Professional Documents
Culture Documents
the postoperative pain experience (AMPA) and N-methyl-D-asparate activates NMDA receptors and
of the patient with CD. The Human (NMDA) to be released from the results in their increased sensitivi-
Response to Illness Model will pro- nociceptor ending. The release of ty to incoming pain messages
vide the framework for this discus- these chemicals in the brain pro- (Riedel & Neeck, 2001). Sensitiza-
sion, which will include recom- vides the awareness that tissue tion leads to hyperalgesia.
mendations for nursing interven- damage is occurring and painful McCance and Huether (2006)
tions to optimize the patient’s sensations thus are experienced described hyperalgesia as the
postoperative care. (McCance & Huether, 2006). increased sensitivity of a painful
stimulus. Marchand, Perretti, and
The Human Response to Pathophysiologic Perspective McMahon (2005) reported that
Illness Model The postoperative patient hyperalgesia can be induced fol-
The Human Response to Illness with CD is not naïve to the experi- lowing an inflammatory response.
Model (HRI) (Mitchell, Gallucci, & ence of pain. As a consequence of Following surgery, the body re-
Fought, 1991) provides an organiz- the disease, the patient with CD sponds with an inflammatory
ing framework to discuss the tends to experience chronic vis- response to fight infection and
unique pain experience of the ceral pain. Visceral pain manifests mast cells release chemicals that
postoperative patient with CD. as a dull, diffuse pain that can interact with nociceptors to acti-
This model uses a holistic arise due to the inflammation of vate pain transmission (Marchand
approach to gain a comprehensive the bowel (McCance & Huether, et al., 2005; McHugh & McHugh,
understanding of the human re- 2006). The primary author’s clini- 2000). Petrenko, Yamakura, Baba,
sponses to illness. Thus, the cal observation indicates that the and Shimoji (2003) reported that
response of pain will be discussed patient can perceive exaggerated the number of NMDA receptors on
within the context of the four per- acute pain during the postopera- peripheral nerve fibers increase
spectives of the HRI model: physi- tive period due to the pathophysi- during inflammation, a process
ological, pathophysiological, be- ologic pain response that devel- that also may contribute to
havioral, and experiential. In addi- ops secondary to the chronic pain increased sensitization during
tion, person and environmental experienced throughout the pa- stages of inflammation.
factors considered to be influ- tient’s history with CD. However, Hyperalgesia also can mani-
ences on the response to illness further clinical research would be fest by repeated stimulation of the
will be identified. necessary to validate this point. nociceptors responsible for pain
Mitchell and colleagues (1991) transmission, which results in
Physiologic Perspective explained that pathophysiologic amplified pain perception in the
Physiologic regulatory re- responses result from disordered spinal cord (Ikeda et al., 2006).
sponses are based on normative, biologic functioning with observ- Thus, the patient requires an
biological functioning and include able, measurable phenomena. increased opioid dose. However,
measurable phenomena (Mitchell Intensified postoperative pain morphine-induced hyperalgesia
et al., 1991). Following surgery, experienced by the postoperative can result after prolonged high
acute pain is a normal, expected, patient with CD is due to changes doses of morphine (Angst & Clark,
physiologic response. Acute post- in the peripheral and central nerv- 2006; Davis, Shaiova, & Angst,
operative pain occurs when a nox- ous system, which are often a 2007). Rather than a decreased
ious stimulus elicits a response result of poorly managed pain release of excitatory neurotrans-
from nociceptors. Two types of (Puntillo, Miaskowski, & Summer, mitters, an increase occurs. A sec-
nerve fibers (myelinated A-fibers 2003). These changes manifest as ondary response following pro-
and non-myelinated C-fibers) central and peripheral sensitiza- longed opioid use is related to
serve as the nociceptors that tion, hyperalgesia, and opioid tol- morphine metabolites creating a
respond to the stimulus and are erance (Jarzyna, 2005; Puntillo et spinal antiglycinergic effect to
responsible for transmitting im- al., 2003). reduce postsynaptic inhibition at
pulses to the dorsal horn of the Sensitization occurs following non-opioid receptor sites; the
spinal cord. When nociceptors are prolonged, uncontrolled pain. The result is hyperalgesia (Angst &
stimulated, mast cells also are neurons responsible for conduct- Clark, 2006; Davis et al., 2007).
