Participation of the nursing team in pain management of burned patients

Abstracts

BACKGROUND AND OBJECTIVES: There are many ways to manage burned patients pain, which require the use of available and specific resources for the treatment of this pain. This study aimed at reflecting about the participation of the Nursing team in the management of burned patient's pain. CONTENTS: Burn-related pain has a major impact in patients' life and the Nursing professional should have an appropriate participation in its management. CONCLUSION: The participation of the Nursing Team is critical to the process and may influence the success and effectiveness of pain relief; however, there is the need for investments in technical-scientific knowledge and awareness of these caregivers.

Burned; Nursing care; Pain

JUSTIFICATIVA E OBJETIVOS: São diversas as maneiras existentes para a assistência à dor em pacientes queimados o que exige emprego dos recursos disponíveis e específicos para o seu tratamento. O objetivo deste estudo foi refletir sobre a participação da equipe de enfermagem na assistência à dor do paciente queimado. CONTEÚDO: A dor relacionada à queimadura tem grande impacto na vida do paciente, sendo de competência do profissional de enfermagem uma adequada participação no seu gerenciamento. CONCLUSÃO: A participação da equipe de enfermagem é fundamental no processo, podendo influenciar no êxito e na eficácia do alívio da dor, no entanto, percebe-se a necessidade de investimentos em conhecimentos técnico-científicos e de sensibilização a esses cuidadores.

Cuidados de enfermagem; Dor; Queimados

ORIGINAL ARTICLE

Participation of the nursing team in pain management of burned patients^*

Bruna Azevedo da Silva^I; Flávia Alves Ribeiro^II

^IStudent of the Nursing School, University of Mogi das Cruzes (UMC). Mogi das Cruzes, SP, Brazil

^IINurse. Máster in Nursing. Professor of the School of Nursing, University of Mogi das Cruzes (UMC). Mogi das Cruzes, SP, Brazil

Correspondence to

SUMMARY

BACKGROUND AND OBJECTIVES: There are many ways to manage burned patients pain, which require the use of available and specific resources for the treatment of this pain. This study aimed at reflecting about the participation of the nursing team in the management of burned patient's pain.

CONTENTS: Burn-related pain has a major impact in patients' lives and the nursing professional should have an appropriate participation in its management.

CONCLUSION: The participation of the nursing team is critical to the process and may influence the success and effectiveness of pain relief; however, there is the need for investments in technical-scientific knowledge and awareness of these caregivers.

Keywords: Burned, Nursing care, Pain.

INTRODUCTION

Nursing assistance to burned patients is essentially to relieve their pain and distress and for such the professional has to forget past individual experiences if they are deleterious, and has to understand painful patients as an integral human being with unique characteristics¹.

The nursing team is critical for the management of painful patients, because it is very close to them. There are even evidences that burned patients pain prognosis mostly depends on how their pain is taken into consideration by the professionals², which means understanding pain since its consequence may be the reestablishment of analgesia or, on the other hand, making it psychologically traumatic or chronic^3,4.

There are different ways to manage burned patients pain and gaps related to the treatment of burn-related acute pain by the nursing team are noticeable^2,3. So, since the treatment of burned patients is characterized as painful and considering that the effective care meets assistance objectives and ensures nursing team service quality, it is clear the importance of the subject⁵.

Taking into account the gap detected by the literature with regard to nursing assistance to burn-related acute pain patients, this study is justified based on the expectation of contributing to future patients' quality of life improvement and to the nursing service condition, so that their participative role is more proactive during the process, in addition to providing input for future studies.

This study aimed at reflecting about the participation of the nursing team in the management of burned patient's pain.

DATA SURVEY

This is a descriptive and qualitative study. Virtual Health Library (BIREME) databases were queried.

Complete studies published in national and international publications in English, Portuguese and Spanish were collected from 2000 to 2010, as from Health Sciences Keywords (DECS): "nursing care", "burned", "pain", being these the inclusion criteria.

After collected, articles data were qualitatively addressed by the Dialectic Hermeneutics method, which describes most important facts of a phenomenon according to the perception of those living it, explaining and interpreting a fact to express its conception by the language, taking into account individual particularities and their pre-established ideas, finding the most significant meaning of the meditated phenomenon and establishing it through the dialogue.

