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22 Cards in this Set
- Front
- Back
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What are the five most important thing for a patient who is facing death?
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Comfort
Sense of control / dignity Relieving burden on loved ones Strengthening and completing relationships with significant others Avoiding prolongation of dying |
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What is the pneumonic and the meaning of the letters in regards to taking a pain history?
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P lace: Where?
A mount: How much? I ntensifiers: Worse? N ullifiers: Better? E ffects: Medication effect/side effect? Effect on QOL? D escription: How does it feel? |
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What are the various types of pain?
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Nociceptive
Somatic Inflammatory Visceral Neuropathic Mixed Acute, chronic, chronic with acute |
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What is the pneumonic and its meaning in regards to the rational approach to pain management?
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T reat treatable causes
O ptimize analgesic medications N on pharmacological modalities I nvasive procedures |
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What are the various non-pharmacologic means of dealing with pain?
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Heat and cold
Massage Physical Therapy TENS Distraction/Relaxation/Music Therapy/Meditation Acupuncture/Energy Work |
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If a patient is suffering from constant pain, it is best to do what in regards to their opiods?
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If patient is taking a short acting opioid, make sure to prescribe a sustained release opioid to provide constant 24 hour pain control.
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A patient who is tolerant to the effect and side effects of one opioid may not be equally tolerant to the effects and side effects of another opioid.
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Incomplete Cross Tolerance
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This is an example of how to conver to a new opioid.
Decrease equi-analgesic dose by 1/3 to 1/2 because of incomplete cross tolerance 240 mg oral morphine – 80mg = 160 mg oral morphine/24 hours New dose: SR Morphine 80mg po q12h |
Decrease equi-analgesic dose by 1/3 to 1/2 because of incomplete cross tolerance
240 mg oral morphine – 80mg = 160 mg oral morphine/24 hours New dose: SR Morphine 80mg po q12h |
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What are three common sustained released opioids?
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Oxycodone SR 80 mg q12h
Morphine SR 80 mg q12h Duragesic 125mcg/hr patch q72h |
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How do you determine the PRN dose?
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Each PRN dose should equal
10-15% of the 24 hour dose of sustained-release or transdermal opioid |
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What is used to manage neuropathic pain?
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Opioids-particularly methadone
Adjuvants: Tricylic antidepressants-amitriptyline, nortriptyline, desipramine (10-150 mg qhs) Anticonvulsants-gabapentin 300 mg qhs to 300-900 mg TID, clonazepam 0.5-1.0 mg TID, carbamepine 200 mg po BID to QID Lidocaine patches (Lidoderm 5%), intravenous lidocaine; Mexilitine Non-pharmacologic-heat, ice, hypnosis, PT, massage, cognitive-behavioral Corticosteroids |
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Pharmacokinetic Considerations:
Morphine is the standard opioid Active metabolite Hydromorphone (Dilaudid) Active metabolite Methadone Long and variable half life necessitates careful monitoring for sedation Fentanyl Liphophillic Codeine Analgesic ceiling effect |
Morphine is the standard opioid
Active metabolite Hydromorphone (Dilaudid) Active metabolite Methadone Long and variable half life necessitates careful monitoring for sedation Fentanyl Liphophillic Codeine Analgesic ceiling effect |
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How do you TX constipation in a pain patient?
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Tx prophylactically:
-stool softener (docusate 100mg BID), -laxatives (senna 2 tablets or 10-15 ml syrup BID); lactulose or sorbital 15 ml BID, Miralax 17-30 gm po -bisacodyl (Dulcolax) 10 mg suppository PR -sodium phosphate or oil retention enema |
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What are some side affects of opiates?
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Respiratory depression
Sedation: -address other causes -consider psychostimulants, methyl- phenidate (Ritalin) Urinary retention-stop tricylic antidepressants Pruritus-antihistamine (diphenhydramine 25 mg QID) |
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How do you TX opiod induced constipation?
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Tolerance does not develop
Aggressively prophylactic with scheduled doses of Stool softener Docusate Mild stimulant laxatives Senna Miralax Lactulose Biscodyl Avoid bulk forming laxatives like Metamucil (phsyllium), Citrucil (methylcellulose) BeneFiber maybe reasonable option if patient wants to continue taking fiber |
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What are signs that death is near?
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Sleeping more
Less responsive Concentrated, low volume urine Coolness of hands, arms, feet, legs Mottling of skin Loss of bowel and bladder control Changes in breathing pattern |
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Withholding or withdrawing artificial hydration/nutrition is ethically justified if such interventions are ?
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Ineffective or futile
Harmful Disproportionately burdensome Slowing of GI function leads to bloating, discomfort that worsens with artificial feeding Circulation slows leading to accumulation of fluid in lungs, abdomen, limbs which may worsen with IV fluids |
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What are the changes in cardiac function before death?
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Pulse may increase; blood pressure decreases
Accumulation of fluid in lungs, abdomen, limbs Limbs feel cool and look bluish; mottled Diaphoretic Tachycardia should not be used as a sign of pain |
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As circulation to kidneys decrease before death, what may be seen?
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Less urine; more concentrated
Failure to rid body of metabolic wastes leading to delirium |
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Lethargic or agitated state that develops over hours to days characterized by
Disorientation Memory deficits Inability to focus or pay attention Occurs in up to 85% of patients at EOL Reversible in up to 50% Symptomatic treatment with medications that may be sedating |
Delirium
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What changes in respiration are seen before death?
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Respirations may increase
Increasing muscle weakness leading to inability to cough, clear secretions (death rattle) Respirations become irregular; sometimes gasping or “agonal”, apneic periods Reassure family these are not a sign of patient distress |
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SUMMARY:
Palliative Care is an approach to care that should be available to all patients with life threatening illness Skilled pain management is a foundation of palliative care and can be effectively applied with a few simple guidelines Understanding the syndrome of imminent death and educating families on what to expect can be very helpful for them |
SUMMARY:
Palliative Care is an approach to care that should be available to all patients with life threatening illness Skilled pain management is a foundation of palliative care and can be effectively applied with a few simple guidelines Understanding the syndrome of imminent death and educating families on what to expect can be very helpful for them |
