Event 3: Assessment by PCP

Nurse With Aides Care Conference

Following the care conference, the aide who works with Margaret pulls the nurse aside to share her concern about Margaret.

Assessment by Nurse Practitioner

The facility’s Nurse Practitioner has come to visit Margaret and perform an examination. She has completed an exam and is finishing up with an oral assessment for Margaret. Let’s watch the oral assessment by the nurse practitioner.

Conference Between Nurse Practitioner and Nurse

The nurse practitioner and nurse meet to discuss Margaret's case.

The nurse practitioner says,  "So, I just saw Margaret. Has she been non-verbal for you?"

The nurse replies, "Yeah, she's expressive, but doesn't use her words."

"Okay," the nurse practitioner says. "Her PAINAD score does indicate she has pain. I think she's got a cracked tooth in the bottom right side of her mouth and I think it could be infected. So, she'll need to see a dentist. Does she have one listed in her chart?"

The nurse says, "She was seeing someone at home but now that she's moved here, I would like to get a local assessment if we can."

The nurse practitioner says,  "Okay. I can put in a referral for that. She'll need to go with a family member."

The nurse says, "I will be in touch with Joe."

The nurse practitioner says,  "Okay. I think that the tooth is what's contributing to the loss of appetite, the weight loss, and behavior changes."

"Okay," says the nurse.

The nurse practitioner says, "So, once she's been to the dentist, we'll re-evaluate."

The nurse replies, "Alright. We'll get an appointment made, see what they think, and get that assessment to you."

Hierarchy of Pain Assessment

In older adults with limited communication, pain assessment is challenging. Incorporating a hierarchy of pain assessment is a systematic method of pain assessment and allows consistency among caregivers for assessment and progression of treatment for pain reduction.

Self-Report

• Try to get a self report even for the patient with moderate to severe dementia.
• Yes/no
• Vocalizations or gestures – hand grasp or eye blink
• Use of simple pain rating tool such as verbal descriptor scale

Search for Potential Causes of Pain

• A change in behavior requires careful evaluation of possible sources of pain
• Pathological conditions – surgery, trauma, wounds, history of persistent pain, osteoarthritis
• Procedural pain
• Physiological compromise
• Other causes- infection, constipation, other

Observe Patient Behaviors

• In the absence of self-report, observation of patient behaviors is a valid approach to pain assessment but may not reflect intensity or another source of distress
• Behaviors indicating pain
• Pain Assessment tools for non-verbal individuals
• Comparison of present to past behaviors

Proxy Reporting

• May include family members, parents, caregivers
• Proxy reporters should be consistent in frequency of interaction
• Combine with other evidence (Above 1 to 3)

Attempt an Analgesic Trial

• In general, if mild to moderate pain is suspected, non-pharmacologic approaches and non-opioid analgesics may be given initially; if pain improves, assume pain was the cause; continue analgesic and combine with non-pharmacological interventions.
• If there is no change in behavior, rule out other potential sources of pain or discomfort. Doses may then be carefully adjusted until a therapeutic effect is seen, bothersome or worrisome side effects occur, or lack of benefit is determined

Treatment Plans

Following the Nurse Practitioner examination, read her treatment plan for Margaret.

Social Work

The facility social worker meets with Margaret’s grandson. Topics discussed during the meeting include:

• Informed consent for dental visit and procedures
• Transportation to and from the dentist; family member to accompany Margaret to Dentist o Financial and insurance concerns
• Education regarding pain and communication in dementia
• Long term planning for Margaret

Hierarchy of Pain Assessment Techniques

The following is the hierarchy of pain assessment techniques from 1 to 5, from where you would begin and the steps of progression on the hierarchy.

1. Attempt first to elicit a self-report from patient and, if unable, document why self-report cannot be used.
2. Identify pathologic conditions or procedures that may cause pain.
3. List patient behaviors that may indicate pain. A behavioral assessment tool may be used.
4. Identify behaviors that caregivers and others knowledgeable about the patient think may indicate pain.
5. Attempt an analgesic trial.

Followup with Nurse and Grandson