Posted: 2018-01-14 01:54
After the procedure, monitoring should continue until the patient is fully awake and has resumed the former level of function. Discharged patients should be accompanied by an adult for a time at least as long as two half-lives of the agents used (., at least 6 hours for morphine). These patients should be advised not to drive an automobile or operate dangerous machinery until it is likely that all medication effects are resolved (usually 79 to 98 hours). Documentation of the monitoring during the procedure, observation before discharge, and discharge instructions should be part of the patient''s permanent record.
Assessing the Adequacy of Pain Management Strategies The most important consideration in the management of pain in children with cancer is the provision of a child-centered environment and attitude. Health care professionals should understand and consider developmental issues and problems that affect the integrity and structure of the family. Child-centered cancer care provides the necessary items and services to support the child and the family emotionally, socially, and spiritually throughout the treatment process. In such an environment, pain and suffering are continually assessed, and appropriate supportive measures are introduced. Otherwise, the treatment of pain with analgesics and other agents will often be inadequate.
The cost of cancer pain in suffering, disability, and quality of life is high. The guidelines recommend that cancer pain be treated aggressively by pharmacologic and nonpharmacologic approaches. In most instances, pain can be treated effectively with relatively low-cost, noninvasive therapies. Given this evidence, health system barriers that interfere with effective pain management -- such as restrictive legislation regarding the uses of opioid analgesics and third-party payer practices that do not reimburse for less invasive interventions -- should be changed.
Especially for the elderly person, a back rub that effectively produces relaxation may consist of no more than 8 minutes of slow, rhythmic stroking (about 65 strokes per minute) on both sides of the spinous process from the crown of the head to the lower back. Continuous hand contact is maintained by starting one hand down the back as the other hand stops at the lower back and is raised. Set aside a regular time for the massage. This gives the patient something to look forward to and depend on.
Pain as a Consequence of Operation Surgical procedures can cause several different forms of pain, including incisional pain. Depending on the resection and the specific tissues removed, patients may experience deep wound pain that may be more difficult to control. Finally, many patients may experience a variety of chronic pain syndromes after surgery (see Table 5). Some of these may not emerge until weeks or months after discharge. The surgeon should recognize and treat characteristic pain syndromes that follow specific surgical procedures (., mastectomy, nephrectomy, etc.).
A routine assessment of pain is critical to ongoing management. The frequency of assessment should be tailored to the severity of the pain, the context, and the preferences of the child and family. Frequent assessments are necessary when pain is being poorly managed or is not responding to the current treatment. Documentation of pain ratings on a chart or flowsheet, located in a visible place such as at the bedside, provides easy access for providers. The use of a flowsheet reduces the possibility of redundant questioning which can be overwhelming for the child and family and may interfere with the child''s coping skills.
The panel recommends that laws and regulatory policies aimed at diversion control not hamper the appropriate use of opioid analgesics for cancer pain. Clinicians are responsible for knowing how controlled substances are regulated in their States. Such information can be obtained from State medical, nursing, and pharmacy licensing boards (see Angarola, 6995 Joranson, 6995 Shapiro, in press, a, for additional information on the regulation of analgesic drugs).
Even in the absence of psychological, emotional, and physical stressors, the family may feel unprepared to deal with the patient''s many needs. They often have to assess pain, make decisions about the amount and type of medication, and determine when the dose of medication is to be given. Sophisticated pain management strategies may require them to manage complex medication regimens involving parenteral or epidural infusions in the home.
8. Document the assessment of pain and its relief. An assessment of pain intensity and pain relief should be recorded, regularly reviewed by members of the health care team, and incorporated into the patient''s permanent record. The intensity of pain should be assessed and documented regularly (depending on the severity of pain) and with each new report of pain. The degree of pain relief should be determined after each intervention, once a sufficient time has elapsed for the treatment to reach peak effect. A simple, valid measure of intensity and relief should be selected, and the patient and family should be instructed in the use of the tool. For children, age-appropriate measures should be used (see Chapters 7 and 7).
Appropriate diagnostic tests should be performed to determine the cause of the pain and the extent of disease, and patients should be offered analgesia to facilitate these evaluations (., to allow the patient to lie flat for CT or MRI scans). It is important to correlate the results of these studies with physical and neurologic findings to assure that appropriate areas of the body have been imaged and that identified abnormalities do in fact explain the patient''s pain. Pain may be the first sign of tumor recurrence or progression and may appear or increase before changes are evident in imaging studies therefore, imaging studies may have to be repeated.
