Topic: 17

Pain: How to Recognize It and How to Help

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What You Need to Know

Effective pain and symptom management can greatly improve a person’s quality of life. As a caregiver, you can play a key role in recognizing signs of pain and in communicating what is observed to the visiting nurse or to a physician. Caregivers can use a range of techniques to help manage pain.

What is pain? Pain is a physical sensation relayed to the brain through a nervous system. Pain is a very subjective symptom that can make it difficult to determine the exact cause of the pain. That means that two people can experience the same type of pain but react to it entirely differently. For example, the same headache can drive one person to bed and another person may continue their day as normal. Because of this subjectivity, it is very important to listen to the person as they are the expert in their own pain.

What factors affect how a person responds to pain?

  • Cultural background
  • Age
  • Gender
  • Previous experiences
  • Meaning of pain to the person
  • Worry, fear, boredom, loneliness, anxiety
  • How much rest and sleep a person is getting
  • The number of sensory receptors in the brain and how the brain processes pain

What pain do people feel at end of life?

People who are nearing end of life may experience distinct types of pain:

  1. Acute pain which is intense, localized, sharp and which usually ends or resolves itself quickly. It can be compared to the type of pain someone feels after surgery.
  2. Chronic or persistent pain is slow and continuous and does not end quickly. It can be compared to a dull ache. Often this pain is associated with arthritis and cancer.
  3. Breakthrough pain refers to pain that “breaks through” or re-emerges before the next round of pain medication is due or breaks through the pain medication that has already been taken.
  4. Referred pain is perceived at a location other than the site where the pain is actually occurring such as the pain a person feels in their neck, shoulders and back when they are having a heart attack.
  5. Radiating pain is a sharp, recurring pain shooting or radiating through a part of the body which is caused by pressure on a nerve or damage to a disc.

Different types of pain are treated differently. As a caregiver, you can help a nurse or doctor understand which type of pain is being experienced so the physician can treat it properly.

How can a caregiver recognize pain?

It is very important that the caregiver observe the person very carefully. As people near end-of-life their ability to communicate lessens so observation is critical at that time.

Signs of acute pain: moaning, grimacing, shielding, protecting or massaging the site of the pain

Signs of chronic pain: harder to observe as the person may show few signs of distress other than looking exhausted or depressed

What questions should you ask?

As the caregiver, you can accurately relay information to the primary care physician about the pain. Ask these questions and use the answers to explain the pain to the physician. The pain medications can then be adjusted based on your observations of the person that you are caring for and their answers to these questions.

  • Are you experiencing pain?
  • When did it start?
  • Where do you feel it? In one place? All over?
  • What does the pain feel like? Is the pain sharp or dull, constant or shooting? On a scale from 1 to 10 with 10 being the worst pain you have experienced, how intense is the pain?
  • What makes it better? Worse?
  • Do you feel nauseous or dizzy from the pain?
  • What can I do to help?
  • What medications are you taking for the pain?

What symptoms show the level of pain is changing?

Increased reaction: Grimacing, guarding against maneuvers

Tiredness: Increased amount of time resting; disturbed sleep

Drowsiness: Decreased level of alertness

Nausea: Retching or vomiting

Decreased Appetite: Quantity of food intake decreases

Shortness of Breath: Increased respiratory effort that appears to be causing the person distress. Note: may be caused by something other than pain

Depression: Tearfulness, flat affect, withdrawal from conversation, irritability, decreased concentration or memory

Anxiety: Agitation, flushing, restlessness, sweating, increased heart rate

Well-Being: How the person appears overall changes

How to Control Pain

Pain management should be part of the plan of care. Any or all of the following techniques might be part of that plan:

  • Opioid and non-opioid prescription drugs as well as non-prescription drugs such as Acetaminophen, anti-inflammatories (However, these are not recommended for long-term use in elderly people or people on blood thinners or with blood clotting problems as it can lead to bleeds.) Ensure the person receives their pain meds at their appropriate time. Be diligent about this! Wait about 30-45 minutes (or for one hour in the case of opioids) for medications to take their full effect.
  • Distraction
  • Relaxation techniques such as deep breathing, gentle exercises
  • Imagery, visualization, meditation
  • Skin stimulation through massage, touch therapy, warm baths, ice
  • Chemotherapy or radiation to shrink the tumour causing the pain
  • Nerve blocks, acupuncture, neurosurgery
  • Use pillows to promote good body alignment
  • Use appropriate turning and lifting
  • Use touch to provide comfort
  • Provide a calm environment
  • Ensure temperature comfort. Provide warm blankets or open a window if desired.

Myths about Pain Management

Myth: Pain meds, especially opioids, cause addiction.

Reality: Addiction is very uncommon in patients who require long-term opioid therapy for pain from an incurable illness.

Myth: People quickly become tolerant of pain medications so after a while they don’t help

Reality: Significant tolerance is uncommon and the need for increasing doses often relates to disease progression not lack of tolerance.

Myth: Opioid analgesia (not to be confused with Tylenol etc.) cause hallucinations

Reality: When people are first put on opioids they may experience hallucinations but this side effect only lasts 24-72 hrs. and then disappears. Opioid doses should always start low and be slowly increased.

 

1. Read this scenario

Mrs. V. is a 70 year old female recently diagnosed with Stage 4 breast cancer. She requires help with meal preparation and personal care. During your visit today, Mrs. V. seems quieter than usual. She looks unhappy but she says that everything is fine. You notice her grimacing when she showers and whenever you move her right arm when you are helping her get dressed. You ask her if she is in pain but she says little. Mrs. V. is seeing the doctor tomorrow afternoon.

2. How could a pain chart recording when the pain began, what Mrs. V was doing when the pain struck, how long it lasted, where it was, what it felt like, what relief was provided… be used to help?
3. What else could you do to help Mrs. V. manage the pain?
Review the list of techniques listed above.

 

Use these additional resources to learn more about the topic of pain and how to help manage it.

People nearing end of life should receive ongoing pain assessments usually conducted by nurses and physicians. There are many tools that these health care professionals might use to assess a person’s pain. Here are some examples of the tools that they might use.

Edmonton Symptom Assessment System
http://www.npcrc.org/files/news/edmonton_symptom_assessment_scale.pdf

Visual-Numeric Scale
https://www.physio-pedia.com/Numeric_Pain_Rating_Scale

How to Manage Your Pain and a Pain Diary - Cancer Care Ontario
http://www.uhn.ca/PatientsFamilies/Health_Information/Health_Topics/Documents/How_to_Manage_Pain_cco.pd

Pain Relief-Canadian Cancer Society
https://www.cancer.ca/~/media/cancer.ca/CW/publications/Pain%20relief/Pain-relief-EN.pdf

Assessing Your Pain
http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/pain/assessing-your-pain/?region=bc

Managing Medications 

Pain and Symptom Managers in local Home and Community Care programs can be a wonderful resource. Contact your Local Health Integration Network (LHIN) Home and Community Care office in your area.