Chronic cancer pain management by the nursing team

ABSTRACT

BACKGROUND AND OBJECTIVES:

Cancer patients' pain is related to the tumor, to diagnostic and therapeutic procedures and to the terminality of the disease; however health professionals, especially nursing teams, still have difficulties in evaluating and managing pain. As from experience in hospitals, it was noticed that nursing teams face barriers, which is intensified in case of cancer patients, marked by the "incurable" cancer pain stigma. This study aimed at identifying in the literature, how nursing teams manage chronic cancer pain.

CONTENTS:

We have found 710 articles being 194 in LI-LACS and 516 in Scielo, being included 14 articles by means of the descriptors "Nursing Care", "Nursing", Chronic pain", "Pain management", "Oncology". In the category "Cancer pain management by the nursing team", studies have reinforced the importance of pain evaluation by the nursing team and present resources and strategies to make it effective. In the category "Pharmacological methods for pain management", drugs appear as the first method of choice with the three steps stair of the World Health Organization and opiophobia is discussed. In the category "Non-pharmacological methods for pain management", there are interventions such as therapeutic massage, spiritual support and comfort measures, such as changing position.

CONCLUSION:

Assisting painful cancer patients goes beyond performing procedures; it is necessary to think about scientific knowledge acquisition and professional-patient link for a safe assistance when managing cancer pain.

Keywords:
Chronic pain; Nurse-patient relationships; Nursing; Nursing care; Oncology; Pain management

RESUMO

JUSTIFICATIVA E OBJETIVOS:

A dor no paciente oncológico se relaciona à presença do tumor, aos procedimentos diagnósticos e terapêuticos e à terminalidade da doença, porém os profissionais de saúde, particularmente a equipe de enfermagem, ainda apresentam dificuldades na avaliação e manuseio da dor. A partir da vivência nos hospitais, percebeu-se que a equipe de enfermagem enfrenta barreiras, o que se intensifica ao se tratar de um paciente oncológico, marcado pelo estigma da dor "incurável" do câncer. O objetivo deste estudo foi identificar, na literatura, como a equipe de enfermagem manuseia a dor crônica nos pacientes oncológicos.

CONTEÚDO:

Foram encontrados 710 artigos, sendo 194 no LILACS e 516 no Scielo; aproveitando-se 14 artigos, com uso dos descritores "Cuidados de Enfermagem", "Enfermagem", "Dor crônica", "Manejo da dor", "Oncologia". Na categoria "Manejo da dor oncológica pela equipe de enfermagem", os estudos reforçam a importância da avaliação da dor pela equipe de enfermagem e apresentam recursos e estratégias utilizados para efetivá-la. Na categoria "Métodos farmacológicos para o manuseio da dor", o fármaco aparece como primeiro método de escolha com a escada de três degraus da Organização Mundial da Saúde e discute-se a opiofobia. Na categoria "Métodos não farmacológicos para o manuseio da dor", tem-se intervenções como massagem terapêutica, apoio espiritual e medidas de conforto, como mudança de decúbito.

CONCLUSÃO:

Cuidar do paciente oncológico com dor ultrapassa a execução de procedimentos; é preciso pensar na aquisição de conhecimento científico e vínculo profissional/paciente para uma assistência segura no manuseio da dor oncológica.

Descritores:
Cuidados de enfermagem; Dor crônica; Enfermagem; Manuseio da dor; Oncologia; Relações enfermeiro-paciente

INTRODUCTION

Pain is a subjective and individual experience associated to physical, cognitive, cultural and psychological manifestations. In 1979, the International Association for the Study of Pain (IASP) has standardized and made international the concept of pain, and has defined pain as "unpleasant, emotional and sensory experience associated to real or potential tissue injury or described in such terms"¹. In oncology, the concept of pain was introduced by Cicely Saunders as "Total Pain", where pain is made up of several components: physical, social, mental and spiritual². Cancer pain is related to tumor and the presence of metastases; it may be induced by diagnostic and therapeutic procedures which may be uncomfortable; and also may be caused by disease terminality^2-4.

The prevalence of cancer pain is estimated in 25 to 50% for recently diagnosed patients, in 33 to 80% for patients under treatment, and in approximately 75 to 100% for those in advanced and terminal states⁵.

Although statistics being alarming regarding cancer pain incidence, studies have shown that the adoption of therapeutic strategies may improve pain in 80 to 90%^2,6,7. Pain is part of healthcare routine, be it during hospitalization or outpatient treatment, however health professionals still have difficulties in evaluating and managing pain^5,8,9.

Insecurity with regard to regular use of morphine and difficulties to administer drugs when requested versus regular analgesia have intensified concerns about the subject. So, based on the assumption that understanding pain events in cancer patients is extremely important, this study aimed at evaluating chronic pain management in cancer patients by the nursing team.

