THE NEW MEXICO RURAL HOSPICE NETWORK BUILDING A NETWORK COMMITMENT TO PAIN MANAGEMENT

Transcription

1 Table of Contents THE NEW MEXICO RURAL HOSPICE NETWORK BUILDING A NETWORK COMMITMENT TO PAIN MANAGEMENT Sponsored by a grant from: The Robert Wood Johnson Foundation "Promoting Excellence in End of Life Care in Rural New Mexico"

2 TABLE OF CONTENTS Mission Statement on Pain Management...2 Standards for Pain Management...6 Policies for Pain Management A. Oral Administration of Pain Management Medication...9 B. Rectal Administration of Opioid Medications...10 C. Administration of Continuous Subcutaneous Pain Management Infusion...11 D. Administration of Continuous Intravenous Pain Management...14 E. Administration of Continuous Epidural Pain Management Infusion...16 Guidelines for Pain Assessment and Intervention for the Cognitively Impaired...20 Discomfort Indicator Scale for the Cognitively Impaired...22 Pain Management Tools A. Pain Assessment Tool...24 B. Patient Pain Relief Diary...25 C. Patient Pain Relief Diary for Cognitively Impaired...26 The Management of Chronic Pain in Older Persons...27 Contact: The Palliative Care Education Research and Training Office (PERT) 2325 Camino de Salud NE Albuquerque, NM Telephone: (505) Fax: (505)

3 The New Mexico Rural Hospice Network Mission Statement On Pain Management 3

4 NEW MEXICO RURAL HOSPICE NETWORK MISSION STATEMENT ON PAIN MANAGEMENT All individuals have a right to pain relief. Health Care Workers will: Inform individuals at the time of their initial evaluation that relief of pain is an important part of their care and respond quickly to reports of pain. Ask individuals on initial evaluation and as a part of regular assessments about the presence, quality, and intensity of pain and use the patients self reports as the primary indicator of pain. Work together with the individual, their family, and other health care workers to establish an interdisciplinary team, whose goal will be pain relief by developing and implementing a plan to achieve that goal. We believe that optimal pain relief enhances the individual s life. 4

5 NEW MEXICO RURAL HOSPICE NETWORK STANDARDS FOR PAIN MANAGEMENT 5

6 NEW MEXICO RURAL HOSPICE NETWORK STANDARDS FOR PAIN MANAGEMENT STANDARD I: All individuals will be assessed for presence, absence, and history of pain. A Initial history must include a comprehensive pain assessment based on the individual s self report. Factors will that may included are: 1. Description 2. Intensity (0-10 scale) or alternate measurement tools (see Appendix A) a. Visual Analog Scale b. Wong-Baker Pain Assessment Scale c. Present Pain Inventory 3. Location 4. Aggravating and alleviating factors 5. Associated signs and symptoms 6. Impact on quality of life 7. Methods of pain management that have been helpful or unhelpful in the past 8. Individual s personal goal for pain relief B The pain intensity and pain relief as reported by the patient will be assessed and documented: 1. On admission; AND 2. After any known pain-producing event; AND 3. With each new report of pain; AND 4. Every visit and/or contact; AND 5. At report of unrelieved pain. C Based on the individual s self report and ongoing assessment, a process of interventions will be initiated and documented. The individual is included in the interdisciplinary process of treatment review and follow-up. D. Patient satisfaction will be surveyed at regular intervals. At regular intervals to be defined by the homecare/hospice interdisciplinary team and from time to time, a randomly selected sample, who have pain, will be reviewed. STANDARD II: Information about analgesics will be made readily available. A. Information will be provided to individuals and their family to manage their pain at home. B. Information about pharmacologic and non-pharmacologic pain management will be available. C. Appropriate orientation and training to treat individual s pain will be available to health care workers and included in continuing education activities. STANDARD III: Patients will be promised attentive analgesic care. A. Individuals and/or family members will be informed that effective pain relief is an important part of their treatment, that their communication of unrelieved pain is essential, and that health care professionals will respond quickly to their reports of pain. 6

