What is Chronic Pain?

Chronic pain can be defined as pain that has lasted for 12 or more weeks. It can also be described as pain that has persisted for a month or more after an active tissue injury resolution. There are two classifications of pain; chronic non-malignant and chronic malignant pain. The original tissue injury in non-malignant pain is said to be non-progressive. The patient may experience pain after the tissue injury has healed. Malignant pain is associated with a particular cause, for example, cancer.

Chronic pain can either be mild or severe, totally incapacitating or merely inconvenient, continuous, or episodic. A patient may eventually find it difficult to identify the pain’s intensity clearly and differentiate the exact pain location. Chronic pain can limit a person’s movements, leading to reduced stamina, strength, and flexibility. Patients cannot carry out important tasks and are often accused of using pain to avoid work, responsibilities, and commitments and to attract attention.

The legitimacy of their pain may be questioned by family members, colleagues, employers, friends, and healthcare providers because they may appear like they are not in pain. The emotional damage caused by chronic pain may worsen the pain experienced by the patient because of the mind-body links associated with it. Effective treatment should address the physical and psychological aspects of the condition.

Causes

Different factors can cause chronic pain. It can result from an injury, illness, or from ongoing pain. Some people suffer chronic pain in absence of past injuries and illnesses. Factors that cause chronic pain include;

• Injuring agents such as Physical, biological, psychological, and chemical agents.
• Chronic physical disability
• Side effects from cancer therapy agents
• Disease process ( compression of body organs, inflammation, infiltration of nerves and their vascular supply).

Signs and Symptoms

• Anorexia
• Fatigue
• Alteration in muscle pain, which vary from flaccid to rigid
• Depression
• Facial pain mask
• Autonomic responses ( changes in BP, pulse, respiration, and diaphoresis).
• Altered abilities to work
• Atrophy of the involved muscle group
• Sleep patterns changes
• Changes in weight and appetite
• Fear of injury
• Distraction and guarding behavior to protect the body part
• Irritability and restlessness
• Facial masks( restlessness, crying, irritability, moaning), self-focusing ( impaired thoughts, altered time perception).
• Fear of reinjury
• Self-focused
• Guarded behavior (repetitive activities, pacing)
• Minimal interaction with people
• Weight changes
• Responses that are mediated sympathetically ( temperature, hypersensitivity, cold, body position changes)
• Coded reports

Goals and Outcomes

Pain is a complex and multifactorial experience that arises from psychological, biological, and social factors. In order to treat pain effectively, a collaborative interdisciplinary approach is required. Goals and expected outcomes are discussed below.

• The patients utilize relaxation techniques and activities for diversion purposes that are appropriate for their individual situations.
• The patient indicates experiencing pain ranging from below 3-4 on a scale of 0-10.
• The patients employ both pharmacological and non-pharmacological approaches to manage their pain.
• The patients express satisfaction with their pain level relief and capacity to participate in desired activities.
• The patients participate in desired activities without experiencing an escalation in their pain level.

Nursing Diagnosis for Chronic Pain

They include;

• Chronic pain due to ineffective and insufficient pain Management, demonstrated by the inability to carry out daily activities and the absence of pain relief.
• Chronic pain associated with psychological distress demonstrated by fatigue, painful facial expressions, and changes in the sleep-wake cycle.
• Chronic pain associated with joint inflammation is demonstrated by swollen joints, erythema on the affected site, and guiding behaviors.

Chronic pain Nursing Assessment.

In order to develop an effective pain management plan, conducting a thorough chronic pain nursing diagnosis assessment is important. Nurses play a vital role in pain assessment because of the way they relate with the patients.

