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Assessment and Management of Pain

Assessment and Management of Pain

Introduction

Pain is among the most complex and at the same time the most threatening of all the domains of ordinary human experience. The quotation above highlights the very personal nature of the pain experience and the bleak sense of loneliness when the experience cannot be conveyed to another. However, in the presence of a compassionate and knowing other, this pain and loneliness can be acknowledged and ameliorated. The compassionate acknowledgement of pain and a resolve to ameliorate pain are primary responsibilities of nurses towards patients in pain.

Nurses use the word comfort to describe goals and outcomes to nursing measures, but the meaning remains vague and essentially abstract to the person who is the recipient of the nursing intervention. The questions explored were the elderly’s definition of comfort, contributors to and distracters from comfort, and how to increase elders’ comfort. The findings identified several themes: disease process (pain, bowel function, and disability); self-esteem (feelings, adjustment, independence, usefulness, faith in God); positioning (if elders could carry out activities in bed, chair, or wheelchair); approach and attitude of staff (relationships, encounters); and hospital life (surroundings and environment—feeling at home, well fed, pleasant surroundings). (Cynthia, 2003)

There is a dilemma in providing comfort. Because bureaucratic policies limit staff, the time that staff spends with patients is confined to the basic needs of treatment, medications, and physical care. Rajagopal et.al. (2004) have noted that the quality of physical care suffers when the paraprofessional is discouraged from taking time to fulfil comfort needs such as providing a back rub or discussing the patient’s concerns. According to Kim et.al (2001) if the caregiver could spend 5 minutes massaging and talking with the older person after a bath or treatment, anxiety, pain, and depression would be reduced. The nurse is in a very influential position to make a meaningful contribution to pain relief. Although this text does not discuss the various pain theories in depth, it would be expected that nurses providing care to the aged would have sufficient knowledge of the physiologic condition of pain and the theories currently accepted by the medical community.

The ability to assess pain of another becomes complicated because of differing attitudes and the multidimensional aspects that pain projects. (Betty, 2005) There are no easy answers of how to evaluate, differentiate, or judge the uniquely personal estimates of the quality of pain. Pain experiences are highly individualized, but there is much yet to learn about pain.

Nurses are most familiar and comfortable with acute temporary pain because it is short lived and amenable to expedient relief. Chronic pain presents a frustrating situation for the nurse and an intolerable situation for the patient. Nurses expect patients suffering from chronic pain to display behaviour characteristics of acute discomfort; an organic basis for pain makes it legitimate. Nurses tend to under-medicate patients with chronic pain because they fear that they will foster addiction. (Cynthia, 2003) Often nurses caring for the patient with chronic pain, especially in long-term care situations, become so familiar with the pain that they ignore it as a means of protecting themselves from feeling overwhelmed and powerless in what seems an insurmountable, futile situation. Frequently patients with chronically painful conditions are told they must “just learn to live with it.” (Gary, 2006) To the individual experiencing pain, that is a dismal pronouncement and implies a withdrawal of interest and concern.

Pain Assessment and Management

Observe the patient for physical and psychological signs. Acute pain precipitates restlessness, grumbling, and audible moans, groans, and crying, to mention a few manifestations. The individual in chronic or acute pain decreases movement; movements are quiet, controlled, and deliberate. According to Tina (2004) vital signs may be unstable, or there may be an increase in pulse rate and an elevation in blood pressure; however, if pain persists for some time, vital signs stabilize and are not a reliable indicator of pain. Ask questions and discuss the situation you observe.

Assessment of pain in the elderly is important for several reasons: pain is the most common symptom of disease; an accurate assessment will lead to an accurate diagnostic; assessment facilitates evaluation of the effects of therapy; assessment can help differentiate acute, endangering pain from long-standing chronic pain; and successful pain management begins with an accurate assessment. (Peter, 2006) The characteristic of pain can be described as sharp and throbbing or as sensations of pressure, dullness, and aching. It can manifest itself in acute physical signs. Psychosocial pain or discomfort was identified as occurring from unkindness by caregivers or while awaiting new procedures.

Derek et.al. (2005) has noted that 70% of patients studied did not like to discuss their pain with others or were ambivalent when they did talk about it. Two thirds of patients remained calm and did not show their pain experience. No verbal communication occurred until the pain was severe. Gary (2006) has noted that accurate assessment includes questioning the patient about pain. Do not rely on the word “pain” alone; use other synonyms: discomfort, sore, ache, hurt, and so on.

According to James (2003) “the cognitively impaired and nonverbal patient is the most difficult to assess and requires astute observation. It is not wise to extrapolate on such limited data, but the findings might be helpful. Individuals who moan and groan may become withdrawn and quiet; disjointed verbalization may turn into an accurate description of the location of pain; the quiet and nonverbal person may be observed rapidly blinking with slight facial grimacing; and the friendly outgoing individual might become agitated and combative”. The person who is easily involved in activities may cry easily and withdraw from activities, or the elderly may rhythmically rock back and forth. It is important to remember that the inability to interpret or detect pain in elders who cannot and do not communicate can lead to under treatment of pain. (Peter, 2006)  At present, the assessment tools for assessing pain in those who are nonverbal are inadequate. The development of new methods of pain appraisal is an inviting area for research.

Relationship Between Pain Assessment And Management

Proper assessment of pain in the patients can be difficult. It involves a confirmation that pain may present peculiarly, principally in the cognitively impaired. Because the physical indications are not obtainable, self-reporting is taken as the best proof for the occurrence of pain and the best way to assess pain intensity.( Cavalieri, 2002)  Pain has been explained as the “fifth vital sign,” and consequently, physicians must frequently inquire about the occurrence of pain in their patients. Pain can be evaluated, even in those with dementia, using uncomplicated questions and testing tools. ( Herr, 2001)

Evaluation of pain in the patients is regularly connected with major obstacles. Older adults normally fail to report pain since they may view that it is a likely part of old age or for the reason that they are worried that it may lead to more investigative testing or added medicines.(AGS, 2002) Some patients may accept pain as penalty for past actions.(Ferrell, 1990) Rather than reporting the occurrence of pain, the patients may use terms such as sore or tenderness. (Miller, 1996)  It has also been noted that some patients are unable to communicate properly which causes disturbances are additional barriers to such assessment. Increased disturbance, changes in efficient status, changed gait, and social segregation may be signs of pain in patients with dementia.( Herr, 2001)

When potential, use of an interdisciplinary team approach to assessment and management of pain in the patients is beneficial. These strategies need to be responsive to cultural and cultural issues, as well as to principles and beliefs of patients and their families. Once etiologic issues are resolute and therapy is started, a pain log or diary is suitable to assess efficacy of treatment. Nurses should support patients to record such documentation on an every day basis. Usual reassessment by use of before managed assessment scales is significant and serves to adjust therapy to guarantee a best response. Reassessment should comprise an evaluation of fulfillment and the existence of unpleasant drug effects

The patients are often untreated or undertreated for pain for the reason that of barriers to detection, assessment, and management in such patients. A better perceptive of clinical demonstration of pain, enhanced methods of assessment, and use of both pharmacologic and nonpharmacologic involvement can result in more constructive outcomes in the management of older adults for pain. There is a deep relation between pain assessment and pain management. They are both interconnected, pain assessment techniques should be understood and practiced to better manage pain the. Once the pain is assessed properly its makes easy for the practitioners to increase or decrease the medication accordingly. The literature on pain management emphasises a lot on proper and timely assessment to control and reduce pain.

Consequences Of Poor Pain Assessment and Management

Apprehension about value of life, counting attention to pain and symptom management, are bring in and happen often in discussions with patients and families in physicians’ every day practice. Physicians need to think who amongst their patients is in likely die in the near future to recognize those who might have a preference a palliative care advance to better meet their needs.

Many studies signify that the rates of untreated severe pain are high amongst the common nursing home patients. It has been noted that on their early assessment, 41% of nursing home residents were in pain. (Cavalieri, 2002) Unsatisfactory assessments, along with the high fraction of cognitively impaired patients, direct to an underestimation of the occurrence of pain. Physicians should make sure that the fast increasing numbers of patients who are dying in long-term-care services obtain good-quality care by integrated sound palliative care practice. (Gary, 2006)

Pain is poorly understood because of deficiency of objective biologic markers. It is generally defined as a person’s repulsive sensory and disturbing experience; it can intensely diminish a person’s value of life. Effective pain assessment and management engage an interdisciplinary approach to treat patients for physical, psychological, social, and spiritual symptoms. (Herr, 2001) Patients in palliative care should be properly assessed for pain and the treatment should be managed properly otherwise it can lead to some unwanted results.

Nurses must seek answers to the following questions to intervene most effectively:

1.         Is the elder concerned about the pain sensation itself or about the future implications of pain?

2.         Is the elder afraid the pain indicates fatal illness or that the pain does or will deprive him or her of some specific pleasures of life?

3.         Does the elder want to be asked about the pain or not be reminded of it?

4.         Does the elder want to be alone for fear of showing an emotional response, or does he or she want to be alone because of having one’s own method of handling pain?

5.         Does the elder want visitors to share the pain or to use visitors as a distraction?

6.         Does the elder expect to obtain relief immediately or to suffer a while?

7.         Does it matter to the elder if relief is palliative or curative?

8.         Does the elder believe drugs are unnatural pain relief measures or fear the consequences of addictive drugs?

9.         Does crying mean the elder wants immediate pain relief or sympathy, or is it a desire for a demonstration of technical skill?

