Ch 29 Pain Management In Patients With Cancer

Front 1

The International Association for the Study of Pain defines pain as...

Back 1

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Front 2

Pain has two major forms...

which is more common in cancer patients?

Back 2

nociceptive pain= which results from injury to tissues
more common in cancer patients.

neuropathic pain= which results from injury to peripheral nerves.

Front 3

Nociceptive pain has two forms, known as somatic and visceral.

Back 3

somatic =Somatic pain results from injury to somatic tissues (eg, bones, joints, muscles)

visceral pain= results from injury to visceral organs (eg, small intestine).

Front 4

How do patients commonly describe somatic pain versus visceral pain?

Back 4

somatic = localized and sharp

visceral = vaguely localized and a diffuse, aching quality

Front 5

What drugs do both forms of nocioceptive pain respond well to?

Back 5

Both forms of nociceptive pain respond well to opioid analgesics (eg, morphine).

In addition, they may respond to nonopioids (eg, ibuprofen).

Front 6

What can chemotherapy cause?

Back 6

mucositis, diffuse neuropathies, and aseptic necrosis of joints.

Front 7

What can radiation cause?

Back 7

Radiation can cause osteonecrosis, chronic visceral pain, and peripheral neuropathy (secondary to causing fibrosis of nerves).

Front 8

• Because pain is a personal experience, ________ is the cornerstone of assessment.

Back 8

the patient’s self-report

Front 9

T/F Behavioral observation is a suitable substitute for the patient self-report as a method of assessment.

Back 9

False

Front 10

What guides drug selection?

Back 10

Drug selection is guided by the WHO analgesic ladder:

As pain intensity increases, treatment progresses from nonopioid analgesics to opioids of moderate strength (eg, oxycodone) and then to powerful opioids (eg, morphine).
Adjuvant analgesics can be used at any time.
If pain is already intense, treatment can start with an opioid, rather than trying a nonopioid first.

Front 11

T/F Because nonopioids and opioids relieve pain by different mechanisms, combining an opioid with a nonopioid is safe and can be more effective than either drug alone

Back 11

True

Front 12

What risk do NSAIDS pose to a patient in need of pain management?

Back 12

• Principal adverse effects of the NSAIDs are gastrointestinal (GI) injury, acute renal failure, and bleeding. In addition, all NSAIDs except aspirin pose a risk of thrombotic events.

By inhibiting platelet aggregation, NSAIDs increase the risk of bruising and bleeding in patients with thrombocytopenia, a common side effect of cancer chemotherapy.

Front 13

Why is the AE of NSAIDS causing decreased platelet aggregation of concern especially in patients undergoing chemotherapy?

Back 13

For patients undergoing chemotherapy, inhibition of platelet aggregation by nonsteroidal anti-inflammatory drugs is a serious concern, because many anticancer drugs suppress bone marrow function and reduce platelet production. Thrombocytopenia may result, putting the patient at risk for bleeding. Nursing would expect to anticipate an order for a platelet count

Front 14

Do NSAIDs cause tolerance, physical dependence, or psychologic dependence?

Back 14

no

Front 15

Where does Acetominephen differ relative to NSAIDS?

Why would this drug be chosen over an NSAID for someone diagnosed with Thrombocytopenia?

Back 15

it does not suppress inflammation, inhibit platelet aggregation, or promote gastric ulceration or renal failure

It does not affect platelet aggregation

Front 16

What type of pain is Choline salicylate (Arthropan) indicated for?

Back 16

moderate,

it does not inhibit platelet aggregation and is therefore safe for use in patients with thrombocytopenia.

Front 17

Acetaminaphen and liquor together even if moderate in amount can cause?

Back 17

fatal liver damage

anyone with a history of both should be tested to establish the damage that has been done.

Front 18

What is the most effective analgesic in tx of pain and therefore is the DOC for tx of severe cancer pain?

Back 18

Opioids

Front 19

• The opioids fall into two major groups: pure (full) agonists (eg, morphine) and agonist-antagonists (eg, butorphanol).

Which are generally preferred and why?

Back 19

There is a ceiling to pain relief with the agonist-antagonists but not with the pure agonists. Hence, for patients with cancer, pure agonists are generally preferred.

Front 20

Which form of administration is available and preferred by cancer paitents taking pain meds?

Back 20

oral is preferred

transdermal is a good alternative

Front 21

T/F Intramuscular opioids are painful and should be avoided.