Participation in pain assistance

As a consequence of the analysis of data found in the articles, the following categories were found: "Aspects related to the nursing team in the participation process of assisting burned patients' pain"; "Pain as the fifth vital sign in the burn process"; "The importance of communication in nursing assistance to burn-related pain"; "The importance of nursing participation as approach to manage (or not) burn-related pain"; "The family as focus of nursing participation in assisting burned patients' pain"; "Emotional aspects of burn-related pain".

Aspects related to the nursing team in the participation process of assisting burned patients' pain

For nursing professionals to be able to work in a burned patients treatment unit they have to be competent and knowledgeable about involved mechanisms; and have to be aware that they will be dealing with painful and subjective conditions. Very often, the complicated living together with the suffering of others, the required responsibility and the difficulty to be impartial may represent obstacles for the correct nursing assistance, thus showing how the burn process may be distressful for those experiencing it, but it may also be complex and wearing for those assisting them.

This statement is supported by expressions extracted from authors perceptions, as follows: "Nursing activity in a BTC (Burned Patients Treatment Center) [...] may be considered a pleasant work due to the possibility of learning; or a work made up of physical, mental and emotional wear; [...] participants experience the challenge of caring, meaning facing patients' pain and their own sufferings [...]"⁶. "Pain is a daily experience for health institutions, and [...] when not adequately treated, affects quality of life both of patients and caregivers [...]"⁷.

To treat patients' pain we need broad knowledge levels of the process which involves:

"Pain, both for who feels it and who treats it, is an experience resulting in culture; [...] the understanding of cultural differences and not the imposition of beliefs and values are essential aspects of the nursing professional approach to treatment. So, it is important to understand the culture of the painful patient and of the caregivers. [...] The nurse must be prepared to deal with other people's pain and with the fact that nursing procedures might worsen pain"⁴.

"[...] To take care of someone with pain does not mean just performing techniques [...], but also to show interest, compassion, affection and consideration in the professional/patient relationship, aiming at relieving, comforting, supporting, helping, favoring, promoting, reestablishing and making him happy with his life"⁷.

From these statements, one may infer that the burn process may also be a stressing experience for caregivers. This shows that the lack of knowledge is not the only obstacle for pain treatment, but rather that pain itself is already complex, thus requiring in addition to technical-scientific knowledge, the professional's ability to stay away from wrong prejudices, keeping a holistic view of the human being to be cared of.

We also stress the importance of the development of coping techniques which focus the professional and, as a consequence, help the participation of the team in the treatment of burn-related pain patients. The burn process also affects caregivers in the emotional aspect as stated by the author below:

"The nursing activity in BTC [...] may be considered a work made up of physical, mental and emotional wear; [...] living with the patient in the BTC, daily witnessing his effort to fight for life, encourages the occurrence of emotional wear among the team [...] physical and mental wear should not be underestimated or ignored because this may have consequences for the mental health of the nursing team and for the care being provided; [...] the BTC nursing team performs a defense aiming at allowing the control of suffering and the maintenance of psychical balance"⁶.

Pain as the fifth vital sign in the burn process

Injuries caused by burns may be painful, making the experience even more traumatic for those living it; so, burn acute pain is very important for health professionals who consider it as a valuable sign as the others, so that it is considered the fifth vital sign during evaluations and clinical interventions. The following statements clearly show this consideration:

"Pain is not adequately treated and documented due to the inadequate initial evaluation, both by clinicians and caregivers"⁸. "Pain is considered a subjective experience which should be evaluated and described as the fifth vital sign; being as important as the others; the effectiveness of the treatment and its follow up depends on a reliable and valid pain evaluation and measurement"⁹.

"Aiming at improving the quality of assistance, the American Agency for Research and Quality in Public Health and the American Society for Pain (ASP) have recognized by guidelines that pain measurement and record should be performed [...] as the fifth vital sign"⁸.

