NSG) 508-concept analysis

Concept Analysis of Identification of Chronic Pain in the Elderly Jinhe YooColorado State University-PuebloIntroductionChronic pain is common, costly, and potentially disabling. According to the Medical Expenditure Panel Survey in 2008, approximately 100 million adults were affected by chronic pain with national costs estimated between $560 and $635 billion annually (Gaskin & Richard, 2012). The prevalence of pain, particularly chronic pain, is strongly related to age, hitting the oldest population the hardest, with prevalence rates of 72% above the age of 85 years (Duncan et al, 2011). The elderly are more likely to have arthritis, bone, and joint disorders, cancer, and other chronic disorders associated with pain (Pickering, et al, 2016). Pain is a subjective feeling, with no known biologic markers. Proof of its presence and measurement of its intensity rely entirely on self-reporting by the patient. The elderly may make accurate pain identification difficult. Because most of the elderly expect pain with aging and do not believe that their pain can be alleviated (AGS, 2002), and major difficulty in identifying pain in the presence of advanced dementia is the inability of these elderly population to self-report their experience of pain (Gabre & Sjoquist, 2002). In nursing practice, nurses assess pain measurement on self-reporting by the patient and manage the pain of the patient, especially patients with dementia who are often unable to express pain adequately and rely on the nurse’s ability to detect pain cues. Nurses working with the elderly must have well-developed pain assessment skills. Because the pain of the elderly contributes to further complications in treatment and care because of the discomfort and distress caused by pain, it is frequently the underlying cause of behavioral symptoms, which can lead to inappropriate treatment with antipsychotic medications. Walker and Avant (2011) guide this concept analysis and will focus on identifying the chronic pain of the elderly. The purpose of this analysis of the identification of chronic pain in the elderly is to develop effective pain assessment to detect and manage pain for the elderly. Definition, Attributes, and Use of ConceptChronic pain in the elderly defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, for persons who are either aged (65 to 79 years old) or very aged (80 and over) and who have had pain for greater than 3 months” (Kaye et al, 2010). The dictionary definition of identification is “the act or process of recognizing something” (Longman Corpus Network, 1995). Therefore, identification of chronic pain in the elderly can be considered to be the act or process of recognizing the unpleasant sensory and emotional experience associated with pain for greater than 3 months of over 65 aged persons.A concept analysis requires defining attributes of the concept by taking note of the recurring characteristics of the concept (Walker & Avant, 1983). Based on this approach, identification of chronic pain in the elderly’s defining attributes are lack of knowledge about pain in the elderly about pain can disrupt accurate chronic pain identification, and the elderly with cognitive impairment to self-report of pain can make difficult identifying chronic pain and lead to the inappropriate nursing diagnosis and prescribing medications.Chronic pain is common in the elderly. The elderly are more likely to suffer from arthritis, bone and joint disorders, back problems, and other chronic conditions. The elderly may make accurate pain assessment difficult because they don’t believe that their pain can be alleviated as well as they may fear the need for diagnostic tests of medications that have side effects, addiction to and dependence on strong analgesics (AGS, 2002). In addition cognitive impairment and poor verbal skills of elderly can lead to difficulties more in communication and identification of chronic pain (Gabre & Sjoquist, 2002). Especially dementia in the elderly is responsible for numerous other symptoms, such as behavioral disturbances, psychological problems, and the breakdown of language and communication. These symptoms arising as a result of pain, such as agitation and aggression, can be extremely distressing for both the individual and their caregiver and can lead to the inappropriate prescribing of antipsychotic medication instead of adequate pain treatment (Achterberg et al. 2013). Therefore, the Identification of chronic pain in elderly will be help nurses to well-developed pain assessment skills, more accurate nursing diagnosis and develop methods in nursing practice.Antecedents and ConsequencesThe elderly commonly have several sources of chronic pain, which is not surprising, as older patients commonly health problems. And a high prevalence of dementia in the elderly makes identification of pain more difficult than the elderly with no dementia. Scherder and Bouma (2000) suggested that the preparation of nurses for pain assessment, the ability of the elderly to express pain including nonverbal and verbal responses about pain can be antecedent of pain identification in the elderly. The consequences of chronic pain in the elderly are numerous like depression, anxiety, sleep disturbance, impaired ambulation, and increased healthcare utilization (AGS, 2002). Expression of pain by the elderly prompts the cycle of pain management, and the changed pattern of the elderly’s expression can be a consequence of pain identification of the elderly (Molony et al, 2005). Poorly treated pain are many and include exacerbation of preexisting cognitive dysfunction, development of depression, possible inhibition of immune function, and the worsening of medical conditions (Abbey et al, 2004).Model CaseA model case is a real-life example of the use of the concept that includes all of the critical attributes as per Walker and Avant (2011). The following is an example of a model case. An 85-year-old man with dementia complained pain and kept saying “Hurting! Hurting!” by pointing to his back and noted restlessness. The nurse assessed pain using the Face Pain Scale because he was unable to answer the pain scale due to dementia, and his pain scale was 5, moderate pain. However, the nurse assessed the skin of his back and found a rash on his back out. And the patient said “Would you please scratch my back? It’s hurting.”. The nurse applied Lotrisone cream for the rash and he calmed down. This case demonstrates the breakdown of language and communication of the elderly with dementia. That elderly couldn’t express his condition and miscommunicate with the nurse, and this situation finally might induce misunderstanding and lead to incorrect treatment. Contrary CaseContrary cases are clear examples of what is not the concept (Walker & Avant, 2011). The following is an example of a contrary case. An 86-year-old woman with dementia was admitted to the rehab unit due to weakness and chronic back pain. A week later, she refused to get out of bed and did not have breakfast. And the nurse noticed the patient’s different behavior and expression patterns from usual such as increased depression. The nurse had checked vital signs, abdominal pain, and range of motion, and everything was in a normal range. When the nurse asked her chronic back pain or discomfort, she said “No pain. I’m alright.”. The nurse knew her family visits her, and her daughter said that the patient was waiting for son and has been a long time since she met her son. The nurse called her son and ask for a visit to her. In the evening, her son visited her, and the patient accepted to get out of bed and dress. She looks happy with a smile, and had dinner in the dining room with her son without any difficulty. In this case, the changed pattern of the elderly patient’s behavior and expression did not cause chronic back pain. Nurses should undergo a comprehensive identifying chronic pain in the elderly. Gather the data from family and other caregivers is very important for identifying chronic pain and should be included in the identification of chronic pain in the elderly (AGS, 2002).ImplicationsChronic pain is an unpleasant feeling persisting for longer than 3 months (International Association for the Study of Pain, 2016), and is common in the elderly. Nurses have many responsibilities related to assessment, diagnosis, intervention, and evaluation when caring for the person experiencing pain. The most accurate and reliable evidence of the existence of pain is the patient’s report. And nurses must believe patients and take their reports of pain seriously. However, a lack of accurate pain identification can lead to incorrect treatment, such as administering an analgesic or antipsychotic medication when the patient has behavior issues such as anxiety or depression (Ashkenazy & Ganz, 2019). Therefore, it is necessary to attain a clear conceptualization of the identification of chronic pain in the elderly. Following the steps of Walker & Avant (2011), an improved understanding of the concept analysis of the identification of chronic pain in the elderly could expand the nursing assessment and care of experiencing chronic pain in the elderly. A variety of pain scale has been accepted for use among the elderly, even those with cognitive impairment. Many nurses and institutions have adopted using a self-report by either rating the pain on a visual among analog scale or numeric rating scale from 0 (no pain) to 10 (worst possible pain) in communitive patients (Cooke et al, 2010). Furthermore, facial pain scales and behavior expression accepted to the identification of pain in noncommunicative patients (Shinde et al, 2014). To develop and using an effective pain assessment tool to detect the elderly, the identification of chronic pain will help nurses to well-developed pain assessment skills, more accurate nursing diagnoses and develop methods in nursing practice.The identification of chronic pain is an inevitable nursing action, it has a significant ramification for comfort and cares in the elderly (Chang et al, 2011). According to Kolcaba’s comfort theory, patients experience comfort needs in stressful health care situations. These needs can be identified by a nurse who then implements comfort measures to meet the needs and enhanced comfort readies the patient for subsequent healthy behaviors (Kolcaba, 1994). The concept analysis can be used to accurate identifying chronic pain as well as providing pain management in the elderly based on evidence-based theory.  