Acute pain (Fig. 23.1)

Acute pain is usually of brief duration (less than 6 weeks) and is commonly nociceptive, associated with tissue injury such as surgery, which subsides as healing takes place (Box 23.1). Acute pain is very common; it can range in intensity from transitory pain felt after a minor bump or a mild headache to severe pain associated with trauma or disease, e.g. fractures or heart attack. Mild acute pain may be managed successfully with patient/parent-initiated interventions at home. However, the pain may also indicate problems and motivate the person to seek medical advice.

Acute nociceptive pain may be referred; this is when pain arises in internal organs (viscera) but is experienced some distance from the source of the pain. For example, a heart attack frequently causes pain down the arms (usually the left) and up the neck and jaw, despite there being no tissue injury in those areas. Sensory impulses from the left arm and heart enter the spinal cord at the same level. Normally, few sensory impulses are processed from the heart so when more impulses are received for processing, this results in perception of pain arising from the arm. Another example of referred pain is the initial pain of acute appendicitis, which is felt around the umbilicus, despite the appendix being sited in the right lower part of the abdomen (Fig. 23.2).

Fig. 23.2 Referred pain – acute appendicitis (adapted with permission from Rutishauser 1994)

Chronic pain (Fig. 23.1)

When pain does not resolve and becomes chronic (usually lasting longer than 3 months) the effect on a person’s quality of life can lead to depression and social isolation. In a child this may seriously influence their education and their future potential as adults. In adults it can cause relationship problems, isolation and financial difficulties and it may be a cause of mental health problems including suicidal ideation. Chronic pain is further subdivided into non-malignant and malignant (life-threatening) pain.

Physiological and behavioural responses to acute pain

It is important for nurses to understand common physiological and behavioural responses to acute pain. This is important as part of pain assessment (see pp. 661–667), particularly so in patients or clients unable to describe their pain, e.g. babies, people with dementia or people with learning disabilities and associated communication problems. The responses may be:

Myths, misconceptions and facts about pain

The complexity of pain makes it difficult to define, describe, explain and measure, thus increasing the likelihood that pain is underdetermined and undertreated. However, there is a school of thought which proposes that complete relief from pain is not achievable or necessarily desirable, especially after minor injury or surgery where low intensity pain limits overexertion. Moreover, pain is a valuable diagnostic tool and can be a learning mechanism. However, pain that is severe and prolonged, or which limits activity and movement, can be detrimental to recovery and general well-being (Box 23.9).

Moreover, enduring myths, misconceptions relating to false judgements, mistaken beliefs or misunderstandings surrounding pain all reflect prejudice, outmoded beliefs and lack of knowledge and understanding. Collectively these present healthcare professionals with enormous challenges to manage pain effectively, as knowledge and beliefs relating to pain and its subsequent management are the foundations upon which healthcare professionals make judgements and decisions.

A number of myths and misconceptions flourish, despite these having been disproved by sound evidence. In particular, two such myths that continue to perpetuate the undertreatment of pain relate to fears about respira-tory depression and addiction from the use of strong opioid analgesics, e.g. morphine. Box 23.10 (p. 662) outlines some pain myths and facts.

In order to dispel myths and misconceptions, nurses need to attain and maintain up-to-date evidence-based knowledge about pain and practical experience of relating this knowledge to preventing and managing pain. According to Davies and Taylor (2003), nurses require knowledge about:

Behavioural responses to pain

Behavioural responses to pain are important in the assess-ment of all patients/clients but can be especially relevant when people are unable to verbalize their pain. Although there are only limited pain assessment tools available for vulnerable groups, it is important to understand that people with special needs experience pain the same as everyone else. It is vital that nurses recognize that they may be unable to verbalize their pain or explain it clearly. Vulnerable people include the following:

Certain behaviours are useful for identifying patients/clients who may be experiencing pain (Box 23.11; see also p. 659). In situations where verbal communication is limited or impossible, observations of behaviour alone can be used.

In addition to the limited availability of assessment tools for vulnerable groups, there may also be a culture where lack of assessment hampers effective evaluation of pain management. Furthermore, pain assessment can fail if there is poor communication between the nurse and the patient/client or family.

