MEDSURG NURSING
SERIES
Postoperative Pain Management:
The Challenges of the Patient
With Crohn’s Disease
Crohn’s disease is a chron-
ic inflammatory disorder of
the digestive tract that tends
to plague its victims with
uncontrolled pain, despite
numerous pharmacologic in-
terventions. Approximately
70% of affected individuals
require surgery during their
disease trajectory, and man-
agement of both their chronic
and acute pain can be a chal-
lenge for nurses. The many
factors that contribute to
these pain management chal-
lenges are described, and rec-
ommendations for nursing
interventions are offered.
Cynthia A. Cameron, BN, RN, is a
Graduate Student, Faculty of Nursing,
University of Manitoba, Canada.
Jo-Ann V. Sawatzky, PhD, RN, is an
Assistant Professor, Faculty of Nursing,
University of Manitoba, Canada.
Notes: The authors and all MEDSURG
Nursing Editorial Board members
reported no actual or potential conflict
of interest in relation to this continuing
nursing education article.
A related article on this topic, “Caring for
the Patient with Crohn’s Disease,” can be
found in the March/April 2008 issue of
Medsurg Matters, the official newsletter of
the Academy of Medical-Surgical Nurses
(www.medsurgnurse.org).
MEDSURG Nursing—April 2008—Vol. 17/No. 2
CNE Objectives and Evaluation Form appear on page 92.
Cynthia A. Cameron
Jo-Ann V. Sawatzky
P ain is a human response to ill-
ness; it is experienced by
patients suffering from a broad
spectrum of diseases. The Inter-
national Association for the Study
of Pain defines pain as “an un-
pleasant sensory and emotional
experience associated with actual
or potential tissue damage, or
described in terms of such dam-
age” (Merskey & Bogduk, 1994, p.
214). Inherent in the definition is
the recognition that pain percep-
tion, management, and evaluation
are influenced by multiple integral
factors, including physical, psy-
chological, social, cultural, and
environmental perspectives unique
to the affected person. Because
pain is a subjective and uniquely
individual experience, pain man-
agement can pose challenges for
the patient and health care
provider alike. Although not com-
monly noted in the literature,
patients who face particular diffi-
culties with pain management are
those who undergo surgery to
treat complications of Crohn’s dis-
ease (CD).
An inflammatory disease of
unknown etiology, Crohn’s disease
affects the digestive tract, most com-
monly the terminal ileum and colon
(Nikolaus & Schreiber, 2007). Cana-
da 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 becom-
ing independent and self-sufficient
(Fuller-Thompson & Sulman, 2006).
In addition, the virulent course of
the disease, frequent exacerba-
tions and remissions, and debilitat-
ing effects of the symptoms (per-
sistent diarrhea, fever, nausea,
fatigue, weight loss, and abdomi-
nal pain), tend to hinder the nor-
mal evolution of independent
adulthood and seriously impair
psychological well-being and quali-
ty of life (Fuller-Thompson &
Sulman, 2006). While conservative
pharmacologic therapy is the ini-
tial 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 develop-
ment of intestinal strictures, perfo-
rations, 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 postopera-
tive patient with CD can be a nurs-
ing 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
85
 Postoperative Pain Management: The Challenges of the Patient with Crohn’s Disease
SERIES
the postoperative pain experience
of the patient with CD. The Human
Response to Illness Model will pro-
vide the framework for this discus-
sion, which will include recom-
mendations for nursing interven-
tions 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 organiz-
ing 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 re-
sponses to illness. Thus, the
response of pain will be discussed
within the context of the four per-
spectives of the HRI model: physi-
ological, pathophysiological, be-
havioral, and experiential. In addi-
tion, person and environmental
factors considered to be influ-
ences on the response to illness
will be identified.
Physiologic Perspective
Physiologic regulatory re-
sponses 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 post-
operative pain occurs when a nox-
ious 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 im-
pulses to the dorsal horn of the
spinal cord. When nociceptors are
stimulated, mast cells also are
stimulated to release histamine.
