Exam 2 Pain Mgmt Flashcards
Nociception is?
Potentially tissue-damaging activity in nervous system
Pain is?
Perception of nociception
Suffering is?
Distress from factors that decrease quality of life
Nociceptive pain is result of?
Stim transmitted along?
Presentation?
Direct stim of intact nociceptors from injury or illness
Normal nn
Sharp, aching, throbbing
Nociceptive pain: Types? (2)
Somatic = mm, joints, bones Visceral = organs
Neuropathic pain caused by?
Result of? (5)
Peripheral or central nn damage/inflammation maintained by sympathetic (autonomic) DYSFUNCTION
Compression Transection Infiltration Ischemia Metabolic injury
Neuropathic pain: Presentation?
Burning, shooting, tingling, stabbing, electric
Chronic, intractable pain is?
“benign” (not from malignant condition)
e.g. back pain, post-herp neuralgia
Chronic, progressive pain is?
“malignant”
e.g. cancer pain
Pain is composed of what 4 things?
1) Physical problem needing dx and tx
2) Anxiety, anger, depression
3) Interpersonal problems affecting sxs
4) Non-acceptance-caused suffering
Approach to pain: ABCDE?
Ask about pain and Assess Believe the pt Choose appropriate pain control Deliver timely, logical, coordinated interventions Empower pt and family
Comprehensive Pain Eval should include? (4)
1) Pain description (OLDCARTS)
2) Exam of organ system involved w/ neuro/orth/mm
3) Psychosocial (beliefs abt pain/meds, social support)
4) 6 mo med hx
Tx of pain should start?
Immediately
Do not delay for investigation of or tx of disease ->
Unmanaged pain = permanent neuro damage
WHO 3-Steps for pain: Mild? (3)
ASA
Acetamin
NSAIDS
+/- adjuvants
WHO 3-Steps for pain: Mod? (3)
Codeine + acetam
-codones + acetam
Tramadol
+/- adjuvants
WHO 3-Steps for pain: Severe? (3)
Morphines Methadone Levorphanol Fentanyl \+/- adjuvants
Acetaminophen toxic dose?
> 4g/24hrs
NSAIDS affective for what type of pain?
bone, inflammatory
NSAIDS drawbacks?
Highest adverse effects (Gastropathy)
Inhibit platelets -> assess coagulopathy
Opioids kinetics?
Conjugated in liver
Excreted in kidney
1st order
Opioids Time to Max Blood Level (Cmax):
PO?
SC/IM?
IV?
PO = 1 hr
SC/IM = 30 min
IV = 6 min
Opioids t 1/2?
3-4 hrs for all routes
Opioids: Immediate Release duration?
PO/PR = 3-5 hr (except methadone)
Parenteral bolus = shorter
Opioids: Routine Oral Dosing for Immediate Release Codeine, -codones, Morphines?
Daily dose adjustment by what percent?
Q4h
Mild/Mod pain = ↑ 25 -50 %
Severe = ↑ 50 - 100%
Opioids: Routine Oral Dosing for Extended Release?
Adjust dose how?
Why do you not crush or chew ext release?
Q8, 12 or 24h
Q2-4d (when steady state reached)
Flushes time-release granules = get whole dose at once
Breakthrough dosing: Use what meds?
Amount?
When?
Immediate-release (NEVER extended-release)
12 - 15% of 24h dose
25 - 30% of 12h dose
After Cmax reached
If dehydration or renal/hepatic failure, next step?
If oliguria or anuria, next step?
↓ dosing interval and amount
STOP routine morphine -> change to PRN ONLY!
Why do we not use Meperidine (Demerol) for pain management?
Poor oral absorb
Makes toxic metabolite = psychosis, myoclonus, seizures
Equianalgesic Doses of Opioids?
See slide 50
Cross-tolerance change in dosing?
Start w/ 50 - 75% of equi dose
Opioid S/E: Common? (5)
Constipation Dry mouth N/V Sedation Sweats
Opioid S/E: Uncommon? (6)
Hallucinations Delirium Seizures Pruritus Resp depress Urinary retention
Adjuvant meds? (6)
Anxiolytics Antidepression Anticonvulsant Antiemetics Laxatives Steroids
Pain Flare is?
Tx how?
Increased pain in setting of chronic pain ->
Keep base dose the same,
Add add’l analgesic for short time
Periodic flairs should NOT be treated w/?
Why not?
breakthrough dosing (for malignant pain)
can lead to escalating opioid use
Pseudo-tolerance is?
Representation of pain flair by pt as tolerance
