8. Alternative Management of Pain

Alternative Methods of Pain Management

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.

Nerve Blocks

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

Table 8. Advantages and disadvantages of pain therapies

Source: Management of Cancer Pain. AHCPR Pub. No. 94-0592 (1994) 42-54

Neurosurgery

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

Nonpharmacologic Pain Management

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

1. Cognitive behavioral interventions that include relaxation and distraction. These interventions decrease pain perception, decrease anxiety and fear, and decrease the amount of medication needed to control pain. These interventions are designed to alter pain behaviors and give individuals a sense of control over their pain.
2. Physical agents such as heat, cold, repositioning, range of motion, acupuncture, acupressure, message, exercise, and touch. Physical agents provide comfort, correct physical defects (decrease swelling, etc.), alter physiologic responses, and decrease fear related to immobility or activity.
3. Transcutaneous stimulation
4. Education and instruction is often an overlooked treatment intervention. Patients who know what to expect experience less anxiety and fear.

Nonpharmacologic treatments are used to support, not replace, pharmacology and invasive treatments. They are appropriate for:³

1. Patients who want this type of intervention
2. Patients experiencing fear and anxiety that is increasing their perception of pain
3. Patients who may benefit from lower doses of medications
4. Patients who have incomplete pain relief from medication

Cognitive and Behavioral Therapy

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

1. What are the results of the patient's pain behaviors?
2. Identify relationships between activity and pain symptoms. This helps to distinguish between pain associated with tissue injury and pain that may be more related to behaviors and coping mechanisms.
3. To identify treatment goals and evaluate the individual's environment, for support of activities associated with the goals.
4. To investigate the influence of significant others (family, friends, co-workers) on the reinforcement of pain behaviors.
5. To assess for other problems that might limit the individual's ability to participate in treatment activities.

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

1. Change the patient's view from helplessness and hopelessness to resourcefulness and self-confidence.
2. Teach patients to monitor thought, behaviors, events and symptoms.
3. Teach patients the necessary behaviors needed to deal with the problems associated with chronic pain.
4. Develop more effective ways of thinking and responding to the chronic pain experience.

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

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.

Imagery

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:

1. Use of guided imagery should be part of a comprehensive treatment approach. All members of the team must be aware that it is being used.
2. It should not be used in patients with depression or with patients who are psychotic. It may increase depression or further confuse individuals who already have difficulty distinguishing reality from fantasy.
3. If a patient is difficult to arouse after an episode of imagery, they may not be a very good candidate for this intervention.12

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

1. Determine if the individual is currently using any form of imagery as a coping mechanism.
2. Explain imagery to patients (use examples).
3. Involve the individual in decisions regarding imagery.
4. Enter the image slowly and gradually. It is a trip to be experienced.
5. Use images that will be familiar to the individual.
6. Use all of the senses. Sight, Sound, Smell, Touch.
7. Use only one image at a time.
8. Avoid the use of the word "pain". Use more soothing words instead.
9. Teach imagery when pain is the least severe.
10. Discuss patient's fear of imagery.
11. Begin sessions with relaxation techniques.
12. Practice imagery.
13. Teach patients how to end imagery.

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

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

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

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

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

1. Tighten bed linen. Nothing feels worse than lying for hours on lumpy sheets.
2. If the patient is diaphoretic, change the linen frequently. How comfortable would you be lying on a damp bed?
3. Be sure patients are not lying on IV or foley tubing.
4. Loosen bandages that are constricting, and check them frequently.
5. If the patient has Ted Hose, remove them and replace them at least every 8 hours. This is rarely done in practice. If you want to see how uncomfortable this can be, put on a pair and leave them on for 24 hours. Chances are you won't be able to complete this experiment because you will begin to feel the discomfort in 4-6 hours.
6. Change wet or damp dressing.
7. Keep the patient clean and dry. We all feel better when we are clean and lying on clean linen.
8. Prevent constipation with diet, fluids, and exercise. Be sure to monitor for this complication and treat this problem before it causes unnecessary suffering.
9. Be sure the environmental temperature is not too hot or cold for the patient (not the nurse). Older patients and individuals with anemia will need extra blankets. Patients with nausea or those who are short of breath prefer cooler environments.
10. Excessive or obnoxious noises should be kept to a minimum, but absolute quiet is usually not preferred. Patients may like soft music or the TV set left on.
11. Keep smells to a minimum. If patients are nauseated, close their door when meals are served. Nurses and other health care professionals should avoid perfumes and after shave lotion. While this may smell good to you, to a patient who has nausea, this smell may be too strong for them to bear.
12. If patients are NPO, allow them to wet their lips frequently with a cold wash cloth.
13. Be sure patients are given or offered frequent oral hygiene. How does your mouth feel in the morning? Patients who are NPO need frequent mouth care. It is a based need that is probably one of the most overlooked nursing care interventions related to basic hygiene.
14. Washing the face frequently with a cool wash cloth makes patients feel better.
15. Back rubs or massages have become a thing of the past but may have been one of nursing's best relaxation and distraction interventions. It promotes circulation and decreases tension. When performing massage, use a warm lotion to decrease friction and increase comfort. The massage strokes should be slow and rhythmic. After massage, allow the patient to relax or sleep.
16. Document all nursing interventions that provided comfort. Encourage colleagues to use the same interventions to increase continuity.
17. Properly position all patients. This area is important and frequently not done properly.

