Advancing Excellence in Pain Assessment (Part 2)
Screening all residents for pain is the baseline step in the management of pain. Due to the barriers previously mentioned, the nursing home needs to create a setting where the “Identification of Pain” is an organization-wide commitment. How questions are asked or phrased and which screening tools are used needs consideration and will influence the perceived response from the resident. Each resident should be screened for pain on a periodic basis, but at least at admission, readmission, and with each MDS assessment and each change in condition.
Best practice incorporates the identification of pain into daily practice. Nursing home policy and procedures should identify the options for pain screening tools, plus when and how the staff will screen for pain. A thorough screening process recognizes the importance of the participation of both clinical and non-clinical staff members. Staff in all departments can assist in identifying pain—CNAs, dietary, activities, etc. Communicating the importance of identifying pain and bringing it to the attention of the Unit Manager/Licensed Nursing is vital. Education regarding the identification of pain should include all staff. The screening process utilizes pain screening tools or pain scales. There are several different types of pain scales available for the cognitively intact or impaired resident.
Cognitively impaired residents
Tools that capture nonverbal expressions of pain are needed for the severely cognitively impaired resident. Residents may have difficulty expressing when they have pain or are unable to participate in the verbal pain assessment. Pain may be assessed by staff observation of behaviors such as restlessness, vocalizations, facial expressions, and breathing patterns.
Several different pain scales suitable for capturing pain in this group of elders are available. Two such scales are the PAINAD (Pain Assessment in Advanced Dementia) and the PADE (Pain Assessment for the Dementing Elderly).
The Pain Assessment in Advanced Dementia (PAINAD) scale refers to five behavior domains that can be scored from 0 through 2. These domain scores are then added to get a total score up to 10. Staff should be aware that these non-verbal behavioral symptoms may indicate something other than pain (e.g., delirium) and a thorough pain assessment and examination should be completed. For more information, refer to https://www.lumetra.com/nursinghomes/resources/pain/index.asp.
Cognitively intact residents
Various types of pain scales are available for screening the cognitively intact elder:
- Visual Analogue Scale (VAS)
- Verbal Numeric Rating Scale
- Faces Scales (Wong-Baker FACES Pain Rating Scale and others)
- Verbal Descriptor Scale (can be customized to resident)
- MDS—Pain Scale
- Other scales, such as a pain thermometer or color scales
Ensure that pain screening is incorporated into the admission process. At this time, determine which tool to use for the resident and ensure that this decision is relayed to staff for consistency of use. Remember, even though a pain scale is selected and explained to the resident, the resident may need the scale and range to be defined frequently to maintain full understanding of the rating.
There may be other identifiers that should trigger a pain screening, such as certain diagnoses and conditions, decreasing ADLs, decreasing ROM and mobility, and behaviors. Take the time to consider if pain is a factor in either the condition or clinical finding.
A comprehensive pain assessment is completed once pain has been identified. Pain may have several different causes, such as acute illness or injury, ADL shortfalls, repositioning, or aggravating treatment or therapy. Persistent pain can be a symptom of many diseases such as cancer, arthritis, and neuropathy or end-stage disease. Identifying the underlying cause and fully understanding the pain symptoms is necessary to adequately treat the pain.
At a minimum, an initial pain assessment should include:
- Quality and description of the pain (sharp, dull, throbbing, etc.)
- Location (use a body drawing to mark the pain area)
- Intensity of the pain (pain scale)
- Frequency of pain
- History of pain (when started, when worse, when better)
- Effects of pain (sleep, appetite, relationships, emotions, etc.)
- Satisfaction and effectiveness of current/past treatments
The following is a helpful method for zeroing in on the pain symptoms that need to be gathered in order to achieve adequate pain management. Refer to CMS Draft Pain Regulation 309—page 13. https://www.ascp.com/resources/nhsurvey/upload/F309QualityofCare%20.pdf. Consider the following acronym (see PQRRSTTA Checklist on left).
