Pain: causes, assessment and management

A universally accepted definition of pain is that it is an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage (International Association for the Study of Pain 2007). Pain is complex and understanding what is both initiating the pain and maintaining it is important for effective management. Chapter 5 on palliative care introduced you to the concept of ‘total pain’. The contemporary way of referring to total pain is from a ‘biopsychosocial’ perspective (Holdcroft & Power 2003) and can be divided into three factors:

The most challenging part of managing pain is the subjectivity of pain; what it means to one person is different from another person, as is the individual’s ability to manage the pain. ‘Pain is whatever the person experiencing it says it is, existing whenever he says it does’ (McCaffery 1968:95). While this work of McCaffery is old, it continues to be a fundamental principle of pain management.

A simple way of developing our understanding of normal pain transmission is to consider it from the following four perspectives:

Types of pain

Table 15.1 gives a simple overview of two types of pain, the basic physiology and words associated with how pain might be experienced.

Table 15.1 Types of pain

Activity

Using Table 15.1, write a few sentences about the impact the different types of pain can have on the activities of living.

To help you do this, you might want to refer back to pain lecture notes from your course. If this is a new subject to you, look at the recommended physiology text for your course and read about pain and pain pathways. Make notes on the new words or phrases you come across to help to retain knowledge and understanding.

NMC Domain 1: 1.1; 1.2;

NMC Domain 2: 2.2; 2.4

NMC Domain 3: 3.2

Doing the above exercise helps link the physiology of the origins of pain and the impact pain can have on holistic wellbeing. This way of thinking starts the assessment process and is the first step in the effective management of pain and is where the understanding of biopsychsocial factors for a holistic approach is important.

Assessing pain correctly is fundamental to ensuring analgesia prescribed is appropriate and effective. Asking how the pain is and getting the patient to describe the pain is a useful way to establish possible causes. Also finding out what makes it worse and what makes it better is important too. The assessment tool in Figure 15.3 is called the Brief Pain Inventory (BPI) and is used in many clinical areas and is a quick way to explore pain with a patient.

Fig 15.3 Pain assessment tool

(reproduced with permission from McCaffery M, Pasero C (1999) Pain, clinical manual, 2nd edn. Mosby, St Louis)

Activity

Find out how the nurses in your practice placement assess a patient’s pain. If a pain assessment tool is used, how often is it completed? How is the information communicated with the healthcare team? How often is a patient’s pain reviewed?

NMC Domain 1: 1.5

NMC Domain 2.2; 2.7

NMC Domain 3.1; 3.3

Management of pain

Once pain is effectively assessed, appropriate analgesia can be prescribed. Often a patient may have analgesia prescribed ‘as required’ or ‘prn’. The potential problem with this is it is reliant on the care team noticing the person is in pain or the patient asking for analgesia. Literature suggests this is something that healthcare professionals do not always do well and patients may not always feel able to ask. It is also important to record if any ‘as required’ analgesia given has helped to relieve the pain. This can be done by returning to the patient within half an hour of giving the analgesia. If analgesia is not relieving pain, it needs to be reviewed by the care team. If several ‘as required’ drugs are given over a period of time with good effect, these should be converted into regular administration. The plan of care should aim for the patient being pain free and not routinely needing ‘as required’ medications.

The World Health Organisation (WHO) analgesic step ladder is shown in Figure 15.4. Here we can see that analgesia is staged from a non-opioid, to a weak opioid and then to a strong opioid. This is the recommended ladder by which analgesia is prescribed.

Fig 15.4 WHO analgesic step ladder (WHO (1996) Cancer pain relief, 2nd edn. WHO, Geneva)

Sometimes morphine analgesia is not prescribed or given ‘as required’ (prn) for fear it will harm the patient. Equally, this may be the reason a patient may refuse to take analgesia or admit to being in pain. An article which will help you to understand this issue in more depth is Stannard (2008) (see References).

