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Recognizing and Treating Pain -

Making a difference in the lives

of your Residents

Will begin at 2:00 pm EST

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Today’s Speakers

Demetria (Demi) Haffenreffer, RN, MBA, has made long-term care her profession since 1973, first as a

Director of Nursing and for the last thirty-five years as a consultant. She is founder and President of

Haffenreffer & Associates, Inc., an Oregon consulting firm supporting skilled and community based care

providers in the delivery of person-centered, compassionate care. Haffenreffer & Associates, Inc. provides

educational and hands-on assistance with the implementation of quality systems and corporate compliance

programs nationwide.

In 2011, Demi assisted the Colorado Foundation for Medical Care with a CMS grant to publish the Model

Program for Quality Performance called 'QAPI.' Demi is a facilitator for the AHCA Leadership Excellence

Self-Assessment System and is currently serving on the Washington Health Care Association Quality

Improvement Committee. She has served on the Oregon State Resident Safety Review Council, the Steering

Committee of MOVE (Making Oregon Vital for Elders, an outreach of the Pioneer Network), as a member of

Oregon Patient Safety Commission, and as a Master Examiner for AHCA's Quality Award. Demi has taught

workshops nationally and internationally on a variety of subjects pertinent to long-term care and has

authored five policy and procedure manuals.

In addition, Demi is retained regularly by nationally known law firms as an expert on regulatory compliance

issues.

Pain Assessment

& Management

in Long Term CareA Person-Centered Holistic Approach

Presented by: Demi Haffenreffer, RN, MBA

demi@consultdemi.net

www.consultdemi.net

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Pain Assessment & Management

in Long Term Care

Outline:

Why is this topic important? The Requirements

Assessment & person-centered care planning

Treatments

Treating special resident populations

Assessing your current program

Case studies / post test / evaluation

Prevalence

Number one reason why people seek

medical attention is acute pain

Chronic pain 50 million of the 75 million who

suffer from pain – suffer from chronic pain

Back and neck; arthritis; headaches; neuropathic

Undertreated

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Consequences

Prolonged hospital stays

Physiological – see next slide

Delayed recovery

Increased healthcare costs

Depression & increased suicide risks

Altered self-image & needless suffering

Economic & social impacts greater than for any

single disease entity

Loss of productivity

Physiological Consequences

Endocrine

Cardiovascular

Respiratory

Gastrointestinal

Musculoskeletal

Immune

Genitourinary

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LET’S EXAMINE

THE

REQUIREMENTS

CFR483.25(k) F309

Pain Management

The facility must ensure that pain

management is provided to resdient who

require such service, consistent with

professional standards of practice, the

comprehensive person-centered care plan,

and the residents’ goals and preferences.

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Care Process

Assess for potential or actual

Assess and address underlying causes

Develop and implement interventions that

use specific strategies for different levels or

sources of pain or pain related symptoms

Utilize both pharmacological and / or non-

pharmacological interventions

Monitor and evaluate effectiveness

Modify approaches as necessary

October 2017 MDS – Section N

Number of Days past 7 days receiving an

opioid

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UNDERSTANDING

PAIN MANAGEMENT

Definitions

Pain:

“Whatever the experiencing person says it is,

existing whenever the resident says it does.

An unpleasant sensory & emotional

experience associated with actual or potential

tissue damage, or described in terms of such

damage, or both.”

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Definitions

Acute Pain:

“A response to injury or illness that is usually

time limited, responds to treatment &

inadequate treatment delays recovery.”

Trauma

Acute medical (including post-op care)

Orthopedic problem

Acute pain associated with chronic illnesses

Definitions

Chronic Pain:

“A state in which pain persists beyond the usual

course of an acute disease or healing injury,

or that may or may not be associated with an

acute or chronic pathologic process & causes

continuous or intermittent pain over months

or years.”