10.       Does the elder view the expression of pain as natural, serving a particular purpose, or indicative of defeat?

In addition, assessment should consider how the pain interferes with the patient’s ability to meet needs of security, belonging, socialization, and self-esteem. (Ronald, 2007) The person who considers himself or herself strong and courageous may find it very humiliating to be forced to whimper or cry out with pain. What does the person want to be able to do? How does the person feel about himself or herself? Is the pain a mask for depression, of which one is unaware? Does the person feel useless, dependent, isolated? Has the pain changed interpersonal relationships? And last, can you, the nurse, help control the pain so that the individual can do what is most important to him or her?

The nurse may not be overtly aware of the influences that the patient’s pain experience has on him or her as a participant and observer in the elder’s care. If the elder patient is in control of the pain, it has a calming effect on the caregiver who observes and ministers. If the elder patient’s pain is uncontrollable, it makes the caregiver agitated and irritated, thus colouring the ability to accurately assess pain. (Kim, 2005) Another impediment to accurate pain assessment is that the patient perceives pain as more severe than do the caregivers, namely, the physicians and nurses. Cultural expectations of the caregiver and preconceived gender expectations also affect the accuracy of assessment.

Conclusion

Despite better drugs, new technology and the presence of pain management teams, pain management is still sub-optimal. The reductionist and hierarchical approach still employed by many clinicians is inadequate and must be replaced by a wholistic multi-disciplinary team approach including psychosocial, cultural and patient-specific elements. Features of effective teams are cooperative management and mentoring of all members of the care team. Multi-disciplinary pain centres provide a rich environment for collaborative research, teaching and clinical practice. Comprehensive guidelines and standards have been published. The challenge for organisations and all of the members of the care team is to incorporate these standards into their philosophy and clinical practice.

References

AGS Panel on Persistent Pain in Older Persons. (2002) The management of persistent pain in older persons. J Am Geriatr Soc. 50(6 Suppl):S205 -S224.

Betty R. Ferrell, Nessa Coyle (2005) Textbook of Palliative Nursing, Oxford University Press, USA

Betty R. Ferrell, Nessa Coyle. (2005) Textbook of Palliative Nursing, Oxford University Press, USA

Cavalieri TA. (2002) Pain management in the elderly. J Am Osteopath Assoc; 102:481-485.

Cynthia H. Kahn (2003) Pain Management: Pretest Self-Assessment and Review, Mcgraw Hill Book Co Ltd.

Derek Doyle, Geoffrey Hanks, Nathan I. Cherny, Kenneth Calman, (2005) Oxford Textbook of Palliative Medicine, Oxford University Press, USA

Ferrell BA, Ferrell BR, Osterweil D. (1990) Pain in the nursing home. J Am Geriatr Soc.  38: 409 -414.

Gary Mccleane, (2006) Clinical Management of the Elderly Patient in Pain, Howard Smith Haworth Medical Press

Herr KA, Garand L. (2001) Assessment and measurement of pain in older adults. Clin Geriatr Med.; 17: 457-478

James L. Hallenbeck, (2003) Palliative Care Perspectives Oxford University Press, USA

Janet L. Abrahm, (2005) A Physician’s Guide to Pain and Symptom Management in Cancer Patients, second edition The Johns Hopkins University Press.

Kim K. Kuebler, Mellar P. Davis, (2005) Crystal Moore Palliative Practices: A Multidisciplinary Approach Mosby

Kim K. Kuebler, Patricia H. Berry, Debra E. Heidrich. (2001) End-of-Life Care: Clinical Practice Guidelines, Saunders.

Mark S. Wallace, Peter Staats, Mark Wallace, (2004) Pain Medicine and Management: Just the Facts, McGraw-Hill Professional

Mary K. Kazanowski, (2002) Nursing Concepts: Pain (Nursing Concepts Series) Jones & Bartlett Publishers

Miller J, Neelon V, Dalton J, Ng’andu N, Bailey D Jr, Layman E, et al. (1996) The assessment of discomfort in elderly confused patients: a preliminary study. J Neurosci Nurs.  28: 175 -182.

Neil MacDonald, Doreen Oneschuk, Neil Hagen, Derek Doyle. (2005) Palliative Medicine: A Case-based Manual, Oxford University Press, USA

Peter Kaye, (2006) Notes on Symptom Control in Hospice and Palliative Care, Hospice Education Inst.

Rajagopal, M. R., David Mazza, Arthur G. Lipman (2004) Pain and Palliative Care in the Developing World and Marginalized Populations: A Global Challenge, Haworth Press.

Ronald Kanner, (2007) Pain Management Secrets, Hanley & Belfus

Tina M. Marrelli, (2004) Hospice and Palliative Care Handbook: Quality, Compliance and Reimbursement,  Mosby

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