Agitation / Secretions / Hiccups / N+V / Nutrition Flashcards
What should you look for if confusion / agiation
Underlying cause to treat Infection Pain Dehydration Retention / constipation Medication Hypercalcaemia Uraemia Electrolyte imbalance
Where are sources of information for reasons for confusion
Nurse Relative NEWS Drug cardex Blood results 4AT + TIME
What examination can you do
Chest
ABdo
Neuro
PEARL
What can you use if specific Rx fails
Side room, regular staff and possible 1:1 nursing
Haloperidol = 1st line
Chloropromazine
Lorazepam if can’t have anti-psychotic
What is used in terminal phase of agitation / restless
Midazolam 2.5-5 SC
Levomepromazine 12.5mg SC 2 hourly PRN
What is licensed for intractable hiccups
Chloropromazine
What is also used if unresponsive
Haloperidol
Gabapentin
Dexamethasone - hepatic
What are common in final days of life
Secretions Due to inability to cough or swallow Rattling sounds in expiration as air passes through More troubling for family Suggests death in next few days
What is conservative Rx for secretions
Consider reversible cause e.g. HF, chest infection, aspiration pneumonia Avoid overload - stop IV or SC fluid Reposition patient Consider suction Educate family that patient not troubled
What is medical management of secretions
Hyoscine hydrobromide - 20mg SC hourly PRN (120max in 24 hours)
- Reduce production
What is used for bowel colic
Hyoscine butyl bromide (Buscopan)
- Oesophageal spasm / crampy abdo pain
What can cause sickness in palliative care / broad spectrums of N+V
Severe pain Metabolic Drugs / chemical e.g. chemo SE Infection Intra-cranial causing raised ICP Vestibular Abdominal / reduced gastro-mobility Psychological
What metabolic
Uraemia from renal failure
Hypercalcaemia
Circulating Ig
Renal failure
What drugs
Opioids Chemo AX SSRI Iron Digoxin NSAID
What abdominal causes
Gastric outlet obstruction
Severe constipation
Mass
Hepatic mets
What is useful if intra-cranial / raised ICP lesion causing N+V
Dexamethasone = 1st line
Cyclizine
Haloperidol - anti-psychotic (D2 antagonist)
What are RF of chemo related N+V
Anxiety
<50
Concurrent use of opioids
Type of chemo
What is used if low risk of N+V Sx in chemo
Metoclopramide
What is added if doesn’t work or if high risk
5HT3 receptor antagonist - ondansetron
Dexamethasone
What are used as anti-emetics
H1 antagonist (anti-histamine) D2 antagonist (pro kinetic) 5HT3 antagonist Anti-psychotics Anti-cholinergic - hyoscine hydrobromide
What are dopamine antagonist and what are they useful for
Metoclopramide 10mg - gut peristalsis - used for GI causes
Domperidone 10-20mg - gut peristalsis
- Useful in gastric stasis, hiccups in palliative, RT induced 2nd line, delayed chemo induced, gastroenteritis, uraemia
Avoid in mechanical bowel obstruction, Parkinson and prolactinoma
Haloperidol- N+V in palliative care / raised ICP
What antihistamine and what useful for and what others
Cyclizine 50mg TDS PO / SC / IV / IM
Useful for inner ear induced nausea / intra-cranial / mechanical bowel
Risk of urinarry retention
Chloropromazine also useful / levomepromazine
What anti-psychotic
Levomepromazine
- Only used in pallaitiv care
- Also provide analgesia
- Avoid in myasthenia graves + Parkinson
- Decreases seizure threshold
What 5HT3 antagonist and what is it useful for
Ondanstron
1st line for chemo induced + RT induced + post-op
Gastroenteritis
Avoid in long QT
What is downside
Very constipation
Expensive
What happens to calcium in a sick person
Albumin is low
Ca levels may be normal but ionised Ca will be too high
What should you do if risk
Add the mission albumin to calcium If Ca 2.6 and albumin 16 (36-52) Missing = 36-16 = 20g Each g carried 0.2m of calcium So if albumin was normal there would be additional 0.4 moll of Ca Corrected calcium = 3
What are consequences of malnutrition
Impaired immune Poor wound healing Muscle wasting and weakness Impaired organ function Altered drug Poor response to Rx
What is cancer cachexia
Unintential body and lean tissue wasting
Metabolic abnormality results in increased energy, fab and oxidation
What does it lead too
GI disturbance
Anorexia
Undernutriton
How do you treat
Adequate replacement and supplements
Appetite stimulates
MUST screening on admission and weekly
What replacement
Energy and protein dense diet Food fortification Oral supplement NGT PEG TPN
What stimulates appetite
Megace
Dexamethasone
Alcohol
What causes constipation in palliative
SE of opioid Hypercalcaemia Dehydration Drugs INtra-abdominal disease
What are causes of breathlessness
Infection Pleural effusion Anaemia Arrhythmia VTE SVC = urgent Rx
How do you Rx
Treat cause
If patient distressed consider low dose morphine as suppress resp drive
Benzo may help if associated anxiety
What are common medications in anticipatory care pan
Morphine for pain Haloperidol for agitation / N+V Midazolam for agitation and anxiety Anti-emetic for N+V Glycopyronium for resp secretion
What is breathlessness in palliative care
A subjective experience of chest discomfort
- Tachypnoea
- Examination
- Hypoxia in patient with no known resp
What can cause
Most common Sx
- Heart
- Lung
- End stage cancer
What investigation
CXR = 1st line for cause
What category
On exertion
At rest
Terminal
What 3 things are involved in perception of breathlessness
Thinking
Breathing
Function
Thinking
Anxiety / distress
Thoughts about dying
Attention to sensation
Breathing
Increased RR
Use of accessory
Increased work of breathing
Function
Reduced activity
More help from others
Deconditioning of chest
How do you treat thinking non-pharmalogically
Distractive stimuli
Relaxation
Cold air
How do you treat breathing non-pharmacologically
Sit upright
Breathing exercise
How do you treat function non
Walking aid
Chest wall vibration and muscle stimulation
What are pharmacological therapy
Opaites
- Reduce response to hypercapnia
- Reduces RR and drive and therefore breathlessness
- Morphine 2mg SC PRN
Benzo
- Used for anxiety
- Midazolam 2mg SC PRN (larger dose may be needed if on background of opiates)
Use of anti-cholinergic in palliative
Bowel colic
Resp secretion
N+V
Hyoscine hydrobromide and butylbromide
When do you have caution
Mechanical bowel
Angle closure glaucoma
Risk of retention an arrhythmia
If opiate naive what should you start morphine at for end of life
Morphine 2mg SC hourly PRN for pain or breathlessness
If on background = 1/6 of total SC dose
Breathless
Morphine 2mg SC hourly PRN
Midazolam 2mg SC PRN
Agitation / anxiety
Midazolam 2mg SC PRN
Secretions
Hyoscine butyl bromide 20mg SC hourly
N+V
Levomepromazine 2.5-5mg SC12 hourly
If patient was of life what should you do
Look for reversible causes Dehydration? Glucose? AKI? Delerium?
What are risks of fluid in end of life
Secretions
SOB
Overload
