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NUR360 LS2 > Pain assessment and management in geriatric care > Flashcards

Pain assessment and management in geriatric care Flashcards

1
Q

What is pain

A
  • An unpleasant sensation and emotional experience
  • Subjective defined
  • Multi-dimensional; shaped by physical and psychological factors
  • Can be influenced by underlying emotional trauma
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2
Q

Types of pain: direct vs indirect

A

Direct versus indirect

- Due to the disease or as a consequence of treatment

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3
Q

Types of pain: acute vs chronic

A

Acute

  • short term and self limiting
  • dissipates after injury heals

Persistent or chronic pain

  • Present for 3 months or longer than the time of expected healing
  • Malignant
  • Nonmalignant; also called chronic non-cancer pain (CNCP)
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4
Q

Types of pain: nociceptive

A
  • Tissue damage

Somatic – localized, sharp, e.g. a broken bone

  • Superficial
  • deep

Visceral – dull, ache, can be vague

  • Colicky (obstruction)
  • Capsular (stretching)

Referred Pain – Originates in one location but is felt in another

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5
Q

Types of pain: central pain

A
  • Caused by damage to the central nervous system

- e.g. stroke

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6
Q

Types of pain: neuropathic

A
  • Injury to the central, peripheral, or autonomic nervous system
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7
Q

Types of pain: sympathetically maintained

A

e.g. complex regional pain syndrome

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8
Q

How do we assess pain?

A
  • Interview and review of systems
  • In-depth pain and medical history
  • Pain assessment tools
  • Physical exam
  • Diagnostic as required to determine the cause of pain
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9
Q

Acronyms for pain interview: OPQRSTUV (PQRSTU-AAA)

A 
O - onset
P - provocation/palliative/preferred analgesic 
Q - quality 
R - region/radiation/relieving factors
S - severity/significance
T - timing
U - understanding 
V - values
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10
Q

Acronyms for pain interview: OLD CART

A 
O - onset
L - location
D - duration
C - character
A - aggravating factors
R - relieving factors
T - treatment
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11
Q

Assessment tools for pain

A
  • Brief pain inventory
  • Short-form McGill pain questionnaire
  • Visual analogue scale
  • Numeric rating scale
  • Faces pain scale
  • Pain diaries or journals
  • Vital signs are not a reliable indicator!!!
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12
Q

Barriers to pain assessment in the elderly (RNAO)

A
  • Less frequent reports of pain
  • Choosing to suffer in silence
  • Perception of pain by others
  • Fear of losing self control
  • Fear of addiction
  • Inability or difficulty swallowing pills
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13
Q

Under-treatment of pain

A
  • Common in patients with cognitive impairment
  • Clinicians often underestimate pain in this population

Consequences:

  • Depression
  • Anxiety
  • Falls
  • Malnutiriton
  • Reduced cognition
  • Impaired sleep
  • Functional disturbances
  • Declines in socialization and recreation
  • Increased healthcare costs
  • Decreased quality of life
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14
Q

Non-verbal signs of pain

A
  • Grimacing
  • Wincing
  • Moaning
  • Rigidity
  • Arching
  • Restlessness
  • Shaking
  • Pushing
  • Responsive behaviour
  • Mood changes
  • Change in routine or activity patterns
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15
Q

PAINAD tool

A
  • Used for cognitively impaired individuals
  • Gives a score out of 10
  • Breathing independent of vocalization
  • Negative vocalization
  • Facial expression
  • Body language
  • Consolability
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16
Q

Types of pain management

A
  • Non-pharmacological
  • Pharmacological
  • Holistic; consider all facets of the individual
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17
Q

Non-pharmacological pain management

A
  • Mindfulness meditation
  • Hot and cold therapies; are these safe? (potential for burn or frostbite)
  • Physical therapy and exercise
  • Massage
  • Reiki
  • Acupuncture
  • Counselling
  • Stress and coping strategies
  • Functional assistance with painful activities
  • TENS; transcutaneous electric nerve stimulation
18
Q

Pharmacological pain management

A
  • Type of pain dictates appropriate management
  • Cancer versus noncancer, acute versus chronic
  • Consider the Beers Criteria; Medications that are high risk for the elderly
  • Take into account over the counter (OTC) medications
  • Follow the WHO pain ladder where possible
  • Always anticipate and prepare for side effects
  • Consider patient safety and falls risk
  • How will medication be administered and monitored?
  • Start low and go slow (based on goals of care)
  • End-of-life pain management is often more aggressive than what is practiced in other clinical areas
19
Q

WHO pain ladder

A
  • Include non-pharm for all treatment of pain
  • Seek out and manage underlying cause

Level 1
non-opioid
+/- adjuvant

Level 2
mild opioid
+/- non-opioid
+/- adjuvant

Level 3
potent opioid
\+/- non-opioid
\+/- non-opioid
\+/- adjuvant
20
Q

Equianalgesic

A
  • Equivalent amounts of medication in a similar drug class (opiates) that also takes into account the route of administration
Morphine 30mg
Codiene 200mg
Fentanyl Transfermal 12.5mcg/hr
Hydrocodone 30mg
Methadone 4mg
Oxycodone 20mg
Oxymorphone 10mg
21
Q

Opioid use in geriatric care

A
  • Can be an appropriate option; do not exclude from consideration
  • Use smaller doses!
  • May be used on a schedule or as needed
  • Short acting or long acting
Examples:
Morphine 2.5-5mg PO Q4H
Hydromorphone 0.5-1mg PO Q4H
Oxycodone 1-2.5mg PO Q4H
Codeine 8-15mg PO Q4H
22
Q

Opioid use in geriatric care

A
  • Can be an appropriate option; do not exclude from consideration
  • Use smaller doses!
  • May be used on a schedule or as needed
  • Short acting or long acting
Examples:
Morphine 2.5-5mg PO Q4H
Hydromorphone 0.5-1mg PO Q4H
Oxycodone 1-2.5mg PO Q4H
Codeine 8-15mg PO Q4H
23
Q

Total pain; holistic management (Dame Cicely Saunders concept of total pain)

A

Realms:

  • Physical
  • Spiritual
  • Psychological
  • Social
24
Q

Other considerations when doing pain management

A
  • Drug coverage
  • Medication management
  • Side effects
  • Fulfilling responsibilities; driving, working, caregiving
  • Tolerance
  • Stigma
  • Preconceived notions and previous experiences
  • Medication interaction
  • Multiple prescribers
  • Prescriber preference
  • Rena; and hepatic function
  • History of or current opioid or substance use disorder
  • Polypharmacy
  • Risk of intentional or unintentional diversion; storage and medication sharing
25
Q

Is it an allergy or a side effect?

A
  • Assess if its an allergy or a just a side effect
  • Look at the dosing
  • Patient and caregiver education is essential
  • Dis-spell myths
  • Start low, go slow
  • Reassess, reassess, reassess!
  • Always anticipate side effects and plan accordingly!
26
Q

Side effect management: opioids

A
  • Constipation; Narcotics must come with cathartics!
  • Nausea and/or vomiting
  • Respiratory depression
  • Myoclonus; neurotoxicity
  • Pruritis
  • Sedation; *NPs must report to MOT if unsafe to drive
  • Delirium
  • Potential for overdose ; Naloxone
  • Follow-up and monitoring!
27
Q

Side effect management: NSAIDs

A
  • Black box warning
  • GI symptoms
  • Risk of bleeding
  • Consider topical to reduce side effects
28
Q

Side effect management: acetaminophen

A
  • Risk of hepatic dysfunction

- Safe to typically take 4g or less daily, new recommendations say <3g/day

29
Q

Points for OTC medication use

A
  • Medication reconciliation is important
  • Ask clients to bring in medications to their
    visit, not just the list
  • Home visits help greatly with this
  • Always ask about over the counter analgesia and any natural/herbal remedies, include topical options as well
  • Did you know? – Gabapentin can be prescribed as a cream compound!
  • Patients often don’t know that OTC options have an upper limit
30
Q

Other therapeutic options

A
  • Antidepressants (TCA, SNRI, SSRI)
  • Anticonvulsants (gabapentin,
    carbamazepine, pregabalin)
  • Steroids; oral or by injection
  • Bisphosphonates for bone pain in cancer
  • Surgical options; e.g. vertebroplasty
  • Radiotherapy
  • Intrathecal
  • Patient controlled analgesia
  • Continuous opioid infusion
  • Cannabis; CBD – not covered by ODB, can be obtained without script
31
Q

