Exam #02 Flashcards
1
Q
Which type of pain arises from skin, bone, joints, or muscle and is usually localized?
A
Nociceptive somatic pain
2
Q
Which type of pain arises from internal organs (large intestine or pancreas) and can manifest as pain feeling as if coming from other structures (referred)?
A
Nociceptive visceral pain
3
Q
Which type of pain is a result of nerve damage and abnormal operation of the nervous system with chronic and unique pain descriptions?
A
Neuropathic pain
4
Q
Name the most common non-surgical and surgical neuropathic pain?
A
Most common non-surgical pain is from diabetes
Most common surgical pain is from mastectomy
5
Q
Pain is described using the following terms: nociceptive (somatic or visceral), neuropathic, acute or chronic. How would you describe the pain of a toothache?
A
Acute nociceptive somatic pain
6
Q
When deciding which analgesic agent to use for a patient in pain, there are several patient and drug characteristics that should be considered. Name 5?
A
- SE
- Allergy
- Co-morbid disorders
- Tolerance
- Previous agents used
7
Q
True or False - typically there is no pathology present for patients in chronic malignant pain?
A
False - Pathology is typically present (i.e. tumor). In chronic non-malignant pain there is typically no pathology present
8
Q
True or False - there is profound psychological effects for both chronic malignant and non-malignant pain?
A
True
9
Q
Which type of pain (acute, chronic non-malignant, chronic malignant) would you frequently use narcotics to treat?
A
Chronic malignant pain
10
Q
What is the common and preferred ROA for surgery or labor?
A
Epidural
11
Q
Which ROA can deliver the greatest potency, but is only used in refractory pain cases?
A
Intrathecal
12
Q
True or False - a feeding tube is considered an oral ROA?
A
True
13
Q
Clinical presentation of a patient in acute pain would show what signs?
A
- Increased BP
- Tachycardia
- obvious discomfort
14
Q
Clinical presentation of a patient in chronic pain would show what signs?
A
None, no obvious sign of pain
15
Q
What does the acronym PQRST in pain assessment refer to?
A
P - Palliation/Provocation - what makes it better or worse?
Q - Quality - how is pain described?
R - Radiates - where is pain and where does it spread?
S - Severity - what is intensity of pain?
T - Temporal - is pain constant or intermittent?
16
Q
What type of analgesic agents are antidepressants, anticonvulsants, anesthetics, and antispasmodics considered?
A
Adjuvants
17
Q
What are Salicylate NSAIDs mostly used to treat? Why is their use limited?
A
Headaches
Limited use because of GI side effects and bleeding
18
Q
Which salicylate NSAID is slightly better than the rest because it has no apparent antiplatelet activity (less bleeding than others), although it still has the same GI effects?
A
Trilisate (choline magnesium trisalicylate)
19
Q
What positive effect on the patient can NSAIDs have regarding narcotic use?
A
NSAIDs can decrease the need for narcotics so they’re said to have a narcotic-sparing effect
20
Q
Name the topical NSAID?
A
Diclofenac
21
Q
Name the NSAID in IV form used in orthopedics in joint injections?
A
Ketorolac
22
Q
Name the (7) NSAID side effects?
A
- GI toxicity
- Renal toxicity
- HT
- Edema
- Reduced platelet activity
- Somnolence (drowsiness)
- CV events (MI, stroke)
(NSAID use is limited mostly by 1 & 2)
23
Q
What is the best option to protect against NSAID GI toxicity?
A
PPI
24
Q
If a patient presents with thrombocytopenia, would it be ok for the patient to continue NSAID use?
A
NO. Thrombocytopenia refers to a decrease in platelets in blood and NSAID already cause reduced platelet activity
25
True or False - each NSAID has a max dose and ceiling effect?
True
26
Name the selective COX-2 inhibitor NSAID that causes less GI ulceration, has no antiplatelet activity, has an FDA warning for CV risk, and is used to treat osteoarthritis, RA, and acute pain?
Celecoxib (Celebrex)
27
Name (5) types of pain in which NSAIDs would be a good choice for treatment?
1. Mild pain
2. Inflammatory pain
3. Bone pain
4. Osteoarthritis
5. Dysmenorrhea (painful menstruation)
28
True or False - exercise caution with NSAID use in patients that have uncontrolled HT, CHF, and peripheral edema?
