Educational Objectives
1. Demonstrate the importance of chronic pain management in an acute care environment.
2. Discuss the special impact of co-morbidity of arthritis upon pain management intervention.
3. Provide education to clinicians, patients, and caregivers that would promote an interdisciplinary plan of care for acute and chronic concurrent pain management

Bykowski, Janet M.

VCU Scholars Compass

Virginia Commonwealth UniversityVCU Scholars CompassCase Studies from Age in Action Virginia Center on Aging2007Acute and Chronic Pain Challenges for ArthritisPatients in an Acute Care SettingJanet M. BykowskiMary Washington HospitalFollow this and additional works at: http://scholarscompass.vcu.edu/vcoa_casePart of the Geriatrics CommonsCopyright managed by Virginia Center on AgingThis Article is brought to you for free and open access by the Virginia Center on Aging at VCU Scholars Compass. It has been accepted for inclusion inCase Studies from Age in Action by an authorized administrator of VCU Scholars Compass. For more information, please contactlibcompass@vcu.edu.Recommended CitationBykowski, J. (2007). Acute and Chronic Pain Challenges for Arthritis Patients in an Acute Care Setting. Age in Action, 22(1), 1-5.Volume 22 Number 1 Winter 2007Acute and ChronicPain Challenges forArthritis Patients in anAcute Care Settingby Janet Bykowski, R.N.Educational Objectives1. Demonstrate the importance of chronic pain management in an acute care environment.2. Discuss the special impact ofco-morbidity of arthritis uponpain management intervention.3. Provide education toclinicians, patients, and care-givers that would promote aninterdisciplinary plan of care foracute and chronic concurrentpain management.BackgroundIn 1998, the American GeriatricsSociety published clinicalpractice guidelines addressingchronic pain in older adults.  Theguidelines identified barriers andrecommended practice improve-ments to enhance routineassessment, pharmacologicaltherapy, and non-pharmaco-logical therapy.  Recommendedimprovements focused onfacilitating access to anddelivery of optimal care for allolder adults living with chronicpain.  Nurses are encouraged toassess older adults routinely forthe presence of chronic pain andto advocate for appropriatetreatment when indicated(American Geriatrics Society,2000).  Eight years later, health-care organizations continue tostruggle to implement inter-disciplinary plans of care thatprovide comprehensive painmanagement for the patientsuffering with chronic pain.Chronic pain is even more com-mon than previously thought.Pain itself is rarely discussed asa condition in and of itself; it ismostly viewed as a symptom ofanother condition (CDC, 2006a).Arthritis introduces a special setof conditions for painmanagement: Centers for Disease Controland Prevention BackgroundInformation on Chronic Painand Arthritis• 10% of Americans strugglewith chronic pain.• Chronic pain is the leadingcause of disability in the UnitedStates.• 25% of adults suffered a day-long bout of pain in the pastmonth.• Three–fifths of adults ages 65and older said their pain hadlasted a year or more.• Almost 1/3 of adults ages 18and older and 1/2 of adults ages65 years and over reported jointpain, aching, or stiffness duringthe past 30 days.• More than 100 forms ofarthritis exist, with rheumatoidarthritis and osteoarthritis themost prevalent forms.• More than 33 millionAmericans have arthritis, 28million of them being over theage of 45.• By 2020, researchers projectthat 60 million people in theInside This Issue:VCoA Editorial, 5 Focus: Sung Hong, 9 Arthritis Summit, 13VGEC Editorial, 7 ARDRAF Call for Proposals, 10 New Elderhostel in Staunton, 13VDA Editorial, 8 MCI Brochure, 11 Calendar of Events, 14Case Study2Untied States will be affected byarthritis.• Osteoarthritis prevalenceincreases with age: as much as80 percent of the populationover 75 years old showradiologic signs of the condition.• Each year, arthritis results in750,000 hospitalizations and 36million outpatient visits.• Fibromyalgia is a debilitatingpain syndrome that affects twoto four percent of the population.Rheumatoid arthritis (RA) is aninflammatory disease that causespain, swelling, stiffness, and lossof function in the joints.  