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Cancer Care > Symptom Management > Flashcards

Symptom Management Flashcards

1
Q

Compare nociceptive vs neuropathic pain

A

nociceptive: functioning nervous system. The pain is localised
neuropathic: dysfunctional nervous system. The pain is generally tingling, it travels and it fluctuates

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2
Q

Describe the WHO pain ladder

A
  1. paracetamol, NSAIDs
  2. codeine, tramadol, dihydrocodeine
  3. morphine, diamorphine, oxycodone, fentanyl
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3
Q

What are some side effects of opioids?

A 
constipation 
drowsiness
dry mouth 
N&V
respiratory depression
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4
Q

What analgesia is best to use in CKD?

A

Mild renal impairment: oxycodone

Severe renal impairment: fentanyl and buprenorphine

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5
Q

When would you consider up titrating a persons opioid?

A

> 3 PRN needed a day

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6
Q

How is someone’s new up titrated dose of morphine calculated?

A

BD dose + PRN doses used = TDD

New BD = TDD/2
New PRN = TDD/6

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7
Q

What does NICE recommend as a regime for an opiate naive patient?

A

Total daily dose of 30mg

Morphine sulphate 5mg immediate release preparation to be given four hourly

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8
Q

What is a typical starting regime for someone new to opioids?

A

15mg BD zomorph (modified release)

5mg PRN oramorph (immediate release)

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9
Q

Compare the side effect profile of oxycodone and morphine

A

oxycodone is more constipating however leads to less nausea and drowsiness and pruritis

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10
Q

What are the causes of vomiting in a cancer patient?

A 
gastric dysmotility 
opioid and chemotherapy induced 
electrolyte disturbances
- uraemia 
- hypercalcaemia 
- hyponatraemia 
anxiety induced 
RICP
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11
Q

How is chemotherapy induced N&V managed?

A

Ondansetron

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12
Q

How is metabolic derangement induced N&V managed?

A

haloperidol or levomepromazine

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13
Q

How is N&V due to reduced gastric motility managed?

A

Metoclopramide

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14
Q

How is N&V due to mechanical bowel obstruction managed?

A

Cyclizine

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15
Q

How is anxiety induced N&V managed?

A

Lorazepam

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16
Q

How is RICP in palliative care managed?

A

Cyclizine + dexamethasone + radiotherapy

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17
Q

What are some causes of breathlessness in palliative care?

A 
anxiety 
pneumonia 
PE
SVCO
rib metastasis
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18
Q

How is breathlessness in palliative care managed?

A 
Open windows and increase air flow 
Sit the patient up
Talk about any anxieties they are having
Breathing exercises and physiotherapy 
Morphine 
Benzodiazepines 
Oxygen
Pleural aspiration/chest drain for pleural effusion
Anticoag for PE
Analgesia for pain with breathing
Diuretics for heart or renal failure
Abx for infection
Stenting
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19
Q

What causes hiccups in palliative patients?

A

Gastric distention
Phrenic nerve involvement
Uraemia

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20
Q

How are intractable hiccups managed?

A

Chlorpromazine

+/- haloperidol, gabapentin and dexamethasone

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21
Q

What causes constipation in palliative care?

A 
Opioids
Weakness to push 
Dehydration and malnutrition 
Immobility 
Hypercalcaemia 
Spinal cord compression
22
Q

How is constipation in palliative care managed?

A

Co-danthramer (stimulant + softener)
Or
Lactulose + Senna

23
Q

How does end stage lymphoedema present?

A

Non-pitting oedema

Chronic skin changes

24
Q

How is lymphoedema managed?

A

Gradient compression bandaging

25
Q

How should psychological distress associated with cancer/ palliation be managed?

How should it be managed in the terminal phase of illness?

A

Non-pharmacologically: breathing exercises, religious support, CBT
Haloperidol or chlorpromazine

Terminal phase: Midazolam

26
Q

What are the drug options for respiratory secretions? What is the advantage of one vs the other?

A

Hyoscine hydrobromide: sedating
Hyoscine butylbromide: non-sedating

Antimuscarinics so causes
constipation, dizziness, drowsiness, dry mouth, flushing, headache, nausea

Can also use glycopyrronium - anticholinergic, causes dry mouth, n+v, dizziness, fatigue, blurred eyesight

27
Q

What are the advantages and disadvantages of using a patch for analgesia?

A

+ Less constipating

  • Analgesia requirements need to be stable to use
  • Increased N&V
  • Withdrawal symptoms
28
Q

When should a dose be titrated for opioids?

A

If using their PRN dose more than 4 times a day, titrate their dose up:
o Total dose per day (PRN + scheduled doses) ÷ 2 = new BD dose
o Total dose per day (PRN + scheduled doses) ÷ 6 = new PRN dose

29
Q

Over how long do zomorph and morphine sulphate act?

A

Over 12 hours

30
Q

How must prescriptions for controlled drugs be written?

