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...in terms of such damage" (Merskey Bogduk, 1994, p. 214). Inherent in the definition is the recognition that pain perception, management, and evaluation are influenced by multiple integral factors, including physical, psychological, social, cultural, and environmental perspectives unique to the affected person. Because pain is a subjective and uniquely individual experience, pain management can pose challenges for the patient and health care provider alike. Although not commonly noted in the literature, patients who face particular difficulties with pain management are those who undergo surgery to treat complications of Crohn's disease (CD).
An inflammatory disease of unknown etiology, Crohn's disease affects the digestive tract, most commonly the terminal ileum and colon (Nikolaus & Schreiber, 2007). Canada has one of the highest incidences of CD, with approximately 0.5% of the Canadian population diagnosed with the disease (Bernstein & Nabalamba, 2006). The incidence in the United States is quite similar; an estimated 436,000 Americans live with CD (Kappelman et al., 2007). Crohn's disease most often is diagnosed during the second to third decade of life, a time when most people are pursuing career goals, starting a family, and becoming independent and self-sufficient (Fuller-Thompson & Sulman, 2006). In addition, the virulent course of the disease, frequent exacerbations and remissions, and debilitating effects of the symptoms (persistent diarrhea, fever, nausea, fatigue, weight loss, and abdominal pain), tend to hinder the normal evolution of independent adulthood and seriously impair psychological well-being and quality of life (Fuller-Thompson & Sulman, 2006). While conservative pharmacologic therapy is the initial treatment of choice, Bernstein and Nabalamba (2006) reported that 70% of patients with CD will require surgery within the first 10 years of diagnosis due to development of intestinal strictures, perforations, or fistulae as a result of chronic inflammation.
The goal of postoperative pain management is to implement safe and effective treatment modalities. However, management of acute and chronic pain experienced simultaneously by the postoperative patient with CD can be a nursing challenge. Under-managed pain can become a major frustration to both the patient and the nurse, and the issue must be explored from the perspective of both. The purpose of this article is to review the postoperative pain experience of the patient with CD. The Human Response to Illness Model will provide the framework for this discussion, which will include recommendations for nursing interventions to optimize the patient's postoperative care.
The Human Response to Illness Model
The Human Response to Illness Model (HRI) (Mitchell, Gallucci, & Fought, 1991) provides an organizing framework to discuss the unique pain experience of the postoperative patient with CD. This model uses a holistic approach to gain a comprehensive understanding of the human responses to illness. Thus, the response of pain will be discussed within the context of the four perspectives of the HRI model: physiological, pathophysiological, behavioral, and experiential. In addition, person and environmental factors considered to be influences on the response to illness will be identified.
Physiologic Perspective
Physiologic regulatory responses are based on normative, biological functioning and include measurable phenomena (Mitchell et al., 1991). Following surgery, acute pain is a normal, expected, physiologic response. Acute postoperative pain occurs when a noxious stimulus elicits a response from nociceptors. Two types of nerve fibers (myelinated A-fibers and non-myelinated C-fibers) serve as the nociceptors that respond to the stimulus and are responsible for transmitting impulses to the dorsal horn of the spinal cord. When nociceptors are stimulated, mast cells also are stimulated to release histamine. This in turn stimulates neurochemicals, such as prostaglandins, potassium ions, substance P, and glutamate. Glutamate activates alpha-amino-3-hydroxy-5methyl-4-isoxazolepropionate acid (AMPA) and N-methyl-D-asparate (NMDA) to be released from the nociceptor ending. The release of these chemicals in the brain provides the awareness that tissue damage is occurring and painful sensations thus are experienced (McCance & Huether, 2006).
Pathophysiologic Perspective
The postoperative patient with CD is not naive to the experience of pain. As a consequence of the disease, the patient with CD tends to experience chronic visceral pain. Visceral pain manifests as a dull, diffuse pain that can arise due to the inflammation of the bowel (McCance & Huether, 2006). The primary author's clinical observation indicates that the patient can perceive exaggerated acute pain during the postoperative period due to the pathophysiologic pain response that develops secondary to the chronic pain experienced throughout the patient's history with CD. However, further clinical research would be necessary to validate this point. Mitchell and colleagues (1991) explained that pathophysiologic responses result from disordered biologic functioning with observable, measurable phenomena. Intensified postoperative pain experienced by the postoperative patient with CD is due to changes in the peripheral and central...
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