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61 Cards in this Set

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Cancer Pain
*"Pain is whatever the experiencing person says it is, existing wherever he/she says it does."
*Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."
Epidemiology of Cancer Pain
*At the time of diagnosis
-One quarter of clients report pain
*During active treatment
-Two thirds of clients report pain
*Hospitalized with advanced cancer
-Three quarters of clients report pain
High Risk Populations for Under Treatment of Cancer Pain
*Minorities
*Elderly (>70 years old)
*Women
Under Treatment of Pain: Healthcare Professionals
*Lack of knowledge and skills to assess pain
*Lack of access to practical treatment protocols
*Inadequate understanding
-Fear of addiction
-Fear of hastening death
Under Treatment of Pain: Patients Attitudes
*Fear of addiction
*Side effects
*fatalism
Dimensions of Pain
*Affective
-Emotions
-Suffering
*Behavioral
-Behavioral response
*Cognitive
-Beliefs
-Attitudes
-Evaluations
-Goals
Sensory:
*P pattern
*A area
*I intensity
*N nature
Dimensions of Pain
*Physiologic
-Transmission of nociceptive stimuli
*Sensory
-Pain perception
Physiologic/Sensory
*Transduction
*Transmission
*Perception
*Modulation
Cancer Pain
*Alteration in comfort r/t cancer pain (back pain) aeb client rates pain as an "8/10" on the pain scale.
*Related Nursing Dx:
-Activity Intolerance
-Altered Family Processes
-Altered Thought Process
-Anxiety
-Constipation
-Fear
-Powerlessness
-Hopelessness
-Ineffective Individual Coping
-Sleep-Pattern Disturbance
Types of Pain
*Acute
-Combination of tissue damage and anxiety
*Chronic
-Pain greater than six months
-Ongoing and not responding to current treatment regime
Manifestations of Acute Pain
*Increased heart rate
*Increased BP
*Increased respirations
*Diaphoresis
*Pallor
*Anxiety, agitation or confusion
*Urinary retention
Goal: pain control
Manifestations of Chronic Pain
*Flat affect
*Decreased mobility
*Fatigue
*Social withdrawal
*Depression
Goal: enhance quality of life with pain control
Malignant Pain
*Malignant pain is a complex, progressive process
-Acute or Chronic
-Resistant to cure
-Intractable, but can be relieved
-All consuming interfering with mood, family, relationships and quality of life
Etiology of Cancer Pain
*Direct Tumor Involvement
-Pressure within organ or extending to other organs
*Nerve Compression
*Unrelated to Cancer
-Pressure ulcers, aching muscles, bedrest
*Cancer Treatment
-Chemotherapy, Radiation Therapy & Surgical Interventions
Physiology of Pain
*Neuropathic Pain
-Pain resulting from injury to the nervous system
Examples:
Diabetic Neuropathy Chemotherapy related (very difficult to relieve)
*Nociceptive Pain
-Pain occuring in the periphery
-Impulses are transmitted to the CNS where interpretations occurs
Examples:
Somatic Pain
Visceral Pain
Neuropathic Pain
*Characteristics
-Sensation of pain elected by a non-noxious stimuli
-Nerve related distribution: follows nerve pathway
-Resistant to standard opiods
Constant pain
Anti-Seizure Drugs
NSAIDS
High Risk Populations for Under Treatment of Cancer Pain
*Minorities
*Elderly (>70 years old)
*Women
Under Treatment of Pain: Healthcare Professionals
*Lack of knowledge and skills to assess pain
*Lack of access to practical treatment protocols
*Inadequate understanding
-Fear of addiction
-Fear of hastening death
Under Treatment of Pain: Patients Attitudes
*Fear of addiction
*Side effects
*fatalism
Dimensions of Pain
*Affective
-Emotions
-Suffering
*Behavioral
-Behavioral response
*Cognitive
-Beliefs
-Attitudes
-Evaluations
-Goals
Sensory:
*P pattern
*A area
*I intensity
*N nature
Dimensions of Pain
*Physiologic
-Transmission of nociceptive stimuli
*Sensory
-Pain perception
Physiologic/Sensory
*Transduction
*Transmission
*Perception
*Modulation
Cancer Pain
*Alteration in comfort r/t cancer pain (back pain) aeb client rates pain as an "8/10" on the pain scale.
*Related Nursing Dx:
-Activity Intolerance
-Altered Family Processes
-Altered Thought Process
-Anxiety
-Constipation
-Fear
-Powerlessness
-Hopelessness
-Ineffective Individual Coping
-Sleep-Pattern Disturbance
Types of Pain
*Acute
-Combination of tissue damage and anxiety
*Chronic
-Pain greater than six months
-Ongoing and not responding to current treatment regime
Manifestations of Acute Pain
*Increased heart rate
*Increased BP
*Increased respirations
*Diaphoresis
*Pallor
*Anxiety, agitation or confusion
*Urinary retention
Goal: pain control
Manifestations of Chronic Pain
*Flat affect
*Decreased mobility
*Fatigue
*Social withdrawal
*Depression
Goal: enhance quality of life with pain control
Malignant Pain
*Malignant pain is a complex, progressive process
-Acute or Chronic
-Resistant to cure
-Intractable, but can be relieved
-All consuming interfering with mood, family, relationships and quality of life
Etiology of Cancer Pain
*Direct Tumor Involvement
-Pressure within organ or extending to other organs
*Nerve Compression
*Unrelated to Cancer
-Pressure ulcers, aching muscles, bedrest
*Cancer Treatment
-Chemotherapy, Radiation Therapy & Surgical Interventions
Physiology of Pain
*Neuropathic Pain
-Pain resulting from injury to the nervous system
Examples:
Diabetic Neuropathy Chemotherapy related (very difficult to relieve)
*Nociceptive Pain
-Pain occuring in the periphery
-Impulses are transmitted to the CNS where interpretations occurs
Examples:
Somatic Pain
Visceral Pain
Neuropathic Pain
*Characteristics
-Sensation of pain elected by a non-noxious stimuli
-Nerve related distribution: follows nerve pathway
-Resistant to standard opiods
Constant pain
Anti-Seizure Drugs
NSAIDS
Nociceptive Pain
*Somatic Pain
-Bone Pain
-Pain in soft tissue
-Throbbing
-Treated with NSAIDS
*Visceral Pain
-Hepatic Capsular Distention
-Referred shoulder pain from pancreatic cancer
-Deep Aching
-Treated with Steroids
Pain Scales
*Visual analog scales
*Simple Descriptive
*Numeric Pain Intensity Scales
Components of Cancer Pain
*Basal Pain
-Constant or Baseline Pain
-Lasts more than 12 hours per day
-Not "cured pain"
-Treat ATC to control pain
-Best treated via
PO
Transdermal
*Breakthrough Pain
-Transient Flare in Pain
-Moderate to severe
-Occurs in conjunction with basal pain
-Usually occurs 4 X day
-NOT END OF DOSE PAIN
Analgesic Ladder for Management of Cancer Pain
*Cancer can be relieved in 80-90% of clients by use of the WHO 3-Step Analgesic Ladder
*Freedom from Cancer Pain
-Strong Opiod
+/- non-opiod
+/- adjuvant
*Pain Persisting or Increasing
-Weak Opiod
+/- non-opiod
+/- adjuvant
*Pain Persisting or Increasing
Non-Opiod
+/- adjuvant
Pharmacological Agents: Analgesic Ladder
*Step 1 - Non-opiods for mild to moderate pain.
Examples: ASA, Tylenol and NSAIDS
*Step 2 - Opiods for moderate pain.
Examples: Percocet, Codeine, MS and Fentanyl
*Step 3 - Opiods for persistent or escalating pain
-Oxycontin, MS contin
*Lewis Table 14-24 Page 142
Adjuvant Analgesics
-Medications for clients with cancer aimed at treating target symptoms
-Neuropathic pain
-Pain associated with spinal cord compression
-Somnolence (prolonged drowsiness or sleepiness)
-Anxiety
-Muscle spasms/myoclonic jerks
Subset of drugs: Anticonvulsants Ex: Neurotin used for neuropathic pain
Routes of Administration
*PO
*Rectal
*IV (opiods work immediately by IV)
*SC
*Transdermal
*Epidural
Dosage Schedule
*ATC
-Opiods should be dosed ATC and PRN
-To manage basal pain
*PRN
-Opiods should be given PRN
-To manage breakthrough pain
Cancer Pain Analgesia: Opiods
*Long Acting
-Morphine CR
-Oxycodone CR
-Transdermal Fentanyl
-Methadone
*Short Acting
-Morphine IR
-Oxycodone IR
-Transmucosal Fentanyl
-Hydromorphone
Management of Cancer Pain
*We have the knowledge and understanding of cancer pain
*We have the drugs and guidelines to effectively manage cancer pain....
-...so why are so many of our clients pain not effectively managed?
Barriers to Effective Pain Management
*Health Care Providers
-Inadequate Assessment
*Clients
-Lack knowledge of untreated pain
*Health Care System
-Making pain the 5th vital sign
Pain Assessment: RELIEF
R Reason for the pain
E Exacerbating factors
L Location
I Intensity
E Effects of pain
F Follow up/Reassessment (always assess 30 minutes after pain med is given)
Pain Assessment:
Essential Components of Cancer Pain
*Quality
*Pattern
*Location
*Intensity
*Measures
*Relief
Plan of Care (Examples of an outcome)
-Assist your client to identify his/her goals for comfort
What is your clients acceptable level of pain?
What side effects need to be addressed?
-Be an advocate in reaching your clients goals
-The outcome will reflect the goals
The client will report pain less than "3/10"
The client will be awake during meals
Interventions
*All nursing interventions are designed to assist the client in achieving the selected goals and outcomes
-Manage basal and breakthrough pain
-Manage side effects of treatment: constipation, nausea, sedation
-Adapt to living with pain: coping, powerlessness, hopelessness, anxiety, depression
-Client education: knowledge deficits, non-pharmacological pain management
Education Strategies
*Assist your client to adapt to living with pain
-Establish a pain management goal and routine
Write down all instructions. Take home materials
Design a schedule around ADL's, commitments
*Discuss types of pain and management of pain
-Basal Pain vs Breakthrough Pain
Help client to determine when to take PRN dose
Explain how long it takes for medication to work
*Discuss communication
-Teach client to report pain: location, intensity, etc.
-Teach client to keep a record of pain
-Teach client to keep track of how many doses left
Management of Side Effects
*Constipation
-Diet, Fluids, Stool Softener, Activity
*Nausea
-Education, Antiemetics
*Sedation
-Education, Assessment, Medication Adjustment
*Respiratory Depression
Management of Less Common Side Effects
*Confusion/Delirium
*Urinary Retention
*Myoclonus (twitching or clonic spasm of a muscle or group of muscles)
*Pruritus
Non-pharmacological Pain Management Strategies
*Physical Modalities
*Cognitive-Behavioral Interventions
Settings for Cancer Pain Management
*Hospital/Acute Care
*Long-term Care
*Home
Psychosocial Considerations
*Cancer diagnosis usually viewed as crisis
*Common fears:
-Disfugurement
-Dependency
-Pain
-Financial depletion
-Abandonment
-Death
Predictors of Client's Ability to Cope with Cancer Diagnosis
*Ability to cope with stress in the past
*Presence of significant others, support
*Ability to express feelings and concerns
*Age at diagnosis
*Extent of disease
*Disruption of body image
*Presence of symptoms (pain, SOB etc.)
Ability to Cope, (cont.)
*Past experience with cancer, ie, is this recurrent disease?
*Attitude associated with cancer, is the client in control or feeling hopeless, helpless?
Role of the Nurse
*Assess client and family's ability to cope
*Assess client and family's readiness to learn about the disease and treatment course
*Teach client and family rationale for diagnostic tests and treatment
**Teach client and family information only as they are ready**
Potential Nursing Diagnosis Related to Cancer Diagnosis
*Knowledge deficit re: new diagnosis
*Ineffective coping - individual, family
*Fear
*Grieving
*Hopelessness
*Self-care deficit
*Caregiver role strain
Nursing Interventions (cont.)
*Use therapeutic touch when appropriate
*Assist client in setting realistic goals
*Assist client in maintaining usual lifestyle patterns
*Maintain hope - key to effective cancer care
*Help client find appropriate resources
Nursing Interventions for Newly Diagnosed Client with Cancer
*Be available, especially during difficult times: new diagnosis, recurrent disease
*Display caring attitude
*Listen actively to fears, concerns
*Provide symptom relief
*Provide information re: treatment
*Maintain open relationship based on trust, caring, honesty
Potential Nursing Diagnosis (cont.)
*Altered role performance
*Risk for lonliness
*Risk for sorrow
*Self-esteem disturbance
Samples of Resources
*American Cancer Society
*www.cancer.org
*National Cancer Institute
*www.nci.nih.gov
*Oncology Nursing Society
*www.ons.org