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Onco/Neuro > Palliative care > Flashcards

Palliative care Flashcards

1
Q

Who are palliative care patients?

A

People who have a progressive, life threatening illness and are confronting death in the foreseeable future

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2
Q

What does PQRST stand for?

A 
Provokes
Quality
Radiates
Severity
Time
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3
Q

What are 2 types of nociceptive pain?

A

Somatic- constant and well localised, variation in intensity related to body position

Visceral- dull ache, ‘deep’ or a pressure

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4
Q

What are 2 types of non- nociceptive pain?

A

Neuropathic- typically burning or stabbing pain

Psychogenic- central pain without obvious somatic source

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5
Q

What are some non pharmacological ways to manage pain?

A

Physical- physiotherapy, RICE therapy, acupuncture, TENS, muscle relaxation

Psychological- CBT, education, family therapy, hypnosis, art and music therapy

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6
Q

Which opioid is used as first line treatment in palliative pain?

A

Morphine

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7
Q

Which opioids are weak and should not be used in palliative pain?

A

Tramadol
Dextropropoxyphene
Codeine

Also not recommended to use methadone or pethidine

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8
Q

6 step dose titration?

A
  1. Initial IR dose
  2. BT dose with initial IR dose
  3. Subsequent IR dose
  4. Subsequent daily IR doses
  5. Switch to CR prep
  6. Subsequent CR daily doses
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9
Q

What is the common dose of morphine in opioid naive patients?

A

Elderly, renal impairment: 2.5-5mg
Younger, larger patient: 5-10mg

EVERY FOUR HOURS

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10
Q

What factors affect oral administration of medication?

A 
Inability to swallow
Severe N+V or bowel obstruction
Depressed conscious state
Need for larger dose
Need for rapid response
Poor patient compliance
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11
Q

How many hours should a regular opioid be continued when a fentanyl patch is applied?

A

12-18 hours

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12
Q

Why is dose reduced when converting opioids?

A

To avoid risk of overdose due to incomplete cross tolerance in individuals, sensitivity different in different opioids

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13
Q

What are some symptoms of opioid overdose?

A

Depressed consciousness and respiratory state
A respiratory rate that has fallen significantly (or below 10)
Sedation that doesn’t respond to moderate voice and gentle movement

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14
Q

What can be used in opioid overdose?

A

Naloxone

very potent opioid reverse agent

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15
Q

What are some symptoms of opioid withdrawal? (list 6)

A 
Anxiety
Nervousness
Chills/ flushes
N+V
Insomnia
Abdominal cramps
Rhinorrhoea
Salivation
Lacrimation

Opioids should be withdrawn slowly, decrease by 20-30% every 24 hours

Clonidine, BZD or b-blockers can be used to treat withdrawal symptoms

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16
Q

Which adjuvants are used for pain in palliative care? (list 6 classes)

A
  1. TCA
  2. Anti convulsants (Gabapentin, lyrica, epilim, tegretol)
  3. Systemic local anaesthetics (Flecainide, lignocaine)
  4. NMDA antagonists (Ketamine)
  5. Corticosteriods
  6. BZD
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17
Q

How should adjuvants be used?

A
  1. Titrate one at a time
  2. Continue titration until good pain relief, intolerable S/E, max acceptable dose
  3. Continue use if good pain relief, acceptable S/E
18
Q

11 non pain palliative symptoms?

A
  1. Mouth care
  2. Anorexia
  3. N+V
  4. Constipation
  5. Dsypnoea
  6. Delirium
  7. Anxiety
  8. Depression
  9. Terminal restlessness
  10. Wounds
  11. Fatigue
19
Q

What are some causes of anorexia?

A

Chronic pain
Mouth conditions
GI motility problems
Reflux

Natural process of dying, don’t force feed

20
Q

Anorexia: non pharm management?

