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NRSG 310- Palliative Care > Week 9- pain/nausea/vomiting > Flashcards

Week 9- pain/nausea/vomiting Flashcards

1
Q

Total Pain

A

physical
spiritual
emotional
social

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2
Q

advanced disease common symptoms

A

pain
loss of appetite
N/V
fatigue
dyspnea
constipation
delirium

lots can overlap

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3
Q

physical symptoms are managed by

A
  • addressing the underlying disease
  • using meds
  • using non-pharm treatment
  • addressing psychosocial needs
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4
Q

What happens when we can’t relieve suffering

A

hopelessness, depression, decrease in QOL

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5
Q

some preventable symptoms

A

constipation
nausea

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6
Q

principles of using medications
- route
- what’s more effective than 1
- consider
- provide meds
- titrate
- continue meds for
- provide
- assess

A

-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

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7
Q

it important to always

A

follow up with patients

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8
Q

pain is an

A

unpleasant sensory & emotional experience associated with actual or potential tissue damage

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9
Q

pain is highly prevalent at

A

the EOL regardless of primary diagnosis

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10
Q

pain can be ____ or _________ in up to ____% of patients using ___________ & _______________ BUT

A

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

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11
Q

people at risk for having underrecognized pain

A
  • 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
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12
Q

components of physical pain
(3)

A
  • usually needs treatment (drugs)
  • causes variable degrees of distress
  • interferes with other aspects of life
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13
Q

components of spiritual pain (3)

A
  • guilt/remorse
  • fears after death
  • sense of connectedness
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14
Q

social parts of total pain

A
  • distress over family members
  • loss of role
  • participation issues
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15
Q

emotional components of total pain

A
  • adjustment disorders, anxiety, depression
  • frustration and hopelessness
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16
Q

one form of a pain assessment

A

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?

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17
Q

Edmonton symptom assessment system

A

rates symptoms on a scale from 0-10

pain
tiredness
drowsiness
nausea
appetite
SOB
depression
anxiety
wellbeing
other

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18
Q

Visual Analogue Scale

A

no pain (10) to worst pain ever (0)
has face on either end
younger children
English not first language

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19
Q

Numerical rating scale (NRS)
Faces rating scale (FRS)

A

0-10 painscale
different faces

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20
Q

Behavioral rating scale

CVMFR

A

for patients unable to provide a self-report of pain: scored 0-10 clinical observation

face
restlessness
muscle tone
vocalization
consolability

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21
Q

PAINAD scale

BBCFN

A

pain assessment for advanced dementia
- breathing
- negative vocalization
- facial expression
- body language
- consolability

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22
Q

before ordering diagnostics consider

A

goals of care

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23
Q

pain emergencies

A
  • spinal cord compression
  • bone fracture or impending fracture of weight bearing bone
  • infection/abscess
  • obstructed or perforated organ
  • ischemic process
  • SVC obstruction
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24
Q

Principles of pain management
- balance
- pain rarely
- reassess
- seek
- assess and treat
- consider use of
- remember

A
  • 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
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25
Q

types of pain

A

nociceptive: somatic or visceral, colic
neuropathic: dysesthesia, lancinating, central

26
Q

examples of somatic visceral pain

A

s= bone metastases, fracture
v= organ, liver metastases, colic: malignant bowel obstruction

27
Q

superficial somatic pain

A

confined to nociceptors in the skin
sharp, sore, burning
ex: Pressure ulcer fungating wounds

28
Q

meds for superficial somatic pain

A

topical morphine, methadone or lidocaine

29
Q

somatic deep pain

A

muscle, bone, joints and ligaments
aching, throbbing, more diffuse
ex: bone metastases, muscle spasms, RA and OA

