The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [332]
Formalization of peri- and postoperative pain management plan.
Use of adjuvant drugs and regional analgesia peri- and postoperatively to spare opioid use.
Physical dependence requires baseline preoperative opioids to be maintained to prevent acute withdrawal symptoms.
Postoperative opioid requirements may vary depending on the effects of surgery.
(Bourne 2008)
Assessment of location and intensity of pain
Location
Many complex surgical procedures involve more than one incision site and the nature and extent of pain at each site may vary. A careful assessment of the location and type of pain is required, because each pain problem may respond to different pain management techniques. Pain location may also help to determine why pain is exacerbated by certain movements or positions (Anderson and Cleeland 2003).
Intensity
As part of the assessment process, it is important to assess the intensity of pain. Only then can the effects of any intervention be evaluated and care modified as appropriate. The simplest techniques for pain measurement involve the use of a verbal rating scale, numerical rating scale or visual analogue scale. Patients are asked to match pain intensity to the scale. Three principles apply to the use of these scales.
The patient must be involved in scoring their own pain intensity. It provides the patient with an opportunity to express their pain intensity and also what it means to them and the effect it has on their lives. This is important because healthcare professionals frequently underestimate the intensity of a patient’s pain and effectiveness of pain relief (Drayer et al. 1999, Idvall et al. 2002, Loveman and Gale 2000).
Pain intensity assessment should incorporate different components of pain. This should include assessment of static (rest) pain and dynamic pain (on sitting, coughing or moving the affected part). For example, in a postoperative patient this is important to prevent complications of delayed recovery such as chest infections and emboli (deep vein thrombosis, pulmonary embolism) and to determine if analgesia is adequate for return of normal function (Hobbs and Hodgkinson 2003, Macintyre and Schug 2007).
It is important to remember that a complete picture of a patient’s pain cannot be derived solely from the use of a pain scale (Lawler 1997). Ongoing communication with the patient is required to uncover and manage any psychosocial factors that may be affecting the patient’s pain experience.
Chronic pain assessment
The prevalence of chronic pain is approximated at being between 30% and 50% amongst patients with cancer who are undergoing active treatment for a solid tumour and between 70% and 90% among those patients with advanced disease (Portenoy and Lesage 1999). For example, approximately two-thirds of advanced cancer patients will also complain of anorexia, one-half will have a symptomatic dry mouth and constipation, and one-third will suffer nausea, vomiting, insomnia, dyspnoea, cough or oedema (Donnelly and Walsh 1995).
It is clear from these figures that chronic pain assessment cannot be seen in isolation; identification of all related symptoms is of equal importance as they will contribute to a lowered pain threshold (the lowest stimulus intensity at which a person perceives pain) and impaired pain tolerance (the greatest stimulus intensity causing pain that a person is prepared to tolerate) (Grond et al. 1996). Furthermore, chronic cancer pain is often multifactorial. Adequate pain assessment requires a comprehensive evaluation of all factors that play a significant role in the cancer pain experience (Zaza and Baine 2002).
A diagnosis of cancer does not necessarily mean that the malignant process is the cause of the pain. Pain in chronic cancer may be:
caused by the cancer itself
caused by treatment
associated with debilitating disease, such as a pressure ulcer
unrelated to either the disease or the treatment, such as headache (Twycross and Wilcock