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NSS201: PROVIDING SAFETY AND COMFORT II – PAIN MANAGEMENT

This unit therefore discusses pain in its entirety with particular focus on pain management strategies.

 

PROVIDING SAFETY AND COMFORT II – PAIN MANAGEMENT

Everyone at one point or the other has experienced some type or degree of pain. Inspite of its universality and eternal presence among mankind, the nature of pain remains an enigma (Fuerst, Wolff, & Weitzel, 1974). Pain is a complex experience that is not easily communicated; yet it is one of the most common reasons for seeking health care.

It is the chief reason people take medication and a leading cause of disability and hospitalization. Pain is subjective and highly individualized and its interpretation and meaning involve psychosocial and cultural factors. In other words the person experiencing pain is the only authority on it. Besides, no two persons experience pain in the same way and no two painful events create identical reports or feeling in a person. And as the average life span increases, more people have chronic disease, in which pain is a common symptom.

In addition medical advances have resulted in diagnostic and therapeutic measures that are often uncomfortable. One therefore cannot but agree with White (1995) that pain is one of the most common problems faced by nurses, yet it is a source of frustration and is often one of the most misunderstood problems that the nurse confronts. The truth however is that when patients are comfortable, encouraging necessary activities often become easier both for the patient and the nurse. This explains why much of nursing care revolves round relieving pain and ensuring comfort

Nature and Concept of Pain

Pain of any kind is difficult to define, in view of its subjective nature. Pain is much more than a single sensation caused by a specific stimulus. Pain is a complex mixture of physical, emotional, and behavioral reactions. Pain is a subjective and highly individualistic, and interpretation and meaning of pain involve psychosocial and cultural factors. Pain cannot be objectively measured, such as with x-ray examination or blood test, and although certain types of pain creates predictable signs and symptoms, often the nurse can only assess pain by relying on the clients words and behaviour.

This coupled with the fact that the nurse along with the physician and other health practitioners cannot see or feel to which they attend, makes the person experiencing pain the only authority on it. No wonder that a noted pain theorist, McCaffery (1980) defined pain as “what the person experiencing it says it is; and existing whenever he says it does”. Therefore to help a client gain relief, the nurse must believe that the pain exists.

The most commonly accepted definition however is that of the International Association for the Study of Pain (IASP) which acknowledges the multi-factorial nature and the importance of individual interpretation and experience: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described by the patient in terms of such damage (Blair, 2002). Pain has also been defined, and occasionally still is, on a philosophical and religious basis as punishment for wrongdoing.

Aristotle defined pain as well as anyone when he wrote that it is the ‘antithesis of pleasure…. the epitome of unpleasantness’ (Fuerst, Wolff, & Weitzel, 1974). Fuerst,Wolff, & Weitzel, (1974) submitted further that another typical definition depicts pain as basically an unpleasant sensation referred to the body which represents the suffering induced by the psychic perception of real, threatened, or phantasied injury. Pain could therefore be viewed as a protective physiological mechanism.

Aperson with sprained ankles for instance avoids bearing full weight on the foot to prevent further injury, warning the body that tissue damaged has occurred. Even though pain may warn of tissue injury or disease, it should be noted that the degree of pain is not necessarily in direct proportion to the amount of tissue damage, nor tissue damage always present when pain occurs.


Prejudices and Misconceptions

Health personnel often hold prejudices against patients/clients in pain especially those suffering from chronic pain, except where the client manifest objective signs. White (1995) outlined the following as common biases and misconceptions about pain:

Drug abusers and alcoholics overreact to discomfort.

Patients/Clients with minor illnesses have less pain than those with severe physical illness.

Administering analgesics regularly will lead to drug dependence.

The amount of tissue damage in an injury can accurately indicate pain intensity.

Health care personnel are the best authorities on the nature of the patient’s/client’ pain.

Psychogenic pain is not real.

Unfortunately, all people are influenced by prejudices based on their culture, education, and experience. As such the extent to which nurses allow themselves to be influenced by prejudices may seriously limit their ability to offer effective pain relief. It is the realization of this fact that makes White (1995) to assert that the nurse must acknowledge his/her prejudices and of course view the experience through the patient’s eyes to be able to render meaningful and formidable assistance to the patient.

