Caring for Older AdultsExperiencing Pain among Older Adults Flashcards
Exam 3
Pain: A Complex Phenomenon
What is the greatest threat to comfort?
Pain is greatest threat to comfort
Pain: A Complex Phenomenon
What kind of phenomenon is pain?
Pain: biopsychosocial phenomenon:
Pain: A Complex Phenomenon
Pain: biopsychosocial phenomenon: How is it explained?
An unpleasant sensory and emotional experience associated with actual or potential tissue damage
Pain: A Complex Phenomenon
Pain: What is pain? What does it rely on?
Pain is subjective and relies on person’s perception:
Pain: A Complex Phenomenon
Pain: Who does it exist for?
Whatever the person experiencing it says, it is existing whenever she or he says it does
Unique aspects of pain in older adults
Who is pain predominantly in?
Predominant in older population, but relatively few studies on pain have focused on this potentially vulnerable population.
Unique aspects of pain in older adults
What is there a growing recognition in?
Research gaps in aspects of pain and older adults-There has been a growing recognition of the need for better pharmacologic management of chronic pain among older adults.
Unique aspects of pain in older adults
What is there a lack of when is comes to pain studies?
Lack of evidence-based information, misconceptions, and misinformation
Unique aspects of pain in older adults
What is it commonly believed about pain in older adults? What does this result in?
It is commonly believed that elderly persons are less sensitive to pain and that experiencing pain is part of the aging process, but these assumptions result in undertreatment of pain.
Unique aspects of pain in older adults
Age-related changes that affect pain:
What is altered?
Pain process is altered
Pain perception and the older adult
Unique aspects of pain in older adults
Age-related changes that affect pain:
What changed occur?
Age-related changes in pharmacokinetics and pharmacodynamics AND increased risk for adverse effects
Unique aspects of pain in older adults
Age-related changes that affect pain:
How does pain present?
Atypical presentation of pain symptoms
Unique aspects of pain in older adults
Age-related changes that affect pain:
Who is less likely to report pain?
Older adults less likely to report pain
Unique aspects of pain in older adults (cont.)
How many types of locations and pain?
several types of locations and pain
Unique aspects of pain in older adults (cont.)
Where does pain occur?
Prevalence and causes -60% of older adults in community setting and 83% -93% of those in nursing homes experiencing persistent pain.
Unique aspects of pain in older adults (cont.)
What is the most common pain?
Musculoskeletal pain is most common
Unique aspects of pain in older adults (cont.)
Who reports a higher prevalence of pain? Who is likely to be undertreated for pain?
Women consistently report a higher prevalence of persistent pain than men
Nociception
physiologic process leads to perception of noxious stimulus as painful.
Nociception:
Nociceptive pain arises from what?
Nociceptive pain arises from mechanical, thermal, or chemical noxious stimuli.
Nociception:
Nociceptive pain - what are the four processes?
Four processes:
transduction,
transmission,
perception,
and modulation.
Neuropathic pain: What is it?
abnormal processing of sensory stimuli by the central or peripheral nervous system
Neuropathic pain:
How can it occur?
Can occur in the absence of immediate tissue damage or inflammation.
Somatic nociceptive pain:
pain that originates from the bones and soft tissue, and is often caused by osteoarthritis.
Chronic pain:
has been present for 3 months or longer.
Visceral pain:
Is associated with disorders that can cause generalized or referred pain and is and is described as deep and aching.
Definitions and types of pain (Cont.)
Acute pain: What is it?
Acute, noncancerous pain experienced late in life is usually episodic in nature and is temporary and time limited (less than 3 months)
Definitions and types of pain (Cont.)
Acute pain: What are examples?
Examples include
postoperative,
procedural,
or posttraumatic.
Definitions and types of pain (Cont.)
Acute pain: What is it considered?
Considered a universal experience for all older adults at some point
Definitions and types of pain (Cont.)
Acute pain: How is it often?
Often is superimposed on a preexisting chronic pain
Definitions and types of pain (Cont.)
