the nuts and bolts of pain and symptom management through ...€¦ · the nuts and bolts of pain...

The Nuts and Bolts of Pain and Symptom Management Through A Case Study

Taryn J. Hamre, DNP, APRN, FNP-BC, CPHON

Mary-Fran McGeary BSN, RN, CPHON

October 2019

Official pediatric teaching

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Mission, Vision and Values

MISSION

Connecticut Children's Medical Center is dedicated to improving the physical and

emotional health of children through family-centered care, research, education and advocacy.

We embrace discovery, teamwork, integrity and excellence in all that we do.

VISION

We are making children in Connecticut the healthiest in the country.

CORE VALUES

Discovery • Family-Centered Care • Integrity • Quality • Respect • Teamwork


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“Water Support Team”


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Pediatric Palliative Care

The Sunflower Kids Program works with the primary team to provide an extra layer of support to patients and families facing serious or potentially life-limiting illness. • Pain & symptom management

• Communication

• Goals of care discussions

• Discharge planning/care coordination needs

• Team support/debriefings

• Bereavement


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Sunflower Kids Team

Dr. Kerry Moss, MD - Director

Dr. Clare Riotte, DO

Dr. Taryn J. Hamre, DNP, APRN

Mrs. Mary Fran McGeary, RN

Ms. Mallory Fossa, APRN


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To Avoid…


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Objectives

• To recognize common symptoms effecting Quality of Life

• To review multimodal pain and symptom management strategies

• To apply new knowledge utilizing a case study


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Types of Pain

To review:

oNociceptive/Somatic

oVisceral

oNeuropathic Pain

oPsycho-social-spiritual-emotional (total pain)

oChronic


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Pain Assessment

• History & Physical

• Location

• Duration/Frequency-When does it occur?

• Quality (sharp/dull/stabbing/burning)

• Intensity

• What makes it better or worse?

• History of prior pain medication use


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Pain Assessment


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Pain Scales

Connecticut Children’s

oWong Baker

oFACES

oNumeric Scale

oR-FLACC

oN-PASS


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Pain Scales


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Distressing Symptoms

• Nausea/Vomiting

• Constipation

• Fatigue

• Pruritus

• Dyspnea

• Agitation

• Secretions


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Symptom Management

• Search for the cause

• Treat the underlying cause

• Treat the symptom

• Integrative Modalities

• Pharmacological

• Re-Evaluate often

•Search for cause of symptom•Treat underlying cause (if reasonable)•Treat the symptom•Re-evaluate frequently


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Child Development - Erikson

Age Stage Tasks

Birth - 1 year Trust vs. Mistrust

Learning basic physical skills, survival;

positive attachment fosters internalized

trust

2 - 3 years Autonomy vs. Shame/Doubt

Growing independence, experimentation

with autonomy, failures leads to self doubt,

attachment allows exploration with safe

return

4 - 6 years Initiative vs. GuiltMaking choices, developing skills, trying

new things, attachment fosters confidence

6 - 12 years Industry vs. Inferiority

Pride in accomplishment, accumulation of

skills, goal direction, growing social

sphere of interaction

13 - 19 years: adolescence Identity vs. Role Confusion

Integration of identity, social participation:

seeking belonging and acceptance,

preparation for work/career


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Meet Gavin…

Gavin is a 10 year old, previously healthy male who presents to his pediatrician with right leg pain. He lives with his parents, older sister and dog. Gavin enjoys school and loves playing hockey.

As the nurse checking him in, what will you do first?

*Developmental Stage

6 - 12 years

Industry vs. Inferiority

Pride in accomplishment, accumulation of skills, goal direction, growing

social sphere of interaction


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World Health Organization Principles of Pain Treatment

• By the Analgesic Ladder

• By the Clock

• By the Appropriate Route

• With the Child


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“By the Analgesic Ladder”

Step 1: Mild Pain

- Tylenol 10-15mg/kg Q4 to 6 hrs. (max 4,000 mg /day; pain dosing recommends 15mg/kg/dose)

- Motrin 10 mg/kg Q6 hrs (2400 mg /day max)-Use in caution in pts with hepatic or renal issues and with those with GI bleeds or ulcers, inhibits plt aggregation.

