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Palliative Care > Midterm Review > Flashcards

Midterm Review Flashcards

1
Q

Dry Mouth

A

Xerostomia

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2
Q

Pain Classifications by Pathophysiology

A
  1. Nociceptive
  2. Neuropathic
  3. Psychogenic
  4. Unknown
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3
Q

**Nociceptive Pain

Cause

Corresponding

Types

A

Cause: Tissue Damage = Noxious Stimuli

Pain Perception corresponds to Stimulus Intensity

Types: Visceral, Somatic and Radicular

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4
Q

Neuropathic Pain

  • Caused by what kind of damage?
  • Poportional?
  • Duration of pain?
A

Cause: NS damage = bad signal processing by CNS/PNS

Disproportionate perception to stimulus intensity

Chronic pain - more likely

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5
Q

**Psychogenic Pain

A

No known physical cause

CNS processing disturbed

Non-localized

Larger areas

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6
Q

Pain Classification by Duration

A
  1. Acute Pain
  2. Chronic Pain
  3. Chronic Non-Cancer Pain
  4. Cancer Pain
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7
Q

Acute Pain

A

Less than 3 months

Serves adaptive purpose

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8
Q

Chronic Pain

A

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

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9
Q

Chronic Non-Cancer Pain

A

Can affect any body system

Ex. Migraines, Arthritis, Back/Neck Pains

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10
Q

Cancer Pain (‘Malignant Pain’)

A

Associated with life-threatening conditions

Caused by Disease or Dx or Tx

also can be HIV

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11
Q

Spontaneous Pain

A

No stimulus

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12
Q

Allodynia

A

Normal stimulus

ex. dental, touch

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13
Q

Hyperalgesia

A

Increased response to a Painful Stimulus

ex. heat, prick

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14
Q

*Dysasthesia

A

Unpleasant, Abnormal Sensation

Spontaneous or Evoked

ex. fluttering when you kick
ex. shooting sensation

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15
Q

*Parasthesia

A

Abnormal Sensation (Not Unpleasant)

Spontaneous or Evoked

ex. foot falling asleep, tingling

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16
Q

Superficial Pain

A

Body surface pain

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17
Q

Localized Pain

A

Restricted to one identifiable area

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18
Q

Diffused Pain

A

Widespread

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19
Q

**Referred Pain

A

Spreads to area of the body which is not the source

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20
Q

**Radicular Pain

A

Radiates to lower extremities

w/ transmission along spinal nerve

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21
Q

Visceral Pain

A

Originates in and around the organs of the body

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22
Q

Somatic Pain

A

Result of injuries to skin, bone, muscle, connective tissues/joints

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23
Q

Deep Pain

A

Deep inside body

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24
Q

Peripheral Categorizations of Neuropathic Pain

A
  1. Mononeuropathy

<> Distribution of one peripheral nerve

<> ex. Sciatic nerve, Bell’s Palsy, Lancinating Pain

  1. Polyneuropathy

<> Symmetrical

<> ex. Diabetic Neuropathy, Guillain-Barre

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25
Q

Greatest Burden of PALL CARE

A
  1. CVD
  2. Cancer
  3. Chronic Lung Diseases
  4. HIV/AIDS
  5. Diabetes
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26
Q

Barriers to PALL CARE Availability

A
  • Policy
  • Education
  • Medication Availability
  • Implementation
  • Psychological, Social/Financial, Cultural
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27
Q

K-R Stages of Dying

A
  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance
  • Non-linear passage through the stages
  • Not everyone experiences all stages
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28
Q

Non-opioids:

(Aspirin/Salicylic Acid Derivatives, Acetaminophen, NSAIDS)

A

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

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29
Q

Non-Opioid Analgesics Side Effects

A

Cardiac

Bleeding

GI

Kidney Dysfunction

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30
Q

Opioids Side Effects

(Morphine, Methadone, Buprenorphine, Hydrocodone, Oxycodone, Vicodin Tramadol)

A
  • Sedation, mental clouding, Confusion
  • Respiratory depression
  • Nausea, vomiting, constipation, pruritis, urine retention
  • Tolerance, Dependence, Addiction
  • Most S/E subside with time (except constipation)
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31
Q

Pain Assessment - WILDA

A

Words

Intensity

Location

Duration

Aggravating/Alleviating Factors

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32
Q

Pain Assessment - WILDA

Duration

(4 elements)

A
  1. Stable (Continuous)
  2. Breakthrough Pain
  3. Intractable Pain
  4. Acute vs. Chronic
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33
Q
  1. Stable (Continuous) Pain
A

Pain all the time

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34
Q
  1. Breakthrough Pain
A
  • Transitory exacerbation
  • Flare of pain
  • Pt already on analgesics for stable pain
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35
Q
  1. Intractable Pain
A
  • Chronic
  • Resistant to cure or relief
36
Q
  1. Acute vs. Chronic
A
  • need to ask:

“Is your pain always there, or does it come and go?”

