Pain and Pain Management

Abstract

Nurses specialising in pain management can have a significant role in postoperative pain care. As integral members of the healthcare system, nurses should adhere to evidence-based practice guidelines to ensure optimal patient treatment. This paper focuses on the interplay between professional practice and the clinical setting, enhancing our comprehension of professional and practice-based knowledge advancement. Future studies will further expand our insights into the culture and methodologies of a specific cohort of nurses, ultimately enhancing their expertise and practice in specialised pain management. This paper will unquestionably contribute valuable knowledge to the nursing profession and its practices. From the patients’ perspective post-surgery, effective pain management is closely tied to their overall health and well-being.

1. Introduction

An individual’s subjective experience of pain can be described as the individual’s own description of the sensation and the time at which they report that it occurred. “Believe the patient” is a premise that McCaffery and Pasero state in their book Pain: Clinical Manual [1], and this idea is consistent with that approach. Both the unpleasant sensory and emotional components that are associated with actual or potential tissue damage, as well as the perception of such damage, are included in the concept of pain. The World Health Organisation’s International Classification of Diseases, Eleventh Revision (ICD-11) [2] defines chronic pain as pain that lasts for more than 3 months or that happens repeatedly during that time period.

Nurses who specialise in pain management greatly enhance postoperative pain care [3, 4]. It is imperative that nurses, who are essential components of the healthcare system, adhere to evidence-based practice guidelines in order to guarantee the best possible treatment for their patients [3, 4]. Increasing our understanding of the progression of professional and practice-based knowledge is the purpose of this paper, which focuses on the interaction that occurs between clinical settings and professional practices. In subsequent research, we will be able to gain a deeper understanding of the culture and approaches utilised by a particular group of nurses, which will ultimately lead to an improvement in their level of experience and practice in the field of specialised pain treatment. This research will undoubtedly contribute valuable knowledge that will benefit the nursing profession and its practices. Effective pain management is closely related to patients’ general health and well-being, as they perceive it after surgery.

2. Anatomy and physiology

One of the most common symptoms that can be seen in hospitalised patients is pain [3, 4, 5, 6, 7]. Acute pain usually results from damage to the tissue and lasts only a short while before going away in 3 months as the injured tissues mend. On the other hand, chronic pain persists beyond the healing phase and continues to be experienced long after the individual has recovered from the acute injury or disease. Inherently subjective in nature, pain is a phenomenon that encompasses both physiological and psychological components [8, 9, 10]. It is a multidimensional phenomenon.

An important protective mechanism that involves numerous interacting peripheral and central mechanisms is the somatosensory system’s ability to identify unpleasant and potentially tissue-damaging stimuli. The term “nociception” refers to the brain processes that are responsible for the encoding and processing of noxious stimuli. Nociceptor activation and subsequent conversion into action potentials for transmission to the central nervous system are necessary for noxious stimulus detection. The nociceptive impulses are set off by chemical, thermal, or mechanical injury, which stimulates the nociceptors [8, 9, 10].

Nociceptive primary afferents contain both lightly myelinated A-delta fibres (diameter 2–5 mm) and slow-conducting unmyelinated C-fibres (diameter < 2 mm). These fibres are widely dispersed throughout the body, including the skin, muscles, joints, viscera, and meninges. The fibres go into the spinal cord’s dorsal horn and connect at various locations, including Ad at Rexed laminae II and V and C at Rexed laminae II. On the contralateral side, the substantia gelatinosa, also known as lamina II, is responsible for integrating these inputs, and second-order neurons are responsible for forming the ascending spinothalamic and spinoreticular pathways (Figure 1). The inhibitory interneurons in the substantia gelatinosa are stimulated by the bigger Ab fibres leading “touch” and descending pathways, which in turn suppress the nociceptive inputs from the C fibres. The gate theory of pain is founded upon this concept. Altering the neural route that transports pain from its point of origin at the nociceptor to its interpretation within the central nervous system can be accomplished by the application of a number of different agents [8, 9, 10].

