Bieng a

NURS 504, PALLIATIVE CARE NURSING

Submitted by

ABUBAKAR SULEIMAN SADDIQ

U19DLNS20138

BNSC NURSING 2019/2020A

E TUTOR: DR. KHALID SANI DALHA

Discuss the management of Pain as the commonest symptom in patients with
palliative care needs.

Introduction

Pain is broadly defined as the unpleasant sensations in the body resulting due to the
complex experience of various factors like physical, psychological and emotional. Pain is
one of the most important symptoms to target in palliative care. Up to two-thirds of
patients with cancer experience pain severe enough to require a strong opioid, and this
proportion is similar or higher in many other advanced and progressive conditions.
Anxiety is also common, being a significant symptom in at least 25% of patients with
cancer and 50% of those with congestive heart failure and COPD.2 The management of
anxiety will be considered in detail in part two of this series.

AIMS OF PAIN MANAGEMENT AS THE COMMONEST SYMPTOMS IN

PALLIATIVE CARE NEEDS

Managing pain in palliative care patients, including checking psychological symptoms,

assessment tools such as the Hospital Anxiety and Depression Scale, and outcome
measures.

Palliative care has been shown to provide significant and diverse benefits for patients
with serious, complex, or life-limiting health problems. Such benefits include the
following:

 Reduced physical, psychological, and spiritual suffering

 Improved quality of life

 Prolonged survival in some situations

 Palliative care and pain control designed to do the following:

  Prevent or relieve the most common and severe suffering related to illness or
injury.

 Be affordable, even in LMICs.

 Provide financial risk protection for patients and families by providing a realistic
alternative to expensive, low-value treatment.

ASSESSING PAIN AS THE COMMONEST SYMPTOMS IN PALLIATIVE

CARE NEEDS

Assessing the pain in palliative care is the first step for the Nurse and other health care
personal. If you are concerned about your loved one’s pain, use the following guide. It
helps to have this information if the pain does not ease and you need to call the palliative
care team or doctor. Ask:

 Where is the pain?

 How long the pain has been there?

 What type of pain is it – sharp, tingling or aching?

 Is it a new type of pain?

 Is the pain persistent, or does it come and go?

 Have any other lifestyle changes occurred?

 Do you feel like vomiting?

 When did you last have a bowel movement? (Constipation can cause pain.)
  -How would you rate the pain on a scale of one to ten? (1 being ‘no pain’ through
to 10 being ‘excruciating pain’). Anything scoring more than 4 out of 10 is
regarded as pain that needs attention.

MANAGING PAIN AS THE COMMONEST SYMPTOMS IN PALLIATIVE

CARE NEEDS

In order to help the person manage their pain:

 Ask them to lie on the bed or to sit down.

 Ask them to take 10 deep breaths.

 If they have been given some medicines for pain, check first to see what pain
medicines they have already taken that day. If they have had as much as they are
allowed, contact the palliative care service. Otherwise give the medication as
directed on the container.

 Try to take their mind off the pain by encouraging them to read, watch television
or listen to music.

 Suggest a complementary or self-management technique [link to Natural

techniques for managing pain (Is it possible to link to an?)] such as those listed
below.

 If you think nausea (feeling like vomiting) or constipation (no bowel action for
several days) may be causing the pain, refer to sections on nausea [link to Nausea]
and constipation [link to Constipation] below.

 If the discomfort has not eased after 30 minutes phone the palliative care team.
They will be able to review the problem and suggest other ways to reduce the pain.
AN ESSENTIAL PACKAGE OF PALLIATIVE CARE AND PAIN
MANAGEMENT

Patients with life-threatening illnesses are the sole focus of palliative care according to
the current WHO definition, and there are calls for it to be revised and expanded
(Gwyther and Krakauer 2011; WHO 2002). There is large-scale, unrelieved health-
related suffering among other groups as well. In particular, patients in LMICs typically
lack access to relief of pain and other types of suffering that result from common health
problems that may be cured (drug-resistant tuberculosis and some malignancies) or
controlled for a long period (HIV/AIDS and musculoskeletal disorders) or from which
patients are likely to recover (serious injuries). The need for palliative care in low-
resource settings is often determined by the magnitude of suffering, the inadequacy of
existing capacity to respond, and the resultant need for relief. Therefore, the EP of
palliative care and pain control that we propose should be as follows:

 Accessible at all levels of health care systems and in patients’ homes.

 Adapted to local cultures, as well as clinical and social situations. For example, in
resource-poor settings, the social circumstances of the patient and family members
may be a major source of the patient’s suffering and may need to be a focus for
palliative care.

