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Pharmacological approaches to pain management are often the only ones considered by practitioners. Research conducted in the area of pain control suggests that several other techniques can be used alone or in conjunction with pharmacology treatment modalities. Alternative therapies include nerve blocks as well as more drastic measures such as neurosurgery. There are also several non-invasive treatment modalities such as relaxation, exercise, distraction, biofeedback, transcutaneous stimulation, acupuncture and acupressure. We will discuss each of these treatment choices in this next section.
A nerve block is performed by injecting a local anesthetic near a nerve to stop the afferent transmission of painful impulses. It is useful for the treatment of chronic pain, low back pain, and pain related to cancer. Medications such as Marcaine do not have the side effects associated with opioids, and provide anesthesia to the area.1
Nerve blocks have several uses. It can be used diagnosrically to determine the source of pain that is difficult to localize. It is also useful for the management of certain types of chronic pain, such as pain related to cancer. The results of nerve blocks usually last longer than the duration of the anesthetic agent used. Permanent nerve destruction can be obtained by injecting ethanol or phenol. The exact procedures vary depending upon the type and location of the pain.
Immediate side effects should be anticipated. They include hypotension, respiratory depression, or paralysis. Pneumothorax, hemorrhage and infection are rare but are potential problems that should also be considered.2
Intervention | Advantages | Disadvantages |
Oral analgesics Acetaminophen Aspirin NSAIDs |
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Oral opioids |
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Transdermal opioids (fentanyl) |
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Rectal opioids |
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Subcutaneous infusion |
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Corticosteroids |
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Anticonvulsants |
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Antidepressants |
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Hydroxyzine |
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Radiation therapy |
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Relaxation, imagery, biofeedback, distraction, and refraining |
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Patient education |
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Psychotherapy, structured support, and hypnosis |
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Cutaneous stimulation (superficial heat, cold, and massage) |
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Transcutaneous electrical nerve stimulation |
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Acupuncture |
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Peer support groups |
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Pastoral counseling |
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Source: Management of Cancer Pain. AHCPR Pub. No. 94-0592 (1994) 42-54
Some types of pain may need to be treated with surgical neural destruction. This is always a last resort for the treatment of intractable pain. Several different procedures are available and selection of procedures depends upon the type and location of die pain.
A peripheral neurectomy is the excision of a peripheral or cranial nerve to relieve localized pain. It can cause complete loss of movement or sensation in the area.
Surgical resection of the posterior root, outside the spinal cord is called a Dorsal Rhizotomy. This can relieve acute pain as well as chronic visceral pain without causing loss of motor function. It is most commonly used to treat neck, chest, and back pain related to cancer.3
For advanced disease states, resulting in intractable pain, a Cordotomy may be performed. This procedure removes the spinal and cerebral tracts which transmit pain impulses. Both pain and temperature sensation are eliminated below the severed level, however, touch and position sensations are maintained. This procedure is hazardous and can result in permanent paralysis.
A sympathectomy can be used to treat phantom pain or pain from vascular disease. This is a permanent severing of afferent nerve pathways. This prevents conduction of pain impulses. All of these procedures carry considerable risk and are usually only considered when conventional pain management has been unsuccessful.4
Contrary to popular belief, there is not a pill for every problem. As consumers and as health care professionals we tend to think that medication is the answer to all pain problems. The most common pain management intervention is medication.1
In addition to pharmacological treatment, there are several nonpharmacologic treatments that help to mediate the pain experience. Their success is based upon the evidence of the multi-dimensionality of the pain phenomena. Pain control options include:2
Nonpharmacologic treatments are used to support, not replace, pharmacology and invasive treatments. They are appropriate for:3
Treatment options such as cognitive and behavioral therapy can be effective adjuncts to traditional pharmacological management of pain syndromes. One use is for the treatment of chronic pain that persists past the time of healing. One suspected cause of this syndrome is prolonged disuse. This could be due to the patient's fear of more pain, families insisting that the individual "take it easy", or even physicians and other health care professionals advising prolonged rest of an affected area. In most cases healing is increased with motion. Prolonged disuse can cause pain to resume when movement is resumed.