OR

- Toradol (no more than 3 to5 days) <2 yrs. 0.25mg/kg Q6 hrs; >2 yrs. 0.5mg/kg Q6 hrs; max 30 mg dose.

OR

*Celebrex Less GI bleeding risks and GI side effects


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Gavin

What might Gavin’s pediatrician recommend to help with his discomfort?


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“By the Analgesic Ladder”

STEP 2 : Medium to Severe Pain

• Morphine, Oxycodone, Hydromorphone, Hydrocodone

• Fentanyl

• Methadone


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“By the Clock”

• Dosing at regular intervals around the clock for persistent pain

• Make prn meds for breakthrough pain available

* “PRN” ~ “patient receives nothing”


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“By the Appropriate Route”

• Simplest, most effective, least painful route

• Oral dosing preferred

• IM obsolete


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“With the Child”

• Tailor therapy to the individual child

• Titrate on an individual basis


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Opioids

• Opioids do NOT have a maximum pharmacologic dose

• Appropriate dose of opioids is the one needed to control pain with the fewest side effects

• May have to rotate opioids, if so begin at 25 to 50% of equianalgesic dose for incomplete cross tolerance


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Gavin

Gavin’s pain continued in spite of the Tylenol and his provider sent him for imaging. He was found to have a mass on his right leg and is sent to Hem/Onc…

You are now a nurse in Hem/Onc clinic. Gavin reports intermittent pain, not relieved with Tylenol or Motrin…what may be the next steps?

How else can you support him and his family?


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Opioid Side Effects

• Constipation

• Pruritus

• Sedation

• Nausea/Vomiting

• Myoclonic Jerking

• Respiratory Depression

• Delirium/Confusion/Hallucinations


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Opioid Rotation

•When side effects become intolerable

•When a drug is not available by a new route

•When pain is not controlled despite optimal dose escalation

•When cost is an issue


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Opioid Conversion

Medication PO (mg) IV (mg)

Morphine 30 10

Hydromorphone 6-8 1.5-2

Oxycodone 15-20 N/A

Fentanyl N/A 0.1 (100 mcg)


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Codeine and Tramadol


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CYP2D6


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Medical Marijuana

• Hot Topic

• Very little data in pediatrics, not AAP recommended

• May be beneficial at the end - of - life…

• In CT, 2 providers to certify and pt diagnosed with 1 of the following:

oCerebral Palsy

oCystic Fibrosis

o Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

oSevere Epilepsy

oTerminal Illness Requiring End-Of-Life Care

oUncontrolled Intractable Seizure Disorder

oOsteogenesis Imperfecta


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Gavin

Fast forward…

Gavin is s/p his tumor resection. He initially did well on his pain plan and has been receiving chemotherapy for ~ 6 months. Gavin is missing his friends and playing hockey.

He presents to clinic with an increase in pain…

Gavin’s pain medicine is not lasting as long as it used to.

What might be an option?

How else may you help?

Constipation is also now an issue…what can be considered?


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Constipation

• Address the “mush” and the “push”

• All patients on an opioid should be on a scheduled bowel regimen


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Constipation

Pharmacologic and Non-Pharm options:

• Miralax

• Senna

• Lactulose

• Milk of Mag/Enema/Suppository

• Methylnaltrexone

• Fluids, ambulation, diet…


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Gavin

Gavin has repeat imaging which shows evidence of tumor progression and metastatic disease in his lungs.

He is using his oxycodone ATC with not much relief and is having nausea/vomiting.

What non pharmacological approaches can you do?

What medications might you advocate for as his nurse?


