Nurse "I am in Pain"

Submitted by Marina E. Bitanga BSN, RN, CCRN

Tags: chronic Chronic Pain pain pain management

The shift just started. You finished taking report on your patients when one patient called. You did not have the time to organize your work yet and check the other patients but you have to answer the call. When you went in the patient’s room, the patient is in the bed very agitated and restless stating that he/ she has been waiting for an hour for his/ her pain medicine and it has been two hours after the other nurse told him/ her that it is change of shift and the nurse following her will be medicating him/ her for the pain. “It is not right that patients have to wait this long to suffer from pain.” “Patients come in the hospital not to suffer but to be medicated and have relief from pain.” “I cannot stand the pain any longer. The medicine given to me earlier did not help me. I need a stronger pain medicine.” You hear these comments frequently. You know as the patient’s nurse, that you are there to help your patients get relief from pain. There are times when not only one but two of your patients will be needing their pain medicines at the same time. You try to do your best as quickly as you can, but you can only medicate one patient each time and you do not also want to make any mistakes. You have to check that you are giving the right medications to the right patient. The patient feels very frustrated and get mad at you for not medicating him/ her on time before the pain get worse. As the patient’s nurse, you also feel frustrated for not able to help your patient. At times you will hear the patient make a comment that you should feel the pain they feel or ask you if you ever have pain. You just take a big sigh and you say to yourself that you are a healthcare worker but it does not exempt you from having pain.

A patient came to the hospital for chronic back pain. Very emotional. In tears saying nobody is helping her. She had this problem for the past 7 years and she saw a neurosurgeon. She was referred to pain clinic and she only went one time claiming she is being given all kinds of drugs. She went to a chiropractor and also did yoga but nothing helps. She has high tolerance to the medications being given to her in the hospital. She said she does not have any quality of life. She has history of anxiety and depression.

This article will explore the definition of pain, cause of pain, signs and symptoms of pain, types of pain with emphasis on acute and chronic pain nursing assessments and interventions, how doctors diagnose and treatments for pain, and the factors affecting person’s tolerance to pain.

What is pain?

Pain is a concept of sensation that nobody wants to feel. It is a reaction to the stimulus of our surrounding, putting us in harm’s way and acting as a form of defense mechanism that our body has permanently installed into its system. It is an uncomfortable feeling that tells you something maybe wrong. It can be steady, throbbing, stabbing, aching, pinching, or pain can be described in many other ways. Pain can be just a nuisance like a mild headache and other times pain can be debilitating. Pain is distressing, subjective and complex phenomenon that all nurses will encounter in their clinical practice. It is one of the most common reasons why people seek care in a hospital. Effective pain management requires nurses to understand and structured assessment to identify the probable causes of pain and guide management. Interventions used to reduce pain can be varied and multimodal.

The International Association for the Study of Pain (IASP) defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Margo McCaffery, a nurse expert on pain, defined pain as “pain is whatever the person says it is and exists whenever the person says it does.”

Nurses are not to judge whether the acute pain is real or not. As a nurse, we should spend more time treating patients. It is our job as nurses and healthcare providers to relieve the pain and suffering of the people in our care. Patients are more likely to report being unhappy and not satisfied with their care if they have unrelieved pain during their stay. Nurses must regularly assess pain and collaborate with both the patient and provider to ensure that timely access to adequate pain relief is a priority of their care.

Pain when it is ongoing and uncontrolled has a detrimental, deteriorative effect on virtually every aspect of a patient’s life. It produces anxiety and emotional distress, undermines well-being, interferes with functional capacity, and hinders the ability to fulfill family, social, and vocational role.

Nurses are in the unique position to make a difference with individual patients as well as system – wide pain management protocols. Treating pain is not simple and it is a complex phenomenon that is experienced differently by everyone and influenced by many factors. The nurse plays a vital role in identifying patients with unrelieved pain and advocating for better pain management strategies.

Pain leads to a big financial burden within the healthcare system with continuous rehabilitation of patients with adverse pain sensations, which might reduce not only their quality of life but also their productivity at work setting backs the pace of our economy. It is estimated that 1 in 5 United States adult had chronic pain in 2019. 1 in 14 adults experienced high impact chronic pain, defined as having pain most days or every day in the past 3 months that limited life or work activities. Chronic pain is the leading cause of disability in the United States.

