Appendix G: Pain Assessment and Management Training “ Where does it hurt?”

1. Appendix G: Pain Assessment and Management Training“Where does it hurt?” Audience: For Registered Staff Release Date: December 10, 2010

2. Objectives To improve and maintain a resident’s optimal functional level and quality of life To optimally control pain for all residents To reduce incidence of unmanaged pain To ensure best practice interventions for residents with pain To monitor and track trends related to pain management

3. Myths About Pain and the Elderly Pain is a normal part of aging The elderly perceive pain to a lesser degree or sensitivity than young people If an elderly person does not complain then they are not in pain Elderly patients should receive lower morphine doses than younger patients

4. Research Says Approximately 25% of Canadian's suffer from chronic pain Chronic pain becomes more common as people get older 50% of Canadian’s take analgesic for chronic pain 45-80% of nursing home residents have substantial pain 25-26% of residents with daily pain receive no analgesia

5. Definition of Pain Pain An unpleasant subjectivesensory and emotional experience that is associated with actual or potential tissue damage, or described in terms of such damage. RAI-MDS Definition: Pain that is reported is unrelieved pain. If the resident does not have any pain due to pain management, then it is coded as “0” for no pain. “Pain is what the patient say it is, and exists whenever the patients says it does”McCaffery & Pasero (1979)

6. Pain Pathways: Pain & the Brain Lewis, Sharon L.. Medical-Surgical Nursing in Canada, 2nd Edition. Mosby Canada, 072009.). vbk:9781897422014#B9781897422014500176_f2>

7. Words Used to Describe Pain Can You Think of Any ? Discomfort Soreness Pressure Burning Hurt

8. Types of Pain 1) Acute Pain: sudden onset, lasts less than 3 months or usual time of healing. Can range from mild to severe. Decreases with time. 2) Chronic Pain: persist after healing occurs. Pain can be disabling and accompanied with depression and anxiety.

9. Types of Pain…cont`d 3) Neuropathic Pain: Pain that is initiated or caused by a primary lesion or dysfunction in the nervous system (Central Nervous System & Peripheral Nervous System)-stimuli abnormally processed by the nervous system. Neuropathic pain is usually described as sharp, burning, or shooting and is often associated with other symptoms such as numbness or tingling in the affected area.

10. Neuropathic Pain Described…

11. Types of Pain…cont`d 4) Referred Pain: is a term used to describe the phenomenon of pain perceived at a site adjacent to or at a distance from the site of an injury's origin.

12. Sites of Referred Pain (Lewis, Sharon L.. Medical-Surgical Nursing in Canada, 2nd Edition. Mosby Canada, 072009.). <vbk:9781897422014#B9781897422014500176_f4

13. Components of Effective Treatment of Pain Pharmacological & Non Pharmacological Treatment Evaluation Of Effectiveness Assessment

14. Pain Assessment Screening should done daily (can be done during routine assessments by asking residents/ SDM about the presence of pain, ache or discomfort Full assessment using a Pain Assessment Tool: • within 24 hours of admission • quarterly (according to the RAI-MDS 2.0 schedule) • when a the resident exhibits a change in health status or pain is not relieved by initial interventions (e.g. is diagnosed with a chronic disease) For example: • states he/she has pain; • diagnosed with chronic painful disease; • has history of chronic unexpressed pain; • taking pain-related medication for >72 hours; • has distress related behaviours (e.g. changes in anxiety level) or facial grimace • indicates that pain is present through family/staff/volunteer observation.

