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Evaluating Pain Management In The Treatment Of Cancer Nursing Essay

For patients, who are diagnosed with cancer, pain management remains a problematic area in the treatment of cancer pain, many cancer patients experience pain at some point during the course of their disease. Pain also appears to be the most common reason that the individuals seek medical intervention (Watson et al, 2005). Pain is defined as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage’ (Watson et al, 2005)

The Scottish Intercollegiate Guidelines Network (SIGN) 1.1, (2008) states, ‘that pain associated with cancer increases with progression of the disease’. Cancer pain has many dimensions, including psychological pain which includes coping, and sense of usefulness, physical pain which is the functional capacity, and social pain which relates to family support, roles and appearance, all these need to be considered in order to improve the patients’ quality of life (SIGN) (4.1). It is estimated that up to 90% of cancer pain can be managed. (World Health Organization (WHO), 2008).

Nurses have an important role in assessing and managing pain in terms of their code of professional practice (Nursing and Midwifery Council (NMC), 2008). This code states that nurses ‘have a duty of care to their patients and clients, who are entitled to receive safe and competent care’, as well as ‘have a responsibility to deliver care based on the best available evidence or best practice. (NMC, 2008)

As pain is such a significant factor in patients with cancer, there has been a large amount of research already been carried out in this specific area and despite advances in pain management there is evidence that cancer pain remains inadequately treated world-wide (Zaza & Baine, 2002). It is therefore the purpose of this assignment, to review current literature, discuss the current evidence on cancer pain, and consider best practice for patients from a nursing perspective.

To achieve this, an extensive systematic literature review was carried out; from this, there were two key areas that emerged in relation to caring for patients with cancer pain, those being the pain assessment and pain management. Cronin et al (2008) state, that by conducting an extensive review, using a systemic approach facilitates the gathering of ideas from many studies, which helps increases ones knowledge on a particular topic. It also aims to identify areas that need further investigation (Greenhalgh, 2007).

The databases searched included Cinahl, Medline, Inter-nurse, and the British Nursing Index. A limited search was carried out in printed books and web sources. The key word used was initially ‘pain’, which returned several thousand hits. The focus was then narrowed down to, ‘cancer pain’; again, this achieved in excess of 29,000 hits. Included in the search criteria were the key words ‘pain assessment tools’ and ‘pain management’ which resulted in 268 hits when all results were combined. In order to condense the search, the criteria was set to display journal articles published in or after 2000 as research before 2000 was felt to be out-dated and may not be accurate today, this resulted in 147 hits. When using databases to look for specific information incorporating key words is very useful when looking for specific information (Polit & Beck, 2006). The abstracts from these articles were then reviewed to make sure they were suitable for this literature review, resulting in ** references being used within this assignment.

The literature revealed that when dealing with cancer pain, it is important to take a holistic approach when evaluating the pain; the assessment process is essential in providing holistic care and is used in all clinical areas. Inadequate pain assessment is identified as one of the reasons why patients experience inadequate pain relief (Watson, 2005). During the initial introduction, the patient starts to build up a healthy relationship with the nursing staff (Kinghorn et al 2007). In order for an in-depth assessment Goodridge et al (2005) states that ‘the nurse must have a high standard of verbal and written communication skills, as well as good listening skills, when all these skills are displayed by the nursing staff during the assessment process, it helps build a good nurse-patient relationship’. Once a good nurse-patient relationship is built, it permits patients to speak more openly about their experiences of pain (Mathews et al, 2007). It has been identified that families associate poor pain control with difficult communication with health professionals (Miettinen et al, 1998 cited in Locker, 2008). To maintain patient confidentiality the assessment is always best to be carried out within a quiet and comfortable environment, this comes from the findings by Locker (2008) who states that ‘assessing patients within a noisy environment acts as a barrier in obtaining an accurate pain assessment’, this is highlighted as only one of the many barriers that nurses face.

