Managing Palliative Symptoms: Advanced Cancer – Flashcards
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What is the most frequent reason for palliative consultation?
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pain
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definition of Pain
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an unpleasent sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage
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Prevalence of pain in advanced cancer
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pain is the cause of much suffering in Cancer -80-90% of cancer patients -often multiple pains -often multiple causes of pain
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What are the classifications of pain based on?
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-Embryology, visceral, deep somatic, cutaneous -duration: acute vs chronic -Cause: benign vs malignant -connections: noncieptive, deafferentation, hysterical -number of locations: unifocal vs multifocal -body location: unilater vs bilateral -persistency: continuous vs intermittent
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Where does visceral pain arise from?
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organs and tissues from the endoderm
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what are examples of organs and tissues that are the cause of visceral pain?
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stomach, bowel , liver, pancreas, kidney, bladder,
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What are the characteristics of visceral pain?
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-dull and aching (cramping) -often felt on the body surface -refered pain , diffuse, and ill defined
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Where does somatic pain arise from?
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mesodermal -bone , muscle, ligament, fascia -most common for cancer patients
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How is somatic pain usually described?
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site specific and described as dull an aching
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Where does cutaneous pain arise from?
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ectodermal (nervous tissue)
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How is cutaneous pain usually described?
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clearly localized and described as a sharp or burning pain,
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What charts are useful to map out cutaneous pain?
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dermatone chart
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visceral pain
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organ in the chest, abdominal cavity, deep somatic , well localized , bone , muscle, fascia, most common in ca pain
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Examples of somatic pain
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-bones, joints -connective tissue -muscles -sharp -dull & aching -can localize site -may be worse with movements ("incident pain")
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Examples of visceral pain
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-organs: heart, liver, pancreas, gut, -may be crampy, dull & aching -referred pain ** -difficult to localize
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Examples of Neuropathic pain
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-difficult to describe not a "typical" pain -numb, buring, tingling, crawling, stabbing, -allodynia -consider it as a possible element of any difficult pain syndrome
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define allodynia
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neuropathic pain, when something should not stimulate , a non-noxious stimulate. ex. clothes touching the body
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what two types of pain make up nociceptive pain?
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somatic and visceral --> superficial and deep
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neuropathic pain
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can be central, peripheral or other -can have a combination of nociceptive pain and neuropathic pain
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What is the most common type of pain?
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nociceptive pain
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what is the cause of nociceptive pain?
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injury (physical or chemical) to tissue
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How is nociceptive pain transmitted?
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nerve endings to dorsal route ganglion to spinal cord and brain pain centers.
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what is Deafferentation pain also called?
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neuropathic pain
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How is deafferentated pain described?
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neuralgic (lacinating/sharp/stabbing) or dysesthetic (constant /burning/tingling)
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What is hysterical or psychogenic pain ?
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has an emotional rather than physical cause -rare in palliative care
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Acute pain
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identified event -resolves days-weeks -usually nociceptive
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Chronic pain
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cause not easily identified -usually mutli-factorial -indeterminate duration -nociceptive or neuropathic
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what do chronic faces of pain look like?
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tired
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List the steps of the incident pain and incident Dyspnea protocol?
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1.fentanyl 50 2.sufentanil 25 3.sufentanil 50 4.sufentanil 100
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how are both fentanyl and sufentanyl given?
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sublingually and intranasal
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What is incident pain?
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predictably elicited by specific activities
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What is end of dose failure?
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pain that occurs at the end of the usual dosing interval or regularly scheduled analgesics
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spontaneous breakthrough pain?
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occurs without predictable cause or frequency
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Causes of Cancer Patient?
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75% caused by the cancer: -tumor invasion of the bones, nerves, plexus or spinal cord -tumor involvement of viscera and ductal system -tumor involvement of blood vessels 10% related to cancer therapy: -post-surgical pain syndrome -post-chemotherapy pain -post-radiation therapy pain -10% related to cancer induced debility -5% unrelated to either the cancer or its treatment
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For incidence pain what is the rule to remember?
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fast acting and of short duration
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What intervention is needing for end of dose failure?
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increase background dose by 25-50% or increase dosing interval BID --> TID
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WHO pain relief ladder
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1. non-opioid +/- adjuvant 2.opioid for moderate pain , +/- non opioid, +/- adjuvant 3.opioids for moderate to severe pain, +/- non opioid, +/- adjuvant
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What are the 7 types of total pain?
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-physical pain -intellectual pain -emotional pain -inter-personal pain -financial pain -bureaucratic pain
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What are the common reasons for unrelieved pain?
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-belief that pain is untreatable -failure to contact MD -pt misleads doctor by putting on a brave face -failure to take meds as prescribed -beleif that analgesics should only be taken prn -fear of addiction -fear of tolerance -side-effects
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Barriers to controlled pain?
