Transcript Nursing Management Emergency Care Situations

SYMPTOM MANAGEMENT
Linda K. Connelly, ARNP, MSN
M. Catherine Hough, PhD, RN
Updated: C. Cummings RN, EdD
University of North Florida
College of Health
School of Nursing
DEFINITIONS
SYMPTOM: a subjective experience reflecting
changes in the biopsychosocial functioning,
sensations, or cognition of an individual
SIGN: any abnormality indicative of disease
that is detectable by the individual or others
MANAGEMENT
DEFINITION:
Act of managing
Control
Judicious use of means to accomplish an end
WHY manage a symptom?
– According to The Institute for John Hopkins Nursing ineffective management of
unpleasant symptoms such as pain, nausea, fatigue, dyspnea and depression contribute
to longer inpatient hospital stays, slower recovery from illness, loss of productivity,
lower quality of life and increased cost of care.
– The reason to manage symptom… make pt as comfortable as possible in order to have pt
improve & decrease length of stay
MORE DEFINITIONS
Symptoms are “perceived indicators of change in normal
functioning as experienced by patients…………they are
the red flags of threats to health.”
HEGYYWARY, 1993
“Symptoms can occur alone or in isolation from one
another, but, more often, multiple symptoms are
experienced simultaneously.”
Lenz, et al, 1997
THEORY OF UNPLEASANT SYMPTOMS
THEORY OF UNPLEASANT SYMPTOMS
THEORY OF UNPLEASANT SYMPTOMS
Distress is one of the four dimensions of a
symptoms and reflects the degree to which
the person is bothered by the symptom.
The other three dimensions of a symptom are
quality, timing, and intensity.
Timing is also duration
Symptom Management Model (Dodd et
al., 2001)
DYSPNEA
Sensation of difficulty or
uncomfortable breathing
Usually reported as
shortness of breath
Severity varies greatly but is
often unrelated to the
severity of the underlying
cause
Most people normally
experience this when they
overexert themselves
The impact on a persons life
Develops slowly and the the patients adapts to
his limitations
fatigue, problems concentrating, loss of appetite and
difficulties sleeping.
feeling of loss, helplessness that can lead to depression, anger
and social isolation
may cause anxiety making the emotional problems worse.
feeling of suffocation and thought that death is close
(not an asthmatic person… maybe COPD, maybe adjust by
only walking up 3 stairs at a time)… pt must learn to adapt to
best handle their symptom! Know that the symptom is real
for that person. Can the person on O2 go to the mall w/out
running out?
DYSPNEA
Four major causes
Chronic obstructive
pulmonary disease (COPD)
Heart diseases (cong heart
failure)
Neurological diseases
(guillian barre, spinal cord
injury)
Cancer (spec lung cancer)
Assessment of Dyspnea
Detailed history (past
med hx, how long,
surgery in hx
Physical examination
Chest X-Ray
PFT (pulmonary
function test in resp
dept & look at how
well exhalation &
inspiration is, xenon
gas)
Assessment
Development of dyspnea
When did it start? was it years, months,
weeks or hours ago
How has it developed? : steady progression,
attacks, acute exacerbations (walking or cat
hair or pollen)
How does it feel ? (compressing
Do you experience more than one sort of
shortness of breath? (some may be brought
on by cough or feels tight like asmatic,)
Assessment
How does it affect daily activities?
Are you able to ------- without becoming breathless?
1.
2.
3.
4.
5.
...climb a hill or stairs (how many)....
...walk on the flat...
...walk more than 100 meters...
...walk indoors....
…on mild exertion (such as undressing)...
Are you breathless at rest? How many pillows do you sleep
on, do you sleep in a chair?
Assessment
Attack of dyspnea
Do you get attacks of breathlessness where you are also
frightened?
when do you experience them?
how do they develop?
how do you cope with them?
It is important to try to find out if the patient experience fear because of
the dyspnea or it is the anxiety that causes the patient to hyperventilate
and thus become dyspneic.
(usually there is more fear w/ a pt who has newer onset of symptoms)
Assessment
other considerations
Provoking factors
What makes it worse? Better?
