May 2015 Clinical Nurse Educator Arohanui Hospice
End of Life Care, what s on top? Feedback from last session (Physiology of Dying) Volunteer to present at August meeting Presentation: Breaking Bad News Over the Telephone Homework Sheet
Resource Network Group Membership page at www.arohanuihospice.org.nz
Jean Clark April 2015 with thanks to Di Boon
Definition and Experience of Pain Pain and the Older Adult Pain Types Principles of Pain Assessment Pain assessment tools Pain Management
Pain is what the patient says hurts. An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. In other words, pain is a somatopsychic phenomenon. Twycross, R. 1997
Sensory dimension: the intensity, location and character of the pain sensation. Affective dimension: the emotional component of pain and how pain is perceived. Impact: the disabling effects of pain on the person s ability to function and participate in society.
An event which alerts the organism to the presence of harmful stimuli in the internal or external environment; occurs at time of diagnosis of the disease or its metastases Ends predictably (e.g. childbirth, procedural pain) May provoke an autonomic response
*Chronic pain has been defined as pain that lasts beyond the time the body needs to heal Pain on long term basis Often impossible to predict the end Often gets worse No biological meaning Comes to occupy the whole attention
Known as intermittent pain Generally associated with chronic cancer pain Important to assess the occurrence Obtain pain history Treated with PRN medications (please relieve now) Titrate medication
Results from a specific event for an individual such as movement, wound care, a procedure Cause is usually obvious Managed by anticipatory prescribing and administration of analgesic prior to pain occurring
Nociceptive (stimulation of nerve endings) includes Somatic - ie bone pain Visceral ie liver capsule pain Musculo-skeletal Neuropathic (originates in nerve fibres) Nerve compression Nerve injury CNS injury Different pains require different responses, and a combination of pain types will usually indicate a combined approach
Physical Caused by ill itself Concurent Illness Other Symptoms, Pressure Sores, Constipation Adverse effects of treatment Psychological Anger at diagnosis or situation Anxiety, Fear. Disfigurement Fear of pain and/or death Feeling of helplessness Depression Total Pain Spiritual/cultural Why has this happened to me? Why does God allow me to suffer? What is the point of all this? Is there any meaning or purpose in life? Am I being punished for my past? Social Worry about family Loss of social role Loss of role in family Feeling of abandonment Concerns about dependency Cultural Concerns
25-50% older people living in the community have persistent pain. 45-80% of nursing home residents report pain that is often left untreated. Pain is associated with depression can result in decreased socialisation and impaired ambulation reducing QOL Older adults tend to minimize pain. Older adults sometimes believe that pain is a normal part of aging Older adults fear they may become addicted to pain medications (Flaherty, 2008)
Arthritis and musculoskeletal Lower back disorders Neuropathic pain disorders include, diabetic neuropathy, herpes zoster Cancer tumour itself; liver capsular pain, bone metastases Infection- UTI, pneumonia Heart conditions- angina Circulatory- claudication, venous ulcers
Facial Expressions Frowning Grimacing Rapid Blinking Sad Expression Movements Tense or rigid posture Guarding/protecting body part Fidgeting, pacing, rocking Changed gait Activity Levels Change to appetite Change to sleep pattern Wandering Changes in normal routine or activity Mental State Confusion Crying Irritability Distress Noises Sighing, moaning or groaning Grunting, Chanting Calling Out Verbal Abuse, swearing Personality Aggressiveness Fighting or resisting care Becoming withdrawn Inappropriate or disruptive behavior
Discomfort Insomnia Fatigue Anxiety Fear Anger Sadness Depression Boredom Social Abandonment Sleep Sympathy Understanding Companionship Creative Activity Relaxation Reduction in Anxiety Elevation in Mood Analgesics
Assessment Explanation Individualised management Attention to detail Re assessment
of the underlying mechanisms discuss options Individualised treatment/management/care review frequently utilise drugs prophylactically for persistent symptoms do not limit management to drugs
Pain assessment The Fifth Vital Sign Important that patient rate their own pain Consider tools that the patient understands For patients with cognitive impairment consider appropriate assessment tools Observation important Comprehensive history
Site of pain - where is the pain? Type of pain - what does it feel like? Severity How severe is pain? Frequency of pain - how often does it occur? Duration of pain - how long has it been present? Aggravating factors - what makes it worse? Relieving factors - what makes it better? Responses to previous and current treatment? Consider medical history Physical examination
Numeric Rating Scale How do you rate the severity of the pain on a scale of 1-10, with 10 being the worse pain you could ever have? Verbal Descriptor Scale Please describe your pain from no pain to mild, moderate, severe or pain as bad as it could be?
What does this pain mean for you? Pain interpretation is influenced by prior experiences, knowledge and cultural values. Asking open ended questions may highlight misconceptions that can be addressed.
What is the worse thing about the pain? Ongoing pain often affects relationships and the ability to continue normal activities. Identifying the patient s personal concerns allows the clinician to address these.
Observe Change in behaviour, increased agitation or aggression Change in appetite or sleeping pattern Change in activity (e.g. More or less wandering) Facial expressions (frowning) Verbalisations (moaning, crying) Is there any guarding of any body part? Obvious physical signs that could indicate pain? Consider observations of caregivers/relatives
Abbey pain scale Does not differentiate between distress and pain Recommended as a movement-based assessment Observe patient when they are being moved. Document pain relief given A second evaluation should be conducted one hour after intervention
A five-item observational scale used to screen individuals with advanced dementia for pain (score from 0 10) Breathing Negative vocalization Facial expression Body language Consolability Assess patient during periods of activity, such as turning, ambulating, transferring Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. Journal of the American Medical Directors Association 2003; 4:9-15.
Titrate for individual patient (by the ladder) Adequate doses Regular doses (by the clock) Oral route where possible (by mouth) Management plan for breakthrough pain (prn) Supervision Keep reviewing and reassessing effectiveness of treatment
Pharmacological oral route is standard analgesic ladder give regularly as prescribed Non-Pharmacological
Regular doses of analgesia prescribed Give analgesia by the mouth, by the clock and by the ladder Pain treatment can be started at any step of the ladder according to pain intensity Adjuvant drugs are used at any time to enhance analgesic efficacy Adequate doses of PRN as required basis Review effectiveness of any medication Ensure all patients on a step 2 or 3 analgesic are on regular laxatives and monitor bowels
Radiotherapy Hypnosis Acupuncture Physiotherapy Massage Address psycho-social and spiritual issues Activities (diversion therapy)
Psychological support Rest and Relaxation Superficial heat (mild) Aromatherapy Mobilising exercise Passive relaxation Listening to the person s story
Mitchell, C. (2001). Assessment and management of chronic pain in the elderly people. British Journal of Nursing (10),5. 296-304. Flaherty, E. (2008). Using Pain-Rating scales with older adults. AJN. 108. (6) 40-47 Guidelines for a Palliative Approach in Residential Aged Care (2004). Australian Govt Dept of Health and Ageing. National Guidelines (2007). The assessment of pain in older people. The British Pain Society PAINAD Warden, Hurley and Volicer, JAMDA 2003; 4(1):9-15 ABBEY Pain Scale developed by Professor J. Abbey 1997-2003