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angel_bear 06-24-2005 03:41 AM

Conference Details: Gaining Control of Pain
[B]**SUBJECT NO. 1 - The Myths of Pain Management Demystified**[/B]

The Myths of Pain Management Demystified

Clients in a Health Care setting should expect to have pain.

• No one should expect to have pain whether they are in a Health Care Setting or at home and should be able to be controlled with the use of medications and/or alternative/complementary therapies.
• When the client is under our care we as Health Care Workers should be able to detect they have pain, report and then relieve the pain.
• Pain is considered in some by some as being the 5th vital sign (following TPR, BP, Skin colour, conscious state and bowel activity .. the basic OB’s your nurse does) and the client is assessed routinely daily for their opinion about any pain.

Pain is a natural ageing process

• No individual of any age should have to endure pain
• Pain does not just occur as we age.
• It is true that many older adults are at a greater risk than younger people for developing and suffering from painful conditions
• It is the condition/disease process that will cause the pain, not ageing.

Aged Clients report more pain as they age

• Research has proven that aged people do not report more pain as they age.
• It is because we work with the aged population that it may seem like that to us.
• As people age their bodies are literally wearing out and it is harder for them to attend to small activities, such as getting out of bed.
• As the client ages there is greater likelihood of them developing a condition such as arthritis, which may be accompanied by pain

Clients with Dementia do not feel pain

• People with dementia may not be able to verbalize their pain like you can, but they can still sense pain.
• It is up to us, as Aged Care Workers to observe our clients for pain behaviours.
• This means we need to record all changes in the client’s behaviour and mood.
• Some non-verbal cues of pain include moaning, facial expressions especially grimacing, rigid posture, shifting posture frequently.

Chronic pain is psychological.

• Pain is a physical response to a stimulus.
• Even though some clients find it difficult to verbalize where the pain is or what type of pain it is, it is still a very real physical injury.
• You may not be able to see the pain, but the client reports they have pain, so pain is ……………………
***What the client says it is and where the client says it is! ***

Health Care Workers are the best people to know how much pain a client has.

• How can you judge someone else’s pain?
• Each person is more aware of his or her own body processes and feelings.
• We must be observant for signs of pain (for eg: Crying, aggression, holding an area), but listen to what the client reports to us as well.
• Listening is our greatest tool to help someone.

angel_bear 06-24-2005 03:43 AM

Pain Management In The Client Who Has Dementia
[B]Definition of Pain[/B]
• Pain is whatever the experiencing person says it is, existing whenever he says it does” by: Margo McCaffery (Pain: Clinical Manual 2nd Edition, St Louis, Mosby 1999)
• This definition highlights the fact that pain is highly subjective and that the patient’s self report and description of pain are very important to understanding the pain experience.

[B]Prevalence of Pain in the Elderly[/B]
• The high prevalence of pain is primarily related to the increased rate of chronic health disorders of older persons; such as arthritis and peripheral vascular disease.
• There is also a greater prevalence of acute conditions, such as cancer and cardiovascular disease.

[B]Implications of Pain on the Elderly[/B]
Chronic pain can have deleterious effects on the physical functional and mental health of elderly adults. For example:
• Depression & withdrawal
• Sleep disturbances
• Impaired mobility
• Decreased activity engagement
• Gait disturbances & falls
• Deconditioning (lack of use of muscles etc)
• Malnutrition
• Increased health care use
• Delayed rehabilitation

[B]Characteristics of Dementia[/B]
• Dementia is a syndrome; there are many types
• Dementia atrophies cortical and sub-cortical areas of the brain
• Neurotransmitters depleted
• Progressive deterioration
• Dementia is characterised by memory loss, loss of judgement, language and communication deficits, confusion, withdrawal, and loss of ability for independent personal care.
[I]NOTE: Alz: Brain shrinkage in itself & special. Depression & confusion are tantamount in dementia patients.[/I]

[B]Effects of Dementia on Pain[/B]
• The destruction of cortical neuronal cells and depletion of neuronal neurotransmitters do not affect the transmission of pain sensations.
• Studies by Benedetti et al (1999) and Bachino & Snow et al (2001) indicate that cognitively impaired elders are no less sensitive to pain (pain threshold), but that they may fail to interpret the sensations as painful (pain tolerance)
[I]NOTE: Pain is still pain – outward expression is different, tolerance is higher. Watch for behaviour. Just because they can’t verbalise doesn’t mean it’s not real or there. Odd behaviour could be pain related, not disorder related.[/I]

[B]Signs of Pain in an Elder with Dementia[/B]
• Restlessness or agitation
• Aggression
• Resistance to care, combativeness
• Increased confusion
• Decreased mobility
• Crying
• Facial grimacing
• Moaning during care activities
• Altered respirations (rate & depth)
[I]NOTE: Odd behaviour could be pain. Don’t write them off just because they have dementia. Violence is higher in patients with pain # constipation # arthritis etc[/I]

[B]Assessment of Pain in Elders with Dementia[/B]
• Relies on communication between the Elder, multi-disciplinary health care providers and family members of the Elder.
• Inclusion of verbal self-reports of pain and non-verbal behaviours
• Comprehensive assessment
• Timing of assessment
• Reporting Assessment findings
• Documentation
• Evaluation
[I]NOTE: Check overall ’wellness’ during regular ob’s. Report discrepancies, confer with others. Believe the patient!! Check “wellness” during physical activity.[/I]

[B]Assessment Tools[/B]
• IN the early stages of dementia, an Elder may still be able to reliably report pain. As the dementia progresses, however, this ability to self-report pain will diminish.
• Pain assessment tools for Elders with Dementia need to be meaningful, effective, reliable, require minimal time for training and minimal time for completion
• Examples: Abbey Pain Scale and Pain-Aide Scale

[B]Pain Management Strategies[/B]
• The main goal is to maximise function & quality of life for the Elder.
• Pain treatment strategies that use a multi-dimensional approach
• Individualised to the Elder’s needs are the most effective
• A combination of pharmacological & non-pharmacological strategies should be used to relieve pain

[B]Pharmacological Strategies[/B]
• Pain treatment with medications is a complex decision-making process between the Elder, family & health care provider.
• Discussion, implementation, evaluation and documentation of medication usage.
• Balance of medication effectiveness and management of poly-pharmacy and side-effects.
• Frequency of use, type of pain, duration of treatment, and cost
• Start low .. GO SLOW !!
[I]NOTE: Too many med’s can cause adverse reactions and symptoms. CHECK![/I]

[B]Non-Pharmacological Strategies[/B]
• Physical relief strategies are interventions such as repositioning to promote comfort & skin breakdown, use of heat & cold, massage and mild exercise.
• Cognitive-behaviour approaches change the Elder’s perception of pain & improve coping strategies; such as relaxation, distraction, guided imagery, hypnosis, & prayer.

[I]NOTE: Classical music as background for listening/singing. Diversional therapy. Massage therapy , face, feet if tolerated. Aromatherapy.[/I]

[B]Barriers to Effective Pain Management[/B]
• Myths
• Labelling
• Fear
• Sensory deficits
• Family Judgements
• Perceived time restraints

[B]Future Considerations[/B]
• An important emerging concept is that Dementia is not a singular entity with regards to pain – different types of dementia are associated with distinct changes in pain perception, and therefore, may require differing pain management strategies.
• Further research into effective pain assessment and development of appropriate tools.

[I]NOTE: Frontal Temporal Lobe – No Awareness
.............Vascular – Pain perception[/I]

angel_bear 06-24-2005 03:51 AM

More coming soon .........
I have two pain scale charts that are IDEAL for the dementia patient that can't communicate .. I will contact a moderator to try and figure out how to, if possible, post it here. It's VERY useful for health care professionals and home carers to use.

Other than that, one is called the Abbey Pain Scale Chart and the other is Pain-Aid (one word, no hyphen) Scale. Do a search. See if it's available.

Hugs .. more coming

angel_bear 06-24-2005 05:12 AM

Bowel Management
Bowel Management & the Advantage of Movicol

What is a normal bowel habit?
• Usually between 3 times a day and 3 times a week
• A stool should be solid, but moist and easy to pass.

