PAIN MANAGEMENT

1. PAIN MANAGEMENT Carole Morgan, RN, MPA, LNHA Director of Nursing Patrick O’Toole, Pharm. D., MPA Director of Pharmacy Sea View Hospital Rehabilitation Center and Home

2. PAIN • Number 1 complaint among older adults • Nearly 60% of older adults taking pain medications • Can significantly affect ones well being • A barrier in treating pain in older adult is inadequate pain assessment

3. ASSESSMENT What’s Needed • A comprehensive tool to capture both subjective/objective on admission, readmission, significant change or a newonset of pain • Anticipation of Pain – before dressing changes, Rehab therapy, ROM exercises • Assessment tool must also identify Residents needs and goals Etiology Severity

4. Subjective data Onset – location and time or origin Contributing factors – Causes of pain beginning or worsening Quality – Description (sharp, dull, crushing, aching, burning, steady, movable) Intensity – Severity on a scale of 1 – 10 Pattern – how often, how long, certain times Relief measures – measures to relieve or control pain Objective data Appearance - Evidence of clenched teeth or fists clenched, swelling, deformity, redness, perspiration, tense muscles, change in pupil size, fatigue Movements – Evidence of guarded movements, rigidity, restlessness, restriction of use Affect – Evidence of mood changes, signs of anger, irritability, or depression Vital signs – Change in pulse, bloodpressure, respiration ASSESSMENT

5. Monitoring Once a resident is identified as having pain, we begin a fluid and on-going process of evaluation of treatment modalities, to see if they are effective

6. Interdisciplinary Treatment • Attention must not only be directed at physiological aspects of addressing pain but also consider providing alternate treatments that focus upon psychosocial and environmental factors • ITC team and resident collaborate to arrive at a measurable treatment goals • Often, trials of various treatment modalities are needed to develop the most effective approach

7. Interdisciplinary Measures • Movies: Comedies - LAUGHTER releases endorphins which act like “Natural Opiates” to the body so that pain severity actually diminishes and even disappears for a period of time • Environmental: Adjusting room temperature, lighting, smoothing out linens, comfortable bedding, and using alternating air mattresses

8. Interdisciplinary Measures Relaxation Techniques: • Guided Imagery • Muscle Relaxation • Reiki Aromatherapy: Increasingly used as part of an integrated approach to pain. Touch and smell affect the parasympathetic nervous system, that can induce deep state of relaxation and this in turn can alter patients perception of pain. Specific aromatherapy contains pharmacological active ingredients which can benefit pain sufferers • Oil from lavender and peppermint have been beneficial in reducing pain. • Vanilla to stimulate appetite

9. Interdisciplinary Measures • Range Of Motion exercises to maintain joint motion and relieve stiffness • Endurance exercises (e.g.) cycling, aerobic exercise can decrease inflammation • Walking – Pain from cancer or Neurological (Neuropatic pain) benefits to keep things moving

10. Interdisciplinary Measures PET THERAPY - Studies show that pets reduce blood pressure, provide comfort and unconditional acceptance MUSIC – Used for centuries to promote physical and emotional healing • Music brings harmony back to the whole self; it is a powerful distraction and promotes relaxation • Music competes with pain signals to the brain

11. OTHER APPROACHES • WRITING • TALKING ON THE PHONE • PLAYING CARDS • CRAFT PROJECTS • READING • HOT AND COLD PACKS • COUNSELING • MASSAGE • SOCIAL SUPPORT

12. PAIN MANAGEMENT Pharmacological Therapy (Medication) • Scheduled dosing instead of PRN • Start with short acting medication – once pain control is achieved, change to long acting meds with short acting PRN med for breakthrough pain • Assess patient’s response to medication

13. Case Snapshot • MR 83 years old, female • DX: Dementia, DM, Depression, HTN, S/P CVA, OA • Meds: Metformin 500 mg. twice a day, Norvasc 10 mg daily, Trazodone 50 mg. at bedtime, Zocor 20 mg. at bedtime, Plavix 75 mg daily, Acetaminophen 650 mg every 6 hours for OA pain • Continue to complain of pain • MD change Acetaminophen to Percocet 5/325 mg. every 6 hours

14. Case Snapshot, cont. After a week , new issues noted • Episodes of falls • Change in mental status • Uncooperative with Rehab/ADLs • Constipation

15. Case Snapshot, cont. Interventions • Taper dose of Percocet, re-start to Acetaminophen for OA pain • Encourage participation with Activities - Pet therapy, Music, aromatherapy • Use of hot packs, cold packs to knees • Use topical pain relieving cream

16. Case Snapshot, cont. • Continue to have discomfort (pins and needles sensations) in extremities • Intervention changed Trazodone to Cymbalta to address for Neuropathic pain • Continue Acetaminophen for OA pain • Percocet discontinued • Resident more cooperative and active with Rehab

17. Staff Education • Identification: Direct care and ancillary staff are often the first to recognize symptoms • Assessment: Review of current standards of practice, and policy • Discussion on cultural barriers and individual perceptions • Interdisciplinary Modalities: Pain Management including non - pharmacological approach • Evaluation of program

18. RIGHT INTERVENTIONS WITH THE RIGHT RESIDENT INDIVIDUALIZED And MAY NEED TO BE MODIFIED

19. For Additional Information Carole Morgan, RN (718) 317-3612 morganc@seaviewsi.nychhc.org Patrick O’Toole, Pharm.D. (718) 317-3308 otoolep@seaviewsi.nychhc.org

20. Resources on Pain Assessment and Management www.americangeriatrics.org/education/cp_index.shtml www.amda.com/tools/guideline.cfm www.cms.hhs.gov/surveycertificationgeninfo/downloads/scletter09-2.pdf