7 B. Special learning needs of individuals will be addressed following assessment of barriers to learning. STANDARD IV: Explicit policies for the use of analgesic technologies will be defined.. Such policies will include definitions of interdisciplinary roles and responsibilities with individual accountabilities assigned. A. Standard treatment protocols and recommended algorithms for treatment modalities will be defined. STANDARD V: Adherence to standards will be monitored. A. A quality improvement committee will monitor compliance with the above standards, consider issues relevant to improving pain treatment, and make recommendations to improve outcomes and their monitoring. B. This committee will include members who have experience working with issues related to effective pain management. C. This committee will meet at least quarterly to review process and outcomes related to pain management. D. This committee will interact with the IDT to establish procedures for improving pain management where necessary, and review the results of these changes within 3 months of their implementation. E. This committee will provide regular reports to administration and IDT. *These standards are adapted from the American Pain Society Standards by the NMRHN Task Force: Pain as the 5 th Vital Sign. 7

8 POLICIES FOR PAIN MANAGEMENT I II III IV V ORAL ADMINISTRATION OF PAIN MANAGEMENT MEDICATIONS RECTAL ADMINISTRATION OF OPIOID ANALGESICS AND ADJUNCTANT MEDICATIONS ADMINISTRATION OF CONTINUOUS SUBCUTANEOUS PAIN MANAGEMENT INFUSIONS ADMINISTRATION OF CONTINUOUS INTRAVENOUS PAIN MANAGEMENT INFUSIONS ADMINISTRATION OF CONTINUOUS EPIDURAL PAIN MANAGEMENT INFUSIONS 8

9 TITLE: ORAL ADMINISTRATION OF PAIN MANAGEMENT MEDICATIONS PURPOSE: EQUIPMENT: To control pain safely and effectively for the hospice/palliative care client by means of the oral route. Pain relief diary PROCEDURE: 1. RN will assess client s pain, including location, duration, quality and intensity by completing the pain assessment form. Determine if client has any allergies (sensitivities) to medications. 2. Coordinate and develop a plan of care with other team members. 3. Implement non-drug and/or drug interventions. 4. Physician s order will be obtained for medication, dose and route. Prescription must be obtained for oral opioids and taken to pharmacy for filling. Arrange for delivery to client. 5. Client/caregiver teaching: A. Review prescription and instructions. B. Administration of medication for breakthrough dosing. C. To take medication as ordered at dose and frequency prescribed by physician. D. Tell client and caregiver to stay on top of pain by taking dose prior to pain becoming severe. E. In assessing effectiveness of medication in reducing pain and actions to take if pain is not controlled. F. In controlling common side effects and interventions to take. G. In assessing possible adverse reactions and interventions to take. H. In assessing medication toxicity and interventions to take. I. Documentation in pain diary to include time and amount of dose taken, pain rating and any side effects. 6. Document (initial and subsequent visits): A. Written and verbal instructions given and client/caregiver response. B. Description of pain(s). C. Level of pain(s) using a 1-10 scale. D. Medication, route and dose. Also include dosing for breakthrough medication. E. Client response prior to and after administration of medication. F. Signs and symptoms of medication side effects, adverse effects or toxicity and interventions taken. Notify physician if any of these occur. 7. Make a follow-up call to client/caregiver within 12 hours after initiation of medication regime in order to monitor ongoing client status and response to medication. Make daily nursing contact until client s desired level of pain is achieved. 8. If client reports effective pain relief and is clinically stable, titrate medication upward per physician s order to achieve optimal level of pain relief. 9. If client reports ineffective pain relief, notify physician and request change in orders or follow titration orders per original prescription to achieve optimal level of pain relief. 9

