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palliative care exam


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somatic nociceptive paion
aching, deep, dull, throbbing, sharp, well localized
visceral nociceptive pain
diffuse, gnawing, cramping, squeezing, pressure, distant sites
neuropathic pain
burning, numb, radiating, shooting, stabbing, tingling
American pain society definition of pain
"Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"
Type of pain - USUALLY A SUDDEN ONSET WITH A PRECIPITATING CAUSE underlying pathology accompanied by physiological signs warning system protective reflexes
acute pain
Type of pain that extends beyond the normal period of helaing. May be nociceptive, neuropathic or both. May exist with no apparent cause. Can affect virtually any body system or region.
Chronic pain
Cancer pain has characteristics of _____ and ____ pain
acute and chronic
nociceptive pain
Normal processing of stimuli caused by ongoing activation of nociceptors. Indicative of real or potential tissue damage.
Pain that arises from bone, joint, muscle, skin or connective tissue. Presents as an aching, throbbing, well localized pain.
Pain that arises from visceral organs (GI tract, pancrease); tumor involvement, obstruction. Pain presents as cramping, poorly localized.
The transmission of noxious stimuli from the site of insult to the CNS. Has four components: - transduction - transmission - perception - modulation
What are the four components of nociception?
Transduction Transmission Perception Modulation
What is transduction?
Changing noxious stimuli in sensory nerve endings to electrical impulses; occurs in the periphery upon activation of nociceptors
What does the "sensitizing soup" contain and what releases it?
Sensitizing soup = prostaglandins, cytokines, bradykinin, substance P, leukotrienes, histamine, serotonin. In the transduction step, damaged cells release sensitizing substances.
What happens in the transduction step?
Action potential is created - influx of sodium causes depolarization; efflux of potassium causes repolarization
Movement of impulses from the site of transduction to the brain
What are the three phases of transmission?
1st order neuron - from nociceptor fibers to the spinal cord 2nd order neuron - from the spinal cord to the brain stem and thalamus 3rd order neuron - from the thalamus to the cortex
Characteristics of alpha-delta fibers
- sparsley myelinated - FAST conducting - transmit WELL-LOCALIZED, SHARP pain - sensitive to mechanical and thermal stimuli
C fibers
- unmyelinated - SLOW conduction - transmit poorly localized, dull and aching pain - sensitive to mechanical, thermal and chemical stimuli
Recognizing, defining and responding to pain. Pain becomes a conscious experience.
What brain structures are involved in perception?
- reticular system - somatosensory cortex - limbic system
changing or inhibiting nerve impulses. Descending neurons release substances that inhibit transmission of noxious stimuli and produce analgesia
What is neuropathic pain?
abnormal processing of sensory input reflects nervous system injury/impairment commonly caused by trauma, inflammation, metabolic disease, infections, tumors, toxins
pain due to stimulus that does not normally provoke pain
an abnormal sensation, whether spontaneous or evoked
unpleasant abnormal sensation whether spontaneous or evoked
an increased response to stimulus that is normally painful
short acting opioid agent with toxic metabolite; CNS irritant; causes muscle twitching, seizures and death
opioid that takes 4-6 days to get to steady state
opioid that can cause itching due to histamine release
opioid that can be administered IV, epidurally, intrathecally or transdermally; inactive metabolites; highly lipid soluble
How would you determine the dose of an immediate release opioid formulation for breakthrough pain? (not for methadone)
10-15% of the total daily dose or regularly scheduled opioid, q 2-4 prn
if patient is using >3 breakthrough doses/day should you increase the long-acting med?
Yes - complaint of pain 1-5 out of 10, increased 25-50% complaint of pain 6-10 out of 10, increase by 50-100%
if you are switching opioids, how/when should you reduce the dose?
if paint is controlled, reduce the new dose by 25-50%
Adjuvant agents approved for the treatment of neuropathic pain
carbamazepine, gabapentin, transdermal lidocaine, duloxetine, pregabalin
Are SSRIs effective in the treatment of neuropathic pain?
A prokinetic that is useful in someone who gets early satiety
Metoclopramide (reglan)
Corticosteroid that is used for someone with impending bowel obstruction
drugs that work for vestibular nausea, also to dry up secretion
anticholinergics - hyoscyamine, scopolamine, mexlizine
antipsychotic agent used to treat chemical-induced nausea
useful for truly anxiety-induced nausea
antisecretory used in total bowel obstruction

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