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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