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Nursing 304 > Palliative Symptom Management > Flashcards

Palliative Symptom Management Flashcards

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1
Q

What are five key things to remember when assessing a palliative patient?

A 
Remember the individual
Holistic care
What works for one will not necessarily work for another
The nursing process
Team work
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2
Q

What are some key points about using assessment tools (the role of assessment tools) for palliative symptom management?

A 
Key points:
Aid to an overall assessment
May provide a focus for symptom management
Reliability/validity
Appropriate/applicable
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3
Q

What are the 8 points of Fraser Health Palliative Symptom Management Assessment Tool?

A 
Onset
Provoking factors
Quality
Region/Radiation
Severity
Treatment
Understanding
Values
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4
Q

What are the levels of the analgesic ladder (and treatment at each level)?

A

Mild pain -> non-opioid +/- adjuvant

Moderate pain -> weak opioid +/- non-opioid +/- adjuvant

Moderate/severe pain -> strong opioid +/- non opioid +/- adjuvant

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5
Q

What is the definition of “pain” according to McCaffery (1972)?

A

“Pain is whatever the experiencing person says it is, existing whenever he/she says it does” (McCaffery 1972)

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6
Q

What is the definition of “pain” according to IASP (1986)?

A

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP 1986)

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7
Q

What is one of the most common symptoms of cancer?

A

In patients with cancer, pain is amongst the most prevalent symptom experienced, and the most distressing.

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8
Q

What are the causes of cancer pain?

A

Caused by disease itself, treatments, related debility e.g. DVT, fungating wound; unrelated causes e.g. other underlying disease; psychosocial issues.
The cause is often multifactoral, requiring combinations of medication and/or other therapies.

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9
Q

What is different about non-malignant disease pain (compared to cancer pain)?

A

In patients with non-malignant disease, pain is also a common symptom.
Cause is often multifactoral.
It has been suggested that patients with non-malignant disease experience their symptoms (including pain) for longer due to the slower nature of disease progression. (Fisher, 2006).

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10
Q

What are three types of pain?

A

Nociceptive (somatic, visceral)
Neuropathic
Complex regional pain syndromes

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11
Q

What are two types of nociceptive pain?

A

Somatic

Visceral

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12
Q

What medication is often used for visceral palliative pain?

A

Dexamethasone

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13
Q

What are the side effects of dexamethasone? (Desirable and undesirable)

A

Dexamethasone (decreases inflammation, therefore decreases pain). Side effects: gives sense of well-being (can cause psychosis at high doses), increases appetite, decreases immunity, increases blood glucose. Some of these are actually helpful (appetite increase, sense of well-being). These might be unwanted in acute patients, but in palliative they might be desirable.

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14
Q

What is incident pain?

A

Incident pain – More related to intervention than acute pain is. For example, they might have a bad coccyx wound and when we change the dressing it is painful. This “incident” of changing the dressing causes pain.

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15
Q

What medication is good for incident pain in the palliative patient? (And why?)

A

sufentanyl. It can be given sublingual, and it is effective within 5 minutes and wears off very quickly.

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16
Q

What are six pain characteristics (of palliative pain)?

A 
Acute
Chronic
Incident pain
Breakthrough pain
End of dose failure pain
Intensity
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17
Q

What is end of dose failure pain?

A

Pain that occurs when the patient’s baseline med wears off, and they experience pain before their next dose.

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18
Q

What are some barriers to pain management?

A

Health Care Professional barriers
System barriers
Patient/family barriers
Societal barriers

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19
Q

What are some health care professional barriers to pain control?

A

stigma (“drug-seekers”), lack of understanding pain control, worry about causing respiratory distress

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20
Q

What are some system barriers to pain control?

A

Communication barriers, interdisciplinary barriers

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21
Q

What are some patient/family barriers to pain control?

A

afraid of getting addicted, afraid that “morphine means you’re dying”, values between patient and family (conflict between what patient believes and what the family believes), other patients getting annoyed with them ringing the bell all the time for pain meds, cultural barriers (eg expressing pain openly, or not). Age, genders, might express pain differently

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22
Q

What are some societal barriers to pain management?

A

Stigma, getting addicted

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23
Q

What are four key points for palliative pain management?

A

Goals for the patient
Cause of pain – total pain concept
Role of pharmacological and non-pharmacological interventions (listen!)
Combinations of therapies

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24
Q

What is important about dosing for palliative pain management?

A

Dosing – we want to make sure they have a baseline med, plus a PRN. It is always better to have your regular medication and your PRN medication the same. Also, try to advocate for it to be given the same route.

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25
Q

What are the 3B’s of palliative pain management?

A

Bowels, barfing, breakthrough.

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26
Q

How do we manage the 3 B’s of palliative pain management?

