CNA Training Advisor

Transcription

1 CNA Training Advisor Volume 12 Issue No. 1 January 2014 Pain management Pain affects many nursing home residents. It often results from injury or sensory stimulation. A variety of factors affect recognition, assessment, and management of pain. Likewise, many factors affect the presence and intensity of pain, as well as the ability to describe it. The inability to communicate does not mean pain is minor or does not exist. Pain is always a symptom of something wrong. Unrelieved pain has many significant physical and psychological consequences. It interferes with residents optimal level of function and self-care. Unfortunately, some residents are resistant or unable to communicate when they are in pain. This issue of CNA Training Advisor will address the types of pain that long-term care residents may experience. It will also focus on some of the common challenges to managing pain in elderly residents. This lesson will uncover a connection between pain and depression among residents. CNAs will learn two key strategies for evaluating pain and take a closer look at their role in effective pain management. Have a good day of training, and stay tuned for next month s issue of CNA Training Advisor, which will cover bowel and bladder management. Program Prep Program time Approximately 30 minutes Learning objectives Participants in this activity will be able to: Identify the various types of pain that affect residents Recall strategies for evaluating pain Describe the challenges of managing pain in elderly residents Describe a connection between pain and depression Preparation Review the material on pp. 2 4 Duplicate the CNA Professor insert for participants Gather equipment for participants (e.g., an attendance sheet, pencils, etc.) A focus on pain management Pain is subjective. Because it cannot be seen, CNAs must rely on input from residents in order to identify it. Not all residents, however, are able to verbally communicate. Thus, CNAs must be able to pick up on nonverbal cues potentially indicating pain. Some of the nonverbal signs of pain CNAs should look for during resident care include moaning, grimacing, guarded positioning, withdrawing from touch, and restlessness. As a group, take time to brainstorm what additional nonverbal signs or cues staff should look for to identify pain. Quiz answer key 1. b 6. d 2. d 7. a 3. a 8. d 4. c 9. b 5. a 10. c Method 1. Place a copy of CNA Professor and a pencil at each participant s seat 2. Conduct the questionnaire as a pretest or, if participants reading skills are limited, as an oral posttest 3. Present the program material 4. Review the questionnaire 5. Discuss the answers see also hcpro.com/long-term-care

2 CNA Training Advisor January 2014 This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. editorial advisory board Product Manager Adrienne Trivers Associate Editor Melissa D Amico mdamico@hcpro.com Stay connected Interact with us and the rest of the HCPro community at HCPro.com Become a fan at facebook.com/hcproinc Follow us at twitter.com/hcpro_inc us at customerservice@hcpro.com Questions? Comments? Ideas? Contact Editor Melissa D Amico at mdamico@ hcpro.com or , Ext Don t miss your next issue If it s been more than six months since you purchased or renewed your subscription to CNA Training Advisor, be sure to check your envelope for your renewal notice or call customer service at Renew your subscription early to lock in the current price. Relocating? Taking a new job? If you re relocating or taking a new job and would like to continue receiving CNA Training Advisor, you are eligible for a free trial subscription. Contact customer serv ice with your moving information at At the time of your call, please share with us the name of your replacement. CNA Training Advisor (ISSN: [print]; [online]) is published monthly by HCPro, Inc., 75 Sylvan Street, Suite A-101, Danvers, MA Subscription rate: $159/year; back issues are available at $15 each. Copyright 2014 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro.com. Visit our website at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of CTA. Mention of products and serv ices does not constitute en dorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Pain that affects function or quality of life is a significant problem in long-term care facilities, where up to 80% of residents have one or more painful conditions. In this setting, musculoskeletal conditions and arthritis are the most common causes of pain. Problems associated with conditions of the nervous system, such as shingles and diabetic neuropathy, are also fairly common. There are several categories of pain, but sometimes one problem cannot be differentiated from another, and signs and symptoms often overlap. Residents may have more than one painful condition. Because of the prevalence of pain in the geriatric population, CNAs must remain alert to the potential for, or presence of, pain in residents. This is especially important for cognitively impaired residents with behavior problems, residents who fail to eat, and those who are able but fail to participate in other ADLs, such as dressing, bathing, and ambulating. Types of pain Long-term care residents may experience a variety of pain types based on their personal conditions. Types of pain include the following: Acute pain is pain with an abrupt onset and limited duration that is usually resolved in fewer than six months. Cancer pain is sometimes considered a subtype of acute pain. If the resident lives long enough, the pain becomes chronic. This pain is associated with a known malignancy. It is difficult to classify and may fall into more than one category, such as neuropathic pain and nociceptive pain. Breakthrough pain is usually associated with pain that is well controlled; it is a transient, situational, or episodic increase in pain that requires treatment with a rapid-acting medication. This pain may also be seen when a drug is wearing off before the next dose is due. If the pain is neuropathic in origin, it may be difficult to predict. Incident pain is sometimes considered a subtype of breakthrough pain. This pain is situational or episodic; it often occurs predictably and is associated with a precipitating event (such as movement) or with a procedure (such as wound care). Mixed or unspecified pain are terms used to describe pain caused by multiple problems or pain in which the exact cause is unknown, such as severe, recurrent headaches. Nociceptive pain occurs when receptive nerve endings are damaged or stimulated by touch, pressure, heat, an irritant, etc. Somatic pain is a type of nociceptive pain with origins in the muscles, joints, connective tissue, bones, and skin; this pain is usually localized in one area. The resident may complain of 2 hcpro.com 2014 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