Figure 1.

Physiology of pain 1.

Pain can be either acute or chronic, and it may persist even after tissue repair. Managing pain effectively requires adhering to a number of core principles, including assessing and meticulously documenting pain as well as evaluating the effectiveness of interventions. Surgical pain management is seen as an ethical requirement and a basic human right. Standards for pain management were initially developed by the Joint Commission on Accreditation of Healthcare Organisations (JCAHO) in 2001 [5, 6]. One of these guidelines emphasised how important it is to consider the assessment of pain to be the “fifth vital sign.”

In 1965, Professors Ronald Melzack and Patrick Wall published the seminal “Pain Mechanisms: A New Theory” [9], which laid the groundwork for the Gate Control Theory of Pain. Pain perception is like being a “passive receiver of messages,” according to an expansion of this notion that came out in 2013 [9].

2.1 Types of pain

Various criteria can classify pain, including the physiological mechanisms responsible for it, the level of intensity, the temporal aspects, the specific tissues affected, and the syndromes linked with it [8, 10]. The following are the criteria that are being considered:

1. Pain Physiology: Pain can be characterised as nociceptive, neuropathic, or inflammatory based on the underlying physiological processes.

2. Intensity: Pain severity can be classified as mild, moderate, or severe and is frequently quantified using a numeric pain rating scale ranging from 0 to 10.

3. Time Course: We can classify pain as acute or chronic based on its length.

4. Type of Tissue Involved: Pain can originate in a variety of tissues, including skin, muscles, viscera, joints, tendons, and bones.

5. Syndromes: Certain illnesses, such as cancer, fibromyalgia, migraine, and others, may produce different pain patterns.

6. Psychological state, age, gender, and cultural background can all impact how pain is perceived and managed.

The clinical assessment and management of pain can be aided by the pain classification system. There are three types of pain: acute, chronic, and acute-on-chronic. Chronic pain, in contrast to acute pain, is often persistent, lasting 3–6 months or longer, and has even been characterised as an illness in and of itself rather than just a symptom of a pathological condition. While surgical procedures are the most common cause of acute pain, trauma, and medical conditions, including myocardial infarction and colic, can also contribute to this type of discomfort. Acute pain serves as a protective mechanism to alert the body to impending or existing tissue harm. This causes the action to be interrupted, it draws attention to the location of the damage, and it encourages behaviour in order to get away from the unpleasant stimuli. This syndrome is known as acute-on-chronic pain, and it occurs when a person taking analgesics for chronic pain experiences abrupt, severe flare-ups or breakthrough pain. It is present in 70 per cent of people who suffer from chronic pain.

Pain can range from low to moderate to severe, depending on the context. It is possible that a patient is experiencing more than one kind of discomfort. There may be a combination of nociceptive and neuropathic pain in a particular clinical condition. Both acute and chronic pain are crippling, and a person’s mental health can have an impact on their pain levels. Patients suffering from persistent or unmanageable pain frequently experience severe affective (emotional) disturbances, which is a compelling but usually maladaptive state. More than 20% of the global population experiences chronic pain, and 20% of all physicians’ visits are attributed to this condition. An increasing number of people around the world are unable to work due to chronic discomfort. Many people with chronic pain do not know what causes it. The gradual onset of this condition is accompanied by feelings of powerlessness and despair. Since chronic pain is never-ending and never-going, it increases the risk of psychological and emotional complications, including anxiety and depression, for the person experiencing it. Anxiety and depression can make the discomfort worse. There are situations when pharmacological approaches to the treatment of chronic pain are not successful.

