Transcript PAIN - Shantou University

CANCER PAIN
Kathy Coulson, RN, MScN,
ACNP, CHPCN(C)
Advanced Practice Nurse
Palliative Care
PALLIATIVE CARE
CURATIVE TREATMENT
BEREAVEMENT
PALLIATIVE CARE
Diagnosis
Death
PAIN
“Pain
is whatever the
experiencing person
says it is, existing
whenever he/she says it
does”
M. McCaffery, R.N., M.S., F.A.A.N.
TOTAL PAIN
Visible Pain
PHYSICAL
EMOTIONAL
SPIRITUAL
SOCIAL
“SUFFERING”
Hidden Pain
CANCER PAIN
VISCERAL
SOMATIC
NEUROPATHIC
CANCER PAIN
Visceral: poorly localized, stretching,
deep aching, distention, cramping
examples: liver capsule pain
bowel obstruction
CANCER PAIN
Somatic: localized, throbbing, aching
example: bone pain (metastasis)
CANCER PAIN
Neuropathic: burning, shooting,
stabbing, numbness, tingling
examples: nerve damage
cord compression
VISCERAL PAIN
PHARMACOLOGIC
opioids
anti-spasmodics (baclofen,
Buscopan)
dexamethasone
BONE PAIN
PHARMACOLOGIC
OTHER MODALITIES
NSAIDs
opioids
bisphosphonates
calcitonin
chemotherapy
dexamethasone
radiotherapy
splints/braces
surgical fixation
positioning +/support surfaces
NEUROPATHIC PAIN
PHARMACOLOGIC
TCA (amytriptilline)
anticonvulsants
(valproic acid,
carbamazepine,
gabapentin)
dexamethasone
opioids
OTHER MODALITIES
acupuncture
nerve blocks
(intercostal, celiac
plexus)
TENS
PAIN ASSESSMENT
Onset and pattern
Location
Description (in pt’s own words)
Intensity (use pain score 0-10, validated
pain assessment tools)
Aggravating Factors
Previous Treatment
Effect
MANAGEMENT
By the mouth
By the clock
By the ladder
W.H.O. LADDER
STEP 3
STEP 2
STEP 1
Strong Opioids +/- adjuvant
Weak Opioids +/- adjuvant
Non -Opioids +/- adjuvant
WHO Analgesic Ladder , 1990
W.H.O. LADDER
Step 3 – STRONG OPIOIDS
Morphine
Hydromorphone
Fentanyl
Step 2 – WEAK OPIOIDS
Codeine
Anileridine
Oxycodone
Step 1 – NON OPIOIDS
Acetominophen
NSAIDs
CHOOSING AN OPIOID
Strength depends on severity of pain
DO NOT initiate patients on long acting
preparations (MS Contin®, M Eslon®,
Hydromorph Contin®) or the fentanyl
patch (Duragesic®) until opioid
requirements have been determined
INITIATING OPIOIDS
regular dosing is essential
5 to 10 mg of po morphine q4h (or
equivalent) starting dose, less in elderly or
renal/liver impairment
breakthrough doses of same agent
available q2h (10% of total 24 hour dose)
MONITORING EFFICACY
Use of 3 or more prn’s in 24 hours
indicates need to reassess and possible
increase regular dose
to titrate dose, calculate total mg’s used
in 24 hours and divide by number of
doses in a day
ANTICIPATE SIDE EFFECTS
constipation - permanent
drowsiness - transient
nausea/vomiting - transient
delirium - especially in elderly, or patients
with liver/renal impairment
CHANGING OPIOIDS
Some Indications:
change in pain severity
intolerable side effects
alternate method of delivery needed
opioid toxicity
OPIOID EQUIVALENCIES
DRUG
P.O. DOSE
S.C. DOSE
SCHEDULE
Morphine
20
10
Q4h
Morphine
(long-acting)
60
n/a
Q12h
Hydromorphone
4
2
Q4h
Hydromorphone
(long-acting)
12
n/a
Q12h
Anileridine
75
25
Q4h
Oxycodone
10
n/a
Q4h
200
100
Q4h
Codeine
OPIOID TOXICITY
decreased level of consciousness (LOC)
myoclonus
delirium - fluctuating LOC, impaired
memory/attention, altered perception
symptoms correspond with increase in
dose or decreased need for medication
Patient Management
pain
reassess
listen/believe
Quality of
life
assess
involve
establish
management
CASE STUDY
Mr. P. G.:
72 year old man recently admitted to
hospital for investigation of a lung mass
noted on CXR, suggestive of ca lung.
bronchoscopy-confirmed non-small cell ca
lung with mets to liver, ribs, thoracic
spine, and brain.
palliative radiotherapy to ribs for pain
management.
CASE STUDY
Concurrent history includes heart disease,
type II diabetes, mild chronic renal failure
(cr. 135).
Discharged home with family, CCAC and
community nursing.
 To be followed by FD.
Comment on these orders
OPIOID ORDERS:
morphine 2.5-5mg PO, IM, SC q3-4h PRN
using morphine 5mg q3h 5-6/day
ESAS 5/10 (for pain)
Telephone Call:
Has mucousy cough,
Increased rib cage pain
ESAS 7/10 (for pain)
Using morphine 5mg q4h PO with 6
breakthrough doses in past 24 hours
Wife indicates he was “twitchy” as he
slept and again this morning
Orders Changed
OPIOID ORDERS:
Hydromorphone 1 mg q4h PO and 0.5mg
PO q2h prn
Naprosyn 500mg PO bid prn
Telephone Call:
more comfortable (used b/t twice in past
24 hours)
less twitchy
ESAS 3/10 (for pain)