Assessment and management of pain in hemodialysis patients: a pilot study.
Chronic Kidney Disease (CKD) is a global phenomenon with increasing incidence and prevalence, poor outcome and high cost . Globally, over 2 million people require Renal Replacement Therapy (RRT) to sustain life, but this likely represents less than 10% of those who are in need of these procedures . Worldwide, each year there is a 7-10% increase in renal patients due to increased prevalence of Diabetes Mellitus (DM), hypertension and cardiovascular disease. Given this increase, the prevalence of CKD is expected to dramatically increase over the next two decades .
Renal patients are frequent consumers of healthcare services and often experience pain either during the pre-dialysis phase of the disease or during renal replacement period [3-7]. Pain is defined as an "unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage" .
Epidemiology data on pain in renal patients are quite limited; however, studies have shown that 37%-50% of hemodialysis (HD) patients experience chronic pain (moderate to severe in intensity) [4, 9] and that affects their Health Related Quality of Life (HRQOL) .
To our knowledge, there is a shortage of clinical and research focus in the area of renal patients' pain. According to Patients' Rights and Maslow's pyramid of needs, the relief of pain is a basic human right. Pain assessment and management are judged to be a priority in nursing, but often pain is undermanaged [11, 12]. It is hypothesized that renal patients experience some kind of pain during RRT, and that they take actions to manage it.
The purposes of this study are to acquaint nurses involved in the delivery of renal care a) with the level of pain as it is perceived by their patients and b) with the chosen management methods. Furthermore, it is aiming to familiarize nurses with the principles of pain assessment and management.
MATERIALS AND METHODS
Participants and data collection
The pilot study involved all HD patients (convenience sample) of a public hospital's dialysis unit in Thessaloniki, Greece (n = 70). Data were collected with face to face interviews with the patients, during the second hour of HD. It was chosen to have the interviews within the HD unit in order for the patients to feel more comfortable and familiar with the setting. The second hour of the HD session was chosen due to the fact that, usually, after the second hour complications (hypotension/vomiting) may appear. It was decided to exclude patients with hearing or seeing problems, comatose or disorientated, minors or unable to communicate in the native language (n = 5).
The Wong-Baker FACES Pain Rating Scale (WBPS)  was used in order to measure pain. This scale consists of six figures ranging from no pain (smiley face) to extreme pain (crying face) and it was initially used with children. During the interview the patient identified the face representing his/her present pain condition.
Secondly, a Visual Analogue Scale (VAS) , ranging from none to extreme pain, was presented by the interviewer in order to measure the amount of pain felt at the moment of the interview. Operationally a VAS is a horizontal line, 100mm in length, anchored by word description at each end (no pain on the left hand end and very severe pain on the right hand end). Renal patients were asked to mark on the line the point that represented their current perception of pain. The VAS score is determined by measuring in millimeters from the left hand end of the line to the point that the patient marks.
Finally, the McGill Pain Questionnaire (short form)  was used in order to assess the patients' pain experience over the last week. It consists of 24 questions describing pain. The questionnaire has already been translated and validated into the native language .
The interviews were anonymous and only the patients' initials, gender, and date of interview were recorded by the researcher. During the interviews it was decided not to use a tape recorder. Instead, answers were filled in a printed version of the questionnaires as patients were more familiar to that kind of data collection. Approval of the ethics committee of the hospital was obtained, as well as written informed consent from the participants.
Data were analysed using SPSS Version 20.0. For data analysis, descriptive statistics were used (frequencies), as well as crosstabs, Chi-square test, correlations and i-test.
Mean age of renal patients studied was 69.72 [+ or -] 12.45 years old, male (58.5%, n=38) and on HD for 35.5 [+ or -] 27.4 months (Table 1). In the WBPS, they choose the face that corresponded to "hurts little more" or number four (31%, n=20) and in the VAS 31% (n = 20) of the patients marked 6cm as the point representing the amount of pain experienced at the moment. The in gender analysis for both pain scales is shown in Table 2.
In the body diagram, included in the McGill Questionnaire, pain of internal origin was marked in the legs (46%, n = 29). In a comparison between genders eighteen (50%) of the male patients pointed legs as the place of internal pain, whereas thirteen (48%) of the female patients experience internal pain in the arms. Pain of external force was pointed at fistula site by 71% (31 male and 15 female) and was attributed to needling. There was no statistical significant correlations between gender and pain of internal origin (p = 0.185), whereas it was correlated with pain of external force/needling (p = 0.027).
