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Advancing Excellence in Pain Assessment (Part 2)

December 10, 2008
by Steven B. Littlehale, MS, GCNS-BC, Jane M. Niemi, MSN, RN, LHNA, and Sheila G. Capitosti, MHSA, RNC, NHA
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Elements for an effective pain management program
  • Quality and description of the pain (sharp, dull, throbbing, etc.)
  • Location (use a body drawing to mark the pain area)
  • Intensity of the pain (pain scale)
  • Frequency of pain
  • History of pain (when started, when worse, when better)
  • Effects of pain (sleep, appetite, relationships, emotions, etc.)
  • Satisfaction and effectiveness of current/past treatments

Pain symptoms

The following is a helpful method for zeroing in on the pain symptoms that need to be gathered in order to achieve adequate pain management. Refer to CMS Draft Pain Regulation 309—page 13. http://www.ascp.com/resources/nhsurvey/upload/F309QualityofCare%20.pdf. Consider the following acronym (see PQRRSTTA Checklist on left).

 

Thorough resident assessment:

Once the pain is identified and then fully described, it needs to be evaluated in the context of the total resident condition. This evaluation is done from the complete assessment or examination of the resident, and is needed to adequately direct treatment options and the plan of care. The following is a list of assessment areas that provide comprehensive information on the resident.

 

  1. 1. Physical examination
  2. 2. Consideration of co-morbidities
  3. 3. Diagnostic tests
  4. 4. Medication history

The identification of pain needs to start immediately at time of admission and then continue throughout the resident’s stay. Identify which pain screening scale is best when the resident first arrives at the nursing home. Cognitive and language ability might define your approach. Many residents admitted from hospital are used to the hospital pain scale. It may be best to perpetuate its use, as long as it is evidence-based and part of your policy and procedure.
 

Plan of care

Both the resident and family should participate in the development of the pain management plan of care. Resident goals should be considered because many residents may choose to not be entirely pain-free, as they may feel side effects of medications are more undesirable than some level of pain. Non-pharmacological interventions may play a key role in maintaining function levels for the resident while at the same time effectively controlling the resident’s pain and allowing them to achieve their goals for both pain management and quality of life. The plan of care should follow facility policies and procedures that have been developed following guidelines of assessment, planning, implementation, monitoring and modification as necessary.

 

Complementary approaches to managing pain

Non-pharmacological interventions used in conjunction with pharmacological interventions can play a key role in the facility’s pain management program and in the control of residents’ pain. Included can be comfort measures such as repositioning, comfortable room temperature and specialized mattresses. Cognitive interventions along with relaxation, diversions, music therapy and spiritual interventions also can be effective. Consultation with chiropractic and rehabilitation services can help to identify physical modalities that can be a successful part of the pain management program. These modalities can include hot or cold packs, massage, baths, TENS, and acupuncture. Finally, education of the resident and family regarding pain symptoms and available interventions will allow for greater participation by the resident in their pain management program and lead to ultimate success in achievement of pain management goals for the resident.

Pharmacological interventions

Pharmacological interventions include the use of analgesic as well as adjuvant medications such as antidepressants and anticonvulsants. The pharmacological plan of care will depend on the cause of the pain and the individual response of the resident to the medications. It is recommended that guidelines for pain medication be based on the resident’s level of pain and a stepwise approach such as the World Health Organization’s Pain Ladder be followed (World Health Organization, 1990, http://www.who.int).

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