PAIN MANAGEMENT GUIDELINE OF THE HEALTHCARE ASSOCIATION OF NEW JERSEY Originally drafted, approved, and adopted for use in 2004, this pain management guideline has received wide acceptance in the United States. Now in its 217 revised version, the Healthcare highlights of this guideline as it relates to the theme of this course follows:
Nonpharmacological pain management interventions Information collected from the pain assessment is to be used to formulate and implement an individualized person-centered pain management plan of care based on the patient’s ability to function comfortably. If it is not possible to achieve the optimal pain management plan for the patient/resident, the patient/ resident shall be referred for pain management to an expert pain consultant. 5. Both PT and OT upon discharge from the therapy program should provide: a. Illustrated home exercise program, and in-service to the caregiver. 6. Guided internet-based psycho-education intervention: Cognitive behavioral therapy: a. Assess the resident, especially those with cognitive impairment, for unmet needs which could be interpreted as pain such as hunger, loneliness, depression, need to be toileted, to speak to a loved one, sleeplessness, anxiety, and meet the need. b. Assure the patient/resident is comfortable; reposition, if appropriate to the patient’s level of function engage in an activity such as walking. For patients/residents who suffer from chronic pain, there is a new system of non-pharmacological interventions known as, “Guided Internet-Based Psycho-Education Intervention Using Cognitive Behavioral Therapy (CBT) and Self-Management (SM) for Individuals with Chronic Pain.” such as acetaminophen, and one that is effective for moderate to severe pain (e.g., morphine, oxycodone, hydromorphone). b. Add or continue adjuvants, if appropriate for the individual: Individualize the pain management program according to the patient’s goals to incorporate person- centered criteria to meet the patient’s pain needs. Other notable recommendations under this guideline a. Before starting opioid therapy for chronic pain, it is recommended, based on person-centered care, that a clinician work to establish pain management goals that utilize nonpharmacological methods that will increase the patient/resident’s daily functional abilities at a comfortable level. What is a comfortable level? The level of pain that is tolerated by the established enables a degree of independence in activities of daily living. With continuing assessment, and evaluation and as increase independence, there is a continued reduction in the necessity for narcotic analgesics. b. Clinicians should establish treatment goals with all patients/ residents and understand at what level on the selected pain scale the patient/resident feels they are comfortable and able to function. Every person’s tolerance to pain is subjective. If a patient says they have pain, they do have pain. If they say they have pain at an 8 they do. A 5 on the pain scale may be uncomfortable for someone else. c. At what level is the pain manageable for this patient? Once that is established, person-centered goals can be set including realistic goals for pain and function and should consider how opioid therapy will be discontinued if the benefits do not outweigh the risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient/resident safety.
Association of New Jersey’s Pain Management Guideline has been redesigned to properly promote the health, safety, and welfare of residents in nursing facilities, assisted living, residential healthcare facilities, and adult day health services, by establishing guidelines to meet the state’s requirements for the assessment, monitoring, and management of pain. The major
Rehabilitation treatment modalities (Physical Therapy-PT/Occupational Therapy-OT): 1. PT intervention: Therapeutic exercise: a. Passive range of motion, active assistive range of motion,
active range of motion, progressive resistive exercise, balance training, gait training, postural correction and reeducation, ergonomics. 2. PT intervention: Manual therapy: a. Mobilization and manipulation of the joints, craniosacral therapy, myofascial release, and massage. 3. PT intervention: Modalities: a. Electrical stimulation, transcutaneous electrical nerve stimulation, iontophoresis, ultrasound, diathermy, infrared, hydrotherapy (warm), fluid therapy, cold laser, hot packs, paraffin wax therapy, and ice packs. 4. OT intervention: Pain reduction: a. The activity of daily living, adaptive devices to simplify tasks, energy conservation techniques, therapeutic exercises, wheelchair measurement, wheelchair positioning devices, bed positioning devices, cushions for appropriate pressure relief, splinting for stretching tight joints/muscles, reducing pain, and preventing pressure sore. Pharmacological intervention As a result of a nationwide effort to reduce unnecessary opioid use and reduce incidents of patient abuse, clinicians are encouraged to carefully assess their patients’ pain through assessment, limit the number of prescribed narcotic analgesics and limit further prescribing by evaluating the patient’s/ resident’s pain relief and increased functional ability. The Healthcare Association of New Jersey’s Pain Management Guideline recommends the WHO pain management ladder as its pharmacological recommendation for pain management. The WHO ladder centers on five key principles: ● “By Mouth”: Use the oral route whenever possible, even for opioids. ● “By the Clock”: For persistent pain, provide medication at regular intervals (around the clock) rather than PRN (as needed). ● “By the Ladder.” Step 1: a. For mild to moderate pain, start with a nonopioid (e.g., acetaminophen, ibuprofen) and increase the dose, if necessary to the maximum recommended dose. b. Use an adjuvant such as an anti-depressant or anticonvulsant, if indicated. c. If the patient presents with moderate or severe pain skip Step 1. Step 2: a. If or when non-opioids do not adequately relieve pain, add an opioid intended for moderate pain such as hydrocodone (combined with acetaminophen). b. Add or continue adjuvants, if appropriate. Step 3: a. If or when the non-opioid for mild to moderate pain no longer adequately relieve the pain, switch to an opioid that is not combined with another agent
Book Code: PYFL4024
Page 144
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