Department of Health (DOH) Academy jointly with

Gerontology Nurses Association of the Philippines (GNAP)

TRAINING PROGRAM ON GERONTOLOGY AND GERIATRIC NURSING
4 July to 7 October 2016

Name of Patient:
Diagnosis:

WORKSHEET ON PAIN MANAGEMENT

UP - PHILIPPINE GENERAL HOSPITAL : PALLIATIVE AND HOSPICE CARE
LUZ VELADO TULIO
Birthdate: 7-2-53
Status:
Age: 63
Ward/Bed #
Ovarian Cancer Stage II
Femal
Gender:
Admission Date
e

PAIN
ACCORDING
TO:
Type
Classification
Metastasis

DESCRIPTION
& ACTUAL
CLINICAL
FINDINGS
(include
reference)

NURSING CARE MANAGEMENT

(Independent or collaborative functions
or algorithm of care)
*Traditional/Conventional Care
**Contemporary/ Evidence Based/ Best
Practices

Assessment of
Pain
1.site
and
number
of
pains
2.intensity/
severity
of
pains
3. radiation of
pain
4. timing of
pain
5. quality of
pain
6. aggravating
and relieving
factors
7. etiology of
pain
- pain caused
by cancer
- pain caused

No somatic or
visceral
pain
noted during the
course of patient
interaction.

1. Determine pain history (location of

pain, frequency, duration, and intensity
using numeric rating scale (010 scale),
or verbal rating scale (no pain to
excruciating
pain)
and
relief
measures used. Believe patients
report.
2. Determine timing or precipitants of
breakthrough
pain
when
using
around-the-clock agents, whether oral,
IV, or patch medications.
3. Evaluate and be aware of painful
effects of particular therapies (surgery,
radiation, chemotherapy, biotherapy).
Provide information to patient and
significant others about what to expect.
4. Provide nonpharmacological comfort
measures
(massage,
repositioning,
backrub) and diversional activities
(music, television)
5.
Encourage
use
of
stress
management skills or complementary

Upon
chart
review,
there
was
no
pain
reported during
admission.
Reason
for
Admission:
For
chemotherapy
and
blood
transfusion
Patient is for
discharge
post
chemotherapy,
the same day

Submitted by: Orlea A. Francisco, R.N. M.A.N.

Nurse II- San Lazaro Hospital

SURGICAL AND
OTHER NONPHARMACOLOGICAL
PHARMACOLOGIC
MANAGEMENT
MANAGEMENT
(Based on WHO Pain Ladder)
(Complementary
therapies, surgery,
etc.)
If pain occurs, there should be Surgical
prompt oral administration of drugs
intervention
on
in the following order: nonopioids
appropriate
(aspirin and paracetamol); then, as
nerves
may
necessary, mild opioids (codeine);
provide
further
then
strong
opioids
such
as
pain relief if drugs
morphine, until the patient is free of
are not wholly
pain. To calm fears and anxiety,
effective.
additional drugs adjuvants Neurostimulation
should be used.
TENS, acupuncture
Anesthesiologic
To maintain freedom from pain, nerve block
drugs should be given by the clock,
Surgical
that is every 3-6 hours, rather than Cordotomy
on
demand
This
three-step Physical therapy
approach of administering the right exercise, heat, cold
drug in the right dose at the right Psychological
time is inexpensive and 80-90% Approach
effective.
-Cognitive
relaxation, imagery,
Hypnosis,
Biofeedback,

M
CI/ 10
9-20-16
PROGRESS
NOTES
(after at
least 3 days
of patient
care)
Not
assessed.

Department of Health (DOH) Academy jointly with

Gerontology Nurses Association of the Philippines (GNAP)
TRAINING PROGRAM ON GERONTOLOGY AND GERIATRIC NURSING
4 July to 7 October 2016
by treatment
-pain
associated
with
cancer
related
debility
(eg
decubitus
ulcers)
pain
unrelated
to
cancer
or
treatment
8. type of pain
- nociceptive
- visceral
- somatic
- neuropathic
complex
regional pain
syndrome.
- mixed
9.
analgesic
drug history
10.
patient
beliefs about
the meaning
of
pain,
effectiveness
of
its
treatments
and
consequences
of
drug
therapies
11. presence
of
clinically
significant

that
patient
interaction
happened.

therapies
(relaxation
techniques,
visualization,
guided
imagery,
biofeedback,
laughter,
music,
aromatherapy, and therapeutic touch).
6. Provide cutaneous stimulation (heat
or cold, massage).
7. Be aware of barriers to cancer pain
management related to patient, as well
as the healthcare system.
8. Evaluate pain relief and control at
regular intervals. Adjust medication
regimen as necessary.
9. Inform patient and significant others
of the expected therapeutic effects and
discuss management of side effects
10. Discuss use of additional alternative
or
complementary
therapies
(acupuncture and acupressure).

