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26 Cards in this Set
- Front
- Back
Assessing Severity of Pain
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- Numeric scales
- Visual analog scale (VAS) - Wrong-Baker FACES of Pain Rating Scale |
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Physiological Responses to Pain
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Increased RR, HR, and BP
Pain and anxiety are reinforcing phenomena |
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Acetaminophen + Hydrocodone
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- Acetaminophen with hydrocodone decrease dosing flexibility and frequently lead to unintended toxic side effects
- chronic admin of acetaminophen >5g/day has been assoc w/ hepatic enzyme changes - NSAIDs used additively with opiates have analgesic effects --> good for controlling moderate to severe pain - NSAIDs have antiplatelet effects |
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Tramadol vs other opioid analgesics
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- tramadol is a synthetic codeine analog
- weak miu-opioid receptor agonist - part of its analgesic effect is due to inhibition of uptake of NE and serotonin |
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Morphine AE
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- nausea, vomiting, itching, constipation
- nausea/vomiting/itching can be reduced w/ antihistamines - stimulative laxative to tx constipation (senna tablet orally at bedtime in addition to docusate orally twice daily) - for more resistant constipation, lactulose can be used every hour - oral naloxone can also work |
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Acute severe pain: First line of tx
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- morphine or hydromorphone
- ketorolac (injectable NSAID) is most beneficial postoperative if used in combination w/ the opioids |
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Ceiling Effect
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- NSAIDs have an analgesic ceiling effect
- NO ceiling effect for pure opioid agonists (morphine, hydromorphone, fentanyl) - Combination of opioid + NSAID --> ceiling effect of NSAID should be dose-limiting factor - Mixed agonist-antagonist opioids (pentazocine, butorphenol, nalbuphin) and the partial agonist opioids (buprenorphine) have a ceiling effect and are poor choices in pts w/ severe pain [if combined w/ pure opioid agonist --> can cause acute pain and opioid w/drawal sx] |
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Analgesic Nephropathy
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after many yrs of exposure to damagind analgesics, renal papillary necrosis results --> chronic interstitial nephritis develops in response and can lead to --> progressive chronic renal failure
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Decrease in Renal Blood Flow
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- in pts w/ compromised renal hemodynamics (eg dec circulating volume), the kidney --> PGE2 and PGI2 to offset effects of vasocontricting mediators (angII, epinephrine)
- NSAID decreases PGE2: inc sodium/water retention, peripheral edema, wt gain, inc BP, and CHF - NSAID decreases PGI2 --> hyperkalemia and ARF |
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Acute Interstitial Nephritis
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- dev't of ARF due to a dramatic inflammatory infiltration of the interstitial compartment of the kidneys
- type I HS rxn - NSAIDs can cause it |
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Three-step WHO pain ladder for cancer pain relief
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1. non-opioid analgesic
2. opioid for mild to moderate pain added 3. opioid for moderate to severe pain substituted - Only one drug from each of the three groups should be used at the same time - If a drug ceases to be effective, prescribe a drug that is stronger, NOT a similar drug |
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Opioids for mild-moderate pain
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- Codeine, Hydrocodone, Oxycodone
- Meperidine - Propoxyphene |
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Opioids for moderate-severe pain
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- Morphine, Hydromorphone, Oxymorphone
- Levorphanol - Fentanyl - Methadone |
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Breakthrough Pain
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- transitory flares of pain at rest and movement
- when such pain lasts for longer than a few mins, extra doses of analgesics (i.e. breakthrough or rescue doses) will provide relief - use immediate-release prep of same opioid that is routinely used |
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Adjuvant Drugs in Cancer Pain Management
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- treat adverse effects of analgesics (anti-emetics and laxatives)
- to enhance pain relief (corticosteroids or hydroxyzine) - to treat psychological disturbances such as insomnia, anxiety, and depression (sedatives, anxiolytics, antidepressants) |
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Amitriptyline
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- TCA
- act as modulators of descending inhibitory pathways via inhibition of reuptake of NE and serotonin - particularly useful in tx neuropathic pain |
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Corticosteroids
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- reduce inflammation by inhibiting PG synthesis and they may reduce axonal sprouting and neurkinin conc in sensory fibers near injured tissue
- dexamethasone most often used |
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Analgesics not recommended for routine dosing
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- Meperidine - principal metabolite normeperidine has a lot of AE
- Propoxyphene - acc of norpropoxyphene, a toxic metabolite; affects elderly pts and those w/ renal dysfunction - Mixed opioid agonist-antagonist (pentazocine, butorphanol, nalbuphine, dezocine) shouldn't be taken in pts already taking pure agonist opioid (codeine, hydrocodone, hydromorphone, methadone, morphine, oxycodone); have a ceiling effect; psychotomimetic AE in some |
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Pain/Nausea relief
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- Immediate relief - Meperidine IM every 3 hrs
- Diclofenac, tenoxicam, and ketorolac: therapeutic benefits in both pain relief and decreased likelihood of progression to acute cholecystitis - Antispasmodics = papaverine, atropine - Nausea - metoclopramide, prochlorperazine, or ondansetron IV |
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Types of pain
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- Nociceptive
- Inflammatory - Neuropathic - Functional |
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Nociceptive Pain
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- transient pain
- nociceptors located in cutaneous tissue, bone, muscle, connective tissue, vessels, and viscera - receptors classified as thermal, chemical, or mechanical |
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Inflammatory Pain
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- when tissue damage occurs despite the nociceptive defense system, inflammatory pain ensues
- body changes focus from protecting against painful stimuli to protecting injured tissue - inflamm response contributes to pain HS that serves to prevent contact or movement of the injured part until healing is complete |
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Neuropathic Pain
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- chronic nonmalignant pain involving disease of the central and peripheral nervous systems
- peripheral or central in nature - ex: post-herpetic neuralgia, peripheral or polyneuropathic pain, trigeminal neuralgia, CRPS |
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Functional Pain
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- pain sensitivity due to an abnormal processing or function of the CNS in response to normal stimuli
- ex: fibromyalgia, IBS |
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Management of Neuropathic Pain
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antidepressants
- TCA - amitriptyline and imipramine [via inhibition of NE and Serotonin reuptake] - Venlafaxine and duloxetine - SSRIs and SNRI - Anticonvulsants - Gabapentin, Pregabalin, carbamazepine, oxcarbazepine, phenytoin, sodium valproate, clonazepam, topiramate, lamotrigine - Other - Hydroxyzine, corticosteroids, clonidine, lidocaine, capsaicin |
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Trigeminal Neuralgia tx
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Carbamazepine = DOC
Gabapentin and lamotrigine |