Acute pain: How does the pain occur?
sharp, immediate pain from injury to tissue
Definitions and types of pain (Cont.)
Acute pain: What is it responsive to?
and responsive to analgesics
Definitions and types of pain (Cont.)
Acute pain: What are examples of things used to treat severe acute pain?
Prescription opioids (like hydrocodone, oxycodone, and morphine) are one of the many options for treating severe acute pain.
Definitions and types of pain (Cont.)
Persistent (chronic) pain: What is it?
Continues for prolonged period; may or may not be associated with a recognizable disease process.
Definitions and types of pain (Cont.)
Persistent (chronic) pain: How long is it?
lasts longer than 3 to 6 months or beyond the expected time of healing
Definitions and types of pain (Cont.)
Persistent (chronic) pain: How can it develop?
May develop insidiously as a disease progresses or may be a sequela to an episode of acute pain
Definitions and types of pain (Cont.)
Persistent (chronic) pain: What percent of the community is thought to have chronic pain?
The pain of more than 75% of those living in the community is thought to be chronic.
Definitions and types of pain (Cont.)
Persistent (chronic) pain: What is the realistic goal for treatment?
For those with persistent pain, the only realistic goals may be reducing the sensation and minimizing its effect on the person’s quality of life and independence.
Which condition is the most common cause of persistent pain in the older adult population?
A. Fibromyalgia
B. Arthritis
C. Polyneuropathy
D. Hip fracture
B. Arthritis
Arthritis, the most common cause of persistent pain in the older adult population, currently affects between 49% and 59% of older adults, or more than 20 million people
Barriers to Pain Management in Older Adults
What are the three major groups
Health Care Professional Barriers
Health Care System Barriers
Older Adults and Family Barriers
Barriers to Pain Management in Older Adults
Health Care Professional Barriers: What is lacking? What is there a concern of?
Lack of education regarding pain assessment and management
Concern regarding regulatory scrutiny
Barriers to Pain Management in Older Adults
Health Care Professional Barriers: What is there a belief of?
Belief that pain is a normal part of aging
Belief that cognitively impaired older adults have less pain Personal beliefs and experiences with pain
Barriers to Pain Management in Older Adults
Health Care Professional Barriers: What is there an inability of?
Inability to accept the person’s report of pain without “objective” signs
Barriers to Pain Management in Older Adults
Health Care System Barriers
Cost
Time Policy regarding opioid use Systemic bias
Barriers to Pain Management in Older Adults
Older Adults and Family Barriers: What is there concern?
Concern that the person will not be believed
Barriers to Pain Management in Older Adults
Older Adults and Family Barriers: What are their fears?
Fear of being a “bad patient” if complaining
Fear of the meaning of the pain, e.g., that the person has cancer Fear of addiction Fear of side effects of treatments Fear of medication side effects
Barriers to Pain Management in Older Adults
Older Adults and Family Barriers: What are concerns?
Concern that the pain is not important to the health care provider/nurse
Concern that the pain is not important to the health care provider/nurse
Barriers to Pain Management in Older Adults
Older Adults and Family Barriers: What are limitations?
Financial limitations
Barriers to Pain Management in Older Adults
Older Adults and Family Barriers: What is the belief?
Belief that pain is a normal part of the aging
Belief that nothing can be done to adequately relieve pain
Barriers to Pain Management in Older Adults
Older Adults and Family Barriers: What coexists?
Coexistence of sensory or cognitive deficits
Which is one of the most common barriers to pain management with the older adult population?
A. Older adults frequently complain of pain
B. An attitude that pain is a normal part of aging
C. Absence of assessment tools
D. Sensory impairment of the older adult
B. An attitude that pain is a normal part of aging
There are many barriers to the appropriate recognition and management of pain.
These obstacles exist at the level of the health care system from health care providers themselves to patients and family members.
A common misconception in the older adult population is that pain is a normal part of aging and cannot be treated effectively
Nursing Assessment of Pain in Older Adults
Obtaining information about pain: What do you assess?
Assess for pain during initial contact, at frequent intervals, when condition changes.
