- Email: [email protected]
Chronic Pain in the Elderly: A Continuing Education Program for Certified Nursing Assistants
Chronic Pain in the Elderly: A Continuing Education Program for Certified Nursing Assistants Paula Siciliano, APRN, MSN, GNP-C, and Rebecca Burrage, APRN, MSN, GNP-C One of the greatest challenges facing nursing today is the provision of proper pain management in patients suffering from both acute and chronic pain. The purpose of this article is to provide an introduction to a continuing education program for use by registered nurse instructors in teaching certified nursing assistants (CNAs) about their role in the management of pain in elderly persons. The article includes a summary of the program content. (Geriatr Nurs 2005;26:252-258) he provision of proper pain management in patients suffering from both acute and chronic pain, is one of the greatest challenges facing nursing today. The purpose of this article is to provide an introduction to a continuing education program for certified nursing assistants (CNAs). Literature and work experience indicate that inadequate assessment and treatment of chronic pain in the elderly exist1 and that there is a significant knowledge deficit amongst most health care providers in regards to pain management.2-5 Factors cited as barriers to pain management are inadequate nursing knowledge and skill in the areas of pain and symptom assessment and management.3,6,7 Certified nursing assistants are a vital part of the health care team. They provide the vast majority of direct personal care. One of the most important roles of the CNA involves pain assessment and management. Nursing assistants can be empowered through education to learn to assess and describe pain and to provide nonpharmacologic interventions under the supervision of a nurse. Ersek and colleagues6 reported findings from 3 preliminary studies on end-of-life care in nursing homes. The CNAs identified learning needs in the following areas: knowing when to consult with the nurse about the patient’s pain, identifying side effects of pain medication, and assisting with administering nonpharmacologic therapies. Estimates of 45% to 80% of nursing home
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residents have been reported as having significant pain that is undertreated.8 Wright and colleagues9 described the role of the CNA in pain management of institutionalized elders. Participants in focus groups of CNAs working in nursing homes expressed the wish for more continuing education. They also articulated the desire to be more involved in the team process as decisions are made regarding pain management for their patients. Because an obvious need exists, a continuing education (CE) program has been developed for use by registered nurses, who serve as staff development coordinators or in-service providers in a variety of settings, including long-term care facilities and home health agencies. The remainder of this article contains a general outline of a training program designed to teach CNAs about pain assessment and management.10 This program is written in a format that describes general objectives, learner objectives, and teaching approaches. We provide strategies that have proven effective when teaching this material to CNAs.
CNA CONTINUING EDUCATION PROGRAM OUTLINE General Program Objectives 1. 2. 3.
Understand the importance of pain management. Describe the role of the CNA in pain identification. Assist other team members in use of pharmacologic and nonpharmacologic pain interventions.
General Objective 1. Understand the Importance of Pain Management Learning Objectives 1. 2. 3. 4.
Discuss the definition of pain. Express awareness of the enormity of the problem of chronic pain in the elderly. Explain one example of a personal experience with pain. Recognize myths related to the experience of pain in older people.
Geriatric Nursing, Volume 26, Number 4
Box 1. Pain Definition (The International Association for the Study of Pain) “An unpleasant sensory and emotional experience associated with actual or potential tissue damage.”
Box 2. Myths Related to Pain and Aging ● ● ● ●
Data from American Geriatrics Society, 2002.8 ●
●
Methodology A. Lecture. Content includes a definition of pain as “an unpleasant sensory and emotional experience”8 (Box 1. Pain Definition). Pain is whatever a patient says it is. There are no objective biological markers specific to pain. Therefore, the most accurate evidence of pain and its intensity is based on the patient’s description and self-report. Hence, it is important to listen to the patient’s verbal reports of pain and observe body language that pain exists. Elderly people suffer more often from chronic afflictions rather than acute illness11 and have many sources of persistent pain, such as osteoarthritis, which is the most common reason for pain in older adults.12 Other common sources of chronic pain in this population are back and spine disorders (such as spinal stenosis, osteoporosis with compression fractures, degenerative disc disease), arthritis, neuropathic disorders (such as postherpetic neuralgia), ischemic pain related to vascular disease, cancer, surgical procedures, pressure ulcers, and cardiovascular disease.13,14 Pain is estimated to be present in 25% to 50% of elderly adults who live in a community setting,8 with a higher incidence of 70% to 80% occurring among nursing home residents.15 Misconceptions about aging contribute to inadequate pain management. Probably because chronic pain is so common, many patients and care providers believe it is a normal part of the aging process. A complaint of pain is not a normal aspect of the aging and always warrants a thorough evaluation.16 B. Discussion. 1.
Let the students share their personal experiences with pain.
●
2.
3.
Pain is a normal part of aging. Older people are not good judges of their own pain. Admitting to pain is a sign of weakness. Pain should be severe before treating it with medication. People with severe pain who need narcotics for pain control quickly become addicted to the medication. Chronic pain always causes the blood pressure and pulse to rise, just as acute pain does. Although pain causes discomfort, it is not harmful.
Encourage students to share times when a relative or someone they know did not receive adequate pain relief. The teacher now uses Box 2, “Myths Related to Pain and Aging,” to generate discussion. The list of myths can be converted to true and false questions and be given to the participants in the class. Allow time for the students to complete the questionnaire prior to discussion. This portion of the course has generated lively interaction between students. A common misconception voiced in classes is that patients are at high risk for drug addiction if prescribed narcotic analgesics.
