Pain & Palliative Care Flashcards
QUESTT
o Question the child and/or parent
o Use a valid and reliable pain scale
o Evaluate the child’s baseline and response to intervention
o Secure parental involvement (this can mean many things!) Can mean they are there during or come back after and console. Can involve breastfeeding. Assess what family wants!
o Take the cause of pain into account
o Take action
what is pain?
- an unpleasant sensory and emotional experience that is associated with actual or potential damage
- can be emotional or physical
what are some of the negative consequences of untreated pain in children?
- increased oxygen consumption
- alterations in blood glucose metabolism
- increased anxiety
what is the sequence of physiologic events in the nervous system that contributes to the sensation of pain?
- transduction (conversion of external stimuli into a pain signal)
- transmission (pain signal being directed to wards spinal cord and brain)
- modulation (process of dampening or amplifying pain signals)
- perception (awareness of pain)
what are nociceptors?
- nociceptors are specialized receptors at the end of peripheral nerve fibres.
- become activated when they are exposed to noxious stimuli (can be mechanical, chemical, or thermal)
- when nociceptors are activated, transduction, the first event in the sensation of pain is occuring
how does transmission of a pain stimulus occur?
- after nociceptors are activated by a stimuli, there is a conversion to electrical impulse that is relayed along peripheral nerves to the spinal cord and brain
- mylenated A-delta fibres are long and conduct the impulse rapidly (pain transmitted along these often called fast pain) and are often associated with mechanical or thermal pain
- unmylenated c fibres transmit impulse slowly, are often associated with chemical pain
- the fibres carry the impulse to the spinal cord via the dorsal horn
- neurotransmitters are released to facilitate transmission to brain
how does perception of pain occur?
- after transmission occurs in the dorsal horn of the spinal cord, the nerve fibres run up to the thalamus
- thalamus responds quickly to send message to somatosensoy cortex of brain where the impulse is interpreted as physical pain
- impulses carried by a-delta fibres leads to perception of sharp, stabbing, localized pain and often involves a reflex response to withdraw from stimulus
- impulses carried by c fibres leads to perception of diffuse, dull, burning or aching pain
- thalamus also sends message to limbic system to interpret sensation emotionally and to the brain stem centres where autonomic nervous system begins to respond
what is the pain threshold?
the point at which a person feels the lowest intensity of a painful stimulus
what are neuromodulators?
- substances that appear to modify pain sensation
- change a persons perception of pain
- include serotonin, endorphins, enkephalins, dynophins
what is nociceptive pain?
- pain that reflects due to activation of a-delta fibres and c fibres by a noxious stimuli
- perceived pain often correlates closely with degree or intensity of stimulus and extent of real or possible damage
- nervous system functioning is intact
what is neuropathic pain?
- nerve pain
- occurs because of malfunctioning of the peripheral or central nervous system
- may be continuous or intermittent
- commonly felt as burning, tingling, shooting, or stabbing
- may be spontaneous or evoked by a trigger
- may be associated with motor abnormalities
what is somatic pain?
pain that develops in tissue
what is visceral pain?
pain that develops within organs
what are the characteristics of acute pain?
- caused by an obvious, often single, cause
- nociceptive and/or neuropathic
- has a protective purpose, activation of sympathetic nervous system
- lasts for days to weeks at most
- pain intensity is usually proportionate to severity of injury
- usually easy to treat with single modalities
- expected to resolve with healing
what are the characteristics of chronic pain?
- usually multiple causative or triggering factors
- neuronal or CNS abnormality (plasticity, sensitization)
- type of pain is nociceptive, neuropathic, or mixed and may involved psychological factors
- there is no protective function
- rarely accompanied by signs of activation of sympathetic nervous system
- long lasting or recurring beyond time of normal healing
- may be associated with chronic disease
- often out of proportion to objective physical findings
- more difficult to treat, requires multidisciplinary, multimodal approach
- pain persists in significant number of patients, with small proportion developing pain-associated disability syndrome
what is nociception?
the encoding and processing of harmful stimuli in the central nervous system
what are some limitations of pain scales when used with children
- can`t always explain why things are being done and so pian as well as fear and anxiety need to be assessed
- don’t incorporate emotional, psychological, behavioral, social/cultural factors
for what ages and how should a faces pain reporting scale be used?
- appropriate for ages 5-12
- should ask child to select the face that describes how they feel
after what age should a numerical rating scale for pain be used?
after about age 8 - discretion about what may work best for child
what is the FLACC scale?
a pain scale that can be used for children aged 2 months to 7 years
-rates pain on face, legs, activity, cry, consolability
how is pain rated using the FLACC scale?
