Transcript Understanding Physical Pain: A Guide for the Hospice IDT

Understanding Physical Pain
at End of Life:
A Guide for the
Hospice IDT
National Hospice and Palliative Care Organization
Objectives
• To teach non--medical interdisciplinary team (IDT)
members basic principles about pain and its’ medical
management
• To teach IDT members their role in determining pain
issues in their patients
• To teach documentation of pain by non--medical IDT
members
Pain at End of Life
• Physical pain
– Physical manifestations of disruption of bodily functions
causing pain
– Considered the fifth vital sign
• Psychosocial pain
– Emotional pain which results from
spiritual/psychological/emotional conflicts/struggles
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Pain is…
Subjective
Whatever the patient says it is
Affected by cultural beliefs
Common symptom at end of life
Controllable with proper management
Common Myths about Pain and
Pain Relief
• Pain is my punishment or burden to bear
– Reality - Being stoic about pain often is valued in our society.
This tendency may be more common among older persons.
Patients need to be encouraged to report their pain so its
management can take place.
• It is best to wait until the pain is severe before taking
pain medications
– Reality - It is best to stay ahead of the pain by taking
medications around the clock when treating persistent pain. The
longer pain goes untreated, the harder it is to ease.
Common Myths, cont…
• People who take strong narcotic pain medication
become addicted
– Reality - Addiction is defined by a compulsive craving and
use of a drug, which results in physical, psychological, and
social harm to the user. Addiction is NOT a problem for
people who take opioid medications for persistent
uncontrolled pain.
Common Myths, cont…
• The side effects of strong pain medications make
people too sleepy which isn’t worth it…
– Reality - The goal of pain management is to achieve
comfort while maintaining optimal alertness. Side effects
of drowsiness will reduce or disappear within a few days.
Types of Pain - Somatic
• Somatic pain
– Localized in the skin, soft tissue, muscles, and bones
– Somatic pain is caused by the activation of pain receptors
in either the body surface or musculoskeletal tissues
• Characteristics of somatic pain
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Achy
Throbbing
Dull
Localized
Types of Pain - Visceral
• Visceral pain
– Viscera refers to the internal areas of the body that are enclosed
in a cavity (i.e.: lungs, liver, stomach)
– Visceral pain results from inflammation, distension, or
stretching of the internal organs
• Characteristics of visceral pain
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Squeezing, pressure
Cramping
Dull
Deep
Vague – in terms of location
Types of Pain - Neuropathic
• Neuropathic pain
– Neuropathic pain results from damage to the peripheral
nervous system or the central nervous system (CNS), or
both
• Characteristics of neuropathic pain
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Burning
Shooting
Tingling
Radiating
Numbness
Characteristics of pain
• Pain can be constant or intermittent
– “Breakthrough” pain happens when pain management
techniques fail to control pain
• Pain has intensity
– Pain can be measured a variety of ways
• Pain can be controlled
– Pharmacological methods
– Non-pharmacological methods
Pain Assessment
• Clinicians want to determine:
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The type of pain
Location of pain
Intensity of pain
Quality of pain
Triggers of pain
What controls the pain
How the pain affects activities of daily living and quality of
life
Measuring Pain intensity
• There are several types of pain measurement scales
• 0–10 Numeric Pain Rating Scale – the patient is
asked to choose the number on the scale that rates
their pain with “0” being no pain and “10” being the
worst possible ever experienced
Measuring Pain intensity
• Wong-Baker FACES Pain Rating Scale – the patient is
asked to choose the face on the scale that best
describes the intensity of their pain. Faces range
from no pain to the worst pain they ever experienced
Pain Assessment in Non-verbal
Patients
• The following are non- verbal behaviors that can
indicate the experience of pain:
– Facial expressions: slight frown, sad, frightened face,
grimacing, wrinkled forehead, closed or tightened eyes,
any distorted expression, rapid blinking
– Verbalizations, vocalizations: sighing, moaning, groaning,
grunting, chanting, calling out, noisy breathing, asking for
help
– Body movements: rigid, tense body posture, guarding,
fidgeting increased pacing, rocking, restricted movement,
gait, or mobility changes
Goals of pain management
• Fulfill the patient’s right to pain management
– What does the patient family/ caregiver want?
• Decrease pain experience and control pain
• Improve function and quality of life for patient
• Minimize side effects of pain management therapy
Pharmacological pain management
• Opioids
– An “opioid” is a family of morphine-like drugs used to treat
moderate to severe pain.
