Yale Palliative care Education - Post-participation Quiz

1. Pain described as burning and limited to the distal extremities is most likely:

Neuropathic pain

Somatic pain

Vascular pain

Visceral pain

Neuropathic pain is often described as burning, numb, radiating, shooting, stabbing, tingling, touch sensitive (hyperalgesia). Distribution of neuropathic pain depends on nerves affected:
Radicular—single or multiple nerve roots: Herpes zoster; Sciatica
Stocking-Glove (fingers/toes): Diabetic or chemotherapy neuropathy

Explanation

Neuropathic pain is often described as burning, numb, radiating, shooting, stabbing, tingling, touch sensitive (hyperalgesia). Distribution of neuropathic pain depends on nerves affected:
Radicular—single or multiple nerve roots: Herpes zoster; Sciatica
Stocking-Glove (fingers/toes): Diabetic or chemotherapy neuropathy

2. The most reliable indicator of pain severity is:

Fluctuations in pulse

Patient behaviors: grimacing and crying

Skilled nursing assessment

The patient's self report

Although patient's appearance, changes in vital signs, reports of nurses and others are useful data in the assessment of pain, pain is a subjective experience and the most reliable indicator of pain severity is the patient's self report.

Explanation

Although patient's appearance, changes in vital signs, reports of nurses and others are useful data in the assessment of pain, pain is a subjective experience and the most reliable indicator of pain severity is the patient's self report.

3. Which one of the following statements about pain management is False?

Addiction is very rare when opioids are used in patients with pain.

Emotional or spiritual distress may affect a patient's experience of pain and its severity.

Respiratory depression from opioids is very rate and occurs only after a patient has a decreased level or arousal.

Opiate-associated constipation often resolves over time so laxatives can be used sparingly.

Nearly 100% of patients taking opioids will experience constipation which will not improve over time. Prevention with stool softener or wetting agent alone is usually not sufficient without the use of a stimulant laxative (e.g., senna or bisocodyl) or a hyperosmotic agent (e.g., laculose, polyethelene glycol ("Miralax")).

Explanation

Nearly 100% of patients taking opioids will experience constipation which will not improve over time. Prevention with stool softener or wetting agent alone is usually not sufficient without the use of a stimulant laxative (e.g., senna or bisocodyl) or a hyperosmotic agent (e.g., laculose, polyethelene glycol ("Miralax")).

4. Benzodiasepines are not the first drug choice for treating delirium because of the:

Risk of aspiration due to sedation

Risk of dependence

Risk of paradoxical worsening of delirium

Risk of respiratory depression when used with opioids

Benzodiazepenes can cause paradoxical worsening of some symptoms of delirium and therefore are not first line agents to treat the agitation or anxiety associated with delirium. Neuroleptics (anti-psychotics) such as haloperidol are first line agents for this purpose. If needed, low dose benzodiazepines (e.g. lorazepam 0.5-1.0 mg) can be used cautiously as co-therapy.

Explanation

Benzodiazepenes can cause paradoxical worsening of some symptoms of delirium and therefore are not first line agents to treat the agitation or anxiety associated with delirium. Neuroleptics (anti-psychotics) such as haloperidol are first line agents for this purpose. If needed, low dose benzodiazepines (e.g. lorazepam 0.5-1.0 mg) can be used cautiously as co-therapy.

5. 300 mg/day of a long-acting morphine preparation is equivalent to what dose-rate of IV morphine as a continuous infusion?

1 mg/hr

4 mg.hr

7 mg/hr

10 mg/hr

The equianalgesic ration of IV:PO morphine = 1:3, so 300 mg of oral morphine = 100 mg of IV morphine (IV morphine is 3 times stronger than oral). A continuous infusion would therefore be 100mg/24 hours which is approximately 4 mg/hour.

Explanation

The equianalgesic ration of IV:PO morphine = 1:3, so 300 mg of oral morphine = 100 mg of IV morphine (IV morphine is 3 times stronger than oral). A continuous infusion would therefore be 100mg/24 hours which is approximately 4 mg/hour.

6. The dose of breakthrough morphine, for a patient taking 300 mg of long acting morphine/day should be approximately:

10 mg

30 mg

60 mg

120 mg

A reasonable starting breakthrough or rescue dose is typically 10 of the total 24 hour dose. So, 10% of 300 mg is 30 mg. For morphine, frequency of dosing should be available: every 2-4 hours PO, every 30-60 minutes IM or SC, and every 10-20 minutes IV as needed.

Explanation

A reasonable starting breakthrough or rescue dose is typically 10 of the total 24 hour dose. So, 10% of 300 mg is 30 mg. For morphine, frequency of dosing should be available: every 2-4 hours PO, every 30-60 minutes IM or SC, and every 10-20 minutes IV as needed.

7. Common metabolic causes of delirium include all the following, except:

Hypocalcemia

Hypercalcemia

Hypernatremia

Uremia

Hypocalcemia does not typically cause delirium. Common effects of hypocalcemia include: skeletal muscle cramps and tetany, abdominal pain, prolongation of the QT interval, parasthesias, convulsions.

Many metabolic derangements and organ can cause delirium, including hypercalcermia, hypo/hypernatremia, hypo/hyperglycemia, and renal (uremia), liver, and cardiac dysfunction.

Explanation

Hypocalcemia does not typically cause delirium. Common effects of hypocalcemia include: skeletal muscle cramps and tetany, abdominal pain, prolongation of the QT interval, parasthesias, convulsions.

Many metabolic derangements and organ can cause delirium, including hypercalcermia, hypo/hypernatremia, hypo/hyperglycemia, and renal (uremia), liver, and cardiac dysfunction.

8. The peak analgesic effect from a dose of short-acting oral morphine can be expected in?

15-30 minutes

20-40 minutes

60-90 minutes

120-180 minutes

The peak analgesic effect of short-acting oral opioids occurs in 60-90 minutes with an expected total duration of analgesia of 2-4 hours.

Explanation

The peak analgesic effect of short-acting oral opioids occurs in 60-90 minutes with an expected total duration of analgesia of 2-4 hours.

9. All of the following metabolic conditions may cause constipation, except:

Hypothyroidism

Hypercalcemia

Hypnotremia

Uremia

Hypercalcemia and uremia are common causes of constipation in patients with advanced cancer. Hypothyroidism also causes constipation. Hyponatremia does not.

Explanation

Hypercalcemia and uremia are common causes of constipation in patients with advanced cancer. Hypothyroidism also causes constipation. Hyponatremia does not.

10. Opioid-induced constipation is caused by all the following except:

Decreased bowel fluid secretion and/or increased absorption

Decreased tone of bowel musculature

Opioid binding to gut and central nervous system opioid receptors

Increase in non-propulsive activity

Opioid-induced constipation is multi-factorial, and through * binding to gut and central nervous system receptors:
*Increase bowel musculature tone and non-propulsive activity--the gut is moving, just not in the normal coordinated manner

Explanation

Opioid-induced constipation is multi-factorial, and through * binding to gut and central nervous system receptors:
*Increase bowel musculature tone and non-propulsive activity--the gut is moving, just not in the normal coordinated manner