Pain Assessment and Management

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Introduction: “Pain is the deepest furrow in the knotted brow of agony,” rightly said the noted physician, Oliver Wendell Holmes. Pain is a complex sense, and its magnitude in human ordinary experience is considered to be immense. According to Margo, McCaffery, and Pasero (1999, P. 16) pain is defined by the American Pain Society (APS) as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. Estimates suggest that more than 34 million Americans experience suffer from nonmalignant chronic pain.

While talking about pain, it immediately indicates two aspects of this human experience, one it is a personal experience, and two a bleak sense of loneliness when it cannot be conveyed to others. Pain has far-reaching repercussions by adversely affecting work and contributing significantly to disability. For example, chronic low back pain is the most common cause of occupational disability among persons under age 45. The economic impact of chronic pain is enormous when one considers the costs of absenteeism, reduced productivity, medical care, and workers compensation.

Apart from that, pain limits enjoyment, interferes with relationships, activities, and interests. From the personal context, the individual suffering from pain of any origin is in a state of affairs where there are significant personal losses, such as, reduced income and autonomy. Accompanied by that, the individual may experience guilt blaming themselves for their inability to overcome or master pain. Pain, thus, is pervasive and has multiple ramifications. These subjects lead to strained relationships both in the family and at work, and the suffering is compounded.

If this situation is acknowledged and the loneliness can be perceived by others, particularly those responsible for managing pain conditions, amelioration can, however, happen, especially if the care-giver is compassionate to the cause. Being compassionate to a patient suffering from incessant pain can only happen if one has been educated in this area with understanding the actual nature of pain in that it is a distinct multifactorial illness with biopsychosocial components. According to Lewis, Heitkemper, and Dirksen (2004), pain is the most common sign occurring with people when they are sick.

Pain is the most fundamental part of the nurse`s responsibility when dealing with patients in pain (Carroll & Bowsher, 1993). Moreover, because of the problems that are associated with ageing, pain is common in older people and it is main cause of their suffering (Elizabeth et al. , 2004). The ability to assess the pain of others becomes complicated because of differing attitudes and the multidimensional aspects that pain projects (Ferrell, 2005). There are no easy answers of how to evaluate, differentiate, or judge the uniquely personal estimates of the quality of pain.

Pain experiences are highly individualized, but there is much yet to learn about pain. Pain Assessment: Today, the best available evidence indicates a major gap between an increasingly sophisticated understanding of the pathophysiology of pain and widespread inadequacy of its management. Every clinicians, nurses, and even pain specialists recognizes that even with limitless resources, not every patient’s pain can be alleviated. Pain whether acute or chronic is inadequately assessed for a variety of reasons, such as, cultural, attitudinal, educational, political, religious, and logistical reasons.

Inappropriate pain management that is most often inadequate treatment has major physiological, psychological, economic, and social ramifications for patients, their families, and society. It can appropriately be commented that unreasonable failure to treat pain is poor medicine, unethical practice, and is an abrogation of a fundamental human right. For nurses, proper education and compassion to the cause can better equip them to assess and manage pain conditions in their practice. Pain is more than just a sensation.

The basic neuroanatomic and functional features of pain include understanding of the basics of nociception that moves in the pathways from the peripheral receptors to the spinal cord, thalamus, and somatosensory cortex. Apart from these, the sensation of pain is modulated by pain-modulating systems and autonomic nervous systems. To be able to assess pain more accurately, the nurse should be well versed with mechanisms of neuropathic pain, phantom pain, autonomic syndromes associated with pain, and central pain syndromes. One involved in assessing and managing pain must be aware about the fact that pain is more than just a sensation.

Given the reciprocal relationships between pain and cognitive patterns, the pathways involved in pain processing warrant knowledge since they appear to play important roles in the cognitive and emotional foundations of pain processing. Furthermore, it is an acknowledged fact that nociceptive, cognitive, and affective pathways involve common neurotransmitter systems, such as, those for norepinephrine and serotonin. By means of activation of autonomic arousal, other cascades of events may occur leading to heightened perception of pain.