2.2 Pain assessment

The process of assessing an individual’s pain is the first stage of history-taking and physical examination. A thorough physical examination, a detailed medical history, a “pain history,” and an evaluation of any functional impairment or treatment-related side effects are all necessary components of an accurate assessment of acute pain. It is crucial to do assessments at suitable intervals when managing severe pain. It is helpful to differentiate between the various types of pain, since the most likely duration of the pain and the response to analgesic techniques can vary from one type of pain to another. This assessment requires the use of appropriate measurement instruments to ensure consistent evaluation in both restful and active phases [11, 12]. As described in 2010 and 2011 [12] by Richard, Powell, Herr, Coyne, and McCaffery, the PQRST Method for Pain Assessment provides a methodical way to comprehend and treat pain. This strategy includes the following questions frequently posed by healthcare providers:

P (Provoking factors): What causes the pain to become more severe or to be triggered? What causes it to improve or make it worse? Q (Quality): How would you describe the pain’s characteristics? Are there any other ways to describe it, such as tingling, scorching, stabbing, or shooting?

R (Region and Radiation): Where is the pain located, and does it spread to other parts of the body? S (symptoms and severity): How severe is the pain? Does it interfere with your daily activities? Could you please tell me how severe the discomfort is, from 1 to 10? Prior to employing this scale with a patient, it is imperative to elucidate the significance of the numerical values. The numerical values on the scale indicate the level of pain, ranging from no pain (0) to the worst possible pain (10). Healthcare workers frequently describe the 0–10 scale and ask patients to identify the corresponding number.

T (Timing and Treatment): Does the discomfort come and go, or does it occur frequently? Did the onset occur abruptly or progressively? How frequently does it occur, and how long does it last? Is there a particular time of day when the pain is more intense, such as in the morning? Does the pain worsen before or after meals?

Triage: The first foundation for triage in a hospital setting is established by employing guidelines for pain management. This strategy assures rapid service and immediate medical reaction, and it serves as a model for patient care in hospitals. Additionally, it makes communication between the physicians and nurses who are responsible for the delivery of treatment easier.

Measuring pain is complicated because it is hard to define. Assessing the level of pain that a person is experiencing can be rather challenging. To evaluate this, the individual patient’s personal report is typically used to evaluate this. The effects of medication, mood, and sleep disruption on these self-reporting measures are unclear. Hyperalgesia (e.g., mechanical withdrawal threshold), the stress response (e.g., plasma cortisol concentrations), behavioural responses (e.g., facial expressions), functional impairment (e.g., coughing and ambulation), or physiological responses (e.g., changes in heart rate) may occasionally serve as supplementary indicators. One way to increase awareness and use of pain assessment is to record pain intensity as “the fifth vital sign.” is one way to do that. It is important to measure pain regularly and repeatedly in order to determine if analgesic medication is effective over time.

The physiological instrument alone is insufficient for pain measurement. The most effective clinical instrument would have physical (physiological), behavioural, and self-report components. Physiological markers of pain, however, can be extremely helpful in assessing a patient’s pain experience in critically ill and unconscious individuals [8, 9].

Physiological manifestations of pain include the following:

1. Tachycardia may manifest;

2. Alterations in respiratory rate and depth of respiration may occur, manifesting as oscillations, contractions, or a shift in pattern;

3. The development of hypertension may follow;

4. A decrease in oxygen saturation;

5. Sweating;

6. High blood glucose;

7. Poor organ perfusion;

8. Decreased gastric acid secretion;

9. Decreased gastrointestinal motility;

10. Pallor or flushing sensation; and

11. Pupillary dilatation.

The occurrence of neuropathic pain, surgical or other complications, or uncontrolled pain should always cause a re-evaluation of the diagnosis. Consideration should be given to having the case reviewed by a specialist group or acute pain service. While there are multidimensional pain scales, unidimensional scales are more commonly employed for post-surgical pain evaluation due to their practicality. Departmental choice is taken into consideration when selecting from the often-described possibilities (Figure 2). It may be difficult to get accurate self-reports of pain from certain patients, such as those with impaired consciousness or cognitive impairment, very young children, very old patients, or in cases where communication breaks down because of language barriers, reluctance to cooperate, anxiety, or extreme nervousness. In these cases, it is necessary to use alternative pain evaluation tools, such as the FACES visual scale.

Figure 2.

Pain rating scales.

