Better Pain Management for Elders in the ICU
Better Pain Management for Elders in the Intensive Care Unit Binta Diallo, BSN, RN, CRRN, CN III; Donald D. Kautz, PhD, RN
By 2040, there will be 70 million people older than 65 years in the United States. Approximately 50% have pain on a daily basis, and research shows that their pain is often underdiagnosed and undertreated. Nurses have an obligation to provide state-of-the-art care and advocate for vulnerable older adults in the intensive care unit (ICU). Untreated pain can complicate an ICU stay and delay discharge. This article briefly reviews difficulties in managing pain in ICU patients, suggests creative methods to properly assess pain, and discusses approaches for encouraging elders in ICU to manage their pain effectively. Keywords: Acute pain, Chronic pain, Nursing care, Pain management in elders, Pain management in ICU, Pain the elderly, Patient education [DIMENS CRIT CARE NURS. 2014;33(6):316/319]
By 2040, there will be 70 million people in the United States older than 65 years. Approximately half experience pain on a daily basis, and research shows that their pain is often underdiagnosed and undertreated. The American Geriatrics Society1 guideline on the use of opioids to treat persistent pain in older adults states that ‘‘Persistent pain or its inadequate treatment can lead to decreased mobility and function, falls, depression, social isolation, poor sleep, and weight lossVlet alone unnecessary suffering.’’(p1) Failure to adequately treat elders’ pain leads to increased emergency department visits and inadequate treatment of chronic illnesses and can begin the downward spiral that leads to decline and death. It is particularly important for intensive care unit (ICU) nurses to address pain because untreated pain can complicate an ICU stay and delay discharge. Fine2 therefore recommends a thorough history, physical examination, and diagnostic tests to adequately assess underlying causes of pain, as well as a team approach in treating pain. Adequate pain treatment may require round-the-clock acetaminophen 316
Dimensions of Critical Care Nursing
Vol. 33 / No. 6
and opiates, as well as adjuvant therapy. Although the diagnostic workup and prescription of pain medication are outside the purview of ICU nurses, the nurses can advocate for patients who have inadequate medical orders for pain relief and suggest new approaches. This article reviews difficulties in managing pain in elderly ICU patients, suggests creative methods for properly assessing pain, recommends strategies to relieve fears about pain medications, and suggests alternatives to pain management, addressing cultural differences and the information elders in the ICU need about pain management. Pain may keep elderly ICU patients on bed rest, and for every day on bed rest, a patient loses 1% to 2% of muscle mass; after a week, the patient may have lost 14% or more.3 This deconditioning may set in motion a cascade of complications, including ventilator-associated pneumonia, atelectasis, and hemodynamic instability. In addition, untreated pain may continue after the ICU stay, prolonging the stay in acute care, creating dependence at home or in an extended care facility, and interfering with rehabilitation and reintegration DOI: 10.1097/DCC.0000000000000074
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Better Pain Management for Elders in the ICU
into the community. Adequate pain relief leads to rehabilitation and better quality of life.4
DIFFICULTIES IN MANAGING PAIN IN ELDERS Research and clinical experience have shown that pain is difficult to treat in elders in part because of fear, lack of understanding, the need for adequate pain management to maintain independence, myths about pain, and cultural issues among elders. Elders have been found to be afraid to report pain for many reasons.5 Some fear that pain will mean more procedures or that their disease has worsened. Those with cancer may fear that new pain means their cancer has metastasized. Some elders fear that taking pain medications will make them addicted to the medication, because they believe old myths.6 They also may fear constipation or fear that pain medicine will make them nauseous. Elders may also be stoic or reluctant to report pain for fear of complaining. Finally, elderly patients may have poor memory, poor health, or psychosocial disorders that interfere with assessing and managing their pain in the ICU.
