Introduction
The assessment and management of pain have not only been a controversial topic within the fields of clinical and nursing but have also been dogged by challenges. The particular reasons behind this scenario are not hard to discern. Palliative care presents numerous challenges to the nursing fraternity given the complexity posed by the different types of medical complications. The ability to carry out pain assessment and management determines to large extent the capacity to deal with the effects and symptoms of the disease.
It must be pointed out that unless clinicians and nurses are equipped with skills and tools to assess pain, they may be deprived of the capacity to maintain the pain on patients.
Acute pain is often as lethal as an epidemic. The preceding events and factors that cause it are mostly unpleasant and the fact is it is more widespread than anticipated. Causes of pain consist of serious accidents such as fire or car accidents, physical assaults such as rape as attempted rape, and diseases that affect the natural functioning of the body. Victims of these conditions at times believe that there is no solution but the management of pain involves a proper appreciation of one’s status, developing a trusting relationship with one’s therapist, understanding one’s diagnosis, and stabilizing one’s self at the expense of uncovering the unpleasant memories (Davis, Weissman, & Arnold, 2004).
One must come to the reality that to manage pain, there is the need to understand that the patient is saving his/her life and thus concerted effort must be put to dilute the adverse effects of this pain. This explorative essay seeks to discuss the aspects of pain assessment and pain management. Towards this end, critical enablers and barriers to effective pain assessment and management of pain in a client with an eventually fatal condition will be dissected. In addition to the above, effective approaches to pain management will also form part of this essay, and a strong conclusion is given based on the discussion within this essay.
Overview of pain
Beck (2005) and Hanks Nugent, Higgs, and Busch (2004) define pain as “a sensation that everyone perceives after an injury has occurred to the body.” Most forms of the pains that are perceived by people have theoretical origins from the organic illnesses of the body. Several kinds of literature have provided varying degrees on the analysis of aspects of pain. However, one fact remains clear; the intensity of pain perceived by an individual depends on several factors that are directly related to the levels of injury.
In addition to the above, there are different types of pain. For example, organic pain draws its origin from the psychological nature of human beings. According to Given, Given, Rahbar, Jeon, McCorkle, Cimprich, Galecki, Kozachik, Brady, Fisher-Malloy, Courtney, and Bowie (2004), “pain signals that are transmitted along with neuronal system different than other signals in the nervous system by their ability to sustain the strength of quality and magnitude.”
The concept of pain is understood to arise from the damage caused to tissue which releases chemicals that stimulate pain receptors in the affected parts of the body (Boswell & Cole, 2006). The message is transmitted to the brain through the nerve endings that eventually give a sensation of pain to an individual. Two common types of pain include fast and slow types of pain. The major difference between the two types of pain depends on the time it takes for the pain sensation to be felt. According to Spiegel and Classen (2000), “fast pain develops quickly after an injury such as the one that occurs after a needle injection or knife cut while slow pain develops over a long period and is usually a continuous sensation of pain”
Pain assessment
Effective assessment of pain requires nurses to answer the important question to effectively carry out a thorough process on pain demographics and arrive at a valid conclusion (Modonesi, Scarpi, Maltoni, Derni, Fabbri, Martini, Sansoni and
Amadori, 2005). The knowledge of the type of pain is critical in the process of pain assessment. The types of pain that will be taken into consideration during pain assessment include nociceptive pain, neuropathic pain, psychogenic pain, and mixed category pain.
The symptoms of pain are clustered under three headings; Intrusive recollection of the trauma, avoidance of stimuli associated with the trauma, and disordered arousal (Scott & Stradling, 2006). Every individual has got different levels of nature, intensity, and levels of pain and thus an appropriate assessment would be important in recommending the kind of treatment to be administered. There is no simple cause and effect relationship between the event and subsequent psychological symptoms in that if a group of people undergoes a similar pain process, each person’s experience of that event will be unique and probably very different from that of other members of the group (CREST, 2003).
Greenstein and Breitbart (2000) also buttress this point by demonstrating that “pain therapy always is individualized to meet the specific concerns and needs of each unique patient based upon careful interview and questionnaire assessments at the beginning of (and during) treatment.” The greatest challenge in assessing the responses of the pain comes about as a result of the constantly overlapping and interrelated signs and symptoms of trauma and those of the other related medical conditions (Montagnini, Lodhi & Born, 2003).
Feldman and Periyakoil (2006) demonstrate that for example, problems with concentration and sleep need careful, differential diagnosis to be distinguished from symptoms of anxiety and depression not directly connected to a traumatic experience and the diagnosis is further compounded when pain-related symptoms occur simultaneously with other psychiatric disorders.
