Friday, November 26, 2010

Chronic pain

Chronic Pain

NANDA Definition
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 intensity from mild to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months.

Discussion of the Problem
Chronic pain is a constant or intermittent pain that continue beyond the anticipated curing time and that can rarely attributed to a specific cause or injury. It may be poorly defined onset. In addition, it is difficult to treat because the cause its unclear origin. Though acute pain may be a useful signal that something is wrong, chronic pain often becomes a problem in its own right. Chronic pain may be classified into two categories: the chronic malignant pain and the chronic nonmalignant pain. Chronic malignant pain is associated with a specific cause, cancer, for example. On the other hand, the original tissue injury is not progressive or has been healed in the chronic nonmalignant pain. It differs from acute pain in a way that it is more difficult for the patient to provide precise information about the pain’s location or intensity. Patient’s level of suffering usually increases over time. Chronic pain could have a intense impact on the following; activities of daily living, mobility, activity tolerance, ability to work, role performance, financial status, mood, emotional status, spirituality, family interactions, and social interactions. Chronic pain is usually experienced by patients who have rheumatoid arthritis, cancer, and those who are in the end of life stage.

Nursing Outcomes Classification (NOC)
  • Family Coping
  • Pain Control
  • Quality of Life

Nursing Interventions Classification (NIC)
  • Acupressure
  • Heat/Cold Application
  • Medication Management
  • Pain Management
  • Progressive Muscle Relaxation
  • Simple Massage
  • Transcutaneous Electrical Nerve Stimulation (TENS)

Goal and Objectives
  • Patient will demonstrate use of different relaxation skills and diversional activities as indicated for individual situation
  • Patient will follow Prescribed pharmacological regimen of the physician
  • Patient will verbalizes acceptable level of pain relief and ability to engage in desired activities.

Subjective and Objective Data
  • 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
  • Distraction/guarding behaviors
  • 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)
  • Reduced interaction with people
  • Self-focusing/narrowed focus
  • 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

Related Factors
  • Chronic physical or psychosocial 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

Assessment (Dx)
  • Monitor and document the following pain characteristics:
Ø  Aggravating factors
Ø  Anatomical location
Ø  Duration (e.g., continuous, intermittent)
Ø  Onset
Ø  Quality (e.g., sharp, burning)
Ø  Relieving factors
Ø  Severity (1 to 10 scale)
Gathering information about the pain can provide accurate and individualized nursing interventions for the patient.,print.jpg

Pain Assessment Tools Neonatal/Infant Pain Scale (NIPS)
(Recommended for children less than 1 year old) - A score greater than 3 indicates pain
Pain Assessment
Facial Expression

0 – Relaxed muscles
Restful face, neutral expression

1 – Grimace
Tight facial muscles; furrowed brow, chin, jaw, (negative facial expression – nose, mouth and brow)


0 – No Cry
Quiet, not crying

1 – Whimper
Mild moaning, intermittent

2 – Vigorous Cry
Loud scream; rising, shrill, continuous (Note: Silent cry may be scored if baby is intubated as evidenced by obvious mouth and facial movement.

Breathing Patterns

0 – Relaxed
Usual pattern for this infant

1 – Change in Breathing
Indrawing, irregular, faster than usual; gagging; breath holding


