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F-tag 309 for Pain
Case Study
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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.
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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)
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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?
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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
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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?
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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?
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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.
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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
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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
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Assessment Documentation
Is Hazel able to self report?Surrogate report on average & worst
pain?PAINAD Score Behavioral Pain IndicatorsPain LocationPain Pattern
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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
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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
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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
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QUESTIONS?
Adapted and used with permission of D. Bakerjian, PhD, MSN, APRN, University of CA, San Francisco, 2009.