Trainers Guideline Pain Management 1. Staff need to understand a definition of pain and that pain Is subjective: Worse if located in the head / eye /

Transcription

1 Trainers Guideline Pain Management 1. Staff need to understand a definition of pain and that pain Is subjective: Worse if located in the head / eye / heart Worse if alone Worse when unsupported Worse if ongoing / chronic Worse if other worries Worse during grief Worse if not positioned comfortably Worse without movement when confined to bed / wheel chair 2. Thus by supporting people in many ways we can reduce pain without resorting to medications as first line action. 3. Pain needs to be recognised A good practical exercise is to encourage care staff to use the pain assessment tool and role play people in different kinds of pain Show then how we must respond in our Care Planning Pain assessments are useless unless we act upon them so focus upon actions arising out of pain assessments 4. Reporting Pain Location Frequency Using residents own words / exact actions when reporting their pain Who to report to [when we need to report] RN responsibility in referral to pain specialist 5. Pain behaviours can be taught from the assessment tool. They are also listed in policy. Behaviours differ among people Behaviours are often calls for help Limping and use of bandages and splints & bandages are pain behaviours that flag an injury [worn when seeing a doctor for ACC then removed / stopped] can be accentuated or minimised Pain can be forgotten when distracted Pain in the elderly confused can result in challenging behaviours E.g. A full bladder can be painful 6. Highlight how good nursing care goes a long way to reducing pain Ask WHAT measures trainees know and use What else could we be doing? What is the role of alternate therapies like heat packs Let trainees think about their own pain experiences 7. Ensure RN understanding of how and when to make referral for specialist pain treatment Via good GP backup Role of pain clinics How pain can magnify and become very problematic in some people.

2 Medicine Management Policy Pain Management Definitions of Pain: Pain is a personal to each person. It can change depending on the amount of physical harm, or medical condition, emotions at the time and personal coping mechanisms. It can be changed by support people [or the lack of them]. Pain cannot be measured like an X-ray or laboratory test. All reports of pain must be regarded as real. Chronic pain For a duration of six months or longer. Craven and Hirnle Fundamentals of Nursing. Pain is whatever the person says it is and occurs whenever the person says it does Elizabeth Kubler Ross. Resident definition of Pain Signs of pain include guarded movements and withdrawal from social contact. Pain behaviours include: moaning, crying, pacing, limping, more. Pain can increase blood pressure, pulse and breathing rate. Or, residents may feel pain but not show it. Signs of chronic pain include: weight change, sleep loss, crabbiness, emotional outbursts and not wanting to socialise. All residents must have a comprehensive pain assessment as part of the RN assessment. This is a quality indicator that we survey to ensure no one misses out. Where pain assessments indicate pain is chronic [ongoing] or not well controlled the GP needs to refer to a Pain Specialist Clinic. The Nursing Process The best means of preventing pain is to control possible sources. This may be achieved by: Regular change of position Comfortable positioning making use of pillows

3 Medicine Management Policy Use of hot baths, rubs and heat packs as appropriate to help prevent stiffness. Regular exercise, including passive exercise, to help prevent stiffness and soreness. Physio & occupational therapy input may be useful here. Promoting an environment where residents feel supported and cared for and not alone (pain endured alone often magnifies) Good assessment so that pain is known as it arises. Use Pain Assessment Form [appendix at end of this policy] if residents exhibits ANY Pain Behaviour - Aim for 95% of residents to have been offered a pain assessment within 6 months of admission to meet Best Practice Guidelines. - Staff may use these forms as an efficient way to report Resident Condition - Corrective Actions may be made AFTER the assessment is endorsed by Trained Clinician [Trained Clinician = someone with a Health Qualification] Make surroundings clean and nice Plenty of fluids Kind words and supportive statements Pain Behaviour - Calling out or Moaning - Rocking - Holding or rubbing a sore part - Wearing a bandage - Limping - Frowning - Being grumpy or otherwise looking unhappy - Not Sleeping - Weight Loss - Difficulty Eating - Not socialising - Emotional Outburst Alternate Therapies Rongoa [Maori Medicine]: Topical applications are known to be successful in place of or alongside Modern Medicine. Massage Mirimiri