Submitted by: Orlea A. Francisco, R.N. M.A.N.

Nurse II- San Lazaro Hospital

Behavior therapy,
Psychotherapy

Complementary
therapy
massage,
art,
music
aromatherapy

Department of Health (DOH) Academy jointly with

Gerontology Nurses Association of the Philippines (GNAP)
TRAINING PROGRAM ON GERONTOLOGY AND GERIATRIC NURSING
4 July to 7 October 2016
psychological
disorder
eg
anxiety and/or
depression.

Name of Patient:
Diagnosis:
COMMON
DISTRESSIN
G
SYMPTOMS
(May classify
per system)
Constipation

WORKSHEET ON SYMPTOM MANAGEMENT

UP - PHILIPPINE GENERAL HOSPITAL : PALLIATIVE AND HOSPICE CARE
LUZ VELADO TULIO
Birthdate: 7-2-53
Status:
Age: 63
Ward/Bed #
Ovarian Cancer Stage II
Gender: Female
Admission Date

DESCRIPTION &
ACTUAL CLINICAL
FINDINGS
(include reference,
PE, ROS, Labs, etc.)
Subjective cue:
"Di
ako
madalas
dumumi, hirap ako
lalo
pa
ngayon
nagche-chemo ako.
Madalas kada 2-3
araw
akong
nadudumi
tapos
paunti
unti
na
parang
dumi
ng
kambing," as patient
verbalized.
-Infrequent
bowel
movements.
-There is no "normal"
schedule for bowel

NURSING CARE MANAGEMENT

(Independent or collaborative
functions or algorithm of care)
*Traditional/Conventional Care
**Contemporary/ Evidence Based/
Best Practices

PHARMACOLOGICAL MANAGEMENT
1st line medications
2nd line medications
Other medicine options

1. Ascertain usual elimination

habits. Assess bowel sounds and
record bowel movements (BMs)
including frequency, consistency
(particularly during first 35 days of
chemotherapy).
2. Monitor I&O and weight.
3. Encourage adequate fluid intake
(2000 mL per 24 hr), increased fiber
in diet; regular exercise.
4. Provide small, frequent meals of
foods low in residue (if not
contraindicated),
maintaining
needed protein and carbohydrates
(eggs., cooked cereal, bland cooked
vegetables).
5. Adjust diet as appropriate: avoid

1.
Bulk-Forming
Laxatives
(Methylcellulose,
Psyllium,
Polycarbophil) - Ideal as first-line
agents in cases of mild or transient
constipation
not
associated
with
opioid--induced constipation.
2. Emollient (Docusate) - First-line
agent concomitantly with stimulant
laxatives in the prevention of iatrogenic
constipation;
beneficial when given with bulk forming
agents to reduce straining.
3.
Osmotic
(Lactulose,
Sorbitol,
Glycerin) - Second-line therapy when a
stimulant laxative and stool softener do
not relieve constipation.
4.
Saline
(Magnesium
hydroxide,

Submitted by: Orlea A. Francisco, R.N. M.A.N.

Nurse II- San Lazaro Hospital

SURGICAL AND
OTHER NONPHARMACOLOGI
C MANAGEMENT
(Complementary
therapies,
surgery, etc.)
Aromatherapy,
massage
therapy,
and
aromatherapy
massage
Biofeedback

M
CI/ 10
9-20-16
PROGRESS
NOTES
(after at
least 3 days
of patient
care)
Not
assessed.

Department of Health (DOH) Academy jointly with

Gerontology Nurses Association of the Philippines (GNAP)
TRAINING PROGRAM ON GERONTOLOGY AND GERIATRIC NURSING
4 July to 7 October 2016
movements.
-Hard, difficult to
pass,
bowel
movements.
Often
will
pass
small
marble-like pieces of
stool,
without
a
satisfactory
elimination.
PE:
Soft,
abdomen

foods high in fat (butter, fried foods,

nuts); foods with high-fiber content;
food and fluids high in caffeine; or
extremely hot or cold food and
fluids.
6. Check for impaction if patient has
not had BM in 3 days or if
abdominal distension, cramping,
headache are present.

flabby

Sodium phosphate) - Indicated when

acute evacuation of the bowel is
desired; third-line
treatment if previous therapy is
ineffective in producing evacuation.
5. Stimulant (Bisacodyl, Senna, Castor
oil) - First-line (senna) for prevention of
opioid-induced constipation; may be
used first-line in combination with stool
softener; useful in
iatrogenic constipation.

