Chronic Pain

 Chronic Pain 

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a duration of greater than six (6) months.

 

Chronic pain is often described as any pain lasting more than 12 weeks. The pain may be classified as chronic malignant pain or chronic nonmalignant pain. Malignant pain is linked top a particular cause like cancer. In nonmalignant pain, the original tissue injury is not progressive or has been healed but the patient still experiences pain.

 

Related Factors

Here are some factors that may be related to Chronic Pain:

 

• Chronic physical disability
• Chronic psychological disability
• Disease process (compression/destruction of nerve tissue/body organs, infiltration of nerves or their vascular supply, obstruction or a nerve pathway, inflammation)
• Injuring agents (biological, chemical, physical, psychological)
• Side effects of various cancer therapy agent

Defining Characteristics

Chronic Pain is characterized by the following signs and symptoms:

• Alteration in muscle tone (varies from flaccid to rigid); facial mask of pain
• Altered ability to continue previous activities
• Anorexia
• Atrophy of involved muscle group
• Autonomic responses (diaphoresis, changes in BP, respiration, pulse)
• Changes in appetite/eating, weight; sleep patterns; altered ability to continue desired activities; fatigue
• Changes in sleep pattern
• Depression
• Distraction/guarding behavior protecting body part
• Facial mask; expressive behavior (restlessness, moaning, crying, irritability); self-focusing; narrowed focus (altered time perception, impaired thought process)
• Fatigue
• Fear of reinjury
• Guarded/protective behavior; distraction behavior (pacing/repetitive activities, reduced interaction with others)
• Irritability, restlessness
• Reduced interaction with people
• Self-focused
• Sympathetic mediated responses (e.g., temperature, cold, changes of body position, hypersensitivity)
• Verbal or coded report or observed evidence of protective behavior, guarding behavior, facial mask, irritability, self-focusing, restlessness, depression
• Verbal/coded report; preoccupation with pain
• Weight changes
• Goals and Outcomes
• The following are the common goals and expected outcomes for Chronic Pain:
•  
• Patient demonstrates use of different relaxation skills and diversional activities as indicated for individual situation
• Patient reports pain at a level less than 3 to 4 on a 0 to 10 rating scale.

Patient uses pharmacological and nonpharmacological pain relief strategies.

Patient verbalizes acceptable level of pain relief and ability to engage in desired activities.

Patient engages in desired activities without an increase in pain level.

Nursing Assessment

Thorough assessment of Chronic Pain is necessary for the development of an effective pain management plan. Nurses play a significant part in the assessment of pain, owing to the nature of their relationship with patients.

Assess and document pain characteristics:

Quality (e.g., sharp, burning)

Severity (scale of 0 [meaning no pain] to 10 [meaning the most severe pain])

Location (anatomical description)

Onset (gradual or sudden)

Duration (e.g., continuous, intermittent)

Precipitating factors

Relieving factors

Rationale ⇒ Patient’s self-report is the most reliable information about the chronic pain experience.

Assess and note for signs and symptoms related to chronic pain such as weakness, decreased appetite, weight loss, changes in body posture, sleep pattern disturbance, anxiety, irritability, agitation, or depression.

Rationale ⇒ Physiological changes and behaviors associated with acute pain may not be exhibited by patients with chronic pain. The guarding behavior of acute pain may become a persistent change in body posture for the patient with chronic pain. Coping with chronic pain can reduce the patient’s energy for other activities.

Assess the patient’s perception of the effectiveness of techniques used for pain relief in the past. 

Rationale ⇒ Patients with chronic pain have a long history of using various pharmacological and nonpharmacological means to control and alleviate their pain.

Evaluate factors such as gender, cultural, societal, and religious features that may influence the patient’s pain experience and reaction to pain relief.

Rationale ⇒ Recognizing the variables that influence the patient’s pain experience can be instrumental in developing a plan of care that is acceptable to the patient.

Know more about side effects, dependency, and tolerance (including alcohol) of patients taking opioid analgesics.

