Pain management and nursing: more than just passing a pill
Chronic pain is the top reason adults seek healthcare
People seek healthcare for many reasons. It may be the need for preventative care that will prompt the patient to see their primary care provider. Experiencing symptoms such as the cold or flu might send someone to an urgent care clinic. The symptoms of a heart attack may precipitate an emergency room visit. However, the number one reason that people seek healthcare today is because of pain. As a provider of that care, the nurse needs to be an astute practitioner when assessing, treating, and evaluating the patient’s pain.
In looking at the statistics regarding pain, the numbers are staggering. According to a 2018 report from the U.S. Center for Disease Control or the CDC, in 2016 20.8% of the population suffered from chronic pain. Further, the report indicated that 8% of the population experience what is called high impact chronic pain. Among other findings, the report revealed that chronic pain is the number one reason adults seek healthcare. The report noted differences in patients suffering from chronic pain that was dependent on the patient’s socioeconomic status, race, and status as a veteran and educational level.
This means that pain is an experience that is highly personal to each patient and should be viewed as such.
What exactly is pain? The textbook definition of pain, according to the International Association for the Study of Pain (IASP) reads as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Other refinements of the definition of pain have been presented over the years, including that by Margo McCaffery. She said that pain is whatever the person experiencing that pain says it is. This means that pain is an experience that is highly personal to each patient and should be viewed as such. As nurses, we must remember that when treating our patients.
There are different types and subtypes of pain, and with those different types of pain are various treatments and options for treating the pain. Pain can be classified as acute or chronic, for starters. Acute pain can be classified as pain that lasts for 3 months or less, while chronic pain is a pain condition that lasts longer than 3 months. The major types of pain, depending on which source is used, are nociceptive, neuropathic, and other non-termed pain. These pain types can be further broken down into subtypes.
This type results from acute trauma, injury process. Examples include incisional pain from surgery, trauma from an accident, or even a headache.
This pain type results from injury to nerves or the nervous system. Examples of this type of pain would be that sharpshooting electrical pain that one experiences with nerve involvement from a ruptured disc or neuropathy.
Other, non-termed pain
The third, or “other” classification, is a pain when neurological functions are out of sync, such as fibromyalgia.
There are also different subtypes of pain and distinct categories that may be discussed separately in the future.
Long-term effects of pain
One of the most important things for a nurse or any healthcare professional to remember is that pain isn’t just pain when chronic, persistent, or uncontrolled. The long-term effects that pain brings about in the body and mind only add to the patient’s suffering. According to Tennent (2012), the effects of persistent uncontrolled pain on the body are deconditioning, hormonal, and neuropsychiatric in nature.
The other body parts soon develop pain because they generate an overuse syndrome from being overused to help compensate.
The deconditioning issues are because affected areas of the body, where the pain is located, atrophy due to non-use of that region. The other body parts soon develop pain because they generate an overuse syndrome from being overused to help compensate.
The hormonal responses can range from alterations in blood pressure and heart function due to catecholamine changes to lipid and insulin metabolism changes. Persistent pain has also been known to accelerate atherosclerosis. These effects are but a few of the impacts pain induces on the endocrine system.
The neuropsychiatric effects are many and can be crippling in and of themselves. These changes can include insomnia, cerebral atrophy, memory loss, attention deficit problems, cognitive decline, depression, and suicide.
These changes can include insomnia, cerebral atrophy, memory loss, attention deficit problems, cognitive decline, depression, and suicide.
Hence, in dealing with the patient experiencing pain, the nurse needs to bear in mind that the sooner the patient’s pain can be reduced, the less likely the patient may suffer from the long terms effects of pain.
The assessment of pain
In assessing the patient’s pain, there are particular questions the nurse can ask the patient that can help diagnose the problem and guide treatment. The questions are pain location and radiation, intensity, quality, duration, exacerbating factors, and alleviating factors. Other questions such as the pain’s effect on daily life and the enjoyment of activities are also essential because they point to the long-term impact of pain on the patient, such as despair and depression. The nurse also needs to perform a thorough history and assessment to determine the cause of the pain.
Take the following example of pain assessment. A 34-year-old patient presents to the emergency room complaining of chest pain. The nurse, in assessing the pain, may perform the evaluation by asking questions including:
- “On a scale from 0-10, how bad is your pain right now?”
- “Is the pain a dull pain, sharp pain, squeezing pain?”
- “Is the pain a dull pain, sharp pain, squeezing pain?”
- “Does the pain radiate to your arms or back?”
- “How long have you had this pain?”
- “Does anything make the pain better or worse?”
The patient reports an 8 out of 10 chest pain level, which he says feels like a vice squeezing his chest that radiates down his left arm. The patient says that he has had this pain for 8 hours and that nothing relieves the pain. He also gives a history of coronary artery disease and hypertension. After asking these initial questions, the nurse goes over the patient’s history to include illnesses, chronic conditions, medication use. The nurse will also key in any behaviors that signal if the patient is currently abusing drugs, or has the potential to do so. After collecting the patient’s history and completing the assessment, the nurse will report to the provider. The provider then examines the patient, orders the appropriate tests, and diagnoses the patient with acute coronary syndrome. The patient is commenced on oxygen, given intravenous morphine for chest pain, and started an intravenous nitroglycerin drip.
