This phase is the acute phase, which follows the

essay will demonstrate the importance of evidence based nursing assessments in
long-term condition and how they are applied into practice. It will look into
patient with lung cancer (LC); this particular patient has been chosen as it is
mostly diagnosed late, there is low survival rates, is one of the most common
cancers in the world (Cancer research UK, 2014) and has the highest prevalence
of pain. Following the phases of chronic illness trajectory (McCorkle
& Pasacreta, 2001), the chosen phase is the acute phase, which follows the
crisis phase and refers to the period when the patient’s symptoms can be
controlled by a prescribed regimen (McCorkle & Pasacreta, 2001). This phase
has been chosen as after a crisis phase patient can have a lot more to consider
involving occupational, financial and psychosocial stress and insurer conflict.
Stress may increase patients’ pain (DP, 2014; Pain in times of stress, 2015) as
chronic pain is an inflammatory state. It is conceivable that the stress can
increase pain perceptions through inflammatory mechanism; Deleo, 2001). Therefore, it is very likely that at
acute phase patient can suffer from more pain compared to other phase.

The care environment takes place in the
hospice-based setting at home,  this way patient can stay in their own home

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will be staff that can assess their pain and provide them with the appropriate
pain relief. The patient is in stage 3B with a non-small lung cancer an
advanced LC which although not curable, is treatable (Lynne, 2016). 3B advanced
lung cancer has been selected as with advance cancer, pain is more likely. It
was estimated that 75% of all cancer patients to be living with chronic pain,
with the pain increases in severity as lung cancer advances, with patient at
later stages of the disease experiencing more pain (Chandrasekhar, 2016). This paper will
discuss on the rationale for the chosen health care need, the assessment for pain
management for LC patient, assessment tools that will help assess this needs,
it will reflect on the importance of nurse-patient relationship, person centred
care approach and the importance in the contribution of families or carers in
the assessment process.

Lung cancer starts with the uncontrollable
growth of abnormal cell that develops into a lump or tumour that starts off in
one or both lungs. The risk factors that increases the likely
hood of the cancer includes, smoking, air pollution, genetic disposition,
pre-existing lung cancer such as Chronic obstructive pulmonary disease (Bennett
and White, 2013). There are two main types of lung cancer; the most common type
comprising approximately 80% of all lung cancer is NON-small cell lung cancer
(NSCLC). The rest of the 20% of lung cancer are Small-cell lung cancer (SCLC)
which were commonly associated with smoking (IASP, 2009).  Pain is what the patient says it is
(McCaffery, 1968) and the person in pain is the only person to know how painful
something is. Since pain is personal and no two people experience it in the
same way, it is very difficult to define and to treat (Britishpainsociety, 2010). International
Association for the study of pain (IASP) defines pain as “an unpleasant sensory
and emotional experience associated with actual or potential tissue damage or
described in terms of such damage” (IASP, 1979). This definition links the sensory experience to emotion,
stating that the only way of deciding whether someone has pain is by asking
them or watching them.

is recognized as impacting all dimensions of quality if life (Burton, 2007). It interferes with every aspect of a
patient’s life their sleep, relationship, work and leisure. This can lead to
patient becoming physically and psychological unwell. They become too unwell to
be able to continue or carry out daily tasks to live a normal life, affecting
their quality of life. Without proper pain management patient can face both
physical and psychological consequences leading to agony and reduction in their
quality of life. This not only affects their life but also impacts their family
and friends. Managing cancer pain is vital for effective treatment
that will help improve patient’s physical, mental state and allowing patient to
have a positive frame of mind. The psychological impact of pain, it has on
patient can take a major toll interfering with patient’s sense of self, their
identity can become pain and they can lose sight of the objective which is
survival (Cancercenter, 2017).Therefore, pain management has been chosen for
the health need for LC patient.  Furthermore,
certain sites of cancer are known
to have a shorter life expectancy than others, for e.g. lung cancer compared to
breast cancer (American cancer society, 2005). The shorter life expectancy may relate to higher
symptom experience in the last year of life. Thus, pointing out that lung
cancer patient could be in much more pain compared to other cancer patient,
making pain management especially essential for them. Additionally
it is an overall healthcare need of this particular patient group, by
controlling pain we are able to remove the constant reminder of cancer, giving
them hope and energy to fight the disease. It
is important that nurses are aware of the cause of pain with advanced lung
cancer. This can be brought about by several different causes the three main
causes of pain in patient with LC been skeletal metastatic disease 34%,
Pancoast tumour 31% and chest wall disease 21% (Watson,1987). This is important when
assessing and administering analgesia for pain management. In order to manage
pain, it is essential to understand and use general principles of pain
management (Claribel, 2012). While the World Health Organisation (WHO)
analgesic ladder is recognised to, provide relief of cancer pain it
has its limitations in the context of long-term survival and increasing
disease complexity. To solve the issue, it was recommended to create a more
comprehensive model for cancer pain management. 
That is mechanism- based and multimodal, using combination therapies
including interventions, which would be tailored to the needs of an individual,
with the aim of optimising pain relief while minimalizing adverse effect
(Raphael, 2010).

