2 Last Class: Discuss the goals of chemotherapy. Describe the agents used in chemotherapy, including classification, methods of administration and side effects.Describe the nursing management of side effects of chemotherapy
3 Today’s Objectives:Describe radiation as a modality for cancer treatment, and the uses of radiotherapyIdentify factors affecting cell response to radiotherapy.Discuss the principles of radiation protectionDescribe the types of radiation therapy and related nursing care.Discuss side-effects of radiation therapy and nursing care.
4 Today’s Class: Define pain Outline the pathophysiology of pain Discuss the concept of “total pain”Compare and contrast acute and chronic painDiscuss the different classifications of pain and common descriptors.Describe the WHO analgesic ladderDescribe common assessments and interventions for painRead Chapter 13 Text
5 Pain DefinitionDifficult to describe b/c it is such a multi-dimensional phenomenon. According to International Association for the Study of Pain:“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
6 Pain DefinitionMcCaffrey’s definition addresses the subjectivity of pain ….“whatever the experiencing person says it is and existing whenever the person says it is”
7 Facts About Pain: Pain is always subjective. The severity of pain is not in linear relation to the amount of tissue damageMany factors influence a person’s perception of pain, including:FatigueDepressionAngerFear & anxiety (including past experience with pain)Feelings of helplessness and hopelessness.Pain tolerance
8 Total Pain Seven “P’s”: Physical Pain Intellectual Pain Emotional pain Interpersonal painSpiritual PainFinancial PainBureaucratic PainPain does not occur in isolation. There are multiple dimensions that can cause or worsen the experience of pain and the pain experience can impact on other dimensions to increase overall suffering.Some of these include;Physical Pain – actual physical pain from any sourceIntellectual Pain- knowledge, memory, self-control, looking aheadEmotional pain- feelings such as anguish, anger, lonlinessInterpersonal pain- strain among family members or othersSpiritual Pain- facing death, after-life, meaning, faithFinancial Pain- disability, loss of work, actual cost of careBureaucratic Pain- frustrations of forms, people, visits, departments, rulesOther factors- Age, Gender, Expectations & placebo effect
9 Pathophysiology of Pain Transduction – initial pain stimulus triggers action potentialTransmission – action potential travels from the site of damage to spinal cord and brainPerception – the conscious perception of painModulation – inhibition of pain impulseTransduction – noxious stimuli (can be chemical, mechanical) causes cell damage which results in the release of sensitizing substancesTransmission – pain impulse travels to spinal cord and brainModulation – inhibition of pain impulse through release of substances such as serotonin, norepinephrine, and endogenous opioids ( e.g.endorphins & enkephalens).Perception – the conscious perception of pain
11 Types of Pain May be Acute or Chronic Acute Pain Short duration (<6 mths)Immediate, identifiable onset (surgery)Limited & often predictable durationOften described as “sharp”, stabbing”, “shooting”SharpStabbingShooting
12 Chronic Pain Three types: chronic non-malignant (low back pain), chronic intermittent (migraine headaches), chronic malignant (cancer-related pain)Characteristics of chronic pain:Lasts long periods of time(months to years)Is not readily treatablePain that is constant, continuous, & moderate is described as “difficult to bear”Often associated with withdrawal & depression
13 Cancer-Related PainMalignant pain has characteristics of both acute & chronic pain.Moderate to severe pain occurs in 30% of clients receiving treatment and in 60-90% in clients with advanced diseaseSources of pain in persons with cancer:The cancer itself %Related to cancer or debility (i.e. muscle spasms, constipation) %Related to treatment (i.e. mucositis, incisional pain) %Concurrent disorder (i.e. arthritis) %This category includes neuropathic, deep visceral and bone pain. Each type of pain is best managed with strategies specific to it.Pain can be completely relieved in 80-90% of clients and an acceptable level of relief can be achieved in most of the rest.
