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Unit 3
Applying concepts from the nursing process
pain, their pain is more frequently characterised as chronic.
(For more information on cancer-related pain, see Chapter 9.)
Cancer can cause pain in various ways (Table 11-8). Pain
is also associated with various cancer treatments. Acute pain is
linked with trauma from surgery. Occasionally, chronic pain
syndromes, such as postsurgical neuropathies (pain related
to nerve tissue injury) occur. Some chemotherapeutic agents
cause tissue necrosis, peripheral neuropathies and stomatitis—
all potential sources of pain—whereas radiation therapy can
cause pain secondary to skin or organ inflammation. Cancer
patients may have other sources of pain, such as arthritis or
migraine headaches, that are unrelated to the underlying
cancer or its treatment.
In today’s society, most people expect pain to disappear or
resolve quickly, and in fact it usually does. Although control-
lable, cancer pain is commonly irreversible and not quickly
resolved. For many patients, pain is a signal that the tumour
is growing and that death is approaching. As the patient
anticipates the pain and anxiety increases, pain perception
heightens, producing fear and further pain. Chronic cancer
pain then can be best described as a cycle progressing from pain
to anxiety to fear and back to pain again, especially when the
pain is not adequately managed.
Pain tolerance, the point past which pain can no longer
be tolerated, varies among people. Pain tolerance is decreased
by fatigue, anxiety, fear of death, anger, powerlessness, social
isolation, changes in role identity, loss of independence
and past experiences. Adequate rest and sleep, diversion,
mood elevation, empathy and medications such as antide-
pressants, antianxiety agents and analgesics enhance toler-
ance to pain.
Inadequate pain management is most often the result
of misconceptions and insufficient knowledge about pain
assessment and pharmacological interventions on the part of
patients, families and healthcare providers (Xue et al., 2007).
Successful management of cancer pain is based on thorough
and objective pain assessment that examines physical, psy-
chosocial, environmental and spiritual factors. A multi
disciplinary team approach is essential to determine optimal
management of the patient’s pain. Unlike instances of chronic
non-malignant pain, systemic analgesics play a central role in
managing cancer pain.
The World Health Organization advocates a three-step
approach to treating cancer pain (see Figure 11-6). Analgesics
are administered based on the patient’s level of pain. Non-
opioid analgesics (e.g. paracetamol) are used for mild pain;
3 months, are usually not considered to be candidates for par-
enteral nutrition (Mirhosseini, Fainsinger & Baracos, 2005).
TPN can be administered in several ways: by a long-term
venous access device, such as a tunnelled central catheter,
an implanted venous port, or a peripherally inserted central
catheter (PICC) (Figure 11-5). The nurse teaches the patient
and family to care for venous access devices and to administer
TPN. Community nurses may assist with or supervise TPN in
the home.
Interventions to reduce cachexia usually do not prolong
survival but may improve the patient’s quality of life. Before
invasive nutritional strategies are instituted, the nurse should
assess the patient carefully and discuss the options with the
patient and family. Creative dietary therapies, enteral (tube)
feedings or TPN may be necessary to ensure adequate nutri-
tion. Nursing care is also directed towards preventing trauma,
infection and other complications that increase metabolic
demands.
Relieving pain
Pain associated with cancer may be acute or chronic. Pain
resulting from cancer is so ubiquitous that when cancer
patients are asked about possible outcomes, pain is reported
to be the most feared outcome (Munoz Sastre et al., 2006).
Pain in patients with cancer can be directly associated with
the cancer (e.g. bony infiltration with tumour cells or nerve
compression), a result of cancer treatment (e.g. surgery or
radiation), or not associated with the cancer (e.g. trauma).
However, most pain associated with cancer is a direct result
of tumour involvement. As in any other situation involving
pain, cancer pain is affected by both physical and psychosocial
influences.
Of all patients with progressive cancer, more than 90 to
95% experience pain (Stoneberg & von Gunten, 2006). Pain,
among the most common symptoms of cancer, impacts on
multiple domains of well-being. Significant numbers of patients
continue to experience pain despite pharmacological interven-
tions. Although there is evidence to suggest that acceptance
of pain is related to better well-being among patients with
chronic non-malignant pain, little is known about acceptance
of cancer pain. Although patients with cancer may have acute
Median
basilic v.
Median cephalic v.
Basilic v.
Cephalic v.
Axillary v.
Subclavian v.
Brachiocephalic v.
Internal jugular v.
Superior vena cava
Figure 11-5
A peripherally inserted central catheter (PICC)
is advanced through the cephalic or basilic vein to the axillary,
subclavian, or brachiocephalic vein or the superior vena cava.
Table 11-8 Sources of Cancer Pain
Source
Descriptions
Underlying cancer
Bone metastasis
Throbbing, aching Breast, prostate,
myeloma
Nerve compression,
Burning, sharp,
Breast, prostate,
infiltration
tingling
lymphoma
Lymphatic or venous
Dull, aching,
Lymphoma, breast,
obstruction
tightness
Kaposi’s sarcoma
Ischaemia
Sharp, throbbing
Kaposi’s sarcoma
Organ obstruction
Dull, crampy,
Colon, gastric
gnawing
Organ infiltration
Distension, crampy Liver, pancreatic
Skin inflammation,
Burning, sharp
Breast, head and
ulceration, infection,
neck, Kaposi’s
necrosis
sarcoma