 

Types of Pain

There are several ways to classify pain. Pain can be classified based on its duration, location and causes. As such the following are the different typologies of pain that exist:

Classification based on Duration

Acute Pain – Acute pain is the sensation that results abruptly from an injury or disease and usually it is short-lived. Meinhart and McCaffery (1983) defined it as pain that follows an acute injury, disease, or types of surgery and has a rapid onset, varying in intensity (mild to severe) and lasting for a brief time. The client can frequently describe the pain, which may subside with or without treatment (Royle and Walsh, 1992).

Acute pain however serves a biologic purpose. It acts as warning signal through activation of the sympathetic nervous system which causes the release of catecholamine neurotransmitters, such as epinephrine that gives rise to various physiologic responses similar to those found in fight reaction (Guyton, 1991).

Acute pain is usually confined to the affected area (localized) sometimes resolve with or without treatment after a damaged area heals. Could however lead to chronic pain if the cause is not discovered or not cared for properly (Cheney- Stern, 1995). In addition, acute pain seriously threatens recovery and therefore should be one of the nurses’ priorities of care. For example, acute post-operative pain hampers the patient’s ability to become mobile and increases the risk of complications from immobility (White, 1995).

Chronic Pain

Chronic pain is prolonged, varies in intensity, and usually last more than six months (Anderson et al, 1987), sometimes lasting throughout life. Onset is gradual and the character and the quality of the pain changes over time. Chronic pain is associated with variety of health problem such as cancer, connective tissue diseases, peripheral vascular diseases and musculoskeletal disorders, posttraumatic problems such as phantom limb pain and low back pain.

While it is true that it is a symptom associated with many of the common primary care conditions, it may also occur as a distinct entity. The effects of chronic pain are far-reaching, and are at least as important as its cause. The degree of chronic pain varies depending on the types of problems and whether it is progressive, stable, or capable of resolution. The patient/client with chronic pain often has periods of remission (partial or complete disappearance of symptoms) and exacerbations (increase in severity). However, chronic pain may be severe and constant i.e. unrelenting. This sort of pain is referred to as intractable pain.

Chronic pain presents a major challenge to primary care and since chronic pain persists for extended period, it can interfere with activities of daily living and personal relationship. It stimulates a huge number of prescriptions, investigations and referrals, causes frustration in its resistance to treatment, and leaves patients and doctors with low expectations of successful outcomes. Hence, can result in emotional and financial burdens sometimes leading to psychological depression. Thus, its management requires the effort of an interdisciplinary health careteam otherwise it may become an overwhelming frustrating experience for both the sufferer and the caregiver.

While treatment of acute pain tends to focus on its cause, with a view to a cure, treatment of chronic pain must also focus on its effects, with a view to limiting disability and maximizing potential. Assessment and management must be multidimensional and rehabilitative, and agreed, realistic treatment goals are important. The goal of nursing nonetheless must be to reduce the patient’s perception of pain and to promote patient’s and family adaptation through identification and enhancement of coping strategies (White, 1995; Blair, 2002).

Classification based on Pain Location

Pain may be categorized in relation to the area of the body where it originates.

Superficial Pain – Originates in the skin or mucous membranes. The source usually can be located easily because there are many nerve endings in the affected structures. The patient often describes superficial pain as prickling, burning, or dull.

Deep Pain – Pain emanating from inner body structures. Could manifest with vomiting, blood pressure changes, or weakness. Unlike superficial pain, the patient may have difficulty in pinpointing the exact location of deep pain. It is sometimes referred. Patient more often than not describes it as aching, shooting, grinding, or cramping.

Central Pain – Believed to originate within the brain itself (in the pain interpretation, and/or receiving centers)

Referred Pain – This is pain felt in a location different from the actual origin e.g. pain felt in the scapular region secondary to diseases of the gall bladder.

Phantom Pain – This is used to describe pain felt in an area that has been amputated.

Angina Pain is pain associated with cardiac pathology while Neuralgia is an intense burning sensation that follows a peripheral nerve. (Cheney-Stern, 1995)

Causes of Pain

There are many causes of pain. According to Cheney-Stern, (1995) these causes can be broadly grouped into three viz:

Physical Causes – Physical causes include: Muscle tightness (secondary to muscle spasm and resultant decrease in blood supply to that muscle); disease; infection; trauma; space-occupying lesions (tumor); metabolic factors; burns and temperature extremes.

