Don't let pain management complicate nutritional care. (Feature Article).

"In this nation, it has been said that people are living longer but are dying more painfully. The healthcare profession as a whole will be judged in the next century not by how it has been able to take technological skills and prolong life by a few more hours, days, or perhaps weeks, but rather by how it controls the pain and suffering in each life that is entrusted to its care."

L. Jean Dunegan, MD, JD, Annals of Long-Term Care, November 2000

Mr. Abbott's family members were very concerned-they could not figure out what was causing his loss of appetite. A large man, his weight had gone from 280 pounds six months ago to an all-time low of 248 pounds. The nursing facility staff were also concerned, because they, too, could not explain the reason for his lost appetite. They began to ask very specific questions and discovered that his pain was so severe that he could not concentrate on anything but controlling his reaction to the pain. He was a proud, strong man and did not want to complain.

Pain and its treatment can have dramatic effects on a resident's nutrition and hydration status. When a resident is suffering from pain, it might be difficult for him or her to focus on anything but the pain. This can lead to loss of appetite, weight loss and potentially resulting weakness, fatigue, decreased immune response, malnutrition, pressure ulcers and poor wound healing. In addition, pain medications themselves often produce side effects that can have a dramatic impact on a resident's desire for food and the body's ability to handle food and fluids.

Medication Timing

If medications are timed to relieve pain prior to mealtime, the resident can enjoy the meal, and mealtime can once again become an event that the resident looks forward to. If not, persuading the resident to eat could become a constant struggle.

Assessing Pain's Effect on Nutrition and Hydration Status

Screening residents on pain medications for nutritional problems can help alleviate their discomfort with food and fluids. By asking the right questions and providing the best interventions, we can prevent weight loss, malnutrition and dehydration. Key questions include: Does pain affect your appetite? In what way? Do you experience any of the following during your bouts of pain or as a result of taking pain medication?

* Nausea

* Vomiting

* Loss of appetite

* Heartburn

* Cramps

* Bloating

* Gas

* Constipation

* Diarrhea

* Dry mouth or sore mouth

* Taste or smell alterations

* Difficulty swallowing

Side Effects' Impact on Nutritional Care

Pain and its management (via medications) can have a domino effect that can alter nutrition and hydration status. Severe pain can create nausea, which leads to decreased appetite and decreased desire for liquids, leading to potential weight loss, malnutrition and dehydration. Pain medications can produce multiple side effects, including loss of appetite, gastrointestinal distress, nausea, vomiting, diarrhea and constipation. All of these have a negative impact on food and fluid intake (Table), in turn creating the potential for weight loss, malnutrition and dehydration.

Here are some of the most common side effects of pain and its management, and suggestions for coping with them.

Nausea. Be sure appropriate staff are notified and are attempting to alleviate the problem. The physician might be able to order an antinausea medication. Here are some additional suggestions:

* Offer small meals and snacks.

* Encourage residents to eat slowly and chew food thoroughly.

* Try "dry meals" with any liquids given between meals (one hour before or after). Offer cool, clear liquids, and encourage the resident to drink slowly.

* Do not force the resident to eat (it might cause a permanent dislike for the foods forced upon him/her); encourage the resident to avoid favorite foods during bouts of nausea to avoid developing an aversion to them.

* Encourage the resident to rest calmly but to remain upright for 30 to 60 minutes after eating, with head of bed elevated.

* Be sure the resident's clothes are loose and comfortable.

* Remember that fresh air might help counteract nausea.

* Avoid any specific food intolerances.

* Remember that cold foods might be more appealing.

* Avoid fatty and fried foods, heavy sweets, spicy foods and foods with very strong odors.

* Offer whatever foods/fluids the resident suggests he/she will try to eat.

* Keep the resident away from the kitchen area because smells of cooking food might increase the feeling of nausea; avoid other unpleasant odors. Remove plate cover while standing away from the resident, and allow food odors to dissipate prior to serving.

* Be sure medications are given as instructed (Some need to be given with food, which might help to alleviate nausea).

* Remember that carbonated beverages such as lemon-lime soda or ginger ale might be helpful.

* Remember that peppermints or spearmints might be helpful, if tolerated.

Vomiting. The resident should remain NPO until severe vomiting passes. Once vomiting is under control, try giving small sips of clear liquids and increase the amount very gradually. When clear liquids are tolerated, advance to a full liquid diet. Begin with small sips and increase amounts as tolerance builds. Gradually advance to the level of the resident's regular diet.

The following foods might be more tolerable for residents with nausea and vomiting:

* Crackers, pretzels, toast

* Angel food cake

* Cream of Wheat or rice cereals

* Soft, bland fruits or vegetables, such as canned peaches or green beans

* Broth or cream soups

* Ginger ale, lemon-lime soda, drinks from powdered drink mixes

* Sherbet, pudding, ice cream, popsicles, gelatin

* Juices (other than citrus or acetic juices), fruit drinks

* Dairy products

* Tuna/chicken salad sandwiches

* Desserts with fruits

Anorexia/loss of appetite. Concentrate on relieving pain symptoms as much as possible. Make food available 24 hours a day so that residents can eat when they feel able to. Liberalize or eliminate dietary restrictions. Focus on food first, and pack each bite of food with as many calories and grams of protein as possible.

There are many ways to boost calories and protein with foods from the typical kitchen, and there are also some great products on the market that can assist you in achieving this goal, e.g., special milkshakes, bars, puddings, cereals, mashed potatoes or other well-accepted food.

Cramps, heartburn and bloating. Consider these suggestions:

* Encourage the resident to eat slowly and chew food well.

* Provide a relaxed atmosphere at mealtime.

* Encourage small, frequent feedings.

* Try liquids between meals.

* Try bland foods that can be easily digested.

* Have the resident try taking a break during the meal.

* Avoid high-fat foods, spicy foods, chewing gum and sweets in excess.

* Avoid gas-forming foods such as apples, asparagus, beans, beer, bran, broccoli, Brussels sprouts, cabbage, carbonated beverages and cauliflower.

Constipation. Take these suggestions into consideration:

* Offer high-fiber foods such as fruit and vegetables with edible skins and seeds, whole grains (breads and cereals, brown rice and other grains) and bran cereals.

* Try lentils, split peas or navy, pinto or kidney beans in casseroles or soups.

* Offer and encourage taking plenty of fluids (minimum of eight 8-oz glasses daily).

* Encourage activity (the physical therapist might be able to give some suggestions).

* Remember that bran flakes or raisin bran for breakfast might be helpful, and bran muffins are a nice alternative. Also, prunes or prune juice are helpful for most residents.

* Increase fiber intake gradually to avoid problems with tolerance.

* Consider fiber-rich products or laxatives if above suggestions are not tolerated.

Diarrhea. Consider these tips:

* Encourage small, frequent feedings. Avoid carbonated beverages, liquids with meals, spicy foods, high-fiber foods, greasy foods, fatty or fried foods.

* Avoid raw fruits and vegetables.

* Encourage fluids between meals. Avoid very hot or very cold foods and beverages.

* Limit caffeine (coffee, tea, cola, chocolate, etc.).

* Encourage bed rest.

* Offer salty foods or salt at the table (if permitted) to replace lost sodium. Offer foods high in potassium (bananas, potatoes, apricot nectar), if permitted, to replace lost potassium.

* Consider using fluid replacements that contain electrolytes.

* Investigate potential food intolerances--especially lactose intolerance.

* If diarrhea is severe, request a clear liquid diet, give liquids at room temperature and advance amounts as tolerated.

The following foods might be better tolerated by residents who experience diarrhea:

* Starches: rice, noodles, Cream of Wheat or farina, white bread

* Fruits and vegetables: pureed cooked vegetables, applesauce, grape or apple juice, ripe bananas, canned or cooked fruit without skins

* Protein foods: yogurt, eggs (completely cooked, not fried), smooth peanut butter, chicken, turkey, tender lean beef, low-fat beef, cottage cheese

Antidiarrheal medications might be needed if the condition is severe or persistent.

Dry mouth/sore mouth. Take these ideas into consideration:

* Provide good mouth care (frequent swabbing or brushing).

* Offer sips of fluids frequently.

* Offer ice chips.

* Remember that sorbets, lemon ice or sherbet, either with meals or in between, might be helpful. Lemon drops might also provide relief.

* If mouth discomfort is severe, refer the resident to a physician for treatment.

* Avoid acetic and spicy foods.

* Offer mild, bland foods.

* Encourage intake of fluids--keep resident well hydrated.

* Offer soft, chopped or ground foods if needed to ease chewing and formation of an easy-to-swallow bolus.

Taste/smell alterations. Consider these suggestions:

* Offer anything that the resident thinks he or she might like.

* Try spicy foods, if tolerated.

* Remember that decreased sense of smell can decrease taste sensations.

* If a heightened sense of smell triggers nausea, keep resident away from food preparation areas.

* Reassess medications, if the condition is severe.

