Effective Relief of Pain for Surgical Patients - Essay Example

INTRODUCTION When something is wrong with a person’s health or body pain is usually the manifestation of such abnormality. Pain usually occurs when a person is in the advanced illness, or is suffering from any acute or chronic conditions. However, despite having effective treatments and the continuing search for therapeutic approaches pain is mostly assessed poorly. It is the major role and responsibility of nurses to make proper assessment of pain and give appropriate management specifically before, during, and after a patient’s operation. Hence, it is important that nurses should know the mechanisms of pain, its epidemiology, and the different barriers to effective pain control, patients’ perception and how they respond to pain, and the different methods available to alleviate pain. It is the objective of this paper to expound on the physiology of pain and the effect of different pain management strategies in relation to pain physiology. This paper will also discuss the effective pain management in children and adult, and how to achieve effective pain management. PHYSIOLOGY OF PAIN The sense organs for pain are the naked nerve endings found in almost every tissue of the body. Pain impulses are transmitted to the central nervous system by two fiber systems. One system is made up of small myelinated A delta fibers and the other consists of unmyelinated C fibers. The latter fibers are found in the lateral division of the dorsal roots and are often called dorsal root C fibers. Both fiber groups end in the dorsal horn; the former terminate primarily on neurons in laminas I and V, whereas the dorsal root C fibers terminate on neurons in laminas I and II. Some of the axons of the dorsal horn neurons end in the spinal cord and brain stem. Others enter the anterolateral system, including the lateral spino-thalamic tract. Some of the anterolateral system neurons project to the specific sensory relay nuclei of the thalamus and from there to the postcentral gyrus. However, many end in the reticular system, which projects to the midline and intralaminar nonspecific projection nuclei of the thalamus and from there to many different parts of the cortex. Other anterolateral neurons end in the periaqueductal gray, an area known to be concerned with pain. The synaptic transmitter secreted by the primary afferent fibers subserving pain sensation is substance P. The presence of two pain pathways gives rise to two kinds of pain: 1. Fast or first pain is characterized by a bright, sharp, localized sensation due to activity in the A delta pain fibers (Ganong, W.F, 1989). The receptors for this first pain are high threshold mechanoreceptors (anaesthetist.com). 2. Slow or second pain is described as dull, intense, diffuse, and unpleasant feeling due to the activity in the C pain fibers (Ganong, W.F, 1989). It is poorly localized due to stimulation of receptors that exist in many tissues but not in the brain (anaesthetist.com). Polymodal nociceptors are the receptors for this kind of pain. Pain receptors are specific, and pain is not produced by overstimulation of other receptors. The adequate stimulus for pain receptors is not as specific as that for others, because they can be stimulated by a variety of strong stimuli. Pain receptors also respond to electrical, mechanical, and, especially, chemical energy. PAIN MANAGEMENT AND ITS EFFECT It is very important to make proper assessment of post operative patient as a whole in order to manage and provide treatment for pain effectively. Since there are several parts of the body or organs that need to be operated different mechanisms of pain arise as there are different pain pathways, and good assessment of the kind of pain a patient is suffering will help clinicians in giving appropriate management. Assessment of pain is in two parts: before operation to make a pain management plan and after operation to see whether the plan is working (Charlton, E., 1997). The preoperative assessment includes clinical factors, patient-related factors, local factors, as well as variables such as age, sex, weight, degree of obesity, current drug intake or past history of drug-related problems (Charlton, E., 1997). However, problems may occur in making the assessment related to age and relief of pain in children and elderly. The second part of the assessment occurs in the postoperative stage. It may be difficult to make an assessment at the early post-operative period so it is necessary that assessment must be made at regular intervals and should form part of the routine post-operative observations; the progress of the patient is more easily assessed if results are charted in graphical form rather than as a number (Charlton, E., 1997). The most common method used in assessing pain is the rating scales which in practice are either in words or numbers. A visual analogue scales can also be given numerical value. An example of words is choices ranging from no pain, mild, moderate, severe, excruciating. A numerical value can be assigned to these words ranging from 0-4 for easy recording purposes. These method is not favorable