Abstract
"About 2% of Americans—more women than men—suffer from fibromyalgia. Primarily a chronic pain syndrome, fibromyalgia may also cause sleep disturbances, thinking difficulties, and fatigue…" (Arnold, p 6). This course is intended for those nurses working with Fibromyalgia diagnosed patients. The intent of this course is to provide assessment and documentation tips, nursing treatment modalities, help in formulating nursing care plans to provide a framework for the nurse treatment, and the most common pharmaceuticals used and their associated risks and benefits, as well as patient education that should be discussed.
By the end of this course, the learner will be able to:
- Define Fibromyalgia as a complex syndrome
– Know how to document assessment findings for the physician
– Create NANDA approved nursing diagnoses with interventions
- Understand how to implement non-pharmacological means of treatment
- List the most common medications and associated side-effects
I. Fibromyalgia: what is it?
Fibromyalgia (FM) is a complex disease which is diagnosed through a series of exclusionary tests and physical exams. It is "what is left" after all else has been investigated. The symptoms of note which appear to define FM are:
Fibromyalgia (FMS) syndrome is a common and chronic disorder characterized by widespread muscle pain, fatigue, and multiple tender points, and ruling out of other processes (NIAMS, 2004).
Arthritis-related conditions due to the syndrome:
| - Sleep disturbances |
- Morning stiffness (minor) |
| - Headaches |
- Irritable bowel syndrome (minor) |
| - Painful menstrual cycles |
- Possible other symptoms |
| - Restless leg syndrome |
- Numbness/tingling of the extremities |
| - Temperature sensitivity |
- Cognitive/memory problem ("fibro-fog") |
FMS is more of syndrome with associated signs & symptoms than a disease "traditional" process, which ends in a prescription for treatment.
Diagnosis is usually made from exclusion of other processes – making it a complex syndrome
| A credible diagnosis according to the American College of Rheumatology (ACR), meets 2 criteria: |
| 1. History of widespread pain lasting >3months |
| 2. The presence of "tender points," as illustrated by grey dots in the diagram to the right |
| 1. Nape region |
a. Upper Clavical |
| 2. Upper Scapula |
b. Sub-clavicular |
| 3. Mid Scapula |
c. Antecubital |
| 4. Upper gluteal maximus |
d. Medial knees |
| 5. Lateral hip |
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II. Documentation
Do you recall the old adage the nursing professors told you while you were in school working on your nursing degree: "If you don't document it, it never happened," that is a true statement; both in your facility and in a court of law.
Documentation in any field of nursing should be the paramount concern of the nurse, as it provides the record of treatment and has been shown to be critical in several court cases. In the case of FM, the nurse's documentation can be instrumental to aid the physician in the diagnosis and treatment.
Due to the diagnosis path of FM, an accurate health history is essential.
| 1. Has anyone in the family been diagnosed? |
| 2. How frequent are rest periods during activity? |
| 3. How long have you been hurting? |
| 4. Assess tender points |
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Once this information has been obtained, ensure it is documented in a way the physician will have easy access to it. Nursing documentation should be thoroughly completed so the physician understands the patient's complaints better prior to repeating a barrage of questions.
While proper documentation takes more time to complete, it is valuable to the care of the patient, and the ability to defend your assessments and care of that patient in a court of law if needed. If your system/organization utilizes computerized documentation, ask to see if there is a way to alter the system so it is easier to document, this may be done by contacting your IT or computer support department. Many organizations have the resources available and do not advertize them. It will be worth looking into to streamline the documentation to be more nurse-friendly.
"Don't put yourself in a position of testifying about things you did, but failed to document. Debra A. Gray, RN, MSN, LNC, principal of Gray's Analysis, a Beaverton, OR-based legal nurse consulting firm, says, "Too often, important details are not documented in the medical record"" (ED Nursing, p99). This act of ommission can be costly in finances and in the nurses' licensure.
III. NURSING diagnoses for FMS
Nursing diagnoses and care plans did not go away when you graduated nursing school, they just changed their form. Instead of the wrote plans and endless pouring over ways to write the diagnoses, we now practice this mentally with little though as to the applications we are applying.