In 2011, researchers estimated that pain cost the United States between $560 billion and $635 billion each year in treatment costs, lost wages, and missed days of work.

Pain is a complex phenomenon that is influenced by many factors, including biological, psychological, and social factors. There are substantial differences in pain treatment effectiveness. Prevention, assessment, and treatment of pain is a persistent challenge for clinicians and health systems.

Importance of Controlling Pain

At some point in life, virtually everyone experiences some type of pain. Inadequately managed pain can lead to adverse physical and psychological patient outcomes for individual patients and their families. Continuous, unrelieved pain activates the pituitary – adrenal axis, which can suppress the immune system and result in postsurgical infection and poor wound healing. Sympathetic activation can have negative effects on the cardiovascular, gastrointestinal, and such as cardiac renal systems which can predispose patients to adverse events such as cardiac ischemia and ileus.

Unrelieved pain reduced patient’s mobility which can result in complications such as deep pain thrombosis, pulmonary embolus, and pneumonia. Continuous, unrelieved pain affects psychological state of the patient and family members which includes anxiety and depression. It may create a sense of helplessness and even hopelessness. Several patients come to the hospital secondary to back pain, either acute or chronic, and they have difficulty getting up in bed or they claimed when they move the pain gets worst. These patients need adequate pain control and management so they can be able to get up and walk. Trauma patients with rib fractures need pain medicines so they can do the incentive spirometer or take deep breathing and coughing. We know as health care providers that patients under our care need our help to make them comfortable.

Poorly managing pain may put clinicians at risk for legal action. Pain must be promptly addressed and managed. Nurses as part of the collaborative team responsible for managing pain during hospitalization maybe liable for legal action for poor pain management. Hospitals tend to loose reputation as well as profit if pain is poorly managed. Patient satisfaction with care is strongly tied to their experiences with pain during hospitalization.

Factors that Influence an Individual’s Pain Tolerance Levels:

A person’s pain tolerance refers to how much pain they can reasonably handle. Some people have a much higher pain tolerance than others.

Genes

One review notes researcher believes genetic factors play a role in up to 60% of responses that lead to pain. However, the study also notes that this varies greatly, depending on the type of pain and stimulus the person experiences.

Scientists believe that genetic variations can determine risk for developing chronic pain, how sensitive we are to painful stimuli, whether certain therapies will reduce our pain, and how we experience acute and/ or chronic pain. Many genes contribute to pain perception, and mutations in one or more pain – related genes account for some of the variability of pain experiences.
Age

May affect certain experiences of pain depending on the patient’s age level. A very young child will often have a much lower pain tolerance than adult.
Stress

Stress level influence other leading to a person being on edge or expecting pain or other stressors.
Expectation

Expectation of pain plays a role in how people feel pain. A person who expects higher pain may feel pain more intensely when it arrives.
Experience of pain

A person’s previous experiences with a certain type of pain can also shape how they experience pain in the future. If a person remembers a painful experience, they may be expecting a similar pain in the future, making the experience more painful when it happens again.
Mental health issues

Some people with depression and anxiety may experience more feelings of pain.
Chronic illnesses

People with chronic pain may become very sensitive to that type of pain, effectively reducing their pain tolerance.
Other factors

- Drugs a person takes
- Severe lack of sleep or insomnia
- Lifestyle choices such as smoking

What causes pain?

People feel pain when specific nerves called nociceptors detect tissue damage and transmit information about the damage along the spinal cord to the brain. If you touch a hot surface, this will send a message through a reflex arc in the spinal cord and cause an immediate contraction of the muscles. This contraction will pull the hand away from the hot surface, limiting further damage.

This reflex occurs before the message reaches the brain. Once the pain message arrives, it causes an individual to feel the pain. The brain’s interpretation of these signals and the efficiency of the communication channel between the nociceptors and the brain dictate how an individual experiences pain. The brain may also release feel-good chemicals, such as dopamine, to counter the unpleasant effects of pain.

