Journal of Gerontological Nursing

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Acute Pain Management Protocol

Diane M Young, MSN, RN

Abstract

Assist patients to enhance their sense of personal control over pain.

REFERENCES

Key:

(R) = Research.

(L) = Literature.

(N) = National Guidelines,

Agency for Health Care Policy and Research. (I992a). Acute pain management: Operative or medical procedures and trauma (AHCPR Publication No. 92-0032). Rockville, MD: United States Department of Health and Human Services. (N)

Agency for Health Care Policy and Research. (1992b). Pain control after surgery: A patient's guide [brochure] AHCPR Publication No. 92-0021). Rockville, MD: United States Department of Health and Human Services. (N)

Ambepitiya, G., Roberts, M., Ranjadayalan, K., & Tallis, R. (1994). Silent exertional myocardial ischemia in the elderly: A quantitative analysis of anginal perceptual threshold and the influence of autonomie function. Journal of the American Geriatrics Society, 42, 732-737. (R)

American Geriatrics Society Pane] on Chronic Pain in Older Persons. (1998). The management of chronic pain in older persons. Journal of the American Geriatrics Society, 46, 635-651. (N)

American Pain Society. (1999). Principles of analgesic use in the treatment of acute pain and chronic cancer pain (4lh ed.). Glenview, IL: Author. (N)

Austin, K.L,, Stapleton, J. V., & Mather, L.E. (1980). Multiple intramuscular injections: A major source of variability in analgesic response to meperidine. Pain, 8, 47-62. (R)

Baker, A., Bowring, L., Brignell, A-, & Kafford, D. (1996). Chronic pain management in cognitively impaired patients: A preliminary research report. Perspectives, 20, 4-8. (R)

Baskin, S.L, & Goldfarb, A.H. (1983). Ageassociated changes of non-narcotic analgesics. In J. Roberts & P. Goldberg (Eds.), CRC handbook on pharmacology of aging (pp. 113-125). Boca-Raton, FL: CRC Press. (L)

Bayer, A., Chadha, J.S., Farag, R.R., & Pathy, M.S. (1986). Changing presentation of myocardial infarction with increasing old age. Journal of the American Geriatrics Society, 34, 263-266. (R)

Bellville, J.W., Forrest, W.H., Miller, E., & Brown, B.W. (1971). Influence of age on pain relief from analgesics. Journal of the American Medical Association, 217, 18351841. (R)

Bender, J-S. (1989). Approach to the acute abdomen. Medical Clinics of North America, 73, 1413-1423. (R)

Bensink, G. W., Godbey, K.L., Marshall, MJ-, & Yarandi, H.N. (1992). Institutionalized elderly: Relaxation, locus of control, selfesteem. Journal of Gerontolagica! Nursing, 18(4}, 30-36. (R)

Butler, R.N., & Gastel, B. (1980). Care of the aged: Perspectives on pain and discomfort. In L. Ng & J. Bonica (Eds.), Pain, discomfort and humanitarian care (pp. 297-311). New York: Eisevier North Holland. (L)

Cariaga, J.( Burgio, L., Flynn, W., & Martin, D. (1991). A controlled study of disruptive vocalizations among geriatric residents in nursing homes. Journal of the American Geriatrics Society, 39, 501-507. (R)

Gasten, R.J., Parmelee, P.A., Kleban, M.H., Lawton, M.P., & Kaiz, LR. (1995). The relationship among anxiety, depression, and pain in a geriatric institutionalized sample. Am, 61, 271-276. (R)

Ceccio, C.M. (1984). Postoperative pain relief through relaxation in elderly patients with fractured hips. Orthopaedic Nursing, ,3(3), 11-19.(R)

Conner, M., & Deane, D. (1995). Patterns of patient-controlled analgesia and intramuscular analgesia. Applied Nursing Research, 8(2), 67-72. (R)

Dietrick-Gallagher, M., Polomano, R., & Carrick, L. (1994). Pain as a quality management initiative. Journal of Nursing Care Quality, 9(1), 30-42. (R)

Donovan, M., Díllon, P., & McGuire, L. (1987). Incidence and characteristics of pain in a sample of medical-surgical inpatients. Pain, 30, 69-78. (R)

Dossey, B. (1995). Complementary modalities: Part 3. Using imagery to help your patient heal. American Journal of Nursing, 95(6), 40-47. (L)

Doucet, J., Chassagne, P., Trivalle, C., Landrin, M., Pauty, M.D., Kadri, N., Menard, J.F. & Bercoff, E. (1996). Drugdrug interactions related to hospital admissions in older adults: A prospective study of 1,000 patients. Journal of the American Geriatrics Society, 44, 944-948. (R)

Duggleby, W., & Lander, J. (1994).…

INTRODUCTION

Undertreatment of acute pain persists despite many efforts to provide clinicians with the necessary tools for effective pain management (McCaffery & Ferrell, 1997). Barriers to effective pain management include: continued lack of knowledge, persistent misperceptions regarding addiction to pain medication, and state and federal regulation of the prescribing of opioid analgesics (American Pain Society Quality of Care Committee, 1995).