Non-drug interventions for pain can be really helpful to patients. These can be done even before a registered nurse is needed to get a prescription. If a patient is in pain, ask where the pain is and what normally helps that pain. They might say ‘sitting up’ or ‘massaging my legs’ or ‘a cup of tea’. These interventions can help bring down a patient’s pain score. Always remember to document any non-drug interventions you do.

Remember, effective management of pain relies on comprehensive assessment of the whole person throughout the time you care for them.

Activity

When you are in your practice placement area, have a look at two or three patient drug cards. Find out if each patient is prescribed any analgesia and, if so, see how their prescription relates to the WHO analgesic step ladder. If the step ladder was not followed, consider why this might be. Do you have enough history about the patient to be able to answer this question? Consider what additional information would be helpful for you. Remember that gathering information about a patient is vital for managing symptoms effectively.

NMC Domain 1: 1.1; 1.2

NMC Domain 2: 2.7

NMC Domain 3: 3.1; 3.2; 3.3

NMC Domain 4: 4.2

Nausea and vomiting

The symptoms of nausea and vomiting are often associated together, bit this is not the right approach. It is important to consider the causes and management of nausea as separate to the causes and management of vomiting. Some patients will have both symptoms. Forty-two percent of patients with cancer have just nausea at some point while 32% have both nausea and vomiting together (Twycross et al 2009).

Nausea and vomiting can be caused by a wide range of factors, so understanding physiological processes is an important part of being able to gather the correct information in the assessment process. In the brain, there are specific areas that provoke the vomiting response: the vomiting centre and chemoreceptor trigger zone (CTZ) in the medulla oblongata, which is at the base of the brain, the cerebral cortex and the vestibular centre. In addition, right through the gastrointestinal tract there are peripheral pathways where receptors send messages via the vagus nerve to the brain to activate the CTZ and vomiting centre. Figure 15.5 is a simple diagram demonstrating how the pathways work.

Fig 15.5 Vomiting pathways

(adapted from: Campbell T, Hately J (2000) The management of nausea and vomiting in advanced cancer. International Journal of Palliative Nursing 6(1):18–25)

There are seven core causes of vomiting, often referred to as vomiting pathways or syndromes. We now look at each in turn to explain what causes the vomiting and to understand treatment options:

Understanding the physiology of vomiting pathways is the first step in assessment of nausea and/or vomiting. The specific treatment and care will depend on the cause(s). Table 15.2 links the vomiting pathways/syndromes to potential treatment options and nursing care and interventions.

Constipation

Half of the people diagnosed with cancer experience a change in their bowel habits leading to constipation (Twycross et al 2009). One in six of these will class this as severe and it is the most common reported gastrointestinal problem. Constipation is defined as the passage of hard, dry stools with excessive straining and decrease in frequency (Doyle et al 2005). How we define normal bowel movement is determined by the patient and their normal pattern. Taking a comprehensive history of bowel movements, and when changes have occurred in the past, can help with management.

Constipation is common in patients receiving analgesic medication. It is essential that anyone prescribed an opioid also have a laxative prescribed. This is because opioids have a direct effect on the smooth muscle of the large intestine and slow down peristaltic movement. This means that more water is absorbed from the large intestine.

Oral care

Maintaining a healthy mouth is a fundamental part of nursing care and essentially an important focus of care for cancer patients. A mouth is kept clean and healthy by having a good diet, adequate flow of saliva, mastication (chewing food) and oral cleaning.

A good diet can be hindered by a patient having surgery, being nauseated, loss of appetite, dysphagia (difficulty swallowing) or being in the last days of life.

Mastication can be altered by having ill-fitting dentures/no dentures, surgery or lethargy. A patient can be encouraged to take a healthy diet by chopping food, or a soft diet if mastication is a problem. This is particularly helpful as well if the patient is suffering with fatigue.

