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Principles of Nursing: Palliative Approach

Introduction to Pain Management

The main objective of palliative care is to mitigate the affliction of the patients along with their families by the inclusive evaluation and treatment of the physical, spiritual, and psychosocial symptoms that have been experienced by the patients (Sholjakova et al., 2018). Pain is considered as one among the most dread symptoms of an advanced, rapidly growing disease and dying. It is the most common but not necessarily experienced in case of both non-malignant and advanced malignant conditions. A patient-centred approach involving systematic and thorough assessment, management and regular review can provide pain relief for most patients (Tredgett, 2019). The palliative care focuses on providing the comfort as well as the prevention from the suffering of the patient’s extreme health issues. However, the treatment of the pain pertain an integral part of the palliative care. An adequate pain management helps in attaining an improved quality of life for the patients as well as their families (Sholjakova et al., 2018).

Target Audience and Rationale for Resource

The target audience of this booklet is third year undergraduate students and new graduate nurses. It will help them in understanding various underpinning concepts of the pain management.

Learning Objectives

1. Pain management

2. Significance of pain management

3. Principles in Palliative care

4. Approaches to pain control palliative care

5. Pain management strategies

6. Effective pain management in terminally ill people

7. How National palliative care standards help in the pain management?

Pain and its types of pain

Pain is the unpleasant sensory and disturbing experience that is related with either actual or potential tissue injury (Smith et al., 2018).

Pain Management

Pain is something that will affect any individual adversely in a direct way or in an indirect way and have the potential to reduce the process of healing if the person is already dealing with some other disorder. It has often been seen that untreated extreme pain results in comorbid situation where along with the disorder and the associated pain there comes some mental disorder too (Tompkins, Hobelmann & Compton, 2017). However, this situation could be managed if proper pain management is done. Adequate pain management under palliative care potentially results into the preclusion of some additional health complexities, the facilitation of healing, and also enhances an individual's quality of life. Pain management focuses on all of the aspects of pain such as the cause of pain and potential treatment that can help in treating that pain and potential causes of that pain (Tompkins, Hobelmann & Compton, 2017). This is done by focusing on the subtle surgical measures, some pharmacological as well as non-pharmacological therapies etc. Pain management is an umbrella term that entails various methods in it. These methods are framed in such a way that it could potentially prevent, reduce, or stop the sensations of pain. It could be by using psychosomatic methods; medications, or physical methods Mwanza, Gwisai & Munemo, 2019).

Significance of Pain Management

The importance of Pain management lies in its roles and the major roles that pain management in palliative care plays are:

  • In improving the quality of life of those who are dealing with some extremely pain causing or severe illness.
  • Pain often hinders a person from doing the regular activities so; appropriate pain management will help such persons in actively participating in pain management (Colvin, 2017).
  • Pain often results in comorbidity of a person’s physical disorder or illness with some psychological illness this leads to worsening of the health of a person and affects the desired health outcome so; pain management will help in preventing the psychological stress that is caused by the pain and helps in preventing the comorbid situations along with fast healing (Gauntlett-Gilbert & Brook, 2018).
  • Effective pain management also helps in maintaining the functional abilities of a person dealing with pain that was hindering him from doing physical activities from a long time (Colvin, 2017).

Principles in Palliative Care

  • High quality
  • Patient-oriented, rather than disease-oriented care
  • Cost effective care
  • Multidisciplinary team (Effective teamwork)
  • Holistic in approach

Approaches to Pain Control Palliative Care (Source: Umberger, 2018)

  1. Systematic assessment of pain by a proficient and knowledgeable clinician:
  • History
  • Physical Examination
  1. Stop here:
  • Discussion regarding the objectives of care, expectations, optimism, and anticipated course of illness with the patient and his family. This will persuade the concern of investigations as well as interventions.
  1. Investigations:
  • CT
  • X-Ray
  • MRI, etc.
  1. Treatments:
  • Pharmacological methods
  • Non-pharmacological methods
  • Interventional analgesia
  1. Continuing the re-evaluation and review of:
  • Options
  • Goals
  • Expectations

Pain Management Strategies

Pain management strategies are the ways in which one can treat the pain and it could be pharmacologic and non-pharmacologic as well (Worley, 2016).

Non- pharmacologic:

The non- pharmacologic ways of pain management entails some nursing interventions with the objective of providing relief from pain to the patient. The first step involves is the assessment of pain which is done by using the pain assessment scale. This scale is used in identifying the pain intensity, assessment and recording that pain. This tells about some of the important features of the pain as documented by Maciel et al. (2019) such as:

  • Pain intensity
  • Quality
  • Location
  • Duration
  • Frequency

The non-pharmacological ways of pain management includes:

  • Acupuncture
  • Behavioral therapy
  • Cognitive therapy
  • Meditation/relaxation
  • TENS
  • Guided imagery
  • Therapeutic massage

Pharmacologic:

When pain management is achieved with the help of medications then this type of strategy is known as pharmacologic strategies of pain management. In case of extreme pain that cannot be treated by simply distracting the person or any other non-pharmacologic ways, pharmacologic ways is used as the drugs and medicines administered for pain works efficiently. This will work exactly in a way that will help in resolving the pain if it is administered in a way the clinician has prescribed regularly or alternatively at right time (Guerriero et al., 2016). It should not be hold back by thinking to consume it until the pain gets worse. The care plan in case of pharmacologic methods for pain management might not just involve a single drug but can also be prescribed in combination of some other pain medicine also. Examples of some pharmacologic agents are:

  • Opioid analgesic agents
  • Lidocaine
  • Nonsteroidal anti-inflammatory drugs
  • Local anesthetic agents
  • Tricyclic antidepressant agents
  • Antiseizure medications agents

Note: All these drugs are administered on some principles according to the type of drug and severity of the patient.

However, these methods must be focused on addressing the patient’s concerns as it has been concerned as one of the most important attribute of pain management (Hemmingson et al., 2018).

Therapeutic Limitations

  • Unpredictable reaction or response to a treatment
  • Lack of clinical depiction of the pain syndromes
  • Limited time is there to get the things right
  • Occurrence of numerous pain in a single patient
  • Wide-ranging frailty
  • Co-morbidities
  • Drug side effects
  • Average of six non-pain symptoms

Effective Pain Management in Terminally Ill People

Effective pain management strategies in case of terminally ill people require:

  1. To understand which pain control strategies must be used
  2. Ongoing assessment
  3. Diagnosis of the pain
  4. Breakthrough pain aid
  5. Fine alterations in medications
  6. Opioid rotation
  7. Untreated psychosocial issue can bring out a great impact on the pain management
  8. The multidisciplinary approach for the management of such includes the utilization of one or even more treatment strategies. This comprises of five broad treatment groups. These implications of them can potentially result in to the best practices. These categories for the treatment are:

Treatment categories

  1. The effectual multidisciplinary management in correspond to the possible complicated attributes for the pain management of terminally ill people should be based on the biopsychosocial care model.
  2. The healthcare systems as well as the healthcare professionals must focus on the pain management preferences and needs of the susceptible populations that are confronted with the exclusive challenges associated terminal illness. This should have include some racial as well as ethnic populations such as children/youth, active duty military, women, pregnant women, older adults, individuals dealing with terminal illness or some chronic relapsing pain illness such as veterans, reserve service members, sickle cell disease, and the cancer patients that are in need of palliative care.
  • However, there is still a need of some more care models. This could be done by effectively educating as well as providing training to the nurses regarding the pain management of terminally ill individuals.

Goals of Pain Management

  • Reducing the intensity of pain
  • Improving the mood, sleep, and the interaction with people
  • Enhancing the physical functioning
  • Proper Use of Medication
  • Impending back to work and normal daily actions

How National Palliative Care Standards Could Be Helpful in The Pain Management?

The National Palliative Care Standards could be helpful in the pain management as it can articulate and promote a vision for the compassionate and appropriate specialist palliative care. The Standards could also be helpful in the recognition of the significance of patient-centered along with focusing on age-appropriate care. This can also help in the organization the pain of the patient competently. Specifically, the standards help in understanding the importance of focusing on to the preferences and the requirements of particular attention of the people who are at risk. This entails some values that come under the National Palliative Care Standards (Schroeder & Lorenz, 2018). They are:

  • Endeavoring for maintaining the dignity of the patient, his family, health care professional, the system, and caregiver
  • Assessing the potency as well as the limitations of the healthcare professionals, patient, and his family, and health care system for empowering them as well working accordingly
  • Working and providing the care with compassion towards the patient
  • Signifying the respect for the patient
  • Focusing on the equity in the expediency of the services along with the provision of resources
  • Sponsoring on the behalf of the articulated needs or desires of the patients and its family
  • Assuring to the detection of excellence in the provision of care
  • Being accountable towards the patents and its family

References for Pain Management

Guerriero, F., Bolier, R., Van Cleave, J. H., & Reid, M. C. (2016). Pharmacological approaches for the management of persistent pain in older adults: What nurses need to know. Journal of Gerontological Nursing42(12), 49–57. https://doi.org/10.3928/00989134-20161110-09

Hemmingsson, E. S., Gustafsson, M., Isaksson, U., Karlsson, S., Gustafson, Y., Sandman, P. O., & Lövheim, H. (2018). Prevalence of pain and pharmacological pain treatment among old people in nursing homes in 2007 and 2013. European Journal of Clinical Pharmacology74(4), 483–488. https://doi.org/10.1007/s00228-017-2384-2

Maciel, H., Costa, M. F., Costa, A., Marcatto, J. O., Manzo, B. F., & Bueno, M. (2019). Pharmacological and nonpharmacological measures of pain management and treatment among neonates. Revista Brasileira De Terapia Intensiva31(1), 21–26.

Mwanza, E., Gwisai, R. D., & Munemo, C. (2019). Knowledge on Nonpharmacological Methods of Pain Management among Nurses at Bindura Hospital, Zimbabwe. Pain Research and Treatment2019, 2703579. https://doi.org/10.1155/2019/2703579

Schroeder, K., & Lorenz, K. (2018). Nursing and the Future of Palliative Care. Asia-Pacific Journal of Oncology Nursing5(1), 4–8. https://doi.org/10.4103/apjon.apjon_43_17

Sholjakova, M., Durnev, V., Kartalov, A., & Kuzmanovska, B. (2018). Pain relief as an integral part of the palliative care. Open access Macedonian Journal of Medical Sciences6(4), 739–741. https://doi.org/10.3889/oamjms.2018.163

Smith, C. A., Levett, K. M. , Collins, C. T., Armour, M., Dahlen, H. G., & Suganuma, M. (2018). Relaxation techniques for pain management in labour. Cochrane Database of Systematic Reviews, 3. doi: 10.1002/14651858.CD009514.pub2.

Tompkins, D. A., Hobelmann, J. G., & Compton, P. (2017). Providing chronic pain management in the "Fifth Vital Sign" Era: Historical and treatment perspectives on a modern-day medical dilemma. Drug and Alcohol Dependence173 Suppl 1(Suppl 1), S11–S21. https://doi.org/10.1016/j.drugalcdep.2016.12.002

Tredgett, K M. (2019). Pain control in palliative care. Physical Problems, 48(1), 2-8. https://doi.org/10.1016/j.mpmed.2019.10.003

Umberger, W. (2018). Complementary and integrative approaches to pain and patient preference. Pain Management Nursing, 20(1), https://doi.org/10.1016/j.pmn.2018.11.059

Wendling, L., Glick, W., & Tighe, P. (2017). Goals and Objectives to Optimize the Value of an Acute Pain Service in Perioperative Pain Management. Techniques in Orthopaedics (Rockville, Md.)32(4), 200–208. https://doi.org/10.1097/BTO.0000000000000245

Worley, Susan L. (2016). New directions in the treatment of chronic pain: national pain strategy will guide prevention, management, and research.” P & T: A Peer-Reviewed Journal for Formulary Management, 41(2), 107-14.

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