1. ELNEC Geriatric Curriculum E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium Session 5 Pain Management: Non-Drug Interventions Fairfield University Quinnipiac University School of Nursing ELDER Project

2. ELNEC Geriatric Curriculum Objectives: Upon completion of this session, the participant will be able to… 1. List some non-drug therapies used to relieve EOL pain symptoms. 2. Describe special considerations and precautions for using specific non-drug therapies. 3. Develop a toolkit that reflects non-drug interventions used in your facility/agency to manage pain at EOL. Activity

3. ELNEC Geriatric Curriculum Non-Drug Techniques Psychological DistractionDistraction RelaxationRelaxation MeditationMeditation MusicMusic Art TherapyArt Therapy Comfort FoodsComfort Foods Guided ImageryGuided Imagery Physical MassageMassage ReflexologyReflexology ColdCold HeatHeat PositioningPositioning ExerciseExercise AromatherapyAromatherapy Therapeutic TouchTherapeutic Touch ReikiReiki AcupunctureAcupuncture

4. ELNEC Geriatric Curriculum Observations Prior to Starting Therapy Understanding of optionsUnderstanding of options Attitude and comfortAttitude and comfort Family interest and availabilityFamily interest and availability Need for educationNeed for education Ability to participateAbility to participate

5. ELNEC Geriatric Curriculum Non-Drug Symptom Relief

6. ELNEC Geriatric Curriculum Massage Decreases pain by soothing the skin and relaxing tense muscles Contraindications include: metatastic bones—massage can cause fractures of theses areas platelet count less than 35,000-40,000---can cause bruising blood clots---can create thrombus formation

7. ELNEC Geriatric Curriculum Massage Examples Brief touch such as rubbing someone’s shoulder orBrief touch such as rubbing someone’s shoulder or handholding handholding A warm foot soak and rubA warm foot soak and rub Wrapping feet in a warm,Wrapping feet in a warm, moist towel moist towel Massaging a hand with warm lotionMassaging a hand with warm lotion Keep in mind the type of pain the person is experiencing, and that certain types of pain may be relieved (arthritis), while others worsen by touch (neuropathic).

8. ELNEC Geriatric Curriculum Reflexology 1.reduce stress, 2.promote relaxation and sleep, 3.improve circulation, and energize 4.reduce pain, anxiety, nausea and vomiting.

9. ELNEC Geriatric Curriculum Reflexology

10. ELNEC Reflexology

11. ELNEC Applications of Cold Reduces pain by:Reduces pain by: –numbing nerve endings –reducing muscle spasms –decreasing inflammation Also decreases the desire to scratch areas that itch!Also decreases the desire to scratch areas that itch!.Avoid areas being treated by radiation, areas with poor circulation, and open wounds.

12. ELNEC Geriatric Curriculum Cold Examples An ice pack to the neck and upper shouldersAn ice pack to the neck and upper shoulders Ice massage to the knee with a Dixie Cup™Ice massage to the knee with a Dixie Cup™ Ice cloth to the hip opposite the one that hurtsIce cloth to the hip opposite the one that hurts Remember that applications of cold require a physician's order; application of heat and cold may be limited to licensed staff. Never use menthol-based products with heat as they can cause burns.

13. ELNEC Geriatric Curriculum Hot Applications Relieves pain by reducing inflammation and sorenessRelieves pain by reducing inflammation and soreness Also decreases sensitivity to pain and increases blood flow to the skinAlso decreases sensitivity to pain and increases blood flow to the skin Avoid heat if the pain increases. Think “warm” not “hot.” Keep a layer of material (pillowcase, towel) between the heat source and the skin. Remember that moisture increases the effect of both heat and cold.

14. ELNEC Geriatric Curriculum Heat Examples Heat Examples Warm washcloth to headWarm washcloth to head Hot water bottle to abdomenHot water bottle to abdomen Jacuzzi ™ bathJacuzzi ™ bath You need a physician order for the use of heat/cold to manage pain. Avoid the use of menthol-containing products with heat as they can cause deeper heat absorption and burns. No Ben-Gay™!