In this context, it is clear the seriousness of evaluating and treating pain as the fifth vital sign, as established by the Joint Commission on Accreditation of Healthcare Organizations - JCAHO, institution which certifies the quality of hospital health assistance, represented in Brazil by the Brazilian Consortium for Accreditation, when normalizing: "[...] included (in 2000) pain relief as one of the items to be evaluated during hospital accreditation. This resulted in the recognition we have today about patients' right for having their pain complaint evaluated, recorded and controlled"⁸.

Although implemented, the standards for pain management as the fifth vital sign, such as evaluation with recognized tools, pharmacological treatment agreed by the World Health Organization (WHO)¹⁰ and non-pharmacological approaches, with reports of inadequate practices:

"There is little evidence [...] that the adoption of pain management standards has led to their execution [...]"¹¹.

"These concepts (about pain as the fifth vital sign) [...] are still not priorities, [...] because what is often seen is the practice of a passive living together [...] of health professionals with the pain of others"⁸.

"There are reports on lack of knowledge, wrong beliefs and attitudes [...]"⁷.

With regard to being the fifth vital sign, pain effective management and control requires specific knowledge by the nursing team; the effective participation in pain evaluation and relief is invaluable for the treatment of burns and it should be treated whenever present with the same seriousness required by other vital signs. The following sentences evidence such statement:

"Pain as the fifth vital sign generates changes throughout the interdisciplinary team [...], nursing plays a critical role as part of the team; [...] so, the whole team must be aware of the importance of their commitment so that they [...] may successfully work to control and handle pain"^*.

The importance of the implementation of pain as the fifth vital sign to manage pain in general is explained, including burn-related pain due to the importance given to it by international and national agencies, and due to its influence on patients' prognosis. So, it is evident the critical participation of the nursing team so that this concept is inserted in their technical-scientific knowledge, helping to structure this idea.

The importance of communication in nursing assistance to burn-related pain

The nursing team is very close to patients and for such they should build a therapeutic relationship and when it comes to burn-related pain, the best the nurse/patient relationship through adequate dialogue, the higher the possibilities of adherence and adequate responses to pain management. This is evident in the following statements:

"[...] the communication between patient and professionals assisting him [...] is extremely important to understand pain and its relief; for such, it is necessary to use communication techniques, [...] to know how to listen and ask with simple and direct questions to help the understanding of patient's pain"⁷.

Communication should be adequate not only between nurse and patient but also between nurse and team:

"[...] even if one element follows pain management recommendations, it is fundamental to communicate patient's pain information so that everyone shares the same approach [...]"⁷.

The adequate pain management is critical to treat burn-related acute pain and there are different ways to approach pain, which require technical skills. So, adequate pain management affirms patient's satisfaction, decreases morbidity/mortality and extra hospital expenses. This stage will be reached by the facilitator of the adequate communication with the patient.

The importance of nursing participation as approach to manage (or not) burn-related pain

Due to their long hospitalization period, there is a closer relationship between nurses and patients and direct nursing care greatly contributes to the whole treatment process, even when pain is present implying more responsibilities and technical qualification to manage and relieve pain. Records below evidence such statement: "The nursing team [...] organizes pain management [...], faced to monitoring [...] the first pain management step is to believe in patient's verbal complaint and ensure analgesic offering [...] it is the nursing team that makes the decision preceding drug administration [...]^"8.

However, it is noticed that the importance of the nursing role to manage burn-related pain is neglected in some moments, concern which is recorded in most consulted articles:

"Many nurses do not know opioid doses [...] and side effects [...] leading to the administration of analgesic doses much lower than those possible [...]"⁸. "Associated to this belief, there is the fear of causing drug dependence and so, very often, pain may not be adequately treated"⁴.

Failures are seen in the first stage, that is, pain record/evaluation:

"[...] inadequate evaluation and insufficient records of pain and analgesia"⁷.

"[...] lack of records [...] with a thorough patient's evaluation may indicate that pain is not being evaluated"¹².

