Advances in pain assessment and their influence on nursing practice
Since health care professionals are aware of the importance of pain management because it influences a patient's quality of life drastically, they shifted their primary care goal from cure and survival in cancer patients to supportive care that includes pain management, promoting comfort and maintaining the quality of life (Crisp & Taylor, 2001). This shift impacted on nursing greatly, since adequate and on-going pain assessment, implementation of the prescribed pain management plan and evaluation of the patient's responses to the implemented interventions, play a major role in effective pain management and ultimately affect the quality of life.
New assessment methods arose and needed to be implemented into the daily care of cancer patients. For example, pain assessment is now considered a priority and many facilities adopt and prioritize pain as the "fifth vital sign" (Smith, Duell & Martin, 2004). This major advance ensures that the patient's pain level will be assessed as frequently as any other vital signs.
Since pain is constantly changing, either because of disease progression or successful implementation of pain relief, assessment is an ongoing process and needs to be continuously reviewed (Smeltzer & Bare, 2004). A thorough pain assessment should cover pain intensity, location, characteristics and pain-related interference with daily activities (Starck, Sherwood & Adams-McNeill, 2000). Decades ago, pain assessment was not considered imperative and therefore, patients were assessed irregularly, which led to unnecessary suffering.
Traditionally, health care professionals did not believe that a patient was in pain, unless they showed objective signs such as physical causes (Crisp & Taylor, 2001). Such attitudes about pain where caused by the medical model of illness, which states that "physical problems result from physical causes" (Crisp & Taylor, 2001). Nurses often relied on their own judgment of how much pain they think patients are experiencing. Today, McCaffery's definition that "pain is whatever and whenever the person says it is" becomes more and more implemented into the pain assessment. Therefore, pain assessment now is patient-centered and self-report is the golden standard for assessing pain (Tollison, Satterthwaite & Tollison, 2002).
Since patients are much more involved in their own pain management today than they have been ever before, it is imperative for the nurse to educate the patient and their families about the importance of pain management and accurate assessment and also about expected outcomes (Oncology Nursing Society, 2004). Only so can the patient be a credible judge of his or her own pain and only so can a patients misunderstanding and lack of knowledge about expectations for pain relief be eradicated.
New assessment tools in pain management and their impact on the nursing practice
To assess pain levels effectively and on a patient-centered basis, new methods have been developed, such as body image charts, McGill Pain Questionnaire, verbal descriptor scales and visual analog scales (Tollison, Satterthwaite & Tollison, 2002). The visual analogue scale for example employs a graded numeric scale of 0 to 10.
Here, the patient is encouraged to assess the severity of his or her pain (Kenner, 1994). Body image charts are very useful to mark the exact location of the pain.
It has also been recognized that difficulties may arise in children, old people, unschooled, cognitive impaired and non-verbal patients when using numeric rating scales. Consequently, novel tools have been developed to assist those patients in making a relevant self-report about their pain level (Tollison, Satterthwaite & Tollison, 2002). Such tools include pain thermometers, color scales, "Oucher" scales and Wong-Baker Faces scales (Smith, Duell & Martin, 2004). However, in a non-verbal patient, signs such as facial expression, behavior and verbal sounds need to be assessed (Smith, Duel &, Martin, 2004). As the audience can notice, there have been many new tools developed over the years which have impacted greatly on the nurse's role since the nurse is the person to use those tools correctly in order to provide current and appropriate pain management. Therefore, nurses need to be educated about the new tools and adapt life long learning skills as health care will develop rapidly.
Nurses need to have a broad knowledge about a patient's pain perception, since not only physical factors play a role but also age, gender, cultural, psychosocial factors and the patient's previous pain experiences (Smeltzer & Bare, 2004). Studies revealed that under-treatment of cancer pain has been common because assessment tools have not been used or have not been used consistently, documentation about pain levels was not or inconsistently provided, and the concept of "Total Pain" where only physical causes were considered and not the whole patient, were not understood (Hawthorn, Aranda & Webb, 1996). This shows once more that nurses need to receive thorough education about pain management in order to adapt those new changes and to use them appropriately.
Changes in administering pain relief and its impact on nursing practice
In addition to the impact of new pain assessment strategies mentioned above, are the changes in administering pain relief and its associated impact on nursing practice. Historically, nurses maintained strict control over pain medications in order to protect the patient from harmful effects of opioids, especially with concerns regarding addiction (Terry, 2004).
Many health care professionals thought that opioids cause addiction, tolerance, dependence and respiratory depression as major side effects (Starck, Sherwood & Adams-McNeill, 2000). Therefore, patients received inadequate amounts of pain relief and their suffering continued.
Not only did nurses hold misbeliefs about opioids, but also patients expressed major concerns about the use of those pain medicines and consequently did not request them (Watt-Watson & Donovan, 1992). Those misbeliefs about opioid use have been questioned over the last years since research showed that addiction to opioids is very rare in cancer patients (Hawthorn, Aranda & Webb, 1996).
Other misbeliefs, such as taking Morphine as the last resort; to wait as long as possible before taking any pain medication; Nurses know best if the patient is in pain and that pain should be expected as a result of cancer were held by nurses and patients alike. Those beliefs have been proven wrong, since new knowledge of the etiology of pain and new ethical guidelines, such that every patient has the right of adequate pain relief, emerged (Watt-Watson & Donovan, 1992).
New developments for safe pain management
Other new developments have been made in order to support safe pain management and to do away with misbeliefs about pain medications. A major tool, the three step analgesic ladder, now frequently used, has been developed by the World Health Organization in 1983 (Magee, 2005). The three step ladder suggests that the best form of analgesia for mild pain is a non opioid, for moderate pain is a non opioid combined with a weak opioid and for severe pain a strong opioid and a non opioid combination (Kenner, 1994).
This guideline has been proven very useful and when used appropriate can bring freedom from cancer pain for the patient (Kenner, 1994). However, to achieve a pain free state, patient self-assessment of pain must be consistent since it aids in decision making whether to step up the ladder or not. Here again, nurses face new challenges in caring for the cancer patient since they need to have a good understanding of pharmacology in order to provide adequate pain relief.
Not only is it important for the nurse to be educated, furthermore, the patient needs to be educated about the cancer pain management and treatment options as well as side-effects in order to make informed decisions (Terry, 2004).
Another vital knowledge that has emerged through research and evidence based practice over the years is that pain should not be allowed to escalate since it is much easier to control pain when it is mild (Smeltzer & Bare, 2004). Patients need to be encouraged to tell health care professionals when pain establishes. However, many health care professionals and patients alike had and still have misconceptions and think that drug tolerance could make medications ineffective and therefore give less medication or wait until the pain escalates (Tollison, Satterthwaite & Tollison, 2002). Beliefs about addiction, tolerance, dependence and major side effects have been more important than the actual pain management. To prevent those misconceptions, nurses need to have a broad knowledge about diverse actions of drugs, dosage, duration of action and their significant function in pain control (Smith, Duell & Martin, 2004).
Advances in pharmacology and how they impact on nursing practice
New advances in pharmacology had a further impact on nursing practice. For example, slow release morphine and transdermal fentanyl patches have been developed, which give the patient more freedom from cancer pain since they are longer acting (Luppino, 2004). The nurse, as the person that mainly administers those drugs, needs to have a broad knowledge about them. If knowledge is insufficient, over-dosing or inadequate pain relief could easily occur.
According to an experienced registered nurse and midwife, opioids were administered mainly by the oral and intramuscular route decades ago (Goode, 2005). With the advances in pharmacology, such as the development of slow release morphine MS Contin, the rectal route for administering medications has opened new ways for achieving pain relief in patients with swallowing difficulty (O'Connor & Aranda, 2003). Studies have revealed that Morphine given rectally is absorbed quickly and therefore is now current practice (O'Connor & Aranda, 2003).
Since health care professionals shifted their approach to cancer pain management from trying to cure the pain to rather minimizing the pain as much as possible, they acknowledged that it is crucial to give analgesia on a regular basis (around the clock) rather than a prn (as needed) one (Crisp & Taylor, 2001) . Only regular administration of pain medication can maintain the blood level for ongoing pain control (Crisp & Taylor, 2001).
However, the nurse needs to be aware of the importance of ongoing pain reassessment to be able to identify possible side effects of too much or too less analgesia. The nurse should also be acknowledgeable of the options that are available to reverse possible side effects (Smith, Duell & Martin, 2004). Other new knowledge in pharmacology leads to the use of adjuvant drugs such as anti-depressants and anti-inflammatory in conjunction with opioids to enhance the effects of the drugs in pain relief (Anderson, Keith, Novak & Elliot, 2002). This again shows that nurses need to have a broad understanding of human physiology and pharmacology in order to administer analgesia safely and efficiently.
New technologies in pain management and their impact on the nurse
The new advances in pharmacology brought with them new technology advances that changed the nurse-patient relationship in pain management. One of those technical advances is the patient controlled analgesia pump (PCA), which allows the patient to self-administer analgesia (Smith, Duell & Martin, 2004). It also enables the patient to assess and control his or her own pain level and thus gives more control of life circumstances (Hawthorn, Aranda & Webb, 1996).
