Research Topics: Palliative Care Nursing

A Systematic Review of Worldwide Cancer Nursing Research: 1994 to 2003

The word cancer elicits dread in nearly everyone. Cancer accounts for considerable mortality and morbidity in both men and women (Kozier, 2004). Certain genes controlling growth and interactions with other normal cells are apparently abnormal in structure or regulation in cancer cells. Humans of all ages develop cancer, and a wide variety of organs are affected. The incidence of many cancers increases as the fourth to sixth power of age, so that as people live longer, many more will develop the disease. Apart from individual suffering, the economic burden to society is immense (Murray, et al, 2000). Cancer cells are characterized by three properties: (1) diminished or unrestrained control of growth; (2) invasion of local tissues; and (3) spread, or metastasis to other parts of the body. Cells of benign tumors also show diminished control of growth but do not invade local tissue or spread to other parts of the body (Murray, et al, 2000).             Cancer is caused in all or almost all instances by mutation or by some other abnormal activation of cellular genes that control cell growth and cell mitosis. The abnormal genes are called oncogenes. Cancer tissue competes with normal tissues for nutrients. Because cancer cells continue to proliferate indefinitely, their number multiplying day by day, one can readily understand that the cancer cells soon demand essentially all the nutrition available to the body or to an essential part of the body. As a result, normal tissues gradually suffer nutritive death (Guyton & Hall, 2000). An abnormal cell mass that develops when controls of the cell cycle and cell division malfunction is called a neoplasm. However, not all neoplasms are cancerous. Benign neoplasms are strictly local affairs. They tend to be surrounded by a capsule, grow slowly, and seldom kill their hosts if they are removed before they compress vital organs. In contrast, malignant (cancerous) neoplasms are nonencapsulated masses that grow more relentlessly and may become killers. Their cells resemble immature cells, and they invade their surroundings rather than pushing them aside, as reflected in the name cancer from the Latin word for “crab.” Malignant cells also tend to spread via the blood to distant parts of the body, where they form new masses. This last capability is called metastasis (Marieb 2004). Genetic aspects of cancer are probably receiving the greatest current attention among genetic abnormalities. Some cancers are caused by oncogenes, genes which are carried in the genomes of cancer cells and are responsible for producing their malignant properties. These genes are derived by somatic mutation from closely related proto-oncogenes, which are normal genes that control their growth. Over 100 oncogenes have been described (Ganong, 2001). Obviously, the initiation of mitosis and normal cell division depends on the orderly occurrence of events during what has come to be called the cell cycle. There is intense interesting the biochemical machinery that produces mitosis, in part because of the obvious possibility of its relation to cancer. When DNA is damaged, entry into mitosis is inhibited, giving the cell time to repair the DNA; failure to repair damaged DNA leads to cancer. The cell cycle is regulated by proteins called cyclins and cyclin-dependent protein kinases, which phosphorylate other proteins (Ganong, 2001). Cell replication involves not only DNA polymerase but a special reverse transcriptinase that synthesizes the short repeats of DNA that characterize the ends (telomeres) of chromosomes. Cells with high telomerase activity, which includes most cancer cells, can in theory keep multiplying indefinitely (Ganong, 2001).             Cell Division in normal and cancer cells. Source: http://www.ch.ic.ac.uk/local/projects/burgoine/origins.txt.html             The stepwise development of a typical colon cancer is as follows:   1 2 3 Cellular changes Increased cell division Growth of polyp Growth of malignant tumor (carcinoma) DNA changes Oncogene activated Tumor-suppressor gene activated Second tumor-suppressor gene activated   The treatment of choice for either type of neoplasm is surgical removal. If surgery is not possible – as in cases where the cancer has spread widely or is inoperable – radiation and drugs (chemotherapy) are used. Chemotherapeutic drugs destroy malignant cells (Kozier, 2004).   When chemotherapy or radiotherapy is used in addition to surgery it is known as ‘adjuvant chemotherapy’ or ‘adjuvant radiotherapy’. For example, following surgery you may be given a course of chemotherapy or radiotherapy. This aims to kill any cancer cells which may have spread away from the primary tumor site. Sometimes, adjuvant chemotherapy or radiotherapy is given before surgery to shrink a large tumor so that the operation to remove the tumor is easier for a surgeon to do, and is more likely to be successful.             Cytotoxic therapy regimens are highly toxic to cells, and can result in a range of acute and chronic adverse effects for persons receiving these treatments (Perry, 1996). A number of these adverse effects are potentially life threatening. The safe and effective delivery of these drugs therefore requires highly complex clinical assessment, technical and problem solving skills. Surgery, radiotherapy, and chemotherapeutic agents are the major modalities used to treat patients with cancer, though various biologic therapies are beginning to have a significant impact. The basic problem is to make available drugs (natural products or synthetics) that kill cancer cells effectively but are not excessively toxic to normal cells. The table below lists seven major classes of compounds that have been widely used in the treatment of cancer: Class of Compound Example Site of Action Treatment Use Alkylating agents Melphalan Alkalytes DNA and other molecules Myeloma Antimetabolites <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify"> Purine antagonists</li> </ul>   <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify"> Pyrimidine antagonists</li> </ul>   <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify"> Folate antagonists</li> </ul>   Mercaptopurine     Fluorouracil     Methotrexate   Converted to a “fraudulent” nucleotide and inhibits purine synthesis Converted to a “fraudulent” nucleotide and inhibits thymidylate synthetase Inhibits dihydrofolate reductase   Acute myelocytic leukemia   Colorectal cancer     Choriocarcinoma Antitumor antibiotics Doxorubicin Intercalates in DNA and stabilizes the DNA-topoisomerase II complex Hodgkin’s disease Other agents Cisplatin   Hydroxyurea Causes strand breakage in DNA Inhibits ribonucleotide reductase Carcinoma of the lung Chronic myelocytic leukemia Plant compounds Vinblastine Binds tubulin and inhibits microtubule formation Kaposi’s sarcoma Sex hormones Estrogens Block effects of androgens in prostatic tumors Cancer of the prostate Corticosteroids Prednisone Inhibits proliferation of lymphocytes Myeloma Source: Harper’s Biochemistry, page 806               Insofar as unrestrained cell division is a feature that typifies many malignant tumors, many of these agents are used because they inhibit DNA synthesis. For this reason, they are also likely to damage normal tissues whose cells divide continuously – e.g. bone marrow (Murray, et al, 2000). Anti-cancer drugs have unpleasant side effects because most target all rapidly dividing cells, including normal ones. The side effects include nausea, vomiting, and loss of hair. X rays also have side effects because, in passing through the body, they kill healthy cells that lie in the path to the cancer cells (Marieb 2004). Life threatening adverse reactions and side effects of the treatment include pulmonary fibrosis and anaphylaxis/anaphylactoid reactions. The most frequent includes fatigue, diarrhea, nausea, vomiting, anemia and neurotoxicity (Deglin & Vallerand, 2004).             Current cancer treatments – “cut, burn, poison” – are recognized as crude and painful. Promising new methods focus on delivering anticancer drugs precisely to the cancer (via monoclonal antibodies that respond to one type of protein on a cancer cell) and on increasing the immune system’s ability to fend off cancer (Marieb 2004). In all these, the senior oncology / colorectal specialist nurses is responsible for co-ordinating care following any operations and/or treatment for bowel cancer. A senior oncology nurse is highly qualified, having specialized training in caring for patients who have bowel disease, and has many years of experience in this field. As well as supporting John and his family through his operation and treatment, the senior oncology nurse provides John and his caregivers with clear written and verbal information; and can also examine John and arrange any tests he might need. The number of patients suffering from cancer has steadily increased in recent years mainly due to an ageing population. Add to this, an increasing number of chemotherapeutic agents and a multitude of regimes, it therefore becomes imperative to educate the nurse on the care of the chemotherapy patient. Because of all these mentioned, it was only fitting that a study was made to assess the cancer nursing research papers published in the past decade; identify their characteristics in terms of country of origin, participants, settings, diagnostic foci, and methodologic choices; and evaluate their quality as this would significantly help cancer treatments. A systematic review was carried out of all published papers in the