4 Medicine Management Policy Suppliments: These need to be shown to the doctor if this resident takes regular medications. Supplements can limit uptake or effectiveness of some medicines. Use of Analgesic Agents All residents admitted on pain medication are maintained on their existing pain management regime until seen and reviewed by the doctor. Analgesic medication is the most common approach to pain management. Analgesics can be broken into three main groups Opioid, Non Opioid and Adjuvant. NB: If resident tells you they hurt: TELL the RN She will tell the DOCTOR He refers to PAIN CLINIC For specialist help Paracetamol is the first line analgesic and may be ordered 2 QID (2 tablets/four times a day) unless otherwise indicated. If stronger pain relief is required, Panadeine 2 QID may be used. If pain remains uncontrolled Paradex 2 Q8H alternating with Paracetamol 2Q8H may be used example. If pain not controlled Non Steroidal Anti Inflammatory Drugs may be considered depending upon the source of pain. Note the side effect of this medication must be made known to staff administering it i.e. give with food or milk to minimise risk of gastric upset and GI Bleed. If pain continues, Morphine or Kapanol or M-Eslon may be appropriate in place of other analgaesics. Chronic pain should not be treated on a PRN basis. Paradex is used as sparingly as possible and not usually on a PRN basis. Any resident commenced on Paradex is monitored for increased risk in falls and other adverse effects. Chest Pain: GTN Spray

5 Medicine Management Policy [Instructions 2 puffs under tongue wait 5 minutes. If pain continues repeat. Wait 5 minutes. if pain persists repeat. Then call RN immediately. If pain persists after 3 doses of GTN spray or at any time residents become agitated, pale, clammy or pain increases call 111 for an ambulance immediately with a view of sending to hospital. Use of Morphine Some General Principles: The amount of morphine required is the amount needed to control a resident s pain. In other words, there is no upper limit for morphine dosage. Generally speaking, if a quantity of morphine fails to control pain the dose of morphine needs to be increased. MST Continuos is designed to be a 12-hourly dose. Adequate control cannot be achieved on a PRN regimen. Should the resident require more MST Continuos, increase the dose not the frequency. Occasionally a resident may be found to have a fast metabolic rate and will require 8 hourly doses. MST Continuos and Kapanol / M-Eslon should not be crushed, as this medication taken whole provides a sustained release of the medication over time. Crushing delivers the full dose too soon. The required dose of morphine may be assessed using prn elixur, then assessing the amount that achieved control (the Doctor does this). Residents with cancer require review at regular intervals. In most cases this means at least once a day. In this way a resident s pain is kept under optimal control. It is important to distinguish between breakthrough pain and Incident pain. PRN analgesia required for breakthrough pain should be incorporated into the regular daily regiment as soon as possible, while incident pain requires anticipatory dosing about 30 minutes before incident. When residents start a new course of morphine we need to ensure:

6 Medicine Management Policy 1. Resident understanding of possible and likely initial side effects [Dr may need to chart an anti-emetic] and reassurance these will only last a short time. 2. Staff understanding also and the knowledge these side effects will need support and good reporting. 3. Resident buy in [good RN and doctor explanation of side effects like initial sleepiness. 4. Effective monitoring by the RN Rectal Morphine: Indications: Obstruction / dysphagia. Persistent vomiting. Administration: Oral = rectal dose. Suppositories require to be given 4-hourly Suppositories may be made in any strength up to 300mg. References A guide to palliative care in NZ 2 nd edition Controlling Breakthrough Pain in Residents with Terminal Illness Breakthrough pain may be due to a worsening of the resident s disease state. The pain usually occurs in the hours before the next dose of MST Continuos / Kapanol is due. Elixur may be prescribed for breakthrough pain. The doctor regularly assessed the prescribed dose in these situations. Record all Morphine Administration according to the Standard for Residential Facilities Controlling Incident Pain: Incident pain, unlike breakthrough pain, is brought about by trauma or by a particular activity, eg. dressing changes. Residents will know which activities precipitate incident pain. Appropriate analgesia, as charted, should be administered where pain is anticipated. Alternative Pain Relief Techniques Many people respond well to alternative therapy such as relaxation massage, Yoga, crystals and oils, acupuncture and acupressure. These options should be available and documented as part of Care Planning.