 Integrated with disease prevention and treatment programs, although not

considered a substitute for these, and assist patients in accessing and adhering to
optimum disease treatment—if they desire such treatment and if it may be more
beneficial than harmful according to patients’ values, balanced with scientific
evidence.

 Applied not only to persons who are dying but also to those living with long-term
physical, psychological, social, or spiritual sequelae of serious, complex, or life-
 limiting illnesses or of their treatment. The EP should be applied to relieve acute
pain and other acute symptoms when medically indicated.

 With adequate levels of palliative care training and skill, applied by health care
workers of various kinds, including primary care providers, generalists, and
specialists in many disciplines and from basic to intermediate to specialist.

ESSENTIAL PACKAGE IN PALLIATIVE CARE PAIN MANAGEMENT

These include:

1. Medicines

Morphine, in oral immediate-release and injectable preparations, is the most clinically

important of the essential palliative care medicines (WHO 2011). It must be accessible in
the proper form and dose by any patient with terminal dyspnea or with moderate or
severe pain that is either acute, chronic and associated with malignancy, or chronic in a
patient with a terminal prognosis. We do not recommend the use of opioids for chronic
pain outside of cancer, palliative, and end-of-life care, except under special circumstances
and with strict monitoring.

All physicians who ever care for patients with moderate or severe pain of the types
described, or for patients with terminal dyspnea, should be able to prescribe oral and
injectable morphine for inpatients and outpatients in any dose necessary to provide
adequate relief as determined by the patients. Physicians should be able to prescribe an
adequate supply of morphine so that obtaining refills is feasible for patients or families
without requiring unreasonably frequent, expensive, or arduous travel.

2. Equipment

The EP includes equipment that often is needed for palliative care yet may not be
available in all health centers and hospitals in LMICs. Such equipment includes pressure-
reducing mattresses, adult diapers, opioid lock boxes nasogastric tubes, and urinary
catheters (annex table 12A.1). For the sake of efficiency, the EP does not include
materials needed for palliative care that should be standard equipment for any health
center or hospital, such as gauze and tape for dressing wounds, nonsterile examination
gloves, syringes, and angiocatheters.

3. Psychological and Spiritual Counseling

Interventions to relieve psychological distress may be provided not only by psychologists

but also by adequately trained and supervised physicians, nurses, or social workers at any
level of the health care system. For patients or family members with complicated
psychological problems, such as suicidality, psychotic disorders, or bipolar disorder,
referral should be made to psychiatrists, if possible. In addition, hospital-based staff
members should routinely ask patients with serious, complex, or life-limiting health
problems if they desire spiritual counseling, and hospitals should allow local volunteer
spiritual counselors to visit inpatients upon request by the patient or family.

4. Social supports

Social supports should be accessible both for any patient in need of palliative care and for
their main caregiver in instances of extreme poverty. Given that extreme poverty is both a
cause and an effect of serious, complex, or life-limiting health problems, it is crucial that
meaningful social supports are accessible (Bamberger 2016). Such social supports
include transportation vouchers, cash payments, food packages, and other types of in-
kind support. In most cases, funding for these social supports should come not from
health care budgets but from antipoverty or social welfare programs. Thus, to be able to
implement all aspects of the full EP, there must be intersectoral coordination.

5. Human Resources

The EP should include adequate time for trained personnel at each level of the health care
system to provide palliative care consisting of the interventions, medicines, equipment,
counseling, and social supports described earlier. These personnel include doctors,
nurses, counselors such as social workers or psychologists, pharmacists, community
health workers, and family caregivers. Community health workers require a minimum of
several hours of training to prepare them to recognize and report any uncontrolled
suffering to a supervisor.

MANAGING PAIN USING COMPLEMENTARY THERAPIES AND SELF-

MANAGEMENT TECHNIQUES

These therapies and techniques can be used to manage pain, as well as taking pain-
relieving medication. Deep physical and mental relaxation can reduce anxiety and
ongoing pain. Your relative’s doctor may be able to recommend reputable therapists for
natural pain relief.

Helpful therapies may include:

 Heat or cold (used safely) – heat packs can aid relief of chronic musculoskeletal
injuries and associated pain. An icepack can be used to help reduce swelling
immediately after an injury, such as after a fall

 Physical therapies – walking, stretching and muscle strengthening exercises may

help relieve pain, depending on its cause. Physical activity can also help people to
maintain mobility and improve mood. A physiotherapist or osteopath can design a
specific program

 Breathing and relaxation – correct breathing technique [

http://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/…],
using the diaphragm and abdomen, can soothe the nervous system and manage
stress
  Hypnotherapy – uses imagery to induce a dreamy, relaxed state of mind.
Hypnotherapy can also help to ease some of the side effects of cancer treatment,
such as nausea

