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Файл:Clinical nursing practice. Study aid for foreign students of medical university
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Emotional and psychological factors are important in determining
people's pain experiences. The cycle — pain leading to stress, stress leading to more pain — can be difficult to break. Pain assessment needs to
acknowledge the influence of factors which alter people's perception and
experience of pain. Nursing care needs to be directed towards pain prevention as well as the cure or management of pain. This can be achieved by
planning care to decrease people's sensitivity to pain and avoiding factors
which heighten pain sensitivity.
3.3. ASSESSING THE PERSON WHO IS EXPERIENCING PAIN
The person’s subjective experience should be taken as the starting
point when assessing need, planning and implementing care, and evaluating its effectiveness or otherwise, in partnership with the person experiencing the pain. The person's description of the pain and observation of his or
her reaction to it are the two main methods of assessing the person in pain.
Assessment of pain is concerned with finding out about the:
• Location(s) of the pain.
• Intensity and duration of the pain.
• Character of the pain.
• Factors which seem to bring on the pain.
• Person's past experience of pain.
• Person's reaction to the pain.
• Things which seem to help or relieve the pain.
Effective pain assessment is a prerequisite for pain control and relief
and is an essential component of nursing care. In the assessment process,
the nurse gathers information from the patient or client that allows an understanding of the person’s experience and its effect on his or her life. The
information obtained guides the nurse in planning and evaluating strategies
for care. Pain is rarely static, therefore its assessment should be an ongoing
process.
Assessment seeks to identify all the factors — physical and nonphysical — which affect the person's perception of pain. It is important to
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note that research and clinical practice suggest that patients and clients
tend not to report pain or do so inadequately or inaccurately, minimizing
the pain experience. Hunt et al. found that nurses tended to overestimate
the pain relief obtained from analgesia and to underestimate the level of
the patient's pain.
Using pain assessment tools. A number of methods or tools have
been developed to help in the assessment of pain and the ongoing evaluation of pain relief strategies. The published literature suggests that “pain
assessment charts” can be helpful tools in assessing and monitoring the
person's pain. These should not be used indiscriminately but they have
been found to improve communication between staff and patients/clients.
They can be particularly valuable where the person is able to participate
actively with the nurse in the process of assessing, monitoring and evaluating and where interventions are likely to make some improvement in the
person's pain experience. Walker et al, however, found that charts appeared to have little value in cases of unresolved or intractable pain.
Evidence suggests that pain assessment tools need to be designed to
meet the specific needs of different client groups and different types of
pain. It is important therefore that you select the tool which is most appropriate for a particular type of pain experience. It would not be appropriate,
for example, to use a pain assessment chart, designed for use with patients/clients with chronic pain, to assess post-operative pain.
3.4. SETTING GOALS FOR PAIN MANAGEMENT
The concept of partnership between the nurse and the person experiencing pain is continued throughout each stage of the nursing process
whenever possible. The principles of goal setting described are used to establish appropriate short-term and longer-term outcomes for the person
experiencing pain.
Establishing the desired outcome and being able to achieve it is not
straightforward in pain management. The management of chronic pain, in
particular, is complex and often may only consist of helping the person to
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cope with their pain. Hanks for example, suggests that in setting goals for
people with pain due to cancer, the goals need to be progressive and work
towards an overall goal. One example is by setting goals related to the time
of day and activity of the person.
The goal for harmful or potentially harmful pain, such as that experienced following surgery or in severe injury, is the immediate relief or reduction of the pain, in order to avoid potential shock and collapse.
3.5. PLANNING INTERVENTIONS TO RELIEVE OR MEDIATE
THE EFFECTS OF PAIN
Exercise
Either on your own, or even better, with a group of colleagues, try
to recall all of the different interventions that you have used to relieve
pain when caring for people.
Now make a list of all the measures you have used to relieve your
own pain. How many of these are in the list of interventions that you
have used for people you have cared for? Are there any that are not?
Why do you think this is?
