Research Topics: Pain Management

The Management of Chronic Pain for a Patient with Breast Cancer

The Management of Chronic Pain for a Patient with Breast Cancer   Introduction Humans express many emotions during the span of their lives. Most of these emotions result from different circumstances and from different situations. Humans can express diverse emotions at the same time and change them according to the given condition. One of the distinct characteristics of humans is expressing pain in different ways. Pain can be felt and expressed either physically, mentally and emotionally, and often times, this emotion can lead to serious problems. A lot of things can cause pain from sickness, heartbreak, age, gender, social situation, disability and many other problems. However, a disease or a sickness causing pain must be the biggest challenge a person will experience. This pain may or may not be endured by the person and may even result to death, such as when it is caused by a serious disease such as cancer. This may affect how the person may function and perform on his or her daily activities. With these, many treatments are being improved and used, to at least, alleviate the pain being experienced by many persons inflicted with a disease. In this paper, the concept of pain will be discussed and its relation to different aspects. The pain associated with breast cancer will also be evaluated, its treatment and how the healthcare professionals do about it to help many patients. The Concept of Pain              (2001) reports that pain has existed since time in memoriam, and perhaps the first documented mention of pain was in the  papyrus dating back to the fourth century B.C., indicating the use of opium for the treatment of headaches (). Since then, pain has been the focus of speculation and scientific attention, and has continued to remain a challenging problem to the sufferer, healthcare providers and the society. The International Association for the Study of Pain defines it as an unpleasant sensory emotional experience associated with actual or potential tissue damage or described in terms of such damage ( 2006). Pain is essential for survival because of its alarm function ( 2001), and can be classified in a number of different ways, such as acute, chronic and many others. It was reported that acute pain is defined as short-term pain or pain with an easily identifiable cause (2006). It is the body’s warning of present damage to tissue or disease and is often fast and sharp, followed by aching pain. Usually, acute pain is centralized in one area before becoming somewhat spread out. It is a normal response to injury and may be accompanied by anxiety or emotional distress, but responds well to medications, and can usually be diagnosed and treated. In comparison, chronic pain is a pain that persists longer that the normal course of time associated with a particular type of injury (2006). This constant or intermittent pain has often outlived its purpose, as it does not help the body to prevent injury, and is believed to represent the disease itself. It is often more difficult to treat than acute pain and can be made much worse by environmental and psychological factors. Expert care is generally necessary to treat any pain that has become chronic and coordinated treatment from an interdisciplinary healthcare team, including medical physicians, physical therapists, and psychologists or psychiatrists, is often beneficial (2006). Pain and the Pain Gate Theory             Pain is a common symptom in people who seek medical assistance accounting for over 70 million office visits to physicians each year (2001). However, to better know what to do about pain, we must know how it is generated and processed. A stimulus causes pain and activates the nervous system. It has been reported that there are specialized “receptors” in the skin and internal organs that are sensitive to stimuli that are painful, which are called nociceptors (2006). These are free nerve endings connected to small diameter myelinated A and unmyelinated C nerve fibers. Nociception, then, is the response of the nervous system to painful stimulation, so when nociceptors detect a nociceptive stimulus, they send a message to the spinal cord (2006).             A famous theory concerning how pain work is called the Gate Control Theory, which was devised by  in 1965 (2006). As reported, the basic concept is that signals elicited in afferent neurons by noxious stimuli can be blocked or filtered by a synaptic gate in the dorsal horn of the spinal cord ( 2006). Furthermore, the gate is believed to be located in the substantia gelatinosa (SG) of the dorsal horn, where the neurons of the SG make connections with the terminals of primary afferent fibers and the dendrites of dorsal horn cells. Through either pre-synaptic or postsynaptic inhibition, the substantia gelatinosa neurons appear to be able to block or reduce activation of second order neurons by nociceptive inputs ( 2006). These gating effects of the SG neurons can be activated either by (a) inputs of large diameter A afferent innervating the injured are, where it provides the basis for pain relief by selective activation of large diameter afferents, as in transcutaneous electrical nerve stimulation, or, (b) by activation of neurons in certain brainstem regions, which send axons to the spinal cord ( 2006). Dimensions of Pain             It has been reported that it is now widely believed that pain affects men and women differently ( 2006). Many investigators are turning their attention to the study of gender differences and pain, as more experts agree that women recover more quickly from pain, seek help more quickly for their pain, and are less likely to allow pain to control their lives, compared to men. This is so, as sex hormones estrogen and testosterone certainly play a role in this phenomenon, psychology and culture, too, may account at least in part for differences in how men and women receive pain signals ( 2006).             According to (2001), clinicians working with chronic pain patients are aware that patients having similar pain histories and reports of pain may differ greatly in their beliefs about pain (). It was suggested that behavior and emotions are influenced by interpretations of events, rather than solely by objective characteristics of the event itself, thus, pain when interpreted as signifying ongoing tissue damage, is likely to produce considerably more suffering and behavioral dysfunction that if it is viewed as being the result of a stable problem that may improve (2001). Due to the fact that the different aspects (such as culture, gender, social status, personality and behavior) of the person experiencing pain affects his illness, gives us an idea that some factors may help the person on how to cope up with it. The author added that certain beliefs might lead to maladaptive coping, increased suffering, and greater disability (2001). This happens when patients who believe their pain is likely to persist may be quite passive in their coping efforts and fail to make use of cognitive or behavioral strategies to cope with pain. In addition, patients who consider their pain to be an unexplainable mystery may negatively evaluate their own abilities to control or decrease pain, and are less likely to rate their coping strategies as effective in controlling and decreasing pain (2001). People’s beliefs, appraisals and expectancies regarding the consequences of an event and their ability are hypothesized to impact functioning in two ways, and may have a direct influence on mood and an indirect one through their impact on coping efforts. Chronic Pain and Pain Assessment             As mentioned earlier in the paper, chronic pain lasts longer than acute pain, and some of its common types include back pain, headaches, arthritis, cancer pain and neuropathic pain, which results from injury to nerves (2004), where breast cancer is also included. Due to the presence of so many toxins around us, these produce carcinogens or cancer-causing substances. These carcinogens increase many people’s susceptibility of having cancer, including breast cancer in men and women. Older men and women are more susceptible to breast cancer nowadays and is one of the fatal diseases present. With this, the elderly must be given care and attention by applying different tools and techniques in the evaluation of their disease. Specific tools can help the health providers in assessing the patient’s suffering from chronic pain.  (2002) reports that although several pain intensity assessment tools exist, the tools most frequently used by nursing practitioners are numeric rating scales, such as the Visual Analog Scale and the Numeric Pain Intensity Scale, where each scale has pain descriptors ranging from 0 or 1 (indicating no pain) to 10 (indicating extreme pain). Other scales include the Present Pain Intensity Rating from the McGill Pain Questionnaire, which rates pain from 1 (indicating no pain) to .3 and 6 (which indicates excruciating pain); the Simple Verbal Descriptive Pain Intensity Scale, which is a line scale that rates pain from no pain to worst possible pain; and the Wong Baker Face Scale, which uses a scale with faces having features ranging from a big smile to tears, linked with a number or letter indicating pain intensity. This scale assesses pain in pediatric or cognitive impaired patients from .1 to 5. As reported, there are advantages to using numeric rating scales for assessing pain and function (2006). Among the pain assessment tools, the Numeric Pain Intensity Scale has been found to be valid and reliable, and to be sensitive to changes in acute, cancer and chronic pain (2006).  In addition, research indicates that “least” and “usual” pain ratings provide the best estimate of actual pain intensity (2006).  Measurement of other aspects of pain-related functioning may be accomplished using one or more validated measures of pain interference or functional status (2006).   Overcoming barriers to assessment is important, as underassessment of pain is a major cause of inadequate pain management. As reported, the most common reason for the under treatment of pain in the hospitals is the failure of clinicians to assess pain and pain relief (2006). Thus, healthcare providers must bear in mind that pain is subjective, and therefore the patient’s report of pain is the single most reliable indicator. Therefore, the treatment of the patient depends on the pain reported to the healthcare professional, especially in the case of breast cancer patients. Evidence Based Nursing and Breast Cancer             It was reported that evidence based nursing (EBN) is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient references (2001). In addition, there are three areas of research competence in EBN, namely, interpreting and using research, evaluating practice, and conducting research. These are very important especially in its application and approach in breast cancer patients. As mentioned, extensive research is done to obtain proper knowledge regarding the disease. Before certain interventions are given to patients, its effects and proper dosages must be known. It has been reported that breast cancer can be treated with surgery, radiation and drugs, such as chemotherapy and hormonal therapy, and doctors may use on of those or a combination, depending on factors such as the type and location of the cancer, whether the disease has spread, and the patient’s overall health ( 2000). While doctors once believed that the spread of breast cancer could be controlled with extensive surgery, they now believe that cancer cells may bread away from the primary tumor and spread through the bloodstream, that is why drugs are now used to reach them, as these cells cannot be felt by examination or seen on x-rays or other imaging methods. In line with this is the pain associated with having breast cancer. Taking painkillers are often the best way of treating cancer pain, and sometimes very high doses of these drugs are needed to control the pain. Aside from morphine, which is an opioid painkiller used, other drugs include diamorphine, fentanyl, buprenorphine, codeine, oxycodone, and anti-inflammatory drugs such as aspirin, ibuprofen, diclofenac and celecoxib, and other available drugs ( 2002).             The education and the skills of the healthcare professionals giving attention to the breast cancer patients matter a lot due to the intensive and delicate conditions of the breast cancer patients. Every healthcare provider must realize that his or her role is very important for the treatment of each patient, as each will be crucial in giving out information to the patient. It would also be better if nursing practitioners will be pursuing doctorate studies and continue education, as the doctoral program is crucial for added skills and knowledge in the nursing profession, and is involved in discovering and disseminating knowledge. Through this, the nursing practitioner can learn more regarding the different diseases and improve on their skill to further develop their expertise in service. Conclusion             Experiencing pain is unavoidable, especially in relation to cancer. Cancer is a vicious disease, which pose negative effects on its victims. With this, the role of the healthcare practitioners is crucial in giving out information and proper care for the breast cancer patients, and not only to help in their treatment, but also to give courage and hope for their survival. As pointed out by (2001), pain is a subjective, perceptual experience, and one characteristic differentiating it from pure sensation is its affective quality (). Pain associated with cancer may be physical and emotional but because of this pain, the patient will never learn to fight for his or her life. Due to pain, humans will never get to appreciate the importance and the beauty of expressing and having many emotions. Experiencing pain can be a good venue for a cancer patient to realize that there is always hope and cure for the illness.               Credit:ivythesis.typepad.com