Pain language

There are many words used to describe the pain experi-ence (Box 23.12). Many patients/clients and children develop their own pain language and behaviours that communicate pain. Instead of the word pain, depending upon the age and stage of development, children may use words such as ‘baddie’, ‘nasty’ or ‘hurt’ (Carter 1994). Descriptions of pain expressions may have little or no meaning outside the family and reinforce the need for partnerships and child and family-centred care in pain management with infants and children and others with communication difficulties. Therefore, identifying pain language in children and adults, including those with a learning disability or older people, is important for the delivery of high quality care and also informs the assessment process.

Assessing children’s pain

Until recently, pain in children was not recognized or prioritized, resulting in poor pain management (Twycross et al 1998). Infants and children have the right to careful consideration as they may experience pain differently from adults. The child’s experience of pain is often separate from their experience of their illness or disease. As with adults, children have different experiences and reactions to pain from the same stimulus, and the relationship between the pain stimulus and the response is neither direct nor simple.

An understanding of how children develop their understanding of health and illness will enhance the quality of care offered to each child (see Chs 1, 8). Evidence suggests that most health professionals do not approach children according to their developmental level but rather address all children according to Piaget’s (1924) concrete operational stage of development (see Ch. 8). Therefore, knowledge about how a child’s understanding of illness develops will mean that age-specific explanations can be given to the child, thus reducing the anxiety and distress that children suffer during hospitalization (Twycross et al 1998). A child’s developmental stage affects their perception and ability to adequately report or express the pain they are feeling.

Children have the right to feel secure and to be nursed in an atmosphere where compassion, trust and caring are at the centre of all decisions. These principles must underpin the child’s pain assessment and management, with the child central to all considerations and decisions.

The QUESTT model (Baker & Wong 1987) encompasses many important features of assessment and involves:

This model provides a comprehensive overview of the child’s pain and informs the treatment and therapeutic management.

Pain history

Establishing a pain history is important as it will not only identify previous pain experiences, but may also offer insights into how the person’s knowledge and perception have influenced and shaped coping strategies, and how this may influence the current situation. This is particularly important for vulnerable groups, e.g. older or confused clients. Children can be better prepared for painful procedures by comparing the previous experience with the new experience and often children develop strategies that compare one situation with another. Furthermore, pain behaviours may be an integral part of the pain history and behavioural cues may be important pain indicators. Being sensitive to pain indicators may mean that practitioners can intervene at an early stage before pain is fully established. It is also useful to establish if there are separate behaviours relating to sudden acute pain compared to chronic pain. Again this is important in patient/client populations where there may be difficulties in articulating pain.

Pain diaries

These are useful tools for the assessment of chronic pain and a means of reflecting upon the many components of pain, e.g. physical, emotional, social. They can also include numerical ratings and descriptions of pain (see Box 23.12, p. 663).

Pain maps

The patient, if able, is asked to identify, mark or sketch areas on a body outline or ‘body map’ that reflects the area(s) of pain (see p. 667). Pain maps are used increasingly as part of the assessment process, especially for patients with complex chronic pain. Pain maps can empower the patient during the assessment process; they can be used across the lifespan and are important tools for informing decisions about pain management and providing a basis for evaluating the effectiveness of treatment.

Self-report scales

Self-report assessment scales include visual analogue scales (VAS), verbal numerical rating scales and categorical verbal rating scales but can also include pain interviews or questionnaires that incorporate variables such as coping skills (Fig. 23.5). Self-report scales can be modified; for example, the pain ‘thermometer’ scale or by using a child’s own words on the scale, e.g. ‘worst hurt’ (Box 23.14, p. 666). They can also be used with pain maps or pain diaries.

Fig. 23.5 Self-report pain scales: A. Visual analogue scale. B. Verbal numerical rating scale. C. Categorical rating scale. D. Faces scales

Observation techniques

This involves recording variables that may include:

Observational tools used for adult pain assessment and measurement show potential when trained observers are used and there are clearly defined terms and boundaries. A number of observational tools have been developed to assess the pain of children aged 0–5 years, who are unable or less able to use self-report scales. Observation may also be useful in cases where self-report tools may be unreliable or unsuitable, as with people with a learning disability and those with communication or language difficulties.

Physiological measurements

The quest for objectivity in pain assessment has led some researchers to measure functions such as increased heart rate, feeling faint, etc. or disease activity as equivalents for the experience of pain (Box 23.15).

Physiological measurements such as respiratory rate, blood pressure, heart rate and oxygen saturation (see Ch. 17) have their limitations. However, they are used for neonatal pain assessment because there are few other comprehensive neonatal assessment tools available.