Itoccurs when the body’s whiteblood cells travel to thesynovium, causing inflammationwhich thickens the synovium.The inflamed synovium invadesand destroys the cartilage andbone within the joint.  Thesurrounding muscles, ligaments,and tendons that support thejoint become weak and unable towork properly.   RA can alsocause fatigue, occasional fevers,anemia, and depression(NIAMS, 2006).  Case StudyJenny is a 52-year-old womanwith severe rheumatoid arthritisand diabetes.  She presented toher doctor’s office with aseverely infected finger from apaper cut.  Jenny assumed thatthe nodule, swelling, redness,and pain of her finger wereassociated with her arthritis.  Asa result, she did not seek medicalattention until the finger becamenecrotic. After the initial handexamination, the physicianimmediately referred her to asurgeon for evaluation.The hand surgeon recognized thepossibility of an amputation ifthe infection had spread to thebone.  He notified the hospital ofher immediate admission and toprepare her for surgery thatevening.  As part of the patientintake process, a nursing assess-ment was conducted whichincluded a complete medicalhistory and listing of allmedications, both prescriptionand non-prescription, includingherbal products, vitamins, etc.As is standard of practice, allmedications were discontinuedprior to surgery and IVantibiotics were started thirtyminutes prior to surgery.Jenny has a history of auto-immune disease.  At 18, shedeveloped Hashimoto’sthyroiditis and has takenreplacement thyroid therapy for27 years.  Hashimoto’s diseasehas been linked to many otherautoimmune diseases, includingrheumatoid arthritis, anddiabetes mellitus (Slatosky et al.,2000).  Jenny was diagnosedwith rheumatoid arthritis (RA) atage 29. Her RA has beendifficult to treat and she has beenon many types of medicationsand treatments during the last 20years in an attempt to alleviatepain and prevent disability fromthe disease.   During the last twoyears, the rheumatologist hasused a multi-prescriptiveapproach, which has been verysuccessful in managing herarthritis.  Jenny was alsodiagnosed with diabetes mellitusat age 46 and is currently takingoral medications to manage thisdisease.The following medications werediscontinued upon admission tothe hospital.• Nabumetone, an NSAID (Non-Steroidal Anti-InflammatoryDrug) for  treatment of RA.Used for pain and to reduceinflammation.• Methotrexate, a DMARD(Disease Modifying Anti-Rheumatic Drug) for treatmentof RA.  Relieves painful,swollen joints and slows jointdamage.•  Remicade, for treatment ofRA.  Slows joint damage.• Metformin HCL, for treatmentof diabetes.  Helps regulateglucose levels.• Synthroid, for treatment ofthyroid disease.  The surgeon performed anincision and drainage of herfinger. The finger did not have tobe amputated, since the infectionhad not spread to the bone.  Theacute pain was managed througha patient-controlled analgesia(PCA) pump, which allowedpain medication to be safelyadministered by preprogram-ming of the narcotic. Post-surgery insulin was ordered tocontrol her diabetes, since3infection increases glucoselevels.  Synthroid medicationwas resumed to control theHashimoto’s Disease.Nabumetone (an NSAID), whichJenny took twice a day, was notreordered, since NSAIDs cancause bleeding, nausea, andvomiting.  Jenny usually tookmethotrexate once a week; onthat schedule it would have beendue on the night of surgery; butmethotrexate, due to immuno-suppressive qualities, canincrease risk for infection.Therefore, Jenny did not takethis medication while in thehospital or during the time sherecovered at home receivingantibiotics. Remicade, anotherscheduled medication for her RAtreatment regime is an infusionthat Jenny received every eightweeks. This was due within twoweeks post-surgery.  Remicadeis also an immuno-suppressivemedication and can increase therisk for infection. Therefore, thistoo was counter-indicated whilereceiving antibiotic therapy.During Jenny’s five days ofhospitalization, acute pain wasroutinely assessed with safe andappropriate interventions.However, chronic pain, notacute pain, was the limitingfactor in mobility of her hands,knees, feet and back.  She wasunable to change position in bedwithout assistance and gettingout of bed to go to the bathroomand other walking activities weredifficult and painful due to jointstiffness.  