The Management of Chronic Pain for a Patient with Breast Cancer

The Management of Chronic Pain for a Patient with Breast Cancer Introduction Humans express many emotions during the span of their l...

PAIN MANAGEMENT

The Management of Chronic Pain for a Patient with Breast Cancer   Introduction Humans express many emotions during the span of their lives. Most of these emotions result from different circumstances and from different situations. Humans can express diverse emotions at the same time and change them according to the given condition. One of the distinct characteristics of humans is expressing pain in different ways. Pain can be felt and expressed either physically, mentally and emotionally, and often times, this emotion can lead to serious problems. A lot of things can cause pain from sickness, heartbreak, age, gender, social situation, disability and many other problems. However, a disease or a sickness causing pain must be the biggest challenge a person will experience. This pain may or may not be endured by the person and may even result to death, such as when it is caused by a serious disease such as cancer. This may affect how the person may function and perform on his or her daily activities. With these, many treatments are being improved and used, to at least, alleviate the pain being experienced by many persons inflicted with a disease. In this paper, the concept of pain will be discussed and its relation to different aspects. The pain associated with breast cancer will also be evaluated, its treatment and how the healthcare professionals do about it to help many patients. The Concept of Pain             (2001) reports that pain has existed since time in memoriam, and perhaps the first documented mention of pain was in the Ebers papyrus dating back to the fourth century B.C., indicating the use of opium for the treatment of headaches (). Since then, pain has been the focus of speculation and scientific attention, and has continued to remain a challenging problem to the sufferer, healthcare providers and the society. The International Association for the Study of Pain defines it as an unpleasant sensory emotional experience associated with actual or potential tissue damage or described in terms of such damage (“”, 2006). Pain is essential for survival because of its alarm function (, 2001, ), and can be classified in a number of different ways, such as acute, chronic and many others. It was reported that acute pain is defined as short-term pain or pain with an easily identifiable cause (“”, 2006). It is the body’s warning of present damage to tissue or disease and is often fast and sharp, followed by aching pain. Usually, acute pain is centralized in one area before becoming somewhat spread out. It is a normal response to injury and may be accompanied by anxiety or emotional distress, but responds well to medications, and can usually be diagnosed and treated. In comparison, chronic pain is a pain that persists longer that the normal course of time associated with a particular type of injury (“”, 2006). This constant or intermittent pain has often outlived its purpose, as it does not help the body to prevent injury, and is believed to represent the disease itself. It is often more difficult to treat than acute pain and can be made much worse by environmental and psychological factors. Expert care is generally necessary to treat any pain that has become chronic and coordinated treatment from an interdisciplinary healthcare team, including medical physicians, physical therapists, and psychologists or psychiatrists, is often beneficial (“”, 2006). Pain and the Pain Gate Theory             Pain is a common symptom in people who seek medical assistance accounting for over 70 million office visits to physicians each year (as cited in , 2001, ). However, to better know what to do about pain, we must know how it is generated and processed. A stimulus causes pain and activates the nervous system. It has been reported that there are specialized “receptors” in the skin and internal organs that are sensitive to stimuli that are painful, which are called nociceptors (“”, 2006). These are free nerve endings connected to small diameter myelinated A and unmyelinated C nerve fibers. Nociception, then, is the response of the nervous system to painful stimulation, so when nociceptors detect a nociceptive stimulus, they send a message to the spinal cord (“”, 2006).             A famous theory concerning how pain work is called the Gate Control Theory, which was devised by  and  in 1965 (“”, 2006). As reported, the basic concept is that signals elicited in afferent neurons by noxious stimuli can be blocked or filtered by a synaptic gate in the dorsal horn of the spinal cord (“: ”, 2006). Furthermore, the gate is believed to be located in the substantia gelatinosa (SG) of the dorsal horn, where the neurons of the SG make connections with the terminals of primary afferent fibers and the dendrites of dorsal horn cells. Through either pre-synaptic or postsynaptic inhibition, the substantia gelatinosa neurons appear to be able to block or reduce activation of second order neurons by nociceptive inputs (“: ”, 2006). These gating effects of the SG neurons can be activated either by (a) inputs of large diameter A afferent innervating the injured are, where it provides the basis for pain relief by selective activation of large diameter afferents, as in transcutaneous electrical nerve stimulation, or, (b) by activation of neurons in certain brainstem regions, which send axons to the spinal cord (“: ”, 2006). Dimensions of Pain             It has been reported that it is now widely believed that pain affects men and women differently (“”, 2006). Many investigators are turning their attention to the study of gender differences and pain, as more experts agree that women recover more quickly from pain, seek help more quickly for their pain, and are less likely to allow pain to control their lives, compared to men. This is so, as sex hormones estrogen and testosterone certainly play a role in this phenomenon, psychology and culture, too, may account at least in part for differences in how men and women receive pain signals (“”, 2006).             