Question

CH 8 Med Surge
7. List the data collected in assessing pain.
8. Describe interventions used in management of pain

Answer 1

7. List the date collected in assessing pain

Pain is a subjective feeling, which is unpleasant sensory and emotional experience which is associated with actual and potential tissue damage.           

Classification of pain

1. Location – classified based on where the pain in the body thus useful in determining the patient’s underlying problems.

2. Duration – As per duration pain, it is further classified as;

· Acute – It is complex and always described as unpleasant. Lasts only through expected recovery period regardless of onset and intensity.

· Chronic – It is prolonged, usually re-occurring and persists over 6 months or longer and always interferes with activities of daily living.

3. Intensity – Classified using standard scales. 0-10 scale, where 0 indicates No pain and 10 indicates Severe pain.          

Pain Assessment

The assessment includes physical examination and the systems in relation to pain evaluation.

1. History and Physical Assessment

History and physical examination is must in assessing pain. It should include, site of the pain, both musculoskeletal and neurological systems. Other components of pain assessment include:

• Patient’s self-report of pain
• Patient’s behaviors and gestures which indicates pain (e.g. crying, guarding, etc.)
• Aspects of pain which includes: Onset and duration of pain , location and quality of pain (as described by patient), intensity of pain, aggravating and alleviating factors
• Medication history
• Disease or injury history
• Pain relief measures includes, medications, any supplements, exercises, massage, complementary and alternative therapies.
  1. Functional and Psychosocial Assessment

This Components of the functional and psychosocial assessment include:

• Reports of patient’s prior level of function
• Observe the patient’s behaviors while performing functional tasks
• Patient reports the impact of pain on their activities of daily living, including work, self-care and leisure
• Patient’s goal on level of function in pain management
• Patient’s and family’s report on impact of pain on activities of daily living and quality of life
• Cultural and developmental considerations of patient and family.
• History of pain in relation to depression, abuse, psychopathology, chemical or alcohol use
• Impact of pain on patient’s cognitive abilities

C. Multidimensional Assessment

Many tools are available for the in-depth and multidimensional pain assessment. This is important for patients who have chronic pain, mixed pain (both acute and chronic), or complex situations (such as multiple disease processes). Common examples of these tools include:

• Brief Pain Inventory: This provides patient input in describing the pain and its effects, which includes psychosocial components.
• McGill Pain Questionnaire: Patient’s use Descriptors for their pain, this provides information on the experience and intensity of pain.

D. Common Pain Scales

There are variety of pain scales which are used for pain assessment. This is used for patients from neonates through advanced ages. The most common scales which are recommended for use for pain assessment are:

1. The numeric scale - The numeric scale is the most commonly used pain scale with adult patients, rating pain on a scale of 0-10. This includes verbal response to the question. Along with verbal response, the visual analog can provide a more accurate response. This scale is appropriate for age group of 9 years and older that they can use numbers to rate their pain intensity.

2. The Wong-Baker scale (also known as the FACES scale) - The Wong-Baker FACES Scale uses drawn faces for patients to express their level of pain. These faces are associated with numbers on a scale which is ranging from 0 to 10. This scale is most commonly used in children and is appropriate for age group of 3 years and older. Adults with developmental or communication challenges will benefit from using this scale.

3. The FLACC scale - FLACC is the acronym for Face, Legs, Activity, Cry, and Consoling ability. This scale is based on the observed behaviors and is commonly used with pediatric patients with less than 3 years of age. The behaviors that are described are associated with a number; each component is added for a number ranging from 0 to 10. This scale will benefit the patients who have developmental delays or are non-verbal.

8. Describe the interventions used in management of pain

· Pain management refers to the appropriate treatment and interventions that are developed in relation to pain assessment and should always be developed in collaboration with the patient and their family.

· Strategies are always developed based on the past experiences with effective and non-effective treatment measures to meet the patient’s goal for pain management.

· Considerations include: Type of pain, intensity & duration, disease processes, risks, benefits of treatment modalities.

· Pain management strategies includes both pharmacological and non-pharmacological approaches.

Pharmacological management

The use of medications used to treat pain; it can be complex. Multiple factors must be considered including age, current medications, patient medical both past and present history, substance use history, type of pain (such as neuropathic versus nociceptive), etc.

Some of pharmacological treatments include: Analgesics, Non-steroidal anti-inflammatories (NSAIDs), Tricyclic antidepressants (TCAs), Selective serotonin reuptake inhibitors (SSRIs), Topical agents, Anesthetics, Opioids, Patient controlled analgesia

These pharmacological interventions are either used single or in combination based on the requirement of the patient condition and will be administered as per the pain assessment protocols.

Non-Pharmacological Treatment

This includes management of pain without any medications. This method utilizes various ways to alter the thoughts and concentrate of patients for better manage and reduce pain.

Some of Non-pharmacological interventions may include:

• Bed rest
• Decreasing environmental stimuli (e.g. sound, lighting, temperature)
• Manipulation & mobilization
• Range of motion or physical therapy
• Repositioning
• Immobilization
• Heat or cold Therapy (as appropriate)

• Hot and cold therapy can be used and is extremely effective for several different conditions and injuries. For best results it can be used as a single treatment or in combination of both.
• As a rule, use ice for acute injuries or pain, along with inflammation and swelling. Use heat for muscle pain or stiffness.
• When applying heat therapy, local, regional, or whole-body treatment can be done. Hot gel packs or hot water bottle or bag can be used to treat an injury locally.
• Regional treatment is best for more widespread pain or stiffness, and could be achieved with a steamed towel, large heating pad, or heat wraps.
• Full body treatment would include options like saunas or a hot bath.
• Cold therapy is also known as cryotherapy. This acts by reducing the blood flow to an area, thus significantly reduces inflammation which causes pain, specially around the joints and tendons. This temporarily reduces the nerve activity, thus relieves pain.
• Types of cold therapy
  • There are several different ways to apply cold therapy to an affected area. Treatments include: ice packs/frozen gel packs, coolant sprays, ice massage, ice baths etc.
  • Other types of cold therapy are:

• Cryostretching, this reduces muscle spasms during stretching using cold.
• Cryokinetics, This combines both cold treatment and active exercise which can be useful for ligament sprains
• Whole-body cold therapy chambers
• Therapeutic touch and Massage
  • Therapeutic massage involves the application of the hands or elbows which helps in solving the physical/musculoskeletal problems, such as back pain. Where in, non-therapeutic or relaxation massages are more passive and is used to promote comfort.
  • It is used to treat conditions which are most common like low back pain, neck and shoulder pain.
  • Other massage styles and techniques include:
    1. Reiki: Involves light touch and is designed to work with the body’s energy.
    2. Craniosacral therapy: Involves only five grams of pressure and influences the central nervous system.
    3. Deep tissue massage: Intense pressure is used to targets the deepest layers of muscle tissue, tendons and fascia.
    4. Rolfing and myofascial release: Involve more aggressive techniques that aim to manipulate the soft tissues.
• Progressive muscle relaxation and imagery

• The Progressive Muscle Relaxation technique involves moving the focus of your attention to various muscle groups around your body and focusing on tensing and relaxing these areas. There is no right or wrong order in which to work through different muscle groups, but you should include the following body areas:

• Hands and fingers
• Face (forehead, eyes, nose, mouth, jaw)
• Back/stomach
• Feet/toes
• Arms
• Neck/shoulders
• Legs

• This technique helps to change or control emotions or responses to negative situations. The technique can also help individuals eliminate undesirable personal habits; adjust to new situations or control phobias, anxiety and pain.

• Biofeedback

• Biofeedback is effective therapeutic modalities for the treatment of chronic, non-cancer pain, it can be used to help patients self-regulate and influence their pain perception.
• There are 3 stages in biofeedback training.
• First stage - The patient gains awareness of his/her problematic physical response. Person identifies how their bodies respond to a variety of stressors around them and thus determines their ability to overcome the undesired physical reactions.

• Second stage - The patient receives the signals from the therapeutic biofeedback sessions which they uses to control his/her physical responses. The person is trained by the therapist to reach certain goals in relation to managing a specific physical response.
• At the final stage, the patient transfers control from the biofeedback equipment to themselves. Patient’s learns through the trial and error to identify the triggers which alerts them to implement the self-regulation skills which they have acquired.

• Music therapy

• In chronic pain management, use music therapy is a means of conditioning the patient to relax and release pain and stress. Music therapy is paired with other relaxation techniques, and eventually the patient learns to relax automatically when listening to the music. Music therapy provides sensory stimulation that evokes a response in the patient. Music is used as a clinical intervention, which can help patients by:

• Reducing the amount of pain which they perceive
• Promoting relaxation, rhythmic breathing and rest
• Alleviating the stress and anxiety
• Giving positive boost to their mood.
• Aromatherapy
  • Aromatherapy refers to the medicinal or therapeutic use of essential oils absorbed through the skin or olfactory system. Essential oils, usually plants extract that are used to treat illness and also enhance physical and psychological well-being.
  • Various studies suggest that olfactory stimulation related to aromatherapy has proven in immediate reduction in pain, and also changes physiological parameters such as pulse, blood pressure, skin temperature, and brain activity.
• Acupressure or acupuncture
  • Acupressure is the technique used in pain relief which uses fingers, palms, elbows, feet to apply pressure to acu points, even special devices are used to apply pressure on the body's meridians. This also involves stretching or massage, and other techniques too.
  • During an acupressure session, patient lie fully clothed on a soft massage table. Gentle press or massage on acupressure points on body. A session typically lasts about one hour. May need several sessions for the best results.
  • Acupuncture is a complex intervention, very fine needles are inserted into different parts of the body and manipulated to correct energy imbalance.
• Transcutaneous electrical stimulus (TENS)
  • TENS is a method of transcutaneous electrical stimulation which is used mainly to provide a degree of symptomatic pain relief by exciting sensory nerves.
  • It refers to the use of electrical stimulation with the specific intention of providing symptomatic pain relief
  • This method is mainly used for the treatment of neck & low back pain
  • It is a non-invasive treatment and has fewer side effects when compared with drug therapy.

Nursing management

Pain management is the vital component of patient care and this can be complex. It is very important to individualize plan of care for each patient and always consider both patient and family in care. Nursing responsibilities include:

1. Pain assessment: The nurse must adequately and completely assess the patient’s pain

2. Pain rating: The nurse should appropriately identify a pain rating scale matched to the patient’s needs

3. Patient and family involvement in pain management: The nurse must include the patient and family in development of the pain management plan of care

4. Physician communication: The nurse should inform the physician/doctor for any new pain, and/or pain which is not managed adequately

5. Medication administration: The nurse must administer medication in an appropriate and safe manner

6. Patient and family involvement in non-pharmacological pain interventions: The nurse should involve the patient and family, and provide appropriate instructions

7. Patient and family education: The nurse should instruct the patient and family on the correct administration and management of medications and side effects, and provide them with pain management resources

8. Involvement of ancillary services: The nurse should involve ancillary services in consultation for planning and implementation of pain management strategies

9. Interdisciplinary communications: The nurse must communicate assessment, interventions, and pain management outcomes through verbal and written documentation

10. Pain evaluation: The nurse should frequently evaluate effectiveness of pain control through pain scale, patient and family satisfaction, and knowledge base