14 Remember that…..A receptor is any functional macromolecule in a cell to which a drug binds to produce an effectThe term affinity to a receptor means the strength of attraction between receptor and drug
15 Pain:Pain - is a perceptual interpretation of nerve activity that reaches consciousness.
16 Pain can be classified according to pathophysiologic mechanism: Nociceptive pain: pain that arises directly from chemical, thermal or physical stimulation of normal nerve endings.Neuropathic pain: results from injury to a nerve or from abnormal nerve function at any point along the line of neuronal transmission from the most peripheral tissues to the CNS.Nociceptors are specialized cells that respond to noxious stimuli.Nociceptive pain: it is the result of tissue damage, and the “pain message” travels from pain receptors (nociceptors) in peripheral tissue along intact neurons. Nociceptive pain comprises somatic and visceral pain
17 Nociceptive Pain Types: Somatic (superficial)Visceral (deep)Somatic pain originates in skin, bone, joints, muscles, or connective tissue.Visceral (deep) originates in the organs (lungs, GI, GU tract)Pain can be classified according to the pathological process and clinical characteristics of the painNociceptive pain is a result of an injury or insult to non-neurologic structures and occurs in the presence of an intact nervous system. Nociceptive pain can be further classified into visceral, bone, soft tissue, and muscle pain.
18 Somatic PainOriginates in bones, joints, muscles, skin or connective tissueUsually localized & non-radiatingOften described as sharp, deep, dull, aching, throbbingConstant or intermittentOften worse with movementPalpation of area usually elicits painNSAIDs should be considered in any patient with bone pain. Often combined with opioidsExamples bee sting, sunburnSomatic or superficial pain originates in the skin, bone, joints and connective tissuesIt is usually localized and non-radiatingOften described as sharp, deep, dull, aching or throbbingConstant and intermittentOften worse with movementPalpation of area elicits painNSAIDs should be considered in any patient wi bone pain; often in combination with opioids.
19 Visceral pain Originates in cardiac, lung, GI or GU tract tissues Is more diffuse over the viscera involvedCramping, gnawing or colicky pain associated with obstruction of hollow viscusOften referred to cutaneous sitesOther visceral tissues, pain described as aching, stabbing, or throbbing, spasm, cramping, pressure.Ex. Acute appendicitis, cholecystitis, bowel obstructionBowel obstruction e.g.Visceral or deep pain originates in the cardiac, lung, GI and GU tract tissuesIt is more diffuse over the viscera involvedIt is often described as cramping, gnawing, colicky pain that is associated with obstruction of hollow viscusOften referred to cutaneous sitesOther visceral tissues, pain described as aching, stabbing, throbbing, spasms, cramping, pressure
20 Neuropathic PainResults from abnormal sensory processing which occurs after damage to a nerve, the spinal cord or brainBurning, deeply aching that may be accompanied by sudden, sharp, lancinating painOften distributed along a dermatome or peripheral nerveNumbness or tingling over the skinHyperesthesia over an area of the skinSevere pain from the slightest pressure or touchEx. Phantom limb painNeuropathiic pain occurs as a result of neural injury and abnormal or pathologic transmission, processing and integration e.g. phantom limb pain
21 Pain relief can be accomplished by: Preventing activation of nociceptive receptors in the peripheryPreventing transmission of electrical signal along a pathwayPreventing transfer of the signal from one neuron to anotherNSAIDS act at the peripheral level whereas opioids act centrally.NSAIDS are drugs that inhibit prostaglandin synthesis involved in the production of pain and inflammation.Opioids prevent the release of substance P.
