Pain can be considered acute or chronic. Chronic pain occurs when pain signals continue to fire in the nervous system. This is ongoing, lasting longer than the typical healing time frame which is typically defined as pain that is present for longer than 3-6 months. Every person will experience pain differently and every individual’s tolerance for pain will be different. Overtime, constant pain can begin to affect other areas of a person’s life including their daily activities. Likewise, individuals suffering from chronic pain are also at an increased risk of depression and anxiety. Individuals may also begin experiencing sleep disturbances due to the pain they experience.
In this article:
- Risk Factors
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Treatment
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Risk Factors
Some individuals may be more prone to developing chronic pain than others. Individuals at a higher risk of experiencing chronic pain include the elderly and obese individuals, as well as, people who have had previous injuries, increased stress, and use tobacco products. Unfortunately, genetics can also play a role in increased risk of chronic pain, particularly as it relates to chronic pain associated with migraines.
Causes (Related to)
The cause of the pain can be extensive and vary from person to person. For example, some individuals may experience chronic pain due to chronic conditions such as arthritis while others may experience chronic pain due to another acute diagnosis such as cancer. Some injuries or illnesses may leave an individual more sensitive to pain, and sometimes people may be experiencing multiple causes of pain that overlap resulting in chronic pain. A brief and non-exhaustive list of additional causes is listed below:
- Infections
- Migraines
- Back injuries
- Fibromyalgia
- Nerve damage
- Previous surgeries
Signs and Symptoms (As evidenced by)
Chronic pain can occur anywhere within the body and is often described as feeling:
- Dull, achy
- Soreness, stiffness
- Stinging
- Throbbing
- Burning
- Shooting
Treatment
As previously mentioned, chronic pain can be complicated and feel differently for each person and it can be the result of multiple factors. Therefore, there are several treatment options available. Various types of treatment include medications, acupuncture, local electrical stimulation, and sometimes surgery. In addition, psychotherapy, relaxation therapies, biofeedback, and behavior modifications have also been shown to have promising effects in treating pain.
Expected Outcomes
- Patient will maintain acceptable pain level.
- Patient’s vital signs will remain stable.
- Patient will be able to verbalize chronic pain management strategies for discharge.
- Patient’s environment will remain free from increased pain triggers.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to chronic pain.
1. Assess the patient’s pain level using age and developmentally appropriate pain scale (i.e. FLACC, Wong-Baker Faces, Visual Analogue Scale).
Assessing the patient’s pain level includes location, description, duration, and intensity. This allows the nurse to receive subjective data from the patient and thereby individualize the treatment plan and treat what the patient is truly experiencing.
2. Complete head-to-toe assessment.
This allows the nurse to note any physiologic signs that may be present as a result of the increased pain level the patient has. (For example, a patient experiencing significant pain may become restless). Completing a head-to-toe assessment may also allow the nurse to uncover underlying causes of the chronic pain.
3. Assess vital signs.
Blood pressure and heart rate may become elevated due to severe pain. Patient’s breathing pattern and respirations may also change resulting in a change in oxygen saturation.
4. Assess the current environment.
Current environmental factors could be increasing the patient’s pain level.
5. Assess the patient’s current psychosocial status/health.
Psychosocial health can impact a patient’s pain level. Patients can be more prone to depression and anxiety when experiencing chronic pain thereby making it harder to control and treat.
6. Assess for precipitating and alleviating factors.
Ask the patients to describe what makes the pain work or better. It can also be helpful to discuss if there is a predictable pattern to the pain to find precipitating or alleviating factors that the patient may be unaware of.
7. Evaluate patient’s ability to complete ADLS
Severe chronic pain may significantly impact the patient’s ability to perform activities of daily living. Assess how the patient is currently coping and if there is a need for extra support to ensure that ADLs are being managed.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with chronic pain.
1. Assist the patient with repositioning.
Certain positions may be more painful than others. Allowing for frequent position changes may assist in pain management
2. Administer analgesics as prescribed.
If the provider has ordered pain medications this may be helpful in controlling the patient’s pain. Administering pain medication should be based on the pain assessment.
3. Assist the patient with developing a regular exercise routine.
Physical and occupational therapy may be beneficial in treating pain or in keeping it at a manageable level.
4. Use complementary and alternative medicine therapies as appropriate (i.e. massage, ice packs, heating pads).
Some therapies such as massage may help decrease a patient’s pain level. In addition, the use of hot or cold therapy may assist in keeping pain at a more manageable pain level.
