Protocol for pain
Protocol for pain
Key points to managing your patients’ pain
Between 25% and 50% of the elderly report pain as a regular incidence, says Mario Cornacchione, DO, CMD, a physician/geriatrician and director of geriatrics in the Eastern Region for Penn State (Hershey) Geisinger Health System. Cornacchione is also president of Geriatric Video Productions, a company whose use of national consultants on the subject of treating the elderly in any health care setting has produced several award-winning video series. All too often, he says, their pain goes unrecognized and therefore, even with today’s advancements in pain management, untreated.
While a proper diagnosis and assessment of the pain’s severity are integral in developing a successful management program, there are multitude barriers — both real and imagined — that can deter the process. (See box, p. 58.) Among these barriers, he notes, are:
Health care workers, patients, and patients’ families believe pain is an inevitable part of aging. Health care workers don’t take into consideration that an elderly person’s sensitivity to pain is the same as that of someone much younger. Sometimes nurses and physicians underestimate the severity and duration of pain. "You have to believe the patient," Cornacchione says. The medical director doesn’t buy into a pain management program. Vital signs aren’t always reliable, especially for geriatric patients. "The body will adjust accordingly," he says, "so even people with moderate pain can sleep and participate in family activities." Patients and families may believe that the treatment of pain and its symptoms will take attention away from the actual disease or ailment causing it. Patients and families may believe pain medication is costly and therefore should only be used in the final stages of a terminal disease. Patients and families fear the patient will become addicted from using opioids.That last barrier can be one of the most difficult to overcome. Having been told to "Just Say No" for the past decade, patients and families alike fear addiction. Yet, says Cornacchione, "in people without a history of drug abuse, the incidence of addiction is less than 1%."
Dawn Muntine, RPH, BS, BA, head clinical pharmacist with Optioncare in Meadville, PA, agrees with that assessment, adding that addiction tends to start "more in emergency rooms and doctors’ offices," where people will make multiple visits to obtain new prescriptions, than with patients experiencing chronic pain.
In her agency, she says, when dealing with terminally ill patients "we do have cases where families get upset and don’t want morphine used because they think of addiction. We must explain that at this point it doesn’t matter; it’s not even important anymore. What does matter is that the patient has pain management and the best possible quality of life."
When it comes to managing pain, the elderly present a unique situation. "Some elderly patients may be cognitively impaired or have dementia. Even so, numerous studies have shown that the pain reports of the mildly cognitively impaired are no less valid than those who are mentally intact," explains Cornacchione.
Vision and hearing may be affected as well and hinder a person’s attempt to explain what is going on. To combat this, both Cornacchione and Muntine, urge health care professionals to become well-acquainted with nonverbal clues such as facial expressions (tightly closed eyes, grimaces), hyperventilation, and body posture (a stiff, rigid stance or the guarding of a body part).
Muntine, who points out that comatose patients are still capable of feeling pain, has seen hospice nurses capable of determining whether an unconscious patient is experiencing pain simply through subtle body changes.
Other signs pointing to the presence of pain are decreased mobility or ability to function, and then depression. Depression often accompanies chronic pain and in fact, can worsen the pain because it can both lower a person’s threshold to pain and cause further discomfort.
Then, too, the elderly react differently to certain medications. "Because of changes in metabolism," says Cornacchione, "they may need only 25% of an opiate dosage." Some of the anti-inflammatory medications should also be avoided because of the risk of stomach and gastrointestinal bleeding, he adds.
Controlling the pain
Once a determination of pain has been made, the next step is controlling it. Cornacchione recommends using a combination of pain log and pain scale to gauge the severity of a patient’s pain and what causes it — or relieves it.
Even though an individual’s reaction to pain will vary, the use of a reliable scale such as one by the World Health Organization is crucial to management, he says. "It helps with establishing a treatment goal so you can shoot for what level of pain will be acceptable to the patient. And keeping a pain log by the patient’s bed and actually having the patient fill it out goes a long way toward management."
Nurses can check the log during their visits to learn when the pain was the highest and what the patient was doing at the time, and what the level of pain was after taking the medication. It’s vital, he continues, that nurses ask about the history of the pain, its location, if there is anything that makes it better or worse, and "in their own words get them to describe it. Is it an ache? Is it burning which may indicate a neuropathic cause?"
It’s a good idea to involve the family or the primary caregiver in the initial assessment to share any insights they have as well as learn more about the situation and how it will be handled.
Muntine and the nurses at her home health agency also use the pain scale to guide their treatment plan. "No pain is the ideal, but we never want it to be above a four on the scale. If it goes higher, then we need to do something different." Because the human body can adjust itself to a medication’s dosage and strength, the pain is able "to burn through," she says.
That’s why Muntine says she is "always trying to guide physicians and nursing agencies not to jump too far ahead with their dosing. Otherwise, when the pain gets worse, you have no place to go."
Most typically, says Cornacchione, a tier-approach to management is used with nurses taking the daily assessments and doctors dispensing the prescriptions. If possible, the lowest rung of the tier will be Tylenol or other non-opioids. As the pain increases, a short-acting opioid, like codeine, is introduced, then a longer-acting one such as morphine, and on up the ladder.
Muntine notes that often times synergy can be gained by prescribing two medications at a time — "getting as much as you can from the most benign drugs." Both Muntine and Cornacchione advocate using alternative approaches, such as massage, acupuncture, prayer, and meditation.
An alternative course called Healing Hands, which Muntine recommends, "expands pain therapy with the idea that touch is a very important pain reliever. These courses show how to touch someone and give patients the emotional and physical support they need in their time of pain."
That attitude emphasizes the importance of education. Patients are not the only ones who need to be educated about their pain, an especially important point, notes Cornacchione, when one considers that "some 25% to 50% of medications go untaken because of a lack of understanding. They think that if the pain is gone they can stop taking their medication."
If possible, family members need to be included in every step of a pain management program. "Families must understand the goals, what we’re doing, and why we’re doing it," explains Muntine. "It can be very traumatic dealing with a family member in pain, and you want them to be educated about the facts and to call us when things get out of control."
Beyond families, though, health care professionals need to educate themselves on the causes and treatments of pain, Muntine says. "There is an emotional trauma when dealing with a lot of pain. A lot of families don’t switch to a hospice setting until it’s too late, and visiting nurses could do a lot to make sure things go smoother. I think [visiting nurses] could use more training so they will better know when a patient can stay in the home or when to push for hospice."
No matter the pain management method, Muntine points out that "experience is the best teacher as to what will work. Over time you learn to fine-tune the steps. It’s always a work in progress."
(For more information, the American Geriatric Society, the American Medical Directors Association, and Geriatric Video Productions are good places to start. To contact Cornacchione and Muntine, see source box, above left.)
Sources
• Mario Cornacchione, DO, CMD, President, Geriatric Video Productions, P.O. Box 1757, Shavertown, PA 18708. Telephone: (570) 829-1095.
• Dawn Muntine, RPH, BS, BA, Head Clinical Pharmacist, Optioncare, 11031 Perry Highway, Suite 105, Meadville, PA 16335. Telephone: (814) 333-9449.
Pain Management 101
A pain management protocol can be extremely detailed, documenting at which pain level to change medications and even the medications themselves in a step-by-step outline. Still, there are general principles that act as the foundation for a successful program. The following guidelines are an excellent point from which to start:
A pain management regimen should provide pain relief while still allowing the patient to maintain optimum functionality.Decisions regarding the initial or ongoing pain management techniques should be based on the patient’s self-report and must be appropriate to the underlying cause, if known.
Whatever method is employed, it should be based on the easiest dosing regimen, both in terms of amount and administration.
Whenever possible, medications should be given orally and should be administered on a regular schedule as opposed to an as-needed basis.
In the event of breakthrough pain, additional medication may be administered.
Side effects associated with the medication will be laid out beforehand and vigorously treated.
Both the patient and caregiver are instructed in the pain management regime and are given written copies, including information on treating side effects and when to contact a doctor or nurse.
The patient’s level of pain is frequently reassessed and the pain management regimen is altered to reflect any changes.
Source: Mary Schroeder RN, Pain Management in the Home (adapted from Haylock, 1993).
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