7 Medicine Management Appendix 1: Pain Assessment Tool Resident/ Client Name: Date: Pain Assessments: Pain is what ever a person says it is Time: [24hr] Resident / Client Self Report of Pain Date Score Sign Wong Baker Pain Assessment Tool Remember pain is worse if you are alone, grieving, in conflict, have not slept, without your usual support people, frightened. Pain Behaviour observed Abbey Pain Scale Absent = 0 Mild = 1 Moderate = 2 Severe = 3 For observations 1 6 below please rate a score Score 1. Vocalisation [what they are saying] Examples: whimpering / moaning / crying 2. Facial Expression Looking tense / frowning / facial grimacing / looking frightened 3. Body Language or change in body language Fidgeting / rocking / guarding part of the body / acting withdrawn 4. Behavioural Change Increased confusion / refusing to eat / alteration in usual patterns 5. Physiological Change TPR or Bp outside normal limits / perspiring / flushing or pallor 6. Physical Skin tears / ulcers / arthritis / contractures KEY 0 2 No Pain 3 7 Mild Pain 8 13 Moderate Pain 14 + Severe Acute Chronic Acute episode on chronic Reviews: Date Score Sign & designation Total Score Care Planning Comment: Please write here notes on actions required arising out of this assessment. Also update the Short Term / Comfort Care Plan Appendix 1

8 Policy Terminal / Comfort Cares Terminal or Comfort Cares When a resident is approaching end of life we begin terminal cares. The Registered Nurse is responsible for filling in the Comfort Cares Planning. Staff may also initiate the use of this form. We must always keep family fully informed when resident condition deteriorates. It is the registered nurse responsibility to ring the family. If family are aware of the reason their loved ones are failing, it helps them accept the situation. Family are likely to gather, as one of their own come closer to the end of their life. We can help: By being quietly spoken and courteous Providing cups of tea and food for any member who is sitting beside the failing person Assisting with personal cares Encouraging family to participate as they wish Ensuring the resident is comfortable and looks nice Keeping the room clean, smelling nice and having some flowers available. Practical Support Comfort & Relaxation Breathing Input & Output Pain Control Skin & Wound Support including support provided to / by family Document on the Comfort Care Log Fluid Balance Position Pain relief Nebulisers or other relief measures. Use one page for each day.

9 Policy Terminal / Comfort Cares Comfort Care Planning Resident Name:. Comfort & Relaxation Date: Intake Carefully positioned in bed Regular change of position. Turned hourly. Pillows positioned supportively. Heals protected: Massage: Sponge bathed as needed: Clean fresh bed linen Peaceful environment Nice pyjamas Allocate 1 care staff available as needed Pain Control: Pain assessment completed Medication as charted Not swallowing medication now with held Medication Review: Airway: Breathless: nurse sitting up pillow supported Use mouth swabs to clear mucous Give nebuliser: Other instruction: Needs help to eat Encourage to drink fluids: Keep Fluids Balance Chart: Soft diet Small amount frequently Spoon or syringe into mouth Use juice bottle Frequent sips water or juice Fluids only now Mouth hygiene hourly Keep lips moist Drinks supplement: Apply: Output Record of fluids out use fluid balance Keep nice & clean wash whenever wet or dirty Use nice toiletries Incontinence product: Other instruction: Support Family well informed Made welcome: Family / friends with resident. Has no one available staff fill this role. Religious: Skin & Wound Soft or ripple mattress: From Hospice From Our own Care of pressure points Report any redness Passive exercises Change of position Creams: Dressings [See Wound Care Log]: Extra staff as needed: Special Instructions [Doctor / other]: Environment of love & Support:

10 Policy Terminal / Comfort Cares Maori Protocol / Guideline for any approaching death Whanau / family may prefer to take their terminally ill relative home Where death is imminently expected, whanau will be notified at once. A single room will be available and family welcomed. Wherever possible, Maori staff members will attend the terminally ill Maori client alternatively the Home will facilitate whanau to provide hands-on care, should they desire to. Similarly for other cultures Should staff not be confident in correct Maori protocol, they will be guided by this policy and by attending whanau / family. No food or drink will be taken into the room. Once the client has died, the body is known as the Tupapaku. Whanau /family should be involved in washing and dressing the Tupapaku. Whanau might wish to lead this personal process. Staff need to ascertain how much support whanau seek from nursing staff. In some cases, whanau may prefer privacy; alternatively, they may welcome nursing support. Separate linen is used for deceased clients. This should be stored in a box and brought out when required. It is culturally sensitive to demonstrate that this linen (sheets / towels / flannels) is special by selecting a different colour from other Home linen. It is especially sensitive to also provide nice soap and an attractive bag for this purpose. Afterwards, this linen will be laundered separately. Staff will allow whanau time to express grief. The Tupapaku should not be dispatched with haste. The Tupapaku [body] will always be handled with respect. The Tupapaku will only be moved feet first. Where possible the Tupapaku will not be taken through public areas. The Tupapaku must be released to whanau as soon as legally possible. Whanau will usually wish to accompany the Tupapaku, and may use their own vehicles.

11 Policy Terminal / Comfort Cares Whanau /family will have the choice of taking the Tupapaku home. Where the Tupapaku is placed into the care of whanau, it is their responsibility to liaise with funeral homes for embalming procedures. Karakia will be performed in the room after the Tupapaku is removed. No physical cleaning of the room will occur until this has occurred. Physical cleaning of the room should not occur in haste. It is preferable to leave the physical cleaning of the room for 24 hours. Please close the door. All effort will be made to avoid post mortem this is seen by Maori as a form of desecration therefore its need must be fully explained to help gain acceptance. All discussion must be conducted in privacy, with the appropriate spokesperson from the whanau group. Sufficient time must be given for discussion and understanding to be reached within the whanau group. Such discussions should be documented in a factual manner in the Service User File.

12 Policy Terminal / Comfort Cares Guideline for the Death of a Resident Expected The person has stopped breathing. In the event of expected death, where it is agreed that the resident is dying, we promote dignity and we do not resuscitate: 1. Report the death to the RN, or to the Manager at the first opportunity. They will notify the family if they are not present. NB: Care staff are NOT to notify family when residents pass away. The RN or Manager will do this. If family are present, allow them time to shed some tears and to say their good byes. This cannot be rushed and different people will react differently. Usually each person present will want to touch / look upon their loved one [this helps them to believe that the death has occurred]. Remember the first stage of grieving is denial. It is important to give all family members the opportunity to view the deceased before they leave the Home. Guide to questions family are likely to ask about / things to discuss with family: - Time of death - Funeral arrangements. - Special religious considerations - Clothing for the deceased to wear / clothing they will bring in. - What to do with jewellery on the body. This needs to be secured. Beware of just handing jewellery to any family member. This is Manager or RN responsibility. NB: If jewellery is left on the body the funeral director must sign that they have taken it. 2. Do NOT wash the body until either the doctor has been [and says that you may] or permission is given by the RN / Manager. 3. Once permission is given get the Mortuary Box which contains: New coloured towels and flannels Nice toiletries Gowns and gloves Micropore Tape [to close eyes] Large mouth swabs Gowns and gloves for staff to wear. Syringe [to remove catheters] Gauze squares [to cleanse eyes or ears] White sheet that will go with the resident to the mortuary [or with whanau if they prefer to take the corpse]. Please restock after use.

