CHRONIC PAIN

(NYERI KRONIS)

Chronic Pain: Unpleasant sensory and emotional experience arising from actual or potential
tissue damage or described in terms of such damage (International Association for the Study
of Pain); sudden or slow onset of any intensity from mild to severe, constant or recurring without
an anticipated or predictable end and a duration of greater than six (6) months.

Chronic pain is often described as any pain lasting more than 12 weeks. The pain may be
classified as chronic malignant pain or chronic nonmalignant pain. Malignant pain is linked top a
particular cause like cancer. In nonmalignant pain, the original tissue injury is not progressive or
has been healed but the patient still experiences pain.

Chronic pain can be mild or excruciating, episodic or continuous, merely inconvenient or totally
incapacitating. Eventually, it becomes more difficult for the patient to differentiate the exact
location of the pain and clearly identify the intensity of the pain. Some may suffer chronic pain
in the absence of any past injury or evidence of body damage. It may limit the persons
movements, which can reduce flexibility, strength, and stamina. This difficulty in carrying out
important and enjoyable activities can lead to disability and despair. Family members, friends,
co-workers, employers, and healthcare providers question the legitimacy of the patients pain
reports because the patient may not look like someone in pain. The patient may also be involved
of using pain to earn attention or to avoid work, commitments, and responsibilities.

The emotional toll of chronic pain also can make pain worse because of the mind-body links
associated with it. Effective treatment requires addressing psychological as well as physical
aspects of the condition.

Related Factors

Here are some factors that may be related to Chronic Pain:

Chronic physical disability

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 Chronic psychological disability

Disease process (compression/destruction of nerve tissue/body organs, infiltration

of nerves or their vascular supply, obstruction or a nerve pathway, inflammation)

Injuring agents (biological, chemical, physical, psychological)

Side effects of various cancer therapy agent

Defining Characteristics

Chronic Pain is characterized by the following signs and symptoms:

Alteration in muscle tone (varies from flaccid to rigid); facial mask of pain

Altered ability to continue previous activities

Anorexia

Atrophy of involved muscle group

Autonomic responses (diaphoresis, changes in BP, respiration, pulse)

Changes in appetite/eating, weight; sleep patterns; altered ability to continue desired

activities; fatigue

Changes in sleep pattern

Depression

Distraction/guarding behavior protecting body part

Facial mask; expressive behavior (restlessness, moaning, crying, irritability); self-

focusing; narrowed focus (altered time perception, impaired thought process)

Fatigue

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 Fear of reinjury

Guarded/protective behavior; distraction behavior (pacing/repetitive activities,

reduced interaction with others)

Irritability, restlessness

Reduced interaction with people

Self-focused

Sympathetic mediated responses (e.g., temperature, cold, changes of body position,

hypersensitivity)

Verbal or coded report or observed evidence of protective behavior, guarding

behavior, facial mask, irritability, self-focusing, restlessness, depression

Verbal/coded report; preoccupation with pain

Weight changes

Goals and Outcomes

The following are the common goals and expected outcomes for Chronic Pain:

Patient demonstrates use of different relaxation skills and diversional activities as

indicated for individual situation

Patient reports pain at a level less than 3 to 4 on a 0 to 10 rating scale.

Patient uses pharmacological and nonpharmacological pain relief strategies.

Patient verbalizes acceptable level of pain relief and ability to engage in desired
activities.

Patient engages in desired activities without an increase in pain level.

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Nursing Assessment

Thorough assessment of Chronic Pain is necessary for the development of an effective pain
management plan. Nurses play a significant part in the assessment of pain, owing to the nature of
their relationship with patients.

Assessment Rationales

Assess and document pain

characteristics:

Quality (e.g., sharp, burning)

Severity (scale of 0 [meaning

no pain] to 10 [meaning the
most severe pain])

Location (anatomical
description)
Patients self-report is the most reliable
information about the chronic pain experience.
Onset (gradual or sudden)

Duration (e.g., continuous,

intermittent)

Precipitating factors

Relieving factors

Assess and note for signs and symptoms
related to chronic pain such as weakness,
decreased appetite, weight loss, changes
in body posture, sleep pattern
disturbance, anxiety, irritability,
agitation, or depression.
Physiological changes and behaviors associated
with acute pain may not be exhibited by patients
with chronic pain. The guarding behavior of acute
pain may become a persistent change in body
posture for the patient with chronic pain. Coping
with chronic pain can reduce the patients energy