Communication is an important part of the assessment process and should be encouraged at all times, even after the initial assessment has been carried out. Many studies found that talking openly about personal pain experiences might be easier for patients, but harder for others. Many studies have shown that being of the female sex is a predisposing factor in relation to pain. (Pfaff, 2002 & McNeil et al, 2007). It is believed that females tend to open up more about their experiences of pain, compared to males, Robinson et al (2001) agrees with this, stating that by displaying male characteristics i.e. masculinity, men are unable to express their pain experiences for fear of showing weakness, Robinson et al (2001) also states that male individuals in general feel they have a higher pain threshold compared to women. Regardless to gender the assessment process is still conducted in the same way. During the assessment process, nursing staff should be specific in regard s to the questions. Any assessment of pain should begin with questions that seek to identify the presence of pain (Department of Health (DH), 2001). Research shows that the P.Q.R.S.T method for assessing pain is commonly used, and that you should establish the following five characteristics, (P) provokes- what causes the pain?, (Q) quality- ‘what does the pain feel like?’ E.g. sharp/dull, (R) radiates- ‘does the pain go anywhere else?’ (S) severity- ‘How bad is the pain?’, and (T) time- ‘when did the pain start?’ and ‘How long does it last?’ (Kinghorn et al, 2007). Questions such as these can be even more useful when used in conjunction with appropriate assessment tools.

There is a variety of tools, which are used for measuring pain, they all have there own merits and limitations. Pain rating scales are imperative within a clinical area; patients can use them to help express their experiences of pain.

Nurses should choose the appropriate assessment tool which best suits the patient (Walker, 2003). There are a number of different pain assessment scales available, which can be used to facilitate the assessment.

Some use body diagrams to locate the location of the pain and some use numbers to mark the pains intensity (Hutton et al, 2008). A common unidimensional assessment scale used, is the visual analogue scale (VAS) this consists of a 10cm line with descriptive words at each end, usually ‘no pain’ and ‘worst possible pain’, it can also be compromised if descriptors or numbers are added between the end points (Cohen et al, 2008). There is also the numerical rating scale (NRS) and verbal rating scale (VRS) all of which are easy to use if the nursing staff are aware of their existence and have been educated in their use, to ensure reliability. The nurse then must explain the use of the tools to the patient.

The World Health Organization Quality of Life Tool (WHOQOL Assessment Group 1998) shows these tools have excellent validity and reliability, but may be difficult to engage the attention of patients with a cognitive impairment. These tools appear quick and easy to use although Hemming & Maher (2008) states, these assessment tools do not reveal the full picture. Hutton et al, (2008) and Hemming & Maher (2008) identify two multidimensional pain assessment tools that’s have proven to be more effective in the management of pain, the ‘brief pain inventory’(BPI), (Daut et al, 1983) and ‘McGill pain questionnaire’ (Melzack, 1975) however these assessments are time consuming and would be unkind to conduct if the patient was in severe pain. This has resulted in a shorter version of the McGill pain questionnaire being created (McGill, 1970). Bird, (2003) states these should be used in the initial assessment, followed by a unidimensional tool. However, Rutledge & Donaldson (1998) as cited in Bird (2003) suggest ‘that by using more than one tool can cause confusion and inconsistency among staff, but that this could be overcome by documenting assessment strategies and suitability for individual patients’. An important factor in controlling cancer pain is to conduct a pain assessment on a regular basis depending on the severity of pain and distress of the patient. (McLafferty & Farley, 2008)

Assessment tools are not the only resources to aid nurses in the assessment process, there are frameworks that are available which are there to promote best practice when caring for cancer patients. The Gold Standard framework (GSF) which was developed by a General Practitioner (GP) in 2001 was created to meet the needs for patients that’s were the final year of their illness. It had been acknowledged, that many terminally ill patients wished to die at home, but for some reasons they were unable to do so. The GSF aims to optimize the health of the individual patient and offer holistic care so that patients who wish to die at home are given the opportunity to do so (Amass, 2006). The Liverpool Care Pathway (LCP), which was developed in the 1990’s, was to improve the care in patients when they were in the final stages of life (Marie Curie palliative Institute, 2008) this is still being used in today’s care settings. Unlike the GSF, its design was specifically for individuals who were in their final days of their life. The use of any of these frameworks can aid nurses to provide the best care for their patients during this time. It is therefore imperative that nurses are made aware of these frameworks, and are advised on how to apply them to practice in able to provide holistic care to enable effective management of pain.

