Chronic Pain, Fibromyalgia, and CAM - NUR 211 Unit 4 PDF

Christina Manning, MSN, RN, CWS, COCN, CHRN  Compare and contrast the pathophysiology, clinical manifestations, and medical/nursing management of the client experiencing complex alterations in comfort: Fibromyalgia Examine risk factors and complications associated w ith fibromyalgia across...

Christina Manning, MSN, RN, CWS, COCN, CHRN  Compare and contrast the pathophysiology, clinical manifestations, and medical/nursing management of the client experiencing complex alterations in comfort: Fibromyalgia Examine risk factors and complications associated w ith fibromyalgia across the lifespan and the nursing care directed at improving health, wellness, and decreasing illness. Compare and contrast various assessments, diagnostics, medications, treatments, and procedures used to manage fibromyalgia, including complementary and alternative therapies for chronic pain. Apply the nursing process as a framework to prove age- appropriate, culturally sensitive care of the client experiencing disorders of comfort Plan, prioritize, and implement evidence-based nursing care for clients w ith disorders of comfort including teaching strategies for client/research and best practices. Explore alternative therapies used in the treatment of clients w ith disorders of comfort. Evaluate patient and family use of alternative therapies to determine safety and the need for patient or family education. Review Potter (11th ed): Chapter 44- Pain Read th Adams (6 ed.): Chapter 10 Lew is (12th ed): p 1725-1726 p 93-104 p 138-145 Potter (11th ed): Chapter 32  “ “Pain is whatever the experiencing person says it is and exists whenever he or she says it exists”  Definition An unpleasant sensory and emotional experience associated w ith actual or potential tissue damage. The most reliable indication of pain is self-report Types of Pain: Acute Pain Unpleasant sensory and emotional experience associated w ith tissue damage that results from acute injury, disease, or surgery. Breakthrough pain Additional pain that “breaks through” the pain being managed by the mainstay analgesic drugs.  Nociceptive Pain The result of actual or potential tissue damage or inflammation and is often categorized as being somatic or visceral. Persistent Pain AKA Chronic Pain Pain that persists or recurs for an indefinite period- usually more than 3 months, often involves deep body structures, is poorly localized, and is difficult to describe. A client with chronic pain is seen for follow- up. To best evaluate pain management, the nurse initially asks. A. Can you describe the quality of your pain? B. Has there been a change in the pain location? C. How would you rate your pain on a 0 to 10 scale? D. Does the pain keep you from doing daily activities or things you enjoy?  Chronic pain syndrome (NOT an inflammatory disease) Common in women 30-50 years of age Precipitating factors: Chronic F atigue Syndrome Lyme disease Trauma Flu-like illness Deep sleep deprivation  True cause is not known It is thought that it is multifactorial w ith “abnormal cortical processing, reductions in inhibitory pain modulatory mechanisms, and molecular changes to the pain pathway” (Gyorfi et al., 2022). Meaning the problem might be a result of overactive nerves in the central nervous system (CNS) which can cause a more intense response to pain.  Pain, stiffness, and soreness of muscles, tendons, and joints/ Trigger points Fatigue Numbness/tingling of extremities Sensitivities to odors, lights, sounds Headaches, jaw pain GI Issues: Abdominal pain, diarrhea, constipation, heartburn GU Issues: Dysuria, frequency, urgency, pelvic pain Cardiovascular: Dyspnea, chest pain, dysrhythmias Visual: Blurred vision, dry eyes Neurological: Forgetfulness, concentration problems  Pain (wide-spread) Altered sleep (insomnia, unrefreshing sleep) Irritable bowel syndrome Numbness and tingling (paresthesia) Memory problems (brain fog, fibro fog) Irritability Stiffness (especially in the morning Tender points Exhaustion (fatigue) Depression (or anxiety)  Elicit pain Pain is Burning Gnawing  Fibromyalgia trigger points These trigger points are painful, stiff, and tender at specific sites or locations on the back of the neck, upper chest, trunk, low back, and extremities. See image on slide. Trigger points can be palpated to elicit pain in a predictable, reproducible pattern. Pain is typically described as burning & gnawing Increased muscle tenderness may be caused by the inability to tolerate pain, possibly related to dysfunction of the thalamus and hypothalamus  Integrated therapy Pharmacological & Complementary Medicine Self-care Limit Caffeine & Alcohol Avoid substances that disrupt sleep Patient Education Medications Pregabalin (Lyrica) Duloxetine (Cymbalta) Amitriptyline (Elavil) Trazadone (Desyrel)-for elderly patients Tramadol (Ultram) NSAIDs Muscle Relaxants C CAM= Complementary & Alternative Medicine Diverse therapies and healing systems outside of “mainstream healthcare.” May be used together or on their own A Although often referred to as the same thing, they are different Complementary- non-mainstream medicine used in conjunction with conventional medicine Alternative- used instead of conventional medicine. M Integrative -Traditional and complementary approaches are being used in a coordinated way to improve wellness. Lack of clinical research