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N304 > Symptom Management > Flashcards

Symptom Management Flashcards

1
Q

What are the key components of symptom management?

A

Physical symptoms; psychological well-being; and patient/family

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2
Q

Describe assessment as the key to symptom management:

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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3
Q

What are the benefits of assessment tools?

A
  • Aid to an overall assessment
  • May provide a focus for symptom management
  • Reliability/validity
  • Appropriate/applicable
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4
Q

Who are common team members we use in symptom management?

A
  • Social Worker
  • Family
  • Volunteers
  • Palliative team
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5
Q

Describe the components of the FH Palliative Symptom Management Assessment tool:

A
  • Onset
  • Provoke – What makes it worse, better?
  • Quality – What is it like? Sharp, ache
  • Radiating – Do you expect any symptoms anywhere else?
  • Severity – Use scale
  • Treatment – What treatment have worked, what doesn’t?
  • Understanding – Understanding of situation – how does that make them feel?
  • Values – What is important to you? E.g. what’s your goal for symptom management? What about their family?
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6
Q

Describe the mild pain treatment of the analgesic ladder:

A
  • Non-opioid

- +/- adjuvant

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7
Q

Describe the moderate pain treatment of the analgesic ladder:

A
  • Weak opioid
  • +/- non-opioid
  • +/- adjuvant
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8
Q

Describe the moderate/severe pain treatment of the analgesic ladder:

A
  • Done if pain persists/increases
  • Strong opioid
  • +/- non-opioid
  • +/- adjuvant
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9
Q

What is pain?

A
  • Pain is whatever the experiencing person says it is, existing whenever he/she says it does
  • HOWEVER, this might not always be the case! Pain might not be what they it is because not everyone expresses their pain the same, some may conceal it, etc. We need a history of pain and the type they’ve experienced before.
  • An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
  • Can be caused by disease itself; treatments; related debility; unrelated causes; psycho-social issues; often multi factorial, requiring combinations of meds/other therapies
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10
Q

What is total pain?

A

Pain that encompasses physical, psychological, social, emotional, spiritual, and cultural - gives us a holistic image of pain!

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11
Q

What are the different types of pain?

A
  • Nociceptive (somatic, visceral)
  • Neuropathic
  • Complex regional pain syndromes
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12
Q

What are characteristics of pain that we evaluate? (i.e. types of pain)

A
  • Acute
  • Chronic
  • Incident pain
  • Breakthrough pain
  • End of dose failure pain
  • Intensity
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13
Q

Describe acute pain:

A

increased heart rate, change in blood pressure, sweaty, increasing RR, facial grimacing (non-verbal), anxiety, distress

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14
Q

Describe chronic pain:

A

pain that persists after what we would anticipate has sorted – can have lots of psychological and social impacts

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15
Q

Describe incident pain:

A

Something occurs and pain occurs for the patient - e.g. patient needs to have surgery, an incident that is going to happen and we know is going to cause pain – ulcer on coccyx have to move them, you know it will cause pain; Predictable!

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16
Q

Describe breakthrough pain:

A

unpredictable; having baseline analgesics, breaks through the underlying pain management; ensuring someone has very appropriate pain meds is important

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17
Q

Describe end-of-dose failure pain:

A

pain coming back 2-3 hours before next dose; so many dose is not large enough; e.g. Patches

18
Q

Describe intensity of pain:

A

subjective how the patient experiences they pain – the pain is what the patient says it is – can be related to personal experiences, etc.

19
Q

What are barriers to pain management?

A
  • HCP barriers (lack of education, fear of OD, lack of experience, stigma/bias/prejudice, hierarchy)
  • System barriers(policy; communication within teams or hierarchy)
  • Patient/family barriers (under-reporting d/t a number of reasons; fear of addiction; cultural reasons)
  • Societal barriers (cultural; you must not act like that in public)
20
Q

What are the 3B’s?

A

Bowels, Barfing and Breakthrough

21
Q

What classes of drugs act as adjuvant analgesics?

A
  • Anti-depressants
  • Anti-convulsants
  • Corticosteroids
  • Topicals
  • Antivirals
  • Antibiotics
  • Bisphosphonates
  • Anticholinergics
  • Muscle relaxants
  • Benzodiazepines
22
Q

What are some adjuvant methods of treatment? (for pain)

A
  • Primary Therapy
  • Anesthetic techniques
  • Neurosurgical procedures
  • Physiotherapy
  • Relaxation techniques
  • Acupuncture
  • Behavioural therapy
  • TENS
23
Q

Why might we use parenteral drug therapy instead of oral?

A
  • Oral issues (e.g. sores from chemo)
  • Absorption issues
  • N/V
  • Bowel obstruction
  • Swallowing difficulties
24
Q

What are common adverse effects of opioids?

A
  • CNS - Sleep, confused, hallucinations, decrease in RR
  • GI – constipation (need to manage from onset)
  • U – can increase muscle retention
  • M – myoclonus can lead to full blown seizures
25
Q

What is methadone?

A
  • Synthetic opioid analgesic
  • Maybe used as an alternative to morphine/hydromorphone/fentanyl etc if these are not effective or if side effects are refractory/unmanageable
  • Used for patients with difficult to manage pain
  • Accumulation can lead to significant cardiac side effects, as well as liver/renal issues, and hypoglycemia/calcemia
  • Can be given PO, SC, IV
26
Q

How is a starting dose of opioids determined?

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
27
Q

When doing a conversion, how much does an oral to SC/IV amount to?

A

1/2 the oral dose

28
Q

What are some guidelines for long-acting preparations?

A
  • When using long acting preparations, pain should be first controlled with short acting opioid for 24-48 hours
  • Once controlled the patient can be switched to long acting q 12 hours(divide 24 hour dose by 2)
  • Continue the q 1 h prns
29
Q

What are the KEY points of symptom management? (the process)

A
  • Determine the cause
  • Diagnostics and prognosis
  • Education and assessment
  • Palliative care principles
  • Treatment
  • Pharmacological
  • Non-pharmacological
30
Q

What is the difference between nausea and vomiting?

A
  • Nausea is the sensation immediately preceding vomiting and can include cold sweat, increased salivation and duodenal contractions and reflux. Subjective.
  • Vomiting is the rapid and forceful expulsion of stomach contents out of the mouth.
  • Both affect quality of life!
31
Q

What are the typical causes of N/V?

A
  • Often multifactorial
  • All pathways stimulate the Integrative Vomiting Centre
  • Nausea is mediated by neurotransmitters
  • CHEMICAL (dopamine and serotonin)
  • GI TRACT-VAGAL
  • CNS (histamine)
  • VESTIBULAR (histamine and serotonin)
32
Q

How can we educate and assess patients with N/V?

A
  • Teaching is important for patient and family
  • Coping strategies
  • Utilise OPQRSTUV assessment tool + (Medication review, Treatments, Environment)
  • Ongoing assessment and evaluation
  • Discuss the type of diet to adhere to (e.g. what to avoid, how often to eat) (ex. have small meals throughout day instead of one single huge meal)
  • Have them sitting up and give themselves to digest food
  • Referral to dietician and protein powders in some cases
33
Q

How do we treat N/V?

A
  • Treat reversible causes where possible and consider goals of care
  • Non-pharmacological techniques (relaxation, anti-anxiety, distraction therapy, acupuncture/acupressure, good oral hygiene)
  • Pharmacological (ondansetron, gravol)
34
Q

What is a malignant bowel obstruction? What are the causes?

A
  • Can occur in large or small bowel
  • Partial or complete (difficult to differentiate)
  • Causes –
    Tumour mass
    Constipation
    Adhesions
    Volvulus
    Ileus
    Peritonitis
    Ascites
35
Q

What are S&S of malignant bowel obstruction?

A
  • Cramps (constant)
  • N/V at some point
  • Constipation
  • BM Might look liquid-y if not a complete bowel obstruction
  • Confirm with abd x-ray, scans and scope
36
Q

How do we treat malignant bowel obstructions?

A
  • Pharmacological (metroclopramide; anti-secretory drugs; bucropan for cramps; anti-emetics)
  • NG can be a really useful intervention
  • NPO
  • Try to keep them hydrated (IV running, SC for hydration)
  • Oral hygiene maintenance
  • Education/support
  • Consider nutritional needs
37
Q

What is the incidence of spinal cord compression?

A
  • lung 16%
  • breast 12%
  • unknown primary 11%
  • lymphoma 11%
  • multiple myeloma 9%
  • 70% distributed to thoracic spine, often at multiple contiguous levels
38
Q

Describe education and assessment of spinal cord compression:

A
  • Educate at risk patients and families of signs and symptoms.
  • Utilize OPQRSTUV assessment tool.
  • Pain –presenting symptom in 95% of patients. Specific, localized to area with compression, and banding pain (nearby). Neuropathy to compressed nerves.
  • Weakness (might have unsteady gate, as numbness will start from bottom up)
  • Sensory disturbances
  • Autonomic dysfunction (sexual dysfunction, bladder issues like urgency and frequency, escalating to retention)
39
Q

How do we diagnosis of spinal cord compression? What is the prognosis?

A
  • Most important intervention – id cause(s) and treat appropriately.
  • Early diagnosis crucial
  • Patient status
  • Tests (MRI/CT when time permitting/possible)
  • Determining factors
  • Onset (if rapid within 48 hours, prognosis poor)
  • Initial treatment (v. high dose of IV dexamethasone – to reduce inflammation and have anticancer effect as well, manage pain, next part is radiation in that area, may get one, two or three doses – not the amount that someone would have to cure their disease)
  • Maybe surgery, rehab
40
Q

How do we assess SC compression? What education should we provide Ca patients?

A
  • OPQRSTUV assessment tool
  • Diagnostics
  • Discuss with patients and family the signs and symptoms: Pain; Abdominal distention; Nausea and vomiting; Fatigue; Anorexia;
    Constipation/diarrhea

N304 (16 decks)

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