According to  (2001), clinicians working with chronic pain patients are aware that patients having similar pain histories and reports of pain may differ greatly in their beliefs about pain (). It was suggested that behavior and emotions are influenced by interpretations of events, rather than solely by objective characteristics of the event itself, thus, pain when interpreted as signifying ongoing tissue damage, is likely to produce considerably more suffering and behavioral dysfunction that if it is viewed as being the result of a stable problem that may improve (as cited in , 2001, ). Due to the fact that the different aspects (such as culture, gender, social status, personality and behavior) of the person experiencing pain affects his illness, gives us an idea that some factors may help the person on how to cope up with it. The author added that certain beliefs might lead to maladaptive coping, increased suffering, and greater disability (, 2001, ). This happens when patients who believe their pain is likely to persist may be quite passive in their coping efforts and fail to make use of cognitive or behavioral strategies to cope with pain. In addition, patients who consider their pain to be an unexplainable mystery may negatively evaluate their own abilities to control or decrease pain, and are less likely to rate their coping strategies as effective in controlling and decreasing pain (as cited in , 2001, ). People’s beliefs, appraisals and expectancies regarding the consequences of an event and their ability are hypothesized to impact functioning in two ways, and may have a direct influence on mood and an indirect one through their impact on coping efforts. Chronic Pain and Pain Assessment             As mentioned earlier in the paper, chronic pain lasts longer than acute pain, and some of its common types include back pain, headaches, arthritis, cancer pain and neuropathic pain, which results from injury to nerves (, 2004), where breast cancer is also included. Due to the presence of so many toxins around us, these produce carcinogens or cancer-causing substances. These carcinogens increase many people’s susceptibility of having cancer, including breast cancer in men and women. Older men and women are more susceptible to breast cancer nowadays and is one of the fatal diseases present. With this, the elderly must be given care and attention by applying different tools and techniques in the evaluation of their disease. Specific tools can help the health providers in assessing the patient’s suffering from chronic pain.  (2002) reports that although several pain intensity assessment tools exist, the tools most frequently used by nursing practitioners are numeric rating scales, such as the Visual Analog Scale and the Numeric Pain Intensity Scale, where each scale has pain descriptors ranging from 0 or 1 (indicating no pain) to 10 (indicating extreme pain). Other scales include the Present Pain Intensity Rating from the McGill Pain Questionnaire, which rates pain from 1 (indicating no pain) to .3 and 6 (which indicates excruciating pain); the Simple Verbal Descriptive Pain Intensity Scale, which is a line scale that rates pain from no pain to worst possible pain; and the Wong Baker Face Scale, which uses a scale with faces having features ranging from a big smile to tears, linked with a number or letter indicating pain intensity. This scale assesses pain in pediatric or cognitive impaired patients from .1 to 5. As reported, there are advantages to using numeric rating scales for assessing pain and function (“”, 2006). Among the pain assessment tools, the Numeric Pain Intensity Scale has been found to be valid and reliable, and to be sensitive to changes in acute, cancer and chronic pain (as cited in , 2006).  In addition, research indicates that “least” and “usual” pain ratings provide the best estimate of actual pain intensity (as cited in , 2006).  Measurement of other aspects of pain-related functioning may be accomplished using one or more validated measures of pain interference or functional status (“”, 2006).   Overcoming barriers to assessment is important, as underassessment of pain is a major cause of inadequate pain management. As reported, the most common reason for the under treatment of pain in the hospitals is the failure of clinicians to assess pain and pain relief (as cited in “: ”, 2006). Thus, healthcare providers must bear in mind that pain is subjective, and therefore the patient’s report of pain is the single most reliable indicator. Therefore, the treatment of the patient depends on the pain reported to the healthcare professional, especially in the case of breast cancer patients. Evidence Based Nursing and Breast Cancer             It was reported that evidence based nursing (EBN) is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient references (“”, 2001). In addition, there are three areas of research competence in EBN, namely, interpreting and using research, evaluating practice, and conducting research. These are very important especially in its application and approach in breast cancer patients. As mentioned, extensive research is done to obtain proper knowledge regarding the disease. Before certain interventions are given to patients, its effects and proper dosages must be known. It has been reported that breast cancer can be treated with surgery, radiation and drugs, such as chemotherapy and hormonal therapy, and doctors may use on of those or a combination, depending on factors such as the type and location of the cancer, whether the disease has spread, and the patient’s overall health (, 2000). While doctors once believed that the spread of breast cancer could be controlled with extensive surgery, they now believe that cancer cells may bread away from the primary tumor and spread through the bloodstream, that is why drugs are now used to reach them, as these cells cannot be felt by examination or seen on x-rays or other imaging methods. In line with this is the pain associated with having breast cancer. Taking painkillers are often the best way of treating cancer pain, and sometimes very high doses of these drugs are needed to control the pain. Aside from morphine, which is an opioid painkiller used, other drugs include diamorphine, fentanyl, buprenorphine, codeine, oxycodone, and anti-inflammatory drugs such as aspirin, ibuprofen, diclofenac and celecoxib, and other available drugs (“”, 2002).             The education and the skills of the healthcare professionals giving attention to the breast cancer patients matter a lot due to the intensive and delicate conditions of the breast cancer patients. Every healthcare provider must realize that his or her role is very important for the treatment of each patient, as each will be crucial in giving out information to the patient. It would also be better if nursing practitioners will be pursuing doctorate studies and continue education, as the doctoral program is crucial for added skills and knowledge in the nursing profession, and is involved in discovering and disseminating knowledge. Through this, the nursing practitioner can learn more regarding the different diseases and improve on their skill to further develop their expertise in service. Conclusion             Experiencing pain is unavoidable, especially in relation to cancer. Cancer is a vicious disease, which pose negative effects on its victims. With this, the role of the healthcare practitioners is crucial in giving out information and proper care for the breast cancer patients, and not only to help in their treatment, but also to give courage and hope for their survival. As pointed out by (2001), pain is a subjective, perceptual experience, and one characteristic differentiating it from pure sensation is its affective quality (). Pain associated with cancer may be physical and emotional but because of this pain, the patient will never learn to fight for his or her life. Due to pain, humans will never get to appreciate the importance and the beauty of expressing and having many emotions. Experiencing pain can be a good venue for a cancer patient to realize that there is always hope and cure for the illness.   References:   Credit:ivythesis.typepad.com

PAIN MANAGEMENT

The Management of Chronic Pain for a Patient with Breast Cancer Introduction Humans express many emotions during the span of their l...

