pain managemnet

MEDSURG Nursing—December 2008—Vol. 17/No. 6 413

A Cancer Pain Primer

In various health care settings, notall patients with cancer are admit-

ted to oncology units. Becausemany medical-surgical units/facili-ties admit patients with cancer,medical-surgical nurses must beknowledgeable about cancer painmanagement. Despite advances inpain management, an estimated25% of patients with newly diag-nosed cancers experience pain. Inaddition, 33% of patients undergo-ing anticancer therapy experiencepain, as do an estimated 75% ofpatients with advanced disease(National Comprehensive CancerNetwork [NCCN], 2008). Continuedimprovement in pain managementis needed because over one-thirdof the patients with cancer painexperience it at a moderate orsevere level (van den Beuken-vanEverdingen et al., 2007).

The International Associationfor the Study of Pain (2007)defined pain as “an unpleasantsensory and emotional experience

associated with actual or potentialtissue damage, or described interms of such damage.” MargoMcCaffery, a nurse and leader inthe pain management arena, of-fered a more useful definition fornurses: “Pain is whatever theexperiencing person says it is,existing whenever he says it does”(McCaffery & Pasero, 1999, p. 17).Nurses must accept the patient’sreport of pain regardless of thepatient’s overall appearance,affect, or vital signs.

The Pain AssessmentCancer pain can range from

mild to severe. It may occur due tothe tumor damaging viscera, nerves,or bone, or because of treatmentssuch as radiation therapy andchemotherapy (Mickle, 2002). Pa-tients with cancer also may havepain unrelated to their cancer ortreatment. The first step in cancerpain management is to perform acomprehensive pain assessment;lack of assessment can lead to inadequate pain management

CNE Objectives and Evaluation Form appear on page 420.

Kathleen Reeves

SERIES

Kathleen Reeves, MSN, RN, CNS, CMSRN, is a ClinicalAssociate Professor, University of Texas Health ScienceCenter, San Antonio, TX; a Medical-Surgical Clinical NurseSpecialist on a limited basis at Methodist Hospital in SanAntonio, TX; and is Past President of the Academy of Medical-Surgical Nurses.

Notes: This column is made possible through an educationalgrant from C-Change, a 501(3)c (not-for-profit) organization.The purpose of the Cancer: Caring and Conquering column isto strengthen the cancer knowledge, skills, and confidence ofmedical-surgical nurses who care for patients at risk for or liv-ing with cancer.

C-Change is a not-for-profitorganization whose mission isto eliminate cancer as a publichealth problem, at the earliestpossible time, by leveraging the expertise and resources of ourmembers. C-Change is the only organization that assemblescancer leaders from the three sectors – private, public, and not-for-profit – from across the cancer continuum – prevention, early detection, treatment, and quality of life. C-Change invests in the resolution of problems that cannot besolved by one organization or one sector alone. For more infor-mation about C-Change, visit www.c-changetogether.org.

The author and all MEDSURG Nursing Editorial Board membersreported no actual or potential conflict of interest in relation tothis continuing nursing education article.

Opportunities exist for im-proving cancer pain manage-ment. Medical-surgical nursesmust partner with patientsand families to achieve opti-mal pain management. Theymust use valid tools to assesspatients and be knowledge-able about pharmacologicand nonpharmacologic meas-ures to manage pain.

414 MEDSURG Nursing—December 2008—Vol. 17/No. 6

(NCCN, 2008). A pain assessmentmust be conducted on admissionto a health care facility, whetherinpatient or outpatient, and thenmust be conducted on a regularlyscheduled basis. A pain assess-ment should include the followingcomponents: location, quality/description, intensity, duration,alleviating and aggravating fac-tors, associative factors, andeffect of pain on the patient’s life(St. Marie, 2002). The patientshould be involved actively in theassessment and pain managementplan (Gordon et al., 2005). TheAmerican Society for Pain Manage-ment Nursing developed clinicalpractice recommendations relatedto assessing nonverbal patients,specifically elders with advanceddementia and patients who areintubated and/or unconscious(Herr et al., 2006). The general rec-ommendations include seekingself-report when appropriate,investigating potential causes ofpain, observing behaviors using abehavioral pain tool, using surro-gate reporting, and initiating ananalgesic trial.