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Assess the patients perception of the
effectiveness of techniques used for pain
relief in the past.
Evaluate factors such as gender, cultural,
societal, and religious features that may
influence the patients pain experience
and reaction to pain relief.
Assess the patients beliefs and
expectations about pain relief.
Evaluate the patients approach towards
pharmacological and
nonpharmacological means of pain
management.
Know more about side effects,
dependency, and tolerance (including
alcohol) of patients taking opioid
analgesics.
Determine patients current medication
use.
Evaluate the patients ability to perform
and fulfill activities of daily living
(ADLs), instrumental activities of daily
living (IADLs), and demands of daily
living (DDLs).
Nursing Interventions
The following are the therapeutic nursing interventions for Chronic Pain:
Interventions
Allow patient to maintain a diary of pain
ratings, timing, precipitating events,
medications, treatments, and what works best
to relieve pain.
Recognize and convey acceptance of the
for other activities.
Patients with chronic pain have a long history of
using various pharmacological and
nonpharmacological means to control and
alleviate their pain.
Recognizing the variables that influence the
patients pain experience can be instrumental in
developing a plan of care that is acceptable to the
patient.
Patients with chronic pain may not anticipate
complete relief of pain but may be satisfied with
diminishing severity of the pain and increasing
activity level.
Patients may perceive medications as the only
effective treatment to alleviate pain and may
question the effectiveness of nonpharmacological
interventions.
Drug dependence and tolerance to opioid
analgesics are concerns in the long-term
management of chronic pain.
Obtain a medication history to aid in planning
pain treatment.
The persons ability to complete self-care
activities and fulfill role responsibilities can be
limited by exhaustion, anxiety, and depression
linked to chronic pain.
Rationales
Systematic tracking of pain appears to be an
important factor in improving pain
management.
Conveying acceptance of the patients pain
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 promotes a more cooperative nurse-patient
patients pain experience.
relationship.

The nurse can increase the patients

willingness to adopt new interventions to
Aid the patient in making decisions about
promote pain relief through guidance and
choosing a particular pain management
support. The patient may begin to feel
strategy.
confident regarding the effectiveness of these
interventions.

Explore the need for medications from the

three classes of analgesics: opioids
(narcotics), non-opioids (acetaminophen, Analgesic combinations may enhance pain
Cox-2 inhibitors, and nonsteroidal anti- relief
inflammatory drugs [NSAIDs]), and adjuvant
medications.

The least invasive route of administration

capable of providing adequate pain control is
If the patient is receiving parenteral analgesia,
recommended. The oral route is the most
use an equianalgesic chart to convert to an
preferred because it is the most convenient
oral or another noninvasive route as smoothly
and cost effective. Avoid the intramuscular
as possible.
(IM) route because of unreliable absorption,
pain, and inconvenience.

Because there is great individual variation in

Allow the patient to describe appetite, bowel
the development of opioid-induced side
elimination, and ability to rest and sleep.
effects, they should be monitored and, if their
Administer medications and treatments to
development is inevitable (e.g., constipation),
improve these functions. Always obtain a
prophylactically treated. Opioids
prescription for a peristaltic stimulant to
cause constipation by decreasing
prevent opioid-induced constipation.
bowel peristalsis.

Obtain prescriptions to increase or decrease

analgesic doses when indicated. Base
prescriptions on the patients report of pain
Opioid doses should be adjusted individually
severity and the comfort/function goal and
to achieve pain relief with an acceptable level
response to previous dose in terms of relief,
of adverse effects.
side effects, and ability to perform the daily
activities and the prescribed therapeutic
regimen.

If opioid dose is increased, monitor sedation Patients receiving long-term opioid therapy
and respiratory status for a brief time. generally develop tolerance to the respiratory

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 depressant effects of these agents.

One of the most important steps toward

Educate patient of pain management approach
improved control of pain is a better patient
that has been ordered, including therapies,
understanding of the nature of pain, its
medication administration, side effects, and
treatment, and the role patient needs to play
complications.
in pain control.

Because of the various misconceptions

Discuss patients fears of undertreated pain,
addiction, and overdose.
concerning 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.

Review patients pain diary, flow sheet, and

medication records to determine overall Systematic tracking of pain appears to be an
degree of pain relief, side effects, and important factor in improving pain
analgesic requirements for an appropriate management.
period (e.g., one week).

Maintain the patients use of Cognitive-behavioral strategies can restore

nonpharmacological methods to control pain, patients sense of self-control, personal
such as distraction, imagery, relaxation, efficacy, and active participation in their own
massage, and heat and cold application. care.

Implement nonpharmacological interventions Nonpharmacological interventions should be

when pain is relatively well controlled with used to reinforce, not replace,
pharmacological interventions. pharmacological interventions.

Plan care activities around periods of greatest

Pain diminishes activity.
comfort whenever possible.