General Objective 2: Describe the Role of the CNA in Pain Identification Learning Objectives 1. 2. 3.
Describe normal aging changes that might impair pain perception and/or pain management. Recognize common reactions to acute and chronic pain. Discuss the role of the CNA in reporting pain problems to their supervisor.
Methodology A. Lecture. The CNA is often the person who is most likely to notice subtle changes in a patient’s behavior because he or she often spends the most time with the patient. Therefore, it is vital to educate CNAs about the importance of empathetic listening, careful assessment, and reporting skills. Educators can tie information about basic changes related to aging to their effects on pain assess-
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Table 1. Examples of Age-Related Changes and Their Impact on Pain Management System
Age-Related Changes
Impact on Pain
Eyes Ears Mental status
Decrease in visual acuity Decrease in hearing Increased risk for cognitive impairment
Respiratory
Decreased vital lung capacity
Cardiovascular
Increased incidence of heart disease and vascular insufficiency
Genitourinary
Decreased kidney function
Gastrointestinal
Slowed peristalsis
Difficultly reading medication labels Misunderstanding instructions Medications may cause changes in mental status Pain causes splinting and bed rest, leading to further reduction in vital capacity Risk of interaction between pain and cardiac medications, pain may be atypical or absent in some life threatening illnesses, such as myocardial infarction Increased risk of drug side effects and toxicity Increased risk for constipation
Data from Dellasea and Keiser, 1997.17
ment and management. For instance, the CNA working in home health may learn that common vision disorders associated with aging make it more difficult for a client to read medication labels. Therefore, patients may self-administer their pain medications incorrectly. Table 1 summarizes age-related physiologic changes and provides examples of their impact on pain. Cognitive, visual, speech disturbances, and cultural diversity can impair a patient’s expression of pain. He or she may deny pain but admit to having discomfort, hurting, or aching. The patient may misunderstand teaching instructions about pain remedies or interventions. Therefore, mistakes can be made in self-administration resulting in a reduction of therapeutic benefits. Practitioners have developed many tools in an effort to improve the evaluation process. Best results occur when selecting one that fits the patient’s situation and using it consistently to monitor treatment response.12 The reader is referred to recent publications that provide excellent summaries and evaluations of tools used to assess and measure pain in older adults.17–21 These tools include selfreport scales for measurement of pain intensity, the presence or absence of pain, pain location, pain behavior, and proxy pain rat-
254
ings. See Box 3 for recently published resources on pain. Certified nursing assistants must be reminded that, although some people with dementia are able to communicate their
Box 3. Pain Resource List (Web sites) ● ●
● ● ● ● ● ● ●
Agency for Health Care Policy and Research (AHCPR): http://www.ahcpr.gov American Academy of Hospice and Palliative Medicine (AAHPM): http:www.aahpm. org American Academy of Pain Medicine (AAPM): http:www.painmed.org American Pain Foundation (APF): http:// www.painfoundation.org American Pain Society (APS): http://www. ampainsoc.org International Association for the Study of Pain (IASP): http://www.halcyon.com/iasp National Pain Education Council (NPEC): http://www.npecweb.org American Pain Society (APS): http://www. ampainsoc.org Joint Commission on Accreditation of Healthcare Organizations (JCAHO): http:// www.jcaho.org
Geriatric Nursing, Volume 26, Number 4
Box 4. Common Reactions to Pain
Box 5. Criteria to Report to the Nursing Supervisor
●
●
● ● ● ● ● ● ● ● ●
● ● ●
Rapid pulse, shallow and rapid breathing, increased blood pressure (may not be present in the elderly) Diaphoresis—may be present in acute pain, but absent in chronic pain Increased fatigue and sleepiness Increased anxiety or depression (or both) Increased restlessness, confusion Withdrawal and decreased communication, lying in a fetal position Increased display of anger Decreased appetite and oral intake of food and fluids Hand and face gestures such as grimace, frown, clenched fists Verbal expressions such as: moaning, groaning, crying, whimpering, yelling out Holding or rubbing a body part, limping Immobility of a body part There may be no signs or symptoms of serious illness such as with silent myocardial infarctions, painless acute appendicitis, and pneumonia
pain and discomfort, others are unable to describe these problems adequately. Long-term care providers may overlook or negate pain in cognitively impaired residents. Horgas and Tsai22 found that these patients are less likely to receive adequate treatment of their pain than those patients without cognition problems. In-depth questioning, physical examination, and discussion with the family or significant others can help determine the cause of pain. People with advanced dementia may demonstrate pain through behavior changes and nonverbal cues, such as grimacing.23 Box 4 lists common reactions to pain, and Box 5 identifies symptoms that must be reported to the nursing supervisor. It is suggested that these boxes be reproduced and given to students as handouts during this section on assessment and evaluation of pain in elder patients. B. Discussion. 1.
Review key components of the pain assessment tool used by the participating facility.
● ● ● ● ● ● ● ● ● ●
2.
Vital signs outside of the following parameters: BP greater than 160/90 or ⬍90/60; pulse ⬎100 or ⬍60; respiratory rate ⬎28; temperature ⬎100° F, orally Episodes of fainting, falling, unconsciousness Increase in confusion and disorientation Acute loss of hearing or vision Acute loss of the ability to move a body part Active bleeding A new wound An increase in shortness of breath A skin color change such as pallor, rubor, jaundice, or cyanosis Complaints of pain, guarding or holding a body part Any of the items listed in Box 4
Ask students to team up with a classmate and practice using the tool. Provide a simple case study of an elderly person with pain, and allow the students to role-play being both CNA and patient.
General Objective 3. Assist Other Team Members in the Use of Pharmacologic and Nonpharmacologic Pain Interventions Learning Objectives 1. 2. 3. 4.
Identify which activities aggravate or increase a person’s pain. Recognize names of commonly used medications for chronic pain management. Monitor for and report common side effects in medication therapies. Describe nonmedicinal ways to treat pain, address basic needs, and promote comfort.
Methodology A. Lecture. The aide is responsible, as part of the health care team, to promote a reduction in a patient’s pain. Tasks and responsibilities may vary depending on work locations. Nursing assistants should become familiar with the job description related to their responsibilities regarding pain management. They should do only the tasks that they have been trained to do. If a need arises for which they have not been pre-
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pared, they must seek the assistance of their supervisor. All patients have basic physical and psychological needs. The aging person meets some of those needs without assistance, and their care providers must meet other needs. These needs may include the following: safety, food, fluids, activity, rest, independence, socialization, trust, affection, security, acceptance, and recognition. When basic needs are interrupted by pain, the patient will display some reaction. It is important for the aide to understand how different patients react to pain, to recognize these responses, and to report them to the supervisor. Elderly people are at increasing risk for adverse drug reactions, and this is especially true as additional medications are added to the profile. This means that frequent monitoring for side effects is essential. Older individuals are more sensitive to central nervous system active drugs, such as opioid analgesics. Common problems or side effects include confusion, dizziness, constipation, and a change in vital signs with an alteration in dosage. Those elders treated with nonsteroidal anti-inflammatory drugs are more likely to develop gastrointestinal bleeding, renal injury, confusion, tinnitus, and hearing loss.8 Although pain control is better accomplished by round-the-clock dosing, patients may have break-through pain. Certified nursing assistants should anticipate pain inducing activities and request the nurse evaluate the patient for dosing of pain relieving drugs. They should also watch for signs of uncontrolled pain and report them to their supervisor. Ross and colleagues24 found that seniors are more likely to use medications as a last resort for pain control, and they often choose to ignore their pain or use distraction. Many older people use complementary and alternative therapy (CAT) for pain control (Table 2).25 The American Geriatric Society8 does not make specific recommendations about the long-term use of complementary and alternative therapies because of the lack of good research in this area. Many of these methods are described as practices that are not considered a fundamental part of conventional medical practice. It is important that nursing staff assess patients for use of these therapies and understand the risks and benefits involved with their use. Students should be encouraged to report to their supervisors if the
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Table 2. Complementary and Alternative Therapy Complementary
Alternative
Prayer Vitamins Diet Massage Meditation Herbs Chiropractic Folk remedies Hypnosis Yoga
Imagery Biofeedback Acupuncture Reflexology Magnets Aromatherapy Acupressure Touch therapies Tai Chi Homeopathy
Data from O’Brien and Pettigrew, 2004.25
patient is using alternative or complementary practices. Physical activity helps to reverse physiologic consequences of deconditioning and may improve psychological health and quality of life. An exercise prescription must be safe, individualized to meet the patient’s needs, and periodically reevaluated.8 People with cognitive loss are often unable to express their pain experience verbally. People with dementia often respond well when staff decrease environmental stressors such as noise from television or phones, glare from lighting, cluttered spaces, and unfamiliar environments or people. Touch that would seem soothing to most people may be distressing for a person with dementia. It is important to pay attention to details of comfort such as room temperature, wrinkled sheets or clothing, and uncomfortable fabrics. Nursing staff can also facilitate general comfort by adjusting activity schedules to allow more rest or stimulation, as indicated. One-onone interactions provide more meaningful experiences than group activities for people with moderate to severe dementia. Nursing staff can learn to validate the individual’s discomfort and provide calm, clear, simple, and soothing interactions.26 The CNA should conduct self-analysis involving understanding one’s own beliefs and values about quality of life, elderly people, and their role in pain management. A study by Mrozek and Werner4 indicated that nurses’ personal pain experiences influence their pain assess-
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Box 6. The Role of the Certified Nursing Assistant (CNA) in Pain Management
Box 7. Other Specific Interventions to Alleviate Pain
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● ● ●
●
●
●
●
● ●
●
Ask for a description of the pain, using words familiar to the patient, such as hurting, discomfort, aching, sharpness, dullness, intermittent, constant, throbbing, referred, localized. Ask what helps decrease the pain; intervene if the action is within the CNA scope of practice. Explain procedures and interventions before they are initiated, asking for feedback during and after care. Remain consistent and timely in approaches to care to decrease anxiety and foster trust and confidence. Observe for increase of pain during activities, alter interventions, and document the action and response. Report changes in pain and response to pain medications to the supervisor. Validate the patient’s pain; encourage the patient to talk and share feelings, fears, frustrations about his or her condition. Be aware of the importance of the CNA sharing his or her feelings with a trusted team member and supervisor.
