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Palliative Care + Oncology > Agitation / Secretions / Hiccups / N+V / Nutrition > Flashcards

Agitation / Secretions / Hiccups / N+V / Nutrition Flashcards

1
Q

What should you look for if confusion / agiation

A 
Underlying cause to treat
Infection
Pain 
Dehydration 
Retention / constipation 
Medication
Hypercalcaemia
Uraemia 
Electrolyte imbalance
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2
Q

Where are sources of information for reasons for confusion

A 
Nurse
Relative
NEWS
Drug cardex
Blood results 
4AT + TIME
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3
Q

What examination can you do

A

Chest
ABdo
Neuro
PEARL

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4
Q

What can you use if specific Rx fails

A

Side room, regular staff and possible 1:1 nursing
Haloperidol = 1st line
Chloropromazine
Lorazepam if can’t have anti-psychotic

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5
Q

What is used in terminal phase of agitation / restless

A

Midazolam 2.5-5 SC

Levomepromazine 12.5mg SC 2 hourly PRN

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6
Q

What is licensed for intractable hiccups

A

Chloropromazine

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7
Q

What is also used if unresponsive

A

Haloperidol
Gabapentin
Dexamethasone - hepatic

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8
Q

What are common in final days of life

A 
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
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9
Q

What is conservative Rx for secretions

A 
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
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10
Q

What is medical management of secretions

A

Hyoscine hydrobromide - 20mg SC hourly PRN (120max in 24 hours)
- Reduce production

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11
Q

What is used for bowel colic

A

Hyoscine butyl bromide (Buscopan)

- Oesophageal spasm / crampy abdo pain

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12
Q

What can cause sickness in palliative care / broad spectrums of N+V

A 
Severe pain 
Metabolic
Drugs / chemical e.g. chemo SE 
Infection
Intra-cranial causing raised ICP 
Vestibular
Abdominal  / reduced gastro-mobility 
Psychological
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13
Q

What metabolic

A

Uraemia from renal failure
Hypercalcaemia
Circulating Ig
Renal failure

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14
Q

What drugs

A 
Opioids 
Chemo
AX
SSRI 
Iron 
Digoxin
NSAID
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15
Q

What abdominal causes

A

Gastric outlet obstruction
Severe constipation
Mass
Hepatic mets

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16
Q

What is useful if intra-cranial / raised ICP lesion causing N+V

A

Dexamethasone = 1st line
Cyclizine
Haloperidol - anti-psychotic (D2 antagonist)

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17
Q

What are RF of chemo related N+V

A

Anxiety
<50
Concurrent use of opioids
Type of chemo

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18
Q

What is used if low risk of N+V Sx in chemo

A

Metoclopramide

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19
Q

What is added if doesn’t work or if high risk

A

5HT3 receptor antagonist - ondansetron

Dexamethasone

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20
Q

What are used as anti-emetics

A 
H1 antagonist (anti-histamine) 
D2 antagonist (pro kinetic) 
5HT3 antagonist 
Anti-psychotics 
Anti-cholinergic - hyoscine hydrobromide
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21
Q

What are dopamine antagonist and what are they useful for

A

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

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22
Q

What antihistamine and what useful for and what others

A

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

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23
Q

What anti-psychotic

A

Levomepromazine

  • Only used in pallaitiv care
  • Also provide analgesia
  • Avoid in myasthenia graves + Parkinson
  • Decreases seizure threshold
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24
Q

What 5HT3 antagonist and what is it useful for

A

Ondanstron
1st line for chemo induced + RT induced + post-op
Gastroenteritis
Avoid in long QT

25
Q

What is downside

A

Very constipation

Expensive

26
Q

What happens to calcium in a sick person

A

Albumin is low

Ca levels may be normal but ionised Ca will be too high

27
Q

What should you do if risk

A 
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
28
Q

What are consequences of malnutrition

A 
Impaired immune
Poor wound healing
Muscle wasting and weakness
Impaired organ function
Altered drug
Poor response to Rx
29
Q

What is cancer cachexia

A

Unintential body and lean tissue wasting

Metabolic abnormality results in increased energy, fab and oxidation

30
Q

What does it lead too

A

GI disturbance
Anorexia
Undernutriton

31
Q

How do you treat

A

Adequate replacement and supplements
Appetite stimulates
MUST screening on admission and weekly

32
Q

What replacement

A 
Energy and protein dense diet
Food fortification
Oral supplement
NGT
PEG
TPN
33
Q

What stimulates appetite

A

Megace
Dexamethasone
Alcohol

34
Q

What causes constipation in palliative

A 
SE of opioid
Hypercalcaemia
Dehydration
Drugs
INtra-abdominal disease
35
Q

What are causes of breathlessness

A 
Infection
Pleural effusion
Anaemia
Arrhythmia
VTE 
SVC = urgent Rx
36
Q

How do you Rx

A

Treat cause
If patient distressed consider low dose morphine as suppress resp drive
Benzo may help if associated anxiety

37
Q

What are common medications in anticipatory care pan

A 
Morphine for pain
Haloperidol for agitation / N+V
Midazolam for agitation and anxiety
Anti-emetic for N+V
Glycopyronium for resp secretion
38
Q

What is breathlessness in palliative care

A

A subjective experience of chest discomfort

  • Tachypnoea
  • Examination
  • Hypoxia in patient with no known resp
39
Q

What can cause

A

Most common Sx

  • Heart
  • Lung
  • End stage cancer
40
Q

What investigation

A

CXR = 1st line for cause

41
Q

What category

A

On exertion
At rest
Terminal

42
Q

What 3 things are involved in perception of breathlessness

A

Thinking
Breathing
Function

43
Q

Thinking

A

Anxiety / distress
Thoughts about dying
Attention to sensation

44
Q

Breathing

A

Increased RR
Use of accessory
Increased work of breathing

45
Q

Function

A

Reduced activity
More help from others
Deconditioning of chest

46
Q

How do you treat thinking non-pharmalogically

A

Distractive stimuli
Relaxation
Cold air

47
Q

How do you treat breathing non-pharmacologically

A

Sit upright

Breathing exercise

48
Q

How do you treat function non

A

Walking aid

Chest wall vibration and muscle stimulation

49
Q

What are pharmacological therapy

A

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)

50
Q

Use of anti-cholinergic in palliative

A

Bowel colic
Resp secretion
N+V

Hyoscine hydrobromide and butylbromide

51
Q

When do you have caution

A

Mechanical bowel
Angle closure glaucoma
Risk of retention an arrhythmia

52
Q

If opiate naive what should you start morphine at for end of life

A

Morphine 2mg SC hourly PRN for pain or breathlessness

If on background = 1/6 of total SC dose

53
Q

Breathless

A

Morphine 2mg SC hourly PRN

Midazolam 2mg SC PRN

54
Q

Agitation / anxiety

A

Midazolam 2mg SC PRN

55
Q

Secretions

A

Hyoscine butyl bromide 20mg SC hourly

56
Q

N+V

A

Levomepromazine 2.5-5mg SC12 hourly

57
Q

If patient was of life what should you do

A 
Look for reversible causes
Dehydration?
Glucose?
AKI?
Delerium?
58
Q

What are risks of fluid in end of life

A

Secretions
SOB
Overload

Palliative Care + Oncology (6 decks)

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