A

Bowels, barfing, breakthrough
Give bowel protocol. If they get nauseated, make sure they are given an antiemetic. Make sure they have a PRN for breakthrough pain.

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27
Q

What are five key points of palliative pain management?

A 
Dosing
3B's
Education
Patient participation
Evaluation
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28
Q

What are some non-opioid analgesics used for palliative pain?

A

Nsaids
Tylenol
Gabapentin (adjuvant)
Corticosteroids (adjuvant)

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29
Q

What are some opioid analgesics used for palliative pain?

A 
Morphine
Codeine
Hydromorphone
Fentanyl
Oxycodone
Sufentanyl
Methadone
Tramadol
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30
Q

Which opioid is not used for palliative pain management? (and why)

A

Demerol - is not used for palliative (it is good for acute pain, not good for long-term) Demerol can have significant accumulation and cause awful side effects (eg. seizures).

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31
Q

What are adjuvant medications?

A

Any drug that’s primary use is not pain control, but has an analgesic effect

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32
Q

What are some examples of adjuvant medications for pain medication?

A

Antidepressants, anticonvulsants, corticosteroids, topicals, antivirals, antibiotics, bisphosphonates, anticholinergics, muscle relaxants, benzodiazepines

33
Q

What are some adjuvant methods of pain treatment?

A 
Primary Therapy
Anesthetic techniques
Neurosurgical procedures
Physiotherapy
Relaxation techniques
Acupuncture
Behavioural therapy
TENS
34
Q

What are some reasons for parenteral pain management instead of oral?

A

Works faster
Not irritating to the stomach
Some can’t tolerate swallowing (difficulty swallowing for whatever reason, level of consciousness, stroke, etc)
Psychological reasons (think parenteral works better)
Might be NPO
Might be anorexic/unable to eat
Easier to give when sleeping without waking the patient up.

35
Q

What are the differences between subcutaneous infusion and IV infusion for pain meds?

A

Sub-cutaneous takes a little bit longer than IV to kick in, and takes about 4 hours to wear off (slower than IV)
Sometimes subcutaneous doesn’t work, if the person doesn’t have enough sub-cutaneous tissue, has absorption issues, etc.
They prefer oral analgesia initially.

36
Q

What are five types of side effects of opioids?

A 
Central nervous system
GI
Urinary
Muscles
Intolerance/hypersensitivity
37
Q

What CNS side effects are caused by opioids?

A

Respiratory depression, CNS depression

38
Q

What are GI side effects of opioids?

A

Constipation

39
Q

What are the urinary side effects of opioids?

A

Urinary retention

40
Q

What are the muscular side effects of opioids?

A

Myoclonus (sudden dropping/twitching movements of limbs)

41
Q

What is the treatment for myoclonus caused by opioids?

A

Give something like lorazepam (or other benzo)

Change the opioid so they don’t have the same side effects.

42
Q

What are some examples of intolerance/hypersensitivity reactions to opioids?

A

Itching, nausea, makes their head fuzzy

43
Q

What are some characteristics of methadone?

A

Synthetic opioid analgesic

May be used as an alternative to morphine

44
Q

What is the potency of methadone compared to morphine?

A

It’s potency is similar to morphine (single dose wise), but it increases in potency much faster. It has a very long half-life, so it tends to stay in the body.

45
Q

What are some side effects of methadone?

A

The major hazards of Methadone are respiratory depression and, to a lesser degree, systemic hypotension. Respiratory arrest, shock, cardiac arrest, (SAV), and death have occurred. The most frequently observed adverse reactions include lightheadedness, dizziness, sedation, nausea, vomiting, and sweating.

46
Q

What are the possible routes of administration for methadone?

A

Methadone can be given orally as a liquid or a pill, IV, IM, subcutaneous

47
Q

What are some guidelines for selecting a starting opioid dose?

A

The starting dose for opioid treatment is merely an estimate
Should be regular + prn doses of short acting opioid
When a starting dose is given it is titrated up or down according to patient response
Once pain is stable or controlled switch to most convenient dosing ie long-acting form ( +prn)
An equianalgesic chart should be used
Consider factors that may influence dosing

48
Q

How long should someone be on short acting opioids before receiving a long-acting opioid?

A

24-48 hours

49
Q

How often are long-acting preparations usually given?

A

Q12h

50
Q

What is nausea?

A

Nausea is the sensation immediately preceding vomiting and can include cold sweat, increased salivation and duodenal contractions and reflux. It is is subjective.

51
Q

What is vomiting?

A

Vomiting is the rapid and forceful expulsion of stomach contents out of the mouth.

52
Q

Do nausea and vomiting affect quality of life?

A

Yes

53
Q

What are the causes of nausea and vomiting?

A 
Determine the cause if possible.
Often multifactorial
All pathways stimulate the Integrative Vomiting Centre
Nausea is mediated by neurotransmitters
CHEMICAL
GI TRACT-VAGAL
CNS
VESTIBULAR
54
Q

What are the four neurotransmitters that moderate nausea and vomiting?