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| Nursing diagnoses are a vital part to organizing our thoughts and actions to provide the best patient care possible. "Nursing diagnosis is the term that represents the clinical judgment made by a professional nurse. Diagnosis of phenomena is an essential step in the application of theory to explain a condition and to determine actions needed for treatment. In the United States, the responsibility of the nurse to diagnose is explicitly included in the nursing practice acts of 41 of the 50 states and the District of Columbia" (Meyer, Lavin, & Perry, p 46, italics added).
For example, when we are told in report we will be getting a new patient admitted to the floor with the diagnoses of post op ________, we immediately begin thinking in terms of nursing care according to the nursing diagnoses we have formulated in our heads. We have such diagnoses as pain, activity intolerance, alteration in nutrition, risk for alteration in oxygenation (aspiration), risk for electrolyte imbalance (related to …); and many more. Is it all coming back to you know? As nurses, we do much more than we typically take credit for. |
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When nurses assess a patient presenting with fibromyalgia, nurses mentally assess the patient's health by the actions and their words. Nurses watch the patient's actions and judge if they correlate in the patient's behavior patterns. These actions and statements need to be documented as thoroughly as possible, as mentioned previously.
Nursing diagnoses affords nurses to practice solid, well founded healthcare with our patients, and serve to reinforce our actions. "Accurate diagnoses are a prerequisite for choosing diagnostic specific interventions in order to achieve favorable nursing-sensitive patient outcomes. Coherence among diagnoses, interventions, and outcome classifications, displayed in evidence-based linkages, is crucial" ( (Müller-Staub, p10). While we do not use the cardex of yester-year, we utilize the principles of the nursing care plan as we mentally prepare to treat the patient, also known as critical thinking. Some examples of well created nursing diagnoses for the patient with Fibromyalgia may include:
1) Chronic pain related to morning stiffness as evidenced by patient states "…it takes me half the day to get moving because it hurts so much."
a. How do you alleviate pain without medication?
i. Heat – typically 20 minutes on and 2 hours off as tolerated
ii. Ice – typically 20 minutes on and 2 hours off as tolerated
iii. Exercise/Yoga to prevent muscle tightness – stretching exercises work best with mild to moderate activity
iv. Massage
v. Meditation/Prayer
vi. Adaptive equipment to prevent pain
vii. Education on how/when to take pain medications
2) Activities of Daily Living (ADL) alteration and/or
Activity intolerance/alteration related to chronic pain and stiffness as evidenced by patient states "...too hard to comb hair, cut food with knife, etc..."
a. Perform a needs assessment of what the patient is unable to complete (i.e.: hygiene, grooming, eating, grasping, etc...)
i. Is there adaptive equipment to aid the patient available?
1. Examples:
a. Use 3/8" (or smaller if available) foam pipe insulation for adapting tooth brushes, combs, and handles
b. Long-handled shoe horn to aid in putting shoes on
c. Suggest "slip on" (i.e. Crocks) shoes with tread/traction to prevent slipping
3) Social isolation...
a. These issues can be met with encouragement for the patient to join a water aerobics program, exercise/yoga club, etc.
b. Referrals to seek clergy/professional help when needed
4) Depression/Anxiety...
a. Is there any social interaction?
b. Is there a family history of this? Is it documented?
c. Does the patient speak of friends, visitations, outings?
d. Encourage them to be civic minded and active. Even just volunteering to work in a library or Meals-On-Wheels program will give purpose and value to their mindset.
5) Knowledge deficits...
a. EDUCATE YOUR PATIENT!!!
i. Listen to them to determine their needs – whet we preconceive as their needs are usually not accurate.
ii. Have a list of resources you can draw from – what organizations are close to the patient that can help them for little to no out of pocket expense.
iii. DOCUMENT the patient's needs in the chart for the physician to see – they cannot help if they do not know what the problems are...
The more conscious your documentation and thought pattern for nursing diagnoses are, the better your practice will become. Proper documentation, based on nursing diagnoses, also prevents possible future legal issues as nurses struggle to read their writing, or recreate the situation in question, to defend their care provided – sometimes years after-the-fact.