Chemical Causes – Chemical factors include caustic chemicals and toxins such as alcohol, drugs, cigarettes, and pollution in the air and water.

Psychogenic Causes – That is, originating from the mind and has no identifiable physical cause. Can be as severe as pain from a physical cause.

Pain Perceptions and Reaction or Response

There are two facets to pain – perception and reaction or response. Pain perception is concerned with the sensory processes when a stimulus for pain is present. The threshold of perception is the lowest intensity of a stimulus that causes the subject to recognize pain. This threshold is remarkably similar for everyone though some authorities have theorized that a phenomenon of adaptation does occur; that is the threshold of pain can be changed within certain ranges (Fuerst, Wolff, & Weitzel, 1974).

While it may be true that there are no specific pain organs or cells, an interlacing network of undifferentiated nerve endings receives painful stimuli. Sensation is transmitted up the dorsal gray horn cells of the spiral cord, then to the spinothalamic tract and eventually to the cerebral cortex. Following pain impulse transmission within the higher brain centers including the reticular formation, limbic system thalamus and sensory cortex, a person then perceives the sensation of pain.

However, there is an interaction of psychological and cognitive factors with neurophysiological ones in the perception of pain. Meinhart and McCaffery (1983) described the three interactional system of pain perception as sensory-discriminative, motivational-affective, and cognitive-evaluative. In addition, the Gate Control Theory suggests that gating mechanism can also be uttered by thoughts, feelings and memories. In essence the cerebral cortex and thalamus can influence whether pain impulses reach a person’s consciousness. This realization that there is a conscious control over pain perception helps explain the different ways people react and adjust to pain.

Pain Reaction

The reaction or response to pain is concerned with the individual’s method of coping with the sensation. This comprises the physiological and behavioral responses that occur after pain is perceived.

Physiological Responses

White (1995) submitted that as pain impulses ascend the spinal cord towards the brain stem and thalamus, the autonomic nervous system become stimulated as part of the stress response. Acute pain of low to moderate intensity, and superficial pain elicit the “flight or fight” reaction of the general adaptation syndrome. Stimulation of the sympathetic branch of the autonomic nervous system results in physiological responses such as: dilation of bronchial tube and increased respiratory rate; increased heart rate; peripheral vasoconstriction (pallor, elevation in blood pressure); increased blood glucose level; diaphoresis; Increase muscles tension; dilation of pupils; and decreased gastrointestinal motility.

However, if the pain is unrelenting, severe, or deep, typically originating form involvement of the visceral organs (such as with a myocardial infarction and colic from gallbladder or renal stones), the parasympathetic nervous system goes into action resulting in the following responses: pallor; muscles tension; decreased heart rate and blood pressure; rapid irregular breathing; nausea and vomiting; weakness and exhaustion.

Sustained physiological responses to pain could cause serious harm to an individual. Except in some cases of severe traumatic pain, which may send a person into shock, most people reach a level of adaptation in which physical signs return to normal. Thus a client in pain will not always exhibit physical signs.

Behavioral Responses

White paraphrasing the work of Meinhart and McCaffery (1983) on behavioral responses to pain identifies the three phases of a pain experience as: anticipation, sensation, and aftermath. The anticipation phase according to her occurs before pain is perceived. A person knows that pain will occur. The anticipation phase is perhaps most important, because it can affect the other two.

In situations of traumatic injury in foreseen painful procedures a person will not anticipate pain. Anticipation of pain often allows a person to learn about pain and its relief. With adequate instruction and support, clients learn to understand pain and control anxiety before it occurs. Nurses play an important role-helping client during the anticipation phase. With proper guidance, clients become aware of the unknown and thus cope with their discomfort. In situation in which clients are too fearful or anxious, anticipation of pain can heighten the perception of pain severity.

She stated further that the Sensation of pain occurs when pain it felt. According to her, the ways that people choose to react to discomfort vary widely adding that a person’s tolerance of pain is the point at which there is an unwillingness to accept pain of greater severity or duration.Howbeit, the extent to which a person tolerates pain depends on attitudes, motivation and values.

She noted that pain threatens physical and psychological well-being and that client may choose not to express pain, considering it as a sign of weakness. In her words ‘often clients believe that being a good client means not expressing pain to avoid bothering people around them. In addition client may not express pain because maintaining self-control is important in their culture.