– Are common narcotics
• Narcotics are chemicals which induce stupor, coma, or insensibility
to pain
– Control pain when administered per physician order
• On a schedule
• Additional dosage for PRN breakthrough pain
Pharmacological pain management
• Opioid use
– Pain relief - when used in equivalent doses
• Opioids can also be used to treat…
– Shortness of breath
– Cough
Pharmacological pain management
• Types of synthetic opioids for pain control
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Hydrocodone
Oxycodone
Methadone
Fentanyl
Hydromorphone
Opioid Brand Names
Generic Name
fentanyl
hydrocodone
hydromorphone
Brand Name
Duragesic
Norco, Vicodin
Dilaudid, Exalgo
morphine
oxycodone
Astramorph, Avinza
OxyContin, Percocet
Pharmacological pain management
• Opioid side effects
– Sedation or drowsiness
– Constipation – patient should begin a bowel regimen
simultaneously with opioid
– Itching
– Nausea
– Confusion
– Myoclonus -irregular involuntary contraction of a muscle
Adjuvant Medications
• Acetaminophen (NSAIDS)
– Tylenol and Motrin
• Steroids
– Relieve swelling and inflammation
• Anti-emetics
– Treatment for nausea and vomiting
• Stimulants
– Combats opioid induced drowsiness
• Antianxiety medications
– Decreases experience of agitation or restlessness
Non-pharmacologic pain management
• Examples of non-pharmacologic therapies include:
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Hot-cold treatments
Positioning
Movement restriction-resting
Acupuncture
Hydrotherapy
TENS (Transcutaneous Electrical Nerve Stimulation)
Massage
Therapeutic touch
The Pain Management Plan
• Developed jointly between IDT, the patient, and
family/caregiver
• Based on continuous pain assessment outcomes
• Includes consideration of patient’s cultural beliefs
• Includes measurable goals for pain control on the
patient’s palliative plan of care
• Includes pharmacologic and non-pharmacologic
interventions per patient’s preferences
IDT Member Role in Pain Assessment
• IDT members may not function outside of their scope
of legal practice, but they can ask about pain when
they visit the patient
• IDT members can document observations and
subjective comments made by the patient and
family/caregiver regarding the patient’s pain
experience
• IDT members should report concerns about a
patient’s pain experience to the RN case manager per
organization policy
Asking about Pain
• “Are you in pain?” or “Do you have pain?”
• “How would you describe your pain?”
• “What does your pain prevent you from doing?”
• “You seem to be frowning today…are you
experiencing any pain?”
Documenting Pain
• Documentation forms for social workers, chaplains,
and hospice aides should not contain prompts for
pain assessment
• Documentation about pain from these disciplines
should contain observations made by the team
member, subjective comments made by the patient,
family/caregiver, and feedback provided to the RN
case manager as needed (per organization policy)
Documenting Observations – Case
Study
• Mr. Smith is a 79 year old man with metastatic prostate
cancer who lives with his 75 year old wife who has multiple
health problems. His pain has been controlled on a long
acting dosage of morphine. On your visit as the Social
Worker (SW), you observe Mr. Smith’s behavior as restless,
he exhibits intermittent grimacing, and frequently closes
his eyes.
• You ask Mr. Smith if he experiencing pain or discomfort and
Mr. Smith states that he is fine. You ask if he taking his pain
medication as prescribed and he states “yes”.
Documenting Observations - SW
• The social worker should include the following
information in the documentation for the visit:
– That he/she observed Mr. Smith as restless, exhibiting
intermittent grimacing, and frequently closing his eyes
– That Mr. Smith stated he was fine when asked about pain
experience and that he stated he was taking his pain
medication as prescribed
– That he/she reported observations to the RN case
manager
Mr. Smith – Follow Up
• The RN will need to assess Mr. Smith’s pain for changes and
communicate changes to the physician for possible new
orders and an update to the plan of care
• Mr. Smith may be experiencing breakthrough pain and the
dosage of his medication can be increased or a medication for
breakthrough pain can be added to his current pain
management regime
Documenting Subjective Comments
• The chaplain visits Mr. Smith the following week and she asks,
“Do you have any pain today?” Mr. Smith responds, “Since
the doctor increased my pain medicine, I feel much better”.
• Mrs. Smith added, “He is sleeping more soundly at night too.”
• Chaplain note should include: Mr. Smith stated, “I am feeling
much better since the doctor increased pain medicine”. And
Mrs. Smith stated, “he is sleeping more soundly at night.”
Education for IDT Members
• Before social workers, chaplains, hospice aides, or
other members of the IDT begin documenting about
pain in the clinical record, they will require education
about:
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How to document
What to document
Where to document
When to document; when to alert RN case manager
Why to document
Policy for IDT Members
• The hospice organization should develop a policy for
the IDT about observation of patient pain experience
and documentation of pain in the clinical record
• The policy should include reference to IDT members
functioning only within their legal scope of practice
and that education is provided about the policy and
documentation parameters
Let’s Review!
We learned about physical
pain…what it is, and how we assess
and measure it
We learned about pain management
and common side effects of
medication therapy
We learned about observation of
pain and documenting observations
and subjective comments in the
clinical record
Questions
Resources
• Palliative and End-Of-Life Care: Clinical Practice Guidelines, Kim
K. Kuebler, Debra E. Heidrich, Elsevier Health Sciences, 2007
• Partners Against Pain, Measuring Pain,
www.partnersagainstpain.com, 2012
• Tools for Assessment of Pain in Nonverbal Older Adults with
Dementia: A State-of-the-Science Review, Keela Herr, PhD, RN,
FAAN, Karen Bjoro, RN, MSN, PhDc, Sheila Decker, PhD, APRNBC, Journal of Pain and Symptom Management, Volume 31,
Issue 2, Pages 170-192, February 2006