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Yr4 - Cancer Care > Palliative > Flashcards

Palliative Flashcards

1
Q

Types of pain

A

Nociceptive
- normal nervous system identifiable lesion causing tissue damage
- somatic - originates from skin/muscles/bone
- visceral - viscus or solid organ
Neuropathic
- malfunctioning nervous system
- nerve structure damaged

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2
Q

Description of types of pain

A

Nociceptive
- somatic - sharp, throbbing, well localised
- visceral - diffuse ache, difficult to localise
Neuropathic
- stabbing, shooting, burning, stinging, numbness

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3
Q

Who analgesic ladder

A

1
- non-opioid +/- adjuvant
2
- opioid for mild to moderate pain +/- non-opioid and adjuvant
3
- opioid for moderate to severe pain +/- non-opioid and adjuvant

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4
Q

Analgesics on WHO ladder

A 
Step 1
- paracetamol
- aspirin
- NSAIDs
Step 2
- co-codamol
- codeine phosphate
- tramadol
- dihydrocodeine
Step 3
- fentanyl
- diamorphine
- buprenorphine
- oxycodiene
- methadone
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5
Q

NSAIDs and COX2 inhibitors

A 
No CV or GI risk 
- ibuprofen
- diclofenac
- naproxen
GI risk but CV risk
- COX2 - celecoxib
CV risk but less GI risk
- naproxen 
- ibuprofen
Prescribe PPI for all
HF exacerbated by all NSAIDS
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6
Q

Adjuvants for pain relief

A 
Antidepressants
- amitriptyline
- duloxetine
Anti-convulsant
- gabapentin
- pregabalin
Benzodiazepines
- diazepam
- clonazepam
Steroids
- dexamthasone
Bisphosphates and radiotherapy for bony pain
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7
Q

Side effects of amitriptyline

A

Confusion

Hypotension

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8
Q

Side effects of gabapentin

A

Sedation
Tremor
Confusion
Dizziness

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9
Q

WHO principles of pain relief

A 
By the mouth
By the clock
By the ladder
Individual dose titration
Use of adjuvants at any step
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10
Q

Common side effects of opioids

A

Constipation
Dry mouth
N+V
Drowsiness/sedation

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11
Q

Dos for opioid prescription

A

Write up laxative and anti-emetic

- laxido and metoclopramide

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12
Q

Features of opioid toxicity

A

Pinpoint pupils, hallucinations, vomiting, confusion, myoclonic jerks and resp depression
Uncommon when following prescribing guidance
Can occur if dose escalated too quickly or AKI/renal impairment

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13
Q

Stepping up from maximum dose codeine

A

Codeine : morphine is 10:1
240mg codeine equates to 24mg of morphine
Total daily dose morphine = 24mg
Generally prescribe
- morphine SR 15mg BD plus morphine IR 5 mg PRN

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14
Q

How to calculate further titration of opioid dose

A

Add up 24 hours worth of morphine = total daily dose (TDD)
TDD/2 = new morphine SR dose
TDD/6 = new morphine IR PRN dose

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15
Q

When to titrate up opioid dose

A

Consistently needing PRN doses over at least 3/7

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16
Q

SC vs oral morphine

A

10mg SC morphine = 20mg oral morphine

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17
Q

How to write controlled drug prescription

A

Name and ID of patient
Write prescription as normal
Write supply and give pharmacist exact instructions
- drug name and formulation
- total number of tables or amount of drugs in words and figures
Morphine SR (Zomorph) capsules 10mg - supply 56 (fifty six) 10mg tablets
Oramorph oral liquid 10mg/5ml - supply 1 (one) 300ml bottle

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18
Q

Features of fentanyl patches

A

25 micrograms/hour - apply every 3 days

Approx 90mg morphine per 24 hours

19
Q

Causes of N+V

A 
Infection
Metabolic
- renal impairment
- hepatic impairment
- low Na
- high Ca
- tumour toxins
Drug related
- opioid
- diuretics
Gastric stasis
- pyloric stenosis
- acites
- hepatomegaly
- opioids
GI disturbance
- constipation
- gastritis
- ulceration
Organ damage
- distension
- obstruction
- RT
Neurological
- raised ICP
- motion sickness
- meningeal disease
Psychological
- anxiety/fear
20
Q

Features of chemical nausea

A 
Persistent severe nausea
Unrelieved by vomiting
Aggravated by sight/smell of food
Drowsiness and confusion
Tx = HALOPERIDOL
21
Q

Features of gastric stasis nausea

A 
Fullness/regurgitation
Reduced appetite
Vomiting - often large volume and relieve nausea
Epigastric discomfort
Hiccups
Tx = METOCLOPRAMIDE or DOMPERIDONE
22
Q

Features of bowel obstruction nausea

A 
High 
- regurgitation
- forceful vomiting of undigested food
Low
- colicky pain
- large faeculent vomits
- visible peristalsis
Tx = CYCLIZINE or DEXAMETHASONE
23
Q

Features of raised ICP nausea

A 
Nausea worse in morning
Projectile vomiting
Worse on head movement
Headache
Tx = CYCLIZINE or DEXAMTHASONE
24
Q

