Have you watched as a patient or loved one suffered from pain that was not well managed? As a nurse, have you felt helpless as you administer pain medications that you know will be ineffective in adequately managing you patient?s pain? You are not alone. Research shows that patients undergoing surgery or suffering from cancer will experience moderate to severe pain 50% of the time. Though our knowledge of pain management has improved, our practice has not. A study of over 1300 patients with metastatic cancer revealed that, of those who had pain, 62% had pain severe enough to limit function and 42% were not prescribed analgesics capable of relieving their pain. As professional nurses, we have a moral, ethical and indeed legal obligation to address the pain management needs of our patients and advocate on their behalf. This course will address the results of inadequate pain assessment and management; outline the physiology of pain as well as discussing interventions to manage pain.
Quality pain management is critical to providing quality care and lack of accountability for ensuring pain management has been seen as a major barrier to achieving this. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised standards regarding pain assessment and management. Compliance with these standards was required by January 2001. They state that all patients have a right to appropriate assessment and management of pain. Pain should be assessed in all patients with an initial screening assessment and a more comprehensive assessment if pain is identified. Results of this assessment should be recorded in a way that facilitates regular follow-up. Policies and procedures should support safe medication prescription. Providers should be educated on pain assessment and management and their competency should be assessed, including new staff members. The discharge planning process should include assessment of pain and a plan for symptom management. Patients and their families should be educated on the importance of effective pain management. Finally, the organization is responsible to collect data to monitor the appropriateness and effectiveness of pain management. By instituting new standards for pain assessment and management, JCAHO is making this a priority for health care organizations.
Benefits of proper pain management
The misconception that pain never killed anyone has been disproved. Unrelieved pain adversely affects many body systems and can add to the cost of the hospitalization. The endocrine and nervous systems work to regulate metabolic activities. Under stress the body releases excessive amounts of hormones, including adrenocorticotrophic hormone (ACTH), cortisol, epinephrine and catecholamines while insulin levels decrease. Together with inflammatory changes this can produce tachycardia, tachypnea, fever, hyperglycemia, shock and death. Poorly relieved pain can prolong this stress response. A study in reported in 1992 revealed that high dose opioids can mitigate these hormonal and metabolic responses (Anand & Hickey, 1992). These hormonal changes in response to stress can also lead to decreased urinary output, urinary retention, increased cardiac work load and hypertension.
Activation of the sympathetic nervous system occurs when the cardiovascular system is under stress, including hypercoagulation from decreased fibrinolysis, increased heart rate, blood pressure, cardiac work load and oxygen demand. This can affect patient outcomes because it can lead to unstable angina, coronary thrombosis, and myocardial ischemia and infarction. Adequate analgesia has been associated with reduced incidences of myocardial ischemia and thrombotic events such as coronary artery and deep venous thrombosis. This increase in sympathetic activity also results in an increase in intestinal secretions and smooth muscle sphincter tone and a decrease in gastric emptying and intestinal motility which can lead to an ileus. Appropriate pain relief had been shown to hasten to return of gastrointestinal function in patients with post-operative ileus.
Painful conditions can also lead to a decrease in tidal volumes, vital capacity and alveolar ventilation as patients "splint" in an attempt to reduce movement and discomfort. This can progress to atelectasis, hypoxia and pneumonia. Studies have shown improved pulmonary function as measured by higher forced vital capacity and peak expiratory flow in patients receiving adequate analgesia. Decreased movement in patients experiencing pain can also interfere with physical therapy and increase the hospital stay in patients undergoing orthopedic procedures. Adequate pain management results in improvement in rehabilitation parameters, such as range of motion, ease of mobility and independence after total knee replacement.
Cognitive function can decline after surgery, especially in the elderly, and has been directly linked to pain and sleep disturbance, among other variables. Though opioids are often implicated, research has shown that pain, not analgesic intake, predicted mental decline in post-operative patients ages 50 to 80. Though many factors contribute, patients also cite incisional pain as the number one cause of sleeplessness after surgery. Stress and pain can also suppress the immune system, which can predispose a patient to post-operative infections. Appropriate use of analgesics and local anesthetics can block the immunosuppressive effects of pain and stress.
