Pain Assessment & Management Flashcards
(52 cards)
1
Q
Discuss whether pain is common in cancer patients
A
- 30-40% with early disease
- 75-90% with advanced cancer
- ⅓ >2 different pains
- Can be controlled in 80% of pts using stepwise approach
*NOTE: 65% dying from non-malignant disease also experience pain
2
Q
Remind yourself of key aspects of a pain history
A
- Site (localised, diffuse)
- Quality
- Intensity
- Timing (onset, duration, breakthrough or incident pain)
- Aggravating factors
- Relieving factors
- Symptoms associated (be sure to ask about power, sensory loss, parasthesia)
- Impact on life (ADLs, sleep)
- ICE (what pt thinks it is, what they are concerned about, any expectations they have)
3
Q
Describe the pathophysiology of each of the following types of pain:
- Nociceptive
- Neuropathic
- Visceral
- Somatic
- Incident
A
- Nociceptive pain: caused by the detection of noxious or potentially harmful stimuli (e.g. mechanical, thermal, chemical) by the nociceptors around the body
- _Neuropathic pain:_pain occurring due to damage or disease of nerves (CNS or PNS)
- Visceral pain: pain from internal organs in thoracic or abdominal cavity
- Somatic pain: pain from nociceptors that are located in skin and deep musculoskeletal tissues. Can be superficial (skin) or deep (muscles, bone, tendons/ligaments)
- Incident pain: pain associated with a particular activity or movement (e.g. coughing, walking etc…)
*NOTE: 40% of pain is mixed
4
Q
Compare nociceptive and neuropathic pain in terms of presentation (focus on features in neuropathic pain that aren’t present in nociceptive)
A
- Burning
- Shooting
- Stinging
- Paraesthesia
- Numbness
- Allodynia
- Less likely to respond to traditional painkillers
5
Q
Compare visceral and somatic pain (both superficial and deep) in terms of presentation
A
Visceral
- Poorly localised
- Crampy, squeezing type pressure, dull, achy
- Referred pain
- Associated nausea, vomiting, sweating
Somatic
- Superficial: sharp, well localised, pulsatile
- Deep: ache, not as well localised as superficial (but usually more so than visceral)
6
Q
What is end of dose failure pain?
A
Pain due to effects of analgesia wearing off; occurs around same time every day (if pt is on round the clock analgesia)
7
Q
For each of the following pain descriptions, suggest a possible cause
(image taken from NICE palliative care pain section)
A
8
Q
State some factors that:
- Increase
- Decrease
… pain sensation
A
9
Q
State some potential sources of pain in a cancer pt
A
- Direct effects of the tumour (for example infiltration of pain-sensitive structures)
- Treatment associated with the cancer (for example surgery, chemotherapy, radiation treatment).
- Pain related to procedures (for example dressing changes, change of position).
- A condition not directly related to the cancer (for example infection, pre-existing osteoarthritis).
10
Q
Describe the WHO pain ladder
A
11
Q
State some examples of non-opioids
A
- Paracetamol
- NSAIDs
12
Q
State some examples of weak opioids
A
- Co-codamol
- Codeine phosphate
- Dihydrocodeine
- Tramadol
13
Q
State some examples of strong opioids
A
- Fentanyl
- Oxycodone (synthetic morphine, more expensive)
- Morphine
- Diamorphine (more soluble than morphine)
- Methadone
- Buprenorphine
14
Q
State some examples of adjuvants
A
Variety of drugs belonging to different classes:
- Amitriptyline (TCA)
- Pregabalin (anticonvulsant)
- Gabapentin (anticonvulsant)
- Duloxetine (SNRI)
- Topical therapies e.g. capsaicin
- Bisphosphonates
- Steroids e.g. dexamethasone
15
Q
What must you always co-prescribe to cancer pts who are taking NSAIDs and/or steroids?
A
PPI
16
Q
If a pt had GI risk but no CV risk what NSAIDs could you prescribe?
