recognizing and assessing pain - ohca assess pain revised augu… · recognizing and treating pain...
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Recognizing and Treating Pain -
Making a difference in the lives
of your Residents
Will begin at 2:00 pm EST
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Today’s Speakers
Demetria (Demi) Haffenreffer, RN, MBA, has made long-term care her profession since 1973, first as a
Director of Nursing and for the last thirty-five years as a consultant. She is founder and President of
Haffenreffer & Associates, Inc., an Oregon consulting firm supporting skilled and community based care
providers in the delivery of person-centered, compassionate care. Haffenreffer & Associates, Inc. provides
educational and hands-on assistance with the implementation of quality systems and corporate compliance
programs nationwide.
In 2011, Demi assisted the Colorado Foundation for Medical Care with a CMS grant to publish the Model
Program for Quality Performance called 'QAPI.' Demi is a facilitator for the AHCA Leadership Excellence
Self-Assessment System and is currently serving on the Washington Health Care Association Quality
Improvement Committee. She has served on the Oregon State Resident Safety Review Council, the Steering
Committee of MOVE (Making Oregon Vital for Elders, an outreach of the Pioneer Network), as a member of
Oregon Patient Safety Commission, and as a Master Examiner for AHCA's Quality Award. Demi has taught
workshops nationally and internationally on a variety of subjects pertinent to long-term care and has
authored five policy and procedure manuals.
In addition, Demi is retained regularly by nationally known law firms as an expert on regulatory compliance
issues.
Pain Assessment
& Management
in Long Term CareA Person-Centered Holistic Approach
Presented by: Demi Haffenreffer, RN, MBA
www.consultdemi.net
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Pain Assessment & Management
in Long Term Care
Outline:
Why is this topic important? The Requirements
Assessment & person-centered care planning
Treatments
Treating special resident populations
Assessing your current program
Case studies / post test / evaluation
Prevalence
Number one reason why people seek
medical attention is acute pain
Chronic pain 50 million of the 75 million who
suffer from pain – suffer from chronic pain
Back and neck; arthritis; headaches; neuropathic
Undertreated
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Consequences
Prolonged hospital stays
Physiological – see next slide
Delayed recovery
Increased healthcare costs
Depression & increased suicide risks
Altered self-image & needless suffering
Economic & social impacts greater than for any
single disease entity
Loss of productivity
Physiological Consequences
Endocrine
Cardiovascular
Respiratory
Gastrointestinal
Musculoskeletal
Immune
Genitourinary
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LET’S EXAMINE
THE
REQUIREMENTS
CFR483.25(k) F309
Pain Management
The facility must ensure that pain
management is provided to resdient who
require such service, consistent with
professional standards of practice, the
comprehensive person-centered care plan,
and the residents’ goals and preferences.
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Care Process
Assess for potential or actual
Assess and address underlying causes
Develop and implement interventions that
use specific strategies for different levels or
sources of pain or pain related symptoms
Utilize both pharmacological and / or non-
pharmacological interventions
Monitor and evaluate effectiveness
Modify approaches as necessary
October 2017 MDS – Section N
Number of Days past 7 days receiving an
opioid
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UNDERSTANDING
PAIN MANAGEMENT
Definitions
Pain:
“Whatever the experiencing person says it is,
existing whenever the resident says it does.
An unpleasant sensory & emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage, or both.”
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Definitions
Acute Pain:
“A response to injury or illness that is usually
time limited, responds to treatment &
inadequate treatment delays recovery.”
Trauma
Acute medical (including post-op care)
Orthopedic problem
Acute pain associated with chronic illnesses
Definitions
Chronic Pain:
“A state in which pain persists beyond the usual
course of an acute disease or healing injury,
or that may or may not be associated with an
acute or chronic pathologic process & causes
continuous or intermittent pain over months
or years.”
