Pain Management Interventions and Chronic Pain Disorders
This essay will identify the issue of how poorly addressed acute pain in hospitalized patients may lead to chronic pain disorders, critically compare and discuss a range of pain assessment tools referring to contemporary research literature and practice guidelines for patients who are able to self describe their pain and who are unable to self describe their pain due to verbal communication barriers, critical illness or delirium/dementia.
According to the International Association for the Study of Pain, pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage. The emphasis of this definition is both the sensory and emotional experience of an individual in pain. According to Tsui, Chen & Ng (2010, p.20.), ” Pain can be emotional, behavioral, sociocultural and spiritual”. The exhibition of pain is multidimensional. Therefore, in the assessment of pain, not only a general guideline for a quick review is needed, but also a specific tool to help the professionals to have a more accurate assessment of the experience of pain from a multidimensional perspective.
Clinically, “Pain is whatever the experiencing person says it is, existing whenever he/she says it does” (McCaffery, 1968). The temporal profile classification is most commonly used to classify pain.This broad classification of pain duration is often used to better understand the biopsychosocial aspects that may be important when conducting assessment and treatment. For example, many times chronic pain is a result of unresolved acute pain episodes, resulting in accumulative biopsychosocial effects such as prolonged physical reconditioning, anxiety, and stress. It is obvious that this type of time categorisation information can be extremely helpful in directing specific treatment approaches to the type of pain that is being evaluated (Gatchel & Oordt, 2003).
Acute pain is usually indicative of tissue damage and is characterized by momentary intense noxious sensations (i.e., nociception). It serves as an important biological signal of potential tissue/ physical harm. Some anxiety may initially be precipitated, but prolonged physical and emotional distress usually is not. Indeed, anxiety, if mild, can be quite adaptive in that it stimulates behaviors needed for recovery, such as the seeking of medical attention, rest, and removal from the potentially harmful situation. As the nociception decreases, acute pain usually subsides. Unlike acute pain, chronic pain persists. Chronic pain is traditionally defined as pain that lasts 6 months or longer, well past the normal healing period one would expect for its protective biological function. Arthritis, back injuries, and cancer can produce chronic-pain syndromes and, as the pain persists, it is often accompanied by emotional distress, such as depression, anger, and frustration. Such pain can also often significantly interfere with activities of daily living. There is much more health care utilization in an attempt to find some relief from the pain symptoms, and the pain has a tendency to become a preoccupation of an individual’s everyday living.
Assessment of a patient’s experience of pain is a crucial component in providing effective pain management. A systematic process of pain assessment, measurement and re-assessment (re-evaluation), enhances the health care teams’ ability to achieve: increased satisfaction with pain management. According to Buckley (2000) nurses are the primary group of health care professionals responsible for the ongoing assessment and monitoring of patients to ensure that pain is effectively and appropriately managed and that patients and families are informed of the consequences of acute pain. Assessment of pain can be a simple and straightforward task when dealing with acute pain and pain as a symptom of trauma or disease. Assessment of location and intensity of pain often sufï¬ces in clinical practice. However, other important aspects of acute pain, in addition to pain intensity at rest, need to be deï¬ned and measured when clinical trials of acute pain treatment are planned. If not, meaningless data and false conclusions may result. The 5 key components: Words, Intensity, Location, Duration, Aggravating factors pain assessment are incorporated into the process. Objective data are collected by using one of the pain assessment tools which are speciï¬c to special types of pain. The main issues in choosing the tool are its reliability and its validity. Moreover, the tool must be clear and, therefore, easily understood by the client, and require little effort from the client and the nurse.
According to Husband (2001) to measure the pain severity or intensity, several scales can be used such as a numeric rating scale (NRS), the visual analog scale (VAS), observation scales with indicators of pain, and even creative depictions of pain intensity with scale using a pain thermometer. The numeric rating scale allows patients to rate their pain on and 11-point scale of 0 (no pain) to 10 (worst pain imaginable). The majority of patients, even older adults can use this scale. The thermometer scale may be useful in the elderly, according to Rakel and Herr (2004). It shows a picture of a thermometer arranged on a background with a vertical word scale. Finally categoric scales use verbal descriptors to quantify the level of pain and those scales have been validated and are considered to be reliable.
Pain assessment in older adults can be challenging and very difficult in some situations (Rakel & Herr, 2004). When the patient cannot report his/her subjective pain experience, proxy measurements of pain must be used, such as pain behaviours and reactions that may indicate that the person is suffering painful experiences. Besides communication difï¬culties caused by language problems, patients in the extremes of age, and critically ill patients in the intensive care setting, are common assessment problems. Older patients may prefer to use alternate means to express their pain through the use of word descriptors that best characterize the pain, such as “aching,” “hurting,” and “soreness” (Herr & Garand, 2001).
The most important components of pain assessment in older adults are regular assessable, standardized tools, and consistent documentation (
). Pain assessment may also be complicated by decreases in hearing and visual acuity, so tools that require extensive explanation or visualization to perform will be more difficult and possibly less reliable. The verbal descriptor scale may be the easiest tool for the elderly to use. This measure allows patients to describe what they are feeling with common words rather than having to convert how they feel to a number, facial representation, or a point somewhere on a straight line. An observational assessment of pain behavior may be more appropriate for people with severe cognitive impairment, for example, the Abbey pain scale. Identifying pain in the cognitively impaired older adult depends heavily on knowing the patient and paying attention to slight changes in behavior (
). An interesting veiw was expressed that “nurses may lack knowledge and have attitudes and practices toward pain management that may compromise pain management for older patients” ( Yates et al., 2002, p.403).
American Geriatric Society Panel on Chronic Pain in Older Persons (2002). The management of persistent pain in older persons: AGS panel on persistent pain in older persons.
Journal of the American Geriatrics Society, 6
(50), supplement 205-224.
Horgas, A.L. (2003). Pain management in elderly adults.
Journal of Infusion Nursing, 26,
Soscia, J. (2003). Assessing pain in cognitively impaired older adults with cancer.
Clinical Journal of Oncology Nursing
, 7, 174-177
Drayer, R. A., Henderson, J., & Reidenberg, M. (1999). Barriers to Better Pain Control in Hospitalised Patients. Journal of Pain and Symptom Management, 17(6), 434-440.
Yates, P. M., Edwards, H. E., Nash, R. E., Walsh, A. M., Fentiman, B. J., Skerman, H. M., & Najman, J. M. (2002). Barriers to Effective Cancer Pain Management: A Survey of Hospitalised Cancer Patients in Australia. Journal of Pain and Symptom Management, 23(5), 393-405.