Limited mobility dueto stiffness, the chronic pain, andthe possible long term affects ofmissing rheumatoid arthritismedications and treatments werecontributing factors.  Signifi-cantly, the interdisciplinary planof care focused on the acute painand recovery from surgery andinfection.   As part of the medi-cation reconciliation process, thephysician determined that Jennywould be discharged with painmedication, antibiotics,Metformin for her diabetes,Synthroid, and NSAIDs.Antibiotic therapy was tocontinue for eight weeks;consequently, methotrexate orremicade were on hold. As a result of the disruption toher usual treatment regimen,Jenny’s RA flared. Aggressivetreatment, managed by herrheumatologist, required ninemonths to gain control andalleviate the chronic pain.Subsequently, Jenny experiencedfrequent absences and decreasedproductivity when she was ableto return to work. This led toincreased stress levels, whichaccelerated the rheumatoidinflammatory response.Additional negative outcomesincluded depression, financialburden, guilt from decreasedproductivity at work and home,ankle trauma due to unstablemobility, and falls.It is important to remember thatJenny received standard of carefor the surgery, the diabetes, andacute pain control during thefive days she was hospitalized.Review of her case identifiedseveral issues:1) Though a well-educatedindividual, at no time did Jennyadvocate for her own chronicdisease management;2) A rheumatology consult wasomitted;3) There was clearly identifieda need to provide both acute andchronic pain management in anacute care environment.             Next StepsThere is an opportunity toimprove pain management ofhospitalized patients with ahistory of arthritis. Reviewingour discharge coding data atMary Washington Hospital forone year, we found that over 5%(1300) of our patients had a co-morbidity diagnosis of arthritis.Their average age was 69; therewas a 2:1 ratio of women tomen; and the length of stay was4.34 days. We are developing anurse-initiated research studythat will involve a retrospectivereview of patients with a co-morbidity of arthritis, anddevelopment of a chronic painprotocol.  The hypothesis is thatpatients with a co-morbidity ofarthritis have increased levels ofpain and lengths of stay as aresult of inadequate treatment ofchronic pain.The Retrospective Review willencompass these measures:1. Check for a completedmedication reconciliation formthat would identify medicationsused in the treatment of symp-toms of arthritis. (In January,2006 the Joint Commission onAccreditation of HealthcareOrganizations (JCAHO)announced the implementationof the National Patient SafetyGoal #8, MedicationReconciliation across theContinuum of Care. Medicationreconciliation applies to all caresettings, including ambulatory,emergency and urgent care,long-term care, home care, aswell as inpatient services.  Acomplete list of the patient’smedications is communicated tothe next provider of service,when the patient is referred ortransferred to another setting,service, practitioner, or level ofcare within or outside theorganization.  Medications inthese references includeprescription, over-the-counter,vitamins, herbals andnutriceuticals, and others(Rogers, 2006).2. Check for reference toarthritis management in thepatient’s medical history prior tohospitalization.3.  Check for evidence ofchronic pain assessment at thetime of admission.4. Check for evidence that bothacute and chronic painmanagement education wereprovided to the patient.5. Ascertain if unmanagedchronic pain contributed toincreased length of stay.The Chronic Pain Protocol willinclude the following:1. Staff and patient education forprotocol implementation.2. Criteria and tools to identifychronic pain upon admission.3.  Chronic pain managementaddressed in the Inter-disciplin-ary Plan of Care (IPOC).4.  Holistic approach todischarge instructions. 5.  Patient and family educationat discharge.People with arthritis canbecome a partner in chronicpain management in an acutecare setting.    The goal for painmanagement is to meet physical,emotional, spiritual, and socialneeds while the person witharthritis is hospitalized. Peopleshould be aware that health careproviders in an acute care settingare focused primarily onassessing and treating acutepain.  