● ●
● ● ● ●
● ● ●
●
Provide empathetic listening. Offer fluids and mouth care. Assist with a bath in the most appropriate way to avoid pain. Give skin care and massage to increase blood flow to muscles and skin tissue. Position the patient, using pillows to support head, back, knees, and other affected joints. Provide range of motion and exercises as indicated in the plan of care. Notify the nurse promptly when the patient needs pain medication. Assist patients in opening medicine bottles if needed. Apply heat or ice packs as ordered, taking precautions not to burn the patient and always observing for skin integrity. Provide an opportunity for toileting on a regular basis. Provide spiritual support, as appropriate. Use distractions such as playing music or games, puzzles, writing letters, and watching movies with patients. Provide other comfort measures.
ment and management practices. Therefore, it is vital to recognize when personal beliefs and biases affect proper pain management. For pain management to be ethically based, the health care team must also try to understand the patients’ value systems and how they interpret their own pain. Recognition that the patient is a member of the health care team and the driving force behind health care choices helps providers to give quality care. B. Discussion.
Conclusion
1.
References
2.
3.
4.
Encourage students to explain one’s own familial and cultural interventions for pain management. Foster class discussion about nonmedicinal pain interventions that are allowed in CNA work environments. Comfort measures that can be undertaken by the aide may be listed on a classroom board. Discuss the items listed in Box 6. Have each student take a turn in reading an item and follow it with a brief discussion. Repeat the process with information in Box 7.
Certified nursing assistants are capable of learning to assess and describe pain in their elderly patients. They can be empowered through education to carry out this role with confidence. The program outlined in this article is meant to be a beginning guideline for use in providing education to CNAs in varied clinical settings. For the full program, contact the authors.
1. Cowan DT, Fitzpatrick JM, Roberts JD, et al. The assessment and management of pain among older people in care homes: current status and future directions. Int J Nurs Stud 2003;40:291-8. 2. Katsma KL, Souza CS. Elderly pain assessment and pain management knowledge of long-term care nurses. Pain Manage Nurs 2000;1:88-95. 3. Kee CC, Epps CD. Pain management practices of nurses caring for older patients with osteoarthritis. West J Nurs Res 2001;23:195-210.
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4. Mrozek JE, Werner JS. Nurses’ attitudes toward pain, pain assessment, and pain management practices in long-term care facilities. Pain Manage Nurs 2001;2:15462. 5. Sloman R, Ahern M, Wright A, Brown L. Nurses’ knowledge of pain in the elderly. J Pain Sympt Manage 2001;21:317-22. 6. Ersek M, Kraybill BM, Hansberry J. Investigating the educational needs of licensed nursing staff and certified nursing assistants in nursing homes regarding end-of-life care. Am J Hospice Palliative Care 1999;16: 573-82. 7. Mitchell C. Assessment and management of chronic pain in elderly people. Br J Nurs 2001;10:296-304. 8. American Geriatrics Society (AGS). The management of persistent pain in older persons: AGS panel on persistent pain in older persons. JAGS 2002;50:S205-25. 9. Wright J, Varholak D, Costello J. Voices from the margin: the nurse aide’s role in pain management of institutionalized elders. Am J Alzheimers Dis Other Demen 2003;18(3):154-8. 10. Siciliano P. Chronic pain in the elderly: a continuing education program for certified nursing assistants. Unpublished manuscript, 2004. 11. Quinn EM, Berding C, Daniels E, et al. Shifting paradigms: teaching gerontological nursing from a new perspective. J Gerontol Nurs 2004;30:21-7. 12. Pharmacologic approaches to chronic pain in the older adult. Nurs Pract 1997;22:29-37. 13. Ettinger WH, Herr KA, Young MG: Chronic pain management in the elderly. Patient Care 2000. Available at www.patientcareonline.com. Accessed June 15, 2004. 14. Kedziera PL. Easing elders’ pain. Holist Nurs Pract 2001;15:416. 15. Horgas AL. Pain management in elderly adults. J Infusion Nurs 2003;26:161-5. 16. Miaskowski C. The impact of age on a patient’s perception of pain and ways it can be managed. Pain Manage Nurs 2000;1(3 Suppl):2-7.
