COURSE TASK 7:

PAIN
GROUP 2E
BSN 3YA-2
GROUP 2E MEMBERS
Nuñez, Dhanniellie Jhaira
Ocampo, Ian Michael
Oanes, Patricia Willane
Pasgala, Fermil
Rosello, Kimberly
Trinidad, Katrina
Vendivil, Joanne
Villareal, Angeline Joy Zoe
 CASE SCENARIO
Jane is an 84-year-old woman diagnosed with breast cancer 2 years ago, now
with metastasis to the bone and lung. She has refused any further active
treatment (i.e chemotherapy and radiation) and has asked her healthcare
representative daughter Patty to help her talk to her oncologist about her
wishes. After this discussion, the patient, daughter, and physician agreed upon
a hospice evaluation. Upon evaluation and subsequent admission to hospice
services, the patient’s most pressing need was adequate pain control.
Previously, she had tried scheduled Tylenol without relief-her pain rated at an 8
on a 0-10 scale. Her oncologist then prescribed Hydrocortisone 7.5/750 mg. 1-2
tabs every 4 hours as needed, which lowered her pain acuity to a 6. At this
point, an adjuvant might be considered for bone pain-possibly Decadron. If
Jane experiences shortness of breath related to lung metastasis, Morphine and
Decadron are both helpful in alleviating this symptom.
1. As the admitting hospice nurse, you recognize that 8 on the pain scale greatly
impairs Jane’s quality of life. Using the WHO step approach, what would be
your plan for intervention?
Assessing pain alleviation on a frequent basis is the first nursing
intervention a hospice nurse makes when a patient is admitted with
severe pain (scale of 8). We modify the drug schedule as needed. Share
with the client and others the anticipated therapeutic results and how
to handle any side effects. A pain rating of 8 is considered severe pain
by the WHO step approach, necessitating medication adjustment to
relieve discomfort.

Medication, extra treatments, exercise, psychological therapy, and

other interventions are used to manage pain. We should also focus on
interventions and goals that help us preserve or improve our functional
ability. Use self-management tactics and procedures that work for us
and incorporate them into our own management plan.
1. As the admitting hospice nurse, you recognize that 8 on the pain scale greatly impairs Jane’s quality of
life. Using the WHO step approach, what would be your plan for intervention?

Pain medications
Analgesics such as morphine and decadron are among the pain medications that can be
beneficial in helping us control this condition.

Exercise and physical therapy

Many therapies, such as heat/cold therapy, peripheral nerve stimulation / transdermal
electronic nerve stimulation (TENS), occupational therapy, and therapeutic exercise, can
be beneficial.

Psychological Counseling
Psychological therapy can help people manage with pain, sadness, and disability. It
focuses on acknowledging our discomfort, stress management, coping with guilt,
identifying negative circumstances and the value of positive thinking, identifying goals
and asking for support, including relaxation therapies, and confronting negative or
unhelpful beliefs / thoughts.
2. Knowing that Jane probably has two types of pain due to the metastasis, what adjuvant
might you consider for the bone pain?
One of the most frequent types of pain among cancer patients is bone pain.
One of the most often utilized adjuvant analgesics for the treatment of
metastatic bone pain is corticosteroids.

Corticosteroids have significant anti-inflammatory and anti-swelling properties.

The lowering of peritumoral edema in response to corticosteroid therapy may
increase analgesia. Dexamethasone is the most often used corticosteroid due
to its lengthy half-life and lack of mineralocorticoid action, which results in
reduced fluid retention.