Assess effectiveness of analgesic 30 to 60 minutes post administration
Nursing Assessment of Pain in Older Adults
Obtaining information about pain: What is the “gold standard”?
“Gold standard”: self-report about pain
Nursing Assessment of Pain in Older Adults
Obtaining information about pain: What is used to assess pain intensity?
Pain rating scales used to assess pain intensity
Nursing Assessment of Pain in Older Adults
Obtaining information about pain: What kind of questions are asked?
Use open-ended questions to identify person’s expectation for pain relief
Nursing Assessment of Pain in Older Adults
What is the priority assessment finding?
*Nursing The client’s subjective self-report of pain is the priority assessment finding and reflects the adage that pain is what the client says it is.
Nursing Assessment of Pain in Older Adults—(cont.)
Baseline vital signs
Ability to walk, stand, or move about in bed
Baseline agitation level
Appetite and eating patterns
Sleep patterns
Elimination habits
Cognitive function and mood
Cultural factors: influence the way people experience pain, express pain, and manage pain
Awareness of cultural differences of expression
culture dictated the expression of pain but doesn’t affect the type of treatment
Nursing Assessment of Pain in Older Adults—(cont.)
What should be avoided by healthcare workers?
Avoid stereotyping
What are the types of pain intensity scales?
Verbal Descriptor Scale (VDS)
0-10 Numerical Rating Scale (NRS)
An older adult client receiving hospice care is pale and irritable. The hospice nurse suspects that the client may be in pain. Which action would be most appropriate?
A. Assume that the client must be in pain.
B. Ask the client if the client is feeling pain.
C. Provide the client with pain relief without asking.
D. Consult the client’s chart for previous presentation of pain.
B. Ask the client if the client is feeling pain.
Clients react in very different ways to pain and express themselves differently. Reports of pain or discomfort, nausea, irritability, restlessness, and anxiety are common indicators of pain; however, the absence of such expressions of pain does not mean it does not exist. The nurse should assume nothing, but rather ask the client about pain and have the client rate it on a scale of 0 to 10.
The client’s subjective self-report of pain is 1st assessment we need to do –even with confused patients.
What is the first assessment for pain that must be done, even for confused patients?
The client’s subjective self-report of pain is 1st assessment we need to do –even with confused patients.
Nursing Assessment of Pain in Older Adults—(cont.)
Pain in Older Adults with Communication or Cognitive Limitations
What is best practice to assume?
It is a best practice to assume “that any condition that is painful to cognitively intact persons would also be painful to those with advanced dementia who cannot express themselves”
Nursing Assessment of Pain in Older Adults—(cont.)
Pain in Older Adults with Communication or Cognitive Limitations
How is there communication about pain?
People with more severe impairment or loss of language skills for whatever reason may not be able to communicate the presence of pain in a manner that is easily understood.
Nursing Assessment of Pain in Older Adults—(cont.)
Pain in Older Adults with Communication or Cognitive Limitations
People with more severe impairment or loss of language skills for whatever reason may not be able to communicate the presence of pain in a manner that is easily understood.
What are nonverbal cues to look for?
Nonverbal cues to the possibility of pain include:
changes in behavior,
alterations in ambulation,
agitation,
aggression,
increased confusion,
or passivity
Nursing Assessment of Pain in Older Adults—(cont.)
Pain in Older Adults with Communication or Cognitive Limitations
In mild-to-moderate stage dementia, or confusion due to medical conditions (infection (UTI),COPD, hyponatremia etc.) –How do they communicate about pain? What is the priority assessment?
In mild-to-moderate stage dementia, or confusion due to medical conditions (infection (UTI),COPD, hyponatremia etc.) –they can verbally communicate about pain *need to ask them -The client’s subjective self-report of pain is the priority assessment
Nursing Assessment of Pain in Older Adults—(cont.)
Pain in Older Adults with Communication or Cognitive Limitations
With moderate-to-severe dementia, what is indicative of pain?
With moderate-to-severe dementia, disruptive behavior may be key to indicator of pain
Nursing Assessment of Pain in Older Adults—(cont.)
