Coping with Pain: a Dauting Endeavor Post-Operatively - Essay Example

COPING WITH PAIN: A DAUNTING ENDEAVOR POST-OPERATIVELY Pain is an integral part of life. Everyone experiences it at various times throughout their lifetime; indeed, pain is the most common reason for an individual to seek medical advice. Yet despite its prevalence, it remains difficult to define. One common definition states that pain is whatever the experiencing person says it is, existing when he says it does. Pain is not only an unpleasant or uncomfortable sensation that occurs as a result of injury, strain or disease, it can also be an emotional experience unrelated to tissue damage. For example, pain is a term used to describe feelings relating to loss, grief and even unrequited love. Pain is also an individual and personal experience. The way someone expresses and deals with their pain will be determined by their culture, life experiences and personality (Nair 2009). Pain is an extremely unlikeable and exceptionally delicate feeling which cannot be conveyed with other individuals. It can dwell in a person’s psyche, command every action, and transform someone’s being. In spite of this, pain is an arduous view for a client to impart. A nurse is incapable of neither experiencing nor perceiving a patient’s pain. The study undertaken is aimed to explore and present the physiology and nature of and the different methods of coping with pain. Physiology of Pain The Gate Control Theory of pain proposes that pain impulses must pass through a theoretical gate at the dorsal horn of the spinal cord before ascending towards the brain (Nair 2009). Pain messages from the A-delta and C fibres will push open the gate; however, the A-beta fibres and the descending pain pathway will push the gate closed (Nair 2009). The intensity of an individual’s pain, therefore is determined by a balance between noxious stimuli and A-beta fibre or descending brain activity; the wider the gate is open the more intense the pain, however, if the gate closes the pain ceases (Nair 2009). Nature of Pain Even though pain is a collective and unanimous experience, its precise nature lingers to be an ambiguity. It is recognized that pain is vastly prejudiced and personal and that it is one of the body’s defense mechanisms that implies a problem (Kozier et al 2004). Hargrove-Huttel (2005) stressed that pain exists wherever and whenever a client says it does. In addition, it may sometimes broaden to encompass emotional hurt. Pain is also a valuable diagnostic indicator; it usually indicates tissue damage or pathology (Hargrove-Huttel 2005). Basic to the said definitions is the care provider’s willingness to believe that the client is experiencing pain and that the client is the real authority on that pain (Kozier et al 2004). Every individual suffer pain in a unique way. Moreover, the disparities in individual pain discernment and response, as well as the many origins and etiology of pain, give the nurse a complicated post when elaborating a plan to alleviate pain and provide ease and relief. Effective and efficient pain management is a vital component of nursing care. Pain is more than an indicator of a predicament; it is a pressing dilemma in itself. Pain raises both physiologic and psychological perils to wellbeing and healing. Grave pain is deemed as an urgent crisis warranting full concentration and immediate action. Pain is a common experience post-operatively and due to its subjective character; it necessitates understanding and utmost care from the nurses especially when dealing with level 2 patients or those patients entailing high dependency care. The said patients do not require admission in an Intensive Care Unit (ICU); however, careful monitoring is required from the nurses for several hours. An example of this is Patient X who is a 65-year old patient who was handled by the author with bowel obstruction experiencing severe pain and needs to undergo an immediate bowel resection procedure, considering his age as a high risk factor compelled that post-operatively, this client be monitored in a High Dependency Unit (HDU). Few hours after bowel surgery, the said patient was brought to the HDU for careful monitoring and as the effect of the anaesthesia fade away; the client begins to experience post-operative pain. Hence, the client warranted regular monitoring of vital signs wherein, pain is considered as the fifth vital sign by Kozier et al (2004) and initiation of nonpharmacologic measures first then pharmacologic measures to be able to provide pain relief. The Function of Adrenaline in Pain and its Effect on the Respiratory System Pain triggers the release of adrenaline because pain is a stress to the human body, and all stresses raise adrenaline levels. Adrenaline aids in controlling the severity of pain. However, chronic pain could result to adrenaline burnout and this can cause more pain (Schwarzbein 2002). Adrenaline shows a strong bronchodilating influence on the respiratory system resulting in dilation of trachea and the bronchi and during stressful events like pain, due to its effect, the tidal volume of the lungs is boosted (Gupta 2009). Phases of Pain Experienced by Patient Hargrove-Huttel (2005) enumerated three phases of the pain experience. The first stage is the “anticipation of pain” which may produce fear and anxiety that could affect a person’s response to sensation and naturally exaggerate the perception of pain. The client handled previously who had a bowel surgery traumatized by pain felt preoperatively due to bowel obstruction predicted that his post-operative pain will be more intense compared to what he had suffered. The second phase of the pain experience according to Hargrove-Huttel (2005) is the “sensation of pain” which is often influenced by how anticipation was controlled; pain elevates anxiety which in turn amplifies pain. Hence, with the case encountered, for the reason that the client perceived that post-operatively his pain will be more grave and severe; comfort measures did not promote relief at all. The last stage is the “aftermath of pain” which according to Hargrove-Huttel (2005) is the most neglected phase. The patient’s reaction to the pain experience may reveal apprehension, mortification or remorse, all of which can shape imminent experiences with pain like the reaction of the client as he compared his pain preoperatively and post-operatively. Duration of Pain Experienced by Patient Pain may be described in terms of duration, location and etiology (Kozier et al 2004). When pain persists merely through the usual recuperation phase, it is described as acute pain. Hargrove-Huttel (2005) adds that this type of pain is distinguished by rapid onset, usually temporary, lasting no more than 6 months and subsiding spontaneously, with or without treatment. Kozier et al (2004) listed the usual characteristics of acute pain such as there is increased pulse rate (tachycardia), increased respiratory rate (tachypnea), elevated blood pressure (hypertension), diaphoresis, and dilated pupils upon eye examination. Furthermore, this type is often associated with tissue injury and is usually resolved with healing. The client commonly appears restless and anxious; reports pain or exhibits behaviour suggestive of pain: crying, rubbing the supposed pain site or holding the area where there is pain. With the case encountered, the client who had a bowel surgery exhibited symptoms of acute pain post-operatively. Few hours, after surgery, the said client is in a dorsal recumbent (supine) position and woke up anxious with excessive perspiration noted. He attempted to draw up his legs however; he is unsuccessful due to pain felt in the abdominal area. He was reluctant to report the pain he felt. However, when he can no longer endure it, he called the attention of the nurse immediately. He rated his pain as 9 in a pain scale of 1-10. His pulse rate was 108 beats per minute accompanied by a respiratory rate of 24 breaths per minute with a blood pressure of 158/92 mmHg; upon physical examination, the client’s skin is pale and moist, his pupils were dilated, and his midline abdominal incision showed that the sutures were dry and intact. The client reports pain and guarding behaviour is evident. On the other hand, pain which is prolonged, usually recurring or persisting over 6 months or longer and interferes with functioning is termed as chronic pain (Kozier et al 2004). The client felt this pain preoperatively for he had been ignoring the abdominal pain he feels for almost 7 months until he can no longer endure the pain anymore hence, he opted for hospital admission. Moreover, this type of pain is also marked by an absence of a useful purpose and denotes a potential for becoming a major complication as emphasized by Hargrove-Huttel (2005), like with our client, for almost 7 months, he ignored the abdominal pain he feels thinking it was just caused by flatus (gas/air in the intestines), unfortunately, the pain felt intensified as months passed by and later on discovered that it was due to bowel obstruction. Furthermore, this kind of pain is characterized by normal vital signs, dry, warm skin and normal or dilated pupils as given emphasis by Kozier et al (2004). Likewise, this kind of pain continues beyond healing; the client usually appears depressed and withdrawn. The client regularly does not mention pain unless asked and in comparison to acute pain, pain behaviour is frequently absent. Kozier et al (2004) cited that this pain category can further be classified as chronic malignant pain, when associated with cancer or life-threatening conditions or as chronic non-malignant pain when the etiology is a nonprogressive disorder. Types of Pain Pain can be characterized according to its origin as cutaneous, deep somatic or visceral (Kozier et al 2004). Cutaneous or superficial pain as coined by Hargrove-Huttel (2005) stems from the skin or the subcutaneous tissue. It involves a hasty onset with intense, vicious quality. A paper cut causing a sharp pain with some burning is an example of cutaneous pain (Kozier et al 2004). On the contrary, deep somatic pain as described by Kozier et al (2004) arises from the ligaments, tendons, bones, blood vessels and nerves. According to Hargrove-Huttel (2005), this pain is manifested by somatic pain from organs in any body cavity. Moreover, it has a slower onset marked by burning quality with diffusion and radiation and at times, with the probability of having nausea and