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Dont Let Pain Management Complicate Nutritional Care

September 1, 2002
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Drug side effects and changes in appetite can, and should, be managed By Becky Dorner, RD, LD
Don't Let Pain Management Complicate Nutritional Care   By Becky Dorner, RD, LD   "In this nation, it has been said that people are living longer but are dying more painfully. The healthcare profession as a whole will be judged in the next century not by how it has been able to take technological skills and prolong life by a few more hours, days, or perhaps weeks, but rather by how it controls the pain and suffering in each life that is entrusted to its care."   L. Jean Dunegan, MD, JD, Annals of Long-Term Care, November 2000     Mr. Abbott's family members were very concerned-they could not figure out what was causing his loss of appetite. A large man, his weight had gone from 280 pounds six months ago to an all-time low of 248 pounds. The nursing facility staff were also concerned, because they, too, could not explain the reason for his lost appetite. They began to ask very specific questions and discovered that his pain was so severe that he could not concentrate on anything but controlling his reaction to the pain. He was a proud, strong man and did not want to complain.   Pain and its treatment can have dramatic effects on a resident's nutrition and hydration status. When a resident is suffering from pain, it might be difficult for him or her to focus on anything but the pain. This can lead to loss of appetite, weight loss and potentially resulting weakness, fatigue, decreased immune response, malnutrition, pressure ulcers and poor wound healing. In addition, pain medications themselves often produce side effects that can have a dramatic impact on a resident's desire for food and the body's ability to handle food and fluids.

Medication Timing

If medications are timed to relieve pain prior to mealtime, the resident can enjoy the meal, and mealtime can once again become an event that the resident looks forward to. If not, persuading the resident to eat could become a constant struggle.

Assessing Pain's Effect on Nutrition and Hydration Status

Screening residents on pain medications for nutritional problems can help alleviate their discomfort with food and fluids. By asking the right questions and providing the best interventions, we can prevent weight loss, malnutrition and dehydration. Key questions include: Does pain affect your appetite? In what way? Do you experience any of the following during your bouts of pain or as a result of taking pain medication?

  • Nausea
  • Vomiting
  • Loss of appetite
  • Heartburn
  • Cramps
  • Bloating
  • Gas
  • Constipation
  • Diarrhea
  • Dry mouth or sore mouth
  • Taste or smell alterations
  • Difficulty swallowing

Side Effects' Impact on
Nutritional Care

Pain and its management (via medications) can have a domino effect that can alter nutrition and hydration status. Severe pain can create nausea, which leads to decreased appetite and decreased desire for liquids, leading to potential weight loss, malnutrition and dehydration. Pain medications can produce multiple side effects, including loss of appetite, gastrointestinal distress, nausea, vomiting, diarrhea and constipation. All of these have a negative impact on food and fluid intake (Table), in turn creating the potential for weight loss, malnutrition and dehydration.

Here are some of the most common side effects of pain and its management, and suggestions for coping with them.

Nausea. Be sure appropriate staff are notified and are attempting to alleviate the problem. The physician might be able to order an antinausea medication. Here are some additional suggestions:

  • Offer small meals and snacks.
  • Encourage residents to eat slowly and chew food thoroughly.
  • Try "dry meals" with any liquids given between meals (one hour before or after). Offer cool, clear liquids, and encourage the resident to drink slowly.
  • Do not force the resident to eat (it might cause a permanent dislike for the foods forced upon him/her); encourage the resident to avoid favorite foods during bouts of nausea to avoid developing an aversion to them.
  • Encourage the resident to rest calmly but to remain upright for 30 to 60 minutes after eating, with head of bed elevated.
  • Be sure the resident's clothes are loose and comfortable.
  • Remember that fresh air might help counteract nausea.
  • Avoid any specific food intolerances.
  • Remember that cold foods might be more appealing.
  • Avoid fatty and fried foods, heavy sweets, spicy foods and foods with very strong odors.
  • Offer whatever foods/fluids the resident suggests he/she will try to eat.
  • Keep the resident away from the kitchen area because smells of cooking food might increase the feeling of nausea; avoid other unpleasant odors. Remove plate cover while standing away from the resident, and allow food odors to dissipate prior to serving.
  • Be sure medications are given as instructed (Some need to be given with food, which might help to alleviate nausea).
  • Remember that carbonated beverages such as lemon-lime soda or ginger ale might be helpful.
  • Remember that peppermints or spearmints might be helpful, if tolerated.

Vomiting. The resident should remain NPO until severe vomiting passes. Once vomiting is under control, try giving small sips of clear liquids and increase the amount very gradually. When clear liquids are tolerated, advance to a full liquid diet. Begin with small sips and increase amounts as tolerance builds. Gradually advance to the level of the resident's regular diet.

The following foods might be more tolerable for residents with nausea and vomiting: