Nurses spend more time with patients than any other member of the healthcare team. They play a critical, active, and very important part in controlling cancer patients’ pain and alleviating suffering.
In controlling cancer pain, the nurse needs to understand the psychological state of the cancer patient, cancer pain, cancer pain treatment, deleterious effects of unrelieved cancer pain, and the patient’s socio-cultural background.
When patients are informed that they have cancer they feel as if they have been given a death sentence. They experience bereavement with their anticipated loss of life. They go through the grieving process until they accept that they have cancer. They suffer physical, psychological, spiritual, and social pains. Unrelieved cancer pain is their most feared symptom. As the pain gets worse they feel they are closer to death and they suffer other symptoms as well.
Cancer pain could be acute, chronic, breakthrough, very severe, searing, or soul destroying. It could be opioid responsive, partly responsive, or opioid resistant. As the tumor grows, it causes pressure on organs causing ischemic or colicky pain or on nerves causing neuropathic pain. The pain could be due to treatment, eg, side effects of radiotherapy, stomatitis due to chemotherapy, or constipation due to opioids. The pain could be related to cancer, for example, muscle spasm, due to coexisting disease such as arthritis or due to a procedure being performed.
To control pain effectively, the nurse needs to understand that there are 2 types of pain, nociceptive and neuropathic pain. In nociceptive pain, there is damage to the tissues, and nerve fibers are stimulated. The pain is usually sharp, throbbing, or aching and responds well to common analgesics and opioids. In neuropathic pain, there is direct damage to the nervous system. The pain is usually burning, shooting, or stabbing and may not respond well to usual analgesics, including opioids.
Eighty percent of the cancer patients who have pain could have 2 or more than 4 different pains at the same time. Therefore, when we assess pain, we must always find out if there is more than 1 pain and what is the quality of each pain so that we can treat each one effectively.
The nurse must know all the drugs that are used for the treatment of cancer pain-the nonopioids such as paracetamol and nonsteroidal anti-inflammatory drugs, weak opioids like Tramadol, strong opioids like morphine and fentanyl, and adjuvant drugs such as antidepressants, anticonvulsants, and steroids. The nurse must learn how these drugs relieve pain and know their side effects.
The deleterious effects of unrelieved pain include higher level of depression, fatigue, anxiety, and anger. There is an increased total mood disturbance and poorer levels of physical well-being. Overall, cancer patients feel low and unwell. They lose their appetite, hence their nutritional status is poor and as a whole they have poor quality of life. It is very important therefore, for the nurse to control pain.
Nurses’ role in controlling cancer pain include believing the patient, assessing pain, identifying the root of the problem, planning the care, administering medication, evaluating effectiveness, ensuring good pain control, and individualizing treatment. It also includes nursing interventions such as giving tender nursing care, preventing pain, educating, advocating, communicating, comforting, supporting, and counseling the patient.
The nurse’s first role in pain management is to believe that the person in pain is the only authority about that pain, to accept and appreciate that the sensation of pain is completely subjective. “Pain is whatever the patient says it is, existing whenever he says it does.” “Lack of pain expression does not necessarily mean lack of pain. Patients must be assessed and not judged.”
When assessing pain the nurse must remain open minded and nonjudgmental, demonstrate sincere interest and acceptance of pain, and develop rapport with the patient. She must find out how the patient wants to be addressed and what is the meaning of pain to him. She must look, listen attentively, ask and feel. If there is a language problem she has to find someone to translate so that she records the right information. The patient must feel respected and believed.
The nurse needs to find out, from the patient, when the pain started, how often it occurs, and how long it lasts. Whether it is worse now than when it started, and whether the pain is more severe at certain times of the day. She must find out where the pain is, whether inside or outside, referred to any other area-if so to which area, and if there is more than one pain. She must enquire what is the intensity of pain at present when it gets worse and when it gets better to know its variation. She must ask the patient to describe what the pain feels like and record the exact words.
