NURS 340 Unit 1: Oncology Part 1: Prevention, diagnosis, treatment & complications Cancer Group of more than 200 diseases Characterized by uncontrolled and unregulated growth of cells Occurs in people of all ages 77% of cases are diagnosed in those over age 55 Mortality rates are declining Incidences of lung, colorectal, breast, and oral cancer have ↓ Largely due to preventive efforts Other cancers have ↑ Lymphomas, kidney, thyroid, pancreas, liver cancer, skin cancers What do you remember from Patho? Benign? Malignant? Prevention and Detection of Cancer Lifestyle habits to reduce risk Know your family history Eat properly Exercise regularly Rest Avoid stress Reduce / avoid exposure to cancer causing agents Physical exams and self-examinations American Cancer Society Resource: http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/american-cancer-society-guidelines-forthe-early-detection-of-cancer What are the 7 warning signs of cancer? Cancer diagnosis? What would be important questions/data to gather related to the following? Past Medical History Current medical history Risk factors Physical exam Diagnostics Radiographic tests X-ray MRI CT Ultrasound Mammography PET scan Direct visualization Colonoscopy Endoscopy Surgical Biopsy Biopsy & Diagnosis Excisional biopsy Complete removal Incisional biopsy Removal of a portion of a lesion Core needle biopsy Needle biopsy Guided by ultrasound/CT Fine needle aspirate Obtains cells Exfoliative cytology Cells shed from a surface Diagnostics Laboratory tests CBC BMP Liver function studies Genetic tests Tumor marker tests Pathology Histology Bone Marrow Biopsy Staging: T2, N1, M0 testicular cancer. What does this mean? Staging: Roman Numerals Stage I Low end of the scale Usually designates localized disease Usually encapsulated or well defined Stage II Limited local spread Stage III Extensive local and regional spread Stage IV High end of the scale Indicates disseminated disease Putting it all together: Stage II, T2,N1,M0 Clinical examination shows evidence of local spread into surrounding tissue and first-station lymph nodes. Usually operable and resectable, but uncertainty as to completeness of resection Good chance of survival Metastasis Spread of cancer to a distant site Lymphatic route Hematogenous route Starts with the tumor penetrating the blood vessels to enter circulation Goals of Cancer Treatment Surgery Chemotherapy Effect on cells Effective against dividing cells, Mutation of cancer cells can result in resistance to chemotherapy Multiple drugs that work at different places in the cell cycle can more effectively kill cancer cells Two major categories Cell cycle phase nonspecific Cell cycle phase specific Effects on Normal Tissue Chemotherapy agents cannot distinguish between normal and cancer cells Side effects are the result of the destruction of normal cells General and drug-specific adverse effects are classified Acute Delayed Chronic Chemotherapy: Treatment Plan Drugs given in combination Dosages are carefully calculated according to body surface area Regimens involve drugs with different mechanisms of action and varying toxicity profiles Preparation & Handling of Chemotherapy Agents May pose an occupational hazard Drugs may be absorbed through Skin Inhalation during preparation, transportation, and administration Only properly trained personnel should handle drugs Methods of Administration Oral IM IV (most common) Intracavitary Intrathecal Intraarterial Subcutaneously Transdermal Injury Due to Chemotherapy Radiation Therapy Radiation is the emission of energy from a source and travels through space or some material Different types of ionizing radiation are used to treat cancer Radiation is used to treat a carefully defined area of the body Not a primary treatment for systemic disease May be used by itself, or with chemotherapy or surgery To treat primary tumors For palliation of metastatic lesions Radiation Therapy External Radiation Internal Radiation Biologic & Targeted Therapy Immune Therapy Examples: Monoclonal antibodies (MAB) Epidermal growth factor receptor (EGFR) Vascular endothelial growth factor (VEGF) Other Treatments Hematopoietic Stem Cell Transplantation Bone marrow transplantation Allogeneic Umbilical cord blood Donor Blood Syngeneic Autologous Alternative Therapy Hormonal Therapy Drug manipulation of hormones Surgical interventions Nursing Implications: Management of Adverse Effects & Complications of Treatment Complication of Treatment: Bone Marrow Suppression Myelosuppression Neutropenia Thrombocytopenia Anemia Pancytopenia = all components are low Nadir Signs & Symptoms Bruising / bleeding Shortness of breath Temperatures Risks Nursing Interventions Neutropenic Precautions Neutropenia Condition of marked decrease in circulating neutrophils Results from cancer pathology or treatment NADIR Absolute Neutrophil Count (ANC) ANC <1000/mm3 = Moderate risk ANC <500/mm3 = Severe risk ANC <100/mm3 = Extreme Risk Precautions Single rooms No flowers Food preparation Masking Sepsis, Septic Shock & DIC Related to overwhelming infection Often neutropenic, so patients don’t display “usual” signs of infection Complication: Fatigue Signs & Symptoms Tired Unable to participate in activities Monitor Assess for reversible causes Risks Ignoring fatigue can cause increased symptoms Stress Nursing Interventions Education: common side effect Rest periodically Walk or other light activity Complication: Gastrointestinal Effects & Mucosal Reactions Signs & Symptoms Nausea Vomiting Diarrhea Stomatitis Monitor Risks Weight loss / dehydration Skin issues Swallowing issues Dysphagia Odynophagia Pain Nursing Interventions Anti-emetics Low fiber, low residue diet Monitor skin Small frequent meals (high calorie, high protein) Encourage fluids Skin Complications Signs & Symptoms Wounds Rash / redness Hair loss Risks Skin breakdown Dryness Photosensitivity Hyperpigmentation Weeping Nursing Interventions Gentle skin cleansing Avoid tight clothing Gentle detergents Avoid sun exposure Creams Emotional support for hair loss Complications of Other Systems Reproductive Cardiac Pulmonary Renal Cognitive “Chemo brain” Oncologic Emergencies Superior Vena Cava Syndrome Hypercalcemia Third Space Syndrome Spinal Cord Compression Oncologic Emergencies Tumor Lysis Syndrome Potentially Fatal Rapid destruction of tumor cells Hyperkalemia Hyperphosphatemia Hypocalemia Hyperuricemia Carotid Artery Rupture Cardiac Tamponade Cancer Pain Inadequate pain assessment is the single greatest barrier to effective cancer pain management Fear of addiction is unwarranted Numerous drug options for pain management Determine Visceral Bone Neuropathic Somatic Nursing Considerations Patient education Treatment Management Symptom management Nausea, Vomiting Diarrhea, Constipation Alopecia Fatigue Stomatitis Pain Skin integrity Psychological Issues Genetic testing End of life issues Issues of Survivorship Fear of recurrence Sexuality Pain Re-entry into “normal” life Nutrition Exercise Lymphedema Insurance Leukemia, Lymphoma, Multiple Myeloma Leukemia Leukemia Results in an accumulation of dysfunctional cells because of a loss of regulation in cell division Occurs in all age groups Classification: acute vs. chronic Clinical Manifestations Weakness Pallor Fever Petechiae Bruising Enlarged lymph nodes Joint / bone pain Enlargement of spleen and liver Diagnostic Studies Bone Marrow Biopsy Laboratory Decreased RBC, Hgb, Hct, Platelets WBC can begin normal, low, or elevated higher the WBC, the poorer the prognosis Cytogenetic Study - Labs look at chromosomes Chest X-Ray - will show swollen lymph CT scans Lumbar Puncture Treatment Chemotherapy: Stages Induction Therapy Post-induction therapy Maintenance Therapy Radiation Bone Marrow Transplant Lymphoma Lymphomas Two major types of lymphoma Hodgkin Lymphoma Non-Hodgkin Lymphoma Hodgkins Lymphoma Characterized Called Reed-Sternberg cells Peaks by abnormal giant cells in two age groups Teens / young adults Adults ages 50-60 Long term survival Hodgkin’s: Clinical Manifestations Onset is usually gradual Weight loss Fatigue Weakness Fever Chills Tachycardia Night sweats Hodgkin’s: Treatment & Care Diagnosis / Treatment Lymph node biopsy Peripheral blood Bone marrow biopsy Xrays, CT, PET Depends on stage Combination chemo Possible radiation After remission consider Bone Marrow Transplant Nursing Implications Complications of treatment Side effects of treatment Risk of secondary malignancies Spiritual issues Fertility Non-Hodgkin’s All ages are affected Several categories divided into 2 large categories Low grade High grade (aggressive) Non-Hodgkin’s: Clinical Manifestations