Another problem is the patient's perception of the meaning of pain. If pain means harm to the individual, the patient may be afraid of reinjuring the area. This encourages further disuse. When dealing with patients with this type of chronic pain, assessment and analysis is essential. The objectives of this behavioral analysis include identification of the following:4
According to Fordyce (1989), the treatment objectives are to decrease the individual's "illness conviction" by education, relaxation training, stress reduction and management techniques, and to encourage active movement of the affected area.
Behavioral approaches to pain management are based on a biopsychosocial view of pain. Pain is a multi-dimensional phenomena. It results from the interaction between painful stimulation, as well as psychological, social, and environmental factors. These multiple factors explain the variable pain experiences of individuals with similar injuries, as well as the variables of individuals over time. Psychosocial influences are even more pronounced with chronic pain. Psychological stress may increase pain perception or muscle hyperactivity. Social or environmental factors may lead to underactivity, causing muscle atrophy or weakness. Physical deconditioning can result in further pain.5
Patients with chronic pain may spend all of their time, money, and energy seeking pain control. It becomes their main goal in life. They stop fulfilling tasks associated with their roles in life. This leads to feelings of inadequacy.
Chronic pain is often treated within the "acute-care framework". When this model is unable to control or eliminate the discomfort, the patient is encouraged to decrease activity and adopt a passive role. They become dependent on the health care providers and they still have no pain relief. This leads to feelings of helplessness and hopelessness. Eventually patients become depressed, they lose control over their lives. They take less interest in roles and responsibilities and pay more attention to pain and discomfort. Interpersonal relationships with patients with chronic pain are strained. They may miss work frequently. When a patient reaches a pain management center it is usually after years of unsuccessful attempts to control pain. They are often tired, frustrated, and angry. They are looking for a "cure".6
Special training in coping with pain and problem-solving are begun to assist the individual to manage the pain on his own. The idea is to alter perceptions of pain, control pain by learning various techniques, and prevent dysfunction. The patient and therapist develop mutually agreeable goals. Patients are given ownership over their pain experience, rather than feelings of helplessness.
Cognitive behavioral treatment includes education, occupational, and physical therapy.
Treatment begins with education of the individual and his family. Topics taught include: healing, pain relief techniques without analgesia, limitations of analgesia due to side effects and tolerance, how to anticipate pain, perception of pain, that "hurt" and "harm" are not the same, activities that decrease pain, relaxation techniques, stress management, body mechanics, and stretching exercises.7
Activity and exercise are the main components of therapy. Patients are encouraged to be more active. Prolonged disuse of the affected area is discouraged. The goal is not to decrease the pain so that activity can be resumed, but to increase activity to control the pain. Physical therapy is begun slowly. It is essential that the individual is convinced that activity and movement is safe. As physical therapy continues, the individual's confidence about resuming activities increases. This serves two purposes, it counters the effects of disuse and it reinforces "well behavior" rather than supporting "ill behavior".8
Exercise programs are begun by assessing the individual's tolerance to specific movements and exercises. When exercises are begun the expectation level should be set low enough to ensure early success. Repetitions should be gradually increased so that the individual can see his progress. The exercises should address body positions, body movement, and general conditioning.
The next step in treatment is called "skills acquisition". Coping techniques focus on behaviors, perceptions, and emotions rather than on pain symptoms. The physical exercises are taught and gradually increased. These activities become a part of the individual's daily routine. Occupational therapy may also be required. The goal is to alter lifestyles and activity level. Relaxation skills and diversion are used to help the individual learn to cope. Patients are taught that they have the skills needed to exert control over their bodies. Since individuals with chronic pain are preoccupied with their pain and depression, distracting their attention away from the all-consuming distress can alter their perception of pain. Patients are taught various distraction techniques to add to their coping skills.
Once skills have been learned, the patient is encouraged to use them frequently. The idea is to reconceptualize the pain experience. The individual and his family are reoriented with the belief that the pain is not an overwhelming experience, but rather it is an experience that can be modified and controlled using various techniques.
To prevent relapses, the individual needs to be prepared for long-term maintenance of behavioral changes. Potential pain-causing situations are identified and patients problem-solve possible ways to cope or modify these situations. This step teaches the patient how to plan for potential pain-causing events and it also teaches the individual that potential setbacks are normal but are within the individual's ability to control or mediate.
The end result of cognitive behavioral treatment is to:9
Let's look at some of the techniques used in cognitive behavioral therapy. Relaxation, distraction, and imagery are easy to learn and could easily be incorporated into the nurse's routine.