5. Assist the patient with behavioral therapy exercises.
Behavioral therapy exercises such as relaxation, deep breathing, or meditation may assist the patient with being able to control pain better.
6. Provide patient education.
Patient education includes helping the patient to understand there is often no complete cure for chronic pain but instead treatment is focused on the management of the pain. Education also allows patients to set realistic goals and expectations. Likewise, education can help the patient to identify what s/he is able to do at home to manage their pain better.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for chronic pain.
Care Plan #1
Diagnostic statement:
Chronic pain-related inflammation of joints secondary to arthritis as evidenced by redness and swelling of joints.
Expected outcomes:
- Patient will report decreased pain intensity using a pain assessment tool.
- Patient will be able to tolerate activities of daily living without an increase in pain level.
Assessment:
1. Assess the patient’s ability to perform ADLs.
Chronic pain associated with fatigue and anxiety can restrict a person’s ability to do self-care and fulfill roles.
2. Review medication history.
Patients with arthritis require long-term management of pain. Patients, especially those who use opioid analgesics, may have misconceptions and fears about drug tolerance, addiction, and dependence that affect their compliance with pain medications. Polypharmacy is also a concern in these patients. Hence pharmacovigilance should be instituted.
Interventions:
1. Encourage the patient to keep a pain diary.
A pain diary helps in identifying aggravating and relieving factors of chronic pain. Knowledge about these guides patients to make more sound decisions about lifestyle modifications that promote more effective pain management.
2. Administer medications as indicated.
Joint inflammation causing chronic pain is precipitated by varying etiologies depending on the type of arthritis. Pain medications rely on the patient’s type of arthritis.
- Rheumatoid Arthritis: disease-modifying anti-rheumatic drugs (DMARDs)
- Osteoarthritis: NSAIDs, topical capsaicin, duloxetine, corticosteroids
- Gouty Arthritis: oral corticosteroids, NSAIDs (i.e., indomethacin or high-dose naproxen), or colchicine
3. Use nonpharmacological approaches in addition to analgesics.
Physical and occupational rehabilitation, behavioral approaches, and movement-based interventions tailored to the patient’s needs and capabilities are effective and should be used to treat chronic pain when possible.
4. Assist the patient in performing ADLs.
Arthritis limits a person’s ability to walk or perform ADLs, causing feelings of powerlessness and decreased self-esteem. Providing assistance yet preventing dependence should be balanced.
5. Educate the patient about lifestyle modification.
An unhealthy diet (i.e., high purine foods, processed red meats), excessive alcohol intake, and smoking may trigger flares. Lifestyle modification strategies on top of pharmacologic therapy are vital for adequate pain control.
6. Instruct on times when pain is less severe.
Pain onset varies depending on the type of arthritis. Joint pain in rheumatic arthritis improves with movement while pain associated with osteoarthritis worsens with physical activity.
7. Encourage supportive devices if necessary (i.e., braces, splints, compression sleeves, etc.).
Supportive devices increase mobility, stabilizes body parts, and promotes independence among patients.
Care Plan #2
Diagnostic statement:
Chronic pain related to dysmenorrhea secondary to endometriosis, as evidenced by reported discomfort and depression.
Expected outcomes:
- Using a numeric rating scale, the patient will report an absence or decreased pain level.
- Patient will utilize pharmacologic and nonpharmacologic pain relief strategies.
Assessment:
1. Assess the patient for signs and symptoms of depression.
Pain and depression are closely linked to each other. Depression causes pain, and pain causes depression. The pain caused by endometriosis may have been debilitating, causing low esteem. Thus, inability to perform usual roles and take part in responsibilities. Nurses should probe more into the patient’s depression signs and symptoms that may aggravate the pain.
2. Assess the characteristic of pain and its associated signs and symptoms.
Sharp and stabbing pelvic pain associated with menstruation is the characteristic of pain caused by endometriosis. More than 80% of women suffer from chronic pelvic pain brought on by endometriosis.
3. Assess the effect of chronic pain in performing daily roles.
Severe pain due to endometriosis negatively affects patients’ health-related quality of life. It involves the social, emotional, and sexual well-being of patients and causes dysfunction in daily routines, family planning, and work productivity. The high stress levels caused by pain worsen sleep quality and lower physical activity.
Interventions:
1. Teach about non pharmacological pain management.
Relaxation techniques such as exercise, meditation, journal writing, art therapy, or other learning coping skills appropriate for the patient may help alleviate pain in conjunction with pharmacologic management.
