Nursing Diagnosis: Chronic Pain
Chris Pasero and Margo McCaffery
NANDA Definition: Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring, without an anticipated or predictable end and a duration >6 months (NANDA); a state in which an individual experiences pain that persists for a month beyond the usual course of an acute illness or a reasonable duration for an injury to heal, is associated with a chronic pathologic process, or recurs at intervals for months or years (Bonica, 1990)
Pain is always subjective and cannot be proved or disproved. The client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). Clients with cognitive abilities who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify their current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).
Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in its assessment, especially in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite or the inability to ambulate, perform activities of daily living (ADLs), work, or sleep. Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, and increase or decrease in respiratory rate and depth may be present but are usually not present with chronic pain that is relatively stable. Clients with chronic, cancer, or nonmalignant pain may experience threats to self-image; a perceived lack of options for coping; and worsening helplessness, anxiety, and depression. Chronic pain may affect almost every aspect of the client's daily life, including concentration, work, and relationships.
Related Factors:Actual or potential tissue damage; tumor progression and related pathology; diagnostic and therapeutic procedures; nerve injury (neuropathic pain)
NOTE: The cause of chronic nonmalignant pain may not be known because pain is a new science and an area of diverse types of problems.
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
· Pain Level
· Pain Control
· Comfort Level
· Pain: Disruptive Effects
· Uses pain rating scale to identify current level of pain intensity, determines a comfort/function goal, and maintains a pain diary (if client has cognitive abilities)
· Describes the total plan for drug and nondrug pain relief, including how to safely and effectively take medicines and integrate nondrug therapies
· Demonstrates ability to pace self, taking rest breaks before they are needed
· Functions on an acceptable ability level with minimal interference from pain and medication side effects (if pain is above the comfort/function goal, takes action that decreases pain or notifies a member of the health care team)
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
· Pain Management, Analgesic Administration
Nursing Interventions and Rationales
· Determine whether client is experiencing pain at time of initial interview. If so, intervene at that time to provide pain relief. The intensity, character, onset, duration, and aggravating and relieving factors of pain should be assessed and documented during the initial evaluation of the patient (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000).
· Ask client to describe past and current experiences with pain and effectiveness of the methods used to manage the pain, including experiences with side effects, typical coping responses, and how he or she expresses pain. A number of concerns (barriers) may affect client's willingness to report pain and use analgesics (Ward et al, 1993).
· Describe the adverse effects of unrelieved pain. Numerous pathophysiological and psychological morbidity factors may be associated with pain (McCaffery, Pasero, 1999; Page, Ben-Eliyahu, 1997; Puntillo, Weiss, 1994).
· Tell client to report pain location, intensity, and quality when experiencing pain. The intensity of pain and discomfort should be assessed and documented after any known pain-producing procedure, with each new report of pain, and at regular intervals (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000).
· Ask client to maintain a diary of pain ratings, timing, precipitating events, medications, treatments, and what works best to relieve pain. Systematic tracking of pain appears to be an important factor in improving pain management (Faries et al, 1991; JCAHO, 2000).
· Determine client's current medication use. To aid in planning pain treatment, obtain a medication history (Acute Pain Management Guideline Panel, 1992).
· Explore need for medications from the three classes of analgesics: opioids (narcotics), non-opioids (acetaminophen, Cox-2 inhibitors, and nonsteroidal antiinflammatory drugs [NSAIDs]), and adjuvant medications. For chronic neuropathic pain, consider adjuvant medications that are analgesic, such as anticonvulsants and antidepressants. Some types of pain respond to non-opioid drugs alone. However, if pain is not responding, consider increasing the dosage or adding an opioid. At any level of pain, analgesic adjuvants may be useful (American Pain Society, 1999). Analgesic combinations may enhance pain relief (McCaffery, Pasero, 1999).
