Linda K. Connelly, ARNP, MSN M. Catherine Hough, PhD, RN

Updated: C. Cummings RN, EdDUniversity of North Florida

College of HealthSchool of Nursing

SYMPTOM MANAGEMENT

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

MANAGEMENTDEFINITION:

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 breathingUsually reported as shortness of breathSeverity varies greatly but is often unrelated to the severity of the underlying causeMost people normally experience this when they overexert themselves

The impact on a persons lifeDevelops 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 isolationmay 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 hxPhysical examinationChest X-RayPFT (pulmonary function test in resp dept & look at how well exhalation & inspiration is, xenon gas)

AssessmentDevelopment of dyspnea

When did it start? was it years, months, weeks or hours agoHow has it developed? : steady progression, attacks, acute exacerbations (walking or cat hair or pollen)How does it feel ? (compressingDo 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. ...climb a hill or stairs (how many)....2. ...walk on the flat...3. ...walk more than 100 meters...4. ...walk indoors....5. …on mild exertion (such as undressing)...Are you breathless at rest? How many pillows do you sleep on, do you sleep in a chair?

AssessmentAttack 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)

Assessmentother considerations

Provoking factorsWhat 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 clothingSupport with pillowsAdminister OxygenPosition

High Fowler’sForward 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 therapyOpioids:

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 themMany patients have attacks of dyspnea that lead to a state of panicBronchodilators and oxygen

COUGHImportant 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 sputumProductive – 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 airwayspleural effusionsprimary lung cancer or lung metastasismediastinal involvementpericardial effusiontracheoesophageal 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, infectionspostnasal drippulmonary embolismAspiration (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 CoughChest X-RayMedications (ACE inhibitors)SmokerRecent exposure to fumes or chemicalsAllergies

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 DIAGNOSISCOUGH –effective/ineffective

Ineffective airway clearance r/t– Decreased energy– Fatigue– Increased age

– These are for SOB & cough

COMPLICATIONS OF COUGHPerception that something is wrongExhaustionFeeling self-consciousInsomniaLife-style changeMusculoskeletal painHoarsenessExcessive perceptionUrinary incontinence

CHRONIC COUGH

Treatment for CoughIdentify the causeIf underlying disease TX the diseasePatient educationAntitussivesExpectorantsAntihistaminesDecongestantsTincture 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 & VomitingNausea is the uncomfortable feeling of needing to vomitWavelike symptom, associated with pallor, flushing, tachycardia, diaphoresisThe 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 symptomBoth 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 & VDrug/treatment - induced

Cancer chemotherapy Opiates Nicotine Antibiotics Radiotherapy

Labyrinth disorders Motion Meniere’s disease

Endocrine causes Pregnancy Infectious causes Gastroenteritis

Viral labyrinthitis Increased intracranial pressure

Haemorrhage Meningitis

Post-operative Anaesthetics Analgesics Procedural

CNS causes Anticipatory Migraine Bulimia nervosa

Factors influencing N & V

Vomiting Centre (medulla)

StomachSmall intestine

Higher cortical centres

Chemoreceptor Trigger Zone

(area prostrema, 4th ventricle)

Memory, fear, anticipation

Surgery

SurgeryLabyrinths

Anaesthetics

Vomiting Reflex

Neuronal pathways

Factors which can cause nausea & vomiting

Chemotherapy

Chemotherapy

Radiotherapy

Opioids

AssessmentDistinguish 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?

PhlegmDigested 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.

AssessmentWhat 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 intakeClient will

Report relief from nauseaExplain methods to decrease nausea

Nausea: NIC Interventions

Distraction, medication administration, progressive muscle relaxation, simple guided imagery, therapeutic touchApply a cold washcloth to foreheadAssess for fluid and electrolyte imbalancesProvide 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 (solu-

medrol) (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 pregnancyMotion sickness and vestibular disorders

Drug treatment of nausea and vomiting

Vomiting Centre (medulla)

StomachSmall intestine

Higher cortical centres

Chemoreceptor Trigger Zone

(area prostrema, 4th ventricle)

Memory, fear, anticipationSensory input (pain, smell, sight)

Surgery

SurgeryLabyrinths

Anaesthetics

Vomiting Reflex

Neuronal pathways

Factors which can cause nausea & vomiting

Chemotherapy

Chemotherapy

Radiotherapy

Opioids

Sites of action of drugs

5HT3

antagonists

Sphincter modulators

Histamine antagonistsMuscarinic antagonists

Gastroprokinetic agents

BenzodiazepinesHistamine antagonistsMuscarinic antagonistsDopamine antagonists

Cannabinoids

Class

Dr u g

A n ti - chol i nergi c scopola m ine ( L - hyoscine)

A n ti - his t a m ine cinnarizin e cyclizine prom e thazine

Dopa m ine an t agoni s t me t oclopr a mid e dompe r idon e droperido l (w i thdraw n 20 0 1) haloperi d ol

Cannabi n oid nabilo n e

Corticos t eroid dexam e thaso n e

H ist a min e an a logu e beta h isti n e

5HT 3 - recep t or a n tag o nist granisetron ondansetr o n tropis e tron

Home care

Family centered approachTeach about regimen

Develop full medication profileAssess for drug interactionsTake 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 painBaseline 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 paindamage to normal tissue

Somaticwell-localized, sharp, aching, throbbing, pressureInflammatoryMuscular

VisceralOriginates in internal organs diffuse, gnawing, aching, sharp, cramping, throbbingReferred 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 painIf 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 onsetManifests as SNS activationSubjective - Self-report most reliable indicatorObjective - what does the pain look like?R/t actual or potential tissue damage

mechanical, thermal or chemical

P : precipitationQ: qualityR: radiatingS: severityT: timing

NOC Outcomes

Comfort level, pain control, pain level, pain: disruptive effectsClient will:

Use systematic self-report to set goals and track progressDescribe treatment regimenFunction safely with adequate cognitive ability while on treatmentIf cognitively impaired, demonstrate reduction in pain behavior and perform ADLs satisfactorily

NIC InterventionsAnalgesic administration, pain management, PCA assistance

Treat first if having pain at time of interviewAssess as reviewed earlierAssume pain for nonverbal client who cannot use scale if:

Classic pain behaviorsHad 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 overdoseEvaluate outcomes using pain diary, client report

Nursing Diagnosis: Chronic Pain

NOCComfort level, pain control, disruptive effects, pain level

NICAnalgesic administration, pain managementAdverse effects of unrelieved painUse of pain diaryPlan activities during times of greatest comfortTitration 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 #2The 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!

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!)

Questions

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”

Questions1. 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

• Moderate

• High-grade

• Hyperpyrexia

• Tylenol is best to bring down fever… not aspirin anymore, ice packs, cooling blankets

• 38-39 C/ 100.4-102.2

• 39-40C/ 102.2-104.0

• 40-41.1C/104-106

• >41.1/ 106 (not compatible with life)

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