Week 7 Flashcards
define pain
- an unpleasant sensory and emotional experience associated w, or resembling that associated w, actual or potential tissue damage
describe the impact that culture has on pain (3)
- influences in an inidividual is stoic or expresses their pain
- how the inidividual describes pain (ex. unsettled vs pain)
- how pain is mnged
how can we provide culturally comfortable care(4)
- recognize the client as an unique individiual
- explore the pt’s experience of pain
- promote shared decision making
- dont assume how the pt will want to manage their pain
describe the onset, cause, and trajectory of acute pain
- sudden onset
- cause generally known
- expected to dissipate w healing process and the treatment of the cause
describe the onset of subacute pain
- aka episodic
- comes on w increasing intensity over time
- associated w movement, dressing changes, or other activities
how is subacute pain managed
- w pain meds befor the triggers activity begins
describe the onset, duration, and cause of chronic pain
- pain that lasts longer than 3 months
- can last years
- may have an unknown cause (not always tho)
- associated w acute exacerbations
what is breakthrough pain
- intermittent surge in pain
- marked worsening of pain despite analgesics
what is nociceptic pain
- includes visceral and somatic pain
what does somatic pain involve (4)
- muscle
- bone
- soft tissue
- cutaneous tissue
describe somatic pain (3)
- well localized (pt can point to)
- gnawing, dull, boring, aching, cramping pain
- worsens w palpation or movement
somatic pain responds to (3)
- NSAIDs
- opioids
- steroids
what does visceral pain involve
-thoracic & abdominal organs
visceral pain occurs d/t
- infiltration, compression, or stretching of viscera
describe visceral pain (4)
- diffuse (not localized)
- may be referred
- constant deep aching, squeezing, or cramping
- may see sweating, pallor, NV
what does visceral pain respond to (3)
- NSAIDs
- opioids
- steroids
what is an example of somatic pain
- bone metastasis
what is an example of visceral pain
- liver metastasis
what is neuropathic pain
- pain d/t damage to the nerves or changes in spinal cord processing
what can cause neuropathic pain (3)
- in cancer pts, may occur d/t compression or infiltration of a nerve by a tumour
- surgical trauma
- infiltration
describe neuropathic pain (5)
- burning
- numbness
- tingling
- sharp, shooting
- electric like
neuropathic pain may also present as…
- constant dull ache w a squeezing sensation that is periodicaly replaced by burning pain
what is an example of neuropathic pain (2)
- peripheral vascular disease
- peripheral neuropathy
describe the mngmt of neuropathic pain
- difficult to manage
how is neuropathic pain managed
- partial response to opioids
- more responsive to adjuvants
what adjuvants can be used for neuropathid pain (5)
- antidepressants
- anticonvulsants
- steroids
- local anasthetics
- NMDA antagonists such as ketamine
what is baseline pain
- stable, constant state of pain experienced thru majority of day
what is incident pain
- type of breakthrough pain
- brief pain that is precipitated by an action
ex. worse w repositioning or wound care
what is the gold standard for pain assessment
- pts own report of pain
“pain is whatever the pt says it is”
what tool is used to assess pain
Onset
Palliating and provoking factors
Radiating pain
Site & severity
Timing and tolerance (what lvl of pain is acceptable to you)
U (what impact does the pain have on you as a whole person & what do you think is causing the pain )
how can pain be assessed if self-report is not available (6)
- observe behaviors
- ask the proxy, family members what behaviors indicate pain
- VS
- trial analgesics
- consider painful procedures
- consider diagnosis
what behaviors may indicate pain (5)
- groaning
- grimace
- agitation
- crying out
- guarding
what is the downside to using VS to assess pain
- not reliable , especially w chronic
what are some challenges associated w assessing pain in a patient who is advanced palliative care (8)
- multiple concurrent medical provlems
- multile S&S clusters
- hepatic & renal failure = susecptible to drug accumulation & adverse s/e
- prevalence of delirium when close to death
- requires more time than pts who are less ill
- pts become easily fatigue & may be SOB
- may be in too much pain or bothered by S&S to answer questions
- possible tendency of family members to answer pts behalf
what are the basic principle of clinical assessment of pain (11)
- accept the pt’s complaint of pain
- take a careful history of the pain complaint
- observe for nonverbal communication of pain
- recognize that the pt near end of life may have multiple symptoms complicating pain assessment
- assess the characteristics of pain (OPQRSTU)
- assess the psychological state of the pt
- based on goals of care, facilitate approp diagnostics
- assess & reassess effectiveness of pain mngmt
- assess & reassess for s/e
- clarify the pattern of the pt’s pain (acute,chronic, etc.)