When performing the painassessment, the nurse should askthe patient about the location ofall the areas of pain. Having thepatient point to the painful areasor marking those areas on a bodydiagram helps to identify themaccurately. The patient may havemore than one area of pain andmay not share this informationunless specifically asked about allthe locations of pain. Although alist of words related to the qualityof pain (sharp, dull, aching, burn-ing) can be provided to thepatient, it is important that nursesdocument the individual’s ownwords and descriptions. The qual-ity or descriptions of pain mayprovide direction related to theselection of appropriate therapy.Somatic nociceptive pain arisingfrom the skin, bone, and musclemay be described as sharp, throb-bing, and aching. Visceral nocicep-tive pain arising from the organs

or viscera may be described ascramping, aching, and sharp.Nociceptive pain generally re-sponds to nonopioids and opi-oids. Neuropathic pain arisingfrom damage to the central orperipheral nervous system maybe described as sharp, shooting,burning, and prickly, and may notrespond well to opioids (NCCN,2008). Neuropathic pain oftenrequires the use of adjuvant med-ications for effective pain manage-ment (Dworkin et al., 2007).

Intensity of pain should bemeasured using a valid, objectivetool that uses a word, phrase, pic-ture, or number to communicatethe severity of pain. Using a scaleprovides a personal measure ofthe patient’s pain and allows eval-uation of pain management usinga consistent measure. A variety ofpain-intensity rating scales areavailable in the Adult Cancer PainPractice Guidelines in Oncology(NCCN, 2008). Once a nurse hasregistered on the NCCN Web site,he or she can locate numerouspain management resources.

Duration of pain can beassessed by asking the patientabout the onset of pain, how longthe pain has been experienced,when the pain is at its worst, andwhen the pain improves (St.Marie, 2002). In addition, thepatient can be asked if the pain iscontinuous or intermittent (Fink,2000).

Assessing the events or activi-ties that aggravate or alleviate paincan engage the patient in the planof care. Aggravating factors arethose that worsen the pain andmight be related to body posi-tions, exercise, or to the time ofday. Conversely, alleviating factorsmight include body positions,rest, or the application of heat or

cold. If the alleviating factors canbe incorporated into the careplan, then the patient may achieveimproved pain control (McCaffery& Pasero, 1999).

A comprehensive pain assess-ment also includes questioningthe patient about associated symp-toms. The patient should be askedabout the presence of nausea,vomiting, constipation, confusion,and sedation (St. Marie, 2002).Additionally, the patient should beasked about the effects of pain onhis or her life such as a disturbedsleep pattern, fatigue, changes inappetite, and activity. Althoughthis component may not be com-pleted with each pain assessment,the nurse should determine theimpact of pain on the patient’s life(St. Marie, 2002) because thepatient may discontinue medica-tions if associated symptoms orthe influence on quality of life isunpleasant or negative.

Along with a thorough painassessment, a history related toprevious pain management thera-pies is important in determiningplanned interventions. To furtherinvolve the patient in the plan ofcare, the patient can be encour-aged to track pain and effective-ness of interventions in a paindiary. A pain diary form is availableon the American Cancer SocietyWeb site (2008) (http://www.cancer.org/downloads/MON/pain_diary.pdf).