stimulated to release histamine. ing pain information undergo Postoperatively, the patient
This in turn stimulates neuro- changes in sensitivity when the with CD often has increased opi-
chemicals, such as prostagland- release of glutamate and sub- oid requirements as a conse-
ins, potassium ions, substance P, stance P is prolonged in response quence of prolonged preoperative
and glutamate. Glutamate acti- to uncontrolled pain. Glutamate opioid consumption, which leads
vates alpha-amino-3-hydroxy-5- and substance P activate nitrous to opioid tolerance (Jones &
methyl-4-isoxazolepropionate acid oxide, which in a cascade effect Loftus, 2005). Opioid tolerance is a
result of compensatory changes of of pain. These scales are the most Experiential Perspective
the neurotransmitters and noci- valid and reliable tools for assess- The experiential perspective
ceptors responsible for pain per- ing postoperative pain (Williamson encompasses the concepts of per-
ception. To treat acute postopera- & Hoggart, 2005). Pain intensity sonal experience, introspection,
tive pain, opioids such as mor- scales, such as the Visual Ana- and the derivation of shared mean-
phine, fentanyl, or hydromor- logue Scale, Verbal Rating Scale, ing. Mitchell et al. (1991) include
phone commonly are prescribed. and FACES, often are seen in clini- these concepts in the Human
The antagonistic properties of cal practice, but it is the Numeric Response to Illness Model, as they
these medications cause them to Rating Scale (NRS) that is the most believe that it is only through the
bind to opioid receptors (mu, well-received and frequently used individual’s verbalization that the
delta, or kappa) located within ter- (Williamson & Hoggart, 2005). The experience and meaning created
minals of the central nervous sys- NRS simply delineates 1 as the through physiologic and patho-
tem. The function of opioids is to least amount of pain, and 10 as the physiologic responses of a certain
bind to the receptor in order to most severe/intolerable amount of illness can be understood. The
inhibit the modulation of synaptic pain. Psychometric analyses sup- experiential perspective is meas-
transmission in the central nerv- port the NRS as the preferred pain ured through self-report. The lived
ous system. This results in a scale for surgical patients from a experience of the postoperative
decreased release of excitatory wide range of ages and cultural patient with CD has not been doc-
neurotransmitters and disruption backgrounds. As well, the NRS has umented in the literature, but the
of pain impulse transmission. low error rates and higher face, author’s clinical experience indi-
However, after prolonged opioid convergent, divergent criterion cates that the unmanaged postop-
consumption, opioid receptors are validity when compared to other erative pain response experienced
desensitized and an increased pain scales (Gagliese, Weizblit, by the patient with CD is substan-
dosage of opioid is required to Ellis, & Chan, 2005). tial. Further studies dedicated to
decrease pain perception (DeLeon- Although less reliable, indirect understanding the experiences of
Casasola, 2002; Jarzyna, 2005; Mitra measures of the pain response the patient with CD would provide
& Sinatra, 2004; Stahl, 2000). also may be used. Facial expres- an awareness of the severity of the
Besides acting on pain recep- sions, such as grimacing or illness and pain management
tors, opioids also decrease intes- clenching of teeth, often are issues, as well as determine the
tinal secretion and gastrointesti- indicative of pain (McCaffery & best approach for patient care
nal motility. The inhibitory effects Pasero, 1999). Physical limitations (Casati, Toner, De Rooy, Drossman,
on gastrointestinal transit can related to pain also are observ- & Maunder, 2000).
