Self Directed Learning Package - University of Queensland

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86 • The Palliative Approach ToolkitKey PointAssessments need to be done:• at the point of contact with the resident, not atthe end of your shift• by careworkers and nurses• REGULARLY.For residents who cannot communicateAssessing pain with a resident with cognitive impairment ordementia requires different assessment methods.We recommend the Abbey Pain Scale which is based on directobservation of the resident as well as knowledge of their usualfunctioning and medical history. You will have read about this inthe introductory education package.Apart from using a tool, it is very important to collectobservations from people who are closely involved with theresident such as family members and careworkers.Pain managementKey PointCombining pharmacological and nonpharmacologicaltreatment strategies is moreeffective than a singular approach.We mentioned earlier that residents experience pain differentlyand that their perception of pain is influenced by their mood,past pain experiences, social and physical situation and themeaning they give to both their illness and their pain.Pharmacological approachesAs a nurse, you are responsible for the medications youadminister. It is vital that you understand the general principlesand pharmacology of managing pain.Comprehensive details of pharmacological painmanagement can be found in “Therapeutic Guidelines:Palliative Care (version 3)” - included in the PA Toolkit.Thinking PointDo careworkers undertake pain assessments inyour facility?If not, can you see any benefit in careworkerinvolvement?What barriers are there and how might youaddress these?
87 • Self Directed Learning Package - Advanced Registered & Enrolled NurseJudy seems to have pain most of the time. She is only prescribedas needed (PRN) analgesics and is rarely comfortable.Despite ever increasing doses of opioids, Judy’s hip pain doesnot seem to be getting any better.Thinking PointHow might you explain the problem to her GP whenhe next visits to ensure she gets more appropriateanalgesia?Judy has been taking paracetamol intermittently for severalweeks. Yesterday, her GP prescribed 20mg of sustained releaseoral morphine/day in response to reports of severe pain. Nightstaff report Judy feeling nauseous as well as slightly confusedwhen they spoke to her.Thinking PointWhy might this have happened?What would have been a better method of startingJudy on opioids?Judy’s daughter Rhonda visits the next day. She becomes angrythat her mother is taking morphine as “She needs to leave thisuntil later. If she starts on it now, it won’t work later and thenwhat will she do?”Thinking PointHow might you respond?You are doing the medication round. You notice that sincestarting on opioids, no one has been administering paracetamolto Judy. A colleague’s response is “She’s on the strong stuff now.She doesn’t need paracetamol as well.”Thinking PointWhy it is important to continue with non-opioidanalgesics?Thinking PointAre there any other pharmacological measures thatmay help?What are they and why are they more likely to beeffective?Key PointConcise answers to all of these questions are in the“Therapeutic Guidelines: Palliative Care (version 3)”- included in the PA Toolkit.Get into the habit of referring to it in your clinicalpractice.Non-pharmacological approachesYou are approached by some careworkers who want to knowwhat they can do to help Judy be more comfortable.ActivityWrite down some key points of what you wouldtell them.Make your instructions specific, detailed and concrete.Be sure to stay focused on their scope of practice.You notice that most evenings over the last week, around 11.00pm,Judy’s pain score seems to increase from 4/10 to 7/10 on a visualanalogue scale. Night staff have documented twice that Judywas teary. She couldn’t identify any one pain that was a particularproblem. Normally she can tell you the location of her pain.Thinking PointWhy might Judy’s pain be worse late at night? Whatstrategies would you use to address the situation?
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