Thisessay will demonstrate the importance of evidence based nursing assessments inlong-term condition and how they are applied into practice. It will look intopatient with lung cancer (LC); this particular patient has been chosen as it ismostly diagnosed late, there is low survival rates, is one of the most commoncancers in the world (Cancer research UK, 2014) and has the highest prevalenceof pain. Following the phases of chronic illness trajectory (McCorkle& Pasacreta, 2001), the chosen phase is the acute phase, which follows thecrisis phase and refers to the period when the patient’s symptoms can becontrolled by a prescribed regimen (McCorkle & Pasacreta, 2001).
This phasehas been chosen as after a crisis phase patient can have a lot more to considerinvolving occupational, financial and psychosocial stress and insurer conflict.Stress may increase patients’ pain (DP, 2014; Pain in times of stress, 2015) aschronic pain is an inflammatory state. It is conceivable that the stress canincrease pain perceptions through inflammatory mechanism; Deleo, 2001). Therefore, it is very likely that atacute phase patient can suffer from more pain compared to other phase. The care environment takes place in thehospice-based setting at home, this way patient can stay in their own hometherewill be staff that can assess their pain and provide them with the appropriatepain relief. The patient is in stage 3B with a non-small lung cancer anadvanced LC which although not curable, is treatable (Lynne, 2016). 3B advancedlung cancer has been selected as with advance cancer, pain is more likely.
Itwas estimated that 75% of all cancer patients to be living with chronic pain,with the pain increases in severity as lung cancer advances, with patient atlater stages of the disease experiencing more pain (Chandrasekhar, 2016). This paper willdiscuss on the rationale for the chosen health care need, the assessment for painmanagement for LC patient, assessment tools that will help assess this needs,it will reflect on the importance of nurse-patient relationship, person centredcare approach and the importance in the contribution of families or carers inthe assessment process. Lung cancer starts with the uncontrollablegrowth of abnormal cell that develops into a lump or tumour that starts off inone or both lungs. The risk factors that increases the likelyhood of the cancer includes, smoking, air pollution, genetic disposition,pre-existing lung cancer such as Chronic obstructive pulmonary disease (Bennettand White, 2013). There are two main types of lung cancer; the most common typecomprising approximately 80% of all lung cancer is NON-small cell lung cancer(NSCLC). The rest of the 20% of lung cancer are Small-cell lung cancer (SCLC)which were commonly associated with smoking (IASP, 2009). Pain is what the patient says it is(McCaffery, 1968) and the person in pain is the only person to know how painfulsomething is.
Since pain is personal and no two people experience it in thesame way, it is very difficult to define and to treat (Britishpainsociety, 2010). InternationalAssociation for the study of pain (IASP) defines pain as “an unpleasant sensoryand emotional experience associated with actual or potential tissue damage ordescribed in terms of such damage” (IASP, 1979). This definition links the sensory experience to emotion,stating that the only way of deciding whether someone has pain is by askingthem or watching them.Painis recognized as impacting all dimensions of quality if life (Burton, 2007). It interferes with every aspect of apatient’s life their sleep, relationship, work and leisure. This can lead topatient becoming physically and psychological unwell.
They become too unwell tobe able to continue or carry out daily tasks to live a normal life, affectingtheir quality of life. Without proper pain management patient can face bothphysical and psychological consequences leading to agony and reduction in theirquality of life. This not only affects their life but also impacts their familyand friends. Managing cancer pain is vital for effective treatmentthat will help improve patient’s physical, mental state and allowing patient tohave a positive frame of mind. The psychological impact of pain, it has onpatient can take a major toll interfering with patient’s sense of self, theiridentity can become pain and they can lose sight of the objective which issurvival (Cancercenter, 2017).
Therefore, pain management has been chosen forthe health need for LC patient. Furthermore,certain sites of cancer are knownto have a shorter life expectancy than others, for e.g. lung cancer compared tobreast cancer (American cancer society, 2005). The shorter life expectancy may relate to highersymptom experience in the last year of life.
Thus, pointing out that lungcancer patient could be in much more pain compared to other cancer patient,making pain management especially essential for them. Additionallyit is an overall healthcare need of this particular patient group, bycontrolling pain we are able to remove the constant reminder of cancer, givingthem hope and energy to fight the disease. Itis important that nurses are aware of the cause of pain with advanced lungcancer. This can be brought about by several different causes the three maincauses of pain in patient with LC been skeletal metastatic disease 34%,Pancoast tumour 31% and chest wall disease 21% (Watson,1987). This is important whenassessing and administering analgesia for pain management.