Pain is extremely common among elderly individuals. It has been estimated that 25% to 50% of community -dwelling elderly people suffer from pain (Gloth, 1996). Further, the prevalence of pain is two-fold higher in individuals older than age 60, as compared with individuals younger than age 60 (Crook, Rideout, Sc Browne, 1984). Among institutionalized older adults, the prevalence is estimated to reach 70% (Ferrell & Ferrei!, 1990). Elderly patients are at increased risk for mismanagement of pain for several reasons. First they have multiple medical problems - all of which could cause pain. Second, they frequently have chronic pain in addition to acute pain. Finally, elderly patients commonly underreport pain and, thus, it is undertreated (Pasero, Reed, & McCaffery, 1999).

In the following abstract of the Acute Pain Management Protocol, we provide research-based practice guidelines for managing acute pain in older adults. We also have included examples of pain intensity scales recommended for use with elderly patients, the reference list from the protocol, and an outcomes monitor that can be used to chart progress toward meeting the goal of effective pain management in the clinical setting. A copy of this complete protocol and others (see the article, "Research Utilization in Gerontological Nursing Practice," in this issue for a list of protocols) are available from Marita Titler, PhD, RN, FAAN, Department of Nursing-RDDC, 200 Hawkins Drive, Tl 52 GH, Iowa City, IA 52242.

REFERENCES

American Pain Society Quality of Care Committee. (1995). Quality improvement guidelines for the treatment of acute pain and cancer pain. Journal of the American Medical Association, 274, 1874-1880.

Crook, J., Rideout, E., Sc Browne, G. (1984). The prevalence of pain complaints in the general population. Pain, 18, 299314.

Ferrell, B.R., & Ferrell, B.A. (1990). More research needed on geriatric pain management. Provider, /6(7), 31-32.

Gloth, F.M. (1996). Concerns with chronic analgesic therapy in elderly patients. American Journal of Medicine, 101(SuppL IA), 19S-24S.

McCaffery, M., & Ferrell, B-R, (1997). Nurses' knowledge of pain assessment and management: How much progress have we made? Journal of Pain and Symptom Management, 14, 175-188.

Pasero, C., Reed, B. A., & McCaffery, M. (1999). Pain in the elderiy. In M. McCaffery & C. Pasero (Eds.), Pain: Clinical manual for nursing practice (2nd ed., pp. 674-710). St. Louis: Mosby.

WRITTEN BY DIANE M. YOUNG, MSN, RN EDITED BY JANET C. MENTES, MS, RNCS, AND MARITA G. TITLER, PhD, RN1 FAAN

PURPOSE

The purpose of this researchbased protocol is to manage acute pain in elderly patients. The outcomes of effective management include reduced pain intensity, reduced respiratory complications, and increased patient satisfaction with pain management.

DEFINITION OF PAIN

Pain is a complex, subjective response characterized by several quantifiable features, including intensity, time, course, quality, impact, and personal meaning (Agency for Health Care Policy and Research [AHCPR], 1992a). "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does," according to McCaffery and Beebe (1989, p. 7).

Acute pain is pain occurring from a time-limited illness, a recent event such as surgery, medical procedures, or trauma (AHCPR, 1992a).

Nursing Interventions Classification (NIC) Definition

Pain management is the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient (McCloskey & Bulechek, 1996).

INDIVIDUALS AT RISK FOR ACUTE PAIN

The guideline is designed for elderly patients who are hospitalized for procedures or conditions associated with acute pain.

ASSESSMENT CRITERIA

The following assessment criteria indicate patients who are likely to benefit the most from use of this research-based protocol:

* Patients who are age 65 or older.

* Patients who are hospitalized for operative/diagnostic procedures or other medical disorders associated with acute pain.

Assessment tools for acute pain management can include:

* Baseline assessment: completed prior to an episode of pain. An example is available in the complete protocol.

* Pain intensity rating: completed during the pain episode in an attempt to rate the severity of the pain (Figure 1).

* Pain flowsheet: completed throughout the patient's pain episode to track characteristics of the episode and nursing measures that lessen the pain. An example is available in the complete protocol.

DESCRIPTION OF INTERVENTION

The proposed intervention to manage acute pain hi elderly individuals is divided into several components including:

* Baseline pain assessment.

