Bakgrund Att arbeta barncentrerat och behandla smärta hos barn inom hälso- och sjukvården är ett komplext arbete. Barn och vuxna har olika fysiologiska och psykologiska behov vilket ställer krav på sjuksköterskans kompetens och kunskap om barn. Syfte Syftet med denna litteraturöversikt var att sammanställa forskningsresultat för att belysa sjuksköterskors upplevelser av att vårda barn med smärta inom slutenvården. Metod Litteraturöversikten genomfördes som en strukturerad litteraturöversikt med inslag av den metodologi som används vid systematiska översikter. Arbetet skrevs som en integrativ översikt där resultatet syntetiserades till en ny helhet. I artikelsökningarna användes databaserna CINAHL och PubMed. Artiklarna var publicerades 2013-2023 och analyserades enligt Fribergs fyrstegsmodell. Resultat Resultatet sammanställdes i två huvudkategorier; faktorer och resurser samt behov av pediatrisk kompetens med fyra underkategorier; tidsbrist, stödfunktioner, teoretiska kunskaper samt erfarenhet som visar på de faktorer som påverkar sjuksköterskornas upplevelser av att vårda barn med smärta. Slutsats Sjuksköterskornas möjlighet att utföra en god och effektiv smärtvård försvårades av faktorer som tidsbrist, personalresurser, brist på fungerande riktlinjer och otillräcklig utbildning inom pediatrisk vård. Välfungerande riktlinjer och utbildning inom pediatrisk vård förbättrade förutsättningarna att kunna utföra en god smärtvård. Sjuksköterskorna ansåg även att familjerna var en viktig resurs, genom att involvera familjen som expert på sitt barn hade sjuksköterskorna goda förutsättningar att göra en individuell bedömning och ge en god smärtvård. / Background To work child-centered and treat pain in children within healthcare is a complex task. Children and adults have different physiological and psychological needs, which demands competence and knowledge about children from the nurse. Aim The aim of this literature review is to compile research literature to highlight nurses' experiences of caring for children with pain in inpatient care. Method The literature review was conducted as a structured literature review in corporating the methodology used in systematic reviews. The work was written as an integrative review where the results were synthesized into a new whole. In the article searches, the databases CINAHL and PubMed were used. The articles were published between 2013 and 2023 and were analyzed according to Friberg's four-step model. Results The results were compiled into two main categories; factors and resources and the need for pediatric expertise, with four subcategories; time constraints, support functions, theoretical knowledge, and experience, indicating the factors influencing nurses' experiences of caring for children with pain. Conclusions Nurses' ability to provide good and effective pain management was hindered by factors such as time constraints, staffing resources, lack of functional guidelines, and inadequate education in pediatric care. Well-functioning guidelines and education in pediatric care improved the conditions for providing good pain management. Nurses also considered families to be an important resource; by involving the family as experts on their child, nurses had good conditions for making individual assessments and providing good pain management.

This study assessed the effect of an eight-minute cycling intervention using varying intensities on exercise-induced hypoalgesia (EIH). Generally, current research examines EIH using protocols that last for more than 10 minutes and reach 75% of an individual's VO2 peak. The main objective of this study was to examine the effect of varying intensities on pressure pain threshold (PPT) and heat pain threshold (HPT) at the thigh and forearm, tested pre- and post-cycling intervention. Healthy male participants (n=16) performed a graded exercise test on a cycle ergometer to establish their peak power output (PPO). In subsequent visits, participants completed five different 8-minute cycling interventions, with intensities randomly assigned to one of three counterbalanced orders. HPT and PPT were applied to the thigh and forearm two times before and after each cycling intervention. Additionally, there was a notable effect of intensity on PPT in the thigh, with significant changes at intensities of 90% (p = 0.024) and 100% (p = 0.003). In the forearm, repeated measures ANOVA indicated that there was no significant interaction or main effect for intensity and time. Similarly, for HPT, the analysis did not show significant interaction or main effects for both intensity and location. This study was the first to examine EIH using an 8-minute cycling intervention on a cycling ergometer at individualized intensities. Higher intensity cycling sessions generated EIH locally in the thigh using PPT. This intervention appeared to target the nociceptors activated by mechanical, rather than thermal stimuli, further highlighting the multi-faceted nature of EIH. A short but high intensity cycling intervention may have clinical relevance, as it can provide an intervention to reduce localized pain immediately after exercise using a pressure pain stimulus.