A better understanding of the identification of chronic pain in the elderly will useful for the healthcare provider who intend to investigate the influence and outcomes of treatments. Therefore, nurses working with the elderly need to further research and investigation for reliable and valid measurement of identifying chronic pain based on evidence-based practice.ConclusionThe purpose of this analysis is to define the identification of chronic pain in the elderly clearly and holistically. Nursing theory provides nurses with a framework and structure on which to base their practice, and guides nursing practice and improves patient care. According to McEwen and Wills, “The theories used by members of a profession clarify basic assumptions and values shared by its members and define the nature, outcome, and purpose of practice” (McEwen & Wills, 2014). This concept analysis based on evidence-based nursing will help the assessment and management of chronic pain in the elderly, and provide comfort for the patient further family, caregiver, and community. However, all patients can respond differently, by applying all patients to the same interventions based on evidence-based nursing, and nurses can give limited nursing care. In addition, the concept analysis of the Identification of chronic pain in the elderly needs to be sensitive and ethnicity as well as the values and beliefs of individuals elderly and families. Information about chronic pain in the elderly from family and caregivers should be also included in the assessment and identification (AGS, 2002).ReferencesAbbey, J., Piller, N., De Bellis, A., Esterman, A., Parker, D., and Giles, L. (2004). The Abbey pain scale: A 1-minute numerical indicator for people with end-stage dementia. International Journal of Palliative Nursing, 10(1): 6-13.Achterberg, P. W., Pieper, J. M., Dalen-Kok, H. A., Waal, W. M., Husebo, S. B., Lautenbacher, S., Kunz, M., Scherder, J. E., and Corbett, A. (2013) Pain management in patients with dementia. Clinical Interventions in Aging. 8: 1471-1482.American Geriatrics Society (2002). The Management of Persist Pain in Older Persons. The American Geriatrics Society. 50: 205-224.Cooner, E., Amorosi, S. (1997). The Study of Pain in Older Americans. New York: Lois Harris and Associates.Duncan, R. Francis, R. M. & Collerton, J. (2011). Prevalence of arthritis and joint pain in the oldest: finding from the Newcastle 85+ study. The Age Aging. 40(6): 752-755.Ferrell, B. A. (1995). Pain evaluation and management in a nursing home. Ann International Medicine. 123: 681-187.Gabre, P. & Sjoquist, K. (2002). Experience and assessment of pain in individuals with cognitive impairments. Special Care in Dentistry. 22(5): 174-180.Gaskin, D. J. & Richard, P. (2012). The economic costs of pain in the United States. The Journal of Pain, 13: 714-724.Horgas, A. L. & Elliott, A. E. (2004). Pain assessment and management in persons with dementia. Nursing Clinic of North America, 39(3): 593-606.International Association for the Study of Pain. (2016). IASP Taskforce for the classification of chronic pain in ICD-11 prepares new criteria on postsurgical and posttraumatic pain. Retrieved from https://www.iasp-pain.org/ PublicationsNews/NewsDetail.aspx?ItemNumber¼5134&navItemNumber¼64. (Accessed September 30, 2019).Johannes, C.B., Le, T. K., Zhou, X., Johnson, J. A. & Dworkin, R. (2010). The prevalence of chronic pain in United States adults: Results of an internet survey. The Journal of Pain, 11: 1230-1239.Molony, S. L., Kobayashi, M., Holleran, E. A., & Mezey, M. (2005). Assessing pain as a fifth vital sign in long-term care facilities: Recommendations from the field. Journal of Gerontological Nursing. 31(3): 16-24.Pickering, M.E., Chapurlat, R., Kocher, L., Peter-Derex, L. (2016). Sleep disturbances and osteoarthritis. Pain Practice. 16(2): 237–44.Scherder, E. J. & Bouma, A. (2000). Visual analogue scales for pain assessment in Alzheimer’s disease. Gerontology. 46(1): 47-53.Stewart, C., Elliott, A. M. and Leveille, S. (2014). What do we mean by “Older Adults’ Persistent Pain Self-management”? A Concept Analysis. Pain Medicine. 15:214-224.Walker, L. O. & Avant, K. C. (1983), Strategies for theory construction in nursing (2nd ed.). Norwalk, CT: Appleton & Lange.Walker, L. O. & Avant, K. C. (2005). Strategies for theory construction in nursing (4th ed). Upper Saddle River, NJ: Pearson/Prentice Hall. P 63-86.Walker, L. O. & Avant, K. C. (2011) Strategies for Theory Construction in Nursing (5th ed.). Upper Saddle River, NJ: Pearson Education.William, C. S. (Dec 11, 208) Medical Definition of Chronic Pain. MedicineNet. Retrieved from https://www.medicinenet.com/script/main/art.asp?articlekey=22430. (Accessed September 30, 2019).Pain Management in the Elderly Population: A Review Alan D. Kaye, MD, PhD,* Amir Baluch, MD,{ Jared T. Scott, MD The Ochsner Journal 10:179–187, 2010

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