Assessing Pain in LTC Residents Annual Training Sept 2024 PDF

ASSESSING PAIN IN LTC RESIDENTS Sept 2024 Annual Training  PURPOSE Woodingford Lodge will have a Pain Assessment and Management Program in place to maintain an interdisciplinary team approach to pain assessment and management that provides the R...

ASSESSING PAIN IN LTC RESIDENTS Sept 2024 Annual Training  PURPOSE Woodingford Lodge will have a Pain Assessment and Management Program in place to maintain an interdisciplinary team approach to pain assessment and management that provides the Resident with optimal comfort, dignity and quality of life. OBJECTIVES to improve and maintain a Resident’s optimal functional level and quality of life to optimally manage pain for all Residents to reduce incidence of unmanaged pain to ensure best practice interventions for Residents with pain to monitor and track trends related to pain management  DEFINITION OF PAIN An unpleasant experience that is a personal, subjective, sensory and emotional experience associated with actual or potential tissue damage that impacts an individual’s psychosocial and physical functioning. For this practice setting we use the definition that pain is whatever the person says it is and it exists whenever he / she says it does. PAIN ASSESSMENT TEAM GOALS WHAT DO WE DO WITH OUR PAIN SCORES CIHI Indicator Woodstock Ontario Q2 2023 Q2 2023 Q2 2023 Has Pain 14.1% 4.9 % (previously 4.9%) (previously 13.5%) Worsened Pain 21.1% (previously 23.6%) 8.8% (Previously 8.7%) WHAT WE DO WITH OUR PAIN SCORES  We assess our pain scores quarterly and make a plan going forward  WOODSTOCK: Percentages for residents with pain has increased slightly; percentages for resident with worsened pain has decreased. Our Goals for 2023 were:  Residents with pain scores of 2 or 3 will have a decrease in their score on their next assessment.  Residents with incidents of unmanaged pain will have a comprehensive pain assessment completed.  Education to staff regarding indications of pain and sequence of interventions to be put in place for residents experiencing pain. WHEN SHOULD WE ASSESS OUR RESIDENTS FOR PAIN? When On admission and readmission Change in condition with onset of pain Quarterly Diagnosis of painful Every Shift by PSW and Registered Staff History of unexpressed pain Initiation of a new pain medication Requiring pain medication for 72 hours (prn) PRN pain medication Resident/family/staff /volunteers indicate pain is present Behaviours exhibited by a Resident that may indicate pain (distress, pacing, resisting care, sad, Resident exhibits a change in health status or pain angry, restless, insomnia, rubbing an area, laying is not relieved by initial interventions in bed for longer than usual) EVALUATE and DOCUMENT Resident outcomes KEY POINTS FOR PAIN ASSESSMENT  Location of pain  Severity of pain  Quality of pain-important in ensuring we treat the right type of pain appropriately  Residents may have more than 1 type of pain in more than 1 area which may have a different pain score. Ensure that you are asking the right questions. Use descriptive words. Prompt the Resident if they are having difficulty  Is their pain affecting their day to day life  Are there activities that they enjoy that they can no longer do  Is their pain affecting their mood  How have they managed their pain in the past TOOLS IN PAIN ASSESSMENTS USED AT WOODINGFORD LODGE  Visual Analogue Scales  Numeric Rating (0-10)  Verbal Rating (Fig. 1)  PAINAD (Fig. 2)  ABBEY Pain Scale HOW TO ASSESS PAIN USING “O,P,Q,R,S,T”  Here are some suggestions on how to approach using OPQRST as a Resident Assessment tool:  Onset: “Did your pain start suddenly or gradually get worse and worse?” This is also a chance to ask, “What were you doing when the pain started?”  Provokes or Palliates: Instead of asking, “What provokes your pain?” use real, casual words. Try, “What makes your pain better or worse?”  Quality: Asking, “Is your pain sharp or dull?” limits your patient to two choices, when their pain might not be either. Instead ask, “What words would you use to describe your pain?” or “What does your pain feel like?”  Radiates: This is another chance to use real, conversational words during the assessment. Asking, “Does your pain radiate?” sounds silly and pompous to the patient. Instead use this question, “Point to where it hurts the most. Where does your pain go from there?”  Severity: Remember, pain is subjective and relative to each individual patient you treat. Have an open mind for any response from 0 to 10.  