Overall messages about pain and it’s management

A
  • Pain is an unpleasant multifaceted experience that can have detrimental consequences for elderly patients
  • Pain is more than just a sign of physical harm; account for psychological pain as well
  • Assessment should be systematic and thorough, and take into account patient deficits
  • Pain assessment tools can help to screen for and evaluate pain overtime
  • Assessment tools must result in intervention to relief suffering
  • Nonpharmacological options should always be incorporated into a plan of care as appropriate
  • Pharmacological options include many options that should be initiated slowly, cautiously, and with the patient’s goals of care in mind
  • Side effects must be anticipated and treated
  • Nurses play a crucial role in pain management and can make a meaningful difference for elderly patients in their advocacy, care, and intervention
32
Q

Pain and Dementia: clinical and experimental pain studies

A
  • Pain not adequately trained in patients with dementia; undertreatment of pain
    ○ Particularly in non-communicative patients with white matter lesions
    ○ Demented patients report less prevalent & intense pain
  • The impact of dementia on pain processing varies in direction and quality, depending on type of pain, neuropathology & stage of dementia
    ○ The more severe the cognitive impairment, the more pronounced the differences in pain experience b/w demented & non-demented populations
  • Findings from clinical &experimental studies do not suggest that pain is less frequent & intense even if no longer reported
    ○ Likely that any sign of pain made in presence of cognitive impairment requires even greater attention and a more proactive treatment response
33
Q

Pain & Dementia: pain assessment

A
  • Way that pain sensation is interpreted by the older person impacts expression of pain and how those are interpreted by observer
    ○ This makes assessment of pain challenging
  • Recommended procedures for identification of pain
  • Simple verbal descriptor scales, pain thermometers, & facial pain scales

○ Assumption: pain conditions are similarly painful in those that can & cannot self-report
○ Recommended first step: self-report to determine & rate pain severity
- Many persons with dementia are able to self report
- Note: if efforts to establish reliability indicate that report is not reliable, use other methods
○ Health care provider can observe key behaviours -> grimacing/guarding
- Or gather info from surrogate reports (from family & caregivers)
- Note: Association b/w patient reports and surrogate reports strong for presence of pain but not strong for reporting pain severity

34
Q

Pain and dementia: treatment

A
  • Few studies in literature on pain treatment in older persons with dementia
  • Adequate pain control in patients with dementia depends on good pain evaluation
    ○ May express itself as improvement in behaviour and activities of daily life
  • Factors to consider
    ○ Serious adverse effects/side effects
    ○ Drug-drug interactions
    ○ synergy of drug treatment with non-pharmacological approaches
  • In general: need a broader holistic approach
35
Q

Clinical barriers in pain assessment

A

● Insufficient training
● Suboptimal communication methods
● Lack of use of appropriate assessment tools
● Relating pain to age
● Misinterpretation and poor detection of pain (usually problem in patients w/ cognitive impairments)
○ Patients w/ dementia are at high risk of under treatment of severe pain
■ Due to diminished ability to describe the characteristics of pain or how it differs throughout the days

36
Q

What can untreated pain in OAs

A

● Burden in their family, family and society. Leading to:

  • Depression
  • anxiety
  • falls
  • malnutrition
  • reduced cognition
  • impaired sleep
  • functional disturbances
  • declines in socialization and recreational activities
  • increased healthcare costs
  • reduced quality of life
37
Q

What does higher postoperative pain lead it

A

● longer hospital stays
● increased time to ambulation
● chronic functional impairment

38
Q

What is the most important risk factor for developing cognitive impairment?

A
  • Advanced age
  • The severity of cognitive impairment has been directly correlated to an increased risk of under treatment of pain
    ● Cognitively impaired persons are more likely to be given “as needed” pain medications , which are inappropriate for individuals with moderate-to-severe cognitive impairment who are unable to communicate the presence of pain
39
Q

Components of a comprehensive clinical assessment of pain

A

● Detailed investigation of the patient’s pain
● Medical history
● Physical examination
● Diagnostic testing

● Consider sensory impairments

  • dysphasia, aphasia and cognitive impairment
  • Limitations on the direct information gathered

● PQRSTAAA
- Use pain assessment instruments

● Non verbal cues for older patients who cant verbalize pain

  • guarding, grimacing and restricted movement
  • Gather information from family members

● Comprehensive assessment in older adults allows
- gathering of complete information on regions of pain and conditions that may be causing the pain

40
Q

Pathological conditions that can cause pain in OAs

A 
● UTI
● Skin infections
● Dental problems 
● Incisions
● Fractures
● Positioning
● Bladder distention or kidney stones
● Skin breakdown
● Ulcer or irritation
● Constipation
● Gout
● Peripheral arterial disease
41
Q

Common sites of pain in OAs

A

● MSK

● Neurological systems

NUR360 LS2 (11 decks)

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