal (e.g., low back pain, osteoarthritis)osteoarthritis)• Neuropathies (e.g., diabetic Neuropathies (e.g., diabetic

neuropathy, post-herpetic neuralgia)neuropathy, post-herpetic neuralgia)• Cancer Cancer

AGS, 2002AGS, 2002


Challenges to Assessing PainChallenges to Assessing Pain

• Stoicism, not wanting Stoicism, not wanting to be a “complainer”to be a “complainer”

• Concerns about taking Concerns about taking pain medicinespain medicines

• Belief that pain is part Belief that pain is part of growing oldof growing old

• Fear of the meaning of Fear of the meaning of the pain the pain


Conditions that Influence Pain Conditions that Influence Pain Experience and ReportingExperience and Reporting

• DepressionDepression

• Sensory impairmentSensory impairment

• Cognitive impairmentCognitive impairment


““I don’t have I don’t have any pain, but I any pain, but I sure am sore!”sure am sore!”

No c/o No c/o ≠ no pain≠ no pain


Pain EvaluationPain Evaluation

• Pain historyPain history• Physical examinationPhysical examination• Laboratory/diagnostic Laboratory/diagnostic

evaluationevaluationPaice & Fine, 2006Paice & Fine, 2006


Analgesic HistoryAnalgesic History• Previous experience with pain Previous experience with pain

medicationmedication• What medications?What medications?• What doses?What doses?• Efficacy?Efficacy?• Side effects? Side effects? • Attitudes?Attitudes?


Pain AssessmentPain Assessment

• EtiologyEtiology• Location Location • Pain IntensityPain Intensity• CharacterCharacter• PatternPattern

• Functional StatusFunctional Status• Side EffectsSide Effects• Goals of CareGoals of Care• Cultural factors, Cultural factors,

meaning of the painmeaning of the pain


EtiologyEtiology• Is the pain location and Is the pain location and

quality consistent with quality consistent with known diagnosis or is known diagnosis or is this a new pain?this a new pain?

• Is it a treatable Is it a treatable etiology?etiology?


Pain LocationPain Location


Pain LocationPain Location

Sites of Sites of Referred Referred PainPain


Pain Intensity Tools

Herr, 2002; Hicks et al., Herr, 2002; Hicks et al., 20012001


Pain IntensityPain Intensity

• Setting goals for pain reliefSetting goals for pain relief– will have will have << 4/10 pain 4/10 pain

• Incorporating pain relief goals into the Incorporating pain relief goals into the treatment plantreatment plan– Oxycontin 20 mg – i tab q12h for pain > 4/10Oxycontin 20 mg – i tab q12h for pain > 4/10– Morphine sl, 10 mg, q4h prn for moderate to Morphine sl, 10 mg, q4h prn for moderate to

severe painsevere pain


Pain CharacterPain CharacterSomatic/NociceptiveSomatic/Nociceptive• AchingAching• DullDull• SoreSore• Throbbing/crampingThrobbing/cramping• DeepDeepNeuropathicNeuropathic• ShootingShooting• BurningBurning• SharpSharp• Electric shock/tinglingElectric shock/tingling


Temporal PatternsTemporal Patterns


What Makes the Pain Worse?What Makes the Pain Worse?

• MovementMovement• Feeling blue or depressedFeeling blue or depressed• Fatigue Fatigue • NauseaNausea


What Makes the Pain Better?What Makes the Pain Better?• Medications Medications • Moderating physical activity Moderating physical activity • DistractionDistraction• Heat and coldHeat and cold• Home remediesHome remedies• Complementary therapiesComplementary therapies


Effect on Function and QOLEffect on Function and QOL

• ADLsADLs• Mobility/transfersMobility/transfers• Participation in meals, social Participation in meals, social

activitiesactivities• Mood interferenceMood interference• Sleep interferenceSleep interference


Examples of Functional GoalsExamples of Functional Goals

– Able to attend bingoAble to attend bingo

– Reports enhanced mood as a result of Reports enhanced mood as a result of decreased paindecreased pain

– Can transfer from bed to chair without Can transfer from bed to chair without crying outcrying out

