Midterm Review Flashcards
(86 cards)
1
Q
Dry Mouth
A
Xerostomia
2
Q
Pain Classifications by Pathophysiology
A
- Nociceptive
- Neuropathic
- Psychogenic
- Unknown
3
Q
**Nociceptive Pain
Cause
Corresponding
Types
A
Cause: Tissue Damage = Noxious Stimuli
Pain Perception corresponds to Stimulus Intensity
Types: Visceral, Somatic and Radicular
4
Q
Neuropathic Pain
- Caused by what kind of damage?
- Poportional?
- Duration of pain?
A
Cause: NS damage = bad signal processing by CNS/PNS
Disproportionate perception to stimulus intensity
Chronic pain - more likely
5
Q
**Psychogenic Pain
A
No known physical cause
CNS processing disturbed
Non-localized
Larger areas
6
Q
Pain Classification by Duration
A
- Acute Pain
- Chronic Pain
- Chronic Non-Cancer Pain
- Cancer Pain
7
Q
Acute Pain
A
Less than 3 months
Serves adaptive purpose
8
Q
Chronic Pain
A
Used to be defined Temporally, now, Contextually.
Time: 3-6 months
Context: pathology does not explain pain, pain disrupts sleep and normal living
Does not serve adaptive purpose
9
Q
Chronic Non-Cancer Pain
A
Can affect any body system
Ex. Migraines, Arthritis, Back/Neck Pains
10
Q
Cancer Pain (‘Malignant Pain’)
A
Associated with life-threatening conditions
Caused by Disease or Dx or Tx
also can be HIV
11
Q
Spontaneous Pain
A
No stimulus
12
Q
Allodynia
A
Normal stimulus
ex. dental, touch
13
Q
Hyperalgesia
A
Increased response to a Painful Stimulus
ex. heat, prick
14
Q
*Dysasthesia
A
Unpleasant, Abnormal Sensation
Spontaneous or Evoked
ex. fluttering when you kick
ex. shooting sensation
15
Q
*Parasthesia
A
Abnormal Sensation (Not Unpleasant)
Spontaneous or Evoked
ex. foot falling asleep, tingling
16
Q
Superficial Pain
A
Body surface pain
17
Q
Localized Pain
A
Restricted to one identifiable area
18
Q
Diffused Pain
A
Widespread
19
Q
**Referred Pain
A
Spreads to area of the body which is not the source
20
Q
**Radicular Pain
A
Radiates to lower extremities
w/ transmission along spinal nerve
21
Q
Visceral Pain
A
Originates in and around the organs of the body
22
Q
Somatic Pain
A
Result of injuries to skin, bone, muscle, connective tissues/joints
23
Q
Deep Pain
A
Deep inside body
24
Q
Peripheral Categorizations of Neuropathic Pain
A
- Mononeuropathy
<> Distribution of one peripheral nerve
<> ex. Sciatic nerve, Bell’s Palsy, Lancinating Pain
- Polyneuropathy
<> Symmetrical
<> ex. Diabetic Neuropathy, Guillain-Barre
25
Greatest Burden of PALL CARE
1. CVD
2. Cancer
3. Chronic Lung Diseases
4. HIV/AIDS
5. Diabetes
26
Barriers to PALL CARE Availability
* Policy
* Education
* Medication Availability
* Implementation
* Psychological, Social/Financial, Cultural
27
K-R Stages of Dying
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
* Non-linear passage through the stages
* Not everyone experiences all stages
28
**Non-opioids:**
(Aspirin/Salicylic Acid Derivatives, Acetaminophen, NSAIDS)
Combine with opioids to facilitate lower opioid dosing & **bi-modal analgesia**.
**Analgesia ceiling**: dose reached beyond which additional S/E occur, but not pain relief
29
Non-Opioid Analgesics Side Effects
Cardiac
Bleeding
GI
Kidney Dysfunction
30
Opioids Side Effects
(Morphine, Methadone, Buprenorphine, Hydrocodone, Oxycodone, Vicodin Tramadol)
- Sedation, mental clouding, Confusion
- Respiratory depression
- Nausea, vomiting, constipation, pruritis, urine retention
- Tolerance, Dependence, Addiction
- Most S/E subside with time (except constipation)
31
Pain Assessment - WILDA
**W**ords
**I**ntensity
**L**ocation
**D**uration
**A**ggravating/Alleviating Factors
32
Pain Assessment - WILDA
Duration
(4 elements)
1. Stable (Continuous)
2. Breakthrough Pain
3. Intractable Pain
4. Acute vs. Chronic
33
1. Stable (Continuous) Pain
Pain all the time
34
2. Breakthrough Pain
- Transitory exacerbation
- Flare of pain
- Pt already on analgesics for **stable pain**
35
3. Intractable Pain
- Chronic
- Resistant to cure or relief
36
4. Acute vs. Chronic
- need to ask:
“Is your pain always there, or does it come and go?”
