total pain Flashcards
If patient is Fully active, able to carry on all predisease performance without restriction, what is his/her ECOG score?
0
If patient is Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work, what is his/her ECOG score?
1
If patient is Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking, what is his/her ECOG score?
2
If patient is Capable of only limited self-care; confined to bed or chair more than 50% of waking hours, what is his/her ECOG score?
3
If patient is completely disabled, cannot carry out any self-care, totally confined to bed/chair, what is his/her ECOG score?
4
If patient is dead, what is his/her ECOG score?
5
What is palliative care?
An approach which focuses on improving QOL of patients suffering from life-limiting illness
By providing relief from physical, emotional and spiritual suffering
Principles of palliative care
Providing relief from distressing symptoms through early identification, assessment and treatment
Affirming life and regard dying as a normal process
Intending to neither hasten nor postpone death
Integrating psychosocial, emotional and spiritual aspects into holistic care of patient
Supporting family and caregivers during patient’s illness and after patient’s death
Which medication route is most preferred?
Subcutaneous route also preferred as less invasive compared to IV or IM routes
Drug dosages have to be adjusted in a palliative patient due to:
impacted drug metabolism and elimination due to deterioration of patient’s liver and renal function
What is Off-label prescription?
when prescribed a drug that is approved to treat a condition different than your condition
When is the use of an off-label prescription needed?
positive effects on symptom control
Example of off-label prescription
Hyoscine Butylbromide (Buscopan)
Dimensions of pain
Physical, psychological, social, spiritual
Pain assessment SOCRATES SMM
Site
Onset
Characteristics
Radiation
Associated factors (any other symptoms)
Time
Exacerbating and relieving factors
Severity
Sleep/Function
Mood (Does the pain affect your mood?)
Meaning (What does the pain mean to you?)
Use numeric scale / faces rating scale
Causes of pain (Physical)
Nociceptive
Neuropathic
What is nociceptive pain?
Pain from tissue injury (lacerating, stinging, heavy, suffocating)
Somatic: tumour invasion of bone, joint, muscle or connective tissue
Visceral- e.g. bowel obstruction, liver infiltration or compression of vital organs)
What is neuropathic pain?
Pain from nerve injury (usually followed after nociceptive); (numbness, pins and needles, burning, aching, throbbing, pulling) e.g. if patient has left iliac artery stenosis, tumours pressing on spine, lots of nerves
Peripheral: tumour compression of peripheral nerves
Central: multiple sclerosis, stroke
Social causes of pain
Loss of family role
Restricted social activities
Psychological causes of pain
Anxiety
Equating pain relief (morphine) with dying
Sense of inevitability of future severe pain
Reminder of ill role
Anger, despair and hopelessness
Spiritual causes of pain
Loss of sense of purpose and identity
Feeling of being punished
Pharmacotherapeutic Intervention basic principles (by mouth)
- the least invasive and safest method.
Pharmacotherapeutic Intervention basic principles (by IV)
- reserved for those not able to take orally or unable to absorb drugs via gastrointestinal tract
Pharmacotherapeutic Intervention basic principles (by clock)
- most oral analgesics act only for 4 hours or less,
- should be prescribed 4 hourly to achieve therapeutic effects.
