7a. Cellular Aberration With PAIN Concept

LECTURE - HANDOUT ON
CELLULAR ABERRATION
(Cancer)
The inflammatory and immune responses are normally helpful to protect the body against invasion
These responses are the same system that also stimulate cell growth, production and repair after injury
or any event requiring cell replacement.
When inflammation or immune response are prolonged, excessive or occur at an inappropriate time,
normal tissues are damaged resulting to:
I. Infection (Communicable Diseases)
II. Hypersensitivity and Autoimmune responses and
III. CANCER CELL FORMATION
I. ESSENTIAL CONCEPTS OF CANCER

Oncology – The field or study of cancer (Ca)
A. What is Cancer?
• Cancer is a term used for diseases in which abnormal cells divide without control and are able to
invade other tissues.
• Cancer cells can spread to other parts of the body through the blood and lymph systems.
Three main characteristics:

• Abnormal cell division
• Proliferation - rapid uncontrolled growth / reproduction of abnormal cells
• Metastasis - spread or transfer of cancer cells from one organ or part to another not directly
connected
B. Normal Cell Growth vs. Cancer Cell Growth

1. Normal Cell Cycle / Growth
It is the life of a eukaryotic cell: - any cells with membrane bound nucleus and each nucleus
having organelles
The way the cells grow, make new copies and divide
It happens in all of somatic (body) cells in order to get the same DNA inside each cell.
Prepared by Prof. Amelia Z. Manaois for AU - College of Nursing to be used as Instructional Material only for the NCM112 – Lecture. Refrain
from reproducing this material without the consent of the preparer and the AU-CON
The reproductive cycle of normal and cancerous cells is essentially the same.
a. (G1) Phase - protein synthesis may occur for cell growth and development for cell
differentiation (the cell is told what to become).
b. (S) Phase, Synthesis of 46 chromosomes is duplicated (DNA) for REPLICATION in
preparation for cell division.
c. (G2) Phase - DNA synthesis halts, checks for errors and prepares for the M phase or
Mitosis
• Mitosis – replicated chromosomes are separated into two new nuclei (equally
identical
• Cytokinesis - physical process that finally splits the parent cell into two identical
daughter cells
d. Cells in (G0) - Comes from the M phase
• May mature, reproduce and die.
• Programmed Cell Death – Apoptosis
• Normal cells divide with appropriate external signals
• Cell death occur after a limited number of cell divisions
To illustrate what is meant by normal growth control, consider the skin. The thin outermost
layer of normal skin, called the epidermis, is roughly a dozen cells thick. Cells in the bottom row
of this layer, called the basal layer, divide just fast enough to replenish cells that are continually
being shed from the surface of the skin. Each time one of these basal cells divides, it produces
two cells. One remains in the basal layer and retains the capacity to divide. The other migrates
out of the basal layer and loses the capacity to divide. The number of dividing cells in the basal
layer, therefore, stays the same.
2. Abnormal Cell Cycle / Growth

All cancers begin in cells, the body's basic unit of life. To understand cancer, it's helpful to know
what happens when normal cells become cancer cells.
The body is made up of many types of cells. These cells grow and divide in a controlled way to
produce more cells as they are needed to keep the body healthy. When cells become old or
damaged, they die and are replaced with new cells.
However, sometimes this orderly process goes wrong. The genetic material (DNA) of a cell can
become damaged or changed, producing mutations that affect normal cell growth and division.
When this happens, cells do not die when they should and new cells form when the body does
not need them. The extra cells may form a mass of tissue called a tumor.
METASTASIS – The spread of cancer cells from the primary site to a secondary site
Three stages:
a. Invasion - neoplastic cells from primary tumor invade surrounding tissue, blood or lymphatic
fluid.
b. Spread - neoplastic cells are transported by circulatory and lymphatic system (lymphatic and
blood)
c. Establishment and growth - neoplastic cells are established and grow in secondary site:
lymph nodes or in organs from venous circulation
Common Sites of Metastasis: 3L, 2B

Lung, Liver, Lymph Nodes
Brain and Bones
Mechanism:
a. Lymphatic Spread – Lymphatic circulation
b. Hematogenous Spread – Bloodstream
c. Angiogenesis – inducing growth of new capillaries from the host tissues to meet their needs
for nutrients
Contributory factors:
a. Cytoskeletal changes and cell adhesion / motility molecules – loss of cell-to-cell adhesion
and anchorage facilitates cancer cells spread and proliferate and survive in the bloodstream
b. Cell surface protein - tumor cell adhesion at a secondary site by the expression of cell
surface protein
c. Loss of contact inhibition – a hallmark of cancer cell behavior facilitating their spread
d. Pseudopod formation – arm-like projections for locomotion
e. Secondary site microenvironment – permissive site for metastatic colonization of cancer
cells (3L, 2B)
C. Etiology and Causative Factors