CONTENTS

This is a narrative literature review as from queries in Latin-American and Caribbean Literature in Health Sciences (LILACS) and Scientific Electronic Library (Scielo). Descriptors were Nursing Care, Nursing, Chronic pain, Pain management, Oncology, Cancer, Nurse-Patient relationships.

Inclusion criteria were articles in Portuguese language and published from 2010 to 2015. Exclusion criteria were articles not published by nurses. We have found 710 articles, being 194 in LILACS and 516 in Scielo. After initial analysis by reading abstracts and checking appropriateness to theme, 23 articles were selected, being 8 from LILACS and 13 from Scielo.

By means of subsequent analysis and application of exclusion criteria, 14 articles were selected and, as from thorough reading, results were organized in categories.

For the category "Cancer pain management by the nursing team", articles have described pain as the fifth vital sign, and so it is believed that the nursing team is linked to possible interventions to relieve it¹⁰; however, there are reports on difficulties to manage cancer patients' pain and to implement adequate therapies¹¹.

There might be difficulties in listening to patients' pain complaints, although nurses understand the complexity of the experience and are sensitive to the theme¹².

Two basic principles are critical to manage cancer pain: total pain involving physical, environmental, emotional, social and spiritual factors and identification of mechanisms inducing and worsening pain¹³.

Most studies mentioning cancer pain management by the nursing team have also presented resources and strategies to be used to minimize it¹³.

All nurses have to know the tools used to measure pain intensity, which requires specific qualifications and skills focused on improving pain¹⁴.

Lima et al. ⁵ have emphasized the use of pain scales, because they may attribute objectivity to the subjective aspect of pain experience. Cunha and Rego¹¹ presented visual analog scale (VAS) and numerical verbal scale (NVS) as the most widely used scales.

For the category "Pharmacological methods for the management of cancer pain by the nursing team", few studies were found addressing the subject.

Study of Chotolli and Luize¹⁰ has reported that the use of drugs seems to be the first method of choice for pain relief. Among these drugs, anti-inflammatory, opioids, antidepressants, and anticonvulsants, among others, were the most commonly mentioned¹⁵.

Pharmacological treatment, according to the three steps ladder proposed by the World Health Organization (WHO) is the basis to control cancer pain^7,16.

WHO states that morphine and its derivatives are underutilized worldwide and in Brazil. This may be related to fear (opiophobia) and/or lack of knowledge of opioids' pharmacology and clinical use. This situation, although very common among nurses, has not yet been adequately studied⁷.

The only approach was mentioned by Simões¹⁷, who cautions that non-treatment of pain due to "lack of knowledge", "fear of adverse reactions" or negligence is a serious violation of perfectly established bioethical principles.

Drugs may control pain, but not the whole context involving cancer patients. In this sense, there is the category "Non-pharmacological methods for cancer pain management by the nursing team", where studies bring interventions such as therapeutic massage, spiritual support and comfort measures, such as changing position in bed. There is also an article mentioning interventionist procedures¹⁶.

Massage seems to be useful to relieve pain and improve mental health, although there are still questions about the efficacy of this protocol. However, it may contribute to promote wellbeing and improved quality of life^18,19. With regard to methods thought by nursing professionals to manage pain, the frequency with which they appeared was: 10 (38.4%) for drugs, 9 (34.2%) for distraction, 2 (7.6%) for lap, 2 (7.6%) for affection, 1 (3.8%) for decreasing noise and 1 (3.8%) for therapeutic touch¹⁰.

It is important to stress that even with drugs and complementary therapies, there is not always success in suppressing pain^7,15.

Nurses, as part of a multidisciplinary team, actively intervene to totally control and relief pain by means of non-pharmacological interventions and should know pharmacological treatments, as well as indications, contraindications and adverse effects^19,20.

Table 1 shows articles organized in this study by categories.

