Page 30 Complete Your CE Test Online - Click Here also consider the patient’s hydration and nutritional status, weakness, weight loss, and mental status. It is important to consider possible causes for N&V beyond chemotherapy, especially if it continues for an unexpectedly long duration after chemo. It is possible that the patient has an underlying problem like gastrointestinal obstruction, increased intracranial pressure, or new metastases [249]. Nursing consideration: Assess the emetogenic potential of the combination of cancer drugs in order to match it with an initial antiemetic drug regimen [231]. Re-assess effectiveness after each cycle and work with the oncologist or palliative care team if a stronger antiemetic regimen is needed, or if antiemetics need to be given for a longer time. Pain Pain is defined by the International Association for the Study of Pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” [130]. Pain is one of the most common symptoms people with cancer face. It can be caused by cancer, treatment for cancer, or a combination of factors. Tumors, surgery, radiation therapy, IV chemotherapy, targeted therapy, supportive care therapies such as bisphosphonates, and/or diagnostic procedures may cause pain [146]. It is important to assess pain as to: cause and chronicity; whether it is somatic, visceral, neuropathic or mixed; and the patient’s concerns regarding and previous experience with opioids when determining the most appropriate treatments. Whether the patient has any renal or hepatic dysfunction is also important in pain management [145]. Younger patients are more likely to have cancer pain and breakthrough pain than older patients. Patients with advanced cancer are likely to have more severe pain, and many cancer survivors have pain that continues after cancer treatment ends. Basic principles of cancer pain include [146]: ● ● Cancer, treatment for cancer, or diagnostic tests may cause pain. ● ● Pain can be managed before, during, and after diagnostic and treatment procedures. ● ● Different cancer treatments may cause specific types of pain. ● ● Cancer pain may affect quality of life and ability to function even after treatment ends. ● ● Pain control can improve quality of life. ● ● Each patient with cancer-related pain needs a plan for controlling pain. Pain can be controlled in most patients with cancer, although it cannot always be completely relieved. Untreated pain can lead to emotional distress, anxiety, requests for physician-assisted suicide, unnecessary hospital admissions, and visits to emergency rooms. Pain control can greatly improve quality of life during and after cancer treatment [145]. Pain can be managed before, during, and after diagnostic and treatment procedures. Many diagnostic and treatment procedures are painful. It helps to start pain control before the procedure begins. Sedative drugs may be used to help the patient feel calm drowsy. Treatments such as imagery or relaxation can also help control pain and anxiety related to treatment. Knowing what will happen during the procedure and having a relative or friend stay with the patient may also help lower anxiety [146]. Different cancer treatments may cause specific types of pain. Patients may have different types of pain depending on the treatments they receive, including [145,146]: ● ● Spasms, stinging, and itching caused by intravenous chemotherapy. ● ● Mucositis caused by chemotherapy, radiation, or targeted therapy. ● ● Skin pain, rash, or erythodysethesia syndrome (i.e. hand-foot syndrome) caused by chemotherapy (such as 5-FU, capecitabine, liposomal doxorubicine, paclitaxel) or targeted therapy (sorafenib, sunitinib). ● ● Arthralgias and myalgias caused by paclitaxel or aromatase inhibitors. ● ● Osteonecrosis of the jaw caused by bisphosphonates given for bone metastases. ● ● Pain syndromes, including mucositis, inflammation in areas receiving radiation therapy, pain flares, and radiation dermatitis. Cancer pain may affect quality of life and ability to function even after treatment ends. Pain that is severe or continues after cancer treatment ends increases the risk of anxiety and depression. Patients may be disabled by their pain, unable to work, or feel that they are losing support once their care moves from their oncology team back to their primary care team. Feelings of anxiety and depression can worsen cancer pain and make it harder to control [146]. Each patient needs a plan to control cancer pain. Each person’s diagnosis, cancer stage, response to pain, and personal preferences around pain relief are different. The nurse, oncologist, patient, and family can work together to help manage pain. The patient and family will need written instructions to manage pain at home, along with contingency plans for common problems, including how to contact the physician or palliative care team on the weekends or evenings [146]. It is imperative that the cause of the pain is found early and treated quickly. Nurses will need to assess pain intermittently, including [146]: ● ● After starting cancer treatment. ● ● When there is new pain. ● ● After starting any type of pain treatment. Patients are often asked to describe the pain with questions like these [146]: ● ● When did the pain start? ● ● How long does the pain last? ● ● Where is the pain? ● ● What is the pain like (sharp, crampy, dull, throbbing, burning, radiating, etc.)? ● ● How severe is the pain on a scale of zero to ten? ● ● Have there been changes in where or when the pain occurs? ● ● What makes the pain better or worse? ● ● Is the pain worse during certain times of the day or night? ● ● Is there breakthrough pain (intense pain that flares up rapidly even when pain-medicine is being used)? ● ● Are there other symptoms, such as trouble sleeping, fatigue, depression, or anxiety? ● ● Does pain interfere with activities of daily life, like eating, bathing, or moving around? A scale from zero to ten is used to measure how severe the pain is and help the cancer team choose pain medication. The World Health Organization (WHO) Pain Ladder categorizes pain on a 3-step scale. Using the 1-10 assessment most often used in clinical settings [145,146]: ● ● Zero indicates no pain. ● ● One to three indicate mild pain (step 1). ● ● Four to six indicate moderate pain (step 2). ● ● Seven to ten indicate severe pain (step 3). The patient’s past and current pain medications, prognosis, comorbidities, nicotine use, alcohol intake, sedatives, personal or family history of substance abuse as well as other factors in the patient history may be considered in formulating a plan for pain relief. In some cases, patients with complex histories and needs are referred to pain specialists or palliative care teams [146]. Pain medications are prescribed based on whether the pain is mild, moderate, or severe. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to relieve mild pain or given with opioids for moderate to severe pain. The following are commonly used NSAIDS: ● ● Acetaminophen. ● ● Celecoxib. ● ● Diclofenac. ● ● Ibuprofen. ● ● Ketoprofen. ● ● Ketorolac. Patients, especially older patients, who are taking acetaminophen or NSAIDs need to be closely watched for side effects [146]. The NCCN recommends that patients older than 60 are at high risk of renal toxicities, as are those with pre-existing renal abnormalities or nephrotoxic drugs. NSAIDs can worsen or cause hypertension, bleeding, gastric upset,