* Educating patient and family about pain management.

* Monitoring the acute pain experience.

* Pharmacologie management.

* Nonpharmacologic management.

* Assessing the effectiveness of pain management.

Baseline Pain Assessment

The baseline pain assessment can be completed prior to a known painful event such as surgery or a diagnostic procedure to best help health care professionals manage the older adult's pain in a proactive manner. The following activities comprise a baseline assessment.

1. While pain is the standard term used in the protocol, it is commonly recognized that many elderly individuals use other terms (e.g., ache, discomfort). Use of preferred terminology will enhance understanding and participation by patients in their pain management program (McCaffery & Beebe, 1989; Miller et al., 1996).

* Investigate pain terminology typically used by the patient and use this term throughout the implementation of protocol (McCaffery & Beebe, 1989; Miller et al., 1996).

2. Provide opportunity for individualized patient/family and nurse interaction. Involve family in all aspects of assessment and planning for pain management (AHCPR, 1992a; Ferrell, Ferrell, Rhiner, Sc Grant, 1991). Assess patient's/ family's current knowledge of pain management strategies that may be implemented during hospitalization (AHCPR, 1992a).

3. Use a standard mental status tool to assess for cognitive function and a functional status tool to assess physical function, remembering to include sensory assessment. Obtain family assistance as needed (McCaffery Sc Pasero, 1999; Sengstaken & King, 1993).

4. Complete a thorough assessment of patient pain levels with the assistance of the patient or the family, which includes the following (a Pain Assessment Inventory is available in the full protocol):

a) Assess patient and family attitudes and beliefs regarding: pain and analgesics, prior successes/failures with analgesics, expectations regarding pain and stress during hospitalization. Fear of addiction and analgesic side effects, beliefs related to ageism, passivity of patient role, and stoicism function as barriers to patient's report of pain (Ferrell, Ferrell, & Osterweil, 1990; Hofland, 1992; Ward et al., 1993; Yates, Dewar, & Fentiman, 1995).

Figure 1. Pain intensity tools recommended for use with elderly individuals. From Herr et al. (1998).

Figure 1. Pain intensity tools recommended for use with elderly individuals. From Herr et al. (1998).

b) Assess sociocultural variables (e.g., ethnicity, acculturation) which may influence pain behavior and expression (Koopman, Eisenthal, & Stoeckle, 1984; Neill, 1993; Streltzer & Wade, 1981).

c) Determine history of other chronic disorders which may also cause pain and interfere with accurate assessment of acute pain (AHCPR, 1992a; Donovan, Dillon, &McGuire, 1987).

d) Investigate medication use for chronic conditions that may interact or interfere with analgesic use (Hutchinson, Flegel, Kramer, Leduc, & Kong, 1986).

e) Assess patient for depression and/or anxiety which may alter pain perception and enhance intensity of pain (Gasten, Parmelee, Kleban, Lawton, & Katz, 1995; Turk, Okifuji, & Scharff, 1995).

f) Investigate methods commonly used by the patient to relieve pain (e.g., folk or home remedies) and methods used to cope with pain (e.g., distraction, prayer) (Ferrell, 1995; McCaffery & Pasero, 1999).

g) If the patient is noncommunicative, try to elicit from the family the patient's usual pain behaviors such as withdrawal, agitation, facial grimacing, guarding, moaning (Hurley, Volicer, Hanrahan, Houde, &: Volicer, 1992; Prkachin, 1993).

h) Assess pain intensity by selecting a tool based on the patient's preferences and cognitive/functional abilities. The Verbal Descriptor Scale, Pain Thermometer, and Numeric Rating Scale have an acceptable accuracy and are preferred by elderly individuals (Herr & Mobily, 1993; Herr, Mobily, & Richardson, 1998). Examples of pain scales used with elderly patients: Verbal Descriptor Scale (VDS).

* Visual Analogue Scale (VAS).

* Pain Thermometer (PT).

* Numeric O to 10 Rating Scale.

* Faces Pain Scale (Herr, Mobily, Kohut, & Wagenaar, 1997).

Please note that mildly to moderately cognitively impaired individuals are often able to rate pain using these instruments; however, individual patient ability to do so should be assessed (DietrickGallagher, Polomano, & Carrick, 1994; Feldt, Ryden, & Miles 1998; Ferrell, Ferrell, & Rivera, 1995; Gueldner & Hanner, 1989; Herr Sí Mobily, 1993; Herr et al., 1998; Jensen, Karoly, & Braver, 1986; Kremer, Atkinson, & Ignelzi, 1981; Parmelee, Smith, & Katz, 1993; Porter et al., 1996).

Educate Patient and Family About Pain Management

Research has demonstrated that implementing an educational program for pain management for the patient and family helps promote effective pain management (Ferrell, Rhiner, & Ferrell, 1993). Although this program was developed for older adults with cancer pain at home, the overall structure of the program can also be adapted for older adults with acute pain. The following activities can be included in this program:

1. General information about pain.

a) Provide information regarding planned procedure and associated painful sensations to the patient and family prior to the upcoming procedure or surgery (AHCPR, 1992a; Wachter-Shikora, 1983). Then offer opportunities for patient and family to discuss fears and concerns regarding the diagnostic procedure or surgery (Schmitt &C Woolridge, 1973).

b) Provide patient and family with a brochure, such as the brochure offered through the AHCPR (1992b), Pain Control After Surgery: A Patient's Guide. This brochure (AHCPR Publication No. 92-0021) is available for sale from AHCPR Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907-8547, or by calling (800) 358-9295 (in the United States) or (410) 381-3150 (outside the United States). To download the guideline, access the Web site at http://www.ahcpr.gov, go to clinical information section, and select clinical practice guidelines.

c) Explain to patient and family that pain can be managed and relieved (AHCPR, 1992a; Yates et al., 1995) and the importance of reporting pain and pain control in the recovery process (e.g., facilitation of postoperative exercises to prevent complications). Coach the patient in accurately reporting pain (AHCPR, 1992a; Puntillo & Weiss, 1994; Ward & Gordon, 1994; Wilkie, Williams, Grevstad, & Mekwa, 1995).

d) Explain to the patient and family the importance of preventing rather than "chasing" pain m effective pain management (AHCPR, 1992a; Ferrell, Ferrell, Ahn, & Tran, 1994).

2. Pain assessment.

a) Explain the pain assessment schedule and method of pain assessment using selected assessment tool(s). Assess the patient's and family's understanding and accurate use of selected tool (AHCPR, 1992a; Ferrell et al., 1994).

b) Communicate with the patient and set an acceptable level of pain control (AHCPR, 1992a) that is based on pain rating criteria.

c) Explain the need to differentiate pain related to procedure and pain related to other chronic disorders (Ferrell, 1995).

3. Pharmacologie management.

a) Allay common fears and misconceptions regarding opiate use, such as addiction and respiratory depression (AHCPR, 1992a; Ferrell et al., 1994).

b) Negotiate pain rating criterion for analgesic administration (i.e., a rating on pain assessment tool) (AHCPR, 1992a).

c) Explain common side effects of analgesics (e.g., constipation) and planned interventions for any side effects experienced (AHCPR, 1992a).

d) Describe as well as demonstrate typical analgesic regimen (e.g., patient-controlled analgesia [PCA]) (AHCPR, 1992a).

4. Nonpharmacologic management.

a) Describe cognitive and behavioral pain management options (e.g., relaxation strategies, imagery) and cutaneous stimulation options (heat and cold, Transcutaneous Electrical Nerve Stimulation [TENS]) and select options based on patient preference and cognitive and functional abilities (AHCPR, 1992a; Mobily, 1994).

b) Explain and demonstrate routine postprocedure exercises or activities (e.g., coughing) and methods to decrease discomfort from these (e.g., splinting) (AHCPR, 1992a).

Monitoring the Acute Pain Experience

1. Be aware that older individuals often suffer from chronic pain in addition to acute pain and implement strategies to relieve pain from chronic disorders as much as possible (AHCPR, 1992a; American Geriatrics Society [AGS] Panel on Chronic Pain in Older Persons, 1998).

2. Assess and document characteristics, intensity, duration, and effects of pain. Use selected assessment tool (AHCPR, 1992a).

a) Assess pain at least every 2 hours and during rest, during activity, and through the night when pain is often heightened (AHCPR, 1992a; American Pain Society, 1999; Nelson, Taylor, Adams, & Parker, 1990). Ability to sleep does not indicate absence of pain (Donovan et al., 1987).

b) Observe for nonverbal cues of pain (e.g., grimacing, guarding) and behavioral changes (e.g., new onset of confusion, agitation, or withdrawal; sleep disruption) (Baker, Bowring, Brignell, & Kafford, 1996; Duggleby & Lander, 1994; Hurley et al., 1992; McCaffery & Pasero; 1999, Miller et al., 1996; Prkachin, 1993; Simons & Malabar, 1995).