According to pain teaching regulatory authorities in Brazil and worldwide:

"Nursing courses do not seem to be preparing nurses to manage pain in the clinical area. To adequately manage pain, nurses must understand all its components; [...] evaluation [...] individualized care attacking the triggering cause; [...] biological, emotional and cultural aspects of the pain experience justify the use of multiple interventions, both pharmacological and non-pharmacological. Nurses must know how it affects the patient [...] it is necessary an interactive process where caregivers [...], in addition to their technical skills [...] must apply lots of sensitivity to the individual to be cared of [...] it is considered that the technical-scientific domain may contribute for a better assistance to painful patients"⁷.

"[...] Priority should be given to pain control knowledge by nurses because [...] they are a valuable source of information [...] since they administer medications [...], early inform disease changes and possible side effects [...] and monitor pain and its relief"².

Pain has to be adequately treated due to the emotional and/or social consequences it may bring to patients and nursing interventions may be pharmacological or complementary, which means, as compared to health care practice observation, that there is the need for more knowledge on part of professionals.

The importance of pain treatment is noted; the participation and critical role of the nursing team in this process as companion and interventionist; and, especially, pain management deficiency due to the lack of knowledge of these professionals about pain meaning and its handling. So, it is evident the importance of technical qualification to fill this gap.

The family as focus of nursing participation in assisting burned patients' pain

During burn patient hospital stay, there is the direct participation of the interdisciplinary team and of the family to manage patient's pain. The nursing team should develop an adequate relationship both with the patient and his relatives, so that they are also inserted in this pain handling process, promoting pain relief.

With regard to painful burn patient relatives, the following records are to be stressed:

"The disease or trauma [...] also affects the family, [...] which has no time to be prepared [...]^"13.

"[...] Disabled patient [...] equals disabled family [...]; family members are a critical connection to obtain positive results in the treatment of burned patients [...]; the participation of family members during hospital stay may [...] help incorporation and coping [...] in addition to decreasing pain experience [...]^"14.

In addition to impacting the burned person, burn psychological impact also affects family members:

"As from the trauma caused by burn and hospitallization, family members live a crisis period with reflexes on their physical and emotional state [...]"¹³.

There are nursing records stating the need for care related to the support system to the burned and painful patient:

"The health professional following this process of family involvement with the burn trauma suffered by one of its members [...] must be closer to family members to listen to them, know them, support them [...] and help them perform and legitimate their role of supporting and taking care of burned patients, after their needs are met"¹³.

"An effective communication between the team (and the family) may contribute to shared care [...] this relationship favors patient's recovery"¹⁴.

It is up to the nurse to develop intervention plans aiming at communication and therapeutic relationship, also including family support system in the process of managing the fifth vital sign.

In the process of treating burn-related pain, there is the commitment of human basic needs which may be met, especially with the presence of family support system. In this context, family members may be inserted in nursing team intervention plans, possibly as an aid support, to benefit patient's healing.

Strategies proposed for nursing participation in burned patient pain assistance.

Pain process is considered complex for its biopsychocultural breadth, which requires a complex approach. For such, there are tools to help pharmacological and non-pharmacological judgment and interventions to decrease pain intensity, which make the process easier both for those living it and for those in charge of its treatment. The following notes show such need:

"Pain [...] is one of the world's most significant reasons for suffering and disability; [...] it has a deep impact in quality of life and may have physical, psychological and social consequences which [...] may influence the course of disease [...] decreasing adherence to treatment ^"15.

"[...] Scales are needed to generate measurement patterns and [...] adequate pain control"⁵_.

"WHO has recognized the need for opioids (as pharmacological approach) to treat pain"¹⁵.

"Analgesic administration is not [...] the only therapeutic way to control pain and associated non-pharmacological interventions [...] may be developed [...] for a more effective pain control"⁸.

With regard to pain evaluation, the use of standardized tools is currently recommended, as stated by the authors:

"A large number of scales [...] may be used to evaluate pain [...] the challenge for the nurse is to adapt each tool to the cognitive and psychomotor capacity of each patient; [...] the use of standardized tools to measure and evaluate pain characteristics has shown to be effective as a strategy to record pain and analgesia data. [...] Examples are the Numerical Visual Scale (NVS), [...] the Visual Analog Scale (VAS), the Descriptive Verbal Scale and the Faces Scale"⁷.