Now compare your list of interventions with tab. 2, below.
Table 2
Nursing interventions in the management of pain
1. Assessment and advocacy to ensure good practice and participation by
the person in their overall pain management.
2. Analgesic and other drug administration.
3. Support ...[for the person's] own methods of pain control. Externally fo-
cused such as rocking, rubbing, “flight into activity”, seeking companions.
Internally focused such as vigilant focusing, mind-body separation, fantasy. Avoidance strategies such as posture, stillness, sleep.
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4. Teaching of, and assisting with, ... coping strategies. Distraction tech-
niques such as guided imagery, mental focusing. Relaxation techniques.
5. Non-invasive physical therapies. Cutaneous stimulation such as pres-
sure, massage, vibration, heat, cold, external analgesia, transcutaneous
nerve stimulation.
In the next part of this section we will use examples from the care of
children undergoing painful or potentially painful procedures to look at
some of the ways of reducing pain and anxiety and evaluating these interventions.
3.6. REDUCING PAIN AND ANXIETY IN CHILDREN
Anxiety, pain and distress are interlinked to an even greater extent in
children, particularly when a child is faced with an acute clinical situation
and one that may be repeated frequently. An initial traumatic experience
may result in the child developing an acute conditioner response to treatments such as repeated venipuncture. It is importee therefore to assess all
the systems that may reflect pain and anxiety behavioral, cognitive (selfreport) and physiological. The interlinking of these responses varies, and
individuals may exhibit certain response in different systems at different
times.
Research undertaken on a pediatric oncology unit into children: undergoing bone-marrow aspiration suggests that the level of pain and distress experienced by those under seven years of age is five to ten times
greater than that of older children.
The behavior and support of the parents is also a factor in a child’s:
ability to cope. Jay et al. state that there is a definite relationship between
parental anxiety and the child's distress, and that parent: provide a model
for the child's behavior. A calm, supportive parent will help both child and
nurse.
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Assessing pain in children:
1. Note the frequency, duration and intensity of the pain.
2. What factors make the pain better or worse? Are environmental
factors involved? Does the presence of a specific person lessen pain and
anxiety?
3. If the child is vocalizing his or her pain, is the vocabulary accu-
rate? As one three-year-old child said: “I've got tummy-ache in my head”.
A popular assessment tool to measure a child's pain is the faces scale
(fig. 4): five faces represent degrees of pain and/or anxiety, and the child
points to the face depicting his or her own feelings. The idea of using color
drawings, with red depicting pain for example, is also becoming popular.
Fig. 4. Faces scale to assess child’s pain
Pain scale/description
Instructions
Recommended age
FACES Pain Rating
Scale; consists of six
cartoon faces ranging
from smiling face
for “no pain”
to tearful face
Explain to child that each face
is for a person who feels happy
because there is no pain (hurt) or sad
because there is some or a lot
of pain. Face 0 is very happy
because there is no hurt. Face 1
hurts just a little bit. Face 2 hurts
a little more. Face 3 hurts even more.
Face 4 hurts a whole lot, but Face 5
hurts as much as you can imagine,
although you don’t have to be crying
to feel this bad. Ask child to choose
face that best describes own pain.
Record number under chosen face
on pain assessment record
Children as young
as 3 years
Adequate pharmacological control must be used as and when necessary. Additional or alternative methods of reducing pain and anxiety will
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also help the child to relax and cope better with pain and distress. As well
as benefiting the child, this can have a directly positive effect on parents
and other careers.
Preparation prior to a procedures such as venipuncture is useful, but
does not teach the child a coping skill. It does, however, offer the child an
opportunity to question, and this may reduce their fears and fantasies about
what might happen. A five-year-old boy was told by the anesthetist that he
was going to be 'put to sleep' for an operation. Given the opportunity to
talk about his fears, the child explained that his dog had been taken to the
veterinary clinic the week before to be ‘put to sleep’ - in other words to be
humanely destroyed. Nurses were able to allay his fears by explaining that,
unlike his pet, he would wake up after the operation.
