Management strategies for adult patients with pain in outpatient clinics
Introduction
The current study describes a framework that applies systems thinking to the issue of under-management of chronic pain in outpatient hospitals. It expands the nursing focus from individual patients to the healthcare system. Consequently, the study investigates the various strategies of chronic pain management and formulates an effective approach for addressing under-management of chronic pain. Subsequently, it discusses the application of the scheme in a Chronic Pain Management Program. The formation of the management program is significant to the advanced nursing practice because it has the potential to ameliorate the care of all patients at a system level. Therefore, system care can accelerate the improvement of healthcare safety, as well as quality.
Chronic pain describes a persistent pain that fails to respond to conventional methods of medical management. Such persistent pain interferes with normal activities and interrupts sleep. It occurs in patients with chronic illnesses such as HIV/AIDS and, therefore, lacks easy solutions. Chronic pain is also experienced after surgery. Vadivelu, Mitra, and Narayan (2010) suggested that 80 % of surgery patients are exposed to postoperative pain with about 20 % experiencing very severe pain. Although analgesics and national guidelines for managing pain are widely available, the level of postoperative pain remains stable (Vadivelu, Mitra, & Narayan, 2010). Hence, pain associated with diagnostic and surgical procedures is common in medical institutions and remains inadequately controlled. The present investigation, therefore, presents a management plan that is expected to control chronic pain among patients, particularly in outpatient infirmaries.
Dealing with a chronic pain requires hard work, patience, and a willingness to alter one’s way of life. It also requires understanding and change on the part of relatives, as well as the participation of skilled health professionals (American Society of Anesthesiologists (ASA), 2010). When a patient is in pain, nothing else apparently matters. Pain, whether a dull or intense aching, interferes quickly with the ability to function normally. However, many persons living with chronic pain have become used to physical distress. For example, over one in five Americans endures pain daily to the point where it interferes with their usual activities (Mozes, 2014). The principal types of pain reported in outpatient clinics may include arthritis, muscle pain, lower back, joint/bone pain, as well as fibromyalgia (Ozer et al., 2013). In time, however, chronic pain quickly leads to isolation, depression, and anxiety. Often, friends and relatives fail to understand the hardships of suffering individuals. Therefore, chronic pain causes the loss of self-esteem in the patient.
Nevertheless, chronic pain can take on different forms or change locations and intensity in the same individual. Moreover, complaints of cancer pain, migraines, and headaches are very common in the outpatient centers. Usually, the lack of efficient long-term solutions exacerbates the difficulty of managing chronic pain (Kaye et al. 2014). Therefore, the present study is significant in the nursing practice because it develops a pain management intervention that will be effective in handling chronic pain in adult patients. The approach combines a variety of non-drug interventions, as well as strategies that utilize drugs.
My Goal: Strategy to Improve Pain Management, For Example in Cancer and HIV Patients
Possible management strategies
A practicing nurse can use various strategies to solve the issue of chronic pain among adult patients. For example, the prescription and over-the-counter drugs are popular strategies for treating chronic pain (Dahi-Taleghani et al., 2014). Consequently, nearly 60 percent of pain sufferers rely on prescription drugs while a relatively higher percentage of patients use over-the-counter drugs. The pharmaceuticals, however, are linked to several side effects and may cause lingering pain (Scherrer et al., 2014). Hence, chronic pain management involving pharmacological intervention is often inadequate. Usually, physicians are loath to prescribe sufficient analgesic treatment due to the fear of causing drug addiction (Tse et al., 2010). Non-pharmacological interventions, therefore, can be appealing in the reduction of pain-induced distress.
Non-drug strategies cover a broad range of physical modalities and interventions. They include education programs, exercise programs, cognitive-behavioral therapy, acupuncture, chiropractic, transcutaneous nerve stimulation, and thermotherapy (Tse et al., 2010). Other non-drug techniques for alleviating the pain linked to chronic illnesses include imagery, massage, relaxation, and distraction (Eccleston, Morley, & Williams, 2013). Hospitalized patients sometimes use non-pharmacological techniques to manage different forms of postsurgical pain. Therefore, the psychological effect of such methods provides a relief that is free of side effects (American Psychological Association (APA), 2014). Nearly 28 % of patients in outpatient clinics use nondrug approaches during the first three days after surgery. Moreover, patients with pain may use a variety of nondrug interventions spontaneously. However, nurses should be aware of the preferred and practical techniques for pain alleviation before instructing patients in the use of nondrug techniques. Usually, patients are unable to use an assigned pain relieving method because of its failure to match their usual coping style. Apart from applying a wrong technique, teaching a particular method to patients may lower their confidence in the methods they commonly use to control pain.