A reduced flow of saliva is experienced by up to 90% of patients with cancer. This can happen during and following radiotherapy and chemotherapy and the use of many medications, for example morphine. Facial oxygen therapy can also drastically reduce saliva. Saliva is important since it breaks down bacteria in the mouth and protects the mouth from extreme temperatures. Artificial saliva is often prescribed and oxygen can be given nasally or humidified.

Oral cleaning can be affected if a patient has bleeding or sore gums. This is seen frequently in patients receiving chemotherapy or with a low platelet count. Patients with an impaired gag reflex may feel frightened of choking.

A clean healthy mouth is essential in reducing the risk of a patient developing thrush. This is an oral fungal infection called Candida albicans which is present in the mouth of about 50% of people. It becomes a problem if the chemistry of the oral cavity changes. Early assessment by taking a history and detecting new problems are important to establish how care can be prioritised and planned (Piper 2008). Many patients may have had poor mouth hygiene prior to their illness; for others, problems are new and distressing. Sorting out poor-fitting dentures early on can prevent a severely sore mouth developing as the disease progresses.

Fatigue

Cancer-related fatigue is the most common symptom experienced by patients receiving cancer treatments (Ahlberg et al 2003) and is described as ‘a persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning’ (Mock et al 2005:1). The incidence of cancer-related fatigue is high – 82% of people with a cancer diagnosis will experience fatigue for a few days per month (Stone et al 2000). So it is very likely you will nurse a person with fatigue in this practice placement.

When a patient experiences fatigue, they may not say ‘I am feeling fatigued today’. Instead, they may use a variety of other words: I am tired; I can’t be bothered; I don’t want visitors; I can’t stand the noise; I don’t want to eat; I can’t brush my hair; I am too tired to sleep. Patients may also indicate fatigue not just by what they say, but how they look and behave. For example, you might notice a woman who, on admission, wore make up but is now not interested in her lipstick or renewing her nail varnish. Or a family member might tell you they are worried about their dad because he is not shaving.

Another definition of fatigue suggests it is a ‘subjective unpleasant symptom which incorporates total body feelings ranging from tiredness to exhaustion, creating an unrelenting overall condition which interferes with the individuals’ ability to function to their normal capacity’ (Ream & Richardson 1996:527). This definition gives a clearer idea of the impact fatigue may have on activities of living and a person’s capacity to maintain normality. It is one of the first definitions of fatigue and continues to be one of the core understandings on which contemporary care is planned and delivered.

Not understanding fatigue can potentially lead to emotional and psychosocial distress that can exacerbate other symptoms, making all of them more difficult to manage effectively. Understanding fatigue can be a particular challenge for family members. Part of the definition of palliative care is to keep the dying process normal. By recognising the impact of fatigue, it is possible to work with the patient and their family to keep as much normality as possible.

There are many causes of fatigue and a patient can have just one or many interacting together. This is why fatigue can be such a complex problem to effectively manage. Fatigue during and following both chemotherapy and radiotherapy is very common. It can also occur due to the cancer growing, infections, pain, medication, co-morbidities and anxiety/depression. Often fatigue and depression are interlinked (O’Regan & Hegarty 2009) and management needs to focus on both aspects of care.

Factors that can contribute to fatigue include inactivity, deconditioning, poor diet, poor sleep, changes in routine and anxiety about the disease process.

Body image and altered body image

How we view our own body is important since it is the way we tell ourselves how we look to others. This image of self is the mental picture we have of ourself but is not necessarily the way other people see us. A change in the mental picture of self can have a big impact on how we view what is happening. For example, a woman receiving chemotherapy may lose her hair and this can impact on how she views herself. It is important to be aware that anticipation of a change in body image can start at diagnosis, well before treatment begins (Frith et al 2007). A change in one’s perception of body image is called ‘altered body image’ and is a complex symptom to manage. Altered body image can be temporary or permanent, depending on the causes and the person’s ability to cope with the change (Salter 1997). Often, altered body image becomes a problem because the patient does not have the ability to cope with the changes or because of the behaviour of others towards them (Price 2000). This can include lack of support, help and information from healthcare professionals who often fail to acknowledge the importance of how patients view themselves.