Spread is unpredictable Lymph node enlargement Can manifest in nonspecific ways Non-Hodgkin’s: Treatment & Care Diagnosis / Treatment Same diagnostics as Hodgkin’s Additional studies may be need if patient has extranodal sites Chemotherapy & Immunotherapy Radiation Bone Marrow Transplant Nursing Implications Complications of treatment Side effects of treatment Risk of secondary malignancies Spiritual issues Fertility Multiple Myeloma Group of plasma cells becomes cancerous Symptoms may not be present or may be non-specific Loss of appetite, bone pain, fever, skeletal pain Pain triggered by movement Destroys bone Risk for pathologic fractures Monoclonal protein Renal insufficiency/failure Hyperviscosity Multiple Myeloma Immunodeficiency Infection Marrow Infiltration Anemia Cytokine release Bone pain Bone destruction Hypercalcemia Treatment & Care Treatment Chemotherapy Radiation Steriods Medications Nursing Implications Zometa Bone Marrow Transplant Pain management Fracture risk Prompt treatment of infection Management of side effects from treatment Leukemia, Lymphoma, Multiple Myeloma Case Study #1 Case Study Patient Profile: James Johnson, 28-yearold man, had a bad fall while hiking in the nearby hills He comes to the ED today because of severe bruising from the fall Case Study Subjective Data: Complains of oral pain and white patches covering his tongue Has had a 2-month history of extreme fatigue, malaise, and flu symptoms Complains of shortness of breath and his heart bounding Has taken numerous prescribed antibiotics and increased rest and sleep in the past 2 months without relief of symptoms Case Study Physical Examination Bruises and ecchymosis present from fall Gingiva has petechiae and patchy white spots Temperature 102.2° F, respiratory rate 26/min, pulse 110/min Has splenomegaly Case Study Blood is drawn in the ED and the patient is admitted to the medical-surgical unit Laboratory Results Hct 20% Hgb 6.9 g/dL WBC count 120,000/µL Platelet count 25,000/µL Case Study What component of the laboratory tests results most highly suggest acute leukemia? What further diagnostic testing should be ordered? Case Study Diagnostic Results Results show multiple myeloblasts (>50%)—Confirms AML How is acute leukemia treated? Case Study What are the priority nursing interventions? What are the priorities for patient teaching with a newly diagnosed person with leukemia? Practice Question James becomes fatigued after starting chemotherapy. He wants to know if he can exercise. What is your best advise? A: Exercise is not recommended during treatment of leukemia. B: Exercise can deplete energy stores during chemotherapy and should be discouraged. C: Exercise can be regarded as beneficial for individuals with cancer-related fatigue during therapy. D: Exercise will increase the risk of injury and should be postponed until after all cycles of chemotherapy are complete. Practice Question A nurse is caring for a client who has leukemia and has developed thrombocytopenia. Which of the following actions should the nurse take first? A: Monitor platelets B: Encourage the client to cough, turn, and deep breathe every 2 hours C: Plan for the client to take rest periods throughout the day. D: Assess a temperature every 4 hours Case Study Continued… James was transferred to the oncology unit of the hospital. He is to receive cytarabine (Cytosar) as a continuous infusion for 7 days and idarubicin IV push for 3 days. He has a hickman cather placed prior to beginning therapy, On the 5th day of continuous infusions of cytarabine (Cytosar), the patient develops a fever of 101F. Vitals are: 110/54, 115, 26. The patient also reports severe nausea. The RN notifies the resident physician and evaluates the patient. Case Study Continued… The resident orders: Blood cultures x2 Acetaminophen suppository 650 mg every 4 hours PRN Imipenem / Cilastatin 500 mg IV piggyback every 8 hours Do these orders seem appropriate for this patient? Why or why not? Case Study Continued… On the last day of continuous chemotherapy, the patient’s CBC shows the following: Lab Patient Results Normal Values WBC 1.5 4.5-11 ANC 500 >1000 Hgb 6.5 12-18 Hct 20 36-54 17,000 150,000-400,000 Platelet What does this count indicate about his immune system? What might you anticipate for interventions and/or cares for this