For several years, nurses have utilized nondrug interventions to help patients manage their pain. The methods have been labeled in different ways over the years. Thus, nondrug, noninvasive, complementary, and non-pharmacological care have been used interchangeably to refer to nonmedical therapies. The techniques can be viewed as either physical or cognitive. Cognitive approaches focus primarily on the mental functions and require a level of attention. Focusing attention away from the pain is one of the primary mechanisms that bring pain relief in cognitive techniques. The category includes relaxation (Subedi & Grossberg, 2011) and the use of music (Guetin et al., 2012). In contrast, physical strategies concentrate on altering physiological processes with the aim of reducing pain. Such techniques include massage, as well as the application of cold and heat presses (Healthline Editorial Team, 2014). A possible action mechanism for heat, cold, and massage therapies is that a stimulation effect on the large-diameter fibers hypothetically reduces central pain transmission. Another response mechanism is that lowering muscle tension helps to reduce pain transmission (Healthline Editorial Team, 2014).
There are numerous schemes for achieving the relaxation response (Subedi & Grossberg, 2011). Some techniques require initial training for efficient utilization, but others require autogenic training, as well as systematic and progressive muscle relaxation skills. A session involving systematic, continuous, or autogenic training takes about 15–30 minutes. The instructions are often delivered through an audiotape, which makes the technique suitable for both hospitalized patients and outpatients (Subedi & Grossberg, 2011).
Pain intervention through music is often delivered through earphones (Guetin et al., 2012). Usually, the duration is 20–30 minutes and involves a single or multiple exposures. Guetin et al. (2012) conducted a study to evaluate the significance of music intervention during the chronic pain management. Their results confirmed the usefulness of the technique in handling depression, anxiety, and chronic pain (Guetin et al., 2012). In addition, the intervention allowed a reduction in the intake of drugs and, hence, managed chronic pain effectively.
Nurses often use massage to relieve various forms of chronic pain. Massage is the systematic soft-tissue manipulation performed either mechanically or manually. Nurses conduct hand and foot massage for 5-20 minutes to ameliorate blood circulation, comfort, and sleep. Consequently, the technique offers relief from pain and reduces anxiety.
The application of ice or heat to enhance comfort is a standard nursing intervention that may require a physician’s order in order to implement (Healthline Editorial Team, 2014). Cold treatment, however, is useful for acute pain while heat application helps to relief chronic pain. As a result, thermotherapy increases the blood supply to various organs and stimulates toxin elimination (Healthline Editorial Team, 2014). Therefore, it is relaxing and helps to reduce the effects of chronic pain.
Strategic Focus
Conventional approaches to handling chronic pain have clung to a biomedical model, with little participation of the patient’s family members (Turk et al. 2010). Hence, they are often ineffective in providing adequate relief from chronic pain. Various aspects mediate the effects of persistent pain in the patient. Such factors include genetics, socioeconomic and environmental resources, previous learning histories, and physical pathology (Turk, Wilson, & Cahana, 2011). Therefore, the high treatment costs associated with chronic pain requires the development of comprehensive interventions that utilize the model of bio-psychosocial care (Stanos, 2012).
The strategy described in the present study is a multimodal approach, which will include a combination of various strategies aimed at controlling pain. The method will utilize anti-inflammatory and non-steroidal drugs, as well as non-pharmacological approaches. The non-drug methods will involve relaxation, music, massage, and thermotherapy. Next, an advanced nursing practitioner will initiate a Chronic Pain Management Program based on the multimodal method of managing chronic pain.
The Pain Management Program will provide education on disability and chronic pain management to the affected parties. In addition, it will increase activity level among adult patients with chronic pain, improve fitness level, and ameliorate emotional functioning. The strategy will not cure the pain; instead, it will enhance the patients’ ability to manage chronic pain, and progressively increase activity levels at home or in the community. Eligible persons will include mature patients referred to the program by a physician. Other suitable patients will include grownups experiencing continuous pain. Moreover, adult patients examined thoroughly and proven non-responsive to the usual medical treatments will be eligible.
Patients referred to the program will be required to attend a 90-minute Information Session whose purpose will be the provision of detailed knowledge regarding the self-management approach to dealing with pain. The course will allow patients to make informed choices regarding their participation. In addition, patients will complete a Pain History Questionnaire during the session. After completing and returning the Questionnaire, patients will undergo various assessments by qualified medical personnel. Next, they will be scheduled to attend an Assessment Week in groups of up to five participants. The week will run from Monday to Thursday, between 12:35 p.m. and 4:15 p.m. In the Assessment Week, patients' readiness and suitability for pain management will be evaluated. Moreover, the week will allow patients’ exposure to a pain management education and an opportunity of interacting with patients in a similar condition. However, patients who wish to discontinue their participation will receive alternate recommendations. The pain management program will last for three weeks; however, the extension of the period will depend on the participants’ requirements. The present program, nevertheless, will commence on Mondays and end on Fridays. It will also operate from 8:35 a.m. to 2:15 pm. In addition, the program activities will occur in groups comprising of up to twelve participants.