result in nausea, vomiting, consti- able, such as altered posture,
pation, and dyspepsia, all distress- guarding of the abdomen, and Environmental and Person
ing for the patient (Wood & decreased mobilization. In addi- Factors
Galligan, 2004). These opioid- tion, mood changes (for example, Environmental factors are
induced side effects, sometimes flat affect, depressed mood) may defined by Heitkemper and Shaver
collectively referred to as narcotic be exhibited by the postoperative (1989) as external factors that
bowel syndrome, result in colicky patient with unmanaged pain increase a person’s vulnerability
abdominal pain (Jones & Loftus, (McCaffery & Pasero, 1999). Some to a response to illness. Environ-
2005). This prompts the patient to physiologic changes tend to occur mental factors for the postopera-
take more opioids with a goal of with acute pain, including in- tive patient with CD may include
relieving pain, while in fact con- creased blood pressure, heart conflicting attitudes with nurse/
tributing to a vicious cycle of rate, respiratory rate, and meta- health care provider regarding
abdominal pain and further opioid bolic rate; diaphoresis; dilated pain management, level of social
consumption. pupils; and decreased urine out- and familial support, and the pos-
put (Puntillo et al., 2003). How- sible negative impact of prolonged
Behavioral Perspective ever, because chronic pain creates hospitalization on finances/job
Behavioral responses are di- an altered stress response, these security stressors.
rectly observable, measurable changes may not be seen in the Person factors, which are
motor and verbal behaviors which postoperative patient with CD. internal to the individual, are
may be an overt indication of the Pathophysiologic responses occur described as either non-modifi-
meaning of the current sign, symp- in patients that endure chronic able or modifiable. Non-modifiable
tom, or experience of the individ- pain. These responses present as factors may influence the re-
ual (Mitchell et al., 1991). Pain fatigue and sleep disturbance, sponse of pain during the postop-
intensity scales are used common- anxiety, and depression (Puntillo erative period for the patient with
ly to obtain the patient’s measure et al., 2003). CD; these include severity of CD,
prior medical/surgical history, co- patterns in relation to prolonged social support mediates the nega-
morbid mood disorders, learned undermanaged pain. Sullivan, tive impact of pain. In addition,
experience with pain, and person- Bishop, and Pivik (1995) devel- years of self-isolation actually may
ality profile. One modifiable per- oped the term pain catastrophizing contribute to pain catastrophizing
son factor that affects the pain to describe the manner in which a as a form of attention-seeking
response in the postoperative patient may magnify the effects of behavior. Recent studies found
patient with CD is his or her previ- pain and exaggerate the threat that displaying a coping mecha-
ous coping mechanisms. The daily value of painful stimuli. Cata- nism such as catastrophizing elic-
pain experiences of the patient strophizing is a learned response to its social support and attention
with CD contribute to the develop- pain by which a patient negatively (Buenaver et al., 2007; Cano, 2004;
ment of coping skills that can be evaluates his or her ability to deal Keefe et al., 2003; Severeijns,
used during postoperative recov- with pain, and feels helpless with lit- Vlaeyen, & van den Hout, 2004).
ery. Some coping mechanisms, tle control over pain (Buenaver, Authors concluded that an isolat-
such as level of perceived psycho- Edwards, & Haythornthwaite, 2007; ed environment serves as a dis-
logical distress, hypervigilance, Sullivan et al., 2001). Based on the criminative stimulus to develop
pain catastrophizing, isolation, author’s clinical experience, the negative coping mechanisms.
