Learning Objectives
1. Identify the major underlying causes of pain.
2. Differentiate between the two major types of pain.
3. Discuss the concept of pain as the fifth vital sign.
4. Identify important nursing considerations when assessing pain.
5. Discuss the impact of chronic pain on a person’s life and family.
6. Describe the function of endorphins in pain management.
7. Explain the role of analgesics in pain management.Name the different classes of analgesics and the specific uses for each.
8. Describe how surgery can provide comfort and pain relief.
9. List and describe physical and cognitive-behavioral measures that can be used to complement pharmacologic pain management.
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IMPORTANT TERMINOLOGY |
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acute pain |
endorphins |
pain |
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adjuvant |
guided imagery |
pain threshold |
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analgesics |
intractable pain |
pain tolerance |
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body cue |
neuropathic pain |
referred pain |
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cancer pain |
nociception |
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chronic pain |
nociceptive pain |
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Acronyms
IASP
NSAIDs
PCA
TENS
Pain, the body’s signal of distress, is very difficult to ignore. It is one of the most common reasons that people seek healthcare. People try many remedies to relieve pain, often without success. Relieving pain and providing comfort are common and ongoing nursing challenges.
PAIN
Pain is difficult to define. It is a subjective symptom; only the client can describe it. It cannot be objectively measured by the practitioner. A noted pain theorist, Margo McCaffery, states in her classic writing that “Pain is whatever the experiencing person says it is, existing whenever he says it does” (McCaffery, 1968). In its clinical practice guidelines for acute pain management, the Agency for Healthcare Research and Quality (AHRQ) states that the “client’s self-report is the single best indicator of pain.” The definition of pain in a medical dictionary includes “a feeling of distress, suffering, or agony, caused by stimulation of specialized nerve endings. Its purpose is chiefly protective; it acts as a warning that tissues are being damaged and induces the sufferer to remove or withdraw from the source” (Miller-Keane & O’Toole, 2003). The North American Nursing Diagnosis Association (NANDA) has also accepted pain as a specific nursing diagnosis.
Causes of Pain
The person in pain seeks relief from discomfort. Determining the pain’s cause is key, so that effective treatment may begin as soon as possible. The causes of pain vary, and sometimes a definite cause may be difficult or impossible to determine. Regardless of the cause, nursing care is directed at relieving pain. Providing relief and comfort through medication administration and various other interventions is an important nursing responsibility.
Several factors can initiate the pain response. Physical causes include the mechanical stress of trauma, surgical incision, or tumor growth. The body responds with pain and discomfort to excesses in pressure, heat and cold, and certain chemical substances (e.g., histamine, bradykinin, and acetylcholine) released when tissues are damaged or destroyed. A lack of oxygen to tissues also causes pain as tissues suffer from oxygen deprivation. Muscle spasms and resulting decreased blood supply to muscles can also cause pain and discomfort. As discomfort increases, the body’s natural response is to tighten muscles further, accentuating the problem. Fatigue, fear of the unknown, and lack of knowledge about pain management can cause further muscle tightening. Without intervention, a vicious cycle of pain can follow (Fig. 55-1). Pain receptors do not become less sensitive to adverse stimulation as the adverse stimulation continues, which makes it necessary to treat the pain or remove the cause.
FIGURE 55-1 · The pain cycle and some factors affecting it. Without intervention, the cycle continues and often worsens.
Key Concept Pain exists, even if no definite physical cause can be found. If the client feels pain, it is real to that person.
Pain Transmission
The term used to describe normal pain transmission and interpretation is nociception. It has four phases:
• Transduction: The nervous system changes painful stimuli in the nerve endings to impulses.
• Transmission: The impulses travel from their original site to the brain.
• Perception: The brain recognizes, defines, and responds to pain.
• Modulation: The body activates needed inhibitory responses to the effects of pain (Craven & Hirnle, 2007). If this modulation response of the body is not successful, external intervention is required to manage the pain. Some of these interventions are discussed later in this topic.