to infants or patients who cannot or having difficulty in communicating. Hence, assessment is made using varied picture scales by clinical or facial observations. An example of which is groaning, sighing, sweating, and ability to move. Some patients are assessed using their vital signs such as blood pressure and heart rate. For children under 3 years of age who are in pain from surgery or trauma a preverbal patient pain scale such as FLACC is used as an effective pain assessment tool. FLACC quantify pain behaviours by observing the Facial expression, Leg movement, Activity, Cry, and Consolability (Manworren, R. & Hynan, L., 2003). However, no single objective assessment strategy, such as interpretation of behaviors, pathology, or estimates by pain of others, is sufficient by itself (Herr, K. et.al, 2006). In the journal published by the American Society for Pain Management (Herr, K. et.al, 2006) here are some of the recommended considerations for prompt recognition and treatment of pain: 1. Use the Hierarchy of Pain Assessment Techniques (McCaffery & Pasero, 1999): a. Self-Report. b. Search for potential causes of pain. c. Observe patient behaviours. d. Surrogate reporting (family members, parents, caregivers) of pain and behavior/ activity changes. e. Attempt an analgesic trial. 2. Establish a procedure for pain assessment. 3. Use behavioural pain assessment tools, as appropriate. 4. Minimize emphasis on physiologic indicators. 5. Reassess and document. In 1986 the World Health organization (WHO) developed a 3-step conceptual model to guide the management of cancer pain, however today, there is a worldwide concensus favoring its use for the medical management of all pain associated serious illness (EPEC Project, 1999). Module 4 of the EPEC Project (1999) further elaborates the three stages of pain management as follows: Step 1 of the conceptual model consists of using non-opioid analgesics that include acetaminophen, and non-steroidal anti-inflammatory drugs (NSAIDs, including aspirin) for mild pain. Acetaminophen does not have significant anti-inflammatory effects and is presumed to have a central mechanism. NSAIDs and aspirin are effective step 1 analgesics and good for bone and inflammatory pain. The mechanism of action is by inhibition of prostaglandin synthesis by the enzyme cyclo-oxygenase which catalyses the conversion of arachidonic acid to the various prostaglandins that are the chief mediators of inflammation (Charlton, E, 1997). WHO steps 2 and 3 involve opioid use for moderate and severe pain such as codeine, hydrocodone, hydromorphone, morphine, oxycodone, and others. These types of analgesics may be administered orally including enteral feeding tube, rectal administration, subcutaneous, intramuscular, and intravenous injections. Understanding the correct drug, route of administration, and mode of action provides appropriate treatment. Generally, intramuscular injection gives effective analgesia despite some drawbacks because of its painful administration and the amount of dose may have side effects if it’s too large or have no pain relief if it’s too small. However, some opioids are effective when taken orally and suitable for patients recovering from surgery. Possibly the best pain control is achieve within 24 hours but if pain does not subside the dosage may be increased. In the preoperative stage it is part of an effective pain management to provide patient with near perfect pain relief while surgery is underway and importantly in the postoperative stage. Administering regional or local anesthetic techniques provides effective relief. It is done by direct injection of local analgesic drugs close to peripheral nerves, major nerve trunks or nerve roots produces analgesia by blocking conduction of afferent impulses (Thompson, C, 2008). Neural blockade with neuraxial administration of local anaesthetics and/ or opioids has now been established as being effective means of postoperative pain treatment (Thompson, C, 2008). Spinal anaesthesia provides excellent analgesia for surgery in the lower half of the body and pain relief can last many hours after completion of the operation if long-acting drugs containing vasoconstrictors are used (Charlton, E., 1997). Notwithstanding the best relief that spinal anaesthesia provides epidural analgesia is widely used. The administration of the epidural technique in postoperative management requires excellent practitioners and trained nursing staff and sterility must be maintained. Epidural catheters can be placed in either the cervical, thoracic or lumbar regions but lumbar epidural blockade is the most commonly used (Charlton, E., 1997). The emergence of patient controlled analgesia (PCA) delivery has improved the postoperative pain management this is due to the realization that opioid requirement varies individually. This system allows patient to personally administer analgesia according to their end-point of relief with the use of a controlled pump. The optimal PCA system would encompass several key characteristics, including: consistent efficacy across a number of surgeries, safety of both the analgesic drug delivered and the