- FACE: score of 0 for no particular expression or smile, 1 for occasional grimace or frown, seeming withdrawn or distressed, 2 for frequent to constant frown, clenched jaw, or quivering chin
- LEGS: score of 0 for normal or relaxed position, 1 for uneasy, restless or tense, 2 for kicking or legs drawn up
- ACTIVITY: score of 0 for lying quietly, normal position, moves easily, 1 for squirming, shifting back & forth, tense, 2 for arched, rigid, or jerking
- CRY: a score of 0 for no crying, 1 for moans or whimpers, occasional complaint, 2 for crying steadily, screams, sobs, or frequent complaints
- CONSOLABILTIY: score of 0 for content or relaxed, 1 for reassured by occasional touching, hugging or being talked to, distractible, 2 for difficult to console or comfort
what is the CRIES scale for pain used for?
a post-operative infant
-looks at gestational age, behavioral state, HR, O2 sats, brow bulge, eye squeeze and nasolabial furrow
what is the NIPP pain scale used for?
for neonatal infants
what is the PIPP pain scale used for?
for premature infants
are combination formulation drugs used with children, why or why not?
no, they are not used because dosing of medication for children is weight based and ratios may not be appropriate for child
multiple drugs can be used at once, but should be used in pure formulations
what may be a contraindication of NSAID use?
non-steroidal anti-inflammatory drugs are hard on kidneys and gut - they should be used carefully or not at all for those with renal impairment or gut problems
for cancer patients, NSAIDS may be inappropriate because they suppress platelet production
what are some parameters of tylenol use in children?
range of dosage is usually between 10-15 mg/kg/dose with doses being q4-6h
upper limit is at most 75mg/kg/day
tylenol affects the liver, so liver function must be considered
is codeine used with children?
no, generally codeine use is not recommended for children
codeine is broken down into morphine, which not everyone has the enzymes to do
is methadone used in children for pain?
sometimes, it is more commonly used with adults
used to treat neuropathic pain
what kind of pain management may steroids be used for in oncology patients?
-pain r/t bone pain or edema with large tumor burden
what are some myths and fears related to opioid use in children?
- only used for end of life
- too strong for children
- fear of side effects
- fear of addiction (generally is truly managing pain, not chasing psychological high, so decreased likelihood of addiction)
- fear r/t administration of a patients last dose (that an individual will give a does and pt will pass)
- fear of escalating doses
what are common side effects of opioids?
- constipation (this is the only side effect that does not dissipate with time)
- nausea
- pruritis (antihistamines not effective, can use ondansetron or naloxone in low doses to treat)
- respiratory depression (this is a toxicity, meaning too much has been given)
- sedation
- confusion
- hallucinations
what are some non-pharmacological methods of managing pain?
- distraction
- relaxation
- hypnosis
- guided imagery
- massage/pressure
- aromatherapy
- heat/cold
- getting family involved
what is the goal of non-pharmacological pain management?
- to augment pharmacologic management
- develop coping strategies
- diminish fear
- provide sense of control within situation
what is palliative care according to the WHO?
-an approach that improves the quality of life in patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment as well as treatment of pain and other problems - physical, psychosocial, and spiritual
what does the active total care of a child involved?
care of the child’s body, mind, spirit and giving support to the family
how does the Saskatoon Health Region define palliative care?
- a service of active compassionate care which centers on achieving the best possible quality-of-life for a person at the end of life’s journey
- focuses on providing for the needs of people living with a life-ending illness
what are the basic principles of palliative care?
- medically appropriate goal setting
- open and honest communication
- aggressive symptom management and control
why is it valuable to discuss a patient or families worries and hope related to serious, life-threatening illness
though death can not be prevented, often concerns can be addressed
this discussion can give insight into the family/individual’s values that can guide appropriate care
there may be peripheral issues that can be addressed to alleviate stress/suffering (for example: concern for other children in the family who are not ill)
what are benefits of integrating a palliative approach early in care?
- unanticipated disease trajectories can be discussed and families/patients prepared for possible difficult decisions or outcomes well ahead of crisis
- continuity of care from symptoms management during curative phase through to end-of-life care if that is the result
- reduction of aggressive treatment if futile at end of life, preserving quality-of-life
- reduces ER visits in palliative patients
- help to actualize wishes regarding care (if not enough time, often can put needed arrangements in place)
- helps to identify goals of care
- helps to initiate EOL discussions
- reduces distress of patient and siblings by enabling discussion of worries and concerns
what are some common symptoms at end-of-life for oncology patients?
-pain // treat with medications, include benzos to decrease disstress if appropriate
-dyspnea // fan, temperature, oxygen maybe if appropriate
-nausea, vomiting, anorexia // anti-emetics, steroids,
-fatigue
-bleeding
constipation, obstruction
-fever
-cough
-secretions or dry mouth
-irritability, agitation, delirium
