Pain is a common experience for most people (Kingdon et al, 1998). McCaffery (1980) states “pain is what the patients says it is and exists when the patient says it does”. This is one of the most widely used definitions of pain (Cunningham, 2001) however, if a patient does not say they are in pain how can a nurse identify their pain? Seers (1987) argues that patients do not always tell the nurse that pain has arisen and that they often expect the nurse to know. Therefore effective assessment of pain is a vital part of nursing care. Lawler (1997) maintains that good communication skills are vital in assessing pain in patients. The implementation and rationale for using pain assessment tools is focused on within this essay, with limitations of use being discussed and analysed.
Pain management is optimised by increasing our understanding of the neurobiology of pain, combined alongside interactions with the patient, coupled with science and knowledge combined with empathy and humanity (Ducharme, 2000). Since the publication of Melzack & Walls (1965) gate control theory of pain, psychology has been accepted as an integral discipline in the study of pain (Skevington, 1995). The physiological and pharmacological aspects of acute pain, and its management are discussed and analysed within this essay. Acute pain management is more than a collection of interventions, it is a package of care which requires examination as a whole, as well as in its parts (McQuay & Moore, 1998).
Holistic nursing care encompasses not only the physical aspects, but also the psychological, emotional and spiritual aspects of human nature. Anxiety can play a major role in an individuals pain experience (Kennerley, 1995). This is an area which is also explored within this essay, with specific focus on reducing anxiety levels by effective communication and development of a therapeutic relationship. Communication is a vital skill within the nursing process to enable accurate assessment, implementation and evaluation of interventions, this is another aspect which is explored and evaluated within this essay.
Mrs Green (patient name has been changed to maintain client confidentiality, Nursing & Midwifery Council 2004), aged 33, was admitted to a female surgical ward after initial assessment in the medical assessment unit. Mrs Green had acute abdominal pain, had a slight pyrexia and had been vomiting. Relevant medical history included pancreatitus, asthma and agoraphobia. Due to Mrs Green’s anxiety it was decided that a side room would be more appropriate as she found staying in a bay in the medical assessment unit heightened her anxiety levels. Mrs Green had also stated that she also suffered from rectal bleeding due to an anal fisser. Upon examination Mrs Green’s stated that her abdomen felt tender and medics concluded that it was slightly distended. Upon admission Mrs Green appeared pale and found lying on her side with the knees bent in the foetal position the only way she could feel comfortable.
Mrs Green is married and has three children, ages 1, 5 and 9, who were being cared for by her husband and parents during her stay in hospital. Although her children were being cared for by her family Mrs Green had expressed concern that her youngest child slept very badly at night and she usually was the only person who could settle him. Upon admission Mrs Green had informed nursing staff that she has had bouts of severe depression, although she didn’t feel that this was an issue at present she did acknowledge that she has felt tired and lower in mood over the last few months. Mrs Green stated that she sometimes drank heavily, although she did not feel that she was dependant on alcohol. When asked how much alcohol she would consume during the day Mrs Green stated that it was usually 1-2 bottles of wine during the evening.
Her agoraphobia obviously features heavily within her daily life and she had stated that although she is able to go out to take her children to school and visit the shops, these outings make her feel very anxious and she prefers not to out alone too often. Mrs Green had stated that she enjoyed a very close relationship with her parents and it appeared that her mother also played an active role in her daily life, often accompanying her when she takes her children to school and going shopping. Upon entering her room Mrs Green appeared anxious as she had stated than being in hospital always makes her feel very vulnerable.
Pancreas and Pancreatitus
The pancreas is an accessory organ of the gastrointestinal tract. It is an elongated gland, which lies in the left hypochondriac and epigastria regions of the abdomen. The pancreatic duct (duct of Wirsung) extends the whole length of the pancreas and forms the hepatopancreatic ampulla where it meets the common bile duct before it enters the duodenum. At the entrance to the duodenum is the sphincter of Oddi. This sphincter allows the passage of the pancreatic juice which contains the enzymes necessary for the digestion of fats, proteins and carbohydrates in the presence of the hormone cholecystokinin (CCK) (Martini 2007).
The pancreas is an endocrine gland that produces and secretes insulin and glucagon and also an exocrine gland that produces digestive enzymes (McCance & Heuther, 2002). The pancreas is responsible for a high proportion of metabolism, with insulin and glucagon helping to regulate carbohydrate, fat and protein metabolism within the body. The pancreas houses the islets of Langerhans which have three types of hormone-secreting cells. A cells secrete glucagon, B cells secrete insulin and D cells secrete gastrin, somatostatin or both. F cells are also found in the pancreas and secrete pancreatic polypeptide (Tortora & Derrickson, 2006).
Proteolytic enzymes produced by the pancreas are secreted in inactive forms, which are not activated until they reach the intestine, this protects the pancreas from digestion by its own enzymes. If these precursor enzymes are activated while in the pancreas, pancreatitis occurs. The severity of the disease is directly related to the amount of pancreatic tissue destroyed.
Mild forms may only damage cells near the ducts, whilst severe forms can cause widespread damage with necrosis and haemorrhage (Rang et al, 2003). Pancreatitus is defined as acute inflammation with secretory cell damage, with two different types of pancreatitus occurring. Oedematous pancreatitus occurs more frequently and is milder in severity, whereby the pancreas becomes swollen but no major haemorrhage occurs. Haemorrhagic pancreatitus is more severe and often associated with major retroperitoneal bleeding (Kaufman & McKee, 1996)
Although Mrs Green has expressed that she was not dependent on alcohol she had said that she sometimes drank heavily, in particular during stages of depression which could last several months or more. One of the causes of pancreatitus can be excessive alcohol intake and Mrs Green had said that she had been consuming more alcohol than usual over the last four to six weeks. Whilst Mrs Green was being assessed in the medical assessment unit she was given an ultrasound scan which had indicated that the pancreas was swollen but there appeared to be no signs of haemorrhage. Test results also indicated elevated serum amylase and lipase alongside hypocalcaemia. It was therefore diagnosed that Mrs Green was suffering from oedematous pancreatitus, with the probability that the cause may have been due to recent excessive alcohol consumption.
Agoraphobia and anxiety
Agora is the Greek word for market, traditionally a busy place, and although agoraphobia is often thought as being a fear of going outside, the definition is actually a fear of busy, crowded places, such as shops or schools (Wilkinson et al, 2000).
As previously noted Mrs Green did take her children to school and visit local shops but preferred not to be alone whilst doing so. It was important for nursing staff to acknowledge that admittance to hospital, a strange and usually busy environment, would have an effect on Mrs Green and endeavour to work with her in order to minimise any feelings of stress and anxiety.
Pain almost always results in some degree of anxiety, and to experience pain without any emotional response would be abnormal. The relationship between pain and anxiety is complicated and a person who is more susceptible to anxious or depressive mood states can find pain more difficult to bear, thus affecting the patient’s outlook and motivation to be involved in their pain control (McCaffery & Beebe, 1997). Evidence suggests that anxious individuals experience heightened pain, alongside increased anxiety which is associated with increased muscle tension and other physiological processes which potentially augment the experience of pain (Irving & Wallace, 1997). The interactions among these biological systems are well illustrated by the pain-anxiety-tension cycle that has been attributed to some forms of acute and chronic pain (Melzack & Wall, 2006).
One of the ways to reduce anxiety is to give adequate information to patients, either about their condition or the treatment which is to be administered (Thomas, 1997). As Mrs Green had already had an episode of pancreatitus previously she seemed to understand her condition well, although she expressed that she felt that her pain seemed more severe during this episode.