A
Cox-2 inhibitors e.g. celecoxib, etoricoxib
17
Q
Remind yourself how NSAIDs work- particularly in inflammatory pain
A
- Inhibition of prostaglandin synthesis by the enzyme cyclooxygenase which catalyses the conversion of arachidonic acid to the various prostaglandins that are the chief mediators of inflammation
- Prostagladins, particularly PGE2, sensitise nociceptive fibre nerve endings to other inflammatory mediators (such as bradykinin)
- It is the other inflammatory mediators that are sending the ‘pain signals’ not the prostaglandin itself
- Hence if have pain caused by these inflammatory mediators then NSAIDs will be more effective against pain
18
Q
Remind yourself how opioids work
A
19
Q
State some common side effects of opioids
A
- Constipation
- N&V (transient)
- Drowsiness (transient)
- Dry mouth
- Rash
- Pruritis
- Urinary retention
- Confusion
20
Q
State some contraindications to opioids
A
- Respiratory depression
- Comatosed pts
- Head injury (mask symptoms & interfere with pupillary response)
- Raised ICP
- At risk of paralytic ileus
*Contraindications according to BNF
21
Q
State some side effects of NSAIDs
A
- GI ADRs (dyspepsia, nausea, peptic ulceration, perforatin)
- Renal ADRs (renal failure/AKI)
- Others may include:
- Hypersensitivity
- Rash
22
Q
State some contraindications to NSAIDs
A
MOST related to GI disorders:
- Active GI bleeding
- Active GI ulceration
- Hx GI bleeding related to NSAIDs
- Hx GI perforation related to NSAIDs
- Hx recurrent GI haemorrhage
- Hx recurrent GI ulceration
- Severe HF
- Varicella infection
23
Q
What adjuvants can you use for neuropathic pain?
A
NICE updated their guidance on the management of neuropathic pain in 2013:
- First line: amitriptyline, duloxetine, gabapentin or pregabalin
- if the first-line drug treatment does not work try one of the other 3 drugs
- in contrast to standard analgesics, drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be switched, not added
- tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
- topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia)
24
Q
State some common side effects of amitriptyline
A
- Confusion
- Hypotension
- Drowsiness
- Dry mouth
- Constipation
25
State some common side effects of gabapentin & pregabalin
* Drowsiness
* Dry mouth
* Sexual dysfunction
* Sleep disturbance
* Headache
* Blurred vision
* Constipation/diarrhoea
26
Discuss whether opioids are good for the following types of pain:
* Soft tissue
* Visceral
* Bone
* Neuropathic
* Incident
27
When initiating someone on opioids, what other medication should you co-prescribe?
* **Anti-emetics:** N&V common when initiate opioids but usually settles after a week or two. First line= haloperidol (or can give metoclopramide if gastric stasis)
* **Laxatives:** constipation is very common and is NOT transient/doesn't settle hence pts often on long term laxative. NICE suggest prescribing both a stimulant and a softener (e.g. Senna + docusate/macrogol/lactulose) or a laxative with both properties (e.g.co-danthramer)
28
Discuss how you modify someone's opioid prescription if their pain is not controlled by their current SR and IR
* To **calculate new total daily dose** (TDD) add up their SR prescription and the amount of drug they have had in form of PRNs (e.g. if have 30mg SR BD and had 6 PRNs of 10mg… then new TDD would be 120mg)
* **New SR is half of the new TDD** (e.g. 120/2=60mg)
* **New IR/PRN dose is 1/6 of the new TDD** (e.g. 120/6=20mg)
29
How many doses of PRN opioid can a pt have in a day?
How often can they have their PRN doses?
* **Up to 6 PRN doses in 24hrs.** If they are having more than 6 PRN doses need to up-titrate their opioid medications
* In LOROS teaching said they could have it **hourly, but NICE CKS states 2hourly**
30
You may need to convert between different opioids; state the conversion factor for:
* PO codeine to PO morphine
* PO tramadol to PO morphine
*\*codeine to morphine is 10:1*
31
You may need to convert between different opioids; state the conversion factor for:
* PO morphine to PO oxycodone
32
You may need to convert between different opioids; state the conversion factor for:
* PO morphine to SC morphine
* PO morphine to SC diamorphine
* PO oxycodone to SC diamorphine
*\*PO to SC morphine is 2:1*
33
What would you use for PRN pain relief if pt on fentanyl patch?
* Usually use oromorph (1/6th of 24hr morphine equivalent dose)
* Smallest fentanyl patch is 12micrograms/hr which equates to about 45mg of morphine in 24hrs
34
Summary of opioid conversions
35
What % increase in opioid dose is generally considered safe?
In general, **dose** **increases** **should be limited to no more than 30% of the total 24-hour morphine dose** *(in LOROS said between 30-50% increase in SR is generally considered safe)*
36
You will often see morphine prescribed as zomorph and oromorph; which is the SR and which is the IR?
In what from are these drugs (e.g. PO, SC, IV etc...)
