aging doesn’t have to hurt · aging doesn’t have to hurt: creating a pain language between...
TRANSCRIPT
Danielle Hersey, BSN, RN
Maine State Director
Danielle Watford, MS, CMQ-OE
Program Administrator
Aging Doesn’t Have to Hurt: Creating a pain language between
patient and provider
This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
CMSMAC22017091151
Learning Session
Objectives
Understanding the pain scale;
Barriers to universal pain scales;
Importance of developing a pain language;
Review other options for pain interventions;
…and discuss other resources and opportunities for training.
9/21/2017 2
‘I don’t want to be perceived as an over prescriber…’ ‘I don’t want to be perceived as an over user…’
How do we view pain
management?
Pain Definition
“An individual’s unpleasant
sensory or emotional experience”
Source:
AMDA CPG for Pain Management for Medical Directors and Attending Physicians
Empirical Evidence
• 10 residents with “difficult” behaviors were
treated with acetaminophen TID.
• Five of ten showed in behavioral episodes
• Psychoactive meds discontinued in 6 people
Source:
Douzjian et al. (1998). Annals of LTC, 174-179
Achieving a Comfort Goal
Ask them & document it
Transfer the comfort level (number) to the
electronic medical record…
Refer to the comfort level goal.
Comfort goal can change over time
Best Practices in Pain Management
Assessment
Establishing Comfort Goal
Monitoring Intervention Effectiveness
Critical Thinking
Additional Assessments as indicated
Pre and Post Documentation
Nursing Best Practice is to:
Evaluate for pain using a (validated) tool – upon report of pain
Evaluate after medicating them according to facility policy – even if he/she appears to be sleeping
Compare results with comfort goal
Measuring Pain
Pain is subjective.
“Pain is what the individual
says it is”: the gold standard in
pain management.
We are trying to put a number
on pain so that we can measure
it.
You can only
manage what you
measure!
Understand the Pain Scale
• Pre-admission
• On admission
• During Activities of Daily Living
Before it’s needed
• We use the scale to measure our progress
• No right or wrong answer
• Don’t compare to others
• We use as part of our approach to pain management
Key points
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Providing a Pain Language
13
Providing a Pain Language
14
Providing a Pain Language
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It’s more than just words…
Source:
AMDA CPG for Pain Management for Medical Directors and Attending Physicians
Change in gait or behavior
Resisting certain movements during care
Decreasing activity levels
Striking out
Sleeping poorly Breathing
heavily Restlessness Sighing
Rubbing Groaning Calling out repeatedly
Non-verbal Pain Assessment
Avoid the Rollercoaster Effect
Pain is still a Vital Sign
• “Most chronic pain is related to arthritis and
musculoskeletal problems”
• “Unrelieved chronic pain is not an inevitable
consequence of aging”
• “When older patients are treated, it may be focused on
current diagnosis or current problem: don’t forget to
address chronic pain issues too”
• “The most common reason for unrelieved pain [in the
elderly] in the U.S., is failure to routinely assess for pain”
Source:
AMDA CPG for Pain Management for Medical Directors and Attending Physicians
Myths or Beliefs about Pain by
some Elderly People
Source:
AMDA CPG for Pain Management for Medical Directors and Attending Physicians
“Acknowledging pain will mean undergoing intrusive and possibly painful tests”
“Chronic pain means death is near”
“Pain always indicates the presence of a serious disease”
“Patients say they are in pain to get attention”
“Elderly patients are likely to become addicted to pain medications”
Bias vs Brainstorm
Bias: Do you have a resident who requests prn pain
meds on the way to BINGO and you think they don’t look
like they are in pain?
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Brainstorm: Is resident afraid that pain may develop
while at activity? Is resident afraid that if she/he does not
complain about pain that you will take away the scheduled
pain meds or reduce the amount of pain meds?
Is there a TRUST issue?
Don’t make an Assumption…
Does patient understand how pain meds work, duration,
purpose, expectations of the med?
Pain is what the patient says it is.
Is there a misunderstanding or lack of understanding
about how to describe pain, what the levels of pain are,
how reporting or not reporting pain will affect care?
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What else can cause pain?
Source of information: AMDA CPG for Pain Management for
Medical Directors and Attending Physicians
Mouth pain from sores, ill-fitting dentures
Bottom “hurts” from sitting in chair too long; pressure ulcers
Feet hurt from diabetic neuropathy
Hands or back hurt from arthritis
Back pain from compression fractures
Leg cramps, Claudication, PVD
Consider…
Keep biases of caregivers out of the equation
Families may need education regarding addiction, dependence and tolerance
Individuals most likely to develop tolerance if medication used long term
The difference between addiction, dependence and tolerance
Definitions
• Tolerance is a decreased subjective and objective effect
of the same amount of opioids used over time, results in
an increasing amount of the drug to achieve the same
effect.
• Physical dependence represents a characteristic set of
signs and symptoms (opioid withdrawal) that occur with
the abrupt cessation of an opioid (or rapid dose reduction
and/or administration of an opioid antagonist).
• Addiction is a chronic disease that “represents an
idiosyncratic adverse reaction in biologically and
psychosocially vulnerable individuals”
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Source:
(ASAM, 2001). Exp Clin Psychopharmacol. 2008 Oct; 16(5): 405–416.
Non-Drug Interventions for Pain
Non-Drug Interventions
Is there a list of non-pharmacological interventions for
pain that work for the patient? Is it accessible to all
whenever needed?
Documentation what works?
Use your Team!
Other Options…
Darkened, Quiet Room
Warm/Cool Compress
Music, listening to IPOD
Relaxation and imagery
Reiki, touch
Whirlpool, shower
Laughter therapy Acupuncture Distraction and
reframing Pastoral
Counseling
PT/OT, Range of Motion
Exercise, Massage,
Repositioning Immobilization
Transcutaneous electrical nerve
stimulation (TENS)
Assistive devices
Psychotherapy Peer support
groups And more…
Identifying a Standard of Care
Based on Clinical Guidelines
• American Geriatrics Society
(AGS), Pharmacological
Management of Persistent
Pain in Older Persons (2009)
www.americangeriatrics.org
• AMDA Clinical Practice
Guideline (CPG):
Pain Management
– 1-800-876-2632
www.amda.com/tools/guidelines.cfm
• American Pain Society (APS)
Arthritis Guidelines
– 1-847-375-4715
www.americanpainsociety.org
• American Society of
Addiction Medicine
– 1-301-656-3920
– Definitions of addiction,
dependence and tolerance
www.asam.org
Other Resources
The AMDA Clinical Practice Guideline (CPG)
for Pain Management – for Medical Directors
and attending Physicians was updated in
2012.
AMDA Clinical Practice Guideline
For Pain Management
Training Tools available:
http://www.geriatricpain.org/Content/Assessment/Impaired/
Pages/PAINADToolInstructions.aspx
There is a training video for healthcare staff as well:
“How To Try This Video: Pain Assessment in Older Adults”
Auditing Tool
Advancing Excellence Campaign website,
www.nhqualitycampaign.org
This website has an auditing tool for Pain Management that
will give you data and graphs identifying several aspects of
your pain management program, including tracking percent
of residents who receive only pharmacological intervention
for pain, only non-pharmacological intervention for pain, and
percent of residents who receive both types of interventions.
Questions?
Connect with the
New England QIN-QIO online! HealthCareForNewEngland.org
For more information…