on efficacy  From a pharmacology perspective, CAM is used to reduce the need for medications. Reduction of medications… Reduces the risk of side effects and adverse effects Improved compliance w ith therapeutic regimens  Ayurveda Illness is viewed as a state of imbalance among the body’s systems Emphasizes the interdependence of the health of the individual and the quality of societal life Traditional Chinese Medicine (TCM) Disease is described as an imbalance or interruption in the flow of qi (the body’s vital energy) Mind, body, and spirit are never separated Native American Healing Connection to the land; balance or harmony between mind and body; the use of rituals as a part of the healing plan; cleansing such as through the traditional sweat lodge; use of music, drumming, chanting, and dancing as part of healing; and use of herbs and botanical treatments. Curanderismo Practitioners may specialize as herbalists, midwives, counselors, spine and joint workers, and massage therapists. Utilize religious rituals, cleansing rites, and prayers in their healing practices. Healers work at one of three levels: the material level, the spiritual level, or the mental level  Herbal Medicine- Using plants to treat illness/symptoms Aroma Therapy- Essential oils of plants in which the odor or fragrance plays an important part. Different oils may calm, stimulate, improve sleep, change eating habits, or boost the immune system. Homeopathy-a self-healing system, assisted by small doses of remedies or medicines, which is useful in a variety of acute and chronic disorders Naturopathy- holds the same view of human physiology, body functions, and disease processes as conventional medicine Goal= Restoration of health and normal body function, rather than the application of a particular therapy. Virtually every CAM therapy is utilized  Types Definitions Whole Medical Systems (Complete systems of theory and practice that have evolved independently from or parallel to conventional biomedicine) One of the oldest systems of medicine, practiced in India since the first century AD. There are eight branches of Ayurvedic medicine, including internal medicine; surgery; treatment of head and neck disease; Ayurvedic medicine gynecology, obstetrics, and pediatrics; toxicology; psychiatry; elder care and rejuvenation; and sexual vitality. Treatments balance the doshas using a combination of dietary and lifestyle changes, herbal remedies and purgatives, massage, meditation, and exercise. Developed in Germany and practiced in the United States since the mid- 1800s. It is a system of medical treatments based on the theory that certain diseases can be cured by giving small, highly diluted doses of Homeopathic medicine substances that in a healthy person would produce symptoms like those of the disease. Prescribed substances called remedies are made from naturally occurring plant, animal, or mineral substances and are used to stimulate the vital force of the body so that it can heal itself. Curanderismo is a Latin American traditional healing system that includes a humoral model for classifying food, activity, drugs, and Latin American traditional healing illnesses and a series of folk illnesses. The goal is to create a balance between the patient and the environment, thereby sustaining health.  Types Definitions Whole Medical Systems (Complete systems of theory and practice that have evolved independently from or parallel to conventional biomedicine) Tribal traditions are individualistic, but similarities across traditions include the use of sweating and purging, herbal remedies, and Native American traditional healing ceremonies in which a shaman (a spiritual healer) makes contact with spirits to ask their direction in bringing healing to people to promote wholeness and healing. A system of therapeutics focused on treating the whole person and promoting health and well-being rather than an individual disease. Therapeutics include herbal medicine, nutritional supplementation, Naturopathic medicine physical medicine, homeopathy, lifestyle counseling, and mind-body therapies with an orientation toward assisting the person’s internal capacity for self-healing (vitalism). An ancient healing tradition identified in the first century AD focused on balancing yin/yang energies. It is a set of systematic techniques and methods, including acupuncture, herbal medicines, massage, Traditional Chinese medicine (TCM) acupressure, moxibustion (use of heat from burning herbs), qi gong (balancing energy flow through body movement), cupping, and massage. Fundamental concepts are from Taoism, Confucianism, and Buddhism.  Consuming specific diets or supplements. Supplements: Vitamins, minerals, amino acids, herbs, botanicals, enzymes, and fish oils. Goal: prevent or treat illness. The specific amount of a substance needed for effectiveness may be unknown. Doses of supplements may not contain consistent amounts of the substance. There are no legal definitions for the terms "standardized," "certified," or "verified" for supplements.  