PAIN MANAGEMENT IN NEONATAL INTENSIVE CARE UNIT

Pain Management in Neonatal Intensive Care Unit             People often times fear to hear the words intensive care unit when a family member or close friend is admitted in the hospital most especially parents. Neonatal Intensive Care Unit is one of the branches of intensive care unit wherein it specialises in taking care of newborn ill and premature babies. The usual first impressions of parents and family members is often shock due to the fact that the room is filled with small and ill babies all hooked up in machines with wires and tubes. In addition, the feeling of shock couple with fear is intensified because most of the parents of these babies did not expect that their child will be in the intensive care, thus most of them are not prepared for the sights inside the neonatal intensive care unit. Furthermore, it is an additional burden for the mother who is just recovering from the intense situation she has just been subjected.             Care in the neonatal intensive care unit is often overlooked by a number of health care professionals. According to  (2001) recent studies have revealed that the patients in the neonatal intensive care are not receiving the proper pain treatment in comparison to adult and paediatric patients. According to  (2001) there are dfifferences in the pain management between patients in the paediatric intensive care unit and neonatal intensive care unit wherein 66% of paediatric intensive care unit patients receive analgesia compare to 26% of patients in the neonatal intensive care. In addition, in the study of  (2000) wherein neonatal intensive care units in United States and Canada were observed and it revealed that neonates that underwent various painful operations and procedures did not receive comfort or pain measures.             Health care professionals, aside from members of the family play a significant role in the neonatal care of patients that are in the neonatal intensive care unit. Health care professionals are the front-runners in the management of pain among neonatal intensive care patients, as well as, the family members. Management of neonatal intensive care unit patients is a difficult and delicate task and needs professional, enough and proper knowledge to determine the specific needs of the patient. The usual painful procedures that infants in the NICU are subjected are the heel prick sampling, endotracheal suction and intravenous cannula insertion and in order to reduce the pain decreasing the number of procedures and altering them together with adequate analgesia could aid in relieving the stress that the infants feel. There are a number of negative effects if neonatal pain is not treated appropriately. According to  and  (2005) the repetitive pain and separations from mother due to being admitted in the neonatal intensive care unit could lead to permanent changes in the spinal cord, peripheral, neuroendocrine function, neurological development and supraspinal pain processing. As mentioned earlier, in comparison to adults and children, the neonates are more sensitive and vulnerable to pain. Neonates have the highest probability of long-term effects due to painful procedures used in the intensive care. According to  (2001) the management of pain must be regarded as a significant constituent of the health care given to neonates regardless of the severity of pain. In addition,  discussed that the sources of pain must be determined and routine assessments of neonatal pain should prescribe the avoidance of procedures that induce recurrent pains and use specific behavioural, environmental, and pharmacological interventions. Although health care professional are already aware and have the appropriate knowledge regarding pain management in infants, the pain related to procedures performed outside the operating room have the possibility of not being managed properly. In the survey conducted by , ,  and  (1997) nurses and doctors believe that infants feel the same pain just like children and adults and they believe that comfort measures and pharmacological interventions must be utilised frequently.  As mentioned earlier, the health care professionals play an important role in the pain management for infants that are in the neonatal care. The prevention of pain in infants in the NICU must be the goal of health care professionals, particularly the nurses because repetitive pains have a negative consequence for neonates in the long run. According to  (2006) the neonates are at risk of developing neurodevelopmental impairments because of preterm births and are most likely to be subjected in painful procedures in the NICU. And due to the fact that the safest and most efficient methods of preventing pains among neonates in the NICU are not yet known, balancing efficient pain relief and avoidance of adverse outcomes from medications is a major challenge for health care professionals. Pain assessment is also important in the neonatal intensive care because it determines the intensity of pain an infant feels during certain procedures. It will also aid in determining the procedures wherein lesser pains are felt by the infants. In addition, through pain assessment interventions can be made for painful procedures. In the study of , , ,  and  (2004) the premature infant pain profile (PIPP) and crying requires oxygen, increased vital signs, expression and sleepless (CRIES) are measures that could provide the health care workers on the intensity and level of pain felt by the neonates in the NICU. Aside from pain assessment a standardised strategy on pain management could also be helpful in the pain management of infants in the neonatal intensive care unit. According to , ,  and  (1998) the following outcomes were observed on infants in the NICU after standardisation of the pain management strategies; reduced length of stay in the NICU, reduced time to extubation, the management of fluid intake is better, and the side effects of narcotics were reduced.  (2001) stated that whatever assessment procedures and tools utilised, the physicians and the nurses, as well as the parents, must have a continuous multidisciplinary training in determining the pain in neonates must be provided.  and  (2001) stated that the neonates often are subjected to painful procedures during routine care like suctioning and insertion of needles. Aside from the painful procedures, disruptions such as diaper changes and physical evaluation could be stressful to infants. According to ,  and  (2003) the most efficient way in decreasing the procedural pain is to reduce the painful procedures performed on the neonates. Strategies could include removing the unnecessary laboratory procedure and minimising repetitive procedures if the first attempts failed. Pain has disruptive effects on infants that are in the neonatal intensive care unit. ,  and  (2000) discussed that the most efficient strategy to reduce the pain among infants in the NICU is to impose rigorous standards on the frequency of painful procedures such as heel lances and endotracheal suctioning, and must only be performed by the most experience professional on unstable and critically ill patients. In addition, pharmacologic and nonpharmacologic strategies are also important to the management and prevention of pain among neonates in the NICU and must only be utilised for complementary use in each infant. A number of studies have pointed out that the efficacy and safety of pharmacologic and nonpharmacologic strategies have decreased pain caused by certain procedures. There are numerous non-pharmacological strategies that could prevent pain and give relief to neonates in the NICU. It includes the utilisation of oral sucrose, developmental care and breastfeeding. According to ,  and  (2004) the non-pharmacological procedures could be useful among preterm and term infants in decreasing the pain from a heel stick, subcutaneous injections, and venipuncture. In addition, according to , , , ,  and  (2003) oral sucrose removes the electroencephalographic changes related to painful procedures in NICU. However, the long term-term safety has not yet been established for multiple dosages of oral sucrose for neonates undergoing painful procedures in the NICU (, , and , 2002). According to  (2001) topical anaesthetics could be an efficient medication for procedures such as intravenous catheter insertion and lumbar puncture for infants. The topical agents must be utilised for an adequate lengths of time prior to the procedure to be effective. Neonates in the NICU undergo mechanical ventilation and the infants are subjected to minor painful procedures. In order to manage the pain medication and sedatives are used for the patients. In the study of ,  and  (2004) intravenous morphine were utilised in order to decrease the poor neurologic outcome and the study revealed that morphine have decreased the pain felt by the neonates, on the other hand it did not alter the possibility of severe intraventricular haemorrhage and cystic periventricular leukomalacia. Most of the neonates in the NICU have undergone major surgery and pain is one of the consequences of that.  