There are four vital signs which are blood pressure, heart rate, respiratory rate, and temperature. However, some research considers that pain is the fifth sign (De Lisa, 1998). Pain is a disagreeable sensation or response to a certain stimulus, with or without an indefinable cause (De Lisa, 1998). It is a subjective perception which may be associated with definite or probable tissue damage (De Lisa, 1998). Pain is a complex issue, which has not only physical effects, but also affective, cognitive, social and motivational aspects of an individual (Kemp, 2000).

Thus, a patient’s report of pain cannot be used to generalize for all patients, as each case is influenced by multiple factors which cannot be easily distinguished and accounted for. Pain assessment and management should also be customized in accordance to the patient’s current condition at a given point in time. Pain assessment aims to describe the patient`s sensory, emotional, behavioural, cognitive, and sociocultural, of pain experience to apply pain management and determine the patient`s goals for therapy (Lewis et al. , 2004).

However, nurses still fail to assess pain levels accurately (Lopez-Castor, 2005) and they appear to lack knowledge of pain and its relief (Carroll & Bowsher, 1993). What is more, pain assessment is a complex process and sometimes is challenging, especially with elderly patients who are at the end of life, because they have communication problems which makes pain assessment difficult. Pain assessment needs to be done for all patients who are suffering pain as soon as possible, because pain assessment will become less effective, especially at the end stages of the disease.

Accordingly, pain assessment is actually collecting subjective and objective information about the patient’s condition (McCaffery & Pasero, 1999), and pain measurement is the transformation of subjective information into objective information. Principles of pain assessment: There are some principles of pain assessment that the nurse must conceder while assessing the patient`s pain such as the subjective rating which comes from the patient, believe what ever the patient said about his or her own pain, take action immediately if pain is at unacceptable level, after any interventions frequent evaluation is required (Carroll & Bowsher, 1993).

Nurses must observe all pain aspects while they are doing pain assessment including pain location, duration, intensity, quality of life, symptoms, physical function, economics of life, and socio-culture issues. Intensity of pain can measured by a numerical scale from zero to ten; zero mean no pain and ten is the worst pain imaginable. In addition, numerical scale is easy to use and quick to get the assessment of pain (Emma, 2001). While using a visual analogue scale, the nurse must remember that pain may be associated with reactive depression, and depressed patients tend to rate pain intensity higher than other patients.

Subjective assessment of pain, therefore, may appear more than the actual intensity due to coexistent depression. In response to pain, anxiety may mobilize self-preserving and self-protective measures, and excess anxiety on the other hand can become so incapacitating that subjective assessment would lead to a higher rating than actual. Substance abuse is frequently a concern in the assessment and management of common chronic pain conditions. The patients may well be dependent on opiate analgesics from long-term management. With long-term suffering, there is a fair chance that there is somatization as a part of the pain disorder.

It is recognized that even organically based pain complaints can have severe psychosocial components contributing to the functional deficits of the pain disorder. The nurse must pay calculated attention to these factors while doing a pain assessment. For this reason, a behavioral pain assessment scale can be utilized where face, restlessness, muscle tone, vocalization, and consolability scores rated from 0 to 2 can be added up to generate scores in the range of 0 to 10, where 0 is no pain and 10 is worst possible pain can be matched with the modified visual analogue scale to correctly assess the pain symptoms of the patient.

Usage of these scales can be combined to rate pain were 0 is no evidence of pain, mild pain is 1-3, moderate pain 4-5, and beyond 6 is excruciating pain. The nurse would use the standard pain scale depending on self-report that is considered the best indicator of presence and intensity of pain. Behavioral scale can be used when the patient is unable to self report. In addition, proxy pain assessment from family or friends close to the patient may be helpful to evaluate pain based on previous knowledge of patient response.

