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Palliative Care > Chapter 4 - management of physical symptoms > Flashcards

Chapter 4 - management of physical symptoms Flashcards

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1
Q

what are some measures to assess performance status?

A

1) Australian-modified Karnofsky performance status (AKPS)
2) phase of illness
3) Integrated palliative outcome scale
4) Views on care
5) Barthel index
6) carer measures

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2
Q

what are the 5 phases of illness?

A 
stable
unstable
deteriorating
dying
deceased
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3
Q

what is “stable” phase of illness?

A

Phase where the patients problems and symptoms are adequately controlled by the established plan of care AND further interventions to maintain control and quality of life have been planned AND family/carer situation is relatively stable with no issues apparent

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4
Q

what is the unstable phase of illness?

A

an urgent change in the plan of care or emergency treatment is required BECAUSE the patient now experiences a new problem that was not anticipated in the original plan and/or the patient experiences a paid increase in the severity of an existing problem and/or the family’s/carers circumstances suddenly change impacting on patient care

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5
Q

what is the deteriorating phase?

A

the care plan is addressing the patients needs however they require periodic review because the patients overall functional status is declining, and the patient experiences worsening of existing problems and/or the patient experiences a new but anticipated problem and/or the family/carer experience gradual worsening distress that impacts on the patient care

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6
Q

what is the dying phase

A

death is expected within days

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7
Q

when does the stable phase end?

A

when the needs of the patient and/or carer increase requiring changes to the existing plan

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8
Q

when does the unstable phase end?

A

the new plan of care is in place, it has been reviewed and no further changes are required. This does not mean the symptoms/crisis has fully resolved, but there is a clear diagnosis and place of care, AND/OR the death is likely within days

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9
Q

when does the deteriorating phase end?

A

patient condition has plateaued, or there is an urgent charge in the care plan or emergency treatment, AND/OR family/carers experience a sudden change in their situation that impacts on patient care and urgent intervention is required OR death is likely within days

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10
Q

what are some cancer related causes of breathlessness?

A 
primary/secondary tumours (in lungs) 
SVC obstruction
ascites
fatigue/weakness
phrenic nerve palsy 
pleural/pericardial effusion
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11
Q

what are some treatment related causes of breathlessness?

A

radio/chemotherapy induced pulmonary fibrosis
surgery - lobectomy/pneumonectomy
bronchospasm or fluid retention due to medications
trachyeostomy complications i.e. secretions

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12
Q

what are some other causes of breathlessness in patients with terminal disease?

A

anemia of chronic disease/bone marrow infiltration
heart failure
PE
COPD
Pneumothorax
trachyeostomy complications
psychological i.e. anxiety, fear, claustrophobia

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13
Q

what are some symptoms that can be associated with breathlessness?

A 
sneezing
chest pain
cough
fever
wheeze
haemoptysis
stridor
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14
Q

what is the management for SVC obstruction?

A

steroids
stenting
radiotherapy

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15
Q

what are the 5 main interventions for breathlessness?

A

1) opioids
2) bronchodilators
3) corticosteroids
4) anxiolytics
5) O2

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16
Q

what doses of opioid is recommended for breathlessness?

A

1.25-2.5mg PO 4 hourly initially
titrate slowly until effective
doses above 10mg per 4 hours are unlikely to be effective

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17
Q

what bronchodilators are recommended for breathlessness?

A

salbutamol 2.5-5mg QDS via nebuliser or spacer

ipratropium bromide 250-500mcg up to QDS via nebuliser

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18
Q

what are the SE when using salbutamol nebs?

A

tachycardia
tremor
anxiety

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19
Q

what is the recommended dose of steroid for breathlessness and for how long?

A

dexamethasone 4-8mg PO OD, one week trial

benefits should be seen in 3-5 days, if no improvement then stop

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20
Q

how do steroids improve breathlessness?

A

reduce peri-tumour oedema which can improve breathlessness in patients with lung cancer or lymphangitis carcinomatosis

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21
Q

how often should blood sugars be monitored in patients starting steroids?

A

once prior to starting

weekly thereafter

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22
Q

what time should steroids be taken?

A

before 3pm, to minimise insomnia

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23
Q

what doses of anxiolytics can be used for breathlessness?

A

lorazepam 0.5-1mg SL PRN 6-8hrly
diazepam 2-5mg
midazolam 5-15mg CSCI over 24 hours in terminal phase

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24
Q

what are some physiotherapy interventions for breathlessness?

