What is a nursing diagnosis? Definition of Nursing Diagnosis A nursing diagnosis is the part of the nursing process, is clinical judgment about individual, family, or community responses to actual or potential health/life processes.  Nursing diagnosis are developed based on data obtained during nursing assessment. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

 Nursing Diagnosis Have two related meanings:

• Nursing diagnosis is an action: the process of analyzing assessment data to arrive at a nursing diagnosis!
• Nursing diagnosis is a label that describes the patient’s response to an actual or potential health problem

How do nurses make a Nursing Diagnosis?

1. Analyze collected data
2. Identify the client’s strengths
3. Identify the client’s normal functional level and indicators of actual or potential dysfunction
4. Formulate a diagnostic statement in relations to this synthesis

Benefits of Nursing Diagnosis

• Gives nurses a common language
• Promotes identification of appropriate expected outcomes
• Provides acuity information
• Can create a standard for nursing practice
• Provide a quality improvement base
• Promotes improved communication among nurses, other healthcare providers, and alternate care settings

Nursing Diagnosis VS Medical Diagnosis

Steps of Developing Nursing Diagnosis

Identify patterns

• Review data and look for cues
• Cluster cues (signs and symptoms)
• Synthesizing the cue clusters
• Three questions to ask self  (What are my concerns about this client, Can I or am I doing something about it, Can the overall risk be decreased by nursing interventions)

Synthesis the data

Look at all data as a whole to provide a comprehensive picture of the client in relation to past, present, and future health status

Validate the diagnosis

Test for a fit, Refer to the NANDA Diagnosis and defining characteristics. Then, compare the assessed possible ETIOLOGY with NANDA’s RELATED FACTORS or RISK FACTORS. Next, compare the assessed client cues with NANDA’s Defining Characteristics, which are used to support and provide an increased level of confidence in your selected nursing diagnosis.

Formulate the nursing diagnosis statement using nursing language

NANDA

Types of Nursing Diagnosis

• Actual Nursing Diagnosis

A client problem that is present at the time of the nursing assessment. It is based on the presence of signs and symptoms. Can be documented from assessment

• Risk Nursing Diagnosis

Risk Nursing diagnosis, a clinical judgment that the client is more vulnerable to develop this problem than others in the same or similar situation. A clinical judgment that a problem does not exist, therefore no S/S are present. This diagnosis indicates from the data, a strong likelihood that it will occur if actions are not taken by the nurses.  The Risk diagnosis only has 2 parts.  It can be used with any NANDA diagnosis

• Potential Nursing Diagnosis

This is also known as a collaborative diagnosis. one in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it, or the causative factors are unknown but a problem is only considered possible to occur. This is a problem the nurse cannot treat independently. Nursing care will focus on monitoring and preventing the problem. A collaborative diagnosis can be written as a one or two part statement.

• Wellness Nursing Diagnosis

Potential for enhancement of current well state, this diagnosis involves a judgment about an individual, family or community in transition from one level of wellness to a higher level of wellness.

• Syndrome Nursing Diagnosis

Associated with a cluster of other diagnoses

Components of Nursing Diagnosis

Diagnostic Label

• P  Problem, Name of the nursing diagnosis as listed in the taxonomy, describes the problem using as few words as possible. DO NOT use the medical diagnosis. Must be a problem the nurse and/or client can change to do something about. Relating the problem to an unchangeable situation

• Qualifier, Used to give additional meaning to the Nursing Diagnosis. words added to the diagnostic label/problem statement to gain additional meaning

• E Etiology. This is the “related to, R/T” portion of the diagnosis. What caused the client to have the problem listed? Do Not use the medical diagnosis, Must be a problem the nurse and/or client can change to do something about
• S Symptom. These are the major and minor clinical cues that validate the presents of an actual nursing diagnosis. Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the Nursing Diagnosis

 Problems to avoid in writing Nursing Diagnosis

• Don’t confuse the etiology with the problem
• Do not use the medical diagnosis.
• Must be a problem the nurse and/or client can change to do something about. Relating the problem to an unchangeable situation
• Focus on the human responses to the problem
• Avoid the use of one piece of assessment data as a Nursing Diagnosis(EDEMA)
• Be specific
• Don’t combine NDX
• Don’t relate one Nursing Diagnosis to another.  There is a different related to factor if this is a valid Nursing Diagnosis
• Nursing interventions should not be included in the Nursing Diagnosis
• Keep your language non-judgmental
• Don’t make assumptions or statements you can’t prove with assessment data
• Be sure your statement is legally advisable

NANDA Nursing Diagnosis for Acute Pain Related factors R/T trauma, injuring agents (biological, chemical, physical, psychological)

Suggestion on using NANDA Nursing Diagnosis Acute Pain: Distinguish between acute pain Nursing diagnosis with the chronicles pain Nursing diagnosis. One of the two sets is that diagnosis of a painful time. ONSET acute pain is less than 6 months, while the painful chronicles ONSET it is more than 6 months.  If you only have two diagnoses to indicate, pain is acute pain and chronic pain. Thus, there is no automatic diagnosis Crashes feel comfortable or feel comfortable painful chronic pain.

Definition Nursing Diagnosis for Acute 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 with an anticipated or predictable end and a duration of less than 6 months

Nursing Outcomes Client Will:

• Report pain is relieved / controlled.
• Follow prescribed pharmacological regimen.
• Verbalize methods that provide relief.
• Demonstrate use of relaxation skills and diversion activities as indicated for individual situation.

Nursing Priority Nursing Diagnosis for Acute Pain

• To assess etiology/precipitating contributory factors:
• evaluate client’s response to pain:
• assist client to explore methods for alleviation/control of pain

Sample Clinical Applications using Nursing Diagnosis for Acute Pain:

Traumatic injuries, surgical procedures, infections, cancer, burns, skin lesions, gangrene, thrombophlebitis/pulmonary embolus, neuralgia

Gout/Gouty Arthritis

Gout also known as gouty arthritis is a metabolic disease marked by monosodium urate deposits that cause red, swollen, and acutely painful joints. Gout can affect any joint but mostly affects those in the feet, especially the great toe, ankle, and midfoot. Gout is a medical condition that usually presents with recurrent attacks of acute inflammatory arthritis (red, tender, hot, swollen joint). It is caused by elevated levels of uric acid in the blood. The uric acid crystallizes and deposits in joints, tendons, and surrounding tissues. Gout affects 1% of Western populations at some point in their lives. Gout is caused by an increased level of uric acid in the blood, salts of which are deposited in the joints. It mostly occurs in middle-aged men and almost always involves pain at the base of the great toe. Gout may result from a primary metabolic disturbance or may be a secondary effect of another disease, as of the kidneys.Gout is treated with drugs to suppress formation of uric acid or to increase elimination of uric acid. Patients who receive treatment for gout have a good prognosis.

The final, unremitting stage of the disease (also known as tophaceous gout) is marked by persistent painful polyarthritis. An increased concentration of uric acid leads to urate deposits in cartilage, synovial membranes, tendons, and soft tissue, called Tophi/tophus . Tophi/tophus form in the fingers, hands, knees, feet, ulnar sides of the forearms, pinna of the ear, Achilles tendon and, rarely, in such internal organs as the kidneys and myocardium. Renal involvement may adversely affect renal function.

Causes for Gout/Gouty Arthritis

Hyperuricemia is the underlying problem of gout, Although the underlying cause of primary gout is unknown, it appears to be linked to a genetic defect in purine metabolism that causes overproduction of uric acid (Hyperuricemia), retention of uric acid, or both.

Secondary gout develops during the course of another disease, such as obesity, diabetes mellitus, hypertension, polycythemia, leukemia, myeloma, sickle cell anemia, and renal disease. Secondary gout can also follow treatment with such drugs as hydrochlorothiazide or pyrazinamide.

Complications for Gout/Gouty Arthritis

Potential complications include:

• Renal disorders such as renal calculi
• Circulatory problems, such as atherosclerotic disease, cardiovascular lesions, stroke, coronary thrombosis, and hypertension
• Infection that develops when occur tophi ruptures and nerve entrapment.

Treatment for Gout/Gouty Arthritis

Gout/Gouty Arthritis management has three goals:

• Stop the acute attack.
• Treat hyperuricemia to reduce urine uric acid levels.
• Prevent recurrent gout and renal calculi.

Treatment for an acute attack:

• Bed rest; immobilization and protection of the inflamed, painful joints; and local application of cold.
• Analgesics, such as acetaminophen, relieve the pain associated with mild attacks.
• Acute inflammation requires nonsteroidal anti-inflammatory drugs or intramuscular corticotropin.