30
Q

meds for bone somatic pain

BDDN

A

NSAIDs
dex
bisphosphonates
denosumab

31
Q

soft tissue deep somatic meds

MND

A

NSAIDs (topical or systemic)
dex
muscle relaxants

32
Q

visceral pain

A

nociceptors in viscera, peritoneum, pleura

33
Q

meds visceral pain

DA

A

antispasmodics
dex

34
Q

central pain =
- meds

A

lesion in brain or SC
- antidepressants
- anticonvulsants
- NMDA antagonists
- Antiarrhythmics

35
Q

common side effects

A
  • 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)
36
Q

WHO analgesic ladder

A

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

37
Q

strong opioids 1st line 2nd line 3rd line

A

1- morphine, hydromorphone, oxycodone
2- fentanyl
3- methadone

38
Q

avoid ____ for opioid

A

codeine
- unpredictable safety and efficacy
- possible interactions with other meds
- often not sufficient for cancer pain

39
Q

adjuvant analgesics principles
- optimize
- use appropriate
- which administered as first line treatment
- consider

A
  • 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
40
Q

breakthrough doses are

A

10 % of total 24 hour dose

41
Q

codeine
tramadol
morphine
hydromorphone

starting dose

A

15 mg q 4hr
37.5 mg TID
5mg q4hr
1mg q4hr

42
Q

1mg hydromorphone= ___ mg of morphine

A

5mg

43
Q

reassess when __ or more breakthrough doses used per 24 hours

A

3

daily dose plus breakthrough becomes new total daily dose

44
Q

titration

TDD=

A
  1. calculate TTD for past 24 hr
    TDD= regular + all BTD
  2. regular dose q4hr for the next 24 hours= past TDD/6
  3. BTD= new regular dosex10 %
    increase he opioid BTD proportionately whenever the regular dose in increased
45
Q

non- pharmacological pain interventions

A

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

46
Q

adjuvant for bone pain (5)

A
  • NSAIDs
  • steroids (useful in pain crisis, trial of several days preferred)
  • bisphosphonates (long term treatment to reduce skeletal events)
  • palliative radiotherapy
  • palliative surgery
46
Q

palliative radiotherapy
-pain reduced in
-few
-response within
-may have
-factions

A
  • 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
47
Q

prevalence of Nausea and vomiting

A
  • 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
48
Q

impact of Nausea and vomiting

A
  • Slightly bothersome
  • Profoundly distressing for patient & family
  • Decrease quality of life
  • Cause delay of active treatments ex. chemotherapy
49
Q

standard of care for nausea and vomiting

4

A
  1. goals of care conversation
  2. assessment and diagnostics
  3. Determine possible causes and reverse as possible if keeping with goals of care
  4. interventions
50
Q

physical assessment of nausea/vomiting

8

A

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

51
Q

Underlying Causes of Nausea & Vomiting 6
- most common 3

A

Chemical: drugs, chemo.
Cortical
Cranial
Vestibular
Visceral or serosal
Gastric Stasis (impaired gastric emptying)

most common gastric irritation, metabolic, infection

52
Q

most common causes of N/V

BIG COM

A

gastric irritation (meds)
obstruction
metabolic imbalances
infection
constipation
brain metastases

53
Q

possible diagnostics N/V (4)

A

Blood work: CBC and differential, calcium, glucose, renal and liver functions

Urine culture

Abdominal imaging: X-ray, ultrasound, CT/MRI

endoscopy

54
Q

principles of management for N/V
- balance
- use
- select
- a single antiemetic is
- monitor for
- if symptoms persist

A
  • 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.
55
Q

non pharmacological measures for N/V

A

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

56
Q

never give metoclopramide if

A

total bowel obstruction

57
Q

Low Distress (1-3/10) N/V

A

-Try non-pharmacological action
-Use first line drug for most -likely cause
-Treat regularly for 48hrs plus additional PRN antiemetic drug

58
Q

Moderate Distress (4-6/10)
N/V

A
  • 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

59
Q

Severe Distress (7-9/10)
N/V

A

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

60
Q
A

NRSG 310- Palliative Care (10 decks)

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