Cumulative Index of Nursing and Allied Health Literature between the years 1994 and 2003, using the keywords “cancer,” “nursing,” and “research.” A total of 619 papers met inclusion criteria and were evaluated by 5 researchers. Almost half the papers were derived from the United States (49.1%), followed by the UK, Sweden, Canada, and Australia. In more than half of the published papers (52.2%), health professionals (mostly nurses) were the studies’ participants. Also, much of the published research used patients with mixed diagnosis, or patients with breast or hematologic cancers. Two-thirds of the studies were quantitative, whereas most studies were descriptive in nature. The quality of both quantitative and qualitative studies was low, with only a small percentage meeting the highest quality criteria. Studies reporting funding and those published in journals with an impact factor showed a higher quality score than those not reporting funding or not published in journals with an impact factor. Concern for global health issues goes with a global perspective in nursing knowledge. As nations become increasingly interdependent, health for all is a worldwide goal, and the framework of health care constrained by national boundaries does not fit nursing (Messias, 2001). A widely recognized advantage of globalization is improved access to information. In nursing, global communication increases through print journals, electronic journals, online educational materials, and international conference proceedings. Worldwide dissemination of nursing information represents a novel opportunity to expand the reach and effect of professional nursing. Accordingly, interest in international collaboration has increased in the published literature in the past decade.             International collaborations are important because they (a) improve knowledge and understanding of human needs across geographic boundaries, (b) support a global perspective for nursing by fostering worldwide inclusiveness, and (c) expand the cultural and ethical values underpinning goals in nursing. Globalization in knowledge development is linked to international publication in nursing. Knowledge about the international content of nursing journals is a necessary part of understanding the trend toward globalization of nursing knowledge. The systematic study of the international content of highly ranked nursing journals in 2000 was a way to benchmark the status of international publication in nursing (Seers, 2004). Many issues about globalization have been raised in the nursing literature. Consensus is apparent that the development of international nursing requires a global focus and international collaboration. Leaders question whether Western science can be adapted to a global health framework and whether Western nursing is appropriate for global nursing practice. Nurses realize that Western science does not have answers in all areas of nursing practice (Holt et al., 2000) because knowledge and research development are embedded within cultural contexts (Lutzen, 2000). In a global nursing framework, nurses should emphasize the concept of cultural sensitivity. International comparisons of cultural values are necessary because they help researchers become aware of how different values influence the development of nursing knowledge and practice (Lutzen, 2000). Scholars should be aware of their own knowledge and cultural values, and they should be encouraged to understand alternative ways of thinking (Holt et al., 2000). International collaboration (a) provides alternative modes of thinking for nursing scholars, (b) enables wide-range testing of theories in practice, (c) facilitates scholarly maturity through self-assessment, and (d) leads to advancement of nursing science (Seers, 2004). To investigate the international focus in journals, those journals have to be identified.             The advancement in biotechnology is also helping to speed up and improve cancer research in many parts around the world. Technology has allowed many medical institutions to do what they are doing today. In cancer research, getting the data and results from DNA sample of patients is important in helping them understand why some people have cancer. In the past, this process was tedious and would take up days, months, and even years before the researcher can get the data and results, let alone the analysis. But with the existence of machines like the DNA sequencer and the microarray technology, cancer research has been sped up and can be done at a higher throughput. For instance, DNA sequencing is now quite a routine procedure in many laboratories and research centers (Ismail, 2003). Progress in the understanding of genetics, and its role in disease and cancer epidemiology, have scientists encouraged that they are on the brink of major advances in methods and treatments. These include the ability to target cancerous cells without harming healthy tissue as well as better targeted treatments for specific cancers based on understanding of their genetic structure. While the billions of dollars being spent on cancer research by the federal government is significant, it seems that now is the time to aggressively push forward, not cut back (Ernst, 2006). Overall worldwide spending for cancer research is growing. This is good news for the health care consumer, who probably doesn’t care where therapies are developed as long as their treatment is successful.             New understanding of how cancer cells survive, thrive, and metastasize has enabled researchers to create new targeted therapies for cancer treatments, such as melanoma and Kaposi’s sarcoma, to minimize the harmful systemic effects (therapy on healthy cells. The specific and selective targets of future oncology drugs will require a detailed understanding of cancer cell biology, genetics, immunology, and biotechnology (Capriotti, 2005).             The search for anti-cancer therapies which target cancer cells specifically and selectively with less toxicity has been a quest in oncology for many years. Conventional chemotherapeutic agents do not target cancer cells selectively, leading to widespread adverse systemic effects. Chemotherapy, radiation therapy, and biological agents all target cells that are in the process of proliferation. Therefore, both cancer cells and mitotically active healthy cells are subject to the cytotoxic effects of these therapies.             The diagnosis of cancer and other life-threatening diseases can be devastating to patients and their families. While many complex, disease-focused medical procedures are routinely prescribed for patients, often little or no consideration is given to prescribing comfort measures and sustaining optimal quality of life. Nurse educators are on the front lines in promoting the holistic care that is essential for the nurturing of persons with cancer and other serious illnesses (Milone, 2004).             Among the many challenges faced by individuals affected by life-threatening illnesses are profound changes in social roles and interpersonal relationships. Maintaining employment is difficult, and parenting, socializing with friends, and spiritual well-being are all affected. The whole person suffers by a threat to any one of four dimensions: physical, psychological, social, or spiritual. However, nurses who possess effective communication skills can positively influence rate of recovery, optimize pain control interventions, and better facilitate emotional well-being.             With regard to the nursing workforce specializing in the care of patients with cancer, little empirically based information is available describing the extent to which the above problems also affect oncology nurses. Because most people who have cancer are older, the aging of the baby boom generation is expected to increase the number of people with cancer substantially, and hence the future demand for oncology nurses. Cancer is the second leading cause of death in the many countries, exceeded only by heart disease. Today, however, reports of shortages of oncology nurses are not uncommon, and because many cancer facilities report difficulty retaining nursing staff, information is needed on the adequacy of the oncology nurse workforce (Mallory, 2001).             A study confirms long-held suspicions that lung cancer, the leading cancer killer of both men and women, is seriously underreported when compared to other major cancers. In an analysis of 600 randomly selected cancer stories that appeared between August 1999 and July 2000, 61 percent reported on breast cancer, 23 percent on prostate, 17 percent on colorectal cancer and only 9 percent focused on lung cancer outside of tobacco and smoking issues. This is especially significant since more people die each year of lung cancer than the combined deaths from breast, prostate and colorectal cancer.             Studies on cancer also further demonstrate the overwhelming ability of celebrities to draw attention to cancer issues. Breast, prostate and colorectal cancers generated significant news attention through a number of celebrities who were affected, either directly or indirectly, by the disease. Television host Katie Couric significantly raised awareness of colorectal cancer on her program The Today Show; New York Mayor Rudolph Giuliani’s prostate cancer diagnosis drove coverage to peak levels. Only one celebrity was quoted speaking out for lung cancer, cyclist and cancer survivor Lance Armstrong, who was involved in the Lung Cancer Awareness Campaign in 1999.             