Symptom management

Pain

Acute Chronic
a warning that something is wrong and is generally viewed as a adversely affects the patients function or well-being
time-limited experience persistent pain worsens and intensifies with the passage of time:
usually associated with tissue damage, inflammation, a disease o months
process that is relatively brief (i.e. post-surgical procedure) o years
acute pain is of relatively brief duration: o lifetime
o hours may accompany a disease process such as cancer, HIV infection
o days and AIDS, arthritis or degenerative joint disease, osteoporosis,
o weeks COPD, neurological disorders (e.g., multiple sclerosis,
o few months cerebrovascular disease), fibromyalgia, sickle cell disease, cystic
fibrosis, and diabetes.
may also be associated with an injury that has not resolved
within an expected period of time, such as low back pain,
trauma, spinal cord injury, reflex sympathetic dystrophy, or
phantom limb pain

Subcategories of pain (4)

nociceptive pain neuropathic pain mixed or unspecified pain pain due to psychological
disorders
visceral or somatic pain resulting pain caused by peripheral or mixed or unknown pain
from stimulation of pain central nervous system mechanisms
receptors stimulation
 The ABCDE mnemonic - a summary of the clinical approach to pain assessment and management:

AAsk about pain regularly. Assess pain systematically (ongoing evaluation to determine effectiveness of pain relief measures and to
identify new pain).
physical examination should focus on an examination of the painful areas as well as common referred pain locations.
In frail or terminally ill patients, physical examination maneuvers and diagnostic tests should be performed only if the findings will
potentially change or facilitate the treatment plan.
o The burden and potential discomfort of any diagnostic test must be weighed against the potential benefit of the
information obtained.
Pain assessment should be individualized and documented so that all multidisciplinary team members involved will have an
understanding of the pain problem
BBelieve the patient and family in their reports of pain and what relieves it.
CChoose pain control options appropriate for the patient, family, and setting.
DDeliver interventions in a timely, logical, and coordinated fashion.
EEmpower patients and their families. Enable them to control their course to the greatest extent possible.

W-ords to describe pain I-ntensity (0-10) L-ocation D-uration A-ggravating and Alleviating factors
Aching 0 no pain Where is your pain? Is the pain always there? What makes the pain worse?
Burning 10- worst pain Does the pain come and go? What makes the pain better?
Shooting in the last 24h? (breakthrough pain)
Sharp How does your pain affect your:
Stabbing Sleep
Numbing Appetite
Pressure Energy
Throbbing ADL
Squeezing Mood/Relationship
Dull
Cramping Are you also experiencing:
Penetrating N/V
Radiating Constipation
Urinary retention
Itchiness
Sleepiness/Confusion
Palliative Performance Scale
11-point scale designed to measure a pts performance status in 10% decrements from 100% (healthy) to 0% (death)
helps to identify and track care needs as pt is changing with disease progression
provides a framework for measuring progressive decline over the course of illness
provides a best guess projection of length of survival and serves as a communication tool for the team
based on 5 observable parameters:
1. ambulation
2. ability to perform activities and evidence of disease
3. self-care (e.g. self-feed, self-wash)
4. food/fluid intake
5. conscious level

Stable Stage Transitional Stage End-of-life Stage

100%-70% 60%-40% 30%-0%

* Crucial for pts goals of care be reviewed and upheld throughout illness to ensure that Tx to prolong life is aligned with their goals.
If pts with CAD (e.g. CHF) has an automated implantable cardiac defibrillator (AICD), a discussion needs to happen when dying is
evident regarding the deactivation of the defibrillator

Information regarding the prognosis promotes informed person centered decision making and allows pts and families to plan their
remaining time, create advanced directives, avoid potentially burdensome interventions that may not be aligned with their values,
beliefs, and preferences.

Edmonton Symptom Assessment Score - Revised (ESAS-r)

Effective method to obtain an overall sense of how the pt is experiencing their illness
Completed by measuring burden of various physical, psychosocial, and spiritual symptoms
Allows for early identification and report of symptoms which may lead to improved management and QOL
Enables person to identify degree of distress/burden r/t to each particular symptom and aid caregivers to understand the impact of
disease on pts QOL
o Understanding the illness experience from the perspective of the pt