“Do you have both chronic and breakthrough pain?”
37
Assessing pain in **cognitively impaired individuals**
## Footnote
**- 3 ways**
* **Can obtain voluntary non-verbal feedback**
* Nod head, squeeze hand, moving eyes...
* Writing materials, pain intensity charts...
* **Predicting Pain**
* After reviewing Hx, is there a reason to suspect this patient is in pain?
* **Past precedent**
38
**Classic descriptions of pain**
**- 4 processes**
***Transduction***
***Transmission***
***Perception***
***Modulation***
39
1. Transduction
Conversion of **noxious stimulus** into **nerve impulses**
By nociceptors
Noxious stimuli = (thermal, mechanical, or chemical)
40
2. Transmission
Transmission of **neural signals**
From: Periphery
To: SC+Brain
41
3. Perception
Appreciation of signals arriving in higher structures as pain
42
4. Modulation
Descending inhibitory and facilitory input, from Brain
that modulates nociceptive transmission, at SC level
43
* **Select a route of administration**
No single route of drug administration is appropriate for all clinical situations.
44
* **Oral administration** (pills) of drugs, especially for chronic treatment, is \_\_\_\_\_.
generally preferred
convenient, flexible
**stable drug levels**
45
* **Rectal**
* **sub-lingual,** and
* **subcutaneous** are useful in patients who \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
cannot take medications by mouth
46
* **IM administratio**n has 3 disadvantages....
* (**intramuscular injection**)
Pain
Erratic absorption = **Fluctuating drug levels**
***Tissue fibrosis***
47
**IV administration** provides a \_\_\_\_\_\_\_.
**rapid onset**
48
**Titrating the dose**
\> Meaning
\> Non-opiods
\> Opioids
– Smallest dosage necessary to provide desired effect with minimal SEs
– Non-opioids have a **ceiling effect** and may cause significant toxicity at high doses
– Most opioids do not have an analgesic ceiling: dosage can be titrated upwards until relief occurs or limiting side effects
49
**Addressing Side Effects**
- 4 ways
1. Changing dosage or route of administration
2. Trying a different drug (within same class)
3. Add a drug that counteracts the side effects
(ex. antihistamine for itch, laxative for constipation)
4. **Combination therapy** can alleviate some side effects
– Adding a nonopioid or adjuvant analgesic to an opioid regimen to use of a lower dose of the opioid
50
**WHO Analgesic Ladder**
**Step 1 (Mild Pain)**
Non-opioids
ex. Paracetamol, NSAIDs
**Step 2 (Moderate Pain)**
Mild Opioid
ex. Codeine +/- non-opioid
**Step 3 (Severe Pain)**
Opioid
ex. Morphine +/- non-opioid
51
Barriers to increasing availability and consumption of opioids for medical and scientific use
- 5 Barries
* Overly strict **regulation**
* Limitations on available **forms** of meds
* ex. oral opioids
* Lack of supply and distribution **systems**
* Limitations on who can **prescribe**
* Fear of **law enforcement** intervention into medical use
52
* **Mechanical Obstruction**
* ****Manifestations
* TX
* Avoid meds
* Bowel tumors or ovarian cancer
* **=\>** external compression, paralytic ileus, diverticuli, hernia
* Surgery
* Avoid prokinetic/motility agents
53
* **Functional/Incomplete Obstruction**
* ****Manifestation****
* TX - meds
* Ischemic bowel, IBD, tuberculosis, endometriosis
* May resolve with conservative TX
* **Dexamethasone** reduces bowel wall edema
* **Prokinetic**
* Stool softener & hydration
* **NG tube** if vomiting is distressing
54
* **Constipation**
* TX - 2 drugs
* 2 things to avoid
* What to do before starting laxatives?