Pain in Older Adults with Communication or Cognitive Limitations
What do studies about older adults who are cognitively impaired show about pain?
Study after study has shown that older adults who are cognitively impaired receive less pain medication for the same conditions and situations that would be painful to those without impairments.
Nursing Assessment of Pain in Older Adults—(cont.)
Pain in Older Adults with Communication or Cognitive Limitations
How is pain with dementia?
Yet there is no convincing evidence that peripheral transmission of the sensation of pain to the brain is altered by dementia.
Nursing Assessment of Pain in Older Adults—(cont.)
Pain in Older Adults with Communication or Cognitive Limitations
How do people with cognitive impairments understand pain?
However, those with cognitive impairments may not understand what they are feeling, why they are feeling it, or where it is coming from.
Nursing Assessment of Pain in Older Adults—(cont.)
Pain in Older Adults with Communication or Cognitive Limitations
How are their expressions of pain compared to others?
Their expressions of pain are most likely different than others.
Research has suggested that older people with mild to moderate cognitive impairment can provide valid reports of pain using self-report scales if the cues are recognized by the nurse and other caregivers.
Pain Cues in older adults with Communication or Cognitive Limitations
What should the nurse do? Where should they obtain baseline data? What else should they use?
Nursing:
Ask pt. directly -Obtain baseline information from a family member- more frequent assessments -observe nonverbal cues –use a valids assessment tool.
Pain Cues in older adults with Communication or Cognitive Limitations
What do they include?
Changes in Behavior
Activities of Daily Living
Vocalizations
Physical Changes
Pain Cues in older adults with Communication or Cognitive Limitations
Changes in Behavior: Like what?
(What kind of movements)
Restlessness and/or agitation or reduction in movement
Repetitive movements
Unusually cautious movements, guarding
Pain Cues in older adults with Communication or Cognitive Limitations
Activities of Daily Living: Like what changes?
(Decreases?)
Sudden resistance to help from others
Decreased appetite
Decreased sleep
Pain Cues in older adults with Communication or Cognitive Limitations
Vocalizations: Like what?
Person groans, moans, or cries for unknown reasons
Person increases or decreases usual vocalizations
Pain Cues in older adults with Communication or Cognitive Limitations
Physical Changes: Like what?
Pleading expression
Grimacing Pallor or flushing Physical tension such as clenching teeth or hands Diaphoresis (sweating) Increased pulse, respirations, or blood pressure
Nursing Assessment of Pain in Older Adults—(cont.)
Assessment tool for older adults with Communication or Cognitive Limitations
What are tools used?
The Pain Assessment in Advanced Dementia (PAINAD)
Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC - II)
Nursing Assessment of Pain in Older Adults—(cont.)
Assessment tool for older adults with Communication or Cognitive Limitations
Research has suggested that older people with mild to moderate cognitive impairment can provide valid reports of pain- How?
Research has suggested that older people with mild to moderate cognitive impairment can provide valid reports of pain using self-report scales if the cues are recognized by the nurse and
other caregivers
Nursing Assessment of Pain in Older Adults—(cont.)
Assessment tool for older adults with Communication or Cognitive Limitations
(PACSLAC - II) Pain assessment for seniors with Limited Ability to communicate: What is this tool valid for?
Valid for discriminating between pain and non pain in long term care settings.
nurses like the shorter version that’s the one in the book - it has the ability to facilitate documentation
Interventions for managing pain
What is used to promote healthy aging?
Using Clinical Judgment to Promote Healthy Aging:
Interventions for managing pain
Using Clinical Judgment to Promote Healthy Aging:
What techniques are used?
What are interventions used for?
What does it minimize?
Relieves both acute and chronic pain
Uses both pharmacological and nonpharmacological techniques
Minimizes side effects
Interventions for managing pain
Using Clinical Judgment to Promote Healthy Aging:
What is part of evidence based practice?
Expert pain management is part of evidence-based practice.
Interventions for managing pain
Using Clinical Judgment to Promote Healthy Aging:
Nursing responsibilities when it comes to pain:
When pt. complains about Pain nursing priority is the need to provide prompt, adequate relief of the client’s pain.
Interventions for managing pain
Using Clinical Judgment to Promote Healthy Aging:
Nursing responsibilities when it comes to pain: What should the nurse assure?
Assuring that the patient is comfortable and has the highest possible health-related quality of life regardless of cognitive or functional status or disease state.
Interventions for managing pain
Using Clinical Judgment to Promote Healthy Aging:
Nursing responsibilities when it comes to pain: What should the nurses counter?
Countering myths, stereotypes, and generalizations about aging and pain
Pharmacologic Interventions for Managing Pain
What is the foundation of effective pain management?
Analgesic medications
Pharmacologic Interventions for Managing Pain
Classifications of analgesics include:
Opioid analgesics:
Nonopioid analgesics:
Adjuvant analgesics:
Pharmacologic Interventions for Managing Pain
Classification of analgesics:
Opioid analgesics: What is included?
codeine,
morphine,
tramadol,
fentanyl,
methadone
Pharmacologic Interventions for Managing Pain
Classification of analgesics:
Opioid analgesics: What do they often cause? What is used to prevent this?
Opioids often cause constipation and necessitate bowel stimulation to prevent constipation.
Pharmacologic Interventions for Managing Pain
Classification of analgesics:
Opioid analgesics: When should a bowel regimen be instituted?
A bowel regimen should be instituted at the same time as opioid treatment.
Pharmacologic Interventions for Managing Pain
Classification of analgesics:
Opioid analgesics: How do opioids effect older people compared to others?
Because of changes in metabolism with aging, opioids have a greater and longer lasting analgesic effect in older clients.
Pharmacologic Interventions for Managing Pain
Classification of analgesics:
Nonopioid analgesics: Like what?
acetaminophen,
NSAID’s,
aspirin
Pharmacologic Interventions for Managing Pain
Classification of analgesics:
Nonopioid analgesics: What are negative effects of these?
NSAIDs can cause gastrointestinal bleeding, kidney and liver damage, and drug interactions with potentially fatal results.
Pharmacologic Interventions for Managing Pain
Classification of analgesics:
Nonopioid analgesics: What is the maximum daily dose? How does it differ for people with kidney and live failure and alcohol users?
The maximum daily dose of acetaminophen is 4000 mg, (4gm) and the limit is lower for clients with kidney or liver failure and clients who use alcohol.
Pharmacologic Interventions for Managing Pain
Classification of analgesics:
Nonopioid analgesics: What is a typical dose?
A typical dose is two 500-mg (“extra-strength”) tablets.
Pharmacologic Interventions for Managing Pain
Classification of analgesics:
Adjuvant analgesics:
primary indication other than pain antidepressants and anticonvulsants, antihistamines, neuroleptics.
Pharmacologic Interventions for Managing Pain
Nonopioid analgesics: What is used for the most common causes of physical pain such as osteoarthritis and back pain?
Acetaminophen
Pharmacologic Interventions for Managing Pain
What med is a first line approach to pain?
Acetaminophen
Should be considered a first-line approach unless contraindicated
Pharmacologic Interventions for Managing Pain
Acetaminophen
Should be considered a first-line approach unless contraindicated- Why?
Does not usually cause gastrointestinal bleeding or renal or cardiac effects
Pharmacologic Interventions for Managing Pain
Nonsteroidal anti-inflammatory drugs: When are they used? What accompanies the use of these drugs?
Used when pain is from inflammation or during a short arthritic flare
Accompanied by higher risk for adverse drug effects
Pharmacologic Interventions for Managing Pain
Adjuvant Medications: How are they usually used?
Usually used with an analgesic but may be used alone
Pharmacologic Interventions for Managing Pain
Adjuvant Medications: What are they most effective for?
Most effective for neuropathic pain syndromes, such as postherpetic neuralgia and diabetic nephropathy
Pharmacologic Interventions for Managing Pain
Adjuvant Medications: Topical agents (e.g., capsaicin, lidocaine patch) can have what kind of effects?
