Textbook of Medical-Surgical Nursing 3e

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Unit 3   Applying concepts from the nursing process

Pain assessment

Evaluate aetiology Evaluate location, intensity, character

Evaluate location ? Consistent with known tumour sites ? Non-malignant pain

Evaluate pain character

Evaluate pain intensity Anticipate drug choices based on pain severity (0–10 scale)

Evaluate aetiology ? New pain → Diagnostic work-up ? Amenable to radiotherapy ? Amenable to chemotherapy ? Amenable to regional neurolysis

Select coanalgesic therapy

Nociceptive

Neuropathic

0–3

4–6

7–10

Coanalgesic therapy with NSAID

Coanalgesic therapy with tricyclic antidepressants, antiseizure agents, corticosteroids

Opioid (e.g. oxycodone)

Strong opioid (e.g. morphine)

Non-opioid (e.g. APAP)

With coanalgesics continue non-opioid

Drug choice decisions Evaluate efficiency of previous therapy Evaluate side effects (current and history) Select agents according to pain assessment

Inadequate efficacy with currrent regimen with side effects

Efficacy with currrent regimen with no side effects

Efficacy with currrent regimen with side effects

Inadequate efficacy with currrent regimen with no side effects

Address side effects Titrate opioids Maximise coanalgesics

No change

Maximise coanalgesics

Titrate opioid Maximise coanalgesics

Reassessment Frequency of patient contact should be related to pain intensity and side effects Method of patient contact should be related to acuity and patient function

Frequency of patient contact

Method of patient contact

Patient reported pain intensity (0–10 scale)

Clinic visit Consider any time physical exam and diagnostics would assist treatment planning Consider routine visits for patients with complex pain-management strategies

Home care visit

Telephone follow-up Consider status—postdrug changes as a re-evaluation Consider frequent phone assessment for rapidly changing situation

Consider for debilitated patients who have difficulty coming to a clinic

0–3

4–6

7–10

Consider for patients with limited caregiver support

PRN

2–3 × wk

qd

Consider for mostly stable patients as a check-in

Consider routine visits for patients with complex pain-management strategies

Return to drug choice decisions after each assessment

? New pain; return to pain assessment

Figure 11-7  The cancer pain algorithm (highest-level view) is a decision-tree model for pain treatment that was developed as an interpretation of the AHCPR Guideline for Cancer Pain, 1994. Redrawn with permission from DuPen, A. R., DuPen, S., Hansberry, J., et al. (2000). An educational implementation of a cancer pain algorithm for ambulatory care. Pain Management Nursing, 1(4), 118.