0 – Relaxed/Restrained
No muscular rigidity; occasional random movements of arms

1 – Flexed/Extended
Tense, straight legs; rigid and/or rapid extension, flexion


0 – Relaxed/Restrained
No muscular rigidity; occasional random leg movement

1 – Flexed/Extended
Tense, straight legs; rigid and/or rapid extension, flexion

State of Arousal

0 – Sleeping/Awake
Quiet, peaceful sleeping or alert random leg movement

1 – Fussy
Alert, restless, and thrashing

Children's Hospital Eastern Ontario Pain Scale (CHEOPS)
(Recommended for children 1-7 years old) - A score greater than 4 indicates pain 
No cry
Child is not crying.
Child is moaning or quietly vocalizing silent cry.
Child is crying, but the cry is gentle or whimpering.
Child is in a full-lunged cry; sobbing; may be scored with complaint or without complaint.
Neutral facial expression.
Score only if definite negative facial expression.
Score only if definite positive facial expression.
Child Verbal
Child not talking.
Other complaints
Child complains, but not about pain, e.g., “I want to see mommy” of “I am thirsty”.
Pain complaints
Child complains about pain.
Both complaints
Child complains about pain and about other things, e.g., “It hurts; I want my mommy”.
Child makes any positive statement or talks about others things without complaint.
Body (not limbs) is at rest; torso is inactive.
Body is in motion in a shifting or serpentine fashion.
Body is arched or rigid.
Body is shuddering or shaking involuntarily.
Child is in a vertical or upright position.
Body is restrained.
Not touching
Child is not touching or grabbing at wound.
Child is reaching for but not touching wound.
Child is gently touching wound or wound area.
Child is grabbing vigorously at wound.
Child's arms are restrained.
Legs may be in any position but are relaxed; includes gentle swimming or separate-like movements.
Definitive uneasy or restless movements in the legs and/or striking out with foot or feet.
Drawn up/tensed
Legs tensed and/or pulled up tightly to body and kept there.
Standing, crouching or kneeling.
Child's legs are being held down.
No particular expression or smile
Occasional grimace or frown, withdrawn, disinterested.
Frequent to constant quivering chin, clenched jaw.
Normal position or relaxed.
Uneasy, restless, tense.
Kicking, or legs drawn up.
Lying quietly, normal position moves easily.
Squirming, shifting back and forth, tense.
Arched, rigid or jerking.
No cry, (awake or asleep)
Moans or whimpers;
occasional complaint
Crying steadily, screams or sobs, frequent complaints.
Content, relaxed.
Reassured by occasional touching hugging or being talked to, distractable.
Difficulty to console or comfort,print.jpg

  • Assess for factors such as gender, cultural, societal, and religious features that may influence the patient’s pain experience and reaction to pain relief. Recognizing the variables that influence the patient’s pain experience can be helpful in developing a plan of care that is acceptable to the patient.

  • Assess for side effects, dependency, and tolerance (including alcohol) of patients taking opioid analgesics. Long-term management of chronic pain is concern about drug dependence and tolerance to opioid analgesics.

  • Evaluate the patient’s approach towards pharmacological and nonpharmacological means of pain management. Patients may see medications as the only treatment to alleviate pain and may question the effectiveness of nonpharmacological interventions.

  • Evaluate the patient’s beliefs and expectations about pain relief. Patients who suffer from chronic pain may not anticipate complete relief of pain, but may be satisfied with diminishing severity of the pain and increasing activity level.

  • Evaluate the patient’s capability to achieve activities of daily living (ADLs), instrumental activities of daily living (IADLs), and demands of daily living (DDLs). The person’s ability to complete self-care activities and fulfill role responsibilities can be limited by exhaustion anxiety, and depression associated with chronic pain.

  • Evaluate the patient’s perception of the effectiveness of techniques used for pain relief in the past. Patients with chronic pain have a long history of using many pharmacological and nonpharmacological means to control and alleviate their pain.

  • Monitor and document for signs and symptoms related with chronic pain such as weakness, decreased appetite, weight loss, changes in body posture, sleep pattern disturbance, anxiety, irritability, agitation, or depression. Physiological changes may not be exhibit by patients with chronic pain and behaviors associated with acute pain. Coping with Chronic pain can reduce the patient’s energy for other activities.

Therapeutic Interventions (Tx)
  • Help the patient in making decisions about choosing a particular pain management strategy. The nurse can increase the patient’s willingness to choose new interventions to promote pain relief through guidance and support. The patient may start to feel confident regarding the effectiveness of these interventions.

