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Although aggressive medical treatment protocols have led to 80% five-year survival rates for most childhood cancer patients, many long-term survivors experience multiple troubling symptoms. Using data from 100 adult survivors of childhood cancers (ACC-survivors), we used latent variable mixture modeling to generate unique subgroups of survivors based on their experiences with a cluster of eight symptoms: lack of energy, worry, pain, difficulty sleeping, feeling irritable, feeling nervous, difficulty concentrating, and feeling sad (as measured by the Memorial Symptom Assessment Scale). We also examined factors that were likely to predict subgroup membership (chronic health conditions [CHCs], health-promoting lifestyle, and demographic variables) and determined the extent to which satisfaction with quality of life (QoL) varied across the subgroups. The final mixture model included three subgroups of ACC-survivors: high symptoms (HS; n=21), moderate symptoms (MS; n=45), and low symptoms (LS; n=34). ACC-survivors who reported at least one CHC were six times as likely to be classified in the HS subgroup as compared with the LS subgroup. Mean health-promoting lifestyle scores were lowest in the HS subgroup and highest in the LS subgroup. Differences in QoL among the subgroups were statistically significant, thus validating that the subgroups were characterized uniquely for identifying those symptoms with highest life impact. To our knowledge, we are the first to identify distinct subgroups of ACC-survivors differentiated by symptom cluster experience profiles. The findings warrant additional research to confirm the subgroup-specific symptom cluster experience profiles in larger studies of ACC-survivors.

Background: Pain is common in head and neck cancer (HNC) patients and may be attributed to the malignancy and/or cancer treatment. Pain mechanisms and patient report of pain in HNC are expected to include both nociceptive and neuropathic components. The purpose of this study was to assess the trajectory of orofacial and other pain during and following treatment, using patient reports of neuropathic pain and nociceptive pain and pain impact., Methods: 124 consecutive HNC patients receiving radiation therapy (RT) (95 men, 29 women; mean age: 54.7 +/- 12.3 years) participated in a patient-reported outcome (PRO) assessment. Patients completed the McGill Pain Questionnaire three times during therapy and 3 months following study entry., Results: The majority of patients related their pain to the tumor and/or cancer treatment. Whereas 59% reported their pain to be less severe than they expected, 29% were not satisfied with their level of pain despite pain management during cancer therapy. Worst pain was 3.0 +/- 1.3 on a 0- to 5-point verbal descriptor scale. Pain intensity was present at entry, highest at 2-week follow-up, declining towards the end of treatment and persisting at 3-month follow-up. The most common neuropathic pain descriptors chosen were aching (20%) and burning (27%); nociceptive words chosen were dull (22%), sore (32%), tender (35%), and throbbing (23%), and affective/evaluative descriptors were tiring (25%) and annoying (41%). 57% of patients reported continuous pain, and combined continuous and intermittent pain was reported by 79% of patients., Discussion: This study provides evidence that patients with HNC experience nociceptive and neuropathic pain during RT despite ongoing pain management. The affective and evaluative descriptors chosen for head and neck pain indicate considerable impact on quality of life even with low to moderate levels of pain intensity. These findings suggest that clinicians should consider contemporary management for both nociceptive and neuropathic pain in head and neck cancer patients.

We aimed to determine the acceptability and feasibility of a pentablet-based software program, PAINReportIt-Plus, as a means for patients with cancer in home hospice to report their symptoms and differences in acceptability by demographic variables. Of the 131 participants (mean age = 59 +/- 13, 58% women, 48.1% African American), 44% had never used a computer, but all participants easily used the computerized tool and reported an average computer acceptability score of 10.3 +/- 1.8, indicating high acceptability. Participants required an average of 19.1 +/- 9.5 minutes to complete the pain section, 9.8 +/- 6.5 minutes for the medication section, and 4.8 +/- 2.3 minutes for the symptom section. The acceptability scores were not statistically different by demographic variables but time to complete the tool differed by racial/ethnic groups. Our findings demonstrate that terminally ill patients with cancer are willing and able to utilize computer pentablet technology to record and describe their pain and other symptoms. Visibility of pain and distress is the first step necessary for the hospice team to develop a care plan for improving control of noxious symptoms.

An important component of end-of-life education is to provide health professionals with content related to dying, loss, and grief. The authors describe the strategies used to develop and offer a blended course (integration of classroom face-to-face learning with online learning) that addressed the sensitive and often emotional content associated with grieving and bereavement. Using Kolb's Experiential Learning Theory, a set of 4 online learning modules, with engaging, interactive elements, was created. Course evaluations demonstrated the success of the blended course in comparison to the traditional, exclusive face-to-face approach.

Palliative Performance Scale (PPS) scores have shown potential for prognosticating survival in Caucasian samples, but have not been studied for prognostic value in cancer patients from minority groups. Using data obtained from a retrospective chart audit of 492 cancer patients admitted over an 18-month period to a minority-serving home-based hospice and palliative care program, we examined the relationship between PPS scores and length of survival (survival days). Patients with PPS scores of 10% to 30% had fewer survival days than those with scores of 40% and those with scores of 50% to 100% (median=6, 19, and 34 days, respectively; F=25.02, P<0.001). A PPS score of 40% serves as a reliable inclusion criterion for a study requiring two weeks for completion, whereas 50% to 100% is required for a three-week study. Findings from a predominantly minority sample are similar to those from predominantly Caucasian samples.

Purpose/objectives: To examine correlates of participation in regular physical activities among young adult survivors of childhood cancers., Design: Descriptive, correlational., Setting: Web-based survey., Sample: 117 well-educated, predominately Caucasian survivors of various types of childhood cancers (-X age = 24 years)., Methods: Participants completed four rating scales, a stages of change measure, and background questions. Logistic regression and graphical methods were used to examine relationships among physical activity correlates and physical activity., Main Research Variables: Physical activity stages of change, autonomous motivation, physical activity pros and cons, self-efficacy, and self-reported worries., Findings: More than 80% of participants reported that they were physically active. Survivors who were autonomously motivated and who perceived fewer cons to being physically active were more likely to report being active than survivors with lower autonomous motivation scores and higher physical activity cons scores. Worries about the present and future moderated the effect of physical activity cons on physical activity. The estimated probabilities of reporting being active for women and men changed as the collective contribution of autonomous motivation, physical activity cons, and worries varied from low to high values., Conclusions: Engaging in physical activity willingly and without a sense of pressure (autonomous motivation), perceiving fewer cons to physical activity participation (cognitive appraisal), and worrying about the present and future (affective response) were important correlates of self-reported physical activity beyond the influence of gender., Implications for Nursing: Interventions that promote autonomous motivation, decrease physical activity cons, and address present and future worries may increase physical activity in young adult cancer survivors and may have a greater impact on women than men.

To compare the symptom experiences between men and women with acute coronary syndromes (ACS), we surveyed a convenience sample of 112 subjects with a final diagnosis of ACS in four hospitals. Our study found that after adjusting for cardiac diagnosis, diabetes, and age, women were more likely than men to experience chest discomfort rather than chest pain; pain/discomfort only in areas of the body other than the chest; pain/discomfort that started first either in the arm(s) or in areas of the body other than the chest; and unexplained anxiety. Women were less likely than men to experience chest pain/discomfort, pain/discomfort in the left side of the chest, and chest pain/discomfort as the most worrisome symptom. Significant gender differences were observed in the reports of several symptoms associated with ACS. This study is the first to identify different pain/discomfort referral patterns between men and women that require further validation.