22 Methods for Pain Control Nonopioid analgesicsOpioid analgesicsAdjuvant drug therpyRadiation therapyChemotherapyHormonal therapyAnesthetic proceduresNeurosurgical proceduresPsychosocial interventions
23 Radiation Good to excellent relief in: Painful bone metastases Acute spinal cord compressionChest pain 2ndary to bronchial carcinomaDysphagia due to esophageal cancer
24 Chemotherapy May provide excellent pain relief in responsive tumors Usually administered in oral formulations when possibleSingle agents with lowest toxicity are usedAdministered in short courses
25 Hormonal therapyIs used primarily for cancers arising in cells that have an endocrine function (breast, endometrium, prostate)Hormonal therapy to relieve pain is most likely to be effective in carcinoma of the prostrate.Bilateral orchidectomy brings relief of bone pain in 60-80% of clients within hours of surgery & may last up to 2 years
26 Palliative surgery Indicated for: Stabilization of long bone with mets to prevent a pathological fractureDecompression of the spinal canal to prevent impending paralysisRelief of bowel obstruction in selected patients
27 Anesthetic & Neurosurgical Procedures Anesthetic procedures are most helpful in treating well-localized somatic or visceral pain.Procedures include injections, inhalation of nitrous oxide, epidural infusion with opioids or local anesthetics.Neuroablation involves interruption of specific nerve tracts
28 Physical/non-pharmaceutical Methods Local heatLocal cold applicationsMassageTENSVibration therapyAcupunctureExerciseLocal heat: joint stiffness, muscle spasms- wrap hot packs in towels to prevent burning-do not apply to areas exposed to radiationLocal Cold application: may relieve burning or muscle spasm when heat is ineffective-wrap in towel to prevent skin irritationMassage: comfort measure;- terminally ill clients generally do not tolerate deep or vigorous rubsso light message with baby oilTENS: mild to moderate pain due to nerve compression, neuralgia, bone pain from metsVibration therapy: not understood – indicated for pain in nerves or muscles-works best at frequency around 100 Hz- apply distal to painful siteAcupuncture –may be helpful for painful; muscle spasms, bladder spasmsExercise – to maintain muscle strength, joint mobility, coordination and balance. (active then passive if possible)
29 Psychosocial Interventions The goal of most psychosocial interventions is to help the client regain a sense of control that has been under-mined by illness and pain. These include:Education and accurate information about pain, pain control, & common misconceptions about the use of opioids (fear of addiction, side effects..)
30 Psychosocial Interventions Con’t Relaxation techniques (focused breathing, meditation)Guided imageryHypnosisMusicHumorTherapeutic touchMusic, humor are thought to stimulate the release of endogenous opioids,Therapeutic touch realigns a person’s energy field to return it to normal.
31 ABCDE’s of PainA- Ask about the pain regularly. Assess pain systematicallyB- Believe the patient and family in their reports of pain and what relieves it.C- Choose pain control options appropriate for the patient and family, and setting.D- Deliver interventions in a timely, logical , and coordinated fashionE- Empower patients and their families. Enable them to control their course as much as possible
32 Pay Attention to Detail: Take nothing for grantedBe precise in history takingExplore the client’s “total pain”Determine what the person knows about the situation, what s/he believes and fears about pain and the things that can relieve itMake sure instructions are precise and written down
33 Pain Assessment “Tell me about your pain” Why is it important to pay attention to the words the patient uses to describe the pain
34 Pain Assessment How intense is your pain? Use a pain scale Where is your pain?How long does it last?What makes it better or worse?How does the pain affect your sleep, appetite, energy, mood, relationships, daily activities?
35 Pain Assessment Are you having any other symptoms? What do you think is causing the pain?What medications are you taking for the pain?Do have any concerns about medications?What are you doing to try to relieve the pain?Do you have support from family and friends?
36 Pain Assessment What investigations have been done? X-rays CT scan Bone scanBlood work
38 Subjective tools such as the Visual Analog Scale (VAS) and the Faces Scale are used to assess pain. The VAS is a straight horizontal 100 mm line anchored with "no pain" on the left end and "worst possible pain" or "pain as bad as it could possibly be" on the right. Clients are asked to choose a position on the line that represents their pain.The Faces Scale depicts facial expression on a scale of 0-6, with 0=smile, and 6=crying grimace. Clients should choose a face that represents how the pain makes them feel.The VAS is particularly useful for children, elderly and the cognitively impaired.
