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CASSIA YI , APRN, MSN, CNS, CCRN
Pain Assessment, the Key to Treating Pain in the Inpatient Setting
Considerations in The Aging And Palliative Populations
Objectives
Apply the Pain Assessment Hierarchy to pain assessment and reassessment in all patient populations
Review importance of sedation assessmentMake the connection between good
assessment and good management
Hierarchy Of Pain Assessment
The Numeric Pain Scale
Ask your patient to rate his or her pain on a scale of 0-10, 0 being no pain, and 10 being the worst pain
Some elderly patients may prefer to describe their pain as mild, moderate, or severe
A Reminder About the FACES Tool:
DO NOT choose a face for the patient based on how he/she looks!
Behavioral Assessment Pain Tools
CPOTCNPIBPSNVPSNPAT
Behavioral Score Does Not Equal Intensity!!!!
Example= Two people may have the same cut on their finger…
Person #1 may be crying, squeezing his finger, and grimacing.
Person #2 may be just grimacing
This does not mean that Person #1 is experiencing more pain….he just displaying behaviors of pain differently.
Pain and the Dying patient
Pain is not automatic!Pain must be assessed, just like with any
other patient population!• Don’t misinterpret other signs/symptoms of
dying with pain! • Restlessness, agitation, moaning, and groaning may
accompany terminal delirium• If the diagnosis is unclear, a trial of opioid
may be necessary to judge whether pain is driving the observed behaviors
Respiratory Variations in the Dying patient- NOT indicator of pain
Patterns: Tachypnea, Apnea Chin-lift, jaw-jerk*
Diminishing tidal volumeOropharyngeal secretions*Symptoms: generally
comfortableDistressing to family, not to
patientManagement
Family support Oxygen variably effective Opioids (rarely)
Palliative Patients are at Increased Risk of Pain
Disease ProcessImmobility (who’s driving this??)Skin break downDyspnea
Pain Reassessment
Reassessment times should coincide with peak medication effectiveness, when the patient will feel the greatest effects of analgesia and will also experience the peak of side effects. 5-45 minutes for IV opioids 45-75 min for PO opioids
Pla
sma
Con
cent
ratio
n
0 Time
IV Peak 30 min
PO / PR/ IM 60 minutes
60 min
SQ PeakA little longer than IV
30 min 60 min
When should you assess??
Assessing for sedation
RASSRamseyPOSSGCS
Why is the Sedation Assessment So Important?
Remember sedation ALWAYS precedes respiratory depression!! If we can catch the patient while they are sedate, we should be able to prevent all opioid related respiratory depression!
If left untreated, can lead to This
This
Sleep and Assessing Pain
If your patient is asleep when you need to reassess
for pain, this could mean 2 things:
Your patient is finally able to sleep! Assess the respiratory status and
review previous sedation assessment. If normal, do not wake the
patient up!
-OR-
The pain medication you gave made your patient sedate. If the
respiratory assessment is abnormal, wake the patient up! Further
evaluation is required.
What is a Good Respiratory Assessment?
Respiratory Assessment Includes: Observe for a full minute! Assess the rate Assess the rhythm Assess the depth Assess respiratory effort. Are they snoring?
Do our Current Assessment Tools work????Self-report= gold standardProblem with self-report using a uni-
dimensional scale Pain is a multi-dimensional complex experience-
Dynamic! Numeric scale difficult for some to use Requires linguistic and social skills Patients modulate pain behaviors and self-report based
on their perception of what’s in their best interest Providers see verbal and non-verbal signs of pain,
but can only respond to reported number
Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676
Patients Modulate Pain
Is There Something Better?
University of Utah – 2012 Pilot ProjectCAPA© developed to replace conventional
numeric rating scale (NRS; 0-10 scale)
Press Ganey© scores increased from 18th to 95th percentile
55% patients preferred CAPA ©
Nurses preferred CAPA © 3:1 over NRS
Clinically Aligned Pain Assessment (CAPA) “Pain is More Than Just a Number” ©
Evaluates intensity of pain effect of pain on
functionality effect of pain on sleep efficacy of therapy progress toward comfort
Engages patient and clinician in a brief conversation about pain resulting in coded evaluation
From, Donaldson & Chapman, 2013.