c) Elicit pain statements from communicative, cognitively impaired patients and use a selected assessment tool (Parmelee et al-, 1 993; Sengstaken & King, 1993). Try several tools to evaluate which one is most easily used by the cognitively impaired individual. Ferrell, Ferrell, and Rivera (1995) reported that 83% of their cognitively impaired subjects could complete at least one of five pain scales administered to them. These scales included the McGiIl Pain Questionnaire Present Pain Intensity Subscale, Horizontal Visual Analog Scale, Memorial Pain Card Subscale, Rand Coop Chart, and a Verbal Scale.

d) In noncommunicative, cognitively impaired patients, observe for changes in usual behavior (e.g., withdrawal, increased confusion, agitation), facial expressions of pain (e.g., grimacing), bodily tension, fidgeting, and vocalizations (Feldt et al., 1998; Ferrell et al., 1995; Miller et al., 1996; Porter et al., 1996; Simons & Malabar, 1995). Research indicates that failure to assess and treat pain in these individuals is often because of an unfounded belief by health care providers that pain sensations are diminished in individuals with cognitive impairments (Cariaga, Burgio, Flynn, &C Martin, 1991; Hurley et al., 1992; Marzinski, 1991; Sengstaken & King, 1993).

e) Assess for autonomie responses typically associated with acute pain (e.g., increased heart rate and blood pressure, increased or decreased respiratory rate, diaphoresis) (Eland, 1988; Kehlet, 1989).

f) Assess pulmonary function (e.g., respiratory rate, lung sounds, signs of hypoxia) for pain-related complications every 4 to 8 hours (AHCPR, 1992a; Puntillo & Weiss, 1994).

g) Differentiate procedural pain from pain due to chronic disorders or complications of procedure (e.g., new pain, increased intensity of pain, pain not relieved by previously effective strategies) (AHCPR, 1992a).

h) Assess the patient for atypical presentation of complications commonly seen in elderly individuals. For example:

* Shortness of breath and confusion with myocardial infarction and absence of or delayed chest pain. (Ambepitiya, Roberts, Ranjadayalan, & Tallis, 1994; Bayer, Chadha, Farag, & Pathy, 1986).

* Absence of pain during intra-abdominal emergencies (Bender, 1989).

* Pain of various conditions often referred from the site of origin (Butler & Gastel, 1980).

i) Document pain assessment findings on a flowsheet that includes: date, time, pain rating, use of analgesics, other pain intervention, vital signs, and side effects. (A pain flowsheet is included in the full protocol).

Pharmacologie Management

1. Use the following guidelines for analgesic administration:

a) Research demonstrates that elderly patients receive significantly less analgesic medication than younger adults experiencing similar painful conditions or procedures, therefore, leading to inadequate pain relief in these older patients. This tendency may be because of a belief on the part of health care providers that, in general, pain sensation decreases with age. There is no research base to support this misguided belief (Donovan et al., 1987; Faherty & Grier, 1984; McCaffery & Pasero, 1999).

b) Safe analgesic administration in elderly individuals is complicated by interactions with multiple chronic disorders, multiple drugs to treat these disorders, nutritional alterations (e.g., protein deficiency), and altered pharmacokinetics (Hutchinson et al., 1986; Lamy, 1983; Nolan & O'Malley, 1988). The incidence of acute confusion and other adverse reactions increases with the number of prescription drugs administered (AHCPR, 1992a; Hutchinson et al., 1986).

c) Elderly individuals generally receive greater peak and longer duration of action from analgesics than younger individuals (Bellville, Forrest, Miller, & Brown, 1971; Koh & Thomas, 1994); thus dosing should be initiated at lower doses (1A to l/2 adult dose) and titrated carefully (AGS Panel on Chronic Pain in Older Persons, 1998).

d) Use PCA for intravenous analgesics particularly during immediate postprocedure period (e.g., 48 hours) but monitor and titrate cautiously due to increased potential for toxicity (Egbert, Parks, Short, & Burnett, 1990; Lamy, 1983).

e) Recognize that cognitively impaired patients may require nurseassisted use of PCA (AHCPR, 1992a; Wasylak, Abbott, English, & Jeans, 1990).

f) Administer oral analgesics on an around-the-clock (ATC) basis (American Pain Society, 1 999). Administer on p.r.n. basis later in course as indicated by patient's pain status. If given on p.r.n. basis, administer 30 minutes prior to activities (e.g., physical therapy) and postoperative exercises. (AHCPR, 1992a; AGS Panel on Chronic Pain in Older Persons, 1998). Assess for breakthrough pain and need for supplemental doses. (AHCPR, 1992a; AGS Panel on Chronic Pain in Older Persons, 1998).

g) If acute confusion develops, assess for other contributing factors prior to altering the prescription or discontinuing analgesìe use. Confusion in postoperative patients has been found to be associated with unrelieved pain rather than opiate use (Duggleby & Lander, 1994; Hurley et al., 1992; Williams et al., 1979).

h) Assess bowel function daily and initiate patient's home protocol or the Constipation Management research-based protocol to prevent the constipating effects of analgesic use. Assess for signs of ileus related to narcotic analgesics (AHCPR, 1992a; Nimmo, Heading, Wilson, Tothill, & Prescott, 1975). (For more information regarding the Constipation Management Protocol, contact Marita Titler, PhD, RN, FAAN, Department of NursingRDDC, 200 Hawkins Drive, Tl 52 GH, Iowa City, Iowa 52242.)

i) Measure intake and output and assess for signs of urinary retention or suppression (AHCPR, 1992a).

j) Slowed intramuscular absorption of analgesics in elderly patients may result in delayed or prolonged effect of intramuscular injections, altered analgesic serum levels, and possible toxicity with repeated injections. This is more common with intramuscular meperidine than intramuscular morphine. Use intravenous or intraspinal analgesia for rapid control of severe pain (Conner & Deane, 1995; Pasero & McCaffery, 1996).

k) Antiemetics for analgesicinduced nausea may result in problems in elderly patients due to anticholinergic effects (e.g., bowel and bladder dysfunction, confusion, movement disorders) (AHCPR, 1992a; Ferrell, 1995).

2. The following analgesics and adjuvants may produce increased confusion levels in elderly patients:

a) Nonsteroidal anti-inflammatory drugs (NSAIDs) (greatest risk during initial use) (Goodwin & Regan, 1982; Roth, 1989; Rozzini, Ferrucci, Losonczy, Havlìk, & Guralnik, 1996).

b) Meperidine (Kaìko et al., 1983).

c) Pentazocine (Talwin) (Ferrell, 1995).

d) Anticholinergics (antihistamines) (e.g., hydroxyzine; Phenothiazines) (Ferrell, 1995).

3. Drug interactions occur more frequently in elderly individuals (Doucet et al., 1996).

4. The analgesic effects of NSAIDs supplement the analgesic effects of prescribed opioids, therefore, reducing the dose of opioid required for effective pain management. Thus, they may reduce the incidence of opioid-induced respiratory depression in elderly patients (AHCPR, 1992a; AGS Panel on Chronic Pain in Older Persons, 1998; Weingart, Sorkness, & Earhart, 1985). The following NSAID complications are common among elderly patients and must be carefully monitored:

a) Gastrointestinal (GI) bleeding especially with initiation of drug or higher doses of a drug (Griffin, Piper, Daugherty, Snowden, & Ray, 1991). Therefore, avoid use if patient has a history of peptic ulcers (Roth, 1989). A meta-analysis of the variability and risk of GI complications of NSAIDs found that low dose ibuprofen (less than 1,600 mg per day) was associated with the lowest relative risk (Henry et al., 1996). Initiate antacid regimen and administer with food. Monitor for signs of GI bleeding.

b) Nephrotoxicity (Perneger, Whelton, & Klag, 1994). Avoid use if patient has a history of renal impairment, congestive heart failure, concurrent volume depletion, or diuretic use.

c) Bleeding disorders (Roche & Forman, 1994; Roth, 1989). Avoid use if patient has a history of bleeding disorders or a concurrent use of anticoagulants, or use a plateletsparing agent (e.g., Salsalte, Diflunisal) (AHCPR, 1992a).

Figure 2. Pain management monitor.

Figure 2. Pain management monitor.

d) Confusion (Goodwin Si Regan, 1982; Roth, 1989). Monitor patient for new onset or increased confusion in demented patients during initial use. Long-term use has been found to have a protective effect on cognitive decline (Rozzini et al., 1996).

e) Other (e.g., constipation, headaches, dizziness) (Rozzini et al., 1996).

5. Age-associated physiologic changes (e.g., reduced renal or liver function) result in increased toxicity with aspirin use (Baskin & Goldfarb, 1983).

6. Acetaminophen is an effective analgesic in elderly patients and does not produce the gastric and bleeding complications seen with NSAIDs. Other complications that may be associated with acetaminophen usage include:

a) Increased risk of end-stage renal disease with long-term use (Perneger et al., 1994).

b) Toxicity because of reduced hepatic metabolism (McCaffery & Beebe, 1989).

c) Overcoagulation with warfarin in the outpatient setting (Hylek, Heiman, Skates, Sheehan, & Singer, 1998).