Cancer nurses report a rising workload and concerns about a national shortage of nurses in the speciality, a Senate inquiry has been told. A federal government report had found there was a shortage of oncology and palliative care nurses in every state and territory except the Northern Territory, the Cancer Nurses Society of Australia (CNSA) told the inquiry into cancer services. Recent research into the workloads of cancer nurses found 50% of cancer nurses did not have time to get through their work, and 70% said they were experiencing ‘moderate to high levels of emotional exhaustion’, the society said in its submission.             The CNSA called for governments to improve cancer nurse staffing models; provide financial support to nurses to pursue further studies; and fund research into innovative models of cancer care involving specialist cancer nurses. A national approach was needed to address the workforce shortages of cancer nurses, particularly improving the available data on cancer nurses in the workforce and developing a national plan to improve staff retention and support strategies (Australian Nursing Journal, 2005).             As a result of improved diagnosis and treatment, more people are surviving cancer (National Cancer Institute, 2003). Cancer survival, however, can be attended by negative physical and psychological syndromes, including weight gain, lowered aerobic capacity, depression, anxiety and an overall decrease in quality of life. In addition, cancer survivors are at increased risk for developing other chronic conditions such as cardiovascular disease, obesity and diabetes. Reasons for these risks are complex and include genetics, treatment factors, lifestyle factors and a sedentary lifestyle (Grubbs, 2004).             Research on cancer survivors suggests that weight gain, depression, anxiety and other issues contributing to decreased longevity and quality of life can continue long after the course of treatment. In a study of breast cancer survivors eight years postsurgery, it was also reported that women had persistent symptoms of psychological and somatic disturbance. Most studies on the physical and psychosocial effects of cancer have focused on the period during treatment or within two to three years of diagnosis. Very little is known regarding the longevity of these sequelae, their impact on the aging survivor or the interventions that will improve quality of life (Grubbs, 2004).             Findings from this study, as well as others, suggest that these health issues may persist beyond the period of chemotherapy and radiation treatments. These studies highlight the longevity of mental and physical changes, depression and decreased quality of life among cancer survivors. The findings emphasize the need for improved systems of care to minimize health disparities, and further research on interventions to improve health outcomes.             Research evaluation is indeed currently enjoying a favoured position in many countries as research budgets expand but there is also pressure from funders to ensure value for money (Saegusa, 1999). In several European countries, for example, there is a move to more competitive funding both of laboratories and of individual research projects (Goddard, 2000). The ultimate test of the utility of research is that it will give rise to new products and processes or, in the biomedical field, to better health for man and animals. However, the route to these tangible benefits is often lengthy, especially for basic research (Patel et al., 1999), so that proxy indicators are needed to show whether given expenditures have been worthwhile. The main proxy indicator is the esteem in which research is held by other researchers, which can be measured by the counting of citations. However, these suffer from some disadvantages: <ul type="disc" style="margin-bottom: 0in"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> they are somewhat costly to determine – typically about US per paper; </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> it takes time for them to accumulate, so that fair comparisons can be made – perhaps five years; and </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> comparisons between different fields and sub-fields are difficult because citation norms differ greatly.</li> </ul> In some ways, the analysis of the factors that lead to high quality research is comparable with epidemiology. In this subject, the factors that lead to ill-health are analyzed. The problem in both analyses is that there may be missing factors, some of which are correlated with the ones used for analysis, and which can confound the apparent conclusions. For example, ill-health is positively associated with smoking, a poor diet, lack of exercise and a low-status job (Marmot and Bobak, 2000). But each of these factors is strongly associated with the three others and indeed with yet more factors that can plausibly lead to ill-health, such as low income, low education level, poor housing and living in a polluted area. If public health measures are to be soundly based, it is essential that the individual effects of all these factors, and probably many more, are teased out, so that policies can be targeted on the most important ones. Similarly, the factors that lead to high quality research may plausibly include: <ul type="disc" style="margin-bottom: 0in"> <li class="MsoNormal" style="line-height: 200%"> the subject area of the research; </li> <li class="MsoNormal" style="line-height: 200%"> whether it is applied or basic (in biomedicine, clinical or basic); </li> <li class="MsoNormal" style="line-height: 200%"> whether it is carried out in an industrial or academic setting (in biomedicine, in a hospital or a university); </li> <li class="MsoNormal" style="line-height: 200%"> whether the team of authors is large and multi-disciplinary or small; </li> <li class="MsoNormal" style="line-height: 200%"> whether there is inter-laboratory collaboration; </li> <li class="MsoNormal" style="line-height: 200%"> whether there is international collaboration and, if so, with which country or countries; </li> <li class="MsoNormal" style="line-height: 200%"> whether the research has been reviewed by a peer-review committee for funding and, if so, by how many; </li> <li class="MsoNormal" style="line-height: 200%"> whether the research has been funded by a particular sector (government, private-non-profit, industry); and </li> <li class="MsoNormal" style="line-height: 200%"> the city in which the research has been conducted. </li> </ul> Cancer nursing research is still in a developmental stage, although it has made a considerable contribution to the evidence base of the discipline. A number of issues need to be tackled before we improve our output, such as organizational or workforce issues, infrastructure support, funding, and methodologic challenges.         Bibliography Capriotti, T. (2005). New Oncology Strategy: Molecular Targeting of cancer Cells. Dermatology Nursing. Doenges, M. and Moorhouse, A. (2004). Nurse’s Pocket Guide: Diagnoses, Interventions, and Rationales 9th Edition. F.S. Davis Publishing. Ernst, S. (2006). What is Cancer Research Worth? Bioscience Technology. Ganong, W. (2001). Review of Medical Physiology 20th Edition. McGraw-Hill. Goddard, A. (2000), “Research faces big overhaul”, THES, No.1 September, pp.4. Grubbs, R. (2004). Health Disparities in Practice and Research for Aging Women with Cancer. Journal of Cultural Diversity. Guyton, A. and Hall, J. (2000). Textbook of Medical Physiology 10th Edition. Harcourt Asia Pte Ltd. Holt, J., Barrett, C., Clarke, D., & Monks, R. (2000). The Globalization of Nursing Knowledge. Nurse Education Today, 20(6), 426-431. Ismail, I. (2003). Adding Value to Cancer Research. New Straight Times. Kozier, B. and Erb, G. (2004). Fundamentals of Nursing: Concepts, Process, and Practice 7th Edition. Pearson Education Inc. Lutzen, K. (2000). A Global Perspective on Domestic and International Tensions in Knowledge Development. Journal of Nursing Scholarship, 32, 335-337. Mallory, G. (2001). State of Oncology Nursing Workforce: Problems and Implications for Strengthening the Future. Nursing Economics. Marmot, M., Bobak, M. (2000), “International comparators and poverty and health in Europe”, British Medical Journal, Vol. 321 pp.1124-8. Messias, D.K. (2001). Globalization, Nursing, and Health for All. Journal of Nursing Scholarship, 33, 9-11. Milone, M.A. (2004). Oncology Nursing Education: Teaching Strategies That Work. Nursing Education Perspectives. Molassiotis, A., Gibson, F., Kelly, D., Richardson, A., Dabbour, R.,  Ahmad, A., & Kearney, N. (2006). A Systematic Review of Worldwide Cancer Nursing Research: 1994 to 2003. Cancer Nursing. 29(6):431-440,. National Cancer Institute. Retrieved April 10, 2003, from http://www.nci.nih.gov/cancer_information/cancer_type/breast Murray, R.K., Granner, D.K., Mayes, P.A. & Rodwell, V.W. (2000). Harper’s Biochemistry 25th Edition. McGraw-Hill. No Author. (2005). Cancer Nurses Burn Out. Australian Nursing Journal. Patel, K., Thomson, A., Tysome, T., Utley, A., Wojtas, O. (1999), Nurturing the creative, THES, No.3 December, pp.6. Perry, M.C. (1996). The Chemotherapy Source Book 2nd Edition. Williams and Wilkins. Saegusa, A. (1999), “Japanese labs balk at bid to boost external evaluation”, Nature, Vol. 397 No.6718, pp.378. Seers, K. (2004). International Content of High Ranking Nursing Journals in the Year 2000. Journal of Nursing Scholarship. Credit:ivythesis.typepad.com

A Systematic Review of Worldwide Cancer Nursing Research: 1994 to 2003

The word cancer elicits dread in nearly everyone. Cancer accounts for considerable mortality and morbidity in both men and women (Kozi...

