Checklist for Development of a Care Plan - Long-Term Care Best ...

Tab 6: Care Planning for PainDevelopment of a Care PlanThis section discusses the resident’s individualized careplan. Information obtained from screening, assessing andmonitoring the resident for pain (with use of a pain ratingscale) brings comprehensive information to the careplanning team.The care planning team, together with the resident andfamily (if available and with the resident’s consent as appropriate)develop acceptable interventions and measurablegoals in managing the resident’s pain.Implementation of the care plan comes next. Ongoingmonitoring of the resident’s pain plan continues, leadingto information that helps the team evaluate the effectivenessof the plan and the need for further adjustment tomaximize relief of pain.In This Section:Checklist: Developing Pain Care PlansImportant components of a pain plan reviewed.Decision Tree for Pain Care ProcessesFlow Diagram: Development of a Plan of Carefor a ResidentKey elements for care planning are citedMDS Coding Instructions For QualityMeasuresReminders:• Ensure that care plan approaches adhere toaccepted clinical guidelines and the facility'spolicies and procedures• Follow the facility’s process for the resolutionof inadequately managed pain• Ensure that the resident's pain plan iscommunicated during transfer and discharge• Ensure that the resident's pain is communicatedto the MDS CoordinatorA Systems Approach to Quality Improvement in Long-Term Care:Pain ManagementPage 82

Care Planning for PainKey Care Plan ApproachesPharmacologic Management• Individualize the regime to the resident.• Use the simplest dosage schedule and least invasivetreatment modalities first (oral medicationvs. intravenous medications). Adjust doses ofmedications to individual resident responses.• Pharmacologic management of mild-to-moderatepain may include a non-steriodal anti-inflammatorydrug (NSAID) or acetaminophen unless they arecontraindicated. Each has maximum daily doselimits.• When pain persists or increases, an opioid isrecommended.• Increase the opioid dose for treatment of persistent,or moderate-to-severe pain.• For persistent pain, it is recommended thatmedication be administered around the clock withadditional "as needed doses" for pain that reoccursbetween routine dosing.• Oral route is the preferred route of analgesicadministration; if the resident cannot takemedicaitons orally, then rectal, transdermal,subcutaneous, or intravenous routes may beconsidered. Avoid intramuscular (IM) injections forpain control.• Monitor for medication side effects.• Since constipation is an expected problem with theuse of opioid pain medication, treat constipationprophylactically and monitor it constantly. Asoftener and stimulant together are usually requiredto manage opioid-induced constipation.• When a resident is transferred from one setting toanother, communication about pain managementhistory is necessary.• Medication not recommended:– Indomethacin, piroxicam, tolmentin, meclofenamate_ Propoxyphene, rneperidin, Pentazocine,butorphanolAdjuvant Drugs• Corticosteroids: Provide a range of effects includinganti-inflammatory, anti-emetic activity, appetitestimulant, and mood elevation.• Anticonvulsants: Used to manage neuropathic pain,especially when the resident reports burning pain.• Antidepressants: Tricyclic antidepressants andSSNRI antidepressants are useful as adjuvantanalgesics in the management of neuropathic pain,as well as potentially enhancing opioid analgesia,and elevating mood. (Monitor carefully foranticholinergic adverse effects.) SSRI antidepressantshave little pain relieving qualities and are not oftenused for pain management.Non-Pharmacologic Management –PhysicalShould be used with or without medications, but shouldnot be used in place of medications.• Cutaneous stimulation techniques- Hot/cold- Massage- Pressure or vibration• Exercise• Immobilization• Transcutaneous electrical nerve stimulation (TENS)• Acupuncture• Assistive devicesPsychosocial Interventions• Relaxation and imagery• Distraction and reframing• Psychotherapy• Hypnosis• Reiki• Peer support groups• Pastoral counselingA Systems Approach to Quality Improvement in Long-Term Care:Pain ManagementPage 83

Care Planning for PainNon-Pharmacologic Interventions –Invasive• Radiation therapy• Nerve blocks• Neurosurgery/surgeryEducationResident and family education including:• The many misconceptions regarding pain and itstreatment• Medications• Non-pharmacological management (physical andinvasive)• Psychosocial interventionsRoutine Care• Positioning• Frequent oral care• Prevention of pressure ulcers and contractures• One-on-one visits• Emotional support to the resident and family• Review advanced directivesReassessment of Pain• It is recommended that on a daily basis, theresident's response to pain medication be monitoredwithin an hour of receiving the medication• If the resident is complaining of worsening pain ornew pain, it is recommended that a comprehensiveassessment of pain be completed and a plan of caredeveloped or revised• Reassessment should occur at regular intervals afterstarting the plan (quarterly and with significantchanges or unrelieved pain)A Systems Approach to Quality Improvement in Long-Term Care:Pain ManagementPage 84

Checklist: Developing Pain Care PlansDoes your facility have a process for developing and implementing a care plan for pain forresidents who have been found to have pain upon screening?______ No. If no, this is an area for improvement. Use this checklist and the QualityImprovement Worksheets to guide your team in implementing a process for developing acare plan for pain.______This is an area we are working on. Our target date for implementing a process fordeveloping a care plan for pain is:__________. If needed, use the Quality ImprovementWorksheets to guide your improvement process.______Yes. Please continue to the questions below.Does the plan of care for pain address all the areas below?1. Does the care plan for pain include a pain control goal as defined by theresident/caregiver/family member?2. Does the care plan include education of the resident and family related to theseareas of pain management:Goal of therapySide effects (e.g., drowsiness)ConstipationOverall treatment plan3. For residents with daily pain, does the plan provide for medication on a regularschedule (e.g., around the clock), not just PRN?4. Does the plan provide for medication use by mouth if at all possible?5. Does the plan provide for using non-pharmacological approaches to painmanagement (e.g., massage, music, aromatherapy, ice or heat, etc.)?6. Does the plan provide for keeping the resident as mobile as possible?7. Does the plan address positioning and proper movement to minimize theresident’s pain?8. Does the plan provide for a regular assessment (e.g., monitoring) of residents’response to pain medications?9. Does the plan outline when the monitoring reassessment of resident’s pain will becompleted?If any of the above elements in your process for care planning for pain are missing:YesNo• Choose one element to focus your quality improvement effort first.• Start with the Quality Improvement Worksheet A: Identifying Areas for Improvement to collect datato investigate further.• Follow the Quality Improvement Worksheets to implement missing element(s) and monitor regularlyto determine whether implementation is successful.If none of the above elements are missing from your facility’s process for care, please continue to anotherchecklist.This material was developed by the QIO program from CMS’ NHQI and is intended as general information. Anyindividual using the material must consider the possibility of human error, changes in medical sciences, and theneed to use clinical judgment in each specific case.