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PR3136 > Suppportive Care in Oncology > Flashcards

Suppportive Care in Oncology Flashcards

1
Q

Common symptoms in advanced cancer (9)

A
  1. Constipation
  2. Intestinal obstruction
  3. Diarrhoea
  4. Dyspnoea
  5. Nausea & Vomiting
  6. Depression
  7. Xerostomia
  8. Delirium
  9. Pruritis
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2
Q

Constipation symptoms

A
  • unable to move bowels
  • having to push harder to move bowels (straining)
  • moving them less often than usual
  • faeces small, dry and hard
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3
Q

Constipation causes (3)

A
  1. Disease-related
    - immobility
    - tumour invasion leading to obstruction
  2. Fluid depletion
  3. Medication
    - opioids
    - calcium
    - iron
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4
Q

Constipation complications (3)

A
  1. Colic or constant abdominal discomfort
  2. Intestinal obstruction
  3. Confusion or restlessness if severe
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5
Q

Before prescribing laxatives for constipation,

2

A
  1. Rule out obstruction
  2. Consider underlying causes
    eg drugs
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6
Q

Laxatives for constipation (3)

A
  1. Bulk forming
    - fybogel
    - not usually in palliative care
  2. Stimulant laxatives
    - senna
    - bisacodyl
  3. Osmotic laxatives
    - lactulose
    - phosphate enema
    - forlax
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7
Q

Precaution/advice for patients taking bulk forming & osmotic laxatives

A

Drink extra fluids

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8
Q

Laxatives not suitable for intestinal obstruction (2)

A
  1. Bulk forming
  2. Stimulant laxatives
    - esp complete obstruction cos increase cramping pains
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9
Q

Rectal examination

A

Is rectum impacted or empty?

  • If rectum is impacted, is stool hard or soft?
  • If rectum is empty, is it “ballooned”/dilated or non-dilated?
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10
Q

Treatment for

  • Impacted rectum
  • Soft stool
A
  1. Use rectal stimulant
    - biscodyl suppositories
    - phosphate enema
  2. If still no defecation, increase oral stimulant or softener
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11
Q

Treatment for

  • Impacted rectum
  • Hard stool
A
  1. Lubricate with glycerin suppositories or soften with olive oil enema
  2. If still no defecation, increase oral stimulant or softener
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12
Q

Treatment for

  • Empty rectum
  • non-dilated
A
  • exclude intestinal obstruction
  • ensure patient is on regular laxatives
  • consider additional laxatives when necessary
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13
Q

Treatment for

  • Empty rectum
  • dilated / “ballooned”
A
  • suggests constipation higher up
  • give high fleet enema over several days until constipation resolves
  • if colic present, reduce any stimulant laxatives & add softener or osmotic agents
  • if colic absent, increase stimulant laxatives
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14
Q

Why reduce dose of stimulant laxatives when colic present?

A
  • reduce cramping pains for the patient
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15
Q

Should preventive treatment for constipation be use before symptoms present?

A

Yes
Check for any possible risk of constipation, if present then introduce laxatives to patient’s regimen
eg opioids use

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16
Q

Intestinal Obstruction classifications (I/O) (3)

A
  • upper vs lower GI I/O
  • mechanical vs functional (ileus)
  • complete vs incomplete
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17
Q

Upper GI I/O symptoms

  • vomiting
  • abdominal distension
  • constipation
  • anorexia
A

Vomiting : large volume, bilious
Abdominal distension : may be absent
Constipation : late feature
Anorexia : early feature

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18
Q

Lower GI I/O symptoms

  • vomiting
  • abdominal distension
  • constipation
  • anorexia
A

Vomiting : small volume, faeculent
Abdominal distension : present
Constipation : early feature
Anorexia : late feature

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19
Q

General treatment for I/O (3)

A

Reversing obstruction if possible & relief symptoms

  1. Gut rest
  2. NBM (nth by mouth)
  3. IV hydration
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20
Q

Management of I/O (operable)

A
  • consider surgery to remove the hard stools
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21
Q

Management of I/O (not operable)

A
  • stenting

- trial of steroids (reduce peritumoral oedema & improve intestinal transit)

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22
Q

Contraindications for stenting (2)

A
  1. Multiple levels of obstruction

2. Rectal tumours (risk of stent migration)

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23
Q

Complete I/O treatment

  • pain (2)
  • n/v (3)
A
  • pain relief with morphine +/- anticholinergics (eg hyoscine)
  • n/v relief with haloperidol, octreotide or NGT suction
  • avoid prokinetics eg metocleopramide
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24
Q

