1. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. CHAPTER Gerontological Nursing, Second Edition Patricia A. Tabloski Pain Management 9 Lecture Note PowerPoint Presentation

2. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 1 Define pain and the consequences of pain in the older adult.

3. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pain and Pain Transmission Involves peripheral receptors and sensory pathways and synaptic contacts in the brain stem and spinal column Classified as nociceptive or neuropathic

4. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pain and Pain Transmission Nociceptive pain –May be visceral or somatic –Designed to signal tissue damage or inflammation Neuropathic pain –Results from damage to the central or peripheral nervous system

5. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Results of Untreated Pain Hyperalgesia –Caused by an increased sensitivity of nociceptors to stimuli and a reduced pain threshold Hypertension, tachycardia, and even coronary ischemia

6. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Results of Untreated Pain Depression, anxiety, decreased socialization Sleep disturbance Impaired ambulation Increased healthcare use and costs

7. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Acute Pain Time limited Result from surgery, medical procedures, or injury May be associated with exacerbations of chronic conditions

8. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Chronic Pain Continues over a prolonged period of time or is associated with an injury that has not resolved in the expected amount of time Affects 1:5 persons Related to –Musculoskeletal disorders –Cancer –Neuropathic disorders

9. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Chronic Pain May impact 45–80% of nursing home residents

10. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Chronic Pain Negative consequences –Decreased socialization –Withdrawal from daily life –Fatigue –Sleep disturbance –Irritability –Physical deconditioning –Stress –Depression

11. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 2 Identify appropriate pain assessment techniques, including those to use with dementia.

12. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pain Assessment Measured subjectively Utilizes the patient’s self-report of pain Multiple complaints of pain must be prioritized

13. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pain Assessment of the Patient with Dementia Use simple questions or screening tools Review nonverbal behaviors Obtain information from family or caregiver Perform more frequently

14. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pain Assessment of the Patient with Dementia Primary types of behaviors consistent with the presence of pain –Facial expression  Grimacing  Frowning  Frightened face –Verbalizations/vocalizations  Sighing  Moaning  Chanting (repeating)

15. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pain Assessment of the Patient with Dementia Primary types of behaviors consistent with the presence of pain –Body movements  Tense posture  Guarding  Gait changes  Mobility changes –Interpersonal reactions  Aggressiveness  Combativeness  Withdrawal

16. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pain Assessment of the Patient with Dementia Primary types of behaviors consistent with the presence of pain –Changes in activity patterns or routines  Appetite changes  Changes in sleep periods  Increased wandering –Mental status changes  Crying  Increased confusion  Irritability

17. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Baseline Pain Assessment Best conducted prior to known painful event Purpose –Investigate pain terminology and behaviors –Identify sociocultural variables influencing pain behaviors and expression –Obtain health history identifying accompanying chronic conditions contributing to the anticipated pain experience

18. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Baseline Pain Assessment Purpose –Investigate past methods of pain relief –Identify pain medications used in the past –Select appropriate pain scale for later use

19. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 3 Describe pharmacological and nonpharmacological approaches useful in treating pain in the older adult.

20. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pain Management Goals Relieve acute and chronic pain Employ appropriate pharmacological and nonpharmacological techniques Minimize side effects

21. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Box 9-5 Pain Care Bill of Rights

22. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Older Adults and Opioid Analgesics More sensitive Require lower starting doses to avoid toxicity

23. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Challenges of Pharmacological Management in the Older Adult Renal impairment Hepatic function impairment Changes in body fat distribution

24. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Nonpharmacological Pain Management Techniques Relaxation techniques Heating pads Cold compresses Biofeedback: is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance Music therapeutic touch

25. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pharmacological Management Non-opioid Analgesics –Used for mild to moderate nociceptive pain –Anti-inflammatory drugs (NSAIDs)  Carry risk of gastrointestinal bleeding and impaired renal function Avoid persistent use in older adult population  Acetaminophen (Tylenol) Use safe with older adults having normal kidney and liver function and no history of alcohol abuse Dosages not to exceed 4,000 mg/day

26. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pharmacological Management Non-opioid Analgesics –Anti-inflammatory drugs (NSAIDs)  Cyclooxygenase-2 (COX-2) Tramadol –Used for moderate pain –May cause dizziness, nausea, and headache

27. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pharmacological Management Opioid analgesics –Used for moderate to severe pain management –May be used for long periods of time without risk of organ damage –Available in a variety of routes –Titrate slowly –Mild sedation and cognitive impairment are anticipated in initial therapy

28. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pharmacological Management Opioid analgesics –Potential medications  Morphine  Meperidine  Methadone

29. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pharmacological Management Opioid analgesics –Potential adverse effects  Constipation  Sedation  Respiratory depression  Nausea and vomiting  Myoclonus  Pruritis

30. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pharmacological Management Adjuvant drugs for older patients with pain –Not typically pain medications –May relieve discomfort –Potentiate the effect of pain medications –Reduce the side effect burden

31. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pharmacological Management Adjuvant drugs for older patients with pain –Examples  Antidepressants and anticonvulsants  Topical analgesics  Muscle relaxants  Antianxiety medications  Medications to dry secretions  Antipruritics  Diuretics  Magic mouthwash

32. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Special Pharmacological Issues Regarding Pain Management in the Older Person True drug addiction to opioid analgesics is rare Physical dependency is an inevitable consequence over time when managing chronic pain

33. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Special Pharmacological Issues Regarding Pain Management in the Older Person Opioids and acetaminophen or aspirin may be mixed together to control pain –Doses may be limited due to the toxic effects of high salicylate or acetaminophen levels –Acetaminophen is hepatotoxic above 4 g/day –Aspirin may cause gastric bleeding and abnormal function at doses above 4 g/day

34. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Special Pharmacological Issues Regarding Pain Management in the Older Person Polypharmacy –Refers to the excessive or unnecessary use of medications –Adjuvant therapy may facilitate the reduction of medication doses to manage pain

35. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pharmacological Principles for Successful Pain Management Oral administration of pain medications is the preferred route for the older adult –Safest –Least expensive Around-the-clock scheduling –Most effective –Avoids the need for the patient to ask and wait for prn dosages

36. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Pharmacological Principles for Successful Pain Management Consistent experiences of breakthrough pain indicates the need to revise the dosing regimen Crushing or chewing sustained-release preparations destroys the controlled- release properties

37. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Complementary and Alternative Therapies Used as stand-alone treatments and adjuncts to traditional pharmacological interventions Assess preferences and attitudes toward nontraditional methods

38. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Complementary and Alternative Therapies Examples –Chiropractic series –Herbal remedies –Relaxation techniques –High-dose megavitamins –Religious or spiritual healing

39. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Nonpharmacological Methods to Manage Pain in the Older Adult Education programs Spiritual intervention Socialization or recreational programs –Movies –Therapeutic use of art and music

40. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Nonpharmacological Methods to Manage Pain in the Older Adult Psychological approaches –Counseling –Biofeedback –Imagery –Hypnosis –Relaxation

41. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Nonpharmacological Methods to Manage Pain in the Older Adult Physical therapy –Ultrasound –Exercise –Hot and cold packs Neurostimulation

42. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 4 Identify the nurse’s role in treating pain in the older adult.

43. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Assess the Patient’s Beliefs and Willingness to Use Relaxation techniques Heating pads or cold compresses Biofeedback Music Therapeutic touch Other methods to enhance or replace analgesics drugs

44. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Medication Assessment of Older Adults with Pain Use of over-the-counter drugs or supplements Use of herbal remedies Prescription medications Identifying medications that may –Be ineffective –Interact with other drugs or supplements –Cause troubling side effects

45. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Urge Patients To seek evaluation when pain becomes uncontrolled To be honest about possible needs for increased medication dosages

46. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Analgesic Medication Administration Interventions Monitor for adverse effects Provide education regarding the pain management plan Implement nonpharmacological methods as appropriate Maintain open lines of communication

47. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski LEARNING OUTCOME 5 Describe patient-family teaching guidelines for pain management.

48. Copyright ©2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Gerontological Nursing, Second Edition Patricia A. Tabloski Family Members Should Recognize signs of pain Keep a diary of pain Keep a diary of responses to interventions