Pain can cause suffering for nursing home residents and can result in inactivity, social withdrawal, depression, and functional decline. That is why effective pain management is so important in improving the quality of life for residents.
MDS 3.0 regulations around pain management seek to assess the presence of pain, pain frequency, effect on function, intensity, management and control.
The goal of any pain management program should be to achieve a consistent level of comfort for the resident while maintaining as much function as possible.
Without a pain management care plan:
- Pain can impact functional decline.
- Immobility can cause complications such as skin breakdown and infections.
- Pain significantly adversely affects a person’s quality of life and is tightly linked to depression, diminished self-confidence and self-esteem, as well as an increase in behavior problems, particularly for cognitively-impaired residents.
- Some older adults limit their activities in order to avoid having pain. Their report of lower pain frequency may reflect their avoidance of activity.
Residents need a comprehensive, individualized pain management regimen. Many with moderate to severe pain will require regularly dosed pain medication, and some will require additional as-needed (PRN) pain medications. Non-medication pain (non-pharmacologic) interventions for pain can be important adjuncts to pain treatment too.
To start, you must assess the resident.
- Review medical record to determine if a pain regimen exists.
- Review the medical record and interview staff and direct caregivers to determine what, if any, pain management interventions the resident received during the 5-day look-back period.
Most residents who are capable of communicating can answer questions about how they feel. Obtaining information about pain directly from the resident is more reliable and accurate than observation alone for identifying pain.
- Directly asking the resident about pain rather than relying on the resident to volunteer the information or relying on clinical observation significantly improves the detection of pain.
- Pain assessment provides a basis for evaluation, treatment need, and response to treatment.
- Assessing whether pain interferes with sleep or activities provides additional understanding of the functional impact of pain and helps you plan for care.
- Assessment helps staff adjust the timing of pain interventions to better cover sleep or preferred activities.
- Pain assessment prompts discussion about factors that aggravate and alleviate pain.
- Consistent use of a standardized pain intensity scale improves the validity and reliability of pain assessment.
An interview allows the resident’s voice to be reflected in the care plan. Information that comes directly from the resident provides symptom-specific information for individualized care planning. If a resident cannot communicate then staff observations for pain behavior will suffice.
- Determine whether the resident is understood at least sometimes.
- If an interpreter is needed or requested, every effort should be made to have an interpreter present for the MDS clinical interview.
- Conduct the interview in a private setting.
- Be sure the resident can hear you. Minimize background noise.
- Ask the resident: “Have you had pain or hurting at any time in the last 5 days?” If the resident answers “no” then the pain interview is complete.
- If the resident answers “yes” then ask: “How much of the time have you experienced pain or hurting over the last 5 days?”
- Ask the resident each of these two questions exactly as they are written.
Over the Past 5 Days, Has Pain Made It Hard for You to Sleep at Night?
Over the Past 5 Days, Have You Limited Your Day-to-day Activities because of Pain?
- Next, you need to assess the level of pain. Ask:
“Please rate the intensity of your worst pain over the last 5 days.”
Acceptable answers are mild, moderate, severe and very severe, horrible or the resident can rate the pain on a scale of 1-10.
When a resident is unable to provide information, a staff assessment may be necessary. The Staff Assessment for Pain should only be completed if the Pain Assessment Interview was not completed. A consistent approach to observation improves the accuracy of pain assessment for residents who are unable to verbally communicate their pain. Particular attention should be paid to using the indicators of pain during activities when pain is most likely (e.g., bathing, transferring, dressing, walking and potentially during eating).
- Review the medical record for documentation of each indicator of pain listed that occurred during the 5-day look-back period.
- Confirm your record review with the direct care staff on all shifts who work most closely with the resident during activities of daily living (ADL).
- Interview staff because the medical record may fail to note all observable pain behaviors.
- Observe the resident during care activities. Observations for pain indicators may be more sensitive if the resident is observed during ADL, or wound care.
- Other things that can be observed or review include: shortness of breath, current tobacco use, fall history on admission, the number of falls since admission or prior assessment.
Pain is sometimes a fact of life for our elders but it does not have to be. The proper assessment of pain, which includes the resident in that assessment, can lead to a care plan that alleviates pain and contributes to quality of life.
Source: CMS’s RAI Version 3.0 Manual