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Clin Mgt Exam 2- Managing pain, end of life, D/c, SDOH > Managing Pain and EOL Care > Flashcards

Managing Pain and EOL Care Flashcards

1
Q

Goal for Treating Acute Pain

A
  • should not be zero pain- rather a tolerable level of pain that allows optimal physical and emotional function
  • expectations should be discussed with patients and their families
  • “The goal is to find the lowest effective analgesic dose as well as the amount needed before re-evaluation is necessary”
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2
Q

Acute Pain Treatment Options

non opiod

opiods

A

•ANALGESICS- NON-OPIOID

Acetaminophen (↓ production of prostaglandins)

  • 4 gram/day limit (325mg, 500 mg)

NSAIDS

  • COX-1
    • •Ibuprofen (Motrin, Advil)
    • •Naproxen (Aleve, Naprosyn)
    • •Meloxicam (Mobic)
  • COX-2- Celecoxib (Celebrex)

SHORT-ACTING: FOR ACUTE PAIN

  • Hydrocodone - Only Combination
  • Oxycodone - Alone or Combination
  • Hydromorphone (Dilaudid)
  • Tramadol- Alone or in Combo
  • Codeine – Combination
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3
Q

short vs long acting opiods

A

SHORT-ACTING: FOR ACUTE PAIN

  • Hydrocodone - Only Combination
  • Oxycodone - Alone or Combination
  • Hydromorphone (Dilaudid)
  • Tramadol- Alone or in Combo
  • Codeine – Combination

LONG-ACTING: avoid in acute pain

  • Oxycodone (OxyContin)
  • Morphine sulfate (MS Contin)
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4
Q

opiod side effects

A

•Somnolence - these medication can make you sleepy

•Depression of brainstem control of respiratory drive

•Urinary retention- make it hard to move your bowels’

•Nausea and vomiting - may make you sick to your stomach’

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5
Q

define multimodal approach

A
  • Uses several agents or techniques, each acting at different sites of the pain pathway
  • Reduces the dependence on a single medication and mechanism, and importantly, may reduce or eliminate the need for opioids
  • Synergy between opioid and nonopioid medications reduces both the overall opioid dose and unwanted opioid-related side effects
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6
Q

Perioperative Pain Management Goals

optimal strategy??

A
  • to relieve suffering
  • achieve early mobilization after surgery
  • reduce length of hospital stay
  • and achieve patient satisfaction

***The optimal strategy for perioperative pain control consists of multimodal therapy to minimize the need for opioids

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7
Q

Opiod examples

combos

A

Codeine 15 to 60 mg orally every four to six hours

Oxycodone 5 to 30 mg orally every four to six hours

Hydrocodone 2.5-10 mg orally every four to six hours

Hydromorphone 2 to 4 mg orally every four to six hours

COMBOS- one or two tablets orally every four to six hours

oxycodone-acetaminophen (combinations of 300 to 325 mg acetaminophen/2.5 to 10 mg oxycodone,oxycodone-aspirin (325 mg aspirin/4.8 mg oxycodone,

hydrocodone-acetaminophen (5mg/325mg,7.5 mg/325mg,10 mg/325 mg;

acetaminophen-codeine (Tylenol No. 3, which is 300 mg acetaminophen/30 mg codeine,

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8
Q

*** A dose reduction of approximately ____ and a____ frequency is warranted for

  • older or debilitated adults
  • patients with impaired liver or kidney functioning
  • low cardiac output, or respiratory compromise
A

*** A dose reduction of approximately 50% and a reduced frequency is warranted for

  • older or debilitated adults
  • patients with impaired liver or kidney functioning
  • low cardiac output, or respiratory compromise
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9
Q

*** A dose reduction of approximately 50% and a reduced frequency is warranted for what pt populations??

A

older or debilitated adults

patients with impaired liver or kidney functioning

low cardiac output, or respiratory compromise

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10
Q

approach for radicular LBP in weekend warrior

A

This approach would offer:

  • Cyclobenzaprine a muscle-relaxant - address the spasm
  • Ibuprofen _anti-inflammator_y - ↓ inflammation of muscles
  • Oxycodone an opioid analgesic -offer an analgesic effect to the current presentation
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11
Q

managing LBP
acute

chronic

A

Acute -

  • 6 wk conservative tx (NSAID + activity modifiers)
  • muscle relaxant - caution causes sedation
  • Glucocortioic inj - only after failure of 4-6 wk conserv therapy
    • MRI is prereq
    • speed short term pain but DOES NOT alter dz progression

