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Pain management


Before discussing what the nurse can do to intervene in the patient’s pain, the nurse’s role in pain management is reviewed. The nurse helps relieve pain by administering pain-relieving interventions (including both pharmacologic and non pharmacologic approaches), assessing the effectiveness of those interventions, monitoring for adverse effects, and serving as an advocate for the patient when the prescribed intervention is ineffective in relieving pain. In addition, the nurse serves as an educator to the patient and family to enable them to manage the prescribed intervention themselves when appropriate.

Identifying Goals for Pain Management:

The information the nurse obtains from the pain assessment is used to identify goals for managing the pain. The goals identified are shared or validated with the patient. For a few patients, the goal may be elimination of the pain. For many, however, this expectation may be unrealistic. Other goals may include a decrease in the intensity, duration, or frequency of pain, and a decrease in the negative effects the pain has on the patient. For example, pain may have a negative effect by interfering with sleep and thereby hampering recovery from an acute illness or decreasing appetite. In such instances, the goals might be to sleep soundly and to take adequate nutrition. 

To determine the goal, a number of factors are considered. The first is the severity of the pain, as judged by the patient. The second factor is the anticipated harmful effects of pain. A high risk patient is at much greater risk for the harmful effects of pain than a young healthy patient. The third factor is the anticipated duration of the pain. In patients with pain from a disease such as cancer, the pain may be prolonged, possibly for the remainder of the patient’s life. Therefore, interventions will be needed for some time and should not detract from the patient’s quality of life.  

A different set of interventions is required if the patient is likely to have pain for only a few days or weeks. Pain relief for dying patients should be a primary goal. The goals for the patient may be accomplished by pharmacologic or non pharmacologic means, but most success will be achieved with a combination of both. In the acute stages of illness, the patient may be unable to participate actively in relief measures, but when sufficient mental and physical energy is present, the patient may learn self-management techniques to relieve the pain. Thus, as the patient progresses through the stages of recovery, a goal may be to increase the patient’s use of self management pain relief measures.

Establishing the Nurse–Patient Relationship and Teaching:

A positive nurse–patient relationship and teaching is the key to managing analgesia in the patient with pain, because open communication and patient cooperation are essential to success. A positive nurse–patient relationship characterized by trust is essential. By conveying to the patient the belief that he or she has pain, the nurse often helps reduce the patient’s anxiety. Acknowledging to the patient, “I know that you have pain” often eases the patient’s mind. 

Occasionally, patients who fear that no one believes the reported pain feel relieved when they know that the nurse can be trusted to believe the pain exists. Teaching is equally important, because the patient or family may be responsible for managing the pain at home and preventing or managing side effects. 

Teaching patients about pain and strategies to relieve it may reduce pain in the absence of other pain relief measures and may enhance the effectiveness of the pain relief measures used. The nurse also provides information by explaining how pain can be controlled. The patient is informed, for example, that pain should be reported in the early stages. 

Providing Physical Care

The patient in pain may be unable to participate in the usual activities of daily living or to perform usual self-care and may need assistance to carry out these activities. The patient is usually more comfortable when physical and self-care needs have been met and efforts have been made to ensure as comfortable a position as possible. 

A fresh gown and change of bed linens, along with efforts to make the person feel refreshed (eg, brushing teeth, combing hair), often increase the level of comfort and improve the effectiveness of the pain relief measures.

Providing physical care to the patient also gives the nurse (in acute, long-term, and home settings) the opportunity to perform a complete assessment and to identify problems that may contribute to the patient’s discomfort and pain. 

Appropriate and gentle physical touch during care may be reassuring and comforting. If topical treatments such as fentanyl (an opioid analgesic) patches or intravenous or intraspinal catheters are used, the skin around the patch or catheter should be assessed for integrity during physical care.

Managing Anxiety Related to Pain:

Anxiety may affect a patient’s response to pain. The patient who anticipates pain may become increasingly anxious. Teaching the patient about the nature of the impending painful experience and the ways to reduce pain often decreases anxiety. The patient’s anxiety may be reduced by explanations that point out the degree of pain relief that can be expected from each measure. For example, the patient who is informed beforehand that an intervention may not eliminate pain completely is less likely to become anxious when a certain amount of pain persists. 

Anxiety resulting from anticipation of pain or the pain experience itself may often be managed effectively by establishing a relationship with the patient and by patient teaching. 

A patient who is anxious about pain may be less tolerant of the pain, which in turn may increase the anxiety level. To prevent the pain and anxiety from escalating, the anxiety-producing cycle must be interrupted. 

Low levels of pain are easier to reduce or control than are more intense levels. Consequently, pain relief measures should be used before pain becomes severe. Many patients believe that they should not request pain relief measures until they cannot tolerate the pain, making it difficult for medications to provide relief. Therefore, it is important to explain to all patients that pain relief or control is more successful if such measures begin before the pain becomes unbearable.