Pain, as described by the patients, after choosing the word most suitable for them in the McGill questionnaire is presented in Table 3. When asked about the type of pain they described it as continuous (61.5%, n = 40), constant (61.5%, n = 40), periodic (66%, n = 43), rhythmic (86%, n = 56) and steady (51%, n = 33). They thought that their pain at the moment of the interview was distressing (41.5%, n = 27) and discomforting (32%, n = 21). In a gender comparison of pain level at the moment of the interview males described it as discomforting and distressing (n = 14). Females used the same description on a reverse order (Figure 1).
After the first five interviews, it was found that the chosen questionnaire did not assess the ways of managing pain. It was, then, decided by the research team to add an open-ended question regarding the mater
According to the sample, pain was treated either with warm towel/cloth (all males and 85% in the female group), massage (84% and 89%, respectively) or going for a walk. In a correlation of gender and ways of managing pain (painkillers, massage, yoga, warm towel/cloth, workout, walk, nothing) statistical significance was found only with warm towel (p = 0.038) (Figure 2).
Furthermore, statistical significance was found between age and some management techniques such as warm towel (p = 0.013) and workout (p = 0.019).
Both scales (WBPS and VAS) used in the research showed that more than one third of our sample rated pain as 6/10 and pinpointed internal pain in the legs. Pain experienced was characterized as wretched, sickening, cold, tiring, burning and flashing (varying from 31-75%). Moreover, the type of pain was described as rhythmic, periodic and continuous.
Multiple factors can cause pain in renal patients. HD sustains life, but it cannot stop underlying systemic diseases and their painful symptoms such as ischemic limbs or neuropathies [6, 17].
Furthermore, there are numerous painful syndromes unique to CKD such as calciphylaxis , renal osteodystrophy  and amyloidosis . Recurrent pain caused by an average of 320 arteriovenous fistula punctures per year , muscle cramps and headaches during dialysis  is perceived, by some patients, as chronic pain [17,22]. Half of the sample population reported that pain caused by external force is targeted at the vascular access site. Musculoskeletal (bone and joint) pain is the most common of the chronic pain in CKD, as in general population . Acute pain can be caused from various surgical procedures such as creation of vascular access and insertion of HD catheter. Quality of life studies in renal patients have shown high scores for bodily pain compared to general population, leading to reduced employment rates and physical functioning [24, 25].
Sample's pain varied from mild to excruciating, and it was always present in their daily routine. Females had more discomforting feeling of pain compared to male patients (35.7% compared to 14.3%). Research suggests that women experience a greater, and more intense, number of symptoms [10, 23].
Patients usually manage pain either with warm towel/cloth (85% of females and all male patients), massage (89% and 84%, respectively) or painkillers (53% and 47%, respectively). Painkillers ranged from plain paracetamol to combinations of paracetamol with codeine phosphate and caffeine. Despite the availability of effective pain management interventions  and guidelines for the management of pain in other patient groups , many renal patients continue to receive inadequate analgesia [6, 26]. Although medication has an important effect on the well-being of HD patients, the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines have not addressed the use of pain management . Renal medical and nursing community is asked to refer to National Kidney Foundation proposals that discourage the prescription of NSAID in patients with CKD who are not yet on dialysis [27,28] and the World Health Organization (WHO) suggestions of limited use of these agents in CKD patients [5,26,27]. The response to pain therapy depends more on patient-related factors such as physical, emotional, social, spiritual and financial rather than the potency of analgesics. These psychosocial and spiritual factors interact with physical symptoms and suffering of the patient and need to be addressed in pain management . Pain in CKD patients is inadequately managed as analgesic use has decreased over the last few years . Morphine was the analgesic of choice for treatment of severe acute and chronic pain syndromes during the last decade. Several authors [6,30,31] have confirmed the variability in the kinetics of morphine and its metabolites in the presence of renal impairment. According to them, renal patients are at greater risk of developing opiate toxicity with prolonged effects and severe respiratory depression .
A variety of management methods (non-pharmacologic and non-invasive) can be used, as our sample suggests. These techniques are more time-consuming for patient and nurse, but they place patient in a more active role.
Reinforce or modify pain control behaviors by observing patients to see what they do to reduce or control pain. Such observation may provide important information for tailoring nursing interventions to a specific patient. Patients often use techniques of positioning, rubbing and splinting to decrease or limit pain. Massage of a painful limp, either by the patient himself or by the nurse, can decrease muscle tension and can break the cycle of tension, increased pain, and increased tension. In addition, it can help bring about mental and physical relaxation and strengthens the nurse-patient relationship .
