Are you having any pain. These are most likely the first words from a registered nurse to an oncology patient. Pain is a concept that creates many challenges for medical professionals. In a review of patients with cancer, pain was reported in 33% of patients after treatment to cure cancer, 59% of patients given anti-cancer treatment with the aim of either curative or palliative treatment, 64% of patients having advanced, metastatic or terminal cancer and 53% of patients with all stages of the disease (Chapman, 2012a). Pain management is a common reason an oncology patient is admitted as an inpatient to a hospital. Nurses are at the forefront of assessing and managing pain to achieve adequate therapy. However, in order to reach this outcome, nurses need to understand the types and causes of pain, assessment tools, non-pharmacological treatment and action of pain medications (Casey, 2011). Nursing staff and other medical professionals need to act as patient advocates when dealing with pain so that symptoms can be managed. Nevertheless, within the healthcare system, the prevalence of pain is increasing and pain is a complex issue that is not always well understood or managed by healthcare professionals and patients (Shaw, 2006).
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Issues with Pain
Nurses are constantly faced with managing pain and need to develop skills to identify when pain is not adequately controlled in order to make recommendations to alleviate a patient’s pain. Unfortunately, there are many times when both nurses and physicians are not well educated in pain management and are not successful in decreasing an individual’s pain level. Regardless of the variety of treatment options, cancer pain is not always effectively managed due to several barriers that include poor assessment, insufficient knowledge about pain and treatment and specific concerns about dependence, tolerance, addiction and drug-related side effects (Chapman, 2012b). In addition, many medical professionals hold inappropriate beliefs and attitudes toward pain management, which can affect providing pain relief for patients (Naylor, 2003). Some practitioners are fearful of prescribing or administering pain medications at a high level that might be required due to a patient’s tolerance. This creates many challenges in providing adequate pain control for patients that are able to verbalize their pain, as well as those patients who are not able to verbally express their pain levels.
Significance in Nursing
Pain is a significant concept in oncology nursing. Physicians and nurses working with this population need to be experts in pain management. It is critical for medical professionals to understand the different types of pain that oncology patients can experience. There are several pain management treatments available and not every medication will work effectively for a patient. It is important for nurses to recognize differences so that patients can be effectively managed. When pain is not adequately controlled, patients can become withdrawn and unable to focus on important aspects of their quality of life including activities of daily living and sexual and social relationships (Chapman, 2012a). In addition, mood, sleep patterns, cognition and existential beliefs can be affected (Chapman, 2012a).
There are several types of pain that an oncology patient can experience. The most common types of pain are chronic pain, acute pain and breakthrough pain. Chronic pain is a constant pain. Acute pain can last anywhere from a few days to a few months and typically resolves when the underlying condition is treated (Chapman, 2012). Breakthrough pain happens briefly with moderate-to-severe flare-ups that occur even when a patient is taking long acting pain medication to address their chronic pain (Kedziera, 1998). Understanding these types of pain is pivotal to determine medications to be prescribed and implement non-pharmacological therapies. When medical staff understands the causes and types of cancer pain, they can individualize pain management strategies in order to improve the quality of patient care as well as provide sufficient pain relief (Chapman, 2012a).
Oncology patient’s pain can be caused by several factors. Pain can be caused by tumors, surgery, chemotherapy and radiation which can affect different parts of the human body (Chapman, 2012a). When staff is knowledgeable about disease processes and treatments, medical professionals can prescribe medications to address specific pain. Nurses must assess an individual’s pain management regimen at home so that dosing can be adjusted when admitted to the hospital. Nurses must be diligent in comparing prescribed medications to home medications. There have been instances when physicians will fail to order a long acting pain medication that a patient might take at home that can result in inadequate relief.
Assessing an individual’s pain is a key component in achieving pain management. Nurses need to evaluate a patent’s pain when considering pain therapy and the nurse needs to focus on the following factors: (1) consistency in pain control, (2) taking action in response to an individual’s pain assessment, (3) maximize effectiveness of medications while reducing side effects and (4) avoid “gaps” in pain control (Casey, 2011). Physicians do not spend as much face-time with patients as nurses, therefore, nurses have the responsibility to understand a patient’s pain and verbalize to the physician to achieve adequate pain control. An accurate and detailed assessment can provide guidance in creating an individualized treatment plan (Naylor, 2003). Each person’s pain is going to be different and it is important to utilize assessment tools to implement the most effective pain management plan. When determining ways to manage pain based on the assessment, nurses need to not only focus on the physical aspects but also include pharmacological and non-pharmacological treatments to reach optimal comfort (Naylor, 2003). Education and training on different types of pain assessment tools and scales that are utilized in practice is essential to effectively manage pain levels of each patient. Without the ability to adequately assess a patient’s pain, there will be profound negative effects on comfort levels and the ability to meet health goals.