True - NSAIDs can cause these conditions
29
What is the maximum daily dose of APAP?
3g / day
30
True or False - APAP can mask a fever?
True
31
Name the DOC for arthritis?
APAP
32
In what type of patient would you want to exercise caution in with the use of APAP?
patients that drink heavily and/or have liver dysfunction
33
What (3) opioids (one being off the market already) are bad choices to treat pain?
1. Meperidine (Demerol) - neurotoxic metabolite
2. Fiorinal/Fioricet - limited use
3. Propoxyphene (Darvon/Darvicet)- off market b/c of fatal heart rhythm abnormalities
34
Name the mixed agonist/antagonist opioid used in women for labor?
Butorphanol (Stadol)
35
Which schedule III opioid is a partial mu agonist that can be used to treat opioid addiction (in combo with Naloxone) and opiate withdrawal?
Buprenorphine
36
Which opioid can prolong QTc and is a major CYP3A4 substrate (i.e. its presence would diminish the activity of CYP3A4 to metabolize other drugs)?
Buprenorphine
37
True or False - Buprenorphine can be used to treat chronic pain in the form of a weekly patch?
True
38
Name (4) low potency opioid agonists used to treat moderate pain (generic and brand)?
1. Codeine (ex. Tylenol #3 w/ codeine)
2. Hydrocodone (Vicodin, Norco, Lorcet)
3. Tramadol (Ultracet, Ultram)
4. Tapentadol (Nucynta)
39
Which low potency opioid agonist is effective for treatment of neuropathic pain? Is this drug controlled?
Tramadol (Ultracet, Ultram)
| No, not controlled
40
Why is the dosing of hydrocodone limited?
Because it is always combined with a non-narcotic agent (APAP or Ibuprofen) which has a ceiling effect and potential toxicities)
41
True or False - codeine is inactive?
True - codeine gets metabolized to morphine (active)
42
Which low potency opioid agonist is schedule II?
Tapentadol (Nucynta)
43
What is the major limitations with the following strong opioid analgesics?
1. Oxycodone
2. Fentanyl
3. Methadone
4. Oxymorphone
1. Oxycodone - No IV form
2. Fentanyl - No oral form
3. Methadone - very long T1/2
4. Oxymorphone - brand only, very expensive
44
Which strong opioid analgesic is frequently utilized for home care pumps and epidural use (give generic and brand)?
Hydromorphone (Dilaudid)
45
What is the onset of a Fentanyl (Duragesic) patch (how long)?
12 hours - takes a long time to reach steady state
46
True or False - methadone can be used in patients that have renal and hepatic dysfunction?
True - methadone has no active metabolites
47
What is the preferred narcotic agent for PCA (patient controlled analgesia)?
Morphine
48
Which strong opioid analgesic can cause QT prolongation and should be avoided in patients with arrhythmias?
Methadone
49
Which narcotic agent would be best for uncontrolled pain? Which narcotic agent would NOT be ok to treat uncontrolled pain?
methadone - ok
| fentanyl - NOT ok
50
Which (2) narcotic agents have a better SE profile with less opiate allergic reactions than the other choices?
1. Fentanyl
| 2. Methadone
51
Name the 3 ways anemias are classified?
1. Decreased RBC production
2. Increased RBC destruction
3. Blood loss
52
Name (4) ways a patient can develop anemia from decreased RBC production?
1. low iron
2. kidney failure
3. bone marrow dysfunction
4. drugs that cause bone marrow suppression
53
Name one way a patient can develop anemia from increased RBC destruction?
Autoimmune disease (ex. Sickle Cell anemia) - RBC get stuck in spleen and get destroyed
54
Name the 3 ways a patient can develop anemia from blood loss?
1. trauma
2. slow GI bleed (ulcer)
3. heavy menstruations
55
What morphology test is used to identify what type of anemia a patient has?
Wintrobe indices MCV*, MCH, MCHC
MCV indicates size and is the most important of the three.
```
MCV = mean corpuscular volume
MCH = mean corpuscular hemoglobin
MCHC = mean corpuscular hemoglobin concentration
```
56
What type of anemia is associated with a low MCV? What is the most common cause of this anemia?
microcytic, hypochromic anemia
| Iron deficiency anemia is most common cause
57
What type of anemia is associated with a high MCV? What is the most common cause of this anemia?
macrocytic-megaloblastic, normochromic anemia
| Folate or B12 deficiency is most common cause
58
What type of anemia is associated with blood loss? What is the value of MCV for this anemia?