Treatment for chronic gout involves

• Decreasing the serum uric acid level.
• Adjunctive therapy emphasizes avoidance of alcohol and sparing use of purine-rich foods.
• Weight reduction program decreases uric acid levels and eases stress on painful joints.
• In some cases, surgery may be necessary excised and drained tophi to improve joint function or correct deformities.

Nursing care plans for Gout/Gouty Arthritis

Nursing Diagnosis for Gout/Gouty Arthritis

Patients teaching and home health guide for Gout/Gouty Arthritis

Nursing Diagnosis for Gout/Gouty Arthritis

Nursing Assessment Nursing care plans for Gout/Gouty Arthritis

Patient history Reveal that the patient has a sedentary lifestyle and a history of hypertension or renal calculi. report waking with pain in toe or another location in the foot.He may complain that initially moderate pain has grown and He may report accompanying chills and a mild fever.

Inspection a swollen, dusky red or purple joint with limited movement. Maybe found tophi, especially in the outer ears, hands, and feet, In  chronic stage of gout, the skin over the tophi may ulcerate and release a chalky white exudate or pus.

Palpation may reveal warmth over the joint and extreme tenderness. The vital signs assessment may disclose fever and hypertension. If the patient has a fever, possible occult infection must be investigated.

Diagnostic tests for Gout/Gouty Arthritis

• Needle aspiration of synovial fluid (arthrocentesis) or  tophaceous material
• Serum uric acid
• X-rays

Nursing Diagnosis Nursing Care Plans For Gout/Gouty Arthritis

Common nursing diagnosis found in Nursing care plans for Gout/Gouty Arthritis

• Acute pain
• Activity intolerance
• Anxiety
• Deficient knowledge (diagnosis and treatment)
• Disturbed sleep pattern
• Impaired physical mobility
• Ineffective coping
• Risk for injury

Nursing diagnosis Diabetes mellitus. Diabetes mellitus is a disorder in which the level of blood glucose is persistently raised above the normal range. Diabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate. Diabetes mellitus occurs in two primary forms: type 1, characterized by absolute insufficiency, and the more prevalent type 2, characterized by insulin resistance with varying degrees of insulin secretory defects.

Focused Nursing assessment For Diabetes Mellitus

• Patient history Patients with type 2 diabetes generally report a family history of diabetes mellitus, gestational diabetes
• Skin changes, especially on the legs and feet, may represent impaired peripheral circulation
• Ask if the patient has experienced excessive thirst (polydipsia), excessive urination (polyuria), or excessive hunger (polyphagia).
• In diagnostic test at least two occasions where the fasting plasma glucose level has been greater than or equal to 126 mg/dl, random blood glucose level greater than or equal to 200 mg/dl, blood glucose level greater than or equal to 200 mg/dl 2 hours after ingestion of 75 g of oral dextrose.

Common nursing diagnosis found in Diabetes Mellitus care plans

Imbalanced Nutrition: More than Body Requirements, Fear, Risk for Injury, Activity Intolerance, Deficient Knowledge, Risk for Impaired Skin Integrity, Ineffective Coping, Deficient knowledge (diagnosis and treatment), Disturbed sensory perception: Visual, tactile, Imbalanced nutrition: Less than body requirements, Impaired urinary elimination, Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral, Risk for infection, Sexual dysfunction

Nursing diagnosis Diabetes Mellitus by nursing priority

1. Imbalanced Nutrition: Less/More than Body Requirements
2. Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral
3. Impaired urinary elimination
4. Disturbed sensory perception: Visual, tactile
5. Activity Intolerance
6. Ineffective Coping
7. Sexual dysfunction
8. Fear
9. Deficient Knowledge
10. Deficient knowledge (diagnosis and treatment)
11. Risk for Impaired Skin Integrity
12. Risk for Injury
13. Risk for infection

Respiratory System

Nursing diagnosis pneumonia. Pneumonia, acute infection of the lung parenchyma that often impairs gas exchange. Pneumonia is an inflammatory condition of the interstitial lung tissue in which fluid and blood cells escape into the alveoli. The inflammatory process causes the lung tissue to stiffen, thus resulting in a decrease in lung compliance and an increase in the work of breathing. The fluid-filled alveoli cause a physiological shunt, and venous blood passes  unventilated portions of lung tissue and returns to the left atrium unoxygenated, patient begins to exhibit the signs and symptoms of hypoxemi