Features of psychological nausea

A

Anxiety
Fear
Anticipation
Tx = NON-DRUG or BENZODIAZEPINES

25
Q

Features of post op/RT nausea

A

Serotonin release

Tx = ONDANSETRON

26
Q

Features of constipation nausea

A

Nausea
Faeculent vomiting
Abdominal distension
Tx = PROKINETIC or LAXATIVES

27
Q

Risk factors for chemotherapy induced nausea and vomiting (CINV)

A

Specific chemo agents
Female
Age < 50
Past Hx of N+V

28
Q

Features of Aprepitant

A

Prevent CINV
NK1 antagonist - acts centrally
Augments 5HT3 and dexamethasone
SE = constipation and headache

29
Q

Causes of consipation

A 
Disease related
- immobility
- reduced food-intake/low residue diet
- intra-abdominal and pelvic disease
Fluid depletion
- poor fluid intake
- increased fluid loss - vomiting, sweating, fistulae, exudating wounds
Weakness
- inability to raise intra-abdominal pressure
Intestinal obstruction
Medication
- opioids
- diuretics
- phenothiazines
- anti-cholinergic drugs
- recent surgery
Biochemical
- hypercalcaemia
- hypokalaemia
30
Q

Laxative in oncology

A 
Stimulant
- senna, bisacodyl
- reduce bowel transit time
Softener
- docusate
- increase water penetration of stool
Stimulant
- sodium picosulfate
Osmotic
- lactulose, movicol, laxido
- can cause flatulence and bloating
- need to drink reasonable volume of water
Suppositories
- glycerin - softner
- bisacodyl - stimulant
31
Q

Clinical features of bowel obstruction

A 
Colicky pain
Vomiting
Nausea
Abdominal distention
Anorexia
Bowel sounds increased
Overflow diarrhoea
Constipation
Continuous pain
Dry mouth
32
Q

Mx of bowel obstruction

A 
Chemo
Stent
Surgery
Gastrostomy
NG drainage
33
Q

Causes of breathlessness

A

Anaemia - transfusion
PE - LMWH
CCF - diuretics, ACEi
COPD - bronchodilators
Respiratory tract infection - abx
Pleural effusion - aspiration, pleurodesis
Pericardial effusion - paracentesis, corticosteroids
SVCO - stent, RV, steroids
Anxiety - CBT, relaxation, benzodiazepines, SSRIs

34
Q

Neurophysiology of breathlessness

A

Mismatch between patient’s perceived need to breath (respiratory drive) and ability to do so (physiological capacity)

35
Q

Mx of breathlessness

A 
Aim to reduce perception
Calm, logical approach
Position patient upright
Air flow across face
Trial of O2 if hypoxic
Non-drug approaches if feasible
Treat underlying cause
Morphine
36
Q

Symptoms and signs of dying

A

Functional and physical ability
- fatigue, increasing weakness, worsening mobility, inability to lift head off pillow
Psychosocial and spiritual symptoms
- concern for those left behind, fear of unknown, nearing death awareness, increased spiritual focus
Reduced food and fluid intake
Loss of ability to swallow
Bowels and bladder
- incontinence, oliguria to anuria urinary retention
CVS changes
- tachycardia, hypertension, cyanosis, mottling of skin, peripheral oedema
Increasing physical symptoms
- pain, N+V, resp symptoms, restlessness
Resp
- SOB, shallow and laboured breathing, apnea
Decreasing level of consciousness

37
Q

Anticpatory prescribing

A

Morphine 2.5-5mg sc PRN
Midazolam - dyspnoa, agitation
Glycopryrronium - secretions
Levomepromazine - nausea

38
Q

Side effects of opioid analgesia

A 
Constipation
- increase fibre and fluid
- increase mobility if possible
- faecal softeners (docusate sodium) with stimulants (senna)
N+V
- dopamine antagonist (domperidone, metoclopramide)
Drowsiness and sedation
Addiction unlikely if used correctly
39
Q

Define consitpation

A

Hard faeces which are uncomfortable to pass
- reduced frequency
Colicky abdo pain, distention and N+V

40
Q

Causes of constipation

A

Disease related – immobility, decreased food intake, intra-abdominal disease
· Fluid depletion – decreased intake, sweating, vomiting
· Weakness
· Intestinal obstruction
· Medication – opioids, diuretics, anti-cholinergics, 5-HT antagonists
· Biochemical – hypercalcaemia, hypokalaemia
· Psychological – pain of defaecation, lack of privacy

41
Q

Complications of constipation

A

Overflow diarrhoea
Acute urinary retention
Haemorrhoids

42
Q

Mx of constipation

A

High fibre high fluid diet
Increase mobility
Stimulants - sodium picosulfate, co-danthramer, senna
Faecal softeners - docusate sodium, glycerol
Osmotic - lactulose

43
Q

Features of an amber care bundle

A

In cases where we are unsure if patients are going to recover
- encourages continued care in aim of recovery while also planning for end of life

Yr4 - Cancer Care (12 decks)

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