The client with high pain tolerance is able to endure periods of severe pain without assistance. In contrast, a client with low pain tolerance may seek relief before pain occurs. The client ability to tolerate pain significantly influences the nurse perception of degree of the discomfort. Often the nurse is willing to attend to the client whose pain tolerance is high. Yet it is unfair to ignore the needs of the client who cannot tolerate even minor pain she declared.

Typical body movements and facial expressions that indicate pain include holding the painful part, bent posture, and grimaces. A client may cry or moan. Often a client expresses discomfort through restlessness and frequent request to the nurse. However, lack of pain expression does not necessarily mean that the client is not experiencing pain. It is equally important to note that unless a client openly reacts to pain it is difficult to determine the nature and extent of the discomfort.

She submitted that the aftermath phase of pain occurs when it is reduced or stopped. Even though the source of discomfort is controlled, the client may still require the nurse’s attention. Pain is a crisis. After a painful experience client may experience physical symptoms such as chills, nausea, vomiting, anger, or depression. If there are repeated episode of pain, aftermath responses can become serious health problems. She therefore In concluded that the nurse should help clients gain control and self-esteem to minimize fear over potential pain experiences.

Factors in Pain Perception

Perception of pain is individualized and since pain is complex, numerous factors influence an individual pain experience. Some of these are:

Age – Developmental differences among different age groups can influence hoe children and older adults react to the pain experience. Infants and young children have difficulty in understanding pain and those that have not developed full vocabularies encounter difficulty in verbalizing pain. To help such children, it has been suggested that the nurse employs simple but appropriate communication techniques to enhance their understanding and description of pain.

The nurse mayshow a series of pictures depicting different facial expressions, such as smiling, frowning, or crying and ask the children to point to the picture that best describes how they feel (White, 1995). School-aged children and adolescents many times try to brave and not give in to pain. Adults’ ability to interpret pain may be occluded by the presence of multiple diseases with varied but similar manifestations. Besides, adult may not report pain for various reasons ranging from fear of unknown consequences, fear of serious illness/death, to such erroneous notion as – ‘it is not acceptable to show pain’. Aging adults may not feel acute pain because of decreased sensations or perceptions.

Sex/Gender – It is doubtful whether gender by itself is a factor in pain expression. Results of studies comparing pain tolerance in males and females to say the least have been at best confusing. As such the only conclusion that could be safely made is that there are certain cultural factors influencing the effect of gender on pain perception.

Culture – Culture influences how people learn to react to and express pain. People respond to pain in different ways, and the nurse must never assume to know how patients/clients will respond. However, an understanding of the cultural background, socioeconomic status, and personal attributes helps the nurse to more accurately assess pain and it’s meaning for patients/clients (Lipton and Marbach, 1984; White, 1995).

Anxiety – The relationship between pain and anxiety is complex. Anxiety often aggravates pain sensation and tense muscle reinforces it while pain may induce feelings of anxiety. White (1995) states that emotionally healthy people are usually able to tolerate moderate or even severe pain better than those whose emotions are labile.

Meaning of Pain – The meaning that a person attributes to pain affects the experience of pain. A person will perceive and cope with pain differently if it suggests a threat, loss, punishment, or challenge (White, 1995).

Fatigue – Fatigue heightens an individual perception of pain i.e. amplifies it and decreases coping abilities.

Previous Experience – Each person learns from painful experiences. If a previous experience was very painful, a person may not feel great pain when the experience is repeated. This probably explains why people who are chronically ill and have almost constant pain often learn to tolerate it.

Attention and Distraction – The degree to which a patient focuses on pain can influence pain perception. According to Gil (1990), increased attention has been associated with increased pain whereas distraction has been associated with a diminished pain response. This concept is applied in some of the pain relieving interventions (relaxation and guided imagery) employed by nurses.

Family and Social Support – People in pain often depend on family members for support, assistance, or protection. An absence of family or friends tends to make pain experience more stressful. The presence of parent is especially important for children experiencing pain (White, 1995)

Neurological Status – A patient/client neurological function can easily affect the client’s /patient’s pain experience. For instance any factor that interrupts or influences normal reception or perception will automatically affect client’s awareness and response to pain. This explains why patients with spinal cord injury, peripheral neuropathy, multiple sclerosis e.t.c. may experience pain differently from patient with normal neurological function.