patient? Practice Question What treatments are commonly used to treat leukemia in hopes of achieving remission? (Select all that apply) A: Hematopoietic Stem Cell Transplantation B: IV administration of packed red blood cells C: Chemotherapy agents D: Epogen (epoetin alfa) E: Internal radiation therapy Case Study Human lymphocyte antigen (HLA) typing has been performed on all siblings. The patient’s oldest brother is a perfect match and has agreed to donate bone marrow cells. The patient is to be readmitted to the Transplant Unit within the next few weeks. Explain the procedure to the patient. What type of bone marrow transplant will he have? Case Study #2 Case Study Ned Larson is a 74year-old man who visits his primary care physician with GI complaints Enlarged cervical lymph nodes are noted on assessment Case Study What lab work would you expect to be ordered? Why would a CT scan, lymph node biopsy, and PET scan be ordered? Case Study Ned is diagnosed with non-Hodgkin’s lymphoma What is his primary treatment option? Would there be other treatment options available to him? Case Study #3 Monoclonal protein Renal insufficiency/failure Hyperviscosity Multiple Myeloma Immunodeficiency Infection Marrow Infiltration Anemia Cytokine release Bone pain Bone destruction Hypercalcemia BREAST & REPRODUCTIVE CANCERS • Alice • 68-year-old • Found large lump in her right breast while showering MEET THE PATIENT • “My breasts are typically lumpy, but this feels different.” • PMH: DM (Type 2), HTN, stress incontinence, osteoarthritis, no surgical history • Menarche age 11; Menopause age 53 • Two adult daughters and one adult son BREAST DISORDERS • Fibrocystic breast alterations—characterized by changes in tissue (benign condition) • Fibroadenoma—small, painless lumps, well-delineated • Intraductal papilloma—benign, soft wart-like growths in mammary ducts • Ductal estasia—nipple discharge not associated with malignancy • Malignancy YOU’RE THE NURSE • What questions would you ask Alice? • What will you include in your physical assessment of Alice? • What are you looking for? DIAGNOSTICS • Mammography • Method used to visualize the breast’s internal structure • Digital mammography – very sensitive • Ultrasound • Used in conjunction with mammography • MRI (of breast) • Additional screening tool if at increased risk of breast cancer • Breast biopsy • Needed for diagnosis • Estrogen / progesterone receptor status THE RESULTS ARE IN… • Biopsy results show she is positive for malignancy • She is estrogen receptor positive • Scheduled for modified radical mastectomy and sentinel lymph node dissection with possible axillary dissection • She has a choice between lumpectomy or modified radical mastectomy WHAT INFORMATION WOULD YOU PROVIDE TO ALICE REGARDING THE 2 PROCEDURES? LUMPECTOMY VS. MODIFIED RADICAL MASTECTOMY POST-SURGICAL Bilateral Mastectomy Breast reconstruction Breast reconstruction with nipple reconstruction COMPLICATION • Post operatively Alice has wanted to stay in bed • She developed a fever and restricted range of motion in her right arm • Her pain rating is a 6-8 with pain medication. • What complication did she develop after surgery? NURSING MANAGEMENT & EDUCATION • Arm exercises are important early in the postoperative period to promote lymph and blood circulation • Helps restore mobility • Early flexion and extending the fingers--Start flexing fingers in recovery room • As the axillary incision heals, patient should gradually increase arm exercises • No blood pressure in affected arm • No lab draws to affected arm • Elevate arm on a pillow • Teach about surgical drains • Offer pain meds before arm exercises IMPORTANT MOVEMENTS • Positive for estrogen receptors • Treatment Plan Includes: • Hormone therapy • tamoxifen (Nolvadex) • Adverse effects—hot flashes, mood swings, vaginal discharge, dryness • Increased risk for—blood clots, cataracts, stroke, and endometrial cancers • Radiation therapy BREAST CANCER • What information is important for you to provide to Alice and her daughters? • What early detection measures are important for them to know? REPRODUCTIVE CANCERS Cervical Cancer Endometrial Cancer Ovarian Cancer CERVICAL CANCER CERVICAL CANCER • Risks • Clinical Manifestations • Pre-cancer is asymptomatic • Discharge (white/yellow) • Bleeding • Pain • Collaborative Care • Prevent • Hysterectomy • Laser surgery • Chemo • Radiation ENDOMETRIAL CANCER • Most common gynecologic cancer • Risks • Exposure to estrogen • Obesity • Age • Nulliparity • Early menarche • Late menopause • Smoking • Symptoms • Abnormal bleeding • Collaborative care OVARIAN CANCER • Deadliest gynecologic cancer • Most diagnosed when disease is advanced • Risks • Clinical Manifestations • Early – no signs or symptoms • Late – vague, general symptoms • Collaborative Care ▪ What is BPH? ▪ Prostate gland increases in size ▪ Disrupts urine flow from the bladder through urethra ▪ Cause is unknown ( possible links to age, hormone production) ▪ Clinical manifestations ▪ Occur gradually ▪ Nocturia ▪ Urinary frequency ▪ Difficulty with urinary stream ▪ Leaking ▪ John Redly is a 59-year-old African-American male ▪ Works as a lawyer ▪ Avid golfer and hunter ▪ Every 5 years John gets a physical from his family physician ▪ He is visiting his health care provider because he has been having difficulty urinating and dribbling for the past year, and it has gradually gotten worse ▪ Past medical history includes hypertension ▪ Subjective Data: ▪ Difficulty starting to urinate, reports a slow stream, the urine flow stops and starts several times while voiding, and there is dribbling at the end ▪ Gets up at least twice per night to void ▪ Has been going on for about one year and has increasingly gotten worse ▪ Objective Data: ▪ T 98.4° F, P 72, R 18, BP138/78, O2 Sat98% ▪ Height 5’8” Weight 255 lb. ▪ Physical exam ▪ Penis circumcised, no lesions or discharge noted ▪ Scrotum symmetric, no masses, descended testes ▪ No inguinal hernia ▪ Digital rectal exam reveals prostrate enlarged symmetrically, firm and smooth ▪ Diagnostics & Labs: ▪ Urinalysis with culture ▪ PSA 3 ng/mL ▪ Post void residual by bladder scan 175 mL ▪ Home Medications ▪ hydrochlorothiazide (Diovan HCT) 25 mg PO every morning. ▪ metoprolol (Lopressor) 50 mg PO BID ▪ 5-alpha Reductase Inhibitors ▪ Work by reducing the size of the prostate gland ▪ Goal is to decrease prostate size ▪ Finasteride (Proscar) ▪ Dutasteride (Avodart) ▪ Alpha 1 Selective Blocking Agents ▪ Erectogenic ▪ Works to decrease symptoms caused by BPH ▪ Tadalafil (Cialis) ▪ Herbal Remedies ▪ Plant based ▪ Saw palmetto ▪ Selectively block alpha1-adrenergic ▪ ▪ ▪ ▪ receptors Relax smooth muscle of the prostate that surrounds urethra Doxazosin (Cardura) Prazosin (Minipress) Tamsulosin (Flomax) ▪ Non-pharmacological interventions ▪ Transurethral Resection of the Prostate (TURP) ▪ Enter through the urethra ▪ Small cuts are made into the prostate to relieve pressure on the urethra ▪ Complications ▪ Hemorrhage ▪ Bladder spasms ▪ Infection ▪ Urinary incontinence ▪ John returns from surgery with IV fluids and a triple-lumen urinary catheter connected to continuous bladder irrigation with sterile normal saline. The catheter tubing has light red drainage with a few small clots, and the irrigation is ordered to be kept at a rate to keep the urine light pink. Two hours after his return to the unit, John asks you to check his catheter for leaks because his bed feels wet. You find the linen under his hips saturated with pink-tinged urine. You further assess him for: ▪ A) Atonic bladder ▪ B) Bladder spasms ▪ C) Hemorrhage ▪ D) Infection ▪ What can be done about the issue? At the end of the shift, John has an intake of 625 mL IV fluid, 120 oral fluids, 3200 mL irrigation fluid, and an output of 3800 mL in the urine drainage bag. His intake for the shift is _____________________ His output is __________________________________ What teaching should John receive prior to discharge home? ▪ Two years after his TURP, John sees his provider for some of the same symptoms he had had previously. ▪ What symptoms would John be experiencing? ▪ The provider performs a rectal exam and notes a firm prostate nodule approximately 2 mm in diameter. His PSA level is 14 ng/mL. A needle biopsy is performed a week later. ▪ What are risk factors for prostate cancer? ▪ Are any of the risk factors specific to John? ▪ Age? ▪ Ethnicity? ▪ Family History? ▪ Dietary implications? ▪ Occupation? ▪ Case study progresses… ▪ The biopsy shows several sites containing cells indicative of adenocarcinoma of the prostate. ▪ MRI of the pelvis and abdomen and a full body PET scan confirm the extent of the tumor and demonstrates lack of lymph node involvement or distant metastasis. ▪ After carefully evaluating the treatment options for an aggressive tumor, John and his wife decide he will have a radical prostatectomy. ▪ Prostate cancer can spread ▪ Direct extension ▪ Lymphatic system ▪ Blood stream ▪ Radical prostatectomy ▪ Entire prostate gland, seminal vesicles, and part of the bladder neck are removed ▪ Either retro-pubic or perineal approach ▪ Large indwelling catheter for 1-2 weeks ▪ Complications: erectile dysfunction and urinary incontinence ▪ Destroys cancer cells by freezing the tissue using liquid nitrogen ▪ Complications ▪ Damage to urethra ▪ Urethorectal fistula ▪ Urethrocutaneous fistula ▪ Tissue sloughing ▪ Erectile dysfunction ▪ Urinary incontinence ▪ Prostatitis ▪ Hemorrhage ▪ External Beam ▪ Targeted area ▪ Treatment 5 days per week for a set number of weeks ▪ Brachytherapy ▪ Radioactive seeds implanted ▪ Radiation directly to tissue while sparing surrounding tissue ▪ What teaching would be included for each of these treatments? ▪ Chemotherapy ▪ Hormonal Therapy ▪ Androgen Deprivation Therapy ▪ Androgen Synthesis Inhibitors ▪ Androgen Receptor Blockers ▪ Orchiectomy (surgical removal of testes) ▪ Combination therapy COMFORT JODY SERFLING, MSN, RN ALTERATION IN COMFORT = PAIN Pain is a complex, multidimensional experience that can cause suffering and decreased quality of life One major reason people seek health care 25 million people experience acute pain from injury or surgery Chronic pain affects over a million American adults 50% to 80% of older adults are estimated to have chronic pain problems 60% of cancer patients experience pain during treatment Definition “Whatever the person experiencing pain says it is, existing whenever the person says it does.” Margo McCaffery “Unpleasant sensory and emotional experience associated with actual or potential tissue damage.” IASP Despite the high prevalence and costs of pain, inadequate pain management occurs CONSEQUENCES OF UNTREATED PAIN DIMENSIONS OF PAIN Affective Emotional responses to pain Behavioral Observable actions use to express or control pain Cognitive Beliefs, attitudes, meaning attributed to pain Physiologic Genetic, anatomic, and physical determinants influence how stimuli are processed, recognized, and described Sociocultural Age, gender, family or caregiver influence, cultural aspects MECHANISM OF PAIN PERCEPTION CLASSIFICATION OF PAIN Nociceptive Damage to somatic or visceral tissue Somatic pain: superficial or deep Superficial pain Arises from skin, mucous membranes and subcutaneous tissues Described as sharp, burning, prickling Deep Arises from bone, joint, muscle, skin, or connective tissue Described as throbbing, aching Visceral pain: Activation of nociceptors in the internal organs and lining of the body cavities Respond to inflammation, stretching, and ischemia Described in many different ways based on organ involved Neuropathic Damage to peripheral nerves or CNS Described as numb, hot, burning, shooting, stabbing, or electric ‘shock-like’ in nature Pain can be sudden, intense, short-lived or lingering Centrally generated CNS damage (spinal cord injury) Peripherally generated Peripheral nerve injury (trauma, surgery, amputation) CLASSIFICATIONS OF PAIN Pain Characteristics Acute Pain Short Duration Recent onset Transient Known causality Chronic pain Duration > 3-6 months Persistent or Recurrent Unknown causality Breakthrough/Flare-up Unpredictable Fear Factor Multi-causality AREAS OF REFERRED PAIN GOALS OF PAIN MANAGEMENT Identify and address the cause of pain Explore “the meaning” of the patient’s pain The meaning – in turn – determines the patient’s experience Treat acute pain aggressively; prevent chronic Treat chronic pain systematically/thoroughly Maintain alertness and function; minimize side effects Improve quality of life, decrease suffering Intervene as minimally invasively as possible PAIN ASSESSMENT Location Elements (multidimensional) Intensity Quality Direct interview Observation Associated symptoms Diagnostic studies Onset, duration, variation & patterns Physical examination Alleviating & exacerbating factors Effects of pain on activity Present pain management regimen & effectiveness Pain management history including pharmacotherapy Presence of common barriers