PAIN ASSESSMENT Because pain is a personal experience, really known only to the person experiencing the pain, it is very difficult to assess. In addition, pain has many dimensions, and it can be difficult to determine the location of pain, its intensity, or how it is affecting an individual. Assessing pain is especially difficult in the ICU when patients are very ill. An elderly person on the ventilator, on cardiac ‘‘drips,’’ or having just had surgery may have trouble focusing on pain enough to accurately report pain level and say where it hurts. Nurses can start with numeric rating scales (0 is no pain, 1-3 is mild pain, 4-6 is moderate pain, 7-10 severe pain or the worse pain I’ve ever had), verbal descriptor scales (none, mild, moderate, severe), or a visual analog scale.5 The nurse may need to go over what the numbers mean each time an assessment is done. This is especially true for elderly patients who are cognitively impaired, hearing impaired, or so ill that they cannot concentrate. To get an accurate assessment, it may be necessary to ask about pain in specific areas. If concerned about the abdomen, or leg, the nurse can say, ‘‘Please rate the pain in your belly (or leg) right now.’’ We may also need to ask, ‘‘Do you ache?’’ or ‘‘Are you too sore to get up (or move)?’’ Research shows that to minimize their pain, elders may not say they are in pain. Thus, the nurse may need to ask about burning, aching, tightness, discomfort, or throbbing.5 Reinforcement of information about the importance of pain management is essential to help elderly patients understand what pain management really means. For example, they need to know that anxiety and nausea can increase pain and interfere with pain treatment.
Research has shown that assessing pain in elders requires creativity.5 After asking a patient to rate his/her pain, if the person reports little or no pain, the nurse may need to observe the patient closely. Is the patient ‘‘guarding’’ or ‘‘bracing’’ or rubbing a painful area? Observing facial expressions may also be helpful. Raising or lowering the eye brow, raising the cheek, tightly closing the eyes, wrinkling the nose, lip corner pulling, lip puckering, and chin raising may all be associated with pain. The Critical-Care Pain Observation Tool is a behavioral assessment tool that has been validated in the critical care setting for patients who are unable to communicate the level or quality of their pain.7 The Critical-Care Pain Observation Tool contains 4 sections, on facial expression, body movements, muscle tension, and either compliance with the ventilator for intubated patients or vocalizations in nonintubated patients. Nurses must take into account cultural differences when they assess and treat pain. Some patients may say no, they are not experiencing pain, or say yes, the pain medication is effective, because they think this is what they are supposed to say. In some cultures, the norm is to be stoic when in pain. In others, the norm is to moan or pray. The nurse can tell the patient who is stoic, ‘‘Being stoic about your pain doesn’t help you to get out of the ICU. Taking pain medication will speed your recovery.’’ The nurse can tell the patient who is praying, ‘‘This pain medication will work with your prayers to relieve the pain.’’ Research also confirms that most adults older than 75 years are ‘‘normally’’ in pain every day. An ICU admission is often accompanied by an event such as trauma or surgery, which leads to additional pain. When we ask about pain, the patient may think we are asking about pain from the surgery or trauma, not the chronic pain he/she feels every day at home. Assessing what a patient does to relieve pain at home every day and incorporating those treatments into care in the ICU will enhance the effectiveness of the medications being used. If the patient is unable to answer, the nurse may need to ask a caregiver, or say, ‘‘Research shows that most elderly are in pain every day, what does ______ do to manage the pain so _______ can get up and participate in usual activities. We need to do these same things here in the ICU so that ______ doesn’t back slide and develop complications.’’ For example, a patient may use a heating pad or ice pack at home. Incorporating the use of heat or an ice pack, a cool washcloth for the face, and medication before activity in the ICU may likely increase the patient’s willingness to get up. Asking a patient ‘‘If you were at home right now, what would you do to treat your pain, so you could get up and do what you need to do?’’ gets the patient involved. Involving patients in pain management strategies and encouraging them to make informed choices not only increase their independence but may also increase the effectiveness of treatments. November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
317
Better Pain Management for Elders in the ICU