3 January 2014 CNA Training Advisor throbbing and/or aching. This pain is usually aggravated by activity and relieved by rest. Visceral pain is a type of nociceptive pain with origins in the internal organs, such as the gallbladder or gastrointestinal tract; it may be well localized or poorly localized, depending on cause. Neuropathic pain is associated with abnormal processing of sensations by the nervous system; this category may be further subdivided into peripherally generated pain and centrally generated pain. Phantom pain is a form of neuropathic pain that may result in burning, tingling, itching, numbness, or pain that seems to originate in a part of the body that has been removed. Persistent pain was formerly known as chronic pain ; it was renamed because of prevalent stereotyping that associated this type of pain with addiction and drug-seeking behavior. Persistent pain typically persists beyond a three- to six-month period, perhaps for life; this pain is recurrent and of varying intensity. It might not be associated with a known diagnosis. New research suggests undamaged nerve fibers cause persistent pain. Until recently, researchers believed damaged nerve fibers were responsible for transmitting pain impulses to the brain. This information is useful in the quest for more effective analgesics. Persistent nonmalignant pain (formerly called chronic nonmalignant pain ) is another term for persistent pain. This type of pain is usually associated with a chronic condition or injury rather than a malignancy. Referred pain travels to another area of the body through shared nerve pathways, such as chest pain radiating to the jaw and arm, and gallbladder pain radiating to the shoulder. Other definitions CNAs should be aware of include: Pain threshold the least stimulus-producing pain Pain tolerance the greatest level of pain a resident can tolerate Sensory threshold the least stimulus a resident can recognize and identify Pain and depression Pain and mood disturbances seem to go hand in hand in older adults. Residents with pain may also experience anxiety, depression, apathy, and sleep disturbance. Fear of the meaning of pain (e.g., worsening of condition, end of life), apprehension, and anxiety can augment the pain response and make coping more difficult. However, avoid thinking that pain is the sole cause of a resident s depression and that controlling the pain will eliminate the depression. Depression, if present, must be treated aggressively, or pain management is not likely to succeed. CNAs often are the first to recognize mood changes in residents. If you observe any notable changes in a resident that may signify depression, report to a supervisor right away. Challenges of managing pain in elderly residents Although people of all age groups experience pain, assessing and managing pain in long-term care residents is especially challenging. Here are a few reasons why: Residents response to pain and signs and symptoms of pain may differ from those of younger adults; signs and symptoms may be atypical for the condition, and residents may use different terminology to describe the pain Residents may have cognitive and/or communication problems that affect their ability to report pain, and staff members may fail to ask cognitively impaired residents about the presence of pain Behavior problems that are usual for the resident may not be associated with pain Some residents may not report pain for a variety of reasons Assessments, tools, policies, procedures, protocols, and guidelines may be unavailable to assist the staff Other illnesses and medications may affect residents interpretation of, response to, or ability to report pain Turnover and staffing problems mean staff may not know each individual resident well, or may not have sufficient time to observe and assess residents Staff members may be inappropriately trained in recognition, assessment, and management of pain; some nursing schools and textbooks have provided 2014 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or hcpro.com 3