In order to managepain, it is essential to understand and use general principles of painmanagement (Claribel, 2012). While the World Health Organisation (WHO)analgesic ladder is recognised to, provide relief of cancer pain ithas its limitations in the context of long-term survival and increasingdisease complexity. To solve the issue, it was recommended to create a morecomprehensive model for cancer pain management. That is mechanism- based and multimodal, using combination therapiesincluding interventions, which would be tailored to the needs of an individual,with the aim of optimising pain relief while minimalizing adverse effect(Raphael, 2010).Comparedto any other pain, the neurophysiology of cancer pain is complex: it not onlyinvolves inflammatory but neuropathic, ischaemic and compression mechanism atmultiple sites (BPS, 2010). By havingthe knowledge of these mechanisms and the ability to decide whether pain isnociceptive, neuropathic, and visceral or a combination of all three will leadto best practice in pain management (Britishpainsociety, 2010). According to NICE (NICE, 2016) when startinga pain assessment health professional should discuss pain with the persondirectly.
If not possible ask family or healthcare professional to help withthe assessment bearing in mind that family members may overestimate andhealthcare professionals underestimate the person’s pain. They should assesseach pain; a person has with a view to establishing an underlying cause, while keepingin mind that there may be more than one. Pain has to be assessed regularly,especially if it is not adequately controlled. Reviewing the medical history and records to determine the known siteand extent of the cancer can help in getting more information such as painoccurring distant from the previously known sites of cancer may indicate eithera non-malignant cause or secondary spread of the cancer.
Additionally, theinfluence of psychological, social and spiritual factors can have an effect onperson’s experience of pain and should be assessed. These aspects ofrecommendation were based on expert opinion from (SIGN, 2008) and (Regnard,2010). Painis not just a physical sensation but is bound up with an emotional response andan act of reasoning; which is why pain is known as a multidimensionalexperience (Fillingim, 2014) It has a physical and emotional consequences, itcan lead to fatigue, irritability, depression or inability to carry outactivities of daily living (Leadley, 2014). Pain is a personal experience andcan be difficult to communicate.
It is vital that nurses know how to bestassess it to ensure the optimal treatment is given. In order to manage pain, healthprofessional must know the level of pain a patient is in, for them to be ableto administer the correct analgesia to the patient. To obtain the correctknowledge of the level of pain, it is vital that we use the correct painassessment tools to help us get the information on pain. Pain assessment toolshelp us to detect and describe pain to help in the diagnostic process. It helpsus to understand the cause of the pain to help determine the best treatment.
Itlets staff monitor the pain to determine whether the underlying disease ordisorder is improving or deteriorating and whether the pain treatment isworking. To get a more accurate and correct information, assessment toolsshould understandable and easy to read with use of plain language. Not onlythat nurse should have the knowledge, skills and attitude to be able to carryout appropriate pain assessment and management.
As this will contribute inpatients receiving higher standard pain assessment and management (Wilson, 2007).Heath professional must remember that patients vary in their ability to lead orparticipate in discussions about their pain and it is important for nurses toconsider this before choosing the most appropriate assessment strategy. Measuringpain intensity is part of universal screening and comprehensive pain assessmentand can be achieved using Validated structured pain assessment tools such asVisual analogue scales (VAS) and numerical rating scales (NRS) (NICE, 2016).
Numericalrating scale (NRS) is a unidimensional measure of pain intensity (Jensen, 1993) in adults including thosein chronic pain. It involves asking the patients to rate their pain intensityon a scale of 0-10, in which 0 means no pain at all and 10 been the worst painthey have ever experienced or the worst imaginable pain. In adults the NRSworks well (Williamson & Hoggart, 2005) and has sufficient sensitivity toenable patients to communicate changes in their pain over time.
The benefits ofNRS is that it only takes 1 min to complete which can be very vital and usefulif patient are in extreme pain, as they would not be in the state to answer toomany questions to assess their pain. Although focus group of patients inchronic pain have found that NRS is inadequate in capturing the complexity and characteristic nature of the painexperience or improvements due to symptom variations (Hawker, 2008; Hush,2010). NRSis easy to administer and score, it is easy to use for both patient and staff.
Therefore, they would be more likely to use it compared to other assessmenttools. Due to its very design it requires minimal language translationdifficulties supports the use of NRS across cultures and languages. NRS is avalid and reliable scale to measure pain intensity (Hawker, 2011). Thestrength of this measure over the VAS is the ability to be administered verballyand in writing as well as its simplicity of scoring.
Wehave McGill Pain Questionnaire (MPQ) which assesses both quality and intensityof subjective pain. Which NRS tool is unable to provide. MPQ consists ofgrouping of words that best their experience of pain. The person rating theirpain ranks the works in each grouping. Once the person has rated their painwords, the administrator assigns a numerical scale, called the pain ratingindex. It measures multiple components (sensory, affective, cognitive,behaviour) of cancer pain (Ahles,1983).
Thetool has been tested and retested for its reliability and has shown strongreliability for measuring cancer pain (Ferraz, 1990; Graham, 1980; Wilikie & Keefe,1991). It has good construct, content and criterion validity (Fischer, 2010; Prieto,1980; Melzack, 1975). Although MPQ’s strength is that it can assess the qualityand intensity of pain, the very long process of assessing this quality can beaggravating to patient in chronic pain. MPQ (Melzack,1975) wastested in interviews with cancer patients who had pain, the patients hadreported that the measures were too complex and too long, making themexcessively burdensome for patient with higher levels of pain.
