E L N E C
Geriatric Curriculum
End-of-Life Nursing Education Consortium
Session 4:
Pain Management
Fairfield University
Quinnipiac University
School of Nursing ELDER Project
E
L
N E
C Geriatric Curriculum
Objectives: Upon completion of this
session, the participant will be able to…
E
1.
Define pain.
2.
Discuss the importance of a thorough and
continual pain assessment.
3.
Identify barriers to adequate pain relief.
L
N E
C Geriatric Curriculum
Activity…
E
L
N E
C Geriatric Curriculum
MYTHS ABOUT PAIN MANAGEMENT
1. It is easy to get addicted to pain medicines.
2. If the patient dies soon after an injection, the last person
who gave the medication has contributed to the death.
3. Patients who talk a lot about their pain are complainers
and want attention.
4. A sleeping person can not be in pain.
5. A person smiling, talking, joking or watching TV can not
be in pain.
E
L
N E
C Geriatric Curriculum
“Pain is …
Whatever the person
says it is…”
Pasero & McCaffery, 2010
E
L
N E
C Geriatric Curriculum
Ms. P is a 55-year old woman with cancer. She got pain
medication less than two hours ago after which she said she felt
much better. A coworker said that Mrs. P is complaining of pain
again. The co-worker says “She can’t be hurting as much as she
says she is.” What is the health care worker’s best response?
1. “Pain is whatever she says it is. Let’s assess her further.”
2. “We need to explore the cultural meaning pain has for
her.”
3. “I will tell her gently that she must wait four hours
between doses.”
4. “I’ll wait to give the next dose and re-assess her a little
early, in an hour.”
E
L
N E
C Geriatric Curriculum
Most Common Types of Persistent
Pain in Older Adults
• Musculoskeletal
• Osteoporosis/compression
fractures/degenerative disc disease
• Neuropathies
• Cancer
• Spinal Stenosis
• Pressure ulcers / wounds
AGS, 2009; Ferrell, 1990; Weiner & Herr, 2002
E
L
N E
C Geriatric Curriculum
Challenges to Assessing Pain
– Stoicism, not wanting
to be a complainer
– Fears: procedures,
side effects, addiction
– Fatalism: Pain is part
of aging
– Culture
– Cognitive or sensory
impairment,
depression, etc.
– Concurrent illnesses
E
•
Why have some of your patients been
reluctant to report pain?
L
N E
C Geriatric Curriculum
-Use of different words to
describe pain
What are the barriers to Pain
Relief?
• Healthcare Professionals
• Healthcare Systems
• Patients/Families
Davis et al., 2002; Gunnarsdottir et al., 2002;
Pasero & McCaffery, 2010; Miaskowski et al, 2005;
Paice, 2010
ACTIVITY
E
L
N E
C Geriatric Curriculum
Pain Evaluation
• Pain history
• Physical examination
• Laboratory/diagnostic
evaluation
• How can different members of the palliative care
team (and family) assist in the assessment of
pain management?
Fink & Gates, 2010
E
L
N E
C Geriatric Curriculum
Pain Assessment
E
•
•
•
•
•
Etiology
Location
Pain Intensity
Character
Pattern
L
N E
C Geriatric Curriculum
• Functional Status
• Goals of Care
Pain Intensity Tools
Fink & Gates, 2010; Herr et al., 2006
E
L
N E
C Geriatric Curriculum
Patients at Risk for
Undertreatment
• Children and older adults
• Non-verbal or cognitively impaired
• Patients who deny pain
• Non-English speaking
• Different cultures
• History of addictive disease
E
L
N E
C Geriatric Curriculum
Reference:
Warden, V., Hurley, A.C. & Volicer, L. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Demetia (PAINAD) scale.
Journal of the American Medical Director Association, 4(1), 9-15.
E
L
N E
C Geriatric Curriculum
The healthcare worker is talking with the parents of a 2-yearold boy diagnosed with leukemia about pain management.
Which of the following statements indicates understanding
about
• pain management in children?
1. “He needs to be assessed carefully so that he gets enough
pain medication.”
2. “He may need less pain medication since he has limited
memory of the pain.”
3. “He may become addicted because he is so young and
getting pain medicine.”
4. “He doesn’t feel that much pain because his nervous
system is still maturing.”
E
L
N E
C Geriatric Curriculum
Impact of Pain on QOL
• ADLs
• Mobility/transfers
• Participation in meals, social
activities
• Mood interference
• Sleep interference
How does being in pain affect
QOL?
E
L
N E
C Geriatric Curriculum
The healthcare team is caring for a woman with advanced
cancer. The client reports ongoing fatigue. Which of the
following statements by the husband shows he understands
the wife’s fatigue?
1. “She sleeps quite a bit, so she shouldn’t be as tired as she
is.”
2. “She’s lost some weight. I know she’ll feel better if she
eats more.”
3. “She’s been in pain. If we control that maybe she’ll have
more energy.”
4. “She seems moody, so we need to cheer her up and make
her laugh.”
E
L
N E
C Geriatric Curriculum
When to Assess and Document
•
•
•
•
•
•
E
L
Admission
Regular intervals
New pain
Exacerbations
Uncontrolled pain
New therapy (new
meds, increased
doses)
N E
C Geriatric Curriculum
Good Pain Management
There are many challenges to
assessing pain in older adults —
nonetheless, there is no pain relief
when there is no pain assessment
E
L
N E
C Geriatric Curriculum
What do you think?