Treatments already tried: medication (Inhaler),
physical therapy (to get strength back), oxygen…
(often not a lot that can be done w/ many of
these symptoms… we can’t fix lungs on COPD
patient… we just work on managing the
symptoms… pain, anxiety
SPECIAL CONSIDERATIONS WITH DYSPNEA
Loosen clothing
Support with pillows
Administer Oxygen
Position
High Fowler’s
Forward leaning
REMEMBER: Treat underlying cause
Nursing Diagnosis
• Dyspnea
NANDA:
» Airway clearance, ineffective (first two are much more common)
» Breathing pattern, ineffective
» Suffocation, inability to sustain spontaneous (not as much)
NIC
» Respiratory management
» Ventilation assistance (cpap or oxygenation)
Pharmacologic therapy
Opioids:
patients with moderate to severe dyspnea
work by slowing down the rate of respiration, thus
allowing the patient to breath more efficiently. (morphine
decreases pain & vasodialates some… codeine is also
good)
Anxiolytics such as lorazepam (Ativan) or xanyx (something to
relax them
Many patients have attacks of dyspnea that lead to a state
of panic
Bronchodilators and oxygen
COUGH
Important protective
mechanism (to get rid of
junk in lungs & keep stuff
from entering lungs, we
don’t want to totally take
away cough as it does good
stuff)
Symptom
Body’s way of removing
foreign material or mucous
from the lungs and throat
COUGH as a SYMPTOM
Acute – lasting less than
three weeks
Chronic – lasting three to
eight weeks or longer
NOTE: they are not mutually
exclusive
Non-productive – noisy forceful
expulsion of air from the lungs
that doesn’t yield sputum
Productive – sudden, forceful,
noisy expulsion of air from the
lungs that contains sputum or
blood (or both)
CAUSES OF COUGH
A mechanism to clear the airways from sputum or other
agents in the lungs or trachea.
– the sputum is too thick and dry
– there is a continuous production of sputum
A stimulation of the cough reflex producing a dry cough
– the cough may cause an irritation of the airways further stimulating
the cough (w/in all bronchial tubes, very receptive allergic response…
stimulation to contract, close off & push things out. Diaphragm is
strong muscle that will push things out. Post nasal drip can be bad
early in the morning, as well as cystic fibrosis or COPD… lung
secretions dropping into the lung all night long.. This is one reason we
turn them every 2 hours & keep head of bed up to at least 30 degrees)
– the cause of the cough may not be obvious.
– If person has ARDS (acute resp distress syndrome… fluid in lungs… turn
to left side, compresses heart… shifts fluid from lungs onto heart
which further compresses heart & drops heart rate… don’t turn on left
side for this)
Causes due to cancer:
involvement of the major airways
pleural effusions
primary lung cancer or lung metastasis
mediastinal involvement
pericardial effusion
tracheoesophageal fistula (hole between trachea &
esophagus, most often causes by pt having both intubation &
NG tube in… they rub together & cause irritation… fistula)
radiation therapy of the lungs and major airways. (causes scar
tissue on lungs)
Cause unrelated to cancer (cough):
asthma, COPD, infections
postnasal drip
pulmonary embolism
Aspiration (common with stroke pts because
they can’t swallow well… neurologic damage…
need to check if they can swallow well before
giving food…, keep head of bed up & chin
down)… get food or fluid in lungs… you get
pneumonia
congestive heart faliure
gastroeosophageal reflux (GERD)
hepatic absess
INITIAL ASSESSMENT OF COUGH
Patient’s History – Including recent
illness, surgery or trauma
Character of Cough
Chest X-Ray
Medications (ACE inhibitors)
Smoker
Recent exposure to fumes or
chemicals
Allergies
PHYSICAL EXAMINATION:
– General appearance
– Vital signs
– Respirations depth & rhythm
– Check nose & mouth
– Check neck
• Trachea deviation (late
stage… maybe mass)
• Distended neck veins
• Enlarged lymph nodes
– Chest evaluation
– Examination of abdomen
NURSING DIAGNOSIS
COUGH –
effective/ineffective
Ineffective airway clearance
r/t
– Decreased energy
– Fatigue
– Increased age
– These are for SOB & cough
COMPLICATIONS OF COUGH
Perception that something is wrong
Exhaustion
Feeling self-conscious
Insomnia
Life-style change
Musculoskeletal pain
Hoarseness
Excessive perception
Urinary incontinence
CHRONIC COUGH
Treatment for Cough
Identify the cause
If underlying disease TX the
disease
Patient education
Antitussives
Expectorants
Antihistamines
Decongestants
Tincture of time (suck it up)
(bring sputum up, maybe
decongestant to stop the mucus,
nebulized saline …netti pots)
Humidifier or
dehumidifier
Nebulized saline
Pulmonary rehabilitation
Relaxation exercises
Case Study
Mrs. Carter is a 56 year old female who was seen five days ago in the clinic by
the nurse practitioner for her cough. Her cough has lasted about 2 weeks and
6 days at the time of her visit. She calls in today still complaining of a cough
and now a feeling of “shortness of breath”. Mrs. Carter if 5’6’ and weighs
187lbs. Mrs. Carter denies any nausea and vomiting, she periodically feels
“warm” and flushed , but is afebrile. Her past medical history: she has no
know allergies; she smokes 1 pack of cigarettes/day for 10 years. Her present
medicine include a medicine for her hypertension and Tylenol PRN for her
arthritis pain. Mrs. Carter reports that she had not had a good night’s sleep
for the past week. She lives with her husband who is also a smoker. She also
has a new cat. She asks what should she do?
What other information do you want from Mrs. Carter?
What do you tell her? Patient education?
Nausea & Vomiting
Nausea is the uncomfortable feeling of needing to vomit
Wavelike symptom, associated with pallor, flushing, tachycardia, diaphoresis
The patient feels sick and does not want to eat, has less energy and may lose
weight.
Vomiting or emesis occurs when the contents of the stomach are propelled
out through the mouth, induced by contractions of the abdominal muscles
and diaphragm.
Vomiting often occurs in connection with nausea. The cause and the
treatment is the same, but vomiting can also occur as the only symptom
Both nausea and vomiting are protective mechanisms against toxins
(may be assoc w/ tachcardia, flushing, diaphoresis may be related to cholergenic
track…
Often chemo will cause vomiting w/out nausea
Mechanisms of N & V
• Activation of neurons in the medulla oblongata,
called the vomiting center
• Activated by the cerebral cortex r/t:
– anticipation, fear, memory
– signals from sense organs sights, smells, pain
– vestibular apparatus in inner ear with motion sickness
• Chemotherapeutic agents stimulate
enterochromaffin cells in the GI tract to release
serotonin, activates the vagal afferent pathway
and triggers the vomiting center (won’t ask
questions about entero cells on test)
Mechanisms of N & V
• Activated by stimuli that effect the chemoreceptor
trigger zone: CTZ, on the surface of the brain and is
outside of the blood-brain barrier (may see CTZ again)
chemo always goes to hair, GI & ? Cells… read about
this!!)
– Triggered by signals from the stomach, small intestine or
emetogenic compounds, like ipecac, opiods (big side effect
of morphine & dilaudid)
– Neurotransmitters identify substances as harmful and
relay impulses to the vomiting center (activated charcoal
will do this)
• Neurotransmitters are: serotonin, dopamine, acetylcholine,
histamine and substance P (released by opiods & pain receptors)
• Antiemetics work to block these neurotransmitters
Major causes of N & V
Drug/treatment induced
Labyrinth disorders
Endocrine causes
Infectious causes
Increased intracranial
pressure
Post-operative
CNS causes
Cancer chemotherapy
Opiates
Nicotine
Antibiotics
Radiotherapy
Motion
Meniere’s disease
Pregnancy
Gastroenteritis
Viral labyrinthitis
Haemorrhage
Meningitis
Anaesthetics
Analgesics
Procedural
Anticipatory
Migraine
Bulimia nervosa
Factors influencing N & V
Higher cortical
centres
Chemotherapy
Anaesthetics
Opioids
Chemoreceptor
Trigger Zone
(area prostrema,
4th ventricle)
Chemotherapy
Surgery
Radiotherapy
Stomach
Small intestine
Memory, fear, anticipation
Vomiting Centre
(medulla)
Vomiting Reflex
Labyrinths
Surgery
Neuronal pathways
Factors which can
cause nausea & vomiting
Assessment
Distinguish between the 3 main causes:
Local: Is the nausea localized in the abdomen? (neurologic,
toxic problem… medication, is it CNS, affected by
movement)
Toxic: Is the nausea systemic – does the thought of food
provoke nausea?