“Do you have both chronic and breakthrough pain?”

37
Q

Assessing pain in cognitively impaired individuals

- 3 ways

A
  • 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
38
Q

Classic descriptions of pain

- 4 processes

A

Transduction

Transmission

Perception

Modulation

39
Q
  1. Transduction
A

Conversion of noxious stimulus into nerve impulses

By nociceptors

Noxious stimuli = (thermal, mechanical, or chemical)

40
Q
  1. Transmission
A

Transmission of neural signals

From: Periphery

To: SC+Brain

41
Q
  1. Perception
A

Appreciation of signals arriving in higher structures as pain

42
Q
  1. Modulation
A

Descending inhibitory and facilitory input, from Brain

that modulates nociceptive transmission, at SC level

43
Q
  • Select a route of administration
A

No single route of drug administration is appropriate for all clinical situations.

44
Q
  • Oral administration (pills) of drugs, especially for chronic treatment, is _____.
A

generally preferred

convenient, flexible

stable drug levels

45
Q
  • Rectal
  • sub-lingual, and
  • subcutaneous are useful in patients who ________________.
A

cannot take medications by mouth

46
Q
  • IM administration has 3 disadvantages….
  • (intramuscular injection)
A

Pain

Erratic absorption = Fluctuating drug levels

Tissue fibrosis

47
Q

IV administration provides a _______.

A

rapid onset

48
Q

Titrating the dose

> Meaning

> Non-opiods

> Opioids

A

– 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

49
Q

Addressing Side Effects

  • 4 ways
A
  1. Changing dosage or route of administration
  2. Trying a different drug (within same class)
  3. Add a drug that counteracts the side effects
    (ex. antihistamine for itch, laxative for constipation)
  4. 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

50
Q

WHO Analgesic Ladder

A

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

51
Q

Barriers to increasing availability and consumption of opioids for medical and scientific use

  • 5 Barries
A
  • 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
52
Q
  • Mechanical Obstruction
    • ​Manifestations
    • TX
    • Avoid meds
A
  • Bowel tumors or ovarian cancer
    • => external compression, paralytic ileus, diverticuli, hernia
  • Surgery
  • Avoid prokinetic/motility agents
53
Q
  • Functional/Incomplete Obstruction
    • ​​Manifestation​
    • TX - meds
A
  • 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
54
Q
  • Constipation
    • TX - 2 drugs
      • 2 things to avoid
    • What to do before starting laxatives?
A
  • Stool softener - docusate
  • Motility agent - senna
    • Avoid bulking agents
      • ​may precipitate impaction
    • Avoid osmotic laxatives
      • ex. lactulose
        • causes cramps, requires lots of H2O
  • Relieve impaction before starting laxatives
55
Q

Somatization Disorder

A
  • NOT feigned
  • Multiple, current somatic complaints
  • Hx: Long and complicated primary care/specialist
  • Tx: Cognitive Behavioral Therapy
56
Q
  • Conversion Disorder (Hysteria)
A
  • 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
57
Q
  • Body Dysmorphic Disorder (BDD)
A
  • 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
58
Q
  • Hypochondriasis
A
  • 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’)
59
Q
  • Pain Disorder
    • Defintion
    • Causes
    • SX
    • Basis
A
  • 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
60
Q

Adjuvant Analgesics

A

Phenytoin, Carbamazepine, Gabapentin

Amitriptyline, Nortriptyline, Imipramine

Lidocaine, Bupivacaine

Capsacin

Prednisone

Sumatriptan, Metoprolol

Ziconotide

61
Q

Management of Pain Without Medications

A
  1. Education & Psychological Counseling
  2. Hypnosis 3. Comfort Therapy
  3. Heat & Cold 5. PT and OT
  4. Psychosocial Therapy & Counseling
  5. Neurostimulation
  6. Religious & Spiritual 9. Nutritive 10. Herbal
62
Q