A

relaxation techniques- reduce WOB by encouraging relaxation of the shoulder girdle, diaphragm, and pursed lips breathing
ABCT - active breathing cycles for secretions
suction
NIV for patients with MND
general repositioning

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25
what are some OT interventions for breathlessness?
energy prioritisation - 5P's (prioritising, planning, pacing, positioning permission) perching stools rise recliners shower boards to aid patients to adapt their environment to help with breathlessness hand held fan
26
what is the calming hand?
widely adapted approach to encourage the breathless patients to focus on their breathing and reduce panic related to breathlessness
27
what are the 5 parts of the calming hand?
1) thumb - RECOGNITION - recognise the signs of breathlessness/panic, hold your thumb firmly with the other hand 2) sigh out - relax shoulders and breath out, stop and droop shoulders 3) inhale- slow and gentle breath in through nose 4) exhale - gentle breath out 5) little finger- STRETCH HAND and stop
28
what are some indicators that a patient is approaching end stages of life?
``` persistent dyspnoea despite maximal therapy increased hospital admissions extra support for all ADLs expressions of fear/anxiety increasing fatigue concerns re family members ```
29
what are some skin issues that a patient may experience when approaching end of life?
``` pruritis - experienced by 50-70% of patients over 70! lymphoedema wound care pressure area care sweating ```
30
what are the most common palliative causes of itching?
haematological cancers - CLL, lymphoma, MM (cause skin changes) carcinoma in situ i.e. vulval/anal paraneoplastic syndromes - breast, colon, lung or stomach carcinomas metastatic infiltration of skin cholestasis psychogenic causes i.e psycholgical causes other causes: uraemia, drugs, DM, thyroid disease, HIV, stroke
31
what are the important q's to ask when taking history of patient with itching?
severity? frequency and duration? generalised or localised? is there a rash? is the skin broken/bleeding/serous fluid? exacerbating factors and sources of relief? drug and previous medical history? social history - does anyone else have the same?
32
what are some general measures for pruritus?
``` skin moisturisers corticosteroid creams avoid scratching - nails short, cotton gloves at night tepid baths/showers pat skin dry rather than rubbing avoid alcohol + spicy clothes hypnotherapy and behavioural treatments topical anti-pruritic preparations address psychological concerns ```
33
what is the management of renal failure/uraemia itching?
aluminium hydroxide 1-3 caps TDS ondansetron gabapentin opioid antagonists - however may reverse the effect
34
what is the management of opioid induced pruritus?
common SE! | ondansetron (5-HT3 antagonist)
35
what are some interventions for fungating tumour pain?
establish exactly type of pain - as this will affect whether systemic or topical treatments are used topical analgesia - ibuprofen 5% gel, hydrogel + morphine pre-incident analgesia i.e. prior to dressing changes - entonox care plan re dressing changes - not too frequently or not enough
36
what are some interventions for fungating tumour exudate?
ensure correct dressing - alginate + hydro fibre dressings topical metronidazole TVN involvement cavilon alcohol free skin barriers to stop it getting worse minimal strapping to the area
37
interventions for malodour from a fungating wound?
aromatherapy around the wound/on dressings special dressing including charcoal and silver diffusers and vaporisers
38
interventions for bleeding from a fungating wound?
topical adrenaline on gauze (1:1000 soaks) tranexamic acid orally 1g TDS or topically kaltostat applied to bleeding point
39
how quickly should pressure areas be assessed on admission?
6 hours
40
which pressure sores should be reported?
category 3 or category 4
41
which is the most common scale for pressure area assessment used in the uk?
Waterlow pressure ulcer prevention/treatment policy takes into consideration - age, immobility, dehydration, hypotension, incontinence, poor nutritional status, sex
42
what are some interventions for pressure sores?
``` profiling/low air loss bed memory foam mattress regular turning avoid friction - use slide sheets nutrition keep skin as dry as possible ```
43
what are some causes of excessive sweating in patients with cancer?
lymphoma (particularly liver mets) medication related - hormone therapies (tamoxifen, aromatase inhibitors), SSRI antidepressants endocrine oestrogen deficiency - androgen deficiency, hyperthyroidism, hypoglycaemia alcohol withdrawal autoimmune neuropathy
44
what are some non-pharmacological interventions for sweating?
maintain fluid intake cool well ventilated room cotton lightweight clothing and bedding tepid sponging
45
what are some pharmacological measures for sweating?