Pain is an important aspect among neonates in NICU, because according to  if appropriate pain management is given the neonate will have improved clinical outcomes such as a decrease in mortality. Intercostal Drains- insertion of a chest drain is a painful procedure that some neonates have undergone and will undergo. The recommendations of health care professionals are the skin site must be infiltrated with an anesthetic prior to incision because it has lasting effects on responses to pain and must be done in routine unless if the procedure threatens the life of the patient (,  2006). Infiltrating the skin must be slow in order to reduce the pain (, , and , 1998). Non-pharmacological procedures could also be utilised to reduce the pain during insertion of chest drains. Chest-Drain Removal- removing the chest drain is likewise painful. In the study of , , and  (2004) the use of methohexital for removing the chest-tubes in infants has shown reduction and control of pain without compromising the respiratory functions of the neonates. Intubation- just like any other surgical procedure intubation is also painful. In reducing the occurrence of severe hypoxia during intubation opiods could be utilised because it reduces the pain while the neonates are undergoing intubation ( and , 1998).     Retinal Examination and Surgery for Retinopathy of Prematurity- retinal examination is painful procedure premature neonates undergo and it cannot be easily relieved by topical agents and oral sucrose. In the study of ( ,  and , 2003) continuous intravenous infusion of remifantil could efficiently decrease the pain from retinal examinations.             Pain management for neonates in the NICU is not an easy task for any health care professional. The health care professionals must be trained to assess the intensity of pain felt be the neonates using various multidimensional tools and procedures. The assessment of pain must be done continuously and routinely in order to determine if there were changes. Each NICU must have its own pain scales to help the health care workers create provisions to relieve the pain felt by neonates in the NICU.             The following procedures could be utilised in order to manage the pain of neonatal patients in the NICU: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The care given to the neonates in the NICU must integrate principles that minimises the pain and disruptions as much as possible. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> For minor procedures such as heel pick, non-pharmacologic methods in reducing pain must be utilised. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Topical agents could also be utilised to decrease the paint related to catheter insertion and lumbar puncture. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Health care facilities that operate neonates must have rules of conduct for the management of pain of neonates in the NICU. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Adequate anaesthesia must be given in order to prevent pains and stress. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Pain assessment must be done continuously using a scale created for prolonged pain in neonates. </li> </ul> In addition, according to (2007) there are three types of intervention wherein the healthcare professionals could relieve the pain in neonates and its adverse effects in the future and these are: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Environment intervention- wherein the light and noise surrounding the neonate is reduced which allows adequate time for the baby to rest between medical procedures. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Behavioural intervention- wrapping the baby in cloth and using pacifiers dipped in sugar could also be helpful in alleviating the pain of the neonates in the NICU. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Pharmacological intervention- the proper use of anaesthetics could also help neonates relieve from pain.  </li> </ul> The feelings of parents are often times overlooked during painful procedures to infants in the NICU. According to ,  and  (2005) the parents perceived that the medical procedures are the main source of the pain that the infants feel, in addition parents wanted more information regarding the procedures and wanted to be more involved in the care for the infants. Furthermore, it emotionally pained the parents seeing their babies undergo painful procedures at such a young age and they voiced out ways in which health care workers could assist and help them and their babies in coping up with the pain associated with neonatal intensive care.             Aside from the parents the siblings of the neonates in the NICU are also affected. According to  (as cited by , 2001) parents may become to focused on the situation of the infant and usually leaves thei other children unnoticed.  discussed that Parent group is one of the ways in which parents and the siblings of the neonates could cope up with the situation. The following are ways in which siblings could be supported by their parents: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Encourage the siblings to open their feelings. Children usually observe the coping mechanisms of their parents and through that they learn the positive and negative responses to crisis. The personalities of the children must also be considered when developing ways to express their feelings. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The parents must assure their siblings that it is not their fault why the baby is sick. Children usually have the tendency to believe that their negative perception towards their baby brother or sister may have cause the illness of the baby. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The parents must be alert on the possible changes of behaviours of their children in attempt to cope up with the situation. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%">  The routine of the household must be maintained as much as possible because children feel more secure when the daily activities in the house are not relevantly altered.  </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Visit the NICU with the siblings because it helps to reinforce the bond between the neonates and siblings.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The parents must share and explain the conditions of the baby because children usually hesitate to ask questions because they fear that they could cause sadness to their parents. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> The parents must have undivided attention to each sibling and must share activities that the parents and the child usually do prior to the birth of the baby. </li> </ul> Pain is often associated in intensive care unit and neonates are not an exemption to that and just like adults and children they experience the same pain when undergoing procedures. Pain must be treated immediately and properly by health care professionals because untreated pain could lead to further complications in the long run which could lead to longer stays in the hospitals. Assessment of pain among neonates in the NICU is a very challenging task in order to resolve it the health care facilities must have a standard measurement and procedures in order to facilitate the management of pain of neonates in the NICU.    References: Credit:ivythesis.typepad.com