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Nausea/Vomiting


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Non Pharmacologic Options

• PT/TENS

• Massage Therapy/Touch/Positioning

• Integrative Medicine/hypnosis/guided imagery/Acupuncture

• Aromatherapy

• Child Life/Distraction

• Warm Packs/Cold packs

• Breathing Techniques


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Multimodal “opioid-sparing” Adjuvants

• Regional anesthesia

• Alpha Agonists: Dexmedetomidine or Clonidine

• Gabapentinoids (neuropathic pain)

• TCA/Antidepressants

• Muscle Relaxants (muscle spasms)

• Benzodiazepines

• Cortocosteroids (musculoskeletal pain)

• NMDA-receptor antagonists - Ketamine

• Lidoderm patches…


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Gavin

Gavin is admitted to the Children’s Hospital.

His PO pain plan is not working.

What are your next steps?

What might you recommend to his provider?


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Gavin

Gavin develops pruritus on his PCA….

What might you, as his bedside nurse, advocate to his provider for?


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Pruritis

• Distressing symptom

• Determine the cause

• Opioid Induced Pruritus = central mu related phenomenon (not histamine)

-Best treated with an opioid agonist-antagonist, not an anti-histamine

-Consider switching opioids

• Options to treat…


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Gavin

Gavin’s pain and pruritus are much better controlled.

However, he develops fatigue and secretions…

What might you advocate for on is behalf?


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Fatigue

Lack of energy,

• Lack of energy

• Subjective

• Not relieved by rest

• Physical/Psychological causes

• No pharmacological and Pharmacologic therapy:

oRitalin, caffeine, steroids, SSRI’s, etc.


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Secretions

• Inability to clear secretions

• Non-pharmacologic

• Pharmacologic: Robinol, Atropine, Scopolamine, Levsin…


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Gavin

Gavin develops Dyspnea….

What are some things you can do to help?


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Dyspnea

• Subjective shortness of breath (SOB)

• Fans are very helpful

• Non-pharmacologic therapies

• Pharmacologic: opioids and benzodiazepines


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Gavin

Gavin is sleeping most of the time now but when he wakes he appears agitated.

What can are some things you may consider?


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Agitation

• Evaluate cause

• Non-pharmacologic

• Pharmacologic: benzodiazepines, Haloperidol or Clonidine


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Gavin

Gavin is nearing his final moments of life…

What can you do to promote the comfort of him and his family?


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Final Thoughts…

• Prompt assessment and management of distressing symptoms impacts Quality of Life and decreases suffering

• Reassess often and adjust plan when needed

• A multimodal, interdisciplinary approach is key

• Tailor treatments to each unique patient

• The Sunflower Kids Team is available to help


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Special Thanks

• EPEC Program

• Stefan J. Friedrichsdorf, MD, FAAP

• Joanne Wolfe, MD, MPH

• Christie Ulrich, MD

• Boston Children’s PACT

• Julie Hauer, MD, FAAP

• Harvard Medical School’s PCEP Program

• Minnesota Children’s Master Pain Class

• Sunflower Kids Team


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References

• EPEC Program 2019

• ELNEC Program 2018

• PCEP Program 2017


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Thank You!About Connecticut Children’s Medical Center

Connecticut Children’s Medical Center is the only hospital in Connecticut dedicated exclusively to the care of

children and is ranked by U.S. News & World Report as one of the best children’s hospitals in

the nation. With a medical staff of more than 1,000, Connecticut Children’s provides comprehensive, world-class

health care in more than 30 pediatric specialties and subspecialties. Connecticut Children’s Medical Center is a not-

for-profit organization, which serves as the primary pediatric teaching hospital

for the UConn School of Medicine, has a teaching partnership with the Frank H. Netter MD School of Medicine at

Quinnipiac University and is a research partner of The Jackson Laboratory. Connecticut Children’s Office for

Community Child Health is a national leader in community-based prevention

and wellness programs.

282 Washington Street, Hartford, CT 06106. © 2017 Connecticut Children’s Medical Center. All rights reserved.

the nuts and bolts of pain and symptom management through ...€¦ · the nuts and bolts of pain...

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