1. Pain Assessment and Management
Lynn Cowling
Macmillan Clinical Nurse Specialist in Palliative Care
Calderdale & Huddersfield NHS Trust

2. Objectives What is pain? Total pain? Cancer pain.
Keys to good pain management.
Types of pain.
Assessment.
Management.

3. What is pain?
Pain is real regardless of its cause; pain is whatever the patient experiencing it says it is and exists where they say it does (McCarthey 1983).
The pain a patient describes may be seen as the tip of the iceburg, underlying this pain is a whole range of factors, physical, emotional, social and spiritual, each inextricably entwined (Saunders and Sykes 1983).
Not only patients with cancer get pain. There are many different conditions, especially in the elderly, that can cause pain and discomfort.
These simple rules can be used to assess and manage any one suffering from pain.

4. TOTAL PAIN PHYSICAL Caused By the illness itself Concurrent illness
Other symptoms
Adverse effects of treatment
Pressure sores weight loss
Constipation muscle tension/spasm
PSYCHOLOGICAL SOCIAL
Anger at diagnosis Worry about family and finances
Anxiety, fear Loss of social position
Disfigurement Loss of role in family
Fear of pain and or death TOTAL Feeling of abandonment and isolation
Feeling of helplessness PAIN Concerns about dependency
Depression Cultural
SPIRITUAL
Why has this happened to me?
Why does god allow me to suffer like this?
What is the point of all this?
Is there any meaning or purpose in life?
Am I being punished for past wrongdoings?

5. Cancer Pain 80% of patients with cancer claim pain as a major symptom.
33% have two pains.
33% have three or more pains.
50-80% of those DO NOT receive adequate pain relief?
Cancer pain can be controlled in 80-90% of patients and ‘acceptable relief is possible in most of the remainder. So why does under treatment remain a problem?

6. KEYS TO GOOD PAIN MANAGEMENT
Understanding of different causes of pain.
Assessment of pain.
Management of pain.
Reassessment and monitoring.

7. Types of Pain There are three types of pain:
Visceral - tumour bulk, bowel obstruction
Bone - replacement of bone by tumour, pathological fracture
Neuropathic - nerve injury or nerve compression

8. The Pains of Malignant Disease
Visceral Deep, dull ache usually over the tumour site
Bone Pain Sharp, may be spasmodic
Neuropathic Pain Injury-Burning, sharp, stinging, stabbing, numb
Compression-Ache, throbbing, stabbing
Headache of Dull, oppressive,
Cerebral Tumour vice-like

9. Assessment (1) Need psychosocial and medical history but also to ask:
Site of pain - where is the pain?
Type of pain – what does it feel like?
Frequency of pain – how often does it occur?
Aggravating factors – what makes it worse?
Relieving factors – what makes it better?

10. Assessment (2)
Disability – How does the pain affect everyday activities?
Duration of pain – how long has it been present?
Responses to previous and current treatments?
Meaning – what does the pain mean to the patient?
If you have a pain assessment tool, use it!

11. PATIENTS THAT HAVE DIFFICULTY COMMUNICATING
Facial expression.
Posture.
Increased agitation or aggression.
Withdrawal.
Change in mood and behaviour.
Guarding one area of body.
Not sleeping at night.

12. WHO Ladder Morphine 10mg every 4 hours +/- Paracetamol
Paracetamol 500mg
+ codeine 30mg
Paracetamol
UNCONTROLLED PAIN

13. CO –ANALGESICS NSAIDs – bone pain, liver capsular pain
Anti-convulsants – neuropathic pain
Anti-depressants – neuropathic pain
Muscle relaxants
Anti-spasmodics

14. Paracetamol
Opioids
Weak
Strong
Adjuvants
Anti depressants
Anticonvulsants
Antispasmodics
Muscle relaxants
NSAID

15. Methods of Administration
Oral
Rectal
Subcutaneous
Spinal
Tens
Patch
Nerve Blocks
Surgery
Radiotherapy
Chemotherapy
NO IM OR IV DRUGS

16. ANALGESIA (1) Regular doses of analgesia must be prescribed
Adequate doses of analgesia on an ‘as required basis’ (PRN), in addition to the regular medication must be made available
Where possible give analgesia by mouth, by the clock and by the ladder

17. ANALGESIA (2)
Pain that does not respond to oral medication is unlikely to respond to analgesia given by a different route e.g. SC, IV unless there are absorption problems
Review the effectiveness of any medication on a regular basis
Ensure all patients on a step 2 or 3 analgesic are on regular laxatives and that the effectiveness of the laxative regime is being monitored

18. Other Pain Control Measures
Remember the role of-
Explanation
Psychological support
Rest
Relaxation
Adequate sleep
Heat pads
TENs machine and massage
Self-help measures

19. Alternative Opioids
Oxycodone
Hydromorphone
Fentanyl
Methadone

20. THE KEYS TO GOOD PAIN ASSESSMENT AND MANAGEMENT ARE:
Understanding the meaning of whole pain.
Understanding of different causes of pain.
Assessment of pain.
Management of pain.
Reassessment and monitoring.

21. THANK YOU