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NURS 3510 - Supportive and Palliative Care > Week 7 > Flashcards

Week 7 Flashcards

1
Q

define pain

A
  • an unpleasant sensory and emotional experience associated w, or resembling that associated w, actual or potential tissue damage
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2
Q

describe the impact that culture has on pain (3)

A
  • influences in an inidividual is stoic or expresses their pain
  • how the inidividual describes pain (ex. unsettled vs pain)
  • how pain is mnged
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3
Q

how can we provide culturally comfortable care(4)

A
  • 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
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4
Q

describe the onset, cause, and trajectory of acute pain

A
  • sudden onset
  • cause generally known
  • expected to dissipate w healing process and the treatment of the cause
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5
Q

describe the onset of subacute pain

A
  • aka episodic
  • comes on w increasing intensity over time
  • associated w movement, dressing changes, or other activities
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6
Q

how is subacute pain managed

A
  • w pain meds befor the triggers activity begins
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7
Q

describe the onset, duration, and cause of chronic pain

A
  • pain that lasts longer than 3 months
  • can last years
  • may have an unknown cause (not always tho)
  • associated w acute exacerbations
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8
Q

what is breakthrough pain

A
  • intermittent surge in pain

- marked worsening of pain despite analgesics

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9
Q

what is nociceptic pain

A
  • includes visceral and somatic pain
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10
Q

what does somatic pain involve (4)

A
  • muscle
  • bone
  • soft tissue
  • cutaneous tissue
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11
Q

describe somatic pain (3)

A
  • well localized (pt can point to)
  • gnawing, dull, boring, aching, cramping pain
  • worsens w palpation or movement
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12
Q

somatic pain responds to (3)

A
  • NSAIDs
  • opioids
  • steroids
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13
Q

what does visceral pain involve

A

-thoracic & abdominal organs

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14
Q

visceral pain occurs d/t

A
  • infiltration, compression, or stretching of viscera
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15
Q

describe visceral pain (4)

A
  • diffuse (not localized)
  • may be referred
  • constant deep aching, squeezing, or cramping
  • may see sweating, pallor, NV
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16
Q

what does visceral pain respond to (3)

A
  • NSAIDs
  • opioids
  • steroids
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17
Q

what is an example of somatic pain

A
  • bone metastasis
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18
Q

what is an example of visceral pain

A
  • liver metastasis
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19
Q

what is neuropathic pain

A
  • pain d/t damage to the nerves or changes in spinal cord processing
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20
Q

what can cause neuropathic pain (3)

A
  • in cancer pts, may occur d/t compression or infiltration of a nerve by a tumour
  • surgical trauma
  • infiltration
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21
Q

describe neuropathic pain (5)

A
  • burning
  • numbness
  • tingling
  • sharp, shooting
  • electric like
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22
Q

neuropathic pain may also present as…

A
  • constant dull ache w a squeezing sensation that is periodicaly replaced by burning pain
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23
Q

what is an example of neuropathic pain (2)

A
  • peripheral vascular disease

- peripheral neuropathy

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24
Q

describe the mngmt of neuropathic pain

A
  • difficult to manage
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25
Q

how is neuropathic pain managed

A
  • partial response to opioids

- more responsive to adjuvants

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26
Q

what adjuvants can be used for neuropathid pain (5)

A
  • antidepressants
  • anticonvulsants
  • steroids
  • local anasthetics
  • NMDA antagonists such as ketamine
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27
Q

what is baseline pain

A
  • stable, constant state of pain experienced thru majority of day
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28
Q

what is incident pain

A
  • type of breakthrough pain
  • brief pain that is precipitated by an action
    ex. worse w repositioning or wound care
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29
Q

what is the gold standard for pain assessment

A
  • pts own report of pain

“pain is whatever the pt says it is”

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30
Q

what tool is used to assess pain

A

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 )

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31
Q

how can pain be assessed if self-report is not available (6)

A
  • observe behaviors
  • ask the proxy, family members what behaviors indicate pain
  • VS
  • trial analgesics
  • consider painful procedures
  • consider diagnosis
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32
Q

what behaviors may indicate pain (5)

A
  • groaning
  • grimace
  • agitation
  • crying out
  • guarding
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33
Q

what is the downside to using VS to assess pain

A
  • not reliable , especially w chronic
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34
Q

what are some challenges associated w assessing pain in a patient who is advanced palliative care (8)