tumour associated: nsaids or dexamethasone 1-2mg daily amitriptyline 10-50mg note pyrexia: paracetamol 1g 6 hourly
46
what are the four interventions for lymphoedema?
skin care lymphatic massage compression banding and garments exercise and elevation
47
what is the antibiotic of choice for cellulitis in lymphedema?
amoxicillin | if staph aureus present - flucloxacillin
48
what are some causes of dry mouth?
medications - antimuscarinics, antidepressants, opioids, diuretics thrush dehydration anxiety mouth breathing non-humidified oxygen therapy
49
interventions for dry mouth?
``` sucking ice chips good mouth care sugar free chewing gum petroleum jelly to the lips use of toothbrush management of oral thrush - nystatin or fluconazole 50mg OD for 7-14 days artificial saliva saliva stimulation i.e. pilocarpine 5mg TDS - parasympathetic agent that stimulates the salivary gland ```
50
what causes stomatitis?
infection - HSV ulceration poor mouth care mucositis post radiotherapy/chemotherapy vitamin C deficiency (gingivitis) iron deficiency (angular stomatitis + glossitis)
51
management of stomatitis or sore mouth?
local anaesthetic agents such as difflam mouth wash (contains benzocaine) soluble aspirin/oramorph mouthwash good mouth care
52
when should pilocarpine be avoided?
``` COPD glaucoma bowel obstruction asthma cardiac disease ```
53
what are some pharmacological agents to stimulate saliva production?
``` pilocarpine 5mg PO TDS pilocarpine 4% eye drops on the tongue salivary orthana (pork based so not suitable for veg/vegans) bethanechol 10mg TDS with meals biotin oralbalance gel ```
54
what are the receptors involved in nausea and vomiting?
5-HT3 Histamine acetylcholine dopamine
55
causes of nausea/vomiting?
constipation raised ICP anxiety and fear metabolic causes - renal failure, hypercalcaemia pain treatment related- post-radiotherapy, chemotherapy intestinal obstruction, gastric stasis infection drug induced - opioids, antibiotics, digoxin, iron oral thrush
56
what are important questions to ask when assessing nausea/vomiting?
``` frequency triggers exacerbating factors vomit appearance related symptoms - dyspepsia, tachycardia, constipation, diarrhoea, headache, cough ```
57
what is the choice of antiemetic in drug/toxin induced antiemetics?
haloperidol 0.5-1.5mg ON/BD | levomepromazine 6.25mg ON
58
what is the choice of antiemetic post-radiotherapy?
ondansetron 8mg TDS haloperidol 0.5-1.5mg ON/BD ganisetron 1mg stat then 1mg BD
59
what is the choice of antiemetic for chemotherapy?
ondansetron 8mg BD dexamethasone 4-8mg OD metoclopramide 10mg QDS ganisetron aprepitant
60
what is the choice of antiemetic in hypercalcaemia?
haloperidol 0.5-1.5mg ON/BD | leveomepromazine 6.25mg ON
61
what is the choice of antiemetic in raised ICP?
cyclizine 50mg PO TDS | dexamethasone 4-15mg OM
62
what is the choice of antiemetic in bowel obstruction?
1st line - cyclizine 150mg/24hrs CSCI (or haloperidol) 2nd line - levo 3rd line - ondansetron 8-16mg/24hrs IV or CSCI colic pain- hyoscine butyl bromide 40-100mg/24hrs CSCI octreotide 300-600mcg/24hrs CSCI
63
what is the choice of antiemetic in delayed gastric emptying?
metoclopramide 10mg TDS | domeperidone 10mg TDS
64
what is the choice of antiemetic in gastric irritation?
treat with PPI stop gastric irritants - NSAIDs cyclizine 50mg TDS
65
what are some non-pharmacological measures of nausea and vomiting?
``` calm reassuring environment small snacks and light meals positioning in bed and chair mouth care avoid precipitating factors hypnotherapy + acupuncture control of malodour ```
66
what does cancer cachexia compromise of and what is it defined as?
ongoing loss of skeletal muscle loss of muscle mass progressive functional impairment defined as involuntary weight loss of more than 5-10% of pre-morbid weight over last 6 months
67
what is the management of cachexia?
``` early referral to dietician exercise to build muscle if appropriate small portions of attractive meals conducive environment for eating appetite enhancers such as alcohol ```
68
what is the pharmacological management of cachexia?
gastric pro kinetics such as metoclopramide in patients with early satiety dexamethasone 2-4mg progesterones - may enhance appetite and increase weight but usually in the form of fat
69
what are some general causes of constipation?
pressure - tumour or ascites tumour infiltration immobility loading to decreased peristalsis decreased oral intake low residue inpatient admission - change in environment, lack of privacy/embarrassment at using a commode.
70
what are fluid related causes of constipation?
poor fluid intake increased fluid loss i.e. vomiting lower residue diet
71
what are some frailty causes of constipation?
inability to reach toilet when urge to defecate occurs inability to get optimum position i.e. using bedpan inability to raise intra-abdominal pressure e..g general debility, paraplegia
72
what are some metabolic causes of constipation?
