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

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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
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