Pain is highly unpleasant physical sensation that is caused by illness or injury. According to Woolf, pain is an early warning physiological protective system which is essential for detecting and minimizing the contact with damaging stimuli (Woolf, 2010). This literature review focuses on post operative pain, which one specific aspect of pain management. The current literature review on post operative pain management attempts to present the pathophysiology of pain. Following this, specific aspects are applied to post operative pain. Management strategies have been discussed in relation to post operative pain. In the next part of the review, professional and ethical issues in post operative pain management have been discussed. The review also provides information on the people who should be involved in post operative pain management. Lastly, the literature review discusses implications for practice. Various data bases were used in the search. These include Cochrane library, PubMed and Medline. Key search words used were post operative pain, pain management and post surgical pain.
For explaining the physiological basis of pain, several theoretical frameworks, known as pain theories have been proposed. They are the following:
Specificity Theory of Pain, as explained in Moayedi and Davis, refers to the presence of dedicated pathways for each somatosensory modality (Moayedi and Davis, 2013). According to this theory, there is a specific receptor and associated sensory fiber in each modality. These are sensitive to one specific stimulus. A nociceptor would be activated by noxious stimuli. This through a pain fiber, would project to higher pain centers. Moayedi and Davis then examined Intensity Theory of Pain, which was first conceptualized by Plato in 1998 (Moayedi and Davis, 2013). This theory was earlier referred to as Summation Theory of Pain. This theory defines pain as an emotion that occurs when stimulus is stronger than usual. In any sensory system, pain occurred when sufficient intensity was reached. As per this theory, for threshold stimuli to become painful to an unbearable extent, there must be some form of summation that takes place. Increased sensory input converges and summates in the gray matter of spinal cord.
In contrast to this, Pick, DeSimone and Harris have included Pattern Theory of pain. This theory stated that there is specific and particular pattern of neural firing that is responsible for the occurrence of a somaesthetic sensation (Pick, DeSimone and Harris, 2010). The type and intensity of the stimulus is encoded by the spatial and temporal profile of firing of the peripheral nerves. As per this theory, cutaneous sensory nerve fibers are the same. If any of these nerve fibers are intensely stimulated, perception of pain is caused.
Buyukyilmaz and et.al., discussed Gate Theory of Pain which was proposed by Melzack and Wall in 1965. Experimental evidence was recognized by the Gate Theory. As per this theory, there are pain and touch fibers (Buyukyilmaz and et.al., 2010). These fibers synapse in two different regions within the dorsal horn of spinal cord. Nerve impulses generated from the site of incision are transmitted to the dorsal horn of the spinal cord. This leads to the projection of neurons forward towards the cerebral cortex in the brain. The brain performs interpretation of the signal and processes information on the basis of experience, knowledge and cultural associations. This leads to the perception of pain. The theory proposed that the transmission of sensory information from primary afferent neurons to transmission cells in the spinal cord is modulated by the gate in the spinal cord. In the situations of nociceptive information reaching a threshold that exceeds the inhibition, the gate is “opened” and pathways are activated. This leads to the experience of pain and the various behaviors related to it.
For the patients in surgical ward, pain is a common experience after surgery because of the tissue trauma. For providing quality care, effective post operative pain management is essential. Letting patients suffer from pain without making adequate efforts for managing the pain is unethical. If post operative pain is poorly controlled, it may lead to certain harmful physiological and psychological effects on the patients.
Pain management involves the use of pharmacological and non-pharmacological interventions. Considering the pharmacological pain relief medications these are classified into non opiods and opiods. According to the study conducted by White, non-opiod pain medications are non narcotics analgesics (White, 2005). Pain associated with increasingly complex surgical procedures can be managed with the use of non-opiod analgesics on a short stay basis. These may provide the advantages in the form of opiod sparing effects which include reduced nausea, vomiting, urinary retention, sedation, constipation etc. In this way, non opiod pain management strategies may lead to an improved quality of recovery for patients with post operative pain.
As per the views of Vadivelu, Mitra and Narayan, non opiod medications not only limit the amount of opiod necessary but also lead to improved pain control (Vadivelu, Mitra and Narayan, 2010). These provide the advantage of overcoming dose limiting side effects of drowsiness and dizziness. However, opiod medications are also used as pain management strategy and hence their advantages and disadvantages can be compared. As per the study conducted by Chu and et.al., opiods can be used as pain management strategy owing to their analgesic effects (Chu and et.al., 2008). These are narcotic medications and provide total relief from pain caused due to surgery. However, these need to be given appropriately. According to Pick, DeSimone and Harris, opiods have a disadvantage as their long term use may lead to risk of many medication relate problems. Although widely used in the treatment of moderate to severe post operative pain, opiods have certain side effects such as nausea and vomiting, constipation, sedation and pruritis (Pick, DeSimone and Harris, 2010). However, tolerance develops to these adverse effects over time. Berde and Nurko found that the addictive properties of opiods are the main concern as a result of which they are hesitatively used for managing post operative pain (Berde and Nurko, 2008).