Many illnesses &/or pathological conditions
Cancer pain vs. non-cancer chronic pain
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Definitions
Intractable Pain:
“A pain state in which the cause of the pain
cannot be removed or otherwise treated and
in the generally accepted course of medical
practice, no relief or cure of the cause of the
pain can be found after reasonable efforts,
including but not limited to, evaluation by
attending physicians.”
Four Processes
Transduction
Transmission
Perception
Modulation
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Transduction
Nociceptor activation and sensitization
Peripheral neuropathic pain
Clinical implications
Transduction
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Perception
Awareness
Emotion based on awareness
Clinical implications
Individual differences
Modulation
Descending pathways
Clinical implications
Peripheral sensitization
Central sensitization
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Nociceptive pain vs. Neuropathic
Classified on basis of presumed underlying
pathophysiology
Caused by ongoing activation of nociceptors
in response to noxious stimulus
Somatic
Neuropathic
Indicates injury to peripheral or central nervous
system
Examples & Characteristics of Nociceptive Pain
Superficial
Somatic Pain
Deep Somatic
Pain
Visceral Pain
Nociceptor Location Skin & more Muscles & more Visceral organs
Potential Stimuli External,
mechanical &
more
Overuse strain,
injury, ischemia,
inflammation
Organ distension,
muscle spasm &
more
Localization Well localized Localized or
diffuse & radiating
Well or poorly
localized
Quality Sharp, pricking
or burning
Usually dull or
aching, cramping
Deep aching or
sharp stabbing
Associated S & S Cutaneous,
hyperalgesia,
allodynia
Tenderness, reflex
muscle spasm, &
hyperactivity
Malaise, N & V,
sweating,
tenderness,
spasm
Clinical examples Sunburn, etc Arthritis pain, etc Appendicitis, etc
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Examples & Characteristics of Neuropathic Pain
Mono & Poly -
Neuropathies
Deafferentation
Pain
Sympathetically Central
Definition Pain along
dist. of 1 or
more nerves –
nerve damage
Due to loss of
afferent input
Maintained by
sympathetic
nervous
system
Primary
lesion or
dysf. Of
CNS
Char. &
Symptoms
3 types = Many symptoms
& char.
Many
symptoms &
char.
Many
symptoms
& char.
Sources Many Damage to p.
nerve or CNS
Damage to p.
nerve & more
Many
Clinical
Examples
Diabetic, more Phantom limb;
post
mastectomy
CRPS;
Phantom limb;
& more
Post-
stroke;
cancer; MS
Barriers to pain management
Health care system
Health care professionals
Patient and family barriers
Legal and Societal barriers
Tolerance, physical dependence, addiction
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Common Misconceptions
Sensitivity and perception decrease in the
elderly therefore they do not feel pain
If you can’t recognize pain it has no effect on
you
Pain w/age is to be expected & is normal
Individuals who do not complain of pain or say, “I
have no pain”, do not have pain (they still may &
will need further assessment)
Cognitively impaired cannot use pain intensity
rating
Common Misconceptions
Individuals who complain of pain, do not have
pain
Opioid medications have side effects that
make them too dangerous to use in the
elderly or they will become addicted.
Physical & behavioral signs best indicator
Addiction may occur
PRN medication is sufficient to control pain
Comparable stimuli produce the same level
of pain in all individuals
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THE FIRST STEP IN TREATING
PAIN IS TO RECOGNITION!!
