Management of Chronic Pain for Patients With Breast Cancer - Literature review Example

Y. M. Leyson For: Unidentified Management of Chronic Pain for Patients With Breast Cancer 24 Mar, 2006 "The capa to give one's attention to a sufferer is a very rare and difficult thing; it is almost a miracle." Simone Weil's quote heavily reflects the nurses' approach to the relief of a patient's condition in a humanitarian way. The unique function of assisting individuals on the road to recovery or on a peaceful submission of letting nature takes its course lies in the hands of the nurse and the entire health team whose expertise is assumed. Pain, considered as the most common symptom and as the most tangible sign of distress among patients should thereby be understood among all. Pain should be treated as the ultimate enemy and therefore needs to be perceived and studied jointly in order to alleviate or limit its tenacity. The International Association for the Study of Pain defines it as: "An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage." Subjectively it could denote any form of unpleasant sensation with varying degrees of intensity. Pain is distinguished based on two basic types identified as acute and chronic. Acute pain results from a disease process whereby there is inflammation or injury to tissues occurring rather suddenly after trauma or surgery and may be accompanied by anxiety or emotional distress. Usually certain medications serve to diminish the intensity of Acute Pain. Chronic Pain however, persists over a longer period than acute pain and is resistant to most medical treatments. Several factors may serve to heighten its perception and frequency thereby causing discomfort to patients in varying degrees. Pain follows a certain train of events before it is detected and proclaimed by a patient. Luckmann and Sorensen traced it to "the nerve receptors, named as nociceptors which differs from the complex receptors of vision and other senses". These nociceptors are simply free nerve endings in almost all types of tissues which react to change and require a high level of stimulation to elicit a response. However once their threshold is exceeded they communicate the presence of the painful stimulus. At times they become so over sensitized that long after the stimulus is removed, pain still persists. Once these nociceptors are stimulated, they discharge an impulse that travels in the form of an electrical activity to the spinal cord and on to the brain. The spinal cord is informed on the activity of the body through nerve fibers carrying somatosensory information. The spinothalamic tract then carries the painful information to the brain via the thalamus by passing through the somatosensory cortex which serves to localize and identify the quality of pain before it is diffused to the many areas of the brain including the reticular formation, medulla, hypothalamus and limbic structures. As a response, the brain sends to the receptors a complex response to the painful stimuli. It dictates the receptors to identify the degree, the character and intensity of the pain; its location and how to behave to reduce or avoid it in the future. "Pain can be inhibited if its pathways are blocked", as presented in the Gate-Control Theory of Melzack and Wall. The "gate" in their report is controlled by a dynamic function of cells that can facilitate or inhibit the transmission of pain signals. The fibers bringing pain information from the tissues are found in layers known as laminae. A certain Laminae II which is different from the rest of the layers and also called the Substantia Gelatinosa(SG) is proposed as the location of the "gate". This serves as the convergence point of all pain information, whether stimulus coming in from the tissues or identification from the brain. A spinal cord transmission cell also known as the t-cell either opens the gate thereby facilitating pain transmission or closing the gate. A variety of sources may close or open the gate but only the brain can manipulate the "gate" to inhibit or enhance the pain pathways. In their recent version called Mark II, their model emphasizes the probability that there is an inhibitory system within the brain stem that also acts as a "gate" inhibiting pain transmission. Bosbaum and Fields believes that "the brain stem inhibitory circuit lies within the midbrain, medulla and the spinal cord". They further postulated that "the activation of cell in the midbrain's gray matter through electrical stimulation, use of opiate analgesic drugs, or other psychologic factors stimulates the medulla to inhibit the pain transmission". Spinal pain transmission is then inhibited as a natural control mechanism to limit its severity. Aside from the physiologic nature, other factors may affect an individual's perception of pain. Socio-cultural backgrounds may dictate one to ignore or minimize any display of pain. Sexual orientation and stereotyping defines that women have lower pain threshold. The presence of fear or a previous experience and attitudes towards pain greatly affects a person's personality. All factors that might affect man and his reaction and perception should be studied before a health practitioner gains the mastery towards the efficient alleviation. Chronic pain due to cancer varies in intensity and "steals away the quality of one's life" as stressed by Marisa Weiss, MD. In breast cancer overcoming pain can be a major part in dealing with the disease. Therefore, as members and front liners of the medical team, nurses are expected to identify pain on a constructive level before any intervention is aimed to correct or alleviate its incidence. She is tasked to gain a response from the patient with regards to the severity of pain through subjective and objective analysis. Luckmann suggest "the use of the rating scale of zero to ten, where "10" reflects the highest amount while "0" denotes no pain". A patient's behavioral response should also be observed at all times. Several approaches might be necessary before relief is actually met, but the amount of support under a holistic approach substantiates the best nursing intervention of all. As alternative courses to treatment, medical science has suggested surgery on breast cancer. Surgery alone causes discomfort in the breast and underarm area. Nurses as efficient caregivers are tasked to prepare the patient psychologically and physically