Relaxation counters the effects of sympathetic stimulation caused by pain and discomfort. It can lower heart rate, blood pressure, respiratory rate, decrease fear and anxiety, and alter the perception of pain.10
Nurses should try these exercises themselves to become as familiar as possible with the sensations and feelings that they evoke. This will make teaching relaxation easier. Many nurses avoid this intervention because they do not feel they are competent in this area. Practice will increase your feelings of competence and make your teaching more effective.
Try several techniques. Begin by making a fist and then gradually relaxing it. Blood flow should increase to the area causing a warm sensation. This is the sensation you want to teach your patients to expect. All relaxation techniques should be combined with slow, steady breathing. The goal is to teach your patients what being relaxed feels like so they can elicit this sensation when they need to control pain and anxiety. Mastery of these techniques takes practice for the patient as well as the nurse. Plan several sessions a day with the individual. Ideally this should be taught when pain is minimal. Once patients are able to perform this technique on their own, encourage them to use it whenever needed.
Relaxation can be combined with guided imagery. This is especially effective for decreasing anxiety and fear. Guided imagery uses a simple fantasy. Have the patient in a comfortable position. The environment should be as free of distraction as possible. Close the door and turn down the lights. Begin with relaxation breathing and exercises, such as progressive relaxation. When the patient begins to relax, the nurse can help the patient to recall times when they were calm or at peace. Have them imagine being at that place and time. The guided fantasy should be something of the patient's choosing. It might be a trip to a beach or forest. Quiet music or background tapes can enhance the imagery. Once the patient has completed the fantasy be sure he is fully alert before allowing him to walk, climb stairs or drive. Sometimes the effects of guided imagery can be sedative-like.11
Some precautions that the nurse needs to be aware of include:
Imagery is most successful in highly motivated individuals. Often times it can be used for painful procedures, such as dressing changes, when medication alone has been unsuccessful. Before forsaking this treatment option, try it and become comfortable with it. The time spent teaching this to a patient can result in less pain and suffering and less trips to the medication room for additional doses of analgesia. McCaffery suggests the following guidelines for the use of imagery.13
An excellent reference for the nurse who is interested in this intervention is McCaffery's book, Nursing Management of the Patient in Pain (1979). Relaxation and imagery are used to achieve mental and physical relaxation which in turn decreases anxiety, muscle tension, and pain perception. It includes focused breathing exercises, progressive muscle relaxation, meditation, music assisted relaxation, and pleasant images.
Advantages of relaxation and imagery are that they are easy to learn no special equipment is necessary; staff can be taught these techniques without extensive training, and it is usually acceptable to patients.14
Distraction is often used by nurses without their realization. Oftentimes when patients use distraction it is misinterpreted by health care personnel. Some examples of distraction include: concentrating on an object, word, or idea; doing math problems in your head; counting, singing, listening to music, watching TV, talking on the phone, being read to, or laughing.
Distraction often requires considerable energy of the individual and afterwards the patient may require pain medication. Often, nurses do not believe the patient's report of pain, especially if they just saw them laughing and talking with visitors. However, when the visitors leave and the distraction is gone, pain perception increases.15
Biofeedback is a technique that uses relaxation techniques to help individuals learn to control physiological responses, such as muscle tension, heart rate, respiratory rate, and blood pressure. It requires special training and special equipment. Patients are attached to various recording devices that measure vital signs or muscle tension and they practice altering these physical responses.
When the desired response is obtained, the patient receives reinforcement via an alarm or light.16
Physical agents consist of several intervention options. These options can be used to alter pain perception, as well as decreasing pain by altering physical complications, such as edema. Hot and cold applications are often used by nurses to improve circulation or to decrease swelling. Heat increases blood flow to the skin. It causes vasodilation, which increases oxygen and nutrient delivery to the area. Care should be taken to prevent bums. Hot packs or heating pads should be wrapped and the patient should never lie directly on them. Use a towel between the device and the patient's skin. Monitor the skin frequently for signs of redness. Never use heat to skin that has been exposed to radiation therapy.17
Cold therapy causes vasoconstriction and local hyperesthesia. It is useful to decrease inflammation and edema after an injury. It is also helpful to reduce muscle spasms. Cold packs should be flexible and comfortable. They should be wrapped to prevent skin irritation. Cold packs should be used for 5-15 minutes. There is no benefit to using them longer than 15 minutes. Cold therapy is contraindicated for skin exposed to radiation therapy or vasoconstrictive syndromes (such as peripheral vascular diseases, Raynaud's phenomena, or connective tissue disorders).18
Fundamental nursing skills are physical interventions that are often undervalued by nurses and other health care professionals. They are frequently overlooked in favor of increasing medication doses. Look for conditions in the patient's environment that may be increasing their discomfort. The following suggestions come from a nursing fundamentals text.19
This is most important for patients who are bedridden either permanently or temporarily due to surgery or a procedure. Don't be naive enough to believe that it takes hours of bed rest to cause a pressure sore, or that they only occur in patients who are debilitated. I developed pressure sores within 2 hours when I was in the hospital to have my second child.