10 TITLE: PURPOSE: EQUIPMENT: RECTAL ADMINISTRATION OF OPIOID ANALGESICS AND ADJUNCTANT MEDICATIONS To control pain and other symptoms safely and effectively by means of the rectal route. Gloves Water-soluble lubricant Syringe (if needed) Foley catheter (if needed) PROCEDURE: 1. Position individual on the left side with the upper leg flexed or in knee-chest position. 2. Lubricate the dosage form with water-soluble lubricant or a small amount of water. If rectum is dry, instill 5 to 10 ml warm water with a syringe attached to a catheter before inserting tablet or capsule. 3. Do not crush controlled-release preparations. 4. Gently insert the dosage form approximately a finger's length into the rectum at an angle toward the umbilicus so that the medication is placed against the rectal wall. If a suppository is used, the blunt end should be introduced first. 5. Keep liquid volumes of drug preparations at less than 60 ml to prevent spontaneous expulsion. Amounts of 25 ml are usually retained without difficulty. These may be injected into the rectal cavity with lubricated rubber-tipped syringe or large-bore Foley catheter and balloon. Inflating the balloon may assist in retention. 6. Minimize the number of insertions. When administering multiple tablets for a single dose, enclose then in a single gelatin capsule. 7. Do not split or halve a suppository as this can cause error is dosing. If it must be halved, cut it lengthwise. 8. After the finger is withdrawn, hold the buttocks together until the urge to expel has ceased. 9. Although rectal irritation is a concern, it need not be a limiting factor when administering commercially prepared suppositories, tablets, or capsules. Irritation may be avoided or treated with lubrication, gentle insertion, and appropriate topical medications, such as cortisone ointment. 10. Prevent chronic rectal irritation. Avoid repeated rectal instillation of solutions of drugs with alcoholic vehicles or drugs that use glycols as solubilizing agents (parenteral forms of lorazepam, diazepam, chlordiazepoxide, and phenytoin). 11. Avoid rectal administration of enteric-coated tablets. The ph of the colon is alkaline and these preparations need an acidic environment to be dissolved and the active drug to be released. The active drug would likely be expelled with the coating intact. 10

11 TITLE: ADMINISTRATION OF CONTINUOUS SUBCUTANEOUS PAIN MANAGEMENT INFUSIONS POLICY: Hospice/Palliative care patients may use this method of pain control when/if IV access is unavailable or inappropriate; or oral analgesia is ineffective or not tolerated; or alternative routes of analgesia are effective. PURPOSE: To control pain safely and effectively by means of the subcutaneous route. EQUIPMENT: 25 or 27 gauge butterfly/sq needle Povidone-iodine swabs Alcohol swabs Sterile gloves Transparent dressing 2x2 inch gauze sponge Infusion pump Pump supplies PROCEDURE: 1. RN will assess client s pain, including location, duration, quality and intensity. Determine if client has any allergies (sensitivities) to medications, iodine, tape, etc. 2. Physician s order will be obtained for medication, dose, route and use of pump. Obtain order for both continuous and bolus infusions. Order should also include titration parameters, if authorized by prescribing physician. 3. Explain the procedure to the client and primary caregiver. Review signs and symptoms of adverse effects, side effects, toxicity and appropriate interventions. 4. Assemble equipment. Obtain prescribed solution and check concentration of medication against physician s order. Connect administration set to solution container. Place tubing in pump and prime as directed in pump instruction booklet. Attach SQ needle set and flush with solution. 5. Set correct setting on infusion pump to deliver solution as ordered by physician. Follow instruction in pump instruction booklet. 6. Place client in a well-lighted area in a comfortable position. It is recommended that the client remain on bedrest (up to BR with assistance) for the first 2 hours after medications are initiated due to the potential for orthostatic hypotension. After 2 hours, if the client tolerates dangling legs, activity may be resumed. 7. Select insertion site: A. Area of chest wall below clavicle and above the nipple line. B. Mid-abdomen above the umbilicus. C. Other sites, such as the upper arms or thighs, or the upper buttocks may be used. 8. Wash hands thoroughly with antibacterial soap and don gloves. 11

12 9. Insert subcutaneous needle: A. With the use of povidine-iodine swabs, cleanse a 3 inch area (diameter) over selected insertion site using a circular motion from the center outwards for 1 minute. B. After 30 seconds, wipe area with alcohol swab. C. If client is sensitive to iodine, scrub area with 70% alcohol for 1 minute and allow to air dry. D. Remove protective covering from subcutaneous needle or butterfly. E. Pinch a small area of skin at chosen insertion site and insert subcutaneous needle or butterfly at a 90 degree angle into subcutaneous tissue. F. Tape needle tabs to skin. Use a sterile 2x2 gauze to support needle if needed. G. Cover the area with a transparent dressing and secure tubing with tape. H. Site for the subcutaneous needle site should be changed every 7 days or if it develops any redness, leakage, or swelling. I. A single subcutaneous site can usually accept up to 2-3 ml. of solution per hour. Because of this, continuous SQ infusions generally need to be a highly concentrated solution. If the infusion site surpasses 2-3 ml per hour, use a stopcock and two SQ infusion sets to branch the infusion into two sites. These sites can be placed as close as 2 inches apart as anatomy and tubing length allow. J. Confirm rate and concentration. Start infusion pump. 10. Write the time and date of placement of the infusion site on a small piece of tape and place it over the tape used to secure the site. 11. For approximately 30 minutes, observe the client for: A. Pain relief. B. Changes in respiratory status. C. Changes in LOC. If changes in respiratory status or LOC occur, reduce medication rate and notify physician for further orders. 12. If client reports effective pain relief and is clinically stable, titrate medication upward per physician s order to achieve optimal level of pain relief. 13. If client reports ineffective pain relief, notify physician and request change in orders or follow titration orders per original prescription to achieve optimal level of pain relief. 13. Instruct primary caregiver: A. To maintain medication infusion at the dose and rate prescribed by the physician. B. In assessing effectiveness of medication in reducing pain and actions to take if pain is not controlled. C. In controlling common medication side effects and intervention to take. D. In assessing for possible adverse reactions and interventions to take. E. In assessing for medication toxicity and interventions to take. F. In operation of infusion pump, if able. G. In observation of the subcutaneous insertion site. Notify nurse of any swelling, redness, or hardness at needle site. 14. Document: (initial and subsequent visits) A. Written and verbal instructions given and client/caregiver response. B. Description of pain(s). C. Level of pain(s) using a 1-10 scale 12