Common causes of pain:

Headache
Toothache
Sore throat
Stomach aching or cramps
Muscle cramps or strains
Cuts, burns, or bruises
Bone fracture
Illnesses or disorders such as flu, arthritis, endometriosis, and fibromyalgia
Back pain, neck pain
Chest pain
Flank pain
Fibromyalgia

Types of Pain:

Acute pain

This pain develops over a short period of time, tends to occur suddenly, often because of a known injury, illnesses, or medical procedure. It tends to be sharp, goes away within a few days, weeks, or months, after the cause has been treated or resolved.

Chronic pain

This type of pain lasts, or comes and goes, over multiple months or years.
Some people may experience chronic pain following an injury, even after the initial injury has healed.
The cause is hard to identify. Some people experience chronic pain when there is no other evidence of underlying injury of illness.
The National Health Interview Survey found that in 2019, roughly 1 in 5 adults in the United States had chronic pain. More than 7 percent had chronic pain that frequently limited their activities at work or in wider life.
Recent studies have found that some people with chronic pain may have low levels of endorphins in their spinal fluid. Endorphins are neurochemicals which have similarity to opiate drugs (like morphine), that are produced in the brain and released into the body in response to pain. Endorphins act as natural pain killers. Chronic pain most often affects older adults, but it can occur at any age.

Complications of Chronic Pain:

Decreased quality of life.
Depression
Anxiety
Substance abuse disorders
Worsening of existing chronic disease
An increased risk of suicidal ideation and/ or suicide

Nociceptive pain

This type of pain is caused by tissue damage or certain health conditions that cause tissue inflammation and damage. Somatic pain is when nociceptive pain develops in your skin, muscles, ligaments, tendons, joints, or bones. It is called visceral pain when it develops in your internal organs.

Maybe acute or chronic
May feel achy, throbbing, or sharp

Neuropathic pain

Results from nerve damage, which maybe caused by variety of injuries and illnesses like disc problem, shingles, diabetes, multiple sclerosis, or cancer.
One study in the United States found that 10 percent of adults experience pain that is likely neuropathic.
This type of pain may feel like stabbing, shooting, burning, or pricking sensation.
Hypersensitive to touch, movement, or hot and cold temperatures.

Functional pain

This is caused by no obvious injury or damage to your body.
Tends to be chronic though acute functional pain may also develop
More than 15 percent of the world’s population has functional pain syndrome, according to report of researchers in BJA Education.

Examples of this type of pain include:

Fibromyalgia – causes widespread pain throughout the body.
Irritable Bowel Syndrome (IBS) – causes abdominal pain.
Temporomandibular syndrome causes jaw pain.
Chronic cardiac chest pain

Indications of Pain:

Restlessness, agitation
Crying
Moaning and groaning
Grimacing
Resistance to care
Reduced social interactions
Increasing wandering
Not eating, loss of appetite
Depression
Sleeping problems
Verbalizations that he/ she is in pain
Rubbing/ massaging affected areas
Hyperventilating, shortness of breath, increased respiration
Increased heart rate
Increased blood pressure

Barriers that Prevent Patients from being Appropriately Treated for their Pain:

Lack of knowledge or skills about nursing interventions for acute pain management.
Heavy nursing workload or lack of time.
Providers' concerns about causing tolerance or addiction.
Patient fears of side effects of the pain medicine or addiction.
Insufficient provider orders or time to premedicate patients before painful procedures.
Providers focus on treating pathophysiology rather than managing pain or other symptoms.

Ways to Reduce Pain:

1. Get some gentle exercise

Walking, swimming, gardening, and dancing can ease some of the pain directly by blocking pain signals to the brain.
Helps lessen pain by stretching stiff and tense muscles, ligaments, and joints.
The benefits of exercise far outweigh any increase in pain.

2. Breathe right to ease pain

Concentrate on your breathing when you are in pain. Breathe slowly and deeply.
When the pain is intense, the patients start taking shallow, rapid breaths, which can make them feel dizzy, get anxious or panicked.

3. Reads books and leaflets on pain

Give advice on how to live better with long term pain.
How to better manage pain.

4. Counseling can help with pain

Pain can make you tired, anxious, depressed, and grumpy making pain even worse.
Counsellor, psychologist, or hypnotherapist help people discover how to deal with their emotions in relation to their pain.

5. Distract yourself

Shift your attention on to something so the pain is not the only thing on your mind.
Find some activity you enjoy as stimulating.

