Pain Management in Nursing Practice

Shelagh Wright

• Publisher: SAGE Publications Ltd
• Year: 2014
• ISBN:
  9781473911239
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Pain is a challenging area to understand for any healthcare professional, and quality training on the subject is required if nurses are to provide effective pain management and person-centred care. Based on the curriculum developed by the International Association for the Study of Pain, this book offers an essential guide to managing pain. Beginning with an examination of the biology of pain, it thengoes on to consider pain management across the life course, looking at key topics including acute pain, cancer pain and pharmacology. Case scenarios are included throughout the book to help readers apply the knowledge they have learned to their own practice.

This book is aimed primarily at meeting the learning needs of undergraduate nurses, and is essential reading for all healthcare professionals studying pain. The text will be helpful as a basic foundation for more advanced postgraduate courses in pain management in nursing practice.

1 Leaders in Pain Care: An Historic Overview

Learning Objectives

The learning objectives of this chapter are to:

• recognize the origins of understanding and treating pain
• be aware of how social practices across ages influenced cultural attitudes to pain
• be cognizant of some eminent leaders in pain treatment and management
• view a transition from a linear view of pain to a complex systems perspective

Introduction

This chapter offers a brief overview of the important contributions of some eminent leaders in pain philosophy, medicine and nursing from ancient to modern times, describing the achievements of these leaders within their socio-political and cultural contexts. There was no linear development from ancient to modern times towards understanding mechanisms underpinning human pain experience. Multiple factors, at different times over very lengthy time spans, provided a context for discoveries which improved understanding of mechanisms underpinning pain experience, as well as pain diagnostics, treatment and management (Dormandy, 2006).

A View of Pain from Antiquity

One of the few human constants between now and antiquity is the inherent anatomical structure and neurobiochemical function underpinning human physiology, with the human person living in a social and cultural context. It is now acknowledged and undisputed that pain is a subjective experience and that this experience always takes place in a context which impacts on both how the pain is experienced as well as the meaning of the pain for the person. Prehistoric man viewed pain relief as part of a package bestowed by the gods, which addressed sleep, happiness, hope and joy, and which was handed down and utilized by healers in early civilizations. The viewpoint began to change with the beginnings of Western civilization in ancient Greece, a context of frequent wars, resulting in serious injuries, without knowledge of a central nervous system and only the rudimentary beginnings of study of anatomy and physiology (Dormandy, 2006).

Records of the experience of pain in ancient Greece emphasize the experience of pain related to war and fighting, more than to long-term illness or death and dying. Homer, for example, in the Iliad (8th–4th-century BC), used a vocabulary which included descriptions of psychological experiences of mourning, grief and worry as well as acute pains of childbirth and pains related to wounds or stings caused by arrows and sharp objects. The pains caused by the latter gave rise to exhaustion, the pain being alleviated by the removal of the sharp object and ‘remedies that relieve afflictions’ (Rey, 1993). The word ‘suffering’ is used in the Iliad in the context of ‘putting up with/working with’ pain and acknowledging the recurrence of pain. Pain in those ancient times was described both in terms of its temporal nature, that is, how long the pain sensation lasted, and the type of pain, for example, ‘sharp’, ‘cutting’, often referring to the instrument which caused the pain (Rey, 1993). Homer's Iliad is a war record of the beginning of Western civilization. Death from injury was described in the context of the person dying, the weapon associated with death and pain, how the weapon entered the body of the person dying and the wound produced. This latter element described painful death as deconstruction of human life. The mortally wounding weapon not only accessed the body of the fighter, but also wounded his close social others. Homer's Iliad portrayed:

the spear that cuts through the sinew of Pedaeus's head, passing through his teeth and severing his tongue, passes also through the work of goodly Theano, who ‘reared him carefully even as her own children’; the Bronze point that enters Phereclus through the right buttock, pierces bladder and bone, and pierces as well the ship building and craftsmanship bodied forth in this son of Tecton, Harmon's son. (Scarry, 1985: 123)

Hippocrates (c. 460–377 BC)

Living in a culture of war, Hippocrates was the first ancient Greek physician to change the concept of causes of disease from punishment by the gods to natural causes. Hippocratic medicine focused on observation, and especially the description of the pain experience provided by the patient to the doctor. Hippocrates took a new perspective of viewing pain as a symptom. With a philosophy that ‘pain signifies’, the elicited pain information formed an essential part of the overall patient examination, contributing to the patient's prognosis in a system of medicine which viewed illness as a process (Rey, 1993). Hippocrates, known as the ‘Father of Medicine’, taught physicians the guiding principle of ‘first do no harm’ (primum non nocere) and required physicians to take the Hippocratic Oath (Boring, 1957; NIH, 2012).