Time: This is a reference to when the pain started or how long ago it started. BARRIERS TO CHANGE  Recognizing pain in dementia is not straightforward and sometimes misconstrued as something else (eg. distress, anxiety)  Individual, family, Practitioners may hold numerous beliefs about pain in dementia/older age that hinders  communication, assessment and treatment  Staff/HCP may not always be aware of pain assessment tools appropriate for advanced dementia,  where to access and how to use  Non-Pharmacological strategies to address pain for people living with dementia may take more time and be more costly than prescribing a pill BARRIERS TO ADDRESSING PAIN IN DEMENTIA Dementia Related Organizational Resident & Provider Recognition of Pain Staff education Attitudes & Beliefs fear of addiction, loss of self control Ability to communicate or self Use of/access to resources, Choosing to suffer- want to feel advocate guidelines and assessment tools the pain. May be cultural beliefs Misdiagnosing and masking Under reporting Inability to swallow meds Side effects of meds (nausea/constipation) PAIN IN DEMENTIA  Correlation, rather than causation  73% older adults living with at least 1 of 10 common chronic diseases.  Prevalence and number of morbidities increases with age  Risk of pain increases with both comorbidity (including dementia) and age Between 40%-80% of individuals living with dementia reported to be experiencing pain TYPES OF PAIN NOCICEPTIVE This is caused by stimulation of peripheral nerve fibers that respond only to stimuli approaching or exceeding harmful intensity (nociceptors) and may be classified according to the mode of noxious stimulation; the most common categories being ‘thermal’ (heat or cold), ‘mechanical’ (crushing, tearing, etc.) and ‘chemical’ (iodine in a cut, chili powder in the eyes). Nociceptive pain is subcategorized into visceral, somatic and increased intracranial pressure. VISCERAL SUB- CATEGORY OF NOCICEPTIVE PAIN  Visceral Pain:  Constant, dull, aching, poorly localized pain that has a gradual onset often felt at a distance from the origin (referred pain).  Solid Viscera: sharp and penetrating (e.g. liver and pancreas)  Hollow Viscera: diffuse or colicky pain (e.g. bowel and bladder) Visceral structures are highly sensitive to stretch, ischemia and inflammation but relatively insensitive to other stimuli that normally evoke pain in other structures, such as burning or cutting.  Diffuse (poorly localized), referred often to a distant, usually superficial structure.  May be accompanied by nausea and vomiting and  May be described as sickening, deep, squeezing and dull  Raised intracranial pressure: e.g., brain tumors and meningeal carcinomatosis. SOMATIC SUB-CATEGORY OF NOCICEPTIVE PAIN  Somatic Pain:  Constant gnawing or aching, usually well-localized worse on movement or weight bearing if in pelvis, hips, femur, joints or spine.  Deep somatic pain is initiated by nociceptors in ligaments, bones, tendons, blood vessels, fasciae and muscles and is a dull, aching, poorly localized pain. Examples include sprains and broken bones. Deep somatic pain involves stimulation of nociceptors found in muscle, bone, joints and ligaments. Examples of somatic pain are bony metastases and skin ulcerations.  Superficial somatic pain is initiated by activation of nociceptors in the skin or other superficial tissue and is sharp, well-defined and clearly location. Examples of injuries that produce superficial somatic pain include minor wounds and minor burns. NEUROPATHIC (NP)   chronic pain initiated by nervous system lesions or dysfunction (i.e.) diabetic peripheral neuropathy (DPN), painful post herpetic neuralgia (PHN), cancer)  sharp, burning, deep aching, ‘electrical’, stabbing, feeling cold possibly with numbness and tingling (‘pins and needles’) caused by pressure, invasion or destruction of peripheral or central nervous tissues.  Hyperalgesia over an area of skin –an increased painful response to a mildly painful stimulus (e.g. pinch, prick) or even slight pressure from clothing or light touch.  Usually constant and severe pain often precedes sensory and motor loss (e.g. spinal cord compression).  Often strange word descriptors e.g. “my feet feel wet all the time” MIXED  combination of visceral, somatic, and / or neuropathic (i.e.) tumor invasion of pancreas, with spread to and destruction of vertebraincluding spinal cord compression ) INCIDENTAL/BREAKTHROUGH PAIN  Breakthrough pain, worse with movement (i.e.) severe osteoarthritis, bone metastases, torn rotator cuff, post fall bruising and soft tissue injury)  This Resident will be resistive to movement, will try to guard their “sore” area. They are not going to want to get dressed or move depending on the area of pain  May exhibit responsive behaviours because they cannot express their pain  Resident should be provided an analgesic at least 45 minutes prior to receiving care (or 20 minutes if given a sc medication)  Intermittent and can also occur spontaneously PAIN AS A VITAL SIGN IN POINT CLICK CARE PAIN ASSESSMENT IN POINT CLICK CARE NUMERICAL SCALE  PAINAD SCALE FOR THE COGNITIVELY IMPAIRED The total score ranges from 0-10 points. A possible interpretation of the scores is: 1-3=mild pain; 4-6=moderate pain; 7-10=severe pain. These ranges are based on a standard 0-10 scale of pain, but have not been substantiated in the literature for this tool. PAINAD SCALE FOR THE COGNITIVELY IMPAIRED Instructions: Observe the resident for three to five minutes before scoring his or her behaviors. Score the behaviors according to the following chart. The patient can be observed under different conditions (e.g., at rest, during a pleasant activity, during caregiving, after the administration of pain medication). POINT OF CARE PAIN ASSESSMENT DOCUMENTATION EMAR PRN DOCUMENTATION At the time of PRN administration that requires a Pain Scale documentation, users are required to enter the Pain Scale value at the time. When documenting PRN - Follow up where Pain Level has been added as a Vital, user will have an option to enter post Pain Scale value by clicking on the "Enter Follow up Pain Scale" button, button will not display where Pain Level is not added as Vital. When User clicks on the 'Enter Follow-up Pain Scale' button, system will open Pain Level screen for User to enter the pain scale value.When user clicks on Populate Note Details, the Progress Note Text field will include post pain scale value (if entered). WHEN TO NOTIFY THE PRACTITIONER  Notify the Practitioner when:  More than 4 “Breakthrough Pain” doses are needed in a 24 hours period depending on the individual circumstances.  The resident consistently reports pain of greater than 4/10 for 24 to 48 hours depending on individual circumstances.  The resident reports sudden onset of new pain. Use the SBAR when notifying the practitioner WORLD HEALTH ORGANIZATION (WHO)PAIN LADDER  "Pain ladder", or analgesic ladder, was created by the World Health Organization (WHO) as a guideline for the use of drugs in the management of pain. Originally published in 1986 for the management of cancer pain, it is now widely used by medical professionals for the management of all types of pain.  The general principle is to start with first step drugs, and then to climb the ladder if pain is still present. The medications range from common, over-the-counter drugs at the lowest rung, to strong opioids. THE LADDER 1. The WHO guidelines recommend prompt oral administration of drugs ("by the mouth") when pain occurs, starting, if the patient is not in severe pain, with non-opioid drugs such as Tylenol (acetaminophen) or aspirin, with or without "adjuvants" such as non-steroidal anti- inflammatory drugs (NSAIDs). 2. If complete pain relief is not achieved or disease progression necessitates more aggressive treatment, a weak opioid such as codeine or tramadol is added to the existing non-opioid regime. 3. If this is or becomes insufficient, a weak opioid is replaced by a strong opioid, such as morphine, dilaudid, Fentanyl, Oxycodone, while continuing the non-opioid therapy, escalating opioid dose until the patient is pain free or at the maximum possible relief without intolerable side effects. 4. If the initial presentation is severe pain, this stepping process should be skipped and a strong opioid should be started immediately in combination with a non-opioid analgesic The guideline directs that medications should be given at regular intervals ("by the clock") so that continuous pain relief occurs, and ("by the individual") dosing by actual relief of pain rather than fixed dosing guidelines. It recognizes that breakthrough pain may occur and directs immediate rescue doses be provided. WHO PAIN LADDER ADJUVANT MEDICATIONS Not all pain yields completely to classic analgesics, and drugs that are not traditionally considered analgesics, but which reduce pain can be used and can also be used together with analgesics  Antidepressants  Anticonvulsant medications  Steroids  Biphosphonates  Antiarrhythmics NON PHARMACOLOGICAL INTERVENTIONS  Exercise (PT)  TENS machine, ultra sound therapy,  Chair Therapy (Rocking Chair, Nordic Chair) Adjust foot/head rest to suit  Massage and touch  Heat/cold therapy  Relaxation and imagery, distraction  Music Therapy  Warm Blankets  Social/meaningful engagement (Including spiritual support, walking with the Resident, engage in conversation)  Human interaction/presence (Holding hands, rubbing back with permission)  Pressure relieving devices What we Hear What we See Verbal reports Physical signs of injury Vocalizations Body Language Breathing Facial Expressions Activity What we Know Diagnoses Daily routines Coping mechanisms Likes and dislikes Attitudes/beliefs RESOURCES  Gentle Persuasive Approaches in Dementia Care: https://ageinc.ca/  PIECES Framework for Regulated HCP: https://piecescanada.com/  Alzheimer’s Society of Canada: https://alzheimer.ca/en  RNAO Self-Directed Learning Package: https://ltctoolkit.rnao.ca/clinical-topics/pain- assessment  RGP Senior Friendly 7 Toolkit: https://www.rgptoronto.ca/wp-content/uploads/2018/04/SF7- Toolkit.pdf  CLRI eLearning Modules: https://clri-ltc.ca/2023/02/new-pain-management-and-distress- elearning-course-available  Snoezelen: https://www.palliativealliance.ca/assets/files/Snoezelen_toolkit_FINAL.pdf  Nordic Wellness Chair: https://www.arjo.com/en-ca/products/medical-beds/wellness-- relaxation/wellness-nordic-relax-chair/