Population-Specific Pain Assessment & Management - Essay Example

Running Head: PAIN ASSESSMENT Population Specific Pain Assessment & Management Protocol of the of the Population Specific Pain Assessment & Management Protocol Pain is one of the most common, and certainly the most feared, symptoms associated with advanced cancer. It is estimated that one third of patients diagnosed with cancer will experience moderate to severe pain on diagnosis with another two thirds experiencing pain with advanced disease (Woodruff, 1996). Figures from the World Health Organization suggest that 3.5 million of the 6.35 million people diagnosed with cancer each year suffer cancer-related pain on a daily basis. (Stjernsward and Teoh, 1997) The consequences of unrelieved pain are well documented. These include: poor sleep, loss of appetite, decreased functioning, elevated levels of depression and anxiety and decreased quality of life (Twycross, 1994). The powerlessness and hopelessness expressed by patients experiencing moderate to severe pain is all too often mirrored by nurses who lack the appropriate knowledge and assessment skills to manage pain effectively (Clements and Cummings, 1991). Common barriers to effective pain management reported in the literature include: knowledge deficits; fear of addiction to opioid medication; and, lack of consistency in the systematic assessment and documentation of pain and the effectiveness of therapeutic interventions. (McCaffery and Ferrell, 1997) Assessment is widely regarded in the literature as the cornerstone to effective pain management. Nurses spend more time with patients than any other member of the health care team and are thus in an optimal position to perform pain assessment. Through the integration of fundamental physiological knowledge, information on the patient's history and the comprehensive assessment of their pain, the nurse plays a major role in optimizing patient management. In our society, information gathering is viewed almost uniformly as a good thing. (It is the "information age," after all.) Nowhere is this truer than in medicine. For doctors, more information is always better. In the past, most of our information came from the patient. Now it increasingly comes from machines. Doctors like tests because we see them as objective and more reliable than our own subjective judgments. We also see tests as something tangible we can offer the patient at the end of a clinic visit. Patients like tests for the same reasons. Ordering a test validates their concerns and promises concrete information-a definitive diagnosis. Sometimes patients even perceive their care as substandard if they are not given some sort of test. While doctors and patients recognize that treatments may have side effects or lead to complications, both tend to view testing as something that can only help. The prevailing attitude seems to be it can't hurt just to gather a little information. Cancer, however, is a diagnosis made by examining human tissue under the microscope. And the only way to look at tissue under the microscope is to do a biopsy: cut a small piece of tissue and remove it from the body. A biopsy is a small operation, and like any operation, it can be disruptive and painful and can lead to complications. So it's not the kind of test you want to perform on everyone. The job of the cancer-screening test is to determine which patients should be biopsied. In other words, a screening test is a preliminary test. It is not a test to determine who has cancer; instead, it is a test to determine who should be tested further. Can a negative screening test be wrong The answer is almost certainly yes, although it is very hard to prove. That is because we do not biopsy people with negative screening tests. The only way we ever come to suspect that a negative screening test might have been wrong is when a new cancer becomes clinically obvious soon after a person has a negative test. Testing In The Real World In the real world, cancer testing is more complex. Test results aren't just positive or negative; often they are somewhere in between. These in-between results may lead to in-between tests: something more thorough than the screening test but a few steps short of a biopsy. Sometimes in between results lead to a recommendation simply to repeat the screening test after a few months have passed. Although the testing process differs depending on which cancer is being sought, some features are common to all cancer testing. The screening test itself is generally the simplest, least disruptive, and safest of all the tests used to detect a cancer. When the screening test is abnormal, confirmatory testing is initiated. The confirmatory testing can range from repeating the screening test earlier than normal (in six months instead of one year, for example) to performing an alternative test that is generally more accurate (and generally more involved) to performing a biopsy (the most definitive test). If the screening test is not too suspicious, an early repeat test or an alternative test is often recommended. But if it is suspicious, a biopsy is generally recommended. You May Receive Unnecessary Treatment Imagine you had gone through a testing process and had avoided the problems like false positive tests, repetitive testing, and ambiguous results. Instead the test result was straightforward and clear: you have cancer. At first, you are devastated. You wonder why it had to happen to you. It's as if you've hit the jackpot in some horrible