Week 9- pain/nausea/vomiting Flashcards
Total Pain
physical
spiritual
emotional
social
advanced disease common symptoms
pain
loss of appetite
N/V
fatigue
dyspnea
constipation
delirium
lots can overlap
physical symptoms are managed by
- addressing the underlying disease
- using meds
- using non-pharm treatment
- addressing psychosocial needs
What happens when we can’t relieve suffering
hopelessness, depression, decrease in QOL
some preventable symptoms
constipation
nausea
principles of using medications
- route
- what’s more effective than 1
- consider
- provide meds
- titrate
- continue meds for
- provide
- assess
-oral when possible (less SE, easier to administer, take home)
- combo o meds
- reality of the care setting and needs of family
- regularly and around the clock
- meds to the dose that meets the persons goal
- as long as the symptom continue
- breakthrough
- regularly a when persons condition or behavior changes
it important to always
follow up with patients
pain is an
unpleasant sensory & emotional experience associated with actual or potential tissue damage
pain is highly prevalent at
the EOL regardless of primary diagnosis
pain can be ____ or _________ in up to ____% of patients using ___________ & _______________ BUT
well or completely controlled in up to 90% of patients using standard therapies & following guidelines BUT pain remains under-recognized and undertreated in many patient groups
people at risk for having underrecognized pain
- Woman
- problematic substance users, hx of addiction
- language barriers
- cognitive or developmental disabilities
- people of colour
- rural
- infants/children
- LGBTQIA +
- elderly
- people who deny pai n
components of physical pain
(3)
- usually needs treatment (drugs)
- causes variable degrees of distress
- interferes with other aspects of life
components of spiritual pain (3)
- guilt/remorse
- fears after death
- sense of connectedness
social parts of total pain
- distress over family members
- loss of role
- participation issues
emotional components of total pain
- adjustment disorders, anxiety, depression
- frustration and hopelessness
one form of a pain assessment
OPQRSTUV
O: onset-When? How long? How often?
P: provoking-What makes it start? What makes it better? What makes it worse?
Q: quality-What does it feel like? Can you describe it?
R: region/radiation-Where is it? Does it spread?
S: severity-How severe? How would you rate it? Right now, at worst, on average?
T: treatment-What medications are you currently taking (western, alternative)? How are you using them? What have you tried in the past?
U: understanding- What do you think is causing this symptom? How is this impacting you?
V: value/belief of what pain means-What goals should we keep in mind? What is an acceptable level?
Edmonton symptom assessment system
rates symptoms on a scale from 0-10
pain
tiredness
drowsiness
nausea
appetite
SOB
depression
anxiety
wellbeing
other
Visual Analogue Scale
no pain (10) to worst pain ever (0)
has face on either end
younger children
English not first language
Numerical rating scale (NRS)
Faces rating scale (FRS)
0-10 painscale
different faces
Behavioral rating scale
CVMFR
for patients unable to provide a self-report of pain: scored 0-10 clinical observation
face
restlessness
muscle tone
vocalization
consolability
PAINAD scale
BBCFN
pain assessment for advanced dementia
- breathing
- negative vocalization
- facial expression
- body language
- consolability
before ordering diagnostics consider
goals of care
pain emergencies
- spinal cord compression
- bone fracture or impending fracture of weight bearing bone
- infection/abscess
- obstructed or perforated organ
- ischemic process
- SVC obstruction
Principles of pain management
- balance
- pain rarely
- reassess
- seek
- assess and treat
- consider use of
- remember
- Balance burden with benefit.
- Pain rarely occurs in isolation in patients with advanced disease
- Reassess regularly and frequently
- Seek consultation if not improving with titration, not adequately relieved within 72 hours. Or not managed with standard guidelines and interventions
- Assess and treat other symptoms to maximize comfort
- Consider use of traditional, Western & nonpharmacologic
- Remember the concept of total pain
types of pain
nociceptive: somatic or visceral, colic
neuropathic: dysesthesia, lancinating, central
examples of somatic visceral pain
s= bone metastases, fracture
v= organ, liver metastases, colic: malignant bowel obstruction
superficial somatic pain
confined to nociceptors in the skin
sharp, sore, burning
ex: Pressure ulcer fungating wounds
meds for superficial somatic pain
topical morphine, methadone or lidocaine
somatic deep pain
muscle, bone, joints and ligaments
aching, throbbing, more diffuse
ex: bone metastases, muscle spasms, RA and OA
meds for bone somatic pain
BDDN
NSAIDs
dex
bisphosphonates
denosumab
soft tissue deep somatic meds
MND
NSAIDs (topical or systemic)
dex
muscle relaxants
visceral pain
nociceptors in viscera, peritoneum, pleura
meds visceral pain
DA
antispasmodics
dex
central pain =
- meds
lesion in brain or SC
- antidepressants
- anticonvulsants
- NMDA antagonists
- Antiarrhythmics
common side effects
- constipation (laxative)
- nausea (usually resolves 3-5 days, metoclopramide or domperidone in the first days)
- somnolence (usually resolves after 3-5 days, don’t drive until pain controlled and no somnolence)
WHO analgesic ladder
step 1= mild pain 1-3/10
- use non opioid
- +/- adjuvant
Step2= moderate pain 4-6/10
- weak opioid (codeine, tramadol)
- +/- adjuvant