Positioning

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

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

1. Directly over the site. This is probably the one most nurses are familiar with.
2. Proximal to the painful area. Select a site between the "pain and the brain".
3. Sites distal to the pain
4. Sites on the opposite side of the pain. For example, if the pain is in the left hand, cutaneous stimulation could be applied to the right hand. This is called Contralateral Cutaneous Stimulation.
5. At acupuncture points.

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

1. Set the pulse width at 50-70 microseconds. Set the frequency at 100 Hertz.
2. Place electrodes at least 2 inches apart around the site of the pain. Attach the lead wires so that each channel has a pair of opposite electrodes.
3. Turn the unit on. Increase the intensity of each channel until adequate paresthesia is experienced by the patient.
4. Periodic increases will be required due to neural accommodation. These increases will maintain the analgesic effect. If maximum intensity has been reached, turn the unit off for a short period of time and restart it at a lower intensity.

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.

Exercise and Body Alignment

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

1. Increased muscle tone and joint mobility.
2. Increased muscle tolerance to exercise.
3. Increased muscle mass.
4. Decreased feelings of fatigue.
5. Increased feelings of wellness.
6. Increased gastric mobility.
7. Increased circulation.
8. Increased general conditioning.

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.

Therapeutic Touch

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

Pain Control for Special Populations

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.

Children

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

1. Pain intensity and relief should be assessed at regular intervals using appropriate instruments.
2. Child and family preferences should be respected with regard to pain management.
3. Children frequently do not report pain. Therefore, caregivers must suspect pain, and treat it appropriately.
4. Organized pain management programs should be developed to evaluate the effectiveness of assessment and management of pain in children.

The following principles of pain management for children were adapted from recommendations published in AHCPR publication number 92-0020.

1. Unrelieved pain has both negative physical and psychological consequences.
2. Pain prevention is more effective than pain treatment.
3. Success requires a good relationship between the health care provider, the child and the child's family.
4. Children and their family need to be actively involved in the pain management plan.
5. Routine assessment and continuity optimizes pain management.
6. Unexplained intense pain associated with altered vital signs should be evaluated quickly.
7. Use self-reports appropriate for the child's age and abilities. If children are unable to communicate, rely on reports of pain suspected by parents.
8. Remember that the use of physiologic measures (heart rate and blood pressure) are unreliable and should only be used as adjuncts to self-reports.

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:

1. Treat anticipated pain before it occurs with appropriate doses of analgesia.
2. Ensure the competency of those who perform procedures on children.
3. Provide adequate time to prepare children and their families to decrease anxiety.
4. Be aware of the environment. Noises, machinery, cold, strange people, or places are frightening and increase both anxiety and distress.
5. Allow parents to stay with their children during procedures. Prepare parents for their role during the procedure.
6. Give pain medication by the least painful route available.
7. When repeated procedures are expected, be sure to maximize pain treatment during the first procedure to decrease anxiety and distress during subsequent procedures.

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

1. Is the child and the family involved in the selection of analgesia?
2. Is the child adequately assessed? (Do a chart audit to determine the current level of assessment at your facility.)
3. Are analgesics ordered for pain prevention, as well as pain treatment?
4. Are the analgesics strong enough for the expected amount of pain?
5. Is the analgesic ordered at appropriate intervals?
6. Is the route appropriate? Is it the least painful route available?
7. Are the side effects of the analgesics routinely monitored?
8. Are side effects of analgesics appropriately managed?
9. Has the treatment plan been effective, based on the child's and or family's self-report?

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

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.

Patient and Family Education

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:

1. The patient's current level of knowledge on the topic.
2. The patient's readiness to learn.
3. The patient's ability to learn.
4. The time available for teaching and learning.

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

1. The belief that a problem exists.
2. The belief that it is possible to take actions that will alter the problem.
3. The belief that the individual is capable of taking the actions required.