to any other pain, the neurophysiology of cancer pain is complex: it not only
involves inflammatory but neuropathic, ischaemic and compression mechanism at
multiple sites (BPS, 2010). By having
the knowledge of these mechanisms and the ability to decide whether pain is
nociceptive, neuropathic, and visceral or a combination of all three will lead
to best practice in pain management (Britishpainsociety, 2010). According to NICE (NICE, 2016) when starting
a pain assessment health professional should discuss pain with the person
directly. If not possible ask family or healthcare professional to help with
the assessment bearing in mind that family members may overestimate and
healthcare professionals underestimate the person’s pain. They should assess
each pain; a person has with a view to establishing an underlying cause, while keeping
in mind that there may be more than one. Pain has to be assessed regularly,
especially if it is not adequately controlled. 
Reviewing the medical history and records to determine the known site
and extent of the cancer can help in getting more information such as pain
occurring distant from the previously known sites of cancer may indicate either
a non-malignant cause or secondary spread of the cancer. Additionally, the
influence of psychological, social and spiritual factors can have an effect on
person’s experience of pain and should be assessed. These aspects of
recommendation were based on expert opinion from (SIGN, 2008) and (Regnard,

is not just a physical sensation but is bound up with an emotional response and
an act of reasoning; which is why pain is known as a multidimensional
experience (Fillingim, 2014) It has a physical and emotional consequences, it
can lead to fatigue, irritability, depression or inability to carry out
activities of daily living (Leadley, 2014). Pain is a personal experience and
can be difficult to communicate. It is vital that nurses know how to best
assess it to ensure the optimal treatment is given. In order to manage pain, health
professional must know the level of pain a patient is in, for them to be able
to administer the correct analgesia to the patient. To obtain the correct
knowledge of the level of pain, it is vital that we use the correct pain
assessment tools to help us get the information on pain. Pain assessment tools
help us to detect and describe pain to help in the diagnostic process. It helps
us to understand the cause of the pain to help determine the best treatment. It
lets staff monitor the pain to determine whether the underlying disease or
disorder is improving or deteriorating and whether the pain treatment is
working. To get a more accurate and correct information, assessment tools
should understandable and easy to read with use of plain language. Not only
that nurse should have the knowledge, skills and attitude to be able to carry
out appropriate pain assessment and management. As this will contribute in
patients receiving higher standard pain assessment and management (Wilson, 2007).
Heath professional must remember that patients vary in their ability to lead or
participate in discussions about their pain and it is important for nurses to
consider this before choosing the most appropriate assessment strategy.

pain intensity is part of universal screening and comprehensive pain assessment
and can be achieved using Validated structured pain assessment tools such as
Visual analogue scales (VAS) and numerical rating scales (NRS) (NICE, 2016). Numerical
rating scale (NRS) is a unidimensional measure of pain intensity (Jensen, 1993) in adults including those
in chronic pain. It involves asking the patients to rate their pain intensity
on a scale of 0-10, in which 0 means no pain at all and 10 been the worst pain
they have ever experienced or the worst imaginable pain. In adults the NRS
works well (Williamson & Hoggart, 2005) and has sufficient sensitivity to
enable patients to communicate changes in their pain over time. The benefits of
NRS is that it only takes 1 min to complete which can be very vital and useful
if patient are in extreme pain, as they would not be in the state to answer too
many questions to assess their pain. Although focus group of patients in
chronic pain have found that NRS is inadequate in capturing the complexity and characteristic nature of the pain
experience or improvements due to symptom variations (Hawker, 2008; Hush,
2010). NRS
is easy to administer and score, it is easy to use for both patient and staff.
Therefore, they would be more likely to use it compared to other assessment
tools. Due to its very design it requires minimal language translation
difficulties supports the use of NRS across cultures and languages. NRS is a
valid and reliable scale to measure pain intensity (Hawker, 2011).  The
strength of this measure over the VAS is the ability to be administered verbally
and in writing as well as its simplicity of scoring.

have McGill Pain Questionnaire (MPQ) which assesses both quality and intensity
of subjective pain. Which NRS tool is unable to provide. MPQ consists of
grouping of words that best their experience of pain. The person rating their
pain ranks the works in each grouping. Once the person has rated their pain
words, the administrator assigns a numerical scale, called the pain rating
index. It measures multiple components (sensory, affective, cognitive,
behaviour) of cancer pain (Ahles,
1983). The
tool has been tested and retested for its reliability and has shown strong
reliability for measuring cancer pain (Ferraz, 1990; Graham, 1980; Wilikie & Keefe,
1991). It has good construct, content and criterion validity (Fischer, 2010; Prieto,
1980; Melzack, 1975). Although MPQ’s strength is that it can assess the quality
and intensity of pain, the very long process of assessing this quality can be
aggravating to patient in chronic pain. MPQ (Melzack,1975) was
tested in interviews with cancer patients who had pain, the patients had
reported that the measures were too complex and too long, making them
excessively burdensome for patient with higher levels of pain. There are also
concerns about the readability issues for some descriptors. The three pain
patterns of the MPQ are not adequate to account for changes in pain experience
by cancer participants (Graham, 1980).