  • Provide support for patient and family in identifying lifestyle modifications that may contribute to effective pain management. Providing the patient and family with ongoing support and guidance will increase the success of this approach.

  • Recognize and communicate acceptance of the patient’s pain experience. Conveying acceptance of the patient’s pain encourages a more cooperative nurse-patient relationship.

  • Refer the patient and family to community support groups and self-help groups for people coping with chronic pain. To reduce the burden of suffering associated with chronic pain and provides additional resources like patient’s support network.

  • Refer the patient to a physical therapist for assessment and evaluation. To promote muscle strength and joint mobility, and therapies to promote relaxation of tense muscles, the physical therapist can help the patient with exercises suitable for his/her condition. These interventions can influence the effectiveness of pain management.

Educative (Edx)
  • Discuss to patient and family the advantages of using nonpharmacological pain management strategies:
    1. Acupressure. Acupressure is a pain management strategy which utilizes finger pressure applied to acupressure points on the body. Using the gate control theory, the technique works to interrupt pain transmission by "closing the gate." This approach requires training and practice.
    2. Cold applications. Cold application reduces pain, inflammation, and muscle spasticity through vasoconstriction and by decreasing the release of pain-inducing chemicals and slowing the conduction of pain impulses. This intervention is cost effective and requires no special equipment. Cold applications should last about 20 to 30 min/hr or depending on the patient’s tolerance.
    3. Distraction. Distraction is a pain management strategy that works temporarily by increasing the pain threshold. It should be utilize for a short duration, usually less than 2 hours at a time. Prolonged utilization can add to fatigue that may lead to exhaustion and may further increase pain when the distraction is no longer present.
    4. Heat applications. Heat application reduces pain through vasodilatation that causes improved blood flow to the area and through reduction of pain reflexes. This requires no special equipment and also cost effective. Heat applications also depends on patient’s tolerance but should last no more than 20 min/hr. Special attention needs to be given to preventing burns with this intervention.
    5. Massaging of the painful area. Massage interrupts pain transmission by increasing the release of endorphins and decreases tissue edema. This intervention may require another person to provide the massage.
    6. Progressive relaxation technique, guided imagery, and music therapy. These pain management techniques are centrally acting that works through reducing muscle tension and stress. The patient may feel an increased sense of control over his/her pain. Guided imagery can aid the patient to explore images about pain, pain relief, and healing. These techniques require practice to be effective.
    7. Transcutaneous Electrical Nerve Stimulation (TENS) TENS utilizes the application of 2 to 4 skin electrodes. Pain reduction occurs when a mild electrical current passes through the electrode then unto the skin. The patient is able to regulate the intensity and frequency of the electrical stimulation that depends to his/her tolerance.

  • Teach the patient and family about the use of pharmacological interventions for pain management:
    1. Antianxiety agents. These drugs are also useful adjuncts in a total program of pain management plan. Its effects are the same with anti-depressants.
    2. Anti-depressants. These drugs may be useful adjuncts in a total program of pain management. In addition to their effects on the patient’s mood, the antidepressants may have analgesic properties apart from their antidepressant actions.
    3. Nonsteroidal anti-inflammatory agents (NSAIDs). These drugs are the first step in the analgesic ladder. They work by inhibiting the synthesis of prostaglandins that cause pain in peripheral tissues, inflammation, and edema. The advantages of these drugs are not associated with dependency and addiction and they can be taken orally.
    4. Opioid analgesics. These drugs reduce pain by binding with opiate receptors throughout the body. They act on the central nervous system so the side effects associated with this group of drugs tend to be more significant that those with the NSAIDs. The primary concern in patients using these drugs for chronic pain management are Nausea, vomiting, constipation, sedation, respiratory depression, tolerance, and dependency.

  • Instruct the patient to take notes to help identify aggravating and relieving factors of chronic pain. Knowledge about factors that influence the pain experience provides guidance for the patient in making decisions about lifestyle modifications that promote more effective pain management strategy.

  • Provide the patient and family with adequate and truthful 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.

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