Pain Management MeasuresPharmacologic and nonphar-

macologic measures should beevaluated in a plan of care to pro-vide optimal pain management.The World Health Organization(1986) developed an analgesic lad-der for the relief of cancer pain. Useof the ladder has resulted in effec-

SERIESA Cancer Pain Primer

Acomprehensive pain assessment also in-cludes questioning the patient about associ-

ated symptoms.


tive pain management for 80%-90%of patients with cancer pain. Theemphasis is on prompt administra-tion of medications to achieve free-dom from pain. Recommendationsinclude the oral administration ofnonopioids (e.g., acetaminophen[Tylenol®], ketorolac [Toradol®])initially and adding adjuvant drugsas needed. As pain increases or per-sists, the pain should be treatedwith mild opioids (e.g., codeine),with nonopioids, and adjuvant med-ications or treatments added ordeleted as needed. If pain increasesor persists then strong opioids(e.g., morphine, hydromorphone[Dilaudid®]) should be adminis-tered, with nonopioids and adju-vants added or deleted until thepatient is pain free. A further recom-mendation is to provide the drugsaround the clock rather than on anas-needed basis.

An algorithm for treating cancerpain is available in the Adult CancerPain Practice Guidelines in On-cology (NCCN, 2008). Recom-mendations include managing painin patients not taking opioids,patients taking opioids, and for pro-cedural or event-related pain. Thealgorithm also provides recommen-dations for pain related to an onco-logic emergency, and pain not relat-ed to an oncologic emergency. In

addition, the algorithm providesmanagement principles for mild,moderate, and severe pain.

When administering anal-gesics, the nurse must use a pre-ventive approach to pain manage-ment. When pain is predictable,such as with cancer pain, anal-gesics are more effective whengiven around the clock (ATC)rather than as needed (PRN). AnATC schedule maintains therapeu-tic blood levels of the analgesics.With a PRN schedule, the patientmay have frequent periods ofunrelieved pain, and increasedepisodes of breakthrough pain(Ellison & Stanley, 2005).

Nonopioid analgesics includeaspirin, acetaminophen, and non-steroidal anti-inflammatory drugs(NSAIDs) (e.g., ibuprofen [Motrin®]).The nonopioids are generally theinitial treatment choice for mildpain, but the use of this class ofdrugs may be limited with cancerpain (Ellison & Stanley, 2005).Nonopioids may have antipyretic,analgesic, and/or anti-inflammato-ry properties. This range ofactions makes them useful forpostoperative pain and bone pain.Unlike opioids, the nonopioidshave a ceiling effect on analgesia;thus, beyond a certain dosage,improved analgesia will not occur.

The nonopioids may be as effec-tive as low-dose opioids. Forinstance, 650 mg of aspirin or acet-aminophen provides the sameamount of analgesia as 32 mg oforal codeine or 50 mg of oralmeperidine. Because nonopioidstend to block pain transmissionperipherally and opioids blockpain transmission in the centralnervous system, it may be advanta-geous to administer both classes ofdrugs. Side effects of nonopioidsmay include gastrointestinal irrita-tion, fluid retention, and increasedbleeding time. Therefore, theyshould be used with caution inpatients with liver or kidney disor-ders, or thrombocytopenia (NCCN,2008). If bleeding is a concern, the COX-2 inhibitor celecoxib(Celebrex®) or nonacetylated sali-cylates (salsalate [Disalcid®]) canbe given because they do not inhib-it platelet aggregation to the sameextent as acetylated salicylates(e.g., aspirin) and may be consid-ered for treatment of mild generalpain or bone pain (NCCN, 2008).

Addiction and OpioidsOpioids are the mainstay in

the treatment of mild cancer painthat does not respond to nonopi-oids and for moderate and severecancer pain (Ellison & Stanley,2005). When discussing opioidanalgesics, the nurse shouldreview terminology that is oftenmisunderstood and may result inundertreatment of pain. For exam-ple, patients, families, nurses, andphysicians have misconceptionsabout addiction; therefore, theterm must be defined and differen-tiated from tolerance and physicaldependence.

