Page 74 Complete Your CE Test Online - Click Here Mrs. Burns, who introduced this section on sleep assessment, needs a good physical and mental health assessment. She may have physical problems that are contributing to her sleep problems. She may also be taking medications that interfere with sleep, or there may be mental health issues that are contributing to a lack of proper sleep and rest. Pain assessment Helen Adams is 85 years old and suffers from severe osteoarthritic pain of the lower spine and knees. She has severe pain when walking and is very unsteady on her feet. Helen takes acetaminophen for pain but only “when she really needs it. Not every day.” She dislikes talking about her pain and mobility problems. Until recently, she was extremely active and walked fairly well. She refuses to use a walker, cane, or other assistive device. Mrs. Adams claims, “I can get around just fine. Nobody’s going to make me use a walker like I was some sick old lady.” During a routine office visit for hypertension monitoring, her daughter accompanies her and insists that she undergo an evaluation for pain management. Pain assessment should be part of the assessment of all patients. Older adults often live with chronic illnesses and disorders that cause varying degrees of pain, thus significance of the degree of pain may differ in older adults. They may also experience more acute types of pain that follow trauma or surgery. Many older adults suffer from persistent undertreated pain, defined as pain that continues over a prolonged period of time [9]. The American Geriatric Society (2002) reported that the incidence of pain more than doubles once individuals surpass the age of 60 with pain frequency increasing with each decade [3,30]. Research shows that about 60% to 75% of people over the age of 65 report at least some persistent pain. This percentage is significantly higher for older adults who are living in long term care or assisted living facilities. Like Mrs. Adams, the most frequent complaint of pain is osteoarthritic pain. For most people this pain is in the lower back or neck. Other commonly reported types of pain include musculoskeletal pain, peripheral neuropathic pain, and chronic joint pain [31]. EBP alert! Research shows that depression can exacerbate pain. Likewise, people in persistent pain can become depressed. Nurses should screen for depression when working with patients who have persistent pain [9]. Nursing consideration: When suffering from persistent pain, older adults may limit their activity because activity makes the pain worse or because they are afraid of injury or falling. However, limiting activity may lead to withdrawal from social interaction and participation in normal activities of daily living. It may also lead to decreased exercise tolerance and decreased cardiovascular efficiency [9,14,30]. Thus, nurses must facilitate good pain assessment and support treatment regimens that manage pain and maintain a good quality of life. With pain being under-reported and therefore undertreated, nurses must be aware of the barriers to adequate pain management for older adults. These barriers are related to strong personal beliefs and fears about the meaning of pain and pain treatment options held by patients, families and health care professionals [31]. Factors that may interfere with proper reporting and management of pain include the following issues [9,30]: ● ● Healthcare professionals may be insufficiently trained or educated in the assessment and management of persistent pain in the older adult population. ● ● Older adults may perceive pain differently. They may believe that their pain is insignificant to other health problems that they may have. They may assume that pain is a “normal” part of aging or may have a cultural bias. In fact, even some healthcare professionals may believe that some degree of pain is “normal” in older adults. ● ● Older adults may be reluctant to admit that pain is interfering with their ability to function. Recall that Mrs. Adams is reluctant to discuss her pain or even admit that it is a problem. Older adults may fear that if they admit to problems they may be restricted in their activities or be “sent” to a long-term care facility. ● ● Older adults may fear side effects of and/or “addiction” to pain medications. ● ● Problems communicating may make it difficult for healthcare professionals to conduct an accurate pain assessment. Cognitive problems, such as those relating to dementia or stroke, may interfere with a patient’s ability to express pain. ● ● Lastly, cost of these medications may be a hindrance to obtaining them. EBP alert! Research shows that persistent pain can lead to sleep disturbances, depression, and exacerbation of other illnesses and disorders [30]. Nurses must realize that pain can negatively impact all aspects of an older adult’s life and must take action to enhance the quality of life of older adults. Nursing consideration: Good coping mechanisms and family support have been shown to decrease pain levels [9]. Nurses must be sure to assess patients’ coping strategies and what types of support networks they have. Assessment tip: Some older adults may not believe that they have pain, but may admit to discomfort or other unpleasant sensations. When assessing for pain, do not only ask a patient, “Do you have any pain?” Also ask whether they have any discomfort, aching or soreness. There are a number of pain assessment techniques in use. Some require the use of numeric pain rating scales while others rely on pictures that illustrate various degrees of pain. Important questions for a nurse to address when conducting a pain assessment include the following [9,10,14,30]: ● ● Ask the patients to describe the pain, aching, or soreness they are experiencing. For example, ask questions like: Is the pain sharp or dull? Is it constant or intermittent? Is it burning or “squeezing?” Does it cause any lack of sensation? Does it cause tingling, numbness, or “pins and needles” feelings? Does the pain stay in one spot or does it radiate? ● ● When does the pain occur? Is it worse at specific times during the day or at night? If so, what is the patient doing or what is happening in the environment when the pain becomes worse? ● ● What makes the pain better or less uncomfortable? ● ● What makes the pain feel worse? ● ● Are there any other symptoms that occur with the pain, such as nausea or vomiting? ● ● Do you take any medications for pain? What are they and how often does are they taken? How well do these medications work to control the pain? (Be sure to ask about ALL medications including prescription, over-the-counter, herbal preparations, minerals, vitamins and other supplements. Remember that some patients do not consider items such as herbal preparations, minerals, vitamins and over-the-counter drugs as “medicine.”) Are the medications causing any side effects? ● ● Do you do anything specific to alleviate pain in addition to medication? (Some patients may drink alcohol or take other drugs (including illegal drugs) to relieve pain. Others may use remedies such as warm milk to induce sleep, relaxation tapes, meditation or prayer.) How successful are these interventions? ● ● What does pain mean to the patient from a cultural and/or religious viewpoint? For example, some patients may believe that pain is punishment for misdeeds. Some cultures value stoicism when confronting pain while others are quite emotionally vocal about expressing pain. Remember to remain objective and respectful of a patient’s cultural and religious beliefs about pain and how it is dealt with. Pain assessment requires that patients undergo a complete history and physical including a cognitive assessment. Pain among cognitively impaired, non-communicative older adults poses a challenge during this assessment. The use of a valid pain assessment tool is also important and must correlate to an understanding of cognitive, language, and sensory impairments that may be present in this population.