A

Histamine
Acetylcholine
Dopamine
Serotonin

55
Q

What are some chemical causes of nausea and vomiting?

A 
Medications
Uremia
Hypercalcaemia
Renal function decreased
Toxic effects of the tumour
56
Q

What are some GI causes of nausea and vomiting?

A

Often feels relieved by vomiting
Obstruction
Gastric irritation
Constipation

57
Q

What are the CNS causes of nausea and vomiting?

A

Increased intracranial pressure (often just vomit, without the nausea) - use mannitol to decrease fluid)
Psychological causes - anticipatory before chemo, sights and smells

58
Q

What are some vestibular causes of nausea and vomiting?

A

Sea-sickness, car sickness

Cerebellar tumours

59
Q

What are some education and assessment methods for palliative patients with nausea and vomiting?

A 
Teaching is important for patient and family 
Coping strategies
Utilise OPQRSTUV assessment tool +
Medication review
Treatments
Environment
Ongoing assessment and evaluation
60
Q

What are some non-pharmacological treatments for nausea and vomiting?

A

Cool cloth

Distraction

61
Q

What are some pharmacological treatments for nausea and vomiting?

A

Gravol
Metoclopromide
Ondansetron
Haloperidol

62
Q

How does metoclopromide help with nause and vomiting in palliative patients?

A

metoclopramide (not covered by palliative benefits) – increases gastric motility. This is contraindicated in patients with a known full bowel obstruction.

63
Q

Where can a malignant bowel obstruction occur?

A

Can occur in large or small bowel.

Can be partial or complete (difficult to differentiate).

64
Q

What are some causes of malignant bowel obstruction?

A 
Tumour mass
Constipation
Adhesions
Volvulus
Ileus
Peritonitis
Ascites
65
Q

What is the incidence of spinal cord compression in various types of cancer?

A

Incidence – lung 16%
breast 12%
unknown primary 11%
lymphoma 11%
multiple myeloma 9%

66
Q

What is the distribution of spinal cord compression (where in the spine)?

A

Thoracic spine 70%

Often multiple contiguous levels

67
Q

What education and assessment should be done for patients with spinal cord compression?

A

Educate at risk patients and families of signs and symptoms.
Utilise OPQRSTUV assessment tool.
Pain –presenting symptom in 95% of patients
Weakness
Sensory disturbances
Autonomic dysfunction

68
Q

What are the diagnosis and prognosis for patients with spinal cord compression?

A 
Most important intervention – id cause(s) and treat appropriately.
Early diagnosis crucial
Patient status
Tests
Determining factors
Onset
Initial treatment
69
Q

What is the pharmacological treatment for spinal cord compression?

A

Dexamethasone

Opioids

70
Q

What are some non-pharmacological treatment for spinal cord compression?

A

MRI
Radiation
Surgery
Physio

71
Q

What are the important assessment and education points for patients with a malignant bowel obstruction?

A 
OPQRSTUV assessment tool
Diagnostics 
Discuss with patients and family the signs and symptoms
Pain
Abdominal distention
Nausea and vomiting
Fatigue 
Anorexia
Constipation/diarrhoea
72
Q

What are the pharamcological and non-pharmacological treatments are indicated for malignant bowel obstruction?

A 
Pharmacological
Buscipan
Anti-emetics
Non-pharmacological
Repositioning
Hot or cold compress
IV fluids (NPO)
Good oral care
NG tube suction
Surgery
Metoclopramide
73
Q

What is the prevalence of dyspnea in palliative patients?

A

Estimated that 95% of patients with COPD, 70-80% of patients with advanced cancer and 75% of patients with advanced disease of any cause experience dyspnea.

74
Q

What are some causes of dyspnea?

A

Can be caused by:
illnesses that prevent airflow,
changes in compliance and/or capacity,
airway obstruction, treatment induced conditions

75
Q

What are some key points to assess for dyspnea?

A 
Patient self-reports
Impact on QOL
Factors that alleviate or exacerbate
Personal meaning
Respiratory assessment
Remember cardiac function!
76
Q

What are some interventions that can be done for dyspnea?

A

First:

Understand the pathology

What is the goal of intervention…treat or cure?

Multiple strategies

Care planning

77
Q

What are some non-pharmacological treatments for dyspnea?

A 
Education
Breath control and energy conservation
Complementary therapies
Positioning
Ventilation
Support
78
Q

What are some pharmacological treatments for dyspnea?

A 
Opioids
Corticosteroids
Neuroleptics
Antianxylitics
Bronchodilators
Diuretics
Antibiotics/antifungals
Anticholinergics
Radiation/chemo
Oxygen

Nursing 304 (12 decks)

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