When patients take opioidsover a period of time, toleranceand physical dependence occur.The tolerant patient requires high-er doses of the opioid to providepain management. Not only doesthe patient become tolerant to theanalgesic effects of the opioid, butalso to side effects with the excep-tion of constipation. Tolerance


Cancer Pain Management Resources

American Cancer Societyhttp://www.cancer.org/docroot/home/index.asp

Cancer-Pain.Orghttp://www.cancer-pain.org

Clinical Practice Guidelineshttp://www.nccn.org

National Cancer Institute Pain Managementwww.cancer.gov/cancertopics/paincontrol

International Association for the Study of Pain provides resourcesincluding the Outline Curriculum on Pain for Schools of Nursing

http://www.iasp-pain.org

Pain Management Pocket Tool, Pain Diaryhttp://www.cancer.org


can develop within a matter of afew days of initiating the drug andis not synonymous with addiction(Ellison & Stanley, 2005).

Physical dependence is aphysiologic response to theabrupt discontinuance or rapidreduction of the opioid, and also isnot synonymous with addiction.Withdrawal symptoms can in-clude nausea, vomiting, diarrhea,insomnia, and diaphoresis (Ellison& Stanley, 2005).

Addiction, on the other hand,is the active, compulsive use ofthe drug (opioid) for effects otherthan pain relief (Mickle, 2002),even if it causes harm (Ellison &Stanley, 2005). Addiction by indi-viduals using opioids for painmanagement is infrequent (Ellison& Stanley, 2005), although patientsand families often fear addictionwill result. It is therefore impera-tive that the nurse discuss thisfear with patients and families.

Opioids vary in potency andduration of action. “The appropri-ate dose is the dose that relievesthe patient’s pain throughout the dosing interval without caus-ing unmanageable side effects”(NCCN, 2008). Some opioids arepresent in combination drugs(e.g., hydrocodone and acetamin-ophen [Vicodin®]). Although thereis no ceiling to the dose of opioid,the limiting factor is the acetamin-ophen dose (usually limited to 4grams per day). Considerationshould be given to change to a sin-gle-entity opioid when dosingexceeds the maximum amount ofacetaminophen (NCCN, 2008). It isimportant to refer to an equianal-gesic table when changing fromone opioid to another. Anequianalgesic table providesdosages of various oral and par-enteral drugs that are essentially

equivalent to each other in theirability to provide pain relief(McCaffery & Pasero, 1999). Forexample, to administer a dose ofhydromorphone equianalgesic toparenteral morphine 10 mg, thenurse would need to administer1.5 mg of parenteral hydromor-phone or 7.5 mg of oral hydromor-phone. When converting one opi-oid to another, however, theamount of opioid required in a 24-hour period is summed. Then theequianalgesic dose of the new opi-oid is calculated. If pain controlwas adequate with the originalopioid, then the total dose of thenew opioid should be reduced by25%-50% initially due to cross-tol-erance between opioids. The dosethen can be titrated upward rapid-ly. If the pain is not managed, thestarting dose of the new opioidcan be as much as 100%-125% ofthe equianalgesic dose (NCCN,2008). Finally, the daily dose isdivided by the number of dosesper day to determine the individ-ual dose. The NCCN Adult CancerPain Guidelines (2008) also pro-vide an equianalgesic table of oraland parenteral opioids.

The most commonly used opi-oids used to control severe cancerpain in the United States are mor-phine, hydromorphone, oxy-codone (Percocet®), and fentanyl(Sublimaze®) (Ellison & Stanley,2005). Opioids can be adminis-tered by various routes dependingon the patient’s needs. The oralroute is preferred if tolerated,especially for patients with chron-ic pain; oral opioids can controlsevere pain when given in ade-quate dosages. The NCCN AdultCancer Pain Guidelines (2008) rec-ommend using short-acting opi-oids initially when titrating to thedose that relieves the pain. Once

an efficacious dose is reached andside effects are managed, sus-tained-released opioids are con-sidered along with rescue medica-tions for breakthrough pain. Thebreakthrough dose is generally10%-20% of the total 24-hour oraldose of the sustained-acting opi-oid.