lottery. On more careful reflection, however, you come to regard the news from a different perspective. Because only people with cancer can benefit from screening, everyone else goes through the testing process for nothing. You are fortunate; you caught the cancer early. Perhaps it can be treated and you will be OK. You may be one of the lucky ones. The truth, of course, is more complicated. Some people really are lucky: their cancers would have caused problems but were found early and will be cured through treatment. For others, however, the situation is different: their cancers never were going to cause problems. Unfortunately, we can't reliably distinguish between these two groups. Consequently, we treat both. This is the biggest downside to screening. The problems of false positive tests, repetitive testing, and ambiguous results are dwarfed by the problem of unnecessary diagnosis and treatment. You may find a cancer you would rather not know about You are probably beginning to appreciate that the diagnosis of "cancer" can have widely different implications. Testing healthy people identifies a spectrum of cancer: while some are destined to cause symptoms, others are not. Unfortunately, it is practically impossible to be certain which is which by looking at a collection of cells under the microscope. So doctors aren't sure about which cancers should be treated. What we are sure about is that the way to avoid this dilemma is not to be tested for cancer in the first place. If you are never tested, you will never have to worry about pseudodisease-those cancers that don't progress to cause symptoms. Most of us, however, will consider some cancer screening at some point in our lives. Many will also be evaluated for medical problems unrelated to cancer, which may involve diagnostic tests that, while appropriate to the problem, are also capable of detecting early cancers. Understanding the chance of finding pseudodisease may help you decide when to be screened and what to do if a cancer is found unexpectedly. Testing and pseudodisease go hand in hand. I focused on the fact that not all cancers progress, therefore not all cancers need treatment. There is a lot of cancer that can be found, which means that testing can find too many cancers. The harder we look for any type of cancer, the more we find. And the more we find, the more likely it is that what we find is pseudodisease. In other words, one downside of testing is that you might find a cancer you would rather not know about. Pathophysiologic Pain Processes Of Cancer While the mechanisms underlying pain are complex and dynamic processes that may never be fully elucidated in the clinical setting, a Pathophysiologic classification of pain can have utility in treatment planning. Pain syndromes may be labeled nociceptive, neuropathic, psychogenic and/or mixed. When the cause of the pain is not apparent most pain experts refer to this as an idiopathic syndrome. http://www.ama-cmeonline.com/pain_mgmt/module10/06inter/03_01.htm Cancer pain has also been classified according to a series of common pain syndromes and their Pathophysiologic mechanisms. The pain syndromes that commonly occur in patients with cancer have been divided into three major categories. The first, and the most common, cause of pain in patients with cancer is that associated with direct tumor involvement. This accounted for 78% of pain problems in a survey of the Memorial Sloan-Kettering Cancer Center inpatient population and for 62% of problems in an outpatient survey. Metastatic bone disease, nerve compression or infiltration, and hollow viscus involvement are the most common causes of pain from direct tumor involvement. The second group of pain syndromes includes those associated with cancer therapy and the pain that occurs in the course of or as a result of surgery, chemotherapy, or radiation therapy and accounts for approximately 19% of pain patients in an inpatient population and 25% of problems in an outpatient population. The third category of pain syndromes includes those unrelated to the cancer or the cancer therapy. Approximately 3% of inpatients have pain unrelated to cancer or cancer therapy, and this figure increases to 10% when an outpatient population is surveyed. The Pathophysiologic mechanisms of these common pain syndromes are not well understood, but they account in part for the differences in the responses of various types of cancer pain to analgesic, neurosurgical and anesthetic approaches. At the current time, however, drug therapy represents the mainstay in the treatment of patients with pain and cancer. http://www.medsch.wisc.edu/painpolicy/publicat/88jpsmr.htm Observer variation: what is the diagnosis The idea that doctors do not always agree about correct treatment is well known. Some patients, in fact, shop doctors until they find one who recommends the therapy they want. But the idea that pathologists may disagree about a diagnosis is less familiar. To their credit, the pathology community has been studying this issue. Two basic problems could lead pathologists to disagree about a diagnosis: either they look at different things or they look at the same thing and see something different. Recall that biopsy specimens (generally obtained by a surgeon or radiologist) are sent to the pathologist, who then takes several thin slices of tissue and places them on glass slides to examine under the microscope. If pathologists examine different slices, they may arrive at different diagnoses. And if they