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Principles of Pain Assessment and Management in Nursing ... ... • Pain is also a perceptual experience that has an impact on all aspects of a person’s emotional, psychological,

Jul 10, 2020

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  • 11/17/2014

    1

    Principles of Pain Assessment

    and Management in Older Nursing

    Home Patients

    Shaida Talebreza M.D.

    [email protected]

    Assistant Professor, Division of Geriatrics,

    University of Utah School of Medicine

    Palliative Care Specialist, Home Based Primary Care (HBPC)

    George E. Wahlen Salt Lake City Veterans Affairs Medical Center

    Medical Director, Inspiration Hospice

    Pain Assessment Outline

    • What is Pain

    • Prevalence of Pain in Older Adults

    • Geriatric Pain Special Considerations

    • Types of Physical Pain

    • Geriatric Pain Assessment: Physical Pain

    History

    – PQRST

    – Cognitively Impaired Adults

    What is Pain?

    • An unpleasant sensory and emotional

    experience associated with actual or

    potential tissue damage

    • Pain is also a perceptual experience that

    has an impact on all aspects of a person’s

    emotional, psychological, social and

    physical functioning.

    Hadjistavropoulos T, Herr K, Turk D, et al. An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons.

    Clin J Pain. 2007;23:S1-S43

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    2

    What is Pain?

    • Physical, psychological, social, and spiritual problems can affect a patient’s perception and tolerance of pain

    • Multidisciplinary approach to assessment and treatment is very important and effective

    Prevalence of Pain in Older

    Adults

    • Substantial pain is experienced by:

    – 25%-50% of community dwelling adults

    – 45%-80% of nursing home residents

    GRS Teaching Slides Web site http://www.frycomm.com/ags/teachingslides.

    Geriatric Pain is Undertreated

    • Geriatric patients may: – Minimize their symptoms

    – Not voluntarily report pain

    – Be unable to report pain due to cognitive impairment

    • Clinicians may: – Inadequately assess pain

    – Treat pain with ineffective therapies

    – Encounter adverse effects with otherwise effective therapies

    GRS Teaching Slides Web site http://www.frycomm.com/ags/teachingslides.

  • 11/17/2014

    3

    Types of Physical Pain Pain Type Nociceptive

    Somatic

    Nociceptive

    Visceral

    Neuropathic

    Description Activation of

    nociceptive sensory

    receptors

    Activation of

    nociceptive sensory

    receptors

    Irritation of

    components of the

    CNS or PNS

    Source •Tissue injury

    •Bones

    •Soft tissue

    •Joints

    •Muscles

    •Viscera

    •Cardiac

    •Lung

    •GI

    •GU

    Peripheral or central

    nervous system

    Examples •Arthritis

    •Fracture

    •Bone metastases

    •Post-op pain

    •Renal Colic

    •Constipation

    •Trigeminal

    neuralgia

    •PHN

    •Diabetic

    neuropathy

    •Herniated disc

    •Post-stroke

    syndrome

    Geriatric Pain Assessment:

    Physical Pain History

    • Provocative (aggravating) factors

    • Palliative (relieving) factors

    • Quality

    • Region (location)

    • Severity

    • Timing

    • Treatments tried

    Geriatric Pain Assessment:

    Physical Pain History

    • Provocative (aggravating) factors

    • Palliative (relieving) factors

    • Quality

    • Region (location)

    • Severity

    • Timing

    • Treatments tried

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    4

    Provocative and Palliating

    Factors

    • What makes the pain better or

    worse?

    – Rest

    – Movement

    – Positioning

    – Eating

    Geriatric Pain Assessment:

    Physical Pain History

    • Provocative (aggravating) factors

    • Palliative (relieving) factors

    • Quality

    • Region (location)

    • Severity

    • Timing

    • Treatments tried

    Quality

    Aching Dull Sharp

    Stabbing Colicky Burning

    Gnawing Squeezing Pricking

    Throbbing Deep Tingling

    Cramping

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    5

    Geriatric Pain Assessment:

    Physical Pain History

    • Provocative (aggravating) factors

    • Palliative (relieving) factors

    • Quality

    • Region (location)

    • Severity

    • Timing

    • Treatments tried

    Region (Location) of Pain

    • Where do you hurt?