The abbreviation “FACES” is widely used in healthcare settings, especially in pediatric care and pain assessment. This acronym refers to the “Faces Pain Scale,” a popular and easy-to-understand method of measuring the severity of pain, particularly in people who have trouble expressing themselves verbally. From happy or neutral features to faces showing escalating degrees of misery or pain, the Pain Scale usually has a variety of expressions to choose from. The abbreviation “FACES” can be broken down into the following:

1. F – Faces: The faces used in the pain scale are what this refers to visually. These expressions cover a wide spectrum of human emotions, from contentment and happiness to sorrow and distress.

2. A – Assessment: The Faces Pain Scale is designed to measure the intensity of pain. It gives patients a consistent way to express their pain levels by pointing to the face that best fits their emotions.

3. C – Communication: When verbal communication is difficult or nonexistent, the Faces Pain Scale can help patients and healthcare providers communicate more effectively. Instead of only describing their suffering verbally, it lets them show how much they’re hurting.

4. E – Evaluation: Medical professionals can track the evolution of pain levels with the use of the Faces Pain Scale. Providers can monitor whether pain is improving or increasing and alter treatment programs appropriately by comparing the patient’s selected face on the scale during several evaluations.

5. S – Standardization: The Faces Pain Scale offers a standardized way to measure pain, allowing for simpler comparisons of pain levels across various people and environments.

Pain assessment techniques are made more consistent and reliable by this standardization. The Faces Pain Scale is a useful instrument for pain assessment and management in healthcare settings, especially for people who may have trouble verbalizing their pain experiences. The expansion of “FACES” emphasizes its main components and goals.

3. Pain management

It is essential for nurses to make diagnoses in order to properly identify and treat patients who are experiencing pain. The management of pain, particularly in surgical settings, is a multidimensional process [4, 8, 12], and this suggests that postoperative patients may continue to experience difficulties in their recovery. Pain management, which is a fundamental nursing duty, is an essential component of postoperative hospital care. One must be aware of the ways in which nursing practices are influenced by cultural norms and expectations in order to learn how to properly treat pain [4, 12, 13]. It is of the utmost importance to acknowledge that pain that is not treated effectively might worsen and result in more severe acute pain, along with additional negative repercussions [12, 13].

Although medical knowledge has progressed and new ideas on pain physiology and pain management have emerged, the World Health Organisation’s (WHO) analgesic ladder has served as a useful and straightforward framework for pharmaceutical pain management since 1986. Patients who suffer from chronic non-cancer pain (CNCP) should continue to use the analgesic ladder. According to the findings of Yang and colleagues [12] research, the WHO analgesic ladder for cancer pain is not suitable for the management of CNCP at the present time (Figure 3). The updated protocol is structured as a four-step ladder, with integrative therapies being implemented at each level to decrease or eliminate the use of opioid analgesics. Interventional therapies are evaluated at step 3, and if non-opioids and weak opioids are unsuccessful in managing CNCP, strong opioids can be upgraded. It has been suggested as a straightforward and helpful guideline by the WHO for analgesia in previous years, but it is not applicable to the present application of CNCP management. As a means of controlling chronic non-specific pain (CNCP), it is recommended to use a revised four-step analgesic ladder that is in line with the principles of integrative medicine and least-invasive therapies.

Figure 3.

Chronic non-cancer pain.

WHO analgesic ladder states that there are three stages that make up the progression of the level of pain that is experienced. The utilisation of non-opioid adjuncts, such as paracetamol, aspirin, or non-steroidal anti-inflammatory medications (NSAIDs), is the initial step in the process. It is possible to supplement step 1 medicine with weak opioids (such as codeine or tramadol) if the pain remains uncontrolled or is getting worse. Stronger opioids are added to the treatment plan for moderate to severe pain, or for pain that does not go away or gets worse after step 2. The term “multimodal analgesia” applies to each of these approaches. Though used in reverse order in cases of acute pain, the analgesic ladder is an essential component of individual patients’ analgesic plans, along with complementary therapy. There are multiple areas of action for analgesics. There are a variety of painkillers, some of which work locally to reduce inflammation-related pain (e.g., non-steroidal anti-inflammatory drugs; NSAIDs); others modify transmission in the dorsal horn; yet others influence the central component and emotional aspects of pain (e.g., opioids and antidepressants); and still others modify nerve conduction (e.g., local anaesthetics).

