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NRSG 310- Palliative Care > Week 9- pain/nausea/vomiting > Flashcards

Week 9- pain/nausea/vomiting Flashcards

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1
Q

Total Pain

A

physical
spiritual
emotional
social

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2
Q

advanced disease common symptoms

A

pain
loss of appetite
N/V
fatigue
dyspnea
constipation
delirium

lots can overlap

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3
Q

physical symptoms are managed by

A
  • addressing the underlying disease
  • using meds
  • using non-pharm treatment
  • addressing psychosocial needs
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4
Q

What happens when we can’t relieve suffering

A

hopelessness, depression, decrease in QOL

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5
Q

some preventable symptoms

A

constipation
nausea

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6
Q

principles of using medications
- route
- what’s more effective than 1
- consider
- provide meds
- titrate
- continue meds for
- provide
- assess

A

-oral when possible (less SE, easier to administer, take home)
- combo o meds
- reality of the care setting and needs of family
- regularly and around the clock
- meds to the dose that meets the persons goal
- as long as the symptom continue
- breakthrough
- regularly a when persons condition or behavior changes

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7
Q

it important to always

A

follow up with patients

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8
Q

pain is an

A

unpleasant sensory & emotional experience associated with actual or potential tissue damage

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9
Q

pain is highly prevalent at

A

the EOL regardless of primary diagnosis

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10
Q

pain can be ____ or _________ in up to ____% of patients using ___________ & _______________ BUT

A

well or completely controlled in up to 90% of patients using standard therapies & following guidelines BUT pain remains under-recognized and undertreated in many patient groups

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11
Q

people at risk for having underrecognized pain

A
  • Woman
  • problematic substance users, hx of addiction
  • language barriers
  • cognitive or developmental disabilities
  • people of colour
  • rural
  • infants/children
  • LGBTQIA +
  • elderly
  • people who deny pai n
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12
Q

components of physical pain
(3)

A
  • usually needs treatment (drugs)
  • causes variable degrees of distress
  • interferes with other aspects of life
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13
Q

components of spiritual pain (3)

A
  • guilt/remorse
  • fears after death
  • sense of connectedness
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14
Q

social parts of total pain

A
  • distress over family members
  • loss of role
  • participation issues
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15
Q

emotional components of total pain

A
  • adjustment disorders, anxiety, depression
  • frustration and hopelessness
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16
Q

one form of a pain assessment

A

OPQRSTUV
O: onset-When? How long? How often?
P: provoking-What makes it start? What makes it better? What makes it worse?
Q: quality-What does it feel like? Can you describe it?
R: region/radiation-Where is it? Does it spread?
S: severity-How severe? How would you rate it? Right now, at worst, on average?
T: treatment-What medications are you currently taking (western, alternative)? How are you using them? What have you tried in the past?
U: understanding- What do you think is causing this symptom? How is this impacting you?
V: value/belief of what pain means-What goals should we keep in mind? What is an acceptable level?

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17
Q

Edmonton symptom assessment system

A

rates symptoms on a scale from 0-10

pain
tiredness
drowsiness
nausea
appetite
SOB
depression
anxiety
wellbeing
other

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18
Q

Visual Analogue Scale

A

no pain (10) to worst pain ever (0)
has face on either end
younger children
English not first language

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19
Q

Numerical rating scale (NRS)
Faces rating scale (FRS)

A

0-10 painscale
different faces

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20
Q

Behavioral rating scale

CVMFR

A

for patients unable to provide a self-report of pain: scored 0-10 clinical observation

face
restlessness
muscle tone
vocalization
consolability

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21
Q

PAINAD scale

BBCFN

A

pain assessment for advanced dementia
- breathing
- negative vocalization
- facial expression
- body language
- consolability

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22
Q

before ordering diagnostics consider

A

goals of care

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23
Q

pain emergencies

A
  • spinal cord compression
  • bone fracture or impending fracture of weight bearing bone
  • infection/abscess
  • obstructed or perforated organ
  • ischemic process
  • SVC obstruction
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24
Q

Principles of pain management
- balance
- pain rarely
- reassess
- seek
- assess and treat
- consider use of
- remember

A
  • Balance burden with benefit.
  • Pain rarely occurs in isolation in patients with advanced disease
  • Reassess regularly and frequently
  • Seek consultation if not improving with titration, not adequately relieved within 72 hours. Or not managed with standard guidelines and interventions
  • Assess and treat other symptoms to maximize comfort
  • Consider use of traditional, Western & nonpharmacologic
  • Remember the concept of total pain
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25
types of pain
nociceptive: somatic or visceral, colic neuropathic: dysesthesia, lancinating, central
26
examples of somatic visceral pain
s= bone metastases, fracture v= organ, liver metastases, colic: malignant bowel obstruction
27
superficial somatic pain
confined to nociceptors in the skin sharp, sore, burning ex: Pressure ulcer fungating wounds
28
meds for superficial somatic pain
topical morphine, methadone or lidocaine
29
somatic deep pain
muscle, bone, joints and ligaments aching, throbbing, more diffuse ex: bone metastases, muscle spasms, RA and OA
30
meds for bone somatic pain | BDDN
NSAIDs dex bisphosphonates denosumab
31
soft tissue deep somatic meds | MND
NSAIDs (topical or systemic) dex muscle relaxants
32
visceral pain
nociceptors in viscera, peritoneum, pleura
33
meds visceral pain | DA
antispasmodics dex
34
central pain = - meds
lesion in brain or SC - antidepressants - anticonvulsants - NMDA antagonists - Antiarrhythmics
35
common side effects
- constipation (laxative) - nausea (usually resolves 3-5 days, metoclopramide or domperidone in the first days) - somnolence (usually resolves after 3-5 days, don't drive until pain controlled and no somnolence)
36
WHO analgesic ladder
step 1= mild pain 1-3/10 - use non opioid - +/- adjuvant Step2= moderate pain 4-6/10 - weak opioid (codeine, tramadol) - +/- adjuvant Step 3= severe pain 7-10/10 - strong opioid - +/- adjuvant
37
strong opioids 1st line 2nd line 3rd line
1- morphine, hydromorphone, oxycodone 2- fentanyl 3- methadone
38
avoid ____ for opioid
codeine - unpredictable safety and efficacy - possible interactions with other meds - often not sufficient for cancer pain
39
adjuvant analgesics principles - optimize - use appropriate - which administered as first line treatment - consider
- Optimize the opioid regimen before introducing an adjuvant analgesic in cancer pain - adjuvant analgesic at any pain severity level - The adjuvant with the greatest benefit and least risk - combination therapy with two or more drugs in the event of a partial response but avoid starting & titrating several adjuvants concurrently
40
breakthrough doses are
10 % of total 24 hour dose
41
codeine tramadol morphine hydromorphone starting dose
15 mg q 4hr 37.5 mg TID 5mg q4hr 1mg q4hr
42
1mg hydromorphone= ___ mg of morphine
5mg
43
reassess when __ or more breakthrough doses used per 24 hours
3 daily dose plus breakthrough becomes new total daily dose
44
titration | TDD=
1. calculate TTD for past 24 hr TDD= regular + all BTD 2. regular dose q4hr for the next 24 hours= past TDD/6 3. BTD= new regular dosex10 % increase he opioid BTD proportionately whenever the regular dose in increased
45
non- pharmacological pain interventions
Physical: physio, exercise, massage, positioning, application of heat/cold Psychological: relaxation, meditation, cognitive therapy Spiritual and cultural practices TENS, acupuncture, acupressure Palliative radiation Palliative surgery Neurotaxial analgesic Cementoplasty
46
adjuvant for bone pain (5)
- NSAIDs - steroids (useful in pain crisis, trial of several days preferred) - bisphosphonates (long term treatment to reduce skeletal events) - palliative radiotherapy - palliative surgery
46
palliative radiotherapy -pain reduced in -few -response within -may have -factions
- pain reduced in 70-80% patients treated - few side effects - response within 1 to 2 weeks - may have increased pain the first few days - single fractions often effective
47
prevalence of Nausea and vomiting
- affects 40-60% of people receiving palliative care - 21-68% of people with cancer - 2-48% of people with chronic illness - Reported most often in people <65yrs of age, female, receiving medications, have a GI obstruction, or have cancer of the stomach, breast or brain
48
impact of Nausea and vomiting
- Slightly bothersome - Profoundly distressing for patient & family - Decrease quality of life - Cause delay of active treatments ex. chemotherapy
49
standard of care for nausea and vomiting | 4
1. goals of care conversation 2. assessment and diagnostics 3. Determine possible causes and reverse as possible if keeping with goals of care 4. interventions
50
physical assessment of nausea/vomiting | 8
Signs of dehydration : sunken eyes, cracked lips, dry mucous membranes, increased respiratory rate, decreased output Electrolyte imbalances: weakness, tingling, Liver: jaundiced, ascites What meds are you taking ETOH Intracranial Pressure- headache Bowels: rectal exam Gait
51
Underlying Causes of Nausea & Vomiting 6 - most common 3
Chemical: drugs, chemo. Cortical Cranial Vestibular Visceral or serosal Gastric Stasis (impaired gastric emptying) most common gastric irritation, metabolic, infection
52
most common causes of N/V | BIG COM
gastric irritation (meds) obstruction metabolic imbalances infection constipation brain metastases
53
possible diagnostics N/V (4)
Blood work: CBC and differential, calcium, glucose, renal and liver functions Urine culture Abdominal imaging: X-ray, ultrasound, CT/MRI endoscopy
54
principles of management for N/V - balance - use - select - a single antiemetic is - monitor for - if symptoms persist
- Balance burden of possible intervention against likely benefit. - Use cause determination, knowledge of emetogenic pathways & a structured approach for selection of antiemetic. - Select the first line drug recommended for the most likely cause of the symptom. - A single antiemetic is effective in most patients - Monitor for symptom resolution and adverse effects for 48 hours. - If symptoms persist, prescribe a regular antiemetic with different antiemetic to be given as needed.
55
non pharmacological measures for N/V
Prevention: Identify triggers and remove or avoid Provide regular and meticulous oral hygiene Keep air fresh and odor free ex. Open windows, fan, clean commode, fresh linens, empty garbage Start anti-emetics when opioids initiated if hx nausea Ice chips, sips ice water: gradual increase in oral intake Offer mints, hard sugarless candy Aromatherapy ex. Peppermint or ginger oils reduced cancer related N&V in small studies Clinically assisted hydration if indicated
56
never give metoclopramide if
total bowel obstruction
57
Low Distress (1-3/10) N/V
-Try non-pharmacological action -Use first line drug for most -likely cause -Treat regularly for 48hrs plus additional PRN antiemetic drug
58
Moderate Distress (4-6/10) N/V
- Select drug based on likely cause - If cause unknown or due to multiple factors: Metoclopramide: treats common causes ex. Gastric stasis, partial bowel obstruction Haloperidol: chemical disturbances, other common causes Methotrimeprazine: broad acting receptor antagonist
59
Severe Distress (7-9/10) N/V
Urgently assess cause & initiate appropriate drug treatment/interventions If inadequate control within 48 hours consider: Hospitalization Hospice admission Consultation with palliative care physician Further antiemetic titration drugs or options, including combination of drugs with broader action
60

NRSG 310- Palliative Care (10 decks)

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