The World Health Organization (WHO)¹⁵ advocates and adopts as pharmacological measure the following scale: "[...] the Analgesia Scale which recommends the administration of different pain relief drugs, depending on the severity; for mild pain WHO recommends simple analgesics (associated to non-steroid anti-inflammatory drugs); for moderate pain, it recommends a combination of analgesics and anti-inflammatory drugs with weak opioids; for severe pain it admits the use of strong opioids"¹⁵.

When pain is unbearable, the treatment involves all already described drugs associated to adjuvants (sedatives, anticonvulsants, antidepressants, neuroleptic drugs) and for acute pain, such as burn-related pain, one may use anesthetic techniques such as, for example, regional anesthesia (epidural, spinal, nervous blocks).

However, even with the description of concepts for the pharmacological pain treatment, some wrong concepts prevent this to occur, among them:

"[...] Lack of health professionals qualification; misinformation about morphine [...] is extremely common among health professionals [...]. Some myths [...] argue that opioids lead to dependence, that pain is necessary because it helps the diagnosis, that pain is inevitable and that it has negligible consequences"¹⁵.

Among currently available non-pharmacological methods (such as acupuncture, massage, relaxation, physical therapy, therapeutic touch and chromotherapy), it has been observed that distraction therapy is the most frequently used to treat burn-related acute pain.

"[...] Cognitive distraction [...] may teach pain perception; [...] less attention to pain may result in pain intensity and discomfort decrease, and of the amount of [...] time spent thinking about pain; being immersing virtual reality [...] a new cognitive distraction found to be an effective non-pharmacological adjuvant [...]"¹⁶.

Para que a dor seja manuseada e controlada da forma correta é necessário que o profissional cuidador possua conhecimento técnico-científico, para auxílio à avaliação e ao tratamento de forma farmacológica e não farmacológica⁶.

For pain to be adequately handled and controlled the caregiver must have technical-scientific knowledge to help the evaluation and the pharmacological or non-pharmacological treatment⁶.

The nurse, as the nursing team leader, is in charge of choosing the best way to evaluate and intervene and may even suggest and validate new methods.

Emotional burn-related pain aspects

Burn, for being a traumatic experience, in addition to the physical aspect related to the injury, also impairs patient's emotional aspect, worsening pain itself as evidenced by the statements:

"A thermal trauma [...] may cause physical and psychological damage to patients [...] may bring about significant changes [...] during the hospitalization period and after hospital discharge [...]^"3.

"Pain is a major cause of human suffering, impairing quality of life and reflecting on physical and psychological state of the individual"⁷.

"Physical and psychological pain effects [...] may influence the course of the disease [...] decreasing adherence to treatment"¹⁵.

"[...] Acute pain in the hospital may lead to [...] side-effects several years after hospital discharge [...], such as depression, suicidal ideation and post-traumatic stress disorder"¹⁷.

Burn injuries are considered the most painful and from this observation emerges the need for nursing strategies which decrease intensity and prevent pain chronification and its potential consequences.

"At the moment in which initial care is given to the patient, health professionals are concerned with reanimating the physiological state [...] so that after the patient may be evaluated also considering the psychological state"³.

'The primary health professional function is to relieve pain and suffering [...]"¹.

It is clear how complex is the burn process, which affects not only the victim, but also his relatives and caregivers. It is also observed the importance of the effective burn-related acute pain management, since it may bring late consequences which may affect quality of life in physical and emotional domains.

CONCLUSION

Burn-related acute pain has a significant impact during the hospitalization process of a burned patient, unbalancing basic human needs and bringing major negative consequences to patient's prognosis if it is inadequately handled. So, it is up to the nurse the adequate participation in managing pain of this patient.

Considering the importance of the nursing team in this process, this study aimed at reviewing the literature on the participation of the nursing team in burn-related pain assistance extracting from the analysis categories related to the team, to pain as the fifth vital sign, to communication, to family, to management (or not) and to emotional aspects.

The nursing team is a basic and indispensable element in the management of burn-related acute pain, so that their participation may influence the success and effectiveness of this type of pain relief. However, it is noticed that there is the need for technical-scientific investment and sensitization of the whole team.

