Transcript Slide 1

Module 2: Part III
Part III:
A. Nursing assistant roles in observing
and relieving pain
B. Nondrug interventions for pain and
other symptoms
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ELNEC Attribution Statement
The End-of-Life Nursing Education Consortium (ELNEC)
Project is a national end-of-life educational program
administered by City of Hope National Medical Center
(COH) and the American Association of Colleges of
Nursing (AACN) designed to enhance palliative care in
nursing. The ELNEC Project was originally funded by a
grant from the Robert Wood Johnson Foundation with
additional support from other funding organizations
(Oncology Nursing, Aetna, Archstone, and California
HealthCare Foundations; National Cancer, and Open
Society Institutes). Materials are copyrighted by COH
and AACN and are used with permission.
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Part III A: Nursing assistant roles
in observing and relieving pain
Objectives:
• Describe the roles of the NA in EOL care
and pain management
• Define pain
• Describe acute and chronic pain
• Describe some common side effects of
medications used to treat pain
• Describe elements of pain observation
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Nursing Assistant Roles in Endof-life Care
• Providing personal care & assisting in
ADLs
• Observation and reporting of EOL
symptoms
• Providing emotional & physical
comfort to residents and families
• Providing care at the time of death
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Nursing Assistant Roles in Pain
Management
• Observe and report the presence and
characteristics of pain
• Observe for and report effectiveness of
therapies
• Observe for and report side effects of
medications
• Deliver some nondrug treatments
• Support and get help for residents in pain
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What is Pain?
an unpleasant
sensory & emotional
experience...
IASP, 1979
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PAIN:
“anything the
patient says it is”
McCaffery & Pasero, 1999
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How Common is Pain in the
Nursing Home?
71% to 83% of residents have pain
Gagliese & Melzack, 1997
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Most Common Types of Pain in LTC
• Musculoskeletal: osteoarthritis,
osteoporosis
• Nerve related: diabetic neuropathy,
pain after shingles, phantom limb
pain
• Constipation
• Cancer pain
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Acute and Chronic Pain
ACUTE
• Sudden onset
symptom
• Occurs in response to
illness or injury
• Usually decreases or
goes away over time as
healing occurs
• Goal: pain goes away
when cause is treated
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CHRONIC
• Slow onset, or follows
acute
• Lasts > 3 months
• Cause sometimes is
unknown
• Sometimes divided into
cancer and noncancer
• Goal: maintain
functioning and quality of
life
Myths About Pain in the Older
Adults
• Pain is a natural part of growing old.
• Older people are less sensitive to pain.
• If an older person doesn’t report pain, that
person doesn’t have pain.
• If a person can sleep or
be distracted from pain,
that person doesn’t
really have pain.
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Myths About Pain in the Older Adult
• Strong pain medicine,
like morphine, can’t be
used safely for the older
adult because they are too
sensitive to dangerous
side effects.
• People who use
morphine-like drugs
become addicted to them.
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Myths About Pain in the Older
Adult (cont.)
• People with dementia
and other brain
conditions don’t feel
pain.
• People with dementia
and other brain
conditions can’t
reliably report their
pain.
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Overview of Analgesics
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Commonly Used Pain Medicines
• Nonopioids
• Opioids
• Adjuvants/co-analgesics
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Nonopioids
• Acetaminophen (Tylenol®)
• Nonsteroidal anti-inflammatory
drugs (NSAIDs):
– Ibuprofen (eg, Advil®)
– Naproxen (eg, Naprosyn®, Aleve®)
– Celebrex®
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Opioids
• Sometimes referred to as “narcotics”
• Examples: morphine, Percocet®,
Vicodin®, Duragesic®, codeine
• Are effective for moderate to severe pain
• Common side effects:
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Constipation
Sleepiness
Nausea, vomiting
Urinary retention
Itchiness
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Adjuvants/Co-analgesics
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Antidepressants
Anticonvulsants
Topicals
Others
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Observing and Reporting Pain
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Common Words for Pain
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Ache
Discomfort
Sore
Heavy
Burning
Stiff
No complaints ≠ no pain
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How Bad is the Pain (Intensity)?
Herr, 2002; Hicks et al., 2001
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Pain Location
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How Does the Resident Describe
the Pain?
Muscle or Bone Pain
• Aching
• Dull
• Sore
• Throbbing/cramping
• Deep
Nerve Pain
• Shooting
• Burning
• Sharp
• Electric shock/tingling
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Pain Patterns
• Is the pain constant?
• Does it come and go?
• What times of the day is it worst?
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What Makes the Pain Worse?
Examples:
• Movement
• Feeling blue or
depressed
• Fatigue
• Nausea
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What Makes the Pain Better?