    • Can use a pain map:

    Geriatric Pain Assessment:

    Physical Pain History

    • Provocative (aggravating) factors

    • Palliative (relieving) factors

    • Quality

    • Region (location)

    • Severity

    • Timing

    • Treatments tried

  • 11/17/2014

    6

    Pain Severity

    Number Severity

    0 None

    1-3 Mild

    (Background Pain)

    4-6 Moderate

    (Generally interferes with function and

    sleep)

    7-10 Severe

    (Generally interferes with function, sleep

    and concentration)

    Quill TE, Holloway RG, Shah MS, et al. Primer of Palliative Care: 2010, 5th Edition. Illinois: American Academy of Hospice and Palliative Medicine; 2010.

    Severity of Pain: Scales

    Numeric Rating Scale Faces Pain Scale

    •Good Validity •Fair Validity

    •Fair Reliability •Fair Reliability

    •Easy to use •Requires hearing or vision and cognition

    •Requires vision, attention, and cognition

    Halter JB, Ouslander JG, Tinetti ME, et al. Hazzard’s Geriatric Medicine and Gerontology, 6th Edition. New York: McGraw Hill; 2009.

    Severity: Numeric Rating Scale

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    Severity: FACES Pain Scale –

    Revised (FPS-R)

    Severity: Wong-Baker FACES

    • Developed for pediatric patients

    Cognitively Impaired Patients

    • It has been shown that pain reports from

    those with mild to moderate cognitive

    impairment are no less valid than other

    patients with normal cognitive function

    • The NRS and FPS-R are feasible for use

    in most patients with cognitive impairment

    Halter JB, Ouslander JG, Tinetti ME, et al. Hazzard’s Geriatric Medicine and Gerontology, 6th Edition. New York: McGraw Hill; 2009.

  • 11/17/2014

    8

    Cognitively Impaired Patients

    • Use both self-report and observational

    measures when possible

    • Solicit the assistance of caregivers familiar

    with the patient

    • Determine if analgesic medications lead to

    a reduction in pain behaviors

    Hadjistavropoulos T, Herr K, Turk D, et al. An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons.

    Clin J Pain. 2007;23:S1-S43

    Cognitively Impaired Patients

    • The Interdisciplinary Expert Consensus

    Statement on Assessment of Pain in Older

    Persons could not reach definitive

    recommendation of any particular scale for

    patients with severe dementia

    Cognitively Impaired Patients

    • Promising tools:

    – PACSLAC

    – Doloplus 2

    • American Academy of Hospice and

    Palliative Medicine

    – PAINAD

  • 11/17/2014

    9

    Physical Pain Assessment in

    Cognitively Impaired Patients PACSLAC DOLOPLUS-2 PAINAD

    60 item checklist

    Present/Absent

    10 items

    0-3 Scale

    Five Items

    0-2 Scale

    5 minutes to

    administer

  • 11/17/2014

    10

    Pain Assessment in Advanced

    Dementia (PAINAD) Scale

    Items 0 1 2 Score

    Breathing Normal •Occasional

    labored breathing

    •Short period

    hyperventilation

    •Noisy labored

    breathing

    •Long period

    hyperventilation

    •Cheyne-Stokes

    Vocalization None •Occasional

    moan or groan

    •Low-level

    speech with a

    negative or

    disapproving

    quality

    •Repeated troubled

    calling out

    •Loud moaning or

    groaning

    •Crying

    Quill TE, Holloway RG, Shah MS, et al. Primer of Palliative Care: 2010, 5th Edition. Illinois: American Academy of Hospice and Palliative Medicine; 2010.

    Pain Assessment in Advanced

    Dementia (PAINAD) Scale

    Items 0 1 2 Score

    Facial

    Expression

    Smiling or

    inexpressive

    •Sad

    •Frightened

    •Frown

    •Facial grimacing

    Body

    Language

    Relaxed •Tense

    •Distressed

    pacing

    •Fidgeting

    •Rigid

    •Fists clenched

    •Knees pulled up

    •Pulling or pushing

    away

    •Striking out

    Consolabillity No need •Distracted or

    reassured by

    voice or touch

    •Unable to console,

    distract or reassure

    Quill TE, Holloway RG, Shah MS, et al. Primer of Palliative Care: 2

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