Med P3 PPT Flashcards
what are some physiological changes near the end of life?
Weakness/Fatigue Decreasing Appetite/Food Intake, Wasting Decreasing Fluid Intake, Dehydration Decreasing Blood Perfusion, Renal Failure Neurological Dysfunction: Decreasing Level of Consciousness Terminal Delirium Changes in Respiration Loss of Ability to Swallow Loss of Sphincter Control Loss of Ability to Close Eyes Changes in Medication Needs
what are some barriers of symptom relief?
health prof (inadequate knowledge, poor assessment, concerns re: regulation of controlled substances, fear of pt addition, etc.)
health care system (low priorirt, inadequate reimbursement, etc.)
pt reluctant to report (fear dx is worse, concern re: not being a good pt)
reluctance (fear of addition/being thought addict, worries about s/e, concern re:tolerance)
what is “total pain”?
including
physical, emotional, spiritual, practical, psychological and social elements
what are some pain syndromes?
- direct tumor involvement (invading bone, nerves)
- involvement of viscera and ducts (obstr, abd, viscera)
- involvement of blood vessels
- related to CA therapy
- Related to CA induced debility
- Unrelated to CA
which nerves might be involved in the pain syndrome?
brachial plexus
lumbosacral plexus
epidural spinal cord compression
what does adjuvant mean?
serving to aid or contribute
what pain med route do you start with ?
oral unless pain crisis
what is step 1 in managing pain?
non opioid or mild plan +/- adjuvant
what is step 2 in managing pain?
opioids for mild to moderate pain +/- a non-opoiod +/- adjuvant
what is step3 in managing pain?
opioids (morphine, dilaudid, methadone) for moderate to severe pain +/- a non-opoiod +/- adjuvant
what is the purpose of adjuvants?
to enhance analgesic effects, to control adverse effects of opioids and to manage symptoms that are contributing to the patient’s pain (anxiety, depression or insomnia).
what are the maximum time effects for opioid mgmt for oral, SC/IM, and IV?
Oral – 1hr
SC/IM – 30 min
IV – 6 min
where are opioids generally excreted?
kidney
how many BTD should a person get before you get an order to increase the regular dose?
> 3
dilaudid is ___ more times portent than morphine
7-10
what is the common ratio of PO: IM/SC
2:1
what are some examples of sustained release opioids?
meslon, oxycontin, hydromoph contin, fentanyl
if you’re giving sustained release opiod and you need to give a BTD, would you give a short r lung acting?
short acting
can oral forms of sustained release drugs be crushed or chewed?
no
what drug cannot be given through an NG tube (long acting sustained release opioid)
meslon
how long does it take for oral forms and patches to reach steady state for sustained release opioids?
24 hours
what route of fentanyl is less likely to cause nausea/costipation?
patch
how can you manage bone pain?
Opioids NSAIDs Corticosteroids Bisphosphonates Calcitonin Radiation External bracing
symptooms of bone pain?
Constant, worse with movement
Mets, compression or pathologic fractures
Prostaglandins from inflammation, mets
Rule out cord compression
are SSRI’s useful for neuropathic pain?
no
what pain medications do you take for neuropathic pain?
Tricyclic antidepressants
Gabapentin
Methadone
what are some non-pharmacological treatments?
Cutaneous stimulation Distraction Relaxation Positioning Companioning Bearing witness
how common is dyspnea in patients with terminal cancer, ALS or end stage lung and heart disease?
60%
what are some treatments for dyspnea?
Treat the cause if possible Obstruction: Radiation/Chemotherapy/Meds Pleural effusion: Thoracentesis Ascites: Abdominal paracentesis Antibiotics: Pneumonia Anemia: Transfusion
what are some medications you use for dyspnea?
Bronchodilators (for bronchospasm) Diuretics Steroids Anti-anxiety medications Neuroleptics, esp if dying (CPZ, Nozinan) Tranquilizers if the above do not settle Cough suppressants Oxygen
what medication might you give to use as a cough suppressant?
codeine
what is the #1 medication for dyspnea?/
opioids
Decreases the sense of breathlessness
Decreases sensitivity to CO2
Need not wait until last hours of days to start
would you give oxygen to a patient in the last hours of dying?
no not unless the pt in panicking
what are some fluid and nutrition symptoms during EOL?
thirst, no hunger (not common sensation at EOL), dry mucous membranes, delirium, anorexia and cachexia
does artificial hydration help with thirst/
no
is dehydration related to symptom of thirst during end of life?
no
why do you experience anorexia and cachexia?
caused by metb disturbance of Ca–loss of protein
what are the 3 psychoscoail process families engage in?
fighting back
letting nature take its course
waffling
what occurs during fighting back? (psychosocial processes families engage in) fluid and nutrition EOL
The knowledge that reduced intake is normal for someone who is dying is in direct conflict with a family’s desperate attempt to prevent just that
Families ask about IV, Tube feedings, TPN
Focus is on food intake – force feeding, bringing in food
what occurs during letting nature take its course (psychosocial processes families engage in) fluid and nutrition EOL
Understand that no amount of nutrition of fluids with prevent the patient from dying
Nurture pt in other ways – mouth care, being present at bedside
what occurs during waffling? (psychosocial processes families engage in) fluid and nutrition EOL
Go between accepting approaching death and wanting to keep fighting
Some care givers fit in here as well
what are the benefits of dehydration?