There is a correlation between effective pain control and better postoperative mobility, which includes activities such as turning over in bed, sitting at the bedside, standing, and walking. Efficient management of pain results in favourable outcomes on multiple levels, including those for the patient, the care unit that the patient is assigned to, and the hospital as a whole.

Among these outcomes are the reduction of complications and suffering for the patient, the enhancement of the quality of care, the enhancement of interdisciplinary teamwork, the establishment of effective referral procedures, and the development of pain management practices within the nursing team [4, 13, 14, 15, 16, 17]. A decrease in readmissions, a shorter length of stay in the hospital, a reduction in medical costs, and an increase in patient satisfaction are all results experienced by hospitals [14, 15, 16, 17]. Activities that comprise pain management include appropriate nursing interventions, administration of pain medication, and provision of information and guidance. Active listening, demonstrating empathy, and the utilisation of physical measures such as breathing exercises, turning and positioning, wound care, therapeutic temperature applications, and massages are all examples of therapies that may be utilised.

Additionally, psychological and behavioural treatments, such as cognitive-behavioural approaches, stress management, patient and family education, self-management counselling groups, and collaboration with multidisciplinary teams of experts, play an important part in the provision of pain management services. The term “quality” has long been defined by nurses as the observance of quality care standards, yet, patients frequently have an unclear understanding of what constitutes quality treatment [4, 13]. As a means of establishing a common understanding of quality care, this study highlights the significance of enhanced communication between nurses and patients. There is a direct correlation between patient happiness and the likelihood that they will seek additional treatment at a facility that is well-known for providing high-quality care. Patient intent to suggest a facility is of the utmost significance in today’s healthcare environments, which are characterised by intense competition and a strong emphasis on economic factors. It has been found in previous studies that patients and healthcare personnel, such as physicians and nurses, are frequently held responsible for inadequate pain treatment. Possible patient-related obstacles may arise from apprehensions over the adverse effects of pain medicine and a refusal to take prescribed medications.

It is intriguing to consider the possibility that the prevalent patterns and rituals in nursing culture, as highlighted by an intriguing discovery by Chatchumni and colleagues [4], could impede the acceptance of innovative multimodal care models, the utilisation of research, and evidence-based practices. This may help to explain why nurses do not always give hospitalised postoperative patients proper pain management.

A crucial component of postoperative patient care is the management of pain that patients experience following surgery. There can be no moral or ethical justification for failing to alleviate pain. Relieving pain effectively is a crucial component of high-quality care. Timely and consistent pain evaluation, on par with other essential health indicators, together with appropriate intervention by all healthcare professionals, possibly utilising acute pain services, will result in enhanced patient outcomes and satisfaction. This can be achieved by providing instruction, implementing departmental protocols, conducting regular practice audits of practice, and providing feedback to the professionals involved.

According to the Nursing Diagnoses Definitions and Classification [18], nursing diagnoses can encompass, among other things, the following, depending on the evidence that is available:

1. Acute pain related to tissue trauma or injury.

2. Ineffective airway clearance related to severe chest pain, which could impair their ability to clear secretions.

3. Ineffective breathing patterns related to pain and respiratory difficulties may make patients hesitant to take deep breaths.

4. Impaired mobility related to conditions such as fractures or arthritis.

5. Knowledge deficits related to a lack of information.

6. Anxiety related to past experiences.

7. Sleep pattern disturbance related to increased pain.

3.1 Non-pharmacological pain management approaches

Both psychological and physical forms of therapy are available. Therapies address a variety of aspects of the human condition are addressed by therapies. Physiotherapy, heat and cold treatment, massage, relaxation techniques, music therapy, and self-hypnosis are the six components that make up the approach.