vomiting. It is diffuse and tends to last longer than cutaneous pain; an example of this is ankle pain (Kozier et al 2004). Visceral pain results from stimulation of pain receptors in the abdominal cavity, cranium and thorax. Visceral pain also verges to appear diffuse and regularly feel like deep somatic pain, that is, burning, aching or a feeling of pressure (Kozier et al 2004). In addition, it is habitually caused by stretching of the tissues, ischemia or muscle spasms. For instance, an obstructed bowel will result in visceral pain (Kozier et al 2004) like with the client handled in the High-dependency Unit (HDU) who undergone bowel resection. Pain may also be depicted as to where it is experienced in the body. Radiating pain is identified at the source and emits to the tissues in close proximity (Kozier et al 2004). For instance, cardiac pain may be felt not only in the chest but also along the left shoulder and down the arm. Hargrove-Huttel (2005) tackled another type of pain which is referred pain; it is pain originating at one site that is perceived in another. Moreover, it follows dermatome and nerve root patterns. For example, pain from one part of the abdominal viscera may be perceived in an area of the skin remote from the organ causing the pain. Kozier et al (2004) mentioned other types of pain. Intractable pain is pain that is extremely resilient to relief. An example of this is the pain from an advanced malignancy. When caring for a client experiencing intractable pain, nurses are challenged to use a number of methods, pharmacologic and nonpharmacologic, to provide the client with pain relief. In the case with Patient X, utilization of nonpharmacologic measures was done before the pharmacologic interventions, which will be discussed further in this paper. To fully understand pain, Kozier et al (2004) added two more categories of pain. Neuropathic pain is the result of recent or past injury to the peripheral or central nervous system and may not have a stimulus, such as tissue or nerve damage, for the pain. This pain is long-lasting, unpleasant and can be portrayed as burning, dull and aching. In addition, episodes of intense, shooting pain may also be felt. Another pain type is phantom pain, which is a painful sensation perceived in a body part that is missing like an amputated leg (Kozier et al 2004). This can be differentiated from phantom sensation according to Kozier et al (2004), which is, the feeling that the absent body part is still there. This type of pain may also be present in a client who had undergone mastectomy according to Hargrove-Huttel (2005). Kozier et al (2004) stressed that the incidence of this type of pain can be decreased when analgesics are administered via epidural catheter prior to the operation (e.g. amputation). Tools for Measuring Pain Measuring pain is an essential element of many clinical trials assessing surgical interventions as emphasized by Souba and Wilmore (2001). The frequently utilized instruments assess pain in a one-dimensional or global sense, these tools are very simple and short although they generally involve of a single question and responses are captured in several diverse but related ways (Souba & Wilmore 2001). The Verbal Rating Scales ask patients to grade their current pain on an ordinal scale, e.g. 0= no pain, 1= some pain, 2= considerable pain, 3= pain that could not be more severe; conversely, with the Numerical Rating Scale and Box Scale, patients are asked to indicate a number between 0 and 10 that best represents their pain, where 0 represents no pain and 10 represents the worst pain ever experienced (Souba & Wilmore 2001). On the contrary, the Visual Analogue Scale or VAS is a modification of the general approach where patients make a mark on a continuous 10-cm line with no pain on one end and worst pain on the other; among the mentioned global pain assessment means, the VAS is most widely used (Souba & Wilmore 2001). Other available instruments measure pain in diverse dimensions such as the McGill Pain Questionnaire or MPQ that assesses pain in three dimensions: sensor, affective and evaluative (Souba & Wilmore 2001). In this written evaluation, patients are presented twenty sets of word descriptors, each containing up to six words per set wherein one word is chosen from sets pertaining to sensory like sharp, cutting, lacerating; affective such as fearful, frightful, terrifying; and evaluative like annoying, troublesome, miserable, intense, unbearable dimensions then scoring is based on the words chosen (Souba & Wilmore 2001). The Present Pain Intensity Scale is included as part of the MPQ and is a global assessment of pain according to Souba and Wilmore (2001). Similar survey instruments include the Brief Pain Inventory Scales; even though these instruments provide more comprehensive data than global pain assessments, they take longer to complete approximately 10-15 minutes; thus, these instruments are probably best reserved for research protocols in which pain is a primary outcome measure (Souba & Wilmore 2001). Analysis of Personal Evidence-based Experiences The main categories and types of pain are the main basis for distinguishing what the patient is suffering. Personally the knowledge of the different