Breakthrough pain is episodicor transient pain that occursdespite stable pain management inpatients receiving chronic opioidtherapy (Payne, 2006; Portenoy &Hagen 1990 ). One of the preferreddrugs for breakthrough pain in apatient who is tolerant to opioidsis fentanyl. Although the sus-tained-release preparation of fen-tanyl is available in transdermalpatches, short-acting fentanyl isavailable in an oral transmucosallozenge or a buccal tablet. Thepatient and family must be taughtthat the two formulations are notthe same. The transmucosallozenge is placed between thecheek and the gum, and is to besucked rather than chewed. It isleft in place for approximately 15minutes (Cephalon, 2006). Thebuccal tablet is placed in themouth above a rear molar and leftin place between the cheek andgum for up to 25 minutes.Whatever part of the tablet thatremains then can be swallowed.The patient must be instructed toleave the tablet whole and notchew or suck on the tabletbecause less medication will bedirectly absorbed across the oralmucosa (Cephalon, 2008).

The sustained-release fentanyltransdermal patch often is usedfor cancer pain because the patchcan provide a constant release ofmedication over time. Althoughthe patch can last up to 72 hours,the time may vary with eachpatient and sometimes may reachonly 48 hours. Many drug interac-tions are possible with fentanyl.Concomitant administration ofdrugs such as clarithromycin(Biaxin®), diltiazem (Cardizem®),erythromycin (Erythrocin®), flu-


Breakthrough pain is episodic or transient painthat occurs despite stable pain management in

patients receiving chronic opioid therapy.


conazole (Diflucan®), and vera-pamil (Calan®) can increase fen-tanyl plasma concentrations andthus increase adverse drugeffects. Grapefruit or grapefruitjuice can increase the plasma con-centration of fentanyl and shouldbe avoided. Patients must beinstructed that they cannot cutthe patches because direct expo-sure to the fentanyl could occurand cause a potentially fatal over-dose. Direct heat, heating pads,and other heat sources should beavoided because heat can pro-duce an increased release of fen-tanyl and result in overdose.Likewise, if the patient has a fever,monitoring for adverse sideeffects should be more frequent(Waknine, 2008). Although respira-tory depression is rare in opioid-tolerant patients, an increasedconcentration of fentanyl could befatal. Sedation precedes respirato-ry depression (McCaffery &Pasero, 1999), making it essentialto monitor the patient for this sideeffect more closely.

Morphine, oxycodone, andhydromorphone are available infast-acting and sustained-releasepreparations. Use of one opioid forpain management is preferred to acombination of several opioids.The use of multiple opioids doesnot always result in good patientadherence, and adds to the complexity and cost of treat-ment (Cooney, 2005). Meperidine(Demerol®) and propoxyphene(Darvon®) are not recommendedfor cancer pain due to toxic metabo-lites. Buprenorphine (Buprenex®),pentazocine (Talwin®), nalpuphine(Nubain®), butorphanol (Stadol®),and dezocine (Dalgan®) also arenot recommended in the treatmentof cancer pain because they canprecipitate withdrawal symptomsin an opiate-dependent patient(NCCN, 2008).

For increases in the dose ofdaily opioid, adjustments can bemade by adding the total amountof rescue medication (needed forbreakthrough pain over a 24-hour

period) to the ATC dose to calcu-late the new daily dose of opioid.The other method of increasingthe opioid dose is to increase thedose by 25%-100% depending onfactors such as the pain severityand the patient’s response to pre-vious adjustments (Cooney, 2005).This increase in dosing can makenurses uncomfortable if they haveonly cared for patients who do nottake opioids or use them only inacute pain episodes. It is importantto remember that patients who takeopioids for extended periods andare tolerant to the side effects of thedrugs may require high doses.There is no ceiling dose for opioids(McCaffery & Pasero, 1999).