In the books of the Hippocratic collection, written from 430 BC to 380 BC, the various treatises emphasize that the doctor's duty was to alleviate suffering and to know when to intervene, through interpretation of the patient's case history. The verb ‘to suffer’ (poneo) was used to describe suffering and illness as an experienced state. Pain location, often defined in approximate terms: ‘in the area of’ or ‘about’, as well as playing a role in illness identification, was linked to the type of treatment prescribed. The Hippocratic understanding of the aetiology of pain varied and was without an empirical foundation. As one example, use of the principles of likes and opposites was invoked, with certain pains being considered to be brought on by heat in ‘cold’ people and by cold in ‘warm’ people. Ignorance of anatomy was due to the legal ban on the dissection of human bodies, so medical practice relied on knowledge obtained from animal dissection. Hippocrates, notwithstanding the limitations imposed by these conditions, aimed for objectivity in his medical teachings and practice, turning away particularly from the use of magic and magical potions (Dormandy, 2006; Rey, 1993).

Hippocratism spread to the entire known world. The fame of Alexandria from 331 BC spread as an advanced, intellectual and scientific Hellenistic culture in Egypt. The Egyptians had better knowledge of anatomy than the Greeks because embalming, with dissection, had been practised for thousands of years. In Alexandria, the great Alexandrian anatomists Herophilus (335–280 BC) and Erasistratus (310–250 BC) revealed the brain as part of the central nervous system (Keele, 1957).

Influences on Pain in the First and Second Centuries AD: Galen and Aristotle

Galen (c. 129–199 AD) was a physician to the Roman emperors. He published extensively in Greek and his works, subsequently translated into Arabic and Latin, were, for more than a millennium, considered the definitive medical references. Galen had a profound influence on the medical profession for longer than any other doctor in history (Dormandy, 2006). Also strongly influenced by the dissection work of the Alexandrian anatomists and localizing the mind in the brain (Boring, 1957), Galen placed considerable importance on pain in his work, which emphasized both sensation and perception. Galen devised a humeral system of pathology in which information characterized by pain, heat, redness and swelling contributed to a differential diagnosis of affliction in various organs. Pain, along with other symptoms, was responsible for identifying unhealthy organs. Galen was responsible for classifying different forms of pain, such as ‘pulsing’, ‘throbbing’, ‘stretching’ or ‘lancinating’, terms which are still used today (Rey, 1993). However, he was very reluctant to use pain-relief potions, especially ‘carotic drugs’, a term which referred, at that time, to medications which could produce stupor or sleep, particularly opium, although he did reluctantly recommend the latter for pain relief but only in older people (Dormandy, 2006).

Galen's particular contribution was to offer the first systemic thinking about pain, which up to that time in ancient Greek medicine was considered as a diagnostic and prognostic tool and was without a theoretical framework. Galen can also be considered as offering the first definition of pain as ‘the sudden change of temperament (the balance of the four forces of blood, phlegm, choler and black bile) and the rupture of continuity’ (Cohen, 2010: 88).

Another of Galen's great contributions to medicine was his re-establishing of the central nervous system as the organ for sensory perception, in contrast to the Greek philosopher Aristotle (384–322 BC), who put forward the concept of correlation of all sensory input by a ‘sensorium commune’ in the heart. While he advanced systemic thinking about pain, Galen had included unsupported anatomical errors and dogma in his writings which would later be refuted by modern scientific evidence. Though there were major differences in both viewpoints across the ages, both Aristotelian and Galenic physiology survived until the end of the eighteenth century. Galen disagreed with Aristotle's assertion allowing immortality to the intellectual part of the soul. The high importance placed on saving the soul may have been one factor which caused Galen's work to become obscured under the shadow of Aristotle's work from the time of the fall of the Roman Empire (Keele, 1957).

The Middle Ages: Christian and Galenic Cultures

Galenic medical tradition, largely published in Greek, was nearly lost to the Latin West after the decline and fall of the Roman Empire. At this time, the need to save the human soul took precedence over everything and determined attitudes to pain. Hospitals and hostels were established in the East and the West to look after the poor and sick and to help those in pain. In the sixth century AD one of the monastic rules composed for the original Benedictine monasteries was: ‘the care of the sick is to be placed above every other duty as if indeed Christ were being directly served by waiting on them’.

By the eighth century, Islam had conquered the Arabian Peninsula and from this time Galen became the supreme medical authority. Galenic medicine was kept alive in the Greek-speaking Asian cultures and passionately translated into Arabic for Muslim cultures. However, it did not go unchallenged, especially regarding pharmacological preparations, at which Islamic chemi...