Midterm Review Flashcards
Dry Mouth
Xerostomia
Pain Classifications by Pathophysiology
- Nociceptive
- Neuropathic
- Psychogenic
- Unknown
**Nociceptive Pain
Cause
Corresponding
Types
Cause: Tissue Damage = Noxious Stimuli
Pain Perception corresponds to Stimulus Intensity
Types: Visceral, Somatic and Radicular
Neuropathic Pain
- Caused by what kind of damage?
- Poportional?
- Duration of pain?
Cause: NS damage = bad signal processing by CNS/PNS
Disproportionate perception to stimulus intensity
Chronic pain - more likely
**Psychogenic Pain
No known physical cause
CNS processing disturbed
Non-localized
Larger areas
Pain Classification by Duration
- Acute Pain
- Chronic Pain
- Chronic Non-Cancer Pain
- Cancer Pain
Acute Pain
Less than 3 months
Serves adaptive purpose
Chronic Pain
Used to be defined Temporally, now, Contextually.
Time: 3-6 months
Context: pathology does not explain pain, pain disrupts sleep and normal living
Does not serve adaptive purpose
Chronic Non-Cancer Pain
Can affect any body system
Ex. Migraines, Arthritis, Back/Neck Pains
Cancer Pain (‘Malignant Pain’)
Associated with life-threatening conditions
Caused by Disease or Dx or Tx
also can be HIV
Spontaneous Pain
No stimulus
Allodynia
Normal stimulus
ex. dental, touch
Hyperalgesia
Increased response to a Painful Stimulus
ex. heat, prick
*Dysasthesia
Unpleasant, Abnormal Sensation
Spontaneous or Evoked
ex. fluttering when you kick
ex. shooting sensation
*Parasthesia
Abnormal Sensation (Not Unpleasant)
Spontaneous or Evoked
ex. foot falling asleep, tingling
Superficial Pain
Body surface pain
Localized Pain
Restricted to one identifiable area
Diffused Pain
Widespread
**Referred Pain
Spreads to area of the body which is not the source
**Radicular Pain
Radiates to lower extremities
w/ transmission along spinal nerve
Visceral Pain
Originates in and around the organs of the body
Somatic Pain
Result of injuries to skin, bone, muscle, connective tissues/joints
Deep Pain
Deep inside body
Peripheral Categorizations of Neuropathic Pain
- Mononeuropathy
<> Distribution of one peripheral nerve
<> ex. Sciatic nerve, Bell’s Palsy, Lancinating Pain
- Polyneuropathy
<> Symmetrical
<> ex. Diabetic Neuropathy, Guillain-Barre
Greatest Burden of PALL CARE
- CVD
- Cancer
- Chronic Lung Diseases
- HIV/AIDS
- Diabetes
Barriers to PALL CARE Availability
- Policy
- Education
- Medication Availability
- Implementation
- Psychological, Social/Financial, Cultural
K-R Stages of Dying
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
- Non-linear passage through the stages
- Not everyone experiences all stages
Non-opioids:
(Aspirin/Salicylic Acid Derivatives, Acetaminophen, NSAIDS)
Combine with opioids to facilitate lower opioid dosing & bi-modal analgesia.
Analgesia ceiling: dose reached beyond which additional S/E occur, but not pain relief
Non-Opioid Analgesics Side Effects
Cardiac
Bleeding
GI
Kidney Dysfunction
Opioids Side Effects
(Morphine, Methadone, Buprenorphine, Hydrocodone, Oxycodone, Vicodin Tramadol)
- Sedation, mental clouding, Confusion
- Respiratory depression
- Nausea, vomiting, constipation, pruritis, urine retention
- Tolerance, Dependence, Addiction
- Most S/E subside with time (except constipation)
Pain Assessment - WILDA
Words
Intensity
Location
Duration
Aggravating/Alleviating Factors
Pain Assessment - WILDA
Duration
(4 elements)
- Stable (Continuous)
- Breakthrough Pain
- Intractable Pain
- Acute vs. Chronic
- Stable (Continuous) Pain
Pain all the time
- Breakthrough Pain
- Transitory exacerbation
- Flare of pain
- Pt already on analgesics for stable pain
- Intractable Pain
- Chronic
- Resistant to cure or relief
- Acute vs. Chronic
- need to ask:
“Is your pain always there, or does it come and go?”