Pharmacotherapeutic Intervention basic principles (by WHO’s pain ladder)
dose must be titrated until:
- the maximum recommended dose is reached
- the pain is relieved
- or the patients experience serious side
WHO’s pain ladder (STEP 1)
Non-opioids e.g. paracet, NSAIDs, COX-2 inhibitors, +/- adjuvant analgesic
WHO’s pain ladder (STEP 2)
Weak opioids e.g. tramadol, codeine +/- adjuvant analgesic
WHO’s pain ladder (STEP 3)
Immediate release:
Morphine solution
Oxycodone Methadone
Controlled release:
Morphine Sulphate Tab
Oxycontin
Transdermal Fentanyl
Examples of adjuvant analgesics
Tricyclic antidepressants
Anticonvulsants
Topical
Steroid
(Adjuvant analgesics) Example of anticonvulsants
Gabapentin
Pregabalin
(Adjuvant analgesics) Example of topical
Lignocaine
(Adjuvant analgesics) Example of steroid
Dexamethasone
Morphine Forms of administration
Liquid
- Mist morphine solution (1mg/ml)
- Oramorph morphine syrup (2mg/ml)
- RA-morphine solution (1mg/ml)
Tablet (cannot be cut/crushed)
- Morphine sulphate (sustained-release) tablet, aka MST (10 or 30mg tablets)
Injectable
- Per ampoule morphine (10mg/ml) given via SC or IV
Side effects of Morphine
Constipation (To prescribe lactulose)
N&V (Give antiemetics)
Fatigue, drowsy
Urine retention
Addiction
Vertigo, confusion, headaches
Itchy skin/rash
Poor appetite
Muscle stiffness
Low energy (sign of low BP)
Allergic rxn
Unintended side effects of morphine
Morphine toxicity (should be monitored closely - this should NOT happen)
Mist morphine onset of action, maximal effect, duration of action
30 min, 60 min, 4-6 hrs
MST onset of action, duration of action
1-2hrs, 8-12hrs
Morphine (SC) onset of action, maximal effect, duration of action
15 min, 10-20 min, 4-6 hr
Morphine (IV) onset of action, maximal effect, duration of action
5 min, 10-20 min, 4-6 hr
Common side effects of morphine
constipation, N&V, sedation and confusion
Morphine toxicity signs
Myoclonic jerks (rapid muscular contraction and relaxation)
Pinpoint/constricted pupils (miosis)
Respiratory depression
Fentanyl is a safe, strong opioid in patients with ____ (medical condition)
Moderate to severe renal failure
Fentanyl is opioid of choice in patients with moderate to severe liver failure or cirrhosis
When using fentanyl, caution is required when: (hint: renal)
!! Caution required when estimated creatinine clearance < 30 ml/min whether or not patient is on dialysis
Which is more potent - fentanyl or morphine?
Fentanyl
Indications of fentanyl
When oral intake not possible (N&V)
Difficult compliance to oral morphine
Patient develops side effect or toxicity of morphine
Severe constipation with morphine
Renal/liver impairment
Patient preference (averse to morphine)
Transdermal Fentanyl Patch dosages available
12mcg/hr
25mcg/hr
50mcg/hr
The nurse is preparing to administer transdermal fentanyl patch to Mr. Lee and wants to administer only half of the patch. How should she split the patch?
Tear away half of the plastic backing if only 6mcg fentanyl ordered, do NOT cut
The nurse is preparing to administer transdermal fentanyl patch to Mr. Lee. Why shouldn’t she cut the patch?
Risk of fatal opioid toxicity to patient and to nurse, dosage of fentanyl is also regulated and needs to be reported to MOH
Maximal effects duration of transdermal fentanyl
8-12 hrs
Residual effect of transdermal fentanyl after removed
8-12 hrs
Injectable fentanyl dosages
100mcg/2ml
500mcg/10ml
Side effect of fentanyl
Similar to morphine, but less constipation
Usual transdermal fentanyl dose given initially
6cmg/hr every 72 hrs (use half 12 mcg/hr patch)
Usual Subcutaneous fentanyl dose given initially
10 mcg/hr (0.2ml/hr)
Drug conversion from Morphine to Transdermal Fentanyl Patch (IMPORTANTTTT)
Easiest way is to use conversion factor 2.4
E.g. Morphine syrup to fentanyl patch
Morphine syrup 5mg 4 hrly = Total morphine dose 5*6 = 30mg
Fentanyl requirement = 30/2.4 = 12.5mcg/hr
E.g. Fentanyl to morphine syrup
* Patient on Fentanyl 25mcg/hr patch who need to convert to Morphine syrup:
* Fentanyl 25mcg x 2.4 = 60mg Morphine (total daily dose [24hrs])
* 60mg/24hrs=2.5mg (per hour) x 4
-> Morphine syrup 10mg q4H
Guide to the use of opioids (3 main points)
- educate pt/caregiver in use of opioid
- advise about common side effects
- empower caregiver to manage side effects
Non-pharmacotherapeutic intervention by healthcare team
Radiotherapy
Palliative surgery
PT/OT
Transcutaneous electrical nerve stimulators (TENS)
Non-pharmacotherapeutic intervention not necessarily by healthcare team
Massage therapy
Acupuncture
Music/art therapy
Namaste?
What are the components of namaste care?
Honouring spirit within
Presence of others
Life Story
Sensory stimulation
Enable people to be themselves
Meaningful activity
Food treats & hydration
Family meetings
Comfort & pain management