Mehta et al (2008), state pain experienced by 85% to 95% of cancer patients, should be controlled with appropriate analgesia and adjuvant therapy.

Pain management all depends of the individual’s experience of pain. Two methods that are used to manage pain are pharmacological and non-pharmacological treatments. According to the WHO analgesia ladder both can be used in conjunction (Hutton et al, 2008) Non-pharmacological treatments include massage therapy, pharmacological treatment is the administration of drugs, which have analgesic properties. The WHO (1986) developed an analgesia ladder for the relief of cancer pain; the use of this ladder had resulted in effective pain management for 80%-90% of patient with cancer. The WHO guidelines on the relief of cancer pain, is widely accepted as the international standard by which treatment should be governed. (WHO, 1996)

The WHO analgesic ladder consists of a three-step ladder, which starts from the bottom with non-opioid pain relief; this includes non-steroidal, anti-inflammatory drugs (NSAIDs). When these drugs are no longer effective, weak to mild opioids such as codeine is used. The next step up from these is opioids such as morphine. For more severe pain, there can be an increase in dosage or the use of other strong opioids and in addition, adjuvant drugs may be considered. Common adjuvant drugs are anti-spasmodics such as buscopan, and anti-depressants such as amitriptyline (Godfrey, 2005). Makin & Smith (2002), state there are many available adjuvants to choose from; however, there is limited research and mixed views on when adjuvants should be used. However Regaard (2000) points out an inconsistency within the WHO analgesic ladder, which is that it only focuses on physical pain which is experienced by the patient and doesn’t consider pain which may be caused through psychological or social influences.

Throughout the healthcare setting the WHO analgesic ladder is widely used, although a study by Cringles (2002) showed that 64% of the individuals used in the study were aware of what the three steps of the WHO analgesia ladder involved, but only 49% actually used the three step protocol within their healthcare settings. This result is evidence of deficits in their knowledge when administering analgesia when delivering effective pain management. Knowledge deficits are not only evident within the nursing staff; they can also be seen within other healthcare professionals, which was evident in a study conducted by Xue et al (2007).

During this study, Xue et al (2007) had a sample group, which consisted of doctors, nurses, and pharmacists. The were all given a questionnaire which contained questions regarding their personal knowledge and understanding of cancer pain, and how they rated their training in regards to pain management. The results showed that the nurses strongest points was their ability to judge the intensity of the pain being experienced by the patient, but when it came to the pharmacological and non-pharmacological they performed badly. Doctors excelled in their knowledge for clinical therapies for pain, but again like the nurse performed badly when it came to the pharmacology and other therapies. The pharmacists were found to have the best knowledge in pain management performing best on pharmacology of pain control, but there were deficits in their knowledge of alternative therapies. All of the individuals who participated within the study rated their training as poor, nursing staff rated their training as the worst. The study indicated that multidisciplinary team involvement would be more effective in the management of cancer pain. (Xue et al, 2007)

In conclusion, it is evident that there is a huge amount of literature available regarding cancer pain and pain management. Literature shows that the key to successful pain management lies with an accurate pain assessment from a holistic perspective, pain changes during the course of the disease and should be reassessed frequently. Good communication is vital when assessing patients as it has been proven to help the patient open up and talk more openly about their experiences of pain. There is a variety of tools available for measuring pain and each has their merits and limitations. It is essential for the nursing staff to be made aware of the assessment tools available to them, and that they are educated to use them correctly when assessing the patient, as failure to do so may result in unreliable information and ineffective pain management. The guidance on how to apply the WHO analgesia ladder into practice should be given to all nursing staff, as the correct use of this has resulted in effective pain management for many cancer patients. Awareness should be applied to the existence of the GSF and LCP frameworks, which are there to aid the nurse and provide best practice for their patient’s. Evidence has highlighted a degree of knowledge in regards to pain management amongst healthcare professionals, which indicates that effective pain management would be more successful if there was multidisciplinary involvement, this could only benefit patients, as the ultimate goal is to ensure effective pain management.

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