Back 21

TRUE

Front 22

_____ is a desirable method of opioid delivery because it gives patients more control over their treatment.

Back 22

PCA (patient controlled analgesia)

Front 23

______ administration is reserved for patients with intractable pain that cannot be controlled by less invasive routes. This route would be _________ in a patient with excruciating bone pain and is also not indicated for patients with gastric cancer.

Back 23

Intraspinal

contraindicated

Front 24

An ________ table can facilitate dosage selection when switching from one opioid to another or from one route to another.

Back 24

equianalgesia

Front 25

Over time, opioids produce physical dependence, a state in which an abstinence syndrome will occur if the drug is abruptly withdrawn.

Back 25

Note: Physical dependence is NOT the same as addiction!

Front 26

What is the most dangerous side effect of opioids?

Back 26

respiratory depression

combining opiates with other CNS depressants should be avoided (barbituates, benzo's, and alcohol)

Front 27

What can severe respiratory depression be reversed with?

Back 27

naloxone (Narcan)

Front 28

• Nursing interventions regarding respiratory depression: measure baseline respiratory pattern and oxygen saturation of patients receiving opioids; then periodically monitor respiratory rate throughout the duration of treatment. Also assess level of consciousness in patients receiving opioids.

Back 28

1. measure baseline respiratory pattern and oxygen saturation of patients receiving opioids


2. then periodically monitor respiratory rate throughout the duration of treatment.

3. Also assess level of consciousness in patients receiving opioids.

Front 29

Opioids cause constipation in most paitents and no tolerance develops for this? What nursing interventions should be employed to manage this AE?

Back 29

increase dietary fiber and fluid intake while also taking some kind of a stool softener or laxative

Front 30

Use of meperidine (a pure opioid agonist) should be limited to________ because, with longer use, a toxic metabolite can accumulate.

Back 30

a few days

Front 31

How do adjuvant analgesics complement the use of opioids?

*they can not be used as substitutes

Back 31

help manage concurrent symptoms that exacerbate pain, and treat side effects caused by opioids. In addition, several adjuvants are effective against neuropathic pain.

Front 32

The adjuvant analgesic Hydroxyzine (Vistaril) relieves/aids in the relief of pain how?

Back 32

which can reduce pain, anxiety, and nausea and which also has sedative properties

Front 33

The adjuvant analgesic Dextroamphetamine (Dexedrine) relieves/aids in the relief of pain how?

Back 33

can enhance opioid-induced analgesia but does not help nausea

Front 34

The adjuvant analgesic Carbamazepine (Tegretol) relieves/aids in the relief of pain how?

Back 34

is indicated for relief of neuropathic pain but does not relieve nausea

Front 35

The adjuvant analgesic Dexamethasone (Decadron) relieves/aids in the relief of pain how?

Back 35

a corticosteroid, reduces edema, which indirectly may reduce pain but does not provide relief of nausea.

Front 36

__________ (nerve blocks, neurosurgical procedures, radiation) are the last resort for relieving intractable pain. All other options should be exhausted before these are tried.

Back 36

Invasive therapies

Front 37

__________ (eg, heat, cold, massage, acupuncture, transcutaneous electrical nerve stimulation [TENS]) and psychosocial interventions (eg, relaxation, imagery, cognitive distraction, peer support groups) can help reduce pain, but the degree of relief is limited. Accordingly, these interventions should be used only in conjunction with drug therapy—not as substitutes.

Back 37

physical intervetions

Front 38

_________ patients are more sensitive to drugs than are younger adults. The principal reason is drug accumulation secondary to a decline in ________ and __________.

Back 38

Elderly

hepatic metabolism and renal excretion

Front 39

_________ is especially common in the elderly

Back 39

Undertreatment of pain

Front 40

Breakthrough pain:
occurs when?
relation to dosing intervals?

Back 40

occurs spontaneously or may be precipitated by other movements. It is not related to dosing intervals; it can occur anytime and spontaneously.

Front 41

End of dose pain:
why does it occur?

Back 41

occurs because analgesic levels are lowest at that time, and not because of breakthrough pain

Front 42

Nonopioid analgesics

Back 42

(NSAIDs and acetaminophen)

Front 43

Opioid analgesics

Back 43

(eg., oxycodone, fentanyl, morphine)

Front 44

Adjuvant analgesics

Back 44

(eg., amitriptyline, carbamazepine, dextroamphetamine)

Front 45

During patient education: Information should be presented at least _____ and in more than one way.

Back 45

TWICE

Front 46

What is considered by TJC as the fifth vital sign?

Back 46

pain