There are alsoconcerns about the readability issues for some descriptors. The three painpatterns of the MPQ are not adequate to account for changes in pain experienceby cancer participants (Graham, 1980). Staffshould differentiate between the person’s usual level of pain, breakthroughpain, incident pain, and ‘end of dose’ failure of regular around the clockanalgesia. Health professional should take in the importance of assessing thelifestyle implications, assess the effect of pain on activities of daily livingand identify factors contributing to the person’s distress (Spiegel, 1994;Abu-Saad & Courtens, 2001; Qaseem, 2008; NHS Lothian, 2014) as thesefactors add in patient’s pain.
Furthermore,pain intensity should be assessed based on patient self-reporting. Self-reportingpain is easy to use such as pain dairy, for outpatients whose performancestatus is relatively good and whose condition is stable. However, it isrelatively difficult for inpatients with poor general health and acute problemsto express their degree of pain. In fact, many studies on cancer painmanagement report that observer and patient assessment do not correlate welland that there is a tendency for medical staff to underestimate pain levels (Jensen, 2003). In a study it was found that a pain assessment system using aself-reporting pain board attached to the patients’ bed provided a reliable andeffective means of assessing pain (NCBI, 2012).
The self-reporting pain boardthat was attached to the patient’s bed used in the study allowed patients toexpress pain intensity by moving an indicator. From the direct expression ofpain by patients, it offers other benefits as well. Because the board wasalways present at the bedside, it helped increase in patient interest to scoretheir pain. Accordingly, patients could communicate with the medical staffregarding their pain severity more frequently compared to when their pain isassessed by the medical staff intermittently at fixed times. Furthermore, asthe self-reporting pain board is visible to medical staff, it helped instimulating staff’s interest in patient pain and encourages active painmanagement. It also reduced staff workload with respect to pain assessment. Andas patient became familiar with the pain board very quickly, they reportedtheir pain scores voluntary, with no encouragement from medical staff. Thesebenefits increased awareness and efficiency of patient-medical staffcommunication and ultimately increased patient satisfaction with painmanagement from 54% to 82% (NCBI, 2012).
Although a lot of pain assessment are performed using self-reportingpain indicators in many institutions. Those assessments are usually carried outby the medical staff and presented to the patient only when medical staffs askabout pain. Many studies on cancer pain management, reported that one of thereason pain is often inadequately managed is because pain may be underestimated(NCBI, 2012). Therefore, health professional should always keep in mind thatpain is what the patient says it is and should not be interpreted in any otherway. This not only leads to undermanaged pain but also cause patient to losstrust in health professional and results in a gap between patient- staff relationship.Staffshould not assume that a patient cannot participate in a pain assessment, asall patients including dementia patient can often use self-report pain scalesbut they may need to be re-taught how to do so each time (Kaasalainen, 2013).Universally most patient change their normal behaviour when they are in pain,so knowing individual patients and their normal demeanour is vital.
Patient canbe afraid to tell doctor or nurse that they are in pain. However mild or severeit feels telling someone is always important as the earlier pain is treated;the easier it is to get it under control. Many people with cancer are scaredthat they will become addicted to painkiller. So they don’t ask for help. Inthese situations, it is important to have a therapeutic relationship betweenthe health professionals and the patient.
This helps support the patient,promote healing and to support or enhance functioning. Although there has beena significant medical, pharmacological and technological advance in the area ofcancer pain assessment and management, up to 90% of patients with advancedcancer experience pain significant enough to require further intervention(NCBI, 2014). Thereare several pain assessment tools; they all have their own weakness andstrength with them. Some tools may seem more reliable and have more validity;its usefulness can sometimes depend from person to person. Since one person isnot similar to another. Although relying on good qualitative date and trustpolicy is important. Assessing what type of assessment is good for theparticular individual is also necessary. Monitoring and keeping record of howuseful the initially used assessment tool was and asking patient’s opinion ofthe tool is important.
If the initially used tools was not as effective inassessing patient’s pain, health professional should have the awareness andresolution to try a different tool. A good nursing assessment ensures patientsafety, continuity and quality of care. It is a nurse’s legal and professionalobligation, and requires attention to NMC standards for record keeping and codeof professional conduct. This essay hasdiscussed the lung cancer, explored the assessment tools to manage cancer painin a hospital setting. It described the importance of assessment of painmanagement in lung cancer patient and the tools that are available. Theassessment tool that was looked into was the NRS and MPQ tools to measure painintensity in lung cancer patient. The strength and weakness of both of thetools was discussed.
It also noted that having an individual pain management isnecessary, although one assessment tool has been said to be brilliant in manypapers and studies. It does not guarantee that it will work on the particularpatient in the hospital. So health professional should always keep an open mindand use other tools to suit the needs of the individual patient and not usetools just because it has worked in general population. Through the discussingwe have found the importance of good nurse-patient relationship and how havinga therapeutic relationship and fully increase the usefulness of the assessmenttool. Additionally, patients also require support other than pain managementsuch as psychological support
