Implementing and sustaining evidence-based practices in long-term care.

Pain Assessment and Management

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    The guideline contains recommendations for best nursing practices in the assessment and management of pain for Registered Nurses (RNs) and Registered Practical Nurses (RPNs). It is acknowledged that the individual competency of nurses varies between nurses and across categories of nursing professionals (RNs and RPNs) and is based on knowledge, skills, attitudes, critical analysis and decision making which is enhanced over time by experience and education. This guideline is endorsed by the International Association for the Study of Pain.

    Registered Nurses’ Association of Ontario. (2013). Assessment and management of pain. (3rd Ed.). Toronto, ON: Author. Retrieved from https://rnao.ca/sites/rnao-ca/files/AssessAndManagementOfPain_15_WEB-_FINAL_DEC_2.pdf

     

     

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    Pain Gap Analysis

    Organizational assessment tool to assist with implementation and evaluation of the RNAO Assessment and Management of Pain by comparing current practice to evidence-based practice. Source: Registered Nurses' Association of Ontario's Long-Term Care Best Practices Program, Toronto, ON. January 2014.

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    This link takes you to a workbook, with a goal to give LTC health care professionals the information and resources they need to improve systems essential for managing pain for residents. The workbook will as assist LTC homes in advancing the quality of pain management services and clinical outcomes for residents.

    The material was prepared by Masspro, the Medicare Quality Improvement Organization for Massachusetts, under contract with the Centres for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human Services.

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    Abbey Pain Scale is an assessment tool for the measurement of pain in people with dementia who cannot verbalize

    Source: Dementia Care Australia Pty Ltd. Website: www.dementiacareaustralia.com

    Reference: Abbey, J; De Bellis, A; Piller, N; Esterman, A; Giles, L; Parker, D and Lowcay, B. Funded by the JH & JD Gunn Medical Research Foundation 1998 – 2002 (This document may be reproduced with this acknowledgment retained)Retrieved from: http://www.wales.nhs.uk/sitesplus/documents/862/FOI-286f-13.pdf

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    The website provides access to resources for those people with neuropathic pain.

    Website: http://www.actionontario.ca/

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    An assessment tool that uses the mnemonic OPQRSTUV to assist health care professionals systematically assess people who screen positively for the presence or risk of any type of pain and who can self report.

    Figure 1 (page 21) RNAO BPG Assessment and Management of Pain 3rd Edition (2012) http://rnao.ca/bpg/guidelines/assessment-and-management-pain

    Adapted from "Symptom Assessment Acronym "OPQRSTUV", in Fraser Health Authority, 2012, Hospice Palliative Care Program Symptom Guidelines. Retrieved from https://www.fraserhealth.ca/-/media/Project/FraserHealth/FraserHealth/Health-Professionals/Professionals-Resources/Hospice-palliative-care/SymptomAssessmentRevised_Sept09.pdf

     

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    This link will take you to the document developed by AdvantAge Ontario to support program objectives, policy, procedures and staff training materials and tools that meet minimum requirements of the LTCH Act and Regulation.

    Retrieved from www.advantageontario.com 

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    A succinct, 2-page newsletter that covers myths and facts about pain. Developed by the BPG in LTC Initiative Central South and The Long Term Care Resource Centre, Hamilton, Ontario.  Source: http://www.rgpc.ca/
     

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    Purpose of the BPI tool is to assess the severity of pain and the impact of pain on daily functions. The tool can be used for patients with pain from chronic diseases or conditions such as cancer, osteoarthritis and low back pain, or with pain from acute conditions such as postoperative pain.

    Assessment areas included are severity of pain, impact of pain on daily function, location of pain, pain medications and amount of pain relief in the past 24 hours or the past week.

    The BPI copyright is held by Dr Charles S. Cleeland (1991). The copyright applies to the BPI and all it's derivatives in any language.

    Retrieved from http://www.mdanderson.org/

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    This resource commences with access to many tools for screening, selection, monitoring and tapering for safe and effective use of opiods for chronic non-cancer pain. The resource then provides recommendations for opioid use in Canada in great detail, which will be of interest to physicians, nurse practitioners and other clinicians.

