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FE > Session 3b > Flashcards

Session 3b Flashcards

1
Q

Assessmeent of dyspnea

A

Severity

Pattern (alleviating and precipitating factors)

Associated symptoms

Associated anxiety

Impact on functional ability/quality of life

Look for reversible causes

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2
Q

Numeric rating scale/ Modified borg scale dyspnea

A
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3
Q

Causes of dyspnea

A

Cancer related:
* Lung: tumour obstruction, pleural effusion or post-obstructive
pneumonia
* Heart: Pulmonary embolism, SVCO
* Lymphatics: Lymphangitis Carcinomatosis
* Extrinsic compression: Mediastinal Lymphadenopathy, diaphragmatic
splinting (ascites/hepatomegaly)

  • Treatment related:
  • Chemotherapy induced pneumonitis
  • Radiation induced pneumonitis
  • Co-morbidities:
  • COPD, interstitial lung disease
  • Heart failure
  • Anaemia
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4
Q

Management of dyspnea

A

Treat reversible causes, if possible

Treat underlying disease, if possible

Pharmacotherapeutic

Non-pharmacotherapeutic measures that optimize coping

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5
Q

Pharmacotherapeutic measures for dyspnea

A

Opioids
* Usual starting dose of Morphine for opioid naive patients is 2.5-
5mg q4h, dose can be titrated according to response.

Steroids
* May reduce peri-tumoural oedema
(e.g. Dexamethasone)

  • Anxiolytics
  • Benzodiazepines -for patient who is anxious
  • Lorazepam – for patient who does not respond to opioid alone
  • Anticholinergics
  • To reduce secretions-in frail patients who are unable to
    expectorate (e.g. Buscopan)
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6
Q

Non-pharmacotherapeutic measures
for dyspnea

A

Supplemental oxygen is beneficial for hypoxic patients

Blowing cool air (using fan)on the face maybe useful by stimulating the trigeminal nerve

Breathing techniques – Pursed lip breathing, anxiety
management techniques

Position – Find the most efficient position for the patient

Environment – Open windows to allow airflow

Plan and pace activities – Break tasks into smaller bits, walking
aids to decrease breathing effort

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7
Q

Management (prepare for future) dyspnea

A

Conversation:
* Advance Care Planning
* Advance Medical Directive
* End-of-life care

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8
Q

Causes of nausea and vomiting

cerebral cortex

A

Fear, anxiety, smell, taste, increased intracranial pressure,
tumor of central nervous system

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9
Q

Causes of nausea and vomiting

Chemoreceptor Trigger
Zone (CTZ)

A

Drugs-Chemotherapy.
Toxin –Infections, radiotherapy.
Metabolic –Uremia, hypercalcemia

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10
Q

Causes of nausea and vomiting

Visceral – GI tract

A

Stasis – Drugs, disease.

Squashed stomach – enlarged liver, ascites

Obstruction – tumour
Irritation, NSAIDs, steroids, antibiotics, chemotherapy,
radiotherapy.

Constipation

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11
Q

Causes of nausea and vomiting

Vestibular nuclei

A

Motion, ear infection, tumor.

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12
Q

Assessment of nausea and vomiting

A

Physical examination:

  • Neurological system
  • Abdominal/GI system
  • Mouth, pharynx, abdomen (including digital rectal
    examination to rule out constipation).
  • History taking
  • Others
    -Sepsis, drug toxicity, hydration status
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13
Q

Management of nausea and vomiting

A
  • Treat the treatable
  • Pharmacotherapeutic
  • Non-pharmacotherapeutic
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14
Q

Pharmacotherapeutic management of nausea and vomiting

A

Appropriate anti-emetics for affected structure that causing
nausea and vomiting:
* Dexamethasone
* Haloperidol
* Metoclopramide
* Prochlorperazine
* Ondansetron
* Cyclizine

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15
Q

Non-pharmacotherapeutic management of nausea and vomitting

A

Management
Non-pharmacotherapeutic

  • Calm, peaceful and fresh every environment if possible.
  • Explain examination, diagnosis and treatment.
  • Emotional support and attention to patients to allay fear and anxiety.
  • Relaxation therapy
  • Appropriate preparation and presentation of food (if patient is able to eat).
  • Foot prepare away from patient to prevent smell stimulating nausea or
    vomiting response.
  • Small meals as tolerated.
  • Upright position during and after meals.
  • Ginger is a good anti emetics-drinks, biscuits or crystallize.
  • Regular mouth care to keep mouth clean and fresh.
  • Acupuncture or acupressure- sea bands
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16
Q

What is constipation?