should differentiate between the person’s usual level of pain, breakthrough
pain, incident pain, and ‘end of dose’ failure of regular around the clock
analgesia. Health professional should take in the importance of assessing the
lifestyle implications, assess the effect of pain on activities of daily living
and identify factors contributing to the person’s distress (Spiegel, 1994;
Abu-Saad & Courtens, 2001; Qaseem, 2008; NHS Lothian, 2014) as these
factors add in patient’s pain. 

pain intensity should be assessed based on patient self-reporting. Self-reporting
pain is easy to use such as pain dairy, for outpatients whose performance
status is relatively good and whose condition is stable. However, it is
relatively difficult for inpatients with poor general health and acute problems
to express their degree of pain. In fact, many studies on cancer pain
management report that observer and patient assessment do not correlate well
and that there is a tendency for medical staff to underestimate pain levels (Jensen, 2003).

In a study it was found that a pain assessment system using a
self-reporting pain board attached to the patients’ bed provided a reliable and
effective means of assessing pain (NCBI, 2012). The self-reporting pain board
that was attached to the patient’s bed used in the study allowed patients to
express pain intensity by moving an indicator. From the direct expression of
pain by patients, it offers other benefits as well. Because the board was
always present at the bedside, it helped increase in patient interest to score
their pain. Accordingly, patients could communicate with the medical staff
regarding their pain severity more frequently compared to when their pain is
assessed by the medical staff intermittently at fixed times. Furthermore, as
the self-reporting pain board is visible to medical staff, it helped in
stimulating staff’s interest in patient pain and encourages active pain
management. It also reduced staff workload with respect to pain assessment. And
as patient became familiar with the pain board very quickly, they reported
their pain scores voluntary, with no encouragement from medical staff. These
benefits increased awareness and efficiency of patient-medical staff
communication and ultimately increased patient satisfaction with pain
management from 54% to 82% (NCBI, 2012). 
Although a lot of pain assessment are performed using self-reporting
pain indicators in many institutions. Those assessments are usually carried out
by the medical staff and presented to the patient only when medical staffs ask
about pain. Many studies on cancer pain management, reported that one of the
reason pain is often inadequately managed is because pain may be underestimated
(NCBI, 2012). Therefore, health professional should always keep in mind that
pain is what the patient says it is and should not be interpreted in any other
way. This not only leads to undermanaged pain but also cause patient to loss
trust in health professional and results in a gap between patient- staff relationship.
should not assume that a patient cannot participate in a pain assessment, as
all patients including dementia patient can often use self-report pain scales
but they may need to be re-taught how to do so each time (Kaasalainen, 2013).
Universally most patient change their normal behaviour when they are in pain,
so knowing individual patients and their normal demeanour is vital. Patient can
be afraid to tell doctor or nurse that they are in pain. However mild or severe
it feels telling someone is always important as the earlier pain is treated;
the easier it is to get it under control. Many people with cancer are scared
that they will become addicted to painkiller. So they don’t ask for help. In
these situations, it is important to have a therapeutic relationship between
the health professionals and the patient. This helps support the patient,
promote healing and to support or enhance functioning. Although there has been
a significant medical, pharmacological and technological advance in the area of
cancer pain assessment and management, up to 90% of patients with advanced
cancer experience pain significant enough to require further intervention
(NCBI, 2014).

are several pain assessment tools; they all have their own weakness and
strength with them. Some tools may seem more reliable and have more validity;
its usefulness can sometimes depend from person to person. Since one person is
not similar to another. Although relying on good qualitative date and trust
policy is important. Assessing what type of assessment is good for the
particular individual is also necessary. Monitoring and keeping record of how
useful the initially used assessment tool was and asking patient’s opinion of
the tool is important. If the initially used tools was not as effective in
assessing patient’s pain, health professional should have the awareness and
resolution to try a different tool. A good nursing assessment ensures patient
safety, continuity and quality of care. It is a nurse’s legal and professional
obligation, and requires attention to NMC standards for record keeping and code
of professional conduct.

This essay has
discussed the lung cancer, explored the assessment tools to manage cancer pain
in a hospital setting. It described the importance of assessment of pain
management in lung cancer patient and the tools that are available. The
assessment tool that was looked into was the NRS and MPQ tools to measure pain
intensity in lung cancer patient. The strength and weakness of both of the
tools was discussed. It also noted that having an individual pain management is
necessary, although one assessment tool has been said to be brilliant in many
papers and studies. It does not guarantee that it will work on the particular
patient in the hospital. So health professional should always keep an open mind
and use other tools to suit the needs of the individual patient and not use
tools just because it has worked in general population. Through the discussing
we have found the importance of good nurse-patient relationship and how having
a therapeutic relationship and fully increase the usefulness of the assessment
tool. Additionally, patients also require support other than pain management
such as psychological support