Pain assessment and management
Pain is generally considered as a fifth vital sign. It is an unpleasant sensation or response to a certain stimulus with or without an indefinable cause (De Lisa, 1998). It is a subjective perception which may be associated with definite or probable tissue damage (De Lisa, 1998; NCI, 2007). Being a multifaceted experience, pain encompasses not only the physical aspect but other factors as well including affective, cognitive, social and motivational aspects of an individual (Kemp, 2000).
Thus, a patient’s report of pain cannot be used to generalize on all patients as each case is influenced by multiple factors which cannot be easily distinguished and accounted for. Pain assessment and management should also be adapted or modified in accordance to the patient’s current condition at a point in time. There are different types of pain and one classification is in terms of the duration of pain. Acute pain has an identifiable nociceptive stimulus such as tissue damage or trauma (De Lisa, 1998; IAHPC, 2004).
The pain experienced is usually self-limiting, lasts for less than two months and can be relieved by removing the cause of the stimulus (De Lisa, 1998; IAHPC, 2004). Chronic pain on the other hand involves pain that persists longer than usual, may be a result of inadequate treatment of acute pain, maybe a result of a persistent pathology or simply an undeniable pain that occurs despite recuperation from a recognized illness (De Lisa, 1998).
Though similar with acute pain in that treatment is generally assumed after removal of stimulus, chronic pain is usually more complicated because emotional and cognitive influences are also involved (Kemp, 2000; De Lisa, 1998; IAHPC, 2004; Yadgood, 2000). Thus, the most appropriate medical assessment and management should consider the complexity of the condition and that would give emphasis on the patient’s perception of the pain. The aim of palliative care is the removal of pain or the control the pain the patient experiences thereby allowing optimal function and quality of life (IAHPC, 2004).
Adequate control and management of pain is achieved by a team of health professionals (De Lisa, 1998; NCI, 2007) who has adequate knowledge on its complexity and has skills on managing the pain. Assessment is considered as the cornerstone of pain management (Abraham & Synder, 2001) and this is emphasized in a number articles focused on pain (Cesaro & Ollat, 1997; Donovan & Miaskowski, 1992; Grossman, 1991; Ferell, 2000; NCI, 2007; Stanik-Hutt, 1999).
Since pain is an individual experience, adequate assessment of pain is necessary to determine the conditions etiology and in development of individualized management. Pain assessment is the evaluation of the patient’s pain characteristics, possible causes as well as how it affects the patient’s activities of daily living and other psychosocial aspects (NCI, 2007; IAHPC, 2004). Over the course of pain management, pain assessment is performed repetitively – initially, by certain interval or scheduled time and during changes in pain characteristics.
These assessments are necessary to determine the efficacy of the medical and rehabilitative management currently used by the patient (NCI, 2007; IAHPC, 2004). There is an agreement in palliative care that the foremost consideration in pain assessment is the description of pain directly coming from the patient (Kemp, 2000; Olsen & Nolan, 1992). Certain parameters are essential to be asked to the patient and this includes basically pain severity or intensity, location and characteristic or qualities (Shannon, 1995) which are primarily asked during initial assessment.
Other essential pain parameters need to be asked as well upon history taking including pain history or how the pain evolved or changed over time, frequency, duration, quality, relieving and aggravating factors observed effect of medication (Kemp, 2000; NCI, 2007; Shannon, 1995). Pain assessment also includes presence of inflammation, impact on daily life or on relevant activities to the patient, inquiry on the presence of other physical symptoms that appears not to be related to the current complaint and other information that may lead to a more accurate diagnosis (Kemp, 2000).
Assessment tools are used as well such as verbal rating scale, verbal analog scale and faces rating scale for pain intensity, Mc Gill Questionnaire for pain quality and the use of body diagram for pain localization (NCI, 2007; Olsen & Nolan, 1992) . Once the condition is adequately assessed it is assumed that the most likely etiology is determined. This in turn would assist the medical team to develop the most cost effective and least demanding management both for the patient and the care providers.
The aim of improvement of quality of life by better control of pain is significant for cancer patients (NCI, 2007; Sadovsky & Abrahm, 1999) especially those who are their severe stages. Pain management in cancer patients is a focus of palliative care. Treatment principles are necessary (Kemp, 2000; NCI, 2007) to standardized care because under treatment was observed to be common among cancer patients (Sadovsky & Abrahm, 1999). The World Health Organization (WHO) developed a analgesic ladder that serves as guide in pharmacologic treatment of pain (IAHPC, 2004; Sadovsky & Abrahm, 1999; Stanik-Hutt, 1999).