Multimethod approaches to pain assessment

These approaches give richer information regarding the pain experience of the patient/client and often pain assessment tools combine quantitative and qualitative elements (see Ch. 5). One such tool is the Pain Anxiety Symptoms Scale (PASS) which incorporates three modes: cognitive, overt behaviour and physiological, including reports of changes, e.g. sweating, feeling faint and dizzy, etc. Various multimethod approaches exist for assessing pain in children and young people (see Further reading), e.g. the Pain Assessment Tool for Children (PATCh) which includes:

Assessment for different types of pain

The choice of assessment method must be appropriate for the person and the pain type. In acute pain a self-report scale such as the categorical rating scale, which concentrates on pain intensity alone, is often sufficient for evaluation of interventions, especially if there is a single pain location.

However, with chronic pain a body map is frequently required to improve multidisciplinary recognition and communication of pain location and pattern. For patients with cancer-related pain, a body map is essential because as the cancer advances several pain locations may develop (see Ch. 12). The different pains locations require regular reassessment as the disease progresses. In addition, the impact of the pain on mood and behaviour are important considerations. These will be missed if a simple self-report scale is used.

Questions that explore quality of sleep and the impact of pain on mobility and social interaction are valuable. Patients are asked about what makes the pain better or worse, thus helping to identify characteristics that may be of value in evaluating treatment options and coping skills that people may have developed. The quality and character of pain may guide pharmacological management, e.g. a pain described as ‘shooting’ may be neuropathic such as after shingles (see p. 655). Pain clinics and specialist nurse practitioners use detailed tools and may ask people to complete pain diaries in order to evaluate the pain experience comprehensively.

Figure 23.6 illustrates an example of a more comprehensive assessment tool that combines a body map, self-report scale and description of the type of pain with factors that increase or decrease pain.

Fig. 23.6 Pain assessment tool

(reproduced with permission from Brooker & Nicol 2003)

Age and analgesic drugs

The patient’s age is an important consideration when analgesics are chosen: the drug type, dose required and the most suitable administration route. Infants, children, adults and older people have different body compositions (see Ch. 19) and the metabolism and elimination of drugs are affected by the stage of development.

The amount of water as a percentage of body weight decreases during the lifespan. For example, a neonate has around 75% water whereas an adult male has around 60% and an older adult between 45 and 50%.

Infants and children metabolize and eliminate drugs differently from adults and this must be considered in the dose calculations. For example, neonates and premature infants are particularly vulnerable to the harmful effects of drugs because liver enzyme systems and kidney function are immature and plasma protein concentrations are low. In children, weight, height and age are important in calculating drug doses (see Ch. 22).

There are also important considerations for the older person as reduced metabolism and excretion of drugs can result in accumulated effect and reduced doses may be required. In addition, polypharmacy causes concern with drug interactions. Poor pain management can significantly reduce quality of life, particularly in chronic pain. Effective pain management is essential in maintaining optimum independence and mobility in older people. This is a particular concern for older people with dementia who are more likely to suffer chronic pain but be unable to express their pain.

Drugs used in pain management

These can be divided into three groups: non-opioids, opioids and adjuvants (Table 23.2).

Table 23.2 Drug groups used in pain management

Nurses need to develop an adequate knowledge of analgesic action and potential side-effects (Box 23.18). Unfortunately there are no perfect analgesics; all drugs that relieve pain also have side-effects. These range from mild light-headedness to more troublesome problems that occur with opioids that include constipation, nausea and sedation, up to life-threatening respiratory depression, or NSAID-induced gastric ulceration or kidney failure. The nurse is responsible not only for the evaluation of pain reduction but also the occurrence of side-effects.

Mild sedation can be a useful side-effect in the management of acute pain, e.g. following major trauma, surgery or heart attack, as it will reduce anxiety and distress. However, for chronic pain management, independence with minimum disruption to daily living is important; frequent administration is therefore undesirable and side-effect management is essential, e.g. minimal sedation.

With opioid analgesics such as morphine, the higher the dose, the greater the risk of side-effects. The dose is therefore increased in graduated amounts known as titration, which allows optimum pain relief without adverse side-effects (Fig. 23.7, p. 670). However, knowledge of likely side-effects allows pre-emptive action to be taken, e.g. ensuring that laxatives are always prescribed for patients who are having regular long-term codeine or morphine.