NURSING CANCER RESEARCH

A Systematic Review of Worldwide Cancer Nursing Research: 1994 to 2003   The word cancer elicits dread in nearly everyone. Cancer accounts for considerable mortality and morbidity in both men and women (, 2004). Certain genes controlling growth and interactions with other normal cells are apparently abnormal in structure or regulation in cancer cells ( & , 2000). People of all ages develop cancer which could affect a wide variety of body organs. The incidence of many cancers increases with age: which means that as people live longer, many more will develop the disease. Apart from individual suffering, the economic burden to society is immense ( , 2000). Cancer cells are characterized by three properties: (1) diminished or unrestrained control of growth; (2) invasion of local tissues; and (3) spread, or metastasis to other parts of the body. Cells of benign tumors also show diminished control of growth but do not invade local tissue or spread to other parts of the body (, 2000).             Cancer is caused in all or almost all instances by mutation or by some other abnormal activation of cellular genes that control cell growth and cell mitosis (, 2001). The abnormal genes are called oncogenes ( & , 2000). Cancer tissue competes with normal tissues for nutrients. Because cancer cells continue to proliferate indefinitely, their number multiplying day by day, one can readily understand that the cancer cells soon demand essentially all the nutrition available to the body or to an essential part of the body. As a result, normal tissues gradually suffer nutritive death ( & , 2000). An abnormal cell mass that develops when controls of the cell cycle and cell division malfunction is called a neoplasm. However, not all neoplasms are cancerous. Benign neoplasms are strictly local affairs. Neoplasms tend to be surrounded by a capsule, grow slowly, and seldom kill its hosts if removed before it compresses vital organs. In contrast, malignant (cancerous) neoplasms are nonencapsulated masses that grow more relentlessly and may become killers. Its cells resemble immature cells, and it invades their surroundings rather than pushing it aside, as reflected in the name cancer from the Latin word for “crab.” Malignant cells also tend to spread via the blood to distant parts of the body, where they form new masses. This last capability is called metastasis (paragraph source from , 2004). Genetic aspects of cancer are probably receiving the greatest current attention among genetic abnormalities. Genetic abnormalities refer to abnormalities in chromosomes (, 2006), such as those that occur in the process of cancer. Some cancers are caused by oncogenes, genes which are carried in the genomes of cancer cells and are responsible for producing their malignant properties (& , 2000). These genes are derived by somatic mutation from closely related proto-oncogenes, which are normal genes that control their growth. Over 100 oncogenes have been described (, 2001). The initiation of mitosis and normal cell division depends on the orderly occurrence of events during the cell cycle. There is intense interest in the biochemical machinery that produces mitosis, in part because of the obvious possibility of its relation to cancer. When DNA is damaged, entry into mitosis is inhibited, giving the cell time to repair the DNA; failure to repair damaged DNA leads to cancer (, 2000). The cell cycle is regulated by proteins called cyclins and cyclin-dependent protein kinases, which phosphorylate other proteins (, 2001). Cell replication involves not only DNA polymerase but a special reverse transcriptinase that synthesizes the short repeats of DNA that characterize the ends (telomeres) of chromosomes. Cells with high telomerase activity, which includes most cancer cells, can in theory keep multiplying indefinitely (Paragraph source , 2001).             Cell Division in normal and cancer cells. Source:             The stepwise development of a typical colon cancer is as follows:   1 2 3 Cellular changes Increased cell division Growth of polyp Growth of malignant tumor (carcinoma) DNA changes Oncogene activated Tumor-suppressor gene activated Second tumor-suppressor gene activated   The treatment of choice for either type of neoplasm is surgical removal. If surgery is not possible – as in cases where the cancer has spread widely or is inoperable – radiation and drugs (chemotherapy) are used (, 2004). Chemotherapeutic drugs destroy malignant cells (, 2004). A process known as ‘adjuvant chemotherapy’ or ‘adjuvant radiotherapy’ is used  when chemotherapy or radiotherapy is used in addition to surgery (, 2004). For example, a patient following surgery may be given a course of chemotherapy or radiotherapy. This aims to kill any cancer cells which may have spread away from the primary tumor site. Sometimes, adjuvant chemotherapy or radiotherapy is given before surgery to shrink a large tumor so that the operation to remove the tumor is easier for a surgeon to do, and is more likely to be successful (, 2004).             Cytotoxic therapy regimens are highly toxic to cells, and can result in a range of acute and chronic adverse effects for persons receiving these treatments (, 1996). A number of these adverse effects are potentially life threatening. The safe and effective delivery of these drugs therefore requires highly complex clinical assessment, technical and problem solving skills. Surgery, radiotherapy, and chemotherapeutic agents are the major modalities used to treat patients with cancer, though various biologic therapies are beginning to have a significant impact. This means that biologic therapies are slowly being used in the realm of cancer treatments. The challenge is to make available drugs (natural products or synthetics) that can kill cancer cells effectively but are not excessively toxic to normal cells. It must be noted that cancer treatments should only kill cancer cells and not the normal cells. This explains the importance of developing drugs and other treatments that can kill cancer cells yet has minimum if not zero harm to the normal cells. Among the many available drugs and compounds used in the treatment of cancer, a few are listed in the table below: Class of Compound Example Site of Action Treatment Use Alkylating agents Melphalan Alkalytes DNA and other molecules Myeloma Antimetabolites <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify"> Purine antagonists </li> </ul>   <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify"> Pyrimidine antagonists </li> </ul>   <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify"> Folate antagonists </li> </ul>   Mercaptopurine     Fluorouracil     Methotrexate   Converted to a “fraudulent” nucleotide and inhibits purine synthesis Converted to a “fraudulent” nucleotide and inhibits thymidylate synthetase Inhibits dihydrofolate reductase   Acute myelocytic leukemia   Colorectal cancer     Choriocarcinoma Antitumor antibiotics Doxorubicin Intercalates in DNA and stabilizes the DNA-topoisomerase II complex Hodgkin’s disease Other agents Cisplatin   Hydroxyurea Causes strand breakage in DNA Inhibits ribonucleotide reductase Carcinoma of the lung Chronic myelocytic leukemia Plant compounds Vinblastine Binds tubulin and inhibits microtubule formation Kaposi’s sarcoma Sex hormones Estrogens Block effects of androgens in prostatic tumors Cancer of the prostate Corticosteroids Prednisone Inhibits proliferation of lymphocytes Myeloma Source:               Insofar as unrestrained cell division is a feature that typifies many malignant tumors, many of these agents are used because they inhibit DNA synthesis. For this reason, these agents are also likely to damage normal tissues whose cells divide continuously – e.g. bone marrow (paragraph source , 2000). To explain further, bone marrow which normally divides at a continuous division, could be stopped once exposed to cancer treatments, causing an abnormality in the bone marrow production yet helping combat cancer cells. Anti-cancer drugs have unpleasant side effects because, as mentioned in the previous paragraph, most target all rapidly dividing cells, including normal ones (, 2000). The side effects include nausea, vomiting, and loss of hair (, 2004). X rays also have side effects because, in passing through the body, the x-rays kill healthy cells that lie in the path to the cancer cells ( 2004). Life threatening adverse reactions and side effects of the treatment include pulmonary fibrosis and anaphylaxis/anaphylactoid reactions ( & , 2004). The most frequent includes fatigue, diarrhea, nausea, vomiting, anemia and neurotoxicity ( & , 2004).             