Consumed by pain: Teach staff how to provide comfort and relief
August 1, 1997 6 minutes read
Consumed by pain: Teach staff how to provide comfort and relief
Five guidelines to pain management of the chronic sufferer
Hospice patients and some other patients in the home care setting often find their lives being consumed by pain. It’s a gnawing constant reminder that their bodies are breaking down, and there’s little they can do to stop it.
The nation has focused more attention on pain management recently as the U.S. Supreme Court decided in June that no American even a person suffering from pain or disease has the constitutional right to physician-assisted suicide.
The controversy over assisted suicide has brought some public criticism over how the health care industry handles patients with chronic pain. So home care professionals and others in the industry are being challenged to improve pain management.
Education managers can help suffering patients by teaching staff various steps to assessing and easing pain. Education also is needed because too often, nurses and home care aides have incorrect perceptions about pain, such as thinking the patient’s pain is merely psychological.
Or perhaps they worry the patient will become addicted to the pain medication. All of these concerns can be addressed in an inservice on pain management.
Health care professionals tend to judge patients’ pain differently than they would judge other chronic health problems because it can’t be measured objectively, says Alice O’Shaughnessy, MD, medical director with Mercy Hospice of Uniondale, NY. Mercy Hospice is an at-home hospice with 40-50 patients.
"If someone says, My blood pressure is up,’ then you can check the blood pressure and see if it’s up," O’Shaughnessy explains. "With pain, the only way anyone knows what the person’s pain is, is when someone tells them."
So it’s an easy trap for a nurse to assume a patient is exaggerating the pain.
O’Shaughnessy and other experts suggest education managers change their staff’s perceptions about pain by using the following guidelines to pain management:
1. Encourage employees to see themselves as advocates for the patient who is in pain.
Advocating for patients could mean telling the patient’s physician the patient’s medication doesn’t seem to be easing the pain. But it also could mean getting to know the patient holistically.
Home care nurses and aides have a rare opportunity to see what the patient’s life is like. They might observe photographs of family members hanging in the house. These might mean the patient has a strong and loving support system, which could help the patient better handle chronic pain, O’Shaughnessy says.
Other clues could be whether the patient is religious and is being visited by a local pastor. Also, there could be signs, such as empty anti-anxiety medication bottles, that the patient has not handled stress well in the past.
All of this information can be used by the nurse to help reduce the outside contributors to a patient’s level of pain.
"We need to look at spiritual causes of pain, psychological causes of pain," O’Shaughnessy says. "There are things that can make pain worse, such as if patients are worried about losing their homes, or if they’re afraid they’re going to hell."
2. Emphasize how there is no objective measure of pain, and all pain assessment is made according to what the patient says.
"The first thing is to find out where their pain is and how much pain they’re having, and if it’s occurring at a specific time," says Carol Foust, RN, public health nurse with Home Health and Hospice of Davie County in Mockville, NC.
Foust’s agency uses a zero-to-10 scale, with zero meaning no pain and 10 meaning the worst imaginable pain. "That gives us an idea if it’s decreasing, staying the same, or becoming worse with activity," she says.
Housecall Home Healthcare of Lawrenceburg, KY, has an admission assessment of pain for all patients, and it uses a zero-to-10 scale, says Karen Webb, RN, director of staff education for a branch office of the Louisville-based agency, which serves central Kentucky and other states.
The assessment includes diagrams of a human body that can be shaded according to where the patient is experiencing pain. And it has scales for how much pain has interfered with the patient’s activities and mood, including walking, bathing, work, meal preparation, dressing, and sleep. (See pain assessments, inserted in this issue.)
Foust says the agency asks its staff to reassure patients that their pain is whatever they say it is, and the staff will believe them. "Sometimes health care workers think they’re just crying wolf, but they’re not," she adds.
O’Shaughnessy says patients, nurses, and doctors sometimes have the impression that the patients’ pain is all in their heads and that it’s related to fear or anxiety. But, virtually all pain is real, she says.
3. Offer pain relief on a regular basis as prescribed, including continual medication.
As patients’ pain increases, the patients will need more pain medicine to combat it, O’Shaughnessy says.
"What happens is we tend to interpret this as drug-seeking behavior, but it’s not," she adds. "But they’ve done studies on people with cancer who are on chronic pain management and not necessarily terminally ill, and the statistics show that if the people are not addicts to start with, then somewhere in the neighborhood of 1% become addicted to the medication."
For some patients, the medication will need to be administered 24-hours a day. And nurses can expect to see that the patient’s body has become physically dependent or habituated to the drugs, but this isn’t the same thing as being a drug addict, O’Shaughnessy says.
Stage three or severe pain often is treated with around-the-clock analgesics, Foust says.
"They’re given something every 12 hours or 8 hours or 6 hours, and they have the patient set the clock and wake up in the middle of the night to take the pill," she explains. "That way the patient doesn’t wake up in excruciating pain at 7 in the morning."
The medication could be administered orally or through a transdermal patch that has a slow release over 72 hours, Foust says.
Webb says her agency has different pain control therapies, including the unusual, such as a transelectric nerve stimulation unit. The unit places electrodes on the patient’s back and diverts pain away from that area. Typically, it’s followed up with physical therapy and occupational therapy.
Housecall Home Healthcare’s policy advises that any pain control measures be taken per a medical order and that the effectiveness of the treatment be monitored at each visit. (See pain management policy, pp. 119-120.)
4. Do the simple things first, especially for patients who have less severe pain.
Ease pain by changing the patient’s position and through relaxation techniques, Foust suggests.
"Get patients to talk about one of the very best times in their lives and what is the best possible vacation they can take to relax," she says. "This gets their mind off their pain and maybe lessens it that way."
Housecall Home Healthcare gives nurses literature on relaxation, visual imagery, and massage techniques, Webb says.
"Both nurses and home health aides are taught how to do massages," Webb says. "If it’s a specific type of massage, mostly a back massage for relaxation, then the nurse would do it, and she can instruct the home health aide."
Webb also suggests staff help chronic pain patients create a relaxing environment when the pain worsens.
"A warm bath is a very simple kind of relaxation measure," she adds. "The patient could turn the lights down, play soft music, and keep the house at a nice temperature."
Foust says her agency’s nurses teach families how to do massages to help relax patients. "If they have certain muscles, like in the shoulders and back, that get real tight and tense, then they can give a massage to help the muscles relax."
Other simple measures include applying heat and cold to the areas that are in pain.
Housecall Home Healthcare nurses apply the heat, and the aides apply cold compresses because if heat is improperly applied, it could burn a patient, Webb says.
5. Observe the patient’s pain to make sure it’s responsive to the prescribed medications.
"A person might have pain in the bone from metastatic bone disease and get little relief from morphine, but get considerable relief when a non-steroidal drug is added in," O’Shaughnessy says.
For example, the patient might be treated with morphine and have little response, but the morphine could work much better at reducing pain if the patient also is given ibuprofen.
If a nurse feels a patient hasn’t been prescribed enough medication, the nurse could notify the physician. But, O’Shaughnessy advises, the nurse first checks state laws to see if there are limits to a physician’s freedom in prescribing narcotics.
"One of the real barriers is the triplicate prescription law, which is present in New York state," O’Shaughnessy says. "The supposition is that any person prescribing large doses of narcotics to young people particularly is fostering addiction.
"I think nurses and physicians need to be aware of the restrictions these laws place on them and what would be a good medical practice."
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