Many illnesses &/or pathological conditions

Cancer pain vs. non-cancer chronic pain

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Definitions

Intractable Pain:

“A pain state in which the cause of the pain

cannot be removed or otherwise treated and

in the generally accepted course of medical

practice, no relief or cure of the cause of the

pain can be found after reasonable efforts,

including but not limited to, evaluation by

attending physicians.”

Four Processes

Transduction

Transmission

Perception

Modulation

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Transduction

Nociceptor activation and sensitization

Peripheral neuropathic pain

Clinical implications

Transduction

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Transmission

Periphery to spinal cord

Spinal cord to brain

Clinical implications

Transmission

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Perception

Awareness

Emotion based on awareness

Clinical implications

Individual differences

Modulation

Descending pathways

Clinical implications

Peripheral sensitization

Central sensitization

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Nociceptive pain vs. Neuropathic

Classified on basis of presumed underlying

pathophysiology

Caused by ongoing activation of nociceptors

in response to noxious stimulus

Somatic

Neuropathic

Indicates injury to peripheral or central nervous

system

Examples & Characteristics of Nociceptive Pain

Superficial

Somatic Pain

Deep Somatic

Pain

Visceral Pain

Nociceptor Location Skin & more Muscles & more Visceral organs

Potential Stimuli External,

mechanical &

more

Overuse strain,

injury, ischemia,

inflammation

Organ distension,

muscle spasm &

more

Localization Well localized Localized or

diffuse & radiating

Well or poorly

localized

Quality Sharp, pricking

or burning

Usually dull or

aching, cramping

Deep aching or

sharp stabbing

Associated S & S Cutaneous,

hyperalgesia,

allodynia

Tenderness, reflex

muscle spasm, &

hyperactivity

Malaise, N & V,

sweating,

tenderness,

spasm

Clinical examples Sunburn, etc Arthritis pain, etc Appendicitis, etc

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Examples & Characteristics of Neuropathic Pain

Mono & Poly -

Neuropathies

Deafferentation

Pain

Sympathetically Central

Definition Pain along

dist. of 1 or

more nerves –

nerve damage

Due to loss of

afferent input

Maintained by

sympathetic

nervous

system

Primary

lesion or

dysf. Of

CNS

Char. &

Symptoms

3 types = Many symptoms

& char.

Many

symptoms &

char.

Many

symptoms

& char.

Sources Many Damage to p.

nerve or CNS

Damage to p.

nerve & more

Many

Clinical

Examples

Diabetic, more Phantom limb;

post

mastectomy

CRPS;

Phantom limb;

& more

Post-

stroke;

cancer; MS

Barriers to pain management

Health care system

Health care professionals

Patient and family barriers

Legal and Societal barriers

Tolerance, physical dependence, addiction

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Common Misconceptions

Sensitivity and perception decrease in the

elderly therefore they do not feel pain

If you can’t recognize pain it has no effect on

you

Pain w/age is to be expected & is normal

Individuals who do not complain of pain or say, “I

have no pain”, do not have pain (they still may &

will need further assessment)

Cognitively impaired cannot use pain intensity

rating

Common Misconceptions

Individuals who complain of pain, do not have

pain

Opioid medications have side effects that

make them too dangerous to use in the

elderly or they will become addicted.

Physical & behavioral signs best indicator

Addiction may occur

PRN medication is sufficient to control pain

Comparable stimuli produce the same level

of pain in all individuals

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THE FIRST STEP IN TREATING

PAIN IS TO RECOGNITION!!