for the procedure. Pre-operative and Post-operative nursing measures should be provided adequately to ensure recovery. In the removal of lymph nodes and in surgery, pain is experienced even a month after surgery. Drainage tubes and pads are placed and monitoring of such should be emphasized to prevent infection. Prescribed pain medications like opioids and narcotics may relieve pain however adverse effect of the drug sets in like constipation and lethargy. Nurses should be prepared to identify the drugs administered and their side effects and contra-indications to minimize other problems from surfacing. In mastectomy, a nurse should carefully assess the chances of a psychological deviations and emotional tendencies commonly occurring after the procedure. Careful notice is laid in the fact that a woman's breast establishes her identity from the male specie. A fair amount of psychological support is expected from family members especially the patient's spouse. Gradual return to normal lives and transition is expected to ease the pain brought about by the disease and change. Exercise helps prevent further complications caused by the sedentary period during treatments. Support Groups for breast cancer patients are currently known to prevent social isolation. A nurse may suggest a particular group within the local area for easy contact. Chemotherapy as an alternative form of treatment can cause joint pain and mouth sores. Nutritional imbalances are quickly noted as an adverse effect of such therapy. Doctors often combine drugs and other medications to provide pain relief and to get the best possible effect. Adverse reactions are quickly noted to provide possible alternative measures to ease recurrence. Drugs like Neurontin in high doses are prescribed for pain. Notably this causes "vaginal dryness" and poses as a discomfort during intercourse. Additionally, chances of other vaginal conditions may set in. Clinical teaching should be aimed at conditions that cause bacterial cross-infections. During metastasis, pain can be experienced and persistent on the other parts of the body. A patient should be encouraged to verbalize her feelings without fear and anxiety of repercussions and reactions from family members. Some doctors would suggest acupuncture as a form of relief during this stage. However, massage, relaxation or yoga may also prove helpful in some cases. Music or art therapy could be encouraged to guide the channeling of emotions and other thought processes to other creative areas as a coping mechanism. Patients are usually monitored carefully to prevent self-inflicted injuries during this difficult stage. Some studies would suggest that breast cancer patients have the greater chance of over extending the amount of pain due to their own perceived fear. While psychological pain may be suggested among adults, pain in breast cancer is rarely due to any psychologic instance or deviation. Nursing care afforded to adults in pain require a variety of holistic approaches to ease the discomfort. Assessment would include the use of simple tools suggested by Wolfe in consonance with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The use of the Initial Pain Assessment and Brief Pain inventory questionnaire may provide assessment for acute and chronic pain. Pain scales are notably suggested either numeric or visual that allows the client to rate the pain intensity. Word Scales and facial expression often denotes guidance and interaction from the patients and may provide a greater value particularly for clients with cognitive impairments or when language barriers exist. Some experts like Narcessian suggest "the use of Opioid Therapy Documentation Kit for the selection of patients whose likelihood of chronic pain" points their candidacy for Opioid Therapy. While the use of such drugs may create an addictive effect on patients who tends to abuse it, the documentation is best conducted by the physician himself who serves to warrant its use. The Health Team should work hand in hand in the effective guidance of pain control among patients with chronic pain. As a debilitating disease in itself, chronic pain requires a more tantamount and organized effort among the entire professional team. The sine qua non of teamwork communication should never stand in between the scientists who are expected to disseminate all information vital to the alleviation of chronic pain to the physicians, specialists, surgeons, nurses, physical therapists, pharmacists, etc. The "12 C's of Defining Teamwork" suggested by Weicha and Pollard suggest the future in Chronic Pain Management. While the surgeon and physicians prescribe and define the type of treatment for a patient, the rest of health team conducts its implementation. In the process, the nurses, physical therapists and other assistants create a first level interaction with the patient to submit their own vital findings and observation to the resident doctors and the rest of the health staff including those with limited yet parallel desire to afford the same expectation of relief. Impartial assessments and observation records should be carefully laid out as a rich resource and a "black box" of data to be shared by the health team for the advancement of chronic pain management. Works Cited Weil,Simone. Quote. Brainyquote.com 23 Mar 2006. Fields, H. and Bosbaum, A. "Endrogenous PainControl Mechanisms". Churchill Livingstone.1984. Lucmann,J. and Sorensen, K.C. "Medical-Surgical Nursing: A Psychophysiologic Approach". W.B.Sunders Co. 1994.174-212. Melzack,R. and Wall, P. "Pain Mechanisms : A New Theory". 1998. UCLA.24 Mar 2006. http://www.library.ucla.edu/libraries/biomed/his/painexhibit/panel6.htm Berger, A. and Weiss, M. "Online Ask the Expert Conference-Chat: Breast Cancer Pain". 2002 April. American Cancer Society Website and breastcancer.org. 23 Mar 2006. http://www.breastcancer.org/cmty_trans_2002_4_18.html Wolfe, Gary. "Obtaining and Using Pain Assessment Tools". 2002. Mason Medical Communications Inc. 24, Mar 2006. http://www.jcaremanagement.com/html/pain__obtaining_and_using_pain.html Narcessian,Elizabeth J. "Opioid Therapy Documentation Kit". 2005. Purdue Pharma. 24, Mar 2006. http://www.partnersagainstpain.com/index-mp.aspxsid=3 Wiecha, J. and Pollard, T. "The Interdisciplinary eHealth Team: Chronic Care for the Future." 2004. J Med Internet Res. 24, Mar 2006. http://www.jmir.org/2004/3/e22/ Read More