PAIN MANAGEMENT IN NEONATAL INTENSIVE CARE UNIT

Pain Management in Neonatal Intensive Care Unit People often times fear to hear the words intensive care unit when a family ...

Communication, Anxiety, and the Management of Postoperative Pain

Communication, Anxiety, and the Management of Postoperative Pain Postoperative pain is a noxious experience for many patients, and pharmacological remedies are not totally effective in pain management. Anxiety is viewed as a major contributor to the perception of pain, and open communication between health care professional and patient appears to be a most appropriate strategy for intervening in the pain-anxiety cycle. Additional nonpharmacological approaches to pain management are reviewed. Implications and suggestions for future research are discussed. Acute pain following surgery is a serious, widespread, and well-documented problem. Thirty percent of all postoperative patients in the United States experience moderate levels of pain, whereas 40% experience severe or very severe pain ( 1980). Severe anxiety often accompanies acute pain as the patient becomes frightened of the intensity or the meaning of the pain ( 1982). Moreover, physical complications may be associated with acute pain ( 1976;  1983 ). For example, patients who hurt may not relieve their respiratory systems of fluid by coughing. Elevated blood pressure associated with acute pain may threaten patients with heart and circulatory problems. The advent of pharmacological remedies to postsurgical pain has been relatively recent. In fact, until the 18th century, the use of chemicals to relieve pain was shunned by doctors who believed that pain was good for body and spirit ( 1982). Today, narcotics are used to manage postoperative pain in most patients; however, narcotics are commonly given in inadequate doses (1980; 1979 ;  1976), and much pain remains unrelieved ( 1984). Of course, even in large doses, narcotics are not totally effective (1981; 1982). In summary, pain following surgery is a serious problem both quantitatively and qualitatively, and pharmacological intervention is an incomplete solution to management of acute pain. Consequently, cognitive and behavioral approaches to the management of pain have been suggested and tested (  1979; 1984; 1982; 1983; , 1977). Because there is no extant review of the literature detailing the relationship between state anxiety, communication, and the experience of acute postoperative pain, the development of such a review is one original contribution of this article. Moreover, theoretical explanations for this relationship are advanced. The need for open communication and the value of communication skills are stressed in nonpharmacological approaches to pain management. Finally, this article contributes suggestions for future research and emphasizes the importance of communication skills development among health care providers. ANXIETY AND PAIN Pain is a subjective experience that cannot be directly observed by the health care professional (1988). Individuals and cultural groups differ widely in the degree to which the experience of pain is outwardly expressed (1983 ;  1977), and health care professionals may give greater attention to the needs of expressive patients, especially patients who express pain through behaviors like moans and grimaces (1980). Understanding the subjective component of pain is important if remedies are to be found for the psychological, as well as the physical, causes of pain and if discriminatory treatment of patients is to be avoided. To say that pain is experienced subjectively, however, is not to deny its reality. Direct neuronal and neurophysiological links between psychological state and the perception of pain have been proposed and supported in the medical literature (1986). Essentially, these pain models suggest that, although anxiety does not increase the neural impulses from the periphery, physiological amplification of the pain signal occurring in the brain, attributable to anxiety, results in increased perception of pain. This means that anxiety has the potential not only for affecting patients’ reactions to pain but also their actual perceptions of pain. The deleterious affects of anxiety cannot be overstated. In addition to a direct impact on the pain experience, prolonged anxiety may weaken patients’ immune response (1985).  (1980) discussed harmful effects associated with both high and unrealistically low anxiety (results were mixed on low anxiety). Depression, hostility, and acute postoperative anxiety were among these negative consequences. There are numerous causes of anxiety following surgery, not the least of which is uncertainty resulting from novelty. Much uncertainty surrounds the conduct of medical procedures; however, many patients also experience uncertainty about pain levels and their ability to cope with pain.  ( 1986 ) stated: Surgery is a new experience for many: hospital procedures constituted the unknown. Most patients ask, “How much will I hurt?” not, “Will I hurt?” They expect the pain. Patients also feared expected undignified situations (bedpans, catheters, bodily exposure) and losing control. This anticipatory anxiety, which can occur before surgery, could have adverse effects if allowed to continue. () ( 1966 ) suggested that states of physiological arousal, such as pain, lead individuals to develop evaluative needs. Briefly, there is a human need to attribute intense feelings to some identifiable cause. When a known cause is available (e.g., “My doctor told me that this is a painful surgical procedure, but I will feel much better in a few days”), attributions of cause may provide reassurance and the reduction of state anxiety. In the absence of reassuring information, however, patients may believe that something is pathologically wrong, that narcotics have not been properly administered, or that some other dire cause is resulting in intense pain. Findings of  ( 1977 ) strongly indicate a correlation between anxiety during recovery and postsurgical pain intensity. Moreover, as expected, they find that “patterns of anxiety response vary among patients who attribute different types of meaning to the surgical experience” (1977). It is important to note that the relationship between pain and anxiety is reciprocal. Painful experiences may lead to anxiety (e.g., “Something must be wrong . . . Will this pain get worse? I won’t be able to stand this much longer”). Increased anxiety will lead to accentuated perception of pain, which further increases the anxiety level. Obviously, potentially traumatic experiences may result unless there is some intervention in this pain-anxiety cycle. Narcotics may be helpful, but psychological interventions are quite appropriate in this regard. PAIN MANAGEMENT ALTERNATIVES As suggested earlier, many nonpharmacological approaches to pain management have been recommended.  ( 1986 ) developed a trimodal classification system for these alternative approaches. The first category, cognitive strategies, is self-initiated and involves thoughts and private events (e.g., imagery, self-statements, and attention diversion). The next category, behavioral manipulation, is public, externally manipulated, and involves actions or behaviors. Some of these strategies are high in external control (e.g., hypnosis, biofeedback, and modeling), whereas others are low (attribution and perceived controllability). Finally, a category of physical intervention is included (e.g., physical relaxation, pharmacological agents, transcutaneous electrical nerve stimulation).Several of these coping strategies emphasize communication skills. A lack of communication is a major problem in the relationship between patient and health care professional ( 1983) and may be one reason why pain patients are undertreated ( 1983). Communicating With Patients in Pain Although physicians believe that patients should be given important information about their condition (etiology, course, and prognosis) and therapy, most patients possess only fragmented and isolated facts (1983 ). Several explanations for this discrepancy have been suggested, including the inability to communicate to patients when using a highly specialized vocabulary, status differences, inability for patients to ask questions while they are in pain, and a perception on the part of some physicians that patients cannot comprehend medical information.  ( 1978 ) detailed a variety of communication problems between physicians and patients and presented data suggesting that health care professionals often deny the existence of patient pain.  ( 1983) concluded: The fact that physicians avoided communicating with patients, viewed them as poorly informed, even dull, and unable to handle information and that patients performed at even a lower level than the physician estimated may be in part the physicians’ self-fulfilling prophecy. This lack of communication extends to the nursing profession. ( 1987 ) found significant gaps in nurses’ knowledge of pain assessment and means of intervention. Sofaer ( 1983 ) outlined several conclusions backed by research: 1. Nurses stereotype patients in surgical wards and subsequently treat them according to their prejudices. 2. Differences exist between patients’ and nurses’ perceptions of the patients’ pain. 3. Preoperative discussions with patients about pain relief are not usually practiced. Any lack of communication is especially troubling because uncertainty about procedures and physical sensations may be a major source of pa- tients’ anxiety. This is consistent with the theoretical positions advanced by ( 1966 ) and, in the area of interpersonal outcomes,  ( 1975 ) uncertainty reduction theory. In fact, several studies have demonstrated that increases in patients’ knowledge and understanding (resulting from preoperative instructions) serve to significantly reduce pain (1986). For example, a classic study by ( 1964 ) indicated that doctors who maintained contact and freely communicated with patients not only reduced perceived pain but also reduced the need for postsurgical narcotics and extended hospital stays. The procedure has also worked well in reducing the postsurgical pain of children (1986). Reduction of pain accompanying increased communication appears to stem directly from the attenuation of state anxiety. ( 1977 ) stated: “Reducing the incongruency between expectations and experience is one way of reducing anxiety based on the fear of the unknown. The sensory component of pain remains the same, but the feeling of distress is changed” ().  ( 1973 ) found that descriptive information regarding sensations to be experienced was more helpful in reducing pain than was information that only dealt with procedures to be used.  ( 1979 ) developed similar findings regarding the efficacy of sensory information but also found that warnings about high levels of pain blocked the reduction of distress that otherwise occurred. Their interpretation of these findings was that sensory information elicited a cognitive, evaluative response, whereas pain information elicited an affective, emotional response. Communicating with patients about possible coping strategies has also proven helpful in reducing postoperative pain ( 1978). ( 1983 ) used the term stress inoculation to identify the process whereby patients learn to cope with anxieties of surgery. To reduce stress, recommended that health care providers communicate with patients about three things: (a) realistic information, including details of inherent risks; (b) feelings of loss of personal control are counteracted by reminding patients of their personal resources and abilities to cope; and (c) asking the patient to develop a personal coping repertoire–strategies for dealing with pain and injury probably most efficient for the particular patient ( 1983 ). The “work of worrying” is also theorized as an essential ingredient in stress reduction and recovery (1983). The idea here is that patients require time to work through preoperative anxieties and to plan personal reactions. Obviously, patients given little preoperative information concerning procedures, sensations, prognosis, and so forth may not have completed the work of worrying and may experience greater postoperative pain and anxiety.  ( 1978 ) concluded, from clinical observation, that the following interventions were most helpful in reducing pain: discussing pain with the patient, teaching the patient (and the patient’s support group) about pain, establishing an interpersonal relationship with the patient, remaining in the presence of the patient, and providing distraction. Obviously, to some extent, the health care professional is the cure. A demonstration of care and concern, a willingness to listen and empathize, and development of an interpersonal relationship may be as important as decreasing patient uncertainty in the management of pain. ( 1986 ) presented a more comprehensive listing of “interventions that could serve as a buffer between the patient and the pain-anxiety cycle” (). These include: 1. Orientation to the environment 2. Reduce environmental stimuli 3. Touch/hand holding 4. Audiovisuals 5. Decrease anticipatory anxiety 6. Ensure confidentiality 7. Psychological support 8. Introduce team members 9. Explain procedures 10. Explain relaxation techniques 11. Discuss new sensations 12. Honesty 13. Discuss postoperative interventions 14. Discuss hospital policy 15. Discuss sequence of surgical events 16. ICU visit 17. Explain pain reduction adjuncts 18. Encourage diversion (of attention) 19. Include family during education 20. Maintain privacy and dignity (p. 681) These interventions span pre-, intra-, and postoperative time periods. Although direct clinical evidence of the effectiveness of many of Bray’s suggested interventions does not exist, most of them seem reasonably appropriate for the reduction of patients’ anxiety. Other Approaches to Pain Management The previous discussion of pain management has focused on the content of health professional-patient communication in reducing anxiety and uncertainty. Although other pain management alternatives may not have an equal emphasis on information, the ability of the health professional to communicate skillfully remains important to the conduct and success of the strategy. One of these pain management alternatives is therapeutic touch.  ( 1967 ) contended that physical contact, from as extensive as a back rub to as brief as a hand stroking the forehead, can potentially reduce patients’ fears and, ultimately, pain. The feeling, on the part of the patient, that “someone cares and is doing something for me” is at least a potentially powerful placebo. At most, tactile stimulation may tap a neurophysiological connection to the pain experience. Encouraging relaxation has also been linked to reduction of pain ( 1976), although the primary benefit of relaxation seems to be psychological: It does not appear to affect physiological variables (1982). Methods for eliciting relaxation may range from hypnosis (1982) to relatively simple techniques where patients are taught to concentrate on pleasant memories ( 1974;  1989). One advantage of relaxation is that patients perceive an increased ability to control their pain ( 1974). Related to relaxation is the coping strategy of distraction. Although inappropriate for moderate to severe levels of pain, distraction may be a preferred strategy for many patients (1982). Getting one’s mind off the pain is a simple approach that can be assisted by nursing staff, family, and friends of the patient. Although this approach sounds reasonable on the surface, recent evidence has challenged the primary role of distraction in reducing pain. For example, ( 1989 ) suggested that it is the production of affect, positive or negative, that occurs during communication with patients, rather than the consumption of attention (distraction) that leads to the reduction of pain. Communication professionals are generally aware of the tremendous power of cognitive restructuring in reducing performance anxiety (1989). Similarly, cognitive approaches can be used quite effectively in the management of postoperative pain (1979). Examples include positive self-statements (e.g., “I’m in control,” “Relax and the pain won’t last long”), reinterpretation of painful stimuli (e.g., visualizing pain as a sensation of healing or as pleasant radiant heat), and stress inoculation. The Role of Family and Friends The possible effects of friends and family on the recovering patient have not been systematically studied. It is known that there is a significant relationship between anxiety, depression, and pain (1986) and that spousal and family support can mediate the relationship and positively impact the perception of pain (1984). It seems reasonable that the emotional support provided by family and friends is useful in motivation and encouragement of the patient. In addition, hospitals may be quite dull and boring, leaving the patient little to think about except painful sensations. The presence of a support group should provide distraction. The environment immediately following surgery–tubes and monitors, a lack of windows and sunlight, and the restriction against visit by family and friends–may be disorienting. Even brief contact with close family members at this point, followed later by liberal visiting privileges, barring medical exigencies, may establish orientation and reduce anxieties. A potential problem exists when family and friends attend and respond only to pain behavior (moaning and crying), thereby reinforcing and encouraging the behavior (1984). Instead of reacting only to pain, family and friends should provide attention and concern at all times. It is important to remind family and friends not to belittle or minimize the patients’ postoperative pain. In fact, if the patient believes he or she is experiencing more pain than is normal, this could further anguish the patient and become yet another source of anxiety. CONCLUSIONS AND IMPLICATIONS Even a cursory examination of the literature base reveals that the great majority of published research dealing with communication and acute pain is located in journals characterized as allied health and clinical psychology. Of this available research, there is an overabundance of case studies and clinical observation and a lack of controlled experimentation. Many relevant questions remain unanswered and should be addressed by future research. For example, although it is generally accepted that preoperative instruction produces beneficial postoperative outcomes, specific characteristics of the preoperative instruction that produce the benefit are not well understood. Physician-initiated communication may be characterized as having either an informational or an affective style (1985). Given the significant negative correlation between amount of physician-patient communication and the experience of postoperative pain, it would be worthwhile to know the extent to which the informational and affective components of communication contribute to pain reduction. In fact,  ( 1982 ) generalized on this concept by suggesting a need to conduct component analyses of cognitive and cognitive-behavioral strategies in order to know which aspects are necessary and sufficient. Research in pain management has focused on coping strategies developed and initiated by health care professionals. Although data support the effectiveness of many of these strategies, the value of others is a matter of conjecture (further investigation is warranted). For example, the list of clin- ical strategies developed by  ( 1986 ), previously discussed, is based on clinical experience and needs to be extended through research. In addition the effectiveness of the strategies within a variety of populations and subgroups is not well understood. Groups differing in cultural, social, and religious backgrounds may differ widely in reactions to pain and approaches to dealing with pain. Although this fact has been widely documented (1977), its potential and unique effect on pain management alternatives warrant study. Further descriptive research is needed to assess the extent to which patients are informed about pain and medical procedures. ( 1973 ) found that information concerning painful sensations was more valuable in reducing pain than information about procedures. Yet, it seems likely that health care professionals concentrate more on procedures than on painful feelings when communicating with patients. In fact, the presence of postoperative pain is not usually a part of informed consent preceding surgery. It would be helpful to know how much information patients typically possess about pain, where they get their information, and which cognitive and behavioral coping strategies are most commonly employed. Finally, in terms of descriptive research, further epidemiological studies of the incidence and prevalence of pain have been called for (1987). A further area requiring research is the dissemination and implementation of new information about pain management, particularly in the areas of communication, psychological coping strategies, and behavior alternation techniques. Although much recent attention has been given to pain management, doctors are not yet making use of much of the information (1987). Lack of knowledge about pain management among health care professionals highlights a final important conclusion: the need for education and training.  ( 1980 ) found a lack of knowledge among nurses of nonpharmacological strategies of pain management. ( 1987 ) found that same lack of information regarding administration of narcotics as well as pain assessment. Typically, the nurses under- or overestimated the severity of pain and then overestimated the effectiveness of pain relief measures (1990; 1987). Beyond a more general emphasis on the management of pain, improvement of communication skills should be strongly considered in the curriculum of medical and nursing schools. Communication skills coursework in medical and nursing schools is presently offered with unremarkable frequency. Premedical programs rarely mandate coursework in communication skills development, unless those courses are contained in broader, university core curriculums. A lack of time and pressures for expertise in other areas (biology, chemistry, etc.) is often cited as the reason for this oversight. This view generally assumes; however, that communication skills contribute more to health care style than to health care substance. The relationship between communication, anxiety, and postoperative pain argues against this viewpoint. Few health care providers today subscribe to the old view that there is moral value in pain and suffering. The reduction of postoperative pain should be viewed as a very worthy and important goal. To facilitate its accomplishment, health care professionals should be competent and openminded listeners, persuasive speakers, and conversationalists willing to devote time to the reduction of patients’ uncertainties about procedures, painful sensations, therapeutic measures, and the like. In short, research should carefully investigate the relationship between communication competence and therapeutic effectiveness, and professional training should place an emphasis on skillful communication. Credit:ivythesis.typepad.com

