Ruth Day, MA, RN.
Nurse Consultant, Pain Management, Luton and Dunstable NHS Trust Hospital, Luton, Bedfordshire and the University of LutonIn her story about living with, and in, pain Judith Thwaite wrote: 'Thank God it is not possible to relive the acuteness of pain' (Thwaite, 1998). And Albert Schweitzer's experiences led him, back in 1937, to write 'Pain is a more terrible Lord of Mankind than Death itself' (Schweitzer, 1937). Whether we like it or not, pain is an experience that almost everybody will have at some time. Many will manage it themselves but a significant number will seek advice from their GP, a nurse or the local pharmacist. This paper will look at the broad areas of pain in the community and, through specific examples, suggest some ways that nurses can help patients manage their pain. The area of pain relief in cancer will not be covered, although the approaches covered here could be applied in that field.
Acute pain is defined by the International Association for the Study of Pain (IASP) as: 'Pain of recent onset and probable limited duration. It usually has an identifiable temporal and causal relationship to injury and disease' (IASP, 1986). Presentation of acute pain in the community can often mean a visit to the accident and emergency (A&E) department (for acute abdominal pain or cardiac pain) but there are a number of clinical situations in which the acute pain is best managed by the primary care team. A good example would be that of simple, or mechanical, back pain.
It is estimated that 80% of people in the UK will develop back pain at some point in their lives. Of these, 90% will improve within 12 weeks. Patients coming to see the GP with back pain need careful screening to ensure that nerve root pain or any suspected serious pathology is not present. However, Waddell states that 93% of patients who present with back pain will fall into the category of mechanical, musculoskeletal back pain (Waddell et al, 1999; Bartley and Coffey, 2001). The Royal College of General Practitioners has published guidelines to assist in the management of these patients (Waddell et al, 1996). This document should be readily available in every GP surgery.
Chronic, non-malignant pain is particularly challenging and an analysis undertaken by Potter in 1990 showed that, of 1000 consultations with a GP, 11.3% were for pain that had lasted more than three months. The IASP defines it as 'pain lasting for a long period of time. It usually persists beyond the time of healing of an injury and there is frequently no identifiable cause' (IASP, 1986). Chronic pain includes not only low back pain but also conditions such as arthritis, diabetic neuropathy, trigeminal neuralgia, post-surgical pain and ischaemic pain. It is clearly beyond the remit of this paper to consider all these and many will benefit from specialist input from a pain clinic.
Osteoarthritis is the most common form of arthritis and is a leading cause of disability in older people. Rheumatoid arthritis is an inflammatory condition of the joints and tendons but it also has systemic features. Table 2 compares and contrasts these two forms of arthritis.
Nurses need to be aware of the input of other health-care professionals in the treatment of these conditions. Physiotherapists, occupational therapists, chiropractors and others can all play some part in the management of pain in patients in the community. Part of working as a multidisciplinary team involves understanding each other's roles - therefore enabling appropriate referrals. The emotional support that nurses can give this patient group is immense and an integral part of their pain management. On occasions input from a psychologist is appropriate and valuable (Eccleston, 2001).
Frequently, advice may be sought from the nurse about painkillers. Both chronic and acute pain are often dealt with using a variety of analgesic drugs and nurses need to develop skills in assisting patients in making sound choices in the use of their medicines. A multi-modal, or balanced, approach to analgesic therapy is often the best (Day, 1998).
It is clear that the nurse is in a key position to make a sound pain assessment and to suggest therapies which may cross professional boundaries. As pain is a multi-modal experience it should come as no surprise that effective pain management needs a multi-professional approach.
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