Cancer - Symptom Management Flashcards
(42 cards)
1
Q
Managing Physical Symptoms: Fatigue
A
- assess and treat cause
- Corticosteroids (only use if there is a reason why the patient needs energy. It is a stimulant that speeds everything up)
2
Q
Managing Physical Symptoms: Constipation
A
- assess and treat cause
- bowel protocol if on narcotics and no risk of mechanical bowel obstruction
3
Q
Managing Physical Symptoms
A
- assess and treat cause (chest tube for pleural effusion; peritoneal tap for ascites)
- comfort measures; O2 for hypoxia, positioning upright, fan, pacing activities
- Pharmaceuticals (morphine/hydromorphone to reduce experience of breathlessness)(corticosteroids if inflammatory conditions causing dyspnea)
4
Q
Managing Physical Symptoms: Nausea and Vomiting
A
- assess and treat cause
- pharmacologic interventions
- squashed stomach syndrome/gastritis/functional bowel obstruction: metoclopramide (not indicated if ? bowel obstruction)
- chemical causes like SE of morphine, hypercalcemia, or CRF: haloperidol
- If due to dysfunction of the vomiting centre in the brain (ie. increased ICP, motion sickness, mechanical bowel obstruction): gravol or meclizine
- General anti-nauseant: ondansetron
5
Q
Managing Physical Symptoms: Dehydration
A
- assess and treat cause. if r/t to poor intake and increasing PO intake not possible, discuss risks and benefits of IV/SC fluids
- if not rehydrating but allowing terminal process, ensure GOOD ORAL HYGIENE
6
Q
Managing Physical Symptoms: Anorexia/Cachexia
A
- comfort measures: reduces odours, treat pain, provide small frequent meals, assist with feeding prn.
- pharmacologic interventions, megestrol, corticosteroids, mirtrazipine
7
Q
Pain management: inadequate pain assessment is a significant barrier to effective pain management:
A
1) Pain scale
2) PQRST or LOTARP pain assessment
8
Q
Pharmacologic pain management
A
- NSAIDs
- Opioids-regular and breakthrough dosing
- Adjuvants (substance that enhances immune system response)
9
Q
Non-pharmacologic Pain management
A
1) relaxation therapy
2) imagery
10
Q
Know your PRNs
A
they are your most immediate means of intervening for pain for your patient
11
Q
Medication management: PRNs
A
- learning what PRNs are potentially of benefit to your resident is key to your ability to intervene and address pain
- intentionally build into your practice ongoing assessment of S&S that can potentially be helped by PRNs
12
Q
5 Steps to effective PRN use:
A
- regular assessment and documentation
- PRN use and documentation
- Evaluation of PRN and documentation
- Advocacy for around-the-clock management if PRN use becomes frequent (ATC is always preferable for persistent pain management)
- Advocacy for different PRNs in initial ones are ineffective
13
Q
Treating the Cause
A
- stabilization of underlying disease process must occur along with pain treatment
- also … consider the originating tissue:
14
Q
Bone pain
A
acetaminophen, NSAIDs
15
Q
Inflammatory pain:
A
NSAIDs, steroids
16
Q
Nerve pain
A
tricyclic antidepressants, CNS agents
17
Q
Cardiac pain
A
oxygen and nitroglycerin, morphine
18
Q
Skin/epithelial pain:
A
numbing agents: lidocaine (viscous lidocaine for mouth and throat pain)
19
Q
Analgesics
A
- medications that relieve pain without causing loss of consciousness
- “painkillers”
- many are OTC (for mild to moderate pain)
Tylenol
ibuprofen
naproxen - these medications are generally better than opioids for bone and inflammation-related pain
20
Q
Use of Non-Opioids
A
- weigh risk versus benefit
- start with low dose to determine patient’s reaction
increase gradually to dose that relieves pain, not to exceed maximum daily dose - if maximum anti-inflammatory effect is desired in addition to analgesia, allow adequate trail before discontinuing or switching
with regular doses for 1 week or longer, pain relief may improve
some non opioids (especially those for neuropathic pain) may take several weeks to begin to work well
21
Q
Use of Adjuvant Medications in Pain Management
A
- check side effects in your drug guide and monitor accordingly
- NSAIDs should be used cautiously in patients with hx of GI bleed, and always taken with food/milk
- Drugs that can cause orthostatic hypotension should be used with caution, especially in a resident with a preexisting cardiac condition
- Interactions with other drugs must be monitored carefully because elders are often prescribed many medications for coexisting conditions (polypharmacy)
22
Q
Opioids
A
- pain relievers that contain opium, derived from the opium poppy (morphine) or are chemically related to opium but synthetically manufactured (fentanyl, considered an opioid)
- narcotics: very strong pain relievers that are controlled substances (used for moderate - severe pain only)
- moderate pain: codeine (poor choice for regular dosing) - tramadol/tramacet.
