Brainscape's Knowledge GenomeTM

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


See full index

Palliative Care > Chapter 3 - pain and its management > Flashcards

Chapter 3 - pain and its management Flashcards

1
Q

what are two broad types of pain?

A

nociceptive pain

neuropathic pain

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

what is nociceptive pain?

A

Pain occurring from a defined lesion, that causes tissue damage leading to stimulation of nociceptors in somatic (bone and soft tissue) and visceral (capsular, hollow, cardiac) tissues.

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

what are the two types of nociceptive pain?

A

1) somatic pain - tissue damage or bone damage

2) visceral pain - lesion in or compression of hollow viscus, capsule, or cardiac solid organ

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

what is neuropathic pain?

A

inflammation, irritation or neural tissue compression, within the central or peripheral nervous system

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

what are the types of neuropathic pain?

A

peripheral - damage to the nervous system
allodynia - caused by stimulus that does not evoke pain e.g. feather or light touch
hyperalgesia - increased response to a normally painful stimulus
central - pain caused by damage to the spinal cord or brain
complex regional pain syndrome
sympathetic maintained neuropathic pain

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

what is breakthrough pain?

A

a transient exacerbation of pain in a person with otherwise stable well controlled background pain

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

what is background pain?

A

persistent pain of long duration managed with regular analgesia

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

what is spontaneous pain?

A

pain experienced prior to when the next dose of analgesia is due - if extra doses are required more than twice a day on a regular basis, then consider increasing the regular background analgesia dose

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

what is incident pain?

A

pain associated with an identifiable incident ie. procedural, involuntary act (cough) or voluntary i.e. walking

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

what is end of dose pain?

A

term used to describe pain that occurs in the period just before the next dose of analgesia is due

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what is the socrates acronym for pain?

A 
site 
onset
character
radiation
association
time course
exacerbating/relieving factors
severity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

what are some pain assessment tools for patients with dementia?

A

DS-DAT (discomfort scale for dementia of alzhiemers type)
DisDAT (disability distress assessment scale)
dolopus-2 (behavioural tool for pain in the elderly)
Abbey pain scale

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what is the WHO pain ladder steps?

A

step 1 - mild to moderate pain (NON OPIOID +/- ADJUVANT)
step 2- moderate pain (WEAK OPIOID + NON OPIOID +/- ADJUVANT)
step 3- severe pain (STRONG OPIOID + NON OPIOID +/- ADJUVANT)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what are the kind of drugs used in the first step of the WHO pain ladder?

A

paracetamol + NSAIDS

if not adequate in 24 hours proceed to the next step

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what kind of drugs are used for the second step in the WHO pain ladder?

A

combination preparations i.e. cocodamol (paracetamol 500mg/codeine 30mg) + dihydrocodeine (30-60mg, 6 hourly) + low dose tramadol (50mg 6 hourly)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what kind of drugs are used for the third step of the WHO pain ladder?

A

oral 1st line - morphine
oral 2nd line - oxycodone

SC 1st line - diamorphine/morphine
SC 2nd line - oxycodone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

what is the pharmacology of opioids?

A

block opioid receptors in the dorsal horn of the spinal cord, brain stem + peripheral nerves.
Opioid receptors - Mu, Kappa, Delta.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

how do opioids cause a constipating effect?

A

act on opioid receptors in the myenteric and sub mucous plexus causing reduction in gut motility

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

what are the different types of opioid receptors?

A

mu, delta and kappa

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

what is the starting dose of morphine?

A

5-10mg IR 4 hourly

if elderly, frail or renal impairment can consider starting 1.25-2.5mg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

what is the conversion factors from codeine to morphine?

A

codeine is 10 times weaker
to convert from codeine to morphine you divide by 10
i.e. if a patient is taking two co-codamol strong tablets four times a day (30/500), they are taking 240mg of codeine a day
so 240/10 = 24mg of oral morphine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

how long does IR morphine last?

A

around 4 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

how long does MR morphine last?

A

12 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

how can you manage incident pain?

A

incident pain = pain associated with doing something i.e. movement or getting out of bed

  • ensure medication timings are given 30 mins before the incident
  • alternatively, can give fentanyl preparations as these act much quicker but are more expensive (i.e. oral transmucous (Actiq) or sublingual (Abstral, Effentora) or intranasal (Instantly).
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

how should you convert a patient from opioid to another?

A

calculate the equivalent opioid dose and reduce by 1/3, ensuring PRN’s are available

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

what is the conversion from PO to SC opioids?

A

divide by 2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

what is the conversion of oral morphine to SC alfentanil?

A

divide by 30

28
Q

what is the conversion of SC diamorphine from oral morphine?

A

divide by 3

29
Q

list the opioids that can be given orally?

A 
morphine
oxycodone
codeine
tramadol 
methadone
30
Q

list the opioids that can be given SC?

A

morphine
oxycodone
diamorphine
alfentanil

31
Q

what are the two types of transdermal patches that are used?

A

fentanyl patch

buprenorphine

32
Q

what dose of morphine should patients be on before rapid acting fentanyl patches are used?

A

when a patient is on 60mg/24hrs oral morphine AT LEAST

33
Q

what are is an example of a trans mucosal fentanyl product?

A

actiq

34
Q

what is an example of a sublingual fentanyl product?

A

abstral

35
Q

what is an example of a nasal spray fentanyl product?