delivery system, ease of set-up, maintenance, and administration, patient comfort during analgesic delivery, avoidance of analgesic gaps, minimal invasiveness, and it would be associated with high patient satisfaction (Viscusi, ER, 2008). Aside from pharmacological analgesics or opioids there is also a surgical management for different types of pain specific for different pain pathways. Categorically it includes section of peripheral nerve pathway, section of central nervous system pathway, procedures to alter affective response to pain, section of efferent arc of vasomotor reflex, suppression by nonablative techniques. ISSUE OF EFFECTIVE PAIN MANAGEMENT IN ADULTS AND CHILDREN Self-report is one mode of assessing pain in children where they can report the feeling and intensity of pain. However, toddlers or children who have cognitive disability cannot respond verbally. Developmentally appropriate children as young as 3 years of age may be able to quantify pain using simple validated pain scales (Fanurik et.al., 1998; Spagrud et.al., 2003). Another mode of pain assessment in non-verbal children is to look for potential causes of pain especially when they undergo surgery it shall be suspected that there is pain. The use of FLACC for assessing pain in children and measuring body changes like increase in heart rate, breathing, paleness or sweating helps determine the appropriate pain management techniques. The gravity of using this kind of assessment tool depends on the child’s age and capacity (Manworren, R. & Hynan, L., 1995). Furthermore, infants and children generally recover faster than adults from anaesthesia and surgery, thus, immediate postoperative care is as critical as the intraoperative care and the child should be taken to a recovery area with a trained staff and any problem should be monitored closely (Rusy, L. & Usaleva, E., 1998). In aging or adult patients particularly those suffering from dementia self-report for pain is impossible as the disability progresses but it does not follow that they cannot feel pain. Observing their behavior and physiological changes as well help in identifying effective pain management. Arthritis is a common source of pain in older patients and it is considered as comorbid condition which must be included in pain management (McDonald, D., 2006). It is an important preoperative preparation in ageing patient to have pain management education to lessen the effect of postoperative pain. It is also necessary that they know how to use the scaling tool in order to have specific assessment of pain. Generally, order adults have a higher peak and longer duration of action from opioids hence, routine pain assessment of every two to four hours is advantageous to prevent under treatment of pain and side effects (Mc Donald, D., 2006). One drawback for obtaining correct pain assessment in adults is that they tend to have greater pain threshold and are satisfied with their pain management even if they are suffering from moderate or greater pain. Older adults also have other words in describing their pain and they have difficulty in ranging their pain in the visual analog scale. CONCLUSION Effective relief of pain for surgical patients is of paramount importance not only for facilitating early discharge from the hospital but for humanitarian reasons as well. Its effectiveness has physiological benefits and reduces the risk for chronic pain syndrome. Subjective assessment of pain should not be relied upon as there are various methods of making accurate assessment. Appropriate assessment tool must be used taking into consideration the area of pain, age, sex, ability to respond verbally, and other underlying conditions among others. The burden of having an effective pain management is upon the skills of the nurses to make proper pain assessment. References: Charlton, E, 1997, ‘The Management of Postoperative Pain’, World Anaesthesia Online, Issue 7. EPEC Project, 1999, Module 4: Pain Management, The Robert Wood Johnson Foundation, viewed 7 April 2009, http://www.epec.net/EPEC/Media/ph/module4.pdf Ganong, W. F, 1989, Review of Medical Physiology, 14th Ed., Appleton & Lange, Connecticut, USA. Herr, K et.al, 2006, ‘Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations’, American Society for Pain Management Nursing. Vol. 7, No. 2, p. 45. Manworren, R.C.B & Hynan, L.S, 2003, ‘Clinical Validation of FLACC: Preverbal Patient Pain Scale’, Pediatric Nursing, Vol. 2, pp. 140-146. McDonald, D.D, 2006, Postoperative Pain Management for the Aging Patient, Geriatrics and Aging, Vol. 9(6), pp. 395-398. Pain Physiology 2006, viewed 7 April 2009, http://www.anaesthetist.com/icu/pain/Findex.htm#pain_how.htm Rusy, L & Usaleva, E, 1998, ‘Paediatric Anaesthesia Review’, World Anaesthesia Online, Issue 8. Thompson, C, 2008, ‘Post-Operative Pain’, The Virtual Anaesthesia Textbook, viewed 7 April 2009, http://www.virtual-anaesthesia-textbook.com/vat/pain.html#management Viscusi, ER, 2008, ‘Patient-controlled Drug Delivery for Acute Postoperative Pain Management: A Review of Current and Emerging Technologies’, Regional Anesthesia and Pain Management, Vol. 33(2), pp. 146-58. Read More