* Zomorph= slow release *(think zo slow)*
* Oromorph= immediate release
Both are oral *(trade names for oral morphine sulphate which is either SR or IR)*
37
Zomorph (SR PO morphine) doses should always be ____ hours apart
**12hrs** (e.g. 8am and 8pm)
38
For oromorph, state:
* Liquid concentration available
* Tablet doses available
* Liquid: 10mg/5ml or 100mg/5ml (100mL or 300mL bottles)
* Tablets: 10mg, 20mg, 50mg
39
For zomorph, state:
* Capsule doses available
* Tablet doses available
* Capsule: 10mg, 30mg, 60mg, 100mg, 200mg
* Tablet: 5mg, 10mg, 15mg, 30mg, 60mg, 100mg, 200mg
40
Which opioids are preferred in pts with renal impairment and why?
* If mild-moderate renal impairment oxycodone is preferred
* If renal impairment more severe then buprenorphine, fentanyl or alfentanil are preferred
*\*metabolised by liver*
41
State some signs of opioid toxicity/overdose
* Drowsiness
* Pinpoint pupils
* Hallucinations
* Confusion
* Vomiting
* Myoclonic jerks
* Respiratory depression
42
What analgesics can we use for metastatic bone pain?
* NSAIDs *(thought to be particularly effective for bone pain although this hasn't been supported by studies)*
* Strong opioids
* Bisphosphonates
* Denosumab *(SC monoclonal antibody that inhibits RANKL= a protein that activates osteoclasts the cells that are involved in bone breakdown)*
* Radiotherapy
43
What is a syringe driver?
Why may someone need a syringe driver?
* “Continuous subcutaneous infusion”. It is a pump that delivers medication, via SC cannula, at a constant rate throughout day & night/over 24hour period
* Unable to take oral medication due to e.g. nausea, dysphagia, intestinal obstruction, weakness, coma
* NOTE: can still be given PRN doses on top of SR dose via syringe drive (PRN doses would also be SC)
44
The majority of drugs can be given via syringe driver; state some example drugs that are commonly given via syringe driver to treat:
* N&V
* Respiratory secretions
* Agitation/restlessness
* Pain
* nausea and vomiting: cyclizine, levomepromazine, haloperidol, metoclopramide
* respiratory secretions/bowel colic: hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide.
* agitation/restlessness: midazolam, haloperidol, levomepromazine
* pain: diamorphine is the preferred opioid
45
Certain drugs can be mixed and given via same syringe driver; true or false?
**True; however must ensure they are compatible** (this includes whether drugs can be mixed, whether they are both diluted with same thing [water for injection or 0.9% NaCl] etc..)
For example cyclizine is incompatible with number of drugs
There is a big database you can check. NICE also have some information.
46
Complete the following prescription chart for zomorph 30mg BD
47
Complete the following prescription chart for oromorph 15mg PRN
48
Complete the following prescription to give morphine sulphate 120mg via syringe driver
49
What information should a TTO prescription for a controlled drug include?
**Controlled drug prescriptions must:**
* Be indelible
* Be dated
* Be signed by the prescriber
* Include the prescriber’s address
* Include the name and address of the patient
* Include the date of birth of the patient (and age if \<12 years)
* Include the form of the preparation (e.g. tablets – even if there is only one form of the drug)
* Include the strength of the preparation (if appropriate)
* Include the total quantity in both words and figures (e.g. 20 (TWENTY) tablets, 100 (ONE HUNDRED) millilitres)
* Include the dose to be taken
**Controlled drug prescriptions should:**
* Include the patient identifier (NHS number in England, Community Health Index number in Scotland, there is no guidance for Wales or Northern Ireland)
* Include the prescriber’s GMC number
* Have a diagonal line drawn underneath the prescription to indicate no more items, OR have “No more items” written under the last prescription.
50
Discuss how to write a TTO for a controlled drug
* Patient details: name, DOB (age if \<12yrs), pt address
* Write prescription including form (e.g. tablets, liquid, patch) & strength if appropriate e.g. zomorph 30mg tablets BD, PO, 12 hourly
* Write SUPPLY and give exact instructions ensuring you write total quantity in both numbers & words (e.g. 12 (twelve) tablets)
* \*NOTE: prescribing liquid doses in mg reduces risk of error*
* \*Remember on on prescriptions can write mg for milligrams but cannot write mcg must be micrograms*
51
When writing a TTO for PRN opioids, how many PRN doses per day do you supply them with?
* Give enough for them to have 2 PRN doses per day for the duration you are prescribing
* E.g. if you are prescribing for 14 days, they need 28 PRN doses worth
52
If you are prescribing a drug that must be increased slowly over a number of days (e.g. full dose is 300mg TDS but day 1 they have 300mg OD, day 2 they have 300mg BD then day 3 they reach full dose) how do you prescribe this?
* Prescribe the full dose (e.g. 300mg TDS)
* Put crosses in boxes where you don't want nurse to give (so two X in day 1, one X in day 2, no X in day 3)