15. ELNEC Geriatric Curriculum Positioning/Movement Positioning eases pain by placing the body into postures that maintain or promote normal function of the musclesPositioning eases pain by placing the body into postures that maintain or promote normal function of the muscles Movement helps maintain or restore ease of function in joints, bones, nerves, and ligamentsMovement helps maintain or restore ease of function in joints, bones, nerves, and ligaments

16. ELNEC Geriatric Curriculum Positioning/Movement Examples Use of full-length body pillowUse of full-length body pillow Pillow between knees when lying on either sidePillow between knees when lying on either side Pretend to write the alphabet by using the feet – switch feet every 6 or 8 lettersPretend to write the alphabet by using the feet – switch feet every 6 or 8 letters

17. ELNEC Geriatric Curriculum Aromatherapy Lavender ------------- Citrus ----------------- Cypress --------------- Indications Indications Insomnia/anxietyInsomnia/anxiety AgitationAgitation Depression/griefDepression/grief TransitionTransition Breathing difficultiesBreathing difficulties

18. ELNEC Geriatric Curriculum Examples of Aromatherapy Essential oilsEssential oils Hydrotherapy bathsHydrotherapy baths MassageMassage DiffuserDiffuser CompressCompress CandlesCandles Atomizer or spritzerAtomizer or spritzer AnointingAnointing

19. ELNEC Geriatric Curriculum Therapeutic Touch Energy exchangeEnergy exchange RebalancingRebalancing

20. ELNEC Geriatric Curriculum Reiki Hands-on healing artHands-on healing art Balances the biofieldBalances the biofield Strengthens the body to heal itselfStrengthens the body to heal itself

21. ELNEC Geriatric Curriculum Acupuncture Needle placed in designated areasNeedle placed in designated areas Releases energy blockagesReleases energy blockages Licensed acupuncturistLicensed acupuncturist

22. ELNEC Geriatric Curriculum Distraction Used to focus attention on something other than pain. By decreasing concentration on pain, it becomes more bearable.

23. ELNEC Geriatric Curriculum Distraction Example Compile a file of picturesCompile a file of pictures Have resident describe picture by:Have resident describe picture by: –Talking about the picture –Pretending they are in the picture –Telling a story about the picture Choose a new picture as soon as their interest decreases in the current oneChoose a new picture as soon as their interest decreases in the current one

24. ELNEC Geriatric Curriculum Relaxation Described as freedom from physical and mental tensionDescribed as freedom from physical and mental tension Relaxation techniques reduce stress, muscle tension and reduce painRelaxation techniques reduce stress, muscle tension and reduce pain

25. ELNEC Geriatric Curriculum Relaxation Examples Put on headphones with a tape of calming musicPut on headphones with a tape of calming music Breathe in deeply; exhale slowlyBreathe in deeply; exhale slowly Think of a calm setting or peaceful place that you’ve enjoyed visitingThink of a calm setting or peaceful place that you’ve enjoyed visiting

26. ELNEC Geriatric Curriculum Meditation Intentional self regulation of attentionIntentional self regulation of attention Enhances concentration and awarenessEnhances concentration and awareness Helps relieve physical andHelps relieve physical and emotional pain emotional pain Promotes feelings ofPromotes feelings of acceptance, well-being, acceptance, well-being, and inner peace and inner peace

27. ELNEC Geriatric Curriculum Music Decreases pain by: Providing distractionProviding distraction Reducing anxietyReducing anxiety Prompting recall of pleasant memoriesPrompting recall of pleasant memories Interrupting the stress responseInterrupting the stress response

28. ELNEC Geriatric Curriculum Art Therapy Creative expressionCreative expression Uncover unconscious strengthsUncover unconscious strengths Trained professionalTrained professional

29. ELNEC Geriatric Curriculum Comfort Foods Assists in decreasing pain by: Providing distractionProviding distraction Evoking comforting memoriesEvoking comforting memories Promoting relaxation and physical calmPromoting relaxation and physical calm

30. ELNEC Geriatric Curriculum Goals of Therapy Promote relaxationPromote relaxation Reduce stressReduce stress Reduce muscle tensionReduce muscle tension Decrease anxietyDecrease anxiety Relieve pain & other symptomsRelieve pain & other symptoms Reduce side effects of the disease & treatmentsReduce side effects of the disease & treatments Improve sleepImprove sleep Decrease sense of suffering & abandonmentDecrease sense of suffering & abandonment Promote safety & trust in caregiversPromote safety & trust in caregivers Increase sense of well- being & control regarding matters of daily living & deathIncrease sense of well- being & control regarding matters of daily living & death

31. ELNEC Geriatric Curriculum Activity: Building a Toolkit

32. ELNEC Geriatric Curriculum We can’t change the course of the illness, but we can help patients through it with a gentle and caring touch.

33. ELNEC 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). Ferrell, B. & Coyle, N, (2010). Oxford Textbook of Palliative Nursing. New York: Oxford University Press, Inc. http://www.hov.org/dementia_programs.aspxhttp://www.hov.org/dementia_programs.aspx (music video) Supported by DHHS/HRSA/BHPR/Division of Nursing Grant # D62HP06858