–Will not strike CNAs during am careWill not strike CNAs during am care

– Attends all PT sessionsAttends all PT sessions


Functional StatusFunctional Status

• Incorporating functional status Incorporating functional status improvement into the treatment planimprovement into the treatment plan– Hydrocodone 5 mg/APAP 500 mg – i tab at 2 Hydrocodone 5 mg/APAP 500 mg – i tab at 2

PM on Tuesdays and Fridays (one hour prior PM on Tuesdays and Fridays (one hour prior to bingo)to bingo)

– Hydrocodone 5 mg/APAP 500 mg – ii tabs at Hydrocodone 5 mg/APAP 500 mg – ii tabs at 7AM on Wednesday mornings (one hour prior 7AM on Wednesday mornings (one hour prior to bath)to bath)


Communicating with Physicians: Communicating with Physicians: Key StrategiesKey Strategies

• Diagnosis, pre-existing Diagnosis, pre-existing pain, recent med changespain, recent med changes

• Summarize your Summarize your assessment data assessment data (intensity, character, location, side effects, (intensity, character, location, side effects, pattern)pattern)

• Report resident’s/family’s concernsReport resident’s/family’s concerns• Your recommendations for changesYour recommendations for changes


When to Assess and DocumentWhen to Assess and Document

• AdmissionAdmission• Regular intervalsRegular intervals• New painNew pain• ExacerbationsExacerbations• Uncontrolled painUncontrolled pain• New therapy (new New therapy (new

meds, increased meds, increased doses)doses)


SummarySummary

There are many challenges to There are many challenges to assessing pain in older adults — assessing pain in older adults — nonetheless, there is no pain relief nonetheless, there is no pain relief when there is no pain assessmentwhen there is no pain assessment


Part I B: Assessment of Pain in Part I B: Assessment of Pain in Nonverbal Older AdultsNonverbal Older Adults

Objectives:Objectives:• List older adults who may be unable to List older adults who may be unable to

reliably report painreliably report pain• Describe behaviors associated with painDescribe behaviors associated with pain• Describe approaches to assessing and Describe approaches to assessing and

treating pain in nonverbal older adultstreating pain in nonverbal older adults


Nonverbal PatientsNonverbal Patients

• Advanced dementiaAdvanced dementia• Progressive neurological Progressive neurological

diseasedisease• Post CVAPost CVA• Imminently dying Imminently dying • Developmentally disabledDevelopmentally disabled• DeliriumDelirium


What is Different about the Pain What is Different about the Pain Experience of Demented Older Adults?Experience of Demented Older Adults?

• Tolerance to Tolerance to acuteacute pain pain possiblypossibly increases increases but pain threshold does not appear to but pain threshold does not appear to change change

• Dementia may blunt response to acute pain Dementia may blunt response to acute pain • Cognitive impairment Cognitive impairment maymay decrease the decrease the

perceived analgesic effectiveness perceived analgesic effectiveness • Pain can negatively affect cognitive functionPain can negatively affect cognitive function


Can Older Adults with Cognitive Can Older Adults with Cognitive Impairment (CI) Give Reliable Pain Impairment (CI) Give Reliable Pain Reports?Reports?

• CI residents slightly underreport pain, but CI residents slightly underreport pain, but their reports are valid their reports are valid (Parmelee et al., 1993)(Parmelee et al., 1993)

• 83% of residents with mild to moderate CI 83% of residents with mild to moderate CI could reliably complete at least one pain could reliably complete at least one pain scale scale (Ferrell et al., 1995)(Ferrell et al., 1995)

• 73% of post-op patients with moderate CI 73% of post-op patients with moderate CI were able to complete a 4-point verbal were able to complete a 4-point verbal descriptor scale descriptor scale (Closs et al., 2004; Feldt et al., 2000)(Closs et al., 2004; Feldt et al., 2000)


Cognitive Impairment & Pain Cognitive Impairment & Pain ManagementManagement• Pain is documented less frequently for CI elders, despite Pain is documented less frequently for CI elders, despite

having similar numbers of painful diagnoses as less having similar numbers of painful diagnoses as less impaired elders impaired elders

(Sengstaken & King, 1993)(Sengstaken & King, 1993)