For the child who is in hospital, it is often beneficial if his or her bed
is kept as a safe place and, where possible, invasive procedures are performed elsewhere.
Methods used to reduce pain and anxiety. Outlined below are
some of the methods used to reduce pain and anxiety in the child. Remember that a relaxed child will cope with pain and anxiety better, and that
both pain and anxiety will be reduced if the child is able to focus on something other than the procedure.
Participation. The child is encouraged to participate in the procedure
by, for example, choosing the site for an injection, cleaning the site or selecting a plaster.
Desensitization. The child is helped to undergo the procedure in a relaxed, rather than a distressed, state. The use of play with safe syringes, if
appropriate, dolls, puppets or a third party who undergoes the procedures
first have all proved helpful. Introducing sensory triggers such as the smell
of med swabs and chlorhexidine can also help at this stage.
Distraction. Questioning the child to discover what he or she likes,
and then using this knowledge, is enormously beneficial. A favorite story
or song, a joke or a pop-up book can provide distractions for the small
child. Blowing bubbles or an imaginary feather off the doctor's nose will
also distract the child and encourage deep breathing. A personal stereo
may be an appropriate distractor for the older child.
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Relaxation. In addition to deep breathing, massage and stroking will
aid relaxation. The child may benefit from squeezing his or her mother's
hand very tightly while counting to five, and then relaxing the grip slowly.
Guided imagery technique. With this technique, control is not removed from the child, as it with hypnosis: he or she can still hear external
noises such as a ringing telephone. The principles of the technique, as
demonstrated in the first of the two case studies which follow, involve attention focusing followed by progressive relaxation. Then, through guided
imagery, the child is given the idea that pain is being reduced. Once the
procedure has been completed, the child is guided back to full wakefulness. This technique is guided imagery and not hypnosis, which should only be performed by a trained therapist.
A combination of techniques can be used and may be backed up
by positive reinforcement, such as awarding a bravery certificate or
a gold star.
The case studies described below illustrate how the techniques described have been used in practice. They are drawn from the experience of
nurses working at the Great Ormond Street Hospital for Children in
England.
Example: case study — Kristina.
Kristina was ten years old when she was admitted to the neurosurgical unit. She was a shy but friendly child who was fond of the babies on the
ward but was reluctant to mix with her own age group.
Kristina underwent a craniotomy for repair of a nasal encephalocele
which had caused repeated bouts of cerebrospinal fluid (CSF) rhinorrhoea
and carried the risk of her developing meningitis. She was psychologically
prepared for her operation and care, and went through the whole experience apparently undisturbed. Unfortunately, a wound breakdown, and the
risk that she might develop osteomyelitis, entailed a long course of intravenous antibiotics. She also developed viral diarrhea, which meant she
had to be isolated in a cubicle. She would clock-watch, waiting until the
time for her next antibiotics, and would become extremely distressed when
a nurse entered the room with the drugs. She was always pleased to see
nurses who went into her cubicle for any other reason.
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Two of the senior nurses on the ward and the play specialist, had
been taught relaxation methods by the unit's psychologists and decided
that relaxation and guided imagery would be used as the best method to
help relieve Kristina's distress. The procedure was discussed with Kristina, who was wary but curious. After discussion with her parents, through
a translator, it was agreed to try it out. She was asked to think of a very
special place she wanted to go to in her “dream”, and to describe it. She
described a walled garden. The play specialist and a nurse would enter the
cubicle and sit quietly with Kristina. When she was settled and comfortable, the play specialist would ask Kristina to lift her own thumb level to
her face, her arm outstretched and follow her thumb with her eyes as her
hand fell downwards and her eyes gradually closed. The play specialist
would then verbally guide Kristina slowly down the ten steps to the garden
gate. She would open the gate, go into her garden and close the gate behind her. Nobody could enter the garden without her invitation. She could
smell and touch the flowers.