Fig. 23.7 Titration of opioids

When an adjuvant drug, e.g. amitriptyline, is prescribed it may take days or weeks before there is a therapeutic effect. This must be explained, as patients will be disappointed if they were expecting a prompt response and may discontinue the therapy. Starting adjuvants at a low dose and gradually increasing the dose helps to reduce side-effects and improves patient tolerance.

Routes of administration

The routes used for the administration of analgesic drugs include:

Nurses need to know about different routes of administration and should be familiar with relative advantages and disadvantages of each route (Ch. 22). Analgesic administration may be low technology, e.g. independent self-administration of oral drugs at home where the nurse’s role is educational, or – in contrast – invasive, high technology approaches where drugs are introduced into the epidural space outside the dura mater (the outer meningeal layer covering the spinal cord; Fig. 23.8), used in clinical areas to manage severe pain with additional staff training and support from pain teams. In general, the analgesic approach should be appropriate for the pain type and intensity, and should suit the person concerned.

Fig. 23.8 Epidural analgesia

An important consideration is the flexibility and availability provided by different routes of administration. In acute severe pain the route needs to be fast acting and the dose easily adjustable to allow optimum effect without development of adverse side-effects. The most widely available routes for adults are i.m. and s.c. opioid administration; the effectiveness of these routes has been greatly improved by the use of algorithms by RNs to provide greater flexibility to meet individual patients needs. Readers requiring more information about the use of algorithms for postoperative pain relief are directed to Davies and Taylor (2003).

Opioids may be required for chronic severe pain, e.g. modified release morphine given twice daily or transdermal fentanyl (patch). Transdermal fentanyl takes 12 hours to reach therapeutic levels but lasts 3 days, thereby avoiding the inconvenience of frequent administration and allowing the patient to get on with their life.

The most common routes of administration (p.o., i.m., i.v.) rely upon sufficient quantity of the drug reaching the circulation to achieve therapeutic effect. An injection is not necessarily more powerful than an oral drug, a common misconception; the analgesic should be matched to pain intensity and a suitable route chosen. The i.v. route allows for rapid therapeutic effect to be achieved within 5 minutes, which makes patient-controlled i.v. administration a fast and flexible method of managing acute pain. Intramuscular and s.c. routes have a delayed onset as the drug has to be absorbed from the muscle or fat before it can reach the circulation.

The oral route can be as fast as i.m. if the drug is designed for rapid absorption. Avoidance of painful injection is essential in children and often desirable in adults because treating pain with injections can lead to reluctance to report pain. It is important to note that oral morphine is subject to first pass effect/metabolism in the liver (see Ch. 22), thus explaining why the oral route requires a dose higher than that given by i.v. or i.m. injection. This has important safety issues for the nurse (see www.bnf.org.uk).

Administration of analgesic drugs

Analgesics with a fast onset and short duration of action need to be administered frequently to maintain therapeutic effect and prevent pain, e.g. oral morphine liquid 4-hourly. This is why the ‘as required’ (p.r.n.) approach to pain management, which relies on patients reporting pain, is criticized; the intermittent administration results in regular pain with periods of relief. Good pain management requires regular administration of a suitable analgesic to avoid pain (Fig. 23.9). Regular administration ‘by the clock’, or techniques which allow the patient to administer as soon as pain is present, e.g. by using i.v. PCA, have greatly improved pain management. Many patients manage pain at home following early discharge or day case surgery. Advice is required about taking painkillers regularly to avoid pain at first and how to step down the ‘analgesic ladder’ (see below) to milder analgesics as the pain subsides. Advice regarding avoidance of constipation (see Ch. 21) should also be included if opioids are prescribed.

Fig. 23.9 Adjusting the dose to keep the patient pain-free

(reproduced with permission from Greenstein & Gould 2004)

Analgesic potency

Pain management is achieved by administration of the most suitable analgesic drug combination. The pain type (acute or chronic) and intensity (mild, moderate or severe), the patient’s age and individual sensitivities are all important considerations. A useful tool when considering the choice of analgesic is the ‘analgesic ladder’ (World Health Organization [WHO] 2005), which groups drugs into categories that match analgesic potency with pain intensity (Fig. 23.10, p. 672; see also Ch. 12):

Fig. 23.10 Analgesic ladder (based on WHO 2005)

This ladder was first proposed for use by the World Health Organization in the management of cancer pain in the 1980s; however, it is also useful to consider when matching analgesic prescription to pain intensity for other pain types. It can be used to guide analgesic prescribing in any patient setting, e.g. community, Emergency Depart-ment and hospital. Postoperative pain relief often starts at the top of the ladder and steps down as pain subsides. In contrast, for chronic malignant cancer pain the analgesia will be adjusted as pain intensity increases with advan-cing disease; for many patients this approach has been successful in achieving good pain control (see Ch. 12).