Positioning serves several purposes, it prevents complications associated with immobility, it promotes comfort, and it decreases pain. If you have any doubts as to the effectiveness of this simple nursing intervention, perform the following experiment on yourself.
Go to bed, with one pillow, the sheets tightly tucked in at the bottom. Place your hands at your sides, on the outside of the covers. Have someone set an alarm clock for 2 hours. Now, DO NOT MOVE. To enhance this experiment, have the room quiet, but the light on. No fair watching TV or listening to music. The only thing you have to concentrate on is your immobility.
If you can make it until the alarm rings you will have noticed many discomforts. Your arms and/or legs may have fallen asleep and become numb. Your back may be sore. All of your extremities will be slightly sore and stiff. Can you imagine being at the mercy of someone else for the simple pleasure of repositioning your hand or foot?
It is recommended that we reposition patients every 2 hours. However, after this experiment I feel compelled to reposition patients more frequently, if at all possible. When positioning patients be sure to have the appropriate equipment. It takes at least four and preferably five pillows to properly position a patient on their side. One at the head, two between the legs, at least one and preferably two behind the patient. When patients are trying to maintain a sidelying position unsupported, the extremities will become quickly fatigued causing increased discomfort.
If there is swelling of an extremity, it should be elevated above the level of the heart. This will require two pillows. By reducing edema, we can decrease the discomfort caused by the edema. In addition to positioning, range-of-motion exercises should be performed at regular intervals. This increases circulation, prevents contractures, and eases muscle tension due to prolonged inactivity.
Cutaneous stimulation includes application of cold, heat, electrical impulses, pressure, or the use of acupuncture needles. This intervention is based on the gate-control theory of pain transmission. It is thought to work by activation of the pain-modifying pathways. Stimulation of peripheral nerve endings causes the release of endorphins, which decreases the perception of pain, by closing the pain gates. Cutaneous stimulation may eliminate pain, or at least decrease its intensity. There are several site options for cutaneous stimulation. They include:20
When choosing between heat and cold applications, keep the following in mind: Cold usually works faster and longer when used for pain reduction. A technique that may be effective for severe pain is alternating heat and cold applications. McCaffery21 describes a simple experiment for nurses to try that will help them to evaluate the effectiveness of cutaneous stimulation for themselves. Often nurses do not use interventions that they are not personally familiar with. If this is the case with you, this simple experiment can be helpful. It is best to work with a partner. One nurse role plays the part of the nurse while the other is the patient. A clothes pin can be placed on the upper forearm. This will produce a sustained pain. Now the nurse should practice using various types of cutaneous stimulation (cold, ice, heat) at various locations. With each intervention the patient should be asked to rate the pain before and after the intervention. This is one way to help the nurse become more familiar with this intervention. It would also be helpful for the two nurses to change roles and repeat the experiment.
Transcutaneous electrical stimulation (TENS) uses low voltage electric stimulus to peripheral nerve fibers via small cutaneous electrodes. Research suggests that patients experience a decrease in the intensity of the pain. Part of the action may be related to the placebo effect. Some people report relief for hours or days after cutaneous stimulation. For patients who only experience relief during the stimulation, a TENS unit can be worn 24 hours a day.22 It should be removed, however, for bathing.