Nursing Assessment	Rationale
Evaluate and record the characteristics of pain	The most reliable information in regard to the experience of chronic pain is the self-report provided by the patient. Healthcare providers should accept the patient’s pain records as accurate unless there is evidence to the contrary. This is because pain is always subjective. However, healthcare providers may consider alternative means of assessing pain and determining its causes. PQRSTU is the commonly used nursing mnemonic and helps in ensuring pain assessment is thoroughly done. P- palliating/ provoking Q- Quality/ quantity R- Radiation/ region S-  Signs/ symptoms T- Timing U- Understanding
Evaluate and record signs and symptoms associated with chronic pain. (Weight loss, reduced appetite, weakness, anxiety, body posture changes, irritability, disruption of sleep patterns, depression, and agitation).	Patients with chronic pain may not exhibit behavior and psychological changes associated with acute pain. For patients with chronic pain, acute pain-guarding behavior may result in a persistent body posture change. While managing chronic pain, a patient may lack the energy to perform other activities. Depression and irritability can be triggered by chronic pain, and these emotions can lead to fatigue and insomnia, which further exacerbate depression, pain, and irritability.
Evaluate the patient’s understanding in regard to the efficacy of pain management strategies used in the past.	Patients who experience chronic pain have a long history of utilizing a variety of pharmacological and non-pharmacological methods to alleviate and manage their pain. Pain treatment should focus on the patient’s condition’s biological, psychological, and social aspects and encourage the development of their self-management abilities.
Evaluate how gender, societal, cultural, and religious features influence the patient’s reaction to pain relief and pain management	In order to develop an acceptable care plan, it is important to recognize the factors that influence a patient’s pain experience. Individuals living in poverty have a low socio-economic status, haunting every financial decision they make. They cannot afford medications and visit healthcare workers for pain management.
Evaluate the patient’s beliefs and expectations regarding pain alleviation.	Patients experiencing chronic pain do not expect to relieve their pain completely but are satisfied with decreasing pain severity and increased activity levels. According to early research, improved adherence to treatment and enhanced functional results are associated with positive pain relief, recognition, and behaviors. Studies have also indicated that changes in pain-related beliefs are linked to alterations in pain intensity, psychological well-being, and pain interference.
Evaluate the patient’s perspective on both pharmacological and non-pharmacological pain management techniques.	Patients may consider medication to be the only effective pain management treatment, and they may doubt the efficacy of non-pharmacological interventions. A study shows that both healthcare providers and patients are skeptical about the effectiveness of non-pharmacological pain management techniques. They lack an understanding of its rationale and the specific techniques involved.
Gain a deeper understanding of the side effects, tolerance, and dependency of individuals using opioid analgesics.	In the long run, managing chronic pain raises concerns regarding drug dependency and tolerance to opioid analgesics. Additionally, opioid-induced hyperalgesia (OIH) poses a major concern. Patients taking chronic opioids have an increased sensitivity to painful stimuli. The side effects of using opioids and the long-term risks include; dependence, arrhythmia, dyspepsia, tolerance, constipation, nausea, and endocrine dysfunction induced by opioids. This can result in impotence, decreased libido and energy, amenorrhea, and gynecomastia
Evaluate the current medication that a patient is using.	The patient’s past use of medication should be obtained to help develop a pain management plan. Numerous medications commonly used for chronic pain treatment have side effects, carry inherent risks, and can lead to complications. Using more than four grams of acetaminophen daily can lead to hepatotoxicity. In the United States of America, it is the major cause of acute liver failure. Adjunct medications (gabapentin and pregabalin), if frequently used, can cause confusion, swelling, sedation, and respiratory depression.
Evaluate the patient’s capacity to carry out and meet the requirements of activities of daily living, demands of daily living, and instrumental activities of daily living.	Anxiety, exhaustion, and depression associated with chronic pain can limit an individual’s ability to do their activities and fulfill roles/responsibilities. Understanding the impact of chronic pain on the patient’s quality of life is crucial.
Assess pain in patients who are unable to communicate it themselves.	Infants, toddlers, old patients with cognitive deficits, and unconscious patients, among others, cannot express their pain. The patient’s behavior should be observed. Accurate, evidence-based behavioral scales which are developed for specific patient groups should be used.
Patients’ vital signs should be monitored routinely.	Increased or decreased vital signs from a patient’s baseline could suggest the presence of pain, although they are not exclusive indicators. The sympathetic nervous system is activated at the beginning of a painful experience, leading to elevated blood pressure, respiratory rate, heart rate, diaphoresis, pallor, and dilated pupils. The central nervous system’s adaptation to chronic pain could result in a physiological response absence.
Assess the effectiveness of painkillers frequently and regularly.	The pain reliever dosage may be inadequate to manage pain or could be causing undesirable or hazardous side effects, or both. Continuous assessment help make adjustments in order to manage pain effectively.

Chronic pain Nursing Interventions.