This describes the three-step progression and suggested modifications, route of administration and dosage, to guide in the prescription of non-opiod medications advancing to opiod medication. The basis of treatment is on the severity and characteristic of pain experienced by the patient. In addition to pharmacologic therapy, adjuncts as well as aggressive measures (chemotherapy, radiotherapy, surgery) in severe cases are suggested to address the complexity of pain. The use of physical modalities to address pain has been practiced since ancient history.
Currently the most commonly used modalities are exercise, cutaneous stimulation such as heat, cold and counter-stimulation through the use of massage or transcutaneous electrical nerve stimulation (TENS) (Abrahm & Synder, 2001; DeLisa, 1998; IAHPC, 2004; NCI, 2007) Pain management have been currently improved because additional interventions is not limited to use of modalities but now also comprise psychosocial interventions (Sadovsky & Abrahm, 1999). These interventions help in the coping mechanism of the by patient by having a sense of control over the condition.
Examples of these are individual and group counseling, imageries, psychotherapy, most importantly patient and caregiver education (Sadovsky & Abrahm, 1999). These adjunct therapies allow the patient to actively participate in the treatment which would enhance the ability to cope with pain. Assessment of pain in cancer patients is emphasized because of the instability of their condition as well as different possible presentation of symptoms in every patient at every point in time.
Some cases may progress faster than the others or there may be instances of remission and aggravation. The different parameters used in assessment each have a significant role in determining pain etiology (IAHPC, 2004). The intensity or severity of pain already gives a number cues to the condition (Miller & Wang, 1999). The more accurate the patient’s response, the more likely a suitable pharmacologic or non-pharmacologic treatment can be prescribed . This can also signify the effect of administered management on the patient.
The location of pain is used to determine the cause of pain or area of metastasis (Kemp, 2000). The temporal factors – frequency an duration are important guides in management in that one of the possible aims of palliative care is to decrease the occurrence and duration of pain experienced. The aggravating and relieving factors are important to be asked so that the patient and health care providers will be knowledgeable on the activities (Kemp, 2000). This will guide the patient to avoid activities that may cause pain and promote those that would reduce the pain.
As mentioned, the parameters are all important as they aid in finding the right etiology for the pain and to monitor changes in the patient’s condition (NCI, 2007; IAHPC, 2004). Certain barriers (Sadovsky & Abrahm, 1999) affecting pain management are threats to obtaining optimal quality of life for cancer patients. Health care professionals may influence assessment with their insufficient assessment and management skill (Hamilton, 1992) and concern for the regulation and possible tolerance and addictive effects of analgesics to patients (Kemp, 2000).
Since assessment primarily depends on patient report, the patient’s fear of worsening, disappointing the physician and concern of addiction are also considered problems in assessment. Another source of dilemma in pain management is the health care system with its restrictions, regulations and prioritization involving cancer pain managements (IAHPC, 2004). In a study by Hamilton conducted among nurses, it was observed that they incomplete knowledge in pain management (1992).
Although the subjects scored high in terms of attitude towards the patients, the inadequacy in providing pharmacologic treatment needs to be addressed. In all clinicians involved in this primary treatment, knowledge is important for there is always a risk of under treatment (Sadovsky & Abrahm, 1999). Improper computation of medical prescription for example, may not meet the palliative need of the patient hence pain aggravates and may even influence further emotional disturbance (Hamilton, 1992).
Although the study was conducted more than a decade ago, this problem may still be faced by different medical practitioners at present. Proper strategies (NCI, 2007) are encouraged since pain assessment may involve great deal of time for the patients. If rapport or proper education was not established, there may also be inadequate cooperation from the patient. Hesitance on the part of the patient may means inaccuracy in pain assessment (Abrahm & Synder, 2001; Sadovsky & Abrahm, 1999). This would cause difficulty in developing management.
In addition, the effect of current management on the patient may not be accurately reported and interpreted (Grossman, 1991) hence modifications may not be done properly. As the disease progresses, cognition appears to deteriorate as well (Sadovsky & Abrahm, 1999). It is thus emphasized that assessment be performed at an earliest possible time during the course of the illness. All the previous assessments, responses, observed changes recorded would be the sole basis in pain management when cognition is impaired. If these are unavailable, no accurate management can be provided.
