Management of Chronic Pain in Relation to Holistic Nursing Practice - Research Paper Example

Assessment and management of chronic pain in relation to holistic nursing practice Introduction Chronic pain is a major health challenge affecting many people in the world. It is one of the most common reasons people seek medical attention. It is caused by different etiologies and in many conditions there may be no definite treatment (Farkas, 2005). Even in cases where successful treatment modalities are available, the need for adjuvant therapies may arise. Chronic pain not only cripples the individuals physically but also has negative effects on the social, emotional, spiritual, psychological and financial well-being of the individuals. It can critically affect the quality of life. Hence, management of chronic pain involves addressing of the human being 'in-total' and not just the 'part of body' which is causing pain (Farkas, 2005). Such an integrated approach is possible through understanding of holistic nursing. Holistic nursing may be defined as “all nursing practice that has healing the whole person as its goal” (AHNA, 1998). This form of nursing is a speciality practice which employs nursing theories, knowledge, intuition and expertise to guide nurses for proper therapeutic care of people. Holistic nursing. A holistic nurse is one who can be an instrument in healing and who can be a facilitator in the process of healing (AHNA, 1998). For this purpose the nurse may have to integrate complementary or alternative modalities of treatment into current clinical practice to meet the spiritual, physiological and psychological needs of the patient (Frisch, 2001). This essay will discuss chronic pain in the context of holistic nursing care. Various definitions of chronic pain, its causes and management will be dealt sequentially to enhance the understanding of a holistic nurse about chronic pain. Definition of chronic pain Pain is a symptom of injury or illness in the part of the body from where the pain arises. Pain may be defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (IASP, 1986; cited in NHS, 2006, p.3). When the onset of pain is sudden and lasts for a brief duration, it is called acute pain. When pain lasts more than 3 months, it is known as chronic pain (Farkas, 2005). Many authors prefer to use 6 months as the cut-off time for chronic pain (Farkas, 2005). Some suggest that any pain that is persisting longer than the expected healing time for the tissues involved should be considered as 'chronic' (Farkas, 2005). According to IASP (1986; cited in NHS, 2006, p.4), chronic pain is "pain without apparent biological value that has persisted beyond normal tissue healing time". Types of chronic pain Chronic pain may be briefly classified into general somatic pain and visceral pain. In the former, pain arises from the skin and muscles. Chronic back pain and fibromyalgia are good examples of this type of chronic pain. Visceral pain arises from internal organs and is difficult to localize. Chronic pain can also be caused by bone pain due to pathologies in the bone, muscle cramps and peripheral neuropathy. Pain due to peripheral neuropathy manifests as painful 'pins and needles' type of sensation, or 'sharp, stabbing sensation' or 'electric feeling'. This condition is seen in many conditions, the most common being diabetes mellitus. Pain due to cancer is chronic in the later stages requiring crucial pain relief management (Delphi Study, 2007). It is known as chronic malignant pain. Such a pain is seen in many other debilitating conditions like AIDS, multiple sclerosis, amyotrophic lateral sclerosis, end stage organ failure, advanced chronic obstructive pulmonary disease, parkinsonism and advanced congestive heart failure is known as chronic malignant pain (Delphi Study, 2007). In certain conditions like chronic tobacco abuse, autoimmune diseases, diabetes, fatty deposits in the arteries and reflex sympathetic dystrophy, poor circulation can cause chronic pain. Chronic pain can occur in burns too until the wounds heal completely (Delphi Study, 2007). Assessment of chronic pain Proper assessment of chronic pain is the cornerstone for effective management of the pain. This requires appropriate pain history, detailed physical examination and specific diagnostic tests (Bird, 2005). History should include onset, site, intensity, description and course of pain, its aggravating and relieving factors, treatments received so far and the affectation of pain on other aspects of life like sleep, employment, social activity, family life, economy, physical functions and sex life. Physical examination should include general physical examination, neurological examination, specific pain evaluation, examination of the musculoskeletal system and assessment of psychological factors (Manias et al, 2002). Some specific diagnostic tests may be necessary for proper evaluation, assessing general personality traits and dispositions, preliminary behavioural analysis, current levels of depression, anger and somatic concern, pain coping strategies, economic, occupational and social influences of pain, beliefs about pain and treatment outcome and spiritual aspects of