Types Definitions Biologically Based Therapies (Natural products) Defined by the Dietary Supplement Health and Education Act of 1994 and used to supplement dietary/nutritional intake by mouth; contain one Dietary supplements or more dietary ingredients, including vitamins, minerals, herbs, or other botanical products Plant-based therapies used in whole systems of medicine or as Herbal medicines individual preparations by allopathic providers and consumers for specific symptoms or issues Predominantly a vegan diet (no animal products except fish); initially Macrobiotic diet used in the management of a variety of cancers; emphasis placed on whole cereal grains, vegetables, and unprocessed foods Mycotherapies Fungi-based (mushroom) products Increased intake of nutrients such as vitamin C and beta-carotene; treats Orthomolecular medicine (megavitamin) cancer, schizophrenia, autism, and certain chronic diseases such as hypercholesterolemia and coronary artery disease Live microorganisms (in most cases, bacteria) that are similar to Probiotics beneficial microorganisms found in the human gastrointestinal system; also called good bacteria Dietary program that requires eating protein, carbohydrate, and fat in a 30:40:30 ratio—30% of calories from protein, 40% from carbohydrate, The “Zone” and 30% from fat; used to balance insulin and other hormones for optimal health  Chiropractic Massage Therapy Acupuncture Acupressure Reflexology  Types Definitions Manipulative and Body-Based Methods (Involve movement of body with focus on body structures and systems) Applying digital pressure in a specified way on designated points on the Acupressure body to relieve pain, produce analgesia, or regulate a body function Chiropractic medicine Manipulating the spinal column; includes physiotherapy and diet therapy Manipulating soft tissue through stroking, rubbing, or kneading to Massage therapy increase circulation, improve muscle tone, and provide relaxation Touching the patient in appropriate and gentle ways to make connection, Simple touch display acceptance, and give appreciation  The use of the hands on or near the body to manipulate energy fields or alter the biofield, to help or to heal. Include: Therapeutic Touch Healing Touch Reiki  Types Definitions Energy Therapies (Use or manipulation of energy fields) Traditional Chinese method of producing analgesia or altering the function of a body system by inserting thin needles along a series of Acupuncture lines or channels, called meridians; direct needle manipulation of energetic meridians influences deeper internal organs by redirecting qi Biofield therapy; uses gentle touch directly on or close to body to influence and support the human energy system and bring balance to the Healing touch whole body (physical, spiritual, emotional, and mental); a formal educational and certification system provides credentials for practitioners Biofield therapy derived from ancient Buddhist rituals; practitioner places hands on or above a body area and transfers “universal life Reiki therapy energy,” providing strength, harmony, and balance to treat a patient’s health disturbances Biofield therapy involving direction of a practitioner’s balanced energies Therapeutic touch in an intentional manner toward those of a patient; practitioner’s hands lay on or close to a patient’s body Bioelectromagnetic therapy; devices (magnets) applied to the body surface, Magnet therapy producing a measurable magnetic field; used primarily to alleviate pain associated with musculoskeletal injuries or disorders  Yoga Meditation Hypnotherapy Guided Imagery Imagery-A two-way communication between the conscious and unconscious mind and involves the whole body and all of its senses Guided imagery- A state of focused attention, much like hypnosis, that encourages changes in attitudes, behavior, and physiologic reactions.  Biofeedback- Uses electronic equipment to provide clients with visible or audible evidence that they are controlling their bodies physical response Qi Gong- breathing and mental exercises combined with body movements T’ai Chi- Combines physical fitness, meditation, and self- defense Pilates- Physical movement and exercise designed to stretch, strengthen, and balance the body, in particular the core or center, including the abdominal region  Types Definitions Mind-Body Interventions (Honor connections between thoughts and physiological functioning using emotion to influence health and well-being) Using art to reconcile emotional conflicts, foster self-awareness, and Art therapy express patients’ unspoken and frequently unconscious concerns about their disease Process providing a person with visual or auditory information about Biofeedback autonomic physiological functions of the body such as muscle tension, skin temperature, and brain wave activity through the use of instruments Using a variety of breathing patterns to relax, invigorate, or open Breathwork emotional channels Concentrating on an image or series of images to treat pathological Guided imagery conditions Self-directed practice for relaxing the body and calming the mind using Meditation focused rhythmic breathing Using music to address physical, psychological, cognitive, and social needs of individuals with disabilities and illnesses; improves physical movement Music therapy and/or communication, develops emotional expression, evokes memories, and distracts people who are in pain Incorporating breath, movement, and meditation to cleanse, strengthen, Tai chi and circulate vital life energy and blood; stimulate the immune system; and maintain external and internal balance Focuses on body musculature, posture, breathing mechanisms, and consciousness; goal is attainment