Peripheral Sensitization

  • Definiton
  • Pain States
A
  • 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
63
Q

Central Sensitization

- Def

- Causes

A
  • 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
64
Q

Clinical manifistations of Central Sensitization

A
  1. Hyperalgesia: increased response to a noxious stimulus
  2. Allodynia: painful response to normal stimulus
  3. Persistent pain: prolonged pain after transient stimulus
  4. Referred Pain: Spread of pain to uninjured tissue
    - expanded receptive field
65
Q
  • 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.
A
  • 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.
66
Q

Reversible causes of Anorexia

A
  • 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
67
Q

Some appetite stimulant drugs

A
  • Corticosteroids
  • Progesterones
  • Cannibinoids
  • Prokinetics
  • Carers can play a vital role in encouraging pt to eat small, visually appealing meals in a comfortable environment
68
Q

Persistent hiccups

Intractable hiccups

A
  • Persistent* hiccups last > 48 hours
  • Intractable* hiccups last > 1 month
69
Q

Factitious Disorders

person acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms to attain a patient’s roll

A

Munchausen’s: severe form of factitious disorder

Munchausen’s by proxy: factitious disorder imposed on another

Malingering

70
Q

Managing Thirst

  • Thirst = desire to drink
  • Contradictory literature on whether dying pt feels thirst

In unconscious pt, experience of thirst will not be possible

A
  • 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

71
Q

Contradictory literature on whether fluid administration will even help reduce thirst in dying pt

- What can be done?

A

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

72
Q

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?
A

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

73
Q

Cachexia

Complex syndrome: weight loss, lipolysis, loss of muscle and visceral protein, anorexia, chronic nausea, and weakness

  • How it relates to Anorexia?
  • Tx?
A
  • Anorexia is a main cause
    • decreased caloric intake
  • TX
    • intensive nutriton
    • corticosteroids improve anorexia
74
Q

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
A
  • Retching
    • Repetitive contraction of abdominal musculature, generating pressure gradient which leads to evacuation of stomach contents
      • “Dry Heaves”
  • 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
75
Q

Non-pharmacological Interventions for Dyspnea

A

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

76
Q

Pall. Care Burdens for Children

A

1. Congenital Anomalies

2. Neonatal Anomalies

3. Protein Energy Malnutrition

4. Meningitis

  1. HIV
  2. CVD
  3. Liver
77
Q

Typical Descriptions:

  • Somatic Nociceptive Pain
A

achy, throbbing, dull

typically well-localized

78
Q

Typical Descriptions:

  • Visceral Nociceptive Pain
A
  • Squeezing, pressure, cramping, distention, dull, deep, and stretching
  • ex. after abdominal or thoracic surgery
79
Q

Typical Descriptions - Neuropathic Pain

A

burning, shooting, tingling, radiating, stabbing, numbness

Fire or Electrical Jolt

80
Q

Types of itch

A
  • Pruritoceptive Itch
  • Neurogenic/Neuropathic Itch
81
Q
  • Pruritoceptive Itch
    • ​Periphery or Central?
    • Causes
    • Treat as for…
A
  • Generated in Periphery
  • Exogenous causes
    • Dry skin
    • Contact irritation
    • Histamine activation
      • Allergy
      • Worm infestation
  • Treat as for Dermatitis
82
Q
  • Neurogenic/Neuropathic Itch
    • ​Where
    • Causes
    • Treat as for…
A
  • generated in PNS/CNS
  • Central causes
    • Psychogenic itch
    • Cholestasis
      • accumulation of bile acids + increase endogenous opioids
    • Drugs (Opioids)
  • Treat as for neuropathic pain
83
Q
  • Respiratory secretions
    • Pharmaceutical interventions
      • Regularly
      • At the end
A
  • SubQ or IV Scopalamine
  • Hyoscine butylbromide
  • Corticosteroids/Bronchodilators
  • Diuretics
  • Atropine (even as eye drops)
    • Better at VERY end; may cause agitation
84
Q
  • Respiratory secretions
    • Non-Pharmaceutical interventions
A
  • 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
85
Q

Ulcers - How to manage them?

Causes:

– Pressure

– Diabetes

– Stasis

– Vitamin Deficiency

– Urine

A

Treat undrelying cause

Prevention

Surgery (Debridement, Amputation, Maggots)

Analgesia

86
Q

PIC of GI Section

Top End

A

Palliative Care (1 decks)

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