39 The African-American version of the Oucher was developed and copyrighted by Mary J. Denyes, PhD, RN, Wayne State University School of Nursing, and Antonia M. Villarruel, PhD, RN, currently of the University of Pennsylvania.The tool was photographed at the Children's Hospital of Michigan, Detroit.
40 What if your client is cognitively impaired? Unable to communicte verbally?
41 Behavioral Cues Non-verbal cues include: Decreased activity or restlessnessFurrowed browGrimacingCrying, moaningWithdrawal from interacting with each otherGuarded or stiffened postureirritabilityPhysical signs include increased BP, rapid pulseAscertain if the patient has a condition that might cause pain. Determine whether the patient has been treated for pain before, and if so, which treatment regimen was most effective. Attempt to obtain nonverbal feedback from the patient to signal the presence of pain (such as head nodding or eye movements). Ascertain the behaviors the patient usually exhibits when in pain. (This information may need to be obtained from family, friends, or other health care providers.) If there are signs of acute pain or reasons to suspect its presence, treat with analgesics, nonpharmacologic interventions, or both. Continue any pharmacologic and nonpharmacologic interventions that appear to result in pain relief. If a behavioral cue persists or intensifies, rule out other causes (such as delirium, adverse effects of treatment, or accumulation of drug metabolites) and focus treatment on the known or suspected cause. Assess family members' and primary caregivers' interpretations of the patient's behavior. If they believe the patient is still in pain, ask why.
42 WHO General Principles of Pain Management By mouthBy clockBy the ladderFor the individualUse of adjuvantsAttention to detailsBy mouthSpares the client painful injectionsGives clients more control over the situationFixed dose around the clockClients hesitate to use meds on a PRN basis “I’ll wait a little longer”Scheduled dosing ensures that the next dose is given before the last dose wears off.When pain is allowed to reemerge before next dose, the client experiences needless suffering and tolerance is more likely requiring escalating doses.Use of AdjuvantsTo enhance analgesic effects (I.e. coticosteroids, anticonvulsants)To control adverse effects of opioids (antiemetics & laxatives)To manage symptoms that contribute to client's pain (anxiety, depression, insomnia)Best Practice!
43 WHO 3-step Analgesic Ladder The WHO has developed a three-step analgesic ladder to guide the use of drugs in treating cancer painFirst step: non-opioid drug with/without adjuvant drug as requiredSecond step: add a weak opioid for mild to moderate pain, with adjuvant drugs as requiredThird step: a strong opioid should be substituted for the weak.know
44 WHO Ladder: outlines pain management principles. The WHO ladder outlines pain management principles. The following guidelines for pain management in palliative care can help nurses understand how to put these principles into practice.Perform a basic assessment of the patient's pain and evaluate its effects on the patient's quality of life. Titrate analgesics according to goals of care, pain severity, need for supplemental analgesics, severity of adverse side effects, measurements of functional abilities (such as interaction with others, mobility, and sleep), emotional state, and effects of pain on quality of life.Use sustained-release formulations and around-the-clock dosing for continuous pain.Treat breakthrough pain with immediate-release formulations.Monitor the patient's status frequently, especially during dose titration.Anticipate adverse effects and prevent or treat them as necessary.Be aware of possible drug-drug and drug-disease interactions.Reassess pain regularly. Determine what level of pain is acceptable to the patient. If pain is not relieved adequately, don't give up. Consult resources outside your institution, including nursing colleagues and experts in related disciplines.
