Holistic Nursing Practice: Assessment and Management of Chronic Pain

Introduction

Definition of Pain

Pain is a multidimensional phenomenon; therefore, it is difficult to define. Pain has been defined in many different ways by health care practitioners. (Sternbach, 1999).

Chronic pain: According to NHS Quality Improvement Scotland (2006, p. ix), chronic pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” in cases where pain lasts for more than three months after an injury causing the pain has healed, the patients presentation becomes more complex with biopsychosocial feature. Other characteristics of chronic pain include that it often has an identifiable cause (although the cause may be difficult to determine); is often described using affective terms, such as hateful or sickening; has the qualities of allow pain; and is often much more difficult to treat than acute pain. Health care providers may feel frustrated and incompetent when their attempts to relieve chronic pain are ineffective. However, understanding of the anatomy, physiology and psychosocial aspects of chronic pain is very helpful in management of chronic pain (Mersky, 1996; Hodgkiss, 1997).

Dysvik (2004, p. 68) says that, “by looking at chronic pain in a biopsychosocial way it allows the nurse to concentrate on the specific area which is having the largest impact on the patient’s symptoms”.

Holistic Nursing Practice

“Holistic nursing practice is about healing the whole person, explicitly recognizing and addressing the interconnectedness of body, mind, emotion, spirit, society/culture, relationships, context, and environment” (American Holistic Nurses Association, 2008).This type of practice does assist people to find the much needed well being. It looks at an individual as a bio-psycho-social being and therefore every aspect of one’s life is considered during provision of nursing care. Holistic nursing practice starts from the time a patient presents her/himself to the nurse for nursing care and ends when the patient is well. It does not only entail that which has brought the patient or that which has made the patient to seek nursing or medical care but all factors that are involved in the patients behavior to seek nursing assistance. (AHNA, 2008; Frisch, Dossey, Guzzetta, & Quinn, 2000).

Assessment and management of chronic pain in the context of holistic nursing practice is one of the best ways in dealing with chronic pain as it will consider the patient as a bio-psycho-social-spiritual being. All the concerns of the patient and all aspects of his/her life will be considered during assessment and management. Holistic care does not only involve the patient but also his/her surrounding/environment. According to Rudin, (2001), guidelines for assessment and management of chronic pain, chronic pain management is defined as “a process wherein physician, and non-physician clinician work together to improve function, reduce pain, develop self-management skills, and maintain those improvements over time.” It further states that “this process requires active participation by the patient (and significant others in the person’s life) and open ongoing communication among all practitioners involved in the treatment process. Holistic care of a patient in chronic pain promotes effective and proper ways of communication, co-operation between nurse and client, shared understanding, health promotion and informed consent (Hamilton & Price 2007, p. 221). Holistic assessment enables the nurse to comprehend of the individual’s precise pain. This type of assessment is normally based on deductive reasoning. Diversity of factors that determine bio-psycho-social-spiritual functioning are assessed (Hamilton & Price 2007).

Assessment of Chronic Pain

In order for a nurse to succeed in chronic pain management, holistic assessment must be done accurately and appropriately. The nurse must incorporate the components of holistic assessment which according to Keef and Bonk (1999, p. 88) are, “clinical history; general personality trait; current level of somatic concern, depression, anger; report of pain and functional limitations; preliminary behavioral analysis; pain coping strategies; beliefs about injury; pain and treatment outcome; and social and occupational influences on symptom presentation.” Holistic assessment of chronic pain recognizes two major parts of the assessment process which are history and examination. The History, when accurately and exhaustively taken, can provide relevant and important information regarding the chronic pain. The history should include pain, treatment and psychological history, patient’s ideas about the cause of pain and goals for evaluation and treatment. Comprehensive examination should include the following; musculoskeletal examination, neurological examination, psychological examination, assessment of function-abilities and deficits (Wall, 1992; Meinhart, 2000). A detailed symptom analysis is performed as explained herein. In order to get accurate information that will help in holistic management of chronic pain, accurate history is essential. The following aspects are considered during assessment of chronic pain:

Location: to determine the location of the client’s pain, the following questions are asked: where in the body is the pain? (A figure of a person is normally used and the client just points to or marks painful areas.), is the pain inside (internal) or on the surface (external)? Is the pain always in these areas? If the pain is in more than one spot, are the pains equal, or does one trigger the others? These questions help the nurse to know the exact spot of the pain and whether the pain(s) is internal or external. The nurse has to know very well the anatomy and physiology of human beings as this will enable her/him to understand deeply the location of pain and the physiology behind it.

Extension and Radiation: in order to determine the extension and radiation of the client’s pain the following questions are asked; does the pain extend from where it started? Does it cover a wide area or can you point to where it is? These questions enable the nurse to know the pattern and which parts of the body in particular are affected. This helps in management interventions such as body psychotherapy and also in positioning of the patient in bed in a comfortable way.

Onset and pattern: onset and pattern of chronic pain is very important in designing the management plan and therefore they have to be very clear. These can be determined by asking the patient the following questions; when did the pain begin? Is it a regular pain, or does it varies? Does it occur in cycles, such as at the same time every day, every month, or every spring: What triggers the pain? Are there specific things that always trigger it? Can you identify any particular patterns? Does the pain begin suddenly or gradually overtime? Is it continuous, or does it vary? Are there separate episodes of pain? If so, does the pain go away completely between episodes, or does it just get better? Has the pain pattern change at all since it began? Has your lifestyle changed since the pain began? Onset and pattern of chronic pain is very vital in the planning of care of a patient. The nurse needs to get accurate information about this so that she/he can be able to know the nature of the pain and what aggravates it.

Duration: Duration of a chronic pain is important in holistic care as it enables the nurse to know accurately the types of medication to administer and also to find the most appropriate method on non pharmacological pain control measures. The questions include; Are you free of pain between attacks? Is the pain constant, intermittent, pulsating, or throbbing?

Precipitating factors: These are gotten from the client through asking questions such as what seems to trigger the pain? Can you identify a specific cause or event that always or sometimes precedes the pain? Does anything make it worse, such as smoking, drinking alcohol, eating, heat, or tension? What helps relieve the pain, such as rest, activity, heat or cold, or medications? These questions also helps the nurse in patient education; what to avoid.

Intensity: this is determined by asking questions such as, (When treatment starts, always have the client rate the pain before and after treatment). Note what nonverbal signs of pain the client exhibits, such as grimacing, crying, mourning, sleeping, appearing exhausted, or remaining immobile.

Associate symptoms: This can be achieved by asking the client if there is any other problems caused by his/her pain, if he/she experiences any nausea, restlessness, insomnia, excessive sleeping, or loss of appetite.

Effect on activities of daily living (ADL): The nurse therefore has to enquire from the client his/her pain has affected his capacity and ability to perform ADLs (McCracken, p. 1998, p. 28). The nurse will get these by asking the client questions such as: Does pain interfere with work, sleep, driving, eating, schoolwork, sexual relations, housework, social activity, or other activity? Has the pain caused any changes in your lifestyle?

Methods of pain relief: Ask about both invasive and noninvasive pain relief methods.

Psychological history: This forms an integral part of holistic care and the nurse should screen the client for anxiety, depression, stress coping styles, personality traits, addiction, personality disorders and traits, and psychiatric conditions (Keefe, et al. 2005, p. 601; Weisenberg, 2000, p. 60).