Therapeutic intervention, according to patients, should aim at improving quality of life. This may be a more feasible goal than achieving a significant pain reduction. Nursing interventions for patients suffering from chronic pain are discussed below.

Nursing Interventions	Rationale
Patients should be allowed to keep a diary of pain ratings, medications, precipitating events,  timing, treatments, and their effective ways of managing pain. This should be reviewed routinely	In order to prove pain management, it is important to do systematic pain tracking. A pain diary is a self-report assessment tool that is simple to use and has demonstrated to be highly reliable, useful, and valid. Pain diaries promote better communication between patients and care givers. They can also improve the sense of self-control. They help patients track variations in their daily pain levels and therapeutic intervention impacts.
Acknowledge and express acceptance of the patient’s experience of pain.	Accepting patients’ pain experiences helps promote a cooperative relationship between nurses and patients. Nurses must have sufficient knowledge and a suitable mindset regarding pain management to help the patient alleviate their distress.
Help the patient decide on a specific pain management technique.	By providing support and guidance, nurses can help patients adopt new interventions to help them relieve their pain. Pain relief therapies are determined by the nature of pain and the degree to which it impacts the patient’s physical and psychological well-being.
Examine the need for medications that belong to the three categories of analgesics. (opioids, non-opioids, and adjuvant medications).	Analgesics are the most commonly used pain relief treatment. However, healthcare professionals will continue to undertreat patients because of worries about addiction, incorrect drug information, anxiety regarding the error of using opioid analgesics, and the delivery of a lower dosage than prescribed. Therefore, nurses must ensure they have a comprehensive understanding of pain relief medications and their pharmacological impacts.
Employ an equianalgesic chart if the patient receives a parenteral analgesic to seamlessly convert to an oral or noninvasive route.	It is recommended to go for a least invasive administration route that can provide sufficient pain relief. The most preferred route is the oral route because it is cost-effective and convenient. Subcutaneous and intramuscular routes should be avoided because of inconvenience, pain, and unreliable absorption.
Patients should be allowed to describe bowel elimination, appetite, and their ability to sleep and rest. Treatment and medications should be administered to enhance these functions. To prevent constipation caused by opioids, make sure you obtain a prescription for a peristaltic stimulant.	Reduced bowel peristalsis results from constipation caused by opioids. Opioid analgesics produce a wide range of adverse effects due to the distribution of opioid receptors present both within and outside the nervous system.
Secure prescription to either increase or decrease analgesic dosage where necessary. To determine a suitable prescription, consider the patient’s records of pain severity and the function goal, as well as their response to the earlier dose in terms of side effects, relief, and abilities to perform activities of daily living.	To attain pain relief with tolerable adverse effects, individual adjustment of opioid doses is necessary. Individual variations in metabolism can significantly impact the effectiveness of opioids in alleviating pain.
Respiratory status and patient sedation should be monitored for a brief period if the opioid dosage is increased.	Large doses of opioids can cause hypotension and respiratory depression. The patient’s respiratory status and level of alertness should always be evaluated before an opioid is administered.
Patients should be educated on the prescribed pain Management methods, including therapies, medication dosing, potential side effects, and complications.	In order to achieve better pain management, it is important for a patient to understand the nature of their pain, its treatment, and the responsibility they hold in managing it.
Patients’ fear of addiction, overdose, and undertreated pain should be discussed.	To address the myths and misconceptions that surround pain and its treatments, it is important to educate patients about pain management and dispel myths about opioid usage in the treatment plan.
Patients’ use of non-pharmacological approaches to manage pain should be maintained.	These approaches include;  massage, distraction, relaxation, imagery, heat, and cold application. When complementary therapies are incorporated into a pain management plan, chronic pain can be alleviated, and the need for medication therapy can also reduce. Non-pharmacological approach stimulates the release of endogenous opioids, providing an alternative for patients with mild pain who prefer not to use potent pain medications.
Non-pharmacological interventions should be incorporated once pharmacological measures have relatively controlled the pain.	Non-pharmacological measures are not used to replace pharmacology measures but to reinforce them. They should be used to complement pharmacological interventions for patients with moderate to severe pain. Recent research studies indicate that about 70 percent of patients with chronic pain using complementary alternative medicine experienced higher satisfaction with the intervention.