Case Study Ms. G. was hospitalized for

poorly managed pain due to ovari-an cancer with metastasis to themeninges. At times, she wouldhave increased intracranial pres-sure and head pain as well as con-stant generalized pain. Ms. G.’sintravenous morphine dose wasincreased to 1,000 mg per hour, adose that was startling to the med-ical-surgical nurses who believedit would be lethal to Ms. G. Thedose was approximately a 25%increase from the patient’s previ-ous dose. Ms. G. was tolerant tothe morphine and to its sideeffects. She was lucid wheneverthe intracranial pressure was nor-mal. She was tachypneic and didnot have depressed respirations.Ms. G. was monitored closely forthe first few hours after the initia-tion of the morphine drip becauseof the nurses’ discomfort in notpreviously caring for a patientreceiving such a high dose of mor-phine. Ms. G. remained on the unitfor several more days beforetransferring to an out-of-state hos-pital near her husband’s new job.

The adverse effects of opioidanalgesics include constipation,nausea, sedation, respiratorydepression, confusion, hypoten-sion, dizziness, itching, and uri-nary retention. These side effectsneed to be addressed proactivelyto insure that the patient contin-ues to take the opioid and haswell-managed pain. Because toler-ance does not develop to consti-pation, prophylactic measures areneeded; these include increasedfluid and fiber intake, exercise ifpossible, and medications, suchas laxatives and stool softeners(NCCN, 2008), and subcutaneous-ly administered methylnaltrexonebromide (Relistor®).

Adjuvant MedicationsAdjuvant medications are

drugs not usually classified asanalgesics but may relieve pain incertain situations. Opioids maycontrol some of the cancer pain,but additional adjuvant medica-tions may have a synergistic effectthat results in improved pain man-agement. Antidepressants, anti-convulsants, and corticosteroidsare examples of medications thatmay be helpful with specific painsyndromes. Pain from nerve com-pression or inflammation mayrespond to corticosteroids. Neuro-pathic pain may respond to anti-depressants and anticonvulsants.First-line medications for neuro-pathic pain include the tricyclicantidepressants and selectiveserotonin and norepinephrinereuptake inhibitors (Dworkin etal., 2007). It is important to teachthe patient and family that antide-pressants or anticonvulsants mustbe taken for several weeks to eval-uate the effectiveness of thedrugs; otherwise the patient maybecome frustrated and stop takingthe drug. Suggested doses of adju-


Adjuvant medications are drugs not usually classi-fied as analgesics but may relieve pain in certain

situations.


vant drugs are provided in theNCCN Guidelines (2008). Topicalmedications such as lidocainepatches (Lidoderm®) and cap-saicin cream may provide addi-tional relief of neuropathic pain.

A Pain Management PocketTool (2005) available on theAmerican Cancer Society Web siteprovides commonly used opioidand nonopioid analgesics withdosing and side effect information.An opioid equianalgesic table andinformation about adjuvant med-ications also are provided. Addi-tional recommendations related tobreakthrough pain and changingfrom one opioid to another areavailable on the pocket tool.

NonpharmacologicInterventions

Nonpharmacologic interven-tions also can be incorporatedinto the plan of care, but they arenot intended to replace medica-tions. Physical interventions caninclude simple comfort measures,such as changing an immobilepatient’s position; providing restperiods for a fatigued patient whois unable to sleep, or ensuring aquiet environment at the correcttemperature for the patient.Comfort measures may increasepain tolerance and ultimatelyallow the patient to experienceless pain. Effective pain manage-ment measures should be docu-mented in the medical record foruse by others on the health careteam (McCaffery & Pasero, 1999).

Cutaneous stimulation throughmodalities such as massage, heatand cold application, and transcu-taneous nerve stimulator hasdemonstrated variable effects.Cutaneous stimulation can de-crease the intensity of pain orchange the sensation so that it is

tolerable for the patient (Cahill,2005). Although not curative, cuta-neous stimulation may reducepain by modifying the transmis-sion of painful stimuli. Cold thera-py may reduce swelling andrelieve pain longer than heat ther-apy. When applied incorrectly,cutaneous stimulation may dam-age tissue and thus the nurse mustbe knowledgeable about the appli-cation of these therapies (Cahill,2005).

Psychological interventionsinclude patient and family teachingabout pain, analgesics, and proce-dures or psychological strategies,including relaxation therapy andguided imagery. These types ofinterventions are complementaryand are used together with anal-gesics to improve pain manage-ment. Distraction techniques canbe helpful in reducing mild-to-mod-erate pain or during brief periodsof procedural pain. Examples ofdistraction methods include listen-ing to music, laughing, counting,watching television, reading, talk-ing on the phone, and visiting withfriends or family. Including severaldistraction techniques in the planof care may be helpful; this allowsthe patient to select the methodsmost effective for individual pain management (McCaffery &Pasero, 1999).

Relaxation is a cognitiveapproach using a self-hypnotictechnique that may produce therelaxation response. The relax-ation response counteracts thestress response and is character-ized by decreased muscle tension,heart rate, and respiratory rate,and normal or decreased bloodpressure. Relaxation decreasesmental stress and physical ten-sion, which may be helpfulbecause pain often is accompa-

nied by increased anxiety andmuscle tension (Cahill, 2005).

Imagery is another cognitiveapproach to pain managementthat uses a person’s imaginationto encourage physical and mentalrelaxation. The nurse shouldassess a patient’s preferencesbefore initiating imagery exercis-es; for example, it is not helpful tohave a patient imagine being atthe beach and then learn that hisor her previous negative experi-ence at the beach creates anxietyin just thinking about being there.Likewise, if a specific activity orlocation promotes relaxation, it ishelpful to incorporate that in theimagery exercise (McCaffery &Pasero, 1999).

Case StudyMrs. B. underwent an allo-

geneic bone marrow transplantand subsequently suffered fromgraft versus host disease. WhenMrs. B. urinated, sloughed tissuepassed through her meatus, whichresulted in significant pain. Animagery exercise helped reduceher pain during these episodes.She imagined herself floating in aninner tube down a lazy river. Sheimagined the wind against herskin, the sounds of birds, the smellof the fresh air, and the peace shefelt during the tubing experience.Mrs. B. practiced the imageryexercise when she was not experi-encing the pain so that when thepain occurred, the imagery exer-cise could be used readily withsuccess.

Sample relaxation and imageryexercises that can be used in clini-cal practice are available at theNational Cancer Institute’s Web site(http://www.cancer.gov/cancertopics/ pain control/page14) Theseexercises can be used easily in out-patient and inpatient settings.Patients can also use the exercisesat home. The patient’s pain shouldbe assessed before and after relax-ation and imagery exercises toevaluate the effectiveness of themodalities.


Comfort measures may increase pain toleranceand ultimately allow the patient to experience

less pain.


Patient and Family EducationPatient and family education

is a key component of safe andeffective pain management. Dis-cussions between the nurse andthe patient and family shouldinclude the following: • Terminology related to pain

management.• Assessment of the patient’s

pain at home (perhaps throughuse of a pain diary).

• Facts about medications andthe rarity of addiction whenopioids are used to relievepain.

• Adjuvant therapies for painmanagement.

• Alternative and complementa-ry therapies for pain manage-ment.

• Vital nature of communicationwith the interdisciplinaryteam, especially related to thepain experience, effectivenessof interventions/medications,side effects, and other modali-ties. The team may consist ofnurses and physicians, as wellas physical and occupationalhealth professionals, psychol-ogists, counselors, socialworkers, and case managers.Team members work with thepatient in achieving optimalpain management.Opportunities exist for im-

proving cancer pain management.Medical-surgical nurses must part-ner with patients and families toachieve optimal pain manage-ment. They must use valid tools toassess patients and be knowledge-able about pharmacologic andnonpharmacologic measures tomanage pain. Evidence supports

the feasibility of attaining appro-priate pain management forpatients with cancer through useof clinical practice guidelines(NCCN, 2008) within health carefacilities. Medical-surgical nursesalso should be involved in evaluat-ing the safety and effectiveness ofnew medications and pain man-agement technologies. The ulti-mate goal is the patient’s effectivepain management.