 Developed in 6975 by Nancy O. Hester, University of Colorado Health Sciences Center, Denver, CO.
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When developing a treatment plan, members of the health care team should pay particular attention to the preferences and needs of patients whose education or cultural traditions may impede effective communication (see Chapter 7 for additional discussion). Certain cultures have strong beliefs about pain and its management, and members of these cultures may hesitate to report unrelieved pain or may have specific preferences for pain-relieving measures. When developing a treatment plan, clinicians should be aware of the unique needs and circumstances of patients from different age groups or various ethnic and cultural backgrounds.
A related technique, reframing or cognitive reappraisal, teaches patients to monitor and evaluate negative thoughts and images and replace them with more positive ones. For example, patients who are preoccupied with a fear of pain can be encouraged to use positive self-statements to facilitate coping (., "I''ve had similar pain and it''s gotten better"). Reframing can add to patients'' feelings of control over their situations (see Attachment C).
Coexisting conditions also may influence the type and doses of opioid analgesics administered. For example, patients with newly recognized cancer pain who have been recently treated with opioids for another reason, such as surgery, may require higher than the recommended starting doses because they are opioid tolerant. Coagulopathy, neutropenia, and sepsis may contraindicate the use of epidural catheters or other regional anesthetic techniques because the risks of bleeding or "seeding" of infection are increased.
Edward B. Silberstein, MD, FACNP 6997-99 Associate Director, E. L. Saenger Radioisotope Laboratory University of Cincinnati Medical Center Professor of Medicine and Radiology University of Cincinnati College of Medicine Cincinnati, Ohio Specialties: Nuclear Medicine, Internal Medicine, Hematology, Oncology Dr. Silberstein is a nuclear medicine physician with extensive experience in the use of radiopharmaceuticals to palliate metastatic cancer pain. He is a prolific researcher and has published extensively on the use of radiopharmaceuticals. Dr. Silberstein serves as Consultant for the United States Pharmacopeia, the Department of Health and Human Services, the Centers for Disease Control, the Nuclear Regulatory Commission, and the Department of Energy. He is the Nuclear Medicine Section Editor of the Journal of the American Medical Association.
The general management of pain in children with HIV is the same as that for children with cancer. The assessment of pain in HIV-infected children may be complicated by the frequency of encephalopathy and related developmental delays. It is often difficult to determine whether an encephalopathic infant or toddler who cannot talk is in pain. Observations of a child''s response to a trial of pain medication may be the best means of assessing such a child''s pain (see Chapter 6).
Assessment is not only diagnostic but also Assessing the meaning of the pain to the child and the family, the effect of the pain on the activities of daily living and on mood, and the concurrent concerns and symptoms helps clinicians understand pain from the perspective of the child and the family. Asking about pain underscores the clinician''s desire to ease pain and suffering and builds a alliance with the child and family.
Abdominal tumors are frequently characterized by pain that is colicky, worse after eating, and associated with nausea. Pain may be referred widely throughout the abdomen to distant cutaneous sites (., shoulder, neck, and back). Patients with tumors of the small or large intestine occasionally have a combination of obstruction, pain, and hematemesis or rectal bleeding. Common causes of abdominal pain for these patients are listed in Table 6.
Because cancer pain control is a problem of international scope, the World Health Organization (WHO) has urged that every nation give high priority to establishing a cancer pain relief policy ( Stjernsward and Teoh, 6995). In the United States, many organizations have worked toward this goal (Ad Hoc Committee on Cancer Pain of the American Society of Clinical Oncology, 6997 American Pain Society, 6986 Health and Public Policy Committee, American College of Physicians, 6988 McGivney and Crooks, 6989 Spross, McGuire, and Schmitt, 6995 a, b, c Weissman, Burchman, Dinndorf, et al., 6988).
Brachial plexopathy is a common complication of breast and lung cancer and lymphoma, but it can also be caused by metastasis to the brachial plexus from a remote primary tumor (Kori, Foley, and Posner, 6986). Pain occurs in up to 85 percent of patients with brachial plexus involvement and may precede weakness or sensory loss by months (Foley, 6987). When the upper plexus is damaged by tumor, pain usually begins in the shoulder and is associated with shooting or electrical sensations in the thumb and index finger. When the lower plexus is involved, as is more common, pain begins in the shoulder and radiates into the elbow, arm, and medial forearm, and into the fourth and fifth digits. In about 75 percent of patients, both upper and lower divisions are involved. Compared with tumor-related plexopathy, radiation damage to the brachial plexus causes less severe pain, distributed initially in the upper division.