15. Pain Assessment…cont’d Behavioural Indicators: Facial Expression (frowning, tightly closed eyes, grimacing) Body Language and Movement ( fidgeting, rocking, rigid posture) Behaviour ( sleeplessness, decreased appetite, mood swings, wanting to sleep all day)

16. Dimensions of Pain Assessment Type of pain Onset of pain Location of pain Intensity Quality Frequency Factors that precipitate and relieve pain Treatments used and the effectiveness

17. Assessment Techniques Self-report Measures • “Gold Standard” of pain assessment for residents that are cognitively intact. When the self-report option is not available, observation of the resident behaviours and reports from family and caregivers are used. Behavioural Measure (e.g. for the cognitively impaired) • Used in conjunction with self-report • Used to assess pain in resident that are unable to speak or not cognitively intact • Refer to Pain Indicator list for the Cognitively Impaired

18. Self Report Tools Descriptive Tools • Where is the pain ? • PQRST • Provocation – what causes that pain? What makes is worse? What makes it better? • Quality- what does your pain feel like? What words would you use to describe your pain? • Radiating – Does the pain move anywhere? • Severity- How much does it hurt on a scale of 0 (no pain)-10( the worst pain) • Timing/ Treatment- when did your pain start? How often does it occur? How long does it last?

19. Pain Intensity Rating Scales Numeric Rating Scale (NRS) Visual Analogue Scale (VAS) Verbal Scale Facial Grimace & Behavioural Flow Chart

20. Pain Intensity Rating Scales…cont’d

21. Facial Grimace Scale & Behavioural Checklist Flow Chart The facial grimace scale scores the level of pain (from 1-10) based on the care givers observations for the resident’s facial expression. Please refer to handout

22. Behavioural Observation • Mild to moderately cognitively impaired older adults can report pain so ASK for self-report • Pain in cognitively impaired resident is measure through behavioural signs • This involves: • Observation of specific, discrete behaviours that vary from the resident’s normal behaviour • Observations from family or care givers

23. Pharmacological Approach

24. Pharmacological Approach Mild Pain • Non-Opioids • Acetaminophen • Aspirin • Non-Steriodal Anti-inflammatory Drugs (NSAIDS) Mild to Moderate Pain • Opioids • Morphine • Hydromorphone • Oxycodone Moderate to Severe • Adjuvant Drugs • Anticonvulsants (neurotin, tegretorl, clonazepam) • Antidepressant (tricyclic, Prozac)

25. Non-Pharmacological Approach Exercise Transcutaneous electrical nerve stimulation (TENs) Heat/Cold Relaxation Therapy Massage Acupuncture Behaviour Therapy

26. Exercise • Exercise improves your mood • Exercise combats chronic diseases • Exercise promotes better sleep • Exercise boosts your energy level

27. Transcutaneous Electrical Nerve Stimulation (Acronym TENS) is the use of electric current produced by a device to stimulate the nerves for therapeutic purposes. TENS by definition covers the complete range of transcutaneously applied currents used for nerve excitation, although the term is often used with a more restrictive intent, namely to describe the kind of pulses produced by portable stimulators used to treat pain.

28. Thermal Treatment

29. Relaxation Therapy Distraction and Imagery:Redirection on something and away from pain. Structure technique that uses the resident’s own imagination to develop sensory images that divert focus away from the pain sensation and emphasize other experiences and pleasant memories. Relaxation: Aim is to free resident’s anxiety and muscle tension. Requires a quiet environment (guided breathing, meditation).

30. Case Study Mrs. V is a 85 year old woman who has just been re-admitted to your LTC home following a brief stay in an acute care hospital. Mrs. V has a diagnosis of dementia. Prior to admission to the hospital she was mobile but because of the dementia was unable to participate in her care and other activities of daily living. She was sent to hospital because of a fall which resulted in a fracture to her left (L) hip. When you receive the resident, she is moaning loudly and her eyes are tightly closed. She is very rigid and grimaces when you attempt to move her in bed. Placing the resident on her Right side and supporting her Left leg appears to relax her and the moaning is less intensive. Several of her children are at her bedside and look to you to help their mother. Indicate how you would assess her pain and what tools and observational skills you would use. How would you determine if the interventions you tried were effective?

31. WORKING TOGETHER TO EASE THE PAIN