Symptoms and Pain (Assessment & Management)

Question 1

what is a symptom

Answer 1

“ a physical or mental phenomena, circumstance or change of condition arising from and accompanying a disorder and constituting evidence for it …specifically a subjective indicator perceptible to the patient” (Ingham and Portenoy 2005:167)

Question 2

how do we assess symptoms

Answer 2

As multidimensional experiences symptoms need to be evaluated in terms of their specific characteristics and impact they have on the patient
As symptoms are subjective patient self report must be the primary source of information
There is no single assessment scale that will fit all settings and meets all the criteria for an ideal assessment tool

Question 3

Validated assessment Tools in Palliative Care include…

Answer 3

Edmonton Symptom Assessment System (ESAS)
MD Anderson Symptom Inventory (MDASI)
Condensed Memorial Symptom Assessment Scale (CMSAS)
Cambridge Palliative Assessment Schedule (CAMPAS-R)

Question 4

What symptoms occur most commonly in life limiting illness?

Answer 4

• Fatigue
• Anxiety
• Depression
• Pain
• Breathlessness
• Nausea
• Vomiting
• Decreased mobility
• Impaired senses
• Dizziness
• Dyspnoea
• Weakness
• Drowsiness
• Oedema
• Dry/sore mouth
• Cachexia-anorexia syndrome
• Delirium
• Constipation

Question 5

What causes symptoms?

Answer 5

• Physiological problem/ disease pathology
• Medications e.g. opioids cause constipation
• Allergies
• Dietary and fluid intake (increase or decrease)
• Mood

Question 6

define pain

Answer 6

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage” (International Association for the Study of Pain 1972)

“Pain is what the experiencing person says it is, and exists whenever the experiencing person says it does” (McCaffery and Pasero 1999)

Question 7

what are the 3 types of pain

Answer 7

Neuropathic, Nociceptive, Breakthrough

Question 8

describe neuropathic pain

Answer 8

Peripheral and/or CNS injury, this pain can radiate so where pain is felt may not always be point of injury/disease. Neuropathic pain arises from damaged nervous tissue which is usually only partially opioid sensitive (needs opiate and something else to relieve pain). Can be intermittent or continuous. May be described as burning, shooting, shock like, stinging, stabbing or aching. Examples – diabetic neuropathy, phantom limb pain, neurotoxic chemotherapy, brachial plexopathy. Up to 40% of cancer related pain may have a neuropathic mechanism involved. Neuropathic pain can be difficult to control. A wide variety of treatments may be needed.

Question 9

describe nociceptive pain

Answer 9

• Somatic: Occurs in the skin, bones, muscle, deep a variety of reasons e.g., bone metastases of tissues and joints. Is typically well localised. Can be continuous, sharp, throbbing or achy. Can arise from any origin, osteoarthritis, lymphoedema, muscular spasm.
• Visceral: Usually caused by infiltration, compression, distension or stretching of viscera of the abdomen or thorax. Poorly localised - can be referred. Deep, gnawing, crampy (especially when caused by an obstruction). Can be as a result of primary or secondary tumour growth eg, liver metastases, choleycystitis, appendicitis

Question 10

what is breakthrough pain

Answer 10

“Breakthrough pain is defined as a transient flare of pain of moderate or severe intensity arising on a background of controlled pain.” (SIGN 106 2008)
Can be spontaneous or incident
Spontaneous pain is sudden and unexpected
Incident pain is associated with an action e.g. moving, breathing, micturition and can be anticipated

Question 11

what are the characteristics of breakthrough pain

Answer 11

¥ Rapid onset (peaks within one to three minutes)
¥ Of moderate to severe intensity
¥ Of short duration (median 30mins)
¥ Associated with worse psychological outcomes, poor functional response, worse response to regular opioids
¥ Associated with negative social and economic consequences

Question 12

what is total pain

Answer 12

all of the patient’s physical, psychological, social and spiritual pain

Question 13

describe spiritual pain

Answer 13

Spiritual relates to ideas of meaning of purpose and of the continuity of life. Not always religious. Aetheists may have spiritual needs. Spiritual pain is the result of the experience of illness and facing death which may cause a patient to struggle with existential questions, lose their sense of meaning and purpose in life and feel isolated doing so. Needs MDT, family, friends, and spiritual advisor.

Question 14

why assess pain

Answer 14

¥ Accurate assessment and diagnosis of the type of pain is essential for planning appropriate intervention and successful management of pain
¥ Successful assessment and control of pain ultimately depends on a trusting, positive relationship between patient and nurse

Question 15

what is the ABCDE approach to pain assessment

Answer 15

¥ Ask the patient and assess regularly, and systematically
¥ Believe the patient: the patient is the expert about their own pain
¥ Choose interventions and treatments that suit the patient
¥ Deliver treatment on time
¥ Empower the patient so that they, or the person they choose, has control of the situation

Question 16

what do SIGN guidelines say to ask about when assessing pain

Answer 16

¥	Site, number and description of pains / patient to list and prioritise
¥	 Time of onset / duration
¥	Severity / pattern of referral
¥	Pain score (vas)
¥	Aggravating/relieving factors

Question 17

describe each step of the WHO analgesic pain ladder

Answer 17

patient has pain
step 1: non-opioid =/- adjuvant
pain persists/increases
Step 2: opioid for mild-moderate pain +/- non-opioid +/- adjuvant
pain persists/increases
Step 3: opioid for moderate to severe pain +/- non-opioid +/- adjuvant

Question 18

give examples of drugs in each step

Answer 18

Step 1
• Paracetamol
• Ibuprofen
• Asprin

Step 2
• Co-codamol
• Dihydrocodine
• Tramadol

Step 3
•	Diamorphine
•	Pethodine
•	Fentynl 
•	Oxycodone
•	Morphine

Question 19

describe adjuvants

Answer 19

¥ Primary indication is not pain; unlicensed apart from gabapentin, pregabalin, duloxetine and lidocaine 5% plasters
¥ Includes NSAIDs, antidepressants, anticonvulsants, NMDA-receptor channel blockers, bisphosphonates, corticosteroids, antiarrhythmics
¥ Can use single agent or combinations

Question 20

describe Routes of Drug Delivery

Answer 20

“Oral route is the preferred route of delivery unless contraindicated” (World Health Organization)
Buccal or Sublingual – increasing number of preparations available suitable for this route. (buccastem, effentora, lorazepam, midazolam)
Transdermal – some strong opioids available but only useful in stable pain states. Limited number of antiemetic or other preparations
Parenteral – Intramuscular, Intravenous or Subcutaneous route
Rectal – may be unacceptable to many patients, invasive, uncomfortable and personal procedure

Question 21

describe subcut route

Answer 21

¥ Often the preferred parenteral route in palliative care
¥ Seen as being less painful than IM injections and avoids the need for IV cannulation
¥ S/C butterfly can be sited for as required (prn) or continuous delivery of medication

Question 22

describe syringe pumps

Answer 22

¥ Administration of drugs by continuous subcutaneous infusion via a portable syringe pump is a valuable option in symptom control and end of life care
¥ Maintenance of steady plasma concentrations of drugs and round the clock comfort minimising peaks and troughs of symptoms
¥ Increased patient comfort by avoiding need for repeated injections
¥ Maintenance of patient mobility because device is lightweight and portable can enhance quality of life
¥ Experience of using many of the commonly used drugs for symptom management via this route