 

Pain Management

On a general note nursing interventions at relieving clients pain can be summarized as follows: understanding the patient; understanding the nature and extent of pain; removing the source of pain and decreasing pain stimuli; offering emotional support; and teaching in relation to pain. Inasmuch as a patient’s background is very likely to influence his reaction to pain, a good starting point will be to learn about the patient including his medical history, diagnosis and the physician’s plan of therapy.

The nature of pain and extent to which it affect physical and psychological well-being is also crucial to determining the choice of pain relief therapies/measures. This, the nurse can establish through good observational techniques and adequate history taking. However, since pain is a complex phenomenon, several treatment options have been developed over the years and it takes a careful selection of the measure beat suited for every particular case but in some cases the much-needed relief is only secured through a combination therapy.

The different measures/therapies employed by nurses in the management of pain are however paraphrased below:

Cutaneous Stimulation: One way to prevent or reduce pain perception is through cutaneous stimulation, the stimulation of a person’s skin to relieve pain. A massage, warm bath, application of liniment, hot and cold therapies, and transcutaneous electrical nerve stimulation (TENS) are simple measures that provides cutaneous stimulation.

Although the specific way in which cutaneous application works is not very clear, some authorities have attributed their action to their inducing the release of endorphins, a naturally occurring analgesic substance that blocks the transmission of pain (White, 1995). While others have believed that they relieve congestion or promote circulation and oxygenation, thereby relieving pain (Cheney-Stern, 1995).

Heat for instance, is said to offer pain relief by increasing blood flow to an area of inflammation or infection. In addition, heat also reduces joint stiffness, relaxes smooth muscles, and reduces peristalsis. Little wonder that it is being employed in the management of some abdominal pain painful infiltrated intravenous sites.

Cold when applied, on the other hand, penetrates the muscle thereby helping to reduce muscle spasm and inflammation. Cold also prevents bleeding and edema through vasoconstriction. Although not the primary treatment for pain cold compresses have been shown to be effective in reducing pain after orthopedic surgery (Bolander, 1994).

Massage and back rub are yet other low cost, safe to use cutaneous stimulation. Massage may lessen pain by relieving congestion and/or promoting circulation and oxygenation, and enhancing muscular relaxation. TENS involves stimulation of nerve beneath the skin with a mild electric current passed through external electrodes. The therapy requires a physician’s order.

TENS unit consist of a battery powered transmitter, lead wires and electrode which are placed directly over or near the site of pain. Hair or skin preparations should be removed before attaching the electrodes. When a client feels pain, the transmitter is turned on. The TENS unit crates a buzzing or tingling sensation.

The client may adjust the intensity and quality of skin stimulation. The tingling sensation can be applied as long as pain relief lasts. TENS is effective for postoperative procedure for example, removing drains and cleaning and repacking surgical wounds (Hargreaves, 1989).

Distraction: This technique is more effective with the short, mild pain lasting a few minutes than severe pain, though can be combined with pain medications to enhance pain relief. It is achieved by encouraging the person in pain to focus on a particular image or stimulus other than the painful one. In this way, the person’s attention becomes drawn away from the painful stimuli with resultant decrease in perception of such painful stimuli.

In some instances, distraction can make client completely unaware of pain. For example a client recovering from surgery may feel no pain while watching a football game on television, only for the pain to resurface when the game is over. An adolescent who feels pain from a fracture foot bone only after he finished playing a basketball game, is yet another example. Therefore, distraction does not only decrease one’s perception of pain but also improve one’s mood while giving a sense of control over the painful situation.

In what look like a pathophysiologic approach, White (1995) explained that the reticular activating system inhibits painful stimuli if a person receives sufficient or excessive sensory input. With meaningful sensory stimuli, a person can try to ignore or become less aware of pain. She asserted further that pleasurable stimuli also cause the release of endorphins to relieve pain.

This possibly explains why the most effective distraction techniques are those that the individual finds interesting and those that stimulate the senses – hearing, seeing, touching, and tasting. Moving activities are equally useful. For example, children and even adults that are in pains can be made to watch television or listen to favorite music or play indoor games.