Contemporary nursing practice needs reengineering to deliver its service effectively and efficiently. Using computer technology to support clinicians' decision making may be a parsimonious way to provide high-quality, patient-centered, efficient care. The process of developing the PAINReportIt and PAINConsultN system is described, and the results of two pilot studies in which the system was tested are summarized. The feasibility of using the system to assess pain and provide decision support for clinicians is demonstrated. The findings show PAINReportIt to be promising as an effective, efficient way for patients to report their pain. Whether PAINConsultN is an effective answer to cancer pain management barriers warrants further evaluation with larger samples. The advantages of using the system, as compared with use of the traditional pain management process, are discussed.

Purpose: Provider-patient communication deficits are often implicated as barriers to adequate cancer pain relief. The purpose of this study was to describe verbal communication behaviors and interactions between providers and patients reporting cancer pain., Methods: As part of a multisite clinical trial, we enrolled 17 oncology physician specialists and 84 patient participants who had reported cancer pain or treatment-related pain in the previous week associated with prostate or head and neck cancer. The study baseline clinic visits (N = 84) were audiotaped, transcribed, and entered into non-numerical unstructured data indexing searching and theorizing (NUD.IST) for content analysis. Each text unit in each transcript was coded as to conversation context: pain, additional symptom/side effects, tumor treatment, and/or personal remarks. Clinician questions were coded as either open-ended or closed-ended, clinician interruptions and subject changes were counted, and a measure of verbal dominance was calculated., Results: The clinicians spent over half the conversations doing the talking. We calculated a close-ended to open-ended question ratio of 5.8:1. In 55% of the visits, the patient with cancer was interrupted by the clinician when the patient attempted to provide information or ask a question. Symptoms/side effects were addressed in practically all visits, whereas sensory pain was addressed in 90% of the visits., Conclusions: The clinicians were attentive to daily problems relevant to treatment side effects; however, the results also indicate a pattern of communication during the clinic visit that is typically clinician oriented. The nature of such communication may prevent the patient from sharing significant facts and experiences relevant to cancer pain and thus compromise the quality of pain management.

Background: To overcome insufficient attention to end-of-life (EOL) care in nursing education, the authors are developing the "Toolkit for Nursing Excellence at End-of-Life Transition" (TNEEL)., Method: An evidence-based design process was used to create a computerized (CD-ROM) multimedia toolkit of instructional aides. An online survey of all U.S. undergraduate nursing programs was conducted to identify their current technologic infrastructures available for innovative teaching aides. Expert review process guided pedagogic decisions., Results: Survey findings enabled TNEEL development to be responsive to nurse educators' needs and preferences., Conclusion: Educators can use TNEEL to actively engage students in meaningful learning about EOL care.

Predictive validity of each word from the McGill Pain Questionnaire (MPQ) has not been investigated in relation to pain etiology. The purpose of this study was to explore differences in the words used to describe nociceptive and neuropathic pain. Patients with lung cancer (N = 123) selected words from the 78 MPQ pain quality descriptors and indicated the corresponding pain site for each word. Using only the MPQ pain location, and the cancer and treatment data abstracted from medical records, each pain site was classified as nociceptive or neuropathic (etiology). Pain etiology and quality descriptors were tested for proportional differences with sensitivity, specificity, and predictive value calculated for statistically significant descriptors. Of the 457 pain sites, 343 were classified as nociceptive (75%), 114 as neuropathic (25%). Lacerating, stinging, heavy, and suffocating were selected for a significantly larger proportion of nociceptive sites whereas throbbing, aching, numb, tender, punishing, pulling, tugging, pricking, penetrating, punishing, miserable, and nagging were selected for a larger proportion of neuropathic sites. Ten words correctly predicted 78% of the sites with 81% sensitivity to nociceptive pain and 59% sensitivity to neuropathic pain. Interestingly, several pain quality descriptors (burning, shooting, flashing, tingling, itching, and cold) previously associated with neuropathic pain did not distinguish between neuropathic and nociceptive pain. Infrequent selection of many MPQ words and lack of neurological exam data in the medical records are possible explanations for inconsistency with previous literature. Prospective studies are needed to validate pain quality descriptors for nociceptive and neuropathic types of lung cancer pain.

