symptoms management (13 Nov) Flashcards
What are some common symptoms in palliative care?
Dysnea
N&V
Constipation
Diarrhoea
Delirium
Assessment for Dyspnea
- Severity (breathlessness scale– numeric scale, modified borg scale)
- Pattern (alleviating and precipitating factors)
- Associated symptoms
- Associated anxiety
- Impact on functional ability, QOL
- Reversible causes?
What are the treatment related causes of dyspnea?
- chemotherapy/radiation indued pneumonitis
What are the cancer related causes of dyspnea?
- lung: tumour obstruction, pleural effusion, post obstructive pneumonia
- heart: pulmonary embolism, SVCO
- lymphatics: lymphangitis carcinomatosis
- extrinsic compression: mediastinal lymphadenopathy, diaphragmatic splinting (ascities/hepatomagly)
What are the co-morbidities that can cause dyspnea?
- COPD, interstitial lung disease
- HF
- Anemia
Pharmaco management of Dyspnea
- Opioids (Morphine)
- Steroids (Dexamethasone for oedema)
- Anxiolytics (Benzodiazepine for anxious patient, lorazepam for pt who does not respond to opioid alone)
- Anticholinergics (Buscopan to reduce secretions in frail patients who are unable to expectorate)
Non-pharmaco management of Dyspnea
- Supplemental oxygen for hypoxic patients
- Blow fan on face
- Pursed lip breathing, anxiety management techniques
- Find the most efficient position
- Open windows to allow airflow
- Plan and pace activities (break tasks into smaller bits, use walking aids to decrease breathing effort)
Management for future:
- ACP
- AMD (Advance Medical Directive)
- EOL care
Causes of N&V
Fear, anxiety, smell, taste, increased ICP, tumor of central nervous system (which affects the CEREBRAL CORTEX)
Chemotherapy drugs, Toxins from infections and radiotherapy, Uremic and hypercalcemia metabolic problems (which affects CHEMORECEPTOR TRIGGER ZONE)
GI stasis due to drugs and disease, enlarged liver and ascites due to squashed stomach, tumour in GI tract, irritation by NSAIDs, steroids, antibiotics, chemotherapy and radiotherapy, constipation (which all affects the GI tract, visceral)
Motion, ear infection, tumour which affect vestibular nuclei
Assessment for Nausea and Vomiting
Phy assessment
- neuro system
- abdominal and GI (mouth, pharynx, abdomen, DRE tro constipation)
- Hx taking
- Sepsis, drug toxicity, hydration status
Pharmaco management of Nausea and Vomiting
Appropriate anti-emetics for affected structure
- dexamethasone
- haloperidol
- metoclopramide
- prochlorperazine
- ondansetron
- cyclizine
Non-pharmaco management for nausea and vomiting
- calm peaceful fresh environment
- explain examination, diagnosis and treatment
- emotional support to allay fear and anxiery
- relax therapy
- appropriate prep and presentation of food (prep food away from pt, small meals, upright position b4 and aft meal)
- ginger
- regular mouth care
- acupuncture or acupressure
What is constipation and its signs and symptoms?
infrequent, difficult passage of stools
Signs and symptoms:
- pain
- bloating
- n&v
- overflow/spurious diarrhoea
- urinary incontinence
Assessment of constipation
Hx taking
- when last bowel movement, when was last “normal”
- previous bowel pattern
- stool consistency, any blood
- any abdo pain, n&v, excessive gas, rectal fullness
- on any laxatives?
- current medication
Phy assessment
- general
- abdomen, DRE
Causes of constipation
Drugs
- e.g. opioids, tricyclic antidepressants
Metabolic
- dehydration, hypercalcaemia, hypokalaemia, uraemia, hypothyroidism, DM
Neuro
- Parkinsons
- Brain tumor
- Spinal cord compression
- Autonomic dysfunction
- sacral nerve infiltration
Structural
- IO secondary to extrinsic/intrinsic tumours/peritoneal disease/adhesions
Pain
- anal fissures
-haemorrhoids
General
- reduced mobility
- decreased food intake
- general weakness
Environmental
- lack of privacy or assistance w toileting
Pharmaco management of constipation
Stimulant laxatives (e.g. senna, bisacodyl/dulcolax)
Osmotic laxatives (e.g. lactulose, macrogol (forlax), polyethylene glycol (PEG))
Bulk-forming laxative (e,g. Fybogel)
MOA, precautions and adverse effects of Stimulant laxatives (senna, bisacodyl)
MOA: Stimulates peristalsis by stimulating smooth muscle of intestine
Precaution: unsuitable for pts with complete bowel obstruction or with colic (pain in stomach due to wind or obstruction)
Adverse effects: dehydration and colic
MOA, precaution and adverse effects of osmotic laxatives (lactulose, macrogol, PEG)
MOA: draw fluid into bowel by osmosis, soften faeces, stimulate peristalsis
Precaution: Must drink fluids!
Adverse effect: colic, flatulence, dehydration, electrolyte imbalance in debilitated pts
Why are bulk-forming laxatives (e.g. Fybogel) not used in palliative care?
Not commonly used as most patients struggle to drink the required 1.5litres/day!
Non-pharmaco management of constipation
- ensure adequate fluid intake (increase intake of high-water content foods)
- encourage mobility
- encourage toileting in morning after breakfast
- maintain privacy, avoid bedpans
What is diarrhoea?
Passage of >3 episodes of unformed stools in a day
What is the classification of diarrhoea (grade 0-4)?
Grade 0: No severity
Grade 1: Increase in <4 stool episodes
Grade 2: Increase in 4-6 episodes
Grade 3: Increase in >6 episodes
Grade 4: Increase in >10 episodes
Causes of diarrhoea
Note: exclude “spurious/overflow diarrhoea” from laxative over-use
- GE causes
- Immunocompromised, receive multiple broad-spectrum antibiotics
- Enteral feeding: high osmotic content, rapid or high-volume feeding, hypoalbuminaemia
- Tumour related: rectal/pancreatic cancer
- Treatment-related: chemotherapy, radiotherapy, post surgical/procedural
Pharmaco management of of diarrhoea
- Loperamide
- Hyoscine Butylbromide (Buscopan!)
- Codeine phosphate
- Avoid Lomotil (Diphenoxylate/Atropine) in elderly as Atropine can cause delirium
Non-pharmaco management of diarrhoea
- Exclude spurious diarrhoea
- Non-milk diet
- Oral rehydration salt or isotonic drinks
- Replace electrolyte lost due to hyponatremia/hypokalemia
- Prevent pressure injury with barrier cream, pressure relief mattresses and regular turning
What is delirium?
Acute deterioration in cognitive function accompanied by fluctuations in conscious level, leading to DISORIENTATION and CONFUSION
3 subtypes of delirium
- Hypoactive: confusion and somnolence (sleepy, drowsy)
- Hyperactive: hypervigilance, restlessness and agitation
- Mixed alternating hypo and hyperactive delirium
Causes of delirium
Drugs
- anti-cholinergic
- steroids
- opioids
- tricyclic antidepressants (TