Evidence-based strategies for pain reduction and a DICE suggestion from a community care partner

Hi everyone,

First off, thank you to Stella Maris of MD for sharing this great example of DICE with us:

 D- Resident urinating in a cup in the dining room and on the floor in the corner of his room.

I- Resident is a retired truck driver and would urinate in empty bottles/ cups in the cab of his truck while traveling long distances.

C- Staff have identified the resident’s cues when needing to go to the bathroom. He seeks out cups and heads toward any corner in the dining room.  Staff redirects resident to bathroom which has a bright colored sign on the door indicating it is the bathroom.

Staff also have placed a urinal next to his bed to cue him to use it when needing to urinate at night.

E- Resident has decreased episodes of public from daily occurrences to 1-2 times a week.

We invite you all to send us your examples too. You’ll win a gift for your residents if you do!

Next, since we discussed identifying and assessing pain in residents with dementia last week, this week we are focusing on some pain interventions. The following link is to a list of evidence-based nonpharmacologic interventions for pain that you may find helpful. It was prepared by Linda Keilman, DNP, GNP-BC of Michigan State University, College of Nursing:

https://www.nhqualitycampaign.org/files/Guide_to_Evidence-based_NonPharmacologic_Interventions_for_Pain.pdf

Dr. Keilman notes that we should address pain with the following outcomes in mind:

  • Improvement in quality of life
  • Maintaining function (physical, emotional, spiritual)
  • Maintaining cognition
  • Alleviating or reducing pain through a combination of medication and alternative interventions

Keilman, Linda (2015). Compendium of Evidence-Based Nonpharmacologic Interventions for Pain in Older Adults. Copyright 2015 by LJKeilman, East Lansing: Michigan State University, College of Nursing.

 Some of the many pain interventions to consider in addition to traditional pain medications such as NSAIDS and acetaminophens include:

  • environment modifications such as adjusting room temperature, lighting and sounds
  • cold or heat therapy (icy-hot lotions, like those with Lidoderm, can be helpful and applied often)
  • exercise
  • controlled breathing
  • music therapy
  • art therapy
  • pet visits
  • distraction or diversion

 Effective interventions will vary by person, so you may need to try several different things before finding an intervention that works for a resident. Considering the many negative physical and emotional consequences for a person in pain, we can all agree that these interventions are well worth the effort.

Have a great week!

Care plan snapshots: Making care plans useful

Developing and updating care plans to ensure they include the required information takes a lot of staff time and attention. Unfortunately, they don’t usually live up to their potential for day to day usefulness and practicality.

To help address this, we’ve developed a Care Plan Snapshot…a “Readers Digest” version of a care plan that highlights the key information that a GNA or other caregiver would find most helpful day to day. It includes short and long terms goal(s), guidance on ADL care that helps residents maintain or improve function, behavioral issues with suggested approaches to care, and motivational ideas based on a resident’s interests. All in just a few pages!

Below is an example of a Care Plan Snapshot for “Mr. WXYZ”, along with an example of a completed capability test for him, which guided the development of the care plan’s goals and ADL care approaches. We invite you to take a look, share with staff, and discuss how this might be beneficial. Feel free to use and adapt as you’d like for your facility. For example, if family members are involved with a resident’s care, you may want to add a section on what family members can do during visits to help their loved one meet his/her goals.

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Capability Test for: Mr. WXYZ                                                     Date: July 19, 2017

Ask and encourage the resident to do each of the following:

  1. Range of Motion (ROM)
  • Full ROM to 180 degrees of abduction (hands over head) __1__ (1 point if yes, 0 if no.)
  • Full external rotation (hands behind head) _1____ (1 point if yes, 0 if no)
  • Full internal rotation and adduction (hands in small of back) __0__ (1 point if yes, 0 if no)
  1. Either lying or sitting, point and flex your toes, bend and straighten your knees, and/or if sitting, ask to march.
  • Able to flex ankle__1__ (1 point if yes, 0 if no)
  • Able to point toe__1___ (1 point if yes, 0 if no)
  • Able to bend and straighten knees ___1___ (1 point if yes, 0 if no)
  • Able to march ___1_(weak)_ (1 point if yes, 0 if no)
  1. Chair rise – observe to do this independently or how much help is needed (give up to 10 minutes to complete the task)
  • How many tries does it take? __0_ (Scoring: 1-3 tries= 1 point; > 3 tries = 0 points)
  • Do they use their arms? ___0___ (0 point if yes, 1 if no)
  • Can they make it to a full stand and stand independently for 1 minute? ___0__

(1 point if yes, 0 if no)

  1. Follow a one, two, or three step commands doing a functional task:

Ask the participant to take a towel, fold it in half, and put it on the table (bedside table or bed or whatever is available).

