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Pain Management

Elena Doyle

Old Dominion University

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Pain Management

I work as an oncology travel registered nurse between two higher level acuity units as a

travel nurse. One unit is acute oncology and has 20 beds. The other unit is an intermediate care

stem cell transplant unit with 13 beds. Both units include extremely immunocompromised

patients actively getting oncological treatment.

Clinical problem

For every health ailment there are symptoms to assess and treat but with oncology

patients it is especially hard to address due to the nature of what’s causing it. I chose this clinical

problem because I feel that between the opioid epidemic and the fear of how they would be

viewed if they asked for it, it is going painfully undertreated. One example is when a patient

develops severe mucositis due to a side effect of the chemotherapy they are having. The

treatment usually focuses on mouthwash swishes and if that doesn’t help for a few days, only

then will they treat it with a pain pill. Another example is when there is a gynecology oncology

patient with severe cramps and they something for every 4-6 hours as needed for multiple days

until they switch to a Patient Controlled Analgesic (PCA).

Current Clinical Practice

The Formal mechanisms that I found were mainly facility policies. I saw that there are

policies in place in the emergency department to initiate immediate intervention of pain control

for patients. There are instructions on what dosage of medications with specific observation

times to be able to treat the patients to allow for triage and evaluation time for further treatment

so that the patients don’t suffer.

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On our specific unit, we are guided by general standards of practice and are encouraged

to use alternate non-opioid interventions prior to considering a low dose intervention for pain

issues. The standard is that there is supposed to be an escalation to utilizing pain medications if

these interventions aren’t effective for a reasonable amount of time. The informal mechanisms

that I have seen time and time again on the unit are that the escalation of actually intervening

with the pain medications are delayed past a day with constant non-opioid interventions, the

constant reply of needing to wait until another shift to consult more people on the care team, and

an overall one-time doses verses giving an as needed order to administer.

With being an oncology unit, we aren’t able to use the standard Tylenol for pain control

because it will mask signs of infection which means that when we escalate to pain medications

we tend to have to jump to the more controlled substances. I feel that with the pain medication

epidemic and the fact that it is a teaching hospital so the doctors prescribing the medications are

fairly new, there is a real hesitancy to being aggressive in treating the pain in the beginning for

fear of either getting in trouble or having the patients getting addicted. Their fears are valid

because of the addictive nature of the medications but what these discrepancies shows is that

there needs more collaboration with the health care team to create a better plan of care to benefit

the patients.

Interventions and Literature

The first intervention I would have would be to implement a risk screening tool for

monitoring patients on opioids outside the normal pain assessments (Del Fabbro et al., 2016). If

we are able to have a screening tool in the flowsheets for the nursing staff for the patients on

opioids, like the fall risk assessment, we would be able to identify and monitor for the signs of

addiction. This is especially important because opioid toxicity can have very subtle signs (Fallon
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et al., 2006). Implementing this tool will also allow better record documentation on the reasoning

behind switching up the patients’ medications during active treatments.

The second intervention I would implement would be to have consulting experts such as

addiction specialists if possible, social workers, and psychiatrists on a regular and consistent

basis involved in the patients care to ensure clear communication and expectations with the

patients and their families (Paice & Ferrell, 2011). I witnessed the doctors requesting palliative

care input on some patient cases but not with others. When they do it is mainly one consult with

recommendations that they may or may not follow and it is many days into the patients stay. I

would have them be involved earlier on in the patients stay because I feel that with this

intervention, we would be able to gain better control at the beginning and maintain it verses

constantly chasing their pain throughout their stay.

Last intervention that I would implement would be improved education of both patients

and medical staff. Patient education helps improve better compliance and increase the likelihood

of maintaining better pain control (Oldenmenger et al., 2018). I feel that this is especially

important in cancer patients. This education should be started very early on in their treatment and

should continue as their care plans evolve throughout their stay.

Adapting to the patient specifically is also extremely important in their education of their

pain medication regimen. Adapting to the illiterate and minority populations are extremely

important because they are more likely to be undertreated (Deandrea et al., 2008). The staff also

needs to be able to learn and adapt about pain control. They need to keep completing continuing

education on how to properly address pain to keep it as a prime concern to assess when coming

in contact with their patients (Baker et al., 2014).

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Summary

As an oncology nurse I am passionate to be able to improve my patients’ quality of life in

any way that I can. Unlike other units that focus on one health system, oncology normally

involves multiple and as such is harder to treat for pain. I feel that with improved education,

early and consistent involvement with experts, and better screening tools for monitoring that the

pain management problem could be greatly improved.

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References

Baker, T. A., O'Connor, M. L., & Krok, J. L. (2014). Experience and Knowledge of Pain

Management in Patients Receiving Outpatient Cancer Treatment: What Do Older Adults

Really Know about Their Cancer Pain? Pain Medicine, 15(1), 52–60.

https://doi.org/10.1111/pme.12244

Deandrea, S., Montanari, M., Moja, L., & Apolone, G. (2008). Prevalence of undertreatment in

cancer pain. A review of published literature. Annals of Oncology, 19(12), 1985–1991.

https://doi.org/10.1093/annonc/mdn419

Del Fabbro, E., Carmichael, A., & Morgan, L. (2016). Identifying and assessing the risk of

opioid abuse in patients with cancer: an integrative review. Substance Abuse and

Rehabilitation, , 71. https://doi.org/10.2147/sar.s85409

Fallon, M., Hanks, G., & Cherny, N. (2006). Principles of control of cancer pain. BMJ,

332(7548), 1022–1024. https://doi.org/10.1136/bmj.332.7548.1022

Oldenmenger, W. H., Geerling, J. I., Mostovaya, I., Vissers, K. C., De Graeff, A., Reyners, A.

K., & Van der Linden, Y. M. (2018). A systematic review of the effectiveness of patient-

based educational interventions to improve cancer-related pain. Cancer Treatment

Reviews, 63, 96–103. https://doi.org/10.1016/j.ctrv.2017.12.005

Paice, J. A., & Ferrell, B. (2011). The management of cancer pain. CA: A Cancer Journal for

Clinicians, 61(3), 157–182. https://doi.org/10.3322/caac.20112