Rationale ⇒ Drug dependence and tolerance to opioid analgesics are concerns in the long-term management of chronic pain.

Evaluate the patient’s ability to perform and fulfill activities of daily living (ADLs), instrumental activities of daily living (IADLs), and demands of daily living (DDLs).

Rationale ⇒ The person’s ability to complete self-care activities and fulfill role responsibilities can be limited by exhaustion, anxiety, and depression linked to chronic pain.

Nursing Interventions

The following are the therapeutic nursing interventions for Chronic Pain:

Allow patient to maintain a diary of pain ratings, timing, precipitating events, medications, treatments, and what works best to relieve pain.

Rationale ⇒ Systematic tracking of pain appears to be an important factor in improving pain management.

Recognize and convey acceptance of the patient’s pain experience.

Rationale ⇒ Conveying acceptance of the patient’s pain promotes a more cooperative nurse-patient relationship.

Aid the patient in making decisions about choosing a particular pain management strategy.

Rationale ⇒ The nurse can increase the patient’s willingness to adopt new interventions to promote pain relief through guidance and support. The patient may begin to feel confident regarding the effectiveness of these interventions.

Explore the need for medications from the three classes of analgesics: opioids (narcotics), non-opioids (acetaminophen, Cox-2 inhibitors, and nonsteroidal anti-inflammatory drugs [NSAIDs]), and adjuvant medications.

Rationale ⇒ Analgesic combinations may enhance pain relief.

Allow the patient to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Always obtain a prescription for a peristaltic stimulant to prevent opioid-induced constipation.

Rationale ⇒ Because there is great individual variation in the development of opioid-induced side effects, they should be monitored and, if their development is inevitable (e.g., constipation), prophylactically treated. Opioids cause constipation by decreasing bowel peristalsis.

Educate patient of pain management approach that has been ordered, including therapies, medication administration, side effects, and complications.

Rationale ⇒ One of the most important steps toward improved control of pain is a better patient understanding of the nature of pain, its treatment, and the role patient needs to play in pain control.

Discuss patient’s fears of undertreated pain, addiction, and overdose.

Rationale ⇒ Because of the various misconceptions concerning pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan.

Review patient’s pain diary, flow sheet, and medication records to determine overall degree of pain relief, side effects, and analgesic requirements for an appropriate period (e.g., one week).

Rationale ⇒ Systematic tracking of pain appears to be an important factor in improving pain management.

Implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions.

Rationale ⇒ Nonpharmacological interventions should be used to reinforce, not replace, pharmacological interventions.

Examine relevant resources for management of pain on a long-term basis (e.g., hospice, pain care center).

Rationale ⇒ Most patients with cancer or chronic nonmalignant pain are treated for pain in outpatient and home care settings. Plans should be made to secure ongoing assessment of the pain and the effectiveness of treatments in these settings.

If patient has growing cancer pain, assist patient and family with managing issues related to death and dying.

Rationale ⇒ Support groups and pastoral counseling may improve the patient’s and family’s coping skills and give needed support.

Refer the patient and family to community support groups and self-help groups for people coping with chronic pain.

Rationale ⇒ This is to reduce the burden of suffering associated with chronic pain and provides additional resources like patient’s support network.

Provide the patient and family with adequate information about chronic pain and options available for pain management. Lack of knowledge about the characteristics of chronic pain and pain management strategies can add to the burden of pain in the patient’s life.

Explain the importance of lifestyle modifications to effective pain management.

Rationale ⇒ Changes in activities such as work routines, household, and home physical environment may be required to promote more effective pain management.

Discuss to patient and family the advantages of using nonpharmacological pain management strategies:

Accupressure

Cold Compress

Heat Application

Massage The Painful Area

Progressive relaxation technique, guided imagery, and music therapy.

Transcutaneous Electrical Nerve Stimulation (TENS) TENS utilizes the application of 2 to 4 skin electrodes.