To get the best pain relief and quality of life (QoL), diverse treatments for
various disease stages and pain mechanisms should be used to treat
cancer-induced bone pain (CIBP), which is complex and involves a number of
processes. In addition to pain alleviation, the therapeutic objective includes the
avoidance of both pain progression and skeletal-related events.
3. Looking to the future, what other comfort issues might Jane face as her metastasis impacts her life?
Jane is dealing with a wide range of problems after learning she has cancer. It leads to
exhaustion on both a physical and mental level, stress, and other health issues. Her capacity
to perform daily tasks may deteriorate. Her body organs' functioning may lose flexibility as
she ages, she may gets more lethargic and reliant on others even for basic daily duties. At
the end of life, comfort care is a crucial component of medical care. Care is what supports or
comforts a person who is dying. Since Jane is aware of her future, she accepts all of the
circumstances in the present and refuses additional care. Her family, particularly Jane, is
affected by her ordeal with breast cancer from two years ago. Even after treatment is over,
cancer discomfort may have an impact on one's quality of life and ability to function.
Anxiety and sadness are more likely to occur when pain is severe or persists after cancer
therapy is finished. Anxiety or depression can exacerbate cancer pain and make it more
difficult to manage. The best thing we can do for her in this position is provide her with
support, love, and care from her family and others around her.
3. Looking to the future, what other comfort issues might Jane face as her metastasis impacts
her life?
First, metastatic breast cancer and its treatment can cause a variety of
quality-of-life issues, such as physical symptom burdens, mental anguish, body
image alteration, and disrupted daily activities. She may expressed feelings of guilt
or frustration because their fatigue interfered with routine activities.

Second, social limits on disclosing cancer-related concerns may worsen patients'

misery.Loss of a sense of control over their lives and fear of future disease progression
and disability were common concerns that leads to feelings of shock and isolation.

Third, Jane may experience a heightened awareness of life's brevity and seek
meaning in their cancer experience.
4. How could you keep Jane reach her goal of selected activities (e.g. shopping, lunch, church?)
Everybody has goals, hopes, and a desire to be in charge of their lives. Each person
gradually develops a highly unique sense of what most enhances his or her quality of
life and gives the most purpose and worth. Their intentions may change as their illness
worsens. One of our responsibilities is to speak with the patient and family, ascertain
their objectives and goals, and then create a treatment plan based on this knowledge.
We can also assist Jane in doing activities that she can still do and giving compliment
from time to time that she is doing good in order to boost her confidence that there
are things that she is capable of doing despite of her illness.

It is always challenging to have conversations about death and dying. When the
subject of death is brought up, a variety of feelings, perceptions, and worries can arise.
All we can do for Jane right now is support her.I will advise her family to be there so
that Jane can get support for her emotional problems and carry out all of her final
wishes.
5. MAKE A DRUG STUDY OF THE MEDICATIONS GIVEN TO JANE

HYDROCORTISONE TYLENOL

MORPHINE
DECADRON
DRUG NAME PHARMACOKIN PHARMACODYNAMI INDICATION CONTRAINDIC SIDE EFFECTS NURSING
ETICS CS S ATIONS RESPONSIBILITIES

Generic According to its Animal and clinical Like other -Contraindicatio Some side effects 1. Routinely monitor the effectiveness
Name: FDA labeling, studies have determined OTC pain ns to using can be serious. If of acetaminophen by assessing pain
Acetaminophen acetaminophen's that acetaminophen has relievers, acetaminophen you experience any levels and fever reduction.
exact mechanism both antipyretic and acetaminophen include of the following 2. For patients who are at risk for
of action has not analgesic effects. This temporarily hypersensitivity symptoms, stop hepatotoxicity or renal toxicity, the
been fully drug has been shown to relieves minor to taking nurse should closely monitor AST and
Brand Name: established. lack anti-inflammatory aches and acetaminophen, acetaminophen and ALT levels and BUN and creatinine.
Tylenol Despite this, it is effects. As opposed to pains due to severe hepatic call your doctor 3. Acetaminophen can cause
often categorized the salicylate drug class, headache, impairment, or immediately or get hematologic reactions. The nurse
Classifications alongside NSAIDs acetaminophen does not backache, the severe active emergency medical should monitor for anemia and
:Analgesics (nonsteroidal disrupt tubular secretion common cold, hepatic disease. attention: decreased red and white blood counts.
(pain relievers) anti-inflammatory of uric acid and does minor pain of 4. The antidote for acetaminophen
and drugs) due to its not affect acid-base arthritis, -Acetaminophen - Red, peeling or overdose is N-acetylcysteine given
Antipyretics ability to inhibit balance if taken at the toothache, can increase blistering skin, rash, either orally or IV.
(fever reducers) the recommended doses. premenstrual anticoagulant hives, itching, 5. Instruct patients to never take more
cyclooxygenase Acetaminophen does and menstrual effects. If the swelling of the face, than 4,000 mg of acetaminophen per
(COX) pathways. not disrupt hemostasis cramps, and patient is taking throat, tongue, lips, 24 hours. This includes all forms of
It is thought to and does not have muscular warfarin, eyes, hands, feet, acetaminophen and
exert central inhibitory activities aches, and acetaminophen ankles, or lower acetaminophen-containing products.
actions which against platelet temporarily can increase the legs, hoarseness and 6. Do not take acetaminophen with
ultimately lead to aggregation. Allergic reduces fever. risk of bleeding. difficulty breathing alcohol due to the risk of liver toxicity.
the alleviation of reactions are rare or swallowing. 7. Acetaminophen may be taken with
pain symptoms. occurrences following or without food.
acetaminophen use.
DRUG NAME PHARMACOKINETI PHARMACODYNAMICS INDICATIONS CONTRAINDICATIONS SIDE EFFECTS NURSING
CS RESPONSIBILITIES