SAMMANFATTNING Introduktion: Postoperativ smärta är en naturlig följd av kirurgiska ingrepp, vilket kräver noggrann utvärdering och hantering av sjuksköterskor för att säkerställa optimal smärtlindring. Påtaglig smärtproblematik rapporteras ännu av nyopererade patienter, vilket kan resultera i påtagliga konsekvenser för både individ och samhälle. Patienters perspektiv kan ge kunskap om påverkande omständigheter och öka förståelsen för smärta.  Syfte: Syftet var att belysa patienters upplevelser av postoperativ smärta. Metod: En deskriptiv allmän litteraturöversikt med kvalitativ ansats tillämpades enligt Fribergs metod. Databaser som användes var PubMed och CINAHL. Resultat: Delaktighet och information gav patienten möjlighet att etablera trygga, realistiska förväntningar. Smärta som upplevdes oförutsedd och okontrollerad hämmade patientens återhämtning. Patientens vilja att kommunicera sin smärta påverkades av personalens tillgänglighet, engagemang, kontinuitet och attityder. Etablerade vårdrelationer underlättade kommunikationen. Smärtbedömningen varierade beroende på vilken vårdpersonal som tjänstgjorde. Det fanns blandade känslor för smärtstillande läkemedel relaterat till biverkningar och om medicineringen var tillräcklig. Patienter kompletterade smärtlindringen med icke-farmakologiska strategier där mobilisering, kyla eller värme var återkommande.  Slutsats: Postoperativ smärta kan innebära stor påfrestning för patienter, deras upplevelser är individuella och komplexa som påverkas av såväl yttre som inre omständigheter. Inom sjukvården kan utmaningar som hög arbetsbelastning bidra till otillräckligt informationsflöde och sämre patientupplevelser. Att vara välinformerad, delaktig och få personcentrerad vård med stöd från engagerad personal främjar positiva upplevelser. Genom att förstå och inkludera dessa aspekter i helhetsbilden kan det bidra till förbättrad vård för patienter med postoperativ smärta. Ytterligare forskning uppmuntras för att öka förståelsen för patientens perspektiv.  Nyckelord: omvårdnad, patientupplevelse, postoperativ smärta, påverkan, smärthantering / ABSTRACT Introduction: Postoperative pain is a natural consequence of surgical procedures, requiring careful evaluation and management by nurses to ensure optimal pain relief. Substantial pain issues are still reported by postoperative patients, impacting both the individual and society. The patient’s perspective provides valuable insights into the understanding of pain.  Aim: The aim was to illuminate patients’ experiences of postoperative pain. Method: A descriptive general literature review with a qualitative approach was applied according to Friberg’s method. The databases used were PubMed and CINAHL.  Result: Participation and information allowed the patient to establish safe, realistic expectations. Pain experienced as unexpected and uncontrollable inhibited patients’ recovery. Staff availability, commitment, continuity, and attitudes influenced patients’ willingness to communicate pain. Established care relationships facilitated communication. Pain assessment varied depending on which healthcare staff was on duty. Analgesic side effects and adequate medication received mixed feelings. Patients supplemented pain relief with non-pharmacological strategies like mobilization, cold or heat. Conclusion: Postoperative pain can be stressful for patients, their experiences are individual and complex and are affected by external as well as internal circumstances. Within healthcare challenges such as high workload can contribute to insufficient information and worse patient experiences. Being well-informed, involved and receiving person-centered care with the support of dedicated staff promotes positive experiences. Understanding and including these aspects in the overall picture can contribute to improved care for patients with postoperative pain. Further research is encouraged to increase the understanding of the patient’s perspective. Keywords: care, patient’s experience, postoperative pain, impact, pain management