7. Opiates produce greater analgesic effect and have a higher serum peak and duration in elderly patients (Bellville et al., 1971; Kaiko, 1980). Therefore:

a) Initiate opioid therapy with 25% to 50% lower dose than that recommended for adults and slowly increase dosage by 25% on an individual basis, balancing analgesic need with undesirable effects (AHCPR, 1992a; American Pain Society, 1999; Nimmo et al., 1975). Use intravenous, intraspinal, or oral routes of administration, not intramuscular (McCaffery & Pasero, 1999).

b) Monitor for respiratory depression (e.g., fewer than 10 respirations per minute) and reduced arterial oxygen saturation (less than 85%), particularly in opioidnaive patients. Cheyne-Stokes respirations during sleep without other adverse signs does not necessitate opioid reduction (AHCPR, 1992a).

c) Omit if respiratory complications develop or if patient experiences excess sedation. Administer naloxone (Narcan) (AHCPR, 1992a).

d) Monitor for other side effects of opioids including sedation, hypotension, urinary retention (especially if coexisting benign prostatic hypertrophy), constipation/ ileus, and exacerbation of Parkinson's disease (AHCPR, 1992a; Ferrell, 1995; Nimmo et al., 1975).

e) Meperidine should be avoided with elderly patients. If used, meperidine should not be continued for more than 48 hours (AHCPR, 1992a; American Pain Society, 1999) or if a patient has a diagnosis of renal impairment or congestive heart failure because of possibility of normeperidine toxicity. Normeperidine is an active metabolite of meperidine with stimulant effects. Therefore, monitor for central nervous system excitability, specifically tremors, seizures, mood alterations, and confusion. (AHCPR, 1992a; Kaiko, Wallenstein, Rogers, Grabinski, & Houde, 1982; McCaffery & Pasero, 1999; Szeto et al,, 1977). If normeperidine toxicity occurs perform the following:

* Stop drug administration.

* Administer anticonvulsant as necessary.

* Do not administer naloxone (Narcan) for meperidine toxicity.

* Substitute another analgesic (McCaffery & Pasero, 1999).

Avoid intramuscular use of meperidine because of tissue irritation and muscle fibrosis, compounding reduced tissue mass in elderly patients (AHCPR, 1992a). Intramuscular meperidine is poorly absorbed and leads to variable analgesic response and may result in increased dosage requirements and associated side effects (Austin, Stapleton, & Mather, 1980; Conner & Deane, 1995).

f) Morphine sulfate is a safer choice than meperidine in elderly individuals for the following reasons:

* Longer duration of action, therefore, less overall dosage is required and less possibility of toxicity (Conner & Deane, 1995; McDonald, 1993; McKenzie, Rudy, & Ponter-Hammill, 1992).

* Reduced hemodynamic alterations (Lee et al., 1976).

* Effects are most understood and predictable (Ferrell, 1995).

g) Transdermal fentanyl is not indicated in management of acute pain (Ferrell & McCaffery, 1997). It has been used in older adults with chronic pain but should be used with caution in opioid-naíve elderly individuals due to extreme potency and potential for delirium and respiratory depression (Ferrell, 1995; Wakefield, Johnson, Kron-Chalupa, & Paulsen, 1998).

h) Combined agonists and antagonists have properties that may be pronounced in elderly patients:

* Butorphanol (Stadol) and pentazocine (Talwin) produce psychotomimetic effects and may lead to confusion (AHCPR, 1992a).

* Buprenorphine (Buprenex) is less likely to produce respiratory depression, but this complication cannot be completely reversed with naloxone (Narcan) (McCaffery & Beebe, 1989).

i) Opioids with long half-lives (i.e. methadone, levorphanol) may result in toxicity in elderly patients (McCaffery & Beebe, 1989).

j) Identify other medications prescribed for chronic conditions that may potentiate opioid side effects (e.g., sedation with sedatives, tranquilizers, and antiemetics; postural hypotension with antihypertensives and tricyclics; confusion with phenothiazines, tricyclics, antihistamines, and other anticholinergics) (Freund, 1987; Koh & Thomas, 1994; Reidenberg, 1982).

Nonpharmacologic Management

1. Assist patients to enhance their sense of personal control over pain (e.g., allow movement at preferred pace) (Bensink, Godbey, Marshall, & Yarandi, 1992; Nelson et al., 1990).

2. Demonstrate interest in patient's comfort level and willingness to implement or alter strategies as needed to facilitate pain relief. Frequently reinforce availability of pain relief measures. Encourage verbalization regarding pain concerns (AHCPR1 1992a; Fraser & Kerr, 1993; Nelson et al., 1990; WilderSmith & Schuler, 1992).