Pain Management: Pain control, therefore, is important to the patients and providers. The nurses as providers need to improve their performances with respect to pain management. The golden rule in this regard is to give an analgesic trial, if there is a reason to suspect pain, an analgesic trial can be diagnostic as well as therapeutic. Pain management is one sign for good palliative care. Inadequate pain management can cause abuse, violation of the patients` rights and poor quality of care (Linda, 2007).

According to Catherine et al. 2007), around 75% of terminal ill patients are suffering from pain because of inadequate pain management, which results from inadequate pain assessment. However, nurses play a vital role in pain management, because they spend more time beside the patients than any other health care members. In addition, health care professionals must refresh their knowledge in order to make improvements in pain management (Catherine et al. , 2007). In addition, numerical scale is easy to use and quick to get the assessment of pain (Emma, 2001).

Nursing interventions for successful pain management include pharmacology interventions, such as opioid and non-opioid pain relief and non-pharmacology interventions, such as massage, transcutaneous nerve stimulation, and hot and cold applications. Non-pharmacologic interventions include cognitive behavioural, such as imagery, distraction, relaxation, breathing techniques, providing information, and positive reinforcement techniques (Lopez-Castor, 2005). These can help reduce the dosage of drugs, which are needed to control pain, and also it will minimize the side effects of drugs (Lewis et al. , 2004).

Consequences of poor pain assessment and pain management: Many consequences result from poor pain assessment and management. These must be avoided, as both the patient and the family or the caregivers are affected in the disease process. Negative consequences also hinder the progression of treatment which would affect the over-all management of the disease process the patient experiences (NCI, 2007; Yadgood, 2000). Many studies signify that the rates of untreated severe pain are high amongst the common nursing home patients. It has been noted that on their early assessment, 41% of nursing home residents were in pain (Cavalieri, 2002).

Unsatisfactory assessments, along with the high numbers of cognitively impaired patients, point to an underestimation of the occurrence of pain. Physicians should make sure that the fast increasing numbers of patients who are dying in long-term-care services obtain good-quality care through sound integrated palliative care practice (Mccleane, 2006). It is to be accepted that pain initiates protective physiological responses and if chronic, pain as a single etiologic agent is enough to induce changes in the peripheral and central nervous systems that can lead to perpetuation of pain.

Apart from managing the pain in the conventional manner, the nurse needs a better understanding of the pain pathophysiology and its psychological implications affecting cognitive and emotional dimensions. When assessing and managing pain depending on subjective ratings, the nurse as a provider must remember that pain impairs mood and thinking and it always involves individual awareness of pain phenomenon, abstraction, and appraisal of pain. The definition of pain is based on personal attitude and historical experiences.

Furthermore, on the physiological somatic level, loss of mobility owing to pain and miscellaneous functional restrictions inhibits daily activities of the subject and hampers work and economy. An ideal pain management strategy would consider the psychological and social adjustments of the subject and his hankering for a quality like and activities. Conclusion: To sum up, skilled assessment and understanding of pain management is important in clinical nursing.

The aim is the alleviation of pain, for the presence and intensity of pain would be possible determinants for the patient and family’s psychosocial well-being. If pain is improperly recognized, inadequately controlled, undertreated, and not associated with the overall well-being of the patient, pain management would even be a cause for aggravation of the condition. The patient’s response and the pain’s etiology determine what pharmacologic, non-pharmacologic or other more extreme invasive procedures are needed to be performed.

Certain guidelines are provided and clarifications about misconceptions regarding concerns regarding the use of opioid medications are discussed widely in the literature. These are suggested to be followed for maximum efficiency of pain management. In addition, nurses must consider the importance of pain management and the different interventions. Pain reassessment must be done by nurses after each intervention to assess the effectiveness of the intervention. Moreover, nurses need to support the patients and their families and educate them about the importance of the pain assessment and pain management.

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