“Do you have both chronic and breakthrough pain?”
Assessing pain in cognitively impaired individuals
- 3 ways
-
Can obtain voluntary non-verbal feedback
- Nod head, squeeze hand, moving eyes…
- Writing materials, pain intensity charts…
-
Predicting Pain
- After reviewing Hx, is there a reason to suspect this patient is in pain?
- Past precedent
Classic descriptions of pain
- 4 processes
Transduction
Transmission
Perception
Modulation
- Transduction
Conversion of noxious stimulus into nerve impulses
By nociceptors
Noxious stimuli = (thermal, mechanical, or chemical)
- Transmission
Transmission of neural signals
From: Periphery
To: SC+Brain
- Perception
Appreciation of signals arriving in higher structures as pain
- Modulation
Descending inhibitory and facilitory input, from Brain
that modulates nociceptive transmission, at SC level
- Select a route of administration
No single route of drug administration is appropriate for all clinical situations.
- Oral administration (pills) of drugs, especially for chronic treatment, is _____.
generally preferred
convenient, flexible
stable drug levels
- Rectal
- sub-lingual, and
- subcutaneous are useful in patients who ________________.
cannot take medications by mouth
- IM administration has 3 disadvantages….
- (intramuscular injection)
Pain
Erratic absorption = Fluctuating drug levels
Tissue fibrosis
IV administration provides a _______.
rapid onset
Titrating the dose
> Meaning
> Non-opiods
> Opioids
– Smallest dosage necessary to provide desired effect with minimal SEs
– Non-opioids have a ceiling effect and may cause significant toxicity at high doses
– Most opioids do not have an analgesic ceiling: dosage can be titrated upwards until relief occurs or limiting side effects
Addressing Side Effects
- 4 ways
- Changing dosage or route of administration
- Trying a different drug (within same class)
- Add a drug that counteracts the side effects
(ex. antihistamine for itch, laxative for constipation) - Combination therapy can alleviate some side effects
– Adding a nonopioid or adjuvant analgesic to an opioid regimen to use of a lower dose of the opioid
WHO Analgesic Ladder
Step 1 (Mild Pain)
Non-opioids
ex. Paracetamol, NSAIDs
Step 2 (Moderate Pain)
Mild Opioid
ex. Codeine +/- non-opioid
Step 3 (Severe Pain)
Opioid
ex. Morphine +/- non-opioid
Barriers to increasing availability and consumption of opioids for medical and scientific use
- 5 Barries
- Overly strict regulation
- Limitations on available forms of meds
- ex. oral opioids
- Lack of supply and distribution systems
- Limitations on who can prescribe
- Fear of law enforcement intervention into medical use
-
Mechanical Obstruction
- Manifestations
- TX
- Avoid meds
- Bowel tumors or ovarian cancer
- => external compression, paralytic ileus, diverticuli, hernia
- Surgery
- Avoid prokinetic/motility agents
-
Functional/Incomplete Obstruction
- Manifestation
- TX - meds
- Ischemic bowel, IBD, tuberculosis, endometriosis
- May resolve with conservative TX
- Dexamethasone reduces bowel wall edema
- Prokinetic
- Stool softener & hydration
- NG tube if vomiting is distressing
-
Constipation
- TX - 2 drugs
- 2 things to avoid
- What to do before starting laxatives?
- TX - 2 drugs
- Stool softener - docusate
- Motility agent - senna
- Avoid bulking agents
- may precipitate impaction
- Avoid osmotic laxatives
- ex. lactulose
- causes cramps, requires lots of H2O
- ex. lactulose
- Avoid bulking agents
- Relieve impaction before starting laxatives
Somatization Disorder
- NOT feigned
- Multiple, current somatic complaints
- Hx: Long and complicated primary care/specialist
- Tx: Cognitive Behavioral Therapy
- Conversion Disorder (Hysteria)
- At least 1 symptom of altered voluntary motor/sensory function
- ‘Hysterical Blindness’, Paralysis, Abnormal Movement, Seizure, Amnesia, Incontinence
- Anxiety => physical symptom
- Little evidence-based TX: hypnosis, psycho/physical therapy, stress management, transcranial magnetic stimulation
- Body Dysmorphic Disorder (BDD)
- Mental disorder: some aspect of one’s health or appearance is severely flawed & requires extreme measures
- Real or imagined flaw
- Pervasive and intrusive obsession
- DSM classifies it on OCD spectrum
- Hypochondriasis
- Persists after physician has evaluated and reassured
- Trigger: serious illness/death of family/friend
- Some avoid; others frequently visit medical facilities
- Cyberchondria, ’Compucondria’ (or ‘WebMD-Itis’)
-
Pain Disorder
- Defintion
- Causes
- SX
- Basis
- Psychological stress => Chronic pain
- in one or more areas, sometimes for years
- Causes
- Trauma/Abuse
- Child’s role in family - ‘the sick one’
- More common in social settings where psychological distress is not as accepted
- Collectivist countries (Japan, China, Mexico) >> individualistic countries (USA, Sweden)
- Sx: negative/distorted cognition, increased pain, sleep disturbance and fatigue; depression and/or anxiety, diminished social life
- No neurological/physiological basis
Adjuvant Analgesics
Phenytoin, Carbamazepine, Gabapentin
Amitriptyline, Nortriptyline, Imipramine
Lidocaine, Bupivacaine
Capsacin
Prednisone
Sumatriptan, Metoprolol
Ziconotide
Management of Pain Without Medications
- Education & Psychological Counseling
- Hypnosis 3. Comfort Therapy
- Heat & Cold 5. PT and OT
- Psychosocial Therapy & Counseling
- Neurostimulation
- Religious & Spiritual 9. Nutritive 10. Herbal
Peripheral Sensitization
- Definiton
- Pain States
-
Sensitized nociceptors exhibit lower threshold for activation and an increased firing rate
- Generate nerve impulses more readily and more often
- Role in central sensitization/clinical pain states
- Hyperalgesia: increased response to a painful stimulus, ex. heat
- Allodynia: pain caused by a normal stimulus, ex. touch
- Increased sensitivity to heat and touch
Central Sensitization
- Def
- Causes
- State of spinal neuron hyperexcitability
- Tissue injury (inflammation)
- Nerve injury (aberrant neural input)
- Or both may cause it
- Ongoing nociceptive input from the periphery is needed to maintain it
- May outlast stimulus by minutes /hours
Clinical manifistations of Central Sensitization
- Hyperalgesia: increased response to a noxious stimulus
- Allodynia: painful response to normal stimulus
- Persistent pain: prolonged pain after transient stimulus
-
Referred Pain: Spread of pain to uninjured tissue
- expanded receptive field
- Central sensitization plays a key role in ____ pain.
- ______ pain often exceeds the provoking stimulus, both spatially and temporally.
- Established pain is ____ difficult to suppress than acute pain.
-
chronic pain, especially pain induced by nerve injury or dysfunction (neuropathic pain)
- neuropathic pain
- more difficult
- In contrast to nociceptive pain, neuropathic pain is often unresponsive to NSAIDs and opioids. However, it may respond to antiepileptic drugs, antidepressants, or local anesthetics.
Reversible causes of Anorexia
- Pain/dyspepsia
- Disordered taste/smell
- Malodour (bad smell, e.g. ulcer or fungating tumour)
- Nausea or vomiting
- Metabolic causes (hypercalcaemia, Uraemia)
- Constipation
- Gastric stasis
- Anxiety, depression or confusion
- Latrogenic causes
Some appetite stimulant drugs
- Corticosteroids
- Progesterones
- Cannibinoids
- Prokinetics
- Carers can play a vital role in encouraging pt to eat small, visually appealing meals in a comfortable environment
Persistent hiccups
Intractable hiccups
- Persistent* hiccups last > 48 hours
- Intractable* hiccups last > 1 month
Factitious Disorders
person acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms to attain a patient’s roll
Munchausen’s: severe form of factitious disorder
Munchausen’s by proxy: factitious disorder imposed on another
Malingering
Managing Thirst
- Thirst = desire to drink
- Contradictory literature on whether dying pt feels thirst
In unconscious pt, experience of thirst will not be possible
- Self-reported and has high individual variability
- Xerostomia (dry mouth) can contribute to thirst
- Not all pts w dry mouth have thirst, vice-versa
**Thirst and dry mouth are SEPARATE issues
Contradictory literature on whether fluid administration will even help reduce thirst in dying pt
- What can be done?
