Pain Management for the Older Adult

Marie Clark here. I'm excited to talk to you guys today about pharmacology related to the older adult. Um, we're going to give people a few minutes to log in before I get started.

Just making sure everything's up and ready. All right. I see some people logging in. Um, why don't you guys tell me where you're from and if you've ever been in the hospital, tell me a drug that you had given to you for pain that we'd switch it up today. So who is on today? All right. Hello everyone. I am married and I currently, I live in Atlanta, Georgia. Welcome Mary. Good to have you.
I've been hospitalized before. I've had a couple of babies. Um, and then I had my appendix out so I've had more phene and then your standard epidural with having babies. So we're just kind of giving if you want, you can tell me what pain med maybe you received in the hospital. All right. Um, let's get started. So more people should jump on and it's relevant no matter when you jump on. Um, but so I'm a question editor here at NRSNG. And so I like to bring these tutoring sessions back to the end for you guys. So after sitting through 30 minutes with me, you should be able to take away a few things that are going to help you on the end. Clacs um, 15% of the questions on the end clax are pharmacology questions. So if you have a hundred questions, that's 15 questions.
And the test plan specifically states that you need to be familiar with administration and documentation of pain medicine for the older adult. So these questions are going to be on the end clock. Um, I'm a med surge nurse and I worked in Med search for 11 years, so I have seen a lot of older adult patients and you know, the baby boomer generation is aging, so there's quite a few, um, patients come in your way that are older and older adults is 65 and oh and up. So I want to share with you my why. Um, older adults can be challenging to say the least. Um, but they're also, it's also very rewarding to take care of these patients and just hear their stories. Um, and I'm going to show you a picture of my why. So if you see here, that's me and my grandma and my grandma passed away in 2016 and I had the privilege of being in the hospice house when she was getting medicated for her pain.
And I, um, just remember feeling so thankful for the nurses who were giving her her rocks and all, and helping her to feel comfortable. So that's my why when I have an older adult, difficult. Um, I think about there's someone's grandma just like my grandma. So that's my way. All right. So some of you have had morphine and dilaudid before Percocet and Vicodin and you found out you're allergic to both. Yikes. All right. So yeah, we're, we're familiar with pain meds, so I'm gonna give the floor over to you and I'm going to have you guys tell me,
okay.
About some age related changes in the cardiovascular system. So does anyone have an idea of what types of changes happen with the Cardio System as you age? Just go ahead and drop it into the chat if you know.
All right, I'm not getting any answers, but that's all right. Um, the first one is, uh, decreased cardiac output. Okay. So in the cardio system, over time your cardiac output goes down and there you go. So Mary says fatigue with activity. That is exactly right. The lower your cardiac output, the more fatigue you're going to have. Um, you're also going to have a decreased pulse as well as an increase in variability of the blood pressure. So blood pressure over time actually does trend up, but in the older adults, so the [inaudible], an older adult may have hypertension, but they're also going to have a variability so it can go down and up depending on positioning and stress and exercise. Um, so those are a few considerations to keep in mind with the cardiovascular system.
Okay.
Next.
Okay,
we're going to talk GI system. So this is my, I'm artist's rendition of his stomach. Um, so this is the GI system. Can anyone named some age-related changes in the cardio system? I'm sorry, GI.
Yeah,
go ahead and drop it. And if you can think of anything. Very good. Decreased appetite. Mary, I think you and I are the only ones that are on the call right now. It seems like, but alright, so GI, yes, we have a decreased appetite. We have decreased metabolism. Yes. That is what you just said. I decreased metabolism, constipation and dehydration. Okay. So I think of the GI system as slowing down and I think if the cardio system as slowing down, so yes.
Okay.
And finally, the other body system that I want to touch on today is the system.
So here's the renal system and can you think of any changes that would happen there?
Steve says decreased perfusion. Very good. Mary says incontinence. Yes, that's true. So over time the kidneys decreased in size and urinary retention. Yes. Urinary retention. Incontinence, not a good combination, but over time the renal system decreases in size. The function of them slows down and the glomerular filtration treatian rate is lower as well. Um, and then that makes it more difficult to excrete medications to get those meds out of the body once they're in. So yes, those are some systems that you need to remember when you think of pain meds for the older adults. All right. So I worked a shift at the hospital on Sunday and I had an older adult patient and I thought that her situation was good. Just mention here. So she was in her seventies, we'll call her Catherine. And Catherine was in the hospital with a swollen and septic, possibly septic joint in the knee.
And she had a history of Murcia. She had cellulitis down both legs and had had this knee replaced a year and a half ago. So she came in and tons of pain. And I was her nurse that I'm looking at her Mar, which is the med administration record. And I see that she has Tylenol and morphine and those are the only two drugs that she had for pain. And I thought it was weird that she didn't have anything in the middle. But then I found out that the orthopedics surgeon, um, was going to come in and do a knee aspiration. Right? If any of you guys some chance asks, what's Murcia, does anybody know what Marissa is?