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Medications
Moderating physical activity
Distraction
Heat and cold
Home remedies
Complementary therapies
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Side Effects of Pain Medicines?
• NSAIDs:
– Swelling
– Stomach upset
– Bleeding
• Opioids:
– Constipation
– Sleepiness
– Nausea/vomiting
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Nonverbal Patients
• Advanced dementia
• Progressive
neurological disease
• Post stroke (CVA)
• Imminently dying
• Developmentally
disabled
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Behavioral/Observational Cues
Obvious:
• Grimacing or wincing
• Bracing/guarding
• Rubbing
• Calling out, moaning, groaning
Less Obvious:
• Changes in activity level
• Sleeplessness, restlessness
• Resistance to movement
• Decreased participation in activities
• Increased agitation, anger, etc.
• Decreased appetite
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Pay particular
attention to
changes from
normal
behaviors
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When to Observe for Pain
• During personal care
• During transfers and
ambulation
• Following activities
• Following pain
management
interventions
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Part III B: NonDrug Pain &
Symptom Management
Objectives
• Describe reasons for using nondrug
therapies to relieve EOL symptoms
• Describe special considerations and
precautions for using specific nondrug
therapies
• Demonstrate the use and teaching of
several nondrug techniques
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Non-Drug Techniques
Physical
• Massage
• Cold
• Heat
• Vibration
• Positioning
• Exercise
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Psychological
• Distraction
• Relaxation
• Music
• Comfort Foods
• Imagery
• Controlled
Breathing
Common Myths
Myth
If people can be
distracted from their
pain, the pain isn’t “real”
or it’s not as bad as they
are saying.
Use nondrug measures
instead of pain
medication
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Reality
People can be
distracted from pain
because distraction
is an effective
nondrug therapy
Nondrug treatments
are not an
appropriate
substitute for pain
medication
Observations Prior to Starting
Therapy
• Understanding of options
• Attitude and comfort
• Family interest and
availability
• Need for education
• Ability to participate
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Non-Drug Symptom Relief:
Specifics
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Massage
Applications of cold and heat
Positioning
Distraction
Relaxation
Music
Comfort foods
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Massage
Decreases pain by soothing the skin
and relaxing tense muscles
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Massage Examples
• Brief touch such as
rubbing someone’s
shoulder
• A warm foot soak and
rub
• Massaging a hand with
warm lotion
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Applications of Cold
• Reduces pain by:
– numbing nerve endings
– reducing muscle spasms
– decreasing inflammation
• Also decreases the desire to scratch
areas that itch!
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Cold Examples
• An ice pack to the neck and
upper shoulders
• Ice massage to the knee with
a Dixie Cup™
• Ice cloth to the hip opposite
the one that hurts
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Hot Applications
• Relieves pain by
reducing inflammation
and soreness
• Also decreases sensitivity
to pain and increases
blood flow to the skin
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Heat Examples
• Warm washcloth to head
• Hot water bottle to abdomen
• Jacuzzi™ bath
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Positioning/Movement
• Positioning eases pain by placing
the body into postures that
maintain or promote normal
function of the muscles
• Movement helps maintain or
restore ease of function in joints,
bones, nerves, and ligaments
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Positioning/Movement Examples
• Use of full-length body pillow
• Pillow between knees when
lying on either side
• Pretend write the alphabet by
using the feet – switch feet
every 6 or 8 letters
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Distraction
Used to focus attention on
something other than pain. By
decreasing concentration on pain,
it becomes more bearable.
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Distraction Example
• Compile a file of pictures
• Have resident describe
picture by:
– Talking about the picture
– Pretending they are in the
picture
– Telling a story about the picture
• Choose a new picture as soon
as their interest decreases in
the current one
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Relaxation
• Described as freedom from
physical and mental tension
• Relaxation techniques reduce
stress, muscle tension and
reduce pain
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Relaxation Examples
• Put on headphones
with a tape of calming
music
• Breathe in deeply;
exhale slowly
• Think of a calm setting
or peaceful place that
you’ve enjoyed visiting
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Music
Decreases pain by:
• Providing distraction
• Reducing anxiety
• Prompting recall of pleasant
memories
• Interrupting the stress response
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Comfort Foods
Assists in decreasing pain by:
• Providing distraction
• Evoking comforting memories
• Promoting relaxation and physical
calm
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Building a Toolkit
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Role of the Nursing Assistant
• Activities not requiring an order:
– Distraction
– Backrub/shoulder massage
– Music
– Positioning
– Reading
– Prayer
– Comfort foods
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Role of the Nursing Assistant
• Activities that require an order or
are clearly part of a care plan:
– Application of heat or cold
– Use of menthol-based product
– Massage of extremities
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