A

Prescriptions for controlled drugs must be written out fully and in block capitals
o Patient name, ID and address
o Drug form (tablets, capsules, bottles) – specify size/formulation (e.g.10mg/5ml solution)
o Amount needed (digits and words) – normally enough for 14 days
o Patient directions

31
Q

What makes up the vomiting reflex?

A

Vomiting centre in the medulla causes reflex

Fed in from
Higher cortical centres - memory, fear, sensory

Chemoreceptor trigger zone - chemo, anaesthetics, opioids
Drugs - histamine, muscarinic and dopamine antagonists

Stomach and small intestine drugs - 5HT3 antagonists

32
Q

What class is haloperidol, some side effects, usual dose?

A

Dopamine antagonist
Acts on CTZ

Extrapyramidal signs
Restlessness/sedation

0.5-5mg PO or SC

33
Q

What class is metoclopramide, some side effects, usual dose?

A

Dopamine antagonist - 5-HT3 antagonist

Prokinetic
Acts on CTZ

Extrapyramidal side effects
Avoid antimuscarinics

10mg TDS PO 30mg/day SC

34
Q

What class is ondansetron, some side effects, usual dose?

A

5-HT3 antagonist

Inhibits serotonin released by bowel injury, chemo, radio

Constipation, headache
Reduce dose in renal failure
Can cause serotonin syndrome

4-8mg TDS
8-16mg day SC

35
Q

What class is levomepromazine, some side effects, usual dose?

A

Phenothiazine

Acts at vomiting centre and chemoreceptor trigger zone

Drowsiness

6.25-12.5mg/day PO or SC

36
Q

What class is aprepitant, some side effects, usual dose?

A

NK1 antagonist
Acts mainly centrally

Constipation, headache

Use to augment 5-HT3 antagonists

37
Q

What are some examples of adjuvants used in palliative care?

A

Antidepressants - amitriptyline, duloxetine

Anti-convulsants - gabapentin, pregabalin

Benzodiazepines - diazepam, clonazepam

Steroids - dexamethasone

Bisphosphonates for bony pain

38
Q

What are examples of treatable causes of breathlessness?

A 
Anaemia
PE
COPD
CCF
Respiratory tract infection
Pleural effusion
Pericardial effusion
SVCO
Anxiety
Transfusion
LMWH, DOAC
Diuretics, ACEi
Bronchodilators
Aspiration, pleurodesis
39
Q

What are common symptoms at the end of life?

A 
Pain and discomfort
Agitation
Delirium
Nausea and vomiting
Breathlessness, Cheyne Stokes breathing - 
Respiratory tract secretions
Mouth care - sips, foam sticks, vaseline to lips
Drinking and eating care
Bladder care
Skin integrity
Emotion/spiritual/psychological needs
40
Q

What is used for the relief of breathlessness?

A

Morphine sulphate for the relief of the sensation of breathlessness
Midazolam for the relief of anxiety associated with breathlessness

41
Q

What might be some causes of restlessness and agitation, and how can it be treated?

A

Uncontrolled pain
Full bladder, full rectum
Breathlessness
Anxiety, fear resolve where possible

If cannot otherwise be relieved - give midazolam 2.5-5mg STAT and PRN by subcutaneous injection

42
Q

What symptoms can be experienced in opiate naive patients?

A

30% experience nausea
Constipation
Drowsiness

43
Q

What types of pain have a good response to analgesics?

A

Nociceptive pain - soft tissue pain, visceral pain

44
Q

What types of pain can have a moderately good response to analgesia?

A

Bone pain

45
Q

Why might extra pain management be required for breakthrough pain?

A

Exacerbations of pain
Pain occurring before the next dose of opioid pain is due
Incident pain - due to specific actions e.g. movement or coughing

46
Q

What are the types of opioids?

A

Weak opioids - codeine, dihydrocodeine
Tramadol classed by BNF as strong opioid
Strong: morphine, diamorphine, oxycodone, hydromorphine, fentanyl, alfentanil, methadone

47
Q

What combination preparations are available?

A

Co-codamol 30/500 - codeine phosphate 30mg and paracetamol 500mg

Co-dydramol - dihydrocodeine 20 or 30mg with paracetamol 500mg

48
Q

What formulations is codeine available as?

A

15mg, 30,g or 60mg tablet

49
Q

How can immediate release morphine be given?

A

Every 4 hours
Immediate release available e.g. 10mg/5ml
Once controlled, then converted to oral morphine modified release given twice a day

50
Q

What is a typical starting dose for an opiate naive patient?

A

20-30mg in divided doses e.g. 10-15mg every 12 hours

And 5mg immediate release oral doses

51
Q

How can altering the dose of morphine be calculated?

A

Add up total dose of morphine received in 24 hours, including regular and as required doses
Divide dose into 2 12 hourly preparations
Prescribe new as required dose - usually 1/6th

Or - if the patient is in pain, increase dose by approx 30%

52
Q

What drugs are good to prescribe for neuropathic pain?

A

Amitriptyline
Gabapentin
Pregabalin

Cancer Care (15 decks)

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