 Massage – soothes muscles, encourages relaxation and increases circulation to the

area being massaged

 Meditation – the deliberate clearing of the mind to bring about feelings of calm
and heightened awareness. The regular practice of meditation offers many long-
term health benefits, such as reduced stress and blood pressure

 Tai chi – a Chinese form of non-combative martial arts that consists of gentle
movements to clear the mind and relax the body

 yoga – an ancient Indian series of postures that are done in time with the breath

 Acupuncture – this ancient form of Chinese medicine involves inserting fine

needles into the skin at specific points. It can be an effective treatment in some
pain syndromes, but there is little research into acupuncture and cancer pain

 Transcutaneous electrical nerve stimulation (TENS) – a very small electrical

current is passed through the skin via electrodes, causing a pain-relieving response
from the body.

PRINCIPLES OF PALLIATIVE CARE AND PAIN MEDICINE

The first step in managing pain is to do a total pain assessment. You may be asked to
choose a number from 0 to 10 to rank your pain, with 0 being very mild pain and 10
being the worst possible pain you could have.

Keep in mind 3 important principles when deciding how to manage pain. First, pain
should always be treated right away. A delay allows pain to get worse. Second, you
should not be afraid of becoming addicted to pain medicine. If medicines are used in the
right way under close supervision of a healthcare provider, this is rarely a problem. Of
course, if you believe that you are losing control of how you are using pain medicines,
you should discuss this with your healthcare provider right away. Third, most pain
problems can be controlled by using the World Health Organization's step-care approach:

Step 1. Start with a nonsteroidal anti-inflammatory drug (NSAID). Examples of NSAIDs

include over-the-counter drugs like ibuprofen and stronger NSAIDs that your healthcare
provider may prescribe. An alternative to NSAIDs for step 1 pain is acetaminophen.

Step 2. If pain continues or gets worse, your healthcare provider may prescribe a weak
opioid medicine, like hydrocodone. A weak opioid may be combined with a nonopioid
pain reliever.

Step 3. If pain continues or gets worse, your healthcare provider may prescribe a stronger
opiate. Examples of strong opioids include morphine and fentanyl.

 Understanding opioid drugs

Opioid drugs are the most effective and commonly used drugs for moderate to severe
pain. A wide range of opioid drugs is available, and they can be taken in a variety of
ways. One drawback of these medicines is that, over time, you will almost certainly
develop a tolerance to the one you're taking and need higher doses to get the same effect.
One way your healthcare provider may get around this problem is by switching the type,
dose, or the way the drug is given.

These are common ways in which opioid drugs can be given:

o Oral medicines.

o These can be taken in pill or liquid form and can be short acting or long acting
(sustained release).
 o Adhesive patch.

o This can be applied to the skin to release medicine over time. An example of this
is a fentanyl patch.

o Opioid drug injection.

o This shot may be given under the skin or into a muscle.

o Opioid drug IV.

o An opiate may be given directly into the blood through an intravenous line.

o Medicine pump.

o Opiate medicine can be given through a pump attached to an IV line that you
control. This is called patient-controlled analgesia.

o Spinal injection.

o For pain that's hard to control, a pain-control specialist may give an opioid drug
directly into the spinal cord area.

 Understanding helper drugs

These medicines, called adjuvant analgesics, can help control pain in certain situations.
These are commonly used adjuvant drugs:

o Steroids. These are strong anti-inflammatory medicines that may help relieve pain
by decreasing inflammation. They may be used along with other pain relievers for
nerve, bone, or other types of pain.

o Antidepressants. Treating any existing depression or anxiety can make pain

easier to control. These drugs may also be useful in pain caused by nerve damage.
 o Anticonvulsants. These medicines are usually used to control seizures, but they
can also help control nerve-related pain.

o Local anesthetics. These are medicines that can block pain signals in the body. A
pain specialist may inject a local anesthetic to block pain.

o Muscle relaxants. Antianxiety medicines and muscle relaxants may be used along
with pain medicine if pain is aggravated by tension or muscle spasms.

o Bisphosphonates. These medicines are sometimes used to prevent fractures in

people whose cancer has spread to the bone. They can play a key role in relieving
bone injury and pain.

 Other pain control interventions

Surgery is often the last thing a patient or his or her healthcare provider would consider at
end of life. But at times surgery can provide pain relief and increase function. Surgery's
primary goal can be to relieve specific symptoms. For instance, a healthcare provider
may recommend surgery to stabilize a hip fracture in someone with advanced cancer. The
surgery is not going to treat the cancer or lengthen the patient's life, but it may be the best
way to reduce hip pain and improve mobility. Radiation therapy can also be used to
improve pain and control symptoms. Because surgery involves risk, the healthcare
provider must clearly define treatment goals for both the patient and the patient's family.

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