When supporting a patient with altered body image, it is important to show you are interested on how they view their body. If a person is distressed at their loss of weight, it is not helpful to dismiss this concern by saying ‘you look just fine’. Instead we need to find out what this loss of weight might mean to them. It might mean they can no longer wear favourite clothes, they may feel a loss of their sexuality or concern that it is a sign the cancer is progressing.

Once we start to understand what altered body image means to a patient, we are in a position to offer support strategies and plan focused and appropriate care.

To explore further the impact of weight loss associated with advancing cancer on body image, read the article by Hinsley and Hughes (2007) (see References).

Breathlessness

Breathlessness is the ‘subjective experience of breathing discomfort’ (Twycross et al 2009:145). The distress a patient feels is individual to that person and does not always correspond to how we might view their breathlessness. A lot of anxiety and fear is associated with both the onset of breathlessness or worry that it will get worse. Breathlessness can be caused by a primary lung cancer, lung metastasis, respiratory muscle weakness or fluid within the lung cavity. This is called a pleural effusion and you may see a patient regularly returning to hospital to have the fluid removed from the lung; a pleural aspiration. Recurring effusions can be a sign of advancing disease. Pain, fatigue and anxiety can exacerbate the feelings of breathlessness and have a great impact on a person’s ability to undertake their activities of living.

The clinical management of breathlessness is divided into two specific areas – for patients breathless at rest and for patients breathless on exertion. It is important to be clear about which type of breathlessness the patient has before an effective treatment regimen can be planned. The assessment process will help with this.

Psychological distress

In Chapter 5, we introduced the concept of psychological distress when exploring the definition of palliative care. Also, we have considered the wellbeing of patients when looking at the activities of living. It is important to remember that a patient can experience a wide range of distressing feelings and emotions at any stage of the cancer journey. Providing support at all stages of this journey is an important part of nursing care. Awareness of the potential for distress and being able to recognise the signs is an important part of providing holistic care. Distress is often linked to the term ‘suffering’ and you will often hear the two linked. The degree of suffering or distress is not directly linked to the diagnosis or specific symptoms but more to how a particular patient associates meaning to what is happening (Payne et al 2008).

As nurses, we cannot always prevent suffering or psychological distress. Recognising the links between the two is the first step in being able to effectively support both the patient and their relatives. It is important to allow patients to express their feelings of distress, so they can be supported to work through their feelings of suffering. They may then be able to develop strength or resilience to help them face what the cancer diagnosis and treatment options may bring. Involving family and friends is really important. Often they feel helpless and distressed themselves when they see a person they care for so ill and unhappy. Encouraging patients and relatives to express these feelings helps to develop the therapeutic relationships (Burzotta & Noble 2010) essential in providing holistic care.

The principles of good psychological care include listening to patients and giving priority to what is distressing them most. By showing an interest in their story, we can create a safe place for them to express thoughts and feelings. This may help to give patients some control back to make decisions, helping to reduce feelings of loss. This is also an important part of developing a therapeutic relationship. Being aware of the potential barriers to providing psychological care for a person who is distressed is important. Read the Burzotta and Noble (2010) article which explores barriers in more detail. Make some notes about how these barriers might be reduced from the perspective of your current clinical placement.

We now look at two symptoms that are often referred to as acute events. They need to be managed quickly to ensure minimal distress for the patient and their family.

Spinal cord compression

Abnormal pressure on the spinal cord is commonly referred to as spinal cord compression (SCC) and is seen predominantly in patients with advanced cancer. Compression can be caused directly or indirectly due to the spread of the cancer, often referred to as metastatic spinal cord compression (MSCC). Metastasis of the spinal column occurs in 3–5% of all patients with cancer (National Collaborating Centre for Cancer 2008). Figure 15.6 illustrates the MSCC of compression along the spinal cord.