· The oral route is preferred. If client is receiving parenteral analgesia, use an equianalgesic chart to convert to an oral or another noninvasive route as smoothly as possible. (See Appendix E for an equianalgesic chart.) The least invasive route of administration capable of providing adequate pain control is recommended. The oral route is the most preferred because it is the most convenient and cost effective. Avoid the intramuscular (IM) route because of unreliable absorption, pain, and inconvenience (Jacox et al, 1994).
· Obtain a prescription to administer a non-opioid, unless contraindicated, around the clock (ATC). NSAIDs act mainly in the periphery to inhibit the initiation of pain signals (Dahl, Kehlet, 1991). The analgesic regimen should include a non-opioid drug ATC, even if pain is severe enough to require the addition of an opioid (American Pain Society, 1999).
· For persistent cancer pain, obtain a prescription to administer opioid analgesics. When pain persists or increases, an opioid such as codeine or hydrocodone should be added to the non-opioid (Jacox et al, 1994). If this is not effective, switch to morphine or other single-entity opioids.
· Establish ATC dosing and administer supplemental opioid doses as needed to keep pain ratings at or below an acceptable level. A PRN order for a supplementary opioid dose between regular doses is an essential backup (American Pain Society, 1999).
· Ask client to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Always obtain a prescription for a peristaltic stimulant to prevent opioid-induced constipation. Because there is great individual variation in the development of opioid-induced side effects, they should be monitored and, if their development is inevitable (e.g., constipation), prophylactically treated. Opioids cause constipation by decreasing bowel peristalsis (Jacox et al, 1994; McCaffery, Pasero, 1999).
· Explain pain management approach that has been ordered, including therapies, medication administration, side effects, and complications. One of the most important steps toward improved control of pain is a better client understanding of the nature of pain, its treatment, and the role client needs to play in pain control (Jacox et al, 1994).
· Discuss client's fears of undertreated pain, addiction, and overdose. A number of concerns (barriers) may affect patients' willingness to report pain and use analgesics (Ward et al, 1993). Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan (McCaffery, Pasero, 1999). Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with addiction (Jacox et al, 1994).
· Review client's pain diary, flow sheet, and medication records to determine overall degree of pain relief, side effects, and analgesic requirements for an appropriate period (e.g., one week). Systematic tracking of pain appears to be an important factor in improving pain management (Faries et al, 1991; JCAHO, 2000).
· Obtain prescriptions to increase or decrease analgesic doses when indicated. Base prescriptions on the client's report of pain severity and the comfort/function goal and response to previous dose in terms of relief, side effects, and ability to perform the daily activities and the prescribed therapeutic regimen. Opioid doses should be adjusted individually to achieve pain relief with an acceptable level of adverse effects (Jacox et al, 1994; McCaffery, Pasero, 1999).
· If opioid dose is increased, monitor sedation and respiratory status for a brief time. Patients receiving long-term opioid therapy generally develop tolerance to the respiratory depressant effects of these agents (Jacox et al, 1994; McCaffery, Pasero, 1999).
· In addition to the use of analgesics, support the client's use of nonpharmacological methods to control pain, such as distraction, imagery, relaxation, massage, and heat and cold application. Cognitive-behavioral strategies can restore clients' sense of self-control, personal efficacy, and active participation in their own care (Jacox et al, 1994).
· Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions. Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions (Acute Pain Management Guideline Panel, 1992).
· Plan care activities around periods of greatest comfort whenever possible. Pain diminishes activity (Jacox et al, 1994; McCaffery, Pasero, 1999).
· Ask clients to describe their appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments directed toward improving these functions. Because there is great individual variation in the development of opioid-induced side effects, clinicians should monitor and, if development is inevitable, prophylactically treat them (Jacox et al, 1994).
· Explore appropriate resources for management of pain on a long-term basis (e.g., hospice, pain care center). Most patients with cancer or chronic nonmalignant pain are treated for pain in outpatient and home care settings. Plans should be made to ensure ongoing assessment of the pain and the effectiveness of treatments in these settings (Jacox et al, 1994).
· If client has progressive cancer pain, assist client and family with handling issues related to death and dying. Peer support groups and pastoral counseling may increase the client's and family's coping skills and provide needed support (Jacox et al, 1994).