Incomplete I/O treatment (4)

  • pain
  • n/v
  • bowel
A
  • pain relief with fentanyl (less constipation)
  • buscopan if pain not relief (laxative > stimulant to reduce pain)
  • n/v relief with metocleopramide
  • clear bowels using high fleet/lactulose
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25
Q

Dietary advice for patients prone to I/O or gastric outlet obstruction (3)

A
  • low residue & fibre diet
  • limit fat intake (fat increase stool bulk)
  • avoid tough fibrous meats

Reduce potential obstruction which can aggravate I/O

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26
Q

Bristol Stool Form Scale

A

Type 1-7

- increasing watery & looseness

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27
Q

Diarrhoea symptoms (2)

A
  • loose or watery stools

- more than 3 unformed stools within 24h

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28
Q

Diarrhoea causes (3)

A
  1. Medications (eg irinotecan, laxatives)
  2. Diets
    - spicy
    - alcohol
    - fruits (fibrous)
  3. Treatment (RT & chemotherapy)
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29
Q

Before prescribing for diarrhoea, (2)

A
  1. Rule out fecal impaction, intestinal obstruction & infective causes
  2. Consider underlying causes
    eg medications, diets
30
Q

Diarrhoea management (4)

A
  1. Diphenoxylate/atropine
    - not to use if liver impairment
  2. Loperamide HCl
  3. Codeine phosphate
    - with pain
  4. Octreotide
    - tumour secretions
31
Q

CI for codeine phosphates (3)

A
  • Asthma
  • COPD
  • hepatic/renal disease
32
Q

CI for diphenoxylate/atropine

A

Liver diseases

33
Q

Dietary advice for patients with diarrhoea (6)

A
  • eat small but frequent meals
  • eat low fibre diets
  • maintain sufficient fluid intake (2L)
  • avoid coffee, tea, milk, alcohol & sweets
  • avoid greasy foods
  • gradually reintroduce proteins then fats as diarrhoea resolves
34
Q

Dyspnoa

A
  • subjective experience of breathing discomfort
35
Q

Principles of management of dyspnoea (2)

A
  • treat reversible

- non-drug measures are essential but as illness progress, medication become alot more necessary

36
Q

Management of dyspnoea (5)

A
  1. Oxygen therapy
    - SpO2 <90% (hypoxic)
  2. Opioids
    - SOB at rest/minimal exertion
    eg morphine, fentanyl (if patient have renal impairment)
  3. Steroids
    - reduce peri-tumoral edema
    eg dexamethasone
  4. Anxiolytics
    eg lorazepam & midazolam
    eg escitalopram (antidepressants if longer prognosis)
  5. Secretions treatment
    - nebulised NaCl 0.9% (loosen secretion)
    - anticholinergics (buscopan)
    - suction (distressing)
37
Q

Advice for patients with dyspnoea (5)

A
  1. Break tasks into smaller bits & use aid when necessary
  2. Breathing techniques
  3. Find comfortable positions
  4. Open windows to allow ventilation/fans for non-hypoxic patients
  5. Use of opioids prior to major movements/tasks for prevention
38
Q

Nausea definition

A
  • subjectively unpleasant sensation associated with flushing, tachycardia and an awareness of the urge to vomit
39
Q

Retching definition

A
  • involves spasmodic contractions of the diaphragm, thoracic & abdominal walls muscles without expulsion of gastric contents
40
Q

Vomiting/emesis

A
  • expulsion of stomach contents from mouth
41
Q

Before prescribing for n/v,

A
  • exclude regurgitation (different approach)
42
Q

Management of n/v (7)

A
  1. Domperidone (prokinetic)
  2. Metoclopramide (prokinetic)
  3. Haloperidol
  4. Olanzapine
  5. Ondansetron (5-HT antagonist)
  6. Buclizine (antihistamine)
  7. Mirtazapine (NaSSAntagonist)
43
Q

Advice for n/v (5)

A
  • eat small but frequent meals
  • rinse mouth before eating (1 tsp of baking soda/sodium bicarb) to remove bad taste
  • candies (lemon & peppermints)
  • drink clear liquids as often as possible to prevent dehydration
  • ensure nutritional status
44
Q