Psychotherapy is an effective method for improving self-management skills in the context of pain by addressing the social, emotional, cognitive, and behavioural aspects that cause and contribute to pain-related dysfunction and misery. Chronic pain has the potential to foster the formation of maladaptive thoughts and actions that impair daily functioning, exacerbate psychiatric distress, or extend the duration of pain perception [12, 13, 14, 15, 16, 17, 19, 20].

Cognitive-behavioural therapy (CBT): Both personal thoughts and physical injury can have an impact on one’s perception of pain. One of the cornerstones of CBT is the idea that dysfunctional ways of thinking lead to the perpetuation of distressing emotions and problematic behaviours. Cognitive-behavioural therapy (CBT) relies on the patient’s ability to recognise negative beliefs about pain and substitute them with more constructive ones. Individuals suffering from chronic pain often find relief through cognitive-behavioural therapy (CBT) [12].

Relaxation techniques: These can help you calm down, get rid of stress, and feel less pain. Some strategies that people often use to relax include aromatherapy, which involves using certain scents to alleviate tension and discomfort and promote relaxation. Additionally, it makes use of oils, extracts, and smells derived from flowers, herbs, and trees. During massages, facials, and baths, the ingredients can be inhaled directly into the lungs or applied directly to the body. These techniques involve deep breathing, which is beneficial for relaxation and has the potential to reduce pain.

Guided imagery is a therapeutic technique whereby patients concentrate on mental pictures to induce positive emotions or a state of relaxation. One learns to prioritise the image over their discomfort [13, 14, 15, 16, 17, 19, 20].

Music therapy has the potential to lift spirits and rev up energy levels. By causing the body to release endorphins, it may be able to assist in the reduction of pain. According to Lopez and colleagues [13], music can be used in conjunction with any of the other approaches described, including relaxation and distraction.

Self-hypnosis is a technique that allows a person to focus their attention on something other than the sensation of pain. One strategy is to tell oneself encouraging things, such as how one can ignore or view the discomfort in a positive light [13].

The nursing profession commonly makes use of the following concepts: environment, health, care, humanity, adaptation, and body, soul, and spirit. The term “integrative nursing” describes a style of care that considers the whole person in their unaltered form. The goal of integrative nursing is to treat the whole person, not just their symptoms, by considering the patient in context with their physical environment. In order to research integrated nursing, which is a means of providing patients with aid in obtaining optimal health by utilising both activities and the environment [17], the purpose of this study is to investigate integrated nursing. The body, the soul, and the spirit all benefited from the sounds that were included in the anthology. The use of five guiding principles and standards of practice is the foundation upon which holistic nursing is founded, as indicated by previous research. The objectives encompass a wide range of topics, such as: holistic theory, ethics, and philosophy; holistic care; holistic communication; holistic practice standards that respect cultural diversity and therapeutic settings; holistic education and research; and holistic self-care for nurses. The educational programme for pain management based on evidence greatly enhanced nurses’ understanding of the symptoms, consequences, and treatments for uncontrolled pain. The education programme and pain management algorithm led to an increase in patient satisfaction with pain management, as evidenced by increased ratings on the Healthcare Providers and Systems Pain.

4. Conclusion

The culture among nurses in the field of pain management may impact the postoperative pain care provided. The nurses, who are essential components of the healthcare system, should adhere to the criteria for evidence-based practice in order to provide patients with the highest possible level of care. This study’s concentration on the dynamic relationship between clinical settings and professional practices will improve our understanding of professional development and practice-based knowledge. The results of subsequent studies will enhance our knowledge of one group of nurses’ practices and culture. Acquiring this knowledge will play a crucial role in elevating the consciousness and implementation of pain management within this specialised cohort. This research will undoubtedly generate insights into nursing and its practices. The health and well-being of patients who have just undergone surgery are inextricably tied to proper pain management from their point of view.

Conflict of interest

The authors declare no conflict of interest.