Generic Volume of -Inhibition of phospholipase Topical The presence of other -Burning, -Tell your doctor if you
Name: Distribution: A2, NF-kappa B, and other hydrocortisone medical problems may itching, have ever had any
inflammatory transcription is used to treat a affect the use of this irritation, unusual or allergic
Hydrocortisone Total hydrocortisone factors, as well as the variety of skin medicine. Make sure you redness, or reaction to this
has a volume of promotion of conditions that tell your doctor if you have dryness of the medicine or any other
distribution of anti-inflammatory genes, are cause redness, any other medical skin medicines. Also tell
39.82L, while the some downstream effects of swelling, problems, especially: your health care
Brand Name: free fraction has a hydrocortisone's binding to itching, and -Cushing's syndrome -Acne professional if you
Hydrocort, volume of the glucocorticoid receptor. discomfort. A (adrenal gland disorder) or have any other types of
Alphosyl, distribution of Hydrocortisone has a broad group of drugs Diabetes or - Unwanted allergies, such as to
Aquacort, 474.38L therapeutic index and a known as Hyperglycemia (high blood hair growth foods, dyes,
Cortef, moderate duration of action. corticosteroids sugar) or Intracranial preservatives, or
Cortenema, and Protein Binding: Patients should stop includes hypertension (increased -Skin color animals.
Solu-Cortef consuming the drug if hydrocortisone. pressure in the head)—Use changes
Corticosteroids are irritation or sensitization It reduces with caution. May make -Monitor signs of
Classifications generally bound to develops. swelling, these conditions worse. -Tiny red thrombophlebitis
: corticosteroid redness, and bumps or rash (lower extremity
binding globulin and -Reduced capillary itching by -Infection of the skin at or around the swelling, warmth,
Anti-inflammat serum albumin in permeability, vasodilation, causing natural near the place of mouth erythema, tenderness)
ory; plasma. and leukocyte migration to substances in application or and thromboembolism
Hydrocortisone is inflammatory sites are some the skin to Large sores, broken skin, or - Small white (shortness of breath,
Corticosteroids 90.1% bound to of the short-term effects of become active. severe skin injury at the or red bumps chest pain, cough,
proteins in plasma, corticosteroids. place of application—The on the skin bloody sputum).
with 56.2% bound to chance of side effects may -
albumin. be increased.
DRUG NAME PHARMACOKINETICS NURSING
(continuation..) RESPONSIBILITIES (continuation..)