Attention to mouth care and moistness will address thirst in final hours/days
Daily oral care and sips of oral fluid administered for comfort can improve thirst
• Offer routinely
Concerned family and friends may be distressed that their loved one is experiencing thirst at the end of life, this can prompt requests for artificial nutrition or hydration.
- Should artificial hydration be considered?
Artificial hydration should be considered on a case-by-case basis
But mainly reassurance that artificial hydration is unlikely to alleviate thirst and comes with significant risks
Cachexia
Complex syndrome: weight loss, lipolysis, loss of muscle and visceral protein, anorexia, chronic nausea, and weakness
- How it relates to Anorexia?
- Tx?
-
Anorexia is a main cause
- decreased caloric intake
-
TX
- intensive nutriton
- corticosteroids improve anorexia
Differentiate GI Side Effects
- Nausea: subjective experience, precedes vomiting
-
Vomiting
- Highly specific event: ‘forceful evacuation of gastric contents out of the mouth’
- Usually (not always) preceded by nausea
-
Retching
- Repetitive contraction of abdominal musculature, generating pressure gradient which leads to evacuation of stomach contents
- “Dry Heaves”
- Repetitive contraction of abdominal musculature, generating pressure gradient which leads to evacuation of stomach contents
-
Regurgitation*
- Passive, retrograde flow of esophageal contents into the mouth
- Reflux or esophageal obstruction
-
Rumination**
- Under-diagnosed, chronic, motility
- Effortless, following meals
- Cause: involuntary contraction of muscles around abdomen
- Not preceded by nausea
-
Dyspepsia
- Chronic
- Structural: Acid-related
- Functional: Dysmotility-related
Non-pharmacological Interventions for Dyspnea
Calm reassurance
Fluid restriction
Elevating head of bed
Smoke-free, dust-free, low-humidity
Cool air on face (open window or a fan)
Distraction/relaxation techniques
Breathing training (Pursed-Lip Breathing)
Begin with relaxing neck and shoulders
Close mouth and inhale slowly through your nose
Purse lips and exhale slowly over a count of 3
Reduce physical exertion/O2 demand
Adjust/Open airway
Acupuncture to sternal points
Pall. Care Burdens for Children
1. Congenital Anomalies
2. Neonatal Anomalies
3. Protein Energy Malnutrition
4. Meningitis
- HIV
- CVD
- Liver
Typical Descriptions:
- Somatic Nociceptive Pain
achy, throbbing, dull
typically well-localized
Typical Descriptions:
- Visceral Nociceptive Pain
- Squeezing, pressure, cramping, distention, dull, deep, and stretching
- ex. after abdominal or thoracic surgery
Typical Descriptions - Neuropathic Pain
burning, shooting, tingling, radiating, stabbing, numbness
Fire or Electrical Jolt
Types of itch
- Pruritoceptive Itch
- Neurogenic/Neuropathic Itch
-
Pruritoceptive Itch
- Periphery or Central?
- Causes
- Treat as for…
- Generated in Periphery
- Exogenous causes
- Dry skin
- Contact irritation
- Histamine activation
- Allergy
- Worm infestation
- Treat as for Dermatitis
-
Neurogenic/Neuropathic Itch
- Where
- Causes
- Treat as for…
- generated in PNS/CNS
-
Central causes
- Psychogenic itch
-
Cholestasis
- accumulation of bile acids + increase endogenous opioids
- Drugs (Opioids)
- Treat as for neuropathic pain
- Respiratory secretions
-
Pharmaceutical interventions
- Regularly
- At the end
-
Pharmaceutical interventions
- SubQ or IV Scopalamine
- Hyoscine butylbromide
- Corticosteroids/Bronchodilators
- Diuretics
-
Atropine (even as eye drops)
- Better at VERY end; may cause agitation
- Respiratory secretions
- Non-Pharmaceutical interventions
- Repositioning
- “High Side Lying”
- Elevate head of bed
- Suction (almost always not helpful; distressing)
- Fluid restriction; stop IV fluids
- Treat infection
- Mouth care
- COUNSEL FAMILY
Ulcers - How to manage them?
Causes:
– Pressure
– Diabetes
– Stasis
– Vitamin Deficiency
– Urine
Treat undrelying cause
Prevention
Surgery (Debridement, Amputation, Maggots)
Analgesia
PIC of GI Section
Top End