of physical and mental well-being through Yoga mastery of body achieved through exercise, holding of postures, proper breathing, and meditation  F aith Refers to our beliefs and expectations about life, ourselves, and others Spiritual vs Religious Prayer Defined simply as a form of communication and fellowship w ith the Deity or Creator  Music Therapy Humor + Laughter Bioelectromagnetics- How living organisms interact with electromagnetic fields Detoxifying Therapies- The belief that physical impurities and toxins must be cleared from the body to achieve better health. Ie: Hydrotherapy, Colonics/Colon Therapy, Chelation Therapy Animal-Assisted Therapy Horticultural Therapy- Gardening or a healing garden Stimulates the five senses, provides leisure activities, improves motor function, provides a sense of achievement, and improves self-esteem  Types Definitions Movement Therapies (Eastern or Western approaches to promote well-being) Intimate and powerful medium because it is a direct expression of the Dance therapy mind and body; treats persons with social, emotional, cognitive, or physical problems A complementary therapy based on establishment of good self-image through awareness and correction of body movements; integrates the Feldenkrais method understanding of the physics of body movement patterns with an awareness of the way people learn to move, behave, and interact A system of exercises (e.g., mat and special apparatus) and body movement used to strengthen, lengthen, and improve the voluntary Pilates control of muscles and muscle groups, especially those used for posture and core strengthening; awareness of breathing and precise movements are integral components Safety Concerns Key concept: Natural does not always mean better or safe. Very little research done May have no effect, mild, or adverse reactions, delay or prevent healing Toxicity may occur- likely underreported d/t not being prescribed by a provider May have drug interactions, especially in older adults- more so with liver or kidney disease Essential oils may cause issues Supplements may cause issues or become dangerous when mixed with other medications.  Safe or Effective Herbs Determined by Non-US Regulatory Authorities Name Use Effects Potential Drug Interactions Skin disorders, including burns, inflammation, and Acceleration of wound Furosemide and loop acute injuries (used healing diuretics topically) Aloe Vera GI ulcerations, including Unknown mechanism, Crohn’s disease and May enhance the effects of although there is a known ulcerative colitis (taken laxatives when taken orally laxative effect orally) Inflammatory diseases of GI Drugs that cause drowsiness Antiinflammatory and upper respiratory tracts (alcohol, barbiturates, Chamomile Generalized anxiety benzodiazepines, narcotics, Calming agent antidepressants) disorder Antirejection drugs and other drugs that weaken immune system Upper respiratory tract Stimulant of immune Echinacea May interact with infections system antiretrovirals and other drugs used in the treatment of HIV/AIDS Warfarin and other Wound healing Antiinflammatory anticoagulants Feverfew Inhibition of serotonin and Arthritis Aspirin and ibuprofen prostaglandins  Safe or Effective Herbs Determined by Non-US Regulatory Authorities Name Use Effects Potential Drug Interactions Elevated cholesterol levels Warfarin and blood thinners Inhibition of platelet Garlic Saquinavir and other anti- Hypertension aggregation HIV drugs Warfarin and anticoagulants Ginger Nausea / Vomiting Antiemetic Aspirin and NSAIDs Memory improvement, although these effects are Alzheimer disease and Warfarin and anticoagulants Ginkgo now in question given dementia Aspirin and NSAIDs results in two recent clinical trials Corticosteroids and other GI disorders, including immunosuppressive drugs Licorice Root Unknown gastric ulcers and hepatitis C Digoxin Antihypertensive drugs Prevention of conversion of testosterone to Benign Prostatic Finasteride and dihydrotestosterone Saw Palmetto Hyperplasia antiandrogen drugs (needed for prostate cell multiplication) Chronic pelvic pain Unknown mechanism None known Barbiturates and other Sleep disorders, mild Central nervous system sleep medications Valerian anxiety, and restlessness depression Alcohol Antihistamines  Include questions on the use of CAM when obtaining medical histories. Ask the patient why they are taking it Polypharmacy Pregnant or lactating women Age considerations Adams, M., Holland, N., & Urban, C. (2020). The role of complementary and alternative therapies in pharmacology. Pharmacology for Nurses: A Pathophysiologic Approach, (6th ed., pp. 107-118). Pearson. Berman, A.J., Snyder, S., Kozier, B., & Erb, G. (2021). Complementary and alternative healing modalities. Kozier & Erb’s fundamentals of nursing: Concepts, process, and practice (11th ed., pp. 392-407). Prentice Hall/Pearson. Gyorfi, M., Rupp, A., & Abd-Elsayed, A. (2022). Fibromyalgia pathophysiology. Biomedicines, 10(12), 3037. https://doi.org/10.3390/biomedicines10123070 Harding, M., Kwong, J., Hagler, D., Reinisch, C. (2023). Lewis’s Medical- Surgical Nursing. (12th ed.) Elsevier. Ignatavicius. D.D., Workman, M.L., & Rebar, C.R. (2021). Assessment and concepts of care for patients with pain. In N.M. Heimgartner (ed.), Medical-surgical nursing: Concepts for interprofessional collaborative care (10th ed., pp. 71-97). Elsevier.