Generic Metabolism: -Monitor and report signs of peptic ulcer,

Name: including heartburn, nausea, vomiting
Hydrocortisone is metabolised to 6-beta hydrocortisol via blood, tarry stools, and loss of appetite.
Hydrocortisone CYP3A, 5-beta tetrahydrocortisol via 3-oxo-5-beta-steroid
4-dehydrogenase, 5-alpha tetrahydrocortisol via -Monitor signs of hypersensitivity reactions
3-oxo-5-alpha-steroid 4 dehydrogenase 2, cortisone via or anaphylaxis, including pulmonary
Corticosteroid 11-beta-dehydrogenase isozyme 1 and symptoms (tightness in the throat and chest,
Brand Name: Corticosteroid 11-beta-dehydrogenase isozyme 2, and wheezing, cough, dyspnea) or skin reactions
Hydrocort, glucuronide products. Cortisone is further metabolized to (rash, pruritus, urticaria). Notify physician
Alphosyl, tetrahydrocortisone and dihydrocortisol. or nursing staff immediately if these
Aquacort, reactions occur.
Cortef, Route of Elimination:
Cortenema, and -Assess any muscle or joint pain. Report
Solu-Cortef Corticosteroids are eliminated predominantly in the persistent or increased musculoskeletal pain
urine.12 However, data regarding the exact proportion is to determine presence of bone or joint
Classifications not readily available. pathology (aseptic necrosis, fracture).
:
Half Life: -Assess signs of increased intracranial
Anti-inflammat pressure in children, including changes in
ory; Total hydrocortisone via the oral route has a half life of mood and behavior, decreased
2.15h while the free fraction has a half life of 1.39h. A consciousness, headache, lethargy, seizures,
Corticosteroids 20mg IV dose of hydrocortisone has a terminal half life of and vomiting. Notify physician immediately
1.9±0.4h. of these signs.
DRUG NAME PHARMACOKINETICS PHARMACOD INDICATIONS CONTRAINDICATIO SIDE NURSING
YNAMICS NS EFFECTS RESPONSIBILITIES

Generic Absorption: Variably absorbed -Binds to opiate - Used to treat -Extreme caution is • Confusion -Assess type, location and
Name: (30%) following oral receptors in the severe pain. necessary with severe • Sedation intensity of pain prior to and
administration. More reliably CNS. Alters the Pain severe respiratory depression • Dizziness 1 hr following PO, subcut,
Morphine absorbed from rectal, subcut, and perception of enough to and asthma • Dysphoria IM and 20 mins following
IM sites. Following epidural and response to require daily, exacerbation cases • Euphoria IV administrations. -When
administration, systemic absorption painful stimuli around-the since morphine can • titrating opioid doses,
and absorption into the intrathecal while clock long term further decrease the Hallucinations increases of 25- 50% should
Brand Name: space via the meninges occurs. producing opioid treatment respiratory drive. • Blurred be administered until there is
Astramorph, Distribution: Widely distributed. generalized and for which vision either a 50% reduction in the
Aaramorph Crosses placenta. Enters breast milk CNS alternative Drug Interactions: • Bradycardia patient’s pain rating on a
Duramorph, in small amounts. depression. • treatment CNS depressants-may • Nausea and numerical or visual analogue
Epimorph, Protein-binding: Premature Therapeutic options are cause profound vomiting scale or patient report
infants; <20%; Adults: 35% effect: inadequate sedation, respiratory • Urinary satisfactory pain relief.
Decrease in depression, coma and retention -Assess level of
Metabolism and excretion: Mostly severity of pain -Used to treat death. • Itching consciousness, BP, pulse and
Classifications metabolized by the liver. Active Addition of pulmonary • Sweating respirations before and
: metabolites excreted renally. naltrexone in edema and pain Cimitidine- decreases periodically during
Embeda associated with metabolism and may administration. If respiratory
OPIOID Route: PO product is myocardial increase effects. rate is <10/min, assess level
ANALGESIC Onset: Unknown designed to infarction. of sedation o Physical
Peak: 60 mins prevent abuse stimulation may be
Duration: 4-5 hrs or misuse by sufficient to prevent
Half life: Adults; 2-4 hr; Children altering the significant hypoventilation.
3-6yrs: 1-2 hr; Children 6-19yrs: formulation.
1.3 h
 DRUG NAME PHARMACOKINETI PHARMACODYNAM INDICATIONS CONTRAINDICA SIDE EFFECTS NURSING
CS ICS TIONS RESPONSIBILITIES