Types of Pain
The International Association for the Study of Pain (IASP) has identified several categories of pain. Among these are acute pain, referred pain, cancer pain, and chronic pain.
Acute pain is usually a sensation that occurs abruptly, most often in response to some sort of trauma. Common causes of acute pain are accidental trauma, infection, and surgery. It exists for only a short period of time, typically 6 months or less, and is usually intermittent, not constant. Acute pain results from the nervous system’s normal processing of trauma to the skin, muscles, and visceral organs. Another term for acute pain is nociceptive pain. After the underlying cause is identified and successfully treated, acute pain disappears.
Referred pain is pain that originates in one body part, but is perceived in another part of the body. It most often originates within the viscera (internal organs) and may be perceived in the skin, although it may be perceived in another internal area as well.
Cancer pain is a result of some sort of malignancy. Often, cancer pain is very severe and may be considered intractable (untreatable) and chronic. Hospice nursing is often involved with the management of cancer pain.
Chronic pain (also called neuropathic pain) is defined as discomfort that continues for a long period (6 months or longer) and may exist for the client’s entire life. Often, chronic pain interferes with a person’s normal functioning. The cause of chronic pain is often unknown. It may actually be a result of faulty processing of sensory input by the nervous system.
Neuropathic pain syndromes are very difficult to treat, and the exact mechanisms involved are not fully understood. Chronic pain often continues beyond what would be expected to be a normal healing period for acute pain. Individuals with neuropathic pain typically report constant burning, tingling sensations, and/or shooting pain. Customary interventions for relieving such pain may be ineffective; more aggressive measures are usually necessary.
The term used for chronic pain that resists therapeutic interventions is intractable pain. This type of pain can have a known cause, such as an inoperable invasive tumor, or the cause may be unknown.
The effects of chronic pain can be destructive to a person’s lifestyle and outlook, especially if the cause is unknown. The person’s reaction may be frustration and anger; however, the person may find that expressing these feelings is difficult because family and friends have become complacent or do not seem to understand. The client may not want to worry loved ones, or the loved ones may have become tired of constantly hearing about the pain. Thus, the client may avoid talking about it. Often, the more anger, anxiety, and distancing the client feels, the more difficult the pain and frustration become. The client may even begin to feel that no one else believes the pain is real.
When a person fails to express feelings, suppressed anger may turn inward and cause depression. Symptoms of depression include extreme fatigue, inability to sleep or sleeping too much, lack of interest in surroundings, lack of or excessive appetite, guilt feelings, sexual impotence, and withdrawal from social activities.Persons with depression often suffer from lack of self-esteem and may feel worthless or burdensome to others. Severe depression, particularly when combined with chronic pain, can contribute to substance abuse and dependency and presents a real danger of suicide or other self-injurious behavior.
Continued chronic pain may cause a person to withdraw socially and to become physically inactive. Unfortunately,inactivity aggravates pain because muscles and joints stiffen and begin to deteriorate; then, the symptoms intensify.
TABLE 55-1. Results of the Chronic Pain Experience
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CHARACTERISTICS |
SUGGESTED APPROACHES |
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Loss of control |
Regain control over one part of life at a time; set intermediate goals with target dates; write out all goals and check off as they are accomplished |
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Decreased self-esteem |
Participate in support groups, affirmations; build on abilities, not disabilities; find recreational activities that are achievable |
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Decreased communication (family members do not want to hear about pain anymore) |
Talk to others with chronic pain; limit talking about pain with family to a specified length each day; attend support group and individual therapy sessions; help family realize that many people experience chronic pain and it is very difficult; encourage family members to also join a support group, to enhance understanding |
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Inappropriate life goals |
Try to control pain while resuming normal activities, trying for a longer period each day; prepare for possible job retraining if necessary; revise goals as necessary, to take chronic pain into consideration |
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Change in relationships; lack of sexual activity; role changes within family |
Attend marriage and family therapy; encourage expressions of love and caring even though sexual activity may be difficult; seek financial counseling; explain to family why life is changed and what activities can continue; encourage family activities; assume leadership again gradually, one step at a time |
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Anger of family and friends over need to "take care of” client or do client’s work |
Participate in family therapy; receive vocational counseling; try to find appropriate job within capabilities (start with volunteer work, if necessary) |
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Decreased activity |
Find alternative activities, hobbies, entertainment; attempt to be active in something, such as a club, part-time job, volunteer work, visiting with grandchildren, or church |
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Decreased endurance |
Build up strength gradually; find activities that are possible at present, such as walking, riding stationary bicycle, swimming, low-impact aerobic exercise; participate in activities with other clients who have chronic pain; keep moving, to avoid further deterioration and depression |
When working with clients, try to recognize as early as possible those who are experiencing chronic pain. Help them and the healthcare team to take aggressive steps toward treatment. Attempt to identify factors that worsen pain because each factor that worsens the pain intensifies and perpetuates the pain cycle and makes it more difficult to break (Table 55-1).