pain (NHS, 2006). There are several different tools to assess pain. These include the Brief Pain Inventory, the McGill Pain Questionnaire, the Short-form McGill Pain Questionnaire, the Massachusetts General Hospital Pain Center's Pain Assessment Form, Neuropathic Pain Screening Tools, the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials or IMMPACT (Breivik et al, 2008), Mccaffery and Pasero Initial assessment Tool, No pain- Non-communicative Patient's Pain Assessment Instrument, Dolopus-2 Scale (NHS, 2006) (Refer Appendix). The diversity of assessment tools makes it difficult to compare results of analgesic management (SIGN, 2008). Which of these tools is the best for assessment of pain is a much debatable topic. The European Association of Palliative Care recommended visual analogue scales, numerical rating scales and verbal rating scales for assessment of pain, and these are useful even in those with cognitive impairment or very elderly (SIGN, 2008). According to SIGN (2008), McGill Pain Questionnaire and brief pain Inventory are much validated tools in different cultures and they also incorporate numerical rating scales and verbal rating scales. For those with severe cognitive impairment, PACSLAC or Pain Assessment Checklist for Seniors with Limited Ability to Communicate and DOLOPLUS2 are good scales to use (SIGN, 2008). As far as possible, self-assessment tools must be used wherever feasible. In those are unable to do this, observational scales are useful (SIGN, 2008). Also, assessment of pain must be frequently, atleast once a day until pain subsides (SIGN, 2008). Management of chronic pain 1. Pharmacotherapy There are many medicines available to treat chronic pain. The medicines must be prescribed as per the requirements of pain. The WHO's Pain Relief Ladder is a useful guide to prescribe medications for pain (WHO, 2009) (Refer Fig.2). This ladder consists of 3 steps of pain from below to up. The lowest is the step of mild pain. Mild pain is that pain which is self-limited and may or may not require treatment. The next step is the moderate pain. This pain is worse than mild pain and it affects functions of the individual. The presence of pain cannot be ignored. This pain goes away with treatment and seldom reappears. The uppermost step is that of severe pain. This pain interferes with most of the daily living activities. The individual may need treatment for many weeks, months or even years. According to this guide, the first drugs which must be recommended for pain are non-opioids like paracetamol and non-steroidal anti-inflammatory drugs or NSAIDs like aspirin and ibuprofen (Alkhenizan et al, 2004). Then if necessary, the treatment must be stepped up to mild opioids like codeine and then to strong opioids like morphine, hydrocodone, oxycodone, methadone, hydromorphone and fentanyl until the patient is relieved of pain. Generally, chronic pain is associated with anxiety and fears, adjuvants like anti-anxiety drugs may be given. Drugs given to relieve pain must be given every 3-6 hours, round the clock. According to the WHO, the 'ladder approach' treatment allows a patient to get the right drug with the right dose at the right time in the most effective manner and at the least possible cost (WHO, 2009). This ladder has been declared useful even by SIGN (SIGN, 2008) . Figure-2: Analgesic ladder (WHO, 2009). Paracetamol and NSAIDs are efficient in relieving pain due to muscle aches and stiffness. Topical forms of these medicines can be used for arthritis and sore muscles. Bone pains may need to be treated with NSAIDS, opiods, bisphonates like alendronate or with hormonal therapy (Farkas, 2005). Muscle relaxants like cyclobenzaprine or baclofen are useful to treat muscle spasms. "Pins and needles" type of nerve pain is usually treated with tricyclic antidepressants. Anticonvulsants are used to treat stabbing peripheral neuropathy and trigeminal neuralgia. Phantom limp pain can be managed with clonidine. For nerve pains associated with shingles, local application of capsaicin is useful. Pain due to poor circulation may be corrected by blood thinners or opioids. Sinusitis will need treatment with antibiotics (Farkas, 2005). Non-opioid anagesics The dose of acetaminophen for relief of pain is 650mg- 1000mg every 6 hours. It rarely causes side effects. Aspirin is given at doses of 500 mg 3-4 times a day. It can cause gastritis and gastrointestinal bleeding. For those who cannot tolerate aspirin, acetaminophen is a good substitute. The most commonly used NSAID is Ibuprofen. It acts by decreasing prostaglandin synthesis. It can be given at doses 400-800 mg every 8 hours. Naproxen sodium is another NSAID useful in mild- moderate pain. It acts by decreasing cyclooxygenase activity which further reduces prostaglandin synthesis. The dosage can be either 275 mg 3 times a day or 550mg 2 times a day (Mann and Carr, 2006). Opioid analgesics Mild opioid analgesics are codeine and its derivatives. Strong opioids are morphine, hydrocodone, oxycodone, methadone, hydromorphone and fentanyl. Oxycodone is long-acting. It can be given at the doses 10- 160 mg orally every 12 hours. Initially, the lowest possible dose must be started with and then gradually increased. Fentanyl can be used for short-relief of pain. The dose in chronic pain is 25-100 mcg/h transdermally every 72 hours. Adjuvants to pain medications Anticonvulsants like gabapentin and pregabalin are useful in neuropathic pain (Rowbotham et al, 1998). Other anti-convulsants which may be useful are topiramate, lamotrigine, tiagabine, zonisamide and clonazepam (Poole, 2008). Certain anti-depressants like amytriptyline, nortriptyline and fluoxetine are useful adjuncts in chronic pain management. 