Pain: An LTC rehab perspective
A big question for long-term care therapists is: What do I do if my patient experiences pain?
LTC therapists seem to be stuck between a rock and a hard place when it comes to patient pain. Pain management is at the forefront of surveyors and scrutinized as a CMS quality measure. The reality of delivering skilled therapy services is that our patients just may experience pain. While we know the old adage “No Pain No Gain” really is untrue, we also know that most post-incident recovery involves skilled therapy supervised and directed activity that WILL cause discomfort and often times pain for our patients. So what do we do with this pain? How much do we let it direct our care? What is the balance between causing pain and ultimately achieving pain management?
Here are a few tips on how to be conscientious and still reach desired therapeutic goals with your patients.
Pain has to be recognized, quantified, described and its cause determined. Without this no therapist can effectively devise a plan of care that will allow a patient to improve.
REMEMBER: Pain is the number one inhibitor to function. Reduce or eliminate pain to improve function-that simple.
Therapists instruct and support patients to do activities that will elicit pain. With this in mind, based on the information gathered by looking at pain, the evaluating therapist must ensure that the plan of care includes pain management interventions to reduce or eliminate pain experienced pre, during and post treatment. It may take several treatments to identify what pain management intervention is the most effective method for the patient.
Some examples may be-medication, breathing and relaxation techniques, meditation, massage/touch and modalities like moist heat, cryotherapy or physical agent modalities.
Document, Document, Document! It is imperative to document all of your attempts at pain management. Quantifying this pain through verbal and non-verbal methods is crucial to show effectiveness of the intervention. A plan of care that shows a constant re-evaluation and measurement of pain is a dynamic plan that will reflect an effective pain management program.
Determine and document your patient's pain level goal. Many times pain cannot be completely alleviated. It is important to help your patient determine what is their “acceptable” level of pan for day to day activities.
Skilled therapy interventions that are known to cause increased pain should be explained in detail to the patient. Together the therapist and patient should determine how the patient should communicate the need for the treatment to stop, be modified and what techniques can be used to “work through” the pain.
Remember DOMS-delayed onset muscle soreness. Your patients may not experience pain during treatment but could have delayed pain specifically DOMS. Educating your patient that this is a possibility will allow them to seek pain management usually an NSAID to reduce the severity of DOMS.
Once the pain management plan has been determined and is effective, the evaluating therapist must communicate this plan in writing thoroughly so that other treating therapists can consistently carry out this plan.
All new onsets of pain or worsening of pain MUST have a re-evaluation of the pain management program explored and documented. New or worsening pain not addressed and with no changes in plan of care can lead to issues with surveyors and reviewers and is a disservice to our patients.
Patients have the right to dictate their preferred method of pain management. Do not underestimate the power of breathing and relaxation techniques as well as therapeutic touch. For these to work you must allow the time necessary to let them work-this is therapeutic time! And again: Document, Document, Document.
As a rule, patient treatment should be done in a way that allows the patient to relax, feel safe and secure and optimally positioned. Patients who may be confused or are unable to verbalize pain are more difficult to manage and require a very specific and consistent approach to pain management. Therapists must be in tune with the patient's non-verbal behaviors and cues. Often, the therapist will need to assume the confused and/or nonverbal patient is in pain and provide proactive pain management especially when dealing with wound care and other presumed painful treatments.
Any time a patient expresses pain-regardless of the circumstances-we should STOP, ASSESS and INTERVENE. It is appropriate to begin with non-pharmacological means and if no immediate relief or desired pain level reached after intervention, involve nursing immediately.
And finally, a note about pain medications:
Pain meds may initially be ordered only PRN. It is necessary to address this if the patient consistently requests or needs pain meds. Routine pain meds that keep pain levels under control will allow a patient to function at a higher and more consistent level and improve overall participation in skilled therapy. Also remember that a confused and/or nonverbal patient may not be able to ask for their PRN pain med so again presumed pain with proactive pain management may be necessary.
Breakthrough pain meds may be necessary if the patient's pain spikes or is exacerbated and the routine med is not effective over the normal course of the day.
Pre-medicating for pain should be addressed in a physician order and should be specific to what event the pre-medication is needed for and how long before the event it is needed to be taken. This could be prior to wound care, prior to contracture management, etc.
Neither the therapist nor the patient needs to surrender to pain. Together, attack it and mitigate it and hopefully eliminate it. Together we can redefine that old saying to read “no pain means maximum gains”!
Tara Roberts, PT, is the corporate director of rehabilitation and wound care services at Nexion Health Management, Inc.