Browsing "Pain"

Pain – Entry 4

Dear Diary,

We continue to try new approaches for helping residents manage their pain. One of our long-stay neighborhoods has worked hard to individualize approaches to pain management. Every time a resident requests a pain med, the staff offers a non-pharmacologic approach. They individualize the approaches based on resident preference and what seems to help. For example, around 2:00 today Leo complained of hip pain and asked the nurse for a pain pill. The nurse got a good description of his pain and, in addition to providing the pain pill, helped him lie down when he asked. About a half hour after the nurse gave Leo the pain medication, she went back to Leo to see if he was feeling better, and he was. The nurse and the nursing assistant have noticed that Leo has increased complaints of hip pain in the afternoon. So, they talked with Leo and all agreed that starting tomorrow, they will offer to help him lie down after lunch to see if this will prevent him from having hip pain. Leo’s open to trying anything that will help, so they discussed ice and heat packs, distractions like music and TV, and trying some different chairs to aid his comfort. They’ll try these different approaches and document what helps. Since this pain is pretty recent, the nurse did a more thorough assessment. She will contact Leo’s physician with her findings and see if some therapy would be appropriate. This team approach has worked well for residents who are able to communicate.

This neighborhood also has been able to reduce the number of PRN pain meds given by doing thorough pain assessments including intensity and duration. They discovered a few residents with chronic pain related to joint and soft tissue changes. So, they consulted with our pharmacist and physician to see if these people would benefit from scheduled pain meds. They’ve got a good titration system starting with scheduled acetaminophen and adding other pain medications as needed for relief. The pharmacist makes recommendations based on the resident’s diagnoses and current medications. The nurse contacts the physician with the recommendations. It’s been going well. We have more residents on scheduled acetaminophen, which is helping a fair number of them with chronic pain issues.

I think I’ll have these nurses talk at our next nurses meeting. I’ll ask all the nurses for their input and see if we can spread these approaches to another neighborhood.

I wonder what other homes are doing to reduce pain.

Signed, Donna

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Pain – Entry 3

Dear Diary:

It’s been a couple of weeks since the team started meeting with Hattie to help her control her pain and keep her moving. They’ve done many quick tests of change and Hattie is improving. The scheduled acetaminophen is helping greatly. The nurses check with her to assure she’s getting relief and not having breakthrough pain. She’s getting a 20-minute rest with an ice pack on her hip after therapy in the morning and again in the afternoon. Her therapy schedule needed to be changed. She seemed to have more pain in the afternoon, so therapy was changed to the morning. She is able to work on her strength and endurance for the whole session and she and the therapist are pleased with her progress.

They also changed her shower from the morning to bedtime. Hattie prefers a shower and the warm water seems to relax her and help her sleep better. She’s requested a shower three evenings a week and doesn’t take the acetaminophen before going to sleep on those evenings. The bed positioning that the therapist was trying with pillows didn’t seem to be helping. She had a conversation with Hattie and Carol and then asked me if they could try another mattress. Apparently, Hattie was used to sleeping on a softer bed at home. We had one, so we gave it a try and it seems to have helped. Carol also brought in two body pillows. Between the mattress and pillows, Hattie says she sleeps great. She’s walking to all meals now and the nursing assistants are taking her for additional walks on their shifts. They always have a lot to talk about and it’s so good to see Hattie enjoy that time with the staff.

The team has been boosted by their success with Hattie. They’re definitely using more individualized approaches with residents, and the residents and their families are noticing the difference! Now, how can I spread this change to a more person-directed culture to our other neighborhoods?

Signed, Donna

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Pain – Entry 2

Dear Diary:

After several unsuccessful attempts at trying to talk with Hattie about what might be bothering her, reading her health record, and talking with staff about her change in condition, I stopped by team conferences today and asked to talk about Hattie. Everyone expressed some concern after I told them that I have observed that she is more withdrawn and is not progressing well in therapy. The physical therapist suggested a conference with Hattie and her daughter to explore what might be happening.

We had the conference this morning and it went very well. Prior to the conference, the social worker shared with Hattie some of the concerns the team was observing: she appeared more withdrawn, seemed more tired, wasn’t participating in activities and seemed to be having trouble walking in therapy. Hattie responded that her hip hurt and she felt she couldn’t do much. When the social worker asked if she had discussed her pain with the nurse, Hattie said, “I don’t want to take pain pills. They make me feel funny. I always tell them the pain is ok.” The social worker asked if she could share this information with the team, and invited Hattie and her daughter Carol to attend a conference to see if the team could come up with some suggestions to help her feel better. Hattie agreed.

