Aim of the Study The aim of this study was to determine if the nursing interventions of patient education and multidisciplinary coordination of care were able to improve pain control in the cancer patient in an acute hospital setting. Background of the Study The role of the nurse in cancer pain management has been defined as being that of an educator, coordinator of care and advocate. A nurse with adequate knowledge of pain and its application to the cancer population and functioning in the role as defined is believed to be able to overcome many of the barriers that exist in implementing adequate analgesia and improve pain management in cancer patients. Design of the Study A randomized experimental control group design was utilized. The study comprised 3 experimental groups and one control group incorporating pre and post testing. The Intervention of the Study Experimental group one: subjects received education regarding their pain management which was tailored to meet their specific needs. Experimental group two: subjects underwent a pain assessment and construction of a care plan which was communicated verbally to the treating medical and nursing team and followed up with a written report which was documented in the history and sent to the treating medical physician. Experimental group three: subjects received the combined interventions administered to groups one and two. Control group four: subjects were assessed and all information was record in the same manner as for the experimental groups. The control group received their usual care during the study and their pain scores were measured at the same time intervals as the three experimental groups. Instrumentation The Wisconsin Brief Pain Questionnaire was used for the assessment of all subjects. The McGill Pain Questionnaire was used as the outcome measure following intervention. Data Analysis A one-way analysis of variance was used to detect the differences between the intervention groups and the control group. T-Tests were used to detect the differences between the groups incorporating a Bonferroni adjustment for frequent T tests. Results The main effect demonstrated a significant difference between the treatment groups and control at a significance level of 0.002. T-Tests showed no significant difference between control and communication groups and no significant difference between education and combined groups. A significant difference was detected between education and control and between combined and control. Conclusions Nursing interventions of patient education, coordination of care and advocacy can significantly improve cancer pain management. Intervention was tailored to meet the specific patient needs based on findings from the assessment and was dependent upon an adequate knowledge base. The nursing intervention of education was the most powerful of the three intervention types and its success was in tailoring to each individual. However, it is believed that with further recognition of the role of the nurse as coordinator of care will lead to greater improvements in cancer pain management.

Despite the fact that as many as 80-90% of patients with cancer pain can be effectively treated using pharmacological therapies and other advanced approaches, 31% to 85% of cancer patients in Taiwan still experience varying levels of pain. Pain is one of the symptoms that patients fear most; it overwhelms all aspects of patients' lives and creates a sense of uncertainly and hopelessness. Pain control is, therefore, a high priority in the treatment of cancer patients. Pharmacological therapy is the cornerstone of cancer pain management. With the current trend toward outpatient care, many patients are being required to assume greater responsibility for self-management of prescribed analgesics at home to deal with the variable and complex nature of cancer pain and side effects of opioids. Patients however, have misconceptions regarding analgesics and a series of difficulties when attempting to put a pain management regimen into practice. This research addressed the hypothesis that self-efficacy beliefs might play an important role in analgesic adherence and pain experience in Taiwanese outpatients with cancer. The purpose of this study was to develop a scale to measure the self-efficacy expectations relating to opioid-taking in Taiwanese outpatients with cancer. Another purpose was to explore how opioid-taking self-efficacy and beliefs about opioid analgesics contribute to patients' analgesic adherence and pain experience in Taiwanese outpatients with cancer. In the first stage semi-structured interviews were conducted to collect data from a purposeful sample (n=10) of oncology outpatients from two teaching hospitals in the Taipei area of Taiwan. The purpose of this phase was to identify behaviours and situational impediments associated with analgesic taking. Findings from this phase were used to develop a scale to measure opioid-taking self-efficacy. In the second stage a pilot test with a convenience sample (n=30) was conducted to test the validity and reliability of the new scale and to identify the feasibility of using the scale in a cross-sectional survey. In the third stage a cross-sectional survey was undertaken (n=92) to describe pain experiences, analgesic adherence, beliefs about opioid analgesics, and opioid-taking self-efficacy in Taiwanese outpatients with cancer and to explore how opioid-taking self-efficacy and beliefs about opioid analgesics contributed to analgesic adherence and pain experience. Results of this study highlight an important issue - under-treatment of cancer pain in this group of Taiwanese outpatients. As well, low adherence rates to opioid analgesics in cancer outpatients arose as an important issue in this study. A range of misconceptions about using opioids for pain was also common amongst the sample. Despite these misconceptions, patients reported being moderately confident in their ability to perform self-management behaviours related to their prescribed opioid-taking. Results of this research supported the notion that patients' self-efficacy in relation to taking their prescribed opioid regimen was a significant independent predictor of patients' adherence behaviour and pain relief, but not of pain severity. Beliefs about opioid analgesics were also an independent predictor of patients' adherence, but not of pain relief or pain severity. In addition, findings from this study provided support for the validity and reliability of the opioid-taking self-efficacy scale. Results suggested there is a need for systematic assessment of beliefs affecting patients' opioid adherence behaviours for cancer pain control, including perceived personal self-efficacy and beliefs about opioid analgesics. Educational programs that focus on overcoming patients' misconceptions (beliefs) about taking opioid analgesics may be particularly beneficial. In addition, this study advocates that conducting self-efficacy-enhancing interventions may improve medication adherence for patients and therefore pain relief. More research is needed to demonstrate the construct validity of the self-efficacy scale and to evaluate self-efficacy enhancing interventions in cancer pain management.

Many common cancers, including breast, prostate and lung cancers, have a propensity to metastasize to bone. Although these cancers go undetected in their native tissues, bone metastases often produce excruciating pain, the etiology of which is poorly understood. Cancer-induced bone pain (CIBP) is not well-controlled with existing medications, severely compromising patient quality of life. While CIBP is multifaceted, increased level of the excitatory neurotransmitter glutamate in the bone-tumor microenvironment may contribute to the pain state. Here, we demonstrate for the first time a relationship between reactive oxygen/nitrogen species, glutamate in the bone-tumor microenvironment and pain behaviors. The murine mammary adenocarcinoma cell line 66.1 is found to release glutamate via the cystine/glutamate antiporter system xc⁻. In a syngeneic model of breast CIBP in which 66.1 cells are inoculated into the femur intramedullary space, administration of sulfasalazine, an established system xc⁻ inhibitor and anti-inflammatory agent, reduces femur glutamate level and attenuates CIBP-related behaviors. Peroxynitrite, a reactive nitrogen species known to be generated in breast tumors, is shown to drive 66.1 system xc⁻ functional expression and tumor cell glutamate release. The elimination of peroxynitrite with the redox modulators FeTMPyP or SRI10 not only modulates tumor cell system xc⁻ functional expression in vitro and in vivo, significantly altering glutamate levels, but also assuages CIBP. In sum, we demonstrate that pharmacological inhibition of system xc⁻ transport attenuates CIBP-related behaviors. These data support a role for tumor-derived glutamate in CIBP and validate system xc⁻ an analgesic target in this pain state.

Bakgrund: Cancersmärta är både akut och långvarig vilket påverkar de drabbade fysiskt, psykiskt och existentiellt. Som sjuksköterska är det av stor vikt att identifiera och värdera smärta med olika smärtskattningsinstrument. Syfte: Att undersöka cancerdrabbade patienters upplevelse av att skatta sin smärta med smärtskattningsinstrument. Metod: En litteraturstudie med utvalda artiklar från databaserna Pubmed, Cinahl och Scopus. Elva kvalitativa originalartiklar som uppfyllde inklusions- och exklusionskriterierna inkluderades. Resultat: Patienter upplevde att smärtskattningsskalor till största del var lätta att använda och förstå sig på, dock upplevde patienterna vissa skattningsinstrument som förvirrande. Flertalet patienter upplevde att det är lättare att beskriva sin smärta med egna ord istället för att använda en skala. Många upplevde även att de inte blev tagna på allvar av vårdpersonal vid smärtskattning. Slutsats: Cancersmärta är komplext och en individuell typ av smärta. Patienter upplevde olika smärtskattningsskalor på olika sätt. Ansvarig sjuksköterska bör ha möjligheten att erbjuda flera typer av skalor för att kunna behandla smärtan på ett adekvat sätt. / Background: Cancer pain causes both acute and long-term pain and affects patients both physically, psychologically and existentially. As a nurse it's important to identify and assess pain with different pain measurements. Aim: To examine how cancer patients experience pain using pain measurement tools.   Method: A literature study was used with articles from the databases Pubmed, Cinahl and Scopus. Eleven qualitative original articles who met the studies inclusion- and exclusion criteria were included. Results: Patients mostly experienced the pain measurement tools to be easy to use and understand. Some patients experienced the measurement tool as confusing and preferred to describe their pain with own words instead of using a scale. Many patients felt that they were not being taken seriously by the staff when they measure their pain. Conclusion: Cancer pain is a complex and individual type of pain. Patients experienced various pain measurement tools differently. Therefore the nurse in charge should have the ability to offer different types of measurement tools to be able to treat the pain adequately

Orientador: Maria Salete de Angelis Nascimento / Banca: Cristina Yoshie Toyoda / Banca: Guilherme Antonio Moreira de Barros / Resumo: Estudos têm relacionado o uso de atividades terapêuticas como uma técnica nãofarmacológica efetiva para o controle da dor oncológica e de outros sintomas decorrentes da doença, contribuindo de maneira significativa na melhora da qualidade de vida. O objetivo deste estudo foi avaliar os resultados de um programa de terapia ocupacional aplicado a pacientes oncológicos sob cuidados paliativos, no que se refere à modulação da dor, qualidade de vida e sintomas emocionais. Após a aprovação do comitê de ética e assinatura do termo de consentimento livre e esclarecido, foram incluídos 59 pacientes portadores de neoplasia avançada, em cuidados paliativos e que apresentavam dor E.V.A 5 cm (Escala Visual Analógica). Foram avaliados: dor (E.V.A, questionário de McGill e consumo de opióides), qualidade de vida (questionário SF-12) e sintomas de ansiedade e depressão (questionário HADS). Os pacientes foram aleatoriamente distribuídos, por sorteio de envelopes, em dois grupos e acompanhados diariamente por 10 dias consecutivos. O grupo intervenção realizou 30 minutos de atividades terapêuticas associado a orientações quanto ao desempenho das atividades de vida diária. O grupo controle recebeu somente orientações quanto atividades de vida diária. Os grupos foram demograficamente e clinicamente semelhantes em relação: sexo, cor, religião, escolaridade, estado civil, presença de cuidador, qualidade da dor, localização da dor e topografia do câncer. O grupo intervenção apresentou redução da dor (E.V.A e questionário de McGill) durante os dez dias de estudo. O grupo controle não apresentou diminuição satisfatória da dor. A média do consumo de morfina foi semelhante quando comparado os grupos (p>0,05). Entretanto, analisando cada grupo separadamente, no grupo controle observou-se maior consumo de morfina quando comparado ao grupo que realizou atividades... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Studies have connected the use of therapeutic activities as non-pharmacological practice effective for the control of cancer pain and other passing symptoms from the disease by helping to improve the quality of life in a significative way. The aim of this study was to create a program of occupational therapy as a helping technique in the modulation of the pain in cancer patients under palliative care. After the approval of the ethics committee and signature of the free and evident consent term, 59 patients who had advanced cancer in palliative care and had VAS 5 cm (Visual Analogue Scale) pain were included. Pain (VAS, McGill questionnaire and opioids consumption), quality of life (questionnaire SF-12) and anxiety and depression symptoms (questionnaire HADS) were evaluated. The patients were aleatorically distributed, by raffle envelopes, into two groups and accompanied daily for consecutive 10 days. The intervention group performed 30 minutes of therapeutic activities associated guidance on the performance of activities of daily life. The control group received only orientations of activities of daily life. The groups were similar demographically and clinically in relation to sex, race, religion, graduation, marital status, the presence of caregiver, quality of pain, localization of the pain and topography of cancer. The intervention group presented decreasing of the pain (VAS and McGill questionnaire) during ten days of the study. The control group did not present satisfactory reduction of pain. The average of morphine consumption was similar compared to the groups (p> 0.05). However, analyzing each group separately in the control group was observed a large consumption of morphine when compared to the group which accomplished therapeutic activities. The quality of life and anxiety and depression symptoms got better in relation to the first and the last day of the study... (Complete abstract click electronic access below) / Mestre

Introduktion: Smärta förekommer hos cirka 55 % av alla patienter med cancer, vilket gördet till ett vanligt problem. Smärtan påverkar patienternas liv på flera olika nivåer. Förutomdet fysiska lidandet påverkas även livskvaliteten negativt, därför är det viktigt attuppmärksamma problemet. Trots farmakologisk behandling underbehandlas cirka 30 % avpatienterna. Det finns ett flertal olika icke-farmakologiska behandlingsmetoder motcancersmärta som skulle kunna verka som komplement till farmakologisk behandling. Idagsläget finns det fortfarande brister gällande huruvida sjuksköterskor informerar ocherbjuder patienter komplement till farmakologisk behandling. Genom att öka medvetenhetenkan smärtproblematiken hos patienter med cancer minska, och vården bli merindividanpassad. Eftersom cancersmärta är komplext behöver även behandlingen vara det. Syfte: Syftet är att undersöka hur akupunktur, massage och avslappning påverkar smärta hospatienter med cancersmärta. Metod: I denna studie användes en allmän litteraturöversikt med beskrivande design sommetod. Totalt har 11 vetenskapliga originalartiklar valts ut och granskats. Samtliga artiklarvar randomiserade kontrollerade studier. Resultat: Resultatet av studien visade att akupunktur, massage och avslappning har ensmärtlindrande effekt, både långtidsverkande och direktverkande, hos patienter medcancersmärta. Likaså visade resultatet att smärtans påverkan på det dagliga livet minskade avdessa behandlingsmetoder. Akupunktur och massage kunde även bidra till ett minskatanvändande av analgetika. Slutsats: Akupunktur, massage och avslappning kan fungera som komplement tillfarmakologisk smärtbehandling hos patienter med cancer. Dessa metoder kan även ha enpositiv effekt på patientens välmående i helhet, då en minskad smärta kan öka livskvaliteten. / Introduction: Pain is very common among patients with cancer, approximately 55%experience it, making it a frequent problem. The pain affects the patients' lives in many ways.In addition to the physical suffering, the quality of life is negatively affected as well. Despitepharmacological treatment, about 30% are undertreated. There are several differentnon-pharmacological treatment methods for cancer pain, which could act as a complement topharmacological treatment. There are shortcomings regarding whether nurses inform andoffer patients complements to pharmacological treatment. By raising awareness, the carecould be more individualized. Since cancer pain is complex, the treatment has to be as well. Aim: The aim of this study is to examine how massage, acupuncture, and relaxation affectsthe pain in patients with cancer pain. Method: A general literature review with descriptive design. A total of 11 scientific articlesof origin have been selected and reviewed. All articles were randomized controlled trials. Result: The results showed that acupuncture, massage and relaxation therapy affect pain,both long- and short term, amongst patients with cancer pain. Furthermore, it showed that theeffect pain has on daily life decreased during the interventions. Acupuncture and massagecould decrease the daily use of analgesics. Conclusion: Acupuncture, massage and relaxation therapy can work as a complement topharmacological treatment among patients with cancer pain. These methods may have apositive effect on the general well being of the patients since reduced pain increases thequality of life.

The primary focus of this thesis is to establish the clinical utility of corticosteroid injections mixed with local anesthetics, when compared to only local anesthetics, for relief of pain in patients with chronic non-cancer pain. Chronic non-cancer pain is common and causes significant pain and suffering to patients, and economic burden to health care system. Injection of steroids is an option, either by targeting the painful structure or the associated neural elements. Steroids are commonly mixed with local anesthetics in the hope of prolonging the pain relief. Since there is no evident inflammation in most chronic pain conditions, and because existing clinical studies do not consistently support its effectiveness in various clinical conditions, the potential value of adding steroids is questionable. This clinical question has been addressed through a comprehensive systematic review and meta-analysis of randomized control trials comparing injections of steroid with local anesthetics against only local anesthetics for chronic non-cancer pain conditions. Our review found that there is paucity of good quality randomized controlled studies specifically addressing this comparison. Although a large numbers of studies were identified, there was a small effect favoring steroids in studies measuring pain relief by dichotomous outcomes. Overall confidence in the effect estimates were limited due to serious concerns of bias, significant heterogeneity and variability in studies, leading to low quality. A majority of the included studies did not aim to capture the full spectrum of adverse effects. Future studies addressing this clinical question should aim to be of optimum size, must aim to limit the threat of bias, and capture all patient important outcomes including pain relief. / Thesis / Master of Science (MSc)

Bakgrund: Cancer är en sjukdom som ökar vilket dels beror på en åldrande befolkning men även på att många cancerformer blir allt vanligare. Det har även skett en ökning av överlevnad av cancer till följd av aggressivare onkologiska behandlingar, vilket innebär att fler cancerdrabbade kan leva betydligt längre med sjukdomen än tidigare. Detta leder i sin tur till att antalet canceröverlevare som lever med smärta ökar. Trots att smärta till stor del är behandlingsbar visar studier att många patienter inte är adekvat smärtlindrade, vilket kan orsaka ett stort lidande hos den drabbade. Syfte: Att beskriva patienters upplevelse av att leva med cancerrelaterad smärta samt deras upplevelser av vårdpersonalens bemötande. Metod: En allmän litteraturstudie med kvalitativ ansats tillämpades. Artikelsökning genomfördes i databaserna PubMed och Cinahl, därefter valdes 18 artiklar ut och analyserades med innehållsanalys. Kvalitetsgranskning utfördes med hjälp av SBU:s granskningsmall för kvalitativa studier. Resultat: Fyra kategorier identifierades: påverkan på det dagliga livet, smärtupplevelse, smärthantering samt bemötande från vårdpersonal. Smärta påverkade patienterna ur flera aspekter, såväl fysiskt och psykiskt som socialt, kulturellt och ekonomiskt. Det fanns en rädsla för att använda opioider vilket utgjorde ett hinder för adekvat smärtlindring. Patienter önskade bättre information och kommunikation från vårdpersonalens sida. Slutsats: Smärtupplevelsen hos cancerdrabbade påverkar individen negativt i en rad olika aspekter av livet, samt att brist på information och förståelse från vårdpersonal ökar patientens lidande. Trots att sjukvårdspersonalens bemötande har sina styrkor så finns det ett stort behov av bättre information och kommunikation. / Background: Cancer is a disease that is increasing, which is partly due to an ageing population, but also because different forms of cancer are becoming more common. There has also been an increase in cancer survival as a result of more aggressive treatments, which means that more cancer sufferers can live significantly longer with the disease than before. This leads to an increase in cancer survivors with pain. Although pain is often treatable, studies show that many patients are not adequately relieved from their pain, which can cause great suffering. Purpose: To examine patient´s experiences of living with cancer-related pain and their experiences of healthcare professional´s treatment towards them. Method: A general literature review with a qualitative approach. The article searches were conducted in PubMed and Cinahl, and 18 articles were included and analysed with content analysis. The articles were quality reviewed with the help of SBU’s review template for qualitative studies. Result: Four categories were identified: impact on daily life, pain experience, pain management and treatment from healthcare professionals. Pain affects the patient physically and psychologically as well as socially, culturally and economically. Patients fear using opioids, which constitutes an obstacle to adequate pain management. Patients express a need for better information and communication from healthcare professionals. Conclusion: The pain experienced by cancer patients affects the individual negatively in different aspects of life, and lack of information and understanding from healthcare professionals worsens the patient suffering. Although healthcare professionals’ treatment towards patient´s has its strengths, there is a need for better information and communication.

Chronic pain has no cure. It is a lifelong condition presenting a growing concern due to its high occurrence and effects on every facet of life. It cost about $635 billion each year in medical treatment and lost productivity (IOM, 2011). The management of chronic pain using prescription painkiller opioids has increased drastically in the last two decades, leading to a consequential increase in deaths from chronic opioid use. This Plan-Do-Study-Act quality improvement project investigates the problem of the prevalence of opioid prescription using agent-based computational modeling method. The simulation models the interaction of 50 patient-agents with pain self-management messages in an episode of 50 patient iterations (visits) for 10 simulated years. This interaction generates health benefit and risk outcomes represented by wellness data obtained when messages are processed. As the simulation runs, data are dynamically captured and visualized using wellness charts, time series plots, and benefit and risk regression plots. The result of the project provides evidence for research and practice on the process of achieving more impact of programs based on administering pain self-management education to patients with chronic non-cancer pain who are currently on opioid therapy and on the process of customizing interventions that might take advantage of the conditions of behavior change driven by pain self-management messages. The tools and the evidences in this project are highly recommended to nurse practitioners primary care providers involve with providing care to the vulnerable groups of patient with chronic non-cancer pain. These evidences might inform the formation of self-management interventions that might lead to a decline in opioid use and prescription and accelerate the acceptance of self-management practices.

Bakgrund: Smärta är ett vanligt symtom hos palliativa patienter medcancersjukdom. En del patienter är inte fullt smärtlindrande och detta kan skapa ettonödigt lidande för patienterna som försämrar deras livskvalité.Syfte: Syftet är att belysa kunskapsläget om hur sjuksköterskor utvärderarsmärtsymtom hos palliativa patienter med cancersjukdomMetod: En litteraturstudie med 16 artiklar av både kvalitativ och kvantitativmetod valdes ut från databaserna Cinahl och Pubmed.Resultat: Sammanställningen av artiklarna resulterade i fyra stycken olika teman.Dessa är bedömningsinstrument, att utvärdera med eller utanbedömningsinstrument, sjuksköterskans utvärderande arbete, utvärdering medolika instrument.Slutsats: Genom att använda smärtbedömningsinstrument kan sjuksköterskansarbete att utvärdera smärtsymtom underlättas och smärtsymtom för patientenminskas. Genom en planerad implementering av dessa bedömningsinstrument meden kompletterande utbildning kan sjuksköterskan få bättre kunskap ombedömningsinstrument vilket kan leda till bättre förståelse och förutsättningar förpalliativa patienternas behov av smärtutvärdering. Detta kan leda till förbättradupplevd livskvalité hos de palliativa patienterna med cancersjukdom. / Background: Pain is a common symptom in palliative cancer patients. Somepatients are not fully relieved of pain which can create unnecessary suffering forthe patients.Aim: The purpose is to describe how nurses evaluate pain symptoms in palliativepatients with cancer.Methods: A literature study with 16 articles consisting of both qualitative andquantitative methods from two databases, Cinahl and Pubmed.Results: The compilation of the articles resulted in four different themes. Theseare pain assessment instruements, to evaluate with or without pain assessmentinstruments, the nurse's evaluation work, and comparison of different instruments.Conclusions: By using pain assessment tools, the nurse's work to evaluate painsymptoms can be facilitated and pain symptoms for the patient reduced. Through aplanned implementation of these assessment instruments with a supplementaryeducation, the nurse can gain better knowledge of the assessment instrument canlead to a better understanding and conditions for palliative patients' needs for painevaluation. This can lead to improved perceived quality of life in the palliativepatients with cancer.