CNS: does the nausea become worse when the patient
moves? – is the nausea provoked by specific situations?
Assessment
How severe is the nausea ?
How much does it interfere with the patient's
life? (if it from motion sickness, give them
something for that)
How often does the patient vomit? (if it is
continuous, give them something to stop
it/prevent deyhdration)
How much food and fluids is the patient able to
keep down? (most imp is to see how affecting
electrolytes & hydration)
Assessment
What is the patient vomiting?
Phlegm
Digested food (the stomach has had
time to work)
Undigested food (vomiting just
after meals or the stomach is not
functioning)
Strong yellow fluid (gastric acid)
Blood-tinged or coffee-grounds
appearance (the patient is
bleeding from stomach or
esophagus)
Green: bile (liver, gall bladder,
pancreas)
Fecal: (smells and looks like feces)
– indicating bowel obstruction
and that the patient needs to be
assessed immediately.
Assessment
What other symptoms?
Irregular bowel movements:
Constipation may be an (additional) factor
Heartburn, a feeling of hunger, pain in the
epigastrium:
Too much gastric acid (dyspepsia) may be
an (additional) factor
Headaches, disturbances of vision or neurological
abnormalities:
The cause may be raised intracranial
pressure. (often subdural bleed slowly
progresses… find them dead 5 days after
the head injury)
Nausea: NOC Outcomes
Comfort level, hydration, nausea and vomiting
severity, nutritional status, food and fluid
intake, nutrient intake
Client will
Report relief from nausea
Explain methods to decrease nausea
Nausea: NIC Interventions
Distraction, medication administration,
progressive muscle relaxation, simple guided
imagery, therapeutic touch
Apply a cold washcloth to forehead
Assess for fluid and electrolyte imbalances
Provide frequent oral care
Main anti-emetic drugs
Serotonin receptors: (works on the
brain… works sooner than the
dopamine
Dopamine receptors:
(longer wait than the serotonin
meds… works on GI tract)
Some pts do better on one meds
than on another
•
•
•
•
•
•
•
•
Ondansetron (Zofran) used a lot for
chemo
Ganisetron (kytril)
Dolasetron (anzemet)
(act on the vomiting chemo sites in
the brain
Promethazine (Phenergan) (very
irritating to veins, mix w/ saline, can
make pt very sleepy)
Chlorpromazine (thorazine) often
given for hiccups post-op
Prochlorperazine (Compazine)
Supposatories work better if not
already vomiting
Main Antiemetics
• Dopamine receptors:
• Histaminic receptors:
• Muscarinic cholinergic
receptors:
• Droperidol (Inapsine) used in
PACU some, has had some
controversary
• Haloperidol (Haldol)
(antipsychotic)
• Metoclopramide (Reglan)
(increases peristalsis in GI
tract… we will see this again!!,
clears out GI tract
• Dimenhydrainate (Dramamine)
motion sickness
• Meclizine (Antivert)
• Scopolamine (cholergenic
receptors… patches
Other medications for antiemesis
• Glucocorticoids:
• Cannabinoids (central
sympathmimetic action):
• Benzodiazipines (Limbic
system inhibition):
• Dexamethasone (Decadron)
• Methylprednisolone (solumedrol) (can be used for pts
w/ brain injuries… takes
swelling down)
• Dronabinol (Marinol) (stop
nausea & increases
appetite)
• Lorazepam (Ativan) (affect
emotional state, calm you
down)
Types of nausea and vomiting
Post-operative nausea and vomiting (PONV)
Opioid-induced nausea and vomiting (morphine related)
Chemotherapy- and radiotherapy-induced (CINV or (RINV)
Nausea and vomiting in early pregnancy
Motion sickness and vestibular disorders
Drug treatment of nausea and
vomiting
Higher cortical
centres
Sensory input (pain, smell, sight)
Memory, fear, anticipation
Histamine antagonists
Muscarinic antagonists
Dopamine antagonists
Cannabinoids
Chemotherapy
Anaesthetics
Opioids
Chemoreceptor
Trigger Zone
(area prostrema,
4th ventricle)
Benzodiazepines
Vomiting Centre
(medulla)
Vomiting Reflex
5HT3
antagonists
Class
Sphincter modulators
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Stomach
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Radiotherapy
Gastroprokinetic
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Neuronal pathways
Factors which can
cause nausea & vomiting
Sites of action of drugs
Home care
Family centered approach
Teach about regimen
Develop full medication profile
Assess for drug interactions
Take antiemetics whenever nausea begins or
before you anticipate stimuli occurring, such as
prior to chemotherapy and motion
Discuss alternatives, such as music, TENS,
acupuncture or acupressure, aromatherapy,
herbs (ginger)
What is pain?
Pain is whatever the person experiencing
it says it is, existing whenever
the person says it does.
(Lewis, Heitkemper & Dirksen, 2004, p. 132)
Pain is the body’s response to illness: it is the first thing many
people associate with illness and what they fear most.
(Frank, 1991, p. 29)
Pain type
Acute pain occurs suddenly usually in association with known
trauma. signs of acute pain: sweating, pallor, perhaps nausea.
(can also cause diaphoresis, nausea…)
Subacute pain develops over several days, often increasing in
intensity with a pattern of progessive pain symptomatology.
Typical cancer pain. (may or may not increase w/ intensity)
Episodic pain occurs over shorter periods of time at regular or
irregular intervals. Arthritic pain that comes and goes is an
example.
Chronic pain
Pain that has persisted for more than 3 months.
– There is an adaptation of the autonomic system and there may not be any
objective signs.
– Characterised by significant changes in the person's personality, lifestyle and
functional ability.
• Importance to acute and subacute pain before becomes a
more complex chronic pain state.
• Chronic pain will change your whole way of life… life can
become centered around the pain
Continuous pain
Baseline pain:
Is the pain reported as an average pain intensity for 12 hours or more out
of 24hrs.
Breakthrough pain:
pain more severe than the baseline pain
End of dose pain:
pain occurring before the next dose of analgesics is due
Whatever they tell you is painful… you need to take it at face value… when
they are in the acute care setting, you are not going to cure them of an
addicton… we don’t w/hold pain meds during acute care meds
Main reason to give pain meds is so they can recover easier / faster
Nociceptive pain
damage to normal tissue
Somatic
well-localized, sharp,
aching, throbbing, pressure
Inflammatory
Muscular
Visceral
Originates in internal organs
diffuse, gnawing, aching,
sharp, cramping, throbbing
Referred pain (gall bladder
& pancreatic pain will
radiate to the left shoulder.)
Almost always responsive to opioids
Neuropathic pain
Caused by an injury to the peripheral or central
nervous system and causes a pain that is in excess of
the initial injury
Overlaying this is a pain that comes without
provocation and may last from a few seconds to
minutes it is described as pins and needles, a burning
pain or a stabbing pain like a knife or a needle.
Pain to the nerve endings: damage or cutting to nerve
endings… phantom limb pain after amputations
Mechanism for pain
• Stimuli begins in the periphery, the impulse is
transmitted to the spinal cord and then to the
central area of the brain. If not transmitted, no
pain occurs (gate theory). Two fibers transmit
pain:
– A delta fibers- skin and muscle. Myelinated and carry
rapid, sharp, piercing sensations, localize feeling
– C fibers- (more internal organ pain)muscle,
periosteum and viscera. Unmyelinated and conduct
thermal, chemical and strong mechanical impulses;
pain is slow, diffuse, dull and burning, usually
persistent pain. (arthritic, cancer, bone pain)
Gate Control theory
• Gate Control (1982) – gating mechanism occurs in
the spinal cord, nerve fibers (A &C) transmit pain
impulses to the dorsal horn of the spinal cord
(substantia gelatinosa), where gating mechanism
is, if gate is open, impulses go through, if not, no
painful stimuli (if the gate is open, brain fibers are
stimulated.. .goal of pain meds is to stop/close
gate… this is how opiods work)
• Endorphins- morphine like substances are
released from large diameter nerve fibers and
close the gate (morphine stimulates… )
Reactions to acute pain:
Physically, besides the actual pain you may feel faint,
nauseous and you may be sweating.