This study evaluated the feasibility of an innovative computerized symptom assessment tool, SymptomReport, and a computerized, tailored education tool, SymptomConsult, in a sample of 41 outpatients with cancer. After patients completed the computerized programs, an audiotaped telephone interview was conducted to assess patients' impressions. The study found that patients required less than 40 minutes on average to complete SymptomReport. The mean acceptability score was high 11 +/- 2. The 12 patients who completed SymptomConsult did so in an average of 20 minutes. The majority of participants indicated that the computer programs were easy, enjoyable, and informative tools. Initial formative research supports further study of these feasible computerized programs.

Nursing strongly values comfort and patient-centered care at the end of life, but little end-of-life content is included in most basic nursing education programs. An innovative way to improve nursing education about the end-of-life transition is to provide nurse educators with an electronic toolkit. This article describes a newly created multimedia toolkit (TNEEL), which includes engaging strategies for teaching and learning about end-of-life care.

Purpose: This prospective, longitudinal study was aimed to describe the prevalence, severity, and pattern of symptoms over the course of radiation therapy in persons with nasopharyngeal carcinoma and to explore symptom severity by treatment modality., Description of Study: Thirty-seven patients completed this study, and 46% received chemotherapy before radiation therapy. A self-reported radiation symptom checklist and an objective mucositis assessment tool were used weekly to document oropharyngeal, skin, nose or ear, or more general side effects, and mucositis., Results: Oropharyngeal problems were the most severe complaints during radiation therapy. All patients experienced dry mouth, taste change, difficulty in swallowing, difficulty in opening their mouths, hoarseness, sore throat, and observable mucositis. Most reported moderate-to-severe dry mouth, difficulty in swallowing, and sore throat from weeks 3 through 7. Skin problems were not prominent until week 4. Patients also lost an average of 3.9 kg during the therapy. Sequential chemotherapy and radiation therapy was associated with more severe oropharyngeal problems than radiation therapy alone, but no significant differences in other problems were found., Clinical Implications: Despite recognition of the oropharyngeal side effects associated with irradiation, effective management protocols for such symptoms have not been implemented in the studied institution. The frequency and intensity of the symptoms reported indicate an urgent need for increased vigilance about radiation-related side effects and pain management. As well, patient education about expected side effects may help mitigate the anxiety that patients experience when these symptoms occur.

Purpose/objectives: To compare patient reports of present and worst cancer-related pain intensity to the recalled intensity of several commonly experienced types of pain., Design: A secondary analysis on baseline data from patients with cancer pain., Setting: Tertiary-care facilities and patients' homes. Patients were enrolled between 1988 and 1995., Sample: Patients who were diagnosed with either primary lung cancer or cancer metastatic to bone, able to read and write English, over 18 years of age, and able to provide written informed consent. The sample of 125 patients was 62% male with a mean age of 60 years (SD = 11)., Methods: Patients completed the McGill Pain Questionnaire as a baseline measure in a pain research study. Investigators conducted comparisons among pain intensity scores reported for present pain intensity and worst cancer pain with the worst toothache, headache, and stomachache ever experienced using the Stuart test of marginal homogeneity., Main Research Variables: Present cancer pain intensity and worst toothache, headache, and stomachache pain intensity., Findings: Only 14% of the subjects reported that their present pain intensity was distressing, horrible, or excruciating, but 83% of them reported that their worst cancer pain was at these levels. The subjects reported that they experienced (a) significantly more intense pain with their worst toothache than either their present pain intensity (p < 0.001) or their worst cancer pain (p < 0.001), (b) significantly more intense pain with their worst headache than their present pain intensity (p < 0.001), and (c) significantly more intense pain with their worst stomachache than their present pain intensity (p < 0.001). In contrast, subjects reported that their worst cancer pain was significantly more intense than their worst headache (p = 0.047) or stomachache (p = 0.001)., Conclusions: The findings suggest that present cancer pain is not only experienced at lower intensity levels than common pains, but at lower levels than expected by patients, their families, and the public. Consistent with common beliefs though, the worst cancer pain is severe and not adequately controlled for 9 out of 10 patients., Implications for Nursing Practice: Healthcare professionals could use study findings to inspire hope in patients with lung cancer or bone metastasis and their families that present pain in cancer can be controlled successfully. Clinicians should devote greater efforts to relieve the worst cancer pain to levels achieved for the present pain experienced by people with cancer.

