PAIN (CHRONIC OR ACUTE) IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION

  • New, recurring, chronic or exacerbated pain
  • New diagnosis known to increase risk for pain: HZ, fall, skin breakdown, fracture, etc.
  • Increased analgesic use without adequate relief
  • Change in mental status, function, body language, respirations or vocalizations in the cognitively impaired
  • Reports of pain from family member in cognitively or language impaired resident

 CONTEXT/COMMUNICATION

All residents should be evaluated for these changes with treatment given to relieve pain. If the resident is moribund and/or suffering from an end-stage condition, pain should be managed in the context of the Palliative Care Guideline. The facility nurse should communicate with the responsible party and the MD or NP should regularly assure the resident and/or health care agent of the intention to manage the pain.  Balance realistic expectations with hopefulness.

 ASSOCIATED RISKS

  • Chronic conditions: osteoporosis, arthropathies, PHN, neurological disorders, diabetic neuropathy, compression fracture, ischemic disorders, depression, anxiety, myofascial pain syndromes, skin/mucosal irritation or breakdown, complex regional pain syndrome, PVD, post stroke syndromes
  • Functional: immobility, lack of independent movement, contractures, improper positioning, use of restraints
  • Psychological: somatization disorders, hysterical reactions, amputations
  • Ageism: underreporting, expectation of pain as part of normal aging

 PHYSICAL EXAMINATION

  • Pertinent to assess overall mental and physical status
  • Distinguish exacerbation of chronic pain from acute pain of new concurrent illness
  • Specific attention to painful area

 DIAGNOSTIC WORK-UP

  • Pertinent to presumed cause and type of pain
  • Pain assessment: PQRST
  • P - provocative (precipitating and palliative factors)
  • Q - quality (burning, stabbing, dull, throbbing, tender, pinching, etc.)
  • R - region (location, radiating)
  • S - severity (mild/annoying to worst possible/unbearable)
  • T - timing (when it occurs)

 TYPES OF PAIN

Nociceptive: actual or potential tissue damage

  • Somatic: skin, muscle, bone (aching, stabbing, throbbing, pressure)
  • Visceral: hollow viscous (gnawing, cramping, sharp, throbbing)
  • Nerve damage: (aching, burning, throbbing)
  • Ex: arthritis, trauma, ischemia, tumors, burns

Neuropathic: aberrant sensations in peripheral or central nervous system

  • “ Pins and needles" , dyesthesias, burning, shooting
  • ex: peripheral neuropathies, nerve trauma, post-stroke thalamic pain

Affective/idiopathic: perceived to be  excessive in relation to disease process

  • Anxiety and agitation may coexist

Iatrogenic: pain induced by therapeutic maneuvers

Other syndromes:

  • Chronic pain: > six months duration, often accompanied by functional, psychosocial impairments
  • Musculoskeletal pain syndrome
  • Headache syndromes

 TREATMENT OPTIONS

 

DRUG/DOSE

RECOMMENDATIONS/PRECAUTIONS

Mild: Tylenol 1000mg Q6 hr

Do not exceed 4 gm in 24 hours

Ibuprofen 600mg Q6-8 hr

 

Avoid if history gastritis or GI bleed, affects renal function. Better to avoid NSAIDs because of increased risk of CHF exacerbation. Weak narcotic preferable.

Trilisate 1000mg Q8-12 hr

Same as for NSAIDs or COX-2 Inhibitors

Moderate: Indocin 25mg Q8 hr

Do not exceed 10 day dose, similar toxicity to NSAIDs

Lortab 5-7.5 mg Q4 hr or T&C #3 Q4 hr

Anticipate constipation and possibly nausea

Titrate the above meds to effective and tolerated dose. If inadequate analgesia consider adjuvant drug* before proceeding to meds for severe pain. This approach would not likely be effective is death is imminent.

Severe: Ultram 50mg Q6 hrs (decrease to 50mg Q12 hrs for cr cl <30ml/min or cirrhosis)

If depression a component and not on antidepressant. Lowers seizure threshold.

Morphine sulfate 15mg p.o. or 10mg supp. p.r. or oral solution (Roxanal) 10mg p.o./s.l. or s.c Q 4 hrs

 

Short acting. Impacts on respiratory distress and function. When oral intake is likely to become impossible quickly, order suppository or subcutaneous form.

OxyContin 10mg Q 12 hrs

Titrate slowly and use short acting opiods for breakthrough pain

Nubain 10mg SC/IM Q3-4 hrs

Fast acting. short term use only. Do not use if on opiod

Methadone 5 mg Q12 hours & 5 mg Q4 hours PRN for breakthrough

Review every 6-7 days and increased - no ceiling dose

Duragesic 25mcg patch Q 3 days

Titrate slowly (Q 6 days) and use short acting opiods for breakthrough pain. This approach would not likely be effective is death is imminent.

