EBN | Cognitive Behavioral Therapy | Pain Management

Centro Escolar University College of Nursing Mendiola, Manila

Evidence-Based Nursing Practice:
Effectiveness of standard practice protocol of Pain Management in Older Adults

Lagrosa, Mark Anthony L. BSN4G1

evidence suggests that pain is often poorly assessed and poorly managed. The promotion of comfort and relief of pain is fundamental to nursing practice. is associated with a number of chronic like osteoarthritis and acute like cancer and surger conditions. Older adults often have multiple medical conditions. both chronic and/or acute. Nurses. an integral part of the interdisciplinary care team. The Joint Commission on Accreditation of Healthcare Organizations. and to work effectively in interdisciplinary health care teams. . especially in older adults. Nurses need to be knowledgeable about pain in late life to provide optimal care. such as osteoarthritis and peripheral vascular disease. to educate patients and families. to provide optimal care and to educate patients and families about managing pain. Because older adults constitute a significant portion of the patient population in many acute care settings.CHAPTER 1 Introduction Pain a common. need to understand myths associated with pain management. Nurses have a key role in pain management. and may suffer from multiple types and sources of pain.6 now requires regular and systematic assessment of pain in all hospitalized patients. Despite its prevalence. nurses need to have the knowledge and skill to address specific pain needs of older adults. including addiction and belief that pain is a normal result of aging. More than 80% of older adults have chronic medical conditions that are typically associated with pain. Cognitive impairment due to dementia and/or delirium represents a particular challenge to pain management because older adults with these conditions may be unable to verbalize their pain. subjective experience for many older adults.

students and especially the staff nurses clear idea on what could be the standard protocol in pain management for older person. It also allow the facilities and institutions to provide evidence of documentation of pain assessment. What are the nursing measures in relieving the pain? . intervention. and to provide evidence of pain management resources for staff like care-planning and pain management references. also to provide evidence of referral to specialists for specific therapies. The study seeks to answer the following questions: 1. and evaluation of treatment effectiveness. How to manage the patient’s pain? 3. This will also shows the nursing care strategies in preventing and treating pain in older person.Significance of the study This study will give clinical instructor. What are the assessement for patient’s pain? 2. Statement of the problem The study aims to identify the standard protocol use in managing pain in older person.

relaxation training. Related approaches and strategies are described under the rubrics "cognitive-behavioral therapy" (CBT). exercise. communication skills. pain in the elderly often is inadequately assessed and treated As the United States population grows older." and "self-management" or "self-help. and physical therapies. they share some or all of the following components: education about pain. and is often associated with significant physical disability and psychosocial problems. the public health problem of chronic pain and its sequelae will worsen. using a variety of techniques. by 2030 there will be an estimated 8 million people who are 85 years or older. osteoarthritis. The intervention resulted in significant decreases in pain interference with daily activities and increases in participants' self- . The goal of the therapies is to enhance function. cognitive-behavioral and selfmanagement pain therapies have been little-studied in elderly populations. Projections show dramatic increases in this age group. and low back pain. decreased mobility. 69 outpatients with chronic pain were randomly assigned either to immediate treatment or delayed (wait list) treatment. low back pain. and physical and social role dysfunction . fibromyalgia. instruction in the identification and modification of negative thoughts. The most common painful conditions among older adults are musculoskeletal conditions such as osteoarthritis. and pain-related disability in this group. there is an urgent and growing need for interventions that are effective in decreasiNg pain. including rheumatoid arthritis. sleep disturbance. suffering." Although there are variations among these approaches. is necessary for the successful treatment of chronic nonmalignant pain. These therapies aim to enhance the ability of patients to successfully self-manage their pain. and previous fracture sites. Estimates of the prevalence of chronic pain problems among community-dwelling older adults range from 58–70% . Despite its high prevalence. in addition to physiological factors. Approximately half of the sample was over 60 years of age. Empirically supported multimodal therapies that incorporate cognitive and behavioral strategies now exist for many chronic pain conditions. Chronic pain often results in depression.CHAPTER 2 Foreign Literature Chronic pain self-management for older adults: a randomized controlled trial Chronic pain is a common problem in the elderly. and age was unrelated to outcome. and decrease pain intensity by changing the emotional. Despite their documented efficacy in young to middle-aged samples. Moreover. increased health care utilization. approximately 25% of the population will be age 65 years or older in 2050. Thus. In one of the first examinations of CBT for elderly patients with pain. There is substantial empirical evidence that attention to cognitive and behavioral factors. and behavioral responses to pain. improve mood. "psycho-educational" or "educational. cognitive.

