Postoperative Pain Management - Research Paper Example

POSTOPERATIVE PAIN MANAGEMENT The Physiology of Pain Pain is described as an unpleasant experience, which is either sensory or emotional, brought about by actual or potential tissue damage (Mersky, 1986). This description underscores the wide latitude of the definition of can be considered pain. A complex phenomenon, pain is founded on emotion, social norms, personal experience, and biology. Technically, pain is a neurophysiological response to physical stimuli (Jay, 2007). Generally, most pain is caused by damage to tissues and is physiological in nature. Different tissues have dissimilar capacity for pain (Encyclopaedia Britannica, 2009). Some tissues like the liver and lung alveoli do not respond to strong pain stimulus, while skin tissues are very sensitive. Traditionally, pain was considered as a symptom or manifestation of a disease or diseased state. Currently, this view still holds, but more than that, pain is considered as a condition that needs to be managed separately from the medical condition from whence it arose. The understanding of the elements that cause pain has been a pursuit of many researches in medical science. People with various life-threatening and non-threatening medical conditions could suffer diverse form of pain, although acute pain could arise from surgical procedures. Chronic pain is a condition suffered by many. The myriad of medications developed for pain relief alone is an indication of the number of individuals who suffer from chronic and acute pain. In a clinical setting, pain is a subjective condition and its definition is based on what the patient decides it to be. The role of the clinician is to know what the patient actually means, and needs. However, many clinicians, nurses included, do not have a clear understanding of pain and its management. As a result, pain management could be ineffective. Understanding pain at the anatomical and physiological level will increase the clinician’s knowledge of it nature and the interventions that can alleviate it. How pain develops was first described in the classic work of Melzack and Wall in 1965, which proposed the “gate control theory of pain”. According to Melzack and Wall, pain is perceived by a neural mechanism by the substantia gelatinosa layer of the dorsal horn of the spinal cord, which acts like a gate modulating the flow of nerve impulse from the peripheral nervous system to the central nervous system (CNS). The pain stimuli are felt by nociceptors, receptors in the somatic and visceral tissues. The nociceptors are free nerve endings that are connected to small-diameter A and C nerve fibers. Pain is felt when there are more pain signals travelling through the small nerve fibers than the big nerve fibers (which have no nociceptors) towards the spinal cord. In the spinal cord, in the absence of a pain stimulus, an inhibitory interneuron blocks the signal of the projection neuron, which is connected to the brain. This is comparative to a closed gate, and therefore no pain is felt. When a painful stimulus is present, the small nerve fibers are activated which also activate the projection neurons (gate is open) that block the action of the inhibitory neurons. Thus, the information reaches the brain through the projection neuron and therefore, pain is felt. This early work spawned many studies on understanding the mechanisms and types of pain, its alleviation, and its management. Four basic processes, transduction, transmission, perception and modulation, are involved in nociception (Wood, 2008). Transduction involves the response of the A and C fibers to noxious (or pain) stimuli which can be categorized as mechanical, thermal and chemical. A pain impulse is generated when an ionic and electrical gradient occurs at the cell membranes throught the transfer of ions across the membrane. After the impulse is generated, pain is transmitted along the nerve fibers towards the spinal dorsal horn to the brain. There are no pain centres in the brain, so the pain impulses are distributed to different areas where they are processed. The reticular system in the brain is responsible for automatic motor responses to the stimuli. The somatosensory cortex perceives and interprets sensations, relating these sensations to experience. The limbic system gives emotional and behavioural responses to pain. Pain is modulated through the descending pain pathway leading to excitation or inhibition of pain transmission (Wood, 2008). Blocking pain transmission is achieved with the use of analgesics and inhibitory neurotransmitters which include endogenous opioids, acetylcholine, serotonin, noradrenalin. Differences in the amounts of endogenous pain modulators explain the differences in the degree that different individuals are able to tolerate pain. However, studies show that the ability to withstand pain arise more from cultural factors rather than heredity (Encyclopaedia Britannica, 2009). Perioperative Pain management Surgery is a common intervention for a disease process that has resulted in injury, disease or disorder. Perioperative refers to the total span of surgical intervention from the preoperative, intraoperative, and the postoperative stages (Nursing Fundamentals II, 2007). In all these phases, nursing activities are carried out, but pain management is a major activity in the postoperative phase which spans the patient’s transfer to the recovery room until