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17. DeWaters T, Popovich J, Faut-Callahan M. An evaluation of clinical tools to measure pain in older people with cognitive impairment. Br J Community Nurs 2003;8:226-34. 18. Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Manage Nurs 2000;1:13-21. 19. Manz GD, Mosier R, Nusser-Gerlach MA, et al. Pain assessment in cognitively impaired and unpaired elderly. Pain Manage Nurs 2000;1:106-15. 20. Rodriguez CS. Pain measurement in the elderly: a review. Pain Manage Nurs 2001;2:38-46. 21. Taylor LJ, Herr K. Pain intensity assessment: a comparison of selected pain intensity scales for use in cognitively intact and cognitively impaired African American older adults. Pain Manage Nurs 2003;4:87-95. 22. Horgas AL, Tsai P-F. Analgesic drug prescription and use in cognitively impaired nursing home residents. Nurs Res 1998;47:234-42. 23. Brignell A. Assessment of pain in non-cognizant elderly. Can Nurs Home 2003;14:71-4. 24. Ross MM, Carswell A, Hing M, et al. Seniors’ decision making about pain management. J Adv Nurs 2001;35: 442-51. 25. O’Brien King MO, Pettigrew AC. Complementary and alternative therapy used by older adults in three ethnically diverse populations: a pilot study. Geriatric Nurs 2004;25:30-7. 26. Kovach CR, Noonan PE, Griffie J, et al. The assessment of discomfort in dementia protocol. Pain Manage Nurs 2002;3:16-27. PAULA SICILIANO, MSN, GNP-C, is an assistant professor and Co-director of the Nurse Practitioner Specialty Program REBECCA BURRAGE, MSN, GNP-C, is an assistant professor and Coordinator of the Acute Care Nurse Practitioner/Clinical Nurse Specialist Program, both at the University of Utah College of Nursing, Salt Lake City, Utah. 0197-4572/05/$ - see front matter © 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.05.008
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residents have been reported as having significant pain that is undertreated.8 Wright and colleagues9 described the role of the CNA in pain management of institutionalized elders. Participants in focus groups of CNAs working in nursing homes expressed the wish for more continuing education. They also articulated the desire to be more involved in the team process as decisions are made regarding pain management for their patients. Because an obvious need exists, a continuing education (CE) program has been developed for use by registered nurses, who serve as staff development coordinators or in-service providers in a variety of settings, including long-term care facilities and home health agencies. The remainder of this article contains a general outline of a training program designed to teach CNAs about pain assessment and management.10 This program is written in a format that describes general objectives, learner objectives, and teaching approaches. We provide strategies that have proven effective when teaching this material to CNAs.
CNA CONTINUING EDUCATION PROGRAM OUTLINE General Program Objectives 1. 2. 3.
Understand the importance of pain management. Describe the role of the CNA in pain identification. Assist other team members in use of pharmacologic and nonpharmacologic pain interventions.
General Objective 1. Understand the Importance of Pain Management Learning Objectives 1. 2. 3. 4.
Discuss the definition of pain. Express awareness of the enormity of the problem of chronic pain in the elderly. Explain one example of a personal experience with pain. Recognize myths related to the experience of pain in older people.
Geriatric Nursing, Volume 26, Number 4
Box 1. Pain Definition (The International Association for the Study of Pain) “An unpleasant sensory and emotional experience associated with actual or potential tissue damage.”
Box 2. Myths Related to Pain and Aging ● ● ● ●
Data from American Geriatrics Society, 2002.8 ●
●
Methodology A. Lecture. Content includes a definition of pain as “an unpleasant sensory and emotional experience”8 (Box 1. Pain Definition). Pain is whatever a patient says it is. There are no objective biological markers specific to pain. Therefore, the most accurate evidence of pain and its intensity is based on the patient’s description and self-report. Hence, it is important to listen to the patient’s verbal reports of pain and observe body language that pain exists. Elderly people suffer more often from chronic afflictions rather than acute illness11 and have many sources of persistent pain, such as osteoarthritis, which is the most common reason for pain in older adults.12 Other common sources of chronic pain in this population are back and spine disorders (such as spinal stenosis, osteoporosis with compression fractures, degenerative disc disease), arthritis, neuropathic disorders (such as postherpetic neuralgia), ischemic pain related to vascular disease, cancer, surgical procedures, pressure ulcers, and cardiovascular disease.13,14 Pain is estimated to be present in 25% to 50% of elderly adults who live in a community setting,8 with a higher incidence of 70% to 80% occurring among nursing home residents.15 Misconceptions about aging contribute to inadequate pain management. Probably because chronic pain is so common, many patients and care providers believe it is a normal part of the aging process. A complaint of pain is not a normal aspect of the aging and always warrants a thorough evaluation.16 B. Discussion. 1.
Let the students share their personal experiences with pain.
●
2.
3.
Pain is a normal part of aging. Older people are not good judges of their own pain. Admitting to pain is a sign of weakness. Pain should be severe before treating it with medication. People with severe pain who need narcotics for pain control quickly become addicted to the medication. Chronic pain always causes the blood pressure and pulse to rise, just as acute pain does. Although pain causes discomfort, it is not harmful.
Encourage students to share times when a relative or someone they know did not receive adequate pain relief. The teacher now uses Box 2, “Myths Related to Pain and Aging,” to generate discussion. The list of myths can be converted to true and false questions and be given to the participants in the class. Allow time for the students to complete the questionnaire prior to discussion. This portion of the course has generated lively interaction between students. A common misconception voiced in classes is that patients are at high risk for drug addiction if prescribed narcotic analgesics.
General Objective 2: Describe the Role of the CNA in Pain Identification Learning Objectives 1. 2. 3.
Describe normal aging changes that might impair pain perception and/or pain management. Recognize common reactions to acute and chronic pain. Discuss the role of the CNA in reporting pain problems to their supervisor.