* Stool softener - *docusate*
* Motility agent - *senna*
* Avoid **bulking agents**
* ****may precipitate impaction
* Avoid **osmotic laxatives**
* ex. lactulose
* causes cramps, requires lots of H2O
* **_Relieve impaction_** before starting laxatives
55
**Somatization Disorder**
* NOT feigned
* Multiple, current somatic complaints
* Hx: Long and complicated primary care/specialist
* Tx: Cognitive Behavioral Therapy
56
* **Conversion Disorder (Hysteria)**
* At least 1 symptom of altered voluntary motor/sensory function
* ‘***Hysterical Blindness***’, Paralysis, Abnormal Movement, Seizure, Amnesia, Incontinence
* Anxiety **=\>** physical symptom
* Little evidence-based TX: hypnosis, psycho/physical therapy, stress management, transcranial magnetic stimulation
57
* **Body Dysmorphic Disorder (BDD)**
* Mental disorder: some aspect of one’s health or appearance is severely flawed & requires extreme measures
* Real or imagined flaw
* Pervasive and intrusive obsession
* DSM classifies it on OCD spectrum
58
* **Hypochondriasis**
* Persists after physician has evaluated and reassured
* Trigger: serious illness/death of family/friend
* Some avoid; others frequently visit medical facilities
* **Cyberchondria**, ’**Compucondria’ (or ‘WebMD-Itis’)**
59
* **Pain Disorder**
* Defintion
* Causes
* SX
* Basis
* Psychological stress =\> Chronic pain
* in one or more areas, sometimes for years
* Causes
* Trauma/Abuse
* Child’s role in family - ‘the sick one’
* More common in social settings where psychological distress is not as accepted
* Collectivist countries (Japan, China, Mexico) \>\> individualistic countries (USA, Sweden)
* Sx: negative/distorted cognition, increased pain, sleep disturbance and fatigue; depression and/or anxiety, diminished social life
* No neurological/physiological basis
60
**Adjuvant Analgesics**
Phenytoin, Carbamazepine, _Gabapentin_
_Amitriptyline_, Nortriptyline, Imipramine
Lidocaine, Bupivacaine
Capsacin
Prednisone
Sumatriptan, Metoprolol
Ziconotide
61
Management of Pain Without Medications
1. Education & Psychological Counseling
2. Hypnosis 3. Comfort Therapy
4. Heat & Cold 5. PT and OT
6. Psychosocial Therapy & Counseling
7. Neurostimulation
8. Religious & Spiritual 9. Nutritive 10. Herbal
62
**Peripheral Sensitization**
* Definiton
* Pain States
* **Sensitized nociceptors** exhibit **lower threshold** for activation and an **increased firing rate**
* Generate nerve impulses more readily and more often
* Role in central sensitization/clinical pain states
* **Hyperalgesia:** increased response to a painful stimulus, ex. heat
* **Allodynia:** pain caused by a normal stimulus, ex. touch
* Increased sensitivity to heat and touch
63
**Central Sensitization**
**- Def**
**- Causes**
* State of **spinal neuron hyperexcitability**
* Tissue injury (inflammation)
* Nerve injury (aberrant neural input)
* Or both may cause it
* Ongoing nociceptive input from the periphery is needed to maintain it
* May outlast stimulus by minutes /hours
64
Clinical manifistations of Central Sensitization
1. **Hyperalgesia**: increased response to a noxious stimulus
2. **Allodynia**: painful response to normal stimulus
3. **P****ersistent pain:** prolonged pain after transient stimulus
4. **Referred Pain:** Spread of pain to uninjured tissue
- expanded receptive field
65
* **Central sensitization** plays a key role in ____ pain.
* * ______ pain often exceeds the provoking stimulus, both spatially and temporally.
* * **Established pain** is ____ difficult to suppress than **acute pain.**
* **chronic pain,** especially pain induced by nerve injury or dysfunction (neuropathic pain)
* **neuropathic pain**
* **more difficult**
* In contrast to nociceptive pain, **neuropathic pain** is often unresponsive to NSAIDs and opioids. However, it may respond to antiepileptic drugs, antidepressants, or local anesthetics.
66
Reversible causes of Anorexia
* Pain/dyspepsia
* Disordered taste/smell
* Malodour (bad smell, e.g. ulcer or fungating tumour)
* Nausea or vomiting
* Metabolic causes (hypercalcaemia, Uraemia)
* Constipation
* Gastric stasis
* Anxiety, depression or confusion
* Latrogenic causes
67
**Some appetite stimulant drugs**
* Corticosteroids
* Progesterones
* Cannibinoids
* Prokinetics
* **Carers can play a vital role in encouraging pt to eat small, visually appealing meals in a comfortable environment**
68
***Persistent* hiccups**
***Intractable* hiccups**
* Persistent* hiccups last **\> 48 hours**
* Intractable* hiccups last **\> 1 month**
69
**Factitious Disorders**
person acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms to attain a patient's roll
**Munchausen's**: severe form of factitious disorder
**Munchausen's by proxy**: factitious disorder imposed on another
**Malingering**
70
**Managing Thirst**
* Thirst = **desire to drink**
* Contradictory literature on whether dying pt feels thirst
In unconscious pt, experience of thirst will not be possible
- Self-reported and has high individual variability
- Xerostomia (dry mouth) can contribute to thirst
- Not all pts w dry mouth have thirst, vice-versa
\*\*Thirst and dry mouth are SEPARATE issues
71
Contradictory literature on whether **fluid administration** will even help **reduce thirst in dying pt**
**-** What can be done?
**Attention to mouth care and moistness** will address thirst in final hours/days
**Daily oral care** and **sips of oral fluid** administered for comfort can improve thirst
• Offer routinely
72
Concerned family and friends may be distressed that their loved one is experiencing thirst at the end of life, this can prompt requests for **artificial nutrition or hydration**.
- Should **artificial hydration** be considered?
Artificial hydration should be considered on a case-by-case basis
But mainly reassurance that artificial hydration is unlikely to alleviate thirst and comes with significant risks
73
**Cachexia**
Complex syndrome: weight loss, lipolysis, loss of muscle and visceral protein, anorexia, chronic nausea, and weakness
- How it relates to Anorexia?
- Tx?
* **Anorexia** is a main cause
* decreased caloric intake
* **TX**
* intensive nutriton
* corticosteroids improve anorexia
74
**Differentiate GI Side Effects**
* **Nausea:** subjective experience, precedes vomiting
* **Vomiting**
* Highly specific event: ‘forceful evacuation of gastric contents out of the mouth’
* Usually (not always) preceded by nausea
* **Retching**
* Repetitive contraction of abdominal musculature, generating pressure gradient which leads to evacuation of stomach contents
* “Dry Heaves”
* **Regurgitation\***
* Passive, retrograde flow of esophageal contents into the mouth
* Reflux or esophageal **obstruction**
* **Rumination\*\***
* Under-diagnosed, *chronic, motility*
* Effortless, **following meals**
* Cause: involuntary contraction of muscles around abdomen
* Not preceded by nausea
* **Dyspepsia**
* Chronic
* *Structural*: Acid-related
* *Functional*: Dysmotility-related
75
**Non-pharmacological Interventions for Dyspnea**
Calm reassurance
Fluid restriction
Elevating head of bed
Smoke-free, dust-free, low-humidity
Cool air on face (open window or a fan)
Distraction/relaxation techniques
Breathing training (Pursed-Lip Breathing)
Begin with relaxing neck and shoulders
Close mouth and inhale slowly through your nose
Purse lips and exhale slowly over a count of 3
Reduce physical exertion/O2 demand
Adjust/Open airway
Acupuncture to sternal points
76
Pall. Care Burdens for Children
**1. Congenital Anomalies**
**2. Neonatal Anomalies**
**3. Protein Energy Malnutrition**
**4. Meningitis**
5. HIV
6. CVD
7. Liver
77
Typical Descriptions:
* **Somatic** Nociceptive Pain
achy, throbbing, dull
typically well-localized
78
Typical Descriptions:
* **Visceral** Nociceptive Pain
* Squeezing, pressure, cramping, distention, dull, deep, and stretching
* ex. after abdominal or thoracic surgery
79
Typical Descriptions - Neuropathic Pain
burning, shooting, tingling, radiating, stabbing, numbness
Fire or Electrical Jolt
80
Types of itch
* **Pruritoceptive Itch**
* **Neurogenic/Neuropathic Itch**
81
* **Pruritoceptive Itch**
* Periphery or Central?
* Causes
* Treat as for...
* Generated in **Periphery**
* Exogenous causes
* Dry skin
* Contact irritation
* Histamine activation
* Allergy
* Worm infestation
* *Treat as for* ***Dermatitis***
82
* **Neurogenic/Neuropathic Itch**
* Where
* Causes
* Treat as for...
* generated in **PNS/CNS**
* **Central causes**
* Psychogenic itch
* **Cholestasis**
* accumulation of bile acids + increase endogenous opioids
* Drugs (Opioids)
* ***Treat as for neuropathic pain***
83
* Respiratory secretions
* **Pharmaceutical interventions**
* Regularly
* At the end
* SubQ or IV Scopalamine
* Hyoscine butylbromide
* Corticosteroids/Bronchodilators
* Diuretics
* **Atropine** (even as eye drops)
* Better at VERY end; may cause agitation
84
* Respiratory secretions
* **Non-Pharmaceutical interventions**
* Repositioning
* “High Side Lying”
* Elevate head of bed
* Suction (almost always not helpful; distressing)
* Fluid restriction; stop IV fluids
* Treat infection
* Mouth care
* COUNSEL FAMILY
85
**Ulcers** - How to manage them?
Causes:
– Pressure
– Diabetes
– Stasis
– Vitamin Deficiency
– Urine
Treat undrelying cause
Prevention
Surgery (Debridement, Amputation, Maggots)
Analgesia
86
PIC of GI Section
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