- give a time frame for when you would expect to see evidence of pt comfort
what is the benefit of using non-pharmacological pain mngmt techniques
- may reduce amt of pain meds needed = decreased s/e
what are cons associated w use of non-pharmacological pain techniques (3)
- can be time consuming
- rely on skills of practioner
- may not be acceptable or work well w all clients
what are 4 examples of nonpharmacological interventions for pain
- music therapy
- heat or cold application
- massage therapy
- repositioning and movement
what is the benefit of music therapy for pain (2)
- promotes wellbeing
- may decrease pulse & BP
who might heat and cold application be beneficial to (2)
- pts w aching muscles, joints, spasms, or itching
- most effective when pain is well localized
when should cold NOT be used as an intervention for pain (5)
- history of PVD
- arterial insuff
- cognitive or communication impairments
- impaired skin sensation
- connective tissue disease
when should heat not be used for pain mngmt (7)
- inability to communicate
- cognitive impairement
- ischemia
- bleeding disorders
- hypersensitivity to touch
- areas w broken skin
- pts w transdermal fentanyl patches
when is massage therapy as an intervention for pain contraindicated (2)
- in sites of tissue damage
- bleeding disorders
describe the intervention of massage therapy (4)
- massaging hands & feet seen as therapeutic and comforting
- pts should be involved in choosing massage sites and duration
- can be done by nurse
- one hand should be on pt at all times
what kind of touch should be used in massage for cancer pts
- light touch
what kind of touch should be used in massage for cancer pts
- light touch
what is the benefit of repositioning and movement for pain (2)
- being in a static position for long periods of time can exacerbate pain
- ROM exercises are imp for palliative pts who are not so close to death (promote physical comfort)
what may be required prior to repositioning for pain
- pain meds
pharmacological interventions for pain should be… (3)
- by the mouth
- by the clock (scheduled dosing preferred)
- by the ladder
what kind of pain is the first stage of the WHO ladder
- mild pain
what type of meds are used for treatment of the first step of the WHO ladder
- non opioids
- with or without adjuvants
what is 3 examples of meds used for the first step of the WHO ladder
- aspirin
- NSAIDs
- Tylenol
what is the second step of the WHO ladder for pain
- mild to moderate pain
what type of meds are used for mngmt of the second step of the WHO ladder (2)
- weak opioid
- without or without adjuvants and non opioids
what is an example of a med for the second step of the who ladder
- codeine
what is the third step of the WHO ladder for pain
- moderate to severe pain
what type of meds are used for treatment of the third step of the WHO ladder
- strong opioid
- with or without adjuvant and nonopioids
what is 3 examples of meds used for mngmt of the third step of the WHO ladder
- morphine
- oxydone
- fentanyl
what combo of meds works well to mng bone pain in pts w bone cancer
- NSAIDs in combo w opioids
what are commonly used non opioid analgesics for pain
- tylenol (paracetamol)
- NSAIDs (aspirin, ibuprofen)
what are potential risks associated w NSAIDs (4)
- GI bleeds
- NSAID-induced renal failure
- gastric irritation
- bleeding
when should NSAIDs be avoided (6)
- in pts w gastroduodenopathy
- bleeding diathesis
- renal insufficiency
- HTN
- severe encephalopathy
- cardiac failure
what should NSAIDs not be used in combo w
- other drugs that have the potential to cause gastric erosion
ex. corticosteroids
in pts without renal or hepatic failure, what is the max daily dose of tylenol
3000mg/24 hr
in pts w renal or hepatic failure, what is the max daily dose
- 2000mg/24h
what are commonly used adjuvant meds (3)
- tricyclic antidepressants
- anticonvulsants
- NMDA antagonists
what is an example of an anticonvulsant (2)
- gabapentin
- pregabalin
what is an example of an NDMA antagonist
- ketamine
weak opioid analegesics have a ____ effect; describe what this means
- ceiling effect
- at a certain point, taking higher doses wont increase its effect
weak opioid analgesics are used for what type of pain
- mild to mod
strong opioid analegesics as used for what type of pain
- mod to severe
describe ceiling effect in relation to strong opioids
- does not occur w strong opioids
- can titrate them up without a limit
what are commonly used strong opioids (5)
- morphine
- hydromorphine (dilaudid)
- fentanyl