to pain reporting PQRST MNEMONIC P: Precipitating cause Q: Quality R: Region S: Severity T: Timing PAIN MEASUREMENT TOOLS PAIN MEASUREMENT TOOLS CHALLENGES IN ASSESSMENT & MANAGEMENT OF PAIN When the patient is medically complicated The patient is non-verbal or confused Language barriers Cultural differences When there is prior exposure to opioids, benzodiazepines, muscle relaxants, etc. When there is a substance abuse history When the patient has chronic pain When the patient displays a “difficult” personality When the family is difficult or challenging LEGAL & ETHICAL CONSIDERATIONS Be knowledgeable about legal considerations related to pain management Ensure your practice is consistent with current nursing standards of care Not adhering to standards of care in pain management can lead to charges of malpractice Follow facility policies and procedures for pain management Managing pain is guided by several ethical concepts (beneficence, nonmaleficence, autonomy, justice) INTERDISCIPLINARY CARE IN PAIN MANAGEMENT The concept of interdisciplinary care refers to a philosophy and process of care that integrates the specialized knowledge of multiple disciplines Medicine Nursing Physical Therapy Nutritionists Pharmacists Social Workers Psychologist/Psychiatrist Medications Opioids Nonopioids Adjuvant Complementary Therapies Acupuncture Acupressure Massage PT/OT TENS Heat/Cold Treatment of Pain Behavioral Modification Psychotherapy Meditation Cognitive Behavioral Therapy Distraction Music/Art therapy Interventions Nerve blocks Neuroablative techniques Neuroaugmentation Steroid injections OPIOIDS “Gold Standard” pain relief Orally, rectally, IM, IV, IT, epidural, transdermal. Extended release & Immediate release formulations Long-term side effects Neurologic Cardiopulmonary Dermatologic Naturally occurring or synthetic Gastrointestinal Mechanism of Action Urologic Tolerance/dependence Opioids have affinity many different receptors, including the 5 opioid receptors: mu, kappa, sigma, delta & epsilon Modify the transmission of painful signals, diminishing pain perception Additionally, opioids work in the lim-bic system, altering emotional response to pain Each opioid has different affinities for different people, so patients may have different responses to different opioids NONOPIOIDS Acetaminophen, aspirin and other salicylates, and NSAIDs Analgesic ceiling Do not produce tolerance or physical dependence Many are OTC Effective for mild to moderate pain Used in combination with opioids ADJUVANT ANALGESIC THERAPY Used alone or in conjunction with opioids and nonopioids Generally developed for other purposes but also effective for pain *Cannabinoids have been added to this list ADMINISTRATION Scheduling Titration Equianalgesic dosing Dose of one analgesic that is approximately equivalent in pain-relieving effects compared with another analgesic Benefits of variable routes PO, IV, IM, PR, transdermal Intraspinal Epidural space (epidural) Subarachnoid space (intrathecal) Intermittent bolus or continuous infusion Implantable pumps Intraspinal catheters may be surgically placed for long-term pain relief Catheter is connected to a subcutaneous pump with reservoir Patient controlled analgesia A dose of opioid is delivered when the patient decides a dose is needed Patient pushes a button to deliver a bolus dose of opioid IV Teach patient that they cannot “overdose” INTRASPINAL IMPLANTABLE PUMP PATIENT CONTROLLED ANALGESIA (PCA) COMPLEMENTARY THERAPIES Massage Exercise Transcutaneous electrical nerve stimulation (TENS) Acupuncture Heat or cold therapy 20 minute time periods Cognitive therapies Distraction Hypnosis Relaxation INTERVENTIONAL / PROCEDURAL THERAPIES Implantable Infusion Pump Nerve Block Spinal Cord Stimulator Injection Goals Reduction in pain Improve mobility Minimize the use of medications Selectively target injured/painful/surgical region Minimize complications (infection/bleeding/injury) PAIN & YOUR PATIENTS Ask about pain regularly, assess systematically Believe the patient in their reports of pain and what relieves it Choose pain control options appropriate for the patient, family and setting Deliver intervention in a timely, logical and coordinated fashion Empower patients and their families Enable them to control their course to the greatest extent possible