13 D. Medication, route, residual volume, infusion site, dose and rate of administration. Document when dose is changed. E. Time infusion started and rate at which infusion initiated. F. Change in infusion site; rotate sites. G. Client response prior to and 30 minutes after infusion started or changes in dose made. H. Signs and symptoms of medication side effects, adverse effects or toxicity and interventions taken. Notify physician if any of these occur. 15. Make a follow-up call to client/caregiver within 12 hours after initiation of therapy in order to monitor ongoing client status and response to medication infusion. Make a daily nursing contact (visit or phone conversation) until the client s desired level of pain management is achieved. 16. To discontinue infusion and site: A. Determine whether client will continue to require alternative analgesia after the pump is discontinued. B. If the client is to receive short-acting oral opioids, give the first scheduled dose 1 hour prior to stopping the infusion. If client is to receive a sustained release preparation, give the first scheduled dose 2 hours prior to stopping the infusion. C. Turn off pump. D. Loosen tape and pull infusion set straight out with a swift motion. Hold a 2x2 gauze sponge over site with pressure for 30 seconds. Dress site if indicated. 13

14 TITLE: ADMINISTRATION OF INTRAVENOUS PAIN MANAGEMENT INFUSIONS POLICY: Hospice/Palliative care patients may use this method of pain control when oral analgesia is ineffective or not tolerated; or alternative routes of analgesia are effective. PURPOSE: To control pain safely and effectively by means of the intravenous route. EQUIPMENT: Appropriate access device Povidone-iodine swabs Alcohol swabs Sterile gloves Transparent dressing 2x2 inch gauze sponge Infusion pump Pump supplies PROCEDURE: 1. RN will assess client s pain, including location, duration, quality and intensity. Determine if client has any allergies (sensitivities) to medications, iodine, tape, etc. 2. Physician s order will be obtained for medication, dose, route and use of pump. Obtain order for both continuous and bolus infusions. Order should also include titration parameters, if authorized by prescribing physician. 3. Explain the procedure to the client and primary caregiver. Review signs and symptoms of adverse effects, side effects, toxicity and appropriate interventions. 4. Assemble equipment. Obtain prescribed solution and check concentration of medication against physician s order. Connect administration set to solution container. Place tubing in pump and prime as directed in pump instruction booklet. 5. Set correct setting on infusion pump to deliver solution as ordered by physician. Follow instruction in pump instruction booklet. 6. Place client in a well-lighted area in a comfortable position. It is recommended that the client remain on bedrest (up to BR with assistance) for the first 2 hours after medications are initiated due to the potential for orthostatic hypotension. After 2 hours, if the client tolerates dangling legs, activity may be resumed. 7. Access existing IV device (i.e. Port-a-Cath, Groshong, PICC, etc). If central venous access is not available, obtain order to insert angiocath, midline cath or PICC line. Follow procedures for inserting these devices. 8. Confirm rate and concentration of infusion. Start pump. 9. Write the time and date of placement of the infusion site on a small piece of tape and place it over the tape used to secure the site. Infusion site and tubing must be changed every 48 to 72 hours or as needed. 10. For approximately 30 minutes to 1 hour, observe the client for: 14