The Bristol Stool Form Scale (can’t insert pictures here, but it’s graphic)
Stage 1 Separate hard lumps, like nuts
Stage 2 Sausage like but lumpy
Stage 3 Like a sausage but with cracks in the surface (2nd choice)
Stage 4 Like a sausage or snake, smooth and soft (perfect poo)
Stage 5 Soft blobs with clear-cut edges
Stage 6 Fluffy pieces with ragged edges, a mushy stool
Stage 7 Watery, no solid pieces

The ideal bowel movement
• The feeling that you need to go is definite but not urgent
• Once you sit down on the toilet there is no delay
• No conscious effort or straining is needed
• The stool is passed smoothly and comfortably
• Afterwards there is only a feeling of relief.

All this is most likely if the stool is Stage 4.

What is Constipation?
• Abnormally infrequent bowel movements
• The passage of dry hard stools
• A sensation of incomplete evacuation

What is Faecal Impaction?
• If constipation goes untreated it can lead to faecal impaction
• Faecal impaction is the accumulation of hardened or dehydrated faeces in the rectum or sigmoid colon, that the individual is unable to move.
• Overflow diarrhoea is often a sign

Signs and Symptoms
• Change in frequency and nature of faeces
• Straining or pain when passing motion
• Loss of the urge to defaecate
• Anal fissure / prolapse
• Bloating
• Increased flatus
• Malaise, headache, nausea, coated tongue
• Altered urinary symptoms (UTI, Frequency, altered urine flow)

Causes of constipation
• inadequate fibre intake
• Inadequate fluid intake
• Inadequate food intake
• Lack of exercise
• Lack of privacy
• Ignoring the need to defaecate (unable to communicate, privacy factors)
• Unable to recognise the need to defaecate (stroke, dementia)
• Diseases of the bowel (diverticular disease, cancer)
• Pain when using bowels (haemorrhoids)
• Poor defaecation technique
• Medications

Management of Constipation
o To promote regular defaecation of soft formed stool

• Plan
o Investigate / treat the cause
o Ensure adequate fibre and fluid in diet
o Encourage activity (active or passive)
o Review medications (senacot must be taken with 1 litre of water)
o Provide an environment that promotes comfort and privacy
o Utilise the gastro colic reflex
o Ensure correct defaecation technique
o Aperients

How drugs work to relieve constipation

…………………………………………OSMOTIC AGENTS…………………………………………
………………………………………..Hydration of the Stool……………………………………….

Increase in faecal bulk …………………………………………….Softening of the stool

Stimulating peristalsis………………………………………..Easing the passage of faeces
…………………………………….RELIEF OF CONSTIPATION……….…………………………

• A range of Products for bowel management:
o NORMAFIBRE ฎ (For IBS assists with 6 x water absorption)
o MOVICOL (requires 1.5 litres water)

Treatment of Constipation
• Mild to moderate constipation
o NORMAFIBE ฎ fibre supplement – for mild constipation/diverticular disease)
o NORMACOL ฎ PLUS – fibre plus a stimulant – to relieve moderate constipation when fibre alone is not enough
o Both contain 62% sterculia –
 Insoluble fibre
 Effective bulk without wind

o Applicable where fluid intake is sufficient

Treatment of Constipation
• Moderate to severe chronic constipation
o MOVICOL ฎ (macrogol 3350 with electrolytes)
 When fibre is inappropriate or ineffective
o Suitable for a wide range of patients
o Delivers water to the colon
o Hydrates faeces
o Enables comfortable bowel movements

MOVICOL ฎ - The formulation

MACROGOL 3350 High molecular weight polymer
Exerts high osmotic pressure in solution
Potassium – to prevent electrolyte loss
Chloride –
Bicarbonate –
Mild citrus taste

How it works:
• When dissolved in 125 ml water
o MOVICOL forms iso-osmotic solution
o Delivers a bolus of water and electrolytes to the bowel
o No ‘net’ loss of electrolytes
o Unlike stimulants does not cause griping pains
o Unlike some fibres and lactulose is not fermented in the gut – minimal bloating and wind
o Gently and effectively relieves constipation

MOVICOL ฎ vs Lactulose in Chronic Constipation
• Randomised, multi-centre, single-blind parallel study
• 115 patients with chronic constipation
• 4 week study
• 2 satchets per day (dose adjusted in last two weeks)

Movicol was able to be reduced vs Lactulose that needed to be increased. Movicol made the bowel work, where lactulose made the bowel lazy.