e. These significant differences were maintained at the 4-month follow-up. The loss of ability to process. that potentially could affect the pain experience and response to pain therapies. This study provides important evidence that CBT can be successfully applied to old-old adults. Volicer & Hurley. the average subject age was 64 years. Volicer. and changing activity patterns to manage pain. those 65–74 years) in several dimensions. 1999. is well known and accepted as an antecedent to behavioral disturbances among people with dementia (Hall & Buckwalter. At 6-month follow-up. in turn. Keefe and colleagues evaluated the efficacy of a pain coping skills training (CST) intervention as compared with arthritis education and standard care in decreasing pain and physical and psychological disability among 99 middle-aged to older outpatients with osteoarthritic knee pain. involvement in recreational and social activities. As a result. & Muchka. and diverse behavioral symptoms. One study that examined a cognitive-behavioral therapy in old-old adults (mean age 77. and attention diversion. pain is an important factor to assess in older adults with dementia. the CST group showed significantly less physical and psychological disability as compared with the education group and marginally less psychological disability as compared with the standard care group.. coping skills training. progressive relaxation. and potential worsening of comorbid conditions. however. contributes to unnecessary discomfort. Griffie. Pain Assessment in Nonverbal Older Adults with Advanced Dementia The role of discomfort.e. both emotional and physical. the results need to be replicated in other. The CST consisted of 10 weekly group sessions focusing on identifying and reducing irrational thoughts. Like other aging individuals. The CST group showed significantly less pain and psychological disability following treatment as compared with the other two groups. . physical and cognitive function. larger samples. dysfunctional behavior. it focused on arthritis patients and not older adults per se. and social support. These groups have been shown to differ from their younger counterparts (i. particularly as the disease progresses (Kovach. Teri & Logsdon. It is not clear whether these findings would generalize to mid-old (i. Matson. which. cognitive restructuring. including pain prevalence. Weissman. CBT participants reported significantly less pain and pain-related disability following the intervention. those with dementia are likely to have one or more chronic health conditions that cause pain. 1999).. 2000. 1987. Although this study provides evidence for the benefits of cognitive-behavioral therapy for older adults.2 years) evaluated the efficacy of a 10-week CBT intervention (n = 11) versus an attention/support (AS) condition (n = 10) for nursing home residents. The CBT condition incorporated pain education. as compared to the AS group. understand. Limitations of this study included the fairly small sample size and the lack of intent-to-treat analysis. 75–85 years) and old-old (85 years and older) adults. and describe internal and external experiences regularly leads to behavioral expressions of distress. diverting attention away from the pain. 2001). including non-institutionalized elderly. Moreover. imagery.reported ability to cope with pain.

Given the complexity of persistent pain and the cumulative literature on mechanisms and management. Through direct care. nursing home. and quality of life. particularly among individuals in late-stage dementia who lack the ability to process their experiences and communicate needs verbally. 'Psychosocial' is a broad term incorporating both psychological (for example. Terms pertinent to the discussion of psychosocial aspects of arthritis pain are defined in Table. and social relationships. treatment. leisure. The way they manage these aspects of their illness influences their ability to engage in meaningful. but adds the equally important psychological and social dimensions as both contributors to the pain experience and targets for intervention. while others may be inferred from observed actions or behaviors. along with other symptoms from arthritis. Not unlike pain. with specific roles and responsibilities. threatens the ability to participate in these activities and may compromise psychological and social well-being. a few definitions may be helpful. nurses may positively influence care practice. Before proceeding. humans engage in a range of life activities. family life. there is a considerable body of literature examining relationships among psychosocial and other factors potentially associated with arthritis pain. The proportion of people with arthritis and related conditions who report experiencing moderate to severe pain is threefold that reported by people with other chronic conditions . are in key positions to facilitate accurate assessment and adequate treatment of pain. obligatory and discretionary activities. As social beings. Such a perspective maintains the important contribution of biological mechanisms to the pain experience. engaging in life activities) dimensions.Nurses. supervisory. and management across the healthcare continuum. Pain. Reliable and valid methods of measuring psychosocial factors are available and many psychosocial factors are modifiable with education. or inpatient unit-both advanced practice and generalist nurses regularly play pivotal roles in managing complex patient care problems like pain assessment in advanced dementia. and interdisciplinary roles. Enhanced awareness of methods to accurately depict the pain experiences of nonverbal individuals with advanced dementia are critically important to effective care. and physical limitations. As a result. Most types of arthritis require people to cope with pain. Psychosocial aspects in the management of arthritis pain Pain is a relatively common and troublesome feature of arthritis. The purpose of this review is to summarize psychosocial factors associated with arthritis pain and highlight recent evidence for psychosocial approaches to managing arthritis pain. interacting with others. disability. fatigue. consultation. The relationship between psychosocial factors and pain is complex and multidimensional: psychosocial factors influence the perception of pain and the presence of pain influences psychological well-being and social participation. a biopsychosocial perspective has been adopted to explain this phenomenon. including the domains of work. and other allied healthcare providers that provide day-to-day care. assessment of many psychosocial factors relies on self reports of feelings and perceptions. Among a group of older . No matter what the care setting-home. educational. stiffness. cognitive and affective) and social (for example. Arthritis and pain. skills training or therapy.

The purpose of this study was to analyze the effect of the perception of the practice environment and clinical expertise on the adoption of EBPM. with some references dating back to the early 1970s. and leisure. implementation of these guidelines was voluntary. Three life domains will be described here: work. higher unemployment and lower self efficacy. Evidence-based pain management. occurred in 1992. family life. Lauded as a helpful resource. The American Pain Society offered a set of guidelines in 1995 specifically geared toward organizations. Successful interventions occur when providers change their behavior and assimilate changes into practice. The wide gap between pain management evidence and practice in the acute care setting continues to challenge administrators and clinical specialists accountable for guideline implementation. Implementing EBPM interventions requires an assessment of environmental readiness with an accurate portrayal of care providers. Foreign studies Evidence-based pain management (EBPM) Evidence regarding pain and pain control has been available for more than 30 years. responsible for EBPM implementation need information to help target interventions. the Joint Commission approved standards for acute care pain management to be implemented in 2001. The American Pain Society cited the need to ‘‘move beyond traditional education and advocacy to focus on increasing pain’s visibility in the clinical environment. and new standards into policies and procedures. new equipment. . those with greater pain disability experienced more psychological distress. aimed at both the organizational and individual level.adults with arthritis. Implementation of evidence-based pain management (EBPM) is impacted by both individual and organizational factors. Effective Pain Management guideline implementation relies on administrative enforcement and individual practitioner adoption. one of the first Agency for Healthcare Research andQuality guidelines introduced to the practice community. Programs to successfully incorporate EBPMinto practice aremultifaceted. In 1999.6 The guidelines are a compilation of the best available evidence. Clinical nurse specialists. The evolving nature of pain management requires organizations to continually integrate new programs.

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