Current cancer treatments – “cut, burn, poison” – are recognized as crude and painful. Promising new methods focus on delivering anticancer drugs precisely to the cancer (via monoclonal antibodies that respond to one type of protein on a cancer cell) and on increasing the immune system’s ability to fend off cancer ( 2004). In all these events in a cancer patient, the senior oncology specialist nurses are responsible for co-ordinating care following any operations and/or treatment for cancer. A senior oncology nurse is highly qualified, having specialized training in caring for patients who have cancer, and has many years of experience in this field. As well as supporting a patient and his or her family through operation and treatment, the senior oncology nurse provides the patient and his or her caregivers with clear written and verbal information; and can also examine and arrange any tests the patient might need. The number of patients suffering from cancer worldwide has steadily increased in recent years mainly due to an ageing population (, 2006). Add to this, an increasing number of chemotherapeutic agents (, , 2000) and a multitude of regimes, it therefore becomes very important to the point that it should be imperative to educate the nurse on the care of the patient who has cancer. In line with the previous paragraphs describing the current situation with cancer, its patients, and the health care professionals, it was only fitting that a study was made to assess the cancer nursing research papers published in the past decade. This also aims to identify their characteristics in terms of country of origin, participants, settings, diagnostic foci, and methodologic choices. Additionally this study evaluates their quality as this would significantly help cancer treatments. A systematic review was carried out of all published papers in the Cumulative Index of Nursing and Allied Health Literature between the years 1994 and 2003, using the keywords “cancer,” “nursing,” and “research.” A total of 619 papers met inclusion criteria and were evaluated by 5 researchers. Almost half the papers were derived from the United States (49.1%), followed by the UK, Sweden, Canada, and Australia. Of all the published papers, more than half of these (52.2%) had health professionals (mostly nurses) as the studies’ participants. Also, much of the published research used patients with mixed diagnosis, or patients with breast or hematologic cancers. Two-thirds of the studies were quantitative, whereas most studies were descriptive in nature. The quality of both quantitative and qualitative studies was low, with only a small percentage meeting the highest quality criteria. Studies reporting funding and those published in journals with an impact factor showed a higher quality score than those not reporting funding or not published in journals with an impact factor. Concern for global health issues goes with a global perspective in nursing knowledge. As nations become increasingly interdependent, health for all is a worldwide goal, and the framework of health care constrained by national boundaries does not fit nursing (, 2001). A widely recognized advantage of globalization is improved access to information. Global communication in the field of nursing increases through print journals, electronic journals, online educational materials, and international conference proceedings. Worldwide dissemination of nursing information represents a novel opportunity to expand the reach and effect of professional nursing. Accordingly, interest in international collaboration has increased in the published literature in the past decade.             International collaborations are important because it would (a) improve knowledge and understanding of human needs across geographic boundaries, (b) support a global perspective for nursing by fostering worldwide inclusiveness, and (c) expand the cultural and ethical values underpinning goals in nursing ( & , 2004). Globalization in knowledge development is linked to international publication in the field of nursing. Knowledge about the international content of nursing journals is a necessary part of understanding the trend toward globalization of nursing knowledge. The systematic study of the international content of highly ranked nursing journals in 2000 was a way to benchmark the status of international publication in nursing (, 2004). Many issues about globalization have been raised in the nursing literature. Consensus is apparent that the development of international nursing requires a global focus and international collaboration. Leaders question whether Western science can be adapted to a global health framework and whether Western nursing is appropriate for global nursing practice (, 2000). Nurses realize that Western science does not have answers in all areas of nursing practice (., 2000) because knowledge and research development are embedded within cultural contexts (, 2000). In a global nursing framework, nurses should emphasize the concept of cultural sensitivity. International comparisons of cultural values are necessary because it helps researchers become aware of how different values influence the development of nursing knowledge and practice (, 2000). Scholars are aware of their own knowledge and cultural values, and they are encouraged to understand alternative ways of thinking (., 2000). International collaboration is important for the following reasons: (a) it provides alternative modes of thinking for nursing scholars, (b) it enables wide-range testing of theories in practice, (c) it facilitates scholarly maturity through self-assessment, and (d) it leads to advancement of nursing science (, 2004). Journals have to be identified in order to investigate the international focus in journals.             The advancement in biotechnology is also helping to speed up and improve cancer research in many parts around the world. Technology has allowed many medical institutions to do what these institutions are doing today. In cancer research, getting the data and results from DNA sample of patients is important in helping them understand why some people have cancer (, 2001). In the past, this process was tedious and would take up days, months, and even years before the researcher can get the data and results, let alone the analysis (, 2005). But with the existence of machines like the DNA sequencer and the microarray technology, cancer research has been sped up and can be done at a higher throughput. For instance, DNA sequencing is now quite a routine procedure in many laboratories and research centers (, 2003). Progress in the understanding of genetics, and its role in disease and cancer epidemiology, have encouraged scientists that they are on the brink of major advances in methods and treatments (, 2005). This progress includes the ability to target cancerous cells without harming healthy tissue as well as better targeted treatments for specific cancers based on understanding of their genetic structure (, 2005). While the billions of dollars being spent on cancer research by governments around the world is significant, it seems that now is the time to aggressively push forward, not cut back on spending (, 2006). Overall worldwide spending for cancer research is growing. This is good news for the health care consumer, who probably doesn’t care where therapies are developed as long as their treatment is successful.             New understanding of how cancer cells survive, thrive, and metastasize has enabled researchers to create new targeted therapies for cancer treatments, such as melanoma and Kaposi’s sarcoma, to minimize the harmful systemic effects (therapy on healthy cells. The specific and selective targets of future oncology drugs will require a detailed understanding of cancer cell biology, genetics, immunology, and biotechnology (paragraph source , 2005).             The search for anti-cancer therapies which target cancer cells specifically and selectively with less toxicity has been a quest in oncology for many years. Conventional chemotherapeutic agents do not target cancer cells selectively, leading to widespread adverse systemic effects. Chemotherapy, radiation therapy, and biological agents all target cells that are in the process of proliferation. Therefore, both cancer cells and mitotically active healthy cells are subject to the cytotoxic effects of these therapies (paragraph source, 2000).             The diagnosis of cancer and other life-threatening diseases can be devastating to patients and their families. While many complex, disease-focused medical procedures are routinely prescribed for patients, often little or no consideration is given to prescribing comfort measures and sustaining optimal quality of life (, 1996). Nurse educators are on the front lines in promoting the holistic care that is essential for the nurturing of patients with cancer and other serious illnesses (, 2004).             Among the many challenges faced by individuals affected by life-threatening illnesses are profound changes in social roles and interpersonal relationships ( & , 2004). Maintaining employment is difficult, and parenting, socializing with friends, and spiritual well-being are all affected. The whole person suffers by a threat to any one of four dimensions: physical, psychological, social, or spiritual. However, nurses who possess effective communication skills can positively influence rate of recovery, optimize pain control interventions, and better facilitate emotional well-being ( & , 2004).             