The Joint Commission has declared pain the ‘‘5th vital sign’’ to encourage health care providers to focus on pain relief in every patient encounter. We can tell our elderly patients, ‘‘I am asking you about your pain again, because just as I take your blood pressure and count your heart rate, your level of pain relief is a good indicator of how well you are doing. I can measure your blood pressure, but the only way I know that you are in pain is if you tell me.’’ We can add, ‘‘When your pain is adequately treated, then you can get up and walk, and then we can transfer you out of the ICU. So, let me ask again, how is your pain?’’ Nurses need to assess pain more frequently than every 4 hours. In the ICU, assessing patients every 1 to 2 hours may be more appropriate. Continuing to reassess pain is helpful in getting to the cause of the pain because elderly patients are admitted with chronic pain and now also have pain due to surgery or trauma. It is also important to assess patients each time they are repositioned or while getting them out of bed to chair or to walk around.8 Patients may need to be premedicated before turning or getting out of bed. The nurse can tell a patient, ‘‘I’m going to get you up in 45 minutes, I want you to take some pain medicine now so you will be able to do that.’’ All of these creative assessment strategies can also serve to guide and educate patients about pain management in the ICU and encourage them to be ‘‘partners’’ in their care. The goal is not to ‘‘convince’’ the patient to take medication on our schedule but to get the patient actively involved in determining when, how often, and how much medication the patient needs to recover and get up and get moving. We can tell the patient, ‘‘We keep asking you about your pain because we know it’s best when you help us to manage your patient. We also know it’s best if you understand why it is important to take these medications.’’ Sometimes, physicians and nurses limit the amount of pain medication to avoid sedating the patient.8 Nurses may withhold pain medication when an elderly patient seems very sleepy. However, upon further assessment, the nurse may find that the patient is in so much in pain he/she will not get out of bed. With a patient who is nauseous or sleepy from a narcotic, the nurse can medicate with an antiemetic and administer an intravenous narcotic slowly. The nurse can also start with a low dose, for example, 2 mg instead of 4 mg of morphine.
RELIEVING FEARS AND RESPECTING REFUSAL OF MEDICATIONS If patients are afraid to take pain medicines, nurses can explain that addiction to narcotics is rare when patients use them appropriately in the ICU.9 The nurse can point out that they will only be on the medication for a short period and that, as soon as possible, the patient will be switched to nonsteroidal anti-inflammatory drugs, acetaminophen, 318
Dimensions of Critical Care Nursing
and adjuvant therapy. We can also teach patients how to avoid the adverse effects of narcotics, such as constipation. For example, we can explain that we encourage plenty of fluids and administer stool softeners to prevent constipation. Nurses can also tell patients, ‘‘Constipation causes further pain, which can limit mobility, making the pain even worse. I am giving you these medications to prevent constipation. If you do experience constipation, we can help you overcome it.’’ The nurse can also explain that nausea can be prevented by taking medicine with food and say that the patient can be given antiemetics if the patient wishes. If patients are afraid that pain means their disease is worse, the nurse can make sure that they have current and accurate information about their disease and prognosis. The nurse can emphasize that new pain may come from muscle strains or procedures in the ICU and encourage patients to identify the cause. Even after the nurse completes a thorough assessment and addresses fears, some patients will refuse medications. At this point, the nurse can say, ‘‘I respect your decision. We will continue to take care of you and help make you as comfortable as possible. We will also continue to assess your pain and ask you about pain medication in case you change your mind.’’
ALTERNATIVES TO NARCOTIC PAIN MANAGEMENT The ‘‘pain ladder’’ approach to pain management in elderly patients recommends using the safest drugs first and then escalating treatment if pain is not relieved.5 Paracetamol is often recommended as the first choice, followed by nonsteroidal anti-inflammatory drugs with a gastroprotective agent. The next step is opioid analgesics. The nurse can teach cognitively intact patients and their families about the pain ladder and their drug regimens in the ICU, review medication management at home, and teach patients not to add overthe-counter medications. This may help to prevent overdoses of acetaminophen. Patients and families may need detailed information about what medications contain acetaminophen and how to best manage their pain at home. Recent articles in Dimensions of Critical Care Nursing suggest that some patients may benefit from alternative treatment options to manage their pain. For example, Hahn and colleagues10 report that instituting a volunteer Reiki program worked at their institution. The Reiki therapists provided a means for patients, family, and staff to reduce pain and anxiety in the acute care setting. Also, Reilly and colleagues11 reported that auricular acupuncture reduced anxiety and increased health care providers’ quality of life and caring ability with patients. This technique may be valuable to use with patients in the ICU as well. Other alternative therapies that have been found to be effective in relieving hospitalized patients’ pain include music and biofeedback.