Physical Examination

The Wisconsin medical association recommends a comprehensive examination of each and every patient. Begin the examination by having the client show where the pain is and describe how it feels. Remember that the client is the expert on the pain and is the one who can best described and pinpoint it. This includes the following area: Musculoskeletal examination: posture; gait; joint examination-symmetry, range of motion, size, ligament stability; spinal examination – focal tenderness, symmetry, range of motion, and provocative movements; muscle examination; strength. Neurologic examination: mental status; sensation – touch, pressure, pinprick, heat, cold, vibration and reflexes – deep tendon and pathologic. Functional assessment will depend on patient self report and /or objective evaluation of mobility, self care, and physical performance. Objective signs of pain can be divided into three categories: sympathetic responses, parasympathetic responses, and behavioral responses. These responses are not diagnostic of chronic pain, but they may give clues about its cause. Sympathetic Responses are often associated with low to moderate pain intensity or superficial pain. They signify that body defenses are mobilized and that the fight or flight responses has begun. Objective signs include pallor, increased blood pressure, increased pulse, increased respirations, skeletal muscle tension, dilated pupils, and diaphoresis. Parasympathetic responses are often associated with pain of severe intensity, or with deep pain. In parasympathetic responses, body defenses may collapse in an attempt to lessen the effects of an external threat. In behavioral responses, the client may assume a posture that minimizes pain, such as lying rigidly, guarding, drawing up the legs, or assuming the fetal position; Moan, sigh, clench the jaws or fist, become quiet, or withdraw from others; Blink rapidly; Cry, appear frightened, exhibit restlessness; Have a drawn facial expression; Have twitching muscles; Withdraw when touched; and hold or protect the painful area, or remain motionless (Vasudevan, 2000; Max, 2004).

Examples of tools and assessment domains

The simplest pain assessment tool to use for both nurse and client are the visual analog or visual descriptor scales. These scales can be combined with numbers and verbal anchors. These tools are easy to use and provide the client and nurse a way to quantify pain. Another common assessment tool used to assess pain is the McGill – Melzack Pain Questionnaire. Although this tool is complex and more difficult than others to use, it can be very useful (Taylor, & Herr, 2003, p. 87). Others include the Doloplus-2 scale which assesses somatic, psychomotor and psychosocial reactions, the No Pain-Non-Communicative Pain Assessment Instrument that majorly assesses activity level and pain response, McCaffery and Pasero Initial Assessment Tool, Patient comfort assessment guide, Brief pain inventory and Oswestry disability questionnaire which was developed with the aim of getting information from a patient experiencing back and leg pain on the pain ahs affected their ability to manage every day life. These tools are limited in that they do not cover bio-psycho-social-spiritual nature of human beings and therefor other methods of assessment such as observation and patient verbalization must be used hand in hand with assessment tools.

Management of Chronic Pain

Nursing and Non-Pharmacologic Intervention

Non pharmacologic interventions are those interventions that do not totally involve the use of medicine/drugs in management of pain (Lin, &Taylor, 1999, p. 155). Holistic management of chronic pain requires that all aspects of chronic pain including its effect on the patient’s life are considered during management. The principle of chronic pain management clearly states that a multidisciplinary team and significant others must be included in the management of chronic pain.

Basic Principle: When caring for a client in pain, the nurse identifies and removes the cause whenever possible. The nurse must work with the client in seeking ways to reduce or remove pain. Listen to what the client thinks will help, and decide with the client and other health care team members what should be done. Allow the client a sense of control over the pain experience, rather than promote a feeling that the client is helpless in the grip of an episode of pain (Rudin, 2001; Lee & Scharff, 2002).

Alleviating Anxiety: the greater the client’s anxiety, the greater the suffering associated with the pain. The nurse should stay with the client for a while, allow client cliet to talk and express feelings and fears (Abram, 1990).

Distraction or diversion: this takes several forms such as occupational therapy, conversation, and reading, watching television, listening to the radio, meditation, self-hypnosis, biofeedback, and autosuggestion. It is upon the nurse to choose and initiate the most appropriate form of distraction. The nurse should encourage the client to use any methods that they have found helpful in the past to relieve pain, provided that these methods are harmful or bothersome to others (Loese, & Butter, 2001).