These activities keep the person occupied leaving no room for boredom, anxiety, loneliness all of which tend to aggravate pain. Furthermore, disturbing stimuli such as loud noise, bright light, unpleasant odour, and argumentative visitor can increase pain perception. Therefore the nurse needs to reduce disturbing stimuli. Some distraction techniques are:

Slow rhythmic breathing: – In slow rhythmic breathing (SRB), the nurse asks the client to stare at an object, inhale slowly through the nose while the nurse counts 1, 2, 3, 4. The nurse encourages the client to concentrate on the sensation of the breathing and to picture a restful screen. This process continues until a rhythmic pattern is established. When the client feels comfortable, he or she can count silently and perform this technique independently.

Massage and slow rhythmic breathing: – The client breathes rhythmically as in SRB but at the same time massages a painful body part with stroking or circular movements.

Rhythmic singing and tapping: – The client selects a well-liked song and concentrate attention on its words and rhythm. The nurse encourages the client to hum or sing the words and tap a finger or foot. Loud, fast songs are best for intense pain.

Active listening: – The client listens to music and concentrate on the rhythm by taping a finger or foot.

Guided imagery: – In guided imagery the patient/client creates an image in the mind, concentrates on that image and gradually becomes less aware of pain. The role of the nurse is to assist the patient/client to form an image and to concentrate on the sensory experience. Asking the patient/client to close his or her eyes and imagine a pleasant scene, and then describing something pleasurable is one way this is achieved.

Relaxation and Guided Imagery

It is an established fact that patients/clients can alter affective-motivational and cognitive pain perception through relaxation and guided imagery. Relaxation per see is mental and physical freedom from tension or stress. However for effective relaxation, the client’s cooperation is needed. The nurse describes the techniques together with common sensations that the client may experience in detail.

The client uses such described sensations as feedback. The client may sit in a comfortable chair or lie in bed. A light sheet or blanket for warmth tends to help the client feel more comfortable and the environment should be free of noises or other irritating stimuli.

The client may have guided imagery and relaxation exercises together or separately. The nurse, acting as a coach guides the client slowly through the steps of the exercise. The nurse’s calm, soft voice helps the client focus more completely on the suggested image, and it becomes unnecessary for the nurse to speak continuously.

If the client shows signs of agitation, restlessness or discomfort, the nurse should stop the exercise and begin later when the client is more at ease. Progressive relaxation of the entire body takes about 15 minutes.

The client pays attention to the body, nothing areas of tension. Some clients relax better with eyes closed. Soft background music may be helpful. Note that considerable practice is needed to achieve consistent pain reduction and it may take five to ten training sessions before clients can efficiently minimize pain.

Progressive relaxation exercise really, involves a combination of controlled breathing exercises and a series of contractions and relaxation of muscle groups. The client begins by breathing slowly and diaphragmatically allowing the abdomen to rise slowly and the chest to expand fully.

When the client establishes a regular breathing pattern the nurse coaches the client to locate any area of muscular tension, think about how it feels, tense muscle fully and then completely relax them. This creates the sensation of removing all discomfort and stress. Gradually the client can relax the muscle without tensing them. When full relaxation is achieved perception is lowered and anxiety towards the pain experience becomes minimal.

Relaxation technique provides clients with self-control when pain occurs reversing the physical and emotional stress of pain. The ability to relax physically also promotes mental relaxation. Examples of relaxation technique include medication, Yoga, guided imagery, and progressive relaxation exercises. Relaxation with or without guided imagery relieves tension-headaches, labor pain, anticipated episode of acute pain (for example a needle stick), and chronic pain disorders.

Anticipatory Guidance

The modifying anxiety directly associated with pain, helps in not only relieving pain but also enhancing the effect of other pain relieving measures. This is because knowledge about pain helps client/patient control anxiety and cognitively gains a level of pain relief (Walding, 1991). White, (1995) asserted that it is important to give clients/patients information that prevents misinterpretation of the painful event and promotes understanding of what to expect. According to her, such information includes:

Occurrence, onset and expected duration of pain

Quality, severity and location of pain

Information on how the client’s/patient’s safety is ensured

Cause of the pain

Methods that the nurse and client/patient use for pain relief.

Expectations of the client/patient during a procedure.

A typical example of anticipatory guidance is preoperative teaching on incisional pain and methods used to control it. It has been observed that this helps the patient to adapt better postoperatively.