One of the reasons cited for not using TENS treatments more often is the belief that it requires special training or expertise. TENS is portable, non-invasive, and has almost no side effects. It has been used on children, as well as older adults. Most units run on a 9-volt battery that will last up to 12 hours. If you have never used a TENS unit you might consider applying it to yourself to gain first-hand experience. There are four basic steps for setting up a TENS unit.23
General nursing care consists of patient and family education, and monitoring skin for signs of irritation from the electrodes. An excellent nursing reference for TENS therapy is found in the September, 1992 issue of The Canadian Nurse (TENS: An Adjunct to Analgesia, by Finlay.
Acupuncture and acupressure are other options for cutaneous stimulation. Acupuncture sites have been mapped and can be found in several resources. The use of acupuncture requires a therapist who is knowledgeable and trained in this technique. Research studies show varied results from this intervention. It requires insertion of small needles into the skin at various locations and depths. Acupressure uses pressure at acupuncture sites.
What is body alignment? Actually this is the correct positioning of joints, tendons, and muscles in a particular position (standing, sitting, lying). Correct alignment reduces muscle skeletal strain, maintains muscle tone, and helps to maintain balance and coordination. The effects of immobility or disuse on the muscle skeletal system can lead to permanent impairment. Muscles that are not used lose endurance and mass. They atrophy and become weak. Exercise should be preceded by stretching. The benefits of an exercise program include the following:24
Specific exercises and tolerance levels will vary from person to person based on their previous level of conditioning, as well as their current medical status. However, most individuals will benefit from some type of regular physical activity.
Exercise 1: Slow rhythmic breathing for relaxation |
|
Source: McCaffery, M., Beebe, A., Pain: Clinical
Manual/or Nursing Practice, CV Mosby Co.: St. Louis, 1989. Adapted and
reprinted with permission. Note: May be duplicated for use in clinical
practice. Found in: Jacox, A. Can-, D.B., Payne, R., et. al. Management of Cancer Pain. Clinical Practice Guidelines Number 9. AHCPR Pub. No. 94-0592 (Rockville, MD, March 1994) 242-245. |
Exercise 2: Simple touch, massage, or warmth for relaxation |
Touch and massage are age-old methods of helping others relax. Some examples
are:
Especially for the elderly person, a back rub that effectively produces relaxation may consist of no more than 3 minutes of stow, rhythmic stroking (about 60 strokes per minute) on both sides of the spinous process from the crown of the head to the lower back. Continuous hand contact is maintained by starting one hand down the back as the other hand stops at the lower back and is raised. Set aside a regular time for the massage. This gives the patient something to look forward to and depend on. |
Source: McCaffery, M., Beebe, A., Pain: Clinical
Manual/or Nursing Practice, CV Mosby Co.: St. Louis, 1989. Adapted and
reprinted with permission. Note: May be duplicated for use in clinical
practice. Found in: Jacox, A. Can-, D.B., Payne, R., et. al. Management of Cancer Pain. Clinical Practice Guidelines Number 9. AHCPR Pub. No. 94-0592 (Rockville, MD, March 1994) 242-245. |
Exercise 3: Peaceful past experiences |
Something may have happened to you a while ago that brought you peace and
comfort. You may be able to draw on that past experience to bring you peace
or comfort now. Think about these questions:
Additional points: Very likely some of the things you think of in answer to these questions can be recorded for you, such as your favorite music or a prayer. Then, you can listen to the tape whenever you wish. Or, if your memory is strong, you may simply close your eyes and recall the events or words. |
Source: McCaffery, M., Beebe, A., Pain: Clinical
Manual/or Nursing Practice, CV Mosby Co.: St. Louis, 1989. Adapted and
reprinted with permission. Note: May be duplicated for use in clinical
practice. Found in: Jacox, A. Can-, D.B., Payne, R., et. al. Management of Cancer Pain. Clinical Practice Guidelines Number 9. AHCPR Pub. No. 94-0592 (Rockville, MD, March 1994) 242-245. |
Exercise 4: Active listening to recorded music |
Additional points: Many patients have found this technique to be helpful. It tends to be very popular, probably because the equipment is usually readily available and is a part of daily life. Other advantages are that it is easy to learn and is not physically or mentally demanding. If you are very tired, you may simply listen to the music and omit marking time or focusing on a spot. |
Source: McCaffery, M., Beebe, A., Pain: Clinical
Manual/or Nursing Practice, CV Mosby Co.: St. Louis, 1989. Adapted and
reprinted with permission. Note: May be duplicated for use in clinical
practice. Found in: Jacox, A. Can-, D.B., Payne, R., et. al. Management of Cancer Pain. Clinical Practice Guidelines Number 9. AHCPR Pub. No. 94-0592 (Rockville, MD, March 1994) 242-245. |
The last area we will discuss is therapeutic touch. Touch is a major intervention used by nurses. It helps to promote and maintain orientation, it reduces fear, anxiety, and depression. All touch is not therapeutic. Therapeutic touch is purposeful. It projects different messages. We can vary the message by changing the duration, location, frequency, or intensity of the touch.
