Transcript Avoiding a Pain F

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F-Tag uses evidence-based practice
recommendations
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Expectations
 Screening to determine if residents experience pain
 Comprehensively assessing the pain
 Identifying when pain can be anticipated
 Developing and implementing a plan, using
pharmacologic and non-pharm interventions to manage
pain and/or try to prevent the pain consistent with the
resident’s goals
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Screening
 Screen for pain at admission, periodically, when
change in condition, anytime pain is suspected
 Recognizing pain involves multiple health care
professionals, direct care staff, therapists,
ancillary staff who have contact with the patient
 Observation at rest and activity
 Verbal and nonverbal information about pain
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Negative verbalizations and vocalizations (e.g. groaning,
crying/whimpering, or screaming)
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Facial expressions (e.g. grimacing, frowning, fright, or
clenching the jaw)
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Changes in gait (e.g. limping), skin color, vital signs (e.g.
increased HR and BP)
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Change in behavior (e.g. resisting care, distressed pacing,
withdrawing, inability to perform ADLs, rubbing specific
location of body, or guarding a limb or other body part)
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Weight loss
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Difficulty sleeping
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Frequency, intensity, symptoms, and
location/site of pain
Other sections that relate
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Sleep cycle
Change in mood
Functional limitations
Instability of condition
Weight loss
Skin conditions
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Often first to notice resident symptoms
Must be trained to recognize most common
signs and descriptors of pain
Must be taught to report findings to the
nurse for follow-up
Nurse must perform a detailed evaluation,
document relevant information and report it
to the practitioner (Fax It)
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At a minimum, an initial pain assessment
should include:
 A thorough pain history, including
▪ A detailed description or symptom analysis such as the
pain PQRSTA mnemonic
▪ The effectiveness of past efforts to relieve pain
▪ Satisfaction with current pain management
PQRSTA
P: Palliative and/or provocative factors
Q: Quality of pain and impact on quality of life
R: Region of body affected
R: Radiation of pain
S: Severity of pain
T: Timing of pain
T: Treatments tried
A: Associated symptoms
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Facility may adopt one or more standard pain
scales
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Different scales emphasize different aspects
of pain assessment
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Faces pain scales
Numerical rating scales
Pain map
Brief Pain Inventory
PAINAD for non-verbal residents
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At a minimum, an initial pain assessment
should include:
 A physical examination including the pain site, the
nervous system, and physical, psychological and
cognitive functioning
 Consideration of co-morbidities and/or diagnoses,
especially those which may typically be associated
with pain
 Diagnostic tests, as indicated
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At a minimum, an initial pain assessment should
include:
 Additional information, which may include but is not
limited to:
▪ The degree to which pain interferes with individual’s
mental, physical, psychosocial and spiritual being
▪ Medication history including allergies, and whether pain
may be associated with any current medications
▪ History of substance abuse such as alcohol, prescription
medications and/or illicit drugs
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To the extent possible, resident should
participate in developing plan of care and
establishing realistic goals for treatment
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Facility is expected to address pain if resident
says he/she is in pain
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Approach to pain management should follow
appropriate clinical protocols and guidelines
Interventions/Treatments should be:
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Preceded by an assessment
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Developed with respect for whether the pain is
episodic or continuous
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Provided or administered to meet resident’s
needs
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Monitored appropriately for effectiveness and/or
adverse consequences
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Modified as necessary
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Care plan should include specific, measurable pain
management goals
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Should indicate how and when more structured,
periodic monitoring with standardized assessment
tools is to occur
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Identifies specific strategies for different levels of
pain, who is to implement the care or supply the
service, and what symptoms, behaviors, or
consequences might indicate need for additional/
alternative approaches
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Depending on the nature and intensity of
pain, may be more appropriate to start with
these approaches
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If ineffective in relieving pain, proceed to
pharmacologic interventions
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If not used at all, resident record should
include reasons why not pertinent
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May include Complementary and Alternative
(CAM)
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Identify and address cause of pain, to extent
possible
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Determine which pain medications and
adjuvant medications and doses to use specific
to the resident
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Balance potential risks and side effects with
benefits, including resident’s wishes
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Follow a rationale approach, such as the WHO
ladder
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All pharmacologic interventions should be
combined with non-pharmacologic
interventions