Normocytic, normochromic anemia
| Has a normal MCV
59
Name some general symptoms of anemia?
1. fatigue
2. dizziness
3. weakness
4. SOB
5. Chest pain
6. vertigo
7. neurologic symptoms
8. palpitations
60
What is the only deficiency associated with neurologic symptoms?
Vitamin B12 deficiency
61
What are some common signs of a patient with anemia?
1. tachycardia
2. pallor (pale)
3. decreased mental acuity
62
What is the most important laboratory test to determine if patient has anemia?
Hgb - Hct (this value will be low)
63
Name 5 factors that would put you at risk for developing iron deficiency anemia (IDA)?
1. premature infants (b/c fetus gets most of iron from mother in 3rd trimester)
2. Young children <2 years
3. Women with heavy menses
4. pregnant women (supplements for mother should start in 2nd trimester)
5. renal failure patients (b/c lack of EPO)
64
What are the 3 common causes of IDA?
1. diet - inadequate intake
2. blood loss
3. decreased absorption
65
Where is dietary iron converted to the ferrous form? Where is iron primarily absorbed?
in the stomach where the pH is acidic
| duodenum
66
True or False - heme iron is more bioavailable than non-heme iron?
True
67
Name 4 things (non-medication) that can inhibit the absorption of iron?
1. phytates (grains and brans)
2. tannates (in tea)
3. calcium
4. phosphates
68
What effect would a PPI have on the conversion of and absorption of iron?
A PPI would increase the pH in the stomach, thus decreasing the conversion of dietary iron to ferrous form and decrease absorption
69
Why should infants avoid cow's milk until >1 year of age?
the Ca+2 in cow's milk can bind to iron and decrease its bioavailability
70
True or False - all infants require an iron supplement? If true give the recommended dose.
True (1-2 mg/kg/day up to 20 mg max)
71
Describe what will happen to the following lab values for a patient with IDA?
1. Hgb, Hct
2. RBC
3. Reticulocyte
4. Serum iron
5. Ferritin (stored form of iron)
6. Transferrin saturation
7. MCV, MCH, MCHC
8. TIBC (total iron binding capacity)
1. Hgb, Hct DECREASE
2. RBC DECREASE
3. Reticulocyte DECREASE
4. Serum iron DECREASE
5. Ferritin (stored form of iron) DECREASE
6. Transferrin saturation DECREASE
7. MCV, MCH, MCHC DECREASE
8. TIBC (total iron binding capacity) INCREASE
72
True or False - a person with low ferritin and low serum iron will start to show symptoms of IDA?
False - patient will only present with symptoms when Hgb/Hct is low
73
What is the recommended therapeutic dose of elemental iron for infants and children?
3 - 6 mg/kg/day in 2-3 divided doses
74
What is the recommended therapeutic dose of elemental iron for adults?
180-200 mg/day
75
Why would a patient have to continue taking iron supplements for 3 - 6 months even after they start to feel better after being on supplements for a few weeks?
The patient's symptoms will begin to disappear as soon as the Hb/Hct is corrected. However, it takes about 3-6 months to fully replenish iron stores (ferritin)
76
What iron salt is commonly used in oral iron therapy? What % of elemental iron does it contain? How many mg of elemental iron does a 325 mg tablet contain?
ferrous sulfate
20%
65mg
77
True or False - it is suitable to recommend sustained release iron dosage formulation or combination products?
False - these products are not recommended
78
When monitoring iron therapy, what is the most important lab values to check after 2-3 weeks and after clinical manifestations diminish?
Check Hgb/Hct
79
What is an increase in platelets called? What are patients at risk for?
thrombocytosis
| clotting embolism
80
What is a decrease in platelets called? What are patients at risk for?
thrombocytopenia
| bleeding risk
81
What 2 coagulation tests are prolonged due to deficiencies of clotting factors and fibrinogen?
Prothrombin Time (PT) and International normalized ratio (INR)
82
Name 2 disease states associated with prolonged PT?
1. vitamin K deficiency (premature newborn, fat malabsorption)
2. liver disease (liver responsible for producing clotting factors)
83
What coagulation test should be monitored for patients on heparin?
aPTT (activated Partial Thromboplastin Time)
84
What coagulation test should be monitored for patients on warfarin?