1. Viruses and Bacteria – clustering of cells in infectious conditions are believed to lead to Cancer
(H.pylori, Human papillomavirus, HepaB)
2. Physical Agents – Exposure to sunlight or radiation, chronic irritation or inflammation and
tobacco use.
3. Chemical Agent – Tobacco use
4. Genetic and Familial Factors
5. Dietary Factors – carcinogenic food
6. Hormonal Agents – ex. Ovarian Ca
D. Pathophysiology
E. Classification of Tumors
1. According to Tumor Behavior

Benign - “Bene” good sort of growth
tumors that cannot spread by invasion or metastasis; hence, they only grow locally
Malignant - “Malign” bad sort of growth

tumors that are capable of spreading by invasion and metastasis. By definition, the term cancer
applies only to malignant tumors
2. According to Pattern of Proliferation

a. Hyperplasia
Tissue growth based on an excessive rate of cell division, leading to a larger than usual
number of cells;
The process of hyperplasia is potentially reversible;

Can be a normal tissue response to an irritating stimulus.
Example: callus
b. Dysplasia
Bizarre cell growth differing in size, shape and cell arrangement
c. Metaplasia
Conversion of one type of cell in a tissue to another type not normal for that tissue
d. Anaplasia
Reversion of cells to an immature or less differentiated form, as occurs in most
malignant tumors
e. Neoplasia
Uncontrolled cell growth, either benign or malignant
Simply known as CANCER
These patterns of proliferation are borderline or defining behavior of a cancer whether

it is benign or malignant
3. According to Origin
a. Carcinoma
The most common types of cancer, arise from the cells that cover external and internal
body surfaces. (Epithelial tissues)
Examples:
Adenocarcimona – cancer of a gland
Pancreas, Prostate, Breast,
Lungs, Colon, Rectum
b. Sarcoma
Cancers arising from cells found in the supporting tissues of the body such as bone,
cartilage, fat, and muscle (connective tissue)
Examples:
Osteosarcoma – cancer of the bone
c. Lymphoma
Cancers that arise in the lymph nodes and tissues of the body's immune system.
d. Leukemia
Cancers of the immature blood cells that grow in the bone marrow and tend to
accumulate in large numbers in the bloodstream (Hematopoietic system)
e. Neuroblastoma
Nervous Tissue Tumors
Cancer / tumors arising from the Nervous tissue
f. Myeloma
Develops in the plasma cells of bone marrow
F. Effects of Cancer
1. Psychological / Emotional
a. Anxiety
b. Depression
c. Distorted body image
2. Spiritual
May loose or strengthen faith
3. Financial - Costly
4. Physical
a. Disruption of Function-can be due to obstruction or pressure
b. Hematologic Alterations: can impair function of blood cells
c. Hemorrhage: tumor erosion, bleeding, severe anemia
d. Anorexia-Cachexia Syndrome: wasted appearance of client
e. Paraneoplastic Syndromes: ectopic sites with excess hormone production
-Parathyroid hormone = Hypercalcemia
-Secretion of insulin = hypoglycemia
-Antidiuretic hormone (ADH) = fluid retention, HTN & peripheral
edema
f. Adrenocorticotropic hormone (ACTH): cause excessive secretion of cortisone (ex. fluid
retention, glucose levels)
g. Physical Stress: body tries to respond and destroy neoplasm
h. PAIN: major concern of clients and families associated with cancer
OVERVIEW OF PAIN
1. PAIN is known as “The Fifth Vital Sign”
2. The priority concept of care of patients with pain is COMFORT.
3. PAIN is defined as an unpleasant sensory and emotional experience associated with
actual or potential tissue damage.
4. McCaffery (1968) offered the more classic and personal definition when she stated
that pain is whatever the experiencing person says it is and exists whenever he or
she says it exists.
This has become the clinical definition of pain worldwide and reflects an
understanding that the patient is the authority and the only one who can describe
the pain experience.
Self-report is always the most reliable indication of pain.
Nurses who approach pain from this perspective can help the patient achieve
effective management by advocating for proper control.
If the patient cannot provide self-report, a variety of other methods such as

observation of behavioral indicators are used for pain assessment
CATEGORIES / TYPES OF PAIN