    Reference: National Opiod Use Guidelines Group (2010), Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain Practice Toolkit. Retrieved from http://nationalpaincentre.mcmaster.ca/opioid/

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    This link to the University of Toronto Centre for the Study of Pain provides access to research and education in pain so as to effect the dissemination and application of new knowledge in pain.

    Website: http://sites.utoronto.ca/pain/

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    The CNPI tool is designed to measure pain in cognitively impaired oler adults by observing their behaviours. The tool considers pain during movement and at rest.

    Reference: Feldt K.S. 2000. St Joseph Health System. Retrieved from: http://kentuckyonehealth.org/documents/Nursing/CNPI.pdf

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    This website provides links to various pain and symptom management and assessment tools. Tools specifically included are pocket reference cards, rating scales, assessment packets, chart forms, database tools, chart documentation packets, etc.

    Website: http://prc.coh.org/pain_assessment.asp

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    The College of Family Physicians of Canada (CFPC) Website provides links to materials, web resources, papers and clinical practice guidelines fort physicians who have special interest in Chronic Non Cancer pain.

    The website http://www.cfpc.ca/Home/ contains materials from external sources. Users wishing to verify the information should consult directly with the identified sources of the materials.

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    The DOLOPLUS-2 Scale can be used for people having mild or moderate cognitive impairment and with proxy rating when a person is unable to self-report.

    Reference: Registered Nurses Association of Ontario (2013) Appendix M of Assessment and Management of Pain, Third Edition. Toronto, ON, Canada Author p. 95

    Used with permission from: Fuchs-Lacelle & Hadistavroplous, 2004; Hadistavropolous et al, 2006: Herr et al, 2011: Lefebvre-Chapiro & the DOLOPLUS Group, 2001: Schofield et al, 2008

    Website: http://www.assessmentscales.com/scales/doloplus

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    Cette ligne directrice fournit des recommandations fondées sur les données probantes à l'intention des infirmières et des autres membres de l'équipe pluridisciplinaire qui évaluent et prennent en charge des personnes qui ressentent ou qui courent le risque de ressentir n'importe quel type de douleur. Cette ligne directrices est approuvé par 'the International Association for the Study of Pain'.

    Association des infirmières et infirmiers autorisés de l’Ontario (2013). Evaluation et prise en charge de la douleur, Troisième edition. Toronto, ON, Canada: Auteur. Récupérée de http://rnao.ca/bpg/translations/%C3%A9valuation-et-prise-en-charge-de-la-douleur

    Ce travail est financé par le ministère de la santé et des soins de longue durée.

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    Le but de cette ligne directrice est de fournir aux infirmières autorisées, aux infirmières auxiliaires autorisées et aux autres prestataires des soins de santé des recommandations fondées sur les données probantes en matière de facilitation de l'apprentissage axé sur les besoins du client qui encourage les clients à prendre les mesures nécessaires pour assurer leur propre santé et qui leur permet de le faire. Voici les questions cliniques abordées par cette ligne directrice : 1. Comment les infirmières peuvent-elles faciliter de façon efficace l'apprentissage axé sur les besoins du client? 2. Quelles sont des méthodes/stratégies d'enseignement efficaces pour l'apprentissage axé sur les besoins du client? 3. Comment les infirmières peuvent-elles évaluer l'apprentissage du client? Cette directive s'appliquera à tous les domaines des soins infirmiers incluant cliniques, l'administration et l'éducation.

    Association des infirmières et infirmiers autorisés de l'Ontario (2012). Facilitation de l'apprentissage axé sur les besoins du client. Toronto, Canada : Association des infirmières et infirmiers autorisés de l'Ontario. http://rnao.ca/bpg/language/facilitation-de-lapprentissage-ax%C3%A9-sur-les-besoins-du-client

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    This link takes you to the resources that include pain assessment terminology and Power Point presentations.

    Reference: Sigma Theta Tau International for the Center for Nursing Excellence in Long Term Care 2013. Pain assessment terminology and narrated power point presentations. Retrieved from http://www.geriatricpain.org

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    This link takes you to the Geriatric Pain website http://www.geriatricpain.org

    The website was created to provide nurses who work in LTC environments with access to free best practice pain assessment tools and resources to help manage pain in older adults, including quality improvement processes focused on pain management

     

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    This website has all the tools you need to initiate a Pain Quality Improvement program in your LTC Home. The document provides you with a overview of how t use the tools in this section. 