Little empirically based information is available describing the extent to which the above problems also affect oncology nurses when referring to the nursing workforce specializing in the care of patients with cancer. Because most people who have cancer are older, the aging of the baby boom generation is expected to increase the number of people with cancer substantially, and hence the future demand for oncology nurses. Cancer is the second leading cause of death in many countries, exceeded only by heart disease. Today, however, reports of shortages of oncology nurses are not uncommon, and because many cancer facilities report difficulty retaining nursing staff, information is needed on the adequacy of the oncology nurse workforce (, 2001).             A study confirms long-held suspicions that lung cancer, the leading cancer killer of both men and women, is seriously underreported when compared to other major cancers. In an analysis of 600 randomly selected cancer stories that appeared between August 1999 and July 2000, 61 percent reported on breast cancer, 23 percent on prostate, 17 percent on colorectal cancer and only 9 percent focused on lung cancer outside of tobacco and smoking issues (, 2004). This is especially significant since more people die each year of lung cancer than the combined deaths from breast, prostate and colorectal cancer (, 2004).             Studies on cancer also further demonstrate the overwhelming ability of celebrities to draw attention to cancer issues (, 2004). Breast, prostate and colorectal cancers generated significant news attention through a number of celebrities who were affected, either directly or indirectly, by the disease. Television host Katie Couric significantly raised awareness of colorectal cancer on her program The Today Show; New York Mayor Rudolph Giuliani’s prostate cancer diagnosis drove coverage to peak levels. Only one celebrity was quoted speaking out for lung cancer, cyclist and cancer survivor Lance Armstrong, who was involved in the Lung Cancer Awareness Campaign in 1999 (, 2003).             Cancer nurses report a rising workload and concerns about a national shortage of nurses in the speciality. A federal government report had found there was a shortage of oncology and palliative care nurses in every state and territory except the Northern Territory, the Cancer Nurses Society of Australia (CNSA) told the inquiry into cancer services (, 2001). Recent research into the workloads of cancer nurses found 50% of cancer nurses did not have time to get through their work, and 70% said they were experiencing ‘moderate to high levels of emotional exhaustion’, the society said in its submission (, 2001).             The CNSA called for governments to improve cancer nurse staffing models; provide financial support to nurses to pursue further studies; and fund research into innovative models of cancer care involving specialist cancer nurses. A national approach is needed to address the workforce shortages of cancer nurses, particularly improving the available data on cancer nurses in the workforce and developing a national plan to improve staff retention and support strategies (, 2005).             As a result of improved diagnosis and treatment, more people are surviving cancer (, 2003). Cancer survival, however, can be attended by negative physical and psychological syndromes, including weight gain, lowered aerobic capacity, depression, anxiety and an overall decrease in quality of life ( & , 2004). In addition, cancer survivors are at increased risk for developing other chronic conditions such as cardiovascular disease, obesity and diabetes. Reasons for these risks are complex and include genetics, treatment factors, lifestyle factors and a sedentary lifestyle (, 2004).             Research on cancer survivors suggests that weight gain, depression, anxiety and other issues contributing to decreased longevity and quality of life can continue long after the course of treatment. In a study of breast cancer survivors eight years postsurgery, it was also reported that women had persistent symptoms of psychological and somatic disturbance (, 2004). Most studies on the physical and psychosocial effects of cancer have focused on the period during treatment or within two to three years of diagnosis (, 2004). Very little is known regarding the longevity of these sequelae, their impact on the aging survivor or the interventions that will improve quality of life (, 2004).             Findings from studies that focused on cancer suggest that these health issues may persist beyond the period of chemotherapy and radiation treatments (, 2003). These studies highlight the longevity of mental and physical changes, depression and decreased quality of life among cancer survivors. The findings emphasize the need for improved systems of care to minimize health disparities, and further research on interventions to improve health outcomes.             Research evaluation is currently enjoying a favored position in many countries as research budgets expand but there is also pressure from those who fund them to ensure value for money (, 1999). In several European countries, for example, there is a move to more competitive funding both of laboratories and of individual research projects (, 2000). The ultimate test of the utility of research is that it will give rise to new products and processes or, in the biomedical field, to better health for humans and animals. However, the route to these tangible benefits is often lengthy, especially for basic research (, 1999), so that proxy indicators are needed to show whether given expenditures have been worthwhile. The main proxy indicator is the esteem in which research is held by other researchers, which can be measured by the counting of citations. However, these suffer from some disadvantages: <ul type="disc" style="margin-bottom: 0in"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> they are somewhat costly to determine – typically about US per paper; </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> it takes time for them to accumulate, so that fair comparisons can be made – perhaps five years; and </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> comparisons between different fields and sub-fields are difficult because citation norms differ greatly (, 1999).</li> </ul> In some ways, the analysis of the factors which lead to high quality research is comparable with epidemiology. In this subject, the factors that lead to ill-health are analyzed. The problem in both analyses is that there may be missing factors, some of which are correlated with the ones used for analysis, and which can confound the apparent conclusions. For example, ill-health is positively associated with smoking, a poor diet, lack of exercise and a low-status job ( and , 2000). Each of these factors is strongly associated with the three others and indeed with yet more factors that can plausibly lead to ill-health, such as low income, low education level, poor housing and living in a polluted area. If public health measures are to be soundly based, it is essential that the individual effects of all these factors, and probably many more, are teased out, so that policies can be targeted on the most important ones. Similarly, the factors that lead to high quality research may plausibly include: <ul type="disc" style="margin-bottom: 0in"> <li class="MsoNormal" style="line-height: 200%"> the subject area of the research; </li> <li class="MsoNormal" style="line-height: 200%"> whether it is applied or basic (in biomedicine, clinical or basic); </li> <li class="MsoNormal" style="line-height: 200%"> whether it is carried out in an industrial or academic setting (in biomedicine, in a hospital or a university); </li> <li class="MsoNormal" style="line-height: 200%"> whether the team of authors is large and multi-disciplinary or small; </li> <li class="MsoNormal" style="line-height: 200%"> whether there is inter-laboratory collaboration; </li> <li class="MsoNormal" style="line-height: 200%"> whether there is international collaboration and, if so, with which country or countries; </li> <li class="MsoNormal" style="line-height: 200%"> whether the research has been reviewed by a peer-review committee for funding and, if so, by how many; </li> <li class="MsoNormal" style="line-height: 200%"> whether the research has been funded by a particular sector (government, private-non-profit, industry); and </li> <li class="MsoNormal" style="line-height: 200%"> the city in which the research has been conducted. </li> </ul> Cancer nursing research is still in a developmental stage, although it has made a considerable contribution to the evidence base of the discipline. A number of issues need to be tackled before we improve our output, such as organizational or workforce issues, infrastructure support, funding, and methodologic challenges. Acquisition of new knowledge is essential in contributing to nursing practice for cancer. The expansion of technology, changes in the health care delivery system, and aging of the population all require nurses to review and apply research findings to identify and solve not only cancer issues but other clinical nursing problems and issues as well. Bibliography Credit:ivythesis.typepad.com

NURSING CANCER RESEARCH

A Systematic Review of Worldwide Cancer Nursing Research: 1994 to 2003 The word cancer elicits dread in nearly everyone. Cancer accou...

