Body mass index above normal range for age and gender
Fear of pain
Fear-avoidance beliefs
Inadequate knowledge of pain management behaviors
Negative affect
Sleep disturbances
AUTHOR'S NOTEChronic Pain Syndrome** is a NANDA-I nursing diagnosis. This "syndrome" is problematic as approved as a nursing diagnosis. As one reviews the defining characteristics, they represent Chronic Pain. As one reviews the list of "related factors," they represent causative or contributing factors for Chronic Pain.
"It is important to distinguish between Chronic Pain and a Chronic Pain Syndrome. The pathophysiology of chronic pain syndrome (CPS) is multifactorial and complex and still is poorly understood. A chronic pain syndrome differs from chronic pain in that people with a chronic pain syndrome, over time, develop a number of related life problems beyond the sensation of pain itself. It is important to distinguish between the two because they respond to different types of treatment" (Singh, 2014; Norris, 2019).
Syndrome nursing diagnoses do not have related factors but instead have a group of nursing diagnoses that represent the lifelong problems or compromised functioning related to living with chronic pain.
Treatment of CPS must be tailored to each individual. The treatment should be aimed at interruption of reinforcement of the pain behavior and modulation of the pain response. The goals of treatment must be realistic and should be focused on restoration of normal function (minimal disability), better quality of life, reduction of use of medication, and prevention of relapse of chronic symptoms.
A self-directed or therapist-directed physical therapy (PT) program, individualized to the individual's needs and goals and provided in association with occupational therapy (OT), has an important role in functional restoration for individuals with chronic pain syndrome (CPS) (*Von Korff & Simon, 1996).
The goal of a PT program is to increase strength and flexibility gradually, beginning with gentle gliding exercises. Individuals usually are reluctant to participate in PT because of intense pain.
PT techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasonographic therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations.
The individual will experience a satisfactory relief measure as evidenced by (specify):
- Increased participation in activities of recovery
- Reduction in pain behaviors (specify)
- Improvement in mood, coping
NOCPain Control, Pain Level, Pain: Disruptive Effects, Depression Control, Pain: Adverse Psychological Response, Coping, Stress Level
NICPain Management, Medication Management, Exercise Promotion, Mood Management, Coping Enhancement, Acupressure, Heat/Cold Application, Distraction
CARP'S CUESGiven the large burden of human suffering that occurs when pain and psychological illness coincide, there is a pressing need to understand the interplay of pain and psychological illness with research of the individual early in the development of their comorbidity (*Von Korff & Simon, 1996). Written almost 25 years ago, how far have we advanced the care of these individuals? Too often these individuals are shunned, overly tested, and referred to multiple specialists, who further test them, only to have them return to our primary care office with the same complaints as in their initial office visit.
Refer to Chronic Pain for interventions related to the individual's pain management.
The interventions to follow are strategies utilizing basic-level principles of cognitive-behavioral therapy that a professional nurse can utilize to (Grossman & Porth, 2014):
- Create a therapeutic relationship with the individual.
- Promote positive self-esteem.
- Reward nonillness-related behaviors
Carefully evaluate your beliefs or biases, which can be barriers to providing empathetic, ethical, professional nursing care to this individual.
R:Because Somatic Symptom Disorder is an extremely complex disorder, confirmations of this diagnosis require an extensive workup and interactive therapeutic sessions. Until this syndrome has been systematically ruled out, the nurse should provide the appropriate interventions for chronic pain. When confirmed the complaints are somatic, appropriate referrals are indicated.
Refer to Key Concepts for the differentiation of Factious Disorder and Malingering.
Do you believe:
- Somatic Symptom Disorder is not valid for this person?
- You can correctly differentiate between "deserving pain patients" and "undeserving addicts"?
- This person is faking?
- This person is drug seeking?
- This person is wasting your time?
- Most people who chronically take opioids are addicted.
R:Dickson, Hay-Smith, & Dean (*2009) interviewed professionals working in rehabilitation units in regard to their feelings when providing care to individuals with somatic symptom syndrome. They reported the unpredictability of the situation, uncomfortableness, and uncertainty of what interventions should be provided. Individuals with this diagnosis are "demonized" and are "too hard." Enmeshed in this clinical situation is that the majority of individuals are not told of their diagnosis and the goals of treatment (*Dickson, Hay-Smith, & Dean, 2009).
As one examines one's biases, keep in mind: "There are no such things as bad thoughts, only bad actions."
Attempt to limit the number of nurses assigned to the person.
R:This can prevent manipulation and allow for consistent intervention. It can also prevent the need "to tell their story" over and over, which reinforces illness behaviors.
Specifically explore what makes her/him feel less stressed or anxious.
R:Encourages the person to engage in this behavior, reinforces strengths and problem-solving abilities, and enhances self-esteem (Halter, 2018).
"Listen to understand rather than listening to respond" (Proctor et al., 2017, p. 93), especially in nonillness-related discussions.
R:When one listens to respond, one is thinking of their response. "Withholding one's reactions to what is being said, hearing what is being said, and then exploring the person's perspective with curious questioning, rather than launching into one's own agenda, leads one to develop a more balanced and inclusive appraisal of the person's situation" (Proctor et al., 2017, p. 93).
Stop by his/her room when the person has not called with a request or comfort.
R:This rewards nonillness-related behavior and reinforces the person does not have to complain for the nurse's attention. This can minimize sick role behaviors (Varcarolis, 2014; Greenberg, 2015).
Reduce his or her anxiety about the illness (Boyd, 2012).
- Explain diagnostic tests that have been ordered
R:This can help to decrease anxiety.
- Do not advise that specific diagnostic testing may be needed.
R:"Often persons with somatic symptom disorder have had numerous diagnostic studies (some repetitive) and specialist consultations in response to their complaints. The primary care provider must remain the responsible caregiver, and the psychiatrist's advice reduces diagnostic uncertainty and potentially harmful procedures and interventions" (Greenberg, 2015).
Explain the various noninvasive stress-relief methods to the individual and family and why they are effective:
- Explain the therapeutic uses of menthol preparations, massage, and vibration.
- Training in mindfulness meditation
R:Ziedan et al. (2012) reported a review of the research and concluded that "training in mindfulness meditation improves anxiety, depression, stress, cognition, and provides pain relief. Mindfulness-related health benefits are associated with enhancements in cognitive control, emotion regulation, positive mood, and acceptance, each of which have been associated with pain modulation."
R:Nonpharmacologic interventions provide a major treatment approach for pain, specifically chronic pain (*McGuire, Sheidler, & Polomano, 2000). They provide individuals with an increased sense of control, promote active involvement, reduce stress and anxiety, elevate mood, and raise the pain threshold (*McGuire, Sheidler, & Polomano, 2000; Grossman & Porth, 2014).
- Relaxation, e.g., yoga, breathing exercises, guided imagery.
R:Studies have shown that relaxation promotes the human brain to secrete endorphins, which have opiate-like properties that relieve pain. The release of endorphins may be responsible for the positive effects of placebos and noninvasive pain-relief measures (*Pasero & McCaffery, 2011).
R:Evidence suggests that music-based interventions can have a positive impact on pain, anxiety, mood disturbance, and quality of life in cancer patients (*Beebe & Wyatt, 2009; Archie, Bruera, & Cohen, 2013).
Initiate Health Teaching and Referrals as Indicated
Clarify with the individual/family what follow-up has been recommended.