Older persons, confused individuals, those who are attached to machinery, isolated, or immobile are most in need of touch. Besides providing comfort and reassurance, it helps individuals differentiate themselves from their surroundings. Some of the benefits of therapeutic touch include enhanced self-esteem, relaxation, decreased fear or anxiety. Massage is considered to be a form of therapeutic touch.25
There have been many problems associated with effective pain management. However, the needs of two specific populations, children and the elderly, should be addressed. Both groups have been victims of less than adequate management of pain.
Infants and children do experience pain. Studies indicate that pain management in this population is even less well managed than pain in the adult population. Guidelines for pain management in children can be found in the AHCPR Publication (92-0020).25
The following principles of pain management for children were adapted from recommendations published in AHCPR publication number 92-0020.
Studies have found that children are often under-medicated after surgical procedures. Invasive or painful procedures cause distress in children, they are often too young to understand the need for the procedures. Some strategies recommended for this population include:
One procedure used with children needs to be discussed in more depth. That is the use of Conscious Sedation. Deep sedation is similar to general anesthesia. Only persons skilled in its use should assist with this procedure. Supervision and monitoring of the child during the procedure should be done by someone who is not taking part in any other part of the procedure. Continuous pulse oximetry is required as well as the immediate availability of all resuscitative equipment and drugs. All persons involved in this procedure should be ACLS trained. Once the procedure is completed, the child will need to be continuously monitored until he is fully conscious. Continuous monitoring requires a nurse in attendance at the bedside. This procedure can be safe and effective if proper training and equipment is available.
If your facility treats pediatric patients, here are some questions to ask about the current practice of pain management in that facility.27
When dealing with children, many of the same theories apply. It is always better to anticipate and prevent pain, than to treat it once it starts. Children have used PCA with good results. Many times exaggerated fears of causing respiratory depression in children cause providers to prescribe less than adequate pain medication. If the child is carefully and routinely monitored and the nurses are well informed about the subject of pain management, this can be managed without untoward problems. Children who experience respiratory depression secondary to opioids are given Narcan using the same procedure used for adults.
Elderly patients often have multiple sources of pain due to several chronic health problems. They are also often taking more than one medication that may result in interactions with analgesics.28 Patients over the age of 60 have twice as many painful conditions than those under the age of 60.29 Institutionalized patients over the age of 60 have an even higher incidence of pain.30 Elderly patients may report pain less often. Cognitive problems such as dementia may cause barriers to pain assessment. Standard instruments are often difficult to use when assessing this population due to vision and hearing problems.
The elderly are at risk for both undertreatment and overtreatment of pain. This population needs to be monitored even more closely than others due to aging changes and problems associated with other chronic disease states such as liver or renal disease. Urinary retention and constipation, which are side effects of opioid analgesics, are even more of a problem in the geriatric population. Prevention and careful monitoring of these side effects is required. Because of all of the problems associated with this group, practitioners are often reluctant to prescribe or administer adequate analgesic doses. Doses should be titrated to their effect. Self-reports of pain and assessment of side effects are the best indicators of the adequacy of analgesic dosing.
Nurses often undervalue the effectiveness of education as a nursing intervention. However, effective teaching can result in decreased anxiety and fear. It gives patients and their families the confidence they need to cope with unfamiliar health care problems. Education helps patients maintain a sense of control over their health by providing them with the tools they need to make informed choices about their health.
Patient education consists of both teaching and learning. Teaching is the action of providing information that will promote cognitive and behavioral changes in the learner. Learning is the acquisition of knowledge and skills that result in cognitive and behavioral changes.