In noticing this, this study is based on the perspective of financing future studies aiming at an effective nursing assistance to these patients and, in parallel, effective changes in the daily quality of life of this category of workers by the development of coping strategies, such as: support group meetings with all involved people, in addition to permanent pain management education strategies for professionals and patients. This way, there will be improvement of the experience of this process for all people involved.

National and international literatures evidence and stress the nursing team participation as critical in the therapeutic pain management and they may influence the success and effectiveness of its relief. However, it is noticed that authors recommend the need for investments in technical-scientific knowledge and in the sensitization of these caregivers.

REFERENCES

• 1. Hortense P, Sousa FAEF. Escalonamento comparativo de diferentes dores nociceptivas e neuropáticas por meio de métodos psicofísicos variados. Rev Latino-Am Enfermagem 2009;17(2):65-72.
• 2. Sanchez-Sanchez RM, Pernía JV, Calatrava J. Tratamiento del dolor en los estúdios de enfermería. Rev Soc Esp Dolor 2005;12(2):81-5.
• 3. Carlucci VD, Rossi LA, Ficher AM, et al. Burn experience from the patient's perspective. Rev Esc Enferm USP 2007;41(1):21-8.
• 4. Rossi LA, Camargo C, Santos CM, et al. The pain of burns: terrible for him Who feels it, stressful for those Who care for him. Rev Lat Am Enfermagem 2000;8(3):18-26.
• 5. Hortense P, Zambrano E, Sousa FA. Validation of the ratio scale of the differences types of pain. Rev Lat Am Enfermagem 2008;16(4):720-6.
• 6. Coelho JAB, Araújo STC. Desgaste da equipe de enfermagem no centro de tratamento de queimados. Acta Paul Enferm 2010;23(1):60-4.
• 7. Rigotti MA, Ferreira AM. Intervenções de enfermagem ao paciente com dor. Arq Ciênc Saúde 2005;12(1):50-4.
• 8. Fontes KB, Jaques AE. O papel da enfermagem frente ao monitoramento da dor como 5º sinal vital. Cienc Cuid Saúde 2007;6(Supppl 2):481-7.
• 9. Pedroso RA, Celich KLS. Dor: Quinto sinal vital, um desafio para o cuidar em enfermagem. Texto Contexto Enferm 2006;15(2):270-6.
• ¹⁰
  World Health Organization. Palliative Care: symptom management end-of-life care. Integrated management of adolescent and adult illness. Interim Guidelines for first level facility health care workers. Geneva: 2003.
• 11. Narasimhaswamy S, Vedi C, Xavier Y, et al. Effect of implementing pain management standards. J Gen Intern Med 2006;21(7):689-93.
• 12. Meneghetti RA, Rossi LA, Barruffini Rde C, et al. Planning care for burn victims: relation between registered problems and the care prescribed. Rev Esc Enferm USP 2005;39(3):268-79.
• 13. de Carvalho FL, Rossi LA, Ciofi-Silva CL. Burns and the family experience as to the hospitalization process. Rev Gaucha Enferm 2008;29(2):199-206.
• 14. Carvalho FL, Rossi LA. Impacto da queimadura e do processo de hospitalização em uma unidade de queimados sobre a dinâmica familiar: Revisão de literatura. Ciência, Cuidado e Saúde 2006;5(2):243-54.
• 15. Lohman D, Schleifer R, Amon JJ. Access to pain treatment as a human right. BMC Med 2010;8:8.
• 16. Carrougher GJ, Hoffman HG, Nakamura D, et al. The effect of virtual reality on pain and range of motion in adults with burn injuries. J Burn Care Res 2009;30(5):785-91.
• 17. Wiechman Askay S, Patterson DR. What are the psychiatric sequelae of burn pain? Curr Pain Headache Rep 2008;12(2):94-7.

*

Recebido do Curso de Enfermagem da Universidade de Mogi das Cruzes (UMC). Mogi das Cruzes, SP.

Publication Dates

• Publication in this collection
  10 Feb 2012
• Date of issue
  Dec 2011

History

• Received
  18 May 2011
• Accepted
  07 Nov 2011