PAIN ASSESSMENT TOOLWinnipeg Health Region疼痛评估工具温尼伯卫生区文档资料.ppt
The Issue of Pain in the Cognitively Impaired,MDS data 2004-2007:74%of PCH residents have dementiaCognitively impaired are less likely to report painCognitively impaired are no less likely to experience painProfessional caregivers underestimate pain severityFamily members tend to overestimate pain,Case Study:Cognitively Impaired,Mrs.Imen PaneMedical Hx:Fractured right hip,right CVA,severe dementia,OA,degenerative spine disease,aphasic.Medications:Tylenol 650mg QID,Hydromorphone Contin 3mg q12h,Dilaudid 1 mg PRN,Sennosides ii tabs HS,Trazadone 100mg HSIncreasing agitated behavior and constantly rubbing her right hip,moaning,sometime shouting,not able to verbalize.Psychiatrist consulted for agitated behavior.,Mrs.Imen Pane,On exam:vital signs normal,R hip-no redness/warmth or tenderness on palpation,recent XR indicate no problems,bloodwork all normal.Grimaces when transferred or turned in bed.Family state that she used to have severe arthritis in her hips and knees and was on“high doses”of Dilaudid(but not sure how much).,Pain Assessment Tool,Is completed:on admission a change in medical condition occurs that may indicate the presence of new pain(eg.hip fracture)verbal and/or behavioural observations of pain are notedperson/family states that they are having pain,Pain Assessment for Cognitively Impaired,Self reports of pain are no less validAsk Are you in pain?Believe the persons report of painMay be able to use pain rating scales or answer yes-no questions about painAllow time to rate pain,ask more than once and in more than one wayAsk about present pain,Guidelines for Pain Assessment for Cognitively Impaired,Assume the presence of pain with certain disease,procedure or injury conditionsEstablish a baseline for behaviorMonitor for presence of pain on a regular basis using a comprehensive list of behaviorsIndicators for pain may not be obviousIf uncertain trial analgesics,Framework for Behavioral Pain Indicators(American Geriatrics Society),Facial expressions:clenched teeth,frowning,grimacing,sadVerbalizations/vocalizations:ouch,cursingNon-verbal:moans,groans,shouting,cryingBody movements:bracing,guarding,massaging affected areaRestlessness:agitation,rocking,Specific Behaviors,Observe at rest&movement,Framework continued,Changes in interpersonal interactionsChanges in activity patterns or routinesMental status changes,Subtle behaviors,Require assessment over time&/or collateral,Pain Assessment for Cognitively Impaired,Gather information from multiple sources to determine history of pain reaction and previous reactions to painDoes the family believe the patient has pain?,Pain Assessment for Cognitively Impaired,Assess for unmet needs:eg.hunger,thirst,elimination emotional needs Rule out other possible causes of pain:eg.infection,constipation,wound,undetected fractures,UTI,Identify Cause(s)of Pain,Review persons:Current and past medical conditions and surgeriesCurrent and previous medicationsPhysical examinationRelevant laboratory and diagnostic tests*Scope of assessment depends on persons care goals.,Physical Exam,Overall impression/appearanceFacial expressionBody position and movementAreas of redness,swelling,warmthPalpation,tendernessFocused assessment:eg.chest pain,Pain Assessment Tools for the Cognitively Impaired,Includes only specific behaviors,lacks subtle behaviors,direct observation focusedCompleted by the nurse/teamScores correlate with 0-6 scale with 0:no pain and 6:as bad as it can beLimited researchSimple&Easy to use,Checklist of Nonverbal Pain Indicators CNPI,Pain Assessment Tools,Non-Communicative Patients Pain Assessment InstrumentIncludes Specific behaviors onlyDesigned for use by health care aidsReliable but should accompany more comprehensive assessment,NOPPAIN,CCHSA Accreditation standards,A new Required Organizational Practice for 2009 will be:“Develop and implement an organizational policy and protocol to identify and treat cognitively impaired residents requiring effective pain management”,Management,Non-PharmacologicPharmacologic,Non-Pharmacologic,Wide range of potential interventionsProvision for other needsReassurance,contactMassage,heat,icePhysiotherapy modalities,Pain Pills,Pharmacologic management includes four general drug groups:AcetaminophenNSAIDsOpioidsNeuropathic pain meds(antidepressants,anticonvulsants),Pain Med-Cognition Quandary,All pain pills but acetaminophen can adversely affect cognition,especially in high-risk people such as those with dementia,frailtyPain can impair cognitionChronic pain causes depression,which impairs cognition,Pain Meds and Cognition,Opiates-sedation,deliriumNSAIDs-deliriumAnticonvulsants-sedation,cognitive effectsTricyclics-anticholinergic effect and sedation,So what to