Box 23.19 outlines a study by Moore et al (2003) that compared analgesic effectiveness in acute pain.

A combination of analgesic drugs, known as the balanced or multimodal approach, may be required for effective pain management. This can enhance pain management because less opioid is required (opioid sparing) when given in combination with other drugs and thus reduces side-effects (Broadbent 2000). Examples include oral co-codamol (paracetamol and codeine) and epidural administration of an opioid with local anaesthetic. In combination, the drugs target different areas involved in pain physiology (see pp. 657–659), which appears to improve the analgesic effect.

Pre-emptive and procedural pain management

The principle of providing analgesia before tissue injury to minimize pain is generally accepted as good practice. Some patients require repeat procedures and previous poor pain management can make patients fearful and reluctant to participate again. This is a particularly important issue for children and leads to further distress. Furthermore, poorly managed procedural pain is thought to contribute to physiological changes, which in some patients have been linked to chronic pain development (Carr & Mann 2000). Certain procedures in clinical practice, e.g. taking blood samples, cannulation, painful dressings and postoperative physiotherapy, are recognized as causing pain, and planning care to minimize this is essential. Both pharmacological treatment and psychological support are required. The management of proced-ural or transitory pain can be achieved by a variety of techniques:

Drug tolerance and dependence

The use of analgesics is influenced by drug tolerance, dependence and addiction. A common misperception that opioid analgesics lead to addiction has a negative influence on pain management. Several authors (Carr & Mann 2000, Mann 2003) identify that nurses and patients have exaggerated fears about addiction risk with opi-oids. This affects drug prescribing by medical staff, pain reporting by patients and drug administration by nurses leading to unrelieved pain.

The management of pain in people who misuse drugs often requires support from the acute pain team, as drug tolerance means that larger doses will be needed. The route of administration also requires careful consider-ation: regular i.m. administration, for example, would not be desirable, as it encourages dependence on an invasive approach (Box 23.21, p. 674).

Simple comfort measures

These can improve the experience of the person in pain and include:

These measures are also valuable for patient/clients and their carers who can become actively involved, especially in the management of chronic pain.

Information giving

Effective communication (see Ch. 9) and the provision of high quality information are vital components of holistic pain management. Inadequate information leads to the fear of pain, especially when the cause is unknown, or fear of not coping and poor understanding of pain relief methods, which can all worsen pain (Box 23.24). RNs must ensure that patients/clients/parents have sufficient information about pain and pain relief. They should discuss options, give explanations and provide written information about methods of managing pain, all of which can help to minimize anxiety and fear. There are also many self-help books designed to help patients cope with pain.

Relaxation

Relaxation may provide relief from pain and/or reduce anxiety. It may not lessen pain intensity but may decrease the distress associated with the pain. A patient/client cannot usually be relaxed and anxious at the same time. Relaxation aims to decrease skeletal muscle tension, as muscle pain can heighten painful stimuli, and the gate control theory predicts that decreasing muscle tension will reduce pain sensation. Relaxation is an effective coping mechanism for chronic or procedural pain. It can be initiated with music therapy, and relaxation techniques (see Ch. 11) can be taught prior to, and in preparation for, painful procedures. A warm bath can also aid relaxation. For infants, holding them in a well-supported comfortable position and/or rocking them rhythmically can facilitate relaxation.

Snoezelen multisensory room/environments, initially developed for people with a learning disability to create an environment for sensory stimulation, have recently been used to promote rest and relaxation for patients with chronic pain as a way to promote their coping strategies (Schofield 1996).

Hypnosis

Hypnosis is defined as focused attention, an altered state of consciousness or a trance that is followed by a period of relaxation. Hypnosis is one way of achieving relax-ation and is useful in relieving the distress caused by pain and improving confidence. It may not take the pain away but reduces or removes pain perception by stimulating the higher centres of the brain so that they inhibit opening of the ‘gate’.

Distraction

Distraction is a means of putting the pain at the periphery of awareness (McCaffery 1990) and focusing attention on something other than the pain. The focus of attention is diverted to the ‘distracter’ rather than the pain. Distracters include:

Children in particular tend to be talented at using distracters as a means of pain relief. Additional distracters for children include:

The distracter can be increased or reduced according to the intensity of the pain (Box 23.25, p. 676).