1. BY DURATION:
A. ACUTE PAIN
Usually temporary, has short duration
Has a sudden onset, and is easily localized.
The pain is typically confined to the injured area and may subside with or
without treatment.
Usually has a well-defined cause and decreases with healing
As the injured area heals, the SENSORY PERCEPTION of pain changes and, in
most cases, diminishes and resolves. Thus, usually reversible
Initially serves a biologic purpose (It acts as a warning signal to withdraw from
painful stimuli or seek help, as it activates the sympathetic nervous system
causing various physiologic responses (fight-or-flight reaction):
Increase HR, BP, RR; Dilated pupils; Sweating
Ranges from mild-to-severe intensity
May be accompanied by anxiety and restlessness
PAIN is one of the most severe accompanying discomfort of CANCER

a. The response to pain with CANCER is highly individual and variable.
b. There is no evidence that shows that one type of cancer is consistently more or
less painful than another.
c. Poorly managed and prolonged acute pain serves no useful purpose and has
many adverse effects, including inability of the patient to participate in the
recovery process with subsequent increased disability.
d. When unrelieved, pain can increase morbidity and mortality and prolong length
of hospital stay
B. CHRONIC PAIN / PERSISTENT PAIN (Chronic Cancer and Chronic-non-cancer

pain)
Usually lasts or recurs for an indefinite period, usually for more than 3 months.
The onset is gradual, and the character and quality of the pain often change
over time.
It is usually poorly localized because it often involves deep body structures
Serves no biologic purpose. It may or may not have well-defined cause
Because it persists for an extended period, it may result to multiple quality-of-

life and functional adverse effects:
Personal relationships and performance of ADLs.
Depression; fatigue; financial burden; and increased dependence on

family, friends, and the health care system
Ranges from mild-to-severe intensity
NOTE: It is important to remember that the response to

pain is highly individual and that humans quickly adapt
physiologically and behaviorally to pain. Be careful not to
expect certain responses when assessing any type of pain.
The absence of the physiologic and behavioral responses
does not mean the absence of pain. Be aware that each
patient is unique and requires a highly individualized plan of
care
2. BY UNDERLYING MECHANISMS / SOURCE OF PAIN:

A. NEUROPATHIC PAIN
Pain that originates from the CNS, spinal cord and nerve fibers
Neuropathic pain is sustained by the abnormal processing of stimuli
Neuropathic pain is difficult to treat and often resistant to first-line analgesics.
Asking patients to describe it is the best way to identify the presence of

neuropathic pain.
Characteristic of pain: Poorly localized, Shooting, Burning, Fiery, Shock like,

Sharp, “tingling and pins and needles sensation”
B. NOCICEPTIVE PAIN
Pain that originates from the different body system other than the CNS, spinal
cord and nerve fibers
There is an essentially normal neural system. Pain involves actual or potential

tissue damage or inflammation
a. Somatic Pain
Cutaneous or superficial: skin, subcutaneous tissues
Deep somatic: bones, muscle, connective tissues
Characteristic of pain: Sharp, burning, dull, aching, cramping
b. Visceral Pain
Organs and the linings of the body cavities
Characteristic of pain: Poorly localized, deep cramping or splitting, sharp,
stabbing
THE PATHOPHYSIOLOGY OF PAIN –

1. “THE GATE CONTROL THEORY”
The gate control theory was introduced by Melzack and Wall (1982) to explain pain as a
physiological and psychoemotional response to pain
Gating mechanism occurs in the spinal cord
PAIN FIBERS AND PATHWAYS

A delta fiber (mechanical nociceptors)
Myelinated fibers that carry rapid, sharp, pricking or piercing
sensations. Produces intermittent pain
C fibers
Unmyelinated fibers that conduct thermal, chemical and strong
mechanical pain impulses. Produces dull, burning or achy
sensations that are persistent in nature
INHIBITORY AND FACILITATORY MECHANISM

Neuroregulators - Chemical substances that influence the sensory input to the
spinal cord:
Neurotransmitters
These are chemicals that exert inhibitory (slowing down) or
excitatory (speeding up) activity of the postsynaptic nerve cell
membranes:
Acetylcholine
Norepinephrine
Epinephrine
Dopamine
Serotonin
Neuromodulators - These are endogenous opiates.
Hormones in the brain.
These substances are composed of large amino acid peptides
called endorphins
These natural opiates-like substances are responsible for pain
relief
Opioids receptors
Binding sites not only for endogenous opiates but also for
opioids analgesics taken to relieve pain.
2. PAIN TRANSMISSION (NOCICEPTION): THE FOUR PROCESSES
Transduction - is the first process by which a painful physical or chemical

stimulus is transformed into signal that can be carried to the CNS and perceived
as pain. A process of nociception by which noxious events activate neurons that
exist throughout the body (skin, subcutaneous tissue, and visceral [or somatic]
structures) and have the ability to respond selectively to specific noxious stimuli.
These neurons are called nociceptors. When they are stimulated directly, a
number of excitatory compounds (e.g., serotonin, bradykinin, histamine,
substance P, and prostaglandins) are released that further activate more
nociceptors (see Fig. 4-1).
Transmission is the second process involved in nociception. Nociceptors have