A

Infrequent or difficult passage of stools, which may be (but not always)
small and; hard

May be associated with inability to defecate, discomfort when defecating, unproductive urges and straining, sensation of incomplete evacuation.

Present with pain, bloating, nausea, vomiting, overflow/spurious
diarrhoea, urinary incontinence.

Constipation can be more distressing than pain, and cause patient to
decline opioids.

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17
Q

Assessment of constipation

A

History taking
* Last bowel movement, when was the last ‘normal’
* Previous bowel pattern
* Stool consistency, any blood
* Any abdominal pain, nausea/vomiting, excessive gas, rectal fullness
* Is patient on laxatives
* Types of current medication taking

Physical examination
* General
* Abdomen, digital rectal examination

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18
Q

Drugs examples

Constipation

A

Opioids, tricyclic antidepressants, 5HT3 antagonists, calcium,
iron supplements

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19
Q

Metabolic examples

Constipation

A

Dehydration, hypercalcaemia, hypokalaemia, uraemia,
hypothyroidism, diabetes mellitus

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20
Q

Structural examples

Constipation

A

Intestinal obstruction secondary to extrinsic/intrinsic
tumours/peritoneal disease/adhesions

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21
Q

Neurological examples

Constipation

A

Parkinson’s disease, brain tumours, spinal cord compression,
autonomic dysfunction, sacral nerve infiltration

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22
Q

Pain examples

Constipation

A

Anal fissures, haemorrhoids

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23
Q

General examples

Constipation

A

Reduced mobility, decreased food intake, general weakness

24
Q

General examples

Environmental

A

Lack of privacy or assistance with toileting

25
Q

Consstipation
Management
Pharmacotherapeutic

A

Stimulant laxatives
(e.g. Senna, Bisacodyl[Dulcolax])

Osmotic laxatives
(e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG)

Bulk-forming laxatives
(e.g. Fybogel)

26
Q

Stimulant laxatives
(e.g. Senna, Bisacodyl[Dulcolax])

Action

A

Stimulates peristalsis by directly
stimulating the smooth muscle of the
intestine

27
Q

Stimulant laxatives
(e.g. Senna, Bisacodyl[Dulcolax])

Precautions

A

Unsuitable for patients with complete
bowel obstruction or with colic

28
Q

Stimulant laxatives
(e.g. Senna, Bisacodyl[Dulcolax])

Adverse effects

A

Dehydration, colic

29
Q

Osmotic laxatives
(e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG)

Action

A

Draws fluid into bowel by osmosis, softens
faeces and stimulates peristalsis

30
Q

Osmotic laxatives
(e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG)

Precaution

A

Patient must drink fluids

31
Q

Osmotic laxatives
(e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG)

Adverse effects

A

Colic, flatulence, dehydration and electrolyte imbalance in debilitated patients

32
Q

Constipation

Management
Non-pharmacotherapeutic

A
  • Ensure adequate fluid intake – Increase intake of high-water
    content foods such as soups, yoghurt and jelly
  • Encourage mobility
  • Encourage toileting in the morning after breakfast
  • Maintain privacy and avoid bedpans, if possible
33
Q

Diarrhea

A

Definition

Passage of > 3 episodes of unformed stools in
a day.

33
Q

Grade 1 Diarrhea

A

Increase < 4 stool episodes
compared to pre-treatment

33
Q

Grade 2 Diarrhea

A

Increase in 4-6 episodes

34
Q

Grade 3 Diarrhea

A

Increase in >6 episodes

35
Q

Grade 4 Diarrhea

A

Increase in >10 episodes

36
Q

Causes of diarrhea

A

First step is to exclude “Spurious/Overflow Diarrhea”, either from laxative over-use, constipation of fecal impaction.

