Long-Term Care Survey Alert

Take notes on this facility's best practice pain management strategies.

An effective pain management arsenal includes more than pills and traditional parenteral medication administration modes.

Case in point: Windsor Place Nursing Center formulates compounded medications as a topical analgesic for pain relief, reports Barbara Golden, RN, director of nursing for the facility in Dainger- field, TX.

The physician may prescribe Keto, Lido, Cyclo Compounded Gel, for example, says Golden. The medications in the gel include ketoprofen (a non-steroidal anti-inflammatory), lidocaine (anesthetic) and cyclobenzaprine (a muscle relaxant). The pharmacist also compounds ibuprofen for residents with a history of gastrointestinal problems, she adds.

"Compounding a medication in a gel is a way to deliver the medication to a patient who may not be taking drugs well orally," explains the facility's consulting pharmacist Kenny Powers. "The medication doesn't have to pass through the person's gastrointestinal track and has less effect on the patient's liver," he says.

Compounded medications such as the ones Windsor Place is using can help relieve arthritis-type pain. That's the "nagging, my knee always hurts and I ignore it the best I can type pain" that people can cope with until they develop dementia, comments Diana Waugh, RN, owner of Waugh Consulting in Waterville, OH. But when someone has dementia, chronic pain drives various nonverbal forms of communication through behaviors, she notes.

Case example: One resident at Windsor Place refused to participate in physical therapy (PT) for her surgically repaired joint--until she began receiving an analgesic topical preparation before the therapy treatments. The lady is now mobile and using a walker, reports Golden.

The facility uses the "least amount" of opioid to meet a patient's comfort goal. And the physicians prescribe anti-seizure medications, such as Neurontin for neuropathy pain; and antidepressants, such as Elavil and benzodiazepenes, such as Xanax, to enhance the opioid medications, says Golden.

Tip: B vitamins have in some cases helped people with neuropathy, she adds.

The facility's physicians also prescribe Nubain rather than morphine, as the former doesn't suppress respirations and relieves the pain longer than morphine, says Golden.

Documentation tip: Assess and document the resident/family's goal for pain relief, advises Nathan Lake, RN, BSN, MSHA, a consultant in Seattle. "If the facility will be administering enough pain medication that the resident ends up sedated to meet his/her comfort needs," make sure the documentation includes the resident's goal for that level of pain control.

Reach Into the Non-Pharmacological Tool Box

Facilities should also incorporate non-pharmacological strategies into their pain management program. "Exercise and keeping the resident mobile and active" can reduce pain, says Golden. The facility also offers a paraffin bath, a therapeutic whirlpool, a TENs unit and a massage therapist. "The therapist does a care plan with realistic goals for her patient and adds to the facility care plan," says Golden.

Don't forget this old remedy: "The old fashioned backrub that nurses used to provide routinely can ease aches and pains, especially for residents confined to bed due to their condition," says Golden. Repositioning a resident is the perfect time to give him or her a back rub. Checking someone's feet for ulcers or skin breakdown offers a good time for a foot rub, she adds.