At the conference, I was so proud of Sherry, the nursing assistant, and Anna, the charge nurse. Sherry told Hattie that she wanted to help her get stronger and was concerned about her not wanting to walk much. Anna said that she thought Hattie was having some pain, but didn’t want to push her to try the pain pills the doctor had ordered. I think Hattie and her daughter were reassured by how much the staff cares about Hattie.

The team, including Hattie and Carol, came up with a plan to help Hattie feel better. Her daily schedule will be changed so she gets rest time with ice on her hip a couple of times throughout the day. Hattie’s agreed to try Tylenol three times a day to help relieve her pain. It’s scheduled before she gets up in the morning, half an hour before therapy in the afternoon, and before going to sleep at night.

The therapist has some pillows and positioning devices she wants to try with Hattie to see if she can help her be more comfortable in bed. She’ll make sure to take pictures of how to place the pillows and put them where the nursing assistants can access them. Hattie agreed to try the plan for two days and then we’ll have another conference to determine what has been effective. We plan to continue to make changes until Hattie feels more comfortable. Hattie seemed really relieved that we’re going to help her without making her take any strong pain pills. She left the conference smiling and said “thank you” to the team. We’re making progress. How can we be assured that these kinds of positive conversations take place with other residents?

Signed, Donna

2 Comments

  • The team approach is very important, as well as having team members talk individually with the resident. Each team member has a different level of rapport with the resident, so the resident may be willing to share more with a different team member. For example, at our facility, we have had different team members approach a resident about her headaches. One member was unsuccessful at obtaining any new information or approaches with her, but another was able to get the resident to try aromatherapy and heat packs. It takes commitment, from an already busy team, but the outcome is worth it!

  • Keeping everyone informed about resident changes (and excited about the benefits of these changes & how they help our residents) is indeed a challenge. Sometimes instead of feeling motiviated & excited the staff feels like they are being weighed down with yet another task, so we must keep them focused also on the benefit not only to the resident but to their workload also. Letting them know how a happier, pain-free resident will no only lighten their workload as the resident will be able to do more for themselves, but the resident will be in a much better mood! Happy resident should = happy staff!!

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Pain – Entry 1

Dear Diary:

Yesterday while stopping by resident rooms to visit with a few people, I stopped by to see Hattie. She was sitting in her wheelchair, staring out the window. When I knocked on the door, she turned toward me and grimaced. I asked if she was ok and she said yes. I asked if I could speak with her for a few moments and she agreed. It was an odd conversation because I couldn’t really get her to talk to me. I asked about how she was feeling, what she was noticing out the window and about her family, but she only said a few words. That really isn’t like Hattie, so I suggested that she might like to rest or lie down and she immediately said she wanted to lie down. I asked Sherry, the nursing assistant, to help Hattie lie down. I was headed to the nurse station to talk with Hattie’s nurse, Anna, but was paged for a phone call and forgot about Hattie.

Later, I stopped by the therapy gym. Hattie recently broke her hip and I was curious to see how she was doing. Hattie was there walking with the therapy aide. Hattie only took a few steps, said she couldn’t do any more, and asked to stop. The aide helped her to sit down in the wheelchair and started to push her out of the gym. I asked Hattie if she was having any pain or if anything was wrong. She looked down into her lap and shook her head no.

I then went to talk with Anna. She said that Hattie never asks for pain meds. She has a PRN pain medication ordered which Anna offers, but Hattie rarely takes it. She said that Hattie has seemed a bit more withdrawn recently. In team conferences this week, the physical therapist said that Hattie hasn’t been trying very hard to improve her walking. I asked what the plan was and she said she is going to continue to try and engage Hattie for a few more days. She also said they’d have to stop therapy if Hattie doesn’t show signs of improvement.

I’m worried about Hattie. If she stops trying to improve her walking at this point, she’ll be pretty dependent on others. I really want my team to think more broadly about what we can do collectively to figure out what’s wrong with Hattie. It doesn’t seem like we’ve done a very good job assessing her pain. Maybe that’s the problem? As a team, we need to determine what assessment we can use to try to get figure that out. I guess the next question would be who should be involved in the discussion?

Signed, Donna

2 Comments

  • We are addressing this issue with our charge nurses here in regards to residents comfort here. Often as in other nursing homes we have medications for our residents to take on a prn basis for pain, however they never receive them because as our staff have stated “they never asked for them” “they never told me they had pain”. It is now one of our goals that we as staff (interdisciplinary) ask the resident if they are having any pain. We have a couple superstar charge nurses who I have heard asking residents as they are “visiting” or doing cares with them this questions. Our therapy department is very good about touching base with nursing about pain meds prior to treating our residents.

  • We are going to review each new admit to see if have dx which would invovle pain, review hospitalization notes for pain and then see at admission if a resident could be on a regularly scheduled pain medication for 2 weeks and then review if should be continued, decreased or discontinued.

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