    Geriatric Pain, Website: http://www.geriatricpain.org

      

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    The revised ESAS-r is available in multiple languages. The link will take you to the guidelines for using the ESAS-r tool. The ESAS-r tool is freely available to use, with appropriate acknowledgement of its source.

    Website: http://www.palliative.org

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    You may need to seek assistance from a health-care professional when you have concerns about people you care for who are in pain. Uncontrolled pain is a common problem. Pain can affect anyone at any age and include people who are unable to communicate that they are experiencing some form of pain. If people have pain during their day-to-day activities or during any medical procedure, this can affect the way they behave and function. This behaviour may cause you to feel helpless and distressed, especially if you can not help them with their pain and they are not able to speak for themselves.

    Retrieved from: http://rnao.ca/bpg/guidelines/fact-sheets/helping-people-manage-their-pain

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    Why you should seek assistance from a health-care professional when you are in pain? Uncontrolled pain is a common problem. Pain can affect anyone at any age. If you are experiencing uncontrolled pain it can affect day-to-day activities and make you feel upset or sad. Members of your family may feel helpless too, especially if they do not know how to help.

    Retrieved from: http://rnao.ca/bpg/guidelines/fact-sheets/helping-you-manage-your-pain

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    Watch a video of nurses implementing the Assessment and Management of Pain Guideline into their practice. 

    RNAO (2009) Implementation of Pain Assessment and management Guideline

    Source: http://www.youtube.com/watch?v=Ssymdf8CFQ4&feature=channel_page.

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    The International Association for the Study of Pain (IASP) is the leading professional forum for science, practice, and education in the field of pain. 

    The link takes you to the website that brings together scientists, clinicians, health care providers, and policy makers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide.

    Retrieved from: http://www.iasp-pain.org/

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    Fiche de renseignements pour la sensibilisation en matière de santé.

    Association des infirmières et infirmiers autorisés de l’Ontario (2002, Novembre). Maîtriser sa douleur. Toronto, ON, Canada: Auteur. Récupérée de http://rnao.ca/sites/rnao-ca/files/Maitriser_sa_douleur_0.pdf.

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    This tool is designed to help family physicians and nurse practitioners (primary care providers) develop and implement a management plan for adult patients with Chronic Non Cancer Pain (CNCP) in the primary care setting. CNCP is defined as pain that typically persists or recurs for more than 3 months or past the time of normal tissue healing.1,2,3,4 This tool applies to, but is not limited to pain conditions such as osteoarthritis (OA), low back pain (LBP), musculoskeletal (MSK) pain, fibromyalgia (FM) and neuropathic pain (NP). This tool focuses on a multi-modal approach to manage CNCP.

    Web Address or Source: https://thewellhealth.ca/wp-content/uploads/2017/03/CEP_CNCP_Main_V1.pdf

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    The McCaffrey Initial Pain Assessment tool can be used to guide health care professionals through an initial assessment of pain. This tool includes diagrams of the human body to help patients locate the pain they experience as well as questions to prompt the patient to describe the intensity, quality, causes, effects, and contributing factors of the pain.

    Reference: McCaffrey M, Pasero C. (1999). McCaffrey Initial Pain Assessment Tool

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    Asks persons to rate their pain from 0 to 10

    • Scored 0-10 with the anchors of 0 being ‘no pain’ and 10 being ‘pain as bad as it can be’ Used in adults, older adults, and adolescents and children over age 8.
    • Well established evidence of reliability, validity, and ability to detect change
    • No equipment is needed to administer this measure
    • High feasibility (quick and easy to use)

     

    Reference:

    Registered Nurses’ Association of Ontario. (2013). Appendix E of Assessment and Management of Pain, Third Edition.Toronto, Canada: Author. 81-82.

    McCaffery, M., Beebe, A., et al. (1989). Pain: Clinical manual for nursing practice, Mosby St. Louis, MO

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    The Opiod Manager condenses key elements from the Canadian Opiate Guideline into a workable format for prescribing opiates for persons with chronic, non-cancer pain.

