F-tag 309 for Pain Case Study

1. F-tag 309 for Pain Case Study

2. Case Study – Hazel P 72 yr old female admitted to facility late Friday afternoon from acute hospital after fall at home. In hospital she had Rt. hip surgery 2 days ago. Other pertinent diagnoses include diabetes, COPD, CAD, CHF, HTN, anemia, osteoporosis, depression, peripheral vascular disease, osteoarthritis, & dementia.

3. What do we know already? • Pain is likely to be an issue • Different types of pain are likely • Acute post operative bone & muscle pain (rt. hip fx.) • Potential chronic muscle & joint pain from osteoarthritis, osteoporosis • Potential cardiac pain (CAD, CHF) • Potential neuropathic pain (DM) • Communication may be an issue (Dementia)

4. Hazel’s Assessment • When you enter the room to perform the pain assessment you observe: • Hazel in bed, grimacing & seems tense • She is verbal, responds to her name, but confused • When you ask if she has pain she says “Yes” • When you ask where she says “all over” • What is the next step?

5. Assessment Tools for Cognitively Impaired • You correctly decide to use a tool for residents with dementia • Choices – PACSLAC or PAINAD • Hazel scores a 6 on the PAINAD indicating that she does have pain

6. Physical Exam • During your physical exam of Hazel, you notice she resists against movement of her upper extremities saying “that hurts” • She also c/o pain when you touch her lower legs • You start to turn her to observe her surgical site but she also cries out that it hurts • What should you do at that point?

7. Impacts on QOL • After medicating Hazel for pain, you complete your exam, you ask the CNA to get Hazel her dinner & assist her to eat • A few minutes later the CNA returns & reports that Hazel did not want to eat stating she wasn’t hungry • What is a potential cause?

8. Finishing the Assessment • Comprehensive assessments cannot always be completed in a single shift • In cognitively impaired residents, additional information may be needed • Nurses must take the time to observe behaviors, response to pain medication, etc.

9. Surrogate Informants • Family members can be great sources of information • Surrogates such as children, spouses or close friends • If not present during admission, call within the first 24 hrs • CNAs can also help complete assessment based on their observations during care

10. Hazel’s Daughter Reports • Hazel has frequent moderate to severe pain in her joints & her legs hurt, burn almost all the time • Hazel’s pain is worse with movement • Hazel can report pain but not how bad it is • Hazel cries out when pain gets really bad but otherwise will not say anything unless moved • Pain improves with analgesics & correct positioning • Her daughter emphasizes that she wants her mom to be comfortable at all times

11. Assessment Documentation • Is Hazel able to self report? • Surrogate report on average & worst pain? • PAINAD Score • Behavioral Pain Indicators • Pain Location • Pain Pattern

12. Assessment Documentation • Acute painful conditions • Diagnosis (es) • Impact on function & quality of life • Current therapeutic regimen from physician orders • Recommended changes to treatment plan – plan not yet developed

13. Were Pain Assessment Standards Met? • History of pain & its treatment • Characteristics of pain • Impact of pain on quality of life • Factors that precipitate pain • Strategies or factors that reduce pain • Associated pain symptoms • Physical Examination • Current medical condition & medications • Resident goals for pain management

14. In Summary • Facilities & staff are responsible for ensuring residents obtain their highest practicable level • Residents must be involved in their pain management & their individual needs & goals should be basis of care plan • Care must be individualized based on a comprehensive assessment &MUST meet clinical standards of quality • Staff must monitor continuously & revise when necessary in a timely manner • Staff must communicate resident status or change of condition with health care practitioners, resident, & family • Staff must document accurately

15. QUESTIONS? Adapted and used with permission of D. Bakerjian, PhD, MSN, APRN, University of CA, San Francisco, 2009.