Patients will be expected to take part in various activities and attend the program daily. Therefore, they will attend all sessions and conduct readings during the off hours. After the sessions, the patients will practice the learned strategies with relatives and friends at home. However, the program will incorporate accommodation facilities for the patients with literacy issues. Such facilities will allow the patients access to adequate information regarding pain management. In addition, patients who live far from the medical center will be provided with various options for accommodation. For example, insurance companies will provide the patients with funds to cover accommodation, meals, and transportation costs.
A family session will be held in the evenings. During the course, spouses, other relatives, and friends will be invited to participate. The family session will help family members in the mastery of the multimodal strategy for managing the different cases of chronic pain.
Strategy evaluation
The establishment and maintenance of an institutional pain management plan is a requirement of the Joint Commission. Medical institutions should establish interdisciplinary approaches to chronic pain management with detailed lines of responsibility aimed at achieving excellent control of chronic pain (Noe & Williams, 2012).
An evaluation of multimodal approaches to the management of chronic pain has revealed a significant success rate. In a study involving 108 patients suffering from chronic pain, a multimodal method was used to manage their pain (Noe & Williams, 2012). The patients were exposed to multiple sessions involving physical therapy, cognitive behavioral therapy, group education, and occupational therapy. At program enrollment, completion, and long-term follow-up, the researchers recorded changes in emotional stress, pain severity, sleep patterns, and perceived control of pain (Noe & Williams, 2012). The follow-up, one year later, showed significant improvement in the patients’ ability to manage chronic pain.
Similarly, the multidisciplinary approach described in the present study includes an individualized, as well as system plan for managing chronic pain. The method’s application will involve the collaboration of patients, relatives, nurses, and other medical staff. Information systems will monitor pain management through alerts that will inform the clinician in the event of inadequate pain management. For example, in a medical institution equipped with a computerized system of documentation, alerts will pop up when the chronic pain experienced by the patient exceeds a particular threshold. Either the patient or clinician will set the verge required to trigger an alert. The limit will range from a moderate to severe sensation of pain. Therefore, the pain that will alert the nurse will have a pain score of above 4 on a scale of 0 to 10.
The plan of system care will provide a basis for quality monitoring of the chronic pain management scheme. The American Pain Society developed one of the first programs aimed at assessing the quality of pain control systems. The guideline, however, was later expanded and refined (ASA, 2010). Consequently, it shifted emphasis from management processes to the outcomes of a management plan. Based on the guideline, the effectiveness of the present management plan will be determined by its:
• Recognition and prompt pain treatment
• Involvement of patients, as well as families in the pain management plan
• Improvement of treatment patterns
• Reassessment and adjustment of the pain management scheme as needed.
• Monitoring of processes and effects of the pain management
Primarily, the objective of a pain management scheme after surgery is to prevent or control pain. Several hours after surgery, postsurgical pain, such as cancer pain, is expected to occur continuously. Next, spikes of increased pain that result from movements, ambulation, coughing and deep breathing follow the postsurgical pain. Therefore, the current management plan will recommend around-the-clock dosing during the early postsurgical period in order to control persistent pain and prevent severe pain.
The quality indicators for the pain management system will concentrate on the appropriate use of analgesics, as well as their impact on pain. The indication of quality will involve:
• Documentation of pain intensity using a descriptive (mild, moderate, severe) and numeric (0–10) rating scale
• Documentation of pain intensity at frequent intervals
• Treatment of pain through routes other than intramuscular
• The treatment of pain with regularly administered analgesics, as well as the nondrug approach
• Prevention and control of pain to a level that improves the quality of life
Patient satisfaction with the pain management plan will define the effectiveness of a multimodal strategy, as well as the quality of care at the system level. The quality indicator will be assessed at both the system and individual levels because of the difficulty in the interpretation of patient satisfaction.
Conclusion
The implementation of a multimodal strategy at the system level will enhance the quality of healthcare in the management of chronic pain. An advanced nursing practitioner will combine both analgesic and nondrug techniques to ensure adequate management of the chronic pain experienced by adult outpatients. Moreover, an evaluation of the multidisciplinary intervention indicates that it is highly efficient because it includes different techniques aimed at alleviating chronic pain. Nondrug techniques are associated with minimal issues of safety and are relatively less effective on their own. In contrast, the interventions that involve the use of drugs are efficient. However, the continuous consumption of various pharmaceuticals increases the risk of harmful side effects. Therefore, the multimodal technique will reduce the issues of safety and side effects. In addition, it will increase efficiency in chronic pain management through a combination of analgesics and non-pharmacological approaches.
References
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