    Reference: National Opiod Use Guidelines Group (2010), Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain Practice Toolkit, Opioid Manager. Retrieved from http://nationalpaincentre.mcmaster.ca/opioidmanager/

    © 2016 McMaster University

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    People with dementia often experience pain that is undetected and under treated because people with dementia are often not able to clearly voice that they have pain. Often they express their pain in ways that are not associated with signs of pain such as social withdrawal.

    Three resources are available on this website:

    1. An online presentation about pain and dementia
    2. Additional materiels to give more detail about the topics covered in the presentation
    3.  A toolkit for organizations who would like to put on a workshop with these materials

    The materials are free of charge but to access them you need to register. The registration is anonymous and personal data will not be collected. The registration allows the developers of the resources to assess how useful the resources are and how often they are being used.

    Retrieved from Website: http://www.painanddementia.ualberta.ca/

     

     

     

     

     

     

     

     

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    PACSLAC is a tool to observe and assess both common and subtle pain behaviours. Copyright © Shannon Fuchs-Lacelle and Thomas Hadjistavropoulos. The PACSLAC may not be reproduced without permission. For permission to reproduce the PACSLAC, please contact the copyright holders (Thomas.Hadjistavropoulos@uregina.ca).

    Retrieved from http://www.geriatricpain.org/content/Assessment/Impaired/Pages/default.aspx

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    Comprehensive pain assessment tool for use in cognitively intact adults with pressure injuries. This pain assessment tool is useful for people with dementia who are unable to verbally express their pain. It focuses on behaviours and provides the ability to score pain levels.

    Reference: Interior Health. Retrieved from http://bcbpsd.ca/docs/part-1/Final%20Provincial%20PAINAD%20Scale.pdf

     

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    The CareSearch Palliative Care Knowledge Network website takes you to resources that will support - clinical evidence, patinet managemnet, and assessment tools for pain.

    Retrieved from: http://www.caresearch.com.au/Caresearch/Default.aspx

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    The link provides access to resources through the Canadian Pain Society related to:

    • Accreditation Canada - Pain Standards
    • Pain Fact Sheets
    • Pain Teaching Scenarios
    • Website Links
    • Journals

    Retrieved from http://www.canadianpainsociety.ca/

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    The link takes you to the required programs for pain management section 52 of the Ontario Regulation 79/10 made under the Long-Term Care Homes Act, 2007, Government of Ontario. Retrieved from https://www.ontario.ca/laws/regulation/r10079

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    The Pain Research Forum (PRF) is an interactive web community dedicated to finding treatments for untreatable pain conditions.

    Website: http://www.painresearchforum.org/

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    This is the link for centralized source for pain and pain management. The Canadian Pain Coalition is in partnership with pain consumer groups, health care professionals who care for people in pain, and scientists studying better ways o treating pain.

    Website: http://www.canadianpaincoalition.ca/index.php/en/

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    This link takes you to PARC which supports, educates and informs persons with Reflex Sympathetic Dystrophy (RSD), otherwise known as Complex Regional Pain Syndrome (CRPS) the community and the medical professionals treating RSD, about the importance of early diagnosis and treatment.

    Website: http://www.rsdcanada.org/parc/english/index.html

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    A validated and reliable sedation scale for assessing and reporting opioid induced sedation.

    Registered Nurses' Association of Ontario. (2013). Appendix O of Assessment and Management of Pain Third Edition. Toronto, ON, Canada p.99

    Used with permission from: Pain Assessment and Pharmacologic Management, by C. Pasero and M. McCaffery, 2011, St. Louis, MO: Mosby/Elsevier. Copyright (1994) by Chris Pasero

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    This policy and procedure for pain assessment and management provides examples for inclusion of evidence –based recommendations in an organization’s policy to address acute and chronic pain. This document was created prior to the LTCHA (2007).
    Toronto Best Practice in LTC Initiative. (2006). Policy and Procedure: Pain Assessment and Management. Retrieved 2013, from http://rgp.toronto.on.ca/torontobestpractice/Policyprocedurepainassessmentmanagement.pdf

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    The link takes you to the Required Programs Sec. 48 of the Ontario Regulation 79/10 made under the Long-Term Care Homes Act, 2007, Government of Ontario. Retrieved from https://www.ontario.ca/laws/regulation/r10079

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    The purpose of this best practice guideline is to provide evidence-based recommendations related to nurses and other health care professionals providing effective client centred learning. This guideline will address the following areas: • How can nurses effectively facilitate client centred learning? • What are effective teaching delivery methods/ strategy for client centred learning? • How do nurses assess client learning? This guideline will be applicable to all domains of nursing including clinical, administration, and education.

