Nurb End of LIfe Pain Management Flashcards
- unpleasant sensory and emotional experience associated with actual or potential tissue damage, is what the person says it is
- can’t communicate doesn’t mean that they are in it: body language, talk with family with what normal is, before most likely now
pain
cancer patients more than half have, AIDS with prognosis less than 6 months have intense
-less research conducted in other chronic illness, inadequate relief will hastens death, relief is essential at end of life not only for patient and family
Current status of pain relief:
- Identify where obstacles exist, Recognize when and what patient teaching is required
- Healthcare professionals, Healthcare system, Patients/families
Barriers to pain relief
a. Importance of discussing barriers:
b. Specific barriers:
- Myth: Addiction with the medication, might not be present bc sedation, might kill them, fine line with law and medication given at home must be given by healthcare professional, access to the health care=distance, meds unavailable
barriers to pain relief
- what they say, words used
- Emotional state
- Acute vs. chronic
- Location(s)=multiple sites, Intensity, Quality, Temporal Pattern
- most won’t pick last of crying, way to describe but no actual crying
- moving, walking, sitting, turning, chewing, breathing, defecating, urinating, swallowing
- what makes it better or worse, medical and non-medical interventions relieve the pain
- Medication history(recent and distant=important, addicted-higher amount to achieve goal) Ibuprophen-3200 mg acetaminophen- 3000mg
- Meaning of the pain- Ex: suffer now or suffer for all eternity= believe
- Cultural factors
Pain History
- Self-report:
- Faces scale
- Aggravating factors
- Alleviating Factors
- observation, palpation, auscultation
- vibration, proprioception, worse or better
- might if potentially treatable cause, if we going to do anything about it, goal of care
- change asses, and make it visible=5th vs
ii. Physical examination:
iii. Neurological examination:
iv. Laboratory/diagnostic evaluation:
v. Reassess:
- : total bod ypain/ seen in bone and soft tissue/ pt describe as dull or aching
b. Common syndromes seen at the end of life
i. Nociceptive pain syndromes
somatic
: pt describe cramping, squeezing sensation/ seen in liver or pancreatitis
b. Common syndromes seen at the end of life
i. Nociceptive pain syndromes
Visceral
ii. - nerve pain/ pt describe as sharp, shooting, burning, electrical
1. - very painful=shingles: older pts/lightest touch causes sever pain
2. =pins in needles in feet/ most common in feet but can occur in hands
3. peripheral pain
Neuropathic pain syndromes
- post herpetic neuropathy
- diabetes neuropathy
- hiv neuropathy
-existential distress=emotional distress not just physical, dimension of QOL, requires interdisciplinary approach
c.Pain Versus suffering at the end of life
- don’t have words to express what pain is, where, how it feels
- fearful for being addicted, fear using now may not work when they really need it, talk about myths
-open up conversation to voice concerns
can be dementia
iv. Patients who deny pain
v. Non-English speaking
-some cultures they are not allowed to express pain, more common in men not women
vii. Uninsured and undeserved individuals
d. Patients at risk for poor pain assessment and treatment (under treatment)
i. Children
ii. Older adults
iii. Non-verbal or cognitively impaired persons/unconscious patients:
vi. Cultural considerations
viii. they often have more of a tolerance, may require higher doses to get adequate relief/ nurse say drug seeking/ current or past history is important to have information
Persons with a history of addictive disease-
improves pain management: better with physician
- describe intensity, limitations and response to treatment
- documentation: before and after getting medication
Communicating assessment findings
- state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time
- normal occurrence, not same thing as addiction
i. Tolerance
- state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and or administration of an antagonist
- normal response, with specific drug class will have withdrawn symptoms
ii. Physiological dependence
addiction, primary chronic neurobiological disease with genetic psychological and environmental factors influencing its development and manifestations, characterized by behaviors that include one or more: impaired control over drug use, compulsive use, continued use despite harm and craving
iii. Psychological dependence
what is backed by ANA, provide analgesic medication with intent to alleviate pain may hasten death and may prolong life, not intentionally cause death= intentional suicide (position statement),ethically acceptable
iv.**Double effect
: keeping them sedated, family thinks we are going to kill them not the intent
v. Terminal (palliative) sedation
: can cause liver dysfunction, determine total dose ingested (combo drugs), analgesic and antifebrile
IV. Pharmacological therapies:
a. Nonopioids
i. Acetaminophen
- anti-inflammatory, antipyretic
IV. Pharmacological therapies:
a. Nonopioids
ii. Nonsteroidal anti-inflammatory drugs (NSAIDs)
- no matter how much more you give will not see increase in pain relief, it increases chances of side effects
nsaid
1. Ceiling effect
- affect platelet activity=cause bleeding, could cause systemic effects
nsaid
2. Gastric toxicity
especially with dehydration, hard to assess at end of life
nsaid
3. Renal dysfunction
increases with concurrent use this and corticosteroids
- stomach and liver itself, risk for bleeding