No / Improving the patient's experience of a bone marrow biopsy ¿ an RCT Aims. To compare nitrous oxide 50%/oxygen 50% (N2O/O2 ¿ entonox) plus local anaesthetic (LA) with placebo (oxygen) plus LA in the management of pain experienced by patients undergoing a bone marrow biopsy. . Bone marrow biopsies are a common procedure for many haematological conditions. Despite the use of a LA, pain during the procedure has frequently been reported by patients. Previous research in pain management of other invasive diagnostic procedures (e.g. sigmoidoscopy) has reported N2O/O2 as an effective alternative to LA. Design. Double-blind randomized controlled trial. Methods. Forty-eight patients requiring a bone marrow biopsy were randomized to receive either N2O/O2 or oxygen in addition to their LA. Participants were asked to complete a pain score and comment on their experience of the procedure. Results. Although the overall pain scores were moderate, there was a wide range of scores. N2O/O2 resulted in significantly less pain for men, but not for women. All patients who had had previous biopsies reported significantly more pain, regardless of the gas used. There were no significant adverse effects in either group. Conclusion. N2O/O2 is a safe, effective, easy-to-use analgesic which merits further investigation in potentially painful diagnostic (and other) interventions.

Exercise-induced hypoalgesia (EIH) is the reduction in pain sensitivity following exercise. High-intensity or prolonged exercise is typically required to elicit an EIH response, but there is limited evidence suggesting that low-load resistance exercise with blood flow restriction (LL+BFR) may be able to elicit a robust EIH response. The purpose of these investigations was to assess the magnitude, duration, and proposed mechanisms of EIH following LL+BFR, LL with normobaric systemic hypoxemia, BFR only without exercise, high-load exercise, and a control intervention. The first study evaluated local and systemic pain pressure threshold and tolerance responses one-hour post-exercise. The results indicated that LL+BFR induced similar EIH responses to high-load resistance exercise 0- and 15-minutes post-exercise but only LL+BFR elicited an EIH response present 60-minutes post-exercise. The second study evaluated neuromuscular and perceptual responses, both proposed EIH mechanisms, during exercise. Similar neuromuscular responses were observed in all interventions. Participants reported higher ratings of perceived exertion during LL+BFR and high-load exercise, and higher levels of perceived pain during LL+BFR. These results suggested that despite high levels of motor unit recruitment, there were divergent EIH responses. However, increased pain during exercise may be a mediating factor of EIH after resistance exercise. The third study evaluated peripheral and central cardiovascular responses, which have also been hypothesized to mediate EIH. LL+BFR resulted in greater increases in systolic blood pressure during the first set of exercise, and diastolic blood pressure during all sets of exercise. LL+BFR and BFR only attenuated changes in heart rate variability (HRV). LL+BFR induced the largest increase in deoxyhemoglobin and total hemoglobin and lowered tissue saturation index. BFR only progressively increased oxyhemoglobin and total hemoglobin levels. The local and systemic cardiovascular responses suggested that prolonged EIH following LL+BFR could be related to increased central or peripheral cardiovascular stress.

Exercise-induced hypoalgesia (EIH) denotes the phenomenon wherein physical activity induces a diminished sensitivity to pain, holding significant implications for pain management modalities. This investigation sought to evaluate the reproducibility of pressure pain thresholds (PPT) subsequent to dynamic resistance exercise and juxtapose PPT measurements during periods of quiet rest against those immediately post-exercise. A cohort of five healthy participants underwent three separate sessions, wherein PPT assessments were conducted pre- and post-exercise. Findings revealed a nuanced reliability in PPT measures during EIH evaluation, necessitating judicious interpretation due to the constrained sample size. Comparative analyses with antecedent research underscored discernible disparities in exercise intensities and methodological approaches, accentuating the imperative of considering idiosyncratic responses and procedural distinctions. Despite inherent limitations, notably the modest sample size, this inquiry furnishes valuable insights into the intricacies of EIH assessment, elucidating the complexities inherent in advancing knowledge within the domain of pain modulation research. Prospective investigations with larger and more heterogeneous cohorts are imperative to fortify the dependability and generalizability of findings in this realm.