Your body will try to adapt by tensing the muscles around the
painful area and unconsciously adapt a unusual posture in
order to minimize the pain. (tensing will make the pain worse)
you may feel restless and worry about the cause of the pain
and the possible consequences it may have (anticipation can
also aggravate it… )
Reactions to chronic pain
Find a position of comfort (find what helps the patient…
sometimes sleep helps)
There is little energy left for all the other issues of life.
Chronic pain leads to fatigue and sleep disturbances.
If the patient has other physical symptoms such as dyspnea or nausea
these will interact with the perception of pain.
Activities of daily living will be affected.
Emotional pain
The effort of coping with the pain will leave
the patient drained of energy
The pain will often symbolize the threats that
the patient is facing..
The pain will be a constant reminder of how
serious the situation is.
Psychological pain
If the pain is persistent it may cause depression
The stress of the constant pain may also cause anxiety (with
symptoms such as abnormal fears, restlessness and tension).
Anxiety and depression will often aggrevate the pain. It is
therefore important to diagnose and treat both conditions at
the same time.
(withdrawl…)
Social pain
The patient is is part of a family and the family members
will be affected by the patient's situation.
Seeing the patient in pain may make the family members
feel even more helpless.
The change in the ability to perform daily activities will
often lead to a change of roles in the family, which may
be difficult for the patient to accept.
Clinical examination
How the patient moves: is he in pain when he walks, does he
favor one leg?
How he sits down: Is it with difficulty? (evidence of back pain)
How comfortable is he sitting in a chair: is he relaxed and
moving freely or is he constantly guarding to avoid painful
movements?
Are there any particular movements that cause pain?
Look at: how does it affect ADLs… can they get dressed,
move, walk, bathe, eat
For each painful area:
Ask the patient to show you where it hurts.
Ask the patient to show you "how it hurts" i.e. where the
different qualities of pain are.
Look at the area in a good light and note any skin changes.
Gently examine the area for changes in sensitivity, palpate the
area to find any abnormal lesions.
If it is in a limb: examine mobility (by passive movement) and
strength.
Nursing Diagnosis:
Acute Pain
Sudden onset
Manifests as SNS activation
Subjective - Self-report most reliable indicator
Objective - what does the pain look like?
R/t actual or potential tissue damage
mechanical, thermal or chemical
P : precipitation
Q: quality
R: radiating
S: severity
T: timing
NOC Outcomes
Comfort level, pain control, pain level, pain: disruptive effects
Client will:
Use systematic self-report to set goals and track
progress
Describe treatment regimen
Function safely with adequate cognitive ability while on
treatment
If cognitively impaired, demonstrate reduction in pain
behavior and perform ADLs satisfactorily
NIC Interventions
Analgesic administration, pain management, PCA assistance
Treat first if having pain at time of interview
Assess as reviewed earlier
Assume pain for nonverbal client who cannot use scale if:
Classic pain behaviors
Had procedure known to cause pain
Explore need for pain medications using ladder
(collaborative)
If the pt can’t talk, look at facial expressions, heart rate & BP,
w/drawing…
NIC Interventions:
Acute Pain
Establish treatment regimen with physician/ARNP and
administration schedule
Assess for side effects of opioid medication side effects.
Discuss client fears re: undertreated pain, addition and
overdose
Evaluate outcomes using pain diary, client report
Nursing Diagnosis:
Chronic Pain
NOC
Comfort level, pain control, disruptive effects, pain level
NIC
Analgesic administration, pain management
Adverse effects of unrelieved pain
Use of pain diary
Plan activities during times of greatest comfort
Titration of pain medication - use of standard orders
WHO Pain Ladder
Bottom rung of ladder
(mild pain): Non opioid
+/- adjuvant
We will see questions
about this!!