Providing physical care: the nurse should ensure that effective physical care for clients experiencing chronic pain is directed at reducing mechanical, chemical and thermal stressors that lower pain tolerance. This include protecting clients from local irritations or inflammations such as infection or thrombosis, muscle spasm or muscle strain, interference with local blood supply and venous and lymphatic drainage, distension of hollow visceral organs such as the bowel and bladder, and further damage to traumatized tissue (Loese, & Butter, 2001).

Key Principles in Holistic Management of Chronic Pain

McCaffery (1999), states that, “the key to successful management of chronic pain is identification of chronic pain, accurate assessment, adequate intervention and frequent evaluation”. These enables the nurse to educate the patient on the process, demonstrate understanding, holistic support of the client; socio-environmental impacts, quality of life improvement where possible and encouragement to return to work where appropriate and possible and creating an environment of understanding of a patient in chronic pain.

Analgesic Ladder: Principles and Guidelines

The World Health Organization published a document entitled “Cancer Pain Relief” which set out principles of cancer pain management based on analgesic three step ladder. The latest version was published in 1996 with the principles of by the mouth, by the clock, and by the ladder (WHO, 1996). According to the principles, the first step begins with non opioid analgesics, plus adjuvants as needed, such as tricyclics antidepressant. The second step uses weak opioids plus or minus (+/-) non opioid analgesics plus or minus adjuvant. The third step uses strong opioids plus or minus non opioid analgesics plus or minus adjuvants. According to Shaun and Richard (2008), patients who have moderate to severe pain when first seen by a clinician should be started at the second or third step of the WHO analgesic ladder. Non opioid analgesics include sallcylates, aspirin, choline magnesium trisallycylate, and other NSAIDS such as acetaminophen. Weak opioids analgesics include codeine, dihydrocodeine, and hydrocodone. Strong opioids analgesics include morphine, oxycodone, fentanyl, methadone and levorphanol (Shaun, & Richard, 2008). Adjuvant analgesics are drugs that are not primarily analgesics but research has shown that they have analgesic properties. They are normally co-administered with analgesics mostly in management of refractory pain. These include diclofenac, Dexamethasone, Prednisilone, gabapentin, and amitriptyline (Ellison, 1993; Brown, & Fleming, 1996). From the above (assessment and management) it can be deduce that there is a relationship between holistic nursing practice and assessment and management of chronic pain in that holistic practice considers all aspects of one’s life just as chronic pain has adverse and varied effects on ones life and therefore needs to be viewed in a way that the whole person and all related factors in his/her life are considered during the process of assessment and management. In holistic practice, factors that are not directly involved in a person’s disease process such as socio-cultural factors, role and functions, psychological and family issues are addressed. This too applies in assessment and management of chronic pain where by these factors are considered but in a different perspective; how the chronic nature of the pain has affected them (Woolf, 2004, p. 441).

Evaluation and Out Come of Chronic Pain Management

The nurse should always maintain accurate and complete records of pain management as part of nursing care. The following out comes should be used as measures of evaluating the effectiveness of chronic pain management; reduction in pain, improved physical, psychosocial functions, improved sleep with reduced depression and anxiety, change in use of medication in terms of dosage, frequency and completion of dose, increased ability to manage pain without external assistance, the reduction in utilization of health care services as a result of pain and verbalization of the client that he/she is feeling well or better (Turk, 2001; Moskovitz, 2002; Olungalunga, 2000). It is the role of the nurse to continuously monitor recovery progress, liaise with the other health professionals such as physicians, social workers, counselors and others. The nurse also ensures that patient receives his/her medication as prescribed.

Conclusion and recommendations

Holistic nursing care forms an integral part of chronic pain assessment and management. Holistic nursing care views an individual as a bio-psycho-social-spiritual being and therefore all aspects of one’s life are considered during assessment and management. Holistic nursing encompasses thorough assessment which involves both history taking and physical examination in order to come up with a proper care plan. The information gained from this paper will be of great help in my future nursing practices as it has opened up a new zeal to acquire more new information on chronic pain.

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