Sammanfattning Bakgrund: Det är fortsatt förekommande med komplikationer relaterat till medelsvår och svår postoperativ smärta. Anestesisjuksköterskan har det samlade omvårdnadsansvaret för patienten perioperativt. En helhetsbedömning av patienten avgör postoperativt smärtlindringsbehov. Den Perioperativa dialogen skapar mening i arbetet och trygghet för patienten. Författarna identifierade avsaknad av riktlinjer vid genomförandet av en individuell helhetsbedömning vid handläggning av postoperativ smärtlindring. Syfte: Syftet var att belysa hur anestesisjuksköterskor planerar, genomför och utvärderar postoperativ smärtlindring i generell anestesi utefter tidsfaserna pre-, intra- och postoperativt samt inverkan av den perioperativa dialogen. Metod: En kvalitativ studie genomfördes med tio semistrukturerade intervjuer. Data analyserades med kvalitativ innehållsanalys med en induktiv ansats. Resultat: I resultatet framkom fyra huvudkategorier med totalt elva underkategorier som berör informanternas handläggning. Preoperativa åtagande - Planeringsprocess Känna ansvar för planering, Skapa vårdrelation, Beakta patientens känslotillstånd. Intraoperativa vårdmoment - Konstant utvärdering av behandling, Anpassa behandling fortlöpande, Självständigt ansvarsområde. Postoperativa förhoppningar - Eftersträva återkoppling, Undvika smärtgenombrott. Perioperativa organisatoriska aspekter - Anpassa utefter arbetsförhållanden, Avsaknad av den Perioperativa dialogen. Slutsats: Handläggningen av postoperativ smärtlindring är ett komplext område vilket kräver beaktning av flera faktorer för ett gott utfall. Den perioperativa dialogen är inte prioriterad. Det saknas konsensus för anestesisjuksköterskans handläggning av postoperativ smärta. Det krävs utveckling och ett utökat samarbete av hela vårdkedjan för att kunna möta den postoperativa smärtproblematiken. / Abstract Background: Complications still occur in connection to moderate and severe postoperative pain. The nurse anaesthetic´s is completely responsible for the patient care perioperative. An overall assessment of the patient all together determine the postoperative need of analgesic. The perioperative dialogue is a method which gives the nurse anaesthetic´s a sense of meaningfulness of the work and creates a perception of safety for the patient. The authors identified the absence of guidelines to make an individual overall assessment when managing postoperative pain. Aim: The aim of the study was to elucidate the nurse anaesthetic´s planning, implement and evaluate postoperative analgesic during total anaesthesia along the time-phases pre-, intra and postoperative and the impact of the perioperative dialogue. Method: A qualitative study was conducted with ten semistructured interviews. A qualitative content analysis was made with an inductive approach. Result: The result is presented in four head categories and eleven sub-categories that illuminate the informants’ experiences. Preoperative undertakings - Feeling responsibility for planning, Create a care-relation, Respect the patients emotional state. Intraoperative steps – Constant evaluation of treatment, Adapt the treatment continuously, Independent responsibility. Postoperative expectations – trying to obtain feedback, Avoid outbreak of pain. Perioperative organizational aspects – Adjustment along work situation, Absence of the perioperative dialogue.    Conclusion: The postoperative pain management is a complex matter that demand consideration of several aspects to achieve a good outcome. The perioperative dialogue is not prioritised. There is a lack of consensus among nurse anaesthetic´s managing postoperative pain. Developing and increasing cooperation along the entire chain of care is necessary to manage the issue of postoperative pain.

Pain is the most prevalent medical problem that elderly persons experience in a long-term care home. Nurses play an essential role in managing their pain. The purpose of this study was to explore nurses’ pain management practices in Ontario long-term care homes facilities. The ultimate aim was to recommend measures for effective pain management in aged people. The setting for this study was a selected long-term care home in Ontario, Canada, a 160-bed nursing home for aged people offering various medical care services. Semi-structured focus group interviews, averaging approximately one hour, were conducted. The population of this study was 45 nurses. The researcher used a purposive sampling method to select a sample of 25 nurses. Open-ended questions were used to explore pain management practices and to find barriers to effective pain management. Qualitative data analysis was used to review the data to identify common issues that recurred, and they were summarised in a narrative form. This study demonstrated the importance of recognising and overcoming barriers to the effective management of pain and reinforcing good practices in long-term care homes. Therefore, improved pain management practices are required to manage pain in a long-term care home effectively. / Health Studies / M.A. (Nursing Sciences)