INR
85
Which coagulation test is more reproducible (meaning if performed at different hospitals, they will arrive at the same results)
INR
86
True or False - you can use PT to monitor patients on warfarin?
False
87
What is the sole parameter to monitor warfarin therapy?
INR
88
What are the 3 most common reasons for seeing patients on warfarin?
1. DVT (diverticulitis)
2. PE (pulmonary embolism)
3. atrial fibrillation
89
What is the INR therapeutic range for a patient on warfarin presenting with DVT/PE or atrial fibrillation?
Range: 2.0 - 3.0 with a target of 2.5
90
What condition would prolong aPTT?
liver disease
91
What biochemical markers are used to diagnose a MI?
1. creatine kinase isoenzyme B (CK-MB)
2. troponin T
3. troponin I
92
Why would it be necessary to wait about 4 hours before drawing blood to check enzymes after patient complains of having chest pain and initial symptoms of MI?
Because the enzymes take about 3-12 hours before leaching into the blood where they can be detected
93
What would be the problem of a patient experiencing chest pain and symptoms of an MI but waiting about 4 days before coming in and the hospital just checking CK-MB enzyme?
The CK-MB enzyme returns to normal range after about 2-3 days so if you just checked this enzyme, it wouldn't indicate the patient had an MI (when he/she really could have). This is why troponin is also checked since it takes 5-10 days to return to normal range
94
During therapeutic drug monitoring of Gentamycin, when should blood be drawn to check drug levels? What is the therapeutic range for the peak? What is the therapeutic range for the trough?
Blood should be checked 60 minutes after the start of a 30 minute IV infusion
Peak = 6-10 mcg/mL
Trough = 0.5-2 mcg/mL
95
What toxicity is associated with a high peak and high trough of gentamycin?
ototoxicity
96
What would a high trough of gentamycin indicate?
nephrotoxicity
97
When should you collect blood to check drug levels of Vancomycin (peak or trough)? What is the therapeutic range for the trough?
Trough
| Trough = 10-20 mcg/mL
98
When should you collect blood to check drug levels of Phenytoin (peak or trough)? What is the therapeutic range for the trough?
Doesn't matter - peak or trough
| Trough = 10-20 mcg/mL
99
What 3 patient counseling points should be made with iron therapy?
1. GI SE
2. Dark stools
3. Take on empty stomach (increases bioavailability)
100
Name 5 medications that interact with oral iron therapy?
1. Antacids containing Al, Mg, and Ca
2. Cholestyramine
3. Tetracycline (and derivatives)
4. H2 blockers
5. PPI
101
How do Antacids containing Al, Mg, and Ca, cholestyramine, and tetracyclines affect oral iron therapy?
They all chelate with iron which decreases bioavailability
102
How do H2 blockers and PPI affect oral iron therapy?
They increase gastric pH which prevents the conversion of dietary iron to ferrous iron and its subsequent absorption in the duodenum
103
What effect does iron have on the following drugs:
1. Fluoroquinolones
2. Levothyroxine
3. Levodopa
4. Methyldopa
5. Tetracycline (and derivatives)
1. Fluoroquinolones - forms ferric ionquinolone complex
2. Levothyroxine - decreases efficacy
3. Levodopa - chelates with iron resulting in decreased absorption
4. Methyldopa - decreases absorption and efficacy
5. Tetracycline (and derivatives) - decreases absorption
* all lot of these interactions can be managed by separating the administration of medication and iron by a few hours
104
Name the 4 indications for parenteral iron?
1. malabsorption
2. long-term non-compliance
3. intolerance to oral iron
4. as an adjunct to EPO therapy in Tx of anemia associated with chronic renal disease or chemo
105
True or False - parenteral iron therapy works faster than oral iron therapy?
False - increase in Hgb does not occur for 2-3 weeks regardless of ROA of iron
106
Which parenteral iron product is the only one indicated for the treatment of iron deficiency anemia in patients who do not respond to or do not tolerate oral iron?
Iron Dextran
107
What is the fastest rate of infusion for iron dextran?
50 mg/min
108
What black box warning does iron dextran carry?
Anaphylactic type reactions
109
True or False - you can give iron dextran IM?
True - although this typically not given IM. If it is given IM, nurse must use Z-track method moving muscle during injection to avoid permanently staining skin
110
What 3 parenteral iron products are indicated for treatment of iron deficiency in dialysis, renal failure, and EPO deficiency patients?
1. Iron Sucrose (Venofer)
2. Ferumoxytol
3. Sodium Ferric Gluconate (Ferriecit)
111
Of the 3 parenteral iron products indicated for dialysis patients, which one(s) has/have black box warning(s)? Which one(s) doesn't/does?
1. Iron Sucrose - Anaphylactic type reactions
2. Ferumoxytol - no black box warning
3. Sodium Ferric Gluconate - no black box warning
112
Name the 5 mild/transient adverse effects associated with iron dextran (parenteral iron product)
1. malaise (general body weakness/discomfort)
2. flushing
3. fever
4. myalgia (muscle pain)
5. arthralgia (joint pain)
113
What is the very rare adverse effect associated with iron dextran?
Anaphylactic reactions
114
True or False - patients with a history of allergies, asthma, or active inflammatory disease are more susceptible to developing adverse reactions to parenteral iron?
True
115
What is the primary advantage of using iron dextran for iron therapy?
Iron dextran can be given as a total dose infusion...meaning the total dose of iron can be administered over 4-6 hours
116
What two things would you want to monitor when administering parenteral iron (HINT: you monitor one for efficacy and one for safety)?
Monitor Hgb/Hct in 2-3 weeks for efficacy and monitor Ferritin and Transferrin saturation for safety
117
What 2 dietary deficiencies are associated with Megaloblastic (Macrocytic) anemias?
Folate deficiency and B12 deficiency
118
What important process are folate and B12 responsible for in the body?
DNA synthesis and subsequent cell division
| remember RNA not affected so cell starts growing with lack of division
119
Why would you always check the B12 levels in a patient with Megaloblastic anemia?
Because of potential permanent neurological effects
120
Where can certain drugs affect the B12 and dietary folate pathway involved in DNA synthesis?
Drugs can affect the DHF reductase enzyme AND the conversion of dietary folate to 5-MTHF
121
True or False - every woman of childbearing age should get 400 mcg/day of folic acid?
True
122
What 2 conditions specifically for females increases their daily requirement of folic acid?
1. pregnant women
| 2. lactating women
123
True or False - conditions in which there is an increased metabolic rate and/or increased cell turnover increases folate requirements?
True
| Ex. pregnancy, infancy, infection, malignancy, hemolytic anemia, chronic inflammatory disorders
124
Name 3 common causes of folate deficiency?
1. alcoholism (diet does not contain folate)
2. third trimester pregnancy
3. inadequate intake (strict vegan)
125
True or False - regular doses of methotrexate results in folate deficiency?
False - HIGH doses can cause folate deficiency (commonly given to cancer patients)
126
What 2 drugs are commonly associated with folate deficiency?
1. Methotrexate
| 2. Phenytoin
127
How does folate deficiency affect the following lab tests:
1. Hbg/Hct
2. MCV
3. Folate
4. Homocysteine
1. Hbg/Hct - DECREASED
2. MCV - INCREASED (megaloblastic anemia)
3. Folate - DECREASED
4. Homocysteine - INCREASED (you need folate and B12 to metabolize homocysteine to methionine...deficiencies in either B12 or folate will result in increased homocysteine)
128
How do you treat folate deficiency?
Give 1mg/daily for 4 months (if patient has risk factors i.e. alcoholic continue therapy after 4 months)
129
What lab test can you use to verify folate therapy is working?
Check Hgb/Hct in 2-3 weeks after starting 1mg folic acid daily
130
Why is it important for women of childbearing age to consume 400 mg/day of folic acid?
To decrease risk of a neural tube defect in their infant should they conceive
131
What does the CDC recommend for folic acid intake for women who have given birth to a child with a neural tube defect and are trying to have another child?
These women should consume 4 mg/day of folic acid for month prior to conception and for the 1st trimester
132
Why is an acidic environment important when consuming food that contains B12?
The acidic environment separates cobalamin (B12) from the food it was bound in
133
What does B12 bind to once it is separated from the food it was bound to?
Intrinsic factor
134
A lack of intrinsic factor results in what type of anemia?