Thorough resident assessment:
Once the pain is identified and then fully described, it needs to be evaluated in the context of the total resident condition. This evaluation is done from the complete assessment or examination of the resident, and is needed to adequately direct treatment options and the plan of care. The following is a list of assessment areas that provide comprehensive information on the resident.
- 1. Physical examination
- 2. Consideration of co-morbidities
- 3. Diagnostic tests
- 4. Medication history
The identification of pain needs to start immediately at time of admission and then continue throughout the resident’s stay. Identify which pain screening scale is best when the resident first arrives at the nursing home. Cognitive and language ability might define your approach. Many residents admitted from hospital are used to the hospital pain scale. It may be best to perpetuate its use, as long as it is evidence-based and part of your policy and procedure.
Plan of care
Both the resident and family should participate in the development of the pain management plan of care. Resident goals should be considered because many residents may choose to not be entirely pain-free, as they may feel side effects of medications are more undesirable than some level of pain. Non-pharmacological interventions may play a key role in maintaining function levels for the resident while at the same time effectively controlling the resident’s pain and allowing them to achieve their goals for both pain management and quality of life. The plan of care should follow facility policies and procedures that have been developed following guidelines of assessment, planning, implementation, monitoring and modification as necessary.
Complementary approaches to managing pain
Non-pharmacological interventions used in conjunction with pharmacological interventions can play a key role in the facility’s pain management program and in the control of residents’ pain. Included can be comfort measures such as repositioning, comfortable room temperature and specialized mattresses. Cognitive interventions along with relaxation, diversions, music therapy and spiritual interventions also can be effective. Consultation with chiropractic and rehabilitation services can help to identify physical modalities that can be a successful part of the pain management program. These modalities can include hot or cold packs, massage, baths, TENS, and acupuncture. Finally, education of the resident and family regarding pain symptoms and available interventions will allow for greater participation by the resident in their pain management program and lead to ultimate success in achievement of pain management goals for the resident.
Pharmacological interventions include the use of analgesic as well as adjuvant medications such as antidepressants and anticonvulsants. The pharmacological plan of care will depend on the cause of the pain and the individual response of the resident to the medications. It is recommended that guidelines for pain medication be based on the resident’s level of pain and a stepwise approach such as the World Health Organization’s Pain Ladder be followed (World Health Organization, 1990, https://www.who.int).
This approach involves administration and evaluation of pain medications in a sequence of nonopioids, such as NSAIDs/acetaminophen; mild opioids such as hydrocodone; and then strong opiods such as morphine. The approach should be individualized and dosage should start low and increase until the desired level of pain control is reached by the resident. Medications can be administered around the clock, as needed, or in a combination approach. PRN (as needed) medications are effective for breakthrough pain but should not be substituted for regularly administered medications. If the resident has received frequent PRN medications, pain is not being effectively managed. When side effects occur, consider lowering the dose of the opioid and introducing an NSAID. This is an effective way of getting control of the side effect, while not losing control of the pain.
If pain medication is found to no longer be needed, the facility is expected to discontinue or taper the dose. If discontinuing the medication is not indicated, this should be clearly documented. If the facility finds it is not successful in adequately controlling a resident’s pain and/or side effects, other resources such as consultation with pain centers and hospice organizations, can be helpful and may be appropriate.
Assessment of pain management programs is the final step in ensuring a successful overall program. Assessments should not only include evaluation of the effectiveness of resident-specific pain management programs as already described, but also evaluation of facility-level pain management policies and procedures. Aggregate data related to an individual resident’s response to a pain management program should be a part of the facility quality improvement program and reviewed on a regular basis.
When data indicate that management of resident-level pain is not successful, a review of facility-level pain management policies and procedures and adherence to the key processes of effective pain management—screening, assessment, care planning, implementing the plan and monitoring effectiveness—is in order. Ongoing assessment of both resident-level and facility-level pain management processes through the facility quality improvement program will ensure success in management of resident pain.
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