Palliative CLASS PPT Flashcards
What did Maureen want us to know most (the take aways)
—just to note this
- Knowing how the drugs work
- Knowing differences in extended release medications
- Knowing that just because the pt is palliative, not necessarily palliating
- Ensure MOST if filled out on chart (code status)
ON EXAM: Pay attention to off label use of medications!!!
PHYSIOLOGICAL CHANGES NEAR
END-OF-LIFE
Weakness/Fatigue Decreasing Appetite/Food Intake, Wasting Decreasing Fluid Intake, Dehydration Decreasing Blood Perfusion, Renal Failure Neurological Dysfunction: - Decreasing Level of Consciousness - Terminal Delirium - Changes in Respiration - Loss of Ability to Swallow Loss of Sphincter Control Loss of Ability to Close Eyes Changes in Medication Needs
What kind of breathing changes occur at end of life?
Cheyne-Stoke breathing
abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.
Barriers to proper pain relief
- Health care prof: inadequate knowledge, poor assessment, concern re: regulation of controlled substances, fear of pt addiction (and self?), concern re:/inattention to side effects; concern about pt tolerance to analgesics
- Health care system: low priority, inadequate reimbursement, restrictive regulations re: controlled substances; problems of availability
- Pt: reluctance to report; concern re: distracting physician from tx of underlying disease, fear disease is worse, concern about not being good pt
- Reluctance: fear of addition/being thought addict, worries about s/e, concern re: tolerance
Principles Of Symptom Relief
Constant symptom requires constant tx Do thorough assessment Consider etiology Remember Total Pain Avoid unnecessary delay Educate all involved Individualize care Consider adjuvants at all stages Use oral route when possible Evaluate frequently (titrate as necessary) Remain in communication with patient and family Treat other symptoms Be flexible
What is “Total Pain”
inclusive of:
physical, emotional, spiritual, practical,
psychological, and social elements.
THE 7 P's of total pain:
Physical pain
Intellectual pain
Emotional pain
Interpersonal pain
Financial pain
Spiritual pain
Bureaucratic painWhat is a main concern for cancer patients?
PAIN!
Between 66 – 80 % of cancer patients in the advanced stage experience pain of moderate to severe degree
Pain Syndromes
what are the sources of pain for CA patients?
Direct tumor involvement
- Invasion of bone
- Involvement of nerves
- -> Brachial plexus
- -> Lumbosacral plexus
- -> Epidural spinal cord compression
Involvement of viscera and ducts - Obstruction - Abdomen - Viscera Involvement of blood vessels
Related to Cancer Therapy - Post surgical pain - Post chemotherapy pain: Peripheral neuropathy, Mucosistis, Aseptic necrosis of bone - Post radiation therapy pain Related to Cancer induced Debility Constipation Decubitus ulcer Gastric distension Bladder spasm
Unrelated to Cancer: Arthritis, Angina, Osteoporosis, Migraine, etc
Outline the pyramid of obtaining effective pain control:
Etiology –> assessement –> principles –> analgesics –> adjuvents
What do PQRSTUV for pain stand for?
P - provoking/palliating Q - Quality R - Regions/radiating S - Severity T - Treatment (past + present, effectiveness) U - Understanding (of pt) V - values (pt goals)
Outline the pain ladder (mild, moderate + severe pain management techniques)
1) Pain intensity that is mild can be treated with step 1 non-opioid drugs such as aspirin, NSAIDS, or acetaminophen and adjuvant drugs as indicated by the type of pain.
2) Pain intensity that is mild to moderate can be treated with opioids such as oxycodone or codeine combined with aspirin or acetaminophen and adjuvant drugs as indicated by the type of pain.
3) Pain intensity that is moderate to severe can be treated with strong opioids such as morphine, hydromorphone, or methadone.
What is the pain med administration method of choice?
Oral
Where are opioids conjugated + excreted?
Conjugated in liver
Excreted via kidney
Opioids
Peak plasma concentration time for oral, SC/IM and IV?
Oral – 1hr
SC/IM – 30 min
IV – 6 min
Opioid half life at steady state?
3 – 4 hours
Which pain meds are given immediate release?
Typically given how frequently?
How should adjustments for these meds be made if:
1) mild/moderate pain
2) severe/uncontrolled pain
codeine, morphine, hydromorphone, oxycodone
q4h
Adjust dose daily
Mild/moderate pain – increase 25 – 50 %
Severe/uncontrolled pain – 50 – 100%
Adjust more quickly for severe uncontrolled pain
How big is a BTD in relation to scheduled q4H dose of opioids?
1/2
Offer more BTD opioid AFTER _____
Peak has been reached (of previous dose)
How do you know if the regular (scheduled) dose of opioid needs to be upped?
If <3 BTDs per day no change in regular dose
If >3 BTDs per day then increase regular dose by the BTD amount
How will a new scheduled dose be calculated based on the opioid required in the day?
Add up the total amount given in past 24 hours including regular and BTDs
Divide total by 6 and give next regular dose by that amount
2 ways that opioids produce respiratory depression?
1) Pain is a potent stimulus to breath
2) Loss of consciousness precedes respiratory depression
What do you need to know to calculate how to switch between PO and SC doses?
SC dose is ½ of PO dose based on the immediate release form of the drug
Common ratio PO: IM/SC is 2:1, but some patients may be 3:1
Switching between immediate to sustained
Conversion is based on the total daily dose of immediate release and divided accordingly
(I assume this is the divide by 6? No sure…)
In the WHO recommendations for opioids, what is the recommendation for “by the clock”
What about “by the ladder”
analgesic medications for moderate to severe pain should be
given on a fixed dose schedule, not on an as needed basis.
analgesics given per the W.H.O three step ladder
What should a physician consider when switching between opioids?
Due to
incomplete cross-tolerance clinicians should consider reducing the dose by 20 to 25%
when ordering and titrate from there depending on the clinical situation. Must be individualized – consult if necessary.
Equianalgesic doses need to be calculated when?
Equianalgesic doses need to be calculated when switching from one drug to another,
when changing routes of administration or both
An equianalgesic table should be used as a guide in dose calculation.
Is it ok to cut a fentyl patch to adjust dosing?
NO!
How potent is dilaudid in comparison to morphine?
7-10x
When giving a breakthrough dose, is it normal to use a different drug than is used for the sustained release?
No, Always look for a short acting form of same drug if possible for BTP
Examples of sustained release opioids?
Meslon, Oxycontin, Hydromorph Contin, Fentanyl patch
If pain is not well controlled by long acting opioids, what to do you do?
If pain not controlled, revert to short acting and re-titrate
Oral forms of long acting opioids and patches take ____ to reach steady state
How to help pt with pain during this time if need be?
24 hours
Give BTDs in first 12 hours if necessary
T/F Oral forms of long acting opioids cannot be crushed or chewed
What about Meslon?
T
Meslon can be opened and sprinkled on food but cannot be put down NG tubes
Fentanyl Patches What is fentanyl? Does it cause histamine release? How does the patch work? A pro of this medication?
A synthetic opioid Doesn’t release histamine Lipophilic and high bioavailability Forms subcutaneous pool Less likely to cause nausea/constipation
Which opioid is not recommended?
Demerol (Meperidine)
What is done in management of bone pain?
Opioids NSAIDs Corticosteroids Bisphosphonates Calcitonin Radiation External bracing