Developing a pain management care plan
In assessing the patient’s pain, the nurse will go a long way in coming to a diagnosis and treatment plan for that particular patient.
There are other things to also consider when assessing pain, such as what measures or treatments have worked for the patient previously, what is an acceptable pain level for the patient, is there the potential for abuse if the patient is given controlled substances such as narcotics? These factors all need to be considered when formulating a plan to treat the patient’s pain.
This care plan is usually formulated in a multidisciplinary fashion that incorporates all healthcare team members. The members may include the patient’s primary healthcare provider, the nurse, physical therapist if indicated, chaplain, and possibly a psychiatrist or social worker. The planning of care for the pain can be as simple as speaking with the physician or as complicated as initiating a care rounds session with all involved. The main point is that a plan is set in motion.
Pain management measures
In taking care of the patient’s pain, it is essential to not wait until the pain has reached a 10 out of 10 pain rating. At that level, it becomes harder to get the pain under control to an acceptable level. An example would be when the nurse takes care of a patient fresh out of the recovery unit from a hip replacement. Suppose the patient reports the pain starting to escalate from a 2 to a 4 or 5 out of 10 scale. That is the cue for the nurses to implement measures to relieve the patient’s pain. If the nurse waits too long to respond, say when the pain is an 8 out of 10, the patient will have a more challenging time getting relief from the measures given. The nurse may also have to coach the patient to ask for pain meds or measures earlier rather than later as sometimes the patient may wait too long to ask for meds due to addiction fears or not wanting to bother the nurse.
Other actions the nurse can do independent of the physician’s orders, depending on state nursing law, of course.
There are many measures to help reduce the patient’s pain. Some of these measures may include giving prescribed pain medications as ordered. Other actions the nurse can do independent of the physician’s orders, depending on state nursing law, of course.
There is more to giving pain meds than just providing a pill or pushing pain medications in the intravenous line, especially when it comes to controlled substances. It is always the nurse’s responsibility to make sure that the patient’s medication is the right medication for that patient at the right time, the correct route, the right dose, and the proper route of administration. For example, it would not be suitable for the nurse to give intravenous morphine to a patient earlier than expected, especially if the patient had respiratory depression, which could lead to a bad outcome for the patient. The nurse has to use critical thinking skills when giving pain medications; this is true for controlled and non-controlled substances. There are side effects to every drug, so the nurse and patient need to agree on which medication will bring about the most pain-relieving benefit with the minimum of side effects.
Numerous other pain control techniques that the nurse can use to help decrease pain for the patient exist. The nurse can do something as simple as repositioning the patient for comfort; pillows go a long way in providing comfort to the patient. The safe utilization of heat and cold therapy have also shown to bring pain relief; although some institutions require a physician’s order for ice or heat. Ice is very good at slowing nerve conduction and decreasing inflammation, while heat is good for relaxing tense muscles.
The point to make is that not all pain management therapies center around taking medications.
Other non-pharmacologic treatments are now gaining a lot of support for the treatment of pain, such as massage therapy, aromatherapy, music therapy, guided imagery, relaxation therapy, yoga, and mindfulness therapy. Some of these therapies can be employed without special training, while others need specialized training. The point to make is that not all pain management therapies center around taking medications.
Evaluation and documentation
In managing the patient’s pain, the nurse needs to assess the pain before therapy and evaluate the effectiveness of the prescribed measures after the therapy has been implemented. The reason for this is to ascertain if the steps taken have helped alleviate the patient’s pain or not. In assessing the response to treatment, changes can be made to modify or replace the treatment regimens as indicated.
It is a nurse’s calling to alleviate the suffering of those affected by pain.
Lastly, proper documentation of pain management is crucial. The reason is more than just a legal record of care given to the patient. It is a written account of communicating the assessment, diagnosis, plan, treatment, and re-assessment of the patient’s pain progress. This information informs and guides other practitioners about the patient and the treatments that have worked and not worked to treat their pain.
Taking care of the patient in pain is not only our responsibility: it is a nurse’s calling to alleviate the suffering of those affected by pain.
Dahlheimer J, Lucas J, Zelaya, C, et al. Prevalence of chronic pain and high-impact chronic pain among adults — United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1001–1006. DOI: http://dx.doi.org/10.15585/mmwr.mm6736a2external icon.
Denali Health Care Pain Chart: Accessed on 1/24/21. http://www.denalihealthcaremi.com/causing-pain/
Forest Tennant, M. D. (2012, January 28). Complications of uncontrolled, persistent pain. Practical Pain Management. https://www.practicalpainmanagement.com/pain/other/co-morbidities/complications-uncontrolled-persistent-pain.
Pirschel, C. (2021, January 22). Remembering Margo McCaffery’s contributions to pain management. ONS Voice. https://voice.ons.org/news-and-views/remembering-margo-mccafferys-contributions-to-pain-management.