- moderate-severe pain: hydromorphone, morphine sulfate, fentanyl, methadone HCl (dolophine): requires special prescribers with a license
23
Q
Opioid Administration: KEY Principles - Start Low
A
start with low doses, especially with impaired renal or liver function and in the elderly
24
Q
Go Slow
A
titrate doses gradually to analgesic response or until patient experiences unacceptable side effects. may begin with less frequent dosing (q6h instead of q4h)
25
By Mouth
while the oral route is most common as the safest and least invasive administration method, oral routes (IV, subcutaneous, rectal, transdermal, transmucosal) can be used as indicated to maximize patient comfort
26
By the Clock
- regular/fixed administration schedule, such as every 4 or 6 hours, rather than only "on demand" including waking from sleep for scheduled dose. Once pain control achieved, switch to long acting agents to improve compliance and sleep
27
Plan for Adverse Effects
anticipate, monitor and manage analgesic adverse effects, including starting laxatives proactively
28
Plan for Breakthrough pain
- when starting an opioid, use immediate release with breakthrough doses (BTD) until dose is stabilized to enable timely and effective titration
29
Opioid Analgesia: Breakthrough dosing
- breakthrough doses are generally 10% of the total regular daily opioid dose
- use immediate release opioids every hour orally or every 30 minutes subcutaneously PRN
- use of the same opioid for breakthrough pain doses and the regularly scheduled opioid improves the ease and clarity for determining future dose titrations
- reassess when 3 or more breakthrough doses used in 24 hr
30
About Opioid Analgesics
- start LOW and GO SLOW with the elderly and those with renal/liver impairment
- narcotic analgesics
- by special (controlled) Rx only
- physical tolerance requires increased doses over time so ongoing assessment in critical to continued good pain management
31
Side effects of opioid analgesics
- constipation (this should be treated prophylactically with Bowel protocol as long as the patient is on opioids)
- N&V - usually short-term with induction of opioid use (3-7 days)
- Cognitive impairment (confusion or sedation) - usually short-term with induction or titration of opioids (3-7 days)
- orthostatic hypotension
- dizziness
- potential respiratory depression (usually associated with newly prescribed opioids and/or significant increase in dose) - must be evaluated for with every opioid administration
32
Opioid Administration: Titration
- use practice tools to monitor pain rating, adverse effects, and track patient goal attainment. numerical or descriptive pain rating scale should be used consistently.
- follow sedation levels using a tool such as pasero opioid-induced sedation scale
- individualize dosing readjustments balancing effectiveness and tolerability
- titrate with caution in patients with risk factors such as decreased renal/hepatic function, chronic lung disease, upper airway compromise, sleep apnea
- adjustment may require a dose adjustment of both regular dose as well as the BTD
- Dose adjustments should not be made more frequently than every 24h.
- the rapidity of the dose escalation should be related to the pain severity, onset and duration, and ability to monitor during dose titration
- individualized dosing readjustments can use fixed dose increases.