CAPA© Tool (modified; original in blue)
The conversation leads to documentation- not the other way around.Question Response
Comfort •Intolerable•Tolerable with discomfort•Comfortably manageable•Negligible pain
Change in Pain •Getting worse•About the same •Getting better
Pain Control •Inadequate pain control Inadequate pain control•Partially effective Effective, just about right•Fully effective Would like to reduce medication (why?)
Functioning •Can’t do anything because of pain•Pain keeps me from doing most of what I need to do•Can do most things, but pain gets in the way of some•Can do everything I need to
Sleep •Awake with pain most of night•Awake with occasional pain•Normal Sleep
From, Donaldson & Chapman, 2013.
Good Assessment is what Makes Good Management Possible!
Pla
sma
Con
cent
ratio
n
0 Time
IV Peak 20 min
PO / PR/ IM 60 minutes
60 min
SQ PeakA little longer than IV
30 min 60 min
Morphine IVPeak effect: 20 minutesHalf-life: 2-4 hoursContinuous morphine infusion :Time to steady state: 10-20 hours
Plas
ma
Con
cent
ratio
n
0
Time to Drip Steady State
164 8 12Time ( hours )20 24
50%75%
87.5%93.75%
97%100%
Pain Control
Change GTT
Steady State
Pain Management with Geriatric Patients
Analgesic therapy issuesPhysiologic changes
Absorption Distribution Metabolism Elimination
Opioids Recommend reducing initial opioid
dosing by 25-50% in elderly patient
• Retrospective study at UC San Diego• Patients who died while receiving Continuous
Morphine Infusion (CMI) from 2012-2013 N=190 • Mean age was 66.4 years (range: 19-99 years)• 109 males and 81 females• At initiation of CMI, 25.8% (n=49) had an oncologic
diagnosis and 73.2% (n=139) were in the ICU.
Morphine Study at UCSDH
Internal data: Lin KJ, Chang A, Edmonds KP, Roeland EJ, Revta C, Ma JD, Atayee RS. Variable Patterns of Continuous Morphine Infusions at End of Life. Submitted to Journal of Palliative Medicine January 2015
• Prior to CMI initiation, 40.5% (n=77) were opioid naïve• 85% (n=160) had documented indication for CMI (e.g.
compassionate extubation or comfort care with pain/dyspnea)• 60% (n=120) did not receive any bolus doses prior to CMI
initiation and of these 23% were opioid naïve (n=44)• Between start and end of CMI +130% in rate of CMI
+442% morphine IV dose Patients on CMI:24.2% (n=46) had a GFR < 30 mL/min73.1% (n=139) a GFR >30 mL/min 2% (n=5) were not recorded
A Few Key Findings from Morphine Study
Internal data: Lin KJ, Chang A, Edmonds KP, Roeland EJ, Revta C, Ma JD, Atayee RS. Variable Patterns of Continuous Morphine Infusions at End of Life. Submitted to Journal of Palliative Medicine January 2015
What is the Goal?
Continuous Infusion Bolus• Achieve continuous
pain/agitation control by administering a continuous infusion (at the lowest possible dose to minimize accumulation)
• Assess the effect of the continuous drip rate when steady state is reached
(5-72 hours with pain meds)• Should not be used for patients
with anuria or oliguria
There are 2 goals of IV boluses for patients who are already on a continuous drip:
1. To treat a pain score or agitation level that is above/beyond the patient’s consistent level.
2. Indicates if the continuous IV infusion needs to be increased
Continuous Infusions- Back to Basics! Bolus 1st!
Start Here!
In Conclusion….
Assess, Assess, Assess before you treat!Assess for sedation, not just pain! Pain and sedation assessment will help you
decide HOW to treat. Pain assessment is still important in the
palliative population! Don’t make assumptions!
Consider lower doses in the aging populationBolus before you titrate!
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