do?,Difficult area to study,few studiesDementia further complicates assessment of benefit,Pain Meds for Agitation,People with severe dementia may not be able to report painAgitation(BPSD-Behavioral and Psychiatric Symptoms of Dementia)is common in dementiaSome BPSD may be triggered by unreported pain,Empiric Analgesia,2 small placebo-controlled cross-over trials of pain meds for BPSDOpiates-10 mg BID of oxycodone SR or 20 mg daily of morphine SR vs placebo in 25 patientsSome reduction in BPSD among those over age 85 with little observed sedation,Empiric Analgesia,Acetaminophen 1 g TID vs placebo in 25 patientsSmall improvements in some observed interactions on Dementia Care MappingNo difference in BPSD,So Really,What To Do?,Assess for painSuspect pain as a cause of BPSD Treat pain or suspected painStart Low,Go Slow,What to do,Try non-pharmacologic managementBut may be difficult to implement and assess benefit due to dementiaTry medicationStart with scheduled acetaminophen,about 1 g TID,What to do,Consider topical non-steroidals for pain localized to an exposed joint(e.g.knee)If ongoing pain,consider trial of opiatesNo evidence-base to favor one over anotherUse recognized pain management principles i.e.basal analgesic with breakthrough prn,What to do,Consider adjunctive analgesics depending on diagnosisConsult a specialist,Serial Trial InterventionDr.Christine Kovach,Behavior Change Identification,Behavior Change Identification,1 PHYSICAL,Target,If behavior continuesProceed to 2,Serial Treatment,Serial Assessment,2 AFFECTIVE,Serial Trial Intervention,2 AFFECTIVE,Target,If behavior continuesProceed to 3,3 Trial:non-pharmacological comfort,4 Trial:analgesics,5 Consultation or trial psychotropic,Study of STI,114 subjects in 14 nursing homesSTI intervention by trained nurses or control group with usual careSTI nurses assessed more,gave more interventions including medsSTI subjects had less discomfort,Case Study:Cognitively Impaired,Mrs.Imen PaneMedical Hx:Fractured right hip,right CVA,severe dementia,OA,degenerative spine disease,aphasic.Medications:Tylenol 650mg QID,Hydromorphone Contin 3mg q12h,Dilaudid 1 mg PRN,Sennosides ii tabs HS,Trazadone 100mg HSIncreasing agitated behavior and constantly rubbing her right hip,moaning,sometime shouting,not able to verbalize.Psychiatrist consulted for agitated behavior.,Mrs.Imen Pane,On exam:vital signs normal,R hip-no redness/warmth or tenderness on palpation,recent XR indicate no problems,bloodwork all normal.Grimaces when transferred or turned in bed.Family state that she used to have severe arthritis in her hips and knees and was on“high doses”of Dilaudid(but not sure how much).,Mrs.Imen Pane,The nurse gives Mrs.Pane a hot pack and puts on some music in her room.She ensures that Mrs.Pane has had something to eat and drink and her incontinence product changed.Mrs.Pane settles for a short while but then starts to become agitated and moaning again.The nurse then gives a breakthrough dose of Dilaudid 1mg Prn and checks in on her one hour later.Mrs.Pane is less agitated and resting more comfortably.,Questions?,Thank You!,References,Bjoro K,Herr K.Assessment of pain in the nonverbal or cognitively impaired older adult.Clin Geriatr Med.2008;24(2):237-262.Chibnall JT,et al.Effect of acetaminophen on behavior,well-being,and psychotropic medication use in nursing home residents with moderate-to-severe dementia.J Am Geriatr Soc.2005;53(11):1921-29.Horgas AL,Elliott AF,Marsiske M.Pain assessment in persons with dementia:Relationship between self-report and behavioral observation.J Am Geriatr Soc.2009;57(1):126-132.Kovach C,et al.The serial trial intervention:An innovative approach to meeting needs of individuals with dementia.J of Geront Nurs 2006;18-27.Kovach C,et al.Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.Am J of Alzheimers Dis Other Demen 2006;21:147-155.Manfredi PL,et al.Opioid treatment for agitation in patients with advanced dementia.Int J Geriatr Psychiatry.2003;18:700-705.McAuliffe L,Nay R,Odonnell M,fetherstonhaugh D.Pain assessment in older people with dementia:Literature review.J Adv Nurs.2009;65(1):2-10.Pesonen A et al.Evaluation of easily applicable pain measurement tools for the assessment of pain in demented patients.Acta Anaesthesiol Scand.2009;53(5):657-664.Reynolds KS et al.Disparities in pain management between cognitively intact and cognitively impaired nursing home residents.J Pain Symptom Manage.2008;35(4):388-396.Scherder E,et al.Pain in dementia.Pain.2009;1-3.Schofield P.Assessment and management of pain in older adults with dementia:A review of current practive and future directions.Current Opinion in Supportive and Palliative Care.2008;2(2):128-132.WRHA Pain Assessment and Management Clinical Practice Guidelines.June 2008.,