- Adverse effects from opioids can be managed by dose reduction, changing to a different opioid or route of administration, or symptomatic management
- impaired swallowing capacity can require a conversion of oral opioids to subcutaneous or intravenous routes; reduce parenteral doses by half for chronic pain reflecting potency difference
- monitor for excessive opioid doses, effects often are sedation or confusion.
33
Always evaluate sedation and vital signs after opioid administration
POSS scale
34
Opiate Antagonists
- Naloxone (narcan)
- bind to opiate receptors and prevent a response
- used for complete or partial reversal of opioid-induced respiratory depression
35
Adjuvant Analgesics: Indications
- often given with opioid analgesic agents to assist the primary agents with pain relief
- NSAIDs (harsh on GI tract) - often for bony type pain in cancer. Ibuprofen. PPI's are given prior to administration of NSAIDs (achy pain)
- Antidepressants (amitriptyline - manage neuropathic pain) often seen in palliative patients. pain isnt always entirely physiological. element of altered mood because of the pain.
- anticonvulsants - neuropathic pain (Gabapentin)
- Corticosteroids (inflammatory pain) - Dexamethasone/prednisone
- Muscle relaxants - treat muscle spasms better than opioid
- Bone-modifying drugs (when cancer is degrading bone or you have osteoporosis)
36
Optimizing Adjuvant Medications for Analgesia: KEY Principles
- optimize the opioid regimen before introducing an adjuvant analgesic in cancer pain
- adjuvant analgesics are medications that have a primary indication other than pain and have analgesic effects in some types of painful conditions
- use of appropriate adjuvant analgesics at any pain severity level
- select based on predominating pain type, symptoms, comorbidities, supporting clinical evidence potential adverse effects, drug interactions, ease of administration and cost
- the adjuvant analgesic with the greatest benefit and least risk should be administered as first-line treatment. often this is an anticonvulsant such as gabapentin, or an antidepressant such as nortiptyline for treatment of cancer-related neuropathic pain
- doses should be increased until the analgesic effect is achieved, adverse effects become unmanageable, or the conventional maximum dose is reached
- reassess regularly and taper or discontinue ineffective medications
- consider combination therapy with two or more drugs in the event of partial response to single drug therapy
- avoid initiating and titrating several adjuvants concurrently
37
Opiate/Opioid Tolerance
- tolerance is a common physiologic result of chronic opioid treatment
- result: larger doses of opioids are required to maintain the same level of analgesia
- this is an expected and physiologically natural event
- pain assessment needs to be ongoing to titrate dose appropriately throughout opioid therapy because of this and the associated symptoms with opioid abstinence syndrome
38
Physical Dependence
- the physiologic adaptation of the body to the presence of an opioid... this is an expected effect of opioid therapy
- the effects of physical dependence on opioids is seen when the opioid is abruptly discontinued, or the dosing is interrupted, or when an opioid antagonist is administered
(narcotic withdrawal) (opioid abstinence syndrome - manifested as anxiety, irritability, chills, hot flashes, joint pain, lacrimation, rhinorrhea, diaphoresis, N&V abdominal cramps, diarrhea)
39
Psychological Dependence
- addiction is NOT a typical concern with opioid use in patients with persistent pain
- addiction is a pattern of compulsive drug use characterized by a continued craving for an opioid and need to use the opioid for effects other than pain (euphoria and psychological escape from life)
- getting high is the goal/drive
- the addicted person's family and/or social life is spiralling downwards as a result of this behaviour
- there is detrimental effects to key relationships in the addicted persons life
40
Physiologic Dependence and Tolerance of Opioids is NORMAL
- opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with psychological dependence (addiction) which is a mental health concern
- misunderstanding of these terms leads to ineffective pain management and contributes to the problem of undertreatment
41
Nursing Response
- learn your pharmacology of analgesics
- educate patients/famillies about pain management and therapeutic effectiveness, both pharmacological and non-pharmacological
42
Evaluate:
- for therapeutic outcomes
- for side effects
- for quality of life issues related to both pain and to medications
- documenting and reporting your findings
