ANNOTATION 1.1
Running Head: ANNOTATION 1.
Annotation 1
Lisa Armstrong
NURS 645.01: Research
October 18, 2010
Professor Gene Harkless
ANNOTATION 1.2
On September 22, 2010 I took care of R.L, a sixty-year-old female who was post-operative
cholecystectomy. Whilst recovering in the PACU, R.L. reported a 10 out of 10 pain level and was given
15 mg morphine and 100 mcg Fentanyl. When R.L.’s pain level was reassessed 20 minutes later, she
reported no change, and rated her pain 10 out of 10 again. R.L. had a history of anxiety, and with this in
mind, the physician suggested that her pain may be anxiety related and prescribed 0.5 mg Ativan.
Within twenty minutes, R.L. reported her pain as significantly improved, with a rating of 3 out of 10.
When R.L. returned to the unit, her nurse gave me report, and emphasized the importance of
maintaining a stress-free environment for R.L. and to monitor her anxiety levels. She explained to me
that her pain was likely associated with her anxiety and that when assessing her for pain, we should also
ask her how she is feeling with regards to her anxiety levels. I was intrigued about the positive
correlation between pain and anxiety and decided to use this case study as a platform for my research. I
wanted to find out to what extent anxiety was related to pain and how this affected evidence-based
nursing interventions in an acute care setting.
I began my search using the library resource databases, specifically CINAHL. I narrowed my
search to focus on research articles published within the last ten years, using keywords “relationship,”
and “pain,” and “anxiety,” within the abstract or editorial. After some sifting, I found a peer-reviewed
article from the Journal of Pain publication titled “A Psychophysical Evaluation of the Relationship
between Trait Anxiety, Pain Perception, and Induced State Anxiety.” (J. Tang & S.J. Gibson, 2005.)
The study examined the interactive effects of state and trait anxiety on pain threshold and subjective
pain intensity, and the outcomes were particularly relevant to my research question about appropriate
pain management interventions in an acute care setting.
A correlational research study, the operational definitions were based on anxiety trait level and
perception of pain. In order to define the operatives, the study separated the term anxiety into ‘state
ANNOTATION 1.3
anxiety’ and ‘trait anxiety’, with ‘state’ being a person’s current level of anxiety and ‘trait’ being a
person’s general disposition to anxiety. Participants were categorized according to either a high trait
anxiety level (HTA) of >45, or a low trait anxiety level (LTA) of <30, based on the Spielberger StateTrait Anxiety Inventory Trait Form (STAI-X2).
Participant pain threshold was measured using a 10-cm Visual Analog Scale (VAS) during a
practice session of receiving varying degrees of electrical stimuli to the left ankle, whilst marking the
VAS according to subjective pain intensity, with “Not Felt” = 0.0 cm, “Strong Pain” = 10.0 cm, and
“Just Noticeable Pain” = 0.5 cm.
Participant anxiety level was also measured using a 10-cm VAS, where subjective feelings of
“Extremely Relaxed” = 0.0 cm, “Extremely Anxious” = 10.0 cm, and “Just Noticeably Anxious” = 0.5
cm were assessed.
A total of 32 people participated in the study; 15 of which were classified LTA and 17 were
classified HTA for trait anxiety. Men represented 41% of the study participants with a mean age of 23.7
and women represented 59% with a mean age of 24.8, making the study reasonably well matched for
gender and age demographics. All participants were recruited through public announcements and no
reimbursement was provided. During the selection process, prospective participants were screened and
excluded for diabetes, neuropathy, and/or psychiatric history, as well as those participants that had
engaged in the experimental recruitment phase of the study and scored between 30 and 45 on the STAIX2 test.
HTA participants “rated all stimulus intensities experience across all warning conditions as
significantly more intense than LTA participants P<.05.” (J. Tang & S.J. Gibson, 2005.) Therefore, the
results of the study suggest that higher state anxiety interacts to exaggerate pain perception to a greater
extent than for non-painful stimuli, and therefore utilizing anxiety-reducing therapies might be
ANNOTATION 1.4
beneficial for individuals experiencing pain. Moreover, the study shows that “higher state anxiety
exacerbates an individual’s sensitivity to pain [and] is associated with higher pain sensitivity
ratings regardless of the level of state anxiety experienced.” (J. Tang & S.J. Gibson, 2005.)
This means that individuals with a propensity for high trait anxiety are likely to experience more
sensitivity to pain, even if their current state of anxiety is not elevated. In a post-operative acute care
setting, this is important evidence-based knowledge -- if a client has a history of anxiety (but is not
necessarily exhibiting outward signs), one may reasonably anticipate them to experience and report
higher pain levels on the numeric rating or visual analog scale post-operatively than a person without a
history of anxiety.
From a nursing intervention perspective, understanding the implications of anxiety as correlated
with perceived pain intensity is critically important, as both symptoms need to be concurrently managed
during the post-operative recovery period. As was evident from R.L., her therapeutic intervention for
pain management was not sufficient until combined with anxiolytic therapy.
For evidenced based practice, if a patient was screened prior to surgery for a history of anxiety,
and were administered anxiolytic concurrently with analgesics or narcotics post-operatively, an anxious
patient may experience less pain. This research could develop into an experimental study design, in
order to support the hypothesis that anxiolytic therapy used concurrently with pain therapy will reduce
the level of pain reported post-operatively in the HTA patient population (and perhaps already has!)
Personally, I feel that as a result of reading this research article, I have gained a significantly
increased awareness with regards to a patient’s diagnosis of anxiety in the post-operative acute care
setting, and believe that I will be better able to advocate for this patient population as a result of this new
knowledge.