Laboratory
findings:
No
baseline
electrolytes
result
that may contribute
to
altered
GI
function.
COMMON
DISTRESSIN
G
SYMPTOMS
(May classify
per system)
Fatigue

DESCRIPTION &
ACTUAL CLINICAL
FINDINGS
(include reference,
PE, ROS, Labs, etc.)

NURSING CARE MANAGEMENT

(Independent or collaborative
functions or algorithm of care)
*Traditional/Conventional Care
**Contemporary/ Evidence Based/
Best Practices

Subjective cue:
"Sa ngayon hindi
ako
mabilis
mapagod
at
nanghihina, kayang
kaya ko pa pero
sigurado pag-uwi ko
nandun na lahat ng

1. Plan care to allow for rest

periods. Schedule activities for
periods when patient has most
energy.
Involve
patient
and
significant
others
in
schedule
planning.
2. Establish realistic activity goals
with patient.

Submitted by: Orlea A. Francisco, R.N. M.A.N.

Nurse II- San Lazaro Hospital

PHARMACOLOGICAL MANAGEMENT
1st line medications
2nd line medications
Other medicine options

SURGICAL AND
OTHER NONPHARMACOLOGI
C MANAGEMENT
(Complementary
therapies,
surgery, etc.)

1. Hematopoietics - Anemia can occur Blood transfusion

in
patients
with
cancer
as
a
as ordered
consequence of either disease-related Exercise,
processes or anticancer treatment.
nutritional and
Treatment
with
epoetin
alfa
or
dietary
darbepoetin alfa one to three times per
assessment,
week for up to 6 months produced
and improved
increases in hemoglobin concentrations
sleep hygiene

PROGRESS
NOTES
(after at
least 3 days
of patient
care)
Not
assessed.

Department of Health (DOH) Academy jointly with

Gerontology Nurses Association of the Philippines (GNAP)
TRAINING PROGRAM ON GERONTOLOGY AND GERIATRIC NURSING
4 July to 7 October 2016
epekto ng chemo.
Andyan yung madali
ako
mapagod,
kailangan ko na ng
tulong
sa
mga
gawain at madalas
isang linggo akong
nakahiga,"
as
patient verbalized.
- Increased energy
requirements
(hypermetabolic
state and effects of
treatment)
-Altered
body
chemistry:
side
effects of pain and
other
medications,
chemotherapy
Unremitting /
overwhelming lack
of energy, inability
to maintain usual
routines, decreased
performance

3. Assist with self-care needs when

indicated; keep bed in low position,
pathways clear of furniture; assist
with ambulation.
4.
Encourage
patient
to
do
whatever possible (self-bathing,
sitting up in chair, walking).
Increase activity level as individual
is able.
5. Monitor physiological response to
activity (changes in BP, heart and
respiratory rate).
6. Perform pain assessment and
provide pain management.
6. Provide supplemental oxygen as
indicated.
7. Refer to physical or occupational
therapy.

PE:
Muscle
strength
grading: 4 - Active
movement
against
resistance
Katz
score:
6
Independent
Laboratory:
RBC 1.87 Low

Submitted by: Orlea A. Francisco, R.N. M.A.N.

Nurse II- San Lazaro Hospital

of 1.8 2.6 g/dl. Patients achieved

significant improvements in energy
level, activity level, and overall quality
of life, and decreases in fatigue.
2. Psychostimulants - Sleep disorders,
including insomnia and excessive
daytime sleepiness, are common in
patients with cancer. Psychostimulant
medications, such as methylphenidate,
could be effective in treating Cancer
Related Fatigue, as they have been
found to produce enhanced alertness,
attention, and vigilance, and to reduce
fatigue in patients with other chronic
conditions.
3. Corticosteroids - Three clinical trials
of glucocorticoids (one study of
methylprednisolone, one of prednisone,
and one of megestrol acetate) reported
improvements in symptoms, especially
pain, and showed improved quality of
life and reduced fatigue in patients with
metastatic cancer.
4. L-carnitine
- Chemotherapy can
adversely affect the levels of lcarnitine, a micronutrient important for
the processing of long-chain fatty acids
and energy production in mammalian
cells. Three studies of l-carnitine in the
treatment of cancer related fatigue
reported
increased
plasma
free
carnitine
concentrations
and
significantly improved fatigue and
quality-of-life measures.