The change that this device brings in the nurse-patient relationship is that the nurse's power to relieve or withhold pain medications is lesser than the power that the patient receives ultimately from using this device (Smith, Duell & Martin, 2004). The PCA is also less time consuming for the nurse, however, nurses need to have a extensive knowledge about those devises in order to educate the patient in the handling and use of such devises and they need to understand that frequent reassessment of the pain is still vital.
Other new technologies, such as epidural catheters and continuous infusion via direct intravenous (IV) bring considerable challenges for nurses, since they need to demonstrate broad knowledge in turn to care for the devices and to administer drugs via the devices (Smith, Duell & Martin, 2004). Another major advantage for the patient in using those new devises is a less invasive approach to pain relief. Whereas decades ago, intramuscular or intravenous injections were given constantly to manage a patients pain, today the PCA and other syringe drivers prevent the patient from those invasive techniques since they can be implanted (Goode, 2005).
Implementation of non-pharmacological interventions in pain management
One can see that many new advances and developments have been made on pain management. However, research has shown that controlling pain with pharmacological options alone is often ineffective (Smeltzer & Bare, 2004). Many cancer patients have become disappointed with inadequate analgesia pain relief, which has led them to seek non-pharmacological or alternative therapies in effort to control their pain (Parris & Smith, 2003). Studies and research has revealed that non-pharmacological therapies such as acupuncture, relaxation, meditation, massage, music therapy and imagery can have good effects on pain relief since pain is a physical and psychological phenomenon, although they are not a substitute to pharmacological options (Tollison, Satterthwaite & Tollison, 2002).
As explained above, a patient's previous experience on pain, anxiety, current environment, stress and other cognitive behavior can influence the perception of this person's pain greatly. Relaxation for example, aids in relaxing muscles and reduces stress, which as a consequence has a positive impact on the persons pain level (Smith, Duell & Martin, 2004). Imagery is another example of non-pharmacological pain control, since it creates distraction from the pain (Tollison, Satterthwaite & Tollison, 2002).
The nurse today is encouraged to explore those non-pharmacological options of pain relief and to implement them into the nursing care. Therefore, the nurse needs to be acknowledgeable about the effects those options have on the patient and how to use them accurately.
It is also thought to be very effective to teach the patient and their families how to use those non-pharmacological methods so they can implement them in their pain management at home (Oncology Nursing Society, 2004).
Changes of the nurses responsibilities in pain management
Decades ago, physicians were seen by nurses and patients alike as "God". What the physician ordered did not need to be questioned by the nurse. Nurses served and cared for their patients by assisting the physician. Therefore, nurses did not have much say in the care of patients and their responsibility and accountability towards the patient was less than it is today (Goode, 2005).
Today, nurses carry a much larger responsibility in pain management than ever before. Since nursing education is now more scientific and tertiary, nurses are expected to have comprehensive and current knowledge in a broad range of health care issues. A classic example of the nurse's responsibility in pain management is to be knowledgeable and skilled in the pain assessment and use of current pain management techniques.
It is the nurses responsibility to assess the patient appropriately, to educate the patient about correct self-report and the importance of pain assessment (Goode, 2005). It is furthermore the responsibility of the nurse to inform the physician to review a patient's pain relief if it is insufficient. Nurses today work in collaboration with physicians and other health care professionals by independently assessing, diagnosing and caring for patients and discussing their cases with other health professionals. One of the largest responsibilities the nurse has towards the patient is to provide current, comprehensive and appropriate nursing care (Twycross, 2002). This can only be achieved with ongoing education.
The nurse as the patients advocate
One of the most critical roles the nurse plays in achieving pain control in the cancer patient is to be the patients advocate (Terry, 2004). This is a crucial role in all aspects of cancer care, in pharmacological as well as in non-pharmacological treatment.
As an advocate, the nurse ensures that the patient and their families have an adequate understanding about the pain management and the treatment options that are available to give them the opportunity to make informed decisions about health care (Crisp & Taylor, 2001). Since there are so many treatment options available today and the access to health care services can be confusing for the patient, the nurse as one of the primary care givers is the ideal person to advocate the patient.
Although there are many more new advances in cancer pain management that affect the nurse and the patient equally, it is not in the scope of this paper to address all of them. The intention of this paper was to explore some of the new treatment options that are now available in cancer pain management and how those options impact on the nurse's practice. In today's highly technological health care system, nurses must be able to demonstrate high levels of humanistic and technological skills. One can easily see that new technologies in cancer pain management dictate versatility in nursing practice to achieve high quality patient outcomes. Therefore, it cannot be stressed enough that nurses' education is the crucial key to achieve maximal pain relief in cancer patients.
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