Recommend resources for long-term pain management.	Many patients with chronic pain are treated in-home care and other outpatient settings such as pain care centers and hospice care. In this case, it is crucial to secure an ongoing assessment of pain and treatment effectiveness in these settings. Palliative care could help the patient live with an incurable condition, while hospice care could help patients with terminal illnesses while promoting their comfort.
For patients with ongoing pain due to cancer, help the patient and family make end-of-life decisions.	Spiritual guidance and support groups could help the patient and the family get the needed support and develop coping skills. For instance, resources such as the National Comprehensive Cancer Network provide aggressive guidelines on treating cancer pain, including pain relief options for the patient, family, and caregivers.
For a patient with non-malignant pain, assist the patient and the family in reducing the effects pain has on daily activities and interpersonal relationships.	Pain is associated with reduced psychological well-being, which makes patients feel vulnerable and helpless, lessening options to exercise control. In this case, supporting involvement in pain management approaches can help. This could include helping the patient actively participate in promoting their own well-being by promoting regular exercise, hygiene, good nutrition, and effective interpersonal relationship management.
Validate and acknowledge the patient’s emotions and feelings on their health status.	This helps the patient to be aware that the nurse understands the situation, improving the nurse-patient relationship. Patients who sense nurses’ doubt about their pain may withhold crucial information hindering effective recovery.
Refer the patient to a physical therapist for further evaluation.	Physical therapists play a crucial role in developing an exercise plan tailored to the patient’s needs and condition. Physical therapists also help promote muscle strength and relax tense muscles. This intervention can help improve pain management.
Provide adequate information to the patient about the available options for chronic pain management.	One key reason for the increased burden of pain in the patient’s life is a lack of information and knowledge about chronic pain characteristics and pain management strategies. Explaining pain causes, medications, and alternative pain management therapies can help promote a sense of well-being in patients.
Discuss non-pharmacological pain management strategies with the patient and the family.	Key non-pharmacological strategies to consider could include: · Acupuncture · Acupressure · Cold and heat application · Distraction · Relaxation techniques · Massaging the painful areas · Guided imagery
Explain the need for lifestyle modification to manage pain effectively.	Lifestyle modification plays a crucial role in pain management. Making specific changes such as daily routines, physical environment, work, and chores can help reduce pain and improve the quality of life. For instance, reducing physical strain and modifying workplaces and home environments to promote comfort, including periods of stretching or exercises, can help reduce pain. In addition, getting adequate sleep and engaging in stress-reducing activities can go a long way to alleviate pain.
The nurse should immobilize the affected part to reduce pain.	Restricting the movement of the painful body part could help manage pain. This could involve the use of supportive devices or splints to keep joints in position.
Maximize the patient’s physical mobility.	Retaining function following limited mobility due to pain should be the goal of every nurse. Instructing the patient to use braces, splints, and elastic bandages to keep the client safe is crucial. In addition, instructing the caregivers and patient on proper positioning techniques to help ambulate is crucial.
Recommend self-management education programs (psychoeducation).	Psychoeducation is a crucial approach to pain management. It involves engaging the patients in self-management education programs to help them develop self-care skills resulting in improved quality of life.
Keep the patient informed about all procedures that may cause discomfort.	This will help modify anxiety associated with painful procedures. A detailed description of the procedures and expected discomforts can help prepare the patient hence reducing treatment and mobility-related pain and reducing analgesic use.
Educate the patient about patient-controlled analgesia (PCA).	Gaining control over one’s pain therapy is beneficial to the patient. PCA can help manage painful conditions by helping the patient self-administer opioids with reduced risks of overdoses. This reduces the need for medication and dependence on a nurse for pain relief.
Provide the patient with a calm and quiet living environment.	A brightly lit environment with noises and increased activity can increase the pain. In this case, a quiet, dimly lighted, and calm environment promotes comfort.
Incorporate the patient’s age when planning for interventions.	The patient’s developmental stage and age is a crucial factor that influences pain expression and reaction. In this case, considering age is essential since this will determine the type of intervention appropriate to manage pain.
Encourage positive coping strategies.	Supporting the use of techniques known to alleviate pain is crucial unless they are contraindicated. This could include socializing, seeking solitude, saying a prayer, and distraction.