A

instantyl/pecfent

36
Q

how should buccal/transmucosal/sublingual/nasal products be started?

A

at the lowest dose- regardless of background opioid usage

37
Q

what is the practical benefit of using diamorphine?

A

comes in powder form and is highly soluble in water, so can be easily used in a CSCI where high doses of opioids are needed

38
Q

when is alfentanil indicated?

A

renal failure - as does not accumulate in renal failure

metabolised in the liver and has inactive metabolites that are excreted via the kidney

39
Q

why alfentanil not used as a breakthrough typically?

A

it has very short duration of action so may not work as effectively

40
Q

when should transdermal patches be considered?

A
  • in STABLE pain
  • poor compliance
  • difficulties swallowing/taking regular PRN’s

breakthroughs are needed until peak conc. levels are achieved. This delay also means patches cannot be used for titration and are only used for stable pain.

41
Q

when are fentanyl patches usually changed?

A

72 hours

42
Q

when are buprenorphine patches changed?

A

72-96 (transtec) hours, or 7 days (butrans)

43
Q

what are some common SE with opioids?

A

drowsiness/sedation - usually only lasts for the first 48hrs
constipation - patients should be on a stimulant + softener ideally
nausea/vomiting - patients advised to be on regular antiemetic for first week (usually metoclopramide)
dry mouth

44
Q

when a patients advised to drive when taking opioids?

A

avoid driving for 7 days after commencing/increasing opioid or within 4 hours of PRN dose

45
Q

which anti-emetic is usually recommended in patients taking opioids and why?

A

metoclopramide - due to its central effects and impact on opioid included gut stasis

46
Q

what can be advised for patients with dry mouth secondary to opioids?

A

chewing sugar free gum to stimulate salvia production, good oral hygiene, salvia substitutes or mouth washes

47
Q

what can be prescribed for opioid induced constipation?

A

stimulant + softener (i.e. Senna + Sodium docusate)
peripherally acting u-opioid antagonist such as naloxegol tablets or methynaltrexone relistor

can also give targinact (oxycodone + naloxegol together) - however this is contraindicated in hepatic failure

48
Q

what can increase the likelihood of opioid toxicity?

A

renal failure - accumulation of active metabolites
rapid upward titration
conversion from one opioid to another
development of acute infection
commencement of adjuvant such as pregabalin

49
Q

symptoms of opioid toxicity?

A 
myoclonic jerks
pinpoint pupils - not most reliable 
confusion/agitation
drowsiness
hallucination/vivid dreams
cognitive impairment 
respirator depression
50
Q

what should be done in mild opioid toxicity?

A

reduce dose of opioid
rehydration
treat underlying cause
if agitation - give 1.5-3mg haloperidol orally or SC

51
Q

what should be done in moderate toxicity?

A

if RR> 8/min + O2 sats normal + patient not cyanosed + easily rousable, omit the next dose (or stop infusion/patch), and adopt “wait and see” approach
when the next dose is due, re-titrated to the patients needs

52
Q

what should be done in severe opioid toxicity?

A

if RR<8/min consider naloxone

stop opioids at current dose + re-titrate as needed

53
Q

how should naloxone be given and what dose?

A

400mcg diluted in 10ml of 0.9 NaCl
administer 0.5mls IV ever 2 mins until RR satisfactory
further boluses may be required
if no iv access, can be given SC - 100mcg

consider infusion pump if multiple doses are needed

54
Q

what is an example of an antidepressant used for pain?

A

amitryptilline (TCA) used in neuropathic pain

55
Q

what is an example of anticonvulsants used for pain?

A

gabapentin
pregabalin
both used for neuropathic pain

56
Q

what is an example of antispasmodic used for pain?

A

hyoscine butyl bromide (i.e. buscopan) for bowel colic

57
Q

what is an example of a bisphosphonate used for pain?

A

pamidronate used for bone pain

there is evidence that bisphosphonates help with metastatic bone pain as they inhibit osteoclast activity
They should not be used first line, side effects include:
- hypocalcaemia
- renal failure
- osteonecrosis of the jaw

58
Q

give three example of situations where nerve blocks are indicated?

A 
solitary rib mets
fractured NOF (lumbar plexus) 
pancreatic pain (coeliac plexus)
59
Q

how long can it take for radiotherapy to improve bone pain?

A

3 weeks

60
Q

what are some interventions for bone pain?

A

NSAIDs
pamidronate/zolendronate. - bisphosphonates
radiotherapy

61
Q

what can be used to ease liver capsule pain?

A

pain due to liver mets stretching the peritoneum on the liver surface can respond to dexamethasone (4-6mg)

62
Q

what can be given for muscle pain?

A

skeletal muscle relaxants such as diazepam 2mg TDS or baclofen 5mg TDS

63
Q

what are some examples of complementary therapies used in pain?

A 
acupuncture
massage
aromatherapy
hypnosis
spiritual healing 
reflexology
art therapy 
relaxation techniques
64
Q

what are some non-pharmacological interventions?

A 
positioning
catheterisation 
splinting
exercise
talking therapies
diversional therapies
psychosocial support
65
Q

how does TENS machine work?

A

sensory nerves are excited by the transcutaneous electrical nerve stimulation and either the pain gate mechanisms and/or opioid system are also stimulated in order to “override” the pain

66
Q

what are contraindications to a TENS machine?

A

pacemaker

recent haemorrhage

Palliative Care (10 decks)

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