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Persistent pain should be treated around-theclock rather than PRN
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Analgesics should be accessible in the facility
and administered when needed
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Monitor the effectiveness of the medication(s)
being used before adding medications or
changing the medication regimen
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Dose, frequency, and medication need to be
reevaluated if pain not adequately controlled
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Periodic use of a facility selected standardized
pain assessment tool facilitates determination
of success
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If no further need for pain medication,
discontinuation or tapering to prevent
withdrawal
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Adverse consequences may be anticipated
and require ongoing monitoring
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Preventive approaches may be indicated
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Staff involved in care should monitor individual closely
over time to identify signs/symptoms that could
indicate pain and adverse medication consequences
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Consistent staff assignment shown to improve pain
care
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If pain not adequately controlled despite repeated
attempts and various approaches, referral to other
resources such as a hospice program, if eligible, or pain
management specialists
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The facility should provide orientation and ongoing
staff education to correct misconceptions, myths,
and biases about pain. Training may include, but is
not limited to:
 Using standardized scales to promote objective
evaluation and effective management of pain
 Recognizing and assessment pain, reporting and
documenting findings, and monitoring Interventions
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The facility should provide orientation and ongoing staff
education to correct misconceptions, myths, and biases
about pain. Training may include, but is not limited to:
 Overcoming misconceptions and increasing understanding
for the distinctions between addiction, physical dependence,
and tolerance
 Identifying appropriate treatment modalities including the
use of and when and how to use non-pharmacologic
interventions
1. Facility must identify each resident having
or at risk for pain and anticipate what
procedures, care, or treatments might
produce pain, and evaluate the resident
regarding the characteristics and causes of
the pain
2. Facility must provide the care and services
for the resident to attain or maintain his/her
goals for pain management and comfort that
is consistent with current standards of
practice, assessment and plan of care
3. The level of pain management is consistent
with a resident’s potential to achieve or
maintain his/her highest practicable level of
physical, mental, and psychosocial well-being
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Screened residents on admission and periodically for the presence of pain
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Recognized and evaluated residents who are experiencing pain to
determine (to the extent possible) causes and characteristics (nature,
intensity, location, frequency, duration) of the pain, as well as factors
influencing the pain
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Developed a care plan to address the pain, consistent with the resident’s
goals, risks, and current standards of practice
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Provided care and services to control the pain to the greatest extent
possible or to the level defined by the resident, in accordance with
standards of practice, or explained adequately n the medical record why
they could not or should not do so
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Recognized and provided pain control measures for situations such as
treatments or activities known to potentially cause or exacerbate pain
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Monitored the effects of interventions and modified the approaches as
indicated
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Contacted the health care practitioner with pertinent information to
advise him/her when a resident was having pain that was not adequately
managed or was having a potential adverse consequence to the
treatment
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Revised the approaches as appropriate, or verified their continued
relevance
The Pain F-tag may motivate, but it is all about quality care
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Pain Website for Nursing Homes
 www.GeriatricPain.org
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Advancing Excellence in America’s Nursing Homes
 http://nhqualitycampaign.org/
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End of Life/Palliative Education Resource Center
 http://www.eperc.mcw.edu/ff_index.htm
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City of Hope Pain Resource Center
 http://prc.coh.org/elderly.asp
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Quality Improvement Organizations
 www.medqic.org
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American Geriatrics Society (AGS): Clinical Guidelines
 www.americangeriatrics.org
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American Medical Directors Association (AMDA): Clinical Guidelines
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www. amda.com
American Pain Society
 www.ampainsoc.org
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Agency for Health Care Research and Quality (AHRQ): Clinical Guidelines
 www.ahcpr.gov/clinic/cpgonline.htm
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National Guideline Clearinghouse
 www.guideline.gov
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National Pain Education Council (NPEC)
 www.npecweb.org
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American Academy of Hospice and Palliative Medicine
 www.aahpm.org
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American Academy of Pain Medicine
 www.painmed.org
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Hospice and Palliative Nurses Association
 www.hpna.org
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Partners Against Pain
 www.partnersagainstpain.com
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Resource Center for Pain Medicine and Palliative Care at Beth Israel Medical Center
 www.stoppain.org/education_research/resources.html
Questions?
Adapted and used with permission from K. Herr, PhD, RN, The University of Iowa, 2009.