Vol. 33 / No. 6
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Better Pain Management for Elders in the ICU
However, Ersek9 recommends that the nurse tell patients that alternative therapies work best for mild pain and that moderate and severe pain is best controlled with a combination of an alternative therapy and analgesics.
PATIENT TEACHING AND REINFORCEMENT It is key for ICU nurses to inform elderly patients about the importance of taking their pain medication when they are hurting and to explain that when their pain is well controlled, they will be able to participate more actively in their physical therapy and get out of bed. The nurse can explain that getting out of bed to the chair is 1 of the first steps in physical therapy. To illustrate, a patient was not sleeping and refused pain medication because of fear of constipation and addition. The nurse told the patient, ‘‘Tell you what, I’ll give you some pain medication now. Let’s see if you can get some rest.’’ When the patient woke up 4 hours later, the patient told the nurse, ‘‘Thank you. You saw I needed medication. I feel so much better now.’’ This rest was a turning point for the patient in getting up and moving and thus getting discharged from ICU. The nurse went on to explain how there was little risk of addiction and talked to the patient about how to prevent constipation and nausea. The nurse reinforced that pain was confining the patient to the bed and delaying recovery. Once the patient’s pain was controlled, she got out of bed to walk. The nurse explained that walking would shorten the patient’s ICU stay and prevent complications. The nurse showed her that pain well managed allowed her to be more independent with daily living activities and enjoy the lifestyle she wanted when she was discharged from the hospital and returned home.
Acknowledgments The authors gratefully acknowledge the vision, inspiration, and editorial assistance of Ms Elizabeth Tornquist, MA, FAAN, and the wonderful assistance of Mrs Dawn Wyrick with this manuscript.
References 1. American Geriatrics Society. Statement on the use of opioids in the treatment of persistent pain in older adults. 2012. www .americangeriatrics.org. Accessed August 20, 2014. 2. Fine PG. Chronic pain management in older adults: Special considerations. J Pain Symptom Manage. 2009;38:S4-S14. 3. Brower RG. Consequences of bed rest. Crit Care Med. 2009; 37(10 suppl):S422-S428. 4. Herr K. Pain assessment strategies in older patients. J Pain. 2011; 12(3):S3-S13. 5. Schofield PA. Review article: the assessment and management of peri-operative pain in older adults. Anaesthesia. 2014;69(Suppl 1): 54-60. 6. Charette SL, Ferrell BA. Pain management in long-term care. In: Gloth FM III ed. Handbook of Pain Relief in Older Adults: An Evidence-Based Approach. 2nd ed. New York: Springer Publishing; 2009:131-146. 7. Buttes P, Keal G, Cronin SN, Stocks L, Stout C. Validation of the Critical-Care Pain Observation Tool in adult critically ill patients. Dimens Crit Care Nurs. 2014;33(2):78-81. 8. Mehta SS, Siegler EL, Henderson CR Jr, Reid MC. Acute pain management in hospitalized patients with cognitive impairment: a study of provider practices and treatment outcomes. Pain Med. 2010;11:1516-1524. 9. Ersek M. Enhancing effective pain management by addressing patient barriers to analgesic use. J Hosp Palliat Nurs. 1999;1(3):87-96. 10. Hahn J, Reilly PM, Buchanan TM. Development of a hospital Reiki training program: training volunteers to provide Reiki to patients, families, and staff in the acute care setting. Dimens Crit Care Nurs. 2014;33(1):15-21. 11. Reilly PM, Buchanan TM, Vafides C, Breakey S, Dykes P. Auricular acupuncture to relieve health care workers’ stress and anxiety: impact on caring. Dimens Crit Care Nurs. 2014;33(3):151-159.
