PAIN MANAGEMENT

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PAIN MANAGEMENT

• Carole Morgan, RN, MPA, LNHA
• Director of Nursing
• Patrick OToole, Pharm. D., MPA
• Director of Pharmacy
• Sea View Hospital Rehabilitation Center and Home

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PAIN

• Number 1 complaint among older adults
• Nearly 60 of older adults taking pain
  medications
• Can significantly affect ones well being
• A barrier in treating pain in older adult is
  inadequate pain assessment

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ASSESSMENT

• Whats Needed
• A comprehensive tool to capture both
  subjective/objective on admission, readmission,
  significant change or a new onset of pain
• Anticipation of Pain before dressing changes,
  Rehab therapy, ROM exercises
• Assessment tool must also identify
• Residents needs and goals
• Etiology
• Severity

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ASSESSMENT

• Subjective data
• Onset location and time or origin
• Contributing factors Causes of pain beginning
  or worsening
• Quality Description (sharp, dull, crushing,
  aching, burning, steady, movable)
• Intensity Severity on a scale of 1 10
• Pattern how often, how long, certain times
• Relief measures measures to relieve or control
  pain

• Objective data
• Appearance - Evidence of clenched teeth or fists
  clenched, swelling, deformity, redness,
  perspiration, tense muscles, change in pupil
  size, fatigue
• Movements Evidence of guarded movements,
  rigidity, restlessness, restriction of use
• Affect Evidence of mood changes, signs of
  anger, irritability, or depression
• Vital signs Change in pulse, blood pressure,
  respiration

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Monitoring

• Once a resident is identified as having
• pain, we begin a fluid and on-going process of
  evaluation of treatment modalities, to see
• if they are effective

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Interdisciplinary Treatment

• Attention must not only be directed at
  physiological aspects of addressing pain but also
  consider providing alternate treatments that
  focus upon psychosocial and environmental factors
• ITC team and resident collaborate to arrive at a
  measurable treatment goals
• Often, trials of various treatment modalities are
  needed to develop the most effective approach

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Interdisciplinary Measures

• Movies
• Comedies - LAUGHTER releases endorphins which
  act like Natural Opiates to the body so that
  pain severity actually diminishes and even
  disappears for a period of time
• Environmental
• Adjusting room temperature, lighting, smoothing
  out linens, comfortable bedding, and using
  alternating air mattresses

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Interdisciplinary Measures

• Relaxation Techniques
• Guided Imagery
• Muscle Relaxation
• Reiki
• Aromatherapy
• Increasingly used as part of an integrated
  approach to pain.
• Touch and smell affect the parasympathetic
  nervous
• system, that can induce deep state of relaxation
  and this in
• turn can alter patients perception of pain.
  Specific aromatherapy
• contains pharmacological active ingredients which
  can benefit pain
• sufferers
• Oil from lavender and peppermint have been
  beneficial in reducing pain.
• Vanilla to stimulate appetite

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Interdisciplinary Measures

• Range Of Motion exercises to maintain joint
  motion and relieve stiffness
• Endurance exercises (e.g.) cycling, aerobic
  exercise can decrease inflammation
• Walking Pain from cancer or Neurological
  (Neuropatic pain) benefits to keep things moving

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Interdisciplinary Measures

• PET THERAPY - Studies show that pets reduce blood
  pressure, provide comfort and unconditional
  acceptance
• MUSIC Used for centuries to promote physical
  and emotional healing
• Music brings harmony back to the whole self it
  is a powerful distraction and promotes relaxation
  
• Music competes with pain signals to the brain

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OTHER APPROACHES

• WRITING
• TALKING ON THE PHONE
• PLAYING CARDS
• CRAFT PROJECTS
• READING
• HOT AND COLD PACKS
• COUNSELING
• MASSAGE
• SOCIAL SUPPORT

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PAIN MANAGEMENT

• Pharmacological Therapy (Medication)
• Scheduled dosing instead of PRN
• Start with short acting medication once pain
  control is achieved, change to long acting meds
  with short acting PRN med for breakthrough pain
• Assess patients response to medication

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Case Snapshot

• MR 83 years old, female
• DX Dementia, DM, Depression, HTN, S/P CVA, OA
• Meds Metformin 500 mg. twice a day, Norvasc 10
  mg daily, Trazodone 50 mg. at bedtime, Zocor 20
  mg. at bedtime, Plavix 75 mg daily, Acetaminophen
  650 mg every 6 hours for OA pain
• Continue to complain of pain
• MD change Acetaminophen to Percocet 5/325 mg.
  every 6 hours

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Case Snapshot, cont.

• After a week , new issues noted
• Episodes of falls
• Change in mental status
• Uncooperative with Rehab/ADLs
• Constipation

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Case Snapshot, cont.

• Interventions
• Taper dose of Percocet, re-start to Acetaminophen
  for OA pain
• Encourage participation with Activities - Pet
  therapy, Music, aromatherapy
• Use of hot packs, cold packs to knees
• Use topical pain relieving cream

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Case Snapshot, cont.

• Continue to have discomfort (pins and needles
  sensations) in extremities
• Intervention changed Trazodone to Cymbalta to
  address for Neuropathic pain
• Continue Acetaminophen for OA pain
• Percocet discontinued
• Resident more cooperative and active with Rehab

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Staff Education

• Identification Direct care and ancillary staff
  are often the first to recognize symptoms
• Assessment Review of current standards of
  practice, and policy
• Discussion on cultural barriers and individual
  perceptions
• Interdisciplinary Modalities Pain Management
  including non - pharmacological approach
• Evaluation of program

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RIGHT INTERVENTIONS WITH THE RIGHT RESIDENT

• INDIVIDUALIZED
• And
• MAY NEED TO BE MODIFIED

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For Additional Information

• Carole Morgan, RN
• [phone]
• morganc_at_seaviewsi.nychhc.org
• Patrick OToole, Pharm.D.
• [phone]
• otoolep_at_seaviewsi.nychhc.org

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Resources on Pain Assessment and Management

• www.americangeriatrics.org/education/cp_index.shtm
  l
• www.amda.com/tools/guideline.cfm
• www.cms.hhs.gov/surveycertificationgeninfo/downloa
  ds/scletter09-2.pdf