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Chapter: Medical Surgical Nursing: Pain Management

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Nurse’s Role in Pain Management

Before discussing what the nurse can do to intervene in the pa-tient’s pain, the nurse’s role in pain management is reviewed.

NURSE’S ROLE IN PAIN MANAGEMENT

 

Before discussing what the nurse can do to intervene in the pa-tient’s pain, the nurse’s role in pain management is reviewed. The nurse helps relieve pain by administering pain-relieving inter-ventions (including both pharmacologic and nonpharmacologic approaches), assessing the effectiveness of those interventions, monitoring for adverse effects, and serving as an advocate for the patient when the prescribed intervention is ineffective in relieving pain. In addition, the nurse serves as an educator to the patient and family to enable them to manage the prescribed intervention themselves when appropriate.

Identifying Goals for Pain Management

 

The information the nurse obtains from the pain assessment is used to identify goals for managing the pain. The goals identified are shared or validated with the patient. For a few patients, the goal may be elimination of the pain. For many, however, this ex-pectation may be unrealistic. Other goals may include a decrease in the intensity, duration, or frequency of pain, and a decrease in the negative effects the pain has on the patient. For example, pain may have a negative effect by interfering with sleep and thereby hampering recovery from an acute illness or decreasing appetite. In such instances, the goals might be to sleep soundly and to take adequate nutrition. Chronic pain may affect the person’s quality of life by interfering with work or interpersonal relationships. Thus, a goal may be to decrease time lost from work or to increase the quality of interpersonal relationships.

 

To determine the goal, a number of factors are considered. The first is the severity of the pain, as judged by the patient. The second factor is the anticipated harmful effects of pain. A high-risk patient is at much greater risk for the harmful effects of pain than a young healthy patient. The third factor is the anticipated duration of the pain. In patients with pain from a disease such as cancer, the pain may be prolonged, possibly for the remainder of the patient’s life. Therefore, interventions will be needed for some time and should not detract from the patient’s quality of life. A different set of interventions is required if the patient is likely to have pain for only a few days or weeks.

 

In a study of the dying experience, family members of 2,451 people who had died were interviewed (Lynn, Teno, Phillips et al., 1997). Of these patients, 55% were conscious during their last 3 days of life. Of the conscious patients, 4 in 10 were con-sidered by their family members to be in severe pain most of the time. These findings strongly suggest that pain relief for dying pa-tients should be a primary goal.

 

The goals for the patient may be accomplished by pharmaco-logic or nonpharmacologic means, but most success will be achieved with a combination of both. In the acute stages of ill-ness, the patient may be unable to participate actively in relief measures, but when sufficient mental and physical energy is pres-ent, the patient may learn self-management techniques to relieve the pain. Thus, as the patient progresses through the stages of recovery, a goal may be to increase the patient’s use of self-management pain relief measures.

 

Establishing the Nurse–Patient Relationship and Teaching

 

A positive nurse–patient relationship and teaching are key to man-aging analgesia in the patient with pain, because open communi-cation and patient cooperation are essential to success. A positive nurse–patient relationship characterized by trust is essential. By conveying to the patient the belief that he or she has pain, the nurse often helps reduce the patient’s anxiety. Acknowledging to the patient, “I know that you have pain” often eases the patient’s mind. Occasionally, patients who fear that no one believes the re-ported pain feel relieved when they know that the nurse can be trusted to believe the pain exists.

 

Teaching is equally important, because the patient or family may be responsible for managing the pain at home and prevent-ing or managing side effects. Teaching patients about pain and strategies to relieve it may reduce pain in the absence of other pain relief measures and may enhance the effectiveness of the pain re-lief measures used.

The nurse also provides information by explaining how pain can be controlled. The patient is informed, for example, that pain should be reported in the early stages. When the patient waits too long to report pain, sensitization may occur and the pain may be so intense that it is difficult to relieve. The phenomenon of sen-sitization is important in effective pain management. Since a heightened response is seen after exposure to a noxious stimulus, the response to that stimulus will be greater, causing the person to feel more pain. When health care providers assess and treat pain before it becomes severe, sensitization is diminished or avoided, and thus less medication is needed.

Providing Physical Care

The patient in pain may be unable to participate in the usual ac-tivities of daily living or to perform usual self-care and may need assistance to carry out these activities. The patient is usually more comfortable when physical and self-care needs have been met and efforts have been made to ensure as comfortable a position as pos-sible. A fresh gown and change of bed linens, along with efforts to make the person feel refreshed (eg, brushing teeth, combing hair), often increase the level of comfort and improve the effec-tiveness of the pain relief measures.

 

Providing physical care to the patient also gives the nurse (in acute, long-term, and home settings) the opportunity to perform a complete assessment and to identify problems that may con-tribute to the patient’s discomfort and pain. Appropriate and gentle physical touch during care may be reassuring and com-forting. If topical treatments such as fentanyl (an opioid anal-gesic) patches or intravenous or intraspinal catheters are used, the skin around the patch or catheter should be assessed for integrity during physical care.

Managing Anxiety Related to Pain

Anxiety may affect a patient’s response to pain. The patient who anticipates pain may become increasingly anxious. Teaching the patient about the nature of the impending painful experience and the ways to reduce pain often decreases anxiety; a person who is experiencing pain will use previously learned strategies to reduce anxiety and pain. Learning about measures to relieve pain may lessen the threat of pain and give the person a sense of control.

 

What the nurse explains about the available pain relief mea-sures and their effectiveness may also affect the patient’s anxiety level. The patient’s anxiety may be reduced by explanations that point out the degree of pain relief that can be expected from each measure. For example, the patient who is informed beforehand that an intervention may not eliminate pain completely is less likely to become anxious when a certain amount of pain persists. Anxiety resulting from anticipation of pain or the pain experience itself may often be managed effectively by establishing a relation-ship with the patient and by patient teaching.

 

A patient who is anxious about pain may be less tolerant of the pain, which in turn may increase the anxiety level. To prevent the pain and anxiety from escalating, the anxiety-producing cycle must be interrupted. Low levels of pain are easier to reduce or control than are more intense levels. (This concept of sensitiza-tion was previously discussed.) Consequently, pain relief mea-sures should be used before pain becomes severe. Many patients believe that they should not request pain relief measures until they cannot tolerate the pain, making it difficult for medications to provide relief. Therefore, it is important to explain to all pa-tients that pain relief or control is more successful if such mea-sures begin before the pain becomes unbearable.

 

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