Chronic

  • same as above can include surgical intervention if all other therapy fails (not reccommended for nonspecific LBP)
    • radicular sx
    • neurgenic claducation from lumbar spinal stenosis
    • worsening nuero deficits
  • opiods as last resort
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12
Q

pharmacologic vs nonpharm tx for MSK pain

A

Nonpharm

  • PT - preferred tx
  • psychological approaches - pts w/ chronic pain likely have anxiety or depression and vice versa
  • complementary therapy

Pharm

  • Acetametophen / NSAIDs - prongly reccommended
  • Muscle relaxants - risk of sedation
  • opiods - typically not reccommended
  • glucocorticoid inj
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13
Q

nonpharm tx for knee & hip osteoarthritis

A

PT / lifestyle modifications - FIRST LINE

  • excercise to build muscle/ dec weight

Knee Brace - compliant pts

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14
Q

non opiod tx of knee & hip osteoarthritis

A

Acetametophen - mild sx

Systemic NSAID - alone or in conjugation w/ acetametophen

  • INC risk of CV events
  • DEC pain in degenerative joint dz

Topical NSAIDs - FIRST line in knee & hand osteoarthitis

  • DEC risk of adverse effects / less systemic absorption

Glucocorticoid Injections - DEC pain w/o significant adverse events

Surgery - joint replacement if fail conserv therapy

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15
Q

Opiod tx of osteoarthritis

A

joint replacement better option

started in select cases

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16
Q

Signs of impending Death

A
  • DEC blood perfusion to skin –> mottled, discolored, cyanotic skin
  • DEC level of consciousness or delirium
  • DEC CO & intravascular volume –> tachycardia, hypotension
  • DEC urinary output –> urinary incontinence & concentrated urine
  • Retention of secretions in the pharynx & upper airway ® noisy respirations (“death rattle”)
  • Respirations w/ mandibular movements
  • Dyspnea
  • Profound weakness & fatigue
  • Disorientation
  • Weight loss/dehydration (third spacing)
  • Swallowing difficulties
  • DEC peripheral pulses
  • Cheyne Stokes Respirations – noisy gurgling respirations due to secretions
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17
Q

Pain at end-of-life –> 3 principles (WHOS step-care approach)

A
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18
Q

list 3 types of pain

A

Nociceptive pain

Neuropathic

Inflammatory

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19
Q

type of pain that can be

Somatic or visceral.

si/sx of somatic vs visceral pain

A

Nociceptive pain

Somatic: Aching, throbbing, stabbing, pressure

Visceral: gnawing, cramping, sharp, stabbing – internal organs

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20
Q

Continuous dysesthesias, chronic lancinating or paroxysmal

described as “burning or electrical”

Tx??

A

Neuropathic

  • Tricyclics
  • SNRI
  • antidepressants
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21
Q

tx of nocioceptive pain

A

NSAIDs

corticosteroids

possibly opioids

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22
Q

pain seen in RA, IBD.

similar to what type of pain?

Tx?

A

Inflammatory- released inflammatory mediators. RA, IBD.

similar to nociceptive pain in terms of character.

Tx: Anti-inflammatory

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23
Q

differetiate acute vs chronic pain

examples of each

A

Acute Pain: Lasting < 3 months and is a neurophysiological response to noxious injury that should resolve with normal healing process.

  • Fx in bones, post labor pain, appendicitis

Chronic Pain: Lasting more than 3 month or beyond the expected course of an acute disease.

  • Extends beyond the time of normal wound healing with the development of neurophysiological changes in CNS
  • Low back pain, neck pain, chronic pancreatitis
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24
Q

define break through pain and how to manage

A

occurs when patient has pain between doses of long-acting formulations

  • Hospice/ Terminal patients on average experience breakthru pain 3 times a day rating it 7 out of 10

Immediate release preparations are helpful

  • Each dose should be 10-30% of the total daily dose of sustained release
  • 60mg of OxyContin a day = breakthru will be 15mg q 4 hours.

Opioid Tolerance can develop, may need to rotate through other pain medications

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25
Q

pt experiencing break through pain:

Frequent immediate release use –> _____ in sustained release dosing.

A

Frequent immediate release use –> increase in sustained release dosing.

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26
Q

pain mgt challenges

A

Failure to recognize or differentiate pain from anxiety

  • “pain catastrophizing” Magnification, rumination, helplessness

Lack of education to health care providers

Safety concerns, fear of patient addiction or prescription legality.

Lack of pre-existing Patient-healthcare provider relationship

Pressure to see patients rapidly

Unstable patients may not be able to verbalize/ express their pain appropriately

Stereotypes

Genetics/ Ethnicity: some groups are known to carry genetic mutations of the liver CYP450 enzyme and may metabolize some pain medications more rapidly.

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27
Q

describe adult nonverbal pain scale (0-2)

face

activity

guarding

physiology

respiratory

A
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28
Q

opiods MOA

A

Mu receptor is 7 trans-membrane G Protein coupled receptor

  • Binding stabilizes the membrane so neuron can’t fire (↓ neuron transmission)
  • Located in the PERIPHERY, dorsal root ganglia of spinal cord, grey matter in brainstem, midbrain and gut
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29
Q

weak vs strong opiods

A

WEAK Opioids = Codeine, Hydrocodone, Oxycodone

STRONG Opioids = Hydromorphone, Fentanyl, Morphine

30
Q

formulationf of opiods

PO

IV

Buccal

TD

A

IV- Morphine, Hydromorphone, Fentanyl

PO – Morphine (LA, SA), Hydromorphone, Oxycodone, Hydrocodone, Methadone

BUCCAL & TD– Fentanyl

31
Q

opiod C/I in AKI / Renal failure

Why??

A

Morphine

•bc toxic metabolites will accumulate causing neuroexcitation/CNS effects (ex. jitters, spasms)

32
Q

opiod C/I in cachexia

A

•Fentanyl – need to have subcutaneous fat to be effective

33
Q

opiod drug of choice in renal failure

A

Hydromorphone – inactive metabolites

34
Q

considerations when prescribing Methadone

A

Phase I metabolism and may cause QTC prolongation

  • caution when changing from one opioid to methadone
  • need three doses
  • EKG before and at every visit/ day if in hospital
35
Q

tx of uncontrolled pain

A

nerve bloks

36
Q

Why are Morphine Mg Equivalents is useful in treating a patient’s chronic pain

A

Useful when determining a treatment threshold and recognizing at what dose a patient is at risk for overdose

50 MME/day

  • Hydrocodone 50 mg/day
  • Oxycodone 33 mg/day
  • Methadone 12 mg/day
37
Q

Most frightening symptom for patients, families and healthcare team during EOL care

causes?

A

Dyspnea

Causes (mismatch in supply/demand)

  • Airway obstruction
  • Muscle weakness
  • Cardiac Causes
  • Anemia
  • Intra abdominal process
  • Psychological
  • Can also be exacerbated by anxiety of the patient and anxiety of the families
38
Q

pharmacological tx of dyspnea

A

Oxygen: may help even when not measured to be hypoxic

OPIODS: Morphine sulfate (fentanyl, hydromorphone, oxycodone)

  • Venodialators, sedatives work by decreasing the sensitivity of the ribcage muscles to decrease perception of dyspne (Does not increase PCO2)
  • If currently on opioid for chronic pain, ­ dose by 25-50%
  • Most effective relief of dyspnea correlates to a steady-state blood level of opioids (AVOID peaks & valleys)

BENZODIAZEPINES/ ANXIOLYTICS: (Ativan 0.25-2mg)

  • Decrease anxiety/ decrease thoracic-abdominal response

bronchospasm, SVC Obstruction, lymphangitic carcinomatosis, tracheal obstruction–> S_TEROIDS: Dexamethasone,_ Prednisone

  • (dec inflammation in airways / nothing else then use it)

THORACENTESIS or PARACENTESIS – pleural effusions

Palliative Radiation if caused by mass lesion

Inhaled bronchodilators if bronchospasm

39
Q

nonpharm tx of dysnpea

A
  • Avoid exacerbating activities but be sensitive to isolation
  • Reduce temp and maintain humidity (cool & moist air)
  • Window, bring patient outside
  • Avoid irritants
  • Elevated HOB
  • Relaxation Therapy – Reiki, meditation, play soothing music
40
Q

if patient on opioid for pain and then develops dyspnea, increase dose by ___-___%

A

, if patient on opioid for pain and then develops dyspnea, increase dose by 25-50%

41
Q

MOST EFFECTIVE Relief of dyspnea best correlates with ???