3. Administer medications as indicated.
Since the patient has chronic pain and depression, antidepressants such as Selective serotonin reuptake inhibitors (SSRIs) may relieve pain and depression among these patients. Patients may take over the counter pain relievers such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve). In severe cases, prescription NSAIDS are also often used. However for people with endometriosis that severely impacts their daily life, the first line of treatment is usually hormonal birth control.
4. Collaborate with a pelvic floor physical therapist.
Pelvic Floor Physical therapists can provide the appropriate exercise training needed to increase resistance, muscle strength, and balance and to decrease further disability.
5. Educate about endometriosis and its management including hormone therapy, medications, and devices.
Compliance with management is essential. Recurrence of endometriosis is common in patients who discontinue therapy without their physician’s advice. Patients with endometriosis are managed with NSAIDs, progestins, or combined hormonal contraceptives administered cyclically or continuously to inhibit follicular development. Knowing the nature of the disease and its management prevent complications like infertility and chronic pelvic pain.
Care Plan #3
Diagnostic statement:
Chronic pain related to immobility is evidenced by altered sleep patterns and irritability.
Expected outcomes:
- Patient will verbalize improved current pain level.
- Patient will report better sleep patterns and mood.
Assessment:
1. Conduct a comprehensive pain assessment using appropriate pain assessment tools.
A comprehensive pain assessment (including intensity, characteristics, underlying cause, and impact on functionality and quality of life) is critical for effective pain management. One mnemonic that nurses can use to assess pain is the PQRST, which stands for Provocation, Quality, Region (or Radiation), Severity (or Scale), and Timing.
2. Assess the patient’s previous experiences with pain.
Information should include previous pain relief approaches and whether the interventions were effective, whether side effects of analgesics were experienced, and any other worries or anxiety towards pain treatment. Pain management should be holistic and individualized. Nurses should consider both physiologic and psychosocial aspects of pain in its management.
3. Assess the patient’s sleeping patterns.
Immobility can cause long-term musculoskeletal problems and pain that can disrupt sleep. Sleeping disturbances can lead to poor quality of life. Knowing sleep patterns and how patients manage sleep disturbance helps the nurse plan appropriate strategies to promote quality sleep.
Interventions:
1. Instruct the patient to maintain a diary of pain ratings, timing, precipitating events, medications, and effectiveness of pain management interventions.
Systematic pain tracking has been demonstrated to be an essential factor in improving pain management.
2. Explain the pain management approach, including therapies, medication administration, side effects, and complications.
Adequate knowledge about the nature of pain, treatment, and its role in pain control facilitates improvement.
3. Administer analgesics around the clock for continuous pain and as needed (PRN) for intermittent or breakthrough pain as prescribed.
The appropriate frequency and dose of analgesic tailored to the type of pain and its intensity is crucial for effective treatment.
4. Select the route of administration of analgesics based on the patient’s condition and pain characteristics.
Nurses should choose the least invasive route that could provide adequate pain control. The oral route is preferred for its convenience, while the intravenous route is used to provide rapid alleviation of severe pain. Oral pain medications also usually last longer than IV pain medications.
5. Teach and implement nonpharmacological interventions.
When pain is relatively well controlled with pharmacological interventions, nonpharmacologic interventions can also be beneficial as adjunct pain control.
6. Encourage patients to plan sleep around periods of greatest comfort whenever possible.
Planning activities by considering when the patient could get enough sleep or rest is necessary to improve sleeping patterns, provide adequate rest, and improve functionality.
References
- Ackley, B.J., Ladwig, G.B., Flynn Makic M.B., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing diagnosis handbook: An evidence-based guide to planning care (12th edition). Mosby.
- American Academy of Family Physicians. (2019). Chronic pain. https://familydoctor.org/condition/chronic-pain/
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Cleveland Clinic. (2021). Chronic pain. https://my.clevelandclinic.org/health/diseases/4798-chronic-pain
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Hall-Flavin, D.K. (2019). Pain and depression: Is there a link?
- National Center for Complementary and Integrative Health (2018). Chronic pain: In depth. https://www.nccih.nih.gov/health/chronic-pain-in-depth
- National Institute of Neurological Disorders and Stroke (2019). Chronic pain information page. https://www.ninds.nih.gov/Disorders/All-Disorders/Chronic-Pain-Information-Page
- Senthelal, S., Li, J., Ardeshirzadeh, S., et al. Arthritis. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK518992/
- Tsamantioti, E.S.& Mahdy, H. (2023). Endometriosis. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK567777/
