Dont Let Pain Management Complicate Nutritional Care
|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.|
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?
Side Effects' Impact on
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:
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:
Anorexia/loss of appetite. Concentrate on relieving pain symptoms as much as possible. Make food available 24 hours a day so that residents can eat when they feel able to. Liberalize or eliminate dietary restrictions. Focus on food first, and pack each bite of food with as many calories and grams of protein as possible.
There are many ways to boost calories and protein with foods from the typical kitchen, and there are also some great products on the market that can assist you in achieving this goal, e.g., special milkshakes, bars, puddings, cereals, mashed potatoes or other well-accepted food.
Cramps, heartburn and bloating. Consider these suggestions:
Constipation. Take these suggestions into consideration:
Diarrhea. Consider these tips:
The following foods might be better tolerated by residents who experience diarrhea:
Antidiarrheal medications might be needed if the condition is severe or persistent.
Dry mouth/sore mouth. Take these ideas into consideration:
Taste/smell alterations. Consider these suggestions:
Dysphagia (difficulty swallowing). Warning signs of dysphagia can include:
If any of the above signs are noted, it is essential to refer the resident to a speech-language pathologist (SLP) for further evaluation. The SLP can complete a bedside examination to assess the need for further diagnostic tests. The SLP can recommend proper food and liquid consistencies and proper positioning of the resident to ensure safe swallowing.
Dehydration risk. Pain medications that cause a decreased sensorium can make it difficult to drink, reach for fluids or communicate fluid needs and can cause a resident to refuse fluids. In addition, side effects that cause fluid loss (e.g., diarrhea, vomiting) can contribute to dehydration. Fluid-needs calculations are generally based on 30 cc/kg body weight (2.2 pounds = 1 kg), although residents with congestive heart failure, renal problems or dehydration might have different needs.
Fluids and products to use might include milk, juice, water, milkshakes, popsicles, ice cream, sherbet, gelatin or any food that is fluid at room temperature. All residents should have a water pitcher at their bedsides (barring any fluid restrictions). For residents with dysphagia who need thickened liquids, fluids should be thickened to the consistency ordered and as recommended by the SLP.
If fluids taken by mouth are not tolerated, an IV or tube feeding might be recommended. In these cases, the dietetics professional should assess IV or tube-feeding practices and adherence to flush recommendations, and re-evaluate as needed.
Becky Dorner, RD, LD, is president of Becky Dorner & Associates, a dietary consulting company based in Akron, Ohio. For further information, phone (800) 342-0285 or visit www.beckydorner.com. To comment on this article, please send e-mail to dorner0902@ nursinghomesmagazine.com.