Remember:
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If you didn't take the time to accurately document the care you provided, you have no proof you really did the work! That's how the law, your employer, and your patient all view your hard work! So take credit for what you do…it may save you in a legal dispute down the road. |
IV. Nursing Interventions
So far, we have seen the needs for accurate documentation and nursing diagnoses. There is strong evidence that intensive patient education is an effective treatment in FMS. Randomized controlled trials compared patient education with wait-listed or untreated controls or with stretching and movement" (Goldberg, et. al., 2004, p2389).
"There is strong evidence that psychological and behavioral therapy, especially cognitive behavioral therapy (CBT), is effective in FMS. Randomized controlled trials of CBT with longitudinal data over 6 to 30 months found decreased pain severity and improved function in FMS. Improvement was also noted (with) meditation, relaxation, and stress management" (Goldberg, et. al., 2004, p2392, italics added).
Exercise
"...recent scientific studies have shown that, for most patients, range of motion, strengthening, and aerobic conditioning exercises are safe and necessary."
"...it (exercise) also boosts levels of natural endorphins -- pain-fighting molecules that may be responsible for the well-known "runner‘s high." Endorphins help to reduce anxiety, stress, and depression." From WebMD, 2008
Yoga:
Simple postures can be done to help loosen and tone the body. "Alternative therapies such as massage, myo-fascial release, acupuncture, chiropractic, herbal supplements, and yoga can be effective tools in managing FM symptoms" (NFA Website, 2009).
What types of exercises work best for fibromyalgia symptoms?
Some new findings suggest that exercises such as walking, strength training, and stretching activities are effective at improving physical, emotional, and social function. They also are effective in addressing key symptoms and self-efficacy in women with fibromyalgia who are also being treated with medication.
Other studies point to long-term aquatic/yoga exercise programs as being effective in reducing symptoms and improving the health-related quality of life of the participants. As the patient begins their exercise program, focus on three different types of exercise:
Range-of-motion or stretching exercises (easiest).
These exercises involve moving a joint as far as it will go (without pain) or through its full range of motion.
Range-of-motion exercises or stretching will helps to maintain flexibility in muscle groups.
Endurance or conditioning exercises.
Increase endurance threshold with cardiovascular forms of exercise such as walking, biking, or swimming
condition body
tone muscles
build coordination and endurance
weight loss.
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Strengthening exercises (YOGA).
Builds strong muscles and tendons needed to support joints
Studies show that strengthening exercises may improve fibromyalgia symptoms
Starting slowly, increasing gradually strength is built.
TIPS FOR COPING
Minimize stress with daily personal time
Remove yourself emotionally from stressful situations
Job site modifications
Improve communication skills
Keep a journal
Soak in a warm bath
Yoga/Exercise regularly
Eliminate/reduce caffeine & nightshade fruits
Evaluate sleep patterns
Join a support group
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Diet Foods to increase:
Water, 100% fruit juices in moderation; limited quantities of skim milk Heart-healthy foods (low fat, low carbohydrate); fresh fish, poultry, and lean meats; fresh fruits & vegetables; and adding multivitamin supplements (high in Omega3 & B's or prenatal vitamins). See diagram below for an inverted food pyramid suggested for arthritis patients.
For example: Vitamin D 400 IU, by mouth, twice daily.
NOTE: Be sure you document the supplement the way the patient takes it. Sometimes the patient may be under a physician's order to double or triple the standard supplemental dose.
A good resource to add to the nurses' station would be an update-able (i.e. electronic) guide on herbal and mineral supplementation.
V. Pharmacological Interventions
The pharmacological options for FM have been limited at best, but there are two very popular medications presently being prescribed to aid patients in their struggle with the systemic presentation of FM.
