Pain and Comfort in Gerontological Nursing (Unit 10/11)
Overview and Multidimensional Nature of Pain
Definition of Pain: Pain is defined as a subjective sensation of physical, psychological, or spiritual distress.
Multidimensional Phenomenon: Pain is not a simple sensory experience; it is a complex, multidimensional phenomenon where one type of pain is usually intertwined with another.
Consequences of Pain: Beyond physical discomfort, pain has many profound consequences, including causing the individual to question the meaning of his or her own life.
Influences on Pain Expression
Individual History: The unique personal history of the individual significantly influences how they express pain.
Ascribed Meaning: Expression is affected by the specific meaning the individual ascribes to their pain.
Cultural Expectations: A person responds to pain in a manner that reflects their own cultural expectations and their understanding of what constitutes acceptable behavior in response to distress.
Classifications of Pain in Older Adults
Acute Pain:
Usually noncancerous and experienced late in life.
Characterized as being episodic in nature and temporary.
Examples include postoperative pain, procedural pain, or posttraumatic pain.
Considered a universal experience for all older adults at some point in their lives.
Often, acute pain is superimposed on a preexisting chronic pain condition.
Chronic Pain:
May develop insidiously as a specific disease progresses.
Can also manifest as a sequela (a condition which is the consequence of a previous disease or injury) to an episode of acute pain.
Prevalence: It is thought that the pain of more than of those living in the community is chronic.
Treatment Goals: For those suffering from persistent pain, the only realistic goals may be reducing the sensation and minimizing its effect on the individual’s quality of life and independence.
Barriers to Effective Pain Management
Provider and Patient Attitudes: Barriers stem from the attitudes and practices of nurses, other health care providers, and from those actually experiencing the pain.
Adherence and Reporting:
Issues with compliance regarding taking analgesic prescriptions.
A significant tendency for underreporting of pain by the patients themselves.
Economic and Safety Concerns:
The cost of medications.
Fear of potential side effects.
Psychological and Misconceptions:
Attributing pain to the normal burdens of "old age."
The belief that nothing can be done to alleviate the pain.
Fear of developing an addiction to pain medications.
Pain in Older Adults with Cognitive Impairments
Treatment Disparity: Pain is consistently untreated and undertreated in older adults who suffer from cognitive impairments.
The Clinical Assumption: Healthcare providers must assume that any condition that is painful to a cognitively intact person is also painful to a person who cannot express him- or herself.
Communication through Behaviors: Those who can no longer speak for themselves due to dementia or other neurological conditions (such as aphasia) communicate their pain through behaviors, such as:
Agitation.
Aggression.
Increased confusion.
Passivity.
Specific Pain Cues for Communication/Cognitive Limitations:
Changes in Behavior: Restlessness, agitation, repetitive movements, or unusually cautious movements and guarding.
Activities of Daily Living (ADLs): Sudden resistance to help, decreased appetite, and decreased sleep.
Vocalizations: Groaning, moaning, crying, or any general increase/decrease in vocalizations.
Physical Changes:
Pleading expression or grimacing.
Pallor or flushing.
Physical tension, such as clenching teeth or hands.
Diaphoresis (sweating).
Increased vital signs: increased pulse, respirations, or blood pressure.
Implications for Gerontological Nursing
Evidence-Based Practice: Expert pain management is a fundamental part of evidence-based practice.
Nursing Responsibilities:
Assuring the client is comfortable.
Ensuring the highest possible health-related quality of life regardless of the patient's cognitive status, functional status, or disease state.
Countering myths, stereotypes, and generalizations regarding aging and pain.
Myths and Facts Regarding Aging:
Myth: Pain is a normal part of aging.
Fact: Pain is NOT a normal part of aging; however, its occurrence does increase with age.
Myth: If clients do not complain of pain, they do not have pain.
Fact: There are multiple barriers to the report and interpretation of expressions of pain in all persons.
Pain Assessment Tools and Methods
History and Physical: Conduct a thorough history and physical examination specifically related to pain symptoms.
OLDCART Assessment Tool: A mnemonic for comprehensive assessment:
O: Onset.
L: Location.
D: Duration.
C: Characteristics.
A: Aggravating factors.
R: Relieving factors.
T: Treatment.
Self-Report: Utilizing a pain intensity rating on a scale.
Medication Review: Assessing medications currently used for treatment as well as those that have been tried in the past.
Specialized Scales for Cognitive Impairment:
PAINAD: Pain Assessment in Advanced Dementia scale.
PACSLAC: Pain Assessment Checklist for Seniors with Limited Ability to Communicate.
Management and Interventions
Management Goals:
Promote comfort.
Maintain the highest level of functioning and self-care possible.
Balance the risks and benefits of various treatment options.
Apply a holistic approach due to the complex nature of pain in later life.
General Pain Interventions:
Identify Reversible Causes: Determine if there is a cause that can be fixed, such as a urinary tract infection (UTI) or a fracture, and address it accordingly.
Comfort Measures: Use pillows for support/positioning, utilize appropriate and comfortable seating and mattresses, ensure frequent rest periods, and practice the pacing of activities.
Activity: Encourage the client to remain as active as possible within their personal comfort range.
Pharmacologic Treatments
Medication Classes: Includes analgesics (nonopioid and opioid agents) and adjuvant medications (antidepressants, anticonvulsants, and herbal preparations).
Age-Related Considerations: Nurses must consider age-related changes, specifically reduced kidney function, changes in the fat-to-muscle ratio, and reduced gastric motility.
Dosing Strategy: Medications should be started at the lowest dose possible and titrated up, summarized by the mantra: "Start low, go slow, but go!"
Timing: Around-the-clock dosing is considered best for the management of chronic pain.
Nonopioid Analgesics:
Acetaminophen: Used for common causes of physical pain like osteoarthritis and back pain. It is considered a first-line approach unless contraindicated. It generally does not cause gastrointestinal bleeding, renal, or cardiac effects.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Used when pain is derived from inflammation or during short arthritic flares. These are accompanied by a higher risk for adverse drug effects.
Opioid Analgesics:
Used to treat both acute and persistent physical pain.
Require the utmost caution when used with older adults.
Older adults may experience a greater analgesic effect, a higher peak, and a longer duration of effect.
Side effects: Gait disturbance, dizziness, sedation, falls, nausea, pruritus, and constipation.
Sedation risks: Increased risk for fall delirium and other geriatric syndromes.
Adjuvant Medications:
Usually used in conjunction with an analgesic but may be used alone.
Most effective for neuropathic pain syndromes (e.g., postherpetic neuralgia and diabetic nephropathy).
Tricyclic Antidepressants: Used less frequently due to adverse effects.
Anticonvulsants: Gabapentin is often used.
SNRIs: Duloxetine is often used.
Topical Agents: Capsaicin or Lidocaine patches may have mild to moderate local effects.
Nonpharmacologic Treatments and Evaluation
Nonpharmacologic Modalities:
Cutaneous nerve stimulation.
Transcutaneous electrical nerve stimulation (TENS).
Acupuncture and acupressure.
Touch therapy.
Biofeedback.
Distraction.
Relaxation, meditation, and imagery.
Referral to pain clinics.
Evaluation of Treatment:
Requires repeated reassessment of the client’s status and comfort level.
Indicators of Effectiveness:
Relaxation of skeletal muscles.
Increased activity level.
Increased sense of self-worth.
Increased ability to concentrate, focus, and increased attention span.
Improved ability to rest, relax, and sleep.
Verbal indication of absent or decreased pain.
Consistency: Use the same instruments that were used in the initial assessment to determine changes in the pain experience.