Carolinas HealthCare System
Blue Ridge
Pain Management(Long Term Care Only)
“Pain” is an unpleasant sensory and emotional experience that can be acute,
recurrent or persistent and is “whatever the person says it is, existing whenever
he/she says it does” (Teno et al.). It is also known as the “Fifth Vital Sign.” The
following are descriptions of several different kinds of pain:
“Acute Pain” is generally pain of abrupt onset and limited duration,
often associated with an adverse chemical, thermal or mechanical
stimulus such as trauma, surgery and acute illness.
“ Breakthrough Pain” refers to an episodic increase in (flare-up) pain in
someone whose pain is generally being managed by his/her current
medication regimen.
“ Incident Pain” refers to pain that is typically predictable and is related
to a precipitating event such as movement (e.g., walking, transferring, or
dressing).
“Persistent Pain” or “Chronic Pain” refers to a pain state that
continues for a prolonged period of time or recurs more than
intermittently for months or years.
Pain in Long Term Care
As many as 83% of nursing home residents experience pain that impairs mobility,
may cause depression, and diminish their quality of life. In 2009, the rate of
persistent pain recorded in nursing homes varied from 37.7% - 49.5%. Yet, the
majority of the states were near 40%. Most chronic pain in nursing homes is related
to arthritis and musculoskeletal problems. Pain may be associated with mood
disturbances as well (depression, anxiety, and sleep disorders).
Common Pain Misconceptions
Among Residents Among Staff
• Pain is a normal part of aging • Pain is a normal part of aging
• Pain is a punishment for past actions • Cognitively impaired residents have a
• Pain medications are addictive high tolerance for pain
• Pain medications have bad side effects • Narcotics will hasten death
• Taking pain medication means I’ll loose my • Residents complain more as they age
independence and mental clarity • Elderly have decrease sensation of pain
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• Pain means death is near • Potent analgesics are addictive
• Acknowledgement of pain is a weakness • Cognitively impaired residents don’t feel
• Nurses don’t have time to give extra medications pain
American Medical Directors Association (AMDA)
Pain Management Steps
1. Recognition/Assessment 2. Treatment 3. Monitoring
1. PAIN RECOGNITION/ASSESSMET
All residents receive a Comprehensive Pain Assessment on admission. Pain is
also evaluated during the weekly nursing assessment and prior to providing any
type of pain medication. Pain is an experience that is highly individualized and
multidimensional. The resident and family’s account of their pain experience is
your most valuable assessment tool. Avoid assumptions – not all residents want
to be completely pain free. Listen carefully for clues about the meaning of pain
and observe for emotional responses, as they tell of their pain experience.
Assessment includes not only resident vocalization of pain but observation of
nonspecific signs and symptoms that suggest the presence of pain:
Frowning, grimacing, fearful facial expressions, grinding of teeth
Bracing, guarding, rubbing
Fidgeting, increasing or recurring restlessness
Striking out, increase in agitation
Eating or sleeping poorly
Sighing, groaning, crying, breathing heavily
Inability to participate in activities of daily living (ADLs)
Change in behavior (especially cognitively impaired residents)
Evaluation of any type of pain includes: Location (where); Onset (time it first
started); Frequency (how often); Quality (description); Intensity (pain scale)
Pain Scales Used In BLUE RIDGE Long Term Care
These scales can be found on the resident’s Pain Management Flow Sheet and should be
used prior to the administration of pain medication and at least one hour after administration.
Numeric Scale Indicators of Pain or Possible Verbal
Pain Descriptor Scale
1. Non-verbal sounds (crying,
whining, grasping, moaning, 1. Mild
groaning) 2. Moderate
2. Vocal complaints of pain (that 3. Severe
hurts, ouch, stop)
4. Very Severe,
3. Facial expressions (grimaces,
winces, clenched teeth or jaw)
horrible
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4. Protective body movements or
postures (bracing, guarding,
rubbing, clutching or holding
body part)
2. PAIN TREATMENT
There are a wide range of pharmacologic, physical and behavioral treatments
related to the differing types of pain. Alternative methods for pain relief should
always be attempted prior to medication use.
Alternative Therapies
• Resident/Family Education
• Exercise
• Physical/Occupational Therapy
• Restorative Nursing
• Positioning (braces, splints, wedges)
• Books on tape
• Activity
• Music/Art Therapy
• Hot/cold packs
• Massage Therapy
• Psychological/Spiritual Counseling
• Aromatherapy
Pharmacological Management
(AMDA General Principles for Use of Analgesics)
• Least invasive route first
• Start with PRN and then switch to
regular dosing if resident uses more
than occasionally
• Start with the lower regular dose and
use PRN for breakthrough pain
• Adjust regular/routine dose depending on
frequency/severity of breakthrough pain
• For acute pain – begin with low or moderate
dose and titrate more rapidly
• For chronic pain – begin with low dose and
titrate until comfort is achieved
• Use the appropriate medication for the pain
the resident is experiencing (e.g., not
using a narcotic for a headache)
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• If pain medication is delayed until the pain is
severe, there is no benefit to the resident
3. MONITORING
Questions to ask:
1. Does the resident have pain relief?
The Pain Management Flow Sheet should be utilized to document the
resident’s pain before implementing the appropriate pain medication and
pain level after medication. Any alternatives to medication should also be
documented on the flow sheet.
2. Are they experiencing any side effects?
Constipation, sedation, nausea and delirium are common side effects to
pain medication. Residents that are receiving routine pain medications
should also be on a routine bowel protocol and receive sufficient liquids to
assure regular bowel movements.
3. Has their functioning improved?
Improved functioning with the minimal amount of pain medication
intervention is the ultimate goal of pain management.
Remember the ABCs of Pain Management
A = Ask and assess pain management on a
regular basis
B = Believe the resident and family in their reports
of pain and what relieves it
C = Choose pain control options appropriate for the
resident and pain type
D = Deliver interventions in a timely, logical, and
coordinated fashion
E = Empower residents and their family and enable
them with as much control as possible
(Center for Gerontology and Health Care Research, Brown
University)
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