Focused Nursing assessment in  pneumonia care plans

• Vital sign: blood pressure,  body temperature, the pulse or rate of heartbeats, the respiration or rate of breathing
• Crackles, wheezing, or rhonchi over the affected lung area
• Dullness when you percuss
• Presence of cyanosis, and presence of dyspnea or tachypnea

Common nursing diagnosis found in pneumonia

Impaired gas exchange, Ineffective coping, Risk for deficient fluid Volume, Risk for infection Ineffective airway clearance, Acute pain, Anxiety, Hyperthermia, Imbalanced nutrition: Less than body requirements,

Nursing diagnosis for pneumonia base in nursing priority

1. Ineffective airway clearance
2. Impaired gas exchange
3. Imbalanced nutrition: Less than body requirements
4. Acute pain
5. Hyperthermia
6. Anxiety
7. Ineffective coping
8. Risk for deficient fluid volume
9. Risk for infection

Gordon’s Functional Health Patterns is a method develops By Marjorie Gordon in 1987 proposed functional health patterns as a guide for establishing a comprehensive nursing data base. By using these categories it’s possible to create a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function:

11 Gordon’s Functional Health Patterns

1. Health Perception Health Management Pattern
2. Nutritional Metabolic Pattern
3. Elimination Pattern
4. Activity Exercise Pattern
5. Sleep Rest Pattern
6. Cognitive-Perceptual Pattern
7. Self-Perception-Self-Concept Pattern
8. Role-Relationship Pattern
9. Sexuality-Reproductive
10. Coping-Stress Tolerance Pattern
11. Value-Belief Pattern

Health Perception and Health Management. It’s focused on the person’s perceived level of health and well-being, and on practices for maintaining health. Also evaluated Habits including smoking and alcohol or drug use.

• Contamination
• Disturbed energy field
• Effective therapeutic regimen management
• Health-seeking behaviors (specify)
• Ineffective community therapeutic regimen management
• Ineffective family therapeutic regimen management
• Ineffective health maintenance
• Ineffective protection
• Ineffective therapeutic regimen management
• Noncompliance (ineffective Adherence)
• Readiness for enhanced immunization status
• Readiness for enhanced therapeutic regimen management
• Risk for contamination
• Risk for infection
• Risk for injury
• Risk for perioperative positioning injury
• Risk for poisoning
• Risk for sudden infant death syndrome
• Risk for suffocation
• Risk for trauma
• Risk-prone health behavior

Nutritional Metabolic Pattern it’s focused on the pattern of food and fluid consumption relative to metabolic need. Is evaluated the adequacy of local nutrient supplies.  Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.

• Adult failure to thrive
• Deficient fluid volume: [isotonic]
• [Deficient fluid volume: hyper/hypotonic]
• Effective breastfeeding [Learning Need]
• Excess fluid volume
• Hyperthermia
• Hypothermia
• Imbalanced nutrition: more than body requirements
• Imbalanced nutrition: less than body requirements
• Imbalanced nutrition: risk for more than body requirements
• Impaired dentition
• Impaired oral mucous membrane
• Impaired skin integrity
• Impaired swallowing
• Impaired tissue integrity
• Ineffective breastfeeding
• Ineffective infant feeding pattern
• Ineffective thermoregulation
• Interrupted breastfeeding
• Latex allergy response
• Nausea
• Readiness for enhanced fluid balance
• Readiness for enhanced nutrition
• Risk for aspiration
• Risk for deficient fluid volume
• Risk for imbalanced fluid volume
• Risk for imbalanced body temperature
• Risk for impaired liver function
• Risk for impaired skin integrity
• Risk for latex allergy response
• Risk for unstable blood glucose

Elimination Pattern. It’s focused on excretory patterns (bowel, bladder, skin).

• Bowel incontinence
• Constipation
• Diarrhea
• Functional urinary incontinence
• Impaired urinary elimination
• Overflow urinary incontinence
• Perceived constipation
• Readiness for enhanced urinary elimination,
• Reflex urinary incontinence
• Risk for constipation
• Risk for urge urinary incontinence
• Stress urinary incontinence
• Total urinary incontinence
• Urge urinary incontinence
• [acute/chronic] Urinary retention

Activity and Exercise Pattern. It’s focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities.

• Activity intolerance
• Autonomic dysreflexia
• Decreased cardiac output
• Decreased intracranial adaptive capacity
• Deficient diversonal activity
• Delayed growth and development
• Delayed surgical recovery
• Disorganized infant behavior
• Dysfunctional ventilatory weaning response
• Fatigue
• Impaired spontaneous ventilation
• Impaired bed mobility
• Impaired gas exchange
• Impaired home maintenance
• Impaired physical mobility
• Impaired transfer ability
• Impaired walking
• Impaired wheelchair mobility
• Ineffective airway clearance
• Ineffective breathing pattern
• Ineffective tissue perfusion
• Readiness for enhanced organized infant behavior
• Readiness for enhanced self care
• Risk for delayed development
• Risk for disorganized infant behavior
• Risk for disproportionate growth
• Risk for activity intolerance
• Risk for autonomic dysreflexia
• Risk for disuse syndrome
• Sedentary lifestyle
• Self-care deficit
• Wandering

Cognitive-Perceptual Pattern. It’s focused on the ability to comprehend and use information and on the sensory functions. Neurologic functions, Sensory experiences such as pain and altered sensory input.

• Acute confusion
• Acute pain
• Chronic confusion
• Chronic pain
• Decisional conflict
• Deficient knowledge
• Disturbed sensory perception
• Disturbed thought processes
• Impaired environmental interpretation syndrome
• Impaired memory
• Readiness for enhanced comfort
• Readiness for enhanced decision making
• Readiness for enhanced knowledge
• Risk for acute confusion
• Unilateral neglect

Sleep Rest Pattern. It’s focused on the person’s sleep, rest, and relaxation practices. To identified dysfunctional sleep patterns, fatigue, and responses to sleep deprivation.

• Insomnia
• Readiness for enhanced sleep
• Sleep deprivation

Self-Perception-Self-Concept Pattern its focused on the person’s attitudes toward self, including identity, body image, and sense of self-worth.

• Anxiety
• disturbed Body image
• Chronic low self-esteem
• Death anxiety
• Disturbed personal identity
• Fear
• Hopelessness
• Powerlessness
• Readiness for enhanced hope
• Readiness for enhanced power
• Readiness for enhanced self-concept
• Risk for compromised human dignity
• Risk for loneliness
• Risk for powerlessness
• Risk for situational low self-esteem
• Risk for [/actual] other-directed violence
• Risk for [actual/] self-directed violence
• Situational low self-esteem

Role-Relationship Pattern. It’s focused on the person’s roles in the world and relationships with others. Evaluated Satisfaction with roles, role strain, or dysfunctional relationships.

• Caregiver role strain
• Chronic sorrow
• Complicated grieving
• Dysfunctional family processes: alcoholism (substance abuse)
• Grieving
• Impaired social interaction
• Impaired verbal communication
• Ineffective role performance
• Interrupted family processes
• Parental role conflict
• Readiness for enhanced communication
• Readiness for enhanced family processes
• Readiness for enhanced parenting
• Relocation stress syndrome
• Risk for caregiver role strain
• Risk for complicated grieving
• Risk for impaired parent/infant/child attachment
• Risk for relocation stress syndrome
• Social isolation

Sexuality and Reproduction. It’s focused on the person’s satisfaction or dissatisfaction with sexuality patterns and reproductive functions.

• Ineffective sexuality patterns
• Rape-trauma syndrome
• Sexual dysfunction

Coping-Stress Tolerance Pattern. its focused on the person’s perception of stress and coping strategies Support systems, evaluated symptoms of stress, effectiveness of a person’s coping strategies.

• Compromised family coping
• Defensive coping
• Disabled family coping
• Impaired adjustment
• Ineffective community coping
• Ineffective coping
• Ineffective denial
• Post-trauma syndrome
• Readiness for enhanced community coping
• Readiness for enhanced coping
• Readiness for enhanced family coping
• Risk for self-mutilation
• Risk for suicide
• Risk for post-trauma syndrome
• Self-mutilation
• Stress overload

Value-Belief Pattern it’s focused on the person’s values and beliefs.

