Note from the National Guideline Clearinghouse (NGC): In this update of the guideline, the process previously used to develop the geriatric nursing protocols has been enhanced.
Levels of evidence (I – VI) are defined at the end of the "Major Recommendations" field.
Assessment Parameters
- Assumptions
- The majority of hospitalized older patients suffer from both acute and persistent pain.
- Older adults with cognitive impairment experience pain but are often unable to verbalize it (Smith, 2005 [Level I]).
- Both patients and health care providers have personal beliefs, prior experiences, insufficient knowledge, and mistaken beliefs about pain and pain management that:
- Influence the pain management process
- Must be acknowledged before optimal pain relief can be achieved (American Geriatric Society [AGS], 2002 [Level VI]).
- Pain assessment must be regular, systematic, and documented in order to accurately evaluate treatment effectiveness (AGS, 2002 [Level VI]).
- Self-report is the gold standard for pain assessment (AGS, 2002 [Level VI]).
- Strategies for pain assessment
- Review medical history, physical examinations, and laboratory and diagnostic tests to understand the sequence of events contributing to pain (AGS, 2002 [Level VI]).
- Assess present pain, including intensity, character, frequency, pattern, location, duration, and precipitating and relieving factors (AGS, 2002 [Level VI]).
- Review medications, including current and previously used prescription drugs, over-the-counter drugs, and home remedies. Determine which pain control methods have previously been effective for the patient. Assess patient's attitudes and beliefs about use of analgesics, adjuvant drugs, and nonpharmacological treatments (AGS, 2002 [Level VI]).
- Use a standardized tool to assess self-reported pain. Choose from published measurement tools, and recall that older adults may have difficulty using 10-point visual analog scales. Vertical verbal descriptor scales or faces scales may be more useful with older adults (Taylor et al., 2005 [Level V]).
- Assess pain regularly and frequently, but at least every 4 hours. Monitor pain intensity after giving medications to evaluate effectiveness.
- Observe for nonverbal and behavioral signs of pain, such as facial grimacing, withdrawal, guarding, rubbing, limping, shifting of position, aggression, agitation, depression, vocalization, and crying. Also watch for changes in behavior from patient's usual patterns (Taylor et al., 2005 [Level V]).
- Gather information from family members about the patient's pain experiences. Ask about patient's verbal and nonverbal/behavioral expressions of pain, particularly in older adults with dementia.
- When pain is suspected but assessment instruments or observation is ambiguous, institute a clinical trial of pain treatment (i.e., in persons with dementia). If symptoms persist, assume pain is unrelieved and treat accordingly (Herr, et al., 2006 [Level VI]).
Nursing Care Strategies
- Prevention of pain
- Assess pain regularly and frequently to facilitate appropriate treatment (AGS, 2002 [Level VI]).
- Anticipate and aggressively treat for pain before, during, and after painful diagnostic and/or therapeutic treatments (AGS, 2002 [Level VI]).
- Educate patients, families, and other clinicians to use analgesic medications prophylactically prior to and after painful procedures (AGS, 2002 [Level VI]).
- Educate patients and families about pain medications, their side effects and adverse effects, and issues of addiction, dependence, and tolerance (AGS, 2002 [Level VI]).
- Educate patients to take medications for pain on a regular basis and to avoid allowing pain to escalate (AGS, 2002 [Level VI]).
- Educate patients, families, and other clinicians to use nonpharmacological strategies to manage pain, such as relaxation, massage, and heat/cold (AGS, 2002 [Level VI]).
- Treatment guidelines
- Pharmacologic (AGS, 2002 [Level VI])
- Older adults are at increased risk for adverse drug reactions.
- Monitor medications closely to avoid over- or under-medication.
- Administer pain drugs on a regular basis to maintain therapeutic levels; avoid as occasion requires (prn) drugs.
- Document treatment plan to maintain consistency across shifts and with other care providers.
- Use equianalgesic dosing and World Health Organization (WHO) three-step ladder to obtain optimal pain relief with fewer side effects (WHO, 1996).
- Nonpharmacologic (AGS, 2002 [Level VI])
- Investigate older patients' attitudes and beliefs about, preference for, and experience with nonpharmacological pain treatment strategies.
- Tailor nonpharmacologic techniques to the individual.
- Cognitive-behavioral strategies focus on changing the person's perception of pain (e.g., relaxation therapy, education, and distraction), and may not be appropriate for cognitively impaired persons.
- Physical pain relief strategies focus on promoting comfort and altering physiologic responses to pain (e.g., heat, cold, transcutaneous electrical nerve stimulation [TENS] units) and are generally safe and effective.
- Combination approaches that include both pharmacological and nonpharmacological pain treatments are often the most effective.
- Follow-up assessment
- Monitor treatment effects within 1 hour of administration and at least every 4 hours.
- Evaluate patient for pain relief and side effects of treatment.
- Document patient's response to treatment effects.
- Document treatment regimen in patient care plan to facilitate consistent implementation.
Definitions:
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
