Introduction

In any clinical setting you will have the potential to care for a person with a cancer diagnosis who is experiencing one or more of the distressing symptoms explored in this chapter. By engaging in the exercises for each symptom, you are given the opportunity to consider how the symptom can be managed in any specific placement. It is important to apply the principles of assessment and holistic care of a patient introduced below. Patient care must also take into consideration the cultural and ethnic needs of patients and family members. These are explored in more detail in the Chapter 16, however it is important to start to consider the implications as you develop cultural competence in symptom management. This chapter explores some of the principles in supporting a patient with a cancer diagnosis who is experiencing one or more distressing symptom. This can happen during treatment for the cancer, as well as if the patient is in the palliative care stage of the illness. Some symptoms can continue after the patient has completely recovered from the cancer. For example, fatigue or taste changes can sometimes occur following chemotherapy or radiotherapy and may last for many years. Sometimes symptoms can occur as ‘acute events’ and need to be dealt with swiftly. These include hypercalcaemia and spinal cord compression.

The principles of assessment

From the first time we meet a patient, we can start to gather information to help us in the care we plan and provide. Don’t forget we can often have a lot of information about the patient before we even meet them, for example a referral letter from the patient’s own doctor, notes from a team discussion, ward handover or the patient’s hospital notes. This process of gathering information about a patient is called ‘assessment’. Data can be gathered from a variety of sources and this is the basis for our actions and decisions. It is important to remember that assessment is an ongoing process rather than one point of interaction.

The nursing process (Roper et al 2000) suggests assessment is the ‘first step’ in the four-step cycle of planning, implementing and evaluating care. Uys and Habermann (2005) recognise the importance of collecting information in the assessment process, while Holland et al (2008) refer to assessment as a ‘cyclical activity’ that includes collecting and reviewing information and linking this assessment to impact on activities of living.

The assessment process is just part of the care planning pathway and it is essential that all information gathered is correct and communicated to the appropriate team members at the appropriate time.

Remember, the information we gather includes that from the patient, family and professional teams.

The principles of planning care

When we have gathered information about a patient, we are then able to plan the care we are going to provide. It is important that any information is clarified and communicated with wider team members in an appropriate way. Remember that any information we have about a patient is confidential and must be respected and kept safe at all times. The NMC code of conduct (NMC 2008) states confidentiality as a patient’s right so, as you gather information, it is important to inform patients how this will be used. Doing this shows the patient respect.

One way to collate this information in a logical and holistic way is by using the Roper, Logan and Tierney model (Roper et al 2000) (Figs 15.1 and 15.2). This model was originally developed in 1980 by Nancy Roper and published under the title The Elements of Nursing and is a collection of core themes around activities of living. They were developed with the idea that activities of living can be applied to patients in any clinical area, are patient focused and can give a clear idea of the needs of a patient and their family at any point in time. You may have already seen this model used in a previous practice placement. Sometimes they are referred to as the activities of daily living (ADLs). Admission assessment forms for both acute hospitals and community settings are often based on this model.

Fig 15.1 The Roper, Logan and Tierney model (Roper et al 2000)

Fig 15.2 Applying the Roper, Logan and Tierney model (Holland et al 2008)

There are 12 activities of living which take a holistic approach:

These activities of living are not separate themes but are linked through biological, psychosocial and political factors. Each of the activities are interlinked and will impact on a person’s degree of dependence or independence (Holland et al 2008).

Collecting information from a family member is called a family assessment. Some specialist units will have a specific assessment form for a family assessment which can include questions about knowledge of a patient’s diagnosis, feelings about this diagnosis, how the family is coping and any dependants, for example children, adolescents, pets or other ill family members.

Gathering information about a patient and their family is not easy. There are many things that can hinder the effective collection of data and this can have a direct impact on the care given or understanding of what the priority needs are for a patient and their family. Information can be gathered about a patient at admission (part 1). If the patient dies, part 2 can be completed about what happened at the time of death and how the family reacted. This information can help with planning ongoing bereavement support (See Appendix 2).

Remember, information gathered is only as good as the process of documenting and communicating this information to the appropriate person at the appropriate time.

Problems are often encountered in gathering assessment information. Knowing something about a patient and not passing it on may have a big impact on how their individual care needs are met. For example, a patient might tell you that his sense of taste has changed since chemotherapy, but he doesn’t like to tell his wife since she will get upset if he can’t taste the food she cooks him. Consider why this information might be important. If the patient becomes more poorly, feels nauseated and goes off his food, tempting him to eat is going to be a really important care intervention by both the professional team and his wife. If he can’t taste, this may be more challenging to achieve. Addressing such issues is harder for a patient, family and care team when the patient is not feeling well or if the patient is deteriorating.

Remember, admission sheets can have information added during the patient stay by any member of the care team. Building up information about a patient and their family is a form of ongoing assessment.

The principles of managing common symptoms experienced by cancer and palliative care patients

Understanding the causes of symptoms and treatment options available is an important part of the assessment and care planning process. We now introduce you to some common symptoms experienced by cancer and palliative care patients and offer explanations about possible causes as well as some care interventions.