It's a drug that's really resistant to antibiotics. It's methylate [inaudible] resistant. Staph. Glorious. Anyway, it's a contact precaution. We have to be really careful with these patients. Um, anyway, so I find out that the orthopedic surgeon is coming in to do an aspiration of the knee. And if you've ever seen an aspiration of the knee, they take like a two inch 18 gauge needle attached to a 20 cc syringe and they're going to stick that right into a space in the kneecap and pull out fluid. So here's the 70 year old lady and I know that she's going to need some pain management for this. So I give her right before the doctor comes in, four milligrams of morphine, I put her on a pulsox and I check her bun and creatinine to make sure that's okay. And I'm just making sure that she is going to be able to handle this four milligrams of morphine.
So the doctor comes in 20 minutes later and we're sitting there at the bedside and he's got her knee already to go. And then the patient gets really anxious about the procedure and decides that we need to, um, she needs more medicine. And so the doctor's like, sure, let's get her more and morphine. So I'm thinking, okay, I already gave her four milligrams, which isn't a lot of morphine, but for an older adult, knowing all the body system changes, it could be. So I go and withdraw four more milligrams of morphine and I give it to her and they do the procedure. Everything goes fine and the doctor leaves and I'm just watching. Okay. So everything turned out to be fine. However, in my nurse brain, I flag that a patient that's older and gets that much medication, like of an opioid just really needs to be watched. So nothing bad happens. She was fine. But you have to have that nursing judgment when you're giving doses of opioids to patients. So that is something to take away. All right, so I have another question for you guys. Is it normal for an older adult to be in pain? What do you guys think?
Wow.
And okay, so Steve says it's normal for some people to be in pain. Mary Says No. Steve says arthritis, et Cetera. Right. That makes sense. Um, while you guys, while I wait, I'm going to drop the link in here because I found this to be super helpful. So Fia says yes, it's normal. All right?
Okay.
All right. This is an article that's really helpful for you guys to read about pain in the older adults. So it is actually not normal for an older adult to be in pain. If a person is in pain, it's an indication of an underlying problem. All right? Um, pain could mean arthritis. Um, it could be osteoarthritis or whatever's going on with this patient over time, but it's not normal. It indicates an underlying problem. So, um, when a patient's in pain,
okay,
they have functional limitations and which means they're not going to want to get out of bed. And when a patient doesn't want to get out of bed, then they start to decondition and their bodies can actually atrophy. The muscles can atrophy within 24 to 48 hours of laying in bed once an older adult has atrophy and deconditioned, they just decline. There's really no getting back that muscle mass that's lost. So pain management is really important. And um, we got to treat our patients pain. Alright, one category onto the categories of meds. I'm going to give you guys too that um, you should not give an older adult if possible. The first one is end ceds. Who can tell me what some n sets are that you know of? It's nonsteroidal anti inflammatory drugs. Anybody knows them Motrin. Yes. Steve says, I've a pro thin, we've got another Ibuprofen.
Yes. And so actually Motrin and Ibuprofen are the same thing, but that is one of the main end sets. And then the other one is aspirin. They proxin yes. And they proxin chance says tore it all. There's aspirin again. So yes. Um, aspirin and Ibuprofen are your main two. And feds. And believe it or not, even though a lot of older adults are on a baby aspirin, which is like the 81 milligram orange chewable that they take every day, it can lead to problems. So [inaudible] lead to increase bleeding and specifically bleeding ulcers, and then they affect the kidneys. And if a patient has heart failure, it will worsen heart failure too. So sides are actually a big no-no for the older adult. All right, so now that you know about and says, let's move on to the big category, which is opioids. Um, opioids are narcotics. There's quite a few examples. Um, morphine, hydrocodone, methadone, dilauded, oxy, cotton, oxycodone. So those are some examples and I would love for you guys to tell me what side effects that you know of that opioids have. I bet you know some.
Do you have an assist? Says Lethargy. Mary says respiratory depression. So Phia and Danny say respiratory depression. Yes. Respiratory depression is a big one. Thank you. Steve says constipation. Yes sir. That is true. So we've got respiratory problems. We have sedation, hypotension, constipation. It affects the kidney, urinary retention and confusion. So imagine these types of side effects in your older adult patient. It can lead to a lot of problems. So there is a decision tree that I want you guys to put in your mind. Okay? When you have an older adult who needs pain management, the very first thing we're going to do is non-pharmacological pain management. Um, what does that mean? Does anybody know what could be non-farm pain management or some interventions you could do for this patient?