ABOUT THE AUTHORS
CONCLUSION Intensive care units are designed to care for patients on ventilators and cardiac drips, but for a patient to be discharged from the ICU, the patient needs to be able to get out of bed. If pain is preventing the patient from getting up, then pain is preventing the person from being discharged from the ICU. As ICU nurses, we need to provide to patients the facts about pain relief and encourage them to become active partners in controlling their pain and increasing their independence.
Binta Diallo, BSN, RN, CRRN, CN III, is a clinical nurse III in the neurosurgery ICU at the University of North Carolina Hospital, Chapel Hill. Donald D. Kautz, PhD, RN, is associate professor of nursing at the University of North Carolina Greensboro. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Address correspondence and reprint requests to: Donald D. Kautz, PhD, RN, University of North Carolina Greensboro School of Nursing, PO Box 26170, Greensboro, NC 27402-6170 ([email protected]).
November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
319
Better Pain Management for Elders in the Intensive Care Unit Binta Diallo, BSN, RN, CRRN, CN III; Donald D. Kautz, PhD, RN
By 2040, there will be 70 million people older than 65 years in the United States. Approximately 50% have pain on a daily basis, and research shows that their pain is often underdiagnosed and undertreated. Nurses have an obligation to provide state-of-the-art care and advocate for vulnerable older adults in the intensive care unit (ICU). Untreated pain can complicate an ICU stay and delay discharge. This article briefly reviews difficulties in managing pain in ICU patients, suggests creative methods to properly assess pain, and discusses approaches for encouraging elders in ICU to manage their pain effectively. Keywords: Acute pain, Chronic pain, Nursing care, Pain management in elders, Pain management in ICU, Pain the elderly, Patient education [DIMENS CRIT CARE NURS. 2014;33(6):316/319]
By 2040, there will be 70 million people in the United States older than 65 years. Approximately half experience pain on a daily basis, and research shows that their pain is often underdiagnosed and undertreated. The American Geriatrics Society1 guideline on the use of opioids to treat persistent pain in older adults states that ‘‘Persistent pain or its inadequate treatment can lead to decreased mobility and function, falls, depression, social isolation, poor sleep, and weight lossVlet alone unnecessary suffering.’’(p1) Failure to adequately treat elders’ pain leads to increased emergency department visits and inadequate treatment of chronic illnesses and can begin the downward spiral that leads to decline and death. It is particularly important for intensive care unit (ICU) nurses to address pain because untreated pain can complicate an ICU stay and delay discharge. Fine2 therefore recommends a thorough history, physical examination, and diagnostic tests to adequately assess underlying causes of pain, as well as a team approach in treating pain. Adequate pain treatment may require round-the-clock acetaminophen 316
Dimensions of Critical Care Nursing
Vol. 33 / No. 6
and opiates, as well as adjuvant therapy. Although the diagnostic workup and prescription of pain medication are outside the purview of ICU nurses, the nurses can advocate for patients who have inadequate medical orders for pain relief and suggest new approaches. This article reviews difficulties in managing pain in elderly ICU patients, suggests creative methods for properly assessing pain, recommends strategies to relieve fears about pain medications, and suggests alternatives to pain management, addressing cultural differences and the information elders in the ICU need about pain management. Pain may keep elderly ICU patients on bed rest, and for every day on bed rest, a patient loses 1% to 2% of muscle mass; after a week, the patient may have lost 14% or more.3 This deconditioning may set in motion a cascade of complications, including ventilator-associated pneumonia, atelectasis, and hemodynamic instability. In addition, untreated pain may continue after the ICU stay, prolonging the stay in acute care, creating dependence at home or in an extended care facility, and interfering with rehabilitation and reintegration DOI: 10.1097/DCC.0000000000000074
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Better Pain Management for Elders in the ICU
into the community. Adequate pain relief leads to rehabilitation and better quality of life.4
DIFFICULTIES IN MANAGING PAIN IN ELDERS Research and clinical experience have shown that pain is difficult to treat in elders in part because of fear, lack of understanding, the need for adequate pain management to maintain independence, myths about pain, and cultural issues among elders. Elders have been found to be afraid to report pain for many reasons.5 Some fear that pain will mean more procedures or that their disease has worsened. Those with cancer may fear that new pain means their cancer has metastasized. Some elders fear that taking pain medications will make them addicted to the medication, because they believe old myths.6 They also may fear constipation or fear that pain medicine will make them nauseous. Elders may also be stoic or reluctant to report pain for fear of complaining. Finally, elderly patients may have poor memory, poor health, or psychosocial disorders that interfere with assessing and managing their pain in the ICU.