Poorly controlled acute pain may lead to chronic pain syndromes. Postmastectomy pain and postthoracotomy pain, for example, are felt to be preventable with early physical rehabilitation, which is less likely to be possible if the acute surgical pain is not well managed. Immobility in these populations post-operatively can lead to the development of pneumonia, deep venous thrombosis, and frozen shoulder, as the patient flexes the arm close to the chest on the affected side in an effort to reduce pain. Quality of life is also affected, as shown is a study of behavioral changes in post-operative children (Kotiniemi, Ryhanen, & Moilanen, 1997). Severe pain on the day of surgery and mild pain at home were predictors of problematic behavioral changes in these children four weeks after surgery, longer than the duration of pain. Similarly, studies have revealed that 69% of patients with cancer would consider committing suicide if their pain was not adequately treated.
Besides the physiologic and emotional benefits of managing pain, economic benefits exist as well. Inadequate management of pain in the acute care setting leads to increased length of stay. Unscheduled admissions for cancer pain and HIV/acquired immunodeficiency syndrome (AIDS) create an economic burden of patients, families and society. An estimated $61.2 billion per year is lost due to diminished or lost productivity resulting from chronic pain (Stewart, 2003). Treatment of chronic pain by multidisciplinary pain centers that address the physical, psychological and behavioral issues of chronic pain have been shown to decrease total medical expenses by 80-85% and medication expenses by 85%.
Ethical and Legal Issues
An exploration of bioethical principles is necessary when discussing pain management. Ethics has been described as proper conduct in human relationships. Health care professionals involved with pain assessment and management must have a deep commitment for the best interest of the patient that is guided by ethical principles. The principle of beneficence is to act in the patient?s best interest for the good of the patient. Thus, if a patient is assessed to have pain and requests treatment for it, the professional nurse should actively seek to relieve or reduce this pain. The principle of nonmaleficence is the duty to do no harm. As discussed above, pain places patients at further risk of physiologic harm and thus should be treated appropriately. The principle of autonomy acknowledges a patient?s right to self-determination and is considered a sacred right in our society. To be considered autonomous a person should be free to choose from various options. On the subject of pain management, patients have the right to know their options for pain management interventions and make their own decisions. Finally, the principle of justice states that resources should be distributed fairly. Pain assessment and management should be extended to all patients, regardless of race, ethnicity or diagnosis.
Indeed, there are legal issues on the subject of pain assessment and management. A standard for pain management can be established medically and legally, and health care professionals have an obligation to meet the standard or be held morally, legally and monetarily accountable. The Project on Legal constraints on Access to Effective Pain Relief, as reported by the American Society of Law, Medicine and Ethics states, in part, that no disciplinary action should be taken against a health care provider for the prescription, dispensing or administration of medical treatment to relieve intractable pain if accepted guidelines are followed (Hyman, 1996). Though guidelines are suggestions of safe conduct developed by nationally recognized organizations or specialty societies, they do not carry the force of law. Lawsuits have been filed, however, that accuse the health care provider with improper pain management. In the Estate of Henry James v. Hillhaven Corporation, the jury awarded the patient?s estate with $15 million in damages for intolerable pain the patient suffered in his dying days. Though the physician had prescribed pain medication, the nurse assessed that the patient was "addicted to morphine" and instituted her own "pain management plan" (Shapiro, 1994). The award included $7.5 million in punitive damages, which is intended to punish the defendant and to deter others from acting in a similar fashion.
The James v. Hillhaven Corp. was brought under a professional liability claim. Due in part to tort reform in the state of California, the case of Bergman v. Chin was brought as an elder abuse claim. This claim requires an elevated burden of proof for conviction in that clear and convincing evidence must be provided to determine that elder abuse has occurred. The jury found that the physician defendant did not meet the standard of care to provide adequate pain relief for the plaintiff who was suffering from lung cancer and grossly inadequate pain management. A verdict of $1.5 million was assessed.
The above two cases are proof that health care providers are being held liable for failure to stay abreast of current literature on pain management, informing patients of treatment options and possible side effects, and providing appropriate pain relief.
Physiology and Classification of Pain
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (Mersky & Bogduk, 1994). No predictable relationship exists between identifiable tissue injury and the report of pain; pain is highly personal and subjective. Though a clear cut distinction between pain types is not always possible, two major types of pain can be inferred by pathology. Nociceptive pain is the term used to describe the normal processing of stimuli that damages normal tissues or has the potential to do so. This pain originates in tissues other than the peripheral and central nervous system. Neuropathic pain is the abnormal processing of sensory input by the nervous system. It can result from lesions on the central nervous system or peripheral nerve lesions.
Four basic processes are involved in becoming conscious of pain, or nociception. Transduction occurs when a noxious stimulus causes tissue damage or potential damage. The noxious stimulus can be mechanical, such as an incision or tumor growth, thermal injury, or chemical. This trauma causes the release of substances, including prostaglandins and bradykinin, which create an action potential, facilitating the movement of the pain impulse from the periphery to the spinal cord. The ascension of the action potential from the periphery to higher centers is called transmission. Becoming conscious of pain is the third process, termed perception. The fourth process, modulation, involves the inhibition of nociceptive impulses. Neurons that originate in the brain stem and descend to the spinal cord release substances, such as serotonin, norepinephrine, and y-aminobutyric acid (GABA) to inhibit the transmission of noxious stimuli and produce analgesia. Nociceptive pain can be divided into somatic pain and visceral pain. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and has an aching or throbbing quality, usually well localized. Visceral pain arises from visceral organs, such as the gastrointestinal tract and pancreas. It can be divided into two types. Tumor involvement of the organ capsule can cause aching and well localized pain. Obstruction of a hollow viscus can cause cramping and poorly localized pain.
Neuropathic pain results from abnormal processing of sensory input by the central or peripheral nervous system; the exact pathophysiologic mechanisms remain unclear. Centrally mediated pain, termed deaffernation pain, results from injury to either the peripheral or central nervous system. Central nervous system pain can result in spontaneous pain and hyperesthesia. Spontaneous pain can be described as numbness, tingling or burning. Hyperesthesia sensations can occur in waves and can be described as a poorly localized discomfort out of proportion to the stimulus. Phantom limb pain, defined as perceived pain in the missing body part after amputation, is a result of an injury to the peripheral nervous system. Patients may describe the perception of burning, aching or cramping in the amputated body part. Reflex sympathetic dystrophy, or complex regional pain syndrome, is a sympathetically mediated pain associated with a deregulation of the autonomic nervous system. It is described as burning pain with associated autonomic dysregulation, sensory abnormalities, motor dysfunction and trophic changes. Peripherally generated pain includes the painful polyneuropathies. Diabetic neuropathy, alcoholic neuropathy and Guillain-Barre? syndrome are examples of this. Painful mononeuropathies are associated with a peripheral nerve injury and pain is experienced along the distribution of the painful nerve. Examples of this are nerve entrapment and trigeminal neuralgia.
Pain can also be classified by acuity. Acute pain is generally of recent onset, short in duration, and may have a single and treatable cause. It is generally brief and subsides as healing takes place. It is felt to be a warning system to the body that something is wrong and needs attention. There may be a mild psychological contribution to the pain. Nociceptive pain is often acute in duration. Chronic pain can be divided into chronic nonmalignant pain (CNP) and cancer pain. CNP is generally defined as pain that lasts more than six months and has an unknown or non-life threatening cause. Symptoms are felt to exceed the typical time course for healing of an acute injury. It is associated with functional impairments, disability and a high rate of medical service use. Pain can be mild to severe, and there is no known nociceptive input. Psychological factors can be important, and treatment is aimed at pain reduction (Rosner, 1996). Cancer pain is due to tumor involvement in 65-85% of cases, but can also result from the cancer treatment or be unrelated to the cancer. Uncontrolled pain is a significant problem for patients with cancer and pain is one of the most common symptoms in cancer. Cancer related pain syndromes can be classified as nociceptive, neuropathic or mixed. The pain is felt to result from an identifiable anatomic cause. The classification of pain is not mutually exclusive, and overlap between the categories can exist.
A thorough pain assessment is required to provide appropriate pain management. Unfortunately, such an assessment is not always completed, or, if it is, appropriate action may not be taken. The nature of pain makes objective evaluation impossible and several barriers to the assessment and management of pain exist. First, the health care provider may fail to ask patients about their pain, believing that they (the health care provider) are the best judge of pain severity. However, research has shown that caregivers are likely to underestimate moderate or severe pain. The patient?s self report of pain is felt to be the most reliable indicator of the presence and severity of pain (McCaffery & Pasero, 1999). Secondly, no objective measures of pain exist. Neither observations of behavior or vital signs have been found to accurately correlate with pain levels. Because pain assessment is inherently subjective, the report of pain by the patient may be received with skepticism. The professional nurse is not required to believe the patient?s report of pain but must accept the patient?s report and act accordingly. A pain threshold, the point at which an increasing intensity of stimuli is felt to be painful, is not uniform among patients. A consistent relationship has not been found to exist between tissue damage and the report of pain. Therefore, relying on the patient?s self report is truly the only way to appropriately assess pain. Finally, patients may have difficulty adequately expressing their pain. Two individuals experiencing the same type of pain may describe their experience differently. Because pain can only be assessed indirectly, the professional nurse must accept the patient?s report as the most reliable indicator of pain.
Routine assessment of pain is felt to be essential in providing adequate pain relief. The nursing admission assessment should include identification of pain problems, and institutions should have policies in place to provide for the routine assessment of pain in all patients. One tool that can be used is the Initial Pain Assessment Tool (Jaecox, Carr, Payne et al., 1994a) which can be completed by the patient or clinician and collects the following information:
Current guidelines recommend screening patients at minimum on admission, re-admission, when warranted by changes in the patient?s condition or treatment plan, when the patient self-reports pain or behavioral cues indicate the presence of pain, to identify and monitor the level of pain an/or the effectiveness of treatment modalities until the patient achieves consistent pain relief or pain control, and on the day of discharge (Pain Management Guidelines, 2005) Pain should be reassessed within 30 minutes after parenteral administration of medication and within 60 minutes of oral therapy.
- Location of pain-The patient can mark the location of pain on a figure drawing or the nurse can ask the patient to point to the location and fill out the figure for them.
- What is patient?s goal in pain relief?
- Intensity-The pain rating scale used will be identified. This will be discussed in detail below.
- Quality of Pain-The patient should attempt to describe their pain and may use words like stabbing, throbbing, burning or aching. The professional nurse should allow the patient to use his or her own words.
- Onset, duration variations, rhythms-Ask the patient to identify certain patterns of pain, including times of the day or month when the pain is worse.
- Manner of expressing pain-Ask if the patient is comfortable discussing their pain and using a pain rating scale.
- What relieves the pain-Interventions, including pharmacologic and adjuvant, should be listed.
- What causes the pain? List the activities or events that may increase their pain.
- Effects of pain--Identify how pain affects the patient?s quality of life or is interfering with recovery from illness.
- Other comments-This allows space for other information regarding their pain that is not elicited above. Ask how the pain has impacted their life including sleep, appetite, socialization and relationships, work and hobbies and sexual activity.
- Plan-Immediate and long-range plans can be mentioned here and developed over time.
- Inquire as to how the patient has managed their pain in the past. Find out what strategies have worked and what has not been effective.
Pain Rating Scales
Several pain rating scales are available, and the pain scale used should be both reasonably valid and reliable, developmentally appropriate and easily administered. The Numeric Rating Scale (NRS) can be either verbally or visually administered. The patient is asked to rate his pain on the scale of 0 to 10, with 0 equaling no pain and 10 equaling the worst possible pain (Figure 1). In clinical practice it is simple to use and score; results can be compared to previous ratings and can detect treatment effects. This tool has been validated with several populations, including trauma patients, cancer patients, illiterate patients and those with chronic pain. It may be less reliable at age extremes and with nonverbal or cognitively impaired patients (McCaffery, 1999).
Figure 1 Numeric Rating Scale