Nursing
Diagnosis: Chronic Pain
Chris Pasero and Margo
McCaffery
NANDA Definition: Pain is
whatever the experiencing person says it is, existing whenever the person says
it does (McCaffery, 1968); an unpleasant sensory and emotional experience
arising from actual or potential tissue damage or described in terms of such
damage; sudden or slow onset of any intensity from mild to severe, constant or
recurring, without an anticipated or predictable end and a duration >6
months (NANDA); a state in which an individual experiences pain that persists
for a month beyond the usual course of an acute illness or a reasonable
duration for an injury to heal, is associated with a chronic pathologic
process, or recurs at intervals for months or years (Bonica, 1990)
Defining Characteristics:
Defining Characteristics:
Subjective
Pain is
always subjective and cannot be proved or disproved. The client's report of
pain is the most reliable indicator of pain (Acute Pain Management Guideline
Panel, 1992). Clients with cognitive abilities who can speak or point should
use a pain rating scale (e.g., 0 to 10) to identify their current level of pain
intensity (self-report) and determine a comfort/function goal (McCaffery,
Pasero, 1999).
Objective
Expressions
of pain are extremely variable and cannot be used in lieu of self-report.
Neither behavior nor vital signs can substitute for the client's self-report
(McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable
responses to pain are helpful in its assessment, especially in clients who cannot
or will not use a self-report pain rating scale. Observable responses may be
loss of appetite or the inability to ambulate, perform activities of daily
living (ADLs), work, or sleep. Clients may show guarding, self-protective
behavior, self-focusing or narrowed focus, distraction behavior ranging from
crying to laughing, and muscle tension or rigidity. In sudden severe pain,
autonomic responses such as diaphoresis, blood pressure and pulse changes,
pupillary dilation, and increase or decrease in respiratory rate and depth may
be present but are usually not present with chronic pain that is relatively
stable. Clients with chronic, cancer, or nonmalignant pain may experience
threats to self-image; a perceived lack of options for coping; and worsening helplessness,
anxiety, and depression. Chronic pain may affect almost every aspect of the
client's daily life, including concentration, work, and relationships.
Related Factors: Actual or potential tissue damage; tumor progression and related pathology; diagnostic and therapeutic procedures; nerve injury (neuropathic pain)
NOTE: The cause of chronic
nonmalignant pain may not be known because pain is a new science and an area of
diverse types of problems.
NOC
Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·
Pain
Level
·
Pain
Control
·
Comfort
Level
·
Pain:
Disruptive Effects
Client Outcomes
·
Uses
pain rating scale to identify current level of pain intensity, determines a
comfort/function goal, and maintains a pain diary (if client has cognitive
abilities)
·
Describes
the total plan for drug and nondrug pain relief, including how to safely and
effectively take medicines and integrate nondrug therapies
·
Demonstrates
ability to pace self, taking rest breaks before they are needed
·
Functions
on an acceptable ability level with minimal interference from pain and
medication side effects (if pain is above the comfort/function goal, takes
action that decreases pain or notifies a member of the health care team)
NIC Interventions (Nursing
Interventions Classification)
Suggested NIC Labels
·
Pain
Management, Analgesic Administration
Nursing Interventions and Rationales
·
Determine
whether client is experiencing pain at time of initial interview. If so,
intervene at that time to provide pain relief. The intensity, character, onset, duration, and
aggravating and relieving factors of pain should be assessed and documented
during the initial evaluation of the patient (American Pain Society Quality of
Care Committee, 1995; JCAHO, 2000).
·
Ask
client to describe past and current experiences with pain and effectiveness of
the methods used to manage the pain, including experiences with side effects,
typical coping responses, and how he or she expresses pain. A number of concerns (barriers) may
affect client's willingness to report pain and use analgesics (Ward et al,
1993).
·
Describe
the adverse effects of unrelieved pain. Numerous
pathophysiological and psychological morbidity factors may be associated with
pain (McCaffery, Pasero, 1999; Page, Ben-Eliyahu, 1997; Puntillo, Weiss, 1994).
·
Tell
client to report pain location, intensity, and quality when experiencing pain. The intensity of pain and discomfort
should be assessed and documented after any known pain-producing procedure,
with each new report of pain, and at regular intervals (American Pain Society
Quality of Care Committee, 1995; JCAHO, 2000).
·
Ask
client to maintain a diary of pain ratings, timing, precipitating events,
medications, treatments, and what works best to relieve pain. Systematic tracking of pain appears
to be an important factor in improving pain management (Faries et al, 1991;
JCAHO, 2000).
·
Determine
client's current medication use. To
aid in planning pain treatment, obtain a medication history (Acute Pain
Management Guideline Panel, 1992).