Methodology A. Lecture. The CNA is often the person who is most likely to notice subtle changes in a patient’s behavior because he or she often spends the most time with the patient. Therefore, it is vital to educate CNAs about the importance of empathetic listening, careful assessment, and reporting skills. Educators can tie information about basic changes related to aging to their effects on pain assess-
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Table 1. Examples of Age-Related Changes and Their Impact on Pain Management System
Age-Related Changes
Impact on Pain
Eyes Ears Mental status
Decrease in visual acuity Decrease in hearing Increased risk for cognitive impairment
Respiratory
Decreased vital lung capacity
Cardiovascular
Increased incidence of heart disease and vascular insufficiency
Genitourinary
Decreased kidney function
Gastrointestinal
Slowed peristalsis
Difficultly reading medication labels Misunderstanding instructions Medications may cause changes in mental status Pain causes splinting and bed rest, leading to further reduction in vital capacity Risk of interaction between pain and cardiac medications, pain may be atypical or absent in some life threatening illnesses, such as myocardial infarction Increased risk of drug side effects and toxicity Increased risk for constipation
Data from Dellasea and Keiser, 1997.17
ment and management. For instance, the CNA working in home health may learn that common vision disorders associated with aging make it more difficult for a client to read medication labels. Therefore, patients may self-administer their pain medications incorrectly. Table 1 summarizes age-related physiologic changes and provides examples of their impact on pain. Cognitive, visual, speech disturbances, and cultural diversity can impair a patient’s expression of pain. He or she may deny pain but admit to having discomfort, hurting, or aching. The patient may misunderstand teaching instructions about pain remedies or interventions. Therefore, mistakes can be made in self-administration resulting in a reduction of therapeutic benefits. Practitioners have developed many tools in an effort to improve the evaluation process. Best results occur when selecting one that fits the patient’s situation and using it consistently to monitor treatment response.12 The reader is referred to recent publications that provide excellent summaries and evaluations of tools used to assess and measure pain in older adults.17–21 These tools include selfreport scales for measurement of pain intensity, the presence or absence of pain, pain location, pain behavior, and proxy pain rat-
254
ings. See Box 3 for recently published resources on pain. Certified nursing assistants must be reminded that, although some people with dementia are able to communicate their
Box 3. Pain Resource List (Web sites) ● ●
● ● ● ● ● ● ●
Agency for Health Care Policy and Research (AHCPR): http://www.ahcpr.gov American Academy of Hospice and Palliative Medicine (AAHPM): http:www.aahpm. org American Academy of Pain Medicine (AAPM): http:www.painmed.org American Pain Foundation (APF): http:// www.painfoundation.org American Pain Society (APS): http://www. ampainsoc.org International Association for the Study of Pain (IASP): http://www.halcyon.com/iasp National Pain Education Council (NPEC): http://www.npecweb.org American Pain Society (APS): http://www. ampainsoc.org Joint Commission on Accreditation of Healthcare Organizations (JCAHO): http:// www.jcaho.org
Geriatric Nursing, Volume 26, Number 4
Box 4. Common Reactions to Pain
Box 5. Criteria to Report to the Nursing Supervisor
●
●
● ● ● ● ● ● ● ● ●
● ● ●
Rapid pulse, shallow and rapid breathing, increased blood pressure (may not be present in the elderly) Diaphoresis—may be present in acute pain, but absent in chronic pain Increased fatigue and sleepiness Increased anxiety or depression (or both) Increased restlessness, confusion Withdrawal and decreased communication, lying in a fetal position Increased display of anger Decreased appetite and oral intake of food and fluids Hand and face gestures such as grimace, frown, clenched fists Verbal expressions such as: moaning, groaning, crying, whimpering, yelling out Holding or rubbing a body part, limping Immobility of a body part There may be no signs or symptoms of serious illness such as with silent myocardial infarctions, painless acute appendicitis, and pneumonia
pain and discomfort, others are unable to describe these problems adequately. Long-term care providers may overlook or negate pain in cognitively impaired residents. Horgas and Tsai22 found that these patients are less likely to receive adequate treatment of their pain than those patients without cognition problems. In-depth questioning, physical examination, and discussion with the family or significant others can help determine the cause of pain. People with advanced dementia may demonstrate pain through behavior changes and nonverbal cues, such as grimacing.23 Box 4 lists common reactions to pain, and Box 5 identifies symptoms that must be reported to the nursing supervisor. It is suggested that these boxes be reproduced and given to students as handouts during this section on assessment and evaluation of pain in elder patients. B. Discussion. 1.
Review key components of the pain assessment tool used by the participating facility.
● ● ● ● ● ● ● ● ● ●
2.
Vital signs outside of the following parameters: BP greater than 160/90 or ⬍90/60; pulse ⬎100 or ⬍60; respiratory rate ⬎28; temperature ⬎100° F, orally Episodes of fainting, falling, unconsciousness Increase in confusion and disorientation Acute loss of hearing or vision Acute loss of the ability to move a body part Active bleeding A new wound An increase in shortness of breath A skin color change such as pallor, rubor, jaundice, or cyanosis Complaints of pain, guarding or holding a body part Any of the items listed in Box 4
Ask students to team up with a classmate and practice using the tool. Provide a simple case study of an elderly person with pain, and allow the students to role-play being both CNA and patient.
General Objective 3. Assist Other Team Members in the Use of Pharmacologic and Nonpharmacologic Pain Interventions Learning Objectives 1. 2. 3. 4.
Identify which activities aggravate or increase a person’s pain. Recognize names of commonly used medications for chronic pain management. Monitor for and report common side effects in medication therapies. Describe nonmedicinal ways to treat pain, address basic needs, and promote comfort.
Methodology A. Lecture. The aide is responsible, as part of the health care team, to promote a reduction in a patient’s pain. Tasks and responsibilities may vary depending on work locations. Nursing assistants should become familiar with the job description related to their responsibilities regarding pain management. They should do only the tasks that they have been trained to do. If a need arises for which they have not been pre-
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pared, they must seek the assistance of their supervisor. All patients have basic physical and psychological needs. The aging person meets some of those needs without assistance, and their care providers must meet other needs. These needs may include the following: safety, food, fluids, activity, rest, independence, socialization, trust, affection, security, acceptance, and recognition. When basic needs are interrupted by pain, the patient will display some reaction. It is important for the aide to understand how different patients react to pain, to recognize these responses, and to report them to the supervisor. Elderly people are at increasing risk for adverse drug reactions, and this is especially true as additional medications are added to the profile. This means that frequent monitoring for side effects is essential. Older individuals are more sensitive to central nervous system active drugs, such as opioid analgesics. Common problems or side effects include confusion, dizziness, constipation, and a change in vital signs with an alteration in dosage. Those elders treated with nonsteroidal anti-inflammatory drugs are more likely to develop gastrointestinal bleeding, renal injury, confusion, tinnitus, and hearing loss.8 Although pain control is better accomplished by round-the-clock dosing, patients may have break-through pain. Certified nursing assistants should anticipate pain inducing activities and request the nurse evaluate the patient for dosing of pain relieving drugs. They should also watch for signs of uncontrolled pain and report them to their supervisor. Ross and colleagues24 found that seniors are more likely to use medications as a last resort for pain control, and they often choose to ignore their pain or use distraction. Many older people use complementary and alternative therapy (CAT) for pain control (Table 2).25 The American Geriatric Society8 does not make specific recommendations about the long-term use of complementary and alternative therapies because of the lack of good research in this area. Many of these methods are described as practices that are not considered a fundamental part of conventional medical practice. It is important that nursing staff assess patients for use of these therapies and understand the risks and benefits involved with their use. Students should be encouraged to report to their supervisors if the
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Table 2. Complementary and Alternative Therapy Complementary
Alternative
Prayer Vitamins Diet Massage Meditation Herbs Chiropractic Folk remedies Hypnosis Yoga
Imagery Biofeedback Acupuncture Reflexology Magnets Aromatherapy Acupressure Touch therapies Tai Chi Homeopathy
Data from O’Brien and Pettigrew, 2004.25
patient is using alternative or complementary practices. Physical activity helps to reverse physiologic consequences of deconditioning and may improve psychological health and quality of life. An exercise prescription must be safe, individualized to meet the patient’s needs, and periodically reevaluated.8 People with cognitive loss are often unable to express their pain experience verbally. People with dementia often respond well when staff decrease environmental stressors such as noise from television or phones, glare from lighting, cluttered spaces, and unfamiliar environments or people. Touch that would seem soothing to most people may be distressing for a person with dementia. It is important to pay attention to details of comfort such as room temperature, wrinkled sheets or clothing, and uncomfortable fabrics. Nursing staff can also facilitate general comfort by adjusting activity schedules to allow more rest or stimulation, as indicated. One-onone interactions provide more meaningful experiences than group activities for people with moderate to severe dementia. Nursing staff can learn to validate the individual’s discomfort and provide calm, clear, simple, and soothing interactions.26 The CNA should conduct self-analysis involving understanding one’s own beliefs and values about quality of life, elderly people, and their role in pain management. A study by Mrozek and Werner4 indicated that nurses’ personal pain experiences influence their pain assess-
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Box 6. The Role of the Certified Nursing Assistant (CNA) in Pain Management
Box 7. Other Specific Interventions to Alleviate Pain
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Ask for a description of the pain, using words familiar to the patient, such as hurting, discomfort, aching, sharpness, dullness, intermittent, constant, throbbing, referred, localized. Ask what helps decrease the pain; intervene if the action is within the CNA scope of practice. Explain procedures and interventions before they are initiated, asking for feedback during and after care. Remain consistent and timely in approaches to care to decrease anxiety and foster trust and confidence. Observe for increase of pain during activities, alter interventions, and document the action and response. Report changes in pain and response to pain medications to the supervisor. Validate the patient’s pain; encourage the patient to talk and share feelings, fears, frustrations about his or her condition. Be aware of the importance of the CNA sharing his or her feelings with a trusted team member and supervisor.
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Provide empathetic listening. Offer fluids and mouth care. Assist with a bath in the most appropriate way to avoid pain. Give skin care and massage to increase blood flow to muscles and skin tissue. Position the patient, using pillows to support head, back, knees, and other affected joints. Provide range of motion and exercises as indicated in the plan of care. Notify the nurse promptly when the patient needs pain medication. Assist patients in opening medicine bottles if needed. Apply heat or ice packs as ordered, taking precautions not to burn the patient and always observing for skin integrity. Provide an opportunity for toileting on a regular basis. Provide spiritual support, as appropriate. Use distractions such as playing music or games, puzzles, writing letters, and watching movies with patients. Provide other comfort measures.
ment and management practices. Therefore, it is vital to recognize when personal beliefs and biases affect proper pain management. For pain management to be ethically based, the health care team must also try to understand the patients’ value systems and how they interpret their own pain. Recognition that the patient is a member of the health care team and the driving force behind health care choices helps providers to give quality care. B. Discussion.
