Monday, January 27, 2020
Assessing Pain in in Post Operative Breast Cancer Patients
Assessing Pain in in Post Operative Breast Cancer Patients Comparison between BriefÃ PainÃ Inventory (BPI) and Numerical Rating Scale (NRS) for post-operative pain assessment in Saudi ArabianÃ breast cancer patients. Questions DoesÃ BPI assessÃ post-operative breast cancer painÃ moreÃ accurately than NRS? Summary: Effective pain assessment is one of theÃ fundamentalÃ criteriaÃ of theÃ management ofÃ pain. It involvesÃ theÃ evaluation of pain intensity, location of the pain and response to treatment. There areÃ aÃ numberÃ of multi and one-dimensional assessment toolsÃ thatÃ have already been established to assess cancer pain. Among theseÃ are theÃ Brief Pain Inventory (BPI) andÃ theÃ Numerical Rating Scale (NRS), Breast cancer isÃ a growing publicÃ concern in Saudi ArabiaÃ as rates continue to escalate, with patientsÃ alsoÃ suffering multiple problems after surgery. Therefore, my research aim is toÃ conduct aÃ comparative studyÃ of toolsÃ used toÃ assess post-operative breast cancer painÃ inÃ Saudi ArabianÃ patientsÃ and determine which is the most effective. In this process I will use questionnaires for both nurses and patients to collect data,Ã followed by statistical analysis andÃ aÃ comparativeÃ study betweenÃ theÃ BPI and NRS. Research Hypothesis: BPI assessesÃ post-operative breast cancer painÃ in Saudi ArabianÃ patientsÃ moreÃ accurately than NRS.Ã Null hypothesis: There is no significant difference between BPI and NRSÃ as tools forÃ assessing post-operative breast cancer painÃ inÃ Saudi ArabianÃ patients Background: Pain is defined asÃ Ã¢â¬Ëthe normal, predicted physiological response to an adverse chemical, thermal or mechanical stimulus related with surgery, trauma or acute illnessÃ¢â¬â¢ (Carr and Goudas, 1999).Ã Pain assessment is a crucial component for the effective management of post-operative pain in relation to breast cancer. The patientÃ¢â¬â¢s report is the mainÃ resourceÃ of informationÃ regarding theÃ characterisation and evaluation of pain; as such, assessment isÃ the Ã¢â¬Ëdynamic method of explanation of the syndrome of the pain, patho-physiology andÃ the basis forÃ designing a protocol for its managementÃ¢â¬â¢Ã (Yomiya, 2011). A recent surveyÃ questioned almost 900 physiciansÃ 897 and foundÃ thatÃ 76% reported substandardÃ pain assessmentÃ proceduresÃ as the single most important barrierÃ toÃ suitableÃ pain management (RoennÃ et al, 1993). Breast cancer is characterized byÃ aÃ lump or thickening inÃ theÃ breast, discharge or bleeding,Ã aÃ change in colour ofÃ theÃ areola, redness or pitting of skinÃ and aÃ marble like area underÃ theÃ skin (WebMD, 2014[A1]). Breast cancerÃ has a high prevalence rate globally and is the second most diagnosed cancer in women. ApproximatelyÃ 1.7 million cases were reported in 2012Ã aloneÃ (WCRFI, 2014). In 2014,Ã just overÃ 15,000Ã womenÃ haveÃ alreadyÃ beenÃ diagnosed with breast cancer: this figure is predicted to rise to around 17,200 in 2020 Breast cancerÃ has also been identifiedÃ as one of the major cancer related problems in Saudi Arabia, with 6,922 women wereÃ assessed[A2]Ã for breast cancer between 2001-2008 (Alghamdi,Ã 2013[A3]). DÃ Pain assessment tools PolitÃ et alÃ (2006) conductedÃ a systematic review of the evidence baseÃ andÃ recorded a total ofÃ 80 different assessment tools thatÃ containedÃ at least one pain item. TheÃ tools were thenÃ categorised into pain toolsÃ (n=48)Ã and general symptoms toolsÃ (n=32) . They were thenÃ separated into uni-dimensionalÃ toolsÃ (which measure the pain intensity)Ã and multi-dimensional toolsÃ (include more than one pain dimension). 33%Ã of all pain toolsÃ (n=16) were uni-dimensional, andÃ 50% of allÃ general symptom toolsÃ (n=16)were uni-dimensional. 58% of the uni-dimensional toolsÃ employedÃ singleÃ item scales such asÃ theÃ VisualÃ AnalogueÃ Scale (VAS), Verbal Rating Scales (VRS)Ã and NRS (NumericalÃ RatingÃ Scale). The most common dimensionÃ includedÃ was pain intensity, present in 60% ofÃ tools. InÃ the assessed tools, 60% assessed painÃ in aÃ multi-dimensionalÃ format. AmongÃ pain tools,Ã 67% were found Ã to beÃ multi-dimensionalÃ compared with 50% of the general symptom tools.Ã 38% of all multi-dimensional tools were two-dimensional.Ã The mostÃ commonly usedÃ dimension wasÃ Ã¢â¬ËintensityÃ¢â¬â¢,Ã presentÃ in 75% ofÃ allÃ multi-dimensional tools. Other commonÃ dimensionsÃ includeÃ interference, locationÃ and beliefs. All the dimensions were specifically targeted by two particular tools which were disease-specific tools and tools that measure pains affect, beliefs, and coping-relatedÃ issues[A4]. Multidimensional Pain assessment tools: FÃ TheÃ adequate measurement of painÃ requiresÃ more than one tool. Melzack and Casey (1968)Ã highlight thatÃ pain assessmentÃ Ã¢â¬Ëshould include three dimensions which are sensory-discriminative, motivational-affective and cognitive-evaluativeÃ¢â¬â¢.Ã This builds on theÃ earlierÃ proposal ofÃ Beecher (1959)Ã who considered that all tools should include theÃ two dimensionsÃ ofÃ pain and reaction to pain. Cleeland (1989)Ã considered thatÃ theÃ two dimensionsÃ should be classifiedÃ as sensory and reactive. Sensory dimensionsÃ should recordÃ the intensity or severityÃ of painÃ and the reactive dimensions should include accurate measures of interferenceÃ in theÃ daily functionÃ of the patient.Ã Multi-dimensional pain assessments generally consist ofÃ sixÃ dimensions: physiologic, sensory, affective, cognitive, behavioural and sociocultural (McGuire, 1992). Cleeland (1989)Ã interviewed patients andÃ foundÃ thatÃ seven items could effectively measure the intensity and effects of the pain in daily activities: theseÃ compriseÃ ofÃ general activity, walking, work, mood, enjoyment of life, relations with others and sleep. These elements were later subdividedÃ into two groups: Ã¢â¬ËREMÃ¢â¬â¢Ã (relations with others, enjoyment of life and mood) andÃ Ã¢â¬ËWAWÃ¢â¬â¢Ã (walking, general activity and work). Later, CleelandÃ et alÃ (1996) developedÃ theÃ BriefÃ PainÃ Inventory (BPI) in bothÃ itsÃ short and long form.Ã It was designedÃ to capture twoÃ categoriesÃ of interference such asÃ activity and affect onÃ emotions.Ã TheÃ BPI providesÃ a relativelyÃ quick and easy methodÃ of measuringÃ theÃ intensityÃ of pa inÃ and theÃ level ofÃ interferenceÃ in theÃ daily activities of theÃ sufferer. With the BPIÃ tool, patients are gradedÃ onÃ a 0-10 and itÃ wasÃ specificallyÃ designedÃ for theÃ assessment ofÃ cancer related pain. PatientsÃ areÃ askedÃ about the intensity of the pain that they are experiencing at present, as well as the pain intensity overÃ the last 24 hours asÃ theÃ worst, leastÃ orÃ averageÃ pain (alsoÃ on a scale of 0-10). EachÃ scale is boundÃ by the words Ã¢â¬Ëno painÃ¢â¬â¢Ã (0) andÃ Ã¢â¬Ëpain as bad as you can imagineÃ¢â¬â¢Ã (10). Patients are alsoÃ requestedÃ to rate the degree to which pain interferesÃ with theirÃ daily activities within the sevenÃ domainsÃ on a scale of 0-10.Ã that comprise general activity, walking, mood, sleep, work, relations with other persons, and enjoyment of life using similar scales of 0 toÃ 10[A5]. These scales are only confined by the words Ã¢â¬Ëdoes not interfereÃ¢â¬â¢ and Ã¢â¬ËinterferesÃ completely[A6]Ã¢â¬â¢ (TanÃ et al, 2004).Ã Validation of BPI across the world among the different language people has already been justified.Ã [A7]Additionally, the localization of the pain in the bodyÃ could beÃ [A8]assessed and details of current medication are assessed (CaraceniÃ et al, 1996). Uni-dimensional pain assessment tool: Ã Previous studiesÃ haveÃ shownÃ thatÃ theÃ NumericalÃ RatingÃ Scale (NRS) had the power to assess pain intensity for patientsÃ experiencing chronic pain and was also an effective assessment tool for patients with cancer related pain. TheÃ NRS consists of a numerical scale range between 0-100 where 0 was considered as one extreme point represented no pain and 100 was considered other extreme point which represented bad/ worse painÃ (Jensen et al, 1986). TurkÃ et alÃ (1993) developedÃ anÃ 11 pointÃ NRS (scale 0-10) where 0 equalledÃ no pain and 10Ã equalledÃ worst pain. Though cancer pain differs from acute, postoperative and chronicÃ pain experiences, the most common feature is its subjective nature. [A9]Ã In this regard a consensus meeting on cancer pain assessment and classification was held in Italy in 2009Ã with theÃ recommendation thatÃ pain intensity should be measuredÃ on aÃ scaleÃ ofÃ 0-10 withÃ Ã¢â¬Ëno painÃ¢â¬â¢Ã andÃ Ã¢â¬Ëpain as bad as you canÃ imagine[A10]Ã¢â¬â¢Ã (HjermstadÃ et al.,Ã 2011). KrebsÃ et al.Ã (2007) categorised NRS scores as mild (1Ã¢â¬â3), moderate (4Ã¢â¬â6), or severe (7Ã¢â¬â10). A rating ofÃ 4 or 5Ã isÃ the most commonly recommended lower limitÃ for moderate pain and 7 or 8 for severe pain. Aimed at moderate pain assessment,Ã For the purpose of clinical and administrative use theÃ recommendation for moderate pain assessment on the scale is a score of 4. Importance of post- operative pain assessment: Post-operative painsÃ isÃ very common after surgeryÃ andÃ theÃ use ofÃ medicationÃ oftenÃ dependsÃ on the intensity of painÃ that the patient is experiencingÃ (ChungÃ et al, 1997). Insufficient assessment of post-operative painÃ can have aÃ Ã¢â¬Ësignificant detrimentalÃ effect on raised levels of anxiety, sleep disturbance, restlessness, irritability, aggression, distress and sufferingÃ¢â¬â¢Ã (CarrÃ et al,Ã 2005). AdditionalÃ physiologicalÃ effects can includeÃ increasedÃ blood pressure, vomiting and paralytic ileus, increased adrenaline production, sleep vein thrombosis and pulmonary embolus (Macintyre and Ready, 2002). Effective post-operative pain assessment ensures better pain managementÃ and can significantly reduce the risk of the symptoms listed above, giving minimal distress or sufferingÃ to patientsÃ and reducingÃ potential complications (Machintosh, 2007). References: Alghamdi IG, Hussain II, Alhamdi MS, El-Sheemy MA (2013) Arabia: an observational descriptive epidemiological analysis of data from Saudi Cancer Registry 2001-2008. Dovepress. Breast cancer: Targets and therapy; 5: 103-109. Caraceni A, Mendoza TR, Mencaglia E (1996) A validation study of an Italian version of the Brief Pain Inventory (Breve Questionario per la Valutazione del Dolore). Pain; 65: 87-92. Carr D and Goudas L. C. (1999) Acute pain. Lancet 353, 2051-2058. Carr EC, Thomas NV, Wilson-Barnet J (2005) Patient experiences of anxiety, depression and acute pain after surgery: a longitudinal perspective. International Journal of Nursing Studies. 42(5): 521-530. Chung F, Ritchie E, Su J (1997) Postoperative pain in ambulatory surgery. Anaesthesia and Analgesia 85: 808-816.Ã Cleeland CS (1989) Measurement of pain by subjective report. Issues in pain measurement. New York: Raven Press; pp. 391-403. Cleeland CS, Nakamura Y, Mendoza TR, Edwards KR, Douglas J, Serlin RC (1996) Dimensions of the impact of cancer pain in a four country sample: new information from multidimensional scaling. Pain 67 (2-3): 267-273. Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, Fainsinger R, Aass N, Kaasa S (2011) Studies comparing numerical rating scale, verbal rating scale and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. Journal of pain and symptom management. 41 (6): 1073-1093. Jensen MP, Karoly P, Braver S (1986) The measurement of clinical pain intensity: a comparison of six methods. Pain 27: 117-126. Krebs EE, Carey TS, Weinberger M (2007) Accuracy of the pain numeric rating scale as a screening test in primary care. Journal of general medicine. 22(10): 1453-1458. Machintosh C (2007) Assessment and management of patients with post-operative pain. Nursing Standard. 22 (5): 49-55. Macintyre PE, Ready LB (2002) Acute pain management. Second edition, WB Saunders, Edinburgh. McGuire DB (1992) Comprehensive and multidimensional assessment and measurement of pain. Journal of pain and symptom management; 7(5): 312-319. Melzack R and Casey KL (1968) Sensory, motivational and central control determinants of pain: a new conceptual model. In: Kenshalo DR, editor. The skin senses proceedings. Springfield IL: Thomas; pp. 423-439. National Breast Cancer Foundation (NBCF): 2014;Ã http://www.nbcf.org.au/Research/About-Breast-Cancer.aspx Polit JCHC, Hjermstad MJ, Loge JH, Fayers PM, Caraceni A, Conno FD, Forbes K, Furst CJ, Radbruch L, Kaasa S (2006) Pain assessment tools: Is the content appropriate for use in palliative care? Journal of pain and symptom management, 32 (6): 567-580. Roenn JHV, Cleeland CS, Gonin R, Hatfield AK, Pandya KJ (1993) Physician attitudes and practice in cancer pain management. A survey from the Eastern Cooperative Oncology Group. Annals of Internal Medicine, 119(2): 121-126. Tan G, Jensen MP, Thornby JI, Shanti BF (2004) Validation of the brief pain inventory for chronic non-malignant pain. The Journal of Pain. 5(2): 133-137. Turk DC, Rudy TE, Sorkin BA (1993) Neglected topics in chronic pain treatment outcome studies: determination of success. Pain (53):3Ã¢â¬â16. WebMD (2014)Ã http://www.webmd.com/breast-cancer/guide/overview-breast-cancer. World cancer research fund international (WCRFI): 2014;Ã http://www.wcrf.org/cancer_statistics/data_specific_cancers/breast_cancer_statistics.php. Youmiya K (2011) Cancer pain assessment. The Japanese Journal of Anesthesiology. 60(9): 1046-1052. [A1]I would consider using a more reputable source for describing medical symptoms themselves (GreyÃ¢â¬â¢s Anatomy, WHO guidelines etc) [A2]and treated? [A3]Is it worth commenting that breast cancer reporting rates in SA might be different from actual prevalence? Lack of awareness regarding certain cancers often results in late diagnosis or misdiagnosis. [A4]This sentence is unclear. I am assuming that you are stating that all dimensions are present in two particular tools? [A5]IÃ¢â¬â¢ve deleted this as you have highlighted the same domains in the previous paragraph and the reader will already be familiar with this term. [A6]Sentence shows up on copyscape / turnitin but itÃ¢â¬â¢s fine as a directly referenced quote. [A7]Is this sentence stating that the BPIs valid internationally because it has been adjusted culturally / linguistically for all groups? [A8]Are you making a suggestion that it could be assessed, or stating that sometimes people do assess localised pain in the body? [A9]Deleted as the next sentence deals with this already. [A10]Again shows up in turnitin: any quotes must be in inverted commas so that tutors / markers will not downgrade or suspect plagiarism.