MDS Alert

Published on Fri Jun 26, 2009 PDF

A 3-step approach will improve care and rein in your pain QMs.

A cognitively intact resident wants to accept a certain level of pain in order to avoid sedation from opioid medications. Yet he sometimes complains of significant pain. Now what?

The revised F309 survey guidance says a resident has the right to choose an acceptable level of pain to avoid medication side effects that interfere with his activities or other goals, says Sheila Capitosti, RN, a consultant with PointRight Inc. in Lexington, Mass. But the care plan should also show that the team continues to look for ways to help the resident achieve his ideal comfort level and maintain his desired level of alertness and activity.

Experts say you can achieve that feat by following these key steps:

1. Do a pain medication history at admission. "Find out what medications the person has taken for the pain and whether they worked -- and any related side effects," advises Susan Gardiner, RN, BSN, director of clinical services for the Illinois Council on Long Term Care in Chicago. If the person reveals a pattern of significant and unexpected side effects from opioids, he may be a genetic poor metabolizer for commonly prescribed medications.

Medicare-covered testing can easily identify if that's the case (for more information, go to en.wikipedia.org/wiki/AmpliChip_CYP450_Test). If it is, the physician and consultant pharmacist can pick a pain medication that isn't metabolized by that pathway.

2. Go to the pros. Hospice providers are experts in providing pain management without over-sedation, observes Diana Waugh, RN, BSN, a consultant in Waterville, Ohio. For example, the physician can order Neurontin for neuropathic pain, such as the burning and tingling of peripheral vascular disease, in conjunction with an opioid to manage non-neuropathic pain, explains Noelle Berardi, RN, with Samaritan Hospice in Brockton, Mass.

Also: You can treat joint inflammation with topical NSAIDs, such as 5 percent Ketoprofen gel, suggests Jim Cooper, RPh, PhD, BCPS, CGP, FASCP, in Watkinsville, Ga.

Another example: "Someone with acute pain might be helped with a long-acting morphine given twice a day with liquid morphine for breakthrough pain," says Berardi.

These might include guided imagery, aromatherapy, and cranial massage, says Gardiner. Application of heat and cold, and proper positioning can also help, she adds -- for example, "does sitting a certain way help relieve the resident's back pain?"

Another example: Some pain programs have practitioners certified in Reiki provide that modality to relieve pain (get an overview of Reiki at www.reiki.org/faq/WhatIsReiki.html).

"Pain wears people out," says Waugh, "and Reiki provides a warm interpersonal exchange with another person so the person in pain realizes he's not alone." Reiki can also help someone relax, easing the muscle tightness that can occur due to pain, she adds.

In some cases, physical therapy might be part of the pain management plan. Selection of a PT modality depends on what's causing the pain, says Pauline Franko, PT, MCSP, in Tamarac, Fla. But options include ultrasound and e-simulation, and manual therapy for muscle tension, such as massage and relaxation.

You can also use an ice cube and work it over the skin surface as part of massage, Franko adds.