Pain management is an essential skill in nursing. Pain is often referred to as the fifth vital sign although the benefit of this has come under some scrutiny in light of the opioid crisis and over prescribing issues. However, understanding pain and its effects on basic physical and mental health is critical to improving patent outcomes.
NursingCE.com has recently added three new continuing education courses to help nurses, and in particular Advanced Practice nurses (APRNs), improve their skills in pain assessment and management. The first part examines the pathophysiology of pain and the pain process.
There are four identified categories of pain. They are acute, chronic, nociceptive and neuropathic pain. These can be further broken down into multiple subcategories to help nurses understand the effects of pain on their patients. An important point to always keep in mind is that pain is subjective and an individual experience. Pain cannot be measured objectively and is solely dependent on the patient to report what he feels and experiences. This includes aspects such as physical, emotional and behavioral components.
- Acute pain is protective and stems from an acute onset illness, injury or trauma, and procedures such as childbirth. The Acute pain is usually a short-term process and resolves with the healing of tissues involved. In addition to the sensation of pain, the patent will also experience physiological symptoms activated by the autonomic nervous system which include hypertension, increase respirations, tachycardia, diaphoresis, and anxiety. Behavioral response includes such things as restlessness, guarding, moaning, groaning and grimacing. Treatment includes addressing the underlying cause as well as the use of pain medications and non-pharmacological methods such as ice or heat as appropriate, rest, compression and elevation. If acute pain is not resolved, it can become chronic pain.
- Chronic pain is non-protective and has a gradual onset. It’s an ongoing and recurrent pain that lasts beyond three months and well past any healing process. Chronic pain is very common and is the reason for the widest use of the healthcare system. About 20% of the cases of chronic pain have pain significant enough to impair life and work activities. It is poorly localized and therefore difficult to explain or describe. While chronic pain doesn’t affect the physiological response from the sympathetic nervous system, it does significantly affect the physical and mental health of the patient. Chronic pain increases the risk for depression, fatigue, impairment of ADLs and a decrease in overall function. It usually interferes with life-work activities, can result in disability and ultimately affect finances. May chronic illnesses that involve pain such as fibromyalgia are not well understood. In many cases the chronic pain is idiopathic, and a root cause is not identified. Low back pain, arthritis and headaches are all associated with chronic pain. Chronic pan does not always respond to medical treatments or interventions. Chronic pain is one of the most challenging and expensive conditions to treat.
- Nociceptive pain is a normal response to injury or damage to tissues from another source. This includes somatic pain that comes from such things as incision pain, wounds, peripheral vascular disease, muscle cramps. Visceral pain is due to causes in internal organs or referred pain from another part of the body not being affected by the noxious causes.
- Neuropathic pain is the result of damages or dysfunction of the nervous system. His pain can be intense and out of proportion to the damage or dysfunction. This is known as hyperalgesia, which is characterized by intense, shooting, or burning pain. There can also be sensory abnormalities that manifest as a prickly pins and needles affect. Numbness is another characteristic of neuropathic pain. Neuropathic pain responds to antidepressants, anticonvulsants and antispasmodics along with muscle and spasms relaxants. There are multiple types neuropathic pain which are usually chronic, unrelenting, and long-lasting. These include postherpetic neuralgia, phantom limb pain, diabetic neuropathy, and trigeminal neuralgia.
There are multiple scales tools to help assess pain and understand the impact it is having on the total patient including his friends and family. The OPQRST tool is one of the most complete and effective tools for obtaining all pertinent information. The FACES, PAINAD tool and the Critical Care Pain Observation (CPOT) tools are helpful to the observer to understand and determine the intensity of the pain especially when the patient cannot verbally provide a complete description.
Essential factors to be considered in pain assessment including culture, age, cognitive abilities, fatigue, support systems, anxiety, previous experience with pain issues including undertreatment of pain. There is also an existential aspect of pain suffered due to anxiety, fear and anticipation of emotional and actual effects of pain on the patient’s life such as loss of abilities, loss of job, financial losses and changes in lifestyle can cause even more suffering than physical pain. This needs to be considered and incorporated into all pain assessment and management processes. Counselling and resources are important to easing this aspect of the pain. As with all aspects of nursing, considering the whole patient is necessary. A full pain assessment and consideration of these factors is necessary to the successful management and treatment of the pain.