The nurse must find out what relieves the pain, the length of time it has been used, frequency of its use, and how much pain relief it gives. She must document what makes the pain start and what makes it worse. She needs to find out whether the pain has reduced his activities of daily living and the effects the pain has on the patient, eg, if it interferes with his sleep, causes nausea/vomiting, decreases appetite, or causes depression. It is important for the nurse to document the patient and the family’s socio-cultural background, beliefs/taboos, and traditional treatments taken or still taking. Documentation of the patient’s past medical history, needs, problems, concerns, and the patient’s pain coping mechanisms must be made.
The nurse must bear in mind that some patients may have difficulties in communicating about their pain. Men may be unwilling to express pain, wanting to appear strong. Some may think that pain is part of the disease, therefore, do not complain unless asked. They wait until pain is severe before complaining or may be reluctant to express the true intensity of pain in front of strangers. Accurate assessment therefore, is essential for appropriate interventions.
The nurse must assess the intensity of pain at regular intervals to know its variations. She must assess each new report of pain, when the pain is expected to occur or reoccur, to track its changes, and to find out the effectiveness of treatment. She must treat side effects as soon as they occur and document everything.
The nurse must understand that the use of drugs is the major but not the only strategy. Use both pharmacological and nonpharmacological treatments to individualize.
The nurse must prevent cancer pain by reducing movement while bathing or getting a patient out of bed. She must be gentle with nursing procedures while removing a drainage for example. If the nurse knows that the patient complains of pain while doing a dressing she must give analgesics before the procedure, allow time for the analgesia to work, and then perform the dressing. First, always prevent, next treat as soon as it occurs but never wait until pain is severe before administering analgesics. Remember: “Prevention is Better than Cure.”
The nurse must use the World Health Organization (WHO) guidelines to treat pain that is if the patient can swallow, to give medication “by mouth“ as oral administration is the route of choice. “By the clock”-Round the clock pain requires round the clock therapy. This means that she must administer analgesia regularly and prophylatically. “As required” medication is irrational and inhumane. “By the ladder”-Use the WHO “ladder” to guide her in the treatment of cancer pain. For good pain control, the nurses must choose the right analgesic or adjuvant for the right pain, the right dose, given at the right time, with the right intervals, and to the right patient. She must evaluate effectiveness of treatment and give PRN doses whenever the patient has breakthrough pain to individualize treatment. She must report if there is a need for prescription change and make suggestions, to the doctor, for specific changes, eg, drug, dose, or route. While treating cancer pain, the nurse must aim at progressive pain relief-first to make sure that the patient has a good night sleep, second has good pain relief while resting, and third aim at good pain relief while moving the patient-this at times may be difficult.
The role of the nurse is to anticipate the patient’s pain needs as culturally and religiously it may inhibit them requesting pain relief. She must advocate for the patient for what feels appropriate for him within his cultural context. Find options that are acceptable, incorporate the patient’s belief rather than contradicting them, and determine an intervention that incorporates alternate treatments, spirituality, and other cultural practices.
The nurse can physically relieve pain by promoting comfort, support painful area, and gentleness in handling the patient. She can massage the patient to sooth and relax tense muscles, for nonlocalized pain and musculoskeletal pain. Use nursing treatments, for example, distraction strategies by encouraging the patient to read books, Qur'an, praying and meditating, allowing patient privacy while performing religious rituals, if it helps to give comfort and relieve spiritual pain. If it pleases the patient allow him to listen to music; watch television; allow visits by family, relatives, and friends; and use relaxation techniques.
The nurse can recommend mobilization and manipulation to stretch muscles, move joints, and increase range of motion. Stimulation produced analgesia such as trans-electrical nerve stimulation or acupuncture helps to relieve the pain. Other recommendations include occupational therapy for creative activities to take away the focus on pain. She can also recommend spiritual support to address spiritual pain, social worker to address social pain, psychologist for psychotherapy treatment such as guided imagery or biofeedback, and a psychiatrist if the patient is depressed.