·
Explore
need for medications from the three classes of analgesics: opioids (narcotics),
non-opioids (acetaminophen, Cox-2 inhibitors, and nonsteroidal antiinflammatory
drugs [NSAIDs]), and adjuvant medications. For chronic neuropathic pain,
consider adjuvant medications that are analgesic, such as anticonvulsants and
antidepressants. Some
types of pain respond to non-opioid drugs alone. However, if pain is not
responding, consider increasing the dosage or adding an opioid. At any level of
pain, analgesic adjuvants may be useful (American Pain Society, 1999).
Analgesic combinations may enhance pain relief (McCaffery, Pasero, 1999).
·
The
oral route is preferred. If client is receiving parenteral analgesia, use an
equianalgesic chart to convert to an oral or another noninvasive route as
smoothly as possible. (See Appendix E for an equianalgesic chart.) The least invasive route of
administration capable of providing adequate pain control is recommended. The
oral route is the most preferred because it is the most convenient and cost
effective. Avoid the intramuscular (IM) route because of unreliable absorption,
pain, and inconvenience (Jacox et al, 1994).
·
Obtain
a prescription to administer a non-opioid, unless contraindicated, around the
clock (ATC). NSAIDs act
mainly in the periphery to inhibit the initiation of pain signals (Dahl, Kehlet,
1991). The analgesic regimen should include a non-opioid drug ATC, even if pain
is severe enough to require the addition of an opioid (American Pain Society,
1999).
·
For
persistent cancer pain, obtain a prescription to administer opioid analgesics. When pain persists or increases, an
opioid such as codeine or hydrocodone should be added to the non-opioid (Jacox
et al, 1994). If this is not effective, switch to morphine or other
single-entity opioids.
·
Establish
ATC dosing and administer supplemental opioid doses as needed to keep pain
ratings at or below an acceptable level. A
PRN order for a supplementary opioid dose between regular doses is an essential
backup (American Pain Society, 1999).
·
Ask
client to describe appetite, bowel elimination, and ability to rest and sleep.
Administer medications and treatments to improve these functions. Always obtain
a prescription for a peristaltic stimulant to prevent opioid-induced
constipation. Because
there is great individual variation in the development of opioid-induced side
effects, they should be monitored and, if their development is inevitable
(e.g., constipation), prophylactically treated. Opioids cause constipation by
decreasing bowel peristalsis (Jacox et al, 1994; McCaffery, Pasero, 1999).
·
Explain
pain management approach that has been ordered, including therapies, medication
administration, side effects, and complications. One of the most important steps toward improved control
of pain is a better client understanding of the nature of pain, its treatment,
and the role client needs to play in pain control (Jacox et al, 1994).
·
Discuss
client's fears of undertreated pain, addiction, and overdose. A number of concerns (barriers) may
affect patients' willingness to report pain and use analgesics (Ward et al,
1993). Because of the many misconceptions regarding pain and its treatment,
education about the ability to control pain effectively and correction of myths
about the use of opioids should be included as part of the treatment plan
(McCaffery, Pasero, 1999). Opioid tolerance and physical dependence are
expected with long-term opioid treatment and should not be confused with
addiction (Jacox et al, 1994).
·
Review
client's pain diary, flow sheet, and medication records to determine overall
degree of pain relief, side effects, and analgesic requirements for an
appropriate period (e.g., one week). Systematic
tracking of pain appears to be an important factor in improving pain management
(Faries et al, 1991; JCAHO, 2000).
·
Obtain
prescriptions to increase or decrease analgesic doses when indicated. Base
prescriptions on the client's report of pain severity and the comfort/function
goal and response to previous dose in terms of relief, side effects, and
ability to perform the daily activities and the prescribed therapeutic regimen.
Opioid doses should be
adjusted individually to achieve pain relief with an acceptable level of
adverse effects (Jacox et al, 1994; McCaffery, Pasero, 1999).
·
If
opioid dose is increased, monitor sedation and respiratory status for a brief
time. Patients receiving
long-term opioid therapy generally develop tolerance to the respiratory
depressant effects of these agents (Jacox et al, 1994; McCaffery, Pasero,
1999).
·
In
addition to the use of analgesics, support the client's use of
nonpharmacological methods to control pain, such as distraction, imagery,
relaxation, massage, and heat and cold application. Cognitive-behavioral strategies can restore clients'
sense of self-control, personal efficacy, and active participation in their own
care (Jacox et al, 1994).
·
Teach
and implement nonpharmacological interventions when pain is relatively well
controlled with pharmacological interventions. Nonpharmacological interventions should be used to
supplement, not replace, pharmacological interventions (Acute Pain Management
Guideline Panel, 1992).
·
Plan
care activities around periods of greatest comfort whenever possible. Pain diminishes activity (Jacox et
al, 1994; McCaffery, Pasero, 1999).