• Less analgesic is prescribed and administered for CI Less analgesic is prescribed and administered for CI elders, despite similar numbers of painful diagnoses elders, despite similar numbers of painful diagnoses

(Horgas & Tsai, 1998)(Horgas & Tsai, 1998)

• Among NH residents, those who are CI are at increased Among NH residents, those who are CI are at increased risk for undertreatment of pain compared with risk for undertreatment of pain compared with cognitively intact residents cognitively intact residents

(Bernabei et al, 1998)(Bernabei et al, 1998)


ASPMN Position ASPMN Position Statement/GuidelineStatement/Guideline• All persons deserve prompt recognition and All persons deserve prompt recognition and

treatment of pain even when they cannot express treatment of pain even when they cannot express their pain verballytheir pain verbally

• Establish a pain assessment procedureEstablish a pain assessment procedure• Use Hierarchy of Pain Assessment TechniquesUse Hierarchy of Pain Assessment Techniques• ““Assume pain is present”Assume pain is present”• Use empirical trialsUse empirical trials• Re-assess and document Re-assess and document (Herr et al., 2006)(Herr et al., 2006)

www.aspmn.org/Organization/position_papers.htmwww.aspmn.org/Organization/position_papers.htm


Hierarchy of Data SourcesHierarchy of Data Sources

• Older adult’s reportOlder adult’s report (if (if possible)possible)

• Prior pain historyPrior pain history• Painful diagnosesPainful diagnoses• Behavioral indicatorsBehavioral indicators• Observer assessmentObserver assessment• Response to empirical Response to empirical

therapytherapy


Painful DiagnosesPainful Diagnoses• Degenerative Joint DiseaseDegenerative Joint Disease• Degenerative Disc DiseaseDegenerative Disc Disease• Spinal StenosisSpinal Stenosis• Osteoporosis/Compression FracturesOsteoporosis/Compression Fractures• DiabetesDiabetes• CancerCancer• Herpes ZosterHerpes Zoster• Pressure Ulcers/woundsPressure Ulcers/wounds


Behavioral/Observational CuesBehavioral/Observational CuesObvious:Obvious:• Grimacing or wincingGrimacing or wincing• BracingBracing• GuardingGuarding• RubbingRubbing

Less Obvious:Less Obvious:• Changes in activity levelChanges in activity level• Sleeplessness, restlessnessSleeplessness, restlessness• Resistance to movementResistance to movement• Withdrawal/apathy Withdrawal/apathy • Increased agitation, anger, etc.Increased agitation, anger, etc.• Decreased appetiteDecreased appetite• VocalizationsVocalizations


Pay particular Pay particular attention to attention to changeschanges from from normal normal behaviorsbehaviors


Pain Behavior Assessment ToolsPain Behavior Assessment Tools

• Checklist for Nonverbal Pain Indicators Checklist for Nonverbal Pain Indicators (CNPI) (CNPI) (Feldt, 2000)(Feldt, 2000)

• NOPAIN NOPAIN (Snow et al., 2004)(Snow et al., 2004)

• PAIN-AD PAIN-AD (Warden et al., 2003)(Warden et al., 2003)

Available at:Available at:

http://prc.coh.org/elderly.asphttp://prc.coh.org/elderly.asp


Causes of Physical Pain in Causes of Physical Pain in Individual’s DementiaIndividual’s Dementia• Constipation or diarrheaConstipation or diarrhea• Lodged food Lodged food

particlesparticles• ContracturesContractures• Pressure ulcersPressure ulcers• UTIUTI Volicer & Hurley, 1999Volicer & Hurley, 1999


Empirical Trials in Nonverbal Empirical Trials in Nonverbal ResidentsResidents

Behaviors suggest it could be pain

Try pain medicine

Behaviors decrease

It’s probably pain!


Communication and Communication and documentation is documentation is critical in successful critical in successful assessment and assessment and treatment of pain in treatment of pain in nonverbal older nonverbal older adultsadults


CENLE End-of-Life Nursing Education Consortium Module 2: Pain Assessment and Management Geriatric Curriculum.

Documents

assessment of pain

prevalence of pain

paindefine pain

nursing pain assessment

nursing pain assessmentdiscuss

pain management b

relieving pain b

general pain assessment