NOTE: Cost: 90c per sachet. 1 sachet per day ‘typical’, 2 sachets per day for harder. It can take 16 – 24 hours to work. Start with 1 sachet, if no result, Day 2 = 2 sachets, if no result, Day 3 = 3 sachets .. if still no result, call a doctor.

(Charts available when scanned if required)

MOVICOL ฎ - The Advantages

• High level of patient satisfaction
• Reduces the need for enemas
• Can be used with nasogastric/ostomy tubes
• Easy to use – simply titrate the dose

Easy to use
• Constipation
 Dissolve contents of one sachet in 125 ml of water and drink.
 Can be flavoured if needed
 Flexible dosage – easy to titrate doses
• 1 sachet per day
• Increase to 2 – 3 per day if needed

PBS Restricted listing
• Restricted PBS Listing for MOVICOL 30’s (1 + 5 repeats)

‘Constipation in patients with malignant neoplasia’

Bowel Management and the Advantage of Movicol

Effective bowel management is extremely important for both preventing constipation and managing faecal incontinence. Both subjects, rarely discussed, are often suffered in silence and ignored until symptoms become serious. Constipation in the Western World affects all ages and can be acute or chronic. Constipation can increase with age and become more frequent.

This presentation will discuss management strategies such as:

• diet
• fluids
• exercise
• handy hints
• the importance of toilet routine
• training the bowel
• medication groups

Movicol is an effective oral treatment for chronic constipation and faecal impaction. Movicol treatment has had documented success in Aged Care, Parkinson’s disease and spinal cord injury. The benefits of Movicol administration will be discussed.

Management of Constipation

To maintain a regular bowel habit:

• Try to have a regular morning routine
• Have a glass of hot water ฝ hour before breakfast
• Eat breakfast containing fibre e.g. muesli, weetbix, bran, porridge, wholemeal toast and fruit (pears, prunes, kiwi fruit) and fruit juice (prune juice, orange juice)
• Increase your fluid intake to 8 to 10 cups a day if you do not have a medical condition which restricts your fluid intake e.g. kidney or heart problems.
• Try to establish a regular time to open your bowels e.g. approximately ฝ hour after breakfast or meals to take advantage of the gastro-colic reflex.
• Do not ignore the urge to open your bowels and allow your bowels time to work. This may mean getting up earlier in the morning.
• To improve posture when emptying your bowels, try sitting on the toilet with your feet supported on the floor or on a footstool placed in front of the toilet. Lean forward slightly to aid bowel movement. Try and keep knees higher than hips.

Exercise: If you can’t walk, do leg raises. Pelvic Floor exercises help bowel and bladder muscles)

Watch water intake with cardiac patients. Pear juice is VERY good for bowel and more tolerant than Prune Juice.

angel_bear 06-24-2005 05:17 AM

Re: Conference Details: Gaining Control of Pain
Do you wanna know how SICK I am of poo? I mean .. guys .. I have pictures of the 'perfect poo' ... **rolling eyes** kids think it's hysterical, Brianna is running around with the chart 'comparing' ....

Did you know EVERYTHING related to our Aged population eventually comes back to POO?

I need dinner ... more later

LuvMyLilDoggie 06-24-2005 07:10 AM

Re: Conference Details: Gaining Control of Pain
I guess you must have the stomach for this. I must admit I couldn't read thru the whole poo post. No stomach for it this early. :)

Dinner??? After THAT??? More poo----eventually..... :D

Thanks for all the info. Maybe this can be turned into a sticky?

Love, Barb

Martha H 06-24-2005 01:24 PM

Re: Conference Details: Gaining Control of Pain
DINNER????? after THAT report ....

Ha ha, Sally, you're the greatest!



Martha H 06-24-2005 01:26 PM

Re: Conference Details: Gaining Control of Pain
turn it into a sticky poopy ??? :rolleyes:

I have missed you lovely people!!!


angel_bear 06-25-2005 03:52 PM

Re: Conference Details: Gaining Control of Pain
Morning :-) *cough* ~splutter~ *sneeze* ~splutter~

I got a winter cold :-( *sniff*

I've still got REAMS to type out, well I'm about 1/2 way anyway LOL

If you want to get into nursing as a 'mature aged student', which I am *grin*, the best way is to start this way .. as an AIN. Hopefully, after that, I will get employed by a hospital who then, in turn, will train me as an EN (Enrolled Nurse) ~ (and pay for it too!!), but if that doesn't happen, I can do Certificate 4 in AIN (Assistant in Nursing) which goes for a YEAR, and then I can actually run diversional therapy day's in nursing homes and stuff like that .. which would be fun ! So if I don't get to be an EN, I have an alternative!