A

MOST EFFECTIVE Relief of dyspnea best correlates with steady-state blood levels of opioids.

  • Suppression of respiratory drive happens with PEAKS AND VALLEYS. (don’t want – need steady-state)
42
Q

tx of excessive oropharyngeal secretions

A

atropine opthalamic 1% drops

Glycopyrollate / Hyoscyamine - most used

scopralamine transdermal patch - avoid in elderly may cause confusion

43
Q

causes of nausea, vomiting

mediators?

A

Nausea: Caused by stimulation of GI Lining, chemoreceptor trigger zone in base of the 4th ventricle, vestibular apparatus or cerebral cortex

Vomiting: a neuromuscular reflex centered in the medulla oblongata

Mediators: Serotonin, dopamine, acetylcholine, histamine

44
Q

etiologies of N/V

A

Think the Ms

  • Mets
  • Meningeal irritation
  • Movement
  • Mentation
  • Medications
  • Mucosal irritants
  • Mechanical Obstruction
  • Motility
  • Metabolic
  • Mircobes
  • Myocardial
45
Q

nonpharm tx of N/V

A

Relaxation

Cognitive Training

TEMS/ Acupuncture

46
Q

pharm tx of N/V

A

Dopamine Antagonists - pramipexole dihydrochloride, roprinole

  • activates receptors in the brain that produce dopamine, a chemical that helps regulate movement and mood

Histamine Antagonists – Diphenhydramine, Meclizine,

Anticholinergics - Promethazine (Phenergan), Scopolamine (↓oral secretions)

Serotonin Antagonists – Zofran (cause constipation & HA)

Pro-kinetic Agents – Metoclopromide – get gut moving –

  • CI in anyone w/ Bowel obstruction

Antacids - Tums

Steroids – Dexamethasone consider in suspected malignant BO or w/ ↑ICP)

anticipatory nausea

Cannabinoids – synthetic and natural & BDZ – Ativan

47
Q

N/V med that cause constipation & HA

A

Zofran

48
Q

N/V med that gets gut moving & CI in anyone w/ Bowel obstruction

A

Pro-kinetic Agents – Metoclopromide

49
Q

N/V med that also ↓oral secretions

A

Anticholinergics - Promethazine (Phenergan), Scopolamine

50
Q

list Dopamine Antagonists used to tx N/V

A

pramipexole dihydrochloride, roprinole

•activates receptors in the brain that produce dopamine, a chemical that helps regulate movement and mood

51
Q

etiology & Dx of constipation

A

Etiologies: Drugs!!! (Opioids in particular), Metabolic, Diet, Decreased Motility, Spinal Cord Compression, Mechanical Obstruction, Dehydration, Autonomic Dysfunction, Ileus

Rectal Exam to detect : mass, impaction, hypotonia

Tx of the CAUSE may not always be appropriate in advanced stages

52
Q

nonpharm tx of constipation

A

Scheduled toileting

Position to sit upright

Encourage fluids

AVOID bulking agents such as bran, may precipitate the obstruction

53
Q

pharm tx of constipation

A

Laxatives:

  • •Stimulant laxatives
  • •Osmotic Laxatives
  • •Detergent laxatives (Stool softeners)

Enemas: lubricant and large volume

Opioid antagonists: Methylnaltrexone – reverse effects of opioids on constipation )

  • NO bowel obstruction or ileus
54
Q

Methylnaltrexone used to tx

C/I??

A

Opioid antagonists: –reverse effects of opioids on constipation

•NO bowel obstruction or ileus

55
Q

Signs and Symptom of terminal delirium

A

can be reversible & look for reversible causes)

  • agitation
  • myoclonic jerks or twitching
  • irritability and impaired consciousness
  • hallucinations
  • paranoia
  • confusion and disorientation.
56
Q

nonpharm tx of terminal delirium,

A

Create a familiar environment

Reassure the family, explain common in terminally ill.