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-poor assessment -lack of knowledge -fear of addiction, tolerance, adverse effects
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Why wont most cancer patients not get addicted to narcotics?
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-people who get addicted to pain medication like the euphoric feeling, in cancer pain with never be brought down enough to give them that feeling, so they will not get addicted. -addiction is a psychological dependence on a drug
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Who must the nurse consult when treating pain in a pt with a history of addiction?
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pain clinic physician
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What is the pain clinic physician consider when prescribing to a pt with a history of addiction?
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Look at total daily dose of street drugs taken before and increase opioids to that level. Requires special expertise. Palliative physician consults pain clinic physicians. It is unethical and unmoral to leave those pt's in pain
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Principles of pain control
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-keep pain in control -focus on the whole family -utilize team approach -treat underlying diseases/causes when appropriate -use multiple methods, adjuncts/therapies -for cancer pain give pain meds around the clock and prn for breakthrough pain -maintain oral route whenever possible -treat other symptoms -refer when pain persists
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What spiritual considerations/questions can the nurse in-cooperate in her pain assessment?
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what are the custums, beliefs and values that impact the pt's expression of pain? -what is the meaing of pain to the pt? -what does the pt think is causing the pain? -how has the pain influenced the persons hopes or meaning of life? -are there other spiritual issues affecting the pain experience?
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What are the appropriate pain assessment tools for adults?
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VAS, NRS, victoria symptometer, Wong-Baker faces pain rating scale,
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what is the difference between the NRS and victoria symptometer?
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Victoria symptomer takes horizontal scale and puts it vertically, easier for seniors
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Who is the Wong-Baker faces pain rating scale good for?
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children, and Chinese (differentiates pain from pressure)
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What does the Compass rating scale give a snap shot of?
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common pain and symptoms but also other factors affecting that patient -allows for snapshot and bring in other specialties as needed.
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Pain Relief Threshold
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medication must cross minimum effective concentration
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For regular dosing , what is the goal? What level do you want to maintain concentration below?
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want to be able to reach steady state, and below the sedation threshold/toxicity
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What factors is pain tolerance lowered by?
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-discomfort -insomnia -fatigue -anxiety -fear -anger -sadness -depression -boredom -introversion -social isolation
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What factors is pain tolerance increased by?
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-relief of symptoms -sleep -rest -sympathy -understanding -companionship -diversional activity -reduction of anxiety -elevation of mood -analgesics -antidepressants -anxiolytics
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Pain crisis with end stage Ca
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-some neuropathic pains, such as invasive and compressive neuropathies, plexopathies, and myelopathies, may be poorly responsive to conventional analgesic therapies -widespread bone metastases or end-stage pathological fractures may present similar challenges
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What treatments can be used for pain crisis with end stage Ca?
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-radiotherapy -anaesthetic -neuroalbative procedures may be indicated
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Bone pain
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-constant -worse with movement -metastases, compression or pathological fractures -prostaglandins from inflammation, metastases -rule out cord compression
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what is the best tx for bone mets?
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radiotherapy and corticosteroids
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What classifications of drugs are used to treat neuropathic pain?
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opioids alone arn't enough -must add other classifications like methadone
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What are the pharmalogical interventions for Bone pain?
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-Opioids -NSAID's -Corticosteroids -Bisphosponates - Pamidronate , Clodronate, zoledronic acid -Calcitonin -Strontium 89 (Metastron)
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What does Strontium prevent?
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further bone mets
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Controlling Pain: Other ways
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-cancer treatments (radiation or chemotherapy) -anesthetic techniques like nerve block -neurostimulation: tens, acupuncture -anesthesiologic: nerve block -surgical: cordotomy -Physical therapy: exercise, heat, cold
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What must the patient be on when going on radiation therapy?
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corticosteroids
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Non-pharmalogical interventions for general pain management
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-psychological approaches -cognitive therapies -biofeedback -behaviour therapy , psychotherapy -complementary therapies: message, music Other ways to Manage pain: -acupuncture/acupressure -therapeutic touch -positioning your body
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Pain control tips
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-if pain is not controlled increase the dose , not the frequency -if pain is not controlled and sedation occurs rule out other factors -"douse the pain with the dose that does it" -older patients may require a longer frequency of administration -always treat total pain. Keep patient and family informed. -Reassess frequently -use morphine early- don't wait until they need it -Narcotics= constipation. Use laxatives -Narcotics= nausea. Use anti-emetics and taper off -forewarn of sedation when starting narcotics -adjunct is not "add junk" -maintain oral route whenever possible -do not use docusate without adding stimulant laxatives -morphine is not usually successful alone