6. Share your story about pain

It can help to talk to someone else who had experienced similar pain themselves and understands what you are going through.

7. The sleep cure for pain.

Stick to normal sleep routine
Sleep deprivation can make pain worse. Go to bed at the same time each evening and get up at regular time in the morning and avoid taking naps in the day.

8. Take a course

Self-management courses help develop new skills to manage their condition on a day-to-day basis.

9. Keep in touch with both friends and family

Good for your health and help you feel better.
Aim to talk anything other than your pain.

10. Relax to beat pain

Practicing relaxation techniques regularly can help reduce persistent pain.
Breathing exercises or some types of meditation.

How Pain is Diagnosed:

How the individual describes the pain subjectively will help the doctor make the diagnosis. Only the person experiencing pain can describe how much pain he/ she is feeling. There is no way to objectively measure pain.

Asking the individual to describe pain history.
Describe character of all pains such as burning, stinging, or stabbing
The site, quality, and radiation of pain meaning where, and if the person feels the pain, what does the pain feels like, and how far it seems to have spread.
What factors aggravate and relieve the pain.
The times at which pain occurs throughout the day.
It’s effect on the person’s daily function and mood.
The person’s understanding of their pain.
For chronic pain, the doctor will want to know whether you have a lot of stress or anxiety in your life. There is high prevalence of depression, anxiety, and emotional distress associated with chronic pain.
It will be helpful to know if you have had any illnesses or surgeries.

The healthcare provider may order diagnostic tests and imaging to assess pain intensity and diagnose or rule out any conditions. Approaches and technologies health care providers use to identify the cause of patient’s pains:

Musculoskeletal and neurological examination

Physician tests movement, reflexes, sensation, balance, and coordination.

Laboratory tests

Tests including blood, urine, cerebrospinal fluid can help the physician diagnose the infection, cancer, nutritional problems, endocrine abnormalities, and other conditions that cause pain.

Electrodiagnostic procedures including electromyography (EMG), nurse conduction studies, evoked potential (EP) studies and quantitative sensory testing.

Measure the electrical activity of muscle and nerves. Help physicians evaluate muscle symptoms that may result from disease or injury to the body’s nerves or muscles.
EMG tests muscle activity and identifies which muscles or nerves are affected by weakness or pain.
Nerve conduction studies (usually performed along with an EMG) record how nerves are functioning.
EP studies measure electrical activity in the brain in response to sight, or touch stimulation.

Quantitative sensory testing

Can establish threshold for sensory perception which can be compared to normal values. These tests are used to detect abnormalities in sensory function and nerve disorders.

Imagings:

Magnetic resonance imaging or MRI

This provides a look inside the body’s structures and tissues such as the brain and spinal cord. MRI uses magnetic fields and radio waves to differentiate between healthy and diseased tissues. Ultrasound imaging uses high- frequency sound waves to obtain images inside the body.

Nerve Blocks

Treat and help to diagnose the cause of pain. A person’s response to nerve blocks may help provider to determine what is causing the pain or where it is coming from.
X-rays

Produce pictures of the body’s structures, such as bones and joints. Bone scans can help diagnose and track infection and fractures, or other bone disorders.

Some of the pain measures that doctors use are:

Numerical rating scale

This measures pain on a scale 0-10 where 0 means no pain at all, and 10 represents the worst pain imaginable. Useful for gauging how pain levels change in respond to treatment or a deteriorating condition
Verbal descriptor scale

May help doctor measure pain levels in children with cognitive impairments, older adults, autistic people, and those with dyslexia. This pain measure scale asks different descriptive questions to narrow down the type of pain.
Faces scale

Doctors show the person in pain a range of expressive faces from distressed to happy. This scale is use with children. There is an effective response in autistic people using this scale.
Brief pain inventory

Detailed written questionnaires that helps doctors gauge the effect of a person’s pain on their mood, activity, sleep patterns, and interpersonal relationships.

Helps chart the timeline of the pain to detect any patterns.
McGill Pain Questionnaire (MPQ)

Encourages people to choose words from 20 words groups to get an in-depth understanding of how the pain feels.