The chart below delineates the four most common medications used in the treatment of Fibromyalgia. There are other medications that can be used as well, so this list is not all inclusive. Prior, to any patient education, always confirm and verify the information. As of the writing of this continuing education all information is correct and accurate.
| Drug Name |
Action |
Side-effects |
Patient education |
| Lyrica |
Although the exact mechanism of action is unknown, results from animal studies suggest that LYRICA is believed to work by reducing the number of "extra" electrical signals that are sent out from damaged or over-excited nerves.
Drug class: anticonvulsant |
Dizziness
Blurry vision
Weight gain
Sleepiness
Trouble concentrating
Swelling of hands and feet
Dry mouth
Feeling "high"
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LYRICA is the first FDA-approved treatment for the management of fibromyalgia. It may help relieve the pain and improve function. Some patients taking LYRICA experience less pain in as soon as 1 week. |
| Cymbalta |
Although the exact way that Cymbalta works in people is unknown, it is believed to be related to an increase in the activity of serotonin and norepinephrine, which are two naturally occurring substances in the brain and spinal cord.
Drug class: antidepressant Serotonin/norepinephrine uptake inhibitor |
Dry mouth
Sleepiness
Constipation
Decreased appetite
Increased sweating
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In DNP and fibromyalgia trials, some patients experienced less pain as early as 1 week. Results may vary from person to person.
Give Cymbalta time to work. And don't stop taking it without talking to your doctor. Work with your doctor to find a treatment program that is right for you. |
| Milnacipran |
In fibromyalgia the drug improved pain, mood, and fatigue compared to placebo. In lupus patients pain was alleviated and a sense of well-being was provided.
Drug class: antidepressant Serotonin/norepinephrine uptake inhibitor |
itching
nausea
vertigo
increased anxiety
sweating
shivering
dysuria
testicle pain Milnacipran does not seem to have a negative impact on sexual functions.
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Teach according to the side effects and how the patient can control, or decrease, the side effects. Also this medication can alter the liver enzymes so frequent lab testing is recommended. For FM, this is an experimental use, and may not be covered by the patient's insurance. |
| Benzodiazepines & non-benzodiazepines |
Used primarily for aiding in painful, tense muscles. Also in the aid of Restless Leg Syndrome (RLS).
Used as a "last resort" many times to aid the patient who seemingly has "tried it all" |
Impaired motor coordination
Drowsiness, lethargy, fatigue
Impaired thinking and memory
Depression
Altered vision
Slurred speech, stuttering
Vertigo
Tremors
Respiratory depression
Nausea, constipation, dry mouth, abdominal discomfort, loss of appetite, vomiting, diarrhea
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Use only as needed to prevent dependency.
Benzodiazepines are prescribed for relaxation, calmness, and relief from anxiety and tension. In some cases side effects will occur; these vary widely depending on the type of benzodiazepine, the dose, and the person.
Tolerance to certain benzodiazepines occurs most often in those who have used for 6 months or more.
Withdrawal symptoms are most severe when a high dose of either a short-acting or intermediate-acting benzodiazepine is abruptly discontinued, so do not stop taking without consulting your physician.
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| Analgesics |
Either narcotic (rarely due to dependency issues) or non-narcotic, analgesics will aid in the control of multiple pain points associated with FM.
Acetaminophen (Tylenol)
Codeine (Tylenol #2,3,4)
Darvocet (Propoxyphene/Acetaminophen)
Darvon (Propoxyphene)
Duragesic (Fentanyl Patch)
Hydromorphone (Palladone, Dilaudid)
Morphine (MSContin, Oramorph)
Oxycodone (OxyContin, Roxicodone)
Percocet (Oxycodone/Acetaminophen)
Percodan (Oxycodone/Aspirin)
Talwin NX (Pentazocine/Naloxone)
Ultracet (Tramadol/Acetaminophen)
Ultram (Tramadol)
Vicodin (Hydrocodone/Acetaminophen)
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nausea
vomiting
drowsiness
dry mouth
Altered vision
miosis (contraction of the pupil)
orthostatic hypotension (blood pressure lowers upon sudden standing)
urinary retention
Respiratory depression
constipation and/or fecal impaction
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Use only as needed to prevent dependency
Constipation Decreased sensation
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| NSAIDS |
Ranging from Tylenol to Tramadol, non-steroidal analgesics are the primary steps that will be directed with the diagnosis of FM.