37
Q

General Causes of diarrhea

A

Gastroenteritis

Immunocompromised, receive multiple broad-spectrum
antibiotics

Enteral feeding
- Due to high osmotic content, rapid or high-volume feeding,
hypoalbuminaemia

  • Tumour related
  • Rectal, pancreatic cancer
38
Q

Treatment-related causes

A

Chemotherapy

Radiotherapy

Post surgical/post procedural

39
Q

Management

Pharmacotherapeutic

Diarrhea

A

Loperamide 2-4mg tds (maximum 16mg/day)

Hyoscine Butylbromide (Buscopan)

Codeine Phosphate

  • Avoid Lomotil (Diphenoxylate/ Atropine) in elderly as Atropine can
    cause delirium.
40
Q

Management

Non-pharmacotherapeutic

Diarrhea

A

Exclude spurious diarrhea

Non-milk diet

Oral rehydration salt or isotonic drinks

Replace electrolytes lost due to hyponatremia or hypokalemia

Prevent pressure injury with barrier cream, pressure relief
mattresses and regular turning

41
Q

Delirium definition

A

Acute deterioration in cognitive function accompanied by
fluctuations in conscious level leading to disorientation and confusion

  • 3 clinical subtypes:
  • Hypoactive- characterized by confusion and somnolence.
  • Hyperactive- associated with hypervigilance, restlessness and
    agitation.
  • Mixed-alternating features of hypoactive and hyperactive
    delirium
42
Q

Hypoactive delirium

A
  • Hypoactive- characterized by confusion and somnolence.
43
Q

Hyperactive delirium

A
  • Hyperactive- associated with hypervigilance, restlessness and
    agitation.
44
Q

Assessment of delirium

A

Confusion assessment method (CAM)

  • Acute onset and fluctuating course
  • Inattention
  • Difficulty focusing attention
  • Clouded consciousness
  • Ranging from hyper-awake to sleepy
  • Disorganised thinking
  • Rambling/irrelevant/incoherent conversation
45
Q

Causes of delirium

Drug

A

Anti-cholinergic drugs

Steroids

Opioids

Tricyclic Antidepressants (TCA)

46
Q

Causes of delirium

Electrolytes

A
  • Hypercalcemia
  • Hypoglycaemia
  • Hypernatremia
  • Hyponatremia
47
Q

Causes of delirium

Lung/Liver

A

Pneumonia

Pulmonary embolism

Hepatic Encephalopathy

48
Q

Causes of delirium

Infections

A

Consider possible infection sites

49
Q

Causes of delirium

Retention/Restraint

A

Urinary retention

Fecal impaction

Use of restraint

50
Q

Causes of delirium

Intracranial

A

Brain metastasis

Stroke

Seizures

51
Q

Causes of delirium

U

A

Uraemia

52
Q

Management of delirium

A

Treat any potentially reversible cause(s), if appropriate

Optimise pain control

Pharmacotherapeutic management

Non- pharmacotherapeutic management

53
Q

Pharmacotherapeutic management of Delirium

A

First Line
* Haloperidol (drops/tablets) 0.5-1.5mg tds
* Risperidone (drops/tablets) 0.5-1.0mg tds (for patients with Parkinson’s
disease or those developed extra-pyramidal side effects with
Haloperidol)

Second Line
* If patient is still agitated despite the above, consider:
* Switching from Haloperidol to oral or sublingual Olanzepine 2.5mg od-
tds
* Chlorpromazine 12.5-50mg on

54
Q

Management of the confused and agitated patient

A
  • Subcutaneous Haloperidol 1.0-2.5mg stat.
  • May need subcutaneous Midazolam 1.0-2.5mg p.r.n., if
    patient is very restless and uncooperative
55
Q

Management of the confused and agitated patient

Non-pharmacotherapeutic management

A

Frequent reorientation

Providing a calm environment that avoids both sensory deprivation and overstimulation

Using clear verbal instructions

Providing emotional support

Avoiding confrontation

Do not confront delusional beliefs

Focus on emotions not content

Promote a normal sleep-wake cycle

Correct sensory deficits

Glasses

Hearing aids

Minimise physical restraints

Consider discontinuing or avoiding intravenous or urinary catheters

Minimise room and staff changes

Request that family members bring in familiar items and sit with the patient

FE (7 decks)

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