small-diameter axons—either A-delta or C fibers (see Fig. 4-1). Effective
transduction generates an electric signal (action potential) that is transmitted in
these nerve fibers from the periphery toward the CNS. A delta fibers are lightly
myelinated and conduct faster than unmyelinated C fibers. The endings of A-
delta fibers detect thermal and mechanical injury. The SENSORY PERCEPTION
accompanying A-delta fiber activation is sharp and well localized and leads to an
appropriately rapid protective response such as reflex withdrawal from the
painful stimuli. C fibers are unmyelinated or poorly myelinated slow conductors
and respond to mechanical, thermal, and chemical stimuli. Activation after
acute injury yields a poorly localized (more widely distributed) typically aching
or burning pain. In contrast to the intermittent nature of A-delta sensations, C
fibers usually produce more continuous pain.
Perception is the third broad process involved in nociception. Perception, which
may be viewed as the end result of the neural activity associated with
transmission of information about noxious events, involves the conscious
awareness of pain (see Fig. 4-1). It requires the activation of higher brain
structures, including the cortex, and involves both awareness and the
occurrence of emotions and drives associated with pain. The physiology of pain
perception is very poorly understood but presumably can be targeted by
therapies that activate higher cortical functions and COGNITION to achieve pain
control or coping. Cognitive-behavioral therapy and specific approaches such as
distraction and imagery (discussed later in the chapter) have been developed
based on evidence that brain processes can strongly influence pain perception.
Modulation refers to the process by which the body alters a pain signal as it is
transmitted along the pain pathway. Modulation of afferent input generated in
response to noxious stimuli happens at every level from the periphery to the
cortex (see Fig. 4-1). The neurochemistry of modulation is complex and not yet
fully understood, but it is known that multiple peripheral and central systems
and dozens of neurochemicals are involved. For example, the endogenous
opioids (endorphins) are found throughout the peripheral nervous system (PNS)
and CNS and, like the exogenous opioids administered therapeutically, they
inhibit neuronal activity by binding to opioid receptors. Other central inhibitory
neurotransmitters important in the modulation of pain include serotonin and
norepinephrine, which are released in the spinal cord and brainstem by the
descending fibers of the modulatory system to inhibit pain.
Additional Video Learning Materials for Pain:
NOCICEPTORS – An Introduction to Pain https://www.youtube.com/watch?v=fUKlpuz2VTs
GATE CONTROL THEORY OF PAIN https://www.youtube.com/watch?v=oQLFfvGM7nI
PAIN CLINICAL FINDINGS: (SIGNS AND SYMPTOMS)

1. SUBJECTIVE:
The patient is the best judge of his pain. Therefore, it is the patient who should be asked to
describe the following components of comprehensive pain assessment:
A. The LOCATION of pain:
Localized pain is confined to the site of origin.
Projected pain is diffuse around the site of origin and is not well localized
Referred pain is felt in an area distant from the site of painful stimuli.
Radiating pain is felt along a specific nerve or nerves.
B. INTENSITY OR SEVERITY of pain using pain assessment tools:

a. Numeric Rating Scale (NRS): The NRS is usually presented as a horizontal 0-to-10
point scale, with word anchors of “no pain” and “mild pain” at one end of the scale,
“moderate pain” in the middle of the scale, and “severe pain” at the end of the
scale.
b. Wong-Baker FACES Pain Rating Scale: The FACES scale consists of six cartoon faces
with word descriptors, ranging from a smiling face on the left for “no pain (or hurt)”
to a frowning, tearful face on the right for “worst pain (or hurt).” The faces are most
commonly numbered 0 to 10. Patients are asked to choose the face that best
describes their pain. It is important to appreciate that faces scales are self-report
tools; clinicians should not attempt to match a face shown on a scale to the
patient's facial expression to determine pain intensity. Fig. 4-3 provides the Wong-
Baker FACES scale combined with the NRS.
There are many other pain scale tools a health practitioner may use
and select to aid them in assessing pain intensity:
Faces Pain Scale
Verbal Descriptor Scale (VDS)
Visual Analog Scale
C. The QUALITY of the pain - sharp, dull, aching, throbbing or burning.
D. The ONSET, FREQUENCY AND DURATION of pain episodes
E. AGGRAVATING AND RELIEVING FACTORS in pain episodes
F. Effect of pain on FUNCTION AND QUALITY OF LIFE: sleep, work, eating pattern, etc
G. COMFORT-FUNCTION (PAIN INTENSITY) OUTCOMES: For patients with acute pain, identify
expected short-term functional outcomes. Reinforce to the patient that adequate pain
control will lead to more successful achievement of those outcomes. For example, tell
surgical patients that they will be expected to ambulate or participate in physical therapy
after surgery. Ask patients to identify a level of pain that will allow accomplishment of the
expected outcomes. A realistic outcome for most patients is 2 or 3 on a scale of 0 to 10. Pain
intensity that is consistently above the desired level requires further evaluation and
consideration of possible adjustment of the treatment plan.
H. Other information: Consider the patient's culture, past pain experiences, and pertinent
medical history such as comorbidities. Current treatments and diagnostic studies are
considered when performing an assessment. For example, patients who are intubated may
be awake and alert but unable to speak.
I. MNEMONICS:
COLDSPA
CHARACTER: Describe the sign or symptom. How does it feel?
ONSET: When did it begin?
LOCATION: Where is it? Does it radiate?
DURATION: How long does it last? Does it recur?
SEVERITY: How bad is it?

PATTERN: What makes it better? What makes it worse?
ASSOCIATED FACTORS: What other symptoms occur with it
OLD CART
O– Onset
L – Location
D – Duration
C – Causative factors
A – Associations
R – Reactions to what has been tried
T - Treatment
“PQRST”
P—Provocation
Q—Quality
R—Radiation / Region
S—Severity
T—Time (onset, duration, frequency)
Sample Guide:
2. OBJECTIVE –
A. Checklist of Nonverbal Pain Indicators (CNPI) has been tested in the acute care setting in
patients with varying levels of cognitive impairment. The tool groups behavioral indicators
of pain into six categories. Each category allows a score of 0 if the behavior is not observed
and a 1 if the behavior occurred even briefly during activity or rest:
Score
Behavior 0 – Behavior Not Observed
1 – Behavior occurred
Facial expression
(e.g., grimacing, crying)
Verbalizations or vocalizations (e.g., screaming, moaning)
Body movements
(e.g., restlessness, guarding behavior)
Changes in interpersonal interactions
(e.g., uncooperative, irritable, reduced interaction with
people)
Changes in activity patterns or routines
(e.g., sleep, rest, meal time, ADL, fatigue)
Mental status changes
(e.g., confusion, depression, irritable, pre-occupation of
pain and re-injury)
SCORE /6
B. Autonomic Response to Pain:

Profuse sweating
Alteration in Vital Signs: BP, HR, RR
Dilation of the pupils
C. Sympathetic mediated responses
Body temperature: cold
Changes of body position
Hypersensitivity
THERAPEUTIC MANAGEMENT FOR PAIN

1. MEDICAL MANAGEMENT – PHARMACOLOGIC
Pain management using pharmacologic methods involves the use of opioids (narcotics),
nonopioids (NSAIDs), and adjuvant (coanalgesic) drugs.
The World Health Organization (WHO) in 1986 published guidelines in the logical usage
of analgesics to treat cancer using a three-step ladder approach – also known as
the analgesic ladder. The analgesic ladder focuses on aligning the proper analgesics with
the intensity of pain.
Step 1: For mild pain (1 to 3 pain rating), the WHO analgesic ladder suggests the use of
nonopioid analgesics with or without coanalgesics. If pain persists or increases despite
providing full doses, then proceed to the next step.
Step 2: For moderate pain (4 to 6 pain rating), opioid, or a combination of opioid and
nonopioid is administered with or without conanalgesics.
Step 3: For severe pain (7 to 10), the opioid is administered and titrated in ATC
scheduled doses until the pain is relieved.
A. Nonopioids include acetaminophen and nonsteroidal anti-inflammatory drugs
(NSAIDs) such as aspirin or ibuprofen.
NSAIDs work in peripheral tissues. Some block the synthesis of prostaglandins, which
stimulate nociceptors. They are effective in managing mild to moderate pain. All NSAIDs
have anti-inflammatory (with the exception of acetaminophen), analgesic, and
antipyretic effects. They work by inhibiting the enzyme cyclooxygenase (COX), a
chemical that is activated during tissue damage, resulting in decreased synthesis of
prostaglandins. NSAIDs also have a ceiling effect meaning that once the maximum
analgesic benefit is achieved, additional amounts of the same drug will not produce
more analgesia and may risk the patient for toxicity.
Common side effects of NSAIDs include heartburn or indigestion. There is also a

possibility of forming a small stomach ulcer due to platelet aggregation. To prevent
these side effects, clients should be taught to take NSAIDs with food and a full glass of
water.
Common NSAIDs include:

Aspirin. It can prolong bleeding time and should be stopped a week before a
client undergoes any surgical procedure. Should never be given to children
below 12 years of age due to the possibility of Reye’s syndrome. May cause
excessive anticoagulation if the client is taking warfarin.
Acetaminophen (Tylenol). May have serious hepatotoxic side effects and

possible renal toxicity with high dosages or with long-term use. Limit
acetaminophen usage to 3 grams per day.
Celecoxib (Celebrex). Is a COX-2 inhibitor that has fewer GI side-effects than