Pernicious anemia
135
True or False - a patient with intrinsic factor deficiency (pernicious anemia) can still be treated orally with vitamin B12?
True - give HIGH doses of B12 and your body can absorb some B12 via passive diffusion
136
True or False - Total body stores of B12 allow 3-4 years before a deficiency develops?
True - body stores are 2000-5000 mcg/ml
137
Name the 2 main causes of B12 deficiency
1. Decreased absorption
| 2. Decreased intake
138
Name 4 factors that can lead to a B12 deficiency due to decreased B12 absorption?
1. Intrinsic factor deficiency
2. Decreased gastric acid
3. Bacterial overgrowth
4. Surgical removal of ileum (absorption site of B12)
139
Name 3 factors that can lead to a B12 deficiency due to decreased B12 intake?
1. Vegan diet
2. Chronic alcoholics
3. elderly on tea and toast diet
140
What 2 common symptoms are seen with B12 deficiency?
1. neurologic effects
| 2. glossitis (red tongue)
141
What very specific (but expensive) lab test can be used to specifically diagnose B12 deficiency?
Methylmalonic acid (MMA)
142
What symptom present in a B12 deficient patient would steer you to treat the deficiency parenterally with an IM injection?
Patient with neurologic symptoms (to get B12 in their body quickly to prevent permanent neurologic damage)
143
What is a typical oral B12 therapy dose in a B12 deficient patient?
1-2 mg daily of cobalamin tablets
144
Which narcotic for severe pain can be used in patients with renal impairment? Which narcotic for severe pain can be used in patients with renal OR hepatic impairment?
Oxycodone - renal impairment
| Methadone - renal OR hepatic impairment
145
Which narcotic for severe pain is preferred over morphine for epidurals since it has less itching SE?
Hydromorphone
146
Name 7 side effects associated with narcotic agents?
1. Constipation
2. Sedation, fatigue
3. Dizziness
4. Nausea
5. Hallucinations
6. Itching
7. Respiratory depression
147
True or False - the itching side effect of narcotics is an allergic reaction?
False - it is not an allergy, just histamine release
148
Name 2 stimulative laxatives (1 combo, 1 single) used to treat constipation associated with opiate use?
1. Senna + Docusate
2. Bisacoydl
Other choices available (ex. PEG, Milk of Magnesia, lactulose, etc.)
149
What's the first thing you should try to manage nausea associated with opiate use?
relieve constipation
150
What first line drug is indicated for management of nausea associated with opiate use?
Prochlorperazine
151
How do you treat pruritis associated with narcotic use?
1. treat with anti-histamine (diphenhydramine)
| 2. change opiate
152
True or False - there is NO MAXIMUM DOSE for narcotics?
True
153
All narcotics can be adjusted daily except what (2)?
1. Duragesic (patch)
| 2. methadone (long T1/2)
154
A patient's daily dose of narcotics must be titrated appropriately based on their pain levels. If a patient is experiencing moderate pain, how much should their dose be increased? If a patient is experiencing severe pain, how much should their dose be increased?
Moderate pain - 25-50%
| Severe pain - 50-100%
155
What type of medication should be used to treat breakthrough (BT) pain?
immediate release narcotics (use same agent if possible, but not absolutely necessary i.e. Morphine ER and Morphine IR)
156
Should the BT narcotic dose be increased or decreased if you are increasing the ER narcotic dose?
Always increase BT dose if increasing ER dose
157
For chronic PO dosing of BT pain, what dose should be given relative to the ER drug?
Give 1/6 of 24 hr requirement or 10-20%
| (Ex. MsContin 60 mg PO q12h --> 120 mg daily dose, 10-20% is 12 -24 mg --> MSIR comes in 20 mg so give 20 mg q4h prn
158
This type of pain is characterized by burning, stinging, lancinating pain, and numbness?
Nerve pain
159
What are 6 common causes of nerve pain?
1. Diabetic neuropathies
2. mastectomy
3. lobectomy
4. limb amputation
5. postherpetic neuralgias
6. peripheral neuropathies
160
What 6 pharmacologic agents are used for nerve pain?
1. antidepressants
2. anticonvulsants
3. LA's
4. Opiates
5. Tramadol
6. Corticosteroids
161
When treating a patient with nerve pain it is imperative that you frequently do this?
Frequently assess effectiveness and side effects of the pain regimen