hypercalcaemia hypokalaemia hypothyroidism
73
what are some pain related causes of constipation?
anal/rectal conditions such as fixes, abscesses or tumours
74
what are some neurological conditions associated with constipation?
parkinsons MND MS lumbar, sacral, caudal equina nerve damage
75
what medications commonly cause constipation?
``` opioids TCA cyclizine levodopa iron supplements diuretics ondansetron ```
76
how do opioids cause constipation?
reduce gastric motility, reduce gastric emptying and increase absorption of water from small and large intestine leading to hard, dry stools
77
what are some clinical complications of constipation?
``` abdominal pain/discomfort overflow diarrhoea urinary retention or frequency embarrassment confusion or restlessness - particularly in last days of life ```
78
what are the four types of laxatives?
stimulant osmotic faecal softeners opioid antagonists
79
what are some examples of stimulant laxatives and how do they work?
Senna bisacodyl tabs/supps they both rely on bacterial transformation in the large bowel to produce active derivatives and so have little small bowel effect
80
when should stimulant laxatives be avoided?
intestinal obstruction
81
give some examples of osmotic laxatives, and explain how they work?
lactulose movicol/laxido phosphate enemas magnesium salts they are not absorbed from the gut, and they increase water in the lumen by osmotic action, leading to increase in volume and stimulation of the gut wall, causing peristalsis and expulsion of faeces
82
give some examples of stool softeners and explain how they work?
sodium docusate glycerol supps poloxamer reduce surface tension and improve water penetration of stools
83
how do you manage faecal impaction?
bisacodyl supps (must be in contact with rectal mucosa) naloxegol phosphate enema gentle abdominal massage movicol (laxido) - orally up to 8 satchets a day encourage diet and fluids
84
what is the definition of diarrhoea?
more than 3 unformed stools in 24 hours
85
what are common causes of diarrhoea in palliative care setting?
``` imbalance of laxatives drugs - antacids, NSAIDs, iron preparations, antibiotics C diff faecal impaction - overflow radiotherapy involving abdomen or pelvis (most commonly in 2nd or 3rd week) pancreatic cancer - malabsorption gastrectomy colectomy colonic/rectal tumour endocrine tumours which secrete hormones causing diarrhoea i.e. carcinoid tumour diets high in fibre ibs/ibd ```
86
what does pale fat smelly stools suggest?
malabsorption - pancreatic or illeal disease
87
what does alternating diarrhoea and constipation suggest?
poor laxative therapy
88
what does profuse watery diarrhoea suggest?
colonic disease
89
what does diarrhoea without warning suggest
incontinence
90
what are some non-pharmacological interventions for diarrhoea?
encourage oral intake particularly fluids reduce consumption of diary products, fatty foods or caffeine good perianal hygiene + barrier creams 1% hydrocortisone cream should be suggested if anal area already irritated
91
management of fat malabsorption?
creon | pancreatin
92
management of radiotherapy induced diarrhoea?
ondansetron | cholestyramine
93
management of pseudomembranous colitis? I.e overgrowth of CDiff?
metronidazole 400mg TDS | vancomycin 125mg QDS
94
management of profuse secretory diarrhoea - this can be associated with HIV?
octreotide
95
general first line management of diarrhoea?
loperamide 2mg after each loose stool, max 16mg | if not managed - codeine 30mg QDS orally
96
which cancers most commonly cause bowel obstruction?
ovarian or bowel cancer
97
what are the two types of bowel obstruction?
mechanical | functional
98
what is functional bowel obstruction?
there is no physical blockage, however there is lack of movement of the bowel (ileus) thought to be due to vascular damage to the myenteric plexus in the bowel wall
99
what are the AXR findings to confirm bowel obstruction?
dilated loops of bowel | air and fluid levels
100
what symptoms of bowel obstruction suggest high bowel obstruction?
frequent vomits of unchanged stomach contents bilious vomiting nausea and vomiting shortly after eating with no warning
101
what are the symptoms of bowel obstruction suggesting low obstruction?
semi digested/faeculent vomit increased background of vomiting less correlation with food intake
102
what are the general symptoms of bowel obstruction?
``` nausea and vomiting colic pain constipation diarrhoea ```
103
what are some pharmacological interventions for bowel obstruction?
dexamethasone - reduce bowel wall oedema associated with bowel obstruction metoclopramide 30-120mg/24hrs hyoscine butyl bromide to reduce cramps (however risk of reducing gut activity further) manage N+V - cyclizine/haloperidol/levo if vomiting very distressing -NG tube to give relief (however rare in palliative care)

Palliative Care (10 decks)

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