types of pain had helped in distinguishing the pain Patient X who was handled by the author, is experiencing at that time, specifically through a clear picture and in-depth knowledge of the different types of pain. When an individual feels pain from an injured tissue, the pain threshold is reached. A person’s pain threshold as defined by Kozier et al (2004) is the amount of pain stimulation an individual requires in order to sense pain. Another common concept of pain cited by Kozier et al (2004) is pain tolerance which is the maximum amount and duration of pain that an individual is willing to endure. Some patients are incapable to bear even the least amount of pain, while others are ready to tolerate severe pain preferably than being cured for it. Consequently, pain tolerance diverges significantly among people and is extensively predisposed by psychological and sociocultural aspects. Patient X post-operatively experienced difficulty of breathing caused by intense abdominal pain he suffered, at first, his complaints of pain was not immediately addressed by the nurse on duty; as a consequence, he tried to get the nurse’s attention further aggravating his pain due to sudden movement post-operatively; thus, he suffered respiratory distress at that time. Kozier et al (2004) pointed out that nurses must understand that patients have their own attitudes and expectations regarding pain. As nurses, the client’s values and belief may also be given consideration. Nurses are in a position of authority as they choose whether to consider the patient’s subjective report of pain like what happened to Patient X if only the nurse believed him at once he might not have suffered respiratory distress post-operatively. For that reason, it is imperative to build an effective, affirmative relationship with the client, a liaison that encompasses the caring behaviours of revering patients as unique individuals by acknowledging that clients can embrace a variety of beliefs about pain and inquiring about the patient’s views and means of dealing with pain (Kozier et al 2004). The nurse must also value the client’s reaction to pain by accepting that patients have the right to act in response to pain in the approach they ascertained is fitting. Moreover, the nurse must also recognize that manifestations of pain differ broadly and no response is noble or dreadful. Kozier et al (2004) highlighted to never stereotype a person on the basis of ethnicity because manifestations of pain differ among traditions and customs and within cultures. Taking into consideration the age of Patient X, as a nurse attention to the patient’s verbalizations of pain is important. According to Kozier et al (2004) elders constitute a major portion of the individuals within the healthcare system and the prevalence of pain in the older population is generally higher due to both acute and chronic disease conditions. Anxiety often goes together with pain. The threat of the unknown and the inability to overcome pain or the events surrounding it often boost the pain perception (Kozier et al 2004). An insight of deficient domination or a sense of vulnerability inclines to augment pain perception. Patient X had suffered pain preoperatively and due to the feeling of helplessness post-operatively, his pain perception amplified. At this point, the client was unable to express pain to an attentive listener for at that moment, the nurse assigned then ignored the patient’s complaint at first, thinking that he was just exaggerating the post-operative pain causing an elevation of vital signs and difficulty of breathing due to panic. Clients’ reports of pain should be given immediate attention to prevent further complications. Patient X also verbalized that he was reluctant to report the pain at first, for the reason that he does not wish to trouble the nurse who he thinks is busy at that precise moment. He also believed that pain is part of the recovery process and intensifies because of his age. Due also to financial constraints, Patient X tried to endure the pain for fear that it would lead to further tests once he complains of pain; thus, leading to more expenses. Pain management as defined by Kozier et al (2004) is the alleviation of pain or the diminution in pain to a level of comfort that is acceptable to the patient. It comprises two basic categories of nursing interventions: pharmacologic and nonpharmacologic. Nursing management of pain consists of both independent and collaborative nursing actions (Kozier et al 2004). In general, non-invasive measures may be performed as an independent nursing function, whereas administration of analgesic medications requires a physician’s order (Kozier et al 2004). However, the choice of giving the prescribed medication is usually the nurse’s judgment of the dose and time of administration. When Patient X complained of pain few hours after his bowel surgery, the previous nurse assigned at first neglected his report of pain which, is a form of negligence in pain management as mentioned previously, every account of pain perception is subjective and necessitates immediate focus and action. Ignoring the client’s report of pain caused him to have difficulty of breathing caused by the pain he feels making him