Treatments for Pain:

1. Injections – used to deliver pain relief medications locally.

Facet injections – target the facet joints. A person may notice longer lasting relief starting two to five days after injection.
Steroid injections – work by decreasing inflammation and reducing the activity of the immune system. Injecting steroids into one or two local areas allows doctors to directly deliver a high dose of medication.
Sacroiliac joint injection – used to diagnose the source of a person’s pain, as well as to provide therapeutic pain relief associated with sacroiliac joint dysfunction. The injection provides pain relief by reducing inflammation within the joint.
Trigger point injections – involves injecting a small amount of local anesthetic, sometimes with a steroid medication directly into a painful trigger point (a specific site on the muscles that causes pain when pressed during an exam).

2. Low-pressure lasers – this low intensity light therapy (not thermal) triggers biochemical changes within cells and may have an effect on pain, inflammation, and tissue repair, but this method is controversial.

3. Marijuana (cannabis) – highly controversial as a medical treatment to manage pain. Several states and the District of Columbia permit the use of medical marijuana as a treatment although marijuana has not been approved for any medical use at the federal level.

Marinol – FDA approved medication with the active ingredient dronabinol, and synthetic form of tetrahydrocannabinol (THC) used to treat chemotherapy – induced nausea and vomiting.

4. Muscle relaxants – used to relax and reduce torsion in muscles. The term “muscle relaxers” describes a group of drugs that act as central nervous system depressants and have sedative properties for musculoskeletal pain.

Anxiolytics include benzodiazepines, used to decrease central nervous system activity.

5. Nerve Blocks – use drugs, chemical agents, or surgical techniques to interrupt the relay of pain messages between specific areas of the body and the brain.

May involve local anesthesia, regional anesthesia, or analgesia, or surgery.
Can be used to prevent or even diagnose pain and may involve injection of local anesthetics to numb the nerve and/ or steroids to reduce inflammation.

6. Neurolytic blocks – employ injection of chemical agents such as alcohol, phenol, or glycerol, or the use of radiofrequency energy, to kill nerves responsible for transmitting nociceptive signals.

7. Sympathectomy or sympathetic blockade typically involves injecting local anesthetic next to the sympathetic nervous system which is involved with regulating heart rate, breathing, blood pressure, and response to stressful or dangerous situations.

8. Surgical blocks – performed on cranial, peripheral, or sympathetic nerves. This includes:

Spinal dorsal rhizotomy in which the surgeon cuts the root of the rootlets of one or more of the nerves radiating from the spinal cord.

9. Relaxation / Mindfulness

Radiofrequency ablation (RFA) – uses electrical current produced by a radio wave to heat up a small area of nerve tissues, thereby decreasing pain signals from that specific area. The degree of pain relief can vary depending on the cause and location of the pain.
Pain relief up to 6 – 12 months to some individuals.

10. Serotonergic agonists – used specifically for acute migraine headaches because they block pathways in the brain.

11. Surgery

Recommended for some people with pain that significantly impacts their daily functioning.
Considered when less invasive treatments have not been helpful.

Acute Pain Nursing Assessment:

1. Perform a comprehensive assessment of pain. Determine the location, characteristics, onset, duration, frequency, quality, and severity of pain via assessment.

The patient experiencing pain is the most reliable source of information about their pain. Their self-report on pain is the gold standard in pain assessment as they can describe the location, intensity, and duration of pain.

As the nurse, you can use the nursing mnemonic “PQRST” to guide you during pain assessment.

Provoking factors: “What makes your pain better or worse?”

Quality (characteristics): “Tell me what it is exactly like, is it sharp pain, throbbing pain, dull pain or stabbing.”

Region (location): “Show me where your pain is.”

Severity: Ask your patient to rate pain by using different pain rating methods.

Temporal (onset, duration, frequency): :Does it occur all the time or does it come and go?”

2. Assess the location of the pain by asking to point to the site that is discomforting.

Using charts or drawings of the body can help the patient, and the nurse determines specific pain locations. Clients with a limited vocabulary, asking to pinpoint the location helps in clarifying your pain assessment.

3. Perform history assessment of pain. The nurse should ask the following questions during pain assessment to determine the history:

Effectiveness of previous pain treatment or management
What medications were taken and when
Other medications being taken
Allergies or known side effects to medications

4. Determine the client’s perception of pain.

Provide an opportunity for the client to express in their own words how they view the pain and the situation to gain an understanding of what the pain means to the client.