    Registered Nurses’ Association of Ontario. (2012). Facilitating client centred learning Toronto, ON: https://rnao.ca/sites/rnao-ca/files/BPG_CCL_2012_FA.pdf

     

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    The Person-and Family-Centred Care best practice guideline can be used to enhance the quality of partnerships between health-care providers with individuals accessing care, ultimately improving clinical outcomes. It is important to acknowledge that person- and family-centred care focuses on the whole person as a unique individual and not just on their illness or disease. By viewing the individual through this lens, health-care providers come to know and understand the person’s life story, experience of health, the role of family in the person’s life, and the role they may play in supporting the person to achieve health. This guideline provides best practice recommendations in three main areas: •Practice recommendations are directed primarily to those who provide direct care to persons in health-system settings and in the community. •Education recommendations are directed to those responsible for staff and student education. •System, organization, and policy recommendations apply to managers, administrators, policy-makers, nursing regulatory bodies, academic institutions, and government bodies. Recommendations in these three areas are most effective when implemented together. This guideline replaces the previous BPG Client Centred Care.

    Registered Nurses’ Association of Ontario. (2015). Person-and family-centred care. Toronto, ON, Canada: Author. Retrieved from https://rnao.ca/sites/rnao-ca/files/FINAL_Web_Version_0.pdf

     

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    Chronic diseases are unlike any acute illness, in that they require considerable professional self-management support over the client’s lifetime, related life management skills, and long term regular follow-up with healthcare professionals. Over the last decade, a dramatic rise in the prevalence of chronic health conditions has emerged, altering the way in which care is sought, managed, delivered and received. The purpose of this guideline is to provide evidence-based recommendations for Registered Nurses and Registered Practical Nurses across the continuum of care in self-management support. These recommendations identify strategies and interventions that enhance an individual’s ability to manage their chronic health condition.

    Registered Nurses’ Association of Ontario. (2010). Strategies to support self-management in chronic conditions: Collaboration with clients. Toronto, ON: Author. Retrieved from https://rnao.ca/sites/rnao-ca/files/Strategies_to_Support_Self-Management_in_Chronic_Conditions_-_Collaboration_with_Clients.pdf

     

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    Le but de la présente ligne directrice est de promouvoir les pratiques fondées sur des données probantes, qui sont associées aux soins axés sur les besoins de la personne et de la famille, et d'aider les infirmières et d'autres fournisseurs de soins de santé à acquérir les connaissances et les compétences nécessaires pour améliorer leur pratique de ces soins. Les recommandations aideront les infirmières et d'autres fournisseurs de soins de santé à obtenir le savoir requis pour collaborer et établir des relations habilitantes avec des personnes et leur famille qui font appel aux services de santé, afin d'optimiser la santé et le bien-être au cours de leur vie. Cette approche fondée sur des données probantes, et combinée à une perspective qui reconnaît la place de la personne au centre des soins de santé, permettra d'améliorer l'expérience de cette personne et sa satisfaction à l'égard des soins et des services offerts par le système de santé. Elle s'applique à tous les domaines de la pratique des soins infirmiers, y compris les secteurs clinique, administratif et éducatif.

    Cette ligne directrice recommande des pratiques exemplaires dans trois domaines principaux : ■ Les recommandations au sujet des pratiques exemplaires ont été rédigées principalement à l'intention des infirmières et d'autres fournisseurs de soins de santé dans l'équipe interprofessionnelle qui offre des soins directs à des personnes dans les milieux de soins du système de santé (p. ex., soins actifs, soins de longue durée et soins à domicile) et dans la collectivité (p. ex., soins primaires, équipes de santé familiale et santé publique). ■ Les recommandations en matière d'éducation s'adressent à ceux qui sont responsables de la formation du personnel et des étudiants, tels que les éducateurs, les équipes d'amélioration de la qualité, les gestionnaires, les administrateurs ainsi que les établissements d'enseignement universitaire et professionnel. ■ Les recommandations sur le système, l'organisation et la politique s'appliquent à divers publics selon le type de recommandation. Les publics comprennent les gestionnaires, les administrateurs, les décideurs, les organismes de réglementation en soins infirmiers, les établissements d'enseignement et les organismes gouvernementaux. Pour obtenir une efficacité optimale, les recommandations dans ces trois secteurs doivent être mises en œuvre simultanément. Cette ligne directrice remplace le soin centré au client précédent .

    Association des infirmières et infirmiers autorisés de l’Ontario. (2015). Soins axés sur les besoins de la personne et de la famille. Toronto (Ontario) : Association des infirmières et infirmiers autorisés de l’Ontario http://rnao.ca/bpg/language/soins-ax%C3%A9s-sur-les-besoins-de-la-personne-et-de-la-famille

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    Les maladies chroniques sont différentes des maladies aiguës qui, dans la plupart des cas, nécessitent l'attention spécialisée, intensive et rapide d'un professionnel de la santé et peuvent inclure un suivi limité. Au cours des dix dernières années, une augmentation considérable de la prévalence des états chroniques est apparue, modifiant la façon dont les soins sont demandés, gérés, fournis et reçus. Le but de cette ligne directrice est de fournir aux infirmières autorisées et aux infirmières auxiliaires autorisées des recommandations fondées sur les données probantes en matière de soutien de l'autogestion. Ces recommandations présentent des stratégies et des interventions qui améliorent la capacité d'un individu à prendre en charge son état chronique. Association des infirmières et infirmiers autorisés de l'Ontario. (2010).

    Stratégies permettant de soutenir l'autogestion des états chroniques : la collaboration avec les clients Toronto, Canada. Association des infirmières et infirmiers autorisés de l'Ontario. http://rnao.ca/bpg/language/strategies-permettant-de-soutenir-lautogestiondes-etats-chroniques-la-collaboration-ave

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    This link takes you to a site that contains Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain and management tools.

    Reference:

    The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain (2017, July). Retrieved from http://nationalpaincentre.mcmaster.ca/documents/Opioid%20GL%20for%20CMAJ_01may2017.pdf

     

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    Brief, easy to use, and have established reliability and validity. The link takes you to screening questionnaires for neuropathic pain that incorporates the persons signs and symptoms.

    Reference: Try This: Best Practices in Nursing Care to Older Adults. Issue Number SP1, 2010 DN-4 Questionnaire

    Adapted from - Bouhassira, D., Attal, N., Alchaar, H, et al. (2005). Comparison of Pain Syndromes Associated with Nervous or Somatic Lesions and Development of a New Neuropathic Pain Diagnostic Questionnaire (DN4). Pain, 114 (1-2), 29-36

    Retrieved from http://consultgerirn.org/

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    The link takes you to the WHO 3-step ladder for pain management. To maintain freedom from pain, rugs should be given "by the clock", that is every 3-6 hours, rather than "on demand". This 3-step approach of administering the right drug ion the right does at he right time is inexpensive and 80-90 percent effective.

    WHOs' cancer pain ladder for adults retrieved from: http://www.who.int/cancer/palliative/painladder/en/

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    This link takes you to the WHO scoping document for the treatment guidelines for chronic non-malignant pain in adults. The overall objective of these guidelines is to provide evidence-based recommendations that, if followed, will improve the pain experience of adult patients with chronic non-malignant pain, such as low back pain, arthritis and fibromyalgia.

    The scoping document is an updated ad merged version of the scoping documents on chronic malignant pain and chronic non-malignant pain from 2008.

    Retrieved from: http://www.who.int/

     

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    The educational website contains:

    • A narrated presentation about pain and dementia
    • A downloadable resource pack for family members, and
    • A downloadable pain-log and the PAINAD assessment tool (Warden, Hurley, Volicer, 2003)

    A facilitator's toolkit of background material, a planning guide, promotional material, and supplemental information for organizations who wish to conduct a workshop using he materials.

    Retrieved from: http://brainxchange.ca/Public/Resource-Centre-Topics-A-to-Z/Pain.aspx

    This link takes you to the CDRAKE and AKE combined activities to form an exciting new network.