To be effective educators nurses must be aware of the needs of the individual and their family. The nurse's knowledge of disease states, procedures, medications and treatment options allows him or her to anticipate the information that the patient will need. Prior to any teaching the nurse should assess the following:
Asking patients what they know about their disease or injury can provide valuable information. It allows the nurse to correct misconceptions and to plan a teaching program that will fill in the gaps in the patient's knowledge. Patients who are very knowledgeable about their problem will have very different learning needs from those with little knowledge or skills. A pre-packaged teaching program will be less effective than one that is individualized to the patient's needs. As adults we learn things when we see them as useful or valuable. Find out what the patient wants to learn and design your teaching plan based on the patient's needs and desires. Explain to patients what options are available so they can determine which ones would be most useful to them.
One area nurses find difficult is determining a patient's readiness to learn. Several factors will affect readiness for learning. One factor is the ability to concentrate. We all find it difficult to concentrate if we are tired, hungry, or in pain. Anxiety may also affect our ability to learn. A high level of anxiety prevents us from being able to concentrate. Environmental distractions will also affect our ability to learn. If you are uncomfortable due to heat or cold, or distracted by sights, sounds, or smells it is difficult to concentrate. Distractions will affect our ability to learn. These factors need to be taken into consideration by the nurse. Plan teaching sessions when the patient is the most comfortable. Find a place where you can control interruptions. Be sure to assess patients for fatigue during the teaching sessions. Short, frequent sessions are better than long sessions. Teaching-learning should be interactive. Encourage participation by the patient.
The advent of the VCR has led to the creation of patient teaching tapes. While these might lead to continuity of information taught, it does not necessarily result in learning. One-on-one contact with the nurse is more effective and more personal. Tapes should be used to augment your teaching. They are not meant to replace the nurse-patient interaction. The use of audiovisuals should be preceded and followed by question and answer periods with the nurse.
Another area the nurse needs to investigate is the patient's motivation to learn. Motivation may occur due to new ideas, new information, or new physical needs. If you perceive a need for new information, you will be motivated to learn.31 Nurses play a part in motivating individuals to want to learn by providing them with new information and ideas that create a need for more knowledge.
Health beliefs will also affect a person's motivation and readiness to learn. The following beliefs will affect motivation.32
Sometimes our teaching needs to be directed toward changing a patient's perceptions or beliefs regarding the existence of a problem, or their ability to do something about it. Teaching involves more than just imparting facts. It also involves changing beliefs and values.
Planning patient education requires that the nurse select methods that are appropriate to the patient's age and abilities. Using material or words that are too simple or too complex decreases the effectiveness of your teaching. Material should be selected based on the nurse's assessment of the individual. Evaluate the preprinted material you use. Is it appropriate for everyone?
Nurses must determine the best time for teaching. With the trend toward earlier discharges and same day surgeries, the nurse is challenged to provide education within very limited time constraints. When planning teaching sessions there are several guidelines to keep in mind.33
Specific Topics Related to Pain Management
Patients should receive a good description of all procedures and expected discomfort. Studies show that good pre-operative teaching can decrease pain, analgesic use, and length of hospital-ization.34
Patients and their families should receive information that will allow then to assess, evaluate, and communicate their pain symptoms. Patients who are candidates for and who are interested in cognitive-behavioral treatment should be taught these strategies prior to procedures and surgery if at all possible. If patients are to use PCA pumps postoperatively, they should be familiarized with this treatment before surgery. This information can then be reinforced after surgery.
Patients need to know how to respond to questions about their pain. The same instrument should be used by all personnel. The patient should be made familiar with the instrument and practice using it, prior to surgery. Patients and their families should receive information regarding pain, pain assessment, the availability of medications, and other treatment options. Misconceptions regarding "fear of addiction" should be addressed.
Patient should be actively involved in their pain management plan. To do this the patient will need an understanding of pain, pain management, pain medications, how to manage side effects, and what resources are available to help them cope. The following sample teaching plan was developed from an article in Cancer, by Ferrell, Rhiner, & Ferrell.35
The last area that needs to be discussed is discharge planning. It is important that patients and their families are confident in their ability to manage pain symptoms once they leave the hospital. They need to know what medications they are taking. They need to know how to take the medication and when to take it. They should also be able to assess and manage side effects. Printed instructions, as well as verbal instructions, should be given to both the patient and their family. I have included an example of discharge planning instructions. In addition to this basic instruction, many pharmacies supply preprinted handouts. If these are available, patients should have these to go home with them.
Please select the best answer for each of the questions below.