Colicky pain after prokinetics

A

Suggests intestinal obstruction

45
Q

Depression symptoms

A

InSADCAGES

  • interest
  • sleep
  • appetite
  • depressed
  • concentration
  • activity
  • guilt
  • energy
  • suicidal

In & D

46
Q

What type of antidepressant to use? (2)

A
  • all antidepressants have similar efficacy

- consider side effect profile & any comorbidity to indicate what type of antidepressant to use

47
Q

Bupropion

  • CI
  • benefit
A

CI :

  • seizures
  • eating disorders
  • psychosis

Benefit :
- no sexual dysfunction

48
Q

Mirtazapine

  • disadvantages
  • benefit
A

Disadvantages :

  • weight gain (due to increased appetite)
  • sedation

Benefit :
- no sexual dysfunction

49
Q

Duloxetine

A

SNRI

Benefit :

  • diabetic neuropathic pain
  • fibromyalgia
  • chronic musculoskeletal pain
50
Q

Venlafaxine

A

Disadvantage :

- worsens HTN

51
Q

Xerostomia symptoms

A
  • dryness of the mouth
  • altered salivation
  • need to expectorate frequently or manually remove thick saliva
52
Q

Management of xerostomia (8)

A
  1. Frequent oral rinses or sips of water/juices
  2. Mouth care before & after meals & at bedtimes
  3. Soft & moist foods > dry & sticky foods
  4. Increase fluid intake during meals
    - avoid alcohol & carbonated drinks
  5. Suck on sugarless candies
  6. Lubricate oral cavity
    - olive oil
    - butter
  7. Apply lip moisturiser to prevent drying/chapping of lips
  8. Medications to promote saliva production
    - pilocarpine
53
Q

Delirium symptoms (4)

A
  • disturbed consciousness
  • inattention / terminal restlessness
  • cognitive impairment / confusional state
  • agitation
54
Q

Assessment tools for delirium (2)

A
  1. Mini Mental State Examinations (MMSE)

2. Confusional Assessment Method (CAM)

55
Q

Causes of delirium (5)

A 
1. Infection 
eg UTI
2. Drug induced 
eg opioid toxicity, corticosteroids 
3. Constipation, urinary retention or catheter problems 
4. Sensory impairment
5. Dehydration
56
Q

Management of delirium (3)

A 
First line : Haloperidol
Second line : Benzodiazepines 
- lorazepam 
- midazolam
- does not improve cognition but help with anxiety to calm patient down

Increase fluid intakes

57
Q

Pruritis symptoms (2)

A
  • persistent scratching leading to skin damage, excoriation & thickening
  • dry skin
58
Q

Management of pruritis (4)

A
  1. Emollients
    - ointments > creams for dry skin
    - use emollient to bath water & soap substitute
  2. Avoid topical antihistamines
    - cause allergic dermatitis
  3. Reserve systemic medication if topical therapy (skin care) doesn’t improve symptoms
  4. Avoid caffeine, alcohol, spices & hot water
59
Q

Cholestasis pruritis treatment (3)

A

RSC

  1. Rifampicin
  2. Sertraline
  3. Cholestyramine
60
Q

Uremia pruritis treatment (1)

A

UG

Gabapentin
- renal dose adjustment req

61
Q

Lymphoma pruritis treatment (1)

A

Prednisolone

62
Q

Systemic opioids-induced pruritis (1)

A

Chlorpheniramine

63
Q

Paraneoplastic pruritis treatment (1)

A

PP

Paroxetine

64
Q

Unknown reason for pruritis

A

Chlorpheniramine

65
Q

Buscospan uses (2)

A
  • relieve pain from intestinal cramps

- decrease respiratory secretions

66
Q

Treatment of N/V from drugs (2)

A
  • metoclopramide

- haloperidol

67
Q

N/V from motility disorder (2)

A
  • metoclopramide

- domperidone

68
Q

N/V from :
- intracranial disorders
eg vestibular dysfunction

  • oral pharyngeal irritation

(2)

A
  1. Anticholinergics
    - hyoscine
  2. Antihistamines
    - buclizine
69
Q

Assessing patients with depression

A
  • rule out medical / drug-induced cause
70
Q

Advice for patients taking anti-depressants (3)

A
  • adverse effect can occur immediately
  • anti-depressant effect may take place 2-4 weeks or even longer
  • need to adhere to treatment plan
71
Q

Drugs that can cause delirium (2)

A
  • opioids toxicity

- corticosteroids

PR3136 (19 decks)

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