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Cancer Pain

Cancer Pain. Assessment and Management. Objectives. The learner will be able to: Identify the components of a pain assessment. Compare and contrast the different types of pain. Describe the use of three pain assessment scales. Types of Pain. Acute pain

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Cancer Pain

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  1. Cancer Pain Assessment and Management

  2. Objectives The learner will be able to: • Identify the components of a pain assessment. • Compare and contrast the different types of pain. • Describe the use of three pain assessment scales.

  3. Types of Pain • Acute pain • Pain with sudden onset, usually follows injury, commonly decreases over a short time when body heals (i.e., days, hours, minutes) • Chronic pain • Pain lasting longer than three months • Breakthrough pain • Transient increase in pain intensity over background pain, typically with rapid onset and severe intensity, generally self-limiting with average duration of 30 minutes

  4. Types of Pain (cont.) • Nociceptive pain • Pain resulting from injury to healthy tissue (tissue-damaging tumors and/or chemicals from tumors) • Neuropathic pain • Pain resulting from damage to the peripheral or central nervous system (toxicities from certain kinds of cancer treatments or a tumor pressing on a nerve) • Characterized by dysesthesia, hyperesthesia, or shooting or lancinatingpain

  5. Pain Assessment Guidelines Pain assessment guidelines were developed by the National Comprehensive Cancer Network (NCCN) Adult Cancer Pain Panel and are reiterated in the ONS PEP recommendations: • Pain intensity must be qualified. • Formal pain assessment must take place. • Reassessment of pain intensity must take place. • Psychosocial support must be available. • Specific educational material must be given.

  6. Pain Assessment • Pain assessment should include: • Screening • Prevention/pretreating • Reassessment.

  7. Initial Rapid Pain Assessment An initial, rapid pain assessment is appropriate for patients presenting in acute pain of moderate to severe intensity. A rapid assessment should include: • Level of consciousness • Characteristics of the pain • Intensity • Location • Duration • Quality • Changes in vital signs • Respiratory status • Heart rate • Blood pressure • HOWEVER, absence of these autonomic responses does NOT mean absence of pain.

  8. Rapid Assessment (cont.) • Rapid assessment can be performed utilizing and/or considering: • Self-report • Pain intensity scales • Numeric, verbal descriptive scales • FACES pain scale • Cultural preferences and sensitivities • Established comfort/function goal (PEP).

  9. Comprehensive Pain Assessment • A comprehensive pain assessment includes: • Physical assessment • Pathophysiology/etiology • Review of relevant laboratory and imaging studies • Subjective assessment • Intensity • Location • Temporal factors • Pain history • Medical history • Psychological history • Risk factors for undertreatment of pain • Patient goal (comfort/function)

  10. Cancer Pain Assessment According to NCCN: • Assess patients with cancer for all types of acute and chronic pain. • Reassure patients and family that most cancer pain can be relieved safely, quickly, and effectively. • Prepare clinicians, through basic and ongoing professional education, to assess cancer pain effectively.

  11. Pain Assessment Scales Commonly used pain assessment scales can measure pain in three different dimensions: • Sensation (intensity) • Affect • Behavior

  12. Numeric Rating Scale • Measures pain intensity • Can measure frequency, duration, unpleasantness, or distress • Can also assess pain relief • Format: • 6-point scale (0–5) • 11-point scale (0–10)

  13. Visual Analog Scale • Measures pain intensity • Can measure frequency, duration, unpleasantness, or distress • Can also assess pain relief • Format: • 10 centimeter line • Includes graphic rating scale that adds words or numbers between the extreme ends of the scale

  14. Verbal Rating Scale • Also known as simple descriptor scale • Measures pain intensity • Can measure frequency, duration, unpleasantness, or distress • Can also assess pain relief • Format: • List of adjectives describing different levels of pain • Example: “no pain/slight pain/mild pain/medium pain/ most severe pain imaginable”

  15. FACES Scale • Measures pain intensity • Can measure frequency, duration, unpleasantness, or distress • Can also assess pain relief • Format: • Series of drawings representing facial expressions associated with varying degrees of pain • Geriatric version available with more human-looking faces

  16. Neuropathic Pain Management • Trial of antidepressant (e.g., nortriptyline, doxepin, desipriamine, venlafaxine, or duloxetine) • Trial of anticonvulsant (e.g., gabapentin, carbamazepine, pregabalin) • Consider topical agents. • If unable to attain satisfactory results, consider referral to a pain specialist.

  17. Mild Pain (Level 13) • Consider NSAID or acetaminophen without opioid if patient is not on analgesic. • Consider short-acting opioid (begin bowel regimen). • Recognize and treat side effects. • Use nonopioidanalgesics as indicated. • Provide psychosocial support. • Provide patient and family education.

  18. Moderate Pain (Level 46) • Titrate short-acting opioid (begin bowel regimen). • Recognize and treat side effects. • Use nonopioidanalgesics as indicated. • Provide psychosocial support. • Provide patient and family education.

  19. Severe Pain (Level 710) • Rapidly titrate short-acting opioid (begin bowel regimen). • Recognize and treat side effects. • Use nonopioidanalgesics as indicated. • Provide psychosocial support. • Provide patient and family education. • Do a comprehensive reassessment in 24 hours. • Reassess and modify regimen to modify side effects. • Consider long-acting opioid. • Consider specific pain problems. • Consider specialty consultation.

  20. Management of Opioid Side Effects • Constipation • Use prophylactic and management medications. • Increase fluids. • Increase dietary fiber. • Exercise, if appropriate. • Nausea/vomiting • Use prophylactic and management medications. • Assess for other causes. • Try opioid rotation or change.

  21. Nonpharmacologic Pain Relief • Physical comforts: • Bed/positioning • Bath positioning • Massage • Physical therapy • Heat/ice • Acupuncture • Cognitive/behavioral: • Imagery • Distraction training • Relaxation training • Active coping training • Cognitive behavioral training • Consider pain and palliative care training.

  22. Pain Follow-Up: Nursing Implications • Routine follow-up • Written follow-up plan • Ensure access to prescribed medications. • Review patient instructions. • Set goals, then revise and review. • Address system barriers. • On-call/prn availability

  23. References American Pain Society. (2005). Guideline for the management of cancer pain in adults and children. Glenview, IL: Author. National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain [v.2.2011]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf Oncology Nursing Society. (2008). Putting evidence into practice (PEP) resources: Pain. Retrieved from http://www.ons.org/Research/PEP/Pain

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