and internal locus of control, can prevalence and degree of pain cata- An increased internal locus of
hinder the efforts of the health strophizing correlate with the sever- control also may be evident in the
care professionals who attempt to ity of disease. patient with CD, most likely devel-
manage the patient’s postopera- Lackner, Quigley, and Blanchard oping as a way to cope with the
tive pain. For example, an individ- (2004) highlighted the importance unpredictability of symptoms asso-
ual with CD has a higher stated of identifying the patient with neg- ciated with the disease. Vigilant
prevalence of psychosocial dis- ative coping mechanisms because adherence to the medication
tress than the general population they have been associated with regime can give the patient a sense
due to constant compensation the development of depression of control over the disease, but this
and awareness that symptoms and anxiety disorders. In addition, can create difficulties because the
may surface and affect daily func- co-morbid mood disorders put a hospitalized postoperative patient
tioning at any time (Cohen, 2002; patient at risk for poor responses with CD loses the sense of control
Kurina, Goldacre, Yeates, & Gill, to pharmacologic pain treatments that medication self-administration
2001). This heightened attention (Drossman et al., 2003), possibly provides. Researchers also found
to factors that trigger psychologi- due to the cycle that endures from higher levels of internal control to
cal distress also affects the post- the effects of undermanaged pain be correlated negatively with re-
operative period. Psychological and respondent coping mecha- ported pain levels (Carter-Snell,
factors play an important role in nisms. Moreover, a strong correla- Fothergill-Bourbonnais, & Durocher-
the expression of pain and the tion exists between depression Hendricks, 1997; Shiloh et al., 2003).
methods with which pain should and pain (Walker et al., 1990); sub-
be treated (Eccleston, 2001). stantive research also supports a Implications for Nursing
As the patient with CD experi- high incidence of depression The physiological, pathophys-
ences recurrent abdominal pain among patients with CD. iological, behavioral, and experi-
during disease exacerbations, he As a patient experiences ential perspectives, along with the
or she is likely to develop a pat- undermanaged pain and the con- person and environmental factors
tern of hypervigilance to pain that sequent depression and anxiety, of the Human Response to Illness
often is evident in the postopera- he or she is likely to seek isolation Model, provide insight into nurs-
tive period. Hypervigilance also from family and social support ing interventions that will opti-
has been offered as a possible network. Isolation also can result mize pain management for the
explanation for the dominant anxi- from years of shame associated postoperative patient with CD.
ety observed in individuals who with daily experiences related to Pain assessment. In caring for
experience poorly managed pain disease symptoms. The literature the patient with CD in the preoper-
over time because heightened consistently reports that isolation ative period, the nurse should per-
attention to pain is associated and a lack of social support can form thorough, accurate preoper-
with high levels of distress (Van hinder positive coping skills and be ative pain assessments. These
Damme, Crombez, Eccleston, & detrimental to effective pain man- assessments will provide baseline
Koster, 2006). agement. Ferreira and Sherman information of the underlying level
A heightened awareness and (2007) found that increased pain of chronic pain, as well as the
attention to pain sensations can was linked to lower social support effectiveness of previous pain
lead to the development of and greater depressive symptoms, interventions. This information
learned behaviors and thinking and therefore concluded that then can be used to guide the
analgesics should address side recommended nursing interven- Davis, M.P., Shaiova, L.A., & Angst, M.S.
effects of medications and fears of tions. Surgical nurses can apply (2007). When opioids cause pain.
Journal of Clinical Oncology, 25(28),
addiction, as these fears pose sig- these strategies to optimize pain 4497-4498.
nificant barriers to effective pain management outcomes for the DeLeon-Casasola, O. (2002). Cellular mech-
management (McCaffery & Pasero, postoperative patient with CD. anisms of opioid tolerance and the clini-
1999). Additional clinical research in this cal approach to the opioid tolerant
patient in the post-operative period. Best
If family members are active area is needed to facilitate the Practice & Research Clinical Anesthesi-
participants in patient care, they development of an effective post- ology, 16(4), 521-525.
should be included in teaching as operative treatment regime for the Doverty, M., Soogyi, A., White, J., Dochner, F.,
well. Research suggests that family patient with Crohn’s disease. ■ Beare, C., Menelaou, A., et al. (2001).
members can have a significant Methadone maintenance patients are
cross-tolerant to the antinociceptive
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