- sufentanil
- methadone
how long does it take to feel the effects of a fentanyl patch
- 12-16 hrs
what risks are increased w methadone (2)
- resp depression
- sedation
what type of med is methadone
- SSRI
what slows the metabolisms of methadone
- omeprazole
what is often given to address breakthroguh pain
- immediate release morphine
what is the preferred route of opioids
- oral
what other routes may be used for opioid analgesics (4)
- subcut
- IV
- intranasal
- sublingual
why arent IM and rectal route used often for opioids
- various absorptions
what are common side effects of opioids (5)
- constipation
- NV
- confusion/delirium
- sedation
- xerostomia (dry mouth)
how can we prevent constipation d/t opioids
- prescribe w stool softener
ex. senokot, poly glycol - docusate sodium
describe the nausea & sedation associated w opioids
- often goes away w time (few days to weeks)
- common initial symptom
how can we prevent NV d/t opioids
- combine w anti emetics
what are 2 less common s/e of opioids
- urinary retention
- pruritis
what may be required for urinary retention d/t opioids
- catheterization
what is a rare s/e of opioids
- resp depression
how can we prevent resp depression d/t opioids (3)
- low and slow dose
- avoid giving too high of dose, or increasing the dose too quickly
- avoid multiple opioids
what 3 things can occur w opioids
- tolerance
- physical dependence
- addiction
what is tolerance
- normal
- state of adaptation in which exposure to a drug induces changes that result in diminution of 1 or more of the drug effects over time
- simplified: require increasing doses to achieve same effects
what is physical dependence
- normal
- state of adaptation that is manifested by a drug-class specific withdrawal symptom
- simplified: body adapts too drug = withdrawal symptoms
when might withdrawal symptoms occur w opioids (4)
- abrupt cessation
- rapid dose reduction
- decreased blood lvl of drug
- admin of an antagonist
what is addiction
- includes problematic and compulsive use
- loss of control over use despite personal & social consequences associated w use
what is addiction characterized by (4)
- impaired control over drug use
- compulsive use
- continued use despite harm
- craving
how can substance abuse be avoided (4)
- opioids should be prescribe around the clock (long acting), aviod PRNs
- use non opioid adjuvants as much as possible
- may need to limit amt of meds prescribed to a week’s count
- treat pain aggressively as this reduces substance abuse behaviors
what is pseduo addiction
- the mistake assumption of addiction in a pt seeking pain relief
what are 4 categories to barriers to pain relief
- clinician related
- healthcare setting related
- pt related
- family related barriers
what are examples of clinical related barrier to pain relief (7)
- inadequate knowledge of pain mngmt
- incomplete assessment of pain
- concern about regulation of controlled substances
- fear of causing pt addiction
- concern about s/e
- concern that tolerance may be built
- inabiliity to understand the impact of pain on a pt
what are examples of healthcare setting related barriers to pain relief (4)
- lack of pain visibility
- lack of a common consistent language to describe pain
- lack of committment to prioritize pain mngmt
- failure to use validated pain measurement tools
what are examples of pt related barrier to pain relief (6)
- reluctance to report pain
- reluctance to follow treatment recommendation
- fears of tolerance & addiction
- concern about s/e
- fears regarding disease progression
- belief that pain is inevitable and must be accepted
what are examples of family related barriers to pain relief (4)
- fear about admin of pain meds to pt
- fears about overdose
- fears abt addiction
- concerns about s/e
what is opioid induced neurotoxicity (OIN)
- hyperexcitation of the nervous system due to accumulation of active opioid metabolites
what meds cause OIN
- certain meds more likely to cause OIN based on the # of metabolites produced
is OIN the same as an opioid overdose? why or why not
- no
- OD = too much opioid
- OIN = too much metabolites
what are risk factors for OIN (6)
- frail/elderly
- impaired renal function
- dehydratyion
- impaired hepatic function
- rapid increase in dose of opioid
- using same opiod for a long period of time
is there a time frame for OIN
- no
what are signs of OIN (6)
- hallucinations
- delirium
- myoclonus
- hyperalgesia
- allodynia
- worsening pain despite an increase in medication
what is myoclonus? what can it lead to?