nsaid
4. Risk for adverse effect
Side effects:
- controversy regarding long term use, increase in cardiovascular events, considers cost and benefit / not used as much
Celecoxib (Celebrex)
nsaid
iii. CoX-2 inhibitors
Adverse effects:
1st symptom= sedated, groggy, more difficult to arouse/ respiratory depression= rare,
b. Opioids (max dose is the one that works)
-reverse effect, don’t want to do in someone who is actively dying
–ampule 0.4 mg mix entire ampule with 10 ml of sterile water/saline/ start with one ml see if it reverse some symptoms give more if not coming back
-effects wear off in 30-60 minutes/ still issues with respiratory issue may have to give again= most opioid life is longer than / could have to give q 10-15 minutes
Naloxone (Narcan)
major problem, know it will happen prevention=stool softener, laxatives/ don’t ever build a tolerance to this must be proactive /exacerbates N/V
-stools too hard, too difficult to expel, too small, or too infrequent / everyone bowl pattern is different-careful history
opioid side effect
2. constipation:
major side effects, if on a long time will build tolerance to sedative effects
opioid
3. sedation:
: more common in individuals who are post op with anesthesia or analgesia
opioid
4. urinary retention
: many will dev a tolerance to this
: can be severe, give antihistamine Benadryl=cause sedation / most will dev a tolerance
- very rare and generally due to preservatives, dyes, and other additives, PT my stat allergic=assess reaction
opioid
- N/V
- pruritus (itching)
- allergic reactions
most common codeine, Morphine, hydrocodone, fentanyl, oxycodone, oxymorphine
Agonist:
- unique properties that make it useful in pain management, long half-life q 8 hrs, cheap
agonist
2. Methadone
- not indicated in EOL care, metabolized to normeperdine in liver then excreted in the kidneys= if renal dysfunction can be toxic and result in seizure, painful injection
- meperidine (Demerol)
- not for chronic pain/not for eol, ceiling dose
Adverse effects: psychotomimetic effects, withdraw
- Mixed Agonist-Antagonist
- Lyrica and Cymbalta=chronic neuropathic syndromes, can cause sedation, administer at bedtime bc side effects, newer agents
c. Adjuvant analgesics
i. Antidepressants
- older agents have significant adverse effects
adjuvant analgesics
ii. Anticonvulsants
: controversial, may feel better, dexamethasone has least mineralocorticoid effect, psychosis, proximal muscle wasting , administer in am, help wake them up a little bit
adjuvant analgesics
iii. Corticosteroids
- legal in 21 states, can be given THC=most potent in pill form, makes you hungry=good for anorexia, N/V,
- helps with nausea
adjuvant analgesics
iv. Medical marijuana
least invasive amount with most effect, excruciating pain titrate up or down to get adequate relief
d. Routes of administration:
pain meds
can be just as effective, higher dose b/c it is being filtered out by liver= 1st pass effect ; doesn’t mean getting worse
i. Oral pain meds
- absorb in mouth, important with break through pain, Roxinol, liquid morphine
ii. Mucosal and buccal
pain meds
delay in onset may take 17 hrs to work , can be just as useful
iv. Transdermal:
pain
- make sure skin is not broken down
topical
pain meds
Intravenous- not at home care, Intramuscular (not recommended)
vi. Parenteral:
pain meds
vii.- not recommended for chronic
Nasal
pain meds
proved no advantages over other routes of administration for dyspnea or pain, good for difficulty swallowing
ix. Nebulized and sublingual opioids – nebulized opioids
3 step ladder analgesia and pain relief
A. : 1-3 start with simple analgesics, Acetaminophen or
B. : nsaids ___4-6 /___ 7-10: pain does not respond to other therapies, add opioids, treat immediately then titrate accordingly
e. Principles regarding the use of analgesics
i. World Health Organization (WHO)
Mild:
Moderate
Severe
- anticipate, prevent= constipation, treat
2. sustain released meds, immediate release for breakthrough, distinguish types of pain
a. Principles regarding the use of analgesics
ii. Prevent and treat adverse effects:
iii. Use of long-acting and breakthrough medications :
- Converting from one route or drug to another, higher does 1st pass effect when to oral =goes to liver to be digested less amount circulated
- use a multimodal approach, best to use sustained release for scheduled drugs then immediate release for break through pain
- opioid naive- doesn’t take often or never takes, start low dose, short acting and titrate for effect
iv. Equianalgesia
e. Principles regarding the use of analgesics
- what to use, don’t use it if it is not working will try to use another
e. Principles regarding the use of analgesics
v. Opioid rotation
- multiple drugs, aware of everything they are taking, oral sup and herbs
e. Principles regarding the use of analgesics
i. Polypharmacy
- pharmacy fixes meds, grind up to make suppository or sprinkle
e. Principles regarding the use of analgesics
vii. Compounding
: very important and can be useful
VI. Non-pharmacological techniques
may be done as palliative measure= pain
-Radiation, Surgery, Chemotherapy, Hormonal therapy
V. Cancer Therapies:
– is contingent on adequate assessment and use of both drug and non-drug therapy, extend beyond physical causes to other causes of suffering and existential distress,
a. Interdisciplinary team
b. Nursing roles
pain relief
- complete information, cause of pain, effects on pt function, medications and side effects/ unhelpful responses: reframe, educate= cause rep depression, and normalize= usual dose
communication