This in turn stimulates neuro-
chemicals, such as prostagland-
ins, potassium ions, substance P,
and glutamate. Glutamate acti-
vates alpha-amino-3-hydroxy-5-
methyl-4-isoxazolepropionate acid
86
(AMPA) and N-methyl-D-asparate
(NMDA) to be released from the
nociceptor ending. The release of
these chemicals in the brain pro-
vides 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 naïve to the experi-
ence of pain. As a consequence of
the disease, the patient with CD
tends to experience chronic vis-
ceral 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 clini-
cal observation indicates that the
patient can perceive exaggerated
acute pain during the postopera-
tive period due to the pathophysi-
ologic pain response that devel-
ops secondary to the chronic pain
experienced throughout the pa-
tient’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 observ-
able, measurable phenomena.
Intensified postoperative pain
experienced by the postoperative
patient with CD is due to changes
in the peripheral and central nerv-
ous system, which are often a
result of poorly managed pain
(Puntillo, Miaskowski, & Summer,
2003). These changes manifest as
central and peripheral sensitiza-
tion, hyperalgesia, and opioid tol-
erance (Jarzyna, 2005; Puntillo et
al., 2003).
Sensitization occurs following
prolonged, uncontrolled pain. The
neurons responsible for conduct-
ing pain information undergo
changes in sensitivity when the
release of glutamate and sub-
stance P is prolonged in response
to uncontrolled pain. Glutamate
and substance P activate nitrous
oxide, which in a cascade effect
activates NMDA receptors and
results in their increased sensitivi-
ty to incoming pain messages
(Riedel & Neeck, 2001). Sensitiza-
tion leads to hyperalgesia.
McCance and Huether (2006)
described hyperalgesia as the
increased sensitivity of a painful
stimulus. Marchand, Perretti, and
McMahon (2005) reported that
hyperalgesia can be induced fol-
lowing an inflammatory response.
Following surgery, the body re-
sponds with an inflammatory
response to fight infection and
mast cells release chemicals that
interact with nociceptors to acti-
vate pain transmission (Marchand
et al., 2005; McHugh & McHugh,
2000). Petrenko, Yamakura, Baba,
and Shimoji (2003) reported that
the number of NMDA receptors on
peripheral nerve fibers increase
during inflammation, a process
that also may contribute to
increased sensitization during
stages of inflammation.
Hyperalgesia also can mani-
fest by repeated stimulation of the
nociceptors responsible for pain
transmission, which results in
amplified pain perception in the
spinal cord (Ikeda et al., 2006).
Thus, the patient requires an
increased opioid dose. However,
morphine-induced hyperalgesia
can result after prolonged high
doses of morphine (Angst & Clark,
2006; Davis, Shaiova, & Angst,
2007). Rather than a decreased
release of excitatory neurotrans-
mitters, an increase occurs. A sec-
ondary response following pro-
longed opioid use is related to
morphine metabolites creating a
spinal antiglycinergic effect to
reduce postsynaptic inhibition at
non-opioid receptor sites; the
result is hyperalgesia (Angst &
Clark, 2006; Davis et al., 2007).
Postoperatively, the patient
with CD often has increased opi-
oid requirements as a conse-
quence of prolonged preoperative
opioid consumption, which leads
to opioid tolerance (Jones &
Loftus, 2005). Opioid tolerance is a
MEDSURG Nursing—April 2008—Vol. 17/No. 2
 Postoperative Pain Management: The Challenges of the Patient with Crohn’s Disease
result of compensatory changes of
the neurotransmitters and noci-
ceptors responsible for pain per-
ception. To treat acute postopera-
tive pain, opioids such as mor-
phine, fentanyl, or hydromor-
phone commonly are prescribed.
The antagonistic properties of
these medications cause them to
bind to opioid receptors (mu,
delta, or kappa) located within ter-
minals of the central nervous sys-
tem. The function of opioids is to
bind to the receptor in order to
inhibit the modulation of synaptic
transmission in the central nerv-
ous system. This results in a
decreased release of excitatory
neurotransmitters and disruption
of pain impulse transmission.
However, after prolonged opioid
consumption, opioid receptors are
desensitized and an increased
dosage of opioid is required to
decrease pain perception (DeLeon-
Casasola, 2002; Jarzyna, 2005; Mitra
& Sinatra, 2004; Stahl, 2000).