If there are any other courses before Semester starts, I would like to go to them, because they've only [b]JUST[/b] started 'adding' points to your education record if you attend .. so it's all going towards a final goal. I'll get dispensation for attending extra activities .. I like that idea.

gotta go find another box of tissues. It's a wet sunday here (was a wet Saturday night too) I ended up sleeping on the lounge with my other box of tissues and spent the night alternatively sleeping and sneezing *sigh*.

Hugs all .. next subject is:

[b]Medication choices for pain management and polypharmacy[/b]


BarbaraH 06-25-2005 04:06 PM

Re: Conference Details: Gaining Control of Pain
Poor sniffly Sally!

Bless you x each sneeze!!

Supper is ready, so gotta go, but hope you feel better! Stay cozy.....

Hugs - Barbara :wave:

LuvMyLilDoggie 06-25-2005 08:06 PM

Re: Conference Details: Gaining Control of Pain
Hope you're feelomh better soon! It's no fun to be sick. It still seems odd to me that you're in winter. We're in a sweltering summer heat wave (upper 90'sm don't know what that translates to in celcius) and in a drought now. We're near the point where we may have to soon start boiling water like a town near us is doing because the water levels are so low.

Oh well. We have bottled water and we're cool with the new air conditioners we bought today. :)

Love, Barb

angel_bear 06-26-2005 04:47 AM

Last One: Current Trends In Pain Management PART 1
For the purpose of this I am going to discuss chronic pain as this is what we are more likely to see.

For many years, people who suffered with chronic pain had basically very few options to deal with the discomfort. Scientists and Researchers have made great strides in understanding pain and how it affects a person’s physiological and psychological make up. Using these findings, they can formulate better pain methods. Everyone has different pain thresholds. What causes a great deal of pain and discomfort for one individual is nothing but a minor annoyance for someone else. Having to deal with pain on an ongoing basis also increases your tolerance for pain.

A person with pain is ruled by their pain. They no longer live their lives in terms of their hopes and dreams and aspirations. Instead, they are so overwhelmed by the wanting their pain to improve, that they are swept away by depression, anxiety, anger, fear, hopelessness, frustration and most importantly, grief. Their sense of loss is justified as they have usually lost a lot of what makes up a life. They may no longer feel they can work to support their family and their family may no longer give them the emotional support they need. At their centre, they may have lost a sense of moving forward in their lives. They also become afraid to move physically or to actively use the part of their body that has caused the pain. It’s as though they were frozen in fear.

What can you do to help?

True pain management involves a multidisciplinary approach of physical therapy, massage, medication management, counselling, occupational therapy, exercise physiology, a case manager and a doctor. It may also involve some type of movement therapy such as Tai Chi, classes on spiritual wellness, yoga or meditation.

It is also important to recognise that just as pain is personal, so is each treatment. What strategy works for one person may not suit another.

• Suggest keeping a record of different pain strategies that your resident has tried and their response to these. This is helpful for future reference for that person. Documentation is our only proof that the strategy works for that person.

Some alternatives and supplements to medication
1. Exercise.
Exercise can:

• Improve circulation. This is important for people with diabetes and atherosclerosis.
• Relax tense muscles and assists in eliminating stress
• Improves mood and helps to overcome mild to moderate clinical depression.
• Keeps joints strong and flexible.
• Reduces risk of osteoporosis

Exercise prompts your body to release special chemicals, called endorphins that actually block pain signals from reaching your brain. These chemicals also help alleviate anxiety and depression, conditions that can make your pain more difficult to control. Athletes often can run on a sprained ankle due to these endorphins. You basically “feel the rush”. They are a truly natural pain relief.