ADJUVANT DRUGS*

 

Tegretol 100mg QD X 7 then BID

Lancinating pain (neuropathic or Trigeminal neuralgia) . check LFTs, CBC, BMP at baseline & Q4 weeks with Tegretol level

Neurontin 100mg QD or Lyrica 150 mg QD

Neuropathic - Increase at 5 day intervals

Doxepin or Pamelor (TCA) 10mg QHS or Desyrel 25mg HS

Neuropathic pain with sleep disturbance and not on antidepressant

Effexor 25mg BID

Neuropathic pain with depression, least anticholinergic effect

Baclofen 5mg TID or Valium 2mg Q8 hrs

Neuropathic pain with muscle spasms

Miacalcin nasal spray 200 IU QD

Bone pain, new compression fracture

Zostrix 0.025% cream QID. Not PRN or Lidocaine patch 1-3 patches for 12 hours a day

Joint pain, post herpetic neuralgia

 GENERAL RECOMMENDATIONS

  • Remind nurses to follow "Pain Control for Terminally Ill Nursing Assessment Guideline" and to contact providers accordingly.
  • Underlying (contributing) diseases should be managed optimally to reduce pain
  • Always review dosing schedule of PRNs with nursing before increasing analgesics. Often not given as ordered. Consider scheduling analgesics until acute pain under control and schedule before activities likely to exacerbate pain
  • If a resident has a history of effective pain management on a med not listed in this guideline and if there are no serious side effects or risks for this resident from the med consider using it
  • Consider starting GI protective med if on NSAID (Zantac 150mg BID)
  • If starting long acting analgesic make sure short acting analgesic available for breakthrough pain
  • Monitor bowel status and add or increase bowel meds to prevent constipation or impaction
  • " Start low and go slow" with analgesics but review pain management often until pain and quality of life is at maximum - make sure all nursing and psychosocial supports are in place to enhance effect of analgesics
  • Residents with chronic pain need regular reassessment (with scheduled visits) for improvement, deterioration, or complication attributable to treatment
  • Educate residents and families with realistic pain management possibilities - complete relief for chronic pain unlikely
  • Offer psychosocial and spiritual support services where requested or appropriate - consider alternative medicine when asked (i.e. massage therapy, naturopathic preparations, spiritual healing) - do not create a feeling of hopelessness
  • Referral to a multidisciplinary pain management center should be considered when pain management efforts do not meet the resident or HC agent's goals or when life-altering intractable pain is present

 

 References for Pain Management:

  1. AMDA: Chronic Pain management in the Long-Term Care Setting, Clinical Practice Guideline, 1999.
  2. Argoff, CE: Pharmacotherapeutic Options in Pain Management  in Supplement to Geriatrics, Nov. 2005.
  3. Brookoff, D: Chronic Pain: The Case for Opiods in Hospital Practice, September 15, 2001, 69-84.
  4. Coney, LM, Cefalu, CS: The Management of Chronic Pain in Older Persons, Clinical Practice Guidelines in Geriatrics, Vol. 53, Supplement 3, October, 1998.
  5. Cornacchione, M. et al: Chronic Pain Management in the Long-Term Care Continuum: Nonopiod and Opiod Analgesics in Supplement to Nursing Home Medicine, April, 2001, 1-4.
  6. Eastman, P.: Protocol Pinpoints Discomfort in Late-Stage Dementia Patients in Caring For The Ages, October 2001, 1 & 15-16.
  7. Ettinger, WH, Kella, AH: Chronic pain management in the elderly in Patient Care, September 30, 2001, 31-48.
  8. Ferrell, BA: Managing Pain and Discomfort in Older Adults Near the End of Life in Annals of Long-Term Care, Vol. 12, No. 12, February 2004, 49-55.
  9. Fine, PG: Pain and Aging: Overcoming Barriers to Treatment and the Role of Transdermal Opiod Therapy in Clinical Geriatrics, Vol. 8, No. 12, November 2000, 28-36.
  10. Grossberg, GT et al: Pain and Behavioral Disturbances in the Cognitively Impaired Older Adult: Assessment and Treatment Issues in Meeting Reporter, Supplement to Annals of Long-Term Care, August 2001.
  11. King, SA: Chronic Pain Control: What’s Adequate – and Appropriate? in Consultant, Vol. 43, No. 13, November 2003,1558-1573.
  12. McElhaney, JE: Chronic Pain in Older Adults in Consultant, March 2001, 337-344.
  13. Reuben, DB, Grossberg, GT et al: Pain in Geriatrics At Your Fingertips, 1998/99 Edition, 43-47& 37.
  14. Schneider, JP: Chronic pain management in older adults With coxibs under fire, what now? In Geriatrics, Vol. 60, No. 5, May 2005, 26-31.
  15. Starr, C.: Opiod analgesia: An essential tool in chronic pain in Patient Care, July 15, 1998, 47-66.
  16. Thomas, DR, et al: The Management of Chronic Pain in Long-Term Care Settings in Supplement to Annals of Long-Term Care, November 2001.
  17. Wallach, S., Beier, MT, et al: Innovative Treatment of Osteoporosis in Annals of Long-Term Care, satellite symposium, March 5, 1999, 1-11.
  18. Wrede - Seaman, L.: Symptom Management Algorithms A Handbook for Palliative Care, 2nd Edition, 1999.

MS/10.99
©EMS
Revised 3.06

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