Symptom Management Flashcards
What are the key components of symptom management?
Physical symptoms; psychological well-being; and patient/family
Describe assessment as the key to symptom management:
- Remember the individual
- Holistic care
- What works for one will not necessarily work for another
- The nursing process
- Team work
What are the benefits of assessment tools?
- Aid to an overall assessment
- May provide a focus for symptom management
- Reliability/validity
- Appropriate/applicable
Who are common team members we use in symptom management?
- Social Worker
- Family
- Volunteers
- Palliative team
Describe the components of the FH Palliative Symptom Management Assessment tool:
- 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?
Describe the mild pain treatment of the analgesic ladder:
- Non-opioid
- +/- adjuvant
Describe the moderate pain treatment of the analgesic ladder:
- Weak opioid
- +/- non-opioid
- +/- adjuvant
Describe the moderate/severe pain treatment of the analgesic ladder:
- Done if pain persists/increases
- Strong opioid
- +/- non-opioid
- +/- adjuvant
What is pain?
- 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
What is total pain?
Pain that encompasses physical, psychological, social, emotional, spiritual, and cultural - gives us a holistic image of pain!
What are the different types of pain?
- Nociceptive (somatic, visceral)
- Neuropathic
- Complex regional pain syndromes
What are characteristics of pain that we evaluate? (i.e. types of pain)
- Acute
- Chronic
- Incident pain
- Breakthrough pain
- End of dose failure pain
- Intensity
Describe acute pain:
increased heart rate, change in blood pressure, sweaty, increasing RR, facial grimacing (non-verbal), anxiety, distress
Describe chronic pain:
pain that persists after what we would anticipate has sorted – can have lots of psychological and social impacts
Describe incident pain:
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!
Describe breakthrough pain:
unpredictable; having baseline analgesics, breaks through the underlying pain management; ensuring someone has very appropriate pain meds is important
Describe end-of-dose failure pain:
pain coming back 2-3 hours before next dose; so many dose is not large enough; e.g. Patches
Describe intensity of pain:
subjective how the patient experiences they pain – the pain is what the patient says it is – can be related to personal experiences, etc.
What are barriers to pain management?
- 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)
What are the 3B’s?
Bowels, Barfing and Breakthrough
What classes of drugs act as adjuvant analgesics?
- Anti-depressants
- Anti-convulsants
- Corticosteroids
- Topicals
- Antivirals
- Antibiotics
- Bisphosphonates
- Anticholinergics
- Muscle relaxants
- Benzodiazepines
What are some adjuvant methods of treatment? (for pain)
- Primary Therapy
- Anesthetic techniques
- Neurosurgical procedures
- Physiotherapy
- Relaxation techniques
- Acupuncture
- Behavioural therapy
- TENS
Why might we use parenteral drug therapy instead of oral?
- Oral issues (e.g. sores from chemo)
- Absorption issues
- N/V
- Bowel obstruction
- Swallowing difficulties
What are common adverse effects of opioids?
- 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
What is methadone?
- 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
How is a starting dose of opioids determined?
- 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
When doing a conversion, how much does an oral to SC/IV amount to?
1/2 the oral dose
What are some guidelines for long-acting preparations?
- 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
What are the KEY points of symptom management? (the process)
- Determine the cause
- Diagnostics and prognosis
- Education and assessment
- Palliative care principles
- Treatment
- Pharmacological
- Non-pharmacological
What is the difference between nausea and vomiting?
- 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!
What are the typical causes of N/V?
- 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)
How can we educate and assess patients with N/V?
- 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
How do we treat N/V?
- 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)
What is a malignant bowel obstruction? What are the causes?
- Can occur in large or small bowel
- Partial or complete (difficult to differentiate)
- Causes –
Tumour mass
Constipation
Adhesions
Volvulus
Ileus
Peritonitis
Ascites
What are S&S of malignant bowel obstruction?
- 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
How do we treat malignant bowel obstructions?
- 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
What is the incidence of spinal cord compression?
- lung 16%
- breast 12%
- unknown primary 11%
- lymphoma 11%
- multiple myeloma 9%
- 70% distributed to thoracic spine, often at multiple contiguous levels
Describe education and assessment of spinal cord compression:
- 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)
How do we diagnosis of spinal cord compression? What is the prognosis?
- 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
How do we assess SC compression? What education should we provide Ca patients?
- OPQRSTUV assessment tool
- Diagnostics
- Discuss with patients and family the signs and symptoms: Pain; Abdominal distention; Nausea and vomiting; Fatigue; Anorexia;
Constipation/diarrhea