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

1. Organize your material. Know what is to be taught. Begin with basic information and progress to more complex information. Teach essential information first.
2. Encourage active participation. It is the teacher's responsibility to keep the patient involved in the teaching-learning experience.
3. Build on a patient's existing knowledge. Don't waste time repeating information they already have.
4. Select appropriate teaching methods. Information can be presented in many forms, however interactive teaching is the most effective. Use of pictures and demonstration will help the patient visualize the information.
5. Evaluate learning and reinforce as needed.
6. Document not only the teaching, but evidence of learning in your nurse's notes.

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.

Review

Please select the best answer for each of the questions below.

1. The most common pain management interventions used by health care providers is
   1. Distraction
   2. Relaxation
   3. Medication
   4. Imagery
   
   
2. Distraction, Imagery, and Relaxation are considered to be which of the following?
   1. Cognitive-behavioral treatments
   2. Physical agents
   3. Cutaneous stimulants
   4. None of the above
   
   
3. Based on the cognitive-behavioral approach to pain management, a patient with chronic low back pain should be advised to
   1. Remain on bed rest
   2. Prepare to limit activity for the rest of their life
   3. Both a and b
   4. Neither a nor b
   
   
4. Results of relaxation training are
   1. Decreased anxiety
   2. Decreased muscle tension
   3. Both a and b
   4. Neither a nor b
   
   
5. Which of the following might be used by patients as a form of distraction?
   1. Listening to music
   2. Watching television
   3. Talking on the phone
   4. All of the above
   
   
6. Which of the following is true regarding the use of guided imagery?
   1. It requires extensive training.
   2. Special equipment is required.
   3. It should not be used with patients who are depressed or confused.
   4. It has no effect on pain perception.
   
   
7. Which of the following is true regarding the use of heat or cold therapy?
   1. Use only one or the other, never both
   2. Cold packs can be placed on skin that has been exposed to radiation.
   3. Cold therapy is especially useful for pain related to vasoconstrictive disorders.
   4. Heat increases the flow of blood to the skin.
   
   
8. How often should you remove Ted Hose?
   1. Every 24 hours
   2. Every 8 hours
   3. Never
   4. Every 48 hours
   
   
9. Patients with anemia will be more comfortable if the environment is
   1. Cool
   2. Warm
   3. Odorless
   4. Dark
   
   
10. Which of the following may be considered a form of cutaneous stimulation?
    1. TENS
    2. Relaxation
    3. Distraction
    4. All of the above
    
    
11. Which populations have had the least adequate pain management in the past?
    1. Infants and children
    2. Elderly
    3. Both a and b
    4. Neither a nor b
    
    
12. Which of the following is true regarding pain management in children?
    1. Opioids should be avoided.
    2. Self-reports should be used to guide pain management.
    3. Infants do not feel pain.
    4. Vital signs are the most reliable pain assessment tools for children.
    
    
13. Which of the following is true regarding patient education?
    1. Use pre-packaged programs whenever available to assure consistency.
    2. Teaching is the act of imparting facts.
    3. Learning results in changes in values, beliefs, or behaviors.
    4. All of the above
    
    
14. Nurses should assess for which of the following prior to planning teaching plans:
    1. Patient's current level of knowledge
    2. Patient's readiness to learn
    3. Patient's ability to learn
    4. All of the above

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1. Burke, S.O. and Jerrett, M., "Pain Management Across Age Groups," Western Journal of Nursing Research 11(2) (1989): 164-180.
   
   
2. Carr, D.B., Jacox, A.K., and Chapman, C.R., Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guidelines Number 1. (Rockville, MD: AHCPRPub. No. 92-0032, 1992).
   
   
3. Jacox, A., Can, D.B., and Payne, R., Management of Cancer Pain: Clinical Practice Guidelines Number 9, (Rockville, MD: AHCPR Pub. No. 94-0592, 1994).
   
   
4. Jordyce, W.E., Cognitive and Behavioral Treatment of Chronic Pain. In Current Therapy of Pain, by Foley, K.M. & Payne, R. (Toronto: B.C. Decker, 1989) 7-13.
   
   
5. Foley, K.M. and Payne, R.M., Current Therapy of Pain (Toronto: B.C. Decker, 1989) 7-13, 428-437.
   
   
6. Turk, D.C. and Rudy T.E., Nonpharmacologic Approaches to Pain Management: Behavioral Approaches to Pain Management. In Current Therapy of Pain, by Foley, K.M. and Payne, R. (Toronto: B.C. Decker, 1989) 428-437.
   
   
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