Clinical Report : Specified Pain Management on Palliative Care

Specified Pain Management on Palliative Care Introduction Human beings undergoes life cycle, we are born, and we pass through various stages in life until we reached the end which is death. The manner of death of an individual varies; it could be sudden due to accidents, old age and the most common way is through the acquisition of illnesses. However, prior to the death of an individual with a severe illness, he or she is still provided extra care due to his or her condition. Palliative care is the care given to patients that are in the end-stage of the disease. According to the  (2007) it is the involvement of holistic care of patients that are in their advanced stage of illness. Healthcare professionals, apart from family members play a huge role in taking palliative care of the patients that are in the last stage of their lives. Health care professionals particularly the nurses are the front-runners in the management of palliative care of patients. Management of palliative care patients is a difficult task and needs an individual knowledgeable enough to identify the specific needs of the patient. A number of individuals and some of them are even health care workers do not have the appropriate knowledge in handling the patients therefore instead of easing the pain that the patient feels they add additional burden. Taking care of an ordinary sick patient is not an easy task what more if the patients is already on his or her last stage of illness and even life. The responsibilities of a health worker become doubled. According to  (2005) providing care to patients that are dying exhibits huge challenges for health workers particularly the nurses because these patients needs careful management of the signs and symptoms of their illness. Moreover, aside from the patients in palliative care, nurses also play an important role in supporting the family members as death approaches until after the patient’s death. Working in a palliative care unit in a hospital as a nurse is a very tough job because most of the patients in this unit are suffering from the end stage of their illnesses and deaths for the patients are inevitable. All of the patients are experiencing pain in their body in various degrees and locations. Managing these patients is not an easy task; fortunately I have enough knowledge to handle different cases. A number of new nurses have been accepted in the hospital and some of them are assigned in the palliative care unit, in order to help the new nurses and enhance their knowledge and skills implementing an orientation kit in managing and handling the pains of palliative patients will be made.             This paper examines the principles behind palliative care and the approaches that will be utilised to help in the management of pain. This paper also gives discussion on the ways to control the pain, the various pain problems that patients experience, and the recent advances on palliative care.   Having an orientation kit is important not just in the health care profession but also other jobs because it helps the newcomers to understand and know the basic necessities in the workplace. In the palliative care unit of hospitals extra care especially when handling the patients because their conditions are extremely sensitive, added to the fact that the patients feel very vulnerable as well as the family members. The clinical project will be started in the month of April 2007; various data will be gathered from April up to June of 2007. Writing of the whole kit will be on the whole month of July and then will be edited on the first two weeks of August. After editing it a copy will be sent to the head of the hospital for approval. Once the kit is approved, printing will began which is approximately two weeks. A projected introduction of the paper to the newcomers will be on the month of September 2007.   Principles of Palliative Care             According to the  (2007) palliative care is the method in which the quality of life of the patients, as well as their families, are enhanced in order to help face the problems related to life-threatening diseases by preventing and relieving the suffering through assessment and identification of pain and problems physically, psychologically and spiritually.             The  (2007) has identified the five principles of palliative care and these are: <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Palliative care respects the goals, like, and choices of the dying person. </li> In palliative care the health care providers must respect the wants and needs of the patients, as well as, those of the family members. The health workers must also determine who should take care of the patient from the patient itself. It aids the patient to understand the illness and the things he or she must expect in the future. Palliative care helps patients to identify the things that are important to him or her, as well as, the dislikes and likes of the patient. <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Palliative care looks after the medical, emotional, social, and spiritual needs of the dying person. </li> Palliative care lets the patients understand the death is a significant time for an individual. The health care workers, particularly the nurses offer ways to ease the pain and physical discomfort of the patient. Nurses must help the patient and the family adjust to the changes if the illness becomes worse. The nurse assures the patient that he or she is not alone and let him or her understand that there are difficulties, and in palliative care the nurse helps the patients look back on his or her life in order to make peace. <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Palliative care supports the needs of the family members. </li> The nurses that provide palliative care understand that the family members also need help in coping up with the situation. Nurses do that through support to family members especially during the time of their grievance. <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Palliative care helps gain access to needed health care providers and appropriate care settings.</li> In palliative care the health care providers are trained professionals and knows the way system works, it also helps the family members and the patients gain access to good doctors, hospitals and other health services. <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Palliative care builds ways to provide excellent care at the end of life. </li> It helps the health care providers, as well as, the family members determine the best ways in caring for dying individuals. It also helps the family members and patients look for funding such as health insurances and organisations.  (1997) enumerated the principles involved in palliative care and these are: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Confirms life and view death as a natural process in life. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> In palliative care the health worker does not speed nor postpone the death of an individual. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Provides relief from pain and other symptoms that lead to stress. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Incorporates the psychological and spiritual aspects of care. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Gives support to aid the patients in actively live until the time of death approaches. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Hive support to aid the families of the patients in coping up during illness and after death. </li> </ul>   Essential Components of Palliative Care              discussed that the significant components of palliative care are the efficient control of the symptoms, effective communication with the patients and their families. It is also important for nurses to help the patients in the rehabilitation with the objective of maximising the patient’s independence as possible. Life threatening illnesses progresses and as it does the nurses and the family members must continuously care the patient. Depression, anxiety, and confusion             Upon receiving the news most of the patients and even family members experience depression. According to (1997) the emotional and cognitive changes in patients with end-stagedisease manifest both psychological and biological impacts ofthe treatment and medical condition.  discussed that the psychological adjustmentreactions after diagnosis or relapse often include fear, sadness,perplexity, and anger. The psychological adjustments can be resolved within a few weekswith the aid of the patients’ own personal feelings, support of the family members, and professional care.   Symptoms and Signs of Depression              discussed that the signs and symptoms of depression are divided into somatic and psychological and these are: Somatic <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The energy decreases and the patients feel fatigue.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The sleep is often disturbed and the patient is waking up in the wee hours of the morning. </li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The appetite is reduced.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> Psychomotor agitation</li> </ul> Psychological <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The mood of the patient is always low and it is usually worst in the morning.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> Lost of interest and pleasure.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> Concentration and attention is decreased.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> Indecisiveness</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The patient feels guilt and worthlessness.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The insights about the future are pessimistic and hopeless.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> Thinking of committing suicide. </li> </ul> Symptoms and signs of confusion <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The patient reduces his or her awareness of the surroundings.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The strength and quality of attention is diminished. </li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The quality of abstract thinking and comprehension is decreased.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The patient feels disoriented in time, place, and person. </li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> The patient has hallucinations and visual distortions. </li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> Temporary delusions.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> Extreme emotional disturbance and under activity.