Heat application causes vasodilatation resulting in increased blood flow and reduced pain levels. Nurses can apply heat through the use of warm blankets or electric heating pads, and by assisting the patient to shower or bathe before or after HD session [33, 34].
Walk or mild exercise programs have been shown to reduce fatigue. Some patients report an improvement in comfort and gradually reduce of pain when joints are kept active, even during HD sessions [35, 36].
Study limitations. The main limitation of this study was that the McGill questionnaire used did not have a section of recording pain management methods. It was realised after the first five interviews so it was decided, by the research group, to add this part as an open question, to exclude the first five interviews and to have a qualitative analysis of that part of the questionnaire. Another limitation was the number of participants, and the fact that the pilot study evolved only one hospital in the region.
As renal patients are an increasing group of healthcare service users, and pain is affecting their everyday life, it is essential to individualize pain evaluation. Pain assessment is a critical component of nursing process. It is mandatory to provide further education to clinical nurses in order to effectively manage pain. A detailed nursing history should be obtained focusing on pain location, duration, associated symptoms and relieving factors. This way nurses, not only renal nurse, can better understand each dimension of pain, assess it and take nursing decisions for its management .
Staff and patients of the "St.Paul-Panagia" Hospital Haemodialysis Unit are thanked for their cooperation with the research team.
Conflicts of interests
The author declared that they had no conflicts of interest with respect to the authorship and/or publication of this article.
Financial Disclosure/Funding: This study has not been funded by any source or authority.
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Kafkia T. (1) *, Vehvilainen-Julkunen K. (2), Sapountzi-Krepia D. (3)
(1) Department of Nursing, Alexander Technological Educational Institution of Thessaloniki, Greece
(2) Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
(3) Department of Nursing, Frederick University, Cyprus
* Corresponding author:
Department of Nursing, Alexander Technological Educational Institution of Thessaloniki 12 Antoniou Nastou Str, 54248 Thessaloniki, Greece e-mail: email@example.com
Tel: +30 6944732279
Fax: +30 2310 858018
Table 1. Patients' characteristics. Age 69.72 ([+ or -]12.45) years old 27-91 years old Gender Male = 58.5% (n = 38) Female = 41.5% (n = 27) Duration 35.49 [+ or -]27.4 months of HD HD-hemodialysis Table 2. In gender pain analysis in Wong Baker Scales and Visual Analogue Scale. Wong Baker Scales Does not Hurts a Hurts hurt (0) little little bit (2) more (4) Male 2.6% (n = 1) 18.4% (n = 7) 31.6% (n = 12) Female 0 11.2% (n = 3) 29.6% (n = 8) Hurts even Hurts whole Hurts more (6) lot (8) worst (10) Male 26.3% (n = 10) 21.05% (n = 8) 0 Female 33.3% (n = 9) 25.9% (n = 7) 0 Visual Analogue Scales 0 cm 1 2 3 4 Male 0 0 15.8% (n = 6) 5.3% (n = 2) 2.6% (n = 1) Female 0 0 3.7% (n = 1) 7.4% (n = 2) 14.8% (n = 4) 5 6 7 Male 13.2% (n = 5) 42.1% (n = 16) 10.5% (n = 4) Female 7.4% (n = 2) 14.8% (n = 4) 29.6% (n = 8) 8 9 10 cm Male 7.9% (n = 3) 2.6% (n = 1) 0 Female 14.8% (n = 4) 7.4% (n = 2) 0 Table 3. Pain described in McGill questionnaire. Valid percent 1 Flickering, quivering, 20% (n=13) throbbing, beating 2 Flashing 64.6% (n=42) 3 Boring 53.8% (n=35) 4 Sharp 50.8% (n=33) 5 Gnawing 41.5% (n=27) 6 Pulling 53.8% (n=35) 7 Burning 66.2% (n=43) 8 Smarting 38.5% (n=25) 9 Dull 30.8% (n=20) 10 Rasping 47.7% (n=31) 11 Tiring 67.7% (n=44) 12 Sickening 70.8% (n=46) 13 Fearful 44.6% (n=29) 14 Grueling 52.3% (n=34) 15 Wretched 75.4% (n=49) 16 Miserable 43.1% (n=28) 17 Penetrating 42.2% (n=27) 18 Drawing, numb 2.2% (n=17) 19 Cold 70.8% (n=46) 20 Agonizing 43.1% (n=28)
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|Author:||Kafkia, T.; Vehvilainen-Julkunen, K.; Sapountzi-Krepia, D.|
|Publication:||Progress in Health Sciences|
|Article Type:||Clinical report|
|Date:||Jun 1, 2014|
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