F-tag 309 for Pain

Case Study

Case Study – Hazel P

72 yr old female admitted to facility late Friday afternoon from acute hospital after fall at home. In hospital she had Rt. hip surgery 2 days ago. Other pertinent diagnoses include diabetes, COPD, CAD, CHF, HTN, anemia, osteoporosis, depression, peripheral vascular disease, osteoarthritis, & dementia.

What do we know already?Pain is likely to be an issueDifferent types of pain are likely

Acute post operative bone & muscle pain (rt. hip fx.)

Potential chronic muscle & joint pain from osteoarthritis, osteoporosis

Potential cardiac pain (CAD, CHF)

Potential neuropathic pain (DM)

Communication may be an issue (Dementia)

Hazel’s Assessment

When you enter the room to perform the pain assessment you observe:

Hazel in bed, grimacing & seems tense

She is verbal, responds to her name, but confused

When you ask if she has pain she says “Yes”

When you ask where she says “all over”

What is the next step?

Assessment Tools for Cognitively Impaired

You correctly decide to use a tool for residents with dementia

Choices – PACSLAC or PAINADHazel scores a 6 on the PAINAD

indicating that she does have pain

Physical Exam

During your physical exam of Hazel, you notice she resists against movement of her upper extremities saying “that hurts”

She also c/o pain when you touch her lower legs

You start to turn her to observe her surgical site but she also cries out that it hurts

What should you do at that point?

Impacts on QOL

After medicating Hazel for pain, you complete your exam, you ask the CNA to get Hazel her dinner & assist her to eat

A few minutes later the CNA returns & reports that Hazel did not want to eat stating she wasn’t hungry

What is a potential cause?

Finishing the Assessment

Comprehensive assessments cannot always be completed in a single shift

In cognitively impaired residents, additional information may be needed

Nurses must take the time to observe behaviors, response to pain medication, etc.

Surrogate Informants

Family members can be great sources of information

Surrogates such as children, spouses or close friends

If not present during admission, call within the first 24 hrs

CNAs can also help complete assessment based on their observations during care

Hazel’s Daughter Reports

Hazel has frequent moderate to severe pain in her joints & her legs hurt, burn almost all the time

Hazel’s pain is worse with movement

Hazel can report pain but not how bad it is

Hazel cries out when pain gets really bad but otherwise will not say anything unless moved

Pain improves with analgesics & correct positioning

Her daughter emphasizes that she wants her mom to be comfortable at all times

Assessment Documentation

Is Hazel able to self report?Surrogate report on average & worst

pain?PAINAD Score Behavioral Pain IndicatorsPain LocationPain Pattern

Assessment Documentation

Acute painful conditionsDiagnosis (es) Impact on function & quality of lifeCurrent therapeutic regimen from

physician ordersRecommended changes to treatment

plan – plan not yet developed

Were Pain Assessment Standards Met? History of pain & its treatment

Characteristics of pain

Impact of pain on quality of life

Factors that precipitate pain

Strategies or factors that reduce pain

Associated pain symptoms

Physical Examination

Current medical condition & medications

Resident goals for pain management

In Summary

Facilities & staff are responsible for ensuring residents obtain their highest practicable level

Residents must be involved in their pain management & their individual needs & goals should be basis of care plan

Care must be individualized based on a comprehensive assessment &MUST meet clinical standards of quality

Staff must monitor continuously & revise when necessary in a timely manner

Staff must communicate resident status or change of condition with health care practitioners, resident, & family

Staff must document accurately

QUESTIONS?

Adapted and used with permission of D. Bakerjian, PhD, MSN, APRN, University of CA, San Francisco, 2009.