Give the patient permission to let go

Use touch, soothing touch

Maintain Sleep-Wake cycles

57
Q

pharm tx of terminal delirium

A

Benzodiazepines – Lorazepam, Midazolam

Nueroleptics – Haldol, Chlorpromazine (Treat Seziures)

58
Q

EOL symptom Frequently seen with Asthenia,

A

anorexia

59
Q

pharm tx of anorexia

A

Steroids: mechanism is unclear – prostaglandin inhibition, DEXAMETHSONE 2-4 mg PO BID, benefit will likely decrease after 4-6 weeks

Progesterone Drugs: inhibit production of Cachexin,

  • TNF – MEGACE 200mg q6-8 hrs

Mitrazapine 15-30 QHS

Androgens

Cannabinoids

60
Q

Easy tiring, generalized weakness, or mental tiredness

May be seen as sign of “failure” or “giving up” by dying person and loved ones

A

Asthenia

61
Q

Causes of asthenia

A
  • Direct tumor effects on energy
  • Paraneoplastic syndromes
  • Humoral and hormonal influences
  • Anemia
  • Chronic infections
  • Sleep disturbances
  • Fluid & electrolyte disturbances
  • Drugs
  • Over-exertion
62
Q

Most distressing symptom in dying patients

A

Asthenia

63
Q

nonpharm tx of asthenia

A
  • Develop a plan with patient and families to allow them to perform enjoyed activities:
  • Coordinate activities with times of most energy
  • Arrange for help from family, home care, CCAC, hospice, nursing home
  • Use energy conservation strategies (occupational/PT consult)
  • Change medications and/or times
  • Daytime rest and effective sleep at night
64
Q

pharm tx of asthenia

A

Among the most difficult symptoms to treat

Steroids: mechanism not clear –? Euphoria (dexamethasone)

Metamphetamines: act as psychostimulant

  • Methylphenidate
  • Side Effects: tremulousness, anorexia, tachycardia, insomnia &myocardial ischemia
65
Q

Causes of Terminal Delirium and Agitation

A

Opioid toxicity- High or prolonged opioid administration -> sedation, neuroexcitation and agitated delirium.

Pain Uncontrolled and severe pain can cause agitation

Drug interactions - Many drugs used in palliative care,

  • hypnotics
  • antimuscarinics
  • anticonvulsants

Fever or sepsis - The onset of delirium can occur with fever (which can reduce cerebral oxidative metabolism).

Hypercalcemia the most common life-threatening metabolic disorder in cancer patients.

  • It can lead to a confused and agitated state
  • calcium levels should be monitored.

Raised intracranial pressure- Brain tumors or cerebral metastasis can increase intracranial pressure, leading to an agitated state.

delirium may be due to an imbalance b/w acetylcholine & dopamine

66
Q

the most common life-threatening metabolic disorder in cancer patients.

A

Hypercalcemia.

  • It can lead to a confused and agitated state
  • calcium levels should be monitored.
67
Q

familt education points about Exsanguination

A

Will occur suddenly and high-volume arterial bleed can cause death within minutes

  • Educate the family about this risk of bleeding.
  • Explain to family members that death due to exsanguination is extremely rapid and thus most patients are dead almost instantaneously and thus their suffering is unlikely to be prolonged.
68
Q

causes of exsingunation deaths

A

head and neck tumors which erode into the carotid artery.

69
Q

nonpharm and pharm tx of exsinguination

A

Nonpharm - Remove all white bed linen and replace with a dark color linen (green or brown preferred)

Pharm - parenteral benzodiazepine to alleviate anxiety/ suffering

  • “midazolam 5 mg sub cutaneous stat on bleeding, may repeat once after 5 minutes for evidence of suffering.”
70
Q

Meds in Hospice Comfort Kit

A
71
Q

define

Bereavement

Anticipatory grief

A

Bereavement - grief that occurs after the death

Anticipatory grief is a normal grief reaction to perceived loss during the dying process. Dying people (and their loved ones) prepare for death by mourning the various losses implicit in the death.

72
Q

N/V med you use in suspected maligannt BO or INC ICP

A

corticosteroid - dexamethosone

Clin Mgt Exam 2- Managing pain, end of life, D/c, SDOH (3 decks)

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