A
  • 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
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35
Q

what are the basic principle of clinical assessment of pain (11)

A
  • 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
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36
Q

what is the benefit of using non-pharmacological pain mngmt techniques

A
  • may reduce amt of pain meds needed = decreased s/e
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37
Q

what are cons associated w use of non-pharmacological pain techniques (3)

A
  • can be time consuming
  • rely on skills of practioner
  • may not be acceptable or work well w all clients
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38
Q

what are 4 examples of nonpharmacological interventions for pain

A
  • music therapy
  • heat or cold application
  • massage therapy
  • repositioning and movement
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39
Q

what is the benefit of music therapy for pain (2)

A
  • promotes wellbeing

- may decrease pulse & BP

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40
Q

who might heat and cold application be beneficial to (2)

A
  • pts w aching muscles, joints, spasms, or itching

- most effective when pain is well localized

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41
Q

when should cold NOT be used as an intervention for pain (5)

A
  • history of PVD
  • arterial insuff
  • cognitive or communication impairments
  • impaired skin sensation
  • connective tissue disease
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42
Q

when should heat not be used for pain mngmt (7)

A
  • inability to communicate
  • cognitive impairement
  • ischemia
  • bleeding disorders
  • hypersensitivity to touch
  • areas w broken skin
  • pts w transdermal fentanyl patches
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43
Q

when is massage therapy as an intervention for pain contraindicated (2)

A
  • in sites of tissue damage

- bleeding disorders

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44
Q

describe the intervention of massage therapy (4)

A
  • 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
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45
Q

what kind of touch should be used in massage for cancer pts

A
  • light touch
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46
Q

what kind of touch should be used in massage for cancer pts

A
  • light touch
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47
Q

what is the benefit of repositioning and movement for pain (2)

A
  • 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)
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48
Q

what may be required prior to repositioning for pain

A
  • pain meds
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49
Q

pharmacological interventions for pain should be… (3)

A
  • by the mouth
  • by the clock (scheduled dosing preferred)
  • by the ladder
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50
Q

what kind of pain is the first stage of the WHO ladder

A
  • mild pain
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51
Q

what type of meds are used for treatment of the first step of the WHO ladder

A
  • non opioids

- with or without adjuvants

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52
Q

what is 3 examples of meds used for the first step of the WHO ladder

A
  • aspirin
  • NSAIDs
  • Tylenol
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53
Q

what is the second step of the WHO ladder for pain

A
  • mild to moderate pain
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54
Q

what type of meds are used for mngmt of the second step of the WHO ladder (2)

A
  • weak opioid

- without or without adjuvants and non opioids

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55
Q

what is an example of a med for the second step of the who ladder

A
  • codeine
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56
Q

what is the third step of the WHO ladder for pain

A
  • moderate to severe pain
57
Q

what type of meds are used for treatment of the third step of the WHO ladder

A
  • strong opioid

- with or without adjuvant and nonopioids

58
Q

what is 3 examples of meds used for mngmt of the third step of the WHO ladder

A
  • morphine
  • oxydone
  • fentanyl
59
Q

what combo of meds works well to mng bone pain in pts w bone cancer

A
  • NSAIDs in combo w opioids
60
Q

what are commonly used non opioid analgesics for pain

A
  • tylenol (paracetamol)

- NSAIDs (aspirin, ibuprofen)

61
Q

what are potential risks associated w NSAIDs (4)

A
  • GI bleeds
  • NSAID-induced renal failure
  • gastric irritation
  • bleeding
62
Q

when should NSAIDs be avoided (6)

A
  • in pts w gastroduodenopathy
  • bleeding diathesis
  • renal insufficiency
  • HTN
  • severe encephalopathy
  • cardiac failure
63
Q

what should NSAIDs not be used in combo w

A
  • other drugs that have the potential to cause gastric erosion
    ex. corticosteroids
64
Q

in pts without renal or hepatic failure, what is the max daily dose of tylenol

A

3000mg/24 hr

65
Q

in pts w renal or hepatic failure, what is the max daily dose

A
  • 2000mg/24h
66
Q

what are commonly used adjuvant meds (3)

A
  • tricyclic antidepressants
  • anticonvulsants
  • NMDA antagonists
67
Q

what is an example of an anticonvulsant (2)

