CE: Appropriate Use of Opioids in Managing Chronic Pain.

: Over the past two decades, the use of opioids to manage chronic pain has increased substantially, primarily in response to the recognized functional, emotional, and financial burden associated with chronic pain. Within this same period, unintentional death related to prescription opioids has been identified as a public health crisis, owing in part to such factors as insufficient professional training and medication overprescription, misuse, and diversion. The authors discuss current best practices for prescribing opioids for chronic pain, emphasizing patient assessment and essential patient teaching points regarding safe medication use, storage, and disposal.

Assessment and management of delirium: a focus on hepatic encephalopathy.

This purpose of this article is to promote comprehensive assessment, differential evaluation and provision of care which optimizes benefit while minimizing burden. Delirium is a debilitating neuropsychiatric complication that is highly prevalent in palliative care. It is multifactorial and may be related to infection, disease progression, metabolic state or medication toxicity. There are three proposed sub-types of delirium with the hypoactive/ hypoalert variant being most often underdiagnosed and undertreated. The inadequate management of all types of delirium is associated with increased personal and family distress, lengthier hospital stays, and escalating healthcare costs. This article reviews the assessment, diagnosis and treatment for delirium in general and hepatic encephalopathy in particular. A number of valid and reliable tools are discussed, as they assist in screening, symptom appraisal, diagnosis, and treatment planning. It is recognized that nurses are particularly well positioned to make bedside observations, to document changes over time, and to educate and support patients and their families. Searching for the etiology of delirium, developing individualized plans of care consistent with patient goals, and endorsing the benefit of consultation/referral are discussed as key roles for palliative care providers from all disciplines. New and novel therapies in the management of hepatic encephalopathy are discussed, as they expand treatment options for patients at all points along the trajectory of liver disease.

Challenges in pain assessment in cognitively intact and cognitively impaired older adults with cancer.

PURPOSE/OBJECTIVES: To describe approaches to pain assessment in cognitively intact and cognitively impaired older adults with cancer. DATA SOURCES: MEDLINE literature search, personal reference collection, and clinical experience. DATA SYNTHESIS: A systematic and comprehensive pain assessment is the cornerstone of effective treatment strategies. Determining the effect of pain on older adults' ability to function is as important as rating pain intensity. Evidence-based recommendations exist to guide practice. CONCLUSIONS: The undertreatment of pain in older adults persists despite a plethora of published guidelines addressing pain assessment and management. Unrelieved pain affects recovery from illness and all aspects of life. Systematic and ongoing assessment is elementary to effective pain management, yet assessments frequently are neither completed nor documented. Because pain is subjective and individual responses to pain interventions vary widely and are unpredictable, assessment is vital to comprehensive pain care in all clinical settings. Reliable and validated pain assessment tools for cognitively intact and cognitively impaired older adults are available to guide practice. IMPLICATIONS FOR NURSING: Pain assessment is a core competency for nurses in all clinical settings. Comprehensive, individualized, and ongoing assessment provides the information necessary so that clinicians can develop interventions to relieve patients' pain and improve their quality of life. Nurses have the knowledge, skills, and tools to adequately screen and comprehensively assess pain in older adult patients, including those with cognitive impairment. By using this knowledge, nurses can change systems and practices, have a significant effect on improving pain care, and increase quality of life and function of older adults with pain.

Consensus statements, positions, standards, and guidelines for pain and care at the end of life.

Standards, guidelines, and position and consensus statements by themselves do not change practice or improve pain management and care at the end of life. However, if they are used effectively, they support best practices, provide a forum for discussion of current recommendations, and provide nurses with the latest science and information to advocate for effective pain and symptom management.