Communication, Anxiety, and the Management of Postoperative Pain

Communication, Anxiety, and the Management of Postoperative Pain Postoperative pain is a noxious experience for many patients, and...

Postoperative Pain Management

Postoperative Pain Management               Every individual, especially patients, experiences and suffers pain. It is associated with a myriad of causes, and is described depending on the range of its intensity. In terms of patients’ care, nurses play an important role in postoperative pain management, such that they spend more time with patients and have the responsibility for appraising the patients’ pain intensity, administering their recommended analgesic treatments and checking their efficacy ( 2003). In addition, the regular monitoring of the pain intensity of patients is essential in evaluating the standard of care provided, and most especially in the detection of the side effects of administered treatments (2003). With this, this paper discusses the concepts related to postoperative pain management, and its use as a means of pain relief. It also seeks to tackle the physiology of pain and the effects of different pain management strategies to adults and children in relation to pain physiology.   Physiology of Pain             In biological and medical terms, the process of feeling pain can be described in its physiology. Primarily, pain receptors, namely, mechanical, thermal, and chemical, are being stimulated, as they are present in all parts of the body, most especially in the skin, surfaces of the joints, walls of arteries, organs, linings around the bone, and specific areas of the skull. From the pain receptors, the stimuli are transferred through the peripheral nerve fibers, having two types, namely, the ‘fast pain’ and ‘slow pain’ peripheral nerve fibers. Fast pain is described as sharp and travels through A-delta nerve fibers, while slow pain is poorly localized and is diffusely felt. Through the peripheral nerve fibers, pain then reaches the spinal cord, from where the fast and slow pain is transferred and processed to the brain ( 2007). With this, the individual then feels the pain sensation and figures out ways on relieving it, depending on its intensity.   Attitudes to Pain             Because the severity and intensity of pain is subjective, it has been perceived that groups or individuals belonging to different cultural, social and religious backgrounds largely differ in their reactions to pain and their approaches on dealing with it (1991). With the differences in approaches, come the differences in the development of attitudes in relation to pain.  (2007) points out eight attitudes that have been developed in relation to assessing pain, namely, hypochondriac attitude, cyberchondriac, researcher, empathic, complainer, shrugger, juggler, and combination attitudes. Hypochondriacs are referred to as paranoid thinkers, as they fear the worst illnesses, and as a response, they habitually visit their doctors for every little scratch or sneeze. Cyberchondriacs are the high-tech counterparts of hypochondriacs, but differ from them as they wrongly diagnose themselves with the rarest and fatal diseases they have read in the Internet. Researchers, as indicated in their name are intelligent individuals, who surf the Internet and search their local libraries for illness that match up with their symptoms and investigate available treatments. Researchers are not contented in seeking only the help of health professionals, but want to be active participants in their own welfare. Fourth is developing an empathic attitude, in which empathic individuals, being most sensitive are considered natural pain magnets, as they naturally take up the sufferings and pain felt by other people surrounding them. They immediately learn to detach themselves from other people and create energetic boundaries that would protect themselves from taking on emotions felt by other people. Fifth is having a complainer attitude, by feeling as if they are suffering more, as being self-absorbed and dependent on their sympathizers. Usually, they give their power over their own sufferings. Shruggers tend to ignore and disregard the signs of pain and suffer in silence out of fear of knowing that something is wrong with them. Oftentimes, they are afraid of hearing and facing bad news, so they adopt a belief that the pain they are feeling is mild or insignificant compared to what others feel. Jugglers are individuals, who are highly coordinated with their own systems, such that before feeling a slight change and imbalance in their bodies, they have already taken necessary steps in bringing themselves back to normal. Lastly is the attitude that combines some or all of the previously discussed attitudes, which depend on the severity or intensity of pain an individual is experiencing ( 2007).             The changes that can be perceived from the discussion of the attitudes toward pain involve the seen initiative of individuals to find the diagnosis and treatment of the illnesses themselves, with or without the guidance of a healthcare professional. With this, it can be recognized that with the high initiative of individuals to learn and gather information from their illness, they would have greater knowledge and chances of survival. Another change is the fact that because the use of the Internet has been utilized to gather information, many individuals use it to learn and diagnose themselves in relation to the pain they are feeling. However, such endeavors may lead many to feel paranoid and neglect seeking medical attention from specialists.   Methods and Effects of Pain Assessment Strategies in relation to Pain Physiology             Postoperative pain is regarded as pain that is usually felt after surgery or operations, such that is exposes patients to severe stress (2005), and increases the body’s sympathetic response, with successive rises is heart rate, cardiac work and oxygen consumption ( 1997). In addition, pain may lead to anxiety, and increased anxiety may lead to accentuated perception of pain, which further increases the levels of anxiety (1991). Because assessment of the patient who is experiencing pain is the foundation of the best possible pain management strategies or methods ( 2000), it must be done in accordance to the healthcare professional’s ability to focus, listen and empathize with his or her patients. With this, several methods have been developed in order to minimize the effects of postoperative pain.             The initial response to alleviating pain is through taking available pain-killing medications, including aspirin and aspirin-like drugs, paracetamol, opioid drugs, such as codeine and morphine, and taking local anaesthetics (2007). However, taking pain-killing medications poses side effects in the long run, thus, affecting the individual’s quality of life, such as becoming immune to the drugs and losing its ability to ease pain, destabilize the value of self-management skills ( 2007), becoming drug-dependent, and the deterioration of the function of organs. With this, new researches have been made and found that along with the use of pain-killing medications, pain management alternatives can also be used. Pain management alternatives involve the use of a trimodal classification system. The first category includes cognitive strategies, which are self-initiated strategies that involve thoughts and private events, such as imagery, self-statements and attention diversion. Second category is behavioral manipulation, which is public, externally manipulated, high in external control, and engages actions or behaviors. Strategies included in this category include hypnosis, biofeedback, modeling, and attribution and perceived controllability ( 1991). The third and final category is of physical interventions (1991), which include complementary therapies like acupuncture, massage, relaxation techniques like yoga and meditation, the TENS or transcutaneous electrical nerve stimulation therapy, and cognitive-behavioral therapy ( 2007).   In relation to pain physiology, the effects of such strategies can be seen as having changes in the intensity of pain, for in the physiology of pain, pain perception is considered a dynamic state (2002). The effect of the implementation of pain management strategies to the physiology of pain can be seen through the change in the pain system, which can be measured in two dimensions, mainly, allodynia and hyperalgesia. Allodynia is referred to as the reduction of pain threshold to the point where non-noxious stimulus is now recognized as painful, while hyperalgesia is referred to as an increase in the magnitude of pain perception, such that a previously painful stimulus is now recognized as having a larger magnitude of perceived pain ( 2002). From this, it can be understood that the effects of pain management strategies can be perceived using two measures or dimensions, which would either produce a positive or negative effect to the individual. This just means that the use and implementation of such strategies would either alleviate or enhance the intensity of pain a patient feels.   Achievement of Pain Management             It has already been mentioned that the management of pain is related to anxiety, which is viewed as a major contributor to the perception of pain ( 1991). Thus, anxiety’s contribution can be addressed in terms of the improvement of open communication between health care professionals and patients appear to be the most appropriate strategy for intervention ( 1991), especially concerning the health conditions of children, elders, disabled and severely ill adults. Achievement of pain management among patients can be done through effective communication, for its lack is the perceived major problem in the relationship that must exist between patient and healthcare professional, and may be one reason why pain patients are under-treated ( 1991). It has been reported that due to the inability to communicate to patients when using a highly specialized vocabulary, status differences, the inability for patients to ask questions while in pain, and a perception on the part of some physicians that patients cannot comprehend medical information (1991), contributes to ineffective pain management. In achieving effective pain management, it must be kept in mind that the increase in the knowledge and understanding of patients regarding pain may be helpful in pain management. With this, doctors and nurses can maintain contact and free communication with patients, not only to reduce perceived pain but also to reduce the need for post-surgical narcotics and extended hospital stays (1991). With increased communication, a clear and effective relationship can exist between the pain patients and healthcare professionals, thus, making the process of pain management more manageable and effective. Second, reduction of pain associated with increased communication appears to come directly from the attenuation of state anxiety, and with this in mind, doctors and nurses can provide descriptive information regarding the sensations involved in procedures that must be done. The interpretation that patients have indicates that the sensory information obtained presents a cognitive and evaluative response, while pain information elicited an affective and emotional response (1991). The balance of the amount of information the patients receive from doctors and nurses gives them confidence in managing pain. In addition, providing the patients with the information they need to know alleviates their anxiety and stress, thus, reducing their pain. Third, healthcare professionals can institutionalize the use of the term stress inoculation, which is a process whereby patients learn to cope with anxieties of surgery (1991). This is done through providing realistic information, including details of inherent risks, by reminding patients of their personal resources and abilities to cope, and by asking the patient to develop a personal coping repertoire, such as strategies for dealing with pain and injury (1991). Fourth strategy emphasizes the fact that part of the nursing profession is nurturing (1987), which stresses the importance of touch. As a strategy in pain management, therapeutic touch must be applied to patients in pain, to help alleviate the pain that they feel. With therapeutic touch, the patient in pain would feel the sense of belongingness and that somebody cares and empathizes with his or her situation. Lastly, pain management would be improved if healthcare institutions would stress on the importance of the visitation of the patient’s family and friends. With this, the patients would have the opportunity to develop and heal with the assistance of his or her family members, such that the family members would help the patient go through the situation without making him or her feel alone, thus, alleviating anxiety and pain that would hasten recovery.  Credit:ivythesis.typepad.com

Postoperative Pain Management

Postoperative Pain Management Every individual, especially patients, experiences and suffers pain. It is associated with a...