Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Year 3 - Clinical (Winter) > 19 - Intro to Pain > Flashcards

19 - Intro to Pain Flashcards

1
Q

Describe the 3 types of pain

A
  • Neuropathic: pain initiated or caused by a primary lesion or dysfunction in the NS (either peripheral or central NS); common descriptors = burning, shooting
  • Nociceptive: pain caused by injury to body tissues (MSK, cutaneous, visceral); common descriptors = aching, sharp, throbbing
  • Mixed: pain w/ neuropathic and nociceptive components (ex: lumbar radiculopathy, cervical radiculopathy, cancer pain, fibromyalgia)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Describe dependence and tolerance to medication in acute vs. chronic pain

A
  • Acute = unusual

- Chronic = common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Describe psychological component in acute vs. chronic pain

A
  • Acute = usually not present

- Chronic = often a problem

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Describe organic cause in acute vs. chronic pain

A
  • Acute = common

- Chronic = may not be present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Describe environmental/ family issues in acute vs. chronic pain

A
  • Acute = small

- Chronic = significant (px often have poor relationships)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Describe insomnia in acute vs. chronic pain

A
  • Acute = unusual

- Chronic = common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Describe general tx goal in acute vs. chronic pain

A
  • Acute = pain reduction

- Chronic = functionality

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Describe presence of depression in acute vs. chronic pain

A
  • Acute = uncommon

- Chronic = common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Describe relief of pain in acute vs. chronic pain

A

Highly desirable in both

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is an acronym that can be used for a brief pain assessment?

A

PQRST

  • P = provokes, precipitates (what brings it on and what takes it away?)
  • Q = quality (in the px own words; prompt only if necessary)
  • R = radiation, referral (does the pain move to another spot? Are there other sx associated w/ the pain, ex: nausea, SOB)
    • Radiation generally means nerves are involved
  • S = severity (how does the pt rate the pain?)
    • Not often used for chronic pain
  • T = timing (when did the pain start? Has it occurred before? Is it constant or does it come and go?)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are some important questions to assess function w/ pain?

A
  • How does the pt look and mobilize?
  • Are they able to perform valued activities?
  • Are they dysphoric, irritable, depressed?
  • How are they sleeping?
  • Do they feel well enough to socialize?
  • Are they enjoying life?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Goals of therapy for acute pain

A
  • Pain reduction**
  • Increased mobility
  • Sleep
  • QOL, exercise, decreased side effects
  • Improved mood
  • Decreased pill burden and cost (minor goals since don’t want pt on meds long term)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Goals of therapy for chronic pain

A
  • Sleep, exercise, increased mobility**
  • QOL, decreased side effects, improved mood
  • Pain reduction
  • Decreased cost
  • Decreased pill burden
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Acetaminophen for pain – dose, onset, pros, cons, efficacy

A
  • Dose -> 325-1000 mg q4-6h
  • Onset ~ 15-30 minutes
  • Pros -> well tolerated; generally, high doses required to result in toxicities; few drug interactions; cheap and accessible
  • Cons -> mild benefit for many chronic conditions, found in many products
  • Max dose = 4 g/day (some proposing to lower to 3 g/day)
  • Minimal effectiveness in acute pain (headache and post-dental surgery) but no significant effect vs. placebo for chronic pain (osteoarthritis & back pain)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Acetaminophen harm

A
  • Major concern = hepatotoxicity (> 50% of serious liver injury associated w/ unintentional overdoses)
  • Decrease dose to max. 3g/day in elderly, poor nutrition status, fasting/anorexia, alcoholism, viral liver disease
  • Contraindication = severe hepatic impairment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

NSAIDs for pain – efficacy, cons

A
  • More effective than acetaminophen for certain conditions (such as dental surgery & OA pain; no effect on chronic low back pain)
  • Can be given topically
  • Use w/ opioids can result in decreased opioid dose requirement
  • Cons -> GI bleeds, acute kidney injury, increased BP, increased risk of MI (depends on pt)
17
Q

Risk factors for GI problems w/ NSAIDs

A
  • Age > 65 y/o
  • Use of anticoagulants, steroids
  • Hx of PUD
  • High dose of NSAID
  • Presence of H. pylori
18
Q

How to decrease risk of GI problems

A
  • PPI cotherapy
  • Use of coxib products
  • Tx of H pylori
19
Q

Risk factors for AKI w/ NSAID use

A
  • Volume depletion
  • CHF
  • ACE/ARB use
  • Renal disease
  • Cirrhosis
  • 70 years and older
20
Q

Risk factors for cardiac problems w/ NSAID use

A
  • Use of diclofenac and high-dose celecoxib

- Absolute risk depends on other risks for CHF, CAD

21
Q

Topical NSAIDs for pain – advantage, disadvantage, when to recommend or not recommend

A
  • Advantage -> less major SE b/c only 2-15% is systemically available
  • Disadvantage -> local skin reaction, “stickiness”
  • Reasonable to recommend for osteoarthritis and for acute pain (ex: sprains, strains, overuse injuries)
  • No evidence to support use for back pain, neuropathic or widespread pain
22
Q