Dysphagia (difficulty swallowing). Warning signs of dysphagia can include:

* Prolonged oral preparatory stage prior to ingesting food

* Need to swallow three to four times with each bite

* Coughing/choking before, during or after swallowing

* Wet, gurgly voice

* Pocketing food in the mouth

* Frequent clearing of the throat

* Persistence of food stuck in throat

* Inability to handle liquids or solids--spillage from mouth

If any of the above signs are noted, it is essential to refer the resident to a speech-language pathologist (SLP) for further evaluation. The SLP can complete a bed-side examination to assess the need for further diagnostic tests. The SLP can recommend proper food and liquid consistencies and proper positioning of the resident to ensure safe swallowing.

Dehydration risk. Pain medications that cause a decreased sensorium can make it difficult to drink, reach for fluids or communicate fluid needs and can cause a resident to refuse fluids. In addition, side effects that cause fluid loss (e.g., diarrhea, vomiting) can contribute to dehydration. Fluid-needs calculations are generally based on 30 cc/kg body weight (2.2 pounds = 1 kg), although residents with congestive heart failure, renal problems or dehydration might have different needs.

Fluids and products to use might include milk, juice, water, milkshakes, popsicles, ice cream, sherbet, gelatin or any food that is fluid at room temperature. All residents should have a water pitcher at their bedsides (barring any fluid restrictions). For residents with dysphagia who need thickened liquids, fluids should be thickened to the consistency ordered and as recommended by the SLP.

If fluids taken by mouth are not tolerated, an IV or tube feeding might be recommended. In these cases, the dietetics professional should assess IV or tube-feeding practices and adherence to flush recommendations, and re-evaluate as needed.

Summary

Pain and the side effects of pain medication can create many challenges for nursing and dietetics professionals. However, working together as a team, there is much that can be done to alleviate suffering and to prevent potential nutrition and hydration problems resulting from attempted pain relief.

Table. Pain Medications and Side Effects.

                                 [down arrow]  GI Distress  Nausea &
                                   Appettie                 Vomiting

Nonopioids:
ibuprofen (such as Motrin and         *             *          *
other NSAIDs)

celecoxib (Celebrex), rofecoxib       *             *
(Vioxx)

Opioids:
hydrocodone/acetaminophen                                      *
(Vicodin, lorcet, etc.)

acetaminophen with codeine                          *          *
(Tylenol #3)

propoxyphene...usually with                         *          *
acetaminophen (Darvocet,
Wygesic) Note: Propoxyphene
should not be used in the
elderly.

codeine                               *                        *

fentanyl patches (Duragesic)                        *          *

meperidine (Demerol)...also                         *          *
should not be used in the
elderly

morphine                              *                        *

oxycodone...both immediate            *             *          *
and time-released formulations

tramadol (Ultram)                     *             *          *

                                  Dry   Constipation  Diarrhe  Edema
                                 Mouth

Nonopioids:
ibuprofen (such as Motrin and      *         *           *       *
other NSAIDs)

celecoxib (Celebrex), rofecoxib              *           *       *
(Vioxx)

Opioids:
hydrocodone/acetaminophen          *         *
(Vicodin, lorcet, etc.)

acetaminophen with codeine         *         *
(Tylenol #3)

propoxyphene...usually with                  *
acetaminophen (Darvocet,
Wygesic) Note: Propoxyphene
should not be used in the
elderly.

codeine                            *         *

fentanyl patches (Duragesic)       *         *           *

meperidine (Demerol)...also        *         *
should not be used in the
elderly

morphine                           *         *           *       *

oxycodone...both immediate         *         *
and time-released formulations

tramadol (Ultram)                  *         *           *

                                 Drowsiness,
                                  Weakness

Nonopioids:
ibuprofen (such as Motrin and         *
other NSAIDs)

celecoxib (Celebrex), rofecoxib       *
(Vioxx)

Opioids:
hydrocodone/acetaminophen             *
(Vicodin, lorcet, etc.)

acetaminophen with codeine            *
(Tylenol #3)

propoxyphene...usually with           *
acetaminophen (Darvocet,
Wygesic) Note: Propoxyphene
should not be used in the
elderly.

codeine                               *

fentanyl patches (Duragesic)          *

meperidine (Demerol)...also           *
should not be used in the
elderly

morphine                              *

oxycodone...both immediate            *
and time-released formulations

tramadol (Ultram)                     *

Data complied from:

Pronsky Z. Food-Medication Interactions, 10th ed. 1997.

Roche Dietitians. Drug-Nutrient Resource. 2001.

Becky Dorner, RD, LD, is president of Becky Dorner & Associates, a dietary consulting company based in Akron, Ohio. For further information, phone [phone] or visit www.beckydorner.com. To comment on this article, please send e-mail to [e-mail].