Implications+for+nursing+practice

From: Textbook of Medical-surgical Nursing (Farrell 2005) pg 235


 * Nurses role in pain management**
 * -** The nurses role in pain managment is to
 * 1) administer pain-releiving interventions (both pharmacologic and non-pharmacologic)
 * 2) assess the effectiveness of these interventions
 * 3) monitor for adverse effects
 * 4) serve as an advocate for the patient when the prescribed intervention is ineffective in relieving pain
 * 5) serve as an educator to the patient and family to enable them to manage the intervention themselves when appropriate

- for some patients the goal is to eliminate pain, however this might be unrealistic. - other goals may include a decrease in the intensity, duration, frequency, or a reduction in the side effects of pain (eg. sleep) - things to consider when devising goals: - goals may be accomplished by pharmacological or non-pharmacological means. The most success will be achieved wiht a combination of both.
 * Identifying goals in pain management**
 * the severity of the pain (as judged by the patient)
 * the anticipated harmful effects of pain
 * anticipatede duration of hte pain

- a positive nurse-patient relationship and teaching are the keys to managing analgesia in the patient with pain - open communication and patient cooperation are essential to success - conveying to the patient the belief that he/she has pain often helps to relieve anxiety, acknowleding 'i know you have pain' often eases the patients mind. - teaching is also important because the patient or family may be responsible for managing pain at home and preventing or managing side effects - the nurse should provide information by explaining how pain can be controlled
 * Establishing the nurse-patient relationship and teaching**

- the patient in pain may not be able to participate in the usual activities of daily living or to perform usual self-care and may need assistance to carry out these activities - patients are more comfortable when physical and self-care needs have been met, such as a fresh gown, change of bed linen, along with efforts to make the person feel refreashed such as : brushing teeth, combing hair. - in some settings, providing physical care to the patient also gives the nurse the opportunity to perform a complete assessment, and to identify problems that may contribute to discomfort and pain - appropriate and gentle physical touch during care may also be reassuring and comforting - skin integrity should also be assessed during care, especially where patches or IV drips have been fitted
 * Providing physical care**

- Anxiety may affect a person's response to pain: the patient who anticipates pain may become increasingly anxious. - a patient who is more anxious about pain is likely to be less tolerant. - Teaching the patient about the nature of an impending potentially painful experience and ways to decrease pain may often decrease anxiety - learning baout measures to relieve pain may lessen the threat of pain, and give the patient a sense of control - anxiety related to the anticipation of pain or the pain experience itself may be managed effectively by establishing a relationship with the patient and through education
 * Managing anxiety related to pain**

Selected nursing diagnoses: (as mentioned in the discussion board) Source: Health Assessment in Nursing (Weber & Kelley 2007)

Wellness diagnoses Risk Diagnoses Actual Diagnoses
 * readiness for enhanced spiritual well-being related to coping with prolonged physical pain
 * readiness for enhanced comfort level
 * risk for activity intolerance related to chronic pain and immobility
 * risk for coonstipation related to non-steroidal anti-inflammatory agents or opiates intake or poor eating habits
 * risk for spiritual distress related to anxiety, pain, life change, and chronic illness
 * risk for powerlessness related to chronic pain, healthcare environment, pain treatment-related regimen
 * Acute pain related to injury agents (biological, chemical, physical or psychologicial)
 * Chronic pain related to
 * ineffective breathing pattern related to abdominal pain and anxiety
 * fatigue related to stress of handling chronic pain
 * impaired physical mobility related to chronic pain'bathing/hygeine self-care deficit related to severe pain
 * impaired comfort

Planning for nurisng care (from Crisp & Taylor) - During planning, the nurse synthesises information from many resources. Critical thinking ensures that the client's care plan integrates everything the nurse knows about the client, as well as key critical thinking elements. - The nurse must establish a therapeutic relationship with the patient, and discuss realistic expectations for an individualised care plan - Planned interventions must be appropriate for the nature and type of pain (e.g. pharmacological or non pharmacological?) - An intervention that works for one client may not work for another. - Goals should be developed with specific and measurable outcomes - Set priorities for treatment - if a patient is experiencing severe acute pain, analgesics can be provided to relieve pain fairly rapidly. This can later be followed up with relaxation or the application of heat to enhance the effects of analgesics. -

Interventions Who might be involved? - Oncology nurse - specialist that is very familiar with pharmacological and non-pharmacological interventions for chronic and cancer pain - Physiotherapist - can plan exercises that can strengthen muscle groups and lessen pain in affected areas - Occupational therapists - can devise splints to support body parts - The family - may need to administer care in the home after discharge - Visiting nurses, pharmacists, general practitioner, palliative care nurses

Implementation - The patient and the nurse must work in partnership when it comes to pain management - It is the nurses role to administer and monitor interventions ordered by the doctor for pain relief, and also imnplement independent pain relief measures that compliment those prescribed by the doctor - Patient remedies are often most successful, particularly if the patient has experienced that sort of pain - Generally, the least invasive theory should be tried first

- Clients are better prepared to handle any situation when they understand it. - Teaching patients about pain experiences will reduce anxiety and help patients acheieve a sense of control. Fear increases the perception of painful stimuli. - Using a confident tone will convey a sense that the nurse will care fr that patient correctly - When patients recieve instruction about an upcoming painful experience, they often percieve the actual experience as being less painful - Relevant play for children reduces anxiety that might otherwise be caused if the nurse tried to explain an upcoming, complicated procedure to a child. For example - letting a child put sutres into a doll's arm... - Holistic health is an ongoing state of wellness that involves taking care of the physical self, expressing emotions appropriately, using the mind constructively, being creatively involved with others and becoming aware of higher levels of consiousness.The use of holistic health assumes a person's own capacity for healing, and returns responsibility for health back to the individual. Common holistic health approachesw include wellness education, regular exercise, rest, attention to good hygeine practices and nutrition, and management of interpersonal relationships.

Pain assessment (Clinical psychomotor skills - third edition, Tollefson)

- People who report acute pain require frequent assessment - every two hours, plus post-analgesia. - Patients whose pain is stable or chronic should be monitored every four to eight hours and post-analgesia - Take care with the words chosen, as using different language such as 'discomfort', 'aches' or 'soreness' may make the person less reluctant to describe their pain.

//Therapeutic interactions// include the nurse believing the patient's report of pain. This is crucial to establishing trust. - If a person says they are not comfortable, or if they cannot undertake post-op exercises effectively, then further assessment is required. - Patients should be told of the nurses intention to assess their pain. This will foster trust in the nurse, and instill a positive attitude that discomfort will be addressed and alleviated. - Patients should be told that they do not need to wait to be asked if they have pain, and should be encouraged to vocalise their pain. - Provision of privacy reduces distractions. It also allows disclosure of intimate information that the patient may otherwise be hesitant to discuss.

//Gathering required information// The tools for assessing pain are minimal. The most important factors are the nurse's understanding of pain perception and atitude towards pain. The physiology of pain should also be well understood. The actual tools for assessment include visual analogue scales, numerical scales, face scales (good for non-English speaking patients) and colour scales. The tools for assessing associated physical effects include the stethescope and sphygmomanometer, a thermometer and a watch to determine vital signs.

//Assessment of pain// - someone in severe acute pain would only be asked a minimum of questions during the assessment: location, intensity, quality, in order to establish a baseline before interventions begin. - otherwise, the assessment would begin with a histor, which would include questions about pain experience. Questions asked should include the effect of pain on: A good pain history will help to identify the condition causing hte pain and assist in making treatment choices.
 * significant others
 * the lifestyle of the patient
 * their activities of daily living;
 * are there any activities or remedies that have been tried, either successfully or unsuccessfully
 * how the patient views the pain
 * if the patient feels he/she has control
 * what the patient thinks is causing the pain

Psychological conditions may contribute to the pain experience including social, emotional and economic problems.

Patients who cannot verbally report pain should be monitored for non-verbal behavioural cues such as restlessness, agitation, withdrawal, tense body-language and any repetitive movement (rubbing, rocking).

The physiological effects of pain need to be observed and recorded such as tachycardia, change in blood pressure, pallor, grimacing, hyperventilation. Anxiety and apprehension may also accompany acute pain. Chronic pain may not alter vital signs, however it may be observed by withdrawal, quiet demeanour, unwillingness to communicate, listlessness, fatigue, and frustration. Any associated symptoms such as nausea, anorexia, visual alterations, shortness of breath etc also need to be determined. Affects on daily activities should be explored.

//Documentation// of a pain assessment outlines a baseline against which response to interventions can be monitored. An initial pain assessment also gives health care workers clues to the cause of the pain and its management.