• Impaired religiosity
• Moral distress
• Readiness for enhanced religiosity
• Readiness for enhanced spiritual well-being
• Risk for impaired religiosity
• Risk for spiritual distress
• Spiritual distress

]]> http://www.lifenurses.com/nursing-diagnosis-and-11-gordons-functional-health-patterns/feed/ 15 http://www.lifenurses.com/pain-nursing-management/ http://www.lifenurses.com/pain-nursing-management/#comments Thu, 26 Nov 2009 22:24:07 +0000 lifenurses http://www.lifenurses.com/?p=85

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (Merskey & Bogduk). Pain is “an unpleasant sensory and emotional experience associatedwith actual or potential damage or described in terms of such damage; ef pain is always subjective” (International Association for the Study of Pain, 1979). Pain is categorized according to its duration, location, and etiology. Three basic categories of pain are generally recognized: acute pain, chronic (nonmalignant) pain, and cancer-related pain.

One view explain that pain is a sense similar to vision or hearing, a component of the sensory that warns us of impending damage, gives accurate information to the brain about injuries, and helps us to heal. The inclusion of pain in The Senses: a Comprehensive Reference, alongside vision, hearing, or olfaction shows that this view is persuasive. But there has always been an alternative interpretation of pain. Pain is seen as a trigger of emotional states, a behavioral drive, and a highly effective learning tool.  Aristotle, who was the originator of this view, made it very clear: there are only five senses – vision, hearing, touch, taste, and smell. Pain and pleasure are not senses but passions of the soul.

Acute Pain

For purposes of definition, acute pain can be described as lasting from seconds to 6 months. However, the 6-month time frame has been criticized (Brook) as inaccurate since many acute injuries heal within a few weeks and most heal by 6 weeks. Usually of recent onset and commonly associated with a specific injury, acute pain indicates that damage or injury has occurred. Pain is significant in that it draws attention to its existence and teaches the person to avoid similar potentially painful situations. If no lasting damage occurs and no systemic disease exists, acute pain usually decreases along with healing.

In a situation where healing is expected in 3 weeks and the patient continues to suffer pain, it should be considered chronic and treated with interventions used for chronic pain. Waiting for the full 6-month time frame in this example could cause needless suffering. Unrelieved acute pain can affect the pulmonary, cardiovascular, gastrointestinal, endocrine, and immune systems. The stress response (neuroendocrine response to stress) that occurs with trauma also occurs with other causes of severe pain. The stress response generally consists of increased metabolic rate and cardiac output, impaired insulin response, increased production of cortisol, and increased retention of fluids.

Chronic (nonmalignant) Pain

Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Chronic pain may be defined as pain that lasts for 6 months or longer, although 6 months is an arbitrary period for differentiating between acute and chronic pain. An episode of pain may assume the characteristics of chronic pain before 6 months have elapsed, or some types of pain may remain primarily acute in nature for longer than 6 months.

Suppression of the immune function associated with chronic pain may promote tumor growth. Also, chronic pain often results in depression and disability. Although health care providers express concern about the large quantities of opioid medications required to relieve chronic pain in some patients, it is safe to use large doses of these medications to control progressive chronic pain.

Cancer-Related Pain

Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that after fear of dying, it is the second most common fear of newly diagnosed cancer patients (Lema).

Pain in the patient suffering from cancer can be directly associated with the cancer (eg, bony infiltration with tumor cells or nerve compression), a result of cancer treatment (eg, surgery or radiation), or not associated with the cancer (eg, trauma). Most pain associated with cancer, however, is a direct result of tumor involvement.

Pathophysiology of Pain

The sensory experience of pain depends on the interaction between the nervous system and the environment. The processing of noxious stimuli and the resulting perception of pain involve the peripheral and central nervous systems.

Peripheral Nervous System

A number of algogenic (pain-causing) substances that affect the sensitivity of nociceptors are released into the extracellular tissue as a result of tissue damage. Histamine, bradykinin, acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain. The transmission of pain is also referred to as nociception. Prostaglandins are chemical substances thought to increase the sensitivity of pain receptors by enhancing the painprovoking effect of bradykinin. These chemical mediators also cause vasodilation and increased vascular permeability, resulting in redness, warmth, and swelling of the injured area.

Once nociception is initiated, the nociceptive action potentials are transmitted by the peripheral nervous system (Porth, 2002). The first-order neurons travel from the periphery (skin, cornea, visceral organs) to the spinal cord via the dorsal horn. There are two main types of fibers involved in the transmission of nociception. Smaller, myelinated Ad (A delta) fibers transmit nociception rapidly, which produces the initial “fast pain.” Type C fibers are larger, unmyelinated fibers that transmit what is called second pain. This type of pain has dull, aching, or burning qualities that last longer than the initial fast pain. The type and concentration of nerve fibers to transmit pain vary by tissue type.