- quick, involuntary jerking
- can lead to a seizure
what is hyperalgesia
- increased pain to a mildly painful stimulus
- hypersensitivity to pain
what is allodynia
- pain from a stimulus that usually doesnt cause pain
ex. clothes on skin, bedsheet
what impact does increasing the opioid have on OIN
- increases metabolites = worsened problem
what might indicate that you should assess for OIN
-anytime a pt is experiencing worsening pain despite an increase in analgesic
- what should you think about during assessment of OIN (3)
- past medical history (any diseases that are risk factors?)
- physical exam (look for symptoms)
- consider if there are any other causes of delirium or seizures
what is included in mngmt of OIN (5)
- hydration (IV, flush out the metabolites)
- decrease opioid dose
- opioid rotation
- calm reassurance
- education
what should be included in education on OIN
- what it is
- normally resolves in 24-48 hrs
what is physical pain
- an unpleasant sensory & emotional experience associated w, or resembling that associated w, actual or potential tissue damage
what psycholgical or emotional pain
- a wide range of subjective experiences characterized as a perception of negative changes in the self and its function that is accompanied by strong negative feelings
ex. fear, uncertainty, guilt, anguish
what is social pain
- the painful experience of actual or potential psychological distance from other people or social groups
what is spiritual pain
- pain associated w circumstances that cause a person to question their existence or meaning of their life
what is total pain
- complex of physical, emotional, social, and spiritual elements
- pain in all 4 domains
- often linked to sufferring
what are characteristics of total pain (2)
- specific to the individual (not everyone experiences it)
- has the ability to change along the disease continuum
what is critical to assess for total pain
- integration of non-physical aspects of the illness experience into pain assessment (ask abt & assess other domains, understand how pain impacts all 4 domains)
how is pain individualized (3)
- in expressions of physical & emotional pain
- mngmt of pain
- culture impacts
describe the assessment of total pain (4)
- no standardized tool
- ask open-ended questions about emotional wellbeing, support systems, fears, concerns, coping
- actively listen to their concerns
- explore more deeply from the cues they give
describe self-reporting of total pain
- pt may have difficulty distinguishing various aspects of their pain & may only report somatic experiences
what are some signs to delve deeper r/t toal pain (3)
- physical symptoms despite an increase in meds
- behavioral cues (ex. crying, angry, withdrawn, flat, not participating in activities they typically enjoy)
- difficulty describing their pain (“all of me is wrong, i just hurt all over”)
what are some examples of open ended questions to assess total pain (3)
- “tell me how youre doing w everything lately”
- “how ru coping w everything”
- “tell me about what fears you have”
why is it important to effectively address physical pain (2)
- bare minimum we can do
- impacts all other domains
what are the potential consequences of only focusing on the physical domain (4)
- not seeing whole person
- QOL does not improve
- may not see s/e of meds
- unrelieved sufferring
what is included in mngmt of total pain (5)
- meds are NOT enough
- interdisciplinary teamwork essential
- may require consult to specialist palliative care team
- build rappport
- use therapeutic communication
what is pain crisis
- severe, uncontrolled and distressing pain
- considered a med emergency
how is pain crisis treated (3)
- opioids
- parental steroids
- ketamine for neuropathic pain
what is palliative sedation
- often used when pain cannot be controlled
what does palliative sedation usually involve (3)
- benzos
- barbs
- anasthetics
must reflect goals of care
what are imp considerations for pain mngmt for older adults (2)
- may be reluctant to report pain
- may believe that pain is a normal part of aging
what is an analgesic rule for pain mngmt in older adults
- start low and go slow
describe pain mngmt for pts w impaired communication (5)
- identify communication deficit & try to find translators
- collab w fam (but dont use them as interpreters bc they may filter info)
- document possible pain behaviors
- provide frequent pain assessments
- analgesic trial
describe pain mngmt for children
- assessment depends on age
- use WHO ladder for kids
- discuss w parents, but ultimately the child’s self-report of pain is most accurate