45 A Stepped Approach Step Three Severe pain (6-10 / 10) Morphine, hydromorphone, methadone, fentanyl, oxycodone ± adjuvants ± nonopioid analgesicsStep TwoModerate pain(3-5 / 10)Acetaminophen with codeine, acetaminophen or ASA with oxycodone ± adjuvants ± nonopioid analgesicsStep OneMild pain(1-2 / 10)Acetaminophen, NSAIDs ±adjuvants
46 Nonopioid Analgesics – Acetaminophen Effective for mild painNo anti-inflammatory effectUsual adult dose mg po q4h (maximum 4000 mg daily)Often combined with opioids
47 Nonopioid Analgesics – NSAIDs Act by inhibiting prostaglandinsAnalgesia and anti-inflammatory actionAppropriate for mild to moderate painEffective adjuvants for bone painSide effect profiles vary between agents within the classGastroprotectants may be necessaryUse cautiously in patients with renal insufficiencyDue to ↓ platelet aggregation, NSAIDs should be avoided in patients at risk of thrombocytopenia
48 Opoid AnalgesicsAct primarily by stimulation of receptors in the brainAre the mainstay of cancer pain management of moderate to severe intensityUse the oral route whenever possibleUse the SC or IV route for rapid pain relief or if the patient is not able to take medications orallyAll parenteral opioids can be given SCIM injections not recommended
49 Opioid Analgesics – Choice of Agent Start with morphine (unless contraindicated) as most patients will achieve pain control and it is easily available in multiple doses and dosage routesHydromorphone and fentanyl may be preferred in the elderlyOxycodone, fentanyl and methadone may be safer in patients with renal failureAvoid meperidine/Demerol
50 A word about meperidine! Useful for short term acute care.Has a long half-lifeThe metabolite of meperidine is associated with many adverse effects and may reach toxic levels, leading to CNS excitation or even seizures.Sphincter of Oddi is sensitive to all narcotics.Gradner, A. (2002). Merperidine: Time for a change. The Distillate, 27(4)PS!
51 Sphincter of Oddi: is sensitive to narcotics PS!Sphincter of Oddi: is sensitive to narcoticsThe sphincter of Oddi is a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the first part of the small intestine (duodenum).Narcotics cause spasms of the spinchter of oddi. The spasms cause a back-up of these digestive juices the result being episodes of severe abdominal pain.
52 Equianalgesic Doses and Half-Lives of Selected Morphine-Like Agonists
53 Equianalgesic Conversion Table Source: Texas Children's Cancer Center. (n.d.). Equianalgesic conversion guide. Available at: and Global RPh.com. (n.d). Narcotic analgesic dosage conversion chart. Available at:
54 For the Individual Requirements vary deeply The average person will require 60 to mg of oral morphine per daySome will require less opioidA small % may require very high doses (>2000mg/day)The dose of analgesic must be titrated against the particular patient painFor the individualRequirements vary tremendously depending on the individualThe dosage must be titrated against the particular client’s painFactors Influencing effectiveness of analgesics:Relative analgesic potencyDuration of actionOral potency
55 Use of AdjuvantsEnhances the analgesic effect (steriods, anticonvulsants)Controls the adverse effects of opiods (e.g. antiemetics, laxatives)To manage symptoms that are contributing to the client’s pain (anxiety, depression, insomnia)See page 492 for more discussion
56 So where do we start? Aim for graded relief Start with a specific drug for a specific painChoose an appropriate route of administrationTitrate the dosage of opioidsProvide for rescue dosesAnticipate and treat side effectsInitial goal is a pain free night’s sleep to break the cycle of pain = insomnia=exhaustion=increased pain. Next step would be relief of pain at rest, then during weight bearing and movement.E.g. Aches = acetaminophen; neuropathic pain=opioid + dexamthasone or opioid + amitriptylineNeed to look at potency of delivery routeFor opioid-naïve clients:- 1st day give immediate-release morphine 7.5mg q4h- 2nd day add total dose taken during previous 24 hours, divide by two to arrive at bid doe of controlled release.5. Rescue dose may be 5-15% of 24 hour amt. Of 24 hour dose of morphine, usually Q1h6. Side effects include constipation (bowel protocol).Nausea/vomiting, etiology is the effect of opioids on CTZ in the medulla, increased vestibular sensitivity, and delayed gastric emptying.Sedation, generally subsides 2-3 days.Confusion & hallucinations, are the most temporary (ARE THERE OTHER CAUSES? Renal failure?) Active metabolites of morphine can cause confusion in clients with impaired renal function.Prutitus caused by histamine result. Treat with haldol or antihistamine.Respiratory depression: “arousable factor” is a satisfactory guide. Naloxone (Narcan) is an opiate antagonist.