However, non pharmacological interventions of pain management can also be used for controlling post operative pain. As per the study conducted by Breivik and Stubhaug, communication is important strategy in the management of post operative pain. The study found out that delivering per operative patients education and fostering effective communication can lead to better management of post operative pain (Breivik and Stubhaug, 2008). Pain management by communication provides the advantages of promoting tolerable pain scores and minimizing the use of narcotics after surgery. According to Sugai and et.al., optimal communication between the patient and physician can lead to improvement in the health outcomes of the patient in various ways (Sugai and et.al., 2013). These include resolution of the symptoms, emotional healing and recovery and pain control. Effective communication between the health care professional and patients helps the patient to experience a sense of control. This makes them to take an active part in decision making regarding the perception of pain, which leads to better outcomes in terms of increased pain tolerance. As per the study conducted by Burchiel, educating the patient about post operative pain leads to increased pain tolerance (Burchiel, 2011). This is because a close relationship has been found between sense of control and increased pain tolerance.
According to the study conducted by Vadivelu, Urman and Hines, relaxation techniques can also serve as effective pain management strategy for controlling pain that is experienced as a result of surgery (Vadivelu, Urman and Hines, 2011). These present advantages in the form of relaxing the patient with the use of abdominal breathing at slow rhythmic rate. Hence, this is free of adverse effects. However, according to Buyukyilmaz and et.al., distraction can also be used as a pain management strategy (Buyukyilmaz and et.al., 2010). By focusing the attention of the patient on something other than the pain, distraction has advantages of reducing the perception of pain produced due to local tissue damage. By stimulating the descending control system, distraction provides the benefit in the form of fewer pain stimuli being transmitted to the brain.
There are various ethical and professional issues that are encountered while managing post operative pain. These may be related to consent, administration of medicines, advocacy, equity etc. autonomy is the right of individuals as per which they are entitled to make decisions regarding their health (Brennan, Carr and Cousins, 2007). Dishonoring the right of the patient to choose the way they want their pain to be treated may violate the principle of autonomy. Due respect must be given to the individuals for their personal health care decisions.
According to National Institutes of Health, beneficence is concerned with doing well for an individual (Bernhofer, 2011). The health care professionals are required to follow this principle regarding pain management after surgery. Although most nurses and clinicians easily ascribe to this principle but unfortunately, pain management may not be efficiently done by them. However, it is rare and unethical to allow pain for diagnostic reasons. All types of pain whether it is moderate to severe, can be controlled in some fashion. Hence, the health care professionals should follow the principles of beneficence and do well for others by providing them comfort and pain relief.
Principle of nonmaleficence can be complicated for nurses during administration of medications. This principle is defined as refraining from doing harm (DuPree and et.al., 2009). Greatest obstacle is faced by the health care professionals with respect to ethical adherence while making decision regarding appropriate treatment for pain. Reasonable fear lies on the part of practitioner of causing harm while providing treatment for the pain. This is because medications for pain management have various side effects. However, as per the views of Hudcova, J. and et.al., pain may cause more harm to the patient as compared to the side effects of the drugs that are to be administered for pain management (Hudcova and et.al., 2005).
Ethical issues may also arise related to advocacy. When patients are not capable of making informed decisions regarding the treatment of their pain, advocacy is taken into hands by the nurses. According to Nursing and Midwifery Council, nurses have a duty of care towards patients (Nurses and midwives, 2014). Hence, it is their responsibility to act as their advocate when appropriate. In the situations when the patients are not physically as well as mentally incapable of making their own decisions, nurses provide assistance to the patients in obtaining what is advantageous for them thereby supporting their health and reducing the risk of harm.
In the management of post operative pain, several disciplines are involved which include pharmacist, physiotherapist, dietician, anesthetist and nurse. Anesthetist performs the job of admitting the patients and ensuring that they are in a stable condition (Breivik and Stubhaug, 2008). He is responsible for prescribing medications and ascertaining that the patient is not suffering from pain. Poorly addressed pain can have harmful consequences on alimentary, respiratory, cardiovascular, immune and urinary system.
Nurses play a more varied role. They are responsible for assessing and documenting the baseline pain of the patient. This is done before the commencement of pain management. As per the views of Wood, while documenting pain, pain intensity should be included prior to intervention and reassessment at the initial assessment stage (Wood, 2010). As many patients are unable of taking medications orally due to nausea and vomiting, it is the role of the nurses to select appropriate route of administration for the medications.
Physiotherapist has the role of teaching coping strategies to the patients so that they are able to participate in their treatment and feel more comfortable. Dieticians play the role of ensuring that the nutritional needs of the patients are met. This is because post operative patients are unable to eat due to pain caused by surgery.
Although pain management is administered well in the surgical ward, there can be various improvements for ensure relief from pain to the patients. There must be adequate pain assessment before commencing pain management. In order to be effective, post operative pain management requires nurses to possess the skills and knowledge required for selecting and implementing appropriate pain management strategies for controlling pain caused after surgery. Pharmacological interventions have various side effects. Hence, these can be used in limited doses along with use of non pharmacological interventions. Distraction and relaxation techniques can be used as these effectively help in reducing the pain and do not have any adverse effects. People’s rights must be supported by the nurses while making decisions regarding their care. They must also ensure that the patients are fully informed.