GOALS
Recognition (requires nurses to be aware of
their own beliefs)
Appropriate assessments & care plans
Appropriate consults
Appropriate treatments
Improved functioning – highest practicable
well-being
Improved quality of life
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Barriers to Recognition
Barriers
Cognitive status of
resident
Sensory problems
Cultural problems
Poor communication
between resident &
care giver
Fear
Not recognizing
behaviors as pain
related
Caregivers don’t
believe the resident
Caregiver lack of
knowledge
Other
ASSESSMENT
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Core Principles
Resident right to assessment and management
Pain is subjective – self-report most reliable
Physiological and behavioral symptoms do not replace
Assessment tools must be appropriate for the population
being treated
Pain can exist without a physical cause
Uniform pain threshold & tolerance does not exist
Residents with chronic pain may be more sensitive to
pain
Unrelieved pain has physical & psychological
consequences – assessment should address both
Assessment Principles
Routine Assessments
Believe what people tell you
Don’t believe what people tell you
Assess comprehensively
Choose the right treatment
Empower the resident
Distinguish between acute and chronic pain
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Comprehensive Assessment
Components
Recent pain history
The interview
Cognitive/Communication
- Ability to recognize
- Ability to report
- Behaviors
Comprehensive Assessment cont’d
Type/Frequency/Location
Localized or radiating
Past History part of the interview with either
the resident or family
Related Conditions/Diagnosis
Treatments that work and don’t work
Current treatment and effectiveness
Resident goal – also part of interview process
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Pain assessment tools
Unidimensional scales
Numeric
Visual
Categorical
Multidimensional tools
Brief pain inventory
Initial
Quarterly
Other
PAIN ASSESSMENT TOOLS
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Treatment
Medications
PRN vs Routine
Non-pharmacological treatment
Pharmacological
Many med options
Non-opiod
Anti-inflammatory
Anti-anxiety agents
Muscle relaxants
Pain perception modifiers
Opiods
Anti-epileptics
Antidepressants
Nerve blocks – local anesthetics
Intraspinal delivery systems
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Pharmacological principles
Optimize administration
PRN vs routine
Start with a low dose and slowly titrate to the
lowest effective dose
Patches are slow to work initially and another
prn medication may be needed for
breakthrough pain. Patches may require body
fat to be effective
Pharmacological principles
For chronic pain, use an analgesic around the clock
For breakthrough pain, use fast onset, short-acting
analgesics
Establish a goal for pain management
Monitor for & manage side effects. Try to avoid over
sedation
Differentiate among tolerance, physical
dependence, & addiction & appropriately modify
therapy
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Pharmacological principles
Reassess effectiveness routinely
Adjuvant drugs may be needed such as
Amitryptyline
Ibuprofen is not the medication of choice if
the resident has GERD
Pharmacological principles
Start with a non-opioid analgesic for mild pain
(Adjuvant therapy is optional)
For mild to moderate pain not relieved by a
non-opioid analgesic attempt a weak opioid
plus a non-opioid analgesic (Adjuvant therapy
is optional)
Avoid use of placebos
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Pharmacological principles
For moderate to severe pain or pain not
relieved by weak opioid, consider a strong
opioid with or without a non-opioid analgesic
(Adjuvant therapy is optional)
Treatments – Non-Pharmacological
Gentle massage
TENS units (electro stimulation)
Implanted nerve stimulators
Hot baths or whirlpools
Heat (15 to 20 minutes only)
Cold (15 to 20 minutes only)
Chiropractic
Acupuncture
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Treatments – Non-Pharmacological
Ointments/creams (BenGay, BioFreeze, Tiger Balm, Salonpas (med. Patches), Aspercreme
Slow movement
Breathing techniques (slow, deep breathing), rest
Music (some music, loud or soft, can make pain better or worse)
Behavioral medicine
Treatments – Non-Pharmacological
Glucosamine
Arnica
Biofeedback
Energy healing
Pilates
Yoga
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Treatments – Non-Pharmacological
Visualizations and other diversional activities
Acupressure
Vocalizing (screaming and/or moaning)
Other approaches:
Therapy
Surgery
Building an Institutional Commitment
to Pain Management Develop an IDT work group
Analyze current pain mgt. issues and practices
Implement a standard for pain mgt.
Establish policies and procedures
Establish accountability for quality & monitor
Provide information for pharm. & non-pharm.
Mgt.
Promise residents prompt response
Provide education
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RESOURCES
www.painmed.org
www.ampainsoc.org/advocacy/