·
Ask
clients to describe their appetite, bowel elimination, and ability to rest and
sleep. Administer medications and treatments directed toward improving these
functions. Because there
is great individual variation in the development of opioid-induced side
effects, clinicians should monitor and, if development is inevitable,
prophylactically treat them (Jacox et al, 1994).
·
Explore
appropriate resources for management of pain on a long-term basis (e.g.,
hospice, pain care center). Most
patients with cancer or chronic nonmalignant pain are treated for pain in
outpatient and home care settings. Plans should be made to ensure ongoing
assessment of the pain and the effectiveness of treatments in these settings
(Jacox et al, 1994).
·
If
client has progressive cancer pain, assist client and family with handling
issues related to death and dying. Peer
support groups and pastoral counseling may increase the client's and family's
coping skills and provide needed support (Jacox et al, 1994).
·
If
client has chronic nonmalignant pain, assist client and family with minimizing
effects of pain on interpersonal relationships and daily activities such as
work and recreation. Pain
reduces clients' options to exercise control, diminishes psychological
well-being, and makes them feel helpless and vulnerable. Therefore clinicians
should support active client involvement in effective and practical methods to
manage pain (Hitchcock, Ferrell, McCaffery, 1994; Jacox et al, 1994).
Geriatric
·
Always
take an elderly client's reports of pain seriously and ensure that the pain is
relieved. In spite of what
many professionals and clients believe, pain is not an expected part of normal
aging (McCaffery, Pasero, 1999).
·
When
assessing pain, speak clearly, slowly, and loudly enough for client to hear;
repeat information as needed. Be sure client can see well enough to read pain
scale (use enlarged scale) and written materials.
·
Handle
client's body gently. Allow client to move at own speed.
·
Use
NSAIDs with caution and avoid ATC NSAID dosing. Opioids ATC are preferable to chronic NSAID
administration in the elderly client because of an increased risk for NSAID
adverse effects (American Geriatric Society Panel on Chronic Pain in Older
Persons, 1998).
·
Use
acetaminophen and NSAIDs with low side effect profiles such as choline and
magnesium salicylates (Trilisate) and diflunisal (Dolobid). Watch for side
effects such as GI disturbances and bleeding problems. Elderly clients are at increased
risk for gastric and renal toxicity from NSAIDs (Griffin et al, 1991; Acute
Pain Management Guideline Panel, 1992).
·
Avoid
or use with caution drugs with a long half-life, such as the NSAID piroxicam
(Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-Dromoran),
and the benzodiazepine diazepam (Valium). A
higher prevalence of renal insufficiency in the elderly than in younger persons
can result in toxicity from drug accumulation (American Pain Society, 1999;
Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).
·
In
an elderly client, avoid the use of opioids with toxic metabolites, such as
meperidine (Demerol) and propoxyphene (Darvon, Darvocet). Meperidine's metabolite,
normeperidine, can produce CNS irritability, seizures, and even death;
propoxyphene's metabolite, norpropoxyphene, can produce both CNS and cardiac
toxicity. Both of these metabolites are eliminated by the kidneys, making
meperidine and propoxyphene particularly poor choices for elderly clients, many
of whom have at least some degree of renal insufficiency (Acute Pain Management
Guideline Panel, 1992; McCaffery, Pasero, 1999).
Multicultural
·
Assess
pain in a culturally diverse client using a self-report 0 to 10 numerical pain
rating scale or the Wong Baker Faces pain rating scale. Use a scale that has
been translated into client's native language if necessary. Inadequate pain management is
widespread, especially among minority groups, and a major reason is the failure
to assess pain properly. The more cultural differences between patient and
nurse, the more difficult it is for the nurse to assess and treat pain.
Self-report of pain is the single most reliable indicator of pain, regardless
of culture (McCaffery, 1999; McCaffery, Pasero, 1999).
·
Administer
analgesics on a preventive basis to keep pain ratings at or below an acceptable
level.
·
Assess
for the influence of cultural beliefs, norms, and values on the client's perception
and experience of pain. The
client's experience of pain may be based on cultural perceptions (Leininger,
1996).
·
Assess
for the role of fatalism on the client's beliefs regarding their current state
of comfort. Fatalistic
perspectives in some African-American and Latino populations involve the belief
that you cannot control your own fate and influence your health behaviors
(Philips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).
·
Incorporate
folk health care practices and beliefs into care whenever possible. Incorporating folk health care
beliefs and practices into pain management care increased compliance with the
treatment plan (Juarez, Ferrell, Borneman, 1998).
·
Use
a family-centered approach when working with Latino, Asian American,
African-American, and Native American clients. Involving family in pain management care increased
compliance with the treatment regimen (Juarez, Ferrel, Borneman, 1998).