  • Follows a one-step verbal command __0____ (1point if yes, 0 if no)
  • Follows a two-step verbal command ___0____(1point if yes, 0 if no)
  • Follows a three-step verbal command ___0___ (1point if yes, 0 if no)
  • Follows a one-step visual/cueing command ___1___ (1 point if yes, 0 if no)
  • Follows a two-step visual/cueing command ___0___ (1point if yes, 0 if no)
  • Follows a three-step visual/cueing command ___0___ (1 point if yes, 0 if no)

Total Score:  7 (max = 16)

HIGHER SCORES ARE BETTER CAPABILITY

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Care Plan Snapshot

Resident Name: Mr. WXYZ
Room number:  0A

 

Care Goals

Short term goal #1: Resident will attend at least one preferred activity each day to decrease boredom and restlessness
Short term goal #2: Resident will perform sit-to-stand exercises at least once daily with assistance from staff to increase strength, maintain ability to transfer, and decrease risk of falls
Short term goal #3: Resident will go outside at least once per day, weather permitting, with assistance from staff
Long-term goal: Resident will show an increase in expressions of wellbeing (smiling, laughing, engaging in activities) and a decrease in expressions of distress (agitation, restlessness, wandering and apathy).
Care Area Resident Responsibilities Staff Responsibilities
Physical

Activity/

Ambulation

Resident will self-propel in WC, perform sit-to-stand exercises with assistance daily, participate in at least one scheduled activity daily, visit outdoor courtyard once daily, and transfer out of WC and into chair for all meals with assistance

 

 

Staff will encourage resident to self-propel in WC, assist with sit-to-stand exercises after lunch daily, encourage and assist resident to attend at least one daily activity with staff; visit outdoor patio with assistance from staff once daily, and assist with transfer out of WC for all meals
Bathing/Grooming Resident will wash/dry face and upper body with visual cuing from staff

 

 

Staff will provide 1-step visual cuing and encouragement for resident to wash/dry face and upper body
Dressing Resident will dress upper body with visual cuing from staff and engage in AROM while getting dressed

e.g., wave to friend in the hallway, march knees up to hit GNA’s hands, swim strokes

 

Staff will provide 1-step visual cuing to assist resident in dressing upper body; assist resident to perform AROM while dressing using 1-step visual cuing; ask resident to lift legs to help dress lower body
Eating Resident will eat finger foods and use utensils as needed with visual cuing from staff

 

 

Staff will place one food on plate/in bowl at a time, cut foods as needed and provide finger foods to encourage independence; use visual cuing with utensils
Oral Care Resident will brush teeth twice each day with 1-step visual cuing from staff as needed

 

Staff will have supplies ready and provide 1-step visual cueing and encouragement
Toileting

 

Resident will assist with transfer to toilet

 

Staff will encourage toileting after meals or at designated intervals; use 1-step cues during transfers; monitor for skin breakdown
Behavioral Issues:  Restlessness, agitation; occasionally engages in disruptive vocalizations, apathetic
Related to: Schizophrenia; Alzheimer’s disease; difficulty adjusting to new surroundings
Approaches by staff:

  • Assess for boredom, pain or other behavioral and psychological symptoms of dementia
  • Engage resident in sit-to-stand exercises, visits outside and other physical activities regularly
  • Provide consistency in care using same caregivers when possible; communicate successful strategies with other caregivers
  • When resident shows signs of boredom or agitation, attempt to engage him in one of his favorite activities, e.g., a game of horseshoes, going outside to courtyard, visit with receptionist
  • Respond calmly to resident during times of agitation, allow resident to vent feelings, and provide ample time for resident to respond to simple questions and direction from staff
  • Model behavior for resident
  • Offer choices to resident when available
 

Motivational ideas/Rewards:

 

(What are his interests, likes/dislikes, strengths? Who are his favorite caregivers?)

Mr. WXYZ loves to go outside and visit with his buddies. They like to talk about their time in the war. He also enjoys listening to jazz music, and it calms him down when he is agitated. His favorite GNA is Mary. He does not like eating in bed or playing games like BINGO, because they are for “old” people.

 

Function focused care exemplars

As you continue to work with the “Champions” at your nursing homes, we encourage you to show them these brief videos from our website: http://www.functionfocusedcare.org/videocoaching

The six videos offer great tips on how to engage residents with cognitive impairment and help them perform activities of daily living such as dressing, oral care and toileting, and reinforce the information we presented during the training sessions. You can even show the videos on a mobile device to GNA’s and other busy staff, as each video is only about 3 minutes long. Consider showing a different video at each of your next staff meetings, and discussing the ideas presented. Could some of the approaches from the video work with one of your more challenging residents?