Interventions are aimed at breaking the cycle of pain. Symptoms surrounding the pain are treated because it may be difficult to identify the exact cause of pain. Treatment is focused on raising the client’s self-esteem and helping him or her to deal with feelings of anger, guilt, and frustration. In Practice: Educating the Client 55-1 lists helpful tips for chronic pain management.
NCLEX Alert You may be asked in examination scenarios to identify information you would include when teaching a client to manage chronic pain.
Key Concept Remember: if a client feels pain, the pain is real.
Factors Affecting Pain Perception
A person’s pain threshold is the “lowest intensity of a stimulus that causes the subject to recognize pain” (Taylor, Lillis, LeMone, & Lynn, 2008). Pain tolerance denotes the point at which a person can no longer endure pain (Fig. 55-2). The body has internal mechanisms that help control pain perception. The central nervous system produces endorphins, naturally occurring substances that relieve pain. Endorphins are released with exercise and other forms of physical stimulation. Unfortunately, endorphins dissipate rapidly. Some authorities believe that activities other than exercise, such as laughter, also increase endorphin production. Theorists believe that the intake of certain chemicals and foods, including caffeine, nicotine, alcohol, salt, and sugar, decrease endorphin production.
IN PRACTICE EDUCATING THE CLIENT 55-1
TEACHING THE CLIENT TO MANAGE CHRONIC PAIN
• Medications: Be sure to follow medication schedules accurately It is best to take medications on a regular schedule to maintain an adequate blood level, rather than to wait until pain occurs.
• Exercise: Stay active. Exercise at a pace and a level that is comfortable. Avoid competing with others. Do your own personal best. Try not to lie in bed for too long. Walking is good exercise and is possible for most clients.
• Nutrition: Develop a healthy diet. Enjoy food and pleasant mealtimes. Drink plenty of water and other fluids, including fruit juices. Try to avoid sugar, caffeine, and artificial sweeteners (particularly aspartame).
• Recreation: Have fun. Participate in activities that bring pleasure. Spend recreational time with family and friends.
• Relaxation: Learn to relax both passively (self-hypnosis, meditation, deep breathing) and actively (knit, sew, read, travel).
• Support: Join a support group. Bond with family and friends when pain is intense.
• Hobbies: Stay occupied. When necessary, do things alone without depending on others. Develop hobbies that are compatible with physical abilities.
• Rest/sleep: Investigate stress management techniques. Coping with pain is easier after rest. Be sure to get an adequate amount of sleep. Take naps during the day if necessary
FIGURE 55-2 · Sample pain distress scales. These are called (top) word scales (using descriptive words); (center) numeric scales (using numbers); or (bottom) linear scales (drawn in a line). (Acute Pain Management Guide Panel, n.d.)
Key Concept Medications and other interventions help to increase the client’s pain threshold and increase the client’s pain tolerance.
NCLEX Alert Your basic understanding of pain as discussed in this topic: the perception of pain as a feeling of distress, causes of pain, pain as a vital sign, factors affecting the perception of pain, phases of pain transmission and three categories of pain are essential to your ability to select nursing interventions for the specific scenarios in the NCLEX examination.