Besides acting on pain recep-
tors, opioids also decrease intes-
tinal secretion and gastrointesti-
nal motility. The inhibitory effects
on gastrointestinal transit can
result in nausea, vomiting, consti-
pation, and dyspepsia, all distress-
ing for the patient (Wood &
Galligan, 2004). These opioid-
induced side effects, sometimes
collectively referred to as narcotic
bowel syndrome, result in colicky
abdominal pain (Jones & Loftus,
2005). This prompts the patient to
take more opioids with a goal of
relieving pain, while in fact con-
tributing to a vicious cycle of
abdominal pain and further opioid
consumption.
Behavioral Perspective
Behavioral responses are di-
rectly observable, measurable
motor and verbal behaviors which
may be an overt indication of the
meaning of the current sign, symp-
tom, or experience of the individ-
ual (Mitchell et al., 1991). Pain
intensity scales are used common-
ly to obtain the patient’s measure
MEDSURG Nursing—April 2008—Vol. 17/No. 2
of pain. These scales are the most
valid and reliable tools for assess-
ing postoperative pain (Williamson
& Hoggart, 2005). Pain intensity
scales, such as the Visual Ana-
logue Scale, Verbal Rating Scale,
and FACES, often are seen in clini-
cal practice, but it is the Numeric
Rating Scale (NRS) that is the most
well-received and frequently used
(Williamson & Hoggart, 2005). The
NRS simply delineates 1 as the
least amount of pain, and 10 as the
most severe/intolerable amount of
pain. Psychometric analyses sup-
port the NRS as the preferred pain
scale for surgical patients from a
wide range of ages and cultural
backgrounds. As well, the NRS has
low error rates and higher face,
convergent, divergent criterion
validity when compared to other
pain scales (Gagliese, Weizblit,
Ellis, & Chan, 2005).
Although less reliable, indirect
measures of the pain response
also may be used. Facial expres-
sions, such as grimacing or
clenching of teeth, often are
indicative of pain (McCaffery &
Pasero, 1999). Physical limitations
related to pain also are observ-
able, such as altered posture,
guarding of the abdomen, and
decreased mobilization. In addi-
tion, mood changes (for example,
flat affect, depressed mood) may
be exhibited by the postoperative
patient with unmanaged pain
(McCaffery & Pasero, 1999). Some
physiologic changes tend to occur
with acute pain, including in-
creased blood pressure, heart
rate, respiratory rate, and meta-
bolic rate; diaphoresis; dilated
pupils; and decreased urine out-
put (Puntillo et al., 2003). How-
ever, because chronic pain creates
an altered stress response, these
changes may not be seen in the
postoperative patient with CD.
Pathophysiologic responses occur
in patients that endure chronic
pain. These responses present as
fatigue and sleep disturbance,
anxiety, and depression (Puntillo
et al., 2003).
SERIES
Experiential Perspective
The experiential perspective
encompasses the concepts of per-
sonal experience, introspection,
and the derivation of shared mean-
ing. Mitchell et al. (1991) include
these concepts in the Human
Response to Illness Model, as they
believe that it is only through the
individual’s verbalization that the
experience and meaning created
through physiologic and patho-
physiologic responses of a certain
illness can be understood. The
experiential perspective is meas-
ured through self-report. The lived
experience of the postoperative
patient with CD has not been doc-
umented in the literature, but the
author’s clinical experience indi-
cates that the unmanaged postop-
erative pain response experienced
by the patient with CD is substan-
tial. Further studies dedicated to
understanding the experiences of
the patient with CD would provide
an awareness of the severity of the
illness and pain management
issues, as well as determine the
best approach for patient care
(Casati, Toner, De Rooy, Drossman,
& Maunder, 2000).
Environmental and Person
Factors
Environmental factors are
defined by Heitkemper and Shaver
(1989) as external factors that
increase a person’s vulnerability
to a response to illness. Environ-
mental factors for the postopera-
tive patient with CD may include
conflicting attitudes with nurse/
health care provider regarding
pain management, level of social
and familial support, and the pos-
sible negative impact of prolonged
hospitalization on finances/job
security stressors.