Preparation of advanced practice nurses (APNs) with acute care skills relevant to today's health care environment is a challenge faced by nurse educators, care providers, professional organizations, and regulatory agencies. The acute care nurse practitioner (ACNP) is prepared to provide multidimensional, risk-appropriate management of medically vulnerable patients with serious illness in a variety of settings. ACNPs conduct comprehensive health assessments, order and interpret diagnostic tests, diagnose and manage health problems and disease-related symptoms, prescribe and evaluate drugs and treatments, and coordinate care during setting transitions. Working independently and collaboratively the ACNP enhances access to care and quality of care for patients and families through cost-effective, outcome-oriented practice. This article describes health care market factors fostering ACNP practice, ACNP practice domain, the University of Washington ACNP program, and collaborative contributions from educators, care providers, professional organizations, and regulatory groups needed to implement the role.

This study was the first to compare patient and family member perceptions of sensory pain and to describe the relationships between these perceptions and psychological factors in patients with lung cancer and pain. Our findings indicate that family members understand the patient's pain location about 75% of the time; however, family members rarely understand the patient's pain intensity, pain quality, or pain pattern. Our findings also indicate that family members tend to overestimate strategies used by patients to cope with pain, especially in patients with low levels of anxiety and in patients with an internal locus of control. Although findings from this study differ from some previous studies, our study provides additional data to suggest that discrepancies may exist between family member and patient perceptions of the cancer pain experience. Nurses need to be aware of potential discrepancies and to combine assessment information from both patients and family members when developing pain management interventions.

Clinical reports rave about the efficacy of sublingual morphine, but most research data suggest that sublingual morphine lacks the necessary physical characteristics to be absorbed through sublingual tissues. This article clarifies these assertions by reviewing the clinical literature that supports sublingual administration, the theories relevant to sublingual morphine administration, and the pharmacokinetic research that supports or negates the benefit of this route. Recommendations for clinical nursing practice are provided to guide decision-making in care of patients with cancer pain.

Pain was measured and analgesic treatment examined in 131 children and adolescents, 8-17 years of age, for 5 days after surgery. Analgesic data were converted to 10 mg intramuscular morphine-equivalent doses (IMMSEQ) and were designated appropriate or inappropriate for body weight. Analgesic onset, peak, and duration were calculated in relation to administration routes and the time pain assessments were made. Children reported moderately severe pain in many body locations. Initially, all but two children were prescribed and ultimately all but one received analgesics. Prescribed and administered doses were frequently less than doses recommended for weight. Two-thirds of the children were beyond analgesic action when pain was assessed. Weak to moderately strong associations were noted between IMMSEQ doses and pain intensity scores on each of the 5 postoperative days. Unfortunately, findings indicate that children continue to be undertreated when they experience postoperative pain.