3. Support usual pain coping methods (e.g., prayer, meditation) (Ferrell, 1995).

4. Facilitate use of home/folk pain remedies, unless contraindicated (McCaffery & Beebe, 1989).

5. Use relaxation strategies and distraction (e.g., breathing, massage, touch, music, imagery) to complement analgesics. Avoid imagery in patients with severe cognitive impairment or psychoses (AHCPR, 1992a; Bensink et al., 1992; Ceccio, 1984; Dossey, 1995; Fraser & Kerr, 1993; Heitz, Symreng, & Scamman, 1992; Mobily, 1994; Swinford, 1987; Weinrich & Weinrich, 1990; Wells, 1982).

6. Tr ans cutaneous Electrical Nerve Stimulation has been used successfully in elderly individuals for postoperative pain (Hargreaves Sc Lander, 1989; Neary, 1981).

7. Elderly individuals can benefit from multimodal pain treatment that includes pharmacologie and nonpharmacologic interventions (Herr ecMobily, 1997).

ASSESSING EFFECTIVENESS OF PAIN MANAGEMENT

For each individual patient:

1. Assess pain relief from interventions (30 minutes after parenteral, 60 minutes after oral) using patient-based feedback through one of the pain intensity scales described herein (AHCPR, 1992a; American Pain Society, 1999).

2. Document all pharmacologie and nonpharmacologic pain interventions on a pain flowsheet. (Document pain assessment findings on a flowsheet that includes: date, time, pain rating, use of analgesics, other pain intervention, vital signs, and side effects. A pain flowsheet is included in the full protocol.) (AHCPR, 1992a; McCaffery Si Pasero, 1999).

3. Monitor each patient's pain flowsheet for patterns to identify the efficacy of the pain intervention activities chosen and to determine any need for revision in the pain plan (AHCPR, 1992a; McCaffery & Pasero, 1999).

The Pain Level Outcome from The Nursing Outcomes Classification (NOC) can also be used to assess the effectiveness of pain management for each patient (Johnson & Maas, 1997, p. 226).

4. In collaboration with patients and their families, develop a discharge plan for pain management and provide written instructions, which include drug dosage, interval, drug interactions, and prevention of common side effects (e.g., constipation). Review routine medications for possible interactions. Assess patient and family member's ability to obtain analgesics and intervene accordingly (AHCPR, 1992a).

For quality improvement of nursing care:

Acute pain management for elderly patients should be evaluated at the organizational level (e.g., unit, hospital, nursing home) to evaluate whether the staff is using the pain management guidelines in a consistent and effective manner. Therefore, it is important to monitor the use of the pain management guidelines in a structured manner. The following form, Evaluation of Implementation of the Acute Pain Research-Based Protocol, can be used for this purpose.

EVALUATION OF IMPLEMENTATION OF ACUTE PAIN RESEARCH-BASED PROTOCOL

Make a copy of the chart in Figure 2 and place it in the chart of each patient who is receiving the acute pain management protocol. The four outcomes on this chart should be assessed and recorded for each patient every 4 to 6 days as an indicator of quality improvement.

To use the chart, place the appropriate key criteria next to the four separate outcomes for each assessment indicator. There are a total of eight boxes provided, which represent the first 8 weeks of evaluation. However, this time frame can be adapted to your institutional needs.

Pain is extremely common among elderly individuals.

Involve family in all aspects of assessment and planning for pain management.

Explain to patient and family that pain can be managed and relieved.

It is important to monitor the use of the pain management guidelines in a structured manner.

Assist patients to enhance their sense of personal control over pain.

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Key:

(R) = Research.

(L) = Literature.

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ABOUT THE AUTHORS

Diane M. Young, MSN, RN is Associate Professor and Chair, Master of Science in Nursing Program, Alien College, Waterloo, Iowa and a Doctoral Candidate, University of Iowa, College of Nursing, Iowa City, Iowa. Janet C Mentes, MS, RNCS is Project Director, Research Development & Dissemination Core, Gerontological Nursing Interventions Research Center, and Marita G. Titler, PhD, RN, FAAN is Director, Nursing Research and Quality Management, Department of Nursing and Patient Care Services, University of Iowa Hospital and Clinics, and Director, Research Development and Dissemination Core, Gerontological Nursing Interventions Center, Iowa City, Iowa.

This work has been supported by grant number P3Ö NR03979from the National Institute for Nursing Research, National Institutes of Health, Washington, DC.

Address correspondence to Marita G. Titler, PhD, RN, FAAN, Director, Nursing Research and Quality Management, Department of Nursing and Patient Care Services, Director, Research Development and Dissemination Core, 200 Hawkins Drive, T152 GH, Iowa City, IA 52242.

Copyright (c) [1999] The university of Iowa Gerontological Nursing Interventions Research Center Research Development and Dissemination Core. All rights reserved. Repuhlished with permission.

10.3928/0098-9134-19990601-06

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