5. Pain should be screened every time vital signs are evaluated.

Pain assessment is set by many health facilities as the “fifth vital sign” therefore should be added to the routine vital signs assessment.

6. Pain assessment must be initiated by the nurse. Each person has unique pain responses. Some clients need to be asked about their pain since they maybe reluctant to report or voice out their pain.

7. Use the Wong-Baker FACES Rating Scale to determine pain intensity.

For patients who may not relate to numerical pain scales. Pain assessment tools help translate the patient’s subjective experience of pain into objective numbers or descriptors.

8. Investigate signs and symptoms related to pain.

Bringing attention to associated signs and symptoms may help the nurse in evaluating the pain.

9. Determine the patient’s anticipation of pain relief.

Some patients may be satisfied when pain is no longer intense, others will demand complete elimination of pain. This influences the perceptions of the effectiveness of the treatment modality and their eagerness to engage in further treatment.

10. Assess the patient’s willingness or ability to explore a range of techniques to control pain.

The nurse has the duty to inform the patient of the different methods to manage pain with the use of nonpharmacological methods and traditional pharmacological methods.

11. Determine factors that alleviate pain.

Ask the client to describe anything they have done to alleviate pain.

12. Evaluate the patient’s response to pain and management strategies.

It is essential to assist patients to express as factually as possible the effect of pain relief measures. Inconsistencies between behavior or appearance and what the patient says about pain relief (or lack of it) may reflect other methods the patient is using to cope with the pain rather than pain relief itself.

13. Provide ample time and effort regarding the patient’s report of the pain experience.

Patients may be reluctant to report their pain as they may perceive staff to be very busy and have competing demands on their time from other nurses, doctors, and patients. Interruptions during pain management can prevent nurses from assessing and managing the patient’s pain experience.

14. Evaluate what the pain suggests to the patient.

The meaning of pain will directly determine the patient’s response.

Nursing Interventions for Acute Pain:

1. Provide measures to relieve pain before it becomes severe

Preferable to provide an analgesic before the onset of pain or before it becomes severe when a larger dose maybe required.

2. Acknowledge and accept the client’s pain

Nurses have the duty to ask their clients about their pain and believe their reports of pain. Challenging or undermining their pain reports results in an unhealthy therapeutic relationship that may hinder pain management and deteriorate rapport.

3. Provide nonpharmacologic pain management

3.1 Includes physical, cognitive, behavioral strategies, and lifestyle pain management

Distraction causing patient’s mind away from the pain lessens the perception of pain and works briefly by increasing the pain threshold. This should be utilized for short duration, usually less than 2 hours at a time to prevent fatigue which may lead to exhaustion and may further increase the pain when the distraction is no longer present.
Relaxation Response

Stress correlates an increase in pain perception by increasing muscle

tension and activating the SNS. Eliciting a relaxation response decreases

the effects of stress on pain.

Guided Imagery

Involves use of mental pictures or guiding the patient to imagine an event

to distract from pain.

Repatterning Unhelpful Thinking

Involves patients with strong self-doubts or unrealistic expectations that

may exacerbate pain and result in failure in pain management.

3.2 Provide cutaneous stimulation or physical interventions

Works by distracting the client away from the painful sensations through tactile

stimuli.

1. Massage – massaging affected area when appropriate interrupts the pain transmission, increases endorphin levels, and decreases tissue edema.

2. Heat and cold applications – cold reduce pain, inflammation, and muscle spasticity by decreasing the release of pain-inducing chemicals and slowing the conduction of pain impulses. Cold best applied within the first 24 hours of injury while heat is used to treat the chronic phase of an injury by improving blood flow to other area and through reduction of pain reflexes.

3. Acupressure – Ancient Chinese healing system of acupuncture wherein the therapist applies finger pressure points that correspond to many of the points used in acupuncture.

4. Collateral stimulation – stimulating the skin in an area opposite to the painful area when the painful area cannot be touch.

5. Transcutaneous electrical nerve stimulation (TENS) – application of low voltage electrical stimulation directly over the identified pain area or along with the areas that innovate pain.