13 Policy Terminal / Comfort Cares 4. At least two people should lay the body out. Family may or may not want to take part in this. If they do, this is a therapeutic and special time. 5. Continue to observe privacy, dignity AND confidentiality as though alive. 6. Leave / put dentures in place. Leave catheters in place initially they prevent incontinence. The RN [or their delegate] will decide whether to leave these in? 7. Remove hearing aids and false limbs unless the family instruct otherwise. 8. Leave dressings in place also. 9. If there is any infection / infectious disease you must advise the funeral director as soon as possible to avoid cross infection. Continue to observe precautions against the infection. Residents must be treated with the same amount of Privacy and Dignity as when they were alive. Please ensure that resident property is protected Relatives should not take property from resident rooms unless they are next-of-kin or all together in a main family group Some families will want staff to pack up resident property, others will want to do this themselves be guided by the family. There is no rush to empty the room. Once it is empty it will be thoroughly cleaned and may be re-decorated. Maori staff / Maori resident s Whanau will need to see the room blessed. It is often nice for whanau to do this themselves. If in doubt talk to the Home s Maori Health Consultant. Telling other residents: Residents very often regard others they have been living with as like their own family. The RN [or their delegate] will inform other residents when one of their own is dying / has died, as sensible. Residents that wish to need to have time to say their farewells to one of their own and to grieve. They attend funeral / memorial services in the Home, as appropriate.

14 Policy Terminal / Comfort Cares Guideline for the Death of a Resident / other staff / visitor Unexpected 1. Check breathing look to see if the chest is rising 2. Shake the persons shoulder and call out loudly: Are you OK? No Response 3. Call for help from another staff member / ring Get the person onto a flat hard surface. 5. Start CPR CPR Guide: Do NOT search for a Pulse if NOT BREATHING & NOT RESPONDING. Start with 30 compressions of the chest on the zippysternum Give two breaths we have: mouth protection device Ambubag Continue with 30 compressions to two breaths. If two people available one will do compressions and one will rescue breathe. 6. If possible other staff will keep other residents away to reduce their distress. 7. Continue CPR until ambulance arrives. 8. Once emergency services arrive take instruction from them.

15 Assessment Knowledge Comfort Cares How can we improve comfort and relaxation for people at the end stages of life? What things can cause pain / discomfort to a dying person? What equipment helps at these times? How can we help people who do not have any family with them? What are some guidelines about when to ring family? What is the BEST indicator that someone is comfortable / not in pain? Name: Designation: Date:

16 Assessment Knowledge Comfort Cares GENERAL GUIDE TO ANSWERS: NB: Staff may have different answers that are also correct. Where everyone s answer is identical, you cannot rely on staff understanding. H ow can we improve comfort and relaxation for people at the end stages of life? 1. Look at their Comfort Care Planning and be guided by that. 2. Positioning 3. Heals protected 4. Heat packs 5. Nice environment 6. Enough fluids 7. Nebulisers 8. Mouth swabs Wh at things can cause pain / discomfort to a dying person? [Many different answers here] 1. Pressure of sheets 2. Blocked airways with mucus 3. Diseases / wounds 4. Fear will increase pain 5. Being alone Wh at e quipment helps at these times? [Call upon Hospice] 1. High low beds / ripple matress 2. Heat packs 3. Jumbo mouth swabs 4. Sheep skins H ow can we help people who do not have any family with them? 1. Not leaving them alone 2. Using key staff rather than many different people 3. Ensuring friends / family available ARE sourced 4. TLC kind & tender loving care Wh at are some guidelines about when to ring family & who can ring family? 1. Family may state their preferences 2. General rule is when there is ANY deterioration 3. If in doubt sooner rather than later 4. Usually RN or Manager responsibility What is the BEST indicator that someone is comfortable / not in pain? That they are relaxed [practical session will demonstrate].

17 Training Signing Sheet Topics: Pain Management Comfort Cares Death & Dying Positioning for Comfort Alternate Therapies [Massage, music, aroma, family support] Date: Trainer: PLEASE PRINT CLEARLY I have undergone the above training. I have been shown and understand what was demonstrated. Anything that I did not understand, I asked for and received adequate explanation. First Name Surname Signed Employee