Palliative Care 20/7 Flashcards
Non-pharmacological management strategies of nausea/vomiting
- Control odours from colostomy, wounds and fungating tumours
- Minimise sight/smell of food
- Give small snacks not large meals
- Try acupressure wrist bands
Pharmacological management of chemical causes of nausea + vomiting e.g. opioids
haloperidol
- acts on D2 dopamine receptors
OR metoclopramide
- act on D2 and 5HT receptors
Pharmacological management of gastro causes of nausea+ vomiting e.g. gastric stasis
metoclopramide/domperidone
- act on D2 and 5HT receptors
Pharmacological management of non-specific/multi-factorial causes of nausea + vomiting
prochlorperazine/levomepromazine
- act on D2, H1 and ACh receptors
Pharmacological management of histaminergic causes of nausea + vomiting
cyclizine/promethazine
- act on central and peripheral H1 receptors
Examples of histaminergic causes of N+V
- obstruction
- peritoneal irritation
- vestibular causes (motion sickness)
- raised intra-cranial pressure
Pharmacological management of radio/chemotherapy-induced nausea + vomiting
granisetron, ondansetron
- act on 5-HT3-receptors
Pharmacological management of spasmodic causes of nausea + vomiting
hyoscine butylbromide (buscopan)
- antispasmodic that acts on ACh receptors (antimuscarinic)
- indicated for IBS, bladder cramps and period pain
cough suppressant (antitussive) medications in palliative care
- codeine
- morphine (COPD/malignancy)
- glycerol (soothing barrier)
titration options for starting morphine/strong opioid
- Prescribe the dose on a four hourly as required PRN basis (this relies on the patient asking for pain relief)
- Prescribe the dose on a regular basis every four hours (patient receives pain relief without needing to request it)
For both methods assess the patient’s pain after 24 hours.
If effective change to BD modified relief
breakthrough pain PRN dose
1/10th to 1/6th of the equivalent total daily dose of the drug is recommended
opioid adverse effects
- N+V co-prescribe a suitable antiemetic, switch opioid if needed.
- Constipation co-prescribe a softening and stimulant laxative
- Cognitive impairment, drowsiness, myoclonic jerks, dysphoria and respiratory depression
- Urinary retention, may be resolved by dose reduction or opioid switch.
- Dry mouth
- Sweating
- Hallucinations
indications for a syringe driver
- Patient unable to take medication orally
- Poor absorption of oral medication (N+V, oedema)
- Intestinal obstruction
syringe driver battery charge required for 24hrs
35%
signs of imminent death (palliative)
- increasing frailty
- difficulty swallowing (last days/hours)
- withdrawal (more sleeping, confusion in last days)
- circulatory changes (cold/pale extremities, low BP)
- breathing changes (Cheyne-Stokes breathing/rattling - last days)
- sudden event (PE/MI/stroke)
verifying a death
- absence of a carotid pulse over one minute
- absence of heart sounds over one minute
- absence of respiratory movements and breath sounds over one minute
- fixed, dilated pupils (unresponsive to bright lights)
- no response to a trapezius squeeze
sc vs oral morphine dose
SC dose is half of PO dose
rattle breathing medication
glycopyrronium
- may reduce rattle from secretions
- not always necessary unless secretions are causing distress
- 200ug SC up to 6 hourly
causes of delirium
Pain (and unable to sleep or move around)
Infection (chest, urine, skin etc)
Nutrition
Constipation (or unable to pass urine properly)
Hydration (dehydration and malnutrition)
Medication (sudden stopping or starting drugs)
Environment (being in an unfamiliar place)
management of irreversible agitation in palliative
Prescribe midazolam 2.5mg SC up to 1 hourly
opioid pain relief options in kidney disease
oxycodone fentanyl buprenorphine alfentanil esp for syringe driver methadone
examples of bulk-forming laxatives
bran
ispaghula husk
examples of stimulant laxatives
bisacodyl (dulcolax)
senna
docusate sodium (also stool softener)
examples of stool softener laxatives
docusate sodium
glycerol suppository
examples of osmotic laxatives
lactulose macrogol (laxido/movicol)
management of short-term constipation
bulk-forming laxative eg. ispaghula husk
- add osmotic/stimulant depending on stool
management of opioid-induced constipation
osmotic and stimulant laxatives
- avoid bulk-forming
management of faecal impaction
depends on stool consistency
- hard stool = oral macrogol (laxido/movicol)
- soft stool = oral stimulant
enema if unresponsive
management of chronic constipation
bulk-forming laxative
- add osmotic (eg. macrogol (laxido/movicol))
constipation in pregnancy
fibre supplements
- add bulk-forming laxative if required
- lactulose (osmotic) next if ineffective
constipation in children
advise increased fibre, exercise and fluid intake
- macrogol (laxido/movicol)
- add stimulant if required