COX-1 NSAIDs.
B. Opioids. Opioids are indicated for severe pain and can be administered orally, IV, PCA
systems, or epidurally.
Opioids for moderate pain. These include codeine, hydrocodone, and tramadol
(Ultram) which are combinations of nonopioid and opioid.
Opioids for severe pain. These include morphine, hydromorphone, oxycodone,

methadone, and fentanyl. Most of these are controlled substances due to
potential misuse. These drugs are indicated for severe pain, or when other
medications fail to control pain.
C. Coanalgesics (adjuvants).
Coanalgesics are medications that are not classified as pain medication but have the
properties that may reduce pain alone or in combination with other analgesics. They
may also relieve other discomforts, increase the effectiveness of pain medications, or
reduce the pain medication’s side effects. Commonly used coanalgesics include:
Antidepressants. Is a common coanalgesic that helps in increasing pain relief,
improve mood, and reduce excitability.
Local Anesthetics. These drugs block the transmission of pain signals and are
used for pain in specific areas of nerve distribution.
Other coanalgesics. Include anxiolytics, sedatives, antispasmodics to relieve

other discomforts. Stimulants, laxatives, and antiemetics are other coanalgesics
that reduce the side effects of analgesics.
2. SURGICAL MANAGEMENT
A. CORDOTOMY – is the disabling selected pain-conducting tracts in the spinal cord
Usually performed to patients experiencing pain due to cancer or other incurable
diseases
Care must be taken to destroy only the sensation of pain, leaving motor functions intact
B. RHIZOTOMY – Sensory nerve roots in the spinal cord are destroyed or severed
A lesion is made in the dorsal root to destroy neuronal dysfunction and reduce
nociceptive input
The spinal roots are divided and banded with a clip to form a lesion and produce
subsequent loss of sensation
Usually performed to relieve severe back pain or joint pain or muscle spasms
NURSING CARE OF CLIENT WITH PAIN

1. ASSESSMENT (Clinical Findings - Signs and Symptoms)
2. NURSING DIAGNOSIS:
a. Pain (Acute or Chronic)
b. Alteration in Comfort
3. PLAN: THERAPEUTIC GOALS AND OUTCOMES
The following are the goals and expected outcomes for Pain (Acute and Chronic) management:
• Patient demonstrates use of different relaxation skills and diversional activities
as indicated for individual situation
• Patient reports pain at a level less than 3 to 4 on a 0 to 10 rating scale.
• Patient displays improved non-verbal pain indicators and well-being such as:
Facial expression, vocalization, body movement, interpersonal interaction, ADL,
and MSE; as well as improved autonomic and sympathetic mediated responses
such as pulse, BP, respirations, and relaxed muscle tone or body posture.
• Patient uses pharmacological and nonpharmacological pain-relief strategies.
4. NURSING MANAGEMENT / INTERVENTION

A. INDEPENDENT NURSING MANAGEMENT:
a. Allow patient to maintain a diary of pain ratings, timing, precipitating events,
medications, treatments, and what works best to relieve pain.
Systematic tracking of pain appears to be an important factor in improving pain
management.
b. Recognize and convey acceptance of the patient’s pain experience.
Conveying acceptance of the patient’s pain promotes a more cooperative nurse-
patient relationship.
c. Aid the patient in making decisions about choosing a particular pain management
strategy.
The nurse can increase the patient’s willingness to adopt new interventions to
promote pain relief through guidance and support. The patient may begin to feel
confident regarding the effectiveness of these interventions.
d. Provide nonpharmacologic pain management.
Nonpharmacologic methods in pain management may include physical, cognitive-
behavioral strategies, and lifestyle pain management
• Distraction. This technique involves heightening one’s concentration upon
non-painful stimuli to decrease one’s awareness and experience of pain.
Drawing the person’s away from the pain lessens the perception of pain.
Examples include reading, watching TV, playing video games, guided
imagery.
• Eliciting the Relaxation Response. Stress correlates to an increase in pain
perception by increasing muscle tension and activating the SNS. Eliciting a
relaxation response decreases the effects of stress on pain. Examples
include directed meditation, music therapy, deep breathing.
• Guided imagery. Involves the use of mental pictures or guiding the patient
to imagine an event to distract from the pain.
• Repatterning Unhelpful Thinking. Involves patients with strong self-doubts
or unrealistic expectations that may exacerbate pain and result in failure in
pain management.
• Other CBT techniques include Reiki, spiritually directed approaches,
emotional counseling, hypnosis, biofeedback, meditation, relaxation
techniques.
• Provide cutaneous stimulation or physical interventions
Cutaneous stimulation provides pain relief that is effective albeit temporary.
The way it works is by distracting the client away from painful sensations
through tactile stimuli. Cutaneous stimulation techniques include:
o Massage. When appropriate, massaging the affected area interrupts
the pain transmission, increases endorphin levels, and decreases
tissue edema. Massage aids in relaxation and decreases muscle
tension by increasing superficial circulation to the area. Massage
should not be done in areas of skin breakdown, suspected clots, or
infections.
o Heat and cold applications. Cold works by reducing pain,
inflammation, and muscle spasticity by decreasing the release of
pain-inducing chemicals and slowing the conduction of pain
impulses. Cold is best when applied within the first 24 hours of
injury while heat is used to treat the chronic phase of an injury by
improving blood flow to the area and through reduction of pain
reflexes.
o Acupressure. An ancient Chinese healing system of acupuncture
wherein the therapist applies finger pressure points that correspond
to many of the points used in acupuncture. Using the gate control
theory, the technique works to interrupt pain transmission by
“closing the gate.” This approach requires training and practice.
o Contralateral stimulation. Involves stimulating the skin in an area
opposite to the painful area. This technique is used when the
painful area cannot be touched.
o Transcutaneous Electrical Nerve Stimulation (TENS). Is the
application of low-voltage electrical stimulation directly over the
identified pain areas or along with the areas that innervate pain.
o Other cutaneous stimulation interventions include therapeutic
exercises (tai-chi, yoga, low-intensity exercises, ROM exercises),
acupuncture.
• Immobilization. Restriction of movement of a painful body part is another
nonpharmacologic pain management. To do this, you need splints or
supportive devices to hold joints in the position optimal for function. Note
that prolonged immobilization can result in muscle atrophy, joint
contracture, and cardiovascular problems. Check with the agency protocol.
e. Educate patient of pain management approach that has been ordered, including
therapies, medication administration, side effects, and complications.
One of the most important steps toward improved control of pain is a better patient
understanding of the nature of pain, its treatment, and the role patient needs to
play in pain control.
f. Explain the importance of lifestyle modifications to effective pain management.
Changes in activities such as work routines, household, and home physical
environment may be required to promote more effective pain management
g. Provide the patient and family with adequate information about chronic pain and
options available for pain management.
Lack of knowledge about the characteristics of chronic pain and pain management
strategies can add to the burden of pain in the patient’s life.
B. DEPENDENT NURSING MANAGEMENT:

a. ADMINISTER PHARMACOLOGIC pain management as ordered:
Identify the need for medications from the three classes of analgesics: opioids
(narcotics), non-opioids (acetaminophen, Cox-2 inhibitors, and nonsteroidal anti-
inflammatory drugs [NSAIDs]), and adjuvant medications. Analgesic combinations
may enhance pain relief
b. Obtain prescriptions to increase or decrease analgesic doses when indicated. Base
prescriptions on the patient’s report of pain severity and the comfort/function
goal and response to previous dose in terms of relief, side effects, and ability to
perform the daily activities and the prescribed therapeutic regimen. Opioid doses
should be adjusted individually to achieve pain relief with an acceptable level of
adverse effects.
c. If opioid dose is increased, monitor sedation and respiratory status for a brief
time. Patients receiving long-term opioid therapy generally develop tolerance to the
respiratory depressant effects of these agents.
d. Manage acute pain using a multimodal approach.
Multimodal approach is based on the use of two or more distinct methods or drugs
to enhance pain relief (rather than resorting to opioid use or other pain
management strategies alone). Using different combinations of analgesic
medications, adjuvants, and procedures can act on different sites and pathways in
an additive or synergistic fashion. Combining medications and techniques allows the
lowest effective dose of each drug to be administered, resulting in reduced side
effects.
C. COLLABORATIVE NURSING MANAGEMENT

a. Refer the patient to a physical therapist for assessment and evaluation.
This is helpful to promote muscle strength and joint mobility, and therapies to
promote relaxation of tense muscles, the physical therapist can help the patient
with exercises suitable for his/her condition. These interventions can influence the
effectiveness of pain management.
b. Refer the patient and family to community support groups and self-help groups
for people coping with chronic pain.
This is to reduce the burden of suffering associated with chronic pain and provides
additional resources like patient’s support network
II. NURSING PROCESS FOR CANCER CARE MANAGEMENT

A. Assessment:
1. Health History
2. Chief complaint
3. History of present illness (onset, course, duration, location, precipitating and alleviating factors)
4. PHYSICAL ASSESSMENT: Cancer signs: CAUTION US!
BREAST
ABCDE
Inspection
-Skin and mucus membranes for lesions, bleeding, petechiae, and irritation
-Assess stools, urine, sputum, vomitus for acute or occult bleeding
-Scalp noting hair texture and hair loss
Palpation
- Masses, bulges or abnormalities
- Lymph nodes for enlargement
Auscultation
Lung sounds, heart sounds and bowel sounds
5. Laboratory & Diagnostic Tests
a. Complete blood cell count (CBC)
b. Tumor markers -identify substance (specific proteins) in the blood that are made by the
tumor
• PSA (Prostatic-specific antigen): prostate cancer
• CEA (Carcinoembryonic antigen): colon, gastrointestinal, cervix, lungs, ovarian,
breast, urinary tract cancer
• Alkaline Phosphatase - Metastasis
• Alpha Fetoprotein (AFP) - Hepatocellular, germ cell tumor
• CA 153 - Breast Cancer
• CA 19-9 - Pancreatic Cancer
• CA 125 - Ovarian, Breast, Uterus, Endometriosis
• BHCG - wide range tumor marker
c. Determine location of cancer:

• X-rays
• Computed tomography
• Ultrasounds
• Magnetic resonance imaging
• Nuclear imaging
• Angiography
d. Direct Visualization:
• Sigmoidoscopy
• Colonoscopy
• Cystoscopy
• Endoscopy
• Bronchoscopy
• Exploratory surgery; lymph node biopsies to determine metastases
e. Diagnostic cell typing:

Tissue samples from:
• Biopsies, shed cells
• Papanicolaou (PAP) smear
• Cytologic Examination: tissue examined under microscope
Reference/s:
1. Medical-Surgical Nursing Concepts for Interprofessional Collaborative Care, 9 th edition,

2018, Single Volume by Donna D. Ignatavicius, M. Linda Workman Cherie Rebar
2. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 13th edition by Smeltzer,

Suzanne C and Bare Brenda
3. Pain Assessment and Management. https://lms.rn.com/getpdf.php/1918.pdf
4. https://nurseslabs.com/acute-pain/
5. https://nurseslabs.com/chronic-pain/
6. https://www.slideshare.net/drjayeshpatidar/ppt-pain

7a. Cellular Aberration With PAIN Concept

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7a. Cellular Aberration With PAIN Concept

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LECTURE - HANDOUT ON

I. ESSENTIAL CONCEPTS OF CANCER

Three main characteristics:

B. Normal Cell Growth vs. Cancer Cell Growth

2. Abnormal Cell Cycle / Growth

Common Sites of Metastasis: 3L, 2B

C. Etiology and Causative Factors

1. According to Tumor Behavior

Malignant - “Malign” bad sort of growth

2. According to Pattern of Proliferation

The process of hyperplasia is potentially reversible;

These patterns of proliferation are borderline or defining behavior of a cancer whether

Self-report is always the most reliable indication of pain.

If the patient cannot provide self-report, a variety of other methods such as

CATEGORIES / TYPES OF PAIN

Has a sudden onset, and is easily localized.

Usually has a well-defined cause and decreases with healing

Increase HR, BP, RR; Dilated pupils; Sweating

Ranges from mild-to-severe intensity

May be accompanied by anxiety and restlessness

PAIN is one of the most severe accompanying discomfort of CANCER

B. CHRONIC PAIN / PERSISTENT PAIN (Chronic Cancer and Chronic-non-cancer

It is usually poorly localized because it often involves deep body structures

Serves no biologic purpose. It may or may not have well-defined cause

Because it persists for an extended period, it may result to multiple quality-of-

Depression; fatigue; financial burden; and increased dependence on

Ranges from mild-to-severe intensity

NOTE: It is important to remember that the response to

2. BY UNDERLYING MECHANISMS / SOURCE OF PAIN:

Neuropathic pain is sustained by the abnormal processing of stimuli

Neuropathic pain is difficult to treat and often resistant to first-line analgesics.

Asking patients to describe it is the best way to identify the presence of

Characteristic of pain: Poorly localized, Shooting, Burning, Fiery, Shock like,

There is an essentially normal neural system. Pain involves actual or potential

THE PATHOPHYSIOLOGY OF PAIN –

Gating mechanism occurs in the spinal cord

PAIN FIBERS AND PATHWAYS

INHIBITORY AND FACILITATORY MECHANISM

Transduction - is the first process by which a painful physical or chemical

Transmission is the second process involved in nociception. Nociceptors have

PAIN CLINICAL FINDINGS: (SIGNS AND SYMPTOMS)

B. INTENSITY OR SEVERITY of pain using pain assessment tools:

SEVERITY: How bad is it?

B. Autonomic Response to Pain:

THERAPEUTIC MANAGEMENT FOR PAIN

Common side effects of NSAIDs include heartburn or indigestion. There is also a

Common NSAIDs include:

Acetaminophen (Tylenol). May have serious hepatotoxic side effects and

Celecoxib (Celebrex). Is a COX-2 inhibitor that has fewer GI side-effects than

Opioids for severe pain. These include morphine, hydromorphone, oxycodone,

Other coanalgesics. Include anxiolytics, sedatives, antispasmodics to relieve

NURSING CARE OF CLIENT WITH PAIN

4. NURSING MANAGEMENT / INTERVENTION

B. DEPENDENT NURSING MANAGEMENT:

C. COLLABORATIVE NURSING MANAGEMENT

II. NURSING PROCESS FOR CANCER CARE MANAGEMENT

c. Determine location of cancer:

e. Diagnostic cell typing:

1. Medical-Surgical Nursing Concepts for Interprofessional Collaborative Care, 9 th edition,

2. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 13th edition by Smeltzer,

3. Pain Assessment and Management. https://lms.rn.com/getpdf.php/1918.pdf

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