57 Attention to Detail Take nothing for granted Be precise in history takingExplore the client’s “total pain”Determine what the person knows about the situation, what s/he believes and fears about pain and the things that can relieve itMake sure instructions are precise and written down
58 Initiating An Opioid Assess the level of pain Start with an immediate-release preparation, q4h around the clockFollow a titration schedule to establish pain controlBreakthrough doses of the same opioid (immediate-release only) should be providedWhen pain is controlled, convert to a sustained-release product
59 Side Effects of Opioids CommonLess FrequentRareConstipationNauseaGI UpsetSedationDry MouthUrinary retentionPruritusSevere myoclonusConfusionHallucinations, nightmaresPostural hypotensionVertigoRespiratory depressionAllergy
60 Use of AdjuvantsEnhances the analgesic effect (steriods, anticonvulsants)Controls the adverse effects of opiods (e.g. antiemetics, laxatives)To manage symptoms that are contributing to the client’s pain (anxiety, depression, insomnia)
61 Ongoing Assessment Important! Pain is a dynamic process and may change from hour to hour!New pains, disease progression, a treatable acute problem may arise.Pain assessment must be documentedAssess for tolerance:the need to increase dosage of a drug over time to maintain a given level of analgesia. (rare)In a study of 1000 persons with advanced cancer – only 5% required an average daily dosage increase of more 10% of previous dose.
62 Factors Affecting Pain Situational factorsSociocultural factorsAgeGenderMeaning of painAnxietyPast experience with painExpectations & placebo effectPage 476 of med/surg text.
65 Rural clients (access) Elderly (natural part of aging? Difficulty describing pain?Cultural differencesEthnic minorities, lower income bracketsGender - womenReligious beliefs (positive & negative impact)Cultural differences include language barriers, variations in the expression and tolerance of pain.Studies demonstrate that:Clients from minority groups may mistrust the health care system b/c of previous traumatic experiencesPhysicians had negative stereotypes about African Americans and people of low socioeconomic status.Intelligence, likelihood of risk-taking behaviors, ability to comply with medical advice was based on race.SES was associated with perception about personality, abilities and behavior.Females are more likely to experience inadequate pain management due to 1) perception that women complain more 2) inaccurately report pain 3) are able to better tolerate pain 4)have better coping skills than men.Religion: increased sense of well being and support; “God is punishing me”
66 Barriers to Pain Management HCPs & FamiliesLack of education about pain management from health professionals.Poor communication (subjectivity)Personal BarriersStigma associated with use of narcoticsFear of addictionSide effectsNeed to be “good patient”Fear it will impede progressFear of injections
67 Barriers to Pain Management Health Care System FactorsPain not recognized as a major management priority in pastLack of prescription drug coverage for many peopleRestrictions on prescriptions for narcotics
68 Health Care Professionals Lack of educationFear of regulatory scrutinyConcerns about addiction and respiratory depression from opioidsPoor pain assessment skillsConcerns about people seeking drugs for illicit use
69 Patients and Family Fears about the meaning of the pain Strong views on the use of opioidsThe belief that pain is a “normal” part of the illnessPast experiences with painCultural, or religious beliefsDenial of disease or disease progressionFears about constipation, addiction, sedation, cognitive changes