In children’s wards a play specialist may be available to support nurses with ‘play as distraction’. This is beneficial, as boredom can be a factor that opens the ‘pain gate’. Similarly, an activities coordinator working in a care home can arrange outings and social events that act as distracters for residents with pain.

Older people who live alone may find that social isolation is a negative influence on pain perception, as it is likely to open the ‘pain gate’. Therefore, encouraging social interaction and hobbies, e.g. lunch clubs, day centres, reading groups, that stimulate and distract may be valuable strategies in pain management

Imagery

Imagery is the use of imagination to modify pain responses and involves using sensory images to modify the pain – for example, that the pain is a balloon and the person is trying to blow the balloon (pain) as far away as possible. In doing so it makes the pain more bearable by providing a focus or substitution and organizes energies that facilitate the healing process. Imagery provides relief through relaxation, distraction and producing an image of the pain. Imagery can also empower patients/clients to take some control over their pain.

Imagery can be used in a guided way with children and is usually described as guided therapeutic imagery. The child imagines something about their pain that will help to reduce it, e.g. their pain flowing out of their bodies.

Massage

Massage may modify the pain experience by stimulating the nerve fibres responsible for inhibiting pain perception by closing the gate and potentially stimulating endorphin production. The relief obtained by rubbing an area after a minor knock demonstrates this.

Where possible, the patient/client/parents should be involved in the decision-making process and appropriate permission should be sought. Using massage involves a level of physical contact that is an essential element of the therapy. Massage can provide carers with a useful role and make them feel that they are contributing something positive to the experience, e.g. the carer or relative can massage their loved one’s back and shoulders. Older adults especially may be deprived of physical contact and massage can have a dual effect of contact with another human being and lead to relaxation.

Massage provides healing and relaxes tightly contracted muscles that may result from pain-induced stress. There-fore, massage can lead to relaxation and provide renewed energy needed for coping strategies.

Therapeutic touch

Touch is a means of communication (see Ch. 9). It is normally a two-way process involving feelings and sensation, and indicates a caring or loving relationship; on the other hand, touch used therapeutically aims to aid healing.

Therapeutic touch is a non-invasive means by which the nurse can help to manage a person’s pain. This is particularly important for certain groups such as children, people with mental distress or those with a learning disability. Some patients in hospital are deprived of therapeutic touch even though they are exposed to high levels of touch, especially in relation to observations and technical procedures (Box 23.26). In fact parents, especially those of children who are severely ill, touch their children more than the nursing staff.

Acupuncture (see Ch. 10)

Acupuncture aims to treat the person and not the disease or the symptoms. Using acupuncture for the treatment of painful conditions is based upon a greater understanding of physiological mechanisms involved in the pain transmission and modulation (Henderson 2002). There is also some evidence to suggest that acupuncture encourages the production of endorphins (see pp. 656, 658, 659).

Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation (TENS) is useful in localized pain and is thought to increase endorphin levels and act as a counterirritant. Ideally TENS should be used in combination with other treatments. The non-invasive device delivers controlled low-voltage electricity to the body via electrodes placed on the skin (Fig. 23.11). People using TENS often describe a tingling sensation when the device is active. It is useful for both acute and chronic pain and is used in labour (Box 23.27).

Fig. 23.11 Transcutaneous electrical nerve stimulation

In chronic pain management TENS provides a modality with fewer side-effects than other treatments and is attractive because it is controlled by the patient and does not limit mobility. However, some people may be unable to tolerate the electrodes on their skin.

Aromatherapy (see Ch. 10)

Aromatherapy is a holistic form of healing using essential oils extracted from aromatic plants. The oils can be used in massage, in the bath, through inhalation and compresses. Aromatherapy massage can offer several ways of reducing the experience of pain, e.g. by acting on the ‘pain gate’ mechanism, positively affecting the cognitive control mechanisms and by the release of endorphins. Aromatherapy is frequently used to reduce stress, promote relaxation, treat symptoms and relieve pain.

Aromatherapy must only be practised by trained practitioners, although once the oils have been made safe into an effective blend patients/clients/parents can use them as prescribed by the therapist. However, nurses must consult local guidelines and polices before using essential oils.

Surgical intervention

Sometimes this is necessary for intractable pain. Surgical interventions include:

These interventions are only used when other pain control methods have proved unsuccessful and usually fall within the remit of the specialist pain clinic.