look at more slices, they may be more likely to diagnose cancer. The studies of how well pathologists agree, however, do not investigate this source of disagreement. Instead, they take the slice as their starting point and make sure the pathologists are looking at the same thing. Thus they address the question "Do pathologists agree about what they see" Pharmacologic And Non-Pharmacologic Pain Treatment The cost of cancer pain in suffering, disability, and quality of life is high. The guidelines recommend that cancer pain be treated aggressively by Pharmacologic and nonpharmacologic approaches. In most instances, pain can be treated effectively with relatively low-cost, noninvasive therapies. Given this evidence, health system barriers that interfere with effective pain management -- such as restrictive legislation regarding the uses of opioid analgesics and third-party payer practices that do not reimburse for less invasive interventions -- should be changed. (http://www.jaoa.org/cgi/content/full/105/suppl_5/S15) Etiologic factors of cancer pain include progression of disease, treatment modalities to arrest cancer (e.g., surgery, chemotherapy, or radiotherapy), musculoskeletal pain from inactivity, and cancer-related infections that result in neuropathic pain (e.g., herpetic neuralgia) (Jacox et al, 1994). A combination of pharmacologic and nonpharmacologic treatment modalities for cancer pain is the standard of care, as presented in current World Health Organization (WHO) guidelines (Jadad and Browman, 1995). (http://www.jaoa.org/cgi/content/full/105/suppl_5/S15) Adjuvant strategies combined with appropriate pharmacologic and interventional modes of treatment include nonpharmacologic and complementary medicine interventions. Develop a strategy that works for you "Chances are you're fine. But why take chances" "Take the test, not the chance." "Early warning signs of colon cancer: You feel great. You have a healthy appetite. You're only 50. " "Mammograms: The chance of a lifetime." Every day you can see strong messages in the media encouraging you to get tested for cancer. And you can be sure there will be no let-up in the near future. Some will try to scare you into action. Others will appeal to your sense of reason. Most will imply that doctors are sure that early cancer detection is always the best strategy. Few, if any, will communicate any reason you would not want to be tested. Their theme will be consistent: the benefits of testing are certain, the downsides nonexistent-or at most, trivial. The Multidimensional Nature Of Cancer Pain It is important to recognize pain as a multidimensional phenomenon that involves more than just physical pain. Total pain' refers to the many interrelated factors that can accentuate the patient's experience of pain. These include physical symptoms, psychological problems, spiritual and cultural concerns, and social issues such as isolation. Holistic cancer pain assessment involves assessment of other common physical symptoms such as constipation or nausea, together with assessment of the impact of pain on the individual's total functioning, i.e. relationship to others, appetite, sleep patterns. (Woodruff, 1996) Conclusion There are a myriad of validated pain assessment tools to choose from in the literature. These range from unidimensional tools that assess pain intensity to more complex, multidimensional tools that are designed to elicit information regarding the multidimensional nature of the pain experience. Whatever assessment tool is used in your clinical practice, it is essential that assessment is conducted regularly, that reassessment takes place following the employment of therapeutic interventions and that the assessment and interventions are clearly documented to facilitate the continuity of the patient's care. References Clements, S. and Cummings, S. 1991, Helplessness and powerlessness: Caring for clients in pain, Holistic Nursing Practice, 6:1, p.76. Foley KM. 1987, Pain syndromes in patients with cancer. In: Foley KM, Payne R, eds. Med Clin N Amer; 7: 169-84. Jacox AR, Carr DB, Payne R, Berde CB, Breitbart W, Cain JM, et al. Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR Publication 94-0592. Rockville, Md: Agency for Health Care Policy and Research. US Department of Health and Human Services, Public Health Service, March 1994 Jadad AR, Browman GP. The WHO analgesic ladder for cancer pain management: stepping up the quality of its evaluation. JAMA. 1995; 274:1870 -1873 McCaffery, M. and Ferrell, B. R. 1997, Nurses knowledge of pain assessment and management: How much progress have we made Journal of Pain and Symptom Management, 14:3, pp.175-186. Nonpharmacologic and Complementary Approaches to Cancer Pain Management, retrieved on July 20, 2006 from http://www.jaoa.org/cgi/content/full/105/suppl_5/S15 Stjernsward, J. and Teoh, N. 1997, The scope of the cancer pain problem, 1990, cited in Riddell, A. and Fitch, M. I. Patients' knowledge of and attitudes toward the management of cancer pain, Oncology Nursing Forum, 24:10, p.1775. Twycross, R. 1994, Pain relief in advanced cancer, Churchill Livingstone, Edinburgh, p.7. Woodruff, R.1996, Cancer Pain, Asperula Pty Ltd, Melbourne, pp.6-8. A report on the Wisconsin State Cancer Pain Initiative, retrieved on July 20, 2006 from http://www.medsch.wisc.edu/painpolicy/publicat/88jpsmr.htm Module 10: Overview and Assessment of Cancer Pain, retrieved on July 20, 2006 from http://www.ama-cmeonline.com/pain_mgmt/module10/06inter/03_01.htm Read More