When managing complex symptoms, it is important to remember the core principles of assessment, planning and evaluation. This can be done simply by using the ‘three Cs’ model:

Pain: causes, assessment and management

A universally accepted definition of pain is that it is an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage (International Association for the Study of Pain 2007). Pain is complex and understanding what is both initiating the pain and maintaining it is important for effective management. Chapter 5 on palliative care introduced you to the concept of ‘total pain’. The contemporary way of referring to total pain is from a ‘biopsychosocial’ perspective (Holdcroft & Power 2003) and can be divided into three factors:

1. The person – includes biological and psychological influences.

2. Type of disease – includes past history and present disease.

3. Environment – includes cultural expectations, upbringing, roles, lifestyle.

The most challenging part of managing pain is the subjectivity of pain; what it means to one person is different from another person, as is the individual’s ability to manage the pain. ‘Pain is whatever the person experiencing it says it is, existing whenever he says it does’ (McCaffery 1968:95). While this work of McCaffery is old, it continues to be a fundamental principle of pain management.

A simple way of developing our understanding of normal pain transmission is to consider it from the following four perspectives:

1. Transduction – involves the process of converting mechanical, thermal or chemical noxious or painful stimulus into a nervous impulse.

2. Transmission – involves the nervous impulse being conducted by sensory nerves to the central nervous system. Different nerves carry different impulses.

3. Perception – conscious perception of pain is perceived by an individual once all the incoming nervous messages are interpreted by the brain.

4. Modulation – throughout the process, various physiological and psychological mechanisms can adjust the nociceptive message to either increase or decrease the pain experienced.

Activity

Re-read the notes you made about your personal experiences of pain on page 39. Now consider how you might know a patient is in pain. Make a list of the words that a person might use to describe pain followed by a list of the behaviours you might observe. Consider how this information might have been gathered and be documented in the patient’s case notes and communicated across the care team.

NMC Domain 1: 1.1

NMC Domain 2: 2.4

NMC Domain 3: 3.2; 3.7

Types of pain

Table 15.1 gives a simple overview of two types of pain, the basic physiology and words associated with how pain might be experienced.

Table 15.1 Types of pain

Activity

Using Table 15.1, write a few sentences about the impact the different types of pain can have on the activities of living.

To help you do this, you might want to refer back to pain lecture notes from your course. If this is a new subject to you, look at the recommended physiology text for your course and read about pain and pain pathways. Make notes on the new words or phrases you come across to help to retain knowledge and understanding.

NMC Domain 1: 1.1; 1.2;

NMC Domain 2: 2.2; 2.4

NMC Domain 3: 3.2

Doing the above exercise helps link the physiology of the origins of pain and the impact pain can have on holistic wellbeing. This way of thinking starts the assessment process and is the first step in the effective management of pain and is where the understanding of biopsychsocial factors for a holistic approach is important.

Assessing pain correctly is fundamental to ensuring analgesia prescribed is appropriate and effective. Asking how the pain is and getting the patient to describe the pain is a useful way to establish possible causes. Also finding out what makes it worse and what makes it better is important too. The assessment tool in Figure 15.3 is called the Brief Pain Inventory (BPI) and is used in many clinical areas and is a quick way to explore pain with a patient.

Fig 15.3 Pain assessment tool

(reproduced with permission from McCaffery M, Pasero C (1999) Pain, clinical manual, 2nd edn. Mosby, St Louis)

Activity

Find out how the nurses in your practice placement assess a patient’s pain. If a pain assessment tool is used, how often is it completed? How is the information communicated with the healthcare team? How often is a patient’s pain reviewed?

NMC Domain 1: 1.5

NMC Domain 2.2; 2.7

NMC Domain 3.1; 3.3

Management of pain

Once pain is effectively assessed, appropriate analgesia can be prescribed. Often a patient may have analgesia prescribed ‘as required’ or ‘prn’. The potential problem with this is it is reliant on the care team noticing the person is in pain or the patient asking for analgesia. Literature suggests this is something that healthcare professionals do not always do well and patients may not always feel able to ask. It is also important to record if any ‘as required’ analgesia given has helped to relieve the pain. This can be done by returning to the patient within half an hour of giving the analgesia. If analgesia is not relieving pain, it needs to be reviewed by the care team. If several ‘as required’ drugs are given over a period of time with good effect, these should be converted into regular administration. The plan of care should aim for the patient being pain free and not routinely needing ‘as required’ medications.

The World Health Organisation (WHO) analgesic step ladder is shown in Figure 15.4. Here we can see that analgesia is staged from a non-opioid, to a weak opioid and then to a strong opioid. This is the recommended ladder by which analgesia is prescribed.

Fig 15.4 WHO analgesic step ladder (WHO (1996) Cancer pain relief, 2nd edn. WHO, Geneva)

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Related

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1. Caring for the patient undergoing haemopoietic stem cell transplant
2. Caring for the patient undergoing radiotherapy
3. Receiving treatment
4. Transferable skills for future placements

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