Biofeedback

White (1995) paraphrasing the work of Flor et al. (1983) defined Biofeedback as a behavioral therapy that involves giving individual information about physiological responses (such as blood pressure or tension) and ways to exercise voluntary control over those responses. This therapy is particularly effective for muscle tension and migraine headache. The procedure employs electrodes, which are attached externally.

These electrodes measure skin tension in microvolts. A polygraph machine visibly records the tension level for the client to see. The client learns to achieve optimal relaxation, using feedback from the polygraph while lowering the actual level of tension experienced. The therapy takes several weeks to learn.

Acupuncture

Acupuncture literally means “needle piercing.” It began with the discovery that stimulating specific areas on the skin via insertion of very fine needles affect the physiological functioning of body’s processes. These specific areas/points on the skin are called acupoints. These acupoints are in very specific locations and lie on channels of energy called meridians. It has traditionally been taught as a preventive form of health care, but has also been found useful in the treatment of a variety of acute and chronic conditions. Acupuncture has been used for over 3,000 years in China as a major part of their primary health care system. In modern times, it is used for the prevention of and treatment of diseases, for the relief of pain, and as an anesthetic for surgery.

There are various painless, non-needle methods of acupuncture administration, including electrical stimulation, ultrasound, and laser. Acupressure is based on the principles of acupuncture. This ancient Chinese technique involves the use of finger pressure (rather than needles) at specific points along the body to treat ailments such as arthritis, tension and stress, aches and pains, and menstrual cramps.

This system is also used for general preventive health care. Shiatsu is a Japanese word that means “finger pressure.” Pressure is applied to points in the body using fingers, palms, elbows, arms, knees, and feet, working on the body’s energy system. Different techniques are used to relieve pain and release energy blockages.

Pharmacological Management of Pain

Quite a number of pharmacological agents provide satisfactory relief from pain. These agents are generally referred as analgesics ranging from mild to strong analgesics. They stand out as the most widely employed pain-relieving measure and are quite potent. Although most, especially the narcotic analgesics, require a physician’s order, the nurse’s judgment in the use of medications and management of clients receiving pharmacological therapies help ensure the best pain relief possible. Analgesics can be broadly classified into four groups viz:

Non-narcotic Analgesic – Provides relief for mild to moderate Example includes Paracetamol.

Non-Steroidal Anti-Inflammatory Drug (NSAID) – Just like the Non-narcotic analgesics NSAID also provides relief for mild to moderate pain especially those associated with rheumatoid arthritis, surgical and dental procedure, episiotomies and low back problems. But unlike the Non-narcotic analgesics Non-steroidal anti-inflammatory drugs (NSAIDS) act by inhibiting the action of the enzymes that forms prostaglandin. With less prostaglandin released peripherally, the generation of pain stimuli is blocked. A reduction in pain sensitivity also occurs.

Opioids – Opioids are generally prescribed for severe pain such as malignant pain. Neurotransmitters and opiate receptors are located in the dorsal horn of the spinal cord. Administration of opiates such as morphine results in the opiates binding to receptors and inhibiting the releases of substances P., as a result, transmission of painful stimuli to the spinal cords is blocked. In addition to the above, morphine sulphate and diamorphine hydrochloride raises the pain threshold and at the same time reduces associated fear and anxiety, thereby reducing pain perception.

Adjuvants or Co-analgesics – These include such drugs as anticonvulsants, antidepressants, and muscle relaxants. Adjuvant analgesics are prescribed for those clients/patients whose pain is less responsive to analgesics alone, usually due to specific co-existing pathophysiology such as neuropathic pain due to nerve compression.

The administration of tricyclic antidepressants such as amitriptyline and imipramine creates an analgesic effect, as well as an antidepressant effect. The tricyclic inhibits the normal reuptake of serotonin at nerve terminals. With one serotonin present in nerve terminal, pain transmission is inhibited (Potter, 1993).

Note: As good and effective as the pharmacological management of pain is, it has its own disadvantages. This is because every drug is a potential poison and there is no drug without its adverse effect. This therefore calls for a thorough understanding of the actions, indications, dosages, routes of administration, side effects, and contraindications of each of these drugs for maximal benefit.

ASSIGNMENT : MARKS :   DURATION : EXPIRED