Page 113 Complete Your CE Test Online - Click Here Treatment of acute pain The goal of acute pain management is to treat the underlying cause and interrupt the nociceptive signals traveling to the brain (Grichnik & Ferrante, 1991). Acute pain indicates an underlying issue; therefore, proper assessment is necessary to effectively diagnose and treat the cause. Opioid and nonopioid medications are effectively utilized in those experiencing acute pain. Opioids may be used for moderate to severe pain; nonopioid analgesics should be used for mild to moderate pain. The risk of becoming dependent on opioid medications is considered low for those experiencing acute pain (Copstead & Banasik, 2013). However, there is an association of opioid use disorder in patients prescribed high dosages of opioid pain killers even for short term use (Blue Cross Blue Shield [BCBS], 2017). Nursing consideration: Acute pain management in the postoperative period is necessary to avoid development of a chronic pain condition. As patient advocates, nurses should assess the patient’s pain frequently and ensure pain is controlled properly. Chronic pain Chronic pain is pain that persists or recurs for more than three months (International Association for the Study of Pain [IASP], 2016). Chronic pain lasts beyond the normal healing time and, as such, does not include the acute warning function of physiological nociception (IASP). Common causes of chronic pain are musculoskeletal pain (including joint and back pain), headache, postsurgical pain, sickle cell disease, cancer, diabetes, irritable bowel, shingles, and fibromyalgia (IOM, 2011). Unlike acute pain, chronic pain serves no biological purpose, can be aggravated or caused by psychological distress, and has no certain endpoint (Grichnik & Ferrante, 1991). Chronic pain does not involve the sympathetic nervous system because over time, the body adjusts to the noxious stimuli and does not sound the alarm as it does in cases of acute pain (Copstead & Banasik, 2013). Those experiencing chronic pain may often have trouble sleeping and may have depression or anxiety. These symptoms intermingle and provoke each other. For example, chronic pain causes depression and trouble sleeping; sleep deprivation leads to a lower threshold for pain and anxiety; and depression is worsened by sleep disturbances and causes difficulty sleeping (Mindruta, Cobzaru, & Bajenaru, 2012). Chronic pain affects all aspects of a person’s life—relationships, ability to work, physical and mental health—and is linked to premature death (IPRCC, 2015). EBP alert! Studies have shown that approximately 9% of patients undergoing hip replacement surgery and 20% of patients undergoing total knee replacement experience chronic pain after surgery (Beswick et al., 2012). It is important to properly control pain relief postsurgery to help minimize the chances of developing a chronic pain condition. Causes of chronic pain Two theories explain the development of chronic pain: peripheral sensitization and central sensitization. Peripheral sensitization In peripheral sensitization, it is thought that there is a reduction in the threshold of nociceptors and a more dramatic response to pain when the sensory neurons are exposed to damaged tissue and inflammation (Copstead & Banasik, 2013). It takes less stimuli to send signals through the pain pathway to the brain, and nociceptors are overly responsive or sensitive. Central sensitization Central sensitization is an overly active state of the neurons in the CNS. Neuroceptors of the dorsal horn develop increased spontaneous activity and require less peripheral stimuli to be activated (Copstead & Banasik, 2013). Central sensitization may be responsible for stress-induced hyperalgesia, a condition of heightened pain sensation thought to be caused by exposure to repeated physical or psychological stressors that provoke anxiety (Jennings, Okine, Roche, & Finn, 2014). Those who experience chronic pain notice an exacerbation of symptoms during stressful times (Jennings, Okine, Roche, & Finn). Physical assessment for chronic pain In addition to a standard pain assessment that includes onset, duration, intensity, quality, and exacerbating factors, musculoskeletal and neurological abnormalities should be noted. For musculoskeletal abnormalities, the clinician should look for atrophy or deformity, cyanosis of extremities, difference in temperature of extremities, gait, and range of motion for neurological abnormalities. The clinician also should evaluate muscle strength and sensation, reflexes, presence of allodynia (pain resulting from light touch or to pressure that normally would not cause pain), and presence of hyperalgesia (an increased pain response). For those suffering chronic pain, it is useful to identify the onset and the progression of pain to evaluate when a problem was localized and became more general or multifocal (ICSI, 2016). The clinician should discuss what treatments and therapies the patient has tried in the past and to what extent those therapies were useful. A functional ability assessment should be obtained that includes the patient’s ability to perform activities of daily living, work, and exercise. Through the identification of impairments of specific activities, a care plan can be crafted and goals and outcomes measured and evaluated (ICSI). Types of chronic pain ● ● Back pain. ● ● Cancer-related pain. ● ● Central pain syndrome. ● ● Complex regional pain syndrome. ● ● Fibromyalgia. ● ● Inflammatory pain. ● ● Ischemic pain. ● ● Migraine. ● ● Neuropathic pain. ● ● Postsurgical pain (acute pain that has progressed to chronic). ● ● Sickle cell pain. Patients with chronic pain may experience the following (Senba, Okamoto, & Imbe, 2012): ● ● Deep tissue and musculoskeletal pain. ● ● Bilateral and widespread pain. ● ● Depression or difficulty sleeping. ● ● Symptoms that are aggravated by stress. Cancer-related pain Cancer-related pain is pain associated with malignancy, whether as a result of pressure on nearby structures from a tumor, the invasion of cancer into organs, or pain from tissue damage from treatment (Copstead & Banasik, 2013). Pain induced from cancer-related causes can be intense and challenging to navigate secondary to side effects. The World Health Organization (WHO) developed a three- step analgesic ladder to manage cancer pain, which has been shown to achieve adequate pain relief in 71% to 100% of patients when used correctly (Quimby, 2005). As pain progresses, the treatment becomes more aggressive.