Conclusion
1.
References
2.
3.
4.
Encourage students to explain one’s own familial and cultural interventions for pain management. Foster class discussion about nonmedicinal pain interventions that are allowed in CNA work environments. Comfort measures that can be undertaken by the aide may be listed on a classroom board. Discuss the items listed in Box 6. Have each student take a turn in reading an item and follow it with a brief discussion. Repeat the process with information in Box 7.
Certified nursing assistants are capable of learning to assess and describe pain in their elderly patients. They can be empowered through education to carry out this role with confidence. The program outlined in this article is meant to be a beginning guideline for use in providing education to CNAs in varied clinical settings. For the full program, contact the authors.
1. Cowan DT, Fitzpatrick JM, Roberts JD, et al. The assessment and management of pain among older people in care homes: current status and future directions. Int J Nurs Stud 2003;40:291-8. 2. Katsma KL, Souza CS. Elderly pain assessment and pain management knowledge of long-term care nurses. Pain Manage Nurs 2000;1:88-95. 3. Kee CC, Epps CD. Pain management practices of nurses caring for older patients with osteoarthritis. West J Nurs Res 2001;23:195-210.
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4. Mrozek JE, Werner JS. Nurses’ attitudes toward pain, pain assessment, and pain management practices in long-term care facilities. Pain Manage Nurs 2001;2:15462. 5. Sloman R, Ahern M, Wright A, Brown L. Nurses’ knowledge of pain in the elderly. J Pain Sympt Manage 2001;21:317-22. 6. Ersek M, Kraybill BM, Hansberry J. Investigating the educational needs of licensed nursing staff and certified nursing assistants in nursing homes regarding end-of-life care. Am J Hospice Palliative Care 1999;16: 573-82. 7. Mitchell C. Assessment and management of chronic pain in elderly people. Br J Nurs 2001;10:296-304. 8. American Geriatrics Society (AGS). The management of persistent pain in older persons: AGS panel on persistent pain in older persons. JAGS 2002;50:S205-25. 9. Wright J, Varholak D, Costello J. Voices from the margin: the nurse aide’s role in pain management of institutionalized elders. Am J Alzheimers Dis Other Demen 2003;18(3):154-8. 10. Siciliano P. Chronic pain in the elderly: a continuing education program for certified nursing assistants. Unpublished manuscript, 2004. 11. Quinn EM, Berding C, Daniels E, et al. Shifting paradigms: teaching gerontological nursing from a new perspective. J Gerontol Nurs 2004;30:21-7. 12. Pharmacologic approaches to chronic pain in the older adult. Nurs Pract 1997;22:29-37. 13. Ettinger WH, Herr KA, Young MG: Chronic pain management in the elderly. Patient Care 2000. Available at www.patientcareonline.com. Accessed June 15, 2004. 14. Kedziera PL. Easing elders’ pain. Holist Nurs Pract 2001;15:416. 15. Horgas AL. Pain management in elderly adults. J Infusion Nurs 2003;26:161-5. 16. Miaskowski C. The impact of age on a patient’s perception of pain and ways it can be managed. Pain Manage Nurs 2000;1(3 Suppl):2-7.
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17. DeWaters T, Popovich J, Faut-Callahan M. An evaluation of clinical tools to measure pain in older people with cognitive impairment. Br J Community Nurs 2003;8:226-34. 18. Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Manage Nurs 2000;1:13-21. 19. Manz GD, Mosier R, Nusser-Gerlach MA, et al. Pain assessment in cognitively impaired and unpaired elderly. Pain Manage Nurs 2000;1:106-15. 20. Rodriguez CS. Pain measurement in the elderly: a review. Pain Manage Nurs 2001;2:38-46. 21. Taylor LJ, Herr K. Pain intensity assessment: a comparison of selected pain intensity scales for use in cognitively intact and cognitively impaired African American older adults. Pain Manage Nurs 2003;4:87-95. 22. Horgas AL, Tsai P-F. Analgesic drug prescription and use in cognitively impaired nursing home residents. Nurs Res 1998;47:234-42. 23. Brignell A. Assessment of pain in non-cognizant elderly. Can Nurs Home 2003;14:71-4. 24. Ross MM, Carswell A, Hing M, et al. Seniors’ decision making about pain management. J Adv Nurs 2001;35: 442-51. 25. O’Brien King MO, Pettigrew AC. Complementary and alternative therapy used by older adults in three ethnically diverse populations: a pilot study. Geriatric Nurs 2004;25:30-7. 26. Kovach CR, Noonan PE, Griffie J, et al. The assessment of discomfort in dementia protocol. Pain Manage Nurs 2002;3:16-27. PAULA SICILIANO, MSN, GNP-C, is an assistant professor and Co-director of the Nurse Practitioner Specialty Program REBECCA BURRAGE, MSN, GNP-C, is an assistant professor and Coordinator of the Acute Care Nurse Practitioner/Clinical Nurse Specialist Program, both at the University of Utah College of Nursing, Salt Lake City, Utah. 0197-4572/05/$ - see front matter © 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2005.05.008
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