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Pain Management: Practical Example

The term pain denotes a lot of feelings – it is complex and universal. Everyone experiences pain, but the explanation and meaning of pain are quite subjective. It is not difficult to describe, yet only the individual suffering from it knows what and how it is.

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Pain management can help in determining the severity of pain a patient suffers, and how the patient can be provided the necessary medication.

Pain and pain management are the concerns of this essay. Other underlying topics of interest will be included here and these are definition, the severity, symptoms, duration, and how management should be administered on the different kinds of pain patients feel.

This essay is most concerned with how care and pain management can be administered on a particular case study: this is the topic involving Jim who has been diagnosed with metastatic cancer, and the problems experienced by both the patient and nursing staff in the management of Jim’s pain.

The situation arose from the following conditions.

Jim has had recent surgery, radiotherapy, and adjuvant chemotherapy as a palliative of the organic cause of pain.

Janjan et al (2003, p. 278) state that palliation ‘represents a large component of cancer treatment and includes the use of therapeutic and supportive care measures.’ They further add that therapeutic success regards the quality of life as important as survival.

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Doctors and staff are now focused on controlling the symptoms in Jim’s situation. But from the surgery onward, Jim has gone into a depression that has affected very much his ability to cope with pain. Another complicated situation has come out because of this. His family, especially his wife Joan, is also affected, though they are very much supportive of him.

Jim’s situation renders him almost unable to communicate. The aftermath of the surgery produced some symptoms too much to bear, and also difficult for Joan and his children. Jim’s situation deteriorated and he was admitted to a hospital. The family continues to receive community support, and Jim also receives care from the community nurses.

Jim experiences severe pain. He self-rated his pain at 8, on a pain scale of 1 to 10 with 10 as the ‘most pain’. This is a self-rating by the patient, which can be said as not too reliable. Jim has developed cognitive deficits, therefore communication is difficult. We can only surmise that the nurses and the people around him must have read his facial expressions in determining the severity of the pain the patient feels.

He complains of pain in his right upper quadrant which becomes more painful as he moves. Jim has shown signs of depression, with dry mouth and throat making it hard to swallow oral medications, and difficult to eat. The deteriorating condition has taken a toll on the patient as well as his wife Joan.

Other symptoms include nausea, dysuria, urgency, and frequency in urination, a symptom of UTI (urinary tract infection), and has a loose frequent malodorous stool, that contains urine and stool as it is potential for skin breakdown. A urine ward analysis shows a pH of 4.2, Ketones+, the specific gravity of 1.080 mmol, leucocytes +, and protein trace, but with no abnormalities detected. Jim has refused to take the prescribed anti-emetics, and his only analgesia consisted of 2 tablets of paracetamol (500mg) and codeine (10mgs).

He has not passed a formed stool for 5 days, is defecating malodorous fecal fluid, which is also present in his urine as a result of an anal bladder fistula. The pain in the right upper quadrant is possibly due to pyelonephritis.

Before we go deeper into this case study, it is time to deal first with what pain is and how it is being addressed by doctors and organizations. The most widely used definition of pain was introduced by The International Association for the Study of Pain. Pain is an “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (Mann and Carr, 2006, p. 2).

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Though this is a widely accepted definition, coming from a respected and well-motivated organization, we still can say that it is incomplete. There is pain that seems to be not caused by tissue damage, for example, a stomach cramp. What about psychological pain?

Pain does not have to be tissue damage; it is unpleasant, with both sensory and emotional components (Hughes, 2008, p. 1).

Pain is described as a subjective feeling because it is only the individual who feels the pain knows how severe it is. Pain denotes a variety of feelings (Hawthorn and Redmond, 1998, p. 1).

All of us feel pain, that’s why it is described as universal. The severity, duration, and meaning of pain can be determined only by the individual. Pain can cause suffering, even remorse for the world we live in.

Pain is characterized by some objective signs and symptoms; however, it cannot be assumed that all people will exhibit these objective signs as a part of the pain experience. In other words, pain is just what the individual experiencing it says it is. (Laccetti and Kazanowski, 2009, p. 2)

Pain can be felt in almost all post-surgery instances. It is thought that more than 50% of patients may still have severe pain after surgery and that more than 30% of medical patients with pain will report their pain as being severe (Macintyre and Schug, 2007, p. 1).