15 B. Pain relief. C. Changes in respiratory status. D. Changes in LOC. 11. If changes in respiratory status or LOC occur, reduce medication rate and notify physician for further orders. 12. If client reports effective pain relief and is clinically stable, titrate medication upward per physician s order to achieve optimal level of pain relief. 13. If client reports ineffective pain relief, notify physician and request change in orders or follow titration orders per original prescription to achieve optimal level of pain relief. 14. Instruct primary caregiver: A. To maintain medication infusion at the dose and rate prescribed by the physician. B. In assessing effectiveness of medication in reducing pain and actions to take if pain is not controlled. C. In controlling common medication side effects and intervention to take. D. In assessing for possible adverse reactions and interventions to take. E. In assessing for medication toxicity and interventions to take. F. In operation of infusion pump, if able. G. In observation of the intravenous insertion site. Notify nurse of any swelling, redness, or hardness at needle/catheter site. 15. Document: (initial and subsequent visits) A. Written and verbal instructions given and client/caregiver response. B. Description of pain(s). C. Level of pain(s) using a 1-10 scale D. Medication, route, residual volume, infusion site, dose and rate of administration. Document when dose is changed. E. Time infusion started and rate at which infusion initiated. F. Change in infusion site; rotate sites. G. Client response prior to and 30 minutes after infusion started. H. Signs and symptoms of medication side effects, adverse effects or toxicity and interventions taken. Notify physician if any of these occur. 16. Make a follow-up call to client/caregiver within 12 hours after initiation of therapy in order to monitor ongoing client status and response to medication infusion. Make a daily nursing contact (visit or phone conversation) until the client s desired level of pain management is achieved. 17. To discontinue infusion and site: A. Determine whether client will continue to require alternative analgesia after the pump is discontinued. B. If the client is to receive short-acting oral opioids, give the first scheduled dose 1 hour prior to stopping the infusion. If client is to receive a sustained release preparation, give the first scheduled dose 2 hours prior to stopping the infusion. C. Turn off pump. D. If client has an IV site or needle access to Port-a-Cath, loosen tape, remove dressing and pull infusion set straight out with a swift motion. Hold a 2x2 gauze sponge over site with pressure for 30 seconds. Dress site if indicated. 15

16 TITLE: ADMINISTRATION OF CONTINUOUS EPIDURAL PAIN MANAGEMENT INFUSIONS POLICY: Hospice/Palliative care clients may require administration of a spinal narcotic via an epidural catheter for pain control if alternative routes of analgesia are not effective. PURPOSE: To control pain safely and effectively for Hospice/Palliative care patients by means of the epidural route. GENERAL INFORMATION: 1. Epidural catheter placement and medications shall be initiated in the acute care setting. 2. Medications infused via an epidural catheter should be preservative free. 3. DO NOT USE ALCOHOL FOR SITE CARE OR ACCESSING. Alcohol can cause nerve damage. 4. A 0.2 micron filter should be used for medication preparation and infusion. 5. The epidural catheter may be aspirated to check placement. 6. A closed system shall be maintained. 7. Documentation shall be made (from direct physician report or xray report) of the exact position of the catheter tip. 8. Bathing cover the external catheter and exit site with a waterproof dressing. After showering, the exit site should be cleansed and redressed. 9. If the filter becomes loosened or dislodged, clean the catheter hub and replace the filter with a new filter. DO NOT USE THE SAME FILTER. EQUIPMENT: Infusion pump capable of delivering at least 400mmHg of pressure. No-port infusion tubing Povidone-iodine swabs Sterile gloves Mask, if appropriate PROCEDURE: 1. RN will assess client s pain, including location, duration, quality and intensity. Determine if client has any allergies (sensitivities) to medications, iodine, tape, etc. 2. Physician s order will be obtained for medication, dose, route and use of pump. Obtain order for both continuous and bolus infusions. Order should also include titration parameters, if authorized by prescribing physician. 3. Explain the procedure to the client and primary caregiver. Review signs and symptoms of adverse effects, side effects, toxicity and appropriate interventions. 4. Assemble equipment. Obtain prescribed solution and check concentration of medication against physician s order. Connect administration set to solution container. Place tubing in pump and prime as directed in pump instruction booklet. 5. Set correct setting on infusion pump to deliver solution as ordered by physician. Follow instruction in pump instruction booklet. 16

