Final - Issacs Flashcards by Blade Joneson

question to asks pts in pain?

PQRSTU
palliative/precipitating
quality
region
severity
time
U - impact on U....

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what are the physiological changes seen in a patient who is in pain

dilated pupils (mydriasis)
paleness
sweating
tachycardia
tachypnea

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wong baker pain scale is described how and is for who?

its the faces

and for young kids

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FLACC scale stands for what? and is used for who?

FLACC = Face, legs, activity, cry, and consolability

is for infants or unconscious people

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Non-Pharm Options for Pain

CORRECT UNDERLYING CAUSE!! (Surgery or avoidance)
RICE (rest/ice/compression/elevation)
Psychotherapy/behavioral modifications
Massage
Acupncture
Physical Therapy

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________ made an analgesic ladder for pharm treatment options

WHO - World health organization

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how many steps are in the WHO analgesic ladder

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what is step 1 in the WHO analgesic ladder

non opioid +/- adjuvant analgesic

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what is step 2 in the WHO analgesic ladder

opioid for mild - moderate pain + non-opioid +/- adjuvant analgesic

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what is step 3 in the WHO analgesic ladder

opioid for moderate to severe pain +/= adjuvant analgesic

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PRN or Scheduled analgesics minimize exposure to limit toxicity

PRN (only treating when pain is above a threshold)

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PRN or Scheduled analgesics may be a better option in chronic/continual pain

scheduled…

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What are the non-opioid analgesics

NSAIDs and APAP

Adjuvants – aka for Neuropathic Therapies

Gabapentinoids
SNRIs
TCAs
Skeletal Muscle Relaxants

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NSAIDs or APAP is the gold standard for OA in geriatric patients? and why?

APAP! because fewer side effects in geriatric patients

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Patients with liver disease can or cannot take APAP?

can!

limit is < 2G/day though

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APAP Peds dosing?

10 - 15 mg/kg PO Q4H prn

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Ibuprofen doing for peds?

5 - 10 mg/kg PO Q6H prn

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NSAIDs or APAP have a black box warning for increased cardiovascular events?

NSAIDs

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NSAIDs or APAP?

leads to fluid retention

NSAIDs

increased CV events!!

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NSAIDs or APAP?

causes hepatoxicity

APAP

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If patient has hx of cardiac history, can you still use topical NSAIDs?

yes

topical is ok, systemic is less ok

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why do we titrate gabapentinoids?

to limit sedation

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ADEs of SNRIs

HTN
Sedation
HA
weakness

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if CrCl is < 30 mL/min – what do you do for the SNRIs

NO duloxetine

Can do venlafaxine but decrease daily dose by 50%

list the drugs that are skeletal muscle relaxants

``` carisoprodol (Soma) Chlorzoxane (Lorzone) Cyclobenzaprine Metaxalone (Skelaxin) Methocarbamol (Robaxin) ```

what opioids are typically used in step 2 in WHO analgesic ladder aka for mild - moderate pain

tramadol codeine morphine hydrocodone

what opioids are typically used in step 3 in WHO analgesic ladder aka for moderate - severe pain

``` oxycodone (+/- APAP) hydromorphone fentanyl methadone meperidine ```

codeine is used for pain and ?

for cough codeine is an antitussive

how old does someone have to be to use codeine?

12 y.o + because rate of metabolism is wack in kids under 12 for codeine

which opioid can lower seizure threshold?

tramadol

which opioid can cause itching/histamine release

morphine

what 2 opioids are save in renal impairment

fentanyl and methadone

which opioid can be used by certain prescribers for opioid detox

methadone

which opioid can cause neurotoxicty

meperidine

which drug comes in a patch and what is a note about giving the patch to patients?

fentanyl! do not give the patch if the patient is "opioid naive" also dont cut patches...

which drug is used for opioid reversal

naloxone | opioid antagonist

which drug is used for opioid dependence

buprenorphine/naloxone (Suboxone)

when naloxone is given does HR go up or down

up!!

which drugs may need to be avoid if patient has derm issues

fentanyl PATCH and morphine (bc itching side effect)

If a patient is experiencing acute pain ---- | should pt use parenteral, IR, or CR?

parenteral and IR are appropriate

what patients are typically eligible for PCA (patient controlled analgesia)

post-op pancreatitis sickle cell crisis

for PCA dosing about how often are the opioids given?

about evert 4 - 10 minutes - aka hella often!!

``` Switching b/w Opioids: Drug: Parenteral: Oral: Fentanyl Hydrocodone Hydromorphone Morphine Oxycodone ```

Drug: Parenteral: Oral: Fentanyl 0.1 Hydrocodone 30 Hydromorphone 1.5 7.5 Morphine 10 30 Oxycodone 20

Switching b/w Opioids: Hydromorphone Conversion b/w parenteral and Oral Morphine Conversion b/w parenteral and Oral

Morphone: Parenteral: 1.5 ----> Oral: 7.5 (5 x) Morphine: Parenteral 10 -----> Oral: 30 (3x)

Opioid Conversion Steps?

1 - collect ALL opioid consumption from any route for 24 hour time frame 2 - convert each dose to oral morphine 3 - add all together to get total daily oral morphine dose 4 - reduce 25 - 50% due to cross tolerance 5 - determine appropriate agent for pt based on pt and med specific factors

Opioid Related Side Effects

``` Constipation N/V Itching Respiratory depression Sedation addiction/abuse tolerance overdose withdrawal ```

opioid induce N/V- how to manage?

take with food!!! also consider is dose too high? may add antiemetics--- but try not to

3 main options for opioid induced constipation

Non-pharm: water + fiber + physical activity OTC: STIMULANT laxative (senna/bisacodyl) Rx: Movantik or Relistor (the peripherally mu opioid antagonists) - $$$$$

When using a laxative for opioid induced constipation - use bulk or stimulant laxatives? (and examples)

stimulant | senna, bisacodyl

how to treat itching caused by opioids (usually morphine tho)

antihistamines!! (oral, topical, or parenteral) or reduce dose of opioid (because it is dose dependent) switch to alternative opioid Change route of administration

respiratory depression (An ADE of opioids) is usually defined by a RR < ____ BPM

8 BPM

Symptoms of opioid withdrawal

``` agitation anxiety increased sweating insomnia restlessness ```

What drugs can be used for symptom management in opioid withdrawal

clonidine - to decrease tachycardia Methodone - for detoxification

CCD Guidelines for Prescribing Opioids: | - for chronic pain -- start with ____ opioids and start with _______ dosage

IR lowest effective

CCD Guidelines for Prescribing Opioids: | Avoid concomitant used of opioids with ______ if possible

BZDs

CCD Guidelines for Prescribing Opioids: For chronic pain: avoid titrating to > _____ mg of oral morphine equivs/day AND evaluate every ______ for opioid benefit/harm

90 mg 1 - 4 weeks

Indiana Opioid Law: | Initial Prescriptions for opioid therapies cannot be greater than _____ days UNLESS its for what 3 things?

7 days Cancer, Palliative care, medication assisted tx of substance abuse

if pt is in hospice --- opioids are used why?

well pain duhhh/providing comfort at end of life and decreasing respiratory drive (to aid in natural end of life processes)