• Mr. F has advanced prostate cancer with spread to the
bone (bone metastasis). He is in a coma, and is being cared
for at home by his daughter. The home health worker is
teaching the daughter about assessing her father’s pain.
Which of the following statements by the daughter shows
she understands her father’s pain level?
1. “If he is not moaning, he’s probably not in pain.”
2. “I’ll have to guess when he is in pain since he can’t tell
me.”
3. “Now that he’s unable to tell me, we can stop his pain
medication.”
4. “Since he was in pain when he could talk, I assume he’s
still in pain.”
E
L
N E
C Geriatric Curriculum
NSAIDS Side Effects
• Risk of adverse events( GI
bleeding) increases with age
AGS, 2009; Paice, 2010
E
L
N E
C Geriatric Curriculum
Opioid Side Effects
E
•
•
•
•
•
•
•
Sedation
Nausea and vomiting
Constipation
Urinary retention
Confusion
Hallucinations
Respiratory depression (rare)
L
N E
C Geriatric Curriculum
Addressing Barriers to Opioid Use
E
L
N E
C Geriatric Curriculum
Definitions
• Addiction
• Tolerance
• Physical Dependence
activity
E
L
N E
C Geriatric Curriculum
Definitions
What is it?
1. Dependence
2. Tolerance
3. Addiction
1. unable to control drug use
2. compulsive drug use
3. continued use despite harm
4. craving the drug
caused by a withdrawal
syndrome that can be produced
by abruptly stopping or a rapid
dose reduction in a drug
a state of adaptation in which
exposure to a drug causes
changes that result in a decrease
in the drug's effects.
.
activity
E
L
N E
C Geriatric Curriculum
Which of the following statements shows a correct
understanding of pain management for clients with a history
of substance abuse?
1. "They should not be given pain medicine for pain because
they become addicted.”
2. "They will need smaller doses of pain medicine to prevent
an overdose.”
3. "They may require higher dose of pain medicine to relieve
their pain."
4. "They need to withdraw from the drugs they are on
before getting pain medicine.”
E
L
N E
C Geriatric Curriculum
The principle of double effect…
• …differentiates between giving medication with
the intent to relieve pain that might inadvertently
hasten death versus giving medication to
intentionally cause death.
• There will always be a last dose of opioid !
E
•
(Prince-Paul & Daly, 2010; Sykes & Thorns, 2003).
•
Have you ever hesitated to medicate a patient because you felt it may hasten the
patient’s death?
L
N E
C Geriatric Curriculum
Which of the following clients is at the highest risk
for developing constipation?
•
1. A 48-year-old with metastatic cancer of the spine on high
doses of opioids who has dehydration.
2. A 76-year-old with cancer of the bowel who has begun
treatment for Clostridium difficile.
3. An 85-year old with hepatic encephalopathy who is
receiving prescribed neomycin (Mycifradin) and lactulose.
4. A 90-year-old with uterine cancer and laboratory
evidence of hypocalcemia and hyperkalemia.
E
L
N E
C Geriatric Curriculum
Case Example: Mr. Rosena
• Mr. Rosena’s story and your connection:
–
–
–
–
He is told by you that his cancer is progressing.
You learn that Mr. Rosena is afraid of pain more than death.
You reassure him that you’re committed to relieving any pain
You assess him frequently for pain / Offer round-the-clock pain service
• Positive result based on visit:
– A major concern is alleviated for Mr. Rosena.
Wong-Baker FACES Pain Rating Scale
NO HURT
E
L
N E
HURTS
LITTLE BIT
C Geriatric Curriculum
HURTS
LITTLE MORE
HURTS
EVEN MORE
HURTS
WHOLE LOT
HURTS
WORST
The 68 year old patient is in the last hours of life after a
lengthy illness. The patient has been receiving – pain
medicine. In assessing the patient as death approaches, the
pain medication may need to be:
1. increased or decreased to maintain pain control
2. given only if the patient asks for it
3. monitored because different types of pain
increase as death approaches
4. stopped because of decreased consciousness and
altered mental state
E
L
N E
C Geriatric Curriculum
Summary
• Pain is whatever the person says it is.
• Pain assessment should on ongoing.
• Identify and overcome barriers to pain
relief.
E
L
N E
C Geriatric Curriculum
Last question…
• What one practice improvement can
you begin as a result of attending this
session?
E
L
N E
C Geriatric Curriculum
References
City of Hope & the American Association of Colleges of Nursing, 2007;
Revised, 2010. The End-of-Life Nursing Education Consortium
(ELNEC)- Geriatric Training Program and Curriculum is a project of
the City of Hope (Betty R. Ferrell, PhD, FAAN, Principal Investigator)
in collaboration with the American Association of Colleges of Nursing
(Pam Malloy, RN, MN, OCN, Co-Investigator).
D.J. Wilkie & TNEEL Investigators, 2001. Toolkit for Nursing Excellence
at End of Life Transition, version 1.0. Cancer Pain & Symptom
Management Nursing Research Group; University of Washington.
Supported by DHHS/HRSA/BHPR/Division of Nursing
Grant # D62HP06858
E
L
N E
C Geriatric Curriculum