17 6. Make conversion from IV to epidural dosing according to equianalgesic dosing, i.e. IV morphine to epidural dosing is approximately 10 to 1, 5 to 1 for hydromorphone and 3:1 for fentanyl.. 7. It is recommended that the client remain on bedrest as per physician s order. Increase activity as per physician s order. 8. Wash hands thoroughly with antibacterial soap and don sterile gloves. 9. Clean hub of epidural catheter with povidone-iodine swab and let dry completely. 10. Remove old filter/administration set. 11. Luer-lock sterile syringe to epidural catheter and aspirate to check placement. Clear fluid of less than 1cc is indicative of epidural placement. Blood return of more than 1 cc is significant for venous or subarachnoid placement. 12. Luer-lock primed filter/administration set to epidural catheter. 13. Confirm rate and concentration of infusion per physician s order. Start infusion pump. 14. Mark line as epidural if other lines are present. 15. Tape all tubing and filter connections to avoid accidental dislodging For approximately 1 hour, observe the client for: A. Pain relief. B. Changes in respiratory status. C. Changes in LOC. 17. If changes in respiratory status or LOC occur, reduce medication rate and notify physician for further orders. 18. If client reports effective pain relief and is clinically stable, titrate medication upward per physician s order to achieve optimal level of pain relief. 19. If client reports ineffective pain relief, notify physician and request change in orders or follow titration orders per original prescription to achieve optimal level of pain relief. 20. Primary caregiver may be taught: A. To maintain medication infusion at the dose and rate prescribed by the physician. B. In assessing effectiveness of medication in reducing pain and actions to take if pain is not controlled. C. In controlling common medication side effects and intervention to take. D. In assessing for possible adverse reactions and interventions to take. E. In assessing for medication toxicity and interventions to take. F. In operation of infusion pump, if able. G. In observation of the epidural catheter site. Notify nurse of any swelling, redness, or hardness at catheter insertion site or if client develops fever Document: (initial and subsequent visits) A. Written and verbal instructions given and client/caregiver response. B. Description of pain(s). 17

18 C. Level of pain(s) using a 1-10 scale D. Medication, route, residual volume, infusion site, dose and rate of administration. Document when dose is changed. E. Time infusion started and rate at which infusion initiated. F. Client response prior to and 30 minutes after infusion started. G. Signs and symptoms of medication side effects, adverse effects or toxicity and interventions taken. Notify physician if any of these occur. 22. Nursing visits must be made as needed until the client s desired level of pain management is achieved. 23. Catheter Exit Site Care: Clean technique daily for one week after placement and then every other day for one month, then as needed. A. Assemble supplies: 1. gloves 2. hydrogen peroxide 3. povidone-iodine swabs 4. sterile cotton swabs 5. sterile 4x4 gauze sponge 6. tape of choice B. Wash hands thoroughly and don sterile gloves. C. Remove old dressing. Do not pull on catheter. D. Observe site for redness, swelling or drainage. Notify physician if any change in site appearance. E. Cleanse area around catheter exit site with a clean cotton swab dipped in hydrogen peroxide, working in a circular motion starting from the catheter site moving out 3 inches. F. Cleanse area around catheter exit site with a povidone swab, working in a circular motion starting from the catheter site moving out 3 inches. G. With a new providone-iodine swab, wipe the catheter gently starting from the catheter exit site down to the injection cap. H. Cover the exit site with a sterile gauze, being careful not to touch the side of the pad that will be touching the client. I. Secure the gauze pad in place with tape of choice. J. Loop the catheter over the dressing and tape in place. 24. Changing the filter and injection cap: Clean technique every 48 hours A. Assemble supplies: 1. sterile filter with preattached cap 2. sterile povidone-iodine swab 3. tape of choice B. Open package containing the new filter and injection cap. Remove the preattached injection cap if utilizing pump for infusion therapy. C. Attach filter to new tubing and prime filter with the medication solution that is in use. D. Remove the tape from the filter connected to the catheter. E. Wipe the area where the filter is attached to the catheter with a povidone-iodine swab and allow to dry. F. Remove old filter and discard. G. Attach the new filter. H. Tape connections between filter and catheter. 25. Report inadequate pain relief (i.e. a previously comfortable client reports loss of pain control) or no pain reduction with increase in opioid. This may indicate a displaced epidural catheter. 18

19 GUIDELINES FOR PAIN ASSESSMENT AND INTERVENTION FOR THE COGNITIVELY IMPAIRED DISCOMFORT INDICATOR SCALE FOR THE COGNITIVELY IMPAIRED 19

20 Guidelines for Pain Assessment and Intervention for the Cognitively Impaired PURPOSE: To provide a pain assessment tool that will allow caregivers and staff to effectively evaluate and intervene in the pain management of individuals who are unable to participate in the evaluation of discomfort because of cognitive impairment or inability to communicate. PROCEDURE: 1. The individual will be assessed for the ability to understand and use any pain intensity scale, i.e. verbal, numerical, PPI (Present Pain Index) or the Wong-Baker faces. Documentation of pain intensity will be made, if possible, according to the appropriate scale. The use of the PPI (Present Pain Index) is recommended for use in cognitively impaired individuals. 2. Document individual s usual discomfort behaviors on the initial pain assessment tool. Interview caregivers for their assessment of observed behaviors that may indicate discomforts. 3. Caregiver or staff will observe the individual for 3-5 minutes. This time frame will allow the observer to rule out any meaningless gestures or postures. 4. Observe the individual for the following behaviors: A. Noisy breathing B. Negative vocalization C. Sad facial expression D. Frightened facial expression E. Tense body language F. Fidgeting 5. Document behavior on the Pain Relief Diary for Cognitively Impaired. 6. If the individual has >3 discomfort indicators, perform a complete physical assessment to rule out discomfort due to physical symptoms, i.e., constipation, urinary retention, incontinence, pressure ulcer, fracture, comfort (hot or cold), hunger, or a need for position change. Look for signs of bruising that may indicate injury or for signs of localized infection. Treat those symptoms as indicated and reassess using the discomfort indicators. 7. If the individual continues to have multiple discomfort indicators, intervene with analgesic medication regime according to the physician s orders. 8. Attempt non-pharmacological interventions as indicated. 9. Reassess individual 1 hour post intervention for behavior changes. Document on the pain relief diary. New orders will be obtained if discomfort indicators persist at the same level 2 hours post intervention. 10. Instruct primary caregiver: A. To observe pain behaviors according to the discomfort indicator scale. B. To medicate as per analgesic medication regime. C. To assess effectiveness of medication in reducing pain and actions to take if pain not controlled. D. In controlling common medication side effects and interventions to take. E. In assessing for possible adverse reactions and interventions to take. 20

21 F. In assessing for medication toxicity and interventions to take. 11. Document: on initial and subsequent visits A. Written and verbal instructions given and caregiver response. B. Discomfort indicators observed by caregivers and staff. C. Client s response (by observed behaviors) prior to and after intervention. D. Signs and symptoms of medication side effects, adverse reactions, toxicity and interventions taken. Notify physician if any of these occur. E. Monitor documentation done by caregiver on the pain relief diary. Original copy to be placed on individual s chart. 12. New evidence of pain will require reassessment and re-observation. 21

22 DISCOMFORT INDICATOR SCALE FOR COGNITIVELY IMPAIRED Observe the individual for 3-5 minutes and check indicators that relate to observed behavior. A. Noisy breathing: 1. Respirations are strenuous, labored, loud, harsh or gasping. 2. Episodic bursts of rapid breaths or hyperventilation. B. Negative vocalization: 1. Noise or speech with negative or disapproving quality. 2. Hushed, low sounds such as constant muttering with a guttural tone. 3. Monotone, subdued, or varying pitched noise with a definite unpleasant sound. 4. Faster rate than a conversation or drawn out as in a moan or groan. 5. Repetitive words with a mournful tone. 6. Grunting or moaning. C. Sad facial expression: 1. Looking hurt worried, lost, troubled, distressed or lonesome. 2. Hang dog look. 3. Crying D. Frightened facial expression: 1. Scared, concerned looking face, fearful or troubled. 2. Alarmed appearance with open eyes and pleading face. E. Tense body language: 1. Extremities tense, wringing hands, clenched fists. 2. Knees pulled up tightly. 3. Strained and inflexible position. F. Fidgeting: G. Other: 1. Restless impatient motion, squirming or jittering. 2. Guarding of a body part. 3. Forceful touching, tugging or rubbing. 4. Rocking 5. Aggressive behavior 6. Hitting or biting 7. Irritable Adapted from: Hurley, A.C., Volicer, B.J.; Hanrahan, P.A.; Houde, S.; & Volicer, L (1992). Assessment of Discomfort in Advanced Alzheimer Patients. Research in Nursing and Health, 15,

23 mission granted to adapt provided by Beaver Dame Community Hospital, Beaver Dam, WI PAIN MANAGEMENT TOOLS PAINP I II PAIN ASSESSMENT TOOL PATIENT PAIN RELIEF DIARY III PATIENT PAIN RELIEF DIARY FOR COGNITIVELY IMPAIRED 23

24 Pain: a. [M0420] Frequency of Pain interfering with patient s activity or movement: 0 Patient has no pain or pain does not interfere with activity or movement 1 Less often than daily 2 Daily, but not constantly 3 All of the time b. [M0430] Intractable Pain: Is the patient experiencing pain that is not easily relieved, occurs at least daily, and affects the patient s sleep, appetite, physical or emotional energy, concentration, personal relationships, emotions, or ability or desire to perform physical activity? 0 No 1 Yes New Mexico Rural Hospice Network PAIN ASSESSMENT TOOL c. Patients Perceived Level: (Scale 0-10) 0 being no pain, and 10 being worst possible pain (If pain level is 0 go to #10 Integument). d. Drug, Dosage and # of doses taken by patient of ALL analgesics in 24 hours: e. Indicate which pain scale used: pictures words 0-10 Pain Intensity Rating Scale: None Annoying Uncomfortable Dreadful Horrible Agonizing 0 No Pain 2 Mild 4 Moderate 6 Severe 8 Very Severe 10 Worst Possible Location (describe) Present (circle number by location) At Worst (circle number by location) At Best (circle number by location) Characteristics Cues: aching, deep, dull, gnawing, sharp, stabbing, crampy, pressure, squeezing, burning, numb, radiating, shooting, tingling, touch sensitive How long has had this pain? Physical findings at the site of pain? What relieves pain? What makes pain worse? Pain Pattern Continuous Intermittent Continuous Intermittent Continuous Intermittent Non-Pharmalogical Methods (see key)? Non-Pharmalogical Methods Key: GI = Guided imagery S = Sleep R = Rest M = Massage GI M D S H RT R C E GI M D S H RT R C E GI M D S H RT R C E H = Heat application C = Cold application None used None used None used D = Distraction RT = Relaxation technique (check all that apply) (check all that apply) (check all that apply) E = Exercises Patient s Pain Intensity Goal (circle number by location) Patient s Overall Pain Control Goal (check all that apply by location) Sleep comfortably Comfort at rest Comfort with movement Total pain control Stay alert Perform activity Other: Sleep comfortably Comfort at rest Comfort with movement Total pain control Stay alert Perform activity Other: Sleep comfortably Comfort at rest Comfort with movement Total pain control Stay alert Perform activity Other: Anterior Posterior Permission granted to modify or adopt provided by Northwest Wisconsin Home Care. 24

25 Patient Pain Relief Diary New Mexico Rural Hospice Network Pain Medication Dose & Route DATE: MR # Mark all sites of pain with # NAME: My goals include: Pain intensity goal Overall activity goal PAIN RATING PRIOR PAIN RATING 1 HOUR TO TAKING MY AFTER TAKING MY MEDICATION MEDICATION DATE TIME PAIN MEDICATION PAIN RATING NON-PHARMACO- PAIN RATING SITE I TOOK None Moderate Severe LOGICAL INTERVENTION None Moderate Severe Refer to numbered site in "Pain Site" column

26 Patient Pain Relief Diary for Cognitively Impaired New Mexico Rural Hospice Network Pain Medication Dose & Route DATE: MR # NAME: Goals include: DISCOMFORT INDICATOR SCALE A. Noisy Breathing Pain intensity goal B. Negative Vocalization Overall activity goal C. Sad Facial Expression PPI DISCOMFORT INDICATOR DISCOMFORT INDICATOR D. Frightened Facial Expression RATING PRIOR TO 1 HOUR AFTER DATE TIME 0-5 MEDICATION TAKING MEDICATION NON-PHARMACO- TAKING MEDICATION GIVEN LOGICAL INTERVENTION E. Tense Body Language F. Fidgeting G. Other H. No Indicators Present PPI RATING SCALE 0. No Pain 1. Mild 2. Discomforting 3. Distressing 4. Horrible 5. Excruciating 26