From the literature available, Jim’s pain and subsequent depression are the results of his cancer and the consequent palliative surgery. His cancer-related pain is multidimensional consisting of physiologic, sensory, affective, cognitive, and behavioral. (McGuire et al, 1995, p. 1)

Pain can lead to significant delays in gastric emptying and a reduction in intestinal motility. This is thought to be due mainly to activation of a spinal reflex arc and increased sympathetic tone. Other causes of inhibition of motility in the postoperative period include opioid administration and surgery. After abdominal surgery colonic motility is inhibited for 48-72 hours, whereas motility in the stomach and small intestine usually recovers within 12-24 hours. Urinary retention may also occur. (Macintyre and Schug, 2007, p. 4)

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The affective dimension of the pain experience encompasses emotional responses to pain, which can include anxiety, depression, mood changes, anger, irritability, and other factors. (McGuire et al, 1995, p. 6)

This is clear in the patient’s symptoms and other depression-related responses which are taking a toll on his wife Joan and even the nurses.

Moreover, the circumstances of Jim’s hospitalization and condition have become complicated. Joan is having a communication gap or a ‘cold war with the nursing staff. Joan is now having symptoms of stress because of the long hours she has devoted to taking care of her husband.

McGuire et al (1995) state that ‘Managing pain imposes a great burden on caregivers, whose own experiences include feelings of helplessness, wishing for the patient’s death, and coping by denying their feelings and being “strong”. … Patients with pain tried to hide it from their families’ (p. 9).

This may not be the case with Jim and Joan, but it can be happening. Joan is very much affected, and Jim possibly knows this. There was one time that the nurses noticed Joan whispering to Jim to eat.

Sometimes, families are at a loss managing patients’ care, and this includes pharmacologic and nonpharmacologic interventions. Their attitudes, beliefs, and knowledge about these areas can be influential in how they manage pain. Thus, again, both patient and caregiver variables potentially affect care. (McGuire et al, 1995, p. 9)

But the nursing staff who are also with the patient have a role to play, not only in caring for the patient but also in understanding the family’s situation or predicament. Instead, their attitude towards Joan can result in a negative atmosphere that is not favorable for a healing atmosphere in the patient’s ward. The comments and counter comments between the nursing staff and Joan can exacerbate Jim’s situation and pain.

The nurses should continue to support Joan and her family because they are in such a situation that right thinking and decision are not theirs to make at the moment. Joan needs understanding and help.

Jim requires regular slow-release, with breakthrough pain management, and has to be administered with opioids and anti-emetics. He should be kept comfortable, clean and can be administered with alternative pain management, for example, additional body massage and some music.

But how can other medications be administered if Joan is not on good terms with the nursing staff? Can she be told to take a break and be disregarded in caring for her husband? This should not be the case. Joan should be a part of administering pain management or should have an important role in caring for her husband.

Something has to be done to unite Joan, the nursing staff, and those involved in giving care to a cancer patient. A family conference is recommended, involving Joan and the patient’s children, the hospital physician, and the nursing staff. All issues in caring for Jim can be talked about, laid open and suggestions and discussions should be considered.

A multidisciplinary, multimodal approach to managing pain is the appropriate way to achieve optimal patient, family, caregiver, and institutional outcomes. There is no perfect health care and no one discipline or professional possesses the knowledge and skills needed to provide truly comprehensive care.

Current views of cancer pain management require the participation of patients and their families or significant others as active contributors in the process.

The nursing staff and the patient’s family should be able to make specific contributions, the nature of which depends on educational and experiential qualifications, collaborative and cooperative clinical practice, individual preferences, and institutional organization and support.

The staff is not helping the patient and his family. Joan deserves a break; the help she receives from the nursing staff is one of scorn and resentment. What they see in Joan are demands, but they are not demands.

Perhaps she could go home for a few days and take a rest. The children can take over in the meantime. Or, Joan and the children can do it together – care for Jim while the situation has not been normalized yet.

An offer of support from empathetic and concerned individuals is in order. Joan should expect help from social workers, or a palliative care nurse/team, and some inspiring words from a hospital chaplain or their church minister.

A rotation or change of nurse assignment regularly should be recommended. Moreover, there must be a good channel of communication between the family and the nursing staff, including the hospital physician.

The affective dimension of the pain experienced can be addressed through the use of a tremendous variety of options, including cognitive approaches (educational and empowerment strategies), cognitive-behavioral coping strategies, psychosocial and psycho-physiologic modalities, and spiritual care.

