Transcript F-tag 309 for Pain With Case Study

72 yr old female admitted to facility
late Friday afternoon from acute
hospital after fall at home. In
hospital she had Rt. hip surgery 2
days ago. Other pertinent diagnoses
include diabetes, COPD, CAD, CHF,
HTN, anemia, osteoporosis,
depression, peripheral vascular
disease, osteoarthritis, & dementia.
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Pain is likely to be an issue
Different types of pain are likely
 Acute post operative bone & muscle pain (rt. hip fx.)
 Potential chronic muscle & joint pain from
osteoarthritis, osteoporosis
 Potential cardiac pain (CAD, CHF)
 Potential neuropathic pain (DM)
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Communication may be an issue (Dementia)
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When you enter the room to perform the pain
assessment you observe:
 Hazel in bed, grimacing & seems tense
 She is verbal, responds to her name, but confused
 When you ask if she has pain she says “Yes”
 When you ask where she says “all over”
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What is the next step?
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You correctly decide to use a tool for
residents with dementia
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Choices – PACSLAC or PAINAD
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Hazel scores a 6 on the PAINAD indicating
that she does have pain
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During your physical exam of Hazel, you notice
she resists against movement of her upper
extremities saying “that hurts”
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She also c/o pain when you touch her lower legs
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You start to turn her to observe her surgical site
but she also cries out that it hurts
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What should you do at that point?
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After medicating Hazel for pain, you
complete your exam, you ask the CNA to get
Hazel her dinner & assist her to eat
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A few minutes later the CNA returns &
reports that Hazel did not want to eat stating
she wasn’t hungry
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What is a potential cause?
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Comprehensive assessments cannot always
be completed in a single shift
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In cognitively impaired residents, additional
information may be needed

Nurses must take the time to observe
behaviors, response to pain medication, etc.
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Family members can be great sources of
information
 Surrogates such as children, spouses or close friends
 If not present during admission, call within the first
24 hrs

CNAs can also help complete assessment based
on their observations during care
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Hazel has frequent moderate to severe pain in her
joints & her legs hurt, burn almost all the time
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Hazel’s pain is worse with movement
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Hazel can report pain but not how bad it is
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Hazel cries out when pain gets really bad but
otherwise will not say anything unless moved
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Pain improves with analgesics & correct positioning
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Her daughter emphasizes that she wants her mom to
be comfortable at all times
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Is Hazel able to self report?
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Surrogate report on average & worst pain?
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PAINAD Score
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Behavioral Pain Indicators
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Pain Location
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Pain Pattern
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Acute painful conditions
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Diagnosis (es)
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Impact on function & quality of life
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Current therapeutic regimen from physician
orders
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Recommended changes to treatment plan –
plan not yet developed
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History of pain & its treatment
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Characteristics of pain
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Impact of pain on quality of life
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Factors that precipitate pain
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Strategies or factors that reduce pain
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Associated pain symptoms
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Physical Examination
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Current medical condition & medications
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Resident goals for pain management
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Facilities & staff are responsible for ensuring residents obtain
their highest practicable level
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Residents must be involved in their pain management & their
individual needs & goals should be basis of care plan
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Care must be individualized based on a comprehensive
assessment &MUST meet clinical standards of quality
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Staff must monitor continuously & revise when necessary in a
timely manner
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Staff must communicate resident status or change of condition
with health care practitioners, resident, & family
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Staff must document accurately
Adapted and used with permission of D. Bakerjian, PhD, MSN, APRN, University of CA, San Francisco, 2009.