Topical agents (e.g., capsaicin, lidocaine patch) may have mild to moderate local effects.
Pharmacologic Interventions for Managing Pain (Cont.)
Best practice using Opioids: What does it treat?
Treat both acute and persistent physical pain.
Pharmacologic Interventions for Managing Pain (Cont.)
Best practice using Opioids: What is required when giving to older adults?
Require utmost caution in their use with older adults
Pharmacologic Interventions for Managing Pain (Cont.)
Best practice using Opioids: Require utmost caution in their use with older adults- Why?
May produce a greater analgesic effect, a higher peak, and a longer duration of effect
Pharmacologic Interventions for Managing Pain (Cont.)
Best practice using Opioids: What increases risks of falls? What should be taught to patients?
Sedation increases risk for fall, delirium and any of the geriatric syndromes.
*teach client to call for assistance when getting out of bed.
Pharmacologic Interventions for Managing Pain (Cont.)
Best practice with pain medications: When can nurses administer pain meds?
Most institutions allow the nurse to administer opioid medications 30 to 60 minutes before the designated time on the prescription.
Pharmacologic Interventions for Managing Pain (Cont.)
Best practice with pain medications: What would violate a patient’s rights?
nurses have an obligation to the client to administer pain medication- not doing so violates the client’s rights.
Pharmacologic Interventions for Managing Pain (Cont.)
Best practice with pain medications: What should the nurse rely on to determine the need for pain meds?
The nurse should rely on the client’s report to determine the need for pain medication.
Pharmacologic Interventions for Managing Pain (Cont.)
Best practice with pain medications:
What circumstances can a nurse administer pain meds when the patient requests it?
As long as the timing is suitable and the client is stable, the nurse should administer pain medication when the client requests it.
Pharmacologic Interventions for Managing Pain (Cont.)
Best practice with pain medications: What should the nurse use to support withholding pain meds?
The nurse should use assessment data to support withholding pain medication in the presence of over sedation or another assessment that would be potentially aggravated by administering the pain medication
Pain Medication Administration
Persistent (chronic) pain: What is the preferred route?
Oral dosing is the preferred route
Pain Medication Administration
Persistent (chronic) pain: How is the med most effective?
Most effective when it is administered round the clock
Pain Medication Administration
Persistent (chronic) pain: What forms of meds improve control?
Long-acting or sustained-release forms of medication improve control
Pain Medication Administration
Acute pain: What should be available?
Breakthrough pain relief should be available
Pain Medication Administration
Acute pain: What is the preferred route?
IV or IM is preferred route *assess after 30-60min.
Pain Medication Administration
Acute pain: What is less effective in elderly and cognitively impaired?
Patient-controlled analgesia (PCA) is less effective in elderly and especially those who are cognitively impaired
Pain Medication Administration
Acute pain: What are one of the many options for treating severe acute pain?
Prescription opioids (like hydrocodone, oxycodone, and morphine) are one of the many options for treating severe acute pain.
Which of the following would be best choice for treating mild back pain in an older adult?
A. Aspirin
B. Ibuprofen
C. Meperidine
D. Acetaminophen
ANS: D
Unless contraindicated, acetaminophen is the first-line approach for managing most common causes of physical pain, such as osteoarthritis and back pain.
Pharmacologic Interventions for Managing Pain
Cutaneous nerve stimulation
Transcutaneous electrical nerve stimulation
Acupuncture and acupressure
Touch
Biofeedback
Distraction
Relaxation, meditation, and imagery
Pain clinics
Pharmacologic Interventions for Managing Pain
What do pain clinics provide?
Provide a specialized, often comprehensive, multidisciplinary approach to the management of pain
Inpatient, outpatient, or both
Pharmacologic Interventions for Managing Pain
Pain clinics: How are they oriented?
Syndrome-oriented,
modality-oriented, or
comprehensive
Pharmacologic Interventions for Managing Pain
Pain clinics: What are the goals of this?
Goals are to decrease pain intensity to a tolerable limit or eliminate it, if possible.