The primary source of assessment, the patient himself (IAHPC, 2004) would be unreliable, thus the records kept must be reliable enough to be the guide of management on worse cases. Undesirable consequences result from poor pain assessment and management. These consequences must be avoided as both the patient and the family or the caregivers are affected in the disease process. Negative consequences hinders as well the progression of treatment which would affect the over-all management of the disease process the patient experiences (NCI, 2007; Yadgood, 2000).
It is recognized that pain should be adequately controlled first before psychosocial management can be executed (IAHPC, 2004). Since pain is also an emotional and cognitive response, the patient would find difficulty participating in discussions as the pain would be a distraction not just in his normal functioning but in his handling situations as well. Therefore, poor cancer pain management is a factor for delayed improvement of the patient regardless if there is a definite or unidentifiable cause (Kemp, 2000; IAHPC, 2004; Sadovsky & Abrahm, 1999).
Poor recognition and management of the influence of psychosocial also contribute to the pain (Sadovsky & Abraham; 1999; IAHPC, 2004). As a person’s perception is involved, the alleviation of pain would not be complete even in the presence of proper pharmacologic management (NCI, 2007). This emphasizes addressing the patient’s problems as a whole than mere pain to avoid failure in management. Even if pain is primarily a subjective issue, certain diagnostic procecures need to be performed (Kemp, 2000) .
However, the diagnostic procedures as well as certain managements are may be time consuming and painful for the patient (Kemp, 2000; Miller & Wang, 1999). Though used throughout the treatment, unecessary procedures may be performed if there is inadequate assessment and management In addition, this may cause financial difficulty for the family or may be questioned by health care insurrance. There is also the risk of under treatment of cancer pain especially when the prescription of opiod drugs is concerned (Grossman, 1991; Kemp, 2000; Sadovsky & Abrahm, 1999 ).
Under treatment is observed as inadequate pain control. As an example, medication such as Morphine (NCI, 2007; Sadovsky & Abrahm, 1999) will not work if it is inappropriately dosed, if concurrent issues are not addressed or if it is a wrong choice for the type of pain the patient experiences. One of the important management is patient and caregiver education (Sadovsky & Abrahm, 1999; Yadgood, 2000). As cancer in itself is not an individual problem, education involves the people who would most likely support the person.
Sound knowledge regarding the disease process, the expected progression, the presence of symptoms as well as its aggravating and alleviating factors and ability to actively participate in the management are important. Home care is chosen for most patients (Sadovsky & Abrahm, 1999; Yadgood, 2000). Proper assessment and clear and effective management is very important in these cases. If the caregivers’ ability to handles stress and to cope with unexpected such as presence of breakthrough pain is not assessed, inadequate management may be performed when these problems are encountered at home.
Part of the management is teaching how to perform certain therapies at home (Yadgood, 2000). It is also important to note that when the concerns or preference of the family are considered, there would be inadequate coping on their side and cooperation in the management may be sacrificed (Sadovsky & Abrahm, 1999; Yadgood, 2000) Pain involves undesirable sensation and responses from the patient. The chronic type of pain, in which cancer pain is classified, is complicated by being multifaceted. It involves physical, psychosocial and spiritual aspects of a person.
It presents with unpredictable changes in status and the possibility of progression happening, it is a problem faced not only by patient but also by his family or care givers. These are the reasons why cancer pain is greatly focused on cancer management. Pain is assessed in details considering primarily the patients descriptions in response to parameters that would lead to the understanding of the pain etiology. As laboratory diagnostics are mostly deemed inconclusive in most cases, the subjective reports are expected to be reliable enough to be used in pain management.
The patient response and the pain’s etiology determine what pharmacologic, non-pharmacologic or other more extreme invasive procedures are needed to be performed. Certain guidelines are provided and clarifications about misconceptions regarding concerns of use of opiod medications are discussed widely in literature. These are suggested to be followed for maximum efficiency of pain management. It cannot be overemphasized that skilled assessment and understanding of the management for cancer patients are important.
The main concern for end of life care is to provide the highest quality of life possible in the case. The goal is alleviation of pain for the presence and intensity of pain would be possible determinants for the patient and family’s psychosocial well being. If pain is improperly recognized, inadequately controlled, under treated and is not associated with the overall well-being of the patient, cancer pain management and would even be a cause for aggravation of the condition.
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