3. Surgical Implants This form of therapy may be an option in cases which have failed to respond to medical and physical therapy. 1. Intrathecal drug delivery: Small pocket is made under the skin by the surgeon. In this pocket an infusion pump is placed which will deliver pain-relieving drug into the intrathecal space by means of a catheter (Mitten, 2001). By this method, the drug is delivered directly into the spinal cord and cause relief from pain. Since this mode of delivery of drugs needs lesser dosage of medication, there are fewer side effects (Brown et al, 2007). 2. Spinal Cord Stimulation Implants: This form of therapy employs low-level electrical signals to block specific nerves in the spinal cord so that pain signals are not transmitted to the brain. Electric signals are delivered by a surgically-implanted device in the body. This device can be operated by the patient through a remote control. This form of treatment is useful to treat certain neuropathic conditions like arachnoiditis, neuropathies, radiculopathies, phantom limb pain, deafferentation syndromes, postherpetic neuralgia, brachial and lumbosacral plexopathies and complex regional pain syndrome. neurostimulation is also useful to treat angina and periphral vascular disease (Kim, 2004). 4. Nerve Blocks Injection of local anesthetics into nerves or their plexus with or without steroids can decrease pain for some time. For headaches, greater occipital nerve can be blocked and in chest wall pain, intercostal nerve can be blocked to relieve pain. The medications can be injected into the joints too. For back pain, facet joints are the site of injections. In osteoarthritis, intra articular hip injections are done (Godfrey, 2005). Regional blocks using epidural steroid injections are done for leg pain due to radicular referred pain. Sympathetic block at stellate ganglion is done for angina and at celiac plexus is done for abdominal pain in pancreatic malignancy (Callin and Bennett, 2008). Neuroma or scar infiltration is done to relieve post-operative or post trauma pain (Kim, 2004). 5. Non-pharmacological approaches to chronic pain management Regular exercise improves muscle tone, flexibility and strength and thus can diminish pain in the long run. Exercise is said to act by causing release endorphins which are natural pain killers of the body. Some of the useful forms of exercises are yoga, walking and swimming (Brenman, 2007). Exercise is useful only in certain types of pain like tension head ache and chronic backache. It is of no use in chronic pain due cancer and other pathological conditions. Other than exercise, there are many alternative therapies that have come up for the treatment of chronic pain though there is not much evidence to support these forms of treatment, the therapies claim to alleviate pain. Mind-Body therapies are the most common non-pharmacological approaches to chronic pain. These therapies adopt the mind's ability to take over the symptoms of the body. Some of the therapies which fit into this category are meditation, relaxation techniques, biofeedback, guided imagery, visualization and hypnosis. In visualization, the patient is asked to close his/her eyes and makeup a visual image of pain by creating a shape and size and adding colour and motion to it. Then, this image is gradually replaced with a much more pleasant image and of smaller size. In electromyographic feedback, there is information about muscle tension in the body, so that the patient learns to control the muscle tension, thus alleviating pain. Self hypnosis and hypnotherapy decrease pain by blocking pain by means of refocusing strategies. Meditation and yoga are relaxation techniques and they are more useful in stress-related pain. Yoga also gently strengthens the muscles of the body (Brenman, 2007). Various studies have demonstrated the role of chondroitin sulfate and glucosamine sulphate in relieving pain due to knee osteoarthritis. These are well tolerated natural compounds. Other natural foods with pain reducing features are fish oils (Brenman, 2007). Weight reduction through diet management might be useful to relieve arthritis pain in those suffering from obesity. Research has shown that raw vegetarian diet can help decrease pain in fibromyalgia (Brenman, 2007). Acupressure and acupuncture are another category of therapies which claim to treat chronic pain, especially chronic back pain. None of these non-pharmacological methods of treatment have scientific basis and evidence and hence proper judgement must be used when recommending them. Role of nurses in chronic pain Nurses are essential in the diagnoses and treatment of pain in all types of settings of