Are any of your patients in pain? Yes, pain ! Anywhere from 37% to 50% of patients undergoing hemodialysis experience chronic pain and of those, 82% state that the pain is moderate to severe in intensity!1 When caring for individuals with chronic kidney disease (CKD), do we routinely assess for the presence and degree of pain?

Individuals with CKD suffer with pain in many different ways whether from vascular access, bone disease and muscle aches, dialysis related complications, or some form of neuralgia, among other causes.

Second in our series of Clinical Solutions is an approach to Pain in CKD.

  1. Recognize that pain is real and requires intervention.
  2. Include pain as a vital sign.
  3. Implement pain management strategies.

Recognition of Pain

Pain is a significant issue for people with CKD and impacts quality of life. The Dialysis Outcomes and Practice Patterns Study (DOPPS) compared analgesic use from 1997 to 2000 for 3,749 patients in 142 U.S. facilities. They report a decrease in use of all types of analgesics and an increase in the number of patients receiving no analgesics at all. Seventy-four percent of patients with pain interfering with work had no analgesic prescribed1 . Hurdles we must overcome:

Patients may:

  • Fail to seek treatment until pain is severe
  • Refuse to use medication unless when absolutely necessary
  • Fear addiction
  • Avoid additional medications

Healthcare professionals may:

  • Desire evidence based practice guidelines for pain management
  • Require additional education specific to assessment and management of pain in CKD

Assessing Pain

The first principle of assessment is to believe the patient’s complaint of pain and initiate discussions: location; when and frequency; severity; and relief tactics used, if any. In addition, patients may have more than one type pain. Educating the patient about pain terms, definitions and descriptors will help as we rely on the patient’s subjective information.

Pain Scales will help diagnose and measure the intensity of a patient’s pain. Most scales used are visual, verbal or neumerical or some combination of all three forms. Commonly used pain scales are listed below. A combination of two or more may illicit a more thorough evaluation.

  1. Visual Analog Scale:www.ndhcri.org/pain/Tools/Visual_Analog_Pain_Scale.pdf
  2. Wong-Baker Scale: www.mdanderson.org/pdf/pted_painscale_faces.pdf
  3. Comfort Scale:http://painconsortium.nih.gov/pain_scales/COMFORT_Scale.pdf
  4. Checklist for Non-verbal:http://painconsortium.nih.gov/pain_scales/ChecklistofNonverbal.pdf

Pain Management

The goal is to help the patient return to the highest level of function and independence possible, while improving overall quality of life – physically, emotionally and socially. Pain management techniques assist in reducing the suffering experienced by a person with chronic pain.

Principles of a Pain Management Program:

  • May not be able to achieve “pain free”. Work to an acceptable level defined by patient.
  • Pain may be affected by other factors including psychological.
  • Manage through a “team” approach. May include an outside referral and subsequent addition to the team.
  • Education on the use of opiods and adjuvants to opiods.
  • Identify any misconceptions to pain management and opoid use.
  • Educate patient and family on the goals of therapy, management and complications2 .

Potential interventions include3 :

  • Medications, including:
    • Over-the-counter (OTC) medications: aspirin and/or acetaminophen.
    • Prescription pain medications
    • Prescription antidepressants
  • Heat and cold treatments
  • Physical and occupational therapy
  • Exercise
  • Local electrical stimulation
  • Nerve blocks and regional anesthesia
  • Surgery
  • Acupuncture
  • Alternative medicine and therapy treatments, as appropriate
  • Emotional and psychological support may include the following:
    • Stress management
    • Relaxation training
    • Meditation
    • Hypnosis
    • Biofeedback
    • Behavior modification
    • Assertiveness training
    • Psychotherapy and group therapy
    • Patient and family education and counseling

Start Now!

  1. Ensure that the multidisciplinary team recognizes and supports the program. Find out which pain medications and treatments physicians prefer to use.
  2. Identify program director – coordinates staff education, identifies pain assessment instrument, describes documentation and treatment plan, oversees patient education plan and materials, and assures outcomes monitoring and reporting.
  3. Educate staff on pain assessment and management. Identify any staff concerns regarding pain management.
  4. Choose pain scale and incorporate into monthly patient assessment.
  5. Assess all patients for pain – Document all aspects of pain in a clear and consistent manner
  6. Educate patients and caregivers: purpose of assessment questions as well as pain terms, definitions and descriptors they can use.
  7. Treatment plans should be individualized to the patient’s needs and include both pharmacologic and non-pharmacologic options. Anticipate and effectively manage side effects of pain medications
  8. Identify community resources for referral
    • Physical therapy
    • Psychotherapy or counseling
    • Exercise programs
    • Pain specialists and clinics
  9. Implement advocacy program for patients, if needed
  10. Outcome monitoring
    • Routinely evaluate effectiveness of treatment plans and adjust as needed
    • Incorporate outcome results into existing quality monitoring program

* Comply with all state and federal laws and regulations regarding prescribing, dispensing, and administering controlled substances

* Stay up to date on pain management practices via continuing educational programs

Let us know how you have approached pain management in your practice. Contact us at vavrinchik@nephrologyclinicalsolutions.com

References

  1. Williams A, Manias E. (2007). A structured literature review of pain assessment and management of patients with chronic kidney disease. J. of Clinical Nursing 69-81
  2. Davison, S. (2005). Chronic Pain in End-Stage Renal Disease. Advances in Chronic Kidney Disease , 12(3), 326-334.
  3. University of Utah University Health Care Web Site. Physical Medicine and Rehabilitation: Chronic Pain. http://healthcare.utah.edu/healthinfo/adult/Rehab/chronic.htm