Natural anaesthetic effect, reduction in resp secretions, decreased GI fluid, reduced urine output
what are the risks of hydration?
Edema, ascites, resp congestion and distress, diarrhea, nausea, pain
what are some neurololgical changes near death?
Hypoxemia Metabolic imbalance Acidosis Toxin accumulation due to liver and renal failure Adverse effects of medication Sepsis Disease-related factors Reduced cerebral perfusion
treatment for EOL
intent to relieve by ___&___
intent to oberve____
Intent to Relieve by Reversal
Intent to Relieve by Sedation
Intent to Observe Delirium
what is the criteria for treatment for relieve by reversal?
- Known patient wish for intervention where possible, even if chances are low
- If readily reversible
- If potentially reversible e.g. opioid neurotoxicity
- If not dying, i.e. earlier stages
- If dying, trial attempts – only if patient had wanted active treatments and reverse is likely; otherwise no.
what is the criteria for treatment for relieve by sedationl?
• If delirium unpleasant and/or worsening• If patient did not want active treatment• If treatment is futile or unlikely to improve delirium• If conditions are unsafe for patient, family or staff e.g. wild agitation, violence
what is a good drug to use (neuroleptic) to give for delirium? tell me more about this drug
Haloperidol is the most suitable drug therapy for the treatment of patients with delirium near the end of life. Haloperidol is generally considered the gold standard. It is a longer acting drug(48) which can be given PO, SC, IM or IV. In delirium, a suggested regimen is 0.5–1.5mg PO (mild), 1.5– 5.0mg PO (severe) or 10mg SC or IV (very severe) [one report of up to 250mg/24hr.
if a small risk of slight cognitive impairment is not a concern, what drug would you give?
Chlorpromazine
what drug would you give as an alternative to haloperidol and has a higher sedation? what else is it used for? dose?
Methotrimeprazine.
It is a higher sedation drug at doses of 15mg or above. It can be given PO, SC, IV as well as SL. Very low doses are used for nausea (0.5–2.5mg) but control of delirium usually requires 10–15mg for mild and up to 50mg for severe delirium. These may be given q4–8h initially, then less often once controlled
should you use a benzo for delirium and cognitive issues?
no they do not clear the sensorium or improve cognition. it may be used as an adjunct primary therapy with haloperidol or another neuroleptic for delirium
would you use lorazepam for cognitive issues and delirium? caution for what kinds of people?
alone it appears to be ineffective and is in fact associated with treatment-limiting adverse effects but it COMBO may provide quicker and more effective control
Particular caution should be used in the elderly or those with hepatic failure.
doses for lorazepam?
Doses vary widely from 0.5mg to 5mg. In mild cases of delirium, it should be avoided as noted above or used on a PRN only basis for agitation until the neuroleptic provides overall control, especially if the goal is reversal of delirium.
when is midazolam used/ for what?
is also frequently used in delirium, but is more helpful for the restlessness aspect. In acute dosing, it is short-acting and rapidly effective
what is propofol ?
a short-acting anesthetic, could also be used.
what is Phenobarbital?
may be helpful or in combination if midazolam fails to provide adequate sedation in refractory cases.
what is the occurrence of n+v for terminally ill cancer?
last week of life?
receiving opioids?
60%
40%
60%
what are some chemical causes of nausea?
drugs, biochemical, tozins
what are some GI tract-vagal causes of nausea?
irritation, obstr, constipation, gastric stasis, mass effect, anatomic
what are some CNS causes of nausea?
inc ICP
what are some vestibular causes of nausea?
motion sickness, cerebellar tumor
Identify Underlying Causes Six Sentinel Questions
1) nausea- movementt
2) nausea- anxiety
3) intermiittent nausea with early satiety, postprandial fullness or bloating-relieved by vomitting
4) intermittent- cramping, altered bowel habit. relieved by large emesis
5) persistent nausea - smell of food. unrelieved by vomitting
6) early morning- headache or ICP
examples of neuroleptics?
Stemetil, Haldol, Nozinan, CPZ, Loxapine, Olanzapine
example of antihistamine for nausea?
gravol
example of anticholinergic for nausea?
scopalamine, atropine
example of steroid for nausea?
dexamethasone
example of 5-HT antagonists for nausea?
ondansetron
non-pharmaceutical - nausea treatment
eliminate msells oral hygiene caupuncture hypnosis distraction SW, PT, etc
cutaneous complications/
petechia, purpura
oropharyngeal complications?
dental, pharyngitis
esophageal complications?
hematoma, inflm
GE junctional complications?
M-W tears, Boorhaave’s rupture
renal complciations?
prerenal azotemia, ATN, hypokalemic nephropathy
metb complications/
electrolytes, acid-base, water