6. Immobilization – splints or supportive device to hold joints in the position optimal to function.

4. Provide pharmacologic pain management as ordered

Narcotics / Opioid analgesics will help lessen pain by binding with opiate receptors throughout the body.
Non opioids (NSAIDs) like aspirin, Tylenol, Celebrex. These agents inhibit the synthesis of prostaglandins that cause pain in peripheral tissues, inflammation, and edema.
Co analgesic drugs like antidepressants which has effects on patient’s mood and have analgesic properties as well, local anesthetics, anxiolytics, sedative, antispasmodics.

5. Manage acute pain using a multimodal approach

Based on using two or more distinct methods or drugs to enhance pain relief. Combining medications and techniques allows the lowest effective dose of each drug to be administered resulting in decreasing side effects.

6. Administer analgesic before painful procedures whenever possible.

7. Perform nursing care during the peak effect of analgesics. Oral analgesics typically peak in 60 minutes and intravenous analgesics in 20 minutes. This will optimize client comfort and compliance in care.

8. Evaluate the effectiveness of analgesics as ordered and observe for any signs and symptoms of side effects.

Nursing Assessment of Chronic Pain:

Assess and document pain characteristics:

-          Quality: sharp, burning
-          Severity: using 0-10 pain scale with 0 meaning without pain and 10 having the most severe pain
-          Location
-          Onset: gradual or sudden
-          Duration: continuous or intermittent
-          Precipitating factors
-          Relieving factors
Assess and note for signs and symptoms related to chronic pain such as weakness, decreased appetite, weight loss, changes in body postures, sleep pattern disturbance, anxiety, irritability, agitation, or depression.
Assess the patient’s perception of the effectiveness of techniques used for pain relief in the past.
Evaluate factors such as genders, cultural, societal, and religious features that may influence the patient’s pain experience and reaction to pain relief.
Assess the patient’s beliefs and expectations about pain relief. Patients with chronic pain may not anticipate complete relief of pain but maybe satisfied with diminishing severity of the pain and increasing activity level.
Evaluate the patient’s approach toward pharmacological and non-pharmacological approach to pain management. Patients may perceive medications as the only effective treatment to alleviate pain and may question the effectiveness of non-pharmacological treatment.
Know more about the side effects, dependency, and tolerance of patients taking opioid analgesics.
Determine patient’s current medication use to aid in planning pain treatment.
Evaluate the patient’s ability to perform and fulfill activities of daily living, instrumental activities of daily living, and demands of daily living. This can be limited by exhaustion, anxiety, and depression linked to chronic pain.

Nursing Interventions of Chronic Pain:

Allow patient to maintain a diary of pain ratings, timing, precipitating events, medications, treatments, and what works best to relieve pain.
Recognize and convey acceptance of the patient’s pain experience. This will promote a more cooperative nurse – patient relationship.
Aid patient in making decisions about choosing a particular pain management strategy. The nurse can increase the patient’s willingness t o adopt new interventions to promote pain relief through guidance and support.
Explore the need for medications from the three classes of analgesics: opioids, non-opioids, Cox-2 inhibitors, and nonsteroidal anti-inflammatory drugs, and adjuvant medications.
If patient is receiving parenteral analgesia, use an equianalgesic chart to convert to an oral or another noninvasive route as smoothly as possible.
Allow the patient to describe appetite, bowel elimination, and ability to rest and sleep. Obtain medications to administer and treatments to improve these functions. Prescription for a peristaltic stimulant must be obtain to prevent opioid-induced constipation.
There must be prescriptions to increase or decrease analgesic doses when indicated. Opioid doses should be adjusted individually to achieve pain relief with an acceptable level of adverse effects.
Monitor sedation and respiratory status for a brief time if opioid dose is increased.
Educate patient regarding pain management approach that has been ordered.
Discuss patient’s fears of undertreated pain, addiction, and overdose.
Review patient’s pain diary, flow sheet, and medication records to determine overall degree of pain relief, side effects, and analgesic requirements for an appropriate period.
Maintain the patient’s use of nonpharmacological methods to control pain including distraction, imagery, relaxation, massage, and heat and cold application.
Implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions.
Plan care activities around periods of greatest comfort whenever possible.
Examine relevant resources for management of pain on a long-term basis example hospice, pain care center.
If patient has growing cancer pain, assist patient and family with managing issues related to death and dying.
If patient has chronic nonmalignant pain, help patient and family in lessening effects of pain on interpersonal relationships and daily activities such as work and recreation. Support active patient’s involvement in effective and practical methods to manage pain.
Validate the patient’s feelings and emotions regarding current health status. This promotes the nurse-client relationship.
Refer the patient and family to community support groups and self-help groups for people coping with chronic pain. This will help client reduce the burden of suffering associated with chronic pain.
Refer the patient to a physical therapist for assessment and evaluation. This is to promote muscle strength and joint mobility and therapies to promote relaxation of tense muscles.
Provide the patient and family with adequate information about chronic pain and options available for pain management.

