**Pain Management and Nursing Approaches in Pediatric Oncology**

Nejla Canbulat1 and Ayşe Sonay Kurt2 *1Karamanoglu Mehmetbey University, Karaman School of Health, Karaman, 2Selcuk University, Faculty of Health Science, Konya, Turkey* 

#### **1. Introduction**

96 Complementary Pediatrics

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Pain is defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (Higginson&Murtagh 2010). Defining "pain" in a succinct manner is a great challenge. What is pain? It has been described as an emotional state, a physical experience, a spiritual sacrament, and a complex set of interconnected subcellular signals (Mirchandani et al., 2011). According to the International Association for the Study of Pain (IASP), pain is defined as "an unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of such damage, or both (Portenoy&Kanner 1996). In different places and in different points over time, both Eastern and Western medical traditions have included a concept of imbalance as an important etiology of painful symptoms (Helms, 1998) ... the difference between the body of a living man and that of a dead man is just like the difference between (Bias&Cope, 2011). Cancer pain may be either acute or chronic. Acute pain; acute pain is initially treated with short-acting non-opioid pharmacologic agents or combination opioid drugs. Acute versus chronic pain is important to clearly differentiate. Acute pain is rapid in onset, self-limiting, a symptom of the disease, and the patient often presents in acute distress. Examples of acute pain include postoperative pain, obstetrical labor pain, and trauma or injury-related pain and characteristically is described as sudden, sharp, and localized pain. It is usually self-limited and may be associated with physiologic changes such as diaphoresis and increases in heart rate and blood pressure (Mirchandani et al 2011). Chronic pain; chronic pain is long-term pain classified as acute, moderate, and severe. It is often differentiated as malignant or non-malignant pain. Chronic pain is often described as gnawing, aching, and diffuse and is more gradual in onset and cessation than acute pain, which can also be simultaneously superimposed on top of the former. It can vary in intensity, may remit briefly, and has definite impact psychologically and socially. Pain characteristics: Acute and chronic was given Table 1. The treatment for such pain is often successful with traditional pharmacologic measures; however, often less traditional drugs and even non-pharmacologic therapies are necessary to achieve relief (Mirchandani et al., 2011).

Pain Management and Nursing Approaches in Pediatric Oncology 99

Physiologic pain is defined as rapidly perceived non-traumatic discomfort of very short duration, alerting the individual of a dangerous stimulus. This is adaptive and initiates the withdrawal reflex that prevents and/or minimizes tissue injury. Physiologic pain can be divided into neuropathic pain and nociceptive pain (Mirchandani et al., 2011). Physiologic

**Two Major Types of Pain** 

A. Centrally Generated Pain B. Peripherally Generated Pain

A. Centrally Generated Pain

B. Peripherally Generated Pain

entrapment, trigeminal neuralgia.

The four predominant etiologies of cancer pain are: (1) that directly produced by the tumor; (2) that due to the various modalities of cancer therapy; (3) that related to chronic debility; and (4) that due to an unrelated, concurrent disease process (Eidelman&Carr, 2006). Tumor-Related Pain; Most cancer-related pain is directly produced by the malignancy itself. The neoplasm may extend into surrounding tissue and exert pressure on nociceptors in diverse organs, as well as nerves. Furthermore, recent studies have found evidence that pain-gene rating mediators are directly released from certain tumors or from surrounding tissue in response to tumor invasion or metastasis such as to bone (Eidelman&Carr, 2006; Unuvar, 1999). Treatment-Related Pain; The various modalities of cancer therapy may paradoxically cause pain. Cancer patients may experience acute discomfort following surgery or other

**II. Neuropathic** Pain: Abnormal processing of sensory input by the peripheral or central nervous system;

1. Deafferentation pain: Injury to either the peripheral or central nervous system. Examples: Phantom pain may reflect injury to the peripheral nervous system; burning pain below the level of a spinal cord lesion

2. Sympathetically maintained pain: Associated with dysregulation of the autonomic nervous system. Examples: May include some of the pain associated with reflect sympathetic dystrophy/causalgia (complex regional pain syndrome, type I, type II).

1. Painful polyneuropathies: Pain is felt along the distribution of many peripheral nerves. Examples: diabetic neuropathy, alcohol-nutritional neuropathy, and those associated with Guillain-Barre syndrome. 2. Painful mononeuropathies: Usually associated with a known peripheral nerve injury, and pain is felt at least partly along the distribution of the damaged nerve. Examples: nerve root compression, nerve

treatment usually includes adjuvant analgesics.

reflects injury to the central nervous system.

I. Nociceptive Pain II. Neuropathic Pain

pain types of pain was given Table 2.

**I. Nociceptive Pain**: Normal process of stimuli that damages normal tissues or has the potential to do so if prolonged; usually responsive to nonopioids and/or opioids.

A. Somatic Pain: Arises from bone, joint, muscle, skin, or connective tissue. It is usually aching or throbbing in quality

B. Visceral Pain: Arises from visceral organs, such as the GI tract and pancreas. This may be

1. Tumor involvement of the organ capsule that causes aching and fairly well-localized

2. Obstruction of hollow viscus, which causes intermittent cramping and poorly localized

Table 2. Physiologic pain types

and is well localized.

subdivided:

pain.

pain.

A. Somatic Pain B. Visceral Pain


Table 1. Pain characteristics: acute and chronic (Mirchandani et al., 2011)

Over time and across cultures, the understanding and expression of pain reflects the contemporary spirit of the age. Universally, the human experience begins through the painful process of birth, and throughout our lifetimes (Dedeli&Karadeniz, 2009). Factors mediating children's pain was given Fig. 1.

Fig. 1. Situational factors mediating children's pain (McGrath&Crawford, 2010)

Over time and across cultures, the understanding and expression of pain reflects the contemporary spirit of the age. Universally, the human experience begins through the painful process of birth, and throughout our lifetimes (Dedeli&Karadeniz, 2009). Factors

1. Multiple causes (malignancy, benign)

3. Persists after 3–6 months of healing 4. Can be a symptom or diagnosis 5. Serves no adaptive purpose 6. May be refractory to treatment

2. Gradual or distinct onset

Acute pain Chronic pain

Table 1. Pain characteristics: acute and chronic (Mirchandani et al., 2011)

Fig. 1. Situational factors mediating children's pain (McGrath&Crawford, 2010)

1. Usually obvious tissue damage

3. Short, well-characterized duration

mediating children's pain was given Fig. 1.

2. Distinct onset

4. Resolves with healing 5. Serves a protective function 6. Effective therapy is available Physiologic pain is defined as rapidly perceived non-traumatic discomfort of very short duration, alerting the individual of a dangerous stimulus. This is adaptive and initiates the withdrawal reflex that prevents and/or minimizes tissue injury. Physiologic pain can be divided into neuropathic pain and nociceptive pain (Mirchandani et al., 2011). Physiologic pain types of pain was given Table 2.


Table 2. Physiologic pain types

The four predominant etiologies of cancer pain are: (1) that directly produced by the tumor; (2) that due to the various modalities of cancer therapy; (3) that related to chronic debility; and (4) that due to an unrelated, concurrent disease process (Eidelman&Carr, 2006). Tumor-Related Pain; Most cancer-related pain is directly produced by the malignancy itself. The neoplasm may extend into surrounding tissue and exert pressure on nociceptors in diverse organs, as well as nerves. Furthermore, recent studies have found evidence that pain-gene rating mediators are directly released from certain tumors or from surrounding tissue in response to tumor invasion or metastasis such as to bone (Eidelman&Carr, 2006; Unuvar, 1999). Treatment-Related Pain; The various modalities of cancer therapy may paradoxically cause pain. Cancer patients may experience acute discomfort following surgery or other

Pain Management and Nursing Approaches in Pediatric Oncology 101

170 - 86% stated pain was a problem, 61%

little pain

made pain

admission

48 hours

reported)

400 - 64% had pain at first assessment

56% had pain

66 - 78% of patients had pain

655 - 70.8% had some pain in the previous 24 hours

scale of 0–10

Table 3. The prevalence of cancer pain in patients with advanced or terminal disease, or who

had pain

had pain

relief

\_ 82% reported data on pain

232 - 81% had pain at the time of

Prevalence Reference

Bucher et al., 1999

Chiu et al., 2000

Potter et al., 2003

Tranmer et al., 2003

Yun et al., 2003

reported a great deal or quite a bit of pain, 25% had some or

intervention, 46% of which

stop/get better, 56% of which made pain a little better or had no effect or made it worse


before death (prevalence not





(assessed using the Memorial Symptom Assessment Scale)


Sample size

Study type Disease definition and tumor type

> Caregivers of general cancer population

Advanced cancer

admitted to hospice

Patients referred to palliative care services – hospice, community, hospital, and

outpatient (95% with

cancer; of these, 71% had advanced disease)

Patients with metastatic cancer or stage IV lymphoma in hospital for 72 hours for complications not treatment

In- and outpatients

metastatic or recurrent cancer

with

patients

Retrospective

Prospective study

Retrospective case note review

Cross-sectional

Prospective survey

are at the end of life

survey

study

invasive procedures. Also, there are numerous postsurgical chronic pain syndromes. The administration of chemotherapy itself may cause immediate acute pain (e.g., intravenous infusion pain, abdominal discomfort during intraperitoneal infusion) or painful sequelae such as mucositis, arthralgias, and headaches. Moreover, chemotherapeutic agents, including vinca alkaloids, cisplatin, and paclitaxel, are associated with peripheral neuropathies. Radiation therapy may injure soft tissue or neuronal structures, resulting in mucositis, proctitis, enteritis, osteonecrosis, peripheral neuro pathies, or plexo pathies. Furthermore, novel anti cancer agents such as hormonal or immunotherapy may produce pain (Eidelman&Carr, 2006; Unuvar, 1999). Debility-Related Pain; Many cancer patients may be inactive or suffer debilities that are associated with painful conditions. Many cancer patients may be inactive or suffer debilities that are associated with painful conditions. For instance, patients who have received immunosuppressive therapy or have hematologic malignancies are at increased risk for developing postherpetic neuralgia. Also, many malignancies are associated with an increased incidence of thrombosis, which may present as pain and swelling in the affected site (Eidelman&Carr, 2006). Non-Malignant Concurrent Disease; Patients with cancer may experience discomfort as a direct consequence of a concurrent, benign disease process (e.g., degenerative joint disease or diabetic neuropathy). Therefore, it is important to review patients' past medical histories and to consider any coexisting nonmalignant condition as a potential source of symptoms (Eidelman&Carr 2006).
