Tutorial 2 Flashcards
definition of sympathy
A pity-based response to a distressing situation that is characterized by a lack of relational understanding and the
self-preservation of the observer. There is no conscious thought and reflection.
definition of empathy
An affective response that acknowledges and attempts to understand an individual’s suffering through emotional resonance
Empathy enters into another’s suffering … it’s just the ability
to be there
definition of compassion
A virtuous response that seeks to address the suffering and needs of a person through relational understanding and action
acute pain
*definable acute injury or illness
*transient and forseeable
*accompanied by clinical signs of sympathetic over activity
*treatment is directed to the acute illness or injury
* positive pain- it is protective
* PRN medication
chronic pain
*chronic pathological process
*continues for years and may become worse
* no sympathetic over activity
*psychological changes
*treatment of underlying conditions where possible but regular analgesia required
*the pain serves no meaning
Physiological pain categories
Nociceptive
Neuropathic
Mixed pain
Nociceptive pain examples
Visceral: e.g pancreatitis, PU, MI
Somatic e.g arthritis, bone metastases, cellulitis
neuropathic pain example
herpes zoster
neuropathy
mixed pain example
cancer pain
classification of chronic pain
nociceptive pain
neuropathic pain (predominant)
sensory hypersensitivity
nociceptive pain
pain related to damage of somatic or visceral tissue due to trauma or inflammation
neuropathic pain
pain related to damage of peripheral or central nerves
sensory hypersensitivity
pain without identifiable nerve or tissue damage thought to result from persistent neuronal dysregulation-
nociceptive pain
produce by nonciceptors (pain receptors) in the tissue
nerve pathways are normal and intact
well localized
responds well to opioids
visceral pain
activation of nociceptors
infiltration, compression, distension of thoracic and abdominal viscera
poorly localised
often referred
neuropathic pain
damage to the central or peripheral nervous system
central vs “deafferentation”
injured nerves react abnormally to stimuli or discharge spontaneously
burning, tingling, shock like, needles and pins
less sensitive to opioids and may require adjuvant
physical causes of pain
primary disease (e.g. tumor inflitration)
treatment (e.g. surgery, radiation)
general debility (e.g. pressure sores, constipation)
concurrent disorders (e.g. arthritis)
pain assessment
*twycross “pain is what the patient says hurts”
*history: precipitating/ relieving factors (including medications tried)
*quality of pain- description
*radiation of pain
*site of pain
*severity of pin
*time course
cultural aspects of pain assessment
barriers of communication
description of pain
access to drugs
under reporting of pain
gender inequalities
management of pain
diagnosis of cause of pain
explain to patient
emotional/ psychological support
treatment options
individualize treatment
assess and reassess
WHO analgesic ladder
step 1: non- opioid +/- adjuvant
step 2: weak opioid +/- step 1
step 3: strong opioid +/- step 1
principles of analgesic use
by the mouth
by the clock
by the ladder
principles
-Weak opioids should not be combined with strong opioids.
-Non-opioids may be combined with strong or weak opioids
-Adjuvant analgesia can be added to any step of the WHO step ladder
analgesic step 1
paracetamol
-aspirin/ NSAIDS
analgesic step 2
codeine/ tramadol
- paracetamol- codeine
-paracetamol- tramadol
analgesic step 3
morphine
-mist morphine
-morphine tabs
-morphine sulphate inj
fentanyl patches
strong opioids
no important differences between morphine, oxycodone, hydromorphone, orally
side effects of morphine
temporary confusion, drowsiness
nausea and/or vomiting
constipation
toxicity
*Opioid toxicity should not occur with careful titration of morphine dose
*The most frequently encountered symptom of toxicity is myoclonus usually at end of life when renal failure precipitates accumulation of M-6-G (metabolite) which causes myoclonus. Reduction of morphine dose is required.
*Severe somnolence/drowsiness
*Hypotension
*Respiratory depression
problems prescribing opioids
-Opioid phobia
-Lack of counselling
-Drugs to manage side effects
-Incorrect labelling
-Drug abuse in our society
contra-indications
- allergy
- renal failure
- liver failure
fatigue
Subjective feeling of tiredness, weakness or lack of energy.
In 80% of cancer patients and in 99% of patient post chemo or radiotherapy
Primary fatigue
The disease itself (cytokine release from the tumour)
Secondary fatigue
anaemia, cachexia, fever, infections or metabolic, disorders as well as sedative drugs for symptom control.
The jug technique
A communication skills technique also effective when addressing emotionally charged conversations
Approach to psychosocial management: CEASER
C- communication skills and attitudes
E- ethical principles
A- advocacy
S- Support
E- empower
R- reassure
Communication skills and attitudes
REC : Respect, Empathy, Compassion
Ethical principles
Autonomy
Beneficence
Non- maleficence
Justice
Advocacy
to be guided by ethical principles (what is to benefit patient and/or Justice)
Support
– offer ongoing support to the family through Information and Networking – refer to HBC/Hospice/NGO’s/CANSA/counselling/Social worker/DG grants etc.
Empower
How can the patient and/or family caregivers/support system be empowered – education/family meeting/physio/OT/dietician/speech
Reassure
to alleviate patient’s concern and worry; (inform patient about something positive to dispel anxiety or fear)
– review/follow up/refer
Family meeting
Who, what, where – ask patient and family
Introductions
How much do the family know?
Information in language they understand, small chunks, written instructions
– ask – tell – ask – tell / make use of silence
Who will be the caregiver?
What else do they need?
S/W/Physio/OT/dietician/HBC etc
Exchange contact details for f/u/review
Approach to spiritual care
Meaning
Legacy
Guilt and blame
Hope
Death and dying
FICA
F - Faith/Belief/Religion?
I - Importance?
C - Community supportive?
A - Assist?
Problem List- Physical
-? Main Diagnosis
-Ongoing pain control
-Anorexia
-Dysphagia -? Side effects/? Reflux
-Pressure care/bedsores
-Addressing concerns of dehydration/nutrition at end of life
Problem list- Psychosocial
Identify preferred place of care
Address family concerns and needs
Problem list- Spiritual
Meaning – what is it that patient attaches to the illness?
Hope – currently, what is the patient hoping for?
Death and Dying – What are the patient’s concerns/views regarding their passing?
