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Pain Management

The fear and reality of pain are often major problems for the hospice patient. Most experts on pain encourage us all to trust the patient and believe that the pain is something that the person experiencing it knows the most about. Therefore, the patient can best tell the doctor and nurse how effective the different ways of relieving pain have been.

Your primary nurse will take the information that the patient (and you) are able to report about the pain experience, and use that information to work with you and your doctor to develop a pain management plan suited for the patient's needs.

During on of the first visits, your primary nurse will ask the patient some questions about their pain. It is important to encourage the patient to be honest about how bad and how often they feel pain. Many people report less pain than they are having. There are many reasons why this happens. Many people fear that an increase in pain means the disease is worsening, or that feeling pain and illness go hand-in-hand and must be tolerated. In addition, some religious beliefs hold that pain is either a punishment for past sins or a method of achieving salvation in the life beyond. Some cultures encourage people to be silent about hteir pain. Finally, fear of addiction to medications or fear that the use of strong pain medicine now will prevent good relief in the future if the pain worsens, may be reasons for reporting less pain. These reasons should be openly discussed, as they are often strong influences on the patient's ability to share and evaluate their plan.

It is important to remember that patients who have long-term pain will not act the same about their pain as someone who has new pain. The person with long-term pain may not show many of the signs we are used to seeing in people with pain. For example, they may not speak or moan about the pain, or may not be restless. Heart rate and breathing may not increase as expected. Just because the patient doesn't act like they are in pain, doesn't mean that the atient is not having pain. For these reasons it is important that you and the patient speak very openly and honestly with your nurse and doctor about hte patient's pain. The doctor and nurse can only effectively work with you and the patient to control or lessen the pain if you are open with them.


What casuses pain?

Pain appears to have a physical cause, meaning that some part of the disease is causing pain messages to be sent to the brain where pain is realized. It is important to try and discover the cause of the pain, but this is not always possible. This does not mean, however, tha thte pain is not real.


Types of Pain Medicine

There are many different kinds of pain medicine. Pain medicines are most commomly available as pills, liquids, transdermal patches, rectal suppositories, and injections. The amount and type of pain medicine the patient should take will be decided by the doctor after talking with the patient and the primary nurse. It is important that the patient tell the doctor about the relief received or not received from the pain medicine. Your primary nurse may ask you and the patient to keep a written pain record between visits. This record will help in making necessary adjustments in the pain management plan. Questions regarding pain medicine should be discussed with the doctor or primary nurse. There are other ways to help lessen the patient's pain. These may be used along with the pain medications. Some methods include: distraction, massage, relaxation exercises, and the application of heat or cold near the pained area.

Most experts on pain encourage us all to trust the patient and believe that the pain is something that the person experiencing it knows the most about. Therefore, the patient can best tell the doctor and nurse how effective the different ways of relieving pain have been.

Assessing Pain

Everyone expresses pain differently. Although some patients may talk freely about their pain, others may feel uncomfortable discussing the issue or is incapable of verbalizing pain.

If you suspect the patient is suffering, it is important to ask about pain. A good way of asking is to say: "How would you rate your pain level right now on a scale from 0 to 10 with 0 being no pain and 10 being the worst pain you ever had?"

Other questions might include:

  • Is it a new pain or has it happened before?

  • Where is it located? Is it in more than one area? If so, which location is most bothersome?

  • Is the pain sharp and stabbing or dull and aching?

  • If the patient is taking pain medicine on schedule, were there times during the day that the patient experienced "breakthrough" pain? How many times did this happen today?

  • Did the patient sleep through the night without pain?

If the patient is unable to verbalize pain or communicate effectively, it may also help to look for behavior or body language that could be a response to pain, because the patient may be unwilling or unable to communicate about pain in words.

Behaviors to look for include: eyes that are closed tightly, knitted eyebrows, crinkled forehead (grimacing), clenched fists, groaning when moved or a stiffened upper or lower body that is held rigidity and moved slowly. Other signs may include rubbing certain parts of the body, slouched or bent posture, and avoiding sitting or standing.


Non-pharmacological Methods of Pain Management

Warm Compresses

Heat may be used as a form of pain relief. A heating pad that generates its own moisture (Hydrocolator) is ideal. Gel packs heated in hot water; hot water bottles; a hot, moist towel; a regular heating pad; or a hot bath or shower can also be used to apply heat. For aching joints, such as elbows and knees, you can wrap the joint in lightweight plastic wrap (tape the plastic to itself). This retains body heat and moisture. Here’s how to make moist heat packs in your microwave.

  1. You need one large Ziploc bag and two large bath towels. Run one towel under warm tap water. Wring towel out. Fold towel into eight equal squares. Place towel in OPEN Ziploc bag.

  2. Place bag in microwave oven set on “high” for two minutes.

  3. Remove hot towel pack from oven and bag. Wrap hot towel with dry second towel.

  4. Cover aching body part with amount of toweling needed to avoid burns, while keeping the area as warm as possible. Leave on body a maximum of 15 minutes.

Good posture when sitting or standing is very important for a healthy back and in preventing back pain. When sitting, make sure both feet are flat on the floor and that your knees are level with your hips. Sit with your back firmly against the back of the chair. A rolled-up towel or small pillow between your lower back and the chair back can support your lower back. Stand as straight as possible. When walking, keep your head high,  tuck in your chin slightly, keep your abdominal muscles tight, and tilt your pelvis to maintain a natural low back curve.

Relaxation relieves pain by easing muscle tension.  Easing muscle tension can also help you feel less tired and anxious and help other pain-relieving methods work better.  

Imagery involves using your imagination to create mental scenes that use all your senses: sight, sound, touch, smell, and taste.  You can imagine exotic locations or revisit one of your favorite places.  You can create stories and characters to add to your scenes.  Imagery can take your mind off your anxiety, boredom, and pain.

Technique to use imagery demonstrated to the patient.

Distraction is any activity that takes your mind off your pain and focuses your attention elsewhere.  Doing crafts, reading a book, watching TV, or listening to music through headphones can all help distract your mind.  Distraction works well when you are waiting for drugs to take effect or if your have brief bouts of pain.  Sometimes people can take their minds off their pain for long periods, especially if the pain is mild.  

Skin stimulation is used to block pain sensation in the nerves.  Pressure, massage, hot and cold applications, rubbing, and mild electrical current are all ways to stimulate the skin.  You can do skin stimulation at the site of the pain, near it, or on the opposite side of pain. 


Things to Remember

The doctor and primary nurse need to know if the patient's pain has increased or become different in any way so that they can ensure the patient receives the correct medicine and remains as comfortable as possible. The following symptoms should be reported by the patient's primary nurse or doctor so that they can address how best to treat the pain if it has changed in any way:

  • No relief after taking pain medicine as prescribed

  • Some pain relief, but there is still a lot of pain 1 or 2 days after starting the medicine

  • A new type of pain, pain is new locations, or new pain when moving or sitting

  • Adverse side effects of pain medicines

  • Changes in sleep

  • Difficulty coping with pain- for example, if the patient becomes anxious, depressed, or irritable

The doctor will determine the proper amount of medicine for the patient. Questions regarding pain medicine should always be discussed with the doctor or primary nurse.

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