These demonstrate the fact that thorough and continuous assessments must be carried out to accurately determine the intensity and levels of pain. In addition to this, overreliance on the conventional and standardized set assessment criteria may lead to a lack of proper identification of critical factors of the disease assessment such as the level of development. Such misjudgments may translate to wrong referrals or delays in the right interventions.
Lunney, Lynn, Foley, Lipson, and Guralnik (2003) elucidated further the purpose of the assessment (whether clinical, research, or forensic) will direct the use of different measures and interview methods. This step must also take into account the cause of the pain behavior in that there are several reasons for pain. Last, good communication etiquette with the client such as direct eye contact, open-minded discussions, and a display of relaxed position and atmosphere would add to the building of trust and quality relationship.
Pain Management
Pain is often characterized by an anxiety disorder that develops in response to a traumatic experience and is characterized by core features of re-experiencing, avoidance behavior, numbing of responsitivity, and hyperarousal (Vasterling & Brewin, 2005). Human beings may try to use their natural ability to avoid the uncovering of unpleasant past life experiences but the underlying truth is that victims of acute pain must seek viable and meaningful counseling and consultative sessions to cope with the effects of this condition.
Once thought of only in psychological terms, pain has emerged as the model of mental disorder for studying the effect of the environment on the human biological system, especially the brain (Kato, Kawata, & Pitman, 2006). Symptoms associated with pain include; re-experiencing the event in varying sensory forms (flashbacks), avoiding reminders associated with the trauma, and chronic hyperarousal in the Autonomic Nervous System (ANS) (Kissane, Clarke and Street, 2001).
The management of pain must focus on the last symptom since those who suffer from this condition demonstrate such behaviors that include increased heartbeat, cold sweating, rapid breathing, and hyper jumpiness. “While such symptoms are commonly understood to be psychological problems, some or all of them may well be related to the physical effects of extreme stress on the brain” (Bremner, 2008). Such abnormal behaviors deprive these people of the ability to have normal sleep.
Exposure to long periods of traumatic pain experiences can have serious adverse effects on one’s life. It is prudent that management of pain begins early at the normal stress response. This will lessen the amount of time and prevent the client from long periods of suffering. The consultation process towards achieving effective pain therapy is a long process that is composed of effective approaches to pain management.
Approaches to Pain Management
Making contact with the consultee
This is the first consultative step in managing pain related to palliative care in the management of pain caused by medical complications such as PTSD. Experiencing trauma is an essential part of a human being; history is written in blood (Van Der Kolk, McFarlane, & Weisaeth, 2006). The counselor must not only strive to develop a relationship with the client but must proceed to develop full trust.
This will create an atmosphere of the sharing and exchange of information between the two parties. “Pain disrupts the functioning of those afflicted by it, interfering with the ability to meet their daily needs and perform the most basic tasks and thus victims have the tendency to withdraw” (Smith, Gomm & Dickens, 2003). There is therefore the need to tactfully engage the client into a long trustworthy relationship that is geared towards achieving the objective. In fact, “victims of acute pain can become extremely restricted, fearing to be together with others or go out of their homes” (Clarke & Kissane, 2002).
They demonstrate high levels of fear, panic, and the tendency to flashback, actions that lead to constant self-isolation. The counselor must make the client feel comfortable and at ease in his/ her presence to reduce loneliness and develop a feeling of appreciation. Such are the benefits of developing a quality relationship with the client and constitute the first meaningful step in the administration of therapy.
Developing the quality relationship between the counselor and the client involves the ability to let the client understand the duty to lead a normal life free of trauma lies in his own hands especially when dealing with psychological pain. This relationship should seek to enable the client to consider the counselor as a role model. To take this trust to a further level, the counselor must be able to demonstrate that he/she is capable of effectively counseling a traumatic individual affected by constant pain.
This can be done by relevant and available examples that the client can be able to see. Such will act as proof to the client that the counselor is capable of handling his/her condition. Due to the sensitivity of the matter, the counselor can win the trust of the client by adhering to high levels of confidentiality. Clients can never feel safe if their medical conditions are not kept confidential.
Defining the Plan and Goal Setting
How people react to pain is influenced by a whole range of factors including the nature, severity, and meaning of the traumatic event, and factors in the individual such as his or her personality, previous history, experience, support, and subsequent experience (O’Brien, 1998). Scott, Stradling, and Dryden (1995) elucidate this fact further by stating that cognitive-behavioral counseling takes note of the everyday observation that people respond differently to the same situation. After the process of a thorough assessment, goals, and objectives of the treatment actions are set so that they remain achievable. In a pain therapy administration of a patient with acute pain, there is a need to first understand the position of the client and appreciate the possible causes of pain.