exert greater effort in trying to catch his breath. Furthermore, due to excruciating pain, he tend to breathe infrequently even though he is catching his breath; for the reason that breathing aggravates the feeling of pain. When the new nurse assigned who is the author took notice of the changes in his vital signs and the unusual manifestations of using the accessory muscles to breathe accompanied by flaring of the nose. He knew that his client was experiencing something unpleasant. The nurse first utilized the nonpharmacologic interventions thinking that the patient’s response was due to panic. The nurse taught relaxation techniques such as deep breathing and abdominal breathing, both of which Patient X refused to utilize since breathing augments pain further. He also taught the client to calm down by yawning and peaceful imaging. After several minutes had passed, the nurse seeing that the nonpharmacologic interventions provided no relief for the client’s pain as evidenced by continued facial grimace, guarding behaviour, excessive perspiration, nasal flaring, employing the use of accessory muscles to breathe and elevated vital signs; the nurse checks the physician’s order for any pharmacologic measures deemed helpful in providing comfort to the patient. The nurse administered oxygen via nasal cannula at 2-3 litres per minute to help the patient in breathing as ordered by his Attending Physician. If non-pharmacologic measures are no longer effective, the nurse should opt to give analgesia as ordered by the attending physician. The physician prescribed Ketorolac 30 mg to be given intravenously every 6 hours and Nalbuphine 10 mg to be administered intravenously every 4 hours. It was already 8pm at that time, the nurse then checked the client’s blood pressure using an automatic pressure cuff connected to the monitor; the blood pressure was 161/89 mmHg. The nurse then opted to give Nalbuphine first, the client verbalized that he feels sleepy; hence, the nurse explained that it is due to the sedative effect of the drug. The nurse continued to monitor the patient for any untoward effects. After an hour though, the client woke up again complaining of pain scoring 7 in a pain scale of 1-10, the nurse learning his lesson previously immediately addressed the pain reported by the patient and started Ketorolac as ordered by the client’s doctor. The client expressed that his pain scale now scores 4 in a pain scale of 1-10. The client’s pain was lessened and partially relieved. Conclusion As nurses, gaining theoretical knowledge is imperative to be able to face the daily duties. In addition continuous self-study and updating of theoretical and practical skills is essential. Armed with the knowledge, the nurses can render holistic care to our clients. Based on the case tackled, it is also mandatory that an institution or the clinical area should have a guide or protocol in managing pain which can be guided by first conducting a study on what the unit needs to formulate a protocol that could be applied in response to the needs of the clients deemed by the healthcare providers in the unit that should be given focus. It may also be useful if the nurses discussed cases handled once in a while in a meeting so that they would know what they should do in such incidents. Moreover, the nurses should be open to the fact that no two individuals experience the same severity of pain, that is, what may be a mild pain to one may feel intense for another. Likewise, the tools for measuring would really be beneficial in assessing the pain that the client is experiencing. Moreover, if non-pharmacologic measures are no longer effective in managing the pain that the client is experiencing, it would be better for the nurse to give analgesia as ordered by the attending physician especially if the pain experienced is already affecting the patient’s breathing and activities of daily living. Combining all of this knowledge based on real life experiences with the proper skills and appropriate attitude are proven beneficial in providing comfort to level 2 clients suffering pain. References Gupta, P.K. (2009) Genetics: Classical to Modern. p. 582. New Delhi, India: Rastogi Publications. Hargrove-Huttel, R. (2005) Pain. Medical-Surgical Nursing. 4th edition, p. 70-82. [n.p.]: Lippincott Williams & Wilkins. Kozier, B., Erb, G., Berman, A., and Snyder, J. (2004) Pain Management. Fundamentals of Nursing: Concepts, Process and Practice. 7th edition, p. 1132-1167. Singapore: Pearson Education South Asia Pte Ltd. Lascaratou, C. (2007) The Language of Pain: expression or description?. p. 1-237. The Netherlands: John Benjamins Publishing Company. Nair, M. (2009) Pain and Pain Management. Fundamentals of Applied Pathophysiology: An Essential Guide for Nursing Students. p. 381-409. United Kingdom: John Wiley and Sons. Schwarzbein, D. & Brown, M. (2002) The Schwarzbein Principle II: the Transition: a Regeneration Process to Prevent and Reverse Accelerated Aging. p. 74-80. [n.p.]: HCl. Souba, W.W. & Wilmore, D.W. (2001) Measuring Pain. Surgical Research. p. 105-110. Oxford: Elsevier Inc. Tolson, D., Booth, J. and Schofield, I. (2011) Evidence Informed Nursing with Older People. p. 1-264. United Kingdom: John Wiley and Sons. Read More