What is it then that causes that under-treatment of pain? Let's take a look at some of the major barriers to effective pain management in this expert long term care training article.
A big one is that staff added to have long been a big problem when it comes to pain management. Physicians and nurses have been sort of notorious for withholding pain medication because of judgmental attitudes about what they see as drug-seeking behavior.
Also there's a tendency to believe mistakenly most of the time that residents overstate their pain. And even the physicians and nurses who think maybe that they're protecting residents from becoming addicted actually are doing a major disservice to their residents.
And another big one is that it's often believed that older people have a higher tolerance for pain or that pain is an inevitable part of aging. And neither one of these is really true.
Another problem and a huge one too, as suggested by our expert in a long term care conference, is that the practice has been generally speaking certainly not by everybody. But generally speaking, the practice has been to use pain medications on a PRN basis on an as needed basis rather than on a routine basis for people who have essentially continuous pain. So that means when you're using PRN meds only that the pain fluctuates including spikes that are very uncomfortable maybe even miserable for the resident. And then, either we observe that they're in pain or they finally ask for the PRN medication. And we give it to them.
Whether the pain is chronic or acute or it's a post-op patient, regardless, the goal should be to provide a consistent level of comfort which a PRN pain medication regimen alone doesn’t do.
Now, of course, you only have to balance the side effects and possible effects on function and alertness and everything against the consistent - against the level of comfort. So does that mean that the level of comfort is going to be, you know, zero on a scale of zero to ten or is it going to be three for this resident because he wants, you know, to be able to stay more alert.
That's an individualized care planning issue that has to be addressed. But generally speaking, the goals should be to provide a consistent level of comfort regardless of the cost or the pain.
Inadequacies in the Nursing Process
Let's take a look at how a breakdown in the nursing process turns out to be a major barrier to effective pain management. Lack of proper assessment is the first problem here. In order to effectively manage pain, it's not enough to know that the resident is in pain and then just go give the pain med. To begin with, it's really crucial to know. And you notice the location of the pain, its origin, the intensity and frequency of the pain, activities and events that make it worse or better.
The resident should also be prompted to describe the type of pain, what it feels like and what changes the way it feels. And of course, strategies for pain relief will vary depending on the answers to all of these questions.
Long Term Care Training Tip: It's also very important to pay attention to the nonverbal as well as the verbal indicators. So we're talking about vocal sounds such as moaning and screaming and crying and facial expressions such as whimsing and frowning or guard a particular area of the body with a certain body posture.
And then of course you can notice an onset or increase in restlessness or agitation or behavior problems. And you might be able to associate that with an increase in pain. You know, try some pain med.
It's critically important to ask the right questions, notice the mood. Observe posture and behavior. Listen to those vocalizations and tone and intensity of the voice. And don’t forget that physical assessments because you can learn a lot from the touch of the physical assessment.
Another significant problem is inadequate risk assessment that can be critical in helping to anticipate pain. So you can take action to prevent or minimize it. So the facility’s evaluation of the resident and admission and during ongoing assessments helps to identify not only the resident who has pain. But also the resident who's at risk for having pain related to special or procedures that they have or, you know, particular care or treatment that they're going to be receiving.
So we're all pretty familiar with the idea of providing pain medication prior to and therapy treatment. But there are other situations like other prior to dressing changes when there's a wound that causes pain and all kinds of other situations like that to consider in advance.
Inadequate frequency of assessment is also an issue. So reassessment should occur. And whenever vital signs are taken and we don’t usually do that daily in a nursing home. But those are really good opportunities to reassess the pain. And the daily one could be - during the med pass. That doesn’t mean that you have to pull out some lengthy form and fill up some forms. It means that you're screening the resident to see if there are signs of pain.
And also the other thing is with the change of condition is also on the list there. And a lot of times we're so busy reacting to the change in condition. The resident’s coughing and sneezing maybe. And we're getting some medication for, you know, decongestion or something. But we're not really necessarily understanding how bad that throat is hurting with that cold or with that flu or maybe even the chest if there's some bronchitis or pneumonia. And so, don’t forget to assess for pain anytime there is a change in condition.
Once the assessment data is collected, now, this is a no doubt for most of you. But it's critical that an analysis of the data be conducted to find out what it's telling you. Unfortunately, that doesn’t always happen. And even when it does, the analysis is not always adequate leading to inadequate or inappropriate care planning.
Once the assessment is completed and analyzed as per the long term care rules, of course, the next step in the nursing process is development and implementation of an individualized care plan based on the unique aspects of this resident pain and surrounding issues and risk areas for pain.
There's just no question that effective pain management requires an organized pain management program designed to balance pain relief interventions with adequate response and minimizing side effects. And of course utilizing a team approach with the focus on the individual resident. Each discipline’s unique focus and skills can be brought there after taking into account all of the resident’s strengths and needs. So of course, for example PT or OT might be appropriate for a resident with chronic pain not just with acute pain to strengthen muscles and improve range of motion to relieve stress on the muscles and bones.
And social services and activity staff, another good example, they should be given long term training to help the resident to overcome some of the effects of pain. And also may be able to provide distraction from the pain. The dietary department may need to alter the resident’s diet to compensate for decrease the appetite related to pain or to help overcome GI effects of pain medications. And of course, the nursing staff and the physician certainly have their roles and responsibilities here too.
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