Heat and Cold Application
The application of heat or cold may help control localized pain by causing vasodilation (heat) or vasoconstriction (cold). Applying heat and cold is commonly used, both in nursing care and by clients at home. One of the few nonpharmacologic techniques proved to relieve pain, it is often very effective.
FIGURE 55-6 · The transcutaneous electrical nerve stimulation (TENS) unit relieves pain by providing physical stimulation. It can be controlled by the client or by healthcare personnel.
Exercise
Actively exercising specific body parts, with a gradual but steady increase in activity levels, increases joint flexibility and muscle strength. Specific exercise is ordered by the primary healthcare provider or physical therapist and should be performed only to the body’s tolerance. Exercise is also required as a part of one’s self-care routine to prevent loss of muscle tone and strength. The client is taught to perform activities to prevent injury and, thus, lessen pain. Activities should vary and be enjoyable. Activities and exercises performed with other individuals often are more enjoyable than those done alone. Encourage client participation in group programs; many health clubs have appropriate exercise programs.
Exercise and activity programs are designed to increase endurance gradually. The client needs to understand that he or she might be uncomfortable while exercising. However, exercising to the point of severe pain is not recommended. Some discomfort often helps prevent further injury or deterioration. The client is taught to increase activity levels a little each day, pushing just beyond discomfort. This helps stimulate endorphin production and increase endurance and strength. Teaching clients to monitor their own body cues (feelings one experiences by paying attention to body rhythms) places the emphasis on self-care and self-monitoring.
Cognitive-Behavioral Measures
Several cognitive-behavioral techniques can also act as complementary pain control measures.
Distraction and Diversion
Activities, such as visiting, games, television, or craft projects, may help divert a client’s attention from pain. Friends can often be helpful to each other (Fig. 55-7).
Deep Relaxation and Guided Imagery
The client can learn deep relaxation techniques that are often helpful. Many relaxation tapes and CDs are available.
FIGURE 55-7 · This informal support group of older adults finds diversion in each other’s company. They may talk about their aches and pains, but being together makes the discomfort seem less bothersome.
The client is taught to perform specific deep-breathing and relaxation exercises. Next, the client concentrates on a pleasant and relaxing experience. Some clients learn through relaxation therapy to relax taut muscles, thereby relieving pain.
Guided imagery is a process through which the client receives a suggestion to concentrate on an image to control the pain or discomfort. Deep relaxation exercises are performed first, so the client is totally relaxed. Then the client is guided through specific images. For example, the suggestion may be that pain occurring over a large area of the body is moving down and out of the body. In this way, a smaller area can be involved; the eventual goal is to eliminate the pain.
Another technique visualizes the destruction of the pain’s origin. For example, this procedure is often used for individuals who have cancer. Clients visualize their defense cells as large and strong and the cancer cells as small and weak. People in pain also learn to visualize themselves as powerful and able to conquer their pain. In addition, they learn to change their pain perceptions, so discomfort is better tolerated.
Support Groups
Support groups and group therapy sessions can help individuals in pain by giving them an opportunity to express their feelings and talk about pain with others who can relate. Group members often offer suggestions as to how they handled similar situations and concerns (Fig. 55-8). Some support groups provide information about financial assistance to help cope with the costs associated with medications, or vocational counseling to aid in maintaining functional abilities or job retraining.
Usually, family members of a client in pain can benefit from participation in a support group as well. They learn how to deal with the client’s concerns and how to be supportive. If pain continues for some time, they can learn to deal with their own feelings about the situation.
Some support group therapists use a program similar to the 12 steps of Alcoholics Anonymous.The first step is accepting that “I am powerless over this pain.” If clients can accept feeling powerless, they can work on measures to regain control. Such programs have proved effective in many cases.
FIGURE 55-8 · By sharing common experiences and concerns, members of a formal support group can enhance their coping skills, increase their ability to handle stress, and find a valuable avenue for understanding and encouragement. In many cases, they have become unable to talk about their pain to loved ones.
Stress Management
Stress may aggravate pain. The client may find stress management techniques helpful. He or she can benefit from them by developing effective coping mechanisms. Learning to be more assertive may help reduce stress. Other stress-reducing measures include physical activity, recreation, adequate fluids, and a well-balanced diet. Antidepressant medications also may be used.
Alternative and Complementary Techniques
Clients may use many nonpharmacologic measures to manage pain. Some measures may be considered nontraditional, such as chiropractic care, acupuncture, acupressure, hypnosis, or biofeedback.Today, these measures are being integrated into traditional pain control regimens more frequently. Other nontraditional measures include homeopathy, use of flower essences and aromatic oils, and herbal remedies. These measures may not frequently be prescribed by the traditional healthcare system, but have proven helpful to many clients. Many alternative and complementary techniques allow clients to take ownership of their pain management. These nonpharmacologic measures seem to be very effective as pain relief in many cases.