health care. Since they are closest to the patients, they are in a position to provide constant personal, emotional and spiritual support. They also have an important role in the assessment and monitoring of management of chronic pain. Nurses can be the first persons to evaluate pain and then can advise the treating physician whether the pain remedy advocated was appropriate. Nurses can also evaluate the effects of the medications prescribed after the patient uses the medicines. Nurses must be aware of the WHO ladder for chronic pain management. They must also be aware of drug-drug interactions, drug side effects and drug-diet interactions (Shaw, 2006). When a patient reports side effects, the nurse must record, manage and monitor the symptoms, guide physician about the condition of the patient and can suggest when to change the step in the analgesic ladder. Nurses have an important role in acting as coordinators of different specialities by educate the patients about the dosage of the drugs and about the need for good pain control (Delphi Study, 2007). This is not answering the question Holistic nursing care in relation to chronic care 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. Holistic care is crucial for the management of many chronic pains because the pain affects not only the physical well-being of the person, but also the cognitive and emotional aspects. The functioning of the individual, his or her social and family life and ability to work at employment (Breivik et al, 2008) can also be affected. Those suffering from chronic pain need a different type of medical attention which cannot be delivered in acute care settings (Mathews, 2002; qtd. in NHS, 2006). Figure.1. Biopsychosocial model for pain (Waddell et al, 1993; qtd. in NHS, 2006) 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). Conclusion Chronic pain is a very common condition demanding medical attention. It affects all aspects of the human-being including physical, emotional, social, spiritual, financial, cultural and psychological domains. The aetiology of chronic pain is diverse and proper assessment is crucial for appropriate management. There are many assessment tools. Most of the times, it is better to use the tools as per hospital policy. In case of no such restrictions, self-assessment tools are the best when cognitive functions are intact. In individuals in whom this is not possible, observational tools may be used. Holistic approach is the most appropriate management for chronic pain, because this problem affects the whole body and concentrating on only the physical aspects of pain cannot provide wholesome treatment. Nurses play an important role in providing holistic care due to their proximity with patients. Nurses are in a position to evaluate response to treatment and thus can provide useful information for further improvements in treatment. While pharmacotherapy is the mainstay of treatment in most chronic pain conditions, certain non-pharmacological methods may be useful in a small portion of people either as main therapy or adjunct therapy. Nurses can identify such suitable candidates and help in proper management of the patient. 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. My perception and attitude on people suffering chronic pain has been positively changed and influenced. References Alkhenizan, A. Librach, L. & Beyene, J. (2004) NSAID’s: are they effective in treating cancer pain? European Journal of Palliative care, 11(1), 5-8. American Holistic Nurses Association or AHNA. (1998). Holistic Nursing. Retrieved on 22nd April, 2009 from http://www.ahna.org/AboutUs/WhatisHolisticNursing/tabid/1165/Default.aspx Bird, J. (2005). Assessing Pain in Older People. Nursing Standard, 19 (19), 45-52. Brenman, E.K. (2007). Pain Management Guide. WebMD. Retrieved on 22nd April, 2009 from http://www.webmd.com/pain-management/guide/cause-treatments Brown, D., O’Neill, O., & Beck, A. (2007). Post op pain management: transition from epidural to oral analgesia. Nursing Standard, 21 (21), 35-40. Callin,S. & Bennett, M.I. (2008). Diagnosis and management of neuropathic pain in palliative care. International journal of palliative nursing, 14 (1), 16-21. Delphi Study. (2007). WHO Normative Guidelines on Pain Management. Retrieved on 22nd April, 2009 from http://72.14.235.132/search?q=cache:XaoHa1yWUgkJ:www.who.int/medicines/areas/quality_safety/delphi_study_pain_guidelines.pdf+Delphi+Study.+(2007).+WHO+Normative+Guidelines+on+Pain+Management&cd=1&hl=en&ct=clnk&gl=in Farkas, H. (2005). Chronic Pain. EmedicineHealth. Retrieved on 22nd April, 2009 from http://www.emedicinehealth.com/chronic_pain/article_em.htm Frisch, N. C. (2001). Standards for Holistic Nursing Practice: A Way to Think About Our Care That Includes Complementary and Alternative Modalities. Online Journal of Issues in Nursing, 6 (2). Godfrey, H., (2005). Understanding pain, part 2: pain management British Journal of Nursing, 14(17), 904-909. Hamilton, P., & Price, T., (2007). 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WHO's pain ladder. retrieved on 24th April, 2009 from http://www.who.int/cancer/palliative/painladder/en/print.html Appendix (Source: NHS, 2007) Read More