Pain is certainly a relevant concern in the field of nursing. Whether working with pediatric patients, adults, or in a geriatric care setting, professionals in the nursing field must often deal with pain assessment and management. Pain is interpreted by the human body when nociceptors are stimulated. They then transmit signals through neurons in the spinal cord and glutamate is released. This neurotransmitter transfers signals from one neuron to another and then sends these signals to the thalamus, which is where the perception of pain takes place. The person experiencing the pain becomes fully aware of the sensation when the signal travels from the thalamus to the cerebrum.
Professionals in the nursing field need to be aware of the fact that there are many different types of pain. Chronic pain is pain that occurs for a period longer than in the normal course of an injury. This type of pain can be constant or intermittent and no longer serves the purpose of helping to prevent injury to the body. Cutaneous pain is caused by an injury to the skin or body tissues. Somatic pain can come from ligaments, bones, tendons, nerves, and blood vessels. This can include broken bones, strains, and sprains. Visceral pain comes from organs located in the human body (Ballantine, 2005).
Acute pain is short-term pain, or pain that has a cause that can easily be determined. The body uses acute pain as a warning system that can possibly prevent injury. This type of pain is localized in one area before spreading out to other areas of the body. Another type of pain is phantom limb pain. This type of pain is a sensation from a limb that is no longer present or can no longer transmit signals. Most amputees and quadriplegics report having this type of pain. Neuropathic pain can result from a disease or injury to nerve tissue. This type of injury can prevent the sensory nerves from transmitting correct information to the thalamus. Because of this, the brain can perceive painful sensations although there is no apparent physiological cause of this (Ballantine, 2005).
Pain assessment is an important nursing concept and is considered the most important aspect of pain management. It is particularly important for nursing professionals to listen to concerns of pain from all patients, regardless of visible signs of pain or other factors. Because acute pain is often more recognizable or has a more visible cause, patients with complaints of chronic pain are often underassessed. Pain assessment often involves the use of intensity scales, including the visual analog scale, word scales, pain diaries, and forms that allow patients to rate their own pain. Nursing professionals must often participate in conducting initial pain assessments, which may involve assessing the type and intensity of pain, physical examination, psychological and social assessment, and evaluating the signs and symptoms of pain (Abraham & Snyder, 2001).
Nursing professionals are also an integral part of pain management activities. Pain management involves an attempt to reverse the underlying cause of a patient’s pain. Nonpharmacologic therapies for pain include acupuncture, electrical stimulation, heat, cold, exercise, and cognitive therapy. Pharmacologic means are also often used to manage pain. The World Health Organization recommends an analgesia ladder in managing pain. This tiered approach suggests aspirin, acetaminophen, or non-steroidal anti-inflammatory drugs for step one of the ladder. Step two of the ladder suggests using oxycodone in low doses, as well as using codeine or hydrocodone. Step three of the ladder is for severe pain and recommends morphine, oxycodone, hydromorphone, and methadone for pain management (Abraham & Snyder, 2001).
There are many nursing theories and models in existence that can be applied to the approach to pain management. These models vary in their approach to pain and must be used to complement a comprehensive patient care plan.
The Orem Model of Nursing
Dorothea Orem developed the Self-Care Model of Nursing between 1959 and 2001. This model is used primarily in rehabilitation and primary care settings. Patients in these settings are usually encouraged to be as independent as possible, making this a more useful nursing model. This model is based on the idea that “all patients wish to care for themselves” (Orem, ). Orem developed this model by identifying groups of needs or requirements that a patient needs for self care. They can be classified as universal requisites, developmental requisites, or health deviation requisites. Universal requisites are required by all people, developmental requisites are unique to the development of individual patients, and health deviation requisites are needs that result from a patient’s condition. When a patient is unable to fulfill his or her self-care requisites, a self-care deficit occurs. According to this model, nursing professionals are responsible for determining what these deficits are and developing ways of supporting patients.
Universal requisites include air, water, food, waste elimination, rest, daily activity, solitude, social interaction, hazard prevention, and promotion of normality. Supportive measures for each of these requisites may include smoking cessation counseling, ensuring access to water, diet education and monitoring, monitoring of elimination, exercise counseling, providing social interaction, medication education and administration, and facilitation of a return to normal lifestyle.
Professionals using Orem’s Self Care Model of Nursing to approach pain would need to be prepared to provide support for patients to participate in their own care. According to this model, all patients want to care for themselves, so pain management would be a part of that self-care. Nursing professionals could provide education on the proper use of pain medications, counseling on and demonstration of relaxation techniques, descriptions of therapeutic treatments like music and art therapy, and information on massage and other self-care techniques. By using this model, nursing professionals could more extensively engage patients in their own pain management process.
Roy’s Adaptation Model
Sister Callista Roy developed a nursing model based on scientific and philosophical assumptions. This adaptive model was also based on characteristics of persons and relating persons. These characteristics were that humans are an adaptive system with coping processes, humans are a whole made up of many parts, humans function for some purposes, and that humans act to maintain adaptation in four modes. These four modes are physiologic-physical, self-concept-group identity, role function, and interdependence (Sitzman & Eichelberger, 2004).
The physiologic-physical mode encompasses the basic needs of persons and groups. For individuals, it consists of the five needs of oxygen, nutrition, elimination, activity and rest, and protection and the four processes-senses of fluid, electrolyte and acid-base balance, neurologic function, and endocrine function. For groups, this mode consists of the operating resources of participants, capacities, physical facilities, and fiscal resources. The self-concept group identity mode includes spiritual and psychic needs. For individuals, this includes spiritual integrity and meaning and purpose in life. For groups, this mode includes group identity integrity, honesty, and soundness of identifications within the group (Sitzman & Eichelberger, 2004).