Nursing Alert The client with chronic pain is vulnerable to unscrupulous practitioners because the client is desperate and often willing to try anything to relieve the pain. Persons promoting "quack” cure-all schemes may take advantage of these clients.
NURSING PROCESS
DATA GATHERING
• The client’s description of the pain and the pain experience: the pain’s character, onset, location, duration, severity, pattern, and associated factors. In addition, consider aggravating factors and any special phenomena associated with pain
• What meaning, if any, the pain has for the client
• The client’s coping strategies and success or failure
• Observation of behaviors in response to pain (moving away from the stimuli; grimacing, moaning, crying; restlessness; protecting or massaging the painful area; isolation)
• Physiologic responses—sympathetic responses when pain is moderate and superficial (increased blood pressure, pulse rate, and respirations; pupil dilation; muscle tension and rigidity; pallor; increased adrenaline output and blood glucose level); parasympathetic responses when pain is severe and deep (nausea and vomiting; fainting or unconsciousness; decreased blood pressure and pulse rate; rapid and irregular breathing)
• Affective responses (weeping and restlessness, withdrawal, stoicism, anxiety, depression, fear, anger, anorexia, fatigue, hopelessness, powerlessness)
• Consider cultural aspects—how does this cultural group usually respond to pain?
POSSIBLE NURSING DIAGNOSES
• Acute Pain
• Chronic Pain
• Ineffective Coping
• Deficient Knowledge (effective pain-management program)
• Powerlessness
• Compromised Family Coping
Note: Initially, the nurse must view pain as a symptom and pursue its physical etiology. Interventions for pain that are performed before an accurate assessment may mask the true cause of the pain, thus causing further suffering and possibly even death by allowing the progression of signs, symptoms, and the disease process.
PLANNING
A plan of care is designed with the primary healthcare provider, the client, and family to achieve the following general goals:
• The client describes a gradual reduction of pain, using a scale of 0 (no pain) to 10 (pain as intense as it can get) or another evaluating device to quantify the pain.
• The client demonstrates competent execution of a successful pain-management program.
For the client with chronic pain, appropriate goals may include the following:
• The client verbalizes (and demonstrates) the ability to control pain sufficiently to manage or enjoy everyday living.
• The client locates and attends an appropriate support group.
• The family relates the feeling of being better able to cope with the client’s pain experience.
IMPLEMENTATION
• Establish a supportive and trusting nurse-client relationship.
• Teach about the function of pain and instill confidence that a successful pain-management program can be developed.
• Remove or alter the cause of pain (whenever possible) and alter factors that decrease pain tolerance.
• Appropriate noninvasive relief measures are used: distraction, imagery, relaxation, cutaneous stimulation (massage, application of heat or cold, vibration, pressure).
• Administer prescribed analgesic; if a patient-controlled analgesia unit (PCA) is being used, instruct the client about its use.
• Learn about the client’s use of other pain therapies, as appropriate: acupuncture, biofeedback, neurosurgery, electrical nerve stimulation, and others.
EVALUATION
Determine the adequacy of the plan of care by evaluating the client’s achievement of the preceding goals. If the client is unable to meet key goals, modify the plan. Key evaluative criteria include:
• Client experiences and expresses adequate relief.
• Client demonstrates knowledge of pain-relief measures.
• Client is satisfied with pain-management program.
• Client feels sufficiently comfortable to attend to demands of everyday living.
• Client is able to return to work or recreational activities.
• Family members are able to recognize and report greater comfort for themselves and perceived relief for the client
KEY POINTS
• Nociception (pain transmission) has four components: transduction, transmission, perception, and modulation.
• Acute pain (nociceptive pain) lasts less than 6 months and is relieved when its cause is identified and treated.
• Chronic pain (neuropathic pain) lasts for more than 6 months. Common treatment measures may fail to eliminate such pain.
• Factors that affect pain perception include a person’s pain threshold and pain tolerance. Culture also influences the expression of pain.
• The body’s naturally occurring endorphins help relieve pain.
• Early intervention in the cycle of pain may help control it.
• Nursing evaluation of the client in pain focuses on the client’s self-report of the experience. A number of tools are available to assist the nurse in quantifying and rating the level of pain, with the assistance of the client.
• Pharmacology is the cornerstone of much pain management.
• Surgical intervention is sometimes necessary to relieve certain kinds of pain.
• Both physical and cognitive-behavioral techniques are used to complement pharmacologic pain management.
• Pain is considered to be the fifth vital sign and is assessed frequently. All nursing interventions should include the gathering of information about a client’s presence or absence of pain. After medications or treatments for pain, the client should be asked if the intervention was helpful or not.