· If client has chronic nonmalignant pain, assist client and family with minimizing effects of pain on interpersonal relationships and daily activities such as work and recreation. Pain reduces clients' options to exercise control, diminishes psychological well-being, and makes them feel helpless and vulnerable. Therefore clinicians should support active client involvement in effective and practical methods to manage pain (Hitchcock, Ferrell, McCaffery, 1994; Jacox et al, 1994).
· Always take an elderly client's reports of pain seriously and ensure that the pain is relieved. In spite of what many professionals and clients believe, pain is not an expected part of normal aging (McCaffery, Pasero, 1999).
· When assessing pain, speak clearly, slowly, and loudly enough for client to hear; repeat information as needed. Be sure client can see well enough to read pain scale (use enlarged scale) and written materials.
· Handle client's body gently. Allow client to move at own speed.
· Use NSAIDs with caution and avoid ATC NSAID dosing. Opioids ATC are preferable to chronic NSAID administration in the elderly client because of an increased risk for NSAID adverse effects (American Geriatric Society Panel on Chronic Pain in Older Persons, 1998).
· Use acetaminophen and NSAIDs with low side effect profiles such as choline and magnesium salicylates (Trilisate) and diflunisal (Dolobid). Watch for side effects such as GI disturbances and bleeding problems. Elderly clients are at increased risk for gastric and renal toxicity from NSAIDs (Griffin et al, 1991; Acute Pain Management Guideline Panel, 1992).
· Avoid or use with caution drugs with a long half-life, such as the NSAID piroxicam (Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-Dromoran), and the benzodiazepine diazepam (Valium). A higher prevalence of renal insufficiency in the elderly than in younger persons can result in toxicity from drug accumulation (American Pain Society, 1999; Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).
· In an elderly client, avoid the use of opioids with toxic metabolites, such as meperidine (Demerol) and propoxyphene (Darvon, Darvocet). Meperidine's metabolite, normeperidine, can produce CNS irritability, seizures, and even death; propoxyphene's metabolite, norpropoxyphene, can produce both CNS and cardiac toxicity. Both of these metabolites are eliminated by the kidneys, making meperidine and propoxyphene particularly poor choices for elderly clients, many of whom have at least some degree of renal insufficiency (Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).
· Assess pain in a culturally diverse client using a self-report 0 to 10 numerical pain rating scale or the Wong Baker Faces pain rating scale. Use a scale that has been translated into client's native language if necessary. Inadequate pain management is widespread, especially among minority groups, and a major reason is the failure to assess pain properly. The more cultural differences between patient and nurse, the more difficult it is for the nurse to assess and treat pain. Self-report of pain is the single most reliable indicator of pain, regardless of culture (McCaffery, 1999; McCaffery, Pasero, 1999).
· Administer analgesics on a preventive basis to keep pain ratings at or below an acceptable level.
· Assess for the influence of cultural beliefs, norms, and values on the client's perception and experience of pain. The client's experience of pain may be based on cultural perceptions (Leininger, 1996).
· Assess for the role of fatalism on the client's beliefs regarding their current state of comfort. Fatalistic perspectives in some African-American and Latino populations involve the belief that you cannot control your own fate and influence your health behaviors (Philips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).
· Incorporate folk health care practices and beliefs into care whenever possible. Incorporating folk health care beliefs and practices into pain management care increased compliance with the treatment plan (Juarez, Ferrell, Borneman, 1998).
· Use a family-centered approach when working with Latino, Asian American, African-American, and Native American clients. Involving family in pain management care increased compliance with the treatment regimen (Juarez, Ferrel, Borneman, 1998).
· Use culturally relevant pain scales (e.g., the Oucher scale) to assess pain in the client. Culturally diverse clients may express pain differently than clients from the majority culture. The Oucher scale has African-American and Hispanic versions and is used to assess pain in children (Beyer, Denyes, Villarruel, 1992).
· Ensure that directions for medications are available in the client's language of choice and are understood by client and caregiver. Bilingual instructions for medications increased compliance with the pain management plan (Juarez, Ferrell, Borneman, 1998).