Conclusion

Pain is a sign that something is wrong in your body. It maybe caused by a wide variety of injuries, diseases, and functional pain syndromes. In general, most effective way to treat pain is to address the underlying cause if it can be identified. In some cases, the injury or illness causing the pain may eventually heal. In other cases, you may need medication, surgery, or other therapies to treat the cause. Sometimes, your provider may not be able to identify the cause.

If you think pain is caused by a serious injury or illness that requires medical attention to treat, contact your doctor or emergency medical services. Let them know if you have been experiencing pain that interferes with your daily life.

Your healthcare professional can help you develop a plan to manage the pain. Education about safe pain management will help prevent undertreatment of pain and the resulting harmful effects. Safety includes the use of appropriate tools for assessing pain in cognitively intact adults and cognitively impaired adults. Use of analgesics, especially opioids is the foundation of treatment for most types of pain. Safe use of analgesics is promoted by utilizing a multimodal approach, that is, using more than one type of analgesics to treat the individual’s pain. Opioid is often avoided or inadequate for fear of causing life-threatening respiratory depression. Nurse monitoring of sedation levels when opioids are initiated is one way to assure safety. While nondrug techniques pose minimal safety issues, the current evidence does not support that these techniques produce consistent, predictable pain management outcomes.

Our foremost duty to patients with chronic pain is not to reduce their pain intensity but to improve their health. This consists of increasing the capacity of patients to be agents in their own lives. We seek to provide patients with the capability to form and sustain relationships. It means the ability to carve one’s own environmental niche in the complex natural and social environmental that is human society. When most potent analgesics erodes that ability, it is time to rethink what duty to relieve pain will actually means.

References:

General pathways of pain sensation and the major neurotransmitters involved in pain regulation. Yam, M F, Loh, Y C, Basin, R. Int J Mol Sci 2018 Aug; 19 (8): 2164. Published on line 2018 July 24 doi: 10.3390/ijms 19082164. https://www.ncbi.nih.gov>pmc. Retrieved July 5, 2022.
What is pain/ types of pain treated? – John Hopkins Medicine. https://www.hopkinsmedicine.org
High pain tolerance: causes, influences, and how to affect it. Medical News Today. Johnson, J. https://www.medicalnewtoday.com>... Retrieved July 5, 2022
Everything you need to know about pain. Gabbey, A E. April 5, 2021. https://www.healthline.com>health.
Healthcare Editorial Staff and Lewis, S. April 28, 2021. Retrieved August 9, 2022
What is pain, and how do you treat it? – Medical News Today. Felman, A. February 2, 2022. https://www.medicalnewstoday.com>...Retrieved July 5, 2022
NHS ways to manage chronic pain. March 26, 2020. https://www.nhs.ok>LiveWell>Pain. Retrieved July 16, 2022.
What do we owe patients with chronic pain? Sullivan, M D. January 14, 2019. https://www.ncbi.nim.nih.gov. Retrieved July 15, 2022.
Improving the quality care through pain assessment and management. Wells, N, Pasero, C, McCaffery, N. ND. www.ncbi.nim.nih.gov. Retrieved August 5, 2022.
Acute pain nursing care plan. Wayne, G. May 8, 2022. https://www.nurselabs.com>acute-pain. Retrieved July 21, 2022
Chronic pain nursing care plan. Wayne, G. March 19, 2022. https://nurselabs.com>...>Nursing Diagnosis. Retrieved July 23, 2022.
Pain: hope through research. NIH- National Institute of Neurological Disorders and Stroke. July 25, 2022. Ninds.nih.gov. https://www.ninds.gov>patient-caregiver-educarion. Retrieved August 4, 2022.