Chronic cancer pain management by the nursing team

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 LILACS 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.


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 spiritual 2 .Cancer pain is related to tumor and the presence of me- tastases; it may be induced by diagnostic and therapeutic procedures which may be uncomfortable; and also may be caused by disease terminality [2][3][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 states 5 .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 it 10 ; however, there are reports on difficulties to manage cancer patients' pain and to implement adequate therapies 11 .There might be difficulties in listening to patients' pain complaints, although nurses understand the complexity of the experience and are sensitive to the theme 12 .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 pain 13 .Most studies mentioning cancer pain management by the nursing team have also presented resources and strategies to be used to minimize it 13 .
All nurses have to know the tools used to measure pain intensity, which requires specific qualifications and skills focused on improving pain 14 .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 Rego 11 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 Luize 10 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 mentioned 15 .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 studied 7 .The only approach was mentioned by Simões 17 , 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 procedures 16 .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 touch 10 .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.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.Most common pain was nociceptive visceral pain, and neuropathic pain was the most difficult to control.There has been adequate pain control in patients admitted to the cancer ward.

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.

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 associated 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.Non-treatment of pain by "fear of adverse reactions" or by negligence leads to serious violation of bioethical principles.Avaliação da dor em pacientes oncológicos internados em um hospital escola do Nordeste do Brasil.Pain evaluation in cancer patients admitted to a teaching hospital of Northeastern Brazil 2013 P r o s p e c t i v e , crossover study Describe cancer patients' pain evaluation and treatment in Clinical Oncology Ward.

Table 1 .
Articles included in the study, according to category Category 1. Cancer pain management by the nursing team