Although reflexes are recognized as protective responses to noxious stimuli, less is known about voluntary behavioral responses to cancer pain, which could provide clinicians with important diagnostic and therapeutic information. Forty-five patients with lung cancer were studied in their homes on 2 occasions to identify pain behaviors and to examine relationships between behaviors and selected variables. Patients completed the McGill Pain Questionnaire (MPQ) and Visual Analogue scale (VAS). Using a videotape observation method, patients sat, stood, walked, and reclined for 10 min. Videotapes were scored using 5 position-related and 31 pain-related behavior definitions. Within 3 days scored behaviors were described to patients who reported whether each scored behavior was performed: to express pain; because pain prevented usual behavior; to control pain; or as a habit. Patients reported that pain was controlled by 42 different behaviors; the number of different pain-reduction behaviors was correlated with pain intensity (r = 0.44) and pain quality (r = 0.64). Simultaneous multiple regression indicated that length of time pain was experienced, number of pain sites, pain quality, and pain intensity accounted for 41% of the variance in the number of pain control behaviors. None of the taped behaviors was reported as performed to express pain, and few of the patients reported that pain prevented behavior during the video session. Results clarify the pain-behavior construct, provide insight about the multidimensional nature of lung cancer pain, and suggest directions for behavioral interventions to augment pharmacological therapy for lung cancer pain.

Previous findings in patients with nonmalignant pain indicate a relationship between pain coping strategies and psychological factors. Although coping strategies have been explored in patients with cancer pain, relationships with such factors have not been reported. We wished to examine relationships between selected pain and psychological variables and the use of pain coping strategies. Forty-five patients with pain related to lung cancer indicated how they expressed their pain to others and completed the McGill-Melzack Pain Questionnaire (MPQ), State-Trait Anxiety Inventory, Visual Analogue Scale of pain intensity, and the Coping Strategies Questionnaire (CSQ). Forty-two percent of the patients reported that they tried not to let others know they had pain, and 40% indicated they told others when they had pain. Preferences for not telling others was associated with more frequent pain coping attempts for all CSQ subscales but those of catastrophizing and reinterpreting pain sensation. State anxiety demonstrated positive correlation with catastrophizing coping strategies (r = 0.48) and negative correlation with ability to control (r = -0.50) and decrease (r = -0.50) pain. The number of pain sites was correlated with coping self-statements (r = 0.34). Pain intensity and state anxiety demonstrated similar relationships. Pain quality as measured with the MPQ demonstrated moderately strong correlation with diverting attention, praying and hoping, catastrophizing, and increased activity. Interventions aimed at reinforcing or expanding a patient's pain coping repertoire should be developed with consideration given to the patient's anxiety level, pain intensity, pain quality, and pain expression preference.

Cancer pain management is a dynamic field. Advances in basic science research have tremendous implications for the clinical management of cancer pain. New drugs and innovative methods of delivering old drugs have been developed. The challenge facing clinicians is to use the newer techniques systematically and appropriately once they have been adequately tested. Nurses play a particularly important role in helping patients with cancer pain to manage their pain experience in ways that are effective for the patients to meet their personal goals.

Although considerable research has been conducted to identify children's and adolescents' language of pain, research is lacking regarding a method to quantify the pain quality described by this language. Three descriptive studies involving 1223 children, aged 8-17 years, were conducted in school and hospital settings. The aims were to develop and examine the validity and reliability of a word list for measuring pain quality that was free of age, gender, and ethnic biases. A word list with 43 words was developed and resulted in sensory, affective, evaluative, and total scores that correlated with pain location and pain intensity scores (r = 0.19-0.44; P less than or equal to 0.01). Pain quality scores decreased over time in a postoperative pain model. Test-retest reliability of the word list scores was high (r = 0.78-0.95; P less than 0.001). This word list was revised and resulted in a word list with 56 words relatively free of gender, ethnic, and developmental biases. Additional research is needed to assess the psychometric properties of this word list in pediatric populations experiencing different pain syndromes.

DADL was administered to a patient who was analgetically tolerant to continuously infused, intrathecal morphine sulfate. DADL restored analgesia without respiratory depression but opiate withdrawal syndrome was not prevented. Somnolence, not responsive to naloxone but completely reversed with morphine, was seen as an idiosyncratic mu receptor opiate withdrawal symptom. Clonidine hydrochloride and decreasing doses of oral morphine were used to successfully treat the withdrawal syndrome, including somnolence. Further research is indicated to verify the findings of this one patient and investigate the efficacy of DADL to provide analgesia for morphine-tolerant patients.