complete recovery. The nurse has the primary role in the direct care of the patient (Campbell, 2006). A 2001 survey for the American Society of Pain Management Nursing showed that the most common activities for nurses, even while they are caring for patients with pain, were assessment, monitoring, and evaluation of the patient’s pain. Improvement in pain management is dependent on the clinical skills and commitment of nurses. Complex nursing roles in pain management have expanded to include patient and community education, pain assessment, administration of interventions, documentation, quality of service improvement, advocacy, and ethics (Campbell, 2006). The discussion in this paper will be limited to the primary care role of perioperative nurses. The strategies that nurses utilize to manage pain in the postoperative setting showed that nurses also place importance in nonpharmacologic measures of pain management in actual practice (Manias, Bucknall, & Botti, 2005). Communication among clinicians, nurses, and patients was found to be critical in improving the effectiveness of postoperative care. Assessment of Pain All perioperative care is aimed towards the ultimate promotion of the patient’s overall health, prevention of complications, and full recovery. Since surgery includes the pain factor, pain assessment is the first step towards effective pain management. In 1992 and 1994, guidelines for the treatment of acute and cancer pain were published by the Agency for Health Care Policy and Research. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) also published standards of pain management in 1999. These standards give the patient’s rights to have a routine pain assessment that is actually more complex than just a measure of pain intensity. This routine assessment needs a skilled interviewer and clinician to understand the patient’s pain and how it may influence the quality of his life. Nurses therefore, being present in this setting, need to develop the empathy and skills to obtain quality information on the patient’s pain history. The information will be shared with other members of the team to draw up a plan to manage the patient’s pain (Campbell, 2006). Factors for formulating a pain management plan are the type of surgery, degree of postoperative pain, presence of other medical conditions and the patient’s preferences. A directed pain history and physical examination, should be included the evaluating the preoperative anaesthetic plan (American Society of Anesthesiologists Task Force on Acute Pain Management, 2004). The patient should be informed of preoperative procedures in order to reduce the anxiety level, which could affect the level of pain that he will later encounter after surgery. It is also recommended that medications should not be suddenly withdrawn to avoid withdrawal symptoms. In adults, the most accurate measurement of pain is the verbal report by the patient. Measurement of pain intensity and quality characteristics is deemed appropriate. The components of pain are found in the acronym COLDERR, which can be used by nurses when taking a patients history (Arnstein, 2002). COLDERR stands for character or sensation, onset, location, duration, exacerbation, relief, radiation. Physical examination is also necessary to identify other factors that may require further examination or intervention. Documentation of all observations is a very important procedure that will allow for reassessment and follow-up. For the perioperative nurse, careful and correct documentation is a challenge because a patient may not be coherent nor conscious enough to give a reliable interview. Normally, a numeric scale, which describes the level pain, or a behavioural rating pain scale gives assessment of pain where the patient’s appearance or body language is noted. Pain in children is more difficult to assess because, depending on the age, children cannot express quantity or quality of pain. The use of questionnaires given to parents and children helps in the assessment. The literature is replete with scales that can be used to assess pain; however, the scale chosen must be appropriate for the child’s age. Behaviour scales or face scales can be used to assess pain (Buttner & Finke, 2000). Effective Postoperative Pain Management Perioperative pain control can be categorized into three major groups which are: epidural or intrathecal opiod analgesia, patient-controlled analgesia (PCA) and regional analgesic techniques. These three are recommended for pain management whenever appropriate and necessary (American Society of Anesthesiologists Task Force on Acute Pain Management, 2004). This group of intervention falls under the first category of pain management strategies, which is pharmacological intervention. Opioids are still the most commonly used treatments for intraoperative and postoperative pain relief. The most common are morphine, hydromorphone (Dilaudid), and meperidine (Demerol). Patient-controlled analgesia (PCA) with systemic opioids allows patients to self-administer small doses of opioid intravenously or subcutaneously at frequent intervals (Rodts, 2009). PCA is effective in managing moderate-to-severe pain and allows the patient to control analgesic administration. A study also showed that PCA can be used in children and has the potential to become the preferred pain management method in children due to its ease in application (Grandinetti & Buck, 2000). Apart from analgesics, many nonmedication therapies are beneficial in managing pain. These include physical treatments like ice or heat application, exercise, and massage. Also in this category are emotional analgesia like music, meditation, and prayer (Campbell, 2006). These interventions allow the patients to become participants in controlling their pain rather than depending on clinician-initiated pharmacologic pain therapies (Arnstein, 2002). However, only few empirical evidences show the effectiveness of these interventions in providing pain relief. Nurses therefore, avoid using these nonmedications singularly, but are administered in addition to the regular analgesics. Roles for Nurses The role of nurses, aside from assistance in the administration of nonmedication intervention, is to assess the emotional and physical readiness of the patient to participate in activities that are pain alleviating. The nurse also selects the interventions, which are thought to be appropriate for the patient, and has the potential to lessen feelings of pain. A consideration here would be the type of surgery that was performed and if healing was enough to allow for nonpharmacologic intervention. Some patients will rely on the nurses to find interventions that they can cope with, considering the limitations posed by the surgical procedures and their medical conditions. The nurse also initiates the collaboration with other team members, which is needed to find and maximize opportunities for nonmedication interventions. These can be simple distractions from the physical pain to physical activities that can reduce inflammation, tension, anxiety, and insomnia. The nurse also plays a very important role as an educator of the patient’s family on the nature of pain and its management. Patients who undergo surgery can leave the hospital but pain, whether chronic or occasional, can recur. Especially for chronic pain, which can be a lifelong condition, management must continue beyond the postoperative stage. The nurse will be instrumental in teaching the patient and his family members on how to handle and manage this pain. Therefore, aside from administering primary care, advances in pain science and nursing research, has lifted nurse educator, researcher, counsellor and pain management specialist (Campbell, 2006). Conclusion An understanding of the physiology of pain leads to the development of effective pain management. The patient who has undergone surgery will experience pain, the severity of which is dependent on emotional, societal and biological factors. Pain has become a condition that needs to be treated separately from the medical conditions which it originated from. A pain management plan can be drawn up based on the assessment of the patient’s pain and history. The role of the nurse is to ensure that the assessment was performed correctly and that the pain management plan is followed. More than that, the nurse looks for other alternatives that can help in alleviating the pain that her patient feels. Advances in research and changes in policy have also expanded the role of the nurse from providing primary care to that of teacher, coordinator, and pain management specialist. The nurse has a bigger role in ensuring the welfare and health of her patients. In a deeper sense, by alleviating pain, the nurse has become a true healer. References American Society of Anesthesiologists Task Force on Acute Pain Management. (2004). Practice guidelines for acute pain management in the perioperative setting. Anesthesiology, 100, 1573-1581. Arnstein, P. (2002). Optimizing perioperative pain management. Retrieved April 10, 2009, from AORN Journal. FindArticles.com.: http://findarticles.com/p/articles/mi_m0FSL/is_5_76/ai_94538197/ Buttner, W., & Finke, W. (2000). Analysis of behavioural and physiological parameters for the assessment of postoperative analgesic demand in newborns, infants and young children: a comprehensive report on seven consecutive studies. Pediatric Anaesthesiology, 10 (3), 303-318. Campbell, C. (2006). The role of nursing in pain management. In M. Boswell, & B. Cole, Weiners Pain Management: A Practical Guide for Clinicians (7th ed., pp. 165-175). Boca Raton: Taylor and Francis Group, LLC. Encyclopaedia Britannica. (2009). ‘pain’. Retrieved April 12, 2009, from Encyclopædia Britannica Online : . Grandinetti, C., & Buck, M. (2000). Patient-controlled analgesia: guidelines for use in children. Pediatric Pharmacology , 6 (11). Jay, G. (2007). Chronic Pain. New York: Informa Healthcare Inc. Manias, E., Bucknall, T., & Botti, M. (2005). Nurses strategies for managing pain in the postoperative setting. Pain Management in Nursing , 2005 (6), 18-29. Melzack, R., & Wall, P. (1965). Pain mechanisms: a new theory. Science , 150, 971-979. Mersky, H. (1986). Classification of chronic pain: description of chronic pain syndromes and definitions. Pain , 16 (supplement), S1-S225. Nursing Fundamentals II. (2007). Retrieved March 30, 2009, from Medical Education Division, Brookside Associates, Ltd.: http://www.brooksidepress.org/Products/Nursing_Fundamentals_II/Index.htm Rodts, M. (2009). What is post-operative care? Retrieved March 30, 2009, from Spineuniverse.com: http://www.spineuniverse.com/ Wood, S. (2008, September 18). Anatomy and physiology of pain. Retrieved April 1, 2009, from NursingTimes.net: http://www.nursingtimes.net/nursing-practice-clinical-research/anatomy-and-physiology-of-pain/1860931.article Read More