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Palliative > Symptom Management > Flashcards

Symptom Management Flashcards

1
Q

What is palliative care?

A
  • Provides relief from pain and other distressing symptoms
  • Integrates physical, psychological, social and spiritual care
  • Affirms life and regards dying as a normal process
  • Neither hastens nor postpones death
  • Helps patients live as actively as possible until death
  • Offers support to help family/carers during the patient’s illness and into bereavement
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2
Q

What may be included in formalised outcomes of advance care planning?

A
  • Advance statement of wishes to inform subsequent best interest judgements
  • Advance decisions to refuse treatment which are legally binding if valid and applicable
  • Appointments of lasting powers of attorney for ‘Health and Wlfare’ and/or ‘property and affairs
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3
Q

What may pain be caused by in cancer patients?

A
  • The disease itself e.g.bone invasion
  • The treatment e.g. radiotheray induced oesophagitis
  • The concurrent disease e.g. oesteoarthritis
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4
Q

How does bone pain clinical present in cancer patients? How do we treat it?

A

Presentation

  • dull ache over a large area or
  • well localised tenderness over the bone
  • Worse on weight bearing or movement

Treatment

  • NSAID e.g. diclofenac 50mg tds
  • Radiotherapy and bisphosphonates e.g. pamidronate infusion
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5
Q

How does visceral pain commonly present in cancer patients? How do we treat it?

A

Presentation

  • Dull, deep-seated
  • Poorly localised pain
  • Tenderness over particular organ (e.g. liver)
  • Some visceral pain is spasmodic i.e. bladder or bowel colic

Treatment

  • For constant: follow analgesic ladder
  • Visceral stretch pain
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6
Q

How does a headache due to raised intracranial pressure present? Treatment?

A

Presentation

  • Dull, oppressive pain
  • Worse on waking, coughing, sneezing
  • Associated with nausea and vomiting

Treatment

  • Corticosterois to reduce oedema (e.g. 16mg dexamethasone daily, reduced to lowest effective dose)
  • NSAIDs and paracetamol
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7
Q

How does neuropathic pain present? Treatment?

A

Presentation

  • Pain in an area of abnormal sensation
  • Localised to specific dematomes, or over wider, less defined area
  • Altered sensation in area such as numbness or hyperaesthesia
  • Autonomic changes: pallor or sweating
  • May describe pain as ‘pins and needles’ or burning

Treatment

  • Antidepressant Tricyclic (amitriptyline 10-75mg Nocte)
  • Anticonvulsants (gabapenting 100-1200mg tds, pregablin 25-300mg bd)
  • Compression of never may be helped by corticosteroids
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8
Q

What are causes of a dry mouth (xerostomia) in palliative medicine? What can a dry mouth result in?

A
  • Reduced intake of oral fluids
  • Adverse effect of drugs e.g. antiemetic, antidepressants
  • Radiotherapy to head and neck
  • A dry mouth can result in: loss of taste, anorexia, halitosis, dysphagia and oral infection
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9
Q

What is the presentation and treatment of oral thrush in palliative care?

A
  • May be asymptomatic, cause altered taste, soreness or pain
  • Treatment
    • systemic antifungals (fluconazole 50mg o.d. 7 dyas
    • Topical agents (nystatin 1ml q.d.s 7 days)
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10
Q

Drug treatments to alleviate anorexia as a symptoms?

A
  • Dexamthasone 4mg o.d. may help effect sbu often wears off after 2-3 weeks
  • Megestrol acetate 160mg o.d is effective but may cause fluid retention
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11
Q

What are the 4 causes of nausea and vomiting?

A
  • Gastric stasis / irriation
  • Toxic causes
  • Cerebral causes
  • Vestibular causes
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12
Q

What are the features of nausea and vomiting caused by gastric stasis / irritation? Caused by what in palliative care patients?

A
  • Early satiety
  • epigastric fullness
  • hiccups
  • heartburn
  • often minimal nausea between vomits
  • may be caused by tumour, hepatomegaly, ascites (‘squased tummy’) and dsymotility (drugs, autonomic failure)
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13
Q

What is the treatment of nausea and vomiting caused by gastric stasis / irritation?

