Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
58 Cards in this Set
- Front
- Back
- 3rd side (hint)
|
What is the gold standard when assessing pain?
|
Patient self-report.
|
Note: Patient's emotional andcognitive responses to the sensation of pain and the underlying cause are subjective.
|
|
|
Pain impulses are initiated by activation of _____________.
|
pain receptors
|
|
|
|
What three types of stimuli activate pain receptors?
|
mechanical (pressure, thermal, and chemical (bradykinin, serotinin, histamine)
|
|
|
|
What two forms of pain do cancer patients have?
|
Nociceptive and neuropathic
|
These 2 forms of pain respond differently to analgesic drugs.
|
|
|
What is nociceptive pain?
|
Nociceptive pain has 2 forms: somatic and visceral. Somatic is felt in somatic tissues (bones, joints, muscles) and visceral pain is pain in visceral organs.
|
Somatic pain is localized and sharp - person can usually point to it with their finger. Visceral pain is vaguely localized with a diffuse, aching quality.
|
|
|
What is neuropathic pain?
|
Pain resulting from injury to peripheral nerves. Described as burning, shooting, jabbing, numb, cold.
|
Does not respond well to opioids like nociceptive pain. Does respond to drugs known as adjuvant analgesics.
|
|
|
What are metastases?
|
Invasion of cancer at distant sites.
|
|
|
|
How can cancer cause pain?
|
From the cancer itself invading tissue, cancer infiltrating nerves, organs and by the therapeutic interventions such as chemotherapy and radiation.
|
|
|
|
Management of cancer pain involves repeating cycles of ____, _____, and _______.
|
assessment, intervention, and reassessment.
|
|
|
|
What does ABCDE stand for?
|
Ask, Assess, Believe, Choose, Deliver, Empower, Enable
|
Ask about pain regularly, Assess pain systematically, Believe the patient and family in reports of pain, Choose appropriate pain control options, Deliver interventions in a timely, logical and coordinated manner, Empower patients and their families, Enable patients to control their treatment to greatest extent possible.
|
|
|
What is the primary objective of assessment?
|
To characterize the pain and identify its cause.
|
|
|
|
What is the FACES scale used for?
|
Young children and for patients with cognitive impairment, who may have difficulty understanding the descriptive and numeric scales.
|
Pain intensity scales are also important for setting pain relief goals and evaluating treatment.
|
|
|
What are the most important drugs for fighting cancer pain?
|
Analgesic drugs.
|
NSAIDS, Opioid analgesics, adjuvant analgesics.
|
|
|
What is the WHO analgesic ladder for cancer pain management?
|
Step 1: Mild to moderate pain - consists of non opiod analgesics NSAIDS & acetaminophen Step 2: more severe pain, ADDS opioid analgesics of moderate strength (oxycodone, hydrocodone), Step 3: severe pain substitutes poewrful opioids (morphine, fentanyl) for the wekaker ones. Adjuvant analgesics can be used at any step on the ladder.
|
Note: there is a limit to how much relief we can provide with the non opioid and adjuvant analgesics, there is no imit to relief with the opioids. Also note that if pain is intense at onset, you can skip the first step in the ladder (patient reported pain in the 4 to 10 range).
|
|
|
What is the difference between acetaminophen and NSAIDS?
|
They are about equal as far as analgesic efficacy but acetaminophen lacks antiinflammatory actions.
|
Acetaminophen works in the brain whereas NSAIDS also work at the site of pain to reduce inflammation.
|
|
|
What are the primary effects of NSAIDS?
|
Pain relief, suppression of inflammation and reduction of fever.
|
All NSAIDS except aspirin increase the risk of thrombotic events (MI, stroke).
|
|
|
Can NSAIDs be used with an opioid?
|
Yes, NSAIDs relieve pain by a different mechanism that that of the opioids and can be combined to produce greater pain relief than with either agent alone.
|
|
|
|
Where do NSAIDs produce their effects?
|
Good and bad effects are produced by inhibiting COX 1 and COX 2 enzymes.
|
Most NSAIDs inhibit both, but drugs such as celecoxib (Celebrex) are selective for COX 2.
|
|
|
What is good and bad about COX 2 inhibitors?
|
Good = less GI damage
Bad = pose a greater risk of thrombotic events, long-term use not recommended |
|
|
|
What is a concern for patients undergoing chemotherapy who take NSAIDs?
|
Inhibition of platelet aggegation. Many anticancer drugs suppress bone marrow function decreasing platelet production. Thrombocytopenia puts patients at risk for bleeding and bruising.