GOALS

Recognition (requires nurses to be aware of

their own beliefs)

Appropriate assessments & care plans

Appropriate consults

Appropriate treatments

Improved functioning – highest practicable

well-being

Improved quality of life

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Barriers to Recognition

Barriers

Cognitive status of

resident

Sensory problems

Cultural problems

Poor communication

between resident &

care giver

Fear

Not recognizing

behaviors as pain

related

Caregivers don’t

believe the resident

Caregiver lack of

knowledge

Other

ASSESSMENT

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Core Principles

Resident right to assessment and management

Pain is subjective – self-report most reliable

Physiological and behavioral symptoms do not replace

Assessment tools must be appropriate for the population

being treated

Pain can exist without a physical cause

Uniform pain threshold & tolerance does not exist

Residents with chronic pain may be more sensitive to

pain

Unrelieved pain has physical & psychological

consequences – assessment should address both

Assessment Principles

Routine Assessments

Believe what people tell you

Don’t believe what people tell you

Assess comprehensively

Choose the right treatment

Empower the resident

Distinguish between acute and chronic pain

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Comprehensive Assessment

Components

Recent pain history

The interview

Cognitive/Communication

- Ability to recognize

- Ability to report

- Behaviors

Comprehensive Assessment cont’d

Type/Frequency/Location

Localized or radiating

Past History part of the interview with either

the resident or family

Related Conditions/Diagnosis

Treatments that work and don’t work

Current treatment and effectiveness

Resident goal – also part of interview process

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Pain assessment tools

Unidimensional scales

Numeric

Visual

Categorical

Multidimensional tools

Brief pain inventory

Initial

Quarterly

Other

PAIN ASSESSMENT TOOLS

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Treatment

Medications

PRN vs Routine

Non-pharmacological treatment

Pharmacological

Many med options

Non-opiod

Anti-inflammatory

Anti-anxiety agents

Muscle relaxants

Pain perception modifiers

Opiods

Anti-epileptics

Antidepressants

Nerve blocks – local anesthetics

Intraspinal delivery systems

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Pharmacological principles

Optimize administration

PRN vs routine

Start with a low dose and slowly titrate to the

lowest effective dose

Patches are slow to work initially and another

prn medication may be needed for

breakthrough pain. Patches may require body

fat to be effective

Pharmacological principles

For chronic pain, use an analgesic around the clock

For breakthrough pain, use fast onset, short-acting

analgesics

Establish a goal for pain management

Monitor for & manage side effects. Try to avoid over

sedation

Differentiate among tolerance, physical

dependence, & addiction & appropriately modify

therapy

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Pharmacological principles

Reassess effectiveness routinely

Adjuvant drugs may be needed such as

Amitryptyline

Ibuprofen is not the medication of choice if

the resident has GERD

Pharmacological principles

Start with a non-opioid analgesic for mild pain

(Adjuvant therapy is optional)

For mild to moderate pain not relieved by a

non-opioid analgesic attempt a weak opioid

plus a non-opioid analgesic (Adjuvant therapy

is optional)

Avoid use of placebos

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Pharmacological principles

For moderate to severe pain or pain not

relieved by weak opioid, consider a strong

opioid with or without a non-opioid analgesic

(Adjuvant therapy is optional)

Treatments – Non-Pharmacological

Gentle massage

TENS units (electro stimulation)

Implanted nerve stimulators

Hot baths or whirlpools

Heat (15 to 20 minutes only)

Cold (15 to 20 minutes only)

Chiropractic

Acupuncture

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Treatments – Non-Pharmacological

Ointments/creams (BenGay, BioFreeze, Tiger Balm, Salonpas (med. Patches), Aspercreme

Slow movement

Breathing techniques (slow, deep breathing), rest

Music (some music, loud or soft, can make pain better or worse)

Behavioral medicine

Treatments – Non-Pharmacological

Glucosamine

Arnica

Biofeedback

Energy healing

Pilates

Yoga

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Treatments – Non-Pharmacological

Visualizations and other diversional activities

Acupressure

Vocalizing (screaming and/or moaning)

Other approaches:

Therapy

Surgery

Building an Institutional Commitment

to Pain Management Develop an IDT work group

Analyze current pain mgt. issues and practices

Implement a standard for pain mgt.

Establish policies and procedures

Establish accountability for quality & monitor

Provide information for pharm. & non-pharm.

Mgt.

Promise residents prompt response

Provide education

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RESOURCES

www.painmed.org

www.ampainsoc.org/advocacy/

demi@consultdemi.net