The nurse must relieve both pain and other symptoms because even if pain is relieved if the patient, for example, has nausea he will still be suffering. She must ensure that the patient has good sleep, and she must show kindness and empathize with him. She must understand the problems the patient is suffering from and offer spiritual, social, and psychological support. The nurse must find time to sit, talk, and comfort the patient, give companionship when he feels lonely, and elevate his mood by making him laugh when he feels sad.
The message patients want to hear is that no matter what happens, I will do all I can to help you; you are very important to me. We will take good care of you, we will see you regularly and one of us will always be available. We will deal with any problems that occur. We will relieve your pain and control your symptoms.
The nurse must educate the patient with the aim to return his control, power, and dignity; this prepares him for better participation and care. Therefore, she must teach both pain coping strategies and share professional knowledge. The patient must be taught how to use a pain scale, so that it can help him to know the severity of his pain. She must teach him the necessity of taking analgesics regularly, the cause of pain and the importance of reporting when it starts and not wait until it is severe. She must also teach him the need to report whether the treatment is effective or not and about analgesics, their dosage, how they relieve pain, good effects as well as side effects.
The cancer patient must also be educated on how the drugs and nursing interventions relieve pain. If there is a PRN prescription, he must be informed that he can request for pain relief whenever he has pain. He must be taught how best to cope with pain and the importance of reporting side effects. The nurse must allay the patient’s fears and concerns on addiction, tolerance, and physical dependence and give him written instructions on drugs (which one to take for which symptom), their action, side effects, and whom to contact in case of emergency.
The nurse must be convinced that her patient has a right to good pain relief, speak out for him on issues he wants, believe in or care about. She must contact the physician if inadequate pain relief, provide an articulate assessment of pain, continue collaboration with physicians until the patient is comfortable, and question the use of placebos. The nurse must learn what the patient’s wishes and hopes are and give support to her patient by clarifying information, answering questions, allaying concerns, and supporting the patient’s choices. She must refrain from being judgmental and labeling patients as addicted, malingering, or manipulative.
After administering analgesia or adjuvants to a cancer patient, the nurse must assess pain with a scale to find out the intensity and then compare with the intensity of pain before administration of medication and ask herself certain questions to find its effectiveness. Has it relieved all the pain?-that is the desired effect! Has the dose relieved most of the pain?-Can the patient tolerate the rest of the pain? Has it relieved only a little of the pain? Is there a need to increase the dose? Is there no relief at all? Is there a need to change the drug? Make sure that at least 90% of pain is relieved. If not, inform the doctor to make changes in the treatment to individualize. It is bad enough for the patient to have cancer the least the nurse can do is to make her patient as comfortable as possible. Other questions to ask while evaluating treatment are-Is the treatment safe? Is there any increase in sedation or a decrease in respiratory rate? The nurse must plan to prevent or minimize side effects such as nausea or vomiting, constipation, pruritus, urinary retention, drowsiness, and confusion. If they occur treat immediately to prevent patient distress. Communicate findings and action taken with team members.
When evaluating the overall care, the nurse must ask herself certain questions to find out what is the total effect of all approaches taken to relieve pain. How successful is pain control day after day? What extent is pain relieved throughout-24 hours? What is the effect on patient’s quality of life? What is the effect on patient’s ability to function? Is the patient able to do things he desires? Is the patient satisfied?
Each patient is unique; the process of controlling cancer pain develops differently each time. The nurse’s role is challenging, she must demonstrate that she is not only clinically proficient but culturally competent. She has to use creative assessment skills, clinical judgment, psychological support, advocacy, and good communication skills in such a way that the contribution of drugs, nursing care, nursing, and other nonpharmacological treatments are maximized to the patient’s benefit.
Nurses can make a difference between a patient who suffers until the last breath of his or her life and a patient who is comfortable and dies pain free and in dignity. Yes, we nurses can make that difference and we have to make that difference!!
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