|
Note: among NSAIDs, only one subclass (nonacetylated salicylates like magnesium salicylate) do not inhibit platelet formation.
|
|
|
Why is aspirin especially dangerous?
|
Aspirin causes irreversible inhibition of platelet aggregation. Its effects persist for the life of the platelet (about 8 days).
|
Because COX 2 inhibitors do not affect platelets, they are safe for patients with thrombocytopenia.
|
|
|
What is the difference between acetaminophen (Tylenol) and other NSAIDs?
|
The benefits from acetaminophen come from inhibiting COX in the CNS, not in the periphery.
|
Combining acetaminophen with an opioid can produce greater analgesia than either drug alone because of the different mechanisms used to relieve pain. You can even use acetaminophen and ibuprofen together since they operate on different mechanisms.
|
|
|
What two drugs does acetaminophen have important interactions with?
|
Alcohol and warfarin. Combining acetaminophen with alcohol (even in moderate amounts, can result in potentially fatal liver damage). Warfarin is an anticoagulant - risk of bleeding high. Mechanism appears to be inhibition of warfarin metabolism, which causes warfarin to accumulate to dangerous levels.
|
|
|
|
What are the most effective analgesics available?
|
Opioids are the most effective and are primary drugs for treating moderate to severe pain.
|
|
|
|
How do opioid analgesics relieve pain?
|
By mimicking the actions of endogenous opioid peptides (enkephalins, dynorphins, endorphins) primarily at mu receptors.
|
|
|
|
Opioids fall into two major groups which are_____ and _______.
|
1. pure (full) agonists (morphine)
2. agonist-antagonists (butorphanol) |
|
|
|
What two categories are the pure agonists subdivided into?
|
1. agents for mild to moderate pain
2. agents for moderate to severe pain |
Note: pure agonists act as agonists at mu receptors and at kappa receptors. Agonist-antagonists act only at kappa receptors.
|
|
|
What do opioids cause over time?
|
Tolerance and physical dependence.
|
Note: see flash cards on Chapter 28 for definitions of tolerance and physical dependence. In cancer patients, need for larger doses isn't always a sign of tolerance, it's usually a sign that disease is getting worse.
|
|
|
What does tolerance develop to?
|
Analgesia, euphoria, respiratory depression, and sedation. In contrast, little or no tolerance develops to constipation.
|
|
|
|
What determines the intensity and duration of the abstinence syndrome?
|
The half life of the drug and the duration of drug use.
|
Drugs with a short half life leave the body quickly, abstinence syndrome is brief but intense. Drugs with long half lives leave the body slowly so abstinence syndrome if prolonged but relatively mild. REMEMBER - physical dependence is not the same as addiction!
|
|
|
Why is opioid addiction an important issue in pain managment?
|
Inappropriate fears of addiction are a major cause for undertreatment.
|
Addiction is primarily a behavior pattern. All cancer patients who take opioids chronically develop substantial physical dependence, but only a few (less than 1%) develop addictive behavior.
|
|
|
Which opioids are preferred in treating cancer patients?
|
Pure opioid agonists are preferred to agonist-antagonist.
|
|
|
|
What is opioid rotation?
|
Switching from one opioid to another because opioids have different side effect profiles, switching among them can help minimize adverse effects while maintaining good analgesia.
|
Special note on codeine: Codeine is capable of producting significant analgesia,but side effects limit the dose that can be given and, as a result, the degree of pain relief that can be safely achieved is limited.
|
|
|
What is an opioid to avoid in treating cancer patients?
|
Merepidine (Demerol) because it may be used for a few days, but longer use results in a toxic metabolite (normeperidine) to accumulate posing a risk of adverse CNS effects.
|
|
|
|
What is the preferred route of administration of pain relief drugs?
|
Oral because it is cheap, convenient, and noninvasive.
|
Note: oral opioids undergo substantial first pass metabolism, oral doses must be larger than parenteral doses to achieve equivalent analgesic effects.
|
|
|
Explain rectal administration.
|
Rectal: preferred for patients who cannot take drugs by mouth. Three opioids - morphine, hydromorphone, and oxymorphone are available in suppositories. When switching from oral to rectal, dose is the same that was used orally and then adjusted as needed.
|
Inappropriate for patients with diarrhea or lesions of the rectum or anus. Also, children frequently object to this route.
|
|
|
Explain transdermal administration.
|
Preferred alternative to oral therapy. Only opioid available for chronic transdermal use is fentanyl (Duragesic). Patches provide steady analgesia for 72 hours.
|
|
|
|
What are the advantages of IV and SQ administration?