PAIN ASSESSMENT Because pain is a personal experience, really known only to the person experiencing the pain, it is very difficult to assess. In addition, pain has many dimensions, and it can be difficult to determine the location of pain, its intensity, or how it is affecting an individual. Assessing pain is especially difficult in the ICU when patients are very ill. An elderly person on the ventilator, on cardiac ‘‘drips,’’ or having just had surgery may have trouble focusing on pain enough to accurately report pain level and say where it hurts. Nurses can start with numeric rating scales (0 is no pain, 1-3 is mild pain, 4-6 is moderate pain, 7-10 severe pain or the worse pain I’ve ever had), verbal descriptor scales (none, mild, moderate, severe), or a visual analog scale.5 The nurse may need to go over what the numbers mean each time an assessment is done. This is especially true for elderly patients who are cognitively impaired, hearing impaired, or so ill that they cannot concentrate. To get an accurate assessment, it may be necessary to ask about pain in specific areas. If concerned about the abdomen, or leg, the nurse can say, ‘‘Please rate the pain in your belly (or leg) right now.’’ We may also need to ask, ‘‘Do you ache?’’ or ‘‘Are you too sore to get up (or move)?’’ Research shows that to minimize their pain, elders may not say they are in pain. Thus, the nurse may need to ask about burning, aching, tightness, discomfort, or throbbing.5 Reinforcement of information about the importance of pain management is essential to help elderly patients understand what pain management really means. For example, they need to know that anxiety and nausea can increase pain and interfere with pain treatment.
Research has shown that assessing pain in elders requires creativity.5 After asking a patient to rate his/her pain, if the person reports little or no pain, the nurse may need to observe the patient closely. Is the patient ‘‘guarding’’ or ‘‘bracing’’ or rubbing a painful area? Observing facial expressions may also be helpful. Raising or lowering the eye brow, raising the cheek, tightly closing the eyes, wrinkling the nose, lip corner pulling, lip puckering, and chin raising may all be associated with pain. The Critical-Care Pain Observation Tool is a behavioral assessment tool that has been validated in the critical care setting for patients who are unable to communicate the level or quality of their pain.7 The Critical-Care Pain Observation Tool contains 4 sections, on facial expression, body movements, muscle tension, and either compliance with the ventilator for intubated patients or vocalizations in nonintubated patients. Nurses must take into account cultural differences when they assess and treat pain. Some patients may say no, they are not experiencing pain, or say yes, the pain medication is effective, because they think this is what they are supposed to say. In some cultures, the norm is to be stoic when in pain. In others, the norm is to moan or pray. The nurse can tell the patient who is stoic, ‘‘Being stoic about your pain doesn’t help you to get out of the ICU. Taking pain medication will speed your recovery.’’ The nurse can tell the patient who is praying, ‘‘This pain medication will work with your prayers to relieve the pain.’’ Research also confirms that most adults older than 75 years are ‘‘normally’’ in pain every day. An ICU admission is often accompanied by an event such as trauma or surgery, which leads to additional pain. When we ask about pain, the patient may think we are asking about pain from the surgery or trauma, not the chronic pain he/she feels every day at home. Assessing what a patient does to relieve pain at home every day and incorporating those treatments into care in the ICU will enhance the effectiveness of the medications being used. If the patient is unable to answer, the nurse may need to ask a caregiver, or say, ‘‘Research shows that most elderly are in pain every day, what does ______ do to manage the pain so _______ can get up and participate in usual activities. We need to do these same things here in the ICU so that ______ doesn’t back slide and develop complications.’’ For example, a patient may use a heating pad or ice pack at home. Incorporating the use of heat or an ice pack, a cool washcloth for the face, and medication before activity in the ICU may likely increase the patient’s willingness to get up. Asking a patient ‘‘If you were at home right now, what would you do to treat your pain, so you could get up and do what you need to do?’’ gets the patient involved. Involving patients in pain management strategies and encouraging them to make informed choices not only increase their independence but may also increase the effectiveness of treatments. November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