Nursing homes are an essential yet understudied provider of cancer-related care for those with complex health needs. Nine percent of nursing home residents have a cancer diagnosis at admission, and it is estimated that one-third of them experience pain on a daily basis. Although pain management is an essential component of disease treatment, few studies have evaluated analgesic medication use among adults with cancer in this setting. Use of opioids, which are the mainstay of pain management in older adults because of their effectiveness in controlling moderate to severe pain, may be significantly related to coverage by the Medicare Part D prescription drug benefit. However, little is known about Medicare Part D’s effects on opioid use in this patient population. A limited body of evidence also suggests that despite known risks of overdose and respiratory depression in opioid-naïve patients treated with long-acting opioids, use of these agents may be common in nursing homes. This dissertation examined access to appropriate and effective pain-related health care services among US nursing home residents, with a special focus on those with cancer. Objectives of this dissertation were to: 1) estimate the prevalence, and identify resident-level correlates, of pain and receipt of analgesic medications; 2) use a quasi-experimental research design to examine the relationship between implementation of Medicare Part D and changes in the use of fentanyl patches and other opioids; and 3) to estimate the prevalence, and identify resident-level correlates, of naïve initiation of long-acting opioids. Data on residents’ health status from the Resident Assessment Instrument/Minimum Data Set (versions 2.0 and 3.0) were linked with prescription drug transaction data from a nationwide long-term care pharmacy (January 2005–June 2007) and the Centers for Medicare and Medicaid Services (January–December 2011). From 2006 to 2007, more than 65% of residents of nursing homes throughout the US with cancer experienced pain (28.3% on a daily basis), among whom 13.5% reported severe pain. More than 17% of these residents who experienced daily pain received no analgesics (95% confidence interval [CI]: 16.0–19.1%), and treatment was negatively associated among those with advanced age, cognitive impairment, feeding tubes, and restraints. These findings coincided with changing patterns in opioid use among residents with cancer, including relatively abrupt 10% and 21% decreases in use of fentanyl patches and other strong opioids, respectively, after the 2006 implementation of Medicare Part D. In the years since Medicare Part D was introduced, some treatment practices in nursing homes have not been concordant with clinical guidelines for pain management among older adults. Among a contemporary population of long-stay nursing home residents with and without cancer, 10.0% (95% CI: 9.4–10.6%) of those who began receiving a long-acting opioid after nursing home admission had not previously received opioid therapy. Odds of naïve initiation of these potent opioids were increased among residents with terminal prognosis, functional impairment, feeding tubes, and cancer. This dissertation provides new evidence on pharmaceutical management of pain and on Medicare Part D’s impact on opioid use in nursing home residents. Results from this dissertation shed light on nursing home residents’ access to pain-related health care services and provide initial directions for targeted efforts to improve the quality of pain treatment in nursing homes.

Introduction. While opioid medications are commonly prescribed for management of neuropathic pain (NP), long-term use has been associated with increased risk for overdose, drug interactions and addiction. New strategies are necessary to better manage chronic pain, thereby reducing need for opioid medications and their associated adverse consequences. N-acetyl-L-cysteine (NAC), an over-the-counter supplement, has shown promise in the treatment of psychiatric and addictive disorders. In addition, NAC has shown promise for reducing physiological signs of NP in laboratory rat models, prompting this study. Purpose. The present study was an open-label clinical trial of NAC as an adjuvant to opioid treatment for poorly controlled, chronic NP. It examined whether 1200 mg NAC twice daily for 4 weeks was associated with: lower ratings of patient-reported pain; reductions in PRN opioid medication for breakthrough pain; and improvements in physical and mental health quality of life (QoL). The study also examined whether appraisal of pain impacts response to medication. Method. Participants were N=28 chronic NP patients who consented to study participation. This consisted of 2 baseline assessments, 4 weeks of NAC and 1 post-trial follow-up visit. The majority (N=17) dropped out or were excluded during baseline. Of the remaining participants, N = 11 started the study medication and N=10 completed the study, with daily recordings of pain severity ratings and use of PRN opioid medication. Small sample size limited analyses to qualitative case reviews and effect sizes. Results. Over 90% of participants receiving NAC completed the study. Case review found varied results. While 4 of 10 participants showed decrease in average pain ratings during NAC, estimated effect sizes for the whole sample were small, bordering on negligible (ω² from .003 to .027) as were those for PRN opioids (Partial Eta-Squared=.0003). Effect size for mental health QoL was medium (Cohen's d=.421). Conclusions. With N=10, findings must be interpreted with caution. Nonetheless, the study found some albeit small evidence supporting NAC for improving mental health QoL and pain ratings. Several participants reported improvements in pain and mental health domains while taking NAC. NAC was well tolerated with minimal side effects. Lessons from this study will inform design and implementation of future NAC studies.