Gerontological Nursing

Fourth Edition

Chapter 9
Pain Management

Copyright © 2019, 2014, 2010 Pearson Education, Inc. All Rights Reserved
 Introduction
• Pain is a common unpleasant sensation experienced by all
human beings at some point during their lives.
• This complex phenomenon is both a sensory and emotional
experience that impacts many aspects of an older person’s
life.
• Older adults are at particular risk for experiencing both acute
pain and persistent pain.
• Nurses working with the older adult population must be
educated in appropriate pain assessment and management
techniques.
Normal Changes of Aging
• Certain types of visceral pain may be less severe in the
older adult, and researchers have found that pain scores
for renal colic, pancreatitis, appendicitis, and migraine
headache decreased as age of the patient increased.
Acute Pain in Older Adults
• It is important for the nurse to adequately identify the
source of the pain and facilitate treatment of the
underlying disease or trauma whenever possible.
Persistent Pain in Older Adults
• Persistent pain that continues over a prolonged period of
time affects one in five adults ages 65 and older.
• This type of pain may not be related to a well-defined
disease process.
• Depression can exacerbate pain.
 Pain Assessment Techniques
• Pain is measured subjectively according to the patient’s self-
report or by careful observation in the nonverbal or who has
severe cognitive impairment.
• A comprehensive clinical assessment for pain is multifaceted
and should include a medical and pain history, a physical
exam, and diagnostic testing.
Categories for Pain Interview
Questions
• Pain history
• Distinguish acute from persistent pain
• Location
• Frequency
• Intensity
• Alleviating and aggravating factors
• Associated symptoms
• Response to previous and current analgesic therapy
• Meaning of the pain
Pain Assessment in the Person with
Severe Cognitive Impairment (1 of 2)
• For those unable to verbally communicate their pain
experience, pain often goes undertreated or untreated.
• The nurse should assess for the presence of pain-related
behaviors.
Pain Assessment in the Person with
Severe Cognitive Impairment (2 of 2)
• Six main types of pain behaviors and indicators in older
adults with dementia:
– Facial expression
– Verbalizations/Vocalizations
– Body movements
– Changes in interpersonal interactions
– Changes in activity patterns or routines
– Mental status changes
The Art and Science of Pain Relief
• The goal of ideal pain management is to relieve both
acute and persistent pain with appropriate
pharmacological and nonpharmacological techniques
while minimizing side effects.
Pharmacological Management
• Pain management in the older adult may be more difficult
due to age-related changes such as declines in renal and
hepatic function and changes in body fat and water
distribution.
• The World Health Organization (WHO) has developed a
“Pain Relief Ladder” to aid in the administration of the
appropriate pain-management plan.
• More than one medication may be necessary to achieve
pain control.
– Nonopioid Analgesics
– Opioid Analgesics
Preventing and Managing Adverse
Effects
• Constipation
• Sedation
• Respiratory depression
• Nausea and vomiting
• Myoclonus
• Pruritis
Adjuvant‫ مساعد‬Drugs for Older
Patients with Pain (1 of 2)
• Examples of adjuvant drugs that nurses may see used in
the clinical setting include:
– Tricyclic antidepressants
– Mixed serotonin- and norepinephrine-uptake inhibitors
– Anticonvulsants
– Corticosteroids
Adjuvant Drugs for Older Patients
with Pain (2 of 2)
• Examples of adjuvant drugs that nurses may see used in
the clinical setting include:
– Topical analgesics
– Muscle relaxants
– Antianxiety medications
– Calcitonin and bisphosphonates
Special Pharmacological Issues (1 of
2)
• With the increased use of opioids in pain management
there is major concern among clinicians, families, and
patients that older adults will become addicted to these
drugs.
• Nurses should urge patients to seek further diagnostic
testing and evaluation of persistent illnesses when the
need for opioid medication increases suddenly, rather
than assuming that tolerance to opioids is the underlying
issue.
Polypharmacy
• Polypharmacy is the excessive or unnecessary use of
medications, both prescription and nonprescription.
Pharmacological Principles for
Successful Pain Management
• The least invasive method of drug delivery should be
used.
• The oral administration of pain medications is the
preferred means of controlling pain in the older adult.
• Pain management is most effective when it is
administered around the clock with the goal of preventing
the occurrence of pain.
Complementary and Alternative
Therapies
• Pain is among the most common reasons that adults use
complementary and alternative therapies.
• Older adults are increasingly using complementary and
alternative medicine therapies to manage painful
conditions, most commonly back pain, arthritis, and
headaches.
Consequences of Unrelieved Pain
• Depression, anxiety, decreased socialization, sleep
disturbance, impaired ambulation, and increased
healthcare costs have all been found to be associated
with the presence of pain in older people.
Your Rights as a Patient with Pain
• As a person with pain, you have a right to:
– Receive a complete assessment of your pain and an
opportunity to meet with physicians, nurses, physical
therapists, clinical pharmacists, and other healthcare
professionals.
– Be informed of the opinions of the pain-treatment
professionals regarding the origin of your pain, and
have the opportunity to give input into the treatment
plan.
Your Rights as a Patient with Pain
• As a person with pain, you have a right to:
– Be informed of the risks, benefits, treatment options,
and cost of treatment for your pain, including
copayments and out of pocket expenses.
– Receive timely and effective treatment for your pain.
– Receive ongoing pain assessment with modification
of the treatment plan as needed.
– Be referred to a pain specialist if your pain cannot be
relieved to your satisfaction.
• Although not required by law, these are the rights you
should expect for your pain care.
Analysis of the Pain Management
Plan
1. Review the initial pain assessment.
2. Analyze the alignment of the intensity of pain with the
analgesia provided.
3. Determine the older person’s medication requirement.
4. Provide feedback and documentation as needed to
refine the plan.
5. Use nondrug techniques to complement the analgesic
regimen.
6. Use all available resources in the clinical setting.