The complete list of well known/used NSAIDs in order of choice:
ibuprofen, Advil, Children's Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever, etc.
naproxen, Anaprox, Naprelan, Naprosyn, Aleve
etodolac, Lodine
diclofenac, Voltaren, Cataflam, Voltaren-XR
celecoxib, Celebrex
nabumetone, Relafen
indomethacin, Indocin, Indocin-SR
acetylsalicylic acid, Aspirin, Ecotrin
Cox-2 Inhibitors
oxaprozin, Daypro
sulindac, Clinoril
ketoprofen None
piroxicam, Feldene
and many more...
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The most common side effects are nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and drowsiness. NSAIDs may also cause fluid retention, leading to edema.
The most serious side effects are kidney failure, liver failure, ulcers and prolonged bleeding after an injury or surgery.
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Educate to be aware of side-effects for each medication used. Be sure to warn of ibuprofen and acetaminophen side effects and the combinations of medications; i.e. NORCO & Viaprofen
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REVIEW
Fibromyalgia is diagnosed as a history of chronic pain accompanied by multiple tender points, and exclusion of other processes – an accurate health history & physical assessment is necessary to complete the diagnosis
Many NANDA nursing diagnoses can be drawn for each patient depending on their present health situation. While there may not be a place to write a care plan in, mentally assess the patient and develop a problem list that can be tracked in the patient medical record.
Diet, exercise/yoga, and relaxation are examples of three methods of non-pharmacological intervention.
Documentation is paramount to record what the nurse has done to provide care for the patient. Accurate and detailed documentation is essential for the physician to hone in on the subtle clues that may help in the overall treatment of the patient. There is also the possible recreation of events is necessary in a court of law. Take credit for your hard work!
There are pharmacological options available, and if prescribed, ensure proper patient education and document the content covered.
Arnold, L. (2009). Treating f bromyalgia in the mental health setting. HARVARD MENTAL HEALTH LETTER , 6-7. Reprinted from "Management of Fibromyalgia and Comorbid Psychiatric Disorders," Journal of Clinical Psychiatry (2008): Vol. 69, Suppl. 2, pp. 14–19.
Cymbalta. (2009). Fibromyalgia . Lilly Corporation website: http://www.cymbalta.com/fibromyalgia.jsp
ED Nursing. (2009). A suit was prevented with this documentation. ED Nursing , 98-100. ISSN:1096-4304
Everything2 website (2005). Nursing diagnosis. Retrieved from web site: http://www.everything2.com/index.pl?node_id=1014512
Goldenberg, D., Burckhardt, C., Crofford, L. (2004). JAMA. Management of fibromyalgia syndrome. 292(19). P 2388-2395.
Lyrica. (2009). Fibromyalgia home page. Retrieved from Lyrica website at: http://www.lyrica.com/fibro_homepage.aspx
Milnacipran. (2009, August 24). In Wikipedia, The Free Encyclopedia. Retrieved from http://en.wikipedia.org/w/index.php?title=Milnacipran&oldid=309877431
Meyer, G., Lavin, M. A., & Perry, A. (2007). Is it time for a new category of nursing diagnosis? International Journal of Nursing Terminologies and Classifications , 18 (2), 45-50. Retrieved from ProQuest Health and Medical Complete. (Document ID: 1304822381).
Müller-Staub, M. (. (2009). Evaluation of the implementation of nursing diagnoses, interventions, and outcomes. International Journal of Nursing Terminologies and Classifications , 20 (1), 9-15. Retreived from ProQuest Nursing & Allied Health Source database.
National Fibromyalgia Association (NFA). (1997-2009). Fibromyalgia fact sheet. Retrieved from: http://www.fmaware.org/site/PageServer?pagename=media_factSheets
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). (2004). Retrieved from website at: http://www.niams.nih.gov/Health_Info/Fibromyalgia/default.asp
WebMD. (2008). Fibromyalgia health center. Retrieved from: http://www.webmd.com/fibromyalgia/default.htm
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