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Oct.26.2020

Pain Chronic (Persistent) (Adult Inpatient)

Clinical Description

  • Care of the hospitalized patient experiencing persistent pain of sufficient duration and intensity to adversely affect wellbeing, level of function and quality of life.

Key Information

  • Pain is a symptom, not a diagnosis. It is real to the patient and it is what he/she says it is (subjective, not objective).
  • Chronic pain frequently results in depressive symptoms, including trouble sleeping, appetite disturbances, loss of interest or pleasure in activities or relationships and isolation.
  • In treating chronic pain, consider presence of depression, substance use or chemical dependency associated with long-term pain management.
  • Lack of physiologic response or absence of pain behavior does not equate with “no pain”. Being quiet, withdrawn or sleeping should not be interpreted as absence of pain.
  • Vital signs tend to “normalize” over time as the body adapts to the presence of chronic pain. It does not indicate that pain is not present.
  • Chronic pain can occur in single or multiple body regions.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Acceptable Pain Control and Functional Ability

B. Patient, family or significant other will teach back or demonstrate education topics and points:
  • Education: Overview
  • Education: Self Management
  • Education: When to Seek Medical Attention

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity
    • age, developmental level
    • sex, gender identity
    • baseline assessment data
    • physiologic status
    • response to medication and interventions
    • psychosocial status, social determinants of health
    • barriers to accessing care and services
    • health literacy
    • cultural and spiritual preferences
    • safety risks
    • family interaction
    • plan for transition of care

Pain Chronic (Persistent)

Signs/Symptoms/Presentation

  • altered time perception
  • anxiety
  • body posture abnormal
  • concentration impaired
  • constant pain
  • eating pattern change
  • fatigue
  • fidgeting
  • flat affect
  • focused on medication timing
  • guarding
  • irritability
  • pacing
  • pain present at rest
  • pain worsens with activity
  • pleasure or interest in activity decreased
  • reluctance to move
  • reluctance to perform self-care
  • reports pain over time
  • restlessness
  • rocking
  • rubbing
  • self-focused
  • sleep pattern altered
  • social withdrawal
  • splinting
  • tense expression
  • weakness

Problem Intervention

Develop Pain Management Plan

  • Acknowledge patient as the expert in pain self-management.
  • Use a consistent, validated tool for pain assessment; include function and quality of life.
  • Evaluate risk for opioid use and dependence.
  • Set pain management goals; determine acceptable level of discomfort to allow for maximal functioning and quality of life.
  • Determine mutually-agreed-upon pain management plan, including both pharmacologic and nonpharmacologic measures.
  • Identify and integrate past successful treatment measures, if able.
  • Encourage patient and caregiver involvement in pain assessment, interventions and safety measures.
  • Re-evaluate plan regularly.

Associated Documentation

  • Pain Management Interventions

Problem Intervention

Manage Persistent Pain

  • Evaluate pain level, effect of treatment and patient response at regular intervals.
  • Minimize pain stimuli; coordinate care and adjust environment (e.g., light, noise, unnecessary movement); promote sleep/rest.
  • Match pharmacologic analgesia to severity and type of pain mechanism (e.g., neuropathic, muscle, inflammatory); consider multimodal approach (e.g., nonopioid, opioid, adjuvant).
  • Provide medication at regular intervals; titrate to patient response.
  • Manage breakthrough pain with additional doses; consider rotation or switching medication.
  • Monitor for signs of substance tolerance (increased dose to reach desired effect, decreased effect with same dose).
  • Avoid abrupt withdrawal of medication, especially agents capable of causing physical dependence.
  • Manage medication-induced effects, such as constipation, nausea, pruritus, urinary retention, somnolence and dizziness.
  • Provide multimodal treatment interventions, such as physical activity, therapeutic exercise, yoga, TENS (transcutaneous electrical nerve stimulation) and manual therapy.
  • Train in functional activity modifications, such as body mechanics, posture, ergonomics, energy conservation and activity pacing.
  • Consider addition of complementary or alternative therapy, such as acupuncture, hypnosis or therapeutic touch.

Associated Documentation

  • Bowel Elimination Promotion
  • Complementary Therapy
  • Medication Review/Management
  • Sleep/Rest Enhancement

Problem Intervention

Optimize Psychosocial Wellbeing

  • Facilitate patient’s self-control over pain by providing pain information and allowing choices in treatment.
  • Consider and address emotional response to pain.
  • Explore and promote use of coping strategies; address barriers to successful coping.
  • Evaluate and assist with psychosocial, cultural and spiritual factors impacting pain.
  • Modify pain perception by using techniques, such as distraction, mindfulness, guided imagery, meditation or music.
  • Assess and monitor for signs and symptoms of behavioral health concerns, such as unhealthy substance use, depression and suicidal ideation.
  • Consider referral for ongoing coping support, such as cognitive behavioral therapy and mindfulness-based stress reduction.

Associated Documentation

  • Diversional Activities
  • Family/Support System Care
  • Spiritual Activities Assistance
  • Supportive Measures

Education

CPG-Specific Education Topics

Overview

  • risk factors

  • signs/symptoms

Self Management

  • activity

  • coping strategies

  • medication management

  • nonpharmacologic pain management

  • pain self-advocacy

  • sleep/rest

When to Seek Medical Attention

  • signs of medication tolerance

  • unresolved/worsening symptoms

General Education Topics

General Education

  • admission, transition of care

  • orientation to care setting, routine

  • advance care planning

  • diagnostic tests/procedures

  • diet modification

  • opioid medication management

  • oral health

  • medication management

  • pain assessment process

  • safe medication disposal

  • tobacco use, smoke exposure

  • treatment plan

Safety Education

  • call light use

  • equipment/home supplies

  • fall prevention

  • harm prevention

  • infection prevention

  • MDRO (multidrug-resistant organism) care

  • personal health information

  • resources for support

Population-Specific Considerations

Geriatric

  • Hearing and vision impairments may hamper use of pain tools that are based on verbal and visual communication.
  • Elderly adults are more likely to tolerate pain versus report it.
  • Prior to the use of opioid medication, the elderly patient should be assessed for risk of falls, renal impairment, respiratory dysfunction and cognitive limitations to assist in determining dosages.
  • In elderly patients with cognitive deficits, ineffective pain management may increase dementia-related behaviors, which may result in decreased pain treatment.

Pregnancy

  • Women of childbearing age and those who are currently pregnant or lactating should have the specific risks of opioid use reviewed prior to administration.

References

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Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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