Most patients with cancer or chronic

nonmalignant pain are treated for pain in
Examine relevant resources for management
outpatient and home care settings. Plans
of pain on a long-term basis (e.g., hospice,
should be made to secure ongoing assessment
pain care center).
of the pain and the effectiveness of treatments
in these settings.

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If patient has growing cancer pain, assist
patient and family with managing issues
related to death and dying.
If patient has chronic nonmalignant pain, help
patient and family in lessening effects of pain
on interpersonal relationships and daily
activities such as work and recreation.
Validate the patients feelings and emotions
regarding current health status.
Refer the patient and family to community
support groups and self-help groups for
people coping with chronic pain.
Refer the patient to a physical therapist for
assessment and evaluation.
Provide the patient and family with adequate
information about chronic pain and options
available for pain management.
Discuss to patient and family the advantages of using nonpharmacological pain
management strategies:
Acupressure
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Support groups and pastoral counseling may
improve the patients and familys coping
skills and give needed support.
Pain lessens patients options to exercise
control, diminishes psychological well-being,
and makes them feel helpless and vulnerable.
Therefore clinicians should support active
patient involvement in effective and practical
methods to manage pain.
Validation lets the patient know the nurse has
heard and understands what was said, and it
promotes the nurse-client relationship.
This is to reduce the burden of suffering
associated with chronic pain and provides
additional resources like patients support
network.
This is helpful to promote muscle strength
and joint mobility, and therapies to promote
relaxation of tense muscles, the physical
therapist can help the patient with exercises
suitable for his/her condition. These
interventions can influence the effectiveness
of pain management.
Lack of knowledge about the characteristics
of chronic pain and pain management
strategies can add to the burden of pain in the
patients life.
Acupressure is a pain management strategy
which employs finger pressure applied to
acupressure points on the body. Using the
gate control theory, the technique works to
interrupt pain transmission by closing the
gate. This approach requires training and
practice.

Cold applications
Distraction
Heat applications
Massaging of the painful area
Progressive relaxation technique,
guided imagery, and music therapy.
Transcutaneous Electrical Nerve
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Cold application diminishes pain,
inflammation, and muscle spasticity through
vasoconstriction and by limiting the release
of pain-inducing chemicals and regulating the
conduction of pain impulses. This
intervention is cost effective and requires no
special equipment. Cold applications should
last about 20 to 30 min/hr or depending on
the patients tolerance.
Distraction is a pain management approach
that works briefly by increasing the pain
threshold. It should be utilized for a short
duration, usually less than 2 hours at a time.
Prolonged utilization can add to fatigue that
may lead to exhaustion and may further
increase pain when the distraction is no
longer present.
Heat application lessens pain through
vasodilatation that causes enhanced blood
flow to the area and through reduction of pain
reflexes. This demands no special equipment
and also cost effective. Heat applications also
depend on patients tolerance but should last
no more than 20 min/hr. Special attention
needs to be given to preventing burns with
this intervention.
Massage suspends pain transmission by
boosting the release of endorphins and
decreases tissue edema. This intervention
may require another person to provide the
massage.
These pain management methods are
centrally acting that works through reducing
muscle tension and stress. The patient may
feel an increased sense of control over his/her
pain. Guided imagery can aid the patient to
explore images about pain, pain relief, and
healing. These techniques require practice to
be effective.
Pain reduction happens when a mild
electrical current passes through the electrode
 Stimulation (TENS) TENS utilizes then onto the skin. The patient is able to
regulate the intensity and frequency of the
the application of 2 to 4 skin electrical stimulation that depends to his/her
electrodes. tolerance.

Educate the patient and family about the use of pharmacological interventions for pain
management:
These drugs are also beneficial addition in a
Antianxiety agents total program of pain management plan. Its
effects are the same with anti-depressants.
These drugs may be helpful adjuncts in a
total program of pain management. In
addition to their effects on the patients
Anti-depressants mood, the antidepressants may have
analgesic properties apart from their
antidepressant actions.
These drugs are the primary step in the
analgesic ladder. They go by inhibiting the
synthesis of prostaglandins that cause pain in
Nonsteroidal anti-inflammatory
peripheral tissues, inflammation, and edema.
agents (NSAIDs) The advantages of these drugs are not
associated with dependency and addiction
and they can be taken orally.
These drugs lessen pain by binding with
opiate receptors throughout the body. They
work on the central nervous system so the
side effects associated with this group of
drugs tend to be more significant that those
Opioid analgesics with the NSAIDs. The main concern in
patients using these drugs for chronic pain
management are nausea,
vomiting, constipation, sedation, respiratory
depression, tolerance, and dependency.
Changes in activities such as work routines,
Explain the importance of lifestyle
household, and home physical environment
modifications to effective pain management.
may be required to promote more effective pa

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