• Acetaminophen (tylenol)
for mild pain
• NSAIDS (bottom rung of
ladder
–
–
–
–
Aspirin
Ibuprofen (motrin)
Naproxen (naprosyn)
Ketoprofen (toradol-only
given 6 doses-decrease
swelling, orudis)
– Etodolac(lodine)
– Celecoxib (celebrex)selective cox 2 inhibitor
WHO Pain Ladder
Next rung of ladder
(worse pain): Weaker
opioid +/- non opioid +/adjuvant (given as an
assist to other med)
•
•
•
Highest rung of ladder
(worst pain): Strong
opioid +/- non opioid +/adjuvant
• Morphine/ fentanyl &
dilaudid are big 3… don’t
see percodan as much
•
•
•
•
•
•
•
•
Codeine
Darvocet
Butorphanol (Stadol)-not given as
often
Nalbuphine (Nubain)-problems w/
these… reaction…
Morphine
Fentanyl
Hydrocodone (Vicoden)
Oxycodone (oxycontin, percodan)
Hydromorphone (Dilaudid)
Methadone (
Meperidine (demerol)- not used,
bad metabolite… can trigger seizure
activity.
WHO pain ladder
• Adjuvants
– Tricyclic antidepressants:
– Anticonvulsants:
– Have GABAs
• Amitriptyline (elavil)
• Desipramine (norpamin)
• Nortriptyline (pamelor)
•
•
•
•
•
•
Gabapentin (neurontin)
Pregabalin (lyrica)
Valproic acid (depakene)
Topiramate (topamax)
Clonazepam (klonopin)
Baclofen (lioresal) muscle
relaxant
WHO pain ladder
• Other adjuvants:
– Alpha-2 adrenergics
– Local anesthetics
– NMDA antagonists
• Clonidine (catapres) be
really careful, drop in BP
• Tizanidine (Zanaflex)
• Mexiletine (mexitil)
• Lidoderm (patch, used w/
children to numb before IV)
• Ketamine (numb throat)
• Dextromethorphan
(coughing
Opioid receptor• Bind to Mu receptors and block release of
substance P, preventing the transmission of
pain
WHO pain ladder?
"If a pain occurs, there should be a prompt oral
administration of drugs in the following order: non-opioids
(aspirin or paracetamol); then, as necessary, mild opioids
(codeine); or the strong opioids such as morphine, until the
patient is free of pain. To calm fears and anxiety, additional
drugs - "adjuvants" - should be used. To maintain freedom
from pain, drugs should be given "by the clock", that is
every 3-6 hours, rather than "on demand".
“…since it was introduced in 1986 there has been a major
development in the field of palliative medicine and thus
some of the recommendations have been modified:
Pain relief should be provided to all seriously ill and dying
patients, not only cancer
the middle step of the ladder using mild opioids is often
skipped in seriously ill and dying patients as their pain is
so severe that strong opioids are needed.
Adjuvant drugs should also be used to treat neuropathic
pain and other specific pain conditions.
Case Study #1
A 76 y/o man is in a home hospice program with end stage metastatic
prostate cancer and severe COPD. He complains of back pain
secondary to multiple bone metastases. He rates the pain at 9/10,
severely limiting his movement. The pain is poorly relieved by 120
mg q8h of Oramorph SR and ibuprofen 600 mg q6h. The patient
understands his condition is "terminal" and wants maximal pain relief.
He does not wish to return to the hospital for any further tests or
procedures since he has already had maximal doses of radiation,
89Strontium, and hormonal therapy.
Case Study #2
The home hospice nurse contacts the primary physician and asks
to have the dose of opioid increased, the physician agrees-the new order is for Oramorph SR 150 mg q8 with MSIR 15
mg. q4 for breakthrough pain. Two days later the nurse calls
the physician saying that the increased dose has not reduced
the severity of pain and the dose of breakthrough MS is not
effective either. The nurse suggests increasing the Oramorph
SR to 300 mg. q8h. The physician explains to the nurse that
due to COPD the patient is at great risk for opioid-induced
respiratory depression and that other, non-opioid, analgesic
modalities should be tried rather than increasing the
Oramorph SR.
Maybe try ativan to relax them… maybe a muscle relaxant…
neurontin … what ever it takes to make them comfortable!
Questions
What are the patient and drug risk factors for respiratory
depression?
If the patient's respiratory rate dropped to 6-8 breaths/min while
he was asleep what would you do? (nothing… he should have an
advanced directive if he is a hospice patient)
What would be your legal liability if this patient died soon after a
dose of morphine? (none, he was terminal & would die anyways
as long as there were orders for this) Would this be euthanasia?
(depending on what you gave, but probably not!)