Person factors, which are
internal to the individual, are
described as either non-modifi-
able or modifiable. Non-modifiable
factors may influence the re-
sponse of pain during the postop-
erative period for the patient with
CD; these include severity of CD,
87
 Postoperative Pain Management: The Challenges of the Patient with Crohn’s Disease
SERIES
prior medical/surgical history, co-
morbid mood disorders, learned
experience with pain, and person-
ality profile. One modifiable per-
son factor that affects the pain
response in the postoperative
patient with CD is his or her previ-
ous coping mechanisms. The daily
pain experiences of the patient
with CD contribute to the develop-
ment of coping skills that can be
used during postoperative recov-
ery. Some coping mechanisms,
such as level of perceived psycho-
logical distress, hypervigilance,
pain catastrophizing, isolation,
and internal locus of control, can
hinder the efforts of the health
care professionals who attempt to
manage the patient’s postopera-
tive pain. For example, an individ-
ual with CD has a higher stated
prevalence of psychosocial dis-
tress than the general population
due to constant compensation
and awareness that symptoms
may surface and affect daily func-
tioning at any time (Cohen, 2002;
Kurina, Goldacre, Yeates, & Gill,
2001). This heightened attention
to factors that trigger psychologi-
cal distress also affects the post-
operative period. Psychological
factors play an important role in
the expression of pain and the
methods with which pain should
be treated (Eccleston, 2001).
As the patient with CD experi-
ences recurrent abdominal pain
during disease exacerbations, he
or she is likely to develop a pat-
tern of hypervigilance to pain that
often is evident in the postopera-
tive period. Hypervigilance also
has been offered as a possible
explanation for the dominant anxi-
ety observed in individuals who
experience poorly managed pain
over time because heightened
attention to pain is associated
with high levels of distress (Van
Damme, Crombez, Eccleston, &
Koster, 2006).
A heightened awareness and
attention to pain sensations can
lead to the development of
learned behaviors and thinking
88
patterns in relation to prolonged
undermanaged pain. Sullivan,
Bishop, and Pivik (1995) devel-
oped the term pain catastrophizing
to describe the manner in which a
patient may magnify the effects of
pain and exaggerate the threat
value of painful stimuli. Cata-
strophizing is a learned response to
pain by which a patient negatively
evaluates his or her ability to deal
with pain, and feels helpless with lit-
tle control over pain (Buenaver,
Edwards, & Haythornthwaite, 2007;
Sullivan et al., 2001). Based on the
author’s clinical experience, the
prevalence and degree of pain cata-
strophizing correlate with the sever-
ity of disease.
Lackner, Quigley, and Blanchard
(2004) highlighted the importance
of identifying the patient with neg-
ative coping mechanisms because
they have been associated with
the development of depression
and anxiety disorders. In addition,
co-morbid mood disorders put a
patient at risk for poor responses
to pharmacologic pain treatments
(Drossman et al., 2003), possibly
due to the cycle that endures from
the effects of undermanaged pain
and respondent coping mecha-
nisms. Moreover, a strong correla-
tion exists between depression
and pain (Walker et al., 1990); sub-
stantive research also supports a
high incidence of depression
among patients with CD.
As a patient experiences
undermanaged pain and the con-
sequent depression and anxiety,
he or she is likely to seek isolation
from family and social support
network. Isolation also can result
from years of shame associated
with daily experiences related to
disease symptoms. The literature
consistently reports that isolation
and a lack of social support can
hinder positive coping skills and be
detrimental to effective pain man-
agement. Ferreira and Sherman
(2007) found that increased pain
was linked to lower social support
and greater depressive symptoms,
and therefore concluded that
social support mediates the nega-
tive impact of pain. In addition,
years of self-isolation actually may
contribute to pain catastrophizing
as a form of attention-seeking
behavior. Recent studies found
that displaying a coping mecha-
nism such as catastrophizing elic-
its social support and attention
(Buenaver et al., 2007; Cano, 2004;
Keefe et al., 2003; Severeijns,
Vlaeyen, & van den Hout, 2004).
Authors concluded that an isolat-
ed environment serves as a dis-
criminative stimulus to develop
negative coping mechanisms.