Step 3= severe pain 7-10/10
- strong opioid
- +/- adjuvant
strong opioids 1st line 2nd line 3rd line
1- morphine, hydromorphone, oxycodone
2- fentanyl
3- methadone
avoid ____ for opioid
codeine
- unpredictable safety and efficacy
- possible interactions with other meds
- often not sufficient for cancer pain
adjuvant analgesics principles
- optimize
- use appropriate
- which administered as first line treatment
- consider
- Optimize the opioid regimen before introducing an adjuvant analgesic in cancer pain
- adjuvant analgesic at any pain severity level
- The adjuvant with the greatest benefit and least risk
- combination therapy with two or more drugs in the event of a partial response but avoid starting & titrating several adjuvants concurrently
breakthrough doses are
10 % of total 24 hour dose
codeine
tramadol
morphine
hydromorphone
starting dose
15 mg q 4hr
37.5 mg TID
5mg q4hr
1mg q4hr
1mg hydromorphone= ___ mg of morphine
5mg
reassess when __ or more breakthrough doses used per 24 hours
3
daily dose plus breakthrough becomes new total daily dose
titration
TDD=
- calculate TTD for past 24 hr
TDD= regular + all BTD - regular dose q4hr for the next 24 hours= past TDD/6
- BTD= new regular dosex10 %
increase he opioid BTD proportionately whenever the regular dose in increased
non- pharmacological pain interventions
Physical: physio, exercise, massage, positioning, application of heat/cold
Psychological: relaxation, meditation, cognitive therapy
Spiritual and cultural practices
TENS, acupuncture, acupressure
Palliative radiation
Palliative surgery
Neurotaxial analgesic
Cementoplasty
adjuvant for bone pain (5)
- NSAIDs
- steroids (useful in pain crisis, trial of several days preferred)
- bisphosphonates (long term treatment to reduce skeletal events)
- palliative radiotherapy
- palliative surgery
palliative radiotherapy
-pain reduced in
-few
-response within
-may have
-factions
- pain reduced in 70-80% patients treated
- few side effects
- response within 1 to 2 weeks
- may have increased pain the first few days
- single fractions often effective
prevalence of Nausea and vomiting
- affects 40-60% of people receiving palliative care
- 21-68% of people with cancer
- 2-48% of people with chronic illness
- Reported most often in people <65yrs of age, female, receiving medications, have a GI obstruction, or have cancer of the stomach, breast or brain
impact of Nausea and vomiting
- Slightly bothersome
- Profoundly distressing for patient & family
- Decrease quality of life
- Cause delay of active treatments ex. chemotherapy
standard of care for nausea and vomiting
4
- goals of care conversation
- assessment and diagnostics
- Determine possible causes and reverse as possible if keeping with goals of care
- interventions
physical assessment of nausea/vomiting
8
Signs of dehydration : sunken eyes, cracked lips, dry mucous membranes, increased respiratory rate, decreased output
Electrolyte imbalances: weakness, tingling,
Liver: jaundiced, ascites
What meds are you taking
ETOH
Intracranial Pressure- headache
Bowels: rectal exam
Gait
Underlying Causes of Nausea & Vomiting 6
- most common 3
Chemical: drugs, chemo.
Cortical
Cranial
Vestibular
Visceral or serosal
Gastric Stasis (impaired gastric emptying)
most common gastric irritation, metabolic, infection
most common causes of N/V
BIG COM
gastric irritation (meds)
obstruction
metabolic imbalances
infection
constipation
brain metastases
possible diagnostics N/V (4)
Blood work: CBC and differential, calcium, glucose, renal and liver functions
Urine culture
Abdominal imaging: X-ray, ultrasound, CT/MRI
endoscopy
principles of management for N/V
- balance
- use
- select
- a single antiemetic is
- monitor for
- if symptoms persist
- Balance burden of possible intervention against likely benefit.
- Use cause determination, knowledge of emetogenic pathways & a structured approach for selection of antiemetic.
- Select the first line drug recommended for the most likely cause of the symptom.
- A single antiemetic is effective in most patients
- Monitor for symptom resolution and adverse effects for 48 hours.
- If symptoms persist, prescribe a regular antiemetic with different antiemetic to be given as needed.
non pharmacological measures for N/V
Prevention: Identify triggers and remove or avoid
Provide regular and meticulous oral hygiene
Keep air fresh and odor free ex. Open windows, fan, clean commode, fresh linens, empty garbage
Start anti-emetics when opioids initiated if hx nausea
Ice chips, sips ice water: gradual increase in oral intake
Offer mints, hard sugarless candy
Aromatherapy ex. Peppermint or ginger oils reduced cancer related N&V in small studies
Clinically assisted hydration if indicated
never give metoclopramide if
total bowel obstruction
Low Distress (1-3/10) N/V
-Try non-pharmacological action
-Use first line drug for most -likely cause
-Treat regularly for 48hrs plus additional PRN antiemetic drug
Moderate Distress (4-6/10)
N/V
- Select drug based on likely cause
- If cause unknown or due to multiple factors:
Metoclopramide: treats common causes ex. Gastric stasis, partial bowel obstruction
Haloperidol: chemical disturbances, other common causes
Methotrimeprazine: broad acting receptor antagonist
Severe Distress (7-9/10)
N/V
Urgently assess cause & initiate appropriate drug treatment/interventions
If inadequate control within 48 hours consider:
Hospitalization
Hospice admission
Consultation with palliative care physician
Further antiemetic titration drugs or options, including combination of drugs with broader action
