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Using a learning contract to develop knowledge of cancer pain for patients with both primary and secondary bone cancer.

Using a learning contract to develop knowledge of cancer pain for patients with both primary and secondary bone cancer.

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An essay for the 2011 Undergraduate Awards (Lecturer Nomination) Competition by Elaine Lombard. It is nominated by Lecturer Maria Bailey of University of Limerick in the category of Nursing & Midwifery
An essay for the 2011 Undergraduate Awards (Lecturer Nomination) Competition by Elaine Lombard. It is nominated by Lecturer Maria Bailey of University of Limerick in the category of Nursing & Midwifery

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Published by: Undergraduate Awards on Sep 01, 2012
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Using a learning contract to develop knowledge of cancer pain for patients with bothprimary and secondary bone cancerAbstract
Bone pain has been considered to be the worst of all chronic pains (Luger et al 2005). Painassociated with bone cancer is thought to be one of the most difficult types of pain to treatand requires several interventions to obtain best control of this pain (Clare et al 2005).This learning contract provides a framework for the student to develop and present evidenceof learning concerning the physiology and management of primary and secondary bone pain.The paper presents a discussion of the pharmacological management of bone pain and theuse of radiotherapy as a method of managing bone pain in cancer.
The purpose of a learning contract is to allow a student to develop an individual learning needthat is relevant to a particular module (McAllister 1996). This type of learning is thought tomotivate the student to learn about a topic of interest which promotes a deeper level of learning (McAllister 1996).In this learning contract, I want to develop knowledge of cancer pain for patients with bothprimary and secondary bone cancer. Generally, bone cancer is due to metastatic spread of cancer cells from a primary tumour elsewhere however in some cases bone cancer can oftenbe a primary tumour as well (Luger et al 2005).
Pain is defined by Faull (1998) as “anunpleasant sensory and emotional experience” and bone cancer is considered the “most
severe and com
mon chronic pain” (Luger et al 2005, S32).
Bone metastasis is very difficulttype of metastasis to treat in relation to pain control and several interventions need to beutilized in order to obtain the best possible control of this pain (Clare et al 2005). Coleman(2006) suggests that two thirds of people with bone metastases experience immense pain.Pain may not only arise from the cancer itself but also from the treatment, the consequencesof this treatment and also concurrent illness may add to the severity of this pain (Dobratz2008)
This aspect of nursing has been an area of interest for me, personally, after nursing a patientwith bone metastasis and observing the pain he was in, both on movement and at rest. Todate my knowledge on bone cancer associated pain has been limited therefore completion of this learning contract will augment my knowledge and influence my care for this patientgroup.
In achieving my aim I will identify and describe the transmission, transduction andmodulation of bone cancer pain, and discuss the factors influencing total pain (physiological,psychological, spiritual and social) and the importance of treating these elements alongsidethe physical symptoms. The pharmacological management of pain and the use of radiotherapy in the management of bone cancer pain will also be addressed.For this learning contract, I utilised various different peer reviewed journal articles that havebeen accessed through the databases CINHAL and EMBASE. I made use of recommendedreading list which contains some very important sources of information. I also accessed
current book publications and reliable, national websites such as “World HealthOrganisation” and the “National Cancer Institute”.
I also accessed resources available to mewhilst on placement i.e. The Clinical Nurse Specialist Pain management and proved to be aninvaluable resource, providing me with some interesting and relevant articles and speaking tome in detail about pharmaceutical agents available and the working mechanisms for these.The Palliative care Clinical Nurse Specialist, was also very helpful and assisted me indeveloping an understanding of when these certain drugs are appropriate. For exampleparacetamol should not be used when the patient is receiving chemotherapy due to fact thatthis type of analgesia masks a temperature which may be a sign the patient is developingneutropenia. She also spoke in detail of the debate about the use of bisphosphonates. Duringone of our reflective practice sessions, we received a talk on care of the dying patient fromanother palliative care nurse. This talk highlighted some very important points in relation tocare of the cancer patient and the total concept of pain and how this affects patients.
Evidence of accomplishment
As cancer advances, it invades and destroys health tissue which in turn causes inflammation,infection, expansion within enclosed areas and oedema (Ferrell 2008). These initiate thereceptors that transmit the pain signals. Due to metastatic spread, several organs arefrequently involved in advanced cancer (Callin et al 2008) therefore pain reported is notlimited to somatic or visceral or neuropathic or nociceptive but may incorporate elements of all four (Bond and Simpson 2002).
Cancer induced bone pain is considered extremely painful due to the fact the bone contains avast number of nociceptive sensory nerve fibres described as C fibres (Raphael et al 2008)These fibres become destroyed by the invading metastatic cells (Callin and Bennett 2008).The C fibres are responsible for the transmission of dull aching pain (Callin and Bennett2008)
. The pain associated with bone cancer has been described as “deep gnawing pain”(Axford and O’ Callaghan 2004) and dull throbbing pain that progressively worsens (Mantyh
2006). The C fibres are unmyelinated so therefore conduct pain in a slow manner incomparison to the A delta fibres which are involved in the transmission of sharp pain e.g.
pricking, pinching. (Bond and Simpson 2006). The C fibres are stimulated by the mechanicalaction of the actual tumour i.e. compression and chemically, by the cytokines released fromthe tumour. The primary afferents A delta and C fibres transmit painful signals to the secondand fifth lamina of the dorsal horn of the spinal cord where they synapse (Urch 2004). Thesesignals undergo excitatory and inhibitory modulation before being transmitted to the brain(Urch 2004). The dorsal horn regulates the transmission of pain signals to the brain. Thebrain and the spinal cord are able to gate pain signals (Melzack and Wall 1965). These gatesare opened and closed based on the activity on the various fibres. A beta fibres also synapsein the in the second and fifth laminae of the dorsal horn and have the ability to close thesegates (Melzack and Wall 1965). A beta fibres respond to a different non painful stimuli. If thestimulus from the A beta fibres is greater than the A delta or C fibres then the gate is closedand the pain signal is not transmitted but a different message is received in the brain i.erubbing. This is called the gate control theory and was developed by Melzack and Wall(Melzack and Wall 1965).Whilst bone cancer pain is primarily nociceptive pain there may be an element of neuropathicpain. Neuropathic pain occurs from damage to the nervous system itself, either centrally orperipherally due to various different reasons including haemorrhage, ischemia, compressionand transaction mainly from cancer destruction but treatment such as chemotherapy can causethis pain (Raphael et al 2010 and Lucas and Lipman 2002). This pain may persist eventhough the damaged site will have appeared to heal (Callin and Bennett 2008). Abnormalsodium and calcium channels accumulate at the point where damage has occurred. Thesedamaged neurons fire spontaneously and the stimulus can hop from one nerve fibre to another(Callin and Bennett 2008). The excitation within the dorsal horn may cause hyperalgesia orallodynia(Callin and Bennett 2008). These two conditions are in themselves very painful andit can be very hard to differentiate which condition the patient has (Callin and Bennett, 2008).Neuropathic pain is described as shooting, burning and tingling (Callin and Bennett 2008;Bond and Simpson 2006).
For the management of cancer pain, a multidisciplinary approach needs be taken in order toachieve satisfactory pain relief (Mercadante and Fulfaro 2007) Comprehensive assessmentensures that the patient is cared for holistically and in a person centred manner (Bond andSimpson, 2006).Bone cancer pain can be very difficult to control (Clare et al 2005), however Dobratz (2009)states that through the utilisation of carful and in-depth holistic assessment of the individualand the initiation of proper interventions then this pain can be managed. All members of themultidisciplinary team should be involved in management of factors that affect pain (Ferrellet al 2008). The WHO (2002) suggests that an individual with cancer pain should be

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