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

Chapter 4 - management of physical symptoms Flashcards

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
Q

what are some OT interventions for breathlessness?

A

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

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26
Q

what is the calming hand?

A

widely adapted approach to encourage the breathless patients to focus on their breathing and reduce panic related to breathlessness

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27
Q

what are the 5 parts of the calming hand?

A

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

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28
Q

what are some indicators that a patient is approaching end stages of life?

A 
persistent dyspnoea despite maximal therapy
increased hospital admissions
extra support for all ADLs
expressions of fear/anxiety
increasing fatigue
concerns re family members
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29
Q

what are some skin issues that a patient may experience when approaching end of life?

A 
pruritis - experienced by 50-70% of patients over 70!
lymphoedema 
wound care
pressure area care
sweating
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30
Q

what are the most common palliative causes of itching?

A

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

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31
Q

what are the important q’s to ask when taking history of patient with itching?

A

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?

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32
Q

what are some general measures for pruritus?

A 
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
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33
Q

what is the management of renal failure/uraemia itching?

A

aluminium hydroxide 1-3 caps TDS
ondansetron
gabapentin
opioid antagonists - however may reverse the effect

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34
Q

what is the management of opioid induced pruritus?

A

common SE!

ondansetron (5-HT3 antagonist)

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35
Q

what are some interventions for fungating tumour pain?

A

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

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36
Q

what are some interventions for fungating tumour exudate?

A

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

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37
Q

interventions for malodour from a fungating wound?

A

aromatherapy around the wound/on dressings
special dressing including charcoal and silver
diffusers and vaporisers

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38
Q

interventions for bleeding from a fungating wound?

A

topical adrenaline on gauze (1:1000 soaks)
tranexamic acid orally 1g TDS or topically
kaltostat applied to bleeding point

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39
Q

how quickly should pressure areas be assessed on admission?

A

6 hours

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40
Q

which pressure sores should be reported?

A

category 3 or category 4

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41
Q

which is the most common scale for pressure area assessment used in the uk?

A

Waterlow pressure ulcer prevention/treatment policy

takes into consideration - age, immobility, dehydration, hypotension, incontinence, poor nutritional status, sex

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42
Q

what are some interventions for pressure sores?

A 
profiling/low air loss bed
memory foam mattress
regular turning 
avoid friction - use slide sheets
nutrition 
keep skin as dry as possible
43
Q

what are some causes of excessive sweating in patients with cancer?

A

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
Q

what are some non-pharmacological interventions for sweating?

A

maintain fluid intake
cool well ventilated room
cotton lightweight clothing and bedding
tepid sponging

45
Q

what are some pharmacological measures for sweating?

A

tumour associated:
nsaids or dexamethasone 1-2mg daily
amitriptyline 10-50mg note

pyrexia:
paracetamol 1g 6 hourly

46
Q

what are the four interventions for lymphoedema?

A

skin care
lymphatic massage
compression banding and garments
exercise and elevation

47
Q

what is the antibiotic of choice for cellulitis in lymphedema?

A

amoxicillin

if staph aureus present - flucloxacillin

48
Q

what are some causes of dry mouth?

A

medications - antimuscarinics, antidepressants, opioids, diuretics
thrush
dehydration
anxiety
mouth breathing non-humidified oxygen therapy

49
Q

interventions for dry mouth?

A 
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
Q

what causes stomatitis?

A

infection - HSV
ulceration
poor mouth care
mucositis post radiotherapy/chemotherapy
vitamin C deficiency (gingivitis)
iron deficiency (angular stomatitis + glossitis)

51
Q

management of stomatitis or sore mouth?

A

local anaesthetic agents such as difflam mouth wash (contains benzocaine)
soluble aspirin/oramorph mouthwash
good mouth care

52
Q

when should pilocarpine be avoided?

A 
COPD 
glaucoma 
bowel obstruction 
asthma 
cardiac disease
53
Q

what are some pharmacological agents to stimulate saliva production?

A 
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
Q

what are the receptors involved in nausea and vomiting?

A

5-HT3
Histamine
acetylcholine
dopamine

55
Q

causes of nausea/vomiting?

A

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
Q

what are important questions to ask when assessing nausea/vomiting?

A 
frequency 
triggers
exacerbating factors
vomit appearance
related symptoms - dyspepsia, tachycardia, constipation, diarrhoea, headache, cough
57
Q

what is the choice of antiemetic in drug/toxin induced antiemetics?

A

haloperidol 0.5-1.5mg ON/BD

levomepromazine 6.25mg ON

58
Q

what is the choice of antiemetic post-radiotherapy?

A

ondansetron 8mg TDS
haloperidol 0.5-1.5mg ON/BD
ganisetron 1mg stat then 1mg BD

59
Q

what is the choice of antiemetic for chemotherapy?