· Validate the client's feelings and emotions regarding current health status. Validation lets the client know the nurse has heard and understands what was said, and it promotes the nurse-client relationship. (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).
Home Care Interventions
· Review with client and caregivers the cause(s) of pain and the medical regimen specific to the cause. Assess client knowledge and teach disease process as necessary. Compliance with the medical regimen for diagnoses involving pain improves the likelihood of successful management (Humphrey, 1994).
· Develop a full medication profile, including medications prescribed by all physicians and all over-the-counter medications. Assess for drug interactions. Instruct client to refrain from mixing medications without physician approval. Pain medications may significantly impact or be impacted by other medications and may cause severe side effects. Some combinations of drugs are specifically contraindicated (Jacox et al, 1994).
· Assess client and family knowledge of side effects and safety precautions associated with pain medications (e.g., use caution when operating machinery when opioids are initiated or dose has been increased). The cognitive effects of opioids usually subside within a week of initial dosing or dose increases (McCaffery, Pasero, 1999). The use of long-term opioid treatment does not appear to affect neuropsychological performance. Pain itself may deteriorate performance of neuropsychological tests more than oral opioid treatment (Sjogren et al, 2000).
· Collaborate with health care team on an ongoing basis (including client and family) to determine optimal pain control profile. Identify the most effective interventions and the medication administration routes most acceptable to the family and client. Success in pain control is partially dependent on the acceptability of the suggested intervention. Acceptability promotes compliance. Dosages vary among routes and will need to be adjusted accordingly to avoid breakthrough or transitional pain (Bohnet, 1995).
· If administering medication using highly technological methods, assess home for necessary resources (e.g., electricity), and ensure that there will be responsible caregivers available to assist client with administration. Some routes of medication administration require special conditions and procedures to be safe and accurate (McCaffery, Pasero, 1999).
· Assess knowledge base of client and family for highly technological medication administration including the use of PCA pump. Teach as necessary. Appropriate instruction in the home increases the accuracy and safety of medication administration (McCaffery, Pasero, 1999).
· Support the client and family in the use of opioid analgesics. Well-intentioned friends and family may create added stress by expressing judgment or fears regarding the use of opioid analgesics (McCaffery, Pasero, 1999).
· NOTE: To avoid the negative connotations associated with the words drugs and narcotics, use the words pain medicine when teaching clients.
· Provide written materials regarding pain control, such as the Agency for Health Care Policy and Research pamphlet, Managing Cancer Pain: Patient Guide.
· Discuss the various discomforts encompassed by the word pain and ask clients to give examples of pain they have experienced. Explain the pain assessment process and the purpose of the pain rating scale that will be used. Teach clients to use the pain rating scale to rate the intensity of current or past pain. Ask them to set a pain relief goal by selecting a pain rating on the scale; if pain goes above this level, they should take action that decreases pain or notify a member of the health care team. (See Appendix E for information on teaching clients to use the pain rating scale.)
· Discuss the total plan for drug and nondrug treatment, including the medication plan for ATC administration and supplemental doses, the maintenance of a pain diary, and the use of supplies and equipment.
· Reinforce the importance of taking pain medications to keep pain under control.
· Reinforce that taking opioids for pain relief is not an addiction.
· Explain to clients with chronic neuropathic pain the process of taking adjuvant analgesics (e.g., tricyclic antidepressants); a low dose is used initially and is increased gradually. Emphasize that pain relief is delayed and the drugs must be taken daily. Reassure the client that although the medicine is an antidepressant, it is used for analgesia and not depression. Comparable teaching should take place when an anticonvulsant is prescribed for analgesia.
· Emphasize to clients with chronic nonmalignant pain the importance of participating in therapeutic regimens other than medication (e.g., physical therapy, group therapy).
· Emphasize to clients the importance of pacing themselves and taking rest breaks before they are needed.
· Demonstrate the use of appropriate nonpharmacological approaches for controlling pain.