A
  • Frequent small meals
  • Small amounts of liquid with meals
  • Sit upright to eat
  • Avoid strong cooking smells
  • Increase calories and protein in diet
  • Soft, cool foods are better than hot food
  • Caffeine beverages can stimulate appetite
21
Q

Anorexia: Pharm management? (3)

A
  1. Prokinetic agents promote gastric emptying (metoclopramide/domperidone)
  2. Corticosteriods
  3. Progestational agents
22
Q

N+V: non pharm management?

A
  • Avoid strong cooking smells
  • Improve food presentation
  • Avoid fatty, fried, rich foods
  • Try cool fizzy drinks
23
Q

N+V: pharm management?

A
  1. Empirical- physician preference

2. Mechanistic approach- emetic pathway

24
Q

What are some causes of constipation?

A
  • Lack of fibre/ fluid in diet
  • Abnormal peristalsis
  • Lack of strength of abdominal and pelvic musculature
  • Opioids, TCA, anticholinergics
25
Q

Constipation: non pharm management?

A

Diet
Encourage fluid intake
Encourage mobility

26
Q

Constipation: pharm management?

A

Introduce laxative with opioids TCA or anticholinergics are used

  1. Coloxyl and senna
  2. Movicol

Avoid bulk forming and stimulants without the use of a softener and enough water

27
Q

What is methylnaltrexone used for?

A

Impacted/ ballooned rectum

Increases bowel movements without reversing analgesia
ONLY used for constipation caused by opioids

Dont used for than ONCE every 24 hours
Bowel movements can occur within 30 mins of injection
Common adverse effects include mild to moderate abdominal pain, nausea and flatulence

28
Q

What are some causes of dyspnoea? (5)

A
  1. Extrinsic compression of airways
  2. Lung infiltration by tumor
  3. Pheumonitis
  4. PE
  5. Hypoventilation
29
Q

Dyspnoea: non pharm management?

A 
Bedside fans
Adjustment of posture
Cold face washers
Open windows
Physio advice on breathing techniques
Meditation therapy
Modify ways of life
Home oxygen readily available
30
Q

Dyspnoea: pharm management?

A

Morphine

Dose drawn up readily available to use immediately

31
Q

How does morphine work to alleviate dyspnoea?

A

Alters perception of breathlessness and decreases anxiety.
This reduces oxygen consumption and improves oxygen supply
It also dilates pulmonary vessels which assists in relieving lung congestion

Relieves symptoms before causes sedation, then causing sedation before depression vital signs

32
Q

What are some causes of delirium?

A 
Underlying conditions (cns disorders, metabolic disorders, constipation)
Medications
33
Q

Delirium: non pharm management?

A 
Quiet, familiar environment
Presence of carer/family
Night light
Appropriate music
Mattress on floor
34
Q

Delirium: pharm management?

A

Sedation:
1. Typical/ Atypical neuroleptics (Haloperidol/ olanzapine)

  1. Morphine- fentanyl / oxycoodone
  2. Midazolam
35
Q

What are some causes of Anxiety?

A 
Psychological factors
Panic disorder
ADR
Hypoxia
Inadequate controlled pain
Withdrawal status
36
Q

Anxiety: non pharm management?

A
  1. Suppport
  2. Adequate explanation of current and future tx needs
  3. Address fears and concerns
  4. Relaxation techniques
37
Q

Anxiety: pharm management?

A

BZD: oxazepam, clonazepam, midazolam

38
Q

What are some causes of fatigue?

A

Physical stressors: disease (anaemia, dehydration, malnutrition) or treatment (chemo)

Psychological: anxiety, depression

39
Q

Fatigue: non pharm management?

A

Educate patient and carer about causes
Give patient permission to rest
Provide nutritional advice
Distraction and stress management techniques

40
Q

Fatigue: pharm management?

A

Corticosteriods
Psychostimulants
Antidepressants

41
Q

What are the 4 parts of the aetiology approach to pain management

A
  1. Psychosocial assessment
  2. Decrease noxious stimuli
  3. Intro opioids
  4. Add adjuvants

Onco/Neuro (7 decks)

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