Advancing Excellence Campaign: Improved Pain Management in Skilled Nursing Facilities An Examination of the Nature and Adverse

Effectsof Pain and Guidelines for Improved PainManagement for Both Long and Short TermNursing Home Residents.

Edited by: Laura McNamara, APRN-BC, ANP, GNP,

ACHPN

Goals For Pain Management

For Long Term Nursing Home Residents, Average of

Moderate to Severe Pain Experienced will be at or

below 4%.

For Short Term Nursing Home Residents, Average of

Moderate to Severe Pain Experienced will be at or

below 15%.

Challenges of Pain Analysis

Complex and Multi-factorialIdentifying specific causes my be

difficult Often subtle and nonspecific“Referred Pain” can be misleadingSubjective vs. Objective mismatchesNociceptive versus Neuropathic pain Communication issues with both

impaired and intact residents of SNFs.

Challenges of Pain Management

Knowledge DeficitsTime/Support ConstraintsCommunication Demands with Patient,

Family, Physician/NP, RN Colleagues, Nursing Aides and Ancillary Service Staff

Evaluation and Measurement of Pharmacological Analgesia, including Adverse Effects

Familiarity of Non-Pharmacological Treatments and follow-up evaluation and measurement

Adverse Effects of Untreated/Undertreated PainNegative Impact upon Health/Quality of LifeSlowed Rehabilitation Increased Depression Increased Anxiety Increased Social Isolation Increased Cognitive Impairment Increased Immobility, Gait Disturbance Increased Sleep DisturbanceSpiritual DespairDisease Progression Increased Pain Sensitivity Increased Health Care Utilization and Costs

Typical Signs of Acute PainHyperactivity of the sympathetic

nervous system:◦ Elevated blood pressure◦Elevated respiratory rate◦Tachycardia◦Diaphoresis◦Dilated pupils◦Agitation/Physical

Movements/Vocalizations

Complicated/Subtle/Multifactorial Signs of Persistent Pain

Vegetative Signs:◦Listlessness◦Decreased Appetite/Loss of Taste for

Food/Weight Loss◦Constipation◦Sleep Disturbance◦Social Withdrawal◦Psychological Impairment◦Functional Impairment and Disability

Complicated/Subtle/Multifactorial Signs of Persistent Pain (Continued…)

Agitation and Anxiety◦Frequent Verbalizations◦Frequent Agitated Movements◦Increased Depression and Anxiety◦Refusal of Care◦Defensive Behaviors◦Overwhelming Self Focus ◦Preoccupation with Physical Status

Let’s Get Started!Need to Evaluate What Tools are

in Place to Evaluate Pain and Implement Improved Pain Management:◦Establish “Buy-In” with

establishment of Focus Group with Members from CNAs, MDS and Staff RNs, Nursing Management, MD/NPs and Spiritual Providers.

◦Review current measurements, strengths and weaknesses.

Review of Standards of CareProvide Authoritative Information

related to Pain in the Elderly/Residents of Nursing Homes:◦AMDA Guidelines◦AGS Pain Guidelines◦Hartford FoundationCompare current tools in place to available expert resources and adjust/readjust SNF Pain Assessment and Management System/Processes

Room for Improvement…Identify Barriers to quality pain assessment and management

Review Current Practices, evaluating for deficits and areas of improvement

Review Cases/Issues that have been previously identified r/t identifying and managing pain

Frame Work EstablishmentImplement Tools for Evaluation of Pain

◦Provide Information/Training in Tools for Evaluation of Pain (Nociceptive vs Neuropathic vs Mixed) in Cognitively Intact and Cognitively Deficient Residents of Nursing Homes

Implement Tools for the Treatment of Pain◦Review of Standards/Guidelines for

treatment of Nociceptive, Neuropathic or Mixed Pain, including both Pharmacological and non-Pharmacological modalities.

PAIN ASSESSMENT TOOLS VISUAL ANALOG SCALES

◦ Wong-Baker FACES Pain Scale◦ Visual Analog Color-Coded Scale

NUMERICAL RATING PAIN SCALE◦ McGill Pain Scale for Pain Assessment◦ PQAS Scale◦ Numerical and Comparative Pain Scale◦ VRS and NRS

OBSERVATIONAL PAIN SCALES◦ COMFORT Scale◦ PLACC Scale◦ CRIES Scale◦ Observer Rated Pain Scale◦ NVP Scale

Provide Education, Resources, Support and Feedback

Arrange presentations on Nature of Pain, Evaluation Tools, and Treatment Modalities

Arrange easily accessible printed materials for review and use

Assign a “point person” or expert in Pain Management who can consult/assist as needed on challenging cases

Provide and Seek prompt feedback r/t specific cases, and overall progress

Invest in the System and IndividualEvaluation of Systemic Approach

ongoing◦What tools are cumbersome/not

working◦Limitations of RN guided treatment

Evaluation of Personal Approach as well…◦Knowledge Deficits◦Past Personal Experience vs.

“Expert” Opinion◦Personal Biases r/t Pain◦Fear of Negative Consequences

Continuous MonitoringPain Recognition

◦ Every Resident Must Be ConsideredPain Assessment

◦ Acute, Persistent, Nociceptive, Neuropathic, Mixed◦ Emotional, Psychological and Spiritual Pain

Cause Identification and Diagnosis◦ Challenges Inherent in Residents with Dementia◦ Special Challenges Inherent in Complicated

PersonalitiesManagement and Treatment

◦ Pharmacological Agents◦ Non-Pharmacological Agents

And Continuous Monitoring!

Strengths and WeaknessesEvaluate Concrete Data

◦Patients with pain◦Patients with well managed pain

Evaluate Nursing Knowledge and Satisfaction◦Current Knowledge of Tools◦Current Knowledge of Available Resources◦Satisfaction with skill/knowledge growth◦Satisfaction with high skill level/quality of

care of both short and long term residents

Goals for Recognition/Assessment

Intitial Assessment within 24 hours of Arrival or Condition Change

Regularly Scheduled Reassessment and Monitoring of Pain Intensity and Quality in the Physical Health, Social, Emotional and Spiritual Context

Consider Each Resident as Individual, but with many possible similarities, i.e., Osteoarthritis is the number one cause of pain in the elderly.

Appropriate Documentation of Assessment

Details, details, details…In Challenging Residents, the “odd”

details often point the way to better treatment.

Indepth Discussion/Communication with resident, family, colleagues, support staff, ancillary service staff, and providers may be necessary in residents with partial or limited improvement with treatments in place or the use of high risk analgesia/possible adverse effects of treatment complicating pain/comfort issues.

DocumentationTelling “the story”Presenting the “facts”Giving some background informationProviding InterpretationUse of forms (scales), but need for

narrativeClose monitoring and documentation

of treatment modalities and effects: positive, negative and neutral

MDS DocumentationSection J0100: Pain Management over the last

5 days to be completed.◦ Scheduled pain regimen:

narcotic/NSAIDs/Acetaminophen (non-pathway analgesia not included).

◦ PRN pain medication use.◦ Non-pharmacological interventions for pain◦ Further documentation concerning

communication deficient residents and non-verbal s/s of pain (“Staff Observation of Pain”).

◦ Further evaluation at 14, 30, 60, and 90 day points ESSENTIAL: important quality indicators for DPH.

INFORM AND DISCUSSCommunicate findings to MD/NP:

◦Periodically◦With every change in treatment plan after a

reasonable period of time◦With new symptom development that may

represent further pain◦When important additional information

becomes available◦When current interventions do no appear to

be adequate◦ When causes of pain and effect of treatment

plan remain unclear/need further exploration

Identify Pain Management GoalsCollaboration is needed with resident,

family, Nursing Staff and Practitioner in the establishment of goals◦ Ideally, underlying cause of pain should be

addressed, but is not always possible to resolve◦Goals can be adjusted to achieving a reduction

of pain to a tolerable level◦Goals may need to be adjusted over time, as

causes/prognosis/effectiveness of interventions evolve.

◦Recognize there may need to be tradeoffs between pain control and undesirable treatment effects.

Managing PainNursing Staff and MD/NP work together

to review causes/characteristics of a resident’s pain.◦Nursing Staff has gathered enough

information to help inform the treatment plan.

Nursing Staff and MD/NP implement plan to manage pain and possible adverse symptoms/effects of plan.◦Use of Pertinent Protocols and Guidelines,

or clinically warranted alternate treatment plan

Pain Management OptionsNon-pharmacological options used

alone or in conjunction with analgesia◦Heat, cold, positioning, distraction,

massage, baths, behavioral/psychological therapies, environmental modifications, exercise, music therapy, OT/PT, pet therapy, prayer, relaxation techniques, therapeutic use of self.

◦Consideration of possible adverse effectsPharmacological options

◦Use of the WHO’s Pain Relief Ladder◦Consideration of possible adverse effects

AnalgesiaFirst line for mild generalized, nonspecific or

osteoarthritic discomfort is Acetaminophen.◦ Periodically monitor LFTs, caution w/liver disease

Possible to use NSAIDs short term for inflammation,musculoskeletal conditions.◦ Adverse GI effects, Cardiovascular and Renal Risks

Opioids are used for moderate to severe pain, both short-acting and extended release.◦ Extensive adverse side effects, including delirium, urinary

retention, constipation, nausea, gait instability, sedation, respiratory depression

Adjunct Therapies, including anticonvulsants, antidepressants, steroids, alpha-2-adrenergic agonists, local anesthetics, NSAIDs, topical (nonsystemic) drugs.◦ Adverse side effects can affect the GI, urinary, and nervous

system, as well as a resident’s psychological/mental status

Reassess and AdjustContinuous ProcessMust Include Treatment Adjustments

for Adverse Side EffectsConsider Changes in Health/Physical

Condition with Acute Changes in Pain Status

Continuous Involvement of CNAs, Staff RNs (all shifts), Nursing Supervisors. Continuous intermittent Involvement of DON/A-DON, MDS, MD/NP, and Ancillary Services Staff.

Challenges Must Be Expected…

When a resident continues to have unacceptable pain/symptoms despite multiple interventions

When increased medication doses do not seem to bring relative relief

When MD/NP is not readily available or not helpful

When it remains unclear if a resident’s symptoms truly represent pain

When pain levels remain elevated despite best efforts

When adverse events occur despite close monitoring

And Met with Further Education, Reassessment and Adjustments!

It is our responsibility to take care of our residents and to ease their suffering.

Nurses and CNAs are residents’ best advocates.Families must be considered in the equation.The guiding principle of doing no harm must be

balanced with providing comfort/alleviating pain and suffering.

The therapeutic use of self by Nursing Staff is an underutilized and rarely recognized tool in the easing of suffering. Intention and caring are meaningful entities, and when combined with skill and education, they possess a powerful force of good for our patients.