Session 3b Flashcards
Assessmeent of dyspnea
Severity
Pattern (alleviating and precipitating factors)
Associated symptoms
Associated anxiety
Impact on functional ability/quality of life
Look for reversible causes
Numeric rating scale/ Modified borg scale dyspnea
Causes of dyspnea
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
Management of dyspnea
Treat reversible causes, if possible
Treat underlying disease, if possible
Pharmacotherapeutic
Non-pharmacotherapeutic measures that optimize coping
Pharmacotherapeutic measures for dyspnea
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)
Non-pharmacotherapeutic measures
for dyspnea
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
Management (prepare for future) dyspnea
Conversation:
* Advance Care Planning
* Advance Medical Directive
* End-of-life care
Causes of nausea and vomiting
cerebral cortex
Fear, anxiety, smell, taste, increased intracranial pressure,
tumor of central nervous system
Causes of nausea and vomiting
Chemoreceptor Trigger
Zone (CTZ)
Drugs-Chemotherapy.
Toxin –Infections, radiotherapy.
Metabolic –Uremia, hypercalcemia
Causes of nausea and vomiting
Visceral – GI tract
Stasis – Drugs, disease.
Squashed stomach – enlarged liver, ascites
Obstruction – tumour
Irritation, NSAIDs, steroids, antibiotics, chemotherapy,
radiotherapy.
Constipation
Causes of nausea and vomiting
Vestibular nuclei
Motion, ear infection, tumor.
Assessment of nausea and vomiting
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
Management of nausea and vomiting
- Treat the treatable
- Pharmacotherapeutic
- Non-pharmacotherapeutic
Pharmacotherapeutic management of nausea and vomiting
Appropriate anti-emetics for affected structure that causing
nausea and vomiting:
* Dexamethasone
* Haloperidol
* Metoclopramide
* Prochlorperazine
* Ondansetron
* Cyclizine
Non-pharmacotherapeutic management of nausea and vomitting
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
What is constipation?
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.
Assessment of constipation
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
Drugs examples
Constipation
Opioids, tricyclic antidepressants, 5HT3 antagonists, calcium,
iron supplements
Metabolic examples
Constipation
Dehydration, hypercalcaemia, hypokalaemia, uraemia,
hypothyroidism, diabetes mellitus
Structural examples
Constipation
Intestinal obstruction secondary to extrinsic/intrinsic
tumours/peritoneal disease/adhesions
Neurological examples
Constipation
Parkinson’s disease, brain tumours, spinal cord compression,
autonomic dysfunction, sacral nerve infiltration
Pain examples
Constipation
Anal fissures, haemorrhoids
General examples
Constipation
Reduced mobility, decreased food intake, general weakness
General examples
Environmental
Lack of privacy or assistance with toileting
Consstipation
Management
Pharmacotherapeutic
Stimulant laxatives
(e.g. Senna, Bisacodyl[Dulcolax])
Osmotic laxatives
(e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG)
Bulk-forming laxatives
(e.g. Fybogel)
Stimulant laxatives
(e.g. Senna, Bisacodyl[Dulcolax])
Action
Stimulates peristalsis by directly
stimulating the smooth muscle of the
intestine
Stimulant laxatives
(e.g. Senna, Bisacodyl[Dulcolax])
Precautions
Unsuitable for patients with complete
bowel obstruction or with colic
Stimulant laxatives
(e.g. Senna, Bisacodyl[Dulcolax])
Adverse effects
Dehydration, colic
Osmotic laxatives
(e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG)
Action
Draws fluid into bowel by osmosis, softens
faeces and stimulates peristalsis
Osmotic laxatives
(e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG)
Precaution
Patient must drink fluids
Osmotic laxatives
(e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG)
Adverse effects
Colic, flatulence, dehydration and electrolyte imbalance in debilitated patients
Constipation
Management
Non-pharmacotherapeutic
- 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
Diarrhea
Definition
Passage of > 3 episodes of unformed stools in
a day.
Grade 1 Diarrhea
Increase < 4 stool episodes
compared to pre-treatment
Grade 2 Diarrhea
Increase in 4-6 episodes
Grade 3 Diarrhea
Increase in >6 episodes
Grade 4 Diarrhea
Increase in >10 episodes
Causes of diarrhea
First step is to exclude “Spurious/Overflow Diarrhea”, either from laxative over-use, constipation of fecal impaction.
General Causes of diarrhea
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
Treatment-related causes
Chemotherapy
Radiotherapy
Post surgical/post procedural
Management
Pharmacotherapeutic
Diarrhea
Loperamide 2-4mg tds (maximum 16mg/day)
Hyoscine Butylbromide (Buscopan)
Codeine Phosphate
- Avoid Lomotil (Diphenoxylate/ Atropine) in elderly as Atropine can
cause delirium.
Management
Non-pharmacotherapeutic
Diarrhea
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
Delirium definition
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
Hypoactive delirium
- Hypoactive- characterized by confusion and somnolence.
Hyperactive delirium
- Hyperactive- associated with hypervigilance, restlessness and
agitation.
Assessment of delirium
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
Causes of delirium
Drug
Anti-cholinergic drugs
Steroids
Opioids
Tricyclic Antidepressants (TCA)
Causes of delirium
Electrolytes
- Hypercalcemia
- Hypoglycaemia
- Hypernatremia
- Hyponatremia
Causes of delirium
Lung/Liver
Pneumonia
Pulmonary embolism
Hepatic Encephalopathy
Causes of delirium
Infections
Consider possible infection sites
Causes of delirium
Retention/Restraint
Urinary retention
Fecal impaction
Use of restraint
Causes of delirium
Intracranial
Brain metastasis
Stroke
Seizures
Causes of delirium
U
Uraemia
Management of delirium
Treat any potentially reversible cause(s), if appropriate
Optimise pain control
Pharmacotherapeutic management
Non- pharmacotherapeutic management
Pharmacotherapeutic management of Delirium
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
Management of the confused and agitated patient
- 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
Management of the confused and agitated patient
Non-pharmacotherapeutic management
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
