**2. Epidemiology**

#### **2.1 Frequency**

World Health Organization (WHO ) states that 25% of cancer patients suffer pain, 33% of such patients suffer pain during treatment of the diseases, the rate of pain is between 75-90% in advanced and terminal period of the disease, 70% of such pain is directly associated with cancer, 20% of such pain is also based on cancer treatment (Aslan, 2006).

When pain reasons of the patients consulted with a algology clinic in Turkey were analyzed, it was found that cancer pain ranked the first (Aslan, 2006). The prevalence of cancer pain in patients with advanced or terminal disease was given Table 3.

Even when WHO guidelines are followed, failure to achieve satisfactory pain relief occurs in 10%–20% of patients. For these instances, some authors have proposed descriptors such as "opioid–poorly responsive pain" or "opioid-irrelevant pain." Therefore, there is a need both in clinical practice and in the standardized comparison of research findings for a systematic approach to identify and categorize factors associated with a poor prognosis (O' leary et al., 2010).

#### **2.2 Pain assessment methods**

Pain assessment and pain measurement in children is challenging. These challenges depend on permanent changes in process of child's perception, interpretation and expression with regards to age, growth phase, previous pain experience and other environmental factors (Manworren&Hynan, 2003; Unuvar, 1999). Pain assessment in children is given in the fig. 2 (Ramamurthy, 2006)

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).

World Health Organization (WHO ) states that 25% of cancer patients suffer pain, 33% of such patients suffer pain during treatment of the diseases, the rate of pain is between 75-90% in advanced and terminal period of the disease, 70% of such pain is directly associated with

When pain reasons of the patients consulted with a algology clinic in Turkey were analyzed, it was found that cancer pain ranked the first (Aslan, 2006). The prevalence of cancer pain in

Even when WHO guidelines are followed, failure to achieve satisfactory pain relief occurs in 10%–20% of patients. For these instances, some authors have proposed descriptors such as "opioid–poorly responsive pain" or "opioid-irrelevant pain." Therefore, there is a need both in clinical practice and in the standardized comparison of research findings for a systematic approach to identify and categorize factors associated with a poor prognosis (O' leary et al.,

Pain assessment and pain measurement in children is challenging. These challenges depend on permanent changes in process of child's perception, interpretation and expression with regards to age, growth phase, previous pain experience and other environmental factors (Manworren&Hynan, 2003; Unuvar, 1999). Pain assessment in children is given in the fig. 2

cancer, 20% of such pain is also based on cancer treatment (Aslan, 2006).

patients with advanced or terminal disease was given Table 3.

**2. Epidemiology** 

**2.1 Frequency** 

2010).

**2.2 Pain assessment methods** 

(Ramamurthy, 2006)


Table 3. The prevalence of cancer pain in patients with advanced or terminal disease, or who are at the end of life

Pain Management and Nursing Approaches in Pediatric Oncology 103

this study, patient's pains were graded with scores ranging between 0 to 10 by using "FLACC" score and the effects of oral and IV analgesics were evaluated. FLACC scores prior to use of analgesic drug were found significantly higher as compared to an assessment carried out subsequent to use of analgesic drug (Manworren&Hynan, 2003). Young children; young children think of their pains until they are able to speak. Child may be asked about the location of the pain. Child should be given help to find the location of the pain. Child might be asked to paint the location of the pain by showing him a picture as

After determination of presence and location of the pain, it is required to determine the level of the pain. Pain might be measured with 3 different methods since it is subjective and individual (Fig. 2) (Unuvar, 1999). First of these methods is personal expressions. This method is the most important one in pain assessment which attempts to assess the cognitive component of the pain. It is necessary to know well the words which children use in describing the pain. The most frequently used method is face scale (Fig. 4) (Hockenberry-

> Consists of six cartoon faces ranging from a smiling face for "no pain" to tearful face

> > **3 Hurts Even More**

**Recommended age** 

**4 Hurts Whole Lot** 

Children as young as 3 years

**5 Hurts Worst** 

**Descriptive** 

for "worst pain"

**2 Hurts Little More** 

indicated below (Fig. 3).

Fig. 3. Location of the pain in children

Eaton et al., 1999).

**FACES Pain Rating Scale** 

**1 Hurts Little Bit** 

Fig. 4. Face scale (Hockenberry-Eaton et al., 1999)

**Pain Scale** 

**0 No Hurt** 

Fig. 2. Pain assesment stages (Hockenberry-Eaton et al., 1999)

The "ABCs" of pain assessment in children are:


Selection of method to be used for pain assessment in children should be made considering child's age, general status, pain recognition (Manworren&Hynan, 2003; Unuvar, 1999). Children show their pains in different ways according to age group. Newborn children move less than normal, cry more frequently and are highly restless, may look pale and sweaty when they have pain. They do not eat as much as they eat normally. They cry if they are touched or moved (Manworren&Hynan, 2003). Toddler; painful toddler may cry more than normal, is restless and moves less than normal like newborn children. Toddler may show location of the pain even though it may not state explicitly when she/he has pain. When toddlers are spoken about the pain, they may understand this. Do not think that you have known your child's pain location. In a study carried out, it is claimed that "FLACC" (Face ,Legs, Activity, Cry, Consolability) pain assessment scale which is conducted by assessing child's facial express, position of legs, movements, crying and being relieved is quite useful in paediatric nurse's assessing pain and pain approach in preverbal patients. In

• Assess: Always evaluate a child with cancer for potential pain. Children may experience pain, even though ther may be unable to expree the fact in words. Infans and toddlers can show their pain only by how they look and act: older children may

• Body: Be careful to consider pain as an integral part of the physical examination. Physical examination should include a comprehensive check of all body areas for potential pain sites. The child's reactions during the examination-grimacing,

• Context: Consider the impact of family, health-care, and environmental factors on the

• Document: Record the severity of a child's pain on a regular basis. Use a pain scale that is simple and appropriate both for the developmental level of the child and fort he

• Evaluate: Assess the effectiveness of pain interventions regularly and modify the treatment plan as necessary, until the child's pain is alleviated or minimized.

Selection of method to be used for pain assessment in children should be made considering child's age, general status, pain recognition (Manworren&Hynan, 2003; Unuvar, 1999). Children show their pains in different ways according to age group. Newborn children move less than normal, cry more frequently and are highly restless, may look pale and sweaty when they have pain. They do not eat as much as they eat normally. They cry if they are touched or moved (Manworren&Hynan, 2003). Toddler; painful toddler may cry more than normal, is restless and moves less than normal like newborn children. Toddler may show location of the pain even though it may not state explicitly when she/he has pain. When toddlers are spoken about the pain, they may understand this. Do not think that you have known your child's pain location. In a study carried out, it is claimed that "FLACC" (Face ,Legs, Activity, Cry, Consolability) pain assessment scale which is conducted by assessing child's facial express, position of legs, movements, crying and being relieved is quite useful in paediatric nurse's assessing pain and pain approach in preverbal patients. In

Fig. 2. Pain assesment stages (Hockenberry-Eaton et al., 1999)

deny their pain for fear of more painful treatment.

contracture, rigidity, etc.- may indicate pain.

cultural context in which it is used.

child's pain.

The "ABCs" of pain assessment in children are:

this study, patient's pains were graded with scores ranging between 0 to 10 by using "FLACC" score and the effects of oral and IV analgesics were evaluated. FLACC scores prior to use of analgesic drug were found significantly higher as compared to an assessment carried out subsequent to use of analgesic drug (Manworren&Hynan, 2003). Young children; young children think of their pains until they are able to speak. Child may be asked about the location of the pain. Child should be given help to find the location of the pain. Child might be asked to paint the location of the pain by showing him a picture as indicated below (Fig. 3).

Fig. 3. Location of the pain in children

After determination of presence and location of the pain, it is required to determine the level of the pain. Pain might be measured with 3 different methods since it is subjective and individual (Fig. 2) (Unuvar, 1999). First of these methods is personal expressions. This method is the most important one in pain assessment which attempts to assess the cognitive component of the pain. It is necessary to know well the words which children use in describing the pain. The most frequently used method is face scale (Fig. 4) (Hockenberry-Eaton et al., 1999).

Fig. 4. Face scale (Hockenberry-Eaton et al., 1999)

Pain Management and Nursing Approaches in Pediatric Oncology 105


eyes, tightly closed, mouth open ans squarish)
















Developmental

Infants May:

Toddlers May:

Preschoolers/ Young Children

School-Age Children

Adolescents May:

Expressions of pain



applied

May:

May:






Table 5. Expression of pain in children




group

The other methods depend on behaviour pattern (such as tone of voice, facial expression and gestures) and biological parameters (such as heart rate, falling of peripheral oxygen saturation). Personal expression is the best measurement method if can be obtained and is accepted as "golden rule" in pain measurement (Unuvar, 1999). Behavioral pain assessment scale for young children was given in the Table 4.


Total is scored from 0-10.

Table 4. Behavioral pain assessment scales for young children (Hockenberry-Eaton et al., 1999)

Adolescents; adolescents give reactions similar to adults. They may look calm, have sleeping problems, loss of appetite, avoid from friends or family, be nervous or angry. They may not say when they have pain since they are afraid of getting addicted to narcotics. The best method determine the pain of adolescent patients is scales which have assessment criteria ranging 0 to 5 (0= presence of no pain, 5= presence of intense unbearable pain). Expression of pain according to age groups was given Table 5.