The same noxious stimulus produces hyperalgesia, and the person reports greater pain than was felt at the first stimulus. For this reason, it is important to treat patients with analgesic agents when they first feel the pain. Patients require less medication and experience more effective pain relief if analgesia is administered before the patient becomes sensitized to the pain.

Chemicals that reduce or inhibit the transmission or perception of pain include endorphins and enkephalins. These morphinelike neurotransmitters are endogenous (produced by the body). Endorphins and enkephalins are found in heavy concentrations in the central nervous system, particularly the spinal and medullary dorsal horn, the periaqueductal gray matter, hypothalamus, and amygdala.

Central Nervous System

After tissue injury occurs, nociception (the neurologic transmission of pain impulses) to the spinal cord via the Ad and C fibers continues. The fibers enter the dorsal horn, which is divided into laminae based on cell type. The laminae II cell type is commonly referred to as the substantia gelatinosa. In the substantia gelatinosa are projections that relay nociception to other parts of the spinal cord.

Nociception continues from the spinal cord to the reticular formation, thalamus, limbic system, and cerebral cortex. Here nociception is localized and its characteristics become apparent to the person, including the intensity. The involvement of the reticular formation, limbic, and reticular activating systems is responsible for the individual variations in the perception of noxious stimuli. Individuals may report the same stimulus differently based on their anxiety, past experiences, and expectations. This is a result of the conscious perception of pain.

The interconnections between the descending neuronal system and the ascending sensory tract are called inhibitory interneuronal fibers. These fibers contain enkephalin and are primarily activated through the activity of non-nociceptor peripheral fibers (fibers that normally do not transmit painful or noxious stimuli) in the same receptor field as the pain receptor, and descending fibers, grouped together in a system called descending control.

The enkephalins and endorphins are thought to inhibit pain impulses by stimulating the inhibitory interneuronal fibers, which in turn reduce the transmission of noxious impulses via the ascending system (Puig & Montes).

The noxious impulses are influenced by a “gating mechanism.” Melzack and Wall proposed that stimulation of the large-diameter fibers inhibits the transmission of pain, thus “closing the gate.” Conversely, when smaller fibers are stimulated, the gate is opened. The gating mechanism is influenced by nerve impulses that descend from the brain.

Factors Influencing the Pain Response

Pain experience is influenced by a number of factors, including;   past experiences with pain, anxiety, culture, age, gender, and expectations about pain relief. These factors may increase or decrease the person’s perception of pain, increase or decrease tolerance for pain, and affect the responses to pain.

Pharmacologic Interventions:

• Approaches for Using Analgesic Agents
• Local Anesthetic Agents
• Opioid Analgesic Agents
• Nonsteroidal Anti-inflammatory Drugs
• Tricyclic Antidepressant Agents and Anticonvulsant Medications

Routes of Administration; Parenteral, Oral, Rectal,Transdermal, Transmucosal, Intraspinal and Epidural

Nonpharmacologic Interventions :

• Cutaneous Stimulation and Massage
• Ice and Heat Therapies
• Transcutaneous Electrical Nerve Stimulation
• Distraction
• Relaxation Techniques
• Guided Imagery
• Hypnosis

Nursing Management of Pain

Nursing Assessment of Pain

The factors to consider in a complete pain assessment are the intensity, timing, location, quality, personal meaning, aggravating and alleviating factors, and pain behaviors. The pain assessment begins by observing the patient carefully, noting the patient’s overall posture and presence or absence of overt pain behaviors and asking the person to describe, in his or her own words, the specifics of the pain. The words used to describe the pain may point toward the etiology.

Instruments for assessing the perception of pain:

Pain Intensity Scales

• Simple Descriptive Pain Intensity Scale

0: No pain

1: Mild pain

2: Moderate pain

3: Severe pain

4: Very severe pain

5: Worst possible pain

• 0 – 10 Numeric Pain Intensity Scale

• Visual Analog Scale (VAS)

1. No pain
2. Pain as bad as it could possibly be

Nurses Role in Pain Management:

• Identifying Goals for Pain nursing management
• Establishing the Nurse–Patient Relationship and Teaching
• Providing Physical Care
• Managing Anxiety Related to Pain