While Kristina was in this relaxed state, the intravenous drug would
be given. Sometimes she would smile when she realized what was happening, but would remain relaxed as the play specialist continued talking to
her about the garden. When the procedure was completed, the play specialist would guide Kristina out of the gate and back up the steps, then she
would ask her to open her eyes. Somebody would remain with her until she
felt “normal”, as she described it. She loved the technique, including the
extra attention from staff. After a short time, Kristina would become relaxed as soon as anybody entered the cubicle to administer drugs and the
technique was continued successfully for ten days. It then appeared to
wear off and she again began to show signs of distress so a handsqueezing technique was used with success.
Six weeks after discharge, Kristina visited the ward for a follow-up
scan. She was calm and cheerful during her stay, and no invasive procedures were performed.
Example: case study — Karen.
Karen was 13 years old when she was admitted with benign intracranial hypertension. The cause of this condition, in which the child pre-
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sents with headache and papilloedema, is unknown but appears to be either cerebral oedema or defective cerebrospinal fluid absorption which
results in increased brain bulk. Treatment is through steroid therapy, in
conjunction with intermittent lumbar puncture, performed as a day-case
admission, every three or four weeks, until the condition settles or until
surgical intervention becomes necessary by means of a lumbar peritoneal
shunt.
Karen was highly distressed by the lumbar puncture procedure, and
therefore amenable to any suggestions as to how we might reduce her pain
and anxiety during her treatment. Temazepam was administered orally on
the day of the procedure, and the use of local lignocaine was maintained
in the usual manner once she had relaxed. To achieve this, several techniques were used after discussion with Karen and her mother. They had a
very close relationship, which made it particularly valuable to involve
Karen's mother fully.
Karen would make herself as comfortable as is possible for this procedure, lying on a trolley supported by pillows. Her mother would then encourage deep, slow breathing while stroking and massaging her daughter.
The two of them would then talk quietly and closely of the holiday they
would have when Karen was better.
Karen did not need any form of physical restraint during the procedure and would fall asleep when it was completed. Although she clearly
did not enjoy the lumbar puncture, she found the coping methods made it
tolerable.
Example: case study — Brian.
Brian was five years old when he required a revision of his shunt system for hydrocephalus. He had required no further surgical intervention
or hospitalization since his shunt had been inserted when he was five
weeks old. It was likely that he would require further surgery at a later
stage in his life, and the staff were keen to minimize his trauma on this
occasion.
Brian's greatest fear was needles: his own experience of injections
when he was immunized and the cries of other children when they had in-
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jections were the cause of his fear. The nursing staff explained what was to
happen to him during his pre-medication injection and gave him an empty
syringe to play with. His condition was deteriorating and he did not wish
to select an injection site or plaster.
The play leader helped him to relax by getting him to blow bubbles,
imitating deep breathing, as we gave his pre-medication injection. This
technique also proved calming whenever he was given post-operative analgesia. Brian's parents were pleased to see that every opportunity was being used to reduce his distress, and supported any attempts to do so.
Evaluation note. Psychological approaches to reducing a child's pain
and anxiety can prove useful. They can be used on their own or in conjunction with pharmacological aids. These techniques are time-consuming
and require patience and persistence, but as they may well result in a child
experiencing less pain and distress, they should be considered valid tools
for use when appropriate.
3.7. CONCLUSION
The complexity of the experience of pain and pain relief may mean
that our understanding of the mechanisms involved may always be incomplete. There is a need for further research, particularly into the experience
and alleviation of chronic or “useless” pain. The biomedical approach to
pain management has yielded many pharmacological and other developments in pain management, but does not hold all of the answers. There has
perhaps been an over-reliance in the last century or so, on interventions
which can be understood from a bio-medical perspective. The case studies
illustrate the value of approaches to pain relief which are based on an understanding of the person experiencing the pain and a willingness to believe in non-pharmacological interventions.
The presence of pain, and the desire for it to be alleviated, is a major
reason why people consult the health care services. The absence of pain
may not be an achievable goal in all instances. Patients/clients understand
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