Pros and cons to opioids

A
  • Pros -> highly effective for some pain types (ex: nociceptive), high dose ceiling effect (no general ceiling dose, depends on pt), IV/SC doses for improved access and quicker onset
  • Cons -> abuse potential, side effects (whether day-to-day or long-term), threshold for serious toxicity can be low in some, tolerance/ dependence, most require a duplicate Rx
23
Q

Morphine, hydromorphone, or oxycodone

A
  • All strong opioids w/ similar analgesic abilities, onsets, and durations (when equipotent doses used)
  • Morphine -> active metabolites renally eliminated, so caution w/ accumulation in renal dysfunction; caution w/ cirrhosis-
  • Hydromorphone -> caution in renal dysfunction, but less so than morphine; caution w/ cirrhosis; less histamine release (so less itchiness as a SE)
  • Oxycodone -> similar to morphine in renal/ hepatic considerations; big street value
    • Not first line for opioid naïve
24
Q

Clinical pearls of opioids

A
  • Codeine -> caution w/ breastfeeding women; lower risk of overdose and addiction than stronger opioids
  • Tramadol -> associated w/ seizures in px w/ high seizure risk or when combined w/ medications that increase serotonin levels
  • Morphine -> avoid in renal dysfunction (active metabolite can accumulate to toxic levels)
  • Oxycodone, hydromorphone, hydrocodone -> use w/ caution for px at higher risk for opioid misuse and addiction; may have higher abuse liability than morphine
25
Q

Clinical pearls – fentanyl

A
  • Before starting, obtain complete hx of opioid use w/in last 2 weeks to ensure pt is fully opioid tolerant
    • Tolerance can be assumed if pt is on a moderate, stable dose of a strong opioid (TDD of at least 60-90 mg/day morphine equivalent for at least 2 weeks)
  • Don’t switch from codeine to fentanyl regardless of codeine dose, as some codeine users may have little or no opioid tolerance
  • Maintain initial dose for at least 6 days; use extra caution w/ px at higher risk for overdose (ex: elderly, px on BZDs)
  • Be alert for signs of overdose (ex: slurred speech, emotionally liable, ataxia, nodding off during conversation or activity) and if detected, remove patch and seek medical attention
    • Also, a good idea to have a naloxone kit
  • Apply as prescribed; don’t apply more than 1 patch at a time or change more often than directed
  • Avoid heat sources
  • Dispose of patches securely; a used patch contains large amounts of fentanyl and could be dangerous to others
26
Q

Switching opioids

A
  • Converting -> safer to under-dose at first, so give 50% (for elderly) to 75% of calculated amount
  • Monitoring** -> what will they do for the next few days and who else can monitor them (ex: in hospital, at home, etc.)
    • Signs and sx of overdose
    • Also, counsel someone who can stay w/ them
    • Recommend naloxone kit
27
Q

Adjuvants for pain relief

A
  • Muscle relaxants -> only used for muscle spasms associated w/ acute injury
    • Limited benefit at OTC doses; only use if pt has hx of good overall effect
    • Cyclobenzaprine meta-analysis showed most of benefit in first 4-7 days; may use up to 2 weeks
    • Common limitation = drowsiness
  • Local corticosteroid injections (ex: knee for OA)
28
Q

Non-pharms for different types of pain

A
  • For acute or chronic -> heat and/or cold; physiotherapy; massage
  • Primarily chronic -> exercise, music, yoga, CBT
  • Likelihood of benefit dependent on type of pain being treated
29
Q

Monitoring pain

A
  • PQRST
  • Analgesic use (dose and frequency)
  • Non-drug approaches being used
  • Pain diary -> helpful for px to look at overall med use and triggers of pain as well as document function (to determine if it’s improving)
30
Q

When might a pain diary be helpful?

A
  • When looking at how to dose long-acting meds
  • Determining what causes pain (and being proactive about tx)
  • Helping pt understand their pain better
  • Document what they were able to do
31
Q

Monitoring function

A
  • Ability to perform valued activities
  • Ability to exercise
  • Relief from dysphoria/irritability or improved depression/anxiety
  • Sleep
  • Minimized medication SE
  • Feeling well enough to socialize
  • Financial
32
Q

Pain in the elderly

A
  • Under-reported, under-recognized, and under-treated
  • Poorly controlled pain can result in -> malnutrition, weight loss, falls, fractures, depression, less socialization
  • Physiologic changes result in increased sensitivity to therapeutic and adverse effects
33
Q

Approach to pain in the elderly

A
  • Vigilant dose titration; start low (1/2 of usual starting dose), go slow, and review often
  • Caution w/ oral NSAID use -> increased risk of GI bleed, CV and renal events
    • Add PPI if ongoing use
    • Monitor renal function
    • Use topical instead if indicated
  • Caution w/ opioid use (elderly, increased fracture risk, renal or hepatic impairment, COPD and sleep apnea, cognitive impairment)
    • Do a “3-day tolerance check” after starting (may want to call after 24 h b/c likely to have effects immediately)
    • Assess for sedation, imbalance, confusion, constipation
  • Avoid skeletal muscle relaxants

Year 3 - Clinical (Winter) (30 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions