Recognizing and Treating Pain - Making a difference in the lives of your Residents

Transcription

1 Recognizing and Treating Pain - Making a difference in the lives of your Residents Will begin at 2:00 pm EST Housekeeping Announcements Problems during the call? Press *0 to be connected to the Operator. Handouts The handouts were attached to the confirmation . If you were unable to access the handouts to print, please contact the Association at 614/ after the call and we can provide those for you. Evaluation Each person listening to the call must complete the evaluation form. FAX or mail to the Association (FAX: ). 1

2 Continuing Education Credit Wait 24 hours and then Go to and click on Request Your Certificates in the column entitled Live Teleconferences & Webinars. Certificates are available for 1 year after the program date. Find your Facility name in the drop down list. If your facility name is not there, contact the Association office at You will enter all participants names at one time. Follow the on screen instructions. You will receive an when your attendance has been verified and your certificates are available for download. Please note: this course is considered a self study course by Ohio BELTSS. Administrators are reminded that BELTSS limits teleconference (home/self study) credits to a total of ten (10.0) per renewal period. 2

3 Recording This live program (as well as all previous webinars) are also available via CD recording. Please note that there are no CEUs available for listening to the recording. Please contact the Association if you would like to purchase a recorded copy of a previous webinar. Also for those listening to the recording, please note the there may have been changes since the live broadcast of this program. Please contact OHCA or the speaker for clarification. Today s Format 90 minutes available for presentation & questions Questions? During the presentation: you can type your questions There will also be time for live questions & answers at the end of the presentation and the operator will explain that procedure 3

4 Today s Speakers Demetria (Demi) Haffenreffer, RN, MBA, has made long-term care her profession since 1973, first as a Director of Nursing and for the last thirty-five years as a consultant. She is founder and President of Haffenreffer & Associates, Inc., an Oregon consulting firm supporting skilled and community based care providers in the delivery of person-centered, compassionate care. Haffenreffer & Associates, Inc. provides educational and hands-on assistance with the implementation of quality systems and corporate compliance programs nationwide. In 2011, Demi assisted the Colorado Foundation for Medical Care with a CMS grant to publish the Model Program for Quality Performance called 'QAPI.' Demi is a facilitator for the AHCA Leadership Excellence Self-Assessment System and is currently serving on the Washington Health Care Association Quality Improvement Committee. She has served on the Oregon State Resident Safety Review Council, the Steering Committee of MOVE (Making Oregon Vital for Elders, an outreach of the Pioneer Network), as a member of Oregon Patient Safety Commission, and as a Master Examiner for AHCA's Quality Award. Demi has taught workshops nationally and internationally on a variety of subjects pertinent to long-term care and has authored five policy and procedure manuals. In addition, Demi is retained regularly by nationally known law firms as an expert on regulatory compliance issues. Pain Assessment & Management in Long Term Care A Person-Centered Holistic Approach Presented by: Demi Haffenreffer, RN, MBA demi@consultdemi.net 4

5 Pain Assessment & Management in Long Term Care Outline: Why is this topic important? The Requirements Assessment & person-centered care planning Treatments Treating special resident populations Assessing your current program Case studies / post test / evaluation Prevalence Number one reason why people seek medical attention is acute pain Chronic pain 50 million of the 75 million who suffer from pain suffer from chronic pain Back and neck; arthritis; headaches; neuropathic Undertreated 5

6 Consequences Prolonged hospital stays Physiological see next slide Delayed recovery Increased healthcare costs Depression & increased suicide risks Altered self-image & needless suffering Economic & social impacts greater than for any single disease entity Loss of productivity Physiological Consequences Endocrine Cardiovascular Respiratory Gastrointestinal Musculoskeletal Immune Genitourinary 6

7 LET S EXAMINE THE REQUIREMENTS CFR483.25(k) F309 Pain Management The facility must ensure that pain management is provided to resdient who require such service, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences. 7

8 Care Process Assess for potential or actual Assess and address underlying causes Develop and implement interventions that use specific strategies for different levels or sources of pain or pain related symptoms Utilize both pharmacological and / or nonpharmacological interventions Monitor and evaluate effectiveness Modify approaches as necessary October 2017 MDS Section N Number of Days past 7 days receiving an opioid 8

9 UNDERSTANDING PAIN MANAGEMENT Definitions Pain: Whatever the experiencing person says it is, existing whenever the resident says it does. An unpleasant sensory & emotional experience associated with actual or potential tissue damage, or described in terms of such damage, or both. 9

10 Definitions Acute Pain: A response to injury or illness that is usually time limited, responds to treatment & inadequate treatment delays recovery. Trauma Acute medical (including post-op care) Orthopedic problem Acute pain associated with chronic illnesses Definitions Chronic Pain: A state in which pain persists beyond the usual course of an acute disease or healing injury, or that may or may not be associated with an acute or chronic pathologic process & causes continuous or intermittent pain over months or years. Many illnesses &/or pathological conditions Cancer pain vs. non-cancer chronic pain 10

11 Definitions Intractable Pain: A pain state in which the cause of the pain cannot be removed or otherwise treated and in the generally accepted course of medical practice, no relief or cure of the cause of the pain can be found after reasonable efforts, including but not limited to, evaluation by attending physicians. Four Processes Transduction Transmission Perception Modulation 11

12 Transduction Nociceptor activation and sensitization Peripheral neuropathic pain Clinical implications Transduction 12

13 Transmission Periphery to spinal cord Spinal cord to brain Clinical implications Transmission 13

14 Perception Awareness Emotion based on awareness Clinical implications Individual differences Modulation Descending pathways Clinical implications Peripheral sensitization Central sensitization 14

15 Nociceptive pain vs. Neuropathic Classified on basis of presumed underlying pathophysiology Caused by ongoing activation of nociceptors in response to noxious stimulus Somatic Neuropathic Indicates injury to peripheral or central nervous system Examples & Characteristics of Nociceptive Pain Superficial Somatic Pain Deep Somatic Pain Visceral Pain Nociceptor Location Skin & more Muscles & more Visceral organs Potential Stimuli External, mechanical & more Overuse strain, injury, ischemia, inflammation Organ distension, muscle spasm & more Localization Well localized Localized or diffuse & radiating Well or poorly localized Quality Sharp, pricking or burning Usually dull or aching, cramping Deep aching or sharp stabbing Associated S & S Cutaneous, hyperalgesia, allodynia Tenderness, reflex muscle spasm, & hyperactivity Malaise, N & V, sweating, tenderness, spasm Clinical examples Sunburn, etc Arthritis pain, etc Appendicitis, etc 15

16 Examples & Characteristics of Neuropathic Pain Mono & Poly - Neuropathies Deafferentation Pain Sympathetically Central Definition Pain along dist. of 1 or more nerves nerve damage Due to loss of afferent input Maintained by sympathetic nervous system Primary lesion or dysf. Of CNS Char. & Symptoms 3 types = Many symptoms & char. Many symptoms & char. Many symptoms & char. Sources Many Damage to p. nerve or CNS Damage to p. nerve & more Many Clinical Examples Diabetic, more Phantom limb; post mastectomy CRPS; Phantom limb; & more Poststroke; cancer; MS Barriers to pain management Health care system Health care professionals Patient and family barriers Legal and Societal barriers Tolerance, physical dependence, addiction 16

17 Common Misconceptions Sensitivity and perception decrease in the elderly therefore they do not feel pain If you can t recognize pain it has no effect on you Pain w/age is to be expected & is normal Individuals who do not complain of pain or say, I have no pain, do not have pain (they still may & will need further assessment) Cognitively impaired cannot use pain intensity rating Common Misconceptions Individuals who complain of pain, do not have pain Opioid medications have side effects that make them too dangerous to use in the elderly or they will become addicted. Physical & behavioral signs best indicator Addiction may occur PRN medication is sufficient to control pain Comparable stimuli produce the same level of pain in all individuals 17

18 THE FIRST STEP IN TREATING PAIN IS TO RECOGNITION!! GOALS Recognition (requires nurses to be aware of their own beliefs) Appropriate assessments & care plans Appropriate consults Appropriate treatments Improved functioning highest practicable well-being Improved quality of life 18

19 Barriers to Recognition Barriers Cognitive status of resident Sensory problems Cultural problems Poor communication between resident & care giver Fear Not recognizing behaviors as pain related Caregivers don t believe the resident Caregiver lack of knowledge Other ASSESSMENT 19

20 Core Principles Resident right to assessment and management Pain is subjective self-report most reliable Physiological and behavioral symptoms do not replace Assessment tools must be appropriate for the population being treated Pain can exist without a physical cause Uniform pain threshold & tolerance does not exist Residents with chronic pain may be more sensitive to pain Unrelieved pain has physical & psychological consequences assessment should address both Assessment Principles Routine Assessments Believe what people tell you Don t believe what people tell you Assess comprehensively Choose the right treatment Empower the resident Distinguish between acute and chronic pain 20

21 Comprehensive Assessment Components Recent pain history The interview Cognitive/Communication - Ability to recognize - Ability to report - Behaviors Comprehensive Assessment cont d Type/Frequency/Location Localized or radiating Past History part of the interview with either the resident or family Related Conditions/Diagnosis Treatments that work and don t work Current treatment and effectiveness Resident goal also part of interview process 21

22 Pain assessment tools Unidimensional scales Numeric Visual Categorical Multidimensional tools Brief pain inventory Initial Quarterly Other PAIN ASSESSMENT TOOLS 22

23 Treatment Medications PRN vs Routine Non-pharmacological treatment Pharmacological Many med options Non-opiod Anti-inflammatory Anti-anxiety agents Muscle relaxants Pain perception modifiers Opiods Anti-epileptics Antidepressants Nerve blocks local anesthetics Intraspinal delivery systems 23

24 Pharmacological principles Optimize administration PRN vs routine Start with a low dose and slowly titrate to the lowest effective dose Patches are slow to work initially and another prn medication may be needed for breakthrough pain. Patches may require body fat to be effective Pharmacological principles For chronic pain, use an analgesic around the clock For breakthrough pain, use fast onset, short-acting analgesics Establish a goal for pain management Monitor for & manage side effects. Try to avoid over sedation Differentiate among tolerance, physical dependence, & addiction & appropriately modify therapy 24

25 Pharmacological principles Reassess effectiveness routinely Adjuvant drugs may be needed such as Amitryptyline Ibuprofen is not the medication of choice if the resident has GERD Pharmacological principles Start with a non-opioid analgesic for mild pain (Adjuvant therapy is optional) For mild to moderate pain not relieved by a non-opioid analgesic attempt a weak opioid plus a non-opioid analgesic (Adjuvant therapy is optional) Avoid use of placebos 25

26 Pharmacological principles For moderate to severe pain or pain not relieved by weak opioid, consider a strong opioid with or without a non-opioid analgesic (Adjuvant therapy is optional) Treatments Non-Pharmacological Gentle massage TENS units (electro stimulation) Implanted nerve stimulators Hot baths or whirlpools Heat (15 to 20 minutes only) Cold (15 to 20 minutes only) Chiropractic Acupuncture 26

27 Treatments Non-Pharmacological Ointments/creams (BenGay, BioFreeze, Tiger Balm, Salonpas (med. Patches), Aspercreme Slow movement Breathing techniques (slow, deep breathing), rest Music (some music, loud or soft, can make pain better or worse) Behavioral medicine Treatments Non-Pharmacological Glucosamine Arnica Biofeedback Energy healing Pilates Yoga 27

28 Treatments Non-Pharmacological Visualizations and other diversional activities Acupressure Vocalizing (screaming and/or moaning) Other approaches: Therapy Surgery Building an Institutional Commitment to Pain Management Develop an IDT work group Analyze current pain mgt. issues and practices Implement a standard for pain mgt. Establish policies and procedures Establish accountability for quality & monitor Provide information for pharm. & non-pharm. Mgt. Promise residents prompt response Provide education 28

29 RESOURCES