In defining the plan and goal setting, there are fundamental questions that must be answered. Are the set goals in line and relevant with the cause of the pain? Are the plans coherent, relevant, and workable? In the determination of a workable plan, the objectives of the treatment can be achieved. This plan must take into consideration the duration required for the treatment, monitoring, and evaluation strategies and techniques of its proper implementation. In the planning process, the goals for the retrieval of the unpleasant pain memories must be well explained to make the client understand the role of these retrievals in achieving the counseling objectives.
To emerge with deeper understanding insights, we must learn to appreciate that every plan must be variable to events causing the pain (Hobfoll, & De Vries, 1995). “Pain treatment typically begins with a detailed evaluation and development of a pain therapy plan that meets the unique needs of the patient” (Hogan & Patertson, 2006). In settings with a plan and goals that are focused on the exploration of the deep root causes of the trauma, the counseling and treatment sessions become effective and effortless. These goals become achievable within a limited period. Hwang, Chang, Fairclough, Cogswell, and Kasimis (2003) expound that “the goal of trauma-focused exploration is to enable the patient to gain a realistic sense of self-esteem and self-confidence in dealing with pain”
Interventions and Strategies
Counselors are better equipped with relevant and effective interventions and strategies that seek to fulfill the goals and laid down plans of the treatment. Is there evidence in support of the fact that early intervention is effective? (Institute of Medicine of National Academies, 2009). By having the knowledge of intensity, type and cause of the pain, the next question a consultant must appropriately answer is how easy or difficult the intervention or strategy will be accomplish (Bercovitch & White, 2004) This constitutes the important elements of the amount of work involved and the time this work will be successfully completed.
The interventions and strategies must also be in line and relevant to the type kind of pain under consideration. A good therapist must be very flexible, interventions and strategies must be flexible too and the overall decision to uncover unpleasant memories must remain relevant with the situations of a client.
Implementing the strategies constitutes the next step in this procedure. This process must encompass the elements of recovery and will eventually determine the next path to take. It then defines the term “recovery” and determine the level at which the development of quality relationship with the client, the treatment plans and counseling. In case of a partial or full recovery, is there the need for the treatment to proceed and what benefits would such a decision be to the client (Movsas, Chang, Tunkel, Shah, Ryan & Millis, 2003).
The evaluation of the results of all the actions taken to ascertain whether the desired results have been achieved must be done. This is done through the measurement of the levels of withdrawal, anger, feelings of loneliness and the ability to mix freely with others. This step must demonstrate that barriers to effective healing process have been overcome.
Historical and basic differences such as in cultural values and the impact of stigma have all been left aside by the application of practical strategies. Furthermore, peer self help can be used to evaluate the effectiveness of the consultation process. This involves the use of other individuals who have gone through the similar experience and have recorded positive improvements in their lives. This class of people can act as role models or yardsticks for the measurement of the ability to improve. Peer self-help, peer advocacy, “warm lines”, and other supports help establish a sense of safety; trust, and sense of community- one is not alone (Hogan & Patertson, 2006).
The consultation termination forms the last step in the consultation process. A final review of the overall results of the consultation process will then determine whether this stage has been finally arrived at. Evidence must support that the consultation process has been effective and its impacts must be easily observed. The need for further re-examination for any relevant symptoms must be undertaken. The quality relationship between the consultant and the consultee comes to an end and the consultee can then embark on journey of normal life. Consultation window must still remain open for a chance to share and exchange ideas on the development of the consultee in efforts to fit in to new life.
Conclusion
There have been tremendous and positive efforts to deal with the adverse effects of pain but further efforts must still be put to shorten the gap that exists between research and practice so that best practices in handling this condition are implemented. Counselors and therapists must lead the pack in making efforts to reduce the pain victims undergo. It is worth appreciating and noting that the amount of psychological distress these individuals undergo is great and as such pain is recognized more than it is today as a significant heath problem.
In addition to the above, correct and consistent compilation of epidemiological data on the cases of pain would help avail the statistics of this condition, reveal the chief root causes and thus adequately provide the knowledge needed for its proper handling. Further training and increase in the number of qualified therapists would make their services readily available and thus prevent most of these cases rather than seeking a long term cure interventions. Lastly, counselors, institutions and therapists must institute clear and workable policies, plans, strategies to effectively minimize the effects of pain.
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