Nurses have a pivotal role in addressing pain in oncology patients. It is essential for nurses to realize that managing pain goes beyond administering medication and that utilizing a holistic nursing care approach can allow a nurse to better understand a patient’s individual pain. Pain responses can be affected by psychological, social and cultural influences, such as anxiety, anger and fear that may enhance an individual’s perception of pain (Naylor, 2003). In addition, cultural beliefs, upbringing and social situations may be the reason for certain expressions of pain (Naylor, 2003). Nurses need to be vigilant in recognizing factors that affect a patient’s pain and the meaning that an individual attaches to pain (Chapman, 2012a). A nurse’s role goes beyond completing tasks on a checklist but having the ability to connect with their patients to identify root causes of pain. It has been found that in order to reach a goal of effective symptom management, the multidisciplinary team must create a positive therapeutic relationship with the patient (Chapman, 2012a). Many times a patient is looking for the opportunity to express themselves and nurses have the ability to provide an environment that allows patients to open-up and verbalize their feelings.
Changes to Nursing Practice
The concept analysis has brought heightened awareness to the idea of pain. When assessing pain, there are many factors to be considered as addressed in the concept analysis. The analysis opened a door to look beyond what medical practitioners physically assess but also the importance of listening and understand the patient. The nurse must reflect on experiences he/she has with patients to improve their ability to effectively manage pain. Nurses need to realize that in order to implement appropriate nursing activities to meet a patients pain needs requires an ongoing learning process to truly understand the concept of pain (Cheng, 2003). Nurses have the ability to manage pain by getting to know their patients to be able to implement change. Nurses need to work on their listening skills so that patients feel that they can openly express their feeling and concerns. This allows the nurse to help guide the patient to becoming involved in his/her care. It is clear that when pain is not adequately controlled it can have negative consequences on not only the patient but the entire family unit.
Through the use of reflecting, provides the opportunity to anticipate outcomes and create successes in managing pain. One tool to achieve effective pain management and evaluate strategies is by conducting pain assessments (Naylor, 2003). Through these assessments, a nurse can identify physical effects of pain and understand both location and intensity. To know if a nurse is successful, the nurse will see a change in level of reported pain or physical attributes that a patient might exhibit. By changing current practice methods, nurses will be able to create an environment where patients will verbally express feelings which will be a sign of progress in better meeting patient needs. In addition, through these encounters nurses will be able to identify their patient’s use of coping mechanisms to address pain. Nurses can also see success when utilizing a holistic nursing approach by looking beyond everyday tasks and viewing the patient as a human being. As nurses identify factors that affect pain management, they will be able to better meet patient needs. Nurses will have the education and skills to recognize and alleviate pain before it occurs by utilizing pain management interventions, methods and medications.
The analysis has relevance to understanding the concept of pain, while also isolating it from other concepts. The concept analysis regarding pain was intended to increase awareness and understanding pain by clarifying the defining attributes of pain, identifying antecedents that affect the perception of pain and the possible consequences of pain (Cheng, 2003). It is clear that pain is a concept that is not always well understood and requires analysis that others can become more conscious and responsive to addressing patient’s pain needs.
The model case discussed pain using a scenario regarding an oncology patient. The model case included all the defining attributes:
(a) unpleasant and distressful experiences originating from physical sensation and having both positive and negative meanings for an individual; (b) an individual human experience; (c) a state of feeling in both sensation and emotion (verbal), and behavioral components; (d) physical and psychological responses to the stimulus; (e) function of pain, including protective and warning signs; (f) pain responses and learned and influenced by personality, environment, emotions, social and cultural (Cheng, 2003).
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This example supported the concept of pain and clearly stated the characteristics of the case to addressing all the points regarding the concept of pain. Due to each patients individuality, personal experiences and views, there are several types of scenarios that could have been utilized as a model case.
The model case creates awareness for nurses of all the factors to consider when understanding a patient’s pain. Nurses have to be able to use the skills to visually assess and listen to patients while understanding a patient’s history and the events that have taken place to bring the patient to the point of the pain that they are reporting. Understanding a patient’s culture and individual beliefs can provide insight regarding a patient’s response and expression of pain. Nurses need to be aware of potential patterns in certain cultural groups, however, nurses should not over generalize or stereotype that everyone within a culture will behave in the same manner (Davidhizar, 1997). This emphasizes the complexities when assessing and understanding a patient’s pain, and nurses need to go beyond the basic assessment tools and understand the individual to achieve effective pain control.
The use of a borderline case and contrary case were used to distinguish the concept of pain from the model case (Cheng, 2003). The cases are important in differentiating the concept of pain from other closely related concepts, as seen in the additional cases. The borderline case did not meet all the elements of the model case and the contrary case addressed the concept of fear related to pain (Cheng, 2003). These cases enhance the model case and allow the reader to see alternate examples of situations that may arise in a clinical setting.
Pain is a universal part of the human experience and will continue to be an integral part of providing nursing care (Shaw, 2006). Pain is a complex concept that does not have one specific answer to meet all patient needs. Pain management requires assessment skills, knowledge and a holistic approach to nursing care to be successful at eliminating or effectively controlling pain in oncology patients. Nurses have both technical and moral tasks in the management of pain because they are the ones conducting assessments, administering pain medications and evaluating effectiveness, as well as, determining which pain relief measures and interventions are provided to patients (Shaw, 2006). Nurses need to continue to expand their knowledge base and be aware of their own values and beliefs in order to be successful in managing the dynamics and complexities of pain.
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