An increased internal locus of
control also may be evident in the
patient with CD, most likely devel-
oping as a way to cope with the
unpredictability of symptoms asso-
ciated with the disease. Vigilant
adherence to the medication
regime can give the patient a sense
of control over the disease, but this
can create difficulties because the
hospitalized postoperative patient
with CD loses the sense of control
that medication self-administration
provides. Researchers also found
higher levels of internal control to
be correlated negatively with re-
ported pain levels (Carter-Snell,
Fothergill-Bourbonnais, & Durocher-
Hendricks, 1997; Shiloh et al., 2003).
Implications for Nursing
The physiological, pathophys-
iological, behavioral, and experi-
ential perspectives, along with the
person and environmental factors
of the Human Response to Illness
Model, provide insight into nurs-
ing interventions that will opti-
mize pain management for the
postoperative patient with CD.
Pain assessment. In caring for
the patient with CD in the preoper-
ative period, the nurse should per-
form thorough, accurate preoper-
ative pain assessments. These
assessments will provide baseline
information of the underlying level
of chronic pain, as well as the
effectiveness of previous pain
interventions. This information
then can be used to guide the
MEDSURG Nursing—April 2008—Vol. 17/No. 2
 Postoperative Pain Management: The Challenges of the Patient with Crohn’s Disease
implementation of appropriate
postoperative pain management
strategies.
To achieve a consistent
assessment of postoperative pain,
the nurse should use a standard
measurement instrument. The
numeric pain intensity scale is reli-
able and valid when all parties
involved understand and use the
tool correctly. According to
McCaffery and Pasero (1999), the
nurse should question the patient
to ensure understanding of the
pain scale. During a pain assess-
ment, the nurse should collect
supportive data to supplement a
patient’s report of pain, such as
the ease or difficulty associated
with mobility, guarding of ab-
domen, and mood. Any changes in
physiologic responses should be
identified and documented. Ul-
timately, the nurse should respect
the patient’s report of pain. It also
is crucial that the nurse assess
and reassess the patient’s pain at
regular intervals. The evaluation
of intervention outcomes may
lead to the identification of effec-
tive and ineffective treatments,
and lead to improved pain man-
agement.
Pharmacologic Interventions
When implementing pharma-
cologic interventions, the nurse
should be aware that increased
opioid requirements may result
from the patient’s opioid toler-
ance. The medication regime must
include adequate analgesia to
relieve acute postoperative pain
(Carrol, Angst, & Clark, 2004;
Doverty et al., 2001; Mitra &
Sinatra, 2004). The acknowledg-
ment of increased opioid require-
ments will ensure that the patient
initially is prescribed an equiva-
lent amount of opioid analgesic in
the hospital compared to what he
or she consumed at home; this
may decrease the likelihood of
withdrawal symptoms. A basal
intravenous infusion equal to the
oral opioid analgesic doses the
patient was consuming prior to
MEDSURG Nursing—April 2008—Vol. 17/No. 2
surgery is recommended to main-
tain patient comfort (Mitra &
Sinatra, 2004; Reid, 2001). The
nurse also should be prepared to
administer liberal additional
doses of opioid and non-opioid
analgesics not only to maintain
the patient’s baseline of opioid
drug, but also to manage acute
postoperative pain.
A multi-modal approach should
be considered when treating post-
operative pain in the patient with
CD, as this technique improves
analgesia (Reuben, 2007). Admin-
istration of nonsteroidal anti-in-
flammatory drugs (NSAIDs) in
combination with opioids and
NMDA antagonists will inhibit mul-
tiple pain receptors, and thus pro-
vide a greater reduction in pain
perception. NSAIDs act by pre-
venting formation of prostaglan-
dins, which are involved in initial
pain transmission (Reuben, 2007).
Administration of a NMDA
antagonist is a key component in
effective pain management be-
cause NMDA receptors largely are
responsible for the phenomenon of
sensitization and the mediation of
visceral pain. Strigo and colleagues
(2005) found that ketamine, an
NMDA antagonist, decreases the
perceived pain intensity of noxious
visceral stimulation. Additional
preliminary studies (Berman et al.,
2000; Zarate et al., 2006) suggest
that low-dose ketamine also is
associated with a robust decrease
in depressive symptoms.