The role function mode encompasses social factors. For individuals, the role function mode includes social integrity, role development, and expressive behaviors. In groups, the role function mode includes role clarity, an understanding of expected tasks, achievement of common goals, and regulation of complementary roles. Finally, the interdependence mode includes giving and receiving of love, respect and value for individuals and the need to achieve relational integrity for groups (Sitzman & Eichelberger, 2004).
According to Roy’s Adaptation Model, nursing is “the science and practice that expands adaptive abilities and enhances person and environment transformation” (Sitzman & Eichelberger, 2004). In addition, Roy believed that nursing goals should promote patient adaptation in the four adaptive modes in order to contribute to the quality of life, health, and dying with dignity of patients. In this model, adaptation encompassed “the process and outcome whereby thinking and feeling persons, as individuals and in groups, use conscious awareness and choice to create human and environmental integration” (Sitzman & Eichelberger, 2004). Following this model, the nursing process consists of six components. These components are assessment of behavior, assessment of stimuli, nursing diagnoses, goal setting, intervention, and evaluation.
Using this model, nursing professionals would use a different approach to pain then if the self-care nursing model were used. Under the Roy Adaptation Model, one approach to pain would be the use of a PCA pump that the patient has individual control over. This has two major benefits. The first benefit is that the patient is able to adapt to his or her environment and alter the stimuli in that environment. The second benefit is that the patient’s stress level is reduced because he or she does not have to wait a long period for a doctor or nurse to alter the environmental stimuli. Nursing professionals may also contribute alternative modalities to pain management, especially considering contextual stimuli. This can include complementary services such as touch, massage, aromatherapy, and music therapy. This can promote adaptation to the patient’s environment (Frisch, 2001).
Johnson’s Behavioral System Model
Dorothy Johnson contended that nursing care was a means for maintaining a state of equilibrium for patients. Johnson believed that patients are stressed by internal or external stimuli, resulting in a state of imbalance. She proposed that nursing care concentrate on two areas in order to maintain the delicate equilibrium of the patient. These two areas are reducing stressful stimuli and supporting adaptive processes. This behavioral system model is a systems model that encompasses interrelated parts joining to form a whole. Johnson categorized human behavior into seven subsystems including attachment, achievement, aggressive, dependence, sexual, ingestive, and eliminative. There are also four assumptions common to these subsystems. The first assumption is that what goal is being sought or what drive is being stimulated can be inferred from the form the behavior takes and the consequences it achieves. The second is that each individual is predisposed to act in certain ways over other ways. The third assumption is that each subsystem has choices available, or alternatives from which choices can be made. Finally, the fourth assumption is that they produce observable outcomes (Johnson, 1980).
In addition, there are also three functional requirements for each subsystem. First, each subsystem must be protected from harmful or upsetting conditions with which the system cannot cope. Secondly, each subsystem must be nurtured through the input of appropriate supplies. Finally, each subsystem must receive the appropriate amount of stimulation to enhance growth. Using this behavioral system model to approach pain assessment and management would involve satisfying the functional requirements for each subsystem as well as integrating the seven assumptions into the nursing plan. Nursing professionals would need to reduce stressful stimuli and support adaptive processes according to the model. This can entail approaching pain as the stressful stimulus and providing a means of removing that stress. This can be accomplished by both pharmacologic and nonpharmacologic means, including some alternative modalities.
Implications of Nursing Models in Practice
There are several key implications of using these three nursing models in professional practice. One of the implications is that using one approach over another may result in different outcomes for different patients. Rather than utilizing one approach, several approaches may need to be attempted before one is found that relieves both the physiologic and psychological feelings associated with pain. In addition, the individual personalities of patients need to be taken into consideration when deciding which nursing model to use. While Orem’s model assumes that all patients want to care for themselves, this may not be the case. Mental problems may cause patients to feel that they don’t want to participate in their own care. Elderly patients may want to participate in their own care, but be unable to do so due to mental or physical impairments. Even though patients may ideally want to care for themselves, some are unable to due to factors outside of the control of the nursing professional.
The financial impact of using one model over another must also be considered, as the activities carried out by nursing professionals in each model may be more costly in terms of time, money, or both. Because nursing professionals are in high demand, these professionals must be aware of the time constraints they are facing and select an approach that meets the patient’s needs. Nursing professionals should also be aware of family members and friends who are participating in a patient’s care. When using one model over another, the nursing professional should be able to explain the benefits of that approach to those who will be caring for the patient once hospital care is discontinued.
Importance of Examining Practice Concerns Using a Nursing Model
There are many benefits of examining practice concerns using a nursing model. One major benefit of this examination is that the nursing professional is able to study each model and select one that is appropriate for the practice concern in question. By studying the concerns using a nursing model, the nursing professional is able to integrate information from a variety of sources and utilize that information to create a well-developed care plan. A second benefit of examining practice concerns using a nursing model is that it provides an opportunity for reflection on patient care as it related to nursing models. Nursing professionals are often reacting to situations. Reflection on practice concerns using nursing models allows these professionals to think about different approaches to practice concerns rather than having to make an immediate decision. Finally, examining practice concerns using a nursing model allows nurses to plan their patient care using several approaches rather than one approach. Examining these nursing models may give nursing professionals new or updated ideas on the management of practice concerns. These ideas are immediately applicable to professional practice and may improve the overall quality of their patient care (Holyoake, 2000).
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