The multidimensional framework of pain enables holistic nursing and can be easily applied to the assessment and management of patients with cancer-related pain. The result is a sensitive evaluation of the individual’s unique experience of pain and adaptation responses, which can then be managed in an individualized manager. (McGuire et al 1995, p. 10)

Nursing home leadership must be committed to effective pain management and “ensure that the basic principles of pain assessment and treatment are thoroughly incorporated into patterns of daily practice” (Iyer, 2006, p. 516).

The nursing staff should be able to play a leadership and coordinating role in the multidisciplinary process of managing cancer pain. They should play a major role in the multidisciplinary framework of cancer-related pain management.

Changing or decreasing sensation or perception of pain and diminishing emotional reactions will address the sensory, affective, cognitive, behavioral, and sociological dimensions of pain, perhaps resulting in lower pain intensity, improved mood, positive attitude, better sleep, and more interaction with loved ones.

Diminishing emotional reactions through the use of treatments that reduce anxiety and depression and enable the use of cognitive and behavioral coping strategies will affect the affective and sensory dimensions of pain, and perhaps the cognitive, behavioral, and sociocultural dimensions as well.

In administering pain management, adequate education of the medical, nursing, and allied health staff and students, patients, and their families and friends should be readily available for them.

Inadequate knowledge, misconceptions, and the persistence of some of the myths that surround pain management continue to result in barriers that prevent optimal analgesia in many patients. Better education of all parties concerned is needed if more sophisticated methods of pain relief (such as patient-controlled and epidural analgesia) are to be managed safely and effectively and if better results are to be gained from conventional methods of pain relief. (Macintyre and Schug, 2007, p. 9)

Jim’s situation deteriorated after the surgery. His attitudes and expectations affect pain perception and analgesic requirements.

Patients who learn to assess their pain, and who are made aware that they should ask for more pain relief when needed, will have more control over the dose and delivery of analgesic drugs, regardless of the analgesic technique used. Appropriate education and information can therefore be a powerful tool in helping to ensure effective pain relief.

But in Jim’s predicament, the patient seems not to know how to rate his pain. His communication with the outside world is almost impossible. Jim is not in a situation to rate his pain.

The nursing staff seems not to know what they are doing. Jim’s pain and depression have taken a toll on him and his wife, the caregiver. Joan is also in distress, physically and emotionally. She needs a break, a rest from the day-to-day activities of caring for her husband. But the nursing staff should know how to deal with patients’ families. They must understand Joan and support her.

Macintyre and Schug (2007, p. 14) recommend the role of an acute pain service that should include initial updates in education. Education should involve doctors, nurses, patients, medical and nursing students, and so forth.

Next is the introduction and supervision of more advanced analgesic techniques, such as patient-controlled analgesia. Assistance in improving traditional analgesic treatment regimens includes intermittent opioid regimes and non-opioid analgesia. Equipment should also be standardized, and then analgesic techniques should be instituted including drugs, doses, and drug dilutions.

Pain service personnel should be available on a 24-hour service, with scheduled rounds of all patients under care. Lastly, close coordination among all the parties concerned should be done for the sake of the patient.

References

Hawthorn, J. and Redmond, K., 1998. Pain: causes and management. Oxford, UK: Blackwell Publishing. pp. 1-3.

Hughes, J., 2008. Pain management: from basic to clinical practice. U.S.A.: Elsevier Limited. pp. 1-2.

Iyer, P. W. (ed.), 2006. Nursing home litigation: investigation and case preparation (Second Ed.). United States of America: Lawyers & Judges Publishing Company, Inc. p. 516.

Janjan, N., Delclos, M., Crane, C., Ballo, M., and Cleeland, C., 2003. Palliative radiotherapy. In Bruera, E. D. and R. K. Portenoy (eds.), Cancer pain: assessment and management. Cambridge, United Kingdom: Press Syndicate of the University of Cambridge. p. 278.

Laccetti, M. S. and Kazanowski, M. K., 2009. Pain Management (2nd ed.). MA, U.S.A.: Jones and Bartlett Publishers, LLC. pp. 1-6.

Macintyre, P. and Schug, S., 2007. Acute pain management: a practical guide. Philadelphia, U.S.A.: Elsevier Limited. pp. 1-7.

Mann, E. and Carr, E., 2006. Pain management. Oxford, UK: Blackwell Publishing Ltd. pp.

McGuire, D. B., 1995. The multiple dimensions of cancer pain: a framework for assessment and management. In McGuire, D. B., C. H. Yarbro, and B. R. Ferrell, Cancer pain management. London, UK: Jones and Bartlett Publishers, Inc. pp. 6-11.

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