|
1. Onset of analgesia is quick
2. these routes permit rapid escalation of dosage. Dosages for IV and SQ are the same. |
Conditions that might justify these routes are nausea and vomiting, inability to swallow, delirium, pain that requires a large number of pills, unstable pain that requires rapid dosage.
|
|
|
Should IM administration be used for cancer patients?
|
No, it should be avoided. Injections are painful and unacceptable for repeated dosing. Absorption can also be inconsistent so pain relief is unpredictable.
|
|
|
|
When is intraspinal pain relief used?
|
Patients with intractable pain that cannot be controlled with less invasive routes. Especially useful for patients with severe pain in the lower body.
|
We can achieve high opioid concentrations at receptors on painpathways in the spinal cord.
|
|
|
When is intraventricular pain relief used?
|
Reserved for patients whose pain cannot be controlled with less invasive routes. Morphine is delivered to the cerebral ventricles via a catheter.
|
Because the blood brain barrier is bypassed, very low doses can achieve pain relief.
|
|
|
How can overdose be prevented with patient controlled anesthesia (PCA)?
|
1. The device limits the total dose of opioid hat can be elivered per hour.
2. The device sets a minimum interval between doses (ex., 10 minutes). |
|
|
|
What is the most serious side effec of opioids?
|
Respiratory depression
|
|
|
|
What is the best way to assess the risk of impending respiratory depression?
|
Monitor opioid induced sedation because an increase in sedation generally precedes an increase in respiratory depression.
|
|
|
|
When are adjuvant analgesics used?
|
To complement the effects of opioids. They can enhance analgesia from opioids, manage concurrent symptoms that exacerbate pain, and treat side effects caused by opioids.
|
Note: adjuvants can relieve pain, but they were all developed to treat other conditions like depression, seizures, dysrhythmias.
|
|
|
What is the goal of a neurolytic nerve block?
|
To destroy neurons that transmit pain from a limited area, thereby providing permanent pain relief.
|
|
|
|
What can heat do for pain?
|
Heat promotes vasodilation which increases delivery of O2 an nutrients to damaged tissue and heat increases elasticity in muscle which reduces stiffness.
|
|
|
|
What can cold do for pain?
|
Cold can reduce inflammation and muscle spasm. Should not be applied longer than 15 minutes or to areas damaged by radiation.
|
Cold should be avoided in patiens with peripheral artery disease because cold promotes vasoconstricion.
|
|
|
What can massage and exercise do for pain?
|
Massage is a comfort measure that provides relief through distraction and relaxation. Exercise can reduce subacute and chronic pain by increasing muscle strength and joint mobility.
|
|
|
|
What do psychosocial interventions such as relaxation and imagery, cognitive distraction and support groups do for pain?
|
They can help patients cope by increasing the sense of control over pain,reversing negative thoughts and feelings, and offering social support.
|
|
|
|
What two issues are of concern with elderly patients?
|
1. undertreatment of pain
2. increased risk of adverse effects |
Heightened drug sensitivity contributes to both problems. Sensitivity is largely due to organ function. Rates of hepatic metabolism and renal excretion decline with age.
|
|
|
What should you be aware of when assessing children for pain?
|
Verbal children often unreport, and nonverbal children must be observed for pain which is unreliable.
|
|
|
|
Why should children not be given NSAIDa when they have he flu or chickenpox?
|
Risk of Reye's Syndrom until age 21.
|
|
|
|
Why are neonates and infants highly sensitive to drugs?
|
The Blood Brain Barrier is incompletely formed giving drugs easy access to the CNS and the kidneys and liver are poorly developed causing drug elimination to be slow.
|
|
|
|
What are our primary obligations when treating opioid abusers with cancer pain?
|
1. Relieve the pain
2. Avoid giving opioid simply because the patient wants to get high. |
Still must base treatment on self report. Because of opioid tolerance, initial doses in abusers must be higher than in nonabusers.
|
|
|
What does patient education do for cancer patients?
|
It can reduce anxiety, dispel hopelessness, facilitate assessment, enhance compliance,provide a sense of control and enable patients to take an active role in their care.
|
|
|
|
How can we reinforce communication and what should be discussed?
|
All information should be presented twice and in more than one way. Topics should include nature and causes of pain, assessment and the importance of self reporting, plans for drug and nondrug therapy.
|
All patients should receive a written pain management plan and shouldknow how to contact the prescriber to report treatment failure and serious side effects.
|
|
|
What misconceptions influence compliance most?
|
Misconceptions regarding tolerance, physical dependence, addiction, and side effects.
|
|