Fig 15.6 Spinal cord compression

Growth of the cancer can cause pressure or bleeding, affecting nerves around the spinal cord. It can also be caused or made worse by localised infection. Patients with MSCC may be receiving active chemotherapy or radiotherapy treatments. Alternatively, they may be in the palliative stage of their illness. For a more detailed explanation of the impact of a spinal cord compression, read the article by Drudge-Coates and Rajbabul (2008a).

Rapid assessment, diagnosis and management are vital for both groups of patients since the priority of care is to manage pain and prevent irreversible paralysis. Once paralysis has occurred, it usually cannot be reversed. Research shows that if a patient has the ability to walk at the time of diagnosis of MSCC, they are more likely to walk following treatment (Drudge-Coates & Rajbabul 2008b). Also, being mobile at the time of diagnosis indicates a better overall outcome following treatment (Levack et al 2001). Often immobility can start due to the onset of pain weeks or months before weakness occurs. MSCC is most common in patients diagnosed with breast, lung, prostate and thyroid cancer; in these patients, the incidence may be as high as 19% (National Collaborating Centre for Cancer 2008).

Table 15.3 compares prognosis for a number of spinal cord compression factors.

Table 15.3 Spinal cord compression factors (National Collaborating Centre for Cancer 2008:40)

The position of compression on the spine determines the symptoms patients experience (Fig. 15.7).

Fig 15.7 Symptoms of spinal cord compression

Accurate assessment is important in diagnosing MSCC. Low back pain is commonly the first symptom, occurring in 95% of patients, with weakness of limbs occurring in 85% of patients (Levack et al 2001). Changes in sensation are common and include numbness of the fingers and toes. It is also important to remember that a diagnosis if MSCC can be the first time a patient is aware that he/she has a diagnosis of cancer – 23% of patients diagnosed with MSCC have no prior cancer diagnosis (National Collaborating Centre for Cancer 2008).

Rapid management of a patient with MSCC is a priority. Once diagnosis is made, steroids may be started to reduce localised inflammation, and radiotherapy over 2 to 4   weeks often works well to alleviate pain. If a patient is well enough, surgery to relieve the pressure and stabilise the spine is the treatment of choice, however often a patient is too sick for surgery or cancer metastases are too far progressed.

For patients with extensive paralysis and advanced symptoms, the priority of care is dignity and comfort. Loss of bowel and bladder function can be distressing and lead to emotional withdrawal and skin breakdown.

Hypercalcaemia

An increase in the normal amount of calcium in the blood is called hypercalcaemia. This is caused by cancer cells stimulating the release of calcium into the blood and involves osteoclast activity, bone resorption and the parathyroid gland. Normal blood calcium is between 2.2   mmol and 2.6   mmol. In a patient who has symptoms of hypercalcaemia, the blood calcium can be raised to over 3.5   mmol, and 3.75   mmol is an emergency situation which may lead to unconsciousness. For a patient with a cancer diagnosis, raised blood calcium is a sign of advancing disease and occurs in 10–20% of patients (Stewart 2005). Hypercalcaemia occurs more commonly in cancers of the breast, myeloma, lung, stomach, small intestine and prostate.

Symptoms are associated with the rate of increase of calcium in the blood, rather than the actual amount of calcium. Commonly a patient will experience nausea or/and vomiting, abdominal pain, dehydration, delirium and drowsiness. Sometimes a patient can get aggressive and this can be mistaken for terminal agitation. This is something we will look at in more detail in the Chapter 16.

Treatment is primarily by immediate rehydration using an intravenous infusion of normal saline over 24 hours. Once this is completed, medication called bisphoshonates will be started intravenously. The drugs used are either pamidronate or zolodronic acid. Bisphosphonates help to reduce bone resorption and lowered blood calcium can be seen after 2 to 3   days. Once a patient has had hypercalceamia, they can have repeated episodes that can occur close together. Application of the ethical principles we looked at on page 47 must be applied when re-treating a patient.

Remember, it is always important to treat the person, not the blood result.

The EEMMA model