A
  • gabapentin

- pregabalin

68
Q

what is an example of an NDMA antagonist

A
  • ketamine
69
Q

weak opioid analegesics have a ____ effect; describe what this means

A
  • ceiling effect

- at a certain point, taking higher doses wont increase its effect

70
Q

weak opioid analgesics are used for what type of pain

A
  • mild to mod
71
Q

strong opioid analegesics as used for what type of pain

A
  • mod to severe
72
Q

describe ceiling effect in relation to strong opioids

A
  • does not occur w strong opioids

- can titrate them up without a limit

73
Q

what are commonly used strong opioids (5)

A
  • morphine
  • hydromorphine (dilaudid)
  • fentanyl
  • sufentanil
  • methadone
74
Q

how long does it take to feel the effects of a fentanyl patch

A
  • 12-16 hrs
75
Q

what risks are increased w methadone (2)

A
  • resp depression

- sedation

76
Q

what type of med is methadone

A
  • SSRI
77
Q

what slows the metabolisms of methadone

A
  • omeprazole
78
Q

what is often given to address breakthroguh pain

A
  • immediate release morphine
79
Q

what is the preferred route of opioids

A
  • oral
80
Q

what other routes may be used for opioid analgesics (4)

A
  • subcut
  • IV
  • intranasal
  • sublingual
81
Q

why arent IM and rectal route used often for opioids

A
  • various absorptions
82
Q

what are common side effects of opioids (5)

A
  • constipation
  • NV
  • confusion/delirium
  • sedation
  • xerostomia (dry mouth)
83
Q

how can we prevent constipation d/t opioids

A
  • prescribe w stool softener
    ex. senokot, poly glycol
  • docusate sodium
84
Q

describe the nausea & sedation associated w opioids

A
  • often goes away w time (few days to weeks)

- common initial symptom

85
Q

how can we prevent NV d/t opioids

A
  • combine w anti emetics
86
Q

what are 2 less common s/e of opioids

A
  • urinary retention

- pruritis

87
Q

what may be required for urinary retention d/t opioids

A
  • catheterization
88
Q

what is a rare s/e of opioids

A
  • resp depression
89
Q

how can we prevent resp depression d/t opioids (3)

A
  • low and slow dose
  • avoid giving too high of dose, or increasing the dose too quickly
  • avoid multiple opioids
90
Q

what 3 things can occur w opioids

A
  • tolerance
  • physical dependence
  • addiction
91
Q

what is tolerance

A
  • 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
92
Q

what is physical dependence

A
  • normal
  • state of adaptation that is manifested by a drug-class specific withdrawal symptom
  • simplified: body adapts too drug = withdrawal symptoms
93
Q

when might withdrawal symptoms occur w opioids (4)

A
  • abrupt cessation
  • rapid dose reduction
  • decreased blood lvl of drug
  • admin of an antagonist
94
Q

what is addiction

A
  • includes problematic and compulsive use

- loss of control over use despite personal & social consequences associated w use

95
Q

what is addiction characterized by (4)

A
  • impaired control over drug use
  • compulsive use
  • continued use despite harm
  • craving
96
Q

how can substance abuse be avoided (4)

A
  • 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
97
Q

what is pseduo addiction

A
  • the mistake assumption of addiction in a pt seeking pain relief
98
Q

what are 4 categories to barriers to pain relief

A
  • clinician related
  • healthcare setting related
  • pt related
  • family related barriers
99
Q

what are examples of clinical related barrier to pain relief (7)

A
  • 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
100
Q

what are examples of healthcare setting related barriers to pain relief (4)

A
  • 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
101
Q

what are examples of pt related barrier to pain relief (6)

A
  • 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
102
Q

what are examples of family related barriers to pain relief (4)

A
  • fear about admin of pain meds to pt
  • fears about overdose
  • fears abt addiction
  • concerns about s/e
103
Q

what is opioid induced neurotoxicity (OIN)

A
  • hyperexcitation of the nervous system due to accumulation of active opioid metabolites
104
Q

what meds cause OIN

A
  • certain meds more likely to cause OIN based on the # of metabolites produced
105
Q

is OIN the same as an opioid overdose? why or why not

A
  • no
  • OD = too much opioid
  • OIN = too much metabolites
106
Q

what are risk factors for OIN (6)

A
  • frail/elderly
  • impaired renal function
  • dehydratyion
  • impaired hepatic function
  • rapid increase in dose of opioid
  • using same opiod for a long period of time
107
Q

is there a time frame for OIN

A
  • no
108
Q

what are signs of OIN (6)

A
  • hallucinations
  • delirium
  • myoclonus
  • hyperalgesia
  • allodynia
  • worsening pain despite an increase in medication
109
Q

what is myoclonus? what can it lead to?

