It's easy to become so involved in the routine of assessing pain and administering pain medications, that we forget about the big picture of pain management. The public health crisis known as The Opioid Epidemic inspired me to do some extra reading on pain, and as a result, I am integrating a new-to-me way of thinking about pain management in my nursing practice: Pain can be prevented (at least to some extent).
According to the Association of Rehabilitation Nurses, part of the official role of a rehab nurse involves preventing pain, in addition to identifying and alleviating it. Indeed, some types of pain and certain pain triggers can be prevented. What that means to me as a nurse practitioner in primary care, is that by preventing some of the conditions and circumstances which can trigger or exacerbate pain, I can, by extension, prevent pain.
Of course, this does not mean all pain can be prevented. And, despite the encouragement nurses have received since the 1980s to alleviate all pain at all costs (see Joy Eastridge's excellent allnurses.com article, "Accidental Pill Pusher"), we actually would not want to eliminate all physiological pain across the board because pain can be a valuable indicator, alerting us to the body's condition.
Although the need for 1-10 scales and pain medications including narcotics, will never go away, I'm convinced that by considering preventive strategies when managing pain, nurses in all roles can set patients up for a far more comfortable existence, involving fewer and less addictive, pain medications. For example, some forms of acute pain can be prevented by anticipatory guidance, such as emphasizing safety practices to reduce injuries and falls. Chronic pain, while arguably more difficult to prevent, can still be approached proactively.
Dehydration
When I began thinking about the possibilities for proactive pain management in nursing practice, preventing dehydration was the first thing that came to mind. Dehydration is a great place to start because not only can dehydration influence a patient's experience of pain, it can be prevented, at least to some extent, and it is something nurses routinely monitor. How much pain can we prevent if we begin to address dehydration in terms of pain prevention? This would be a great topic for a research project. Meanwhile, below are my initial thoughts on some things we can do to prevent dehydration, and by extension, help prevent pain.
Several considerations can help us think differently about dehydration and motivate us to prevent it in the name of pain prevention:
1) Many patients, more than we think, are at risk for dehydration;
2) fluid balance measures may mask dehydration;
3) dehydration contributes both directly and indirectly to pain.
Helping Those at Risk for Dehydration
First, Consider how many individuals are at risk for dehydration every moment of every day-diabetics, athletes, elders, people taking diuretic medication, and more. That's a lot of people. Consider the number of patients who take prescription diuretics for blood pressure control. Taking a diuretic means the patient should be drinking more water, not less. Yet, I often hear from my ambulatory patients who take diuretics that they choose to drink less water because they want to avoid "running to the bathroom all the time."
We can help these patients evaluate their water-drinking habits and understand the longer-term costs of chronic dehydration. Beyond refilling the patient's bedside water container and encouraging the patient to drink it, help the patient make plans to drink more water at home, every day, and commit to doing so. I find that it is often helpful to demonstrate the ideal amount of water that should be consumed daily by show-and-tell. One well known basic guideline for determining fluid intake states that the patient's weight in pounds divided by 2 is the minimum number of ounces per day that the patient should be drinking. When patients visualize this volume, they invariably respond with amazement, "That's a lot!" It gets their attention, and the image stays with them.
Next, every nurse is educated about the crucial importance of fluid balance, yet proper hydration involves so much more than the bottom line of input versus output. When we think of dehydration only in terms of fluid balance instead of specifically addressing the body's need for pure water, we get fooled into thinking they are properly hydrated when in fact they are not. We are generally taught that fluid is fluid, but the fact remains that some of our most beloved fluids tea, coffee, soda, contain caffeine which has a diuretic effect.Think about it: if we are counting fluids that are caffeinated, we are getting a false sense of the patient's actual hydration level. It is important to understand the value of pure water vs other fluids, and encourage actual water intake as opposed to intake of other fluids, which may contain salt, sugar, and caffeine which will affect (and likely inhibit) the body's assimilation and processing of plain water.
We can prevent dehydration by honoring the value of plain water. Instead of simply thinking of the ratio of fluid input to fluid output as an exercise in monitoring bodily functions, we can also think about what kind of fluid the patient is regularly consuming and how it may be affecting the patient's experience of pain. There is no substitute for pure fresh water-the body knows what to do with it.
Finally, dehydration can trigger pain both directly and indirectly. Dehydration headaches, for example, can be a very real and direct cause of pain. Scientists believe this happens when a lack of sufficient fluid causes a decrease in brain volume and the shrinking tissue activates meningeal pain receptors. It stands to reason, then, that adequate hydration can help prevent this type of pain. Dehydration can also exacerbate constipation, which is not only one of the most unpleasant, and often painful, side effects of opioid pain medication, but can also occur due to reduced physical activity.
Drink More Water
Encouraging patients to drink more water by connecting the dots for them about how dehydration is contributing to their discomfort can help. In cases where I have recommended that my patient drink warm water first thing in the morning on an empty stomach to stimulate peristalsis, the patient has enjoyed good results. In my experience, the more water a patient at risk for constipation can drink, the less severe his symptoms will be.
Some pain can be prevented, and one way to start is by preventing dehydration to prevent pain. This article has explored several practical ways to proactively prevent pain by thinking approaching dehydration proactively. No doubt, there are many ways to not only prevent dehydration but to prevent pain. I firmly believe nurses at all levels of practice can contribute in a meaningful way to managing pain effectively while reducing the need for opioid medications-just by thinking a little differently about some of the things we are already doing. The notion that pain can be prevented is a useful concept for finding new ways of approaching pain management in light of the current opioid crisis- especially for managing chronic pain.
Questions for discussion:
- How does your view of pain change when you think in terms of proactively preventing it rather than reactively treating it?
- What other possible ways to prevent pain can you think of in addition to those listed in this article?
Sources and Resources:
Accidental Pill Pusher
https://allnurses.com/general-nursing-discussion/accidental-pill-pusher-1131809.html
Aging and Preventive Health
Aging and Preventive Health
American Chronic Pain Association - September is Pain Awareness Month
American Chronic Pain Association - September is Pain Awareness Month
Are You Drinking Enough Water
Drinking Enough Water to Prevent Dehydration
Back Pain Prevention
Back pain - Symptoms and causes - Mayo Clinic
Dehydration Headache: Know the Causes, Signs, and Treatments
Dehydration Headache: Know the Causes, Signs, and Treatments - University Health News
Hydration Assessment
Hydration Assessment
Prevent Dehydration with Nursing Interventions
Prevent dehydration with nursing interventions - www.hcpro.com
Resource Guide to Chronic Pain Management
American Chronic Pain Association - Resource Guide to Chronic Pain Management
The Opioid Epidemic: A Crisis Years in the Making
https://www.nytimes.com/2017/10/26/us/opioid-crisis-public-health-emergency.html
The Role of the Rehabilitation Nurse in Pain Management
http://www.rehabnurse.org/pubs/role/Role-Pain-Management-Rehab-Nurse.html