Activity
enhancement

Maintain
optimal level of
activity
Consider
initiation
of
exercise
program
Consider
referral
to
physical
therapy/physic
al medicine &
occupational
therapy
as
appropriate
Physically-based
therapies
-Massage
therapy
Psychosocial
interventions:
Cognitive
behavioral
therapy
(CBT)/Behavior
al therapy (BT)

Psychoeducational
therapies/Educati
onal therapies

Supportive
expressive
therapies

Department of Health (DOH) Academy jointly with

Gerontology Nurses Association of the Philippines (GNAP)
TRAINING PROGRAM ON GERONTOLOGY AND GERIATRIC NURSING
4 July to 7 October 2016
Nutrition
consultation
Sleep restriction
Sleep hygiene
Stimulus control

Hemoglobin: 1.1 Low

Hematocrit
0.40
Normal

COMMON
DISTRESSIN
G
SYMPTOMS
(May classify
per system)
Oral
Problem: Dry
mouth

DESCRIPTION &
ACTUAL CLINICAL
FINDINGS
(include reference,
PE, ROS, Labs, etc.)
Subjective cue:
"Isa
sa
mga
problema ko yang
tuyong tuyo ang
buong
bibig
ko,
minsan nagsusugat
pa, pati ang pagkain
ko
ay
naaapektuhan," as
verbalized
by
patient.
-Side
effect
of
chemotherapeutic
agents
PE:
Moist oral mucosa
during assessment
Laboratory:
Hematocrit
Normal

0.40

NURSING CARE MANAGEMENT

(Independent or collaborative
functions or algorithm of care)
*Traditional/Conventional Care
**Contemporary/ Evidence Based/
Best Practices
1. Assess dental health and oral
hygiene periodically. Encourage
patient to assess oral cavity daily,
noting
changes
in
mucous
membrane
integrity
(dry,
reddened). Note reports of burning
in the mouth, changes in voice
quality, ability to swallow, sense of
taste, development of thick or
viscous saliva, blood-tinged emesis.
2. Discuss with patient areas
needing
improvement
and
demonstrate methods for good oral
care.
3. Initiate and recommend oral
hygiene program to include:
Avoidance of commercial
mouthwashes,
lemon
or
glycerine swabs;
Use of mouthwash made
from warm saline, dilute
solution
of
hydrogen
peroxide or baking soda and

Submitted by: Orlea A. Francisco, R.N. M.A.N.

Nurse II- San Lazaro Hospital

PHARMACOLOGICAL MANAGEMENT
1st line medications
2nd line medications
Other medicine options

SURGICAL AND
OTHER NONPHARMACOLOGI
C MANAGEMENT
(Complementary
therapies,
surgery, etc.)

1. Analgesic rinses (mixture of Koatin, Cryotherapy - It

pectin, diphenhydramine , and topical
has
been
lidocaine)
-Aggressive
analgesia
hypothesized
program may be required to relieve
that cooling of
intense pain. Note: Rinse should be
oral
mucosa
used as a swish-and-spit rather than a
using ice chips
gargle,
which
could
anesthetize
will reduce the
patients gag reflex.
blood flow to
2. Antifungal mouthwash preparation
the
oral
such as nystatin, and antibacterial
mucosa,
thus
Biotane may be needed to treat or
reducing
the
prevent secondary oral infections, such
availability
of
as Candida, Pseudomonas, herpes
chemotherapeu
simplex.
tic agents to
3. Antinausea agents When
the
oral
given before beginning mouth care
mucosa
regimen,
may
prevent
nausea
associated with oral stimulation.
4. Opioid analgesics: hydromorphone
(Dilaudid), morphine. May be required
for acute episodes of moderate to
severe oral pain.

PROGRESS
NOTES
(after at
least 3 days
of patient
care)
Not
assessed.

Department of Health (DOH) Academy jointly with

Gerontology Nurses Association of the Philippines (GNAP)
TRAINING PROGRAM ON GERONTOLOGY AND GERIATRIC NURSING
4 July to 7 October 2016
water;
Brush with soft toothbrush or
foam swab;
Floss gently;
Keep lips moist with lip gloss
or balm, K-Y Jelly, Chapstick;
Encourage use of mints or
hard candy or artificial saliva
as indicated.
4.
Instruct
regarding
dietary
changes: avoid hot or spicy foods,
acidic juices; suggest use of straw;
ingest soft or blenderized foods,
popsicles, and ice cream as
tolerated.
5. Encourage fluid intake as
individually tolerated.
6. Monitor for and explain to patient
signs of oral superinfection (thrush).
7. Refer to dentist before initiating
chemotherapy.

Submitted by: Orlea A. Francisco, R.N. M.A.N.

Nurse II- San Lazaro Hospital

Department of Health (DOH) Academy jointly with

Gerontology Nurses Association of the Philippines (GNAP)
TRAINING PROGRAM ON GERONTOLOGY AND GERIATRIC NURSING
4 July to 7 October 2016

Submitted by: Orlea A. Francisco, R.N. M.A.N.

Nurse II- San Lazaro Hospital