Table 1
Articles included in the study, according to category

Category 1. Cancer pain management by the nursing team
Article	Year	Type of study	Objective	Conclusion
Palliative care: pain evaluation according to nurses	2015	Integrative literature review	Identify in Brazilian scientific production the status of nursing team assistance and knowledge of cancer pain.	Results have contributed for the scientific armamenta-rium of the nursing team, giving it support for better pain management with regard to its adequate measurement, major intervention aspects and predominant stumbling blocks for fighting against pain.
Postoperative management of cancer pain patients by nurses	2010	Convergent assistential qualitative research	Reveal concepts and contributions of nurses acting in palliative care about cancer patients’ pain evaluation	Implementation of systematized pain management entailed in nursing assistance systematization enables redirecting actions and this way a more complete and effective pain management.
Nurses and cancer pain	2013	Descriptive qualitative study	Describe the management of immediate postoperative pain of cancer patients by the nursing team	Nursing team should be prepared to manage postoperative pain of cancer patients, with the use of available tools and identification of pharmacological and complementary interventions needed for each patient.
Spiritual dimension in pain and suffering control of advanced cancer patients.	2015	Case report	Show the integration of spiritual aspects in pain sensation manifestation and their influence on pain and suffering control of advanced cancer patient.	Importance of recognizing the spiritual dimension in adequate total pain evaluation
Dialogues with nurses about oncologic pain assessment of patients under palliative care	2010	Experience re-port	Report the experience of developing a labor education process focused on the awareness of nurses about pain evaluation of patients under palliative care	Nurses stress the need to build pain evaluation systematization so that nurses may reinforce the importance of its control, and justify practice and ongoing education.
Category 2. Pharmacological methods for the management of cancer pain by the nursing team
Irruptive pain in advanced cancer	2011	Literature review	Systematize pain concepts and definitions as-sociated to cancer, understand onset mechanisms of irruptive pain and know the best ways to relieve it.	Severe non-relieved pain brings adverse physical, psychological and social consequences. Patients have the right to adequate treatment.
Avaliação da dor em pacientes oncológicos inter-nados em um hospital es-cola do Nordeste do Brasil.	2013	Prospective, crossover study	Describe cancer patients’ pain evaluation and treatment in Clinical Oncology Ward.	Non-treatment of pain by “fear of adverse reactions” or by negligence leads to serious violation of bioethical principles. Most common pain was nociceptive visceral pain, and neuropathic pain was the most difficult to control. There has been adequate pain control in patients admit-ted to the cancer ward.
Pain evaluation in cancer patients admitted to a teaching hospital of Northeastern Brazil Pain in cancer patients under chemotherapeutic treatment	2012	Quantitative, de script ive, crossover study	Evaluate cancer patients pain by means of standardized scales validated to the Portuguese language	Moderate and sensory pain is present in most cancer patients leading to loss of energy to perform daily activities.
Category 3. Non-pharmacological methods to manage cancer pain
Massage in children with cancer: effectiveness of a protocol	2013	Prospective, longitudinal, randomized, controlled study	Evaluate the efficacy of the implementation of a massage protocol to relieve pain of hospitalized children with cancer.	Massage seems to be a useful intervention to relieve pain in children with cancer, in spite of questions about the efficacy of this protocol. Authors recommend its use due to its contribution to children’s wellbeing and quality of life.
Effect of therapeutic massage on mental health of cancer patients	2015	Systematic literature review	Evaluate the effect of therapeutic massage on mental health of cancer patients	Therapeutic massage has short-term beneficial effects in terms of emotional wellbeing, physical and emotional discomfort, depressed mood, sleep pattern, relaxation and stress of cancer patients.
Complementary techniques to control cancer symptoms	2014	Literature review	Identify evidences in the scientific literature for the use of complementary techniques to control signs and symptoms of cancer patients.	Scientific evidences show the benefit of nonpharmacological treatment to control signs and symptoms such as pain in oncology.
Non-pharmacological methods to control pediatric cancer pain: view of the nursing team	2015	Descriptive, exloratory qualiquantitative study	Identify non-pharmacological methods to control pain used by nurses in hospitalized children, check most widely used pain scales and evaluate nursing team view about pain management with nonpharmacological methods.	The need for training on pain measurement scales according to age, possible non-pharmacological methods used by nurses and their association with the nursing process has been identified.
Pain in cancer patients under palliative care	2014	Crossover study	Evaluate pain and quality of life of cancer patients under palliative care.	Results have shown the presence of pain affecting quality of life and impairing daily life activities.
Interventionist procedures for cancer pain management.	2012	Quantitative, de script ive, crossover study	Describe the number and types of procedures performed by the Pain Interventionist Medicine Center of a private hospital of São Paulo.	Results are in line with the literature and confirm the efficacy of interventionist procedures for different types of cancer pain.

CONCLUSION

In terms of assistance, nurses have resources, management strategies and tools able to maximize assistance to painful cancer patients, such as pain evaluation scales, tailored appreciation of pain complaint, administration of continuous analgesics and rescue drugs, according to medical prescription, to contribute to dose titration adjustments and development and execution of nursing prescriptions to painful cancer patients.

Even if all resources and apparatus are needed, taking care of painful cancer patients goes beyond the administration of analgesic drugs, the performance of techniques and procedures and the execution of protocols; it is especially necessary to establish in professional/patient relationships empathy, interest and affective link aiming at relieving, comforting, supporting, promoting reestablishing and making patients happy so that their lives are not limited to cancer pain.

It is necessary to think on nurses' qualification for pain management, with regard to graduation teaching, bringing contemporaneity to qualification and better qualification of students to face the reality of the area and to bring excellence to doing in nursing.

• Sponsoring sources: none.

ACKNOWLEDGMENTS

To Sônia Regina de Souza, doctor associate professor I of Universidade Federal do Estado do Rio de Janeiro who have cooperated in the interpretation of results, review and final formatting.

To Andrea dos Santos Garcia, specialist nurse in Medical-Surgical Nursing, who contributed to final formatting of the article.

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Publication Dates

• Publication in this collection
  Jul-Sep 2016

History

• Received
  28 Feb 2016
• Accepted
  20 June 2016