Danny says a hot pack or a cold pack. Mary says massage. Very good. Yes. So heat, good cold, good relaxation, massage, music. These are all first line interventions for a patient in pain. All right? And number two, if that doesn't work, imagine that. If that doesn't work, then we move on to a non opioid. So we don't want to give Anne sides remember, because Anne says affect the kidney and increase the bleeding. So Danny says, give Tylenol. Exactly. So Tylenol is the gold standard for the older adults. It's unfortunately not an antiinflammatory. It would be nice if it was, but it is the gold standard. It affects the liver rather than the kidneys. And that isn't as big of a deal as affecting the kidneys in an older adult. So Tylenol is perfect. Um, the other intervention that's a non opioid is a nerve block.
So a lot of older adults that break a hip come into the hospital and you can actually get in touch with the anesthesiologist on call or whoever's in house at the time and ask for this patient to get a nerve block. And so they can actually, with a local anesthetic, numb the pain to the whole entire hip or even other areas of the body to face, arms, back, legs, it, nerve blocks work all over the body. Um, and the patient can be completely pain free and not have those narcotics circulating in their system. So remember nerve blocks in your practice. All right, so we try the non-farm, let's say we try to non opiod, we gave them Tylenol. The anesthesiologist wasn't around for a nerve black and they are still having pain.
Yeah.
And the pain is not manageable for them. What will we do? We will start low and go slow. All right, so we are at the point now where this patient needs to have an opioid administered and we are going to give them their narcotic, their opioid, their morphine to lotted but we are going to start low and go slow. The link I put in the chat talks about starting at just 25% of a normal healthy person's pain dose for the older adults. So like one fourth of the amount of meds you would give a younger adult is what you're going to start with with an older adult. Then you also want to make sure that you have narcan on board or Narcan in your mar available to give them if they need it in case we overdo it. All right, so those, that's kind of my information. I want you guys to remember the three body systems that you need to keep in mind when giving pain meds. So can you guys, do you guys remember the three that we talked about at the beginning? If anybody knows, just put it in. We'd love to hear from you.
There were three body systems. Mary says Cardiac, GI and renal. Very good. So those are the three systems you have to keep in mind and the age related changes all involve slowing down. So that's the first thing. The second thing is remember this decision tree, you're going to start with non-farm, then you're going to go to non opioid and finally you're going to start low and go slow if you do have to end up giving that opioid. All right, so I have two end CLECs questions that I'm going to ask you. You're going to give me the answer. So let's start with the first one and then I'll take questions after that. Alright, so question number one, there's a 75 year old that's submitted to your floor. They fell and they broke a hip and you check their labs and their bun and creatinine are normal. All right, this patient does not take any pain meds chronically at home and they rate their pain at an eight out of 10 so which pain intervention do you do first? I'm going to run them down here. Do you give number one is give Tylenol number two give delighted.
Okay.
Number three, give a nerve block or number four, give put ice on it. Mary says ice. Sofia says ice. Steve says non-farm. Yep. Dang, I thought you guys are good. So yes, you're going to do ice first and then what would you do second with this patient? If the ice doesn't work, which it likely won't, although it will help. So Danny says Tylenol. Very good. Um, so do the ice. We just always throw ice on them. And then we're going to do Tylenol next and after the we get the Tylenol on board, what I would recommend is you see if the anesthesiologist is available. Yes, Mary for the nerve block. And then a last resort would be the [inaudible]. Okay. Four one, three, two. Good Job Steve. You got it. All right. So that was that question. And then I have one more for you guys. [inaudible] so now you have a 64 year old post op hernia repair. 65 year old, older adult is 65 and up. So you have a 65 year old postdoc hernia repair. This patient has a history of history of osteoarthritis and a heart attack. Okay. The patient takes Tylenol with coding for the Osteo and a baby aspirin to prevent heart attack. Okay, so Tylenol with coding baby aspirin. The patient asks for IB Morphine. And which of the following are you wanting to need to verify as the nurse before you give this patient morphine?
Number one, would you verify LFTs? Number two, urinary output number three, respiratory rate or number four of B. And p. Danny says respiratory rate. Mary says respirate respiratory and Steve, you all got it right? Again, good job. So yes, because opioids affect the respiratory drive, you're going to do number three first. And then is there something else you would want to check as well?
You got it, Steve. All right, so you're going to start with respirations because airway breathing circulation is always first and it's always first on the NCLEX questions. And then you would also check their urine output because you know that opioids can decrease or stop the flow of urine actually through the ladder. All right. So that is my presentation and I'm wondering if you guys have any questions for me about pain meds or anything like that. And while you think of questions, I'm gonna put this tutor feedback form into the chat here and I'd love your feedback on how I did today. Alright, so does anyone have any questions for me about pain meds in the older adult?
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all right, well, if there's no other questions, then thanks so much for spending time with me and, um, you know, to go out and be your best self today and happy nursing. Thanks guys.
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