·
Use
culturally relevant pain scales (e.g., the Oucher scale) to assess pain in the
client. Culturally diverse
clients may express pain differently than clients from the majority culture.
The Oucher scale has African-American and Hispanic versions and is used to
assess pain in children (Beyer, Denyes, Villarruel, 1992).
·
Ensure
that directions for medications are available in the client's language of
choice and are understood by client and caregiver. Bilingual instructions for medications increased
compliance with the pain management plan (Juarez, Ferrell, Borneman, 1998).
·
Validate
the client's feelings and emotions regarding current health status. Validation lets the client know the
nurse has heard and understands what was said, and it promotes the nurse-client
relationship. (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).
Home Care Interventions
·
Review
with client and caregivers the cause(s) of pain and the medical regimen
specific to the cause. Assess client knowledge and teach disease process as
necessary. Compliance with
the medical regimen for diagnoses involving pain improves the likelihood of
successful management (Humphrey, 1994).
·
Develop
a full medication profile, including medications prescribed by all physicians
and all over-the-counter medications. Assess for drug interactions. Instruct client
to refrain from mixing medications without physician approval. Pain medications may significantly
impact or be impacted by other medications and may cause severe side effects.
Some combinations of drugs are specifically contraindicated (Jacox et al,
1994).
·
Assess
client and family knowledge of side effects and safety precautions associated
with pain medications (e.g., use caution when operating machinery when opioids
are initiated or dose has been increased). The
cognitive effects of opioids usually subside within a week of initial dosing or
dose increases (McCaffery, Pasero, 1999). The use of long-term opioid treatment
does not appear to affect neuropsychological performance. Pain itself may
deteriorate performance of neuropsychological tests more than oral opioid
treatment (Sjogren et al, 2000).
·
Collaborate
with health care team on an ongoing basis (including client and family) to
determine optimal pain control profile. Identify the most effective
interventions and the medication administration routes most acceptable to the
family and client. Success
in pain control is partially dependent on the acceptability of the suggested
intervention. Acceptability promotes compliance. Dosages vary among routes and
will need to be adjusted accordingly to avoid breakthrough or transitional pain
(Bohnet, 1995).
·
If
administering medication using highly technological methods, assess home for
necessary resources (e.g., electricity), and ensure that there will be
responsible caregivers available to assist client with administration. Some routes of medication
administration require special conditions and procedures to be safe and
accurate (McCaffery, Pasero, 1999).
·
Assess
knowledge base of client and family for highly technological medication
administration including the use of PCA pump. Teach as necessary. Appropriate instruction in the home
increases the accuracy and safety of medication administration (McCaffery,
Pasero, 1999).
·
Support
the client and family in the use of opioid analgesics. Well-intentioned friends and family
may create added stress by expressing judgment or fears regarding the use of
opioid analgesics (McCaffery, Pasero, 1999).
Client/Family Teaching
·
NOTE: To avoid the negative
connotations associated with the words drugs and narcotics, use the words pain
medicine when teaching clients.
·
Provide
written materials regarding pain control, such as the Agency for Health Care
Policy and Research pamphlet, Managing Cancer Pain: Patient Guide.
·
Discuss
the various discomforts encompassed by the word pain and ask clients to give
examples of pain they have experienced. Explain the pain assessment process and
the purpose of the pain rating scale that will be used. Teach clients to use
the pain rating scale to rate the intensity of current or past pain. Ask them
to set a pain relief goal by selecting a pain rating on the scale; if pain goes
above this level, they should take action that decreases pain or notify a
member of the health care team. (See Appendix E for information on teaching
clients to use the pain rating scale.)
·
Discuss
the total plan for drug and nondrug treatment, including the medication plan
for ATC administration and supplemental doses, the maintenance of a pain diary,
and the use of supplies and equipment.
·
Reinforce
the importance of taking pain medications to keep pain under control.
·
Reinforce
that taking opioids for pain relief is not an addiction.
·
Explain
to clients with chronic neuropathic pain the process of taking adjuvant
analgesics (e.g., tricyclic antidepressants); a low dose is used initially and
is increased gradually. Emphasize that pain relief is delayed and the drugs
must be taken daily. Reassure the client that although the medicine is an
antidepressant, it is used for analgesia and not depression. Comparable
teaching should take place when an anticonvulsant is prescribed for analgesia.
·
Emphasize
to clients with chronic nonmalignant pain the importance of participating in
therapeutic regimens other than medication (e.g., physical therapy, group
therapy).
·
Emphasize
to clients the importance of pacing themselves and taking rest breaks before
they are needed.
·
Demonstrate
the use of appropriate nonpharmacological approaches for controlling pain.
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