Pain & Palliative Care

Question 1

QUESTT

Answer 1

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

Question 2

what is pain?

Answer 2

• an unpleasant sensory and emotional experience that is associated with actual or potential damage
• can be emotional or physical

Question 3

what are some of the negative consequences of untreated pain in children?

Answer 3

• increased oxygen consumption
• alterations in blood glucose metabolism
• increased anxiety

Question 4

what is the sequence of physiologic events in the nervous system that contributes to the sensation of pain?

Answer 4

• 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)

Question 5

what are nociceptors?

Answer 5

• 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

Question 6

how does transmission of a pain stimulus occur?

Answer 6

• 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

Question 7

how does perception of pain occur?

Answer 7

• 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

Question 8

what is the pain threshold?

Answer 8

the point at which a person feels the lowest intensity of a painful stimulus

Question 9

what are neuromodulators?

Answer 9

• substances that appear to modify pain sensation
• change a persons perception of pain
• include serotonin, endorphins, enkephalins, dynophins

Question 10

what is nociceptive pain?

Answer 10

• 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

Question 11

what is neuropathic pain?

Answer 11

• 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

Question 12

what is somatic pain?

Answer 12

pain that develops in tissue

Question 13

what is visceral pain?

Answer 13

pain that develops within organs

Question 14

what are the characteristics of acute pain?

Answer 14

• 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

Question 15

what are the characteristics of chronic pain?

Answer 15

• 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

Question 16

what is nociception?

Answer 16

the encoding and processing of harmful stimuli in the central nervous system

Question 17

what are some limitations of pain scales when used with children

Answer 17

• 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

Question 18

for what ages and how should a faces pain reporting scale be used?

Answer 18

• appropriate for ages 5-12

- should ask child to select the face that describes how they feel

Question 19

after what age should a numerical rating scale for pain be used?

Answer 19

after about age 8 - discretion about what may work best for child

Question 20

what is the FLACC scale?

Answer 20

a pain scale that can be used for children aged 2 months to 7 years
-rates pain on face, legs, activity, cry, consolability

Question 21

how is pain rated using the FLACC scale?

Answer 21

• 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

Question 22

what is the CRIES scale for pain used for?

Answer 22

a post-operative infant

-looks at gestational age, behavioral state, HR, O2 sats, brow bulge, eye squeeze and nasolabial furrow

Question 23

what is the NIPP pain scale used for?

Answer 23

for neonatal infants

Question 24

what is the PIPP pain scale used for?

Answer 24

for premature infants

Question 25

are combination formulation drugs used with children, why or why not?

Answer 25

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

Question 26

what may be a contraindication of NSAID use?

Answer 26

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

Question 27

what are some parameters of tylenol use in children?

Answer 27

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

Question 28

is codeine used with children?

Answer 28

no, generally codeine use is not recommended for children

codeine is broken down into morphine, which not everyone has the enzymes to do

Question 29

is methadone used in children for pain?

Answer 29

sometimes, it is more commonly used with adults

used to treat neuropathic pain

Question 30

what kind of pain management may steroids be used for in oncology patients?

Answer 30

-pain r/t bone pain or edema with large tumor burden

Question 31

what are some myths and fears related to opioid use in children?

Answer 31

• 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

Question 32

what are common side effects of opioids?

Answer 32

• 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

Question 33

what are some non-pharmacological methods of managing pain?

Answer 33

• distraction
• relaxation
• hypnosis
• guided imagery
• massage/pressure
• aromatherapy
• heat/cold
• getting family involved

Question 34

what is the goal of non-pharmacological pain management?

Answer 34

• to augment pharmacologic management
• develop coping strategies
• diminish fear
• provide sense of control within situation

Question 35

what is palliative care according to the WHO?

Answer 35

-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

Question 36

what does the active total care of a child involved?

Answer 36

care of the child’s body, mind, spirit and giving support to the family

Question 37

how does the Saskatoon Health Region define palliative care?

Answer 37

• 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

Question 38

what are the basic principles of palliative care?

Answer 38

• medically appropriate goal setting
• open and honest communication
• aggressive symptom management and control

Question 39

why is it valuable to discuss a patient or families worries and hope related to serious, life-threatening illness

Answer 39

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)

Question 40

what are benefits of integrating a palliative approach early in care?

Answer 40

• 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

Question 41

what are some common symptoms at end-of-life for oncology patients?

Answer 41

-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