A
  • quick, involuntary jerking

- can lead to a seizure

110
Q

what is hyperalgesia

A
  • increased pain to a mildly painful stimulus

- hypersensitivity to pain

111
Q

what is allodynia

A
  • pain from a stimulus that usually doesnt cause pain

ex. clothes on skin, bedsheet

112
Q

what impact does increasing the opioid have on OIN

A
  • increases metabolites = worsened problem
113
Q

what might indicate that you should assess for OIN

A

-anytime a pt is experiencing worsening pain despite an increase in analgesic

114
Q
  • what should you think about during assessment of OIN (3)
A
  • 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
115
Q

what is included in mngmt of OIN (5)

A
  • hydration (IV, flush out the metabolites)
  • decrease opioid dose
  • opioid rotation
  • calm reassurance
  • education
116
Q

what should be included in education on OIN

A
  • what it is

- normally resolves in 24-48 hrs

117
Q

what is physical pain

A
  • an unpleasant sensory & emotional experience associated w, or resembling that associated w, actual or potential tissue damage
118
Q

what psycholgical or emotional pain

A
  • 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
119
Q

what is social pain

A
  • the painful experience of actual or potential psychological distance from other people or social groups
120
Q

what is spiritual pain

A
  • pain associated w circumstances that cause a person to question their existence or meaning of their life
121
Q

what is total pain

A
  • complex of physical, emotional, social, and spiritual elements
  • pain in all 4 domains
  • often linked to sufferring
122
Q

what are characteristics of total pain (2)

A
  • specific to the individual (not everyone experiences it)

- has the ability to change along the disease continuum

123
Q

what is critical to assess for total pain

A
  • integration of non-physical aspects of the illness experience into pain assessment (ask abt & assess other domains, understand how pain impacts all 4 domains)
124
Q

how is pain individualized (3)

A
  • in expressions of physical & emotional pain
  • mngmt of pain
  • culture impacts
125
Q

describe the assessment of total pain (4)

A
  • 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
126
Q

describe self-reporting of total pain

A
  • pt may have difficulty distinguishing various aspects of their pain & may only report somatic experiences
127
Q

what are some signs to delve deeper r/t toal pain (3)

A
  • 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”)
128
Q

what are some examples of open ended questions to assess total pain (3)

A
  • “tell me how youre doing w everything lately”
  • “how ru coping w everything”
  • “tell me about what fears you have”
129
Q

why is it important to effectively address physical pain (2)

A
  • bare minimum we can do

- impacts all other domains

130
Q

what are the potential consequences of only focusing on the physical domain (4)

A
  • not seeing whole person
  • QOL does not improve
  • may not see s/e of meds
  • unrelieved sufferring
131
Q

what is included in mngmt of total pain (5)

A
  • meds are NOT enough
  • interdisciplinary teamwork essential
  • may require consult to specialist palliative care team
  • build rappport
  • use therapeutic communication
132
Q

what is pain crisis

A
  • severe, uncontrolled and distressing pain

- considered a med emergency

133
Q

how is pain crisis treated (3)

A
  • opioids
  • parental steroids
  • ketamine for neuropathic pain
134
Q

what is palliative sedation

A
  • often used when pain cannot be controlled
135
Q

what does palliative sedation usually involve (3)

A
  • benzos
  • barbs
  • anasthetics

must reflect goals of care

136
Q

what are imp considerations for pain mngmt for older adults (2)

A
  • may be reluctant to report pain

- may believe that pain is a normal part of aging

137
Q

what is an analgesic rule for pain mngmt in older adults

A
  • start low and go slow
138
Q

describe pain mngmt for pts w impaired communication (5)

A
  • 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
139
Q

describe pain mngmt for children

A
  • assessment depends on age
  • use WHO ladder for kids
  • discuss w parents, but ultimately the child’s self-report of pain is most accurate

NURS 3510 - Supportive and Palliative Care (11 decks)

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