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Waknine, Y. (2008). FDA safety changes:Ultram ER, reyataz, duragesic. RetrievedAugust 24, 2008, from http://www.med-scape.com/viewarticle/577278

World Health Organization. (1986). WHO’spain ladder. Retrieved August 24, 2008from http://www.who.int/cancer/pallia-tive/painladder/en/

Additional ReadingMiaskowski, C., Cleary, J., Burney, R.,

Coyne, P., Finley, R., Foster, R., et al.,2005. Guideline for the management ofcancer pain in adults and children.Glenview, IL: American Pain Society.


M edical-surgical nurses must partner withpatients and families to achieve optimal pain

management.



Answer/Evaluation Form: A Cancer Pain Primer

MSN J0818

COMPLETE THE FOLLOWINGThis test may be copied for use by others.

Name: __________________________________________________________________

Address: ________________________________________________________________

City:________________________________________State: ______ Zip: _____________

Preferred telephone: (Home)_________________ (Work) _________________________

Registration fee: Complimentary CNE provided as an educational service by C-Change (www.c-changetogether.org).

OBJECTIVESThis continuing nursing educational(CNE) activity is designed for nurses andother health care professionals who carefor and educate patients and their fami-lies regarding cancer pain. For thosewishing to obtain CNE credit, an evalua-tion follows. After studying the informa-tion presented in this article, the nurse will be able to:1. List key considerations in assessing

pain in the patient with cancer.2. Discuss pain management meas-

ures in the patient with cancer.3. Describe issues related to addiction

and opioids in the patient with can-cer.

4. Define the role of adjuvant medica-tions and nonpharmacologic inter-ventions in treatment of pain in thepatient with cancer.

ANSWER FORM1. If you applied what you have learned from this activity into your

practice, what would be different?

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Strongly StronglyEvaluation disagree agree

2. By completing this activity, I was able to meet thefollowing objectives:

a. List key considerations in assessing pain in the patient with cancer. 1 2 3 4 5

b. Discuss pain management measures in the patient with cancer. 1 2 3 4 5

c. Describe issues related to addiction and opioidsin the patient with cancer. 1 2 3 4 5

d. Define the role of adjuvant medications and nonpharmacologic interventions in treatment of pain in the patient with cancer. 1 2 3 4 5

3. The content was current and relevant. 1 2 3 4 5

4. The objectives could be achieved using 1 2 3 4 5the content provided.

5. This was an effective method 1 2 3 4 5to learn this content.

6. I am more confident in my abilities 1 2 3 4 5since completing this material.

7. The material was (check one) ___new ___review for me

8. Time required to complete the reading assignment: _____minutes

I verify that I have completed this activity: _____________________________

Comments

______________________________________________________________________

______________________________________________________________________

CNE Instructions1. To receive continuing nursing education

credit for individual study after readingthe article, complete the answer/evalua-tion form to the left.

2. Photocopy and send the answer/evalu-ation form to MEDSURG Nursing, CNESeries, East Holly Avenue Box 56,Pitman, NJ 08071–0056.

3. Test returns must be postmarked byDecember 31, 2010. Upon completionof the answer/evaluation form, a certifi-cate for 1.0 contact hour(s) AND 30minutes of pharmacology hours will beawarded and sent to you.

4. CNE forms can also be completedonline at www.medsurgnursing.net.

This independent study activity is co-pro-vided by AMSN and Anthony J. Jannetti,Inc. (AJJ).

AJJ is accredited as a provider of continu-ing nursing education by the AmericanNurses Credentialing Center's Com-mission on Accreditation (ANCC-COA).

Anthony J. Jannetti, Inc. is a providerapproved by the California Board ofRegistered Nursing, Provider Number,CEP 5387.

This article was reviewed and formatted forcontact hour credit by Dottie Roberts, MSN,MACI, RN, CMSRN, OCNS-C®, MED-SURG Nursing Editor; and Sally S.Russell, MN, CMSRN, AMSN EducationDirector.

pain managemnet

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