A
  • Metoclopramide 10-20mg po/sc 30 minutes before meals or30-60mg SC over 24hours
  • Stop any causative drugs if possible
  • Consider proton pump inhibitor if gastric irritation
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14
Q

What are the features of nausea and vomiting caused by ‘toxic’ causes? What are some of the ‘toxic’ causes of nausea and vomiting?

A

Features:

  • Persistent or intermitten nausea
  • small vomits = “possets”
  • retching

Causes:

  • Drugs (opioids, digoxin, antiepileptics)
  • Hypercalcaemia
  • uraemia and infections (UTI and pneumonia)
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15
Q

What is the treatment of nausea and vomiting caused by toxic causes?

A
  • Haloperidol 1.5-5mg po/sc nocte
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16
Q

What are the cerebral causes of nausea and vomiting? Features of each?

A
  1. Raised Intracranial pressure
    • Early morning headache
    • vomiting
    • may be little nausea
    • associated with neurological symptoms/signs
  2. Anxiety, anticipatory nausea and vomiting
    • specific precipitant such as certain situations
    • overly anxious or depressed
  3. Indeterminate
17
Q

What is the treatment of nausea and vomiting caused by raised intracranial pressure?

A
  • Dexamethasone 8-16mg po od (reduced if possible) plus Cyclizine 50mg TDS po/sc or 150mg SC/24hrs
18
Q

What is the treatment of nausea and vomiting caused by anxiety?

A
  • Benzodiazepines
  • CBT
  • Complementary therapies
19
Q

Why is constipation common in palliative medicine?

A
  • Immobility
  • reduced food and fluid intake
  • drugs e.g. opioids
  • bowel pathology
  • hypercalcaemia
20
Q

What are the different types of laxatives that can be given? What do most patients in palliative care require?

A
  • Bulk forming (rarely appropriate in palliative care setting)
  • Stool softerners
    • Movicol
    • Lactulose
    • Sodium docusate
  • Stimulants
    • Senna
    • Dantron

Mosy patients in palliative care require a softener and a stimulant

21
Q

What drugs are commonly chosen to treat opioid induced constipation?

A

Laxatives

  • Co-danthrusate = dantron + docusate
  • Co-danthramer
  • Movicol
22
Q

What type of cancer causes a high incidence of intestinal obstruction?

A
  • Ovarian cancer
  • Bowel cancer
23
Q

What are the symptoms of intestinal obstruction?

A
  • Nausea and vomiting
  • Colicky pain
  • Abdominal distension
  • Dull aching pain
  • Diarrhoea and/or constipation
24
Q

What is the management of intestinal obstruction in a paliiative care setting?

A
  • Surgical intervention depends on:
    • patients disease status
    • co-mobidity
    • level of obstruction + co-existing symptoms
  • IV fluids and NG tubes may be appropriate in short-term intervention
  • Oral intake of foot and drink can continue for patient’s enjorment and is often surprisingly well tolerated
    • patient decideds whether risk of vomiting outweights the pleasure of eating
  • medication given SC infusion continues
    • combination of antiemetics, analgesics and antispasmodics
    • colic a feature: stumulant laxatives and prokinetic drugs (metoclopramide) stopped and antispasmodics prescribeds
25
Q

What is the non-pharmacological treatment of dyspnoea?

A
  • Discussion of fears and explanation vital
  • Modification of lifestyle: breathing retraining and relaation beneficial
  • Oxyen can help acute dyspnoea -not always helpful in palliative care setting
  • Fan directed onto face
26
Q

What is the pharmacological management of dyspnoea?

A

Opioids

  • they decrease respirratory effect and therefore breathlessness
  • oramorph 2.5mg four hourly -gradually titrate dose upwards according to response

Benzodiazepines

  • Lorazepam (0.5-1mg sub-lingual) may help anxiety associated with breathlessness or give relief during panic attacks
  • Midazolam (2.5-5mg SC) may benefit patients who can’t tolerate oral/sub-lingual route
27
Q

What is the management of a cough in palliative care?

A
  • Treat underlying cause
  • If patient has difficulty expectorating = trial of saline nebulisers may be helpful
  • Cough is dry and irritating then simple lincuts may help
  • Alternatively opioids are cough suppressants

Palliative (4 decks)

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