A

ondansetron 8mg BD
dexamethasone 4-8mg OD
metoclopramide 10mg QDS

ganisetron
aprepitant

60
Q

what is the choice of antiemetic in hypercalcaemia?

A

haloperidol 0.5-1.5mg ON/BD

leveomepromazine 6.25mg ON

61
Q

what is the choice of antiemetic in raised ICP?

A

cyclizine 50mg PO TDS

dexamethasone 4-15mg OM

62
Q

what is the choice of antiemetic in bowel obstruction?

A

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
Q

what is the choice of antiemetic in delayed gastric emptying?

A

metoclopramide 10mg TDS

domeperidone 10mg TDS

64
Q

what is the choice of antiemetic in gastric irritation?

A

treat with PPI
stop gastric irritants - NSAIDs
cyclizine 50mg TDS

65
Q

what are some non-pharmacological measures of nausea and vomiting?

A 
calm reassuring environment 
small snacks and light meals 
positioning in bed and chair 
mouth care
avoid precipitating factors 
hypnotherapy + acupuncture 
control of malodour
66
Q

what does cancer cachexia compromise of and what is it defined as?

A

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
Q

what is the management of cachexia?

A 
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
Q

what is the pharmacological management of cachexia?

A

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
Q

what are some general causes of constipation?

A

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
Q

what are fluid related causes of constipation?

A

poor fluid intake
increased fluid loss i.e. vomiting
lower residue diet

71
Q

what are some frailty causes of constipation?

A

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
Q

what are some metabolic causes of constipation?

A

hypercalcaemia
hypokalaemia
hypothyroidism

73
Q

what are some pain related causes of constipation?

A

anal/rectal conditions such as fixes, abscesses or tumours

74
Q

what are some neurological conditions associated with constipation?

A

parkinsons
MND
MS
lumbar, sacral, caudal equina nerve damage

75
Q

what medications commonly cause constipation?

A 
opioids 
TCA
cyclizine 
levodopa
iron supplements
diuretics
ondansetron
76
Q

how do opioids cause constipation?

A

reduce gastric motility, reduce gastric emptying and increase absorption of water from small and large intestine leading to hard, dry stools

77
Q

what are some clinical complications of constipation?

A 
abdominal pain/discomfort
overflow diarrhoea 
urinary retention or frequency 
embarrassment 
confusion or restlessness - particularly in last days of life
78
Q

what are the four types of laxatives?

A

stimulant
osmotic
faecal softeners
opioid antagonists

79
Q

what are some examples of stimulant laxatives and how do they work?

A

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
Q

when should stimulant laxatives be avoided?

A

intestinal obstruction

81
Q

give some examples of osmotic laxatives, and explain how they work?

A

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
Q

give some examples of stool softeners and explain how they work?

A

sodium docusate
glycerol supps
poloxamer

reduce surface tension and improve water penetration of stools

83
Q

how do you manage faecal impaction?

A

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
Q

what is the definition of diarrhoea?

A

more than 3 unformed stools in 24 hours

85
Q

what are common causes of diarrhoea in palliative care setting?

A 
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
Q

what does pale fat smelly stools suggest?

A

malabsorption - pancreatic or illeal disease

87
Q

what does alternating diarrhoea and constipation suggest?

A

poor laxative therapy

88
Q

what does profuse watery diarrhoea suggest?

A

colonic disease

89
Q

what does diarrhoea without warning suggest

A

incontinence

90
Q

what are some non-pharmacological interventions for diarrhoea?

A

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
Q

management of fat malabsorption?

A

creon

pancreatin

92
Q

management of radiotherapy induced diarrhoea?

A

ondansetron

cholestyramine

93
Q

management of pseudomembranous colitis? I.e overgrowth of CDiff?

A

metronidazole 400mg TDS

vancomycin 125mg QDS

94
Q

management of profuse secretory diarrhoea - this can be associated with HIV?

A

octreotide

95
Q

general first line management of diarrhoea?

A

loperamide 2mg after each loose stool, max 16mg

if not managed - codeine 30mg QDS orally

96
Q

which cancers most commonly cause bowel obstruction?

A

ovarian or bowel cancer

97
Q

what are the two types of bowel obstruction?

A

mechanical

functional

98
Q

what is functional bowel obstruction?

A

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
Q

what are the AXR findings to confirm bowel obstruction?

A

dilated loops of bowel

air and fluid levels

100
Q

what symptoms of bowel obstruction suggest high bowel obstruction?

A

frequent vomits of unchanged stomach contents
bilious vomiting
nausea and vomiting shortly after eating with no warning

101
Q

what are the symptoms of bowel obstruction suggesting low obstruction?

A

semi digested/faeculent vomit
increased background of vomiting
less correlation with food intake

102
Q

what are the general symptoms of bowel obstruction?

A 
nausea and vomiting 
colic
pain 
constipation 
diarrhoea
103
Q

what are some pharmacological interventions for bowel obstruction?

A

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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