DIFFERENTIATING “REAL” PAIN FROM ADDICTION
Case Study #3
A 25 y/o man has been hospitalized for 2 weeks with newly
diagnosed lymphoma. He is being treated with combination
chemotherapy. Ten days after the start of chemotherapy he
develops severe pain on swallowing--upper GI endoscopy
reveals herpes simplex esophagitis. He is unable to eat solid
foods due to the pain although he can swallow some liquids.
The pain is described as "really bad" and is not relieved by
acetaminophen with codeine elixir ordered q4h prn.
Case Study #3 continued
The patient repeatedly asks for something for pain prior to the 4
hour dosing interval and is often seen moaning. The physician is
concerned about using an opioid of greater potency or
administering opioids more frequently because the patient
admitted to a history of poly-drug abuse, although none in the last
two years. The nurses are angry at the patient because of the
repeated requests for medication and have written in the chart
that the patient is drug seeking, possibly an addict.
We needs to give him something else, if we can… has to be what
the physician orders. Sometimes you need to be really direct w/
the doc… “I think you need to come in & see this patient”
Questions
1.
Put yourself in the position of the resident physician or staff nurse--what are their major concerns about providing stronger analgesics to
this patient? List at least four fears/concerns.
2.
Is this patient a drug addict? (don’t think so) List criteria you would you
use to decide that the patient was drug seeking for illicit or euphoric
purposes rather than for relief of pain?
Addiction
• Addiction: disease state that is characterized by
impaired control over drug use, occurs over time
usually from unrelieved pain
• Tolerance: adapt to the drug’s benefit over time,
usually r/t receptor binding sites or excretion (need
higher & higher tolerance to get the benefit)
• Physical dependence: exhibits as withdrawal
symptoms from cessation of the drug, usually opiods
over a long period of time; signs are N&V, abdominal
cramps, muscle spasms, diaphoresis, delirium
• Terms we need to know the difference!!!
Fever
• Fever (pyrexia) medical sign: classed as temp over 101F or 38 C,
chills(vasoconstriction prevents heat loss) and malaise
• Normal immune response that can help to destroy pathogens (we don’t
treat fevers under 101, so it can kill what is wrong)
• Regulated in the hypothalamus. Pyrogen causes a release of prostaglandin
E2, E2 goes to the hypothalamus and triggers the systemic response.
Pyrogens can be:
– Endogenous- cytokine (interleukin 1) from phagocytic cells or IL-6 and
TNF
– Exogenous- LPS (lipopolysaccharide) present on the cell wall of gram
negative bacteria; LPS binds to the CD14 receptor on a macrophage,
this causes IL-1, IL-6 and TNF to be released (don’t have to remember
all of this)
If it gets to 106 (brain damage in an adult)… children can tolerate highter
temps
The fever is the body immune response
Fever Classifications
• Low grade
• 38-39 C/ 100.4-102.2
• Moderate
• 39-40C/ 102.2-104.0
• High-grade
• 40-41.1C/104-106
• Hyperpyrexia
• >41.1/ 106 (not
compatible with life)
• Tylenol is best to bring
down fever… not aspirin
anymore, ice packs,
cooling blankets
Causes of Fever
• Infectious disease
• Skin inflammation
• Immunological diseases
(lupus, IBD)
• Tissue destruction
(surgery, trauma; we
don’t treat under 101)
• Drug fever
(chemotherapy, allergic
reaction)
• Reaction to blood
products
• Cancers
• Metabolic disorders
(gout)
• Thrombo-embolisms
Treatment of Fever
• Medications:
– Antipyretics
• Aspirin
• Acetominophen
• Ibuprofen
• Administer when temp
is > 38 C /101
• Other treatment:
– Water intake
– Wet cloths to neck or
forehead, under armpits
– Sports drinks
– Cool environment
Palliative Care
• What does this mean? (make pt comfortable)
• How is palliative care implemented in the acute
care setting? Distraction, lights off
• Goal is to prevent and relieve suffering
• What types of resources may be needed?
• What is the difference between a living will and
DNR? (AND… allow natural death), you need an
order from physician for a DNR. DNR is recinded
during surgery. May allow for meds, but not
ventilation…
• What is a health care surrogate?
• Palliative care