Most providers ask theperson to rate pain using a 0–10subjective pain scale.  However,a behavioral scale is used forpatients who cannot verbalizetheir pain rating.  Assisting theproviders in differentiatingbetween one’s chronic and acutepain is essential to safe, effectivetreatment outcomes.You can become a care partnerby doing the following:1. Obtain a current universalmedication form, update itregularly, and give it to yourclinicians.a. This form is availablefrom the Institute for SafeMedication Practices atwww.ismp.org.b. Read the instructions foruse, including the importance ofkeeping the form with you.c. Include non-pharmaco-logical interventions which havebeen effective in the manage-ment of chronic pain, such asrelaxation techniques (i.e., deepbreathing, visualization);massage; yoga or other Easternmeditation exercises; walking,swimming, other exercises,according to your body’sabilities and needs; musictherapy; nutrition; etc.2. Develop a chronic pain logthat includes the following:a. The pain log should be a 0–10 scale, with 0 as the lowestpain and 10 as the worst pain.This is consistent with the painscale used in hospitals.b. Note how chronic painaffects your daily functions:Physical Effects: Is it difficultfor you to do what you wantwhen in pain? Are you takingpain medications even if  theyprovide little relief? Does it takeyou longer to complete dailytasks such as dressing orpersonal grooming? Do youaccept that fatigue is a limitingfactor?  Emotional Effects: Areyou depressed, angry, orfrustrated due to pain and yourlimitations? Do you think thatother people do not believe howbad you feel? Do you feel guiltywhen you have to rest? Do youexperience feelings ofhelplessness or inadequacy? 45Social Effects: Are you takingmore time off from work?Are you unable to plan activitiesthat would be fun? Do youbecome isolated from friendsand family?3. Create your own chronic painscale.a. An example that includes aprintable form can be down-loaded from www2.rpa.net/~lrandall/print.html.  Patientinstructions can be downloadedfrom the Randall Chronic PainScale web page at www2.rpa.net/~lrandall/scale.html.Study Questions 1. Do patients, professionals andemployers recognize andunderstand the negative out-comes of untreated chronic pain?  2. What are some of the systembarriers that compromise chronicpain management in an acutecare setting?3. What steps can adults witharthritis and family caregiverstake to become partners in painmanagement?About the AuthorFor the past sixyears, Janet M.Bykowski, R.N.,has been thePain Manage-ment ClinicalManager for theDepartment of Nursing at MaryWashington Hospital (MedicorpHealth System), Fredericksburg.Prior to this, Janet managed theOncology Unit for 12 years andhelped launch the first PalliativeCare Unit in a communityhospital. Actively nursing for 45years, Janet has receivedcertifications, honors, andawards, including the VirginiaNurses Association ResearchPoster Award for “Pain Manage-ment Evidence Based Research.”She is a member of the editorialboard of the American Journalof Hospice and PalliativeMedicine.ReferencesAmerican Geriatrics Society Panelon Chronic Pain in Older Persons.(1998). The management of chronicpain in older persons. Journal of theAmerican Geriatrics Society, 46,635-651.Centers for Disease Control andPrevention (CDC). (2006a). Health,United States, 2006. SpecialFeature: Pain. Washington, D.C.:U.S. Department of Health andHuman Services, Centers forDisease Control and Prevention,National Center for HealthStatistics. 68-88.Centers for Disease Control andPrevention (CDC). (2006b).Targeting arthritis: Reducingdisability for 16 million Americans.Washington, D.C.: U.S. Departmentof Health and Human Services,Centers for Disease Control andPrevention.National Institute of Arthritis andMusculoskeletal and Skin Diseases(NIAMS). Handout on health:Rheumatoid arthritis. Accessed

Acute and Chronic Pain Challenges for Arthritis Patients in an Acute Care Setting

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Acute and Chronic Pain Challenges for Arthritis Patients in an Acute Care Setting

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