317
Better Pain Management for Elders in the ICU
The Joint Commission has declared pain the ‘‘5th vital sign’’ to encourage health care providers to focus on pain relief in every patient encounter. We can tell our elderly patients, ‘‘I am asking you about your pain again, because just as I take your blood pressure and count your heart rate, your level of pain relief is a good indicator of how well you are doing. I can measure your blood pressure, but the only way I know that you are in pain is if you tell me.’’ We can add, ‘‘When your pain is adequately treated, then you can get up and walk, and then we can transfer you out of the ICU. So, let me ask again, how is your pain?’’ Nurses need to assess pain more frequently than every 4 hours. In the ICU, assessing patients every 1 to 2 hours may be more appropriate. Continuing to reassess pain is helpful in getting to the cause of the pain because elderly patients are admitted with chronic pain and now also have pain due to surgery or trauma. It is also important to assess patients each time they are repositioned or while getting them out of bed to chair or to walk around.8 Patients may need to be premedicated before turning or getting out of bed. The nurse can tell a patient, ‘‘I’m going to get you up in 45 minutes, I want you to take some pain medicine now so you will be able to do that.’’ All of these creative assessment strategies can also serve to guide and educate patients about pain management in the ICU and encourage them to be ‘‘partners’’ in their care. The goal is not to ‘‘convince’’ the patient to take medication on our schedule but to get the patient actively involved in determining when, how often, and how much medication the patient needs to recover and get up and get moving. We can tell the patient, ‘‘We keep asking you about your pain because we know it’s best when you help us to manage your patient. We also know it’s best if you understand why it is important to take these medications.’’ Sometimes, physicians and nurses limit the amount of pain medication to avoid sedating the patient.8 Nurses may withhold pain medication when an elderly patient seems very sleepy. However, upon further assessment, the nurse may find that the patient is in so much in pain he/she will not get out of bed. With a patient who is nauseous or sleepy from a narcotic, the nurse can medicate with an antiemetic and administer an intravenous narcotic slowly. The nurse can also start with a low dose, for example, 2 mg instead of 4 mg of morphine.
RELIEVING FEARS AND RESPECTING REFUSAL OF MEDICATIONS If patients are afraid to take pain medicines, nurses can explain that addiction to narcotics is rare when patients use them appropriately in the ICU.9 The nurse can point out that they will only be on the medication for a short period and that, as soon as possible, the patient will be switched to nonsteroidal anti-inflammatory drugs, acetaminophen, 318
Dimensions of Critical Care Nursing
and adjuvant therapy. We can also teach patients how to avoid the adverse effects of narcotics, such as constipation. For example, we can explain that we encourage plenty of fluids and administer stool softeners to prevent constipation. Nurses can also tell patients, ‘‘Constipation causes further pain, which can limit mobility, making the pain even worse. I am giving you these medications to prevent constipation. If you do experience constipation, we can help you overcome it.’’ The nurse can also explain that nausea can be prevented by taking medicine with food and say that the patient can be given antiemetics if the patient wishes. If patients are afraid that pain means their disease is worse, the nurse can make sure that they have current and accurate information about their disease and prognosis. The nurse can emphasize that new pain may come from muscle strains or procedures in the ICU and encourage patients to identify the cause. Even after the nurse completes a thorough assessment and addresses fears, some patients will refuse medications. At this point, the nurse can say, ‘‘I respect your decision. We will continue to take care of you and help make you as comfortable as possible. We will also continue to assess your pain and ask you about pain medication in case you change your mind.’’