Readers Digest: Conquer Pain: 2001 (page 61)

‘Exercise naturally causes a certain amount of pain as it exerts extra pressure on the muscles, tendons, ligaments and other body structures. This prompts the brain to step up production of endorphins, body chemicals that block any messages in much the same manner as morphine. In fact endorphins attach themselves to the same brain receptors as morphine. Not only do endorphin’s block out the pain messages that are being sent to the brain from peripheral nerves, but they also elevate mood.’

Endorphin’s can also help alleviate anxiety and depression, which are conditions that make controlling pain more difficult. Exercise also increases the body’s serotonin levels. Serotonin inhibits the
• Production of the type of prostaglandin that causes inflammation
• Cures insomnia by facilitating falling asleep at night
• Reduces pain signals by launching a counter attack inside your brain
• Makes you feel happier by lifting your mood which in itself reduces pain
• Reduces the leakage of fluid from blood vessels. Leakage is a problem associated with some types of pain eg. Migraine and irritable bowel syndrome.

Inactivity can cause chronic pain to become worse. Muscles become weaker and joints stiffer. People also stop moving, fearing more pain or damage occurring. However the way to reduce your pain and increase function is to start moving again under the guidance of a skilled therapist. They can teach the best ways to gradually rebuild your flexibility, strength, endurance and coordination.

Flexibility exercises could include simple range of motion and stretching movements. Such exercises help reduce joint stiffness and allow the client to move more comfortably. They also prevent muscles from shortening and tightening.

Strengthening exercises assist in lean muscle mass and can assist in weight loss if this is needed, as extra weight that is carried by the person will out strain on their body and cause more pain. Aerobic exercises will challenge your heart and lungs and muscles. It will increase your heart rate. These exercises help your body work more effectively and reduce your risk of heart disease, high blood pressure, high cholesterol and diabetes.

2. Socialisation and emotions. Emotions can make a painful situation worse. Anger, depression, frustration or anxiety commonly accompanies pain. It is also common to feel a loss of control or helplessness with chronic pain.

Wellbeing magazine (2002) states that:

Pain is personal. We all feel and respond to it differently and our tolerance levels vary. Long-term pain, or chronic pain, can be a lonely experience and sufferers can feel isolated and powerless. Perhaps the most destructive aspect of chronic pain is the way in which it steadily erodes and fragments the consciousness and life force of the person in pain. It leeches not only physical energy, but also psychic energy. Those suffering often live in a labyrinth of dead ends. They lose a sense of being in charge of their life, becoming demoralised. They become imprisoned in a pain trap. By its very nature it will affect all aspects of the sufferers life – their relationship with themselves and with others, their finances, and if they are able to work their work performance.

Family attitudes to pain are vital to cultural influence as in some Middle Eastern or European cultures; the whole family becomes involved with the person who is suffering the pain. This may reinforce the patient’s belief that pain is acceptable and increase their pain behaviours negatively and disempower them. Social and environmental factors also determine how a person can cope with pain. Lack of a support network of family or friends, previous bad pain experiences and/or the environment the person may be in such as a stressful one of a hospital setting, can all contribute to negative pain influences. IN some cultures the ability to endure severe pain is a rite of passage or a badge of honour. Youths may make cuts on the body as the scars testify that they can endure enough pain to become warriors. Religion also can teach people that pain is something to be endured as a consequence of original sin or transgressions in an earlier life.

Twinlynn 06-26-2005 07:59 AM

Re: Conference Details: Gaining Control of Pain
Sally, et al --

If you have the psychological strength to linger a few moments in the heads of those with unremitting the Health Board's "Pain Management" site. It's heartbreaking. I suddenly realized that my own aches and pains were too low on a scale to even register!

Thanks, Sally, for presenting all this infomation. My cousin, who lives in my apartment building, has suffered chronic pain since she was in her twenties (she's 62 now)--she's got osteoarthritis, AND rheumatoid arthritis...and her joints, bones, spinal column, etc. are in a terrible state. The poor thing has had more "replacement part" surgeries than I ever knew there were parts to replace! Hips, knees, neck, fusion, etc, etc.

The pain ebbs and times it dominates her. In eventually came to define her. Over the decades, she has been given everything from over the counter drugs to the strongest opiates (she is, fortunately, not addicted to them, although she has to taper each time she changes drugs.) She does phsyical therapy and tries to keep walking. But all this pain management occupies so much of her life.

I really appreciate your posts, Sally. :-)

Lynn xxx

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