Clinical observation by the
primary author provided anecdot-
al evidence that the patient with
CD is more satisfied with pain
management when medication is
provided as patient-controlled
analgesia (PCA). Carter-Snell and
colleagues (1997) and Shiloh
(2003) agreed that if patients with
a predominantly internal locus of
control are placed on PCA, their
need for increased control is met
and less anxiety and pain should
be reported when compared to
patients receiving nurse-adminis-
tered analgesia.
SERIES
Non-pharmacologic interven-
tions. The following non-pharmaco-
logical interventions, including
alternative pain management strat-
egies and patient education, are
recommended to address both the
physiologic and psychologic fac-
tors that influence postoperative
pain in the patient with CD.
Because psychological distress
plays an important role in the per-
ception of pain, stress reduction
should be a priority of care when
considering postoperative pain
management of the patient with
CD. The Gate Control Theory of
pain (Melzack & Wall, 2003) indi-
cated that some non-pharmaco-
logic pain management interven-
tions actually inhibit the ascend-
ing transmission of noxious stim-
uli through the central nervous
system, thus interfering with pain
perception. Cognitive behavioral
therapy interventions are able to
block pain transmission from the
dorsal horn by activating the
descending neural pathways from
higher brain centers that are
responsible for cognition and
affect (Keefe et al., 2000). Ex-
amples of cognitive behavioral
therapies include fear-avoidance
practices, development of positive
coping skills and self-efficacy, pos-
itive imagery, distraction, relax-
ation training, and effective com-
munication.
Patient education should be
part of all pain management
strategies and initiated preopera-
tively. This enables the patient to
process the information and com-
municate with the nurse regarding
expectations for pain manage-
ment. Teaching should include
self-care interventions the patient
can implement to aid in pain man-
agement (Bedard, Purden, Sauve-
Larose, Certosini, & Schein, 2006).
Understanding the effects of non-
pharmacological treatments and
physical therapies for pain man-
agement and recovery enhances
patient cooperation and willing-
ness to try these alternatives.
Education related to prescribed
89
 Postoperative Pain Management: The Challenges of the Patient with Crohn’s Disease
SERIES
analgesics should address side
effects of medications and fears of
addiction, as these fears pose sig-
nificant barriers to effective pain
management (McCaffery & Pasero,
1999).
If family members are active
participants in patient care, they
should be included in teaching as
well. Research suggests that family
members can have a significant
influence over a patient’s pain man-
agement beliefs (Bosch, & Banos,
2002; Hazard Vallerand, Collins-
Bohler, Templin, & Hasenau, 2007).
Fears of family members regarding
analgesic use and pain manage-
ment strategies also can be detri-
mental to the patient’s effective
pain management. Therefore, fam-
ily involvement in pain-related
education should begin as early as
possible.
The nurse also should encour-
age the patient to accept available
social support following surgery.
By learning effective communica-
tion skills as part of a non-pharma-
cologic treatment plan, the patient
is encouraged to voice feelings
regarding the family situation and
the available social network.
Support from social networks pro-
vides a distraction from the over-
whelming aspects of dealing with
chronic illness and postoperative
recovery. The presence of social
support and the patient’s percep-
tion of strong social support are
linked to fewer depressive symp-
toms, greater life satisfaction, and
less perceived pain (Finch &
Graziano, 2001; Sherman, 2003;
Walen & Lachman, 2000).
Conclusion
Effective pain management for
the postoperative patient with CD
represents a nursing challenge.
Knowledge of acute and chronic
pain; the nature of CD; the specific
physiological, pathophysiological,
behavioral, and experiential per-
spectives; and the person and
environmental factors related to
the human response to illness
establish a sound rationale for the
90
recommended nursing interven- Davis, M.P., Shaiova, L.A., & Angst, M.S.
tions. Surgical nurses can apply (2007). When opioids cause pain.
Journal of Clinical Oncology, 25(28),
these strategies to optimize pain 4497-4498.
management outcomes for the DeLeon-Casasola, O. (2002). Cellular mech-
postoperative patient with CD. anisms of opioid tolerance and the clini-
Additional clinical research in this cal approach to the opioid tolerant
patient in the post-operative period. Best
area is needed to facilitate the Practice & Research Clinical Anesthesi-
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