4 CNA Training Advisor January 2014 misinformation about pain assessment and management, including promoting the fear of addiction Residents often have several chronic diseases, making the cause of their pain difficult to identify Residents bodies react differently to drugs compared with that of younger persons; normal aging changes affect how residents metabolize and eliminate drugs, making them much more sensitive to the therapeutic and toxic effects of analgesics and other medications Water is a diluent for medications; many long-term care residents have chronic, mild dehydration, and their fluid intake may be inadequate Evaluating pain There are several techniques nurses may use to evaluate resident pain. Some nurses use the PQRST mnemonic: P Provocation and palliation. What causes or precipitates the pain? What makes it better or worse? Q Quality (verbal descriptors). What is the nature of the pain? How can it be described (e.g., throbbing, burning, stabbing, shooting, tingling, etc.)? R Region, radiation, and referral. What is the location of the pain? Does it radiate or move to other areas of the body? S Severity (using a pain scale or intensity rating, if possible). How severe is the pain? Does it interfere with functioning or ADLs? T Temporal relationship/timing of pain (onset, duration, variation). Is the pain constant or does it come and go? Is its onset sudden or gradual? How often does the pain occur? How long does it last? Does it occur most often at a particular time of day? Is the pain associated with meals (before or after)? Is the pain associated with a particular activity? Others use the PQRSTA mnemonic: P Palliative and/or provocative factors Q Quality of pain (e.g., burning, stabbing, etc.) and how it affects quality of life (e.g., ADLs, mobility, sleep, appetite, and mood) R Region of body affected R Radiation S Severity of pain (e.g., using a pain scale) T Timing of pain (e.g., frequency, duration, or occurrence at a predictable time of day) T Treatments tried A Associated symptoms (e.g., shortness of breath, chest pressure, inflammation, warmth, tenderness) The CNA s role When it comes to pain management, CNAs may be responsible for: Screening residents and reporting signs of pain to the nurse, contributing to his or her assessment Observing for and reporting the presence and characteristics of pain Recognizing and reporting pain behaviors in residents with cognitive impairment Observing for and reporting effectiveness of treatment Monitoring for and reporting side effects of medications and other treatments Providing nursing comfort measures and nondrug treatments to increase comfort and relieve pain Providing emotional support and getting help for persons in pain Monitoring residents overall response to pain, such as how it affects quality of life The absence of a report of pain does not mean that pain does not exist. Some residents simply cannot express or respond to pain. Consider the many potential barriers that may keep someone from reporting pain. You should be alert and carefully observe residents for pain: During personal care and ADLs. During movement, transfers, and ambulation. During and after activities. After pain medications or nondrug nursing interventions have been given. Inform the nurse if problems are noted. Relieving pain is a key nursing measure and an important responsibility. You are an important partner in the pain management team. Using basic comfort measures will increase resident satisfaction and quality of life. H 4 hcpro.com 2014 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 january 2014 Volume 12 Issue No. 1 CNA Professor pain management Mark the correct response. Name: Date: 1. In long-term care settings, and are the most common causes of pain. a. fractures; arthritis b. musculoskeletal conditions; arthritis c. cancer; skin conditions d. fractures; HIV/AIDS 2. Because of the prevalence of pain in the geriatric population, CNAs should maintain a high level of suspicion related to the potential for or presence of pain, especially for. a. cognitively impaired residents b. residents who fail to eat c. residents who refuse to participate in ADLs d. All of the above 3. Pain with an abrupt onset and limited duration that is usually resolved in fewer than six months is known as. a. acute pain b. cancer pain c. breakthrough pain d. incident pain 4. pain is associated with abnormal processing of sensations by the nervous system. a. Nociceptive b. Somatic c. Neuropathic d. Persistent 5. Sensory threshold is the least stimulus a resident can recognize and identify. A supplement to CNA Training Advisor 6. In the PQRSTA mnemonic, R stands for: a. Region b. Radiation c. Right side d. a and b 7. One of the major challenges of managing pain in elderly residents is that they often have several chronic diseases and the cause of the pain is difficult to identify. 8. Elderly residents bodies react differently to drugs compared with that of younger individuals, which makes them sensitive to the therapeutic and toxic effects of analgesics and other medications. a. much less b. less c. more d. much more 9. Pain and mood disturbances are completely unrelated, especially in older adults. 10. In the PQRST mnemonic, S stands for: a. Section b. Sound c. Severity d. Symptoms