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> Disturbed cycle of sleep.</li> <li class="MsoNormal" style="color: #333333; line-height: 200%; margin-bottom: 7.5pt"> Emotional disturbance.</li> </ul>   Approaches to pain management in palliative care             Palliative care is the care given to patients that are in their last stage of life, and usually these patients experience pains in various parts of their body.  (2007) discussed the different approaches to pain management during palliative care and these are: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Reduce the noxious stimulus</li> </ul> In decreasing the noxious stimulus the patient is deliberated to appropriately provide proper treatment of the fundamental cause of the pain through various measures such as chemotherapy, radiotherapy and surgery.   <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="color: black; text-align: justify; line-height: 200%; margin-bottom: 7.5pt"> Raise the pain threshold</li> </ul> Most of the palliative care patients feel depressed, anxious, and confused upon receiving the news thus the pain that they are feeling worsens. Support of the health workers does not necessarily help the some of the patients cope up with the situation. In this case, aside from the support of the nurses, family, it is necessary to require support from the church and professionals.             Aside from the family members the use of drugs could also aid in raising the threshold of pain of the patients, there are anti-depressant drugs in the market that could help suppress the feelings of the patients.             The easiest way to suppress pain due to depression is to make certain that the patients get enough sleep at night. <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="color: black; text-align: justify; line-height: 200%; margin-bottom: 7.5pt"> Consider an opoid</li> </ul> Giving analgesic to patients also helps suppress the pains of an individual particularly during the end-stage of life of an individual.             Pharmacologic Approaches to Pain Management               According to  (2007) the world Health Organization developed a three-step pahramacological approach to pain management and these are: <li class="MsoNormal" style="text-autospace: none"> Nonopioid Analgesics. Ceiling Effects of Nonopioid Analgesics </li>   There are two types of nonpioid analgesics and these are the acetaminophen and the nonsteroidal anti-inflammatory drugs. Acetaminophen- it is a useful medicine for coanalgesic situation such as headache and it does not have anti-inflammatory effects, however if the patient has hepatitis and has high alcohol intake the risks would be increased. Nonsteroidal Anti-Inflammatory Drugs- it is a useful coanalgesics and efficient in decreasing the bone and inflammatory pain. However the adverse effects include Gastrophy, Renal failure and inhibition of platelet aggregation. <li class="MsoNormal" style="line-height: 200%; text-autospace: none"> ad 3. Opioid Analgesics</li> Opioids reach the peak plasma concentration 60 to 90 minutes after it is induced orally, 30 minutes if it is induced through injection, 6 minutes after intravenous injection and they are removed from the body the liver conjugates the opioids, the kidney excretes the metabolites, the metabolic pathways do not clog, each opioid metabolite has a half life which has an efficiency approximately 3 to 4 hours, therefore, steady state of the concentration of plasma is achieved daily.   Nonpharmacologic Approaches to Pain Management              (2005) nonpharmacologic interventions are significant additions in reducing the pain, disturbance of mood and even aid in increasing the quality of life of the patients.  discussed the four interventions utilised in the nanpharmocologic approach and these are: Psychological Interventions- a health worker particularly nurses in the palliative care units must identify the psychological issues such as beliefs and ways of coping because it is a relevant aspect in the pain treatment. The fear of death and advancement of the disease is a common occurrence among palliative patients however the level of psychological distress differs among patients ( 2004). Moreover, Brietbart et al discussed that psychiatric disorders often occurs among patients that experienced pain. Cognitive Behavioural Intervention- in cognitive interventions the nurses must identify and determine the track of their pain, the emotions and thoughts are determined, and follow the increase of the severity of pain. Controlling the pain and perceiving that they can decrease the pain that they feel could decrease the pain that a patient feels ( 2003). Behavioural Interventions- in behaviour interventions analysis of the behaviour of an individual is done and the condition is evaluated, prevented and treated. Behavioural interventions such as music therapy, meditation, and hypnosis are utilised. According to the study of  (2002) hypnosis has been efficient in suppressing the pain during postoperative processes. Psychosocial Interventions- (2005) found out that in treating the pain of cancer patients it involves three steps and these are education about cancer, hypnosis and imagery methods. Letting patients understand the disease and assess the pain helps patients overcome pains.             In the study of  (2005) they found out that health workers who joined the cognitive-behavioural program have reported that it enhanced the self-efficiency in helping the patients control the pain that they feel, health workers become less strain because of the education they got. Therefore educating health providers about pain helps ease the pain of the patients because they become more knowledgeable.   Difficult Pain Problems              (1997) identified and discussed the three pains patients in the palliative care experience and these are: Neuropathic pain- neuropathic pain is caused by damaged tissues wherein it may be produced by a tumour penetrating the nervous tissues, surgery, radiotherapy, and chemotherapy can also contribute to the neuropathic pain. The characteristics of neuropathic pain are burning, stinging, aching, and stabbing, which can either be spontaneous or not.             Treatment could be through the use of opoids or through counter irritation, with the emergence of alternative medicines such as acupuncture some of the patients with neuropathic pain use it. Incident Pain- it is a pain caused by voluntary action like movement of the patients with pain. The treatments of incident pain are through physiotherapy and occupational therapy, and surgery. Visceral Pain- it can be difficult to describe however if it is determined bloating and nausea are the symptoms, however there are organs in the body that experience visceral pain such as the epigastric pain. The causes of visceral pain in cancer patients are the growth of tumour, invasion of the tumour in the parietal surfaces, distension due to blockage in the ducts, bowel, bladder due to tumour, inflammation, rupture in the viscous, and the release of the pancreatic enzymes. Treatment with drugs such as analgesics and non-drug measures such as alternative medicines could be utilised to treat visceral pain.   Advances in Palliative Care Advances in Pain Management              (2000) discussed that there are new drugs identified for management of pain and these are: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Bisphosponates blocks and treats bony metastases and the pain in various types of cancers. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> New types of opoids are created which are long acting. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Methodically administered anaesthetics like parenteral lignocaine. </li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Psychostimulants that counters the effects of opids.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Topical anaesthetics</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Specialised pain relieving procedures like nerve blocks. </li> </ul>   Advances in alleviating other symptoms             Aside from the advances in pain management Billings also discussed the advances in alleviating other symptoms that contributes to the pain of the patients and these are: Gastrointestinal Symptoms- patients are administered with prokinetic drugs new serotonin antagonist antiemetics has helped patients manage the symptoms in gastrointestinal cancer such as nausea and vomiting. In the case of AIDS the drugs helped in alleviating and managing intestinal obstruction. Dyspnoea- the addition of benzodiazepines to opioids and oxygen has helped in management of anxiety of patients in the palliative care. Confusional States- in recent studies researchers have determined that haloperidol and chlorpromazine in low doses have helped enhance the condition of AIDS patients and the neuropletics improved the organisational thinking of patients with emotional disturbances. Depression and use of psychostimulants- nurses and health workers must assess the patients and identify the symptoms, in this process health workers can identify whether the patients experiences depression or not. Psychostimulants are the new drugs in the treatment of depression due to terminal illness.    Advancement in the institutions             The world has now seen the importance of palliative care of patients, therefore a number of countries have started to acknowledge and incorporate it in their health system. According to  (2005), 20 percent of American hospitals (1,100) have developed palliative care units and/or consultation teams. Increasingly, palliative care is identified as part of quality medical care, at the same time, a series of initiatives has been launched to foster hospital- and hospice-based initiatives that will bridge the gap in services, enhance care, and support hospice teams that provide palliative care consultations to hospitalized patients.   Conclusion             Palliative care is not an easy task to be undertaken by a medical professional, it needs knowledgeable and skilful health workers that could address the needs of these sensitive patients. Nurses must have the basic knowledge in pain management in order to help patients that are in their palliative stage in the disease. Through having an orientation kit that states the basic ideas on pain management on palliative care and the new advances in pain management it would greatly help newcomers in addressing the needs of their patients.     Credit:ivythesis.typepad.com

Clinical Report : Specified Pain Management on Palliative Care

Specified Pain Management on Palliative Care Introduction Human beings undergoes life cycle, we are born, and we pass through various s...