Generic Name: Absorption: Dexamethasone’s -Decadron relieves Contraindicated -Abnormal heart -Instruct patient to take
Dexamethasone effect on the body inflammation in to patient with: rhythm Decadron with food to
DEXAMETHASON median time to peak occurs in a variety of various parts of the -Systemic fungal (arrhythmia) lessen an upset stomach.
E concentrations ways. It works by body. It is used infectio -Adrenal Also, advise to take
(Tmax) is 1 hour suppressing the specifically to suppression Decadron early on in the
Brand Name: (range: 0.5 to 4 migration of decrease swelling -Documented -Cardiac arrest day (before 12:00 noon, if
Decadron hours). A high-fat, neutrophils and (edema), associated hypersensitivity -Cataracts possible), so you will be
high-calorie diet decreasing lymphocyte with tumors of the -Cerebral malaria -Delayed wound able to sleep better at night.
decreased C max by colony proliferation. spine and brain, and -Administration of healing
23% of a single 20 The capillary to treat eye live or live, -Diabetes -If patient have diabetes,
Classifications: mg dose of membrane becomes inflammation. attenuated -Pulmonary Decadron may increase
dexamethasone. less permeable, as vaccines is edema their blood sugar levels.
Glucocorticosteroid,: Distribution: well. Lysosomal -As treatment for a contraindicated in -Glaucoma You may need more
Anti-inflammatories, Dexamethasone is membranes have variety of cancers, patients receiving -Insomnia frequent monitoring.
corticosteroids about 77% bound to increased stability. such as leukemia, immunosuppressi -Rash
human plasma lymphoma, and ve doses of -Redness -In general, drinking
Dosage proteins in vitro. multiple myeloma. corticosteroids -Seizure alcoholic beverages should
Considerations: -Dexamethasone -Slow heart rate be avoided. Patient should
-To treat nausea and is excreted in -Small red or be advise to also limit
Adult: 0.75-9 vomiting associated breast milk; it is purple spots on caffeine intake (colas, tea,
mg/day with some not recommended the skin coffee and chocolate,
intravenous/intramus chemotherapy for use while -Vertigo especially). These
cular/oral drugs. breastfeeding -Weight gain beverages may irritate your
(IV/IM/PO) divided stomach.
every 6-12 hours
 DRUG NAME PHARMACOKINETICS
(Continuation…)
Generic Name: Elimination: The mean
terminal half-life of
DEXAMETHASONE dexamethasone is 4 hours
(18%), and oral clearance
Brand Name: Decadron is 15.7 L/hr following a
single dose of
dexamethasone.
Metabolism:
Classifications: Dexamethasone is
metabolized by CYP3A4.
Glucocorticosteroid,: Excretion: Renal
Anti-inflammatories, excretion of
corticosteroids dexamethasone is less
than 10% of total body
Dosage Considerations: clearance. Less than 10%
of dexamethasone is
Adult: 0.75-9 mg/day excreted in the urine.
intravenous/intramuscular/
oral (IV/IM/PO) divided
every 6-12 hours
PHARMACODYNAMICS NURSING
(Continuation…) RESPONSIBILITIES
(Continuation…)
There are higher -Advise patient to not stop
concentrations of vitamin taking the oral drug without
A compounds in the serum, consulting your healthcare
prostaglandin, and some provider.
cytokines (interleukin-1,
interleukin-12, -Instruct patient to avoid
interleukin-18, tumor exposure to infection and
necrosis factor, report unusual weight gain,
interferon-gamma, and swelling of the extremities,
granulocyte-macrophage muscle weakness, black or
colony-stimulating factor) tarry stools, fever, prolonged
become inhibited. sore throat, colds or other
infections, worsening of this
disorder.
6. Make a pain and comforting cycle for your patient using the diagram.
THANK YOU!
GROUP 2E/ BSN 3YA-2