ALTERNATIVES TO NARCOTIC PAIN MANAGEMENT The ‘‘pain ladder’’ approach to pain management in elderly patients recommends using the safest drugs first and then escalating treatment if pain is not relieved.5 Paracetamol is often recommended as the first choice, followed by nonsteroidal anti-inflammatory drugs with a gastroprotective agent. The next step is opioid analgesics. The nurse can teach cognitively intact patients and their families about the pain ladder and their drug regimens in the ICU, review medication management at home, and teach patients not to add overthe-counter medications. This may help to prevent overdoses of acetaminophen. Patients and families may need detailed information about what medications contain acetaminophen and how to best manage their pain at home. Recent articles in Dimensions of Critical Care Nursing suggest that some patients may benefit from alternative treatment options to manage their pain. For example, Hahn and colleagues10 report that instituting a volunteer Reiki program worked at their institution. The Reiki therapists provided a means for patients, family, and staff to reduce pain and anxiety in the acute care setting. Also, Reilly and colleagues11 reported that auricular acupuncture reduced anxiety and increased health care providers’ quality of life and caring ability with patients. This technique may be valuable to use with patients in the ICU as well. Other alternative therapies that have been found to be effective in relieving hospitalized patients’ pain include music and biofeedback.
Vol. 33 / No. 6
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Better Pain Management for Elders in the ICU
However, Ersek9 recommends that the nurse tell patients that alternative therapies work best for mild pain and that moderate and severe pain is best controlled with a combination of an alternative therapy and analgesics.
PATIENT TEACHING AND REINFORCEMENT It is key for ICU nurses to inform elderly patients about the importance of taking their pain medication when they are hurting and to explain that when their pain is well controlled, they will be able to participate more actively in their physical therapy and get out of bed. The nurse can explain that getting out of bed to the chair is 1 of the first steps in physical therapy. To illustrate, a patient was not sleeping and refused pain medication because of fear of constipation and addition. The nurse told the patient, ‘‘Tell you what, I’ll give you some pain medication now. Let’s see if you can get some rest.’’ When the patient woke up 4 hours later, the patient told the nurse, ‘‘Thank you. You saw I needed medication. I feel so much better now.’’ This rest was a turning point for the patient in getting up and moving and thus getting discharged from ICU. The nurse went on to explain how there was little risk of addiction and talked to the patient about how to prevent constipation and nausea. The nurse reinforced that pain was confining the patient to the bed and delaying recovery. Once the patient’s pain was controlled, she got out of bed to walk. The nurse explained that walking would shorten the patient’s ICU stay and prevent complications. The nurse showed her that pain well managed allowed her to be more independent with daily living activities and enjoy the lifestyle she wanted when she was discharged from the hospital and returned home.
Acknowledgments The authors gratefully acknowledge the vision, inspiration, and editorial assistance of Ms Elizabeth Tornquist, MA, FAAN, and the wonderful assistance of Mrs Dawn Wyrick with this manuscript.
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ABOUT THE AUTHORS
CONCLUSION Intensive care units are designed to care for patients on ventilators and cardiac drips, but for a patient to be discharged from the ICU, the patient needs to be able to get out of bed. If pain is preventing the patient from getting up, then pain is preventing the person from being discharged from the ICU. As ICU nurses, we need to provide to patients the facts about pain relief and encourage them to become active partners in controlling their pain and increasing their independence.
Binta Diallo, BSN, RN, CRRN, CN III, is a clinical nurse III in the neurosurgery ICU at the University of North Carolina Hospital, Chapel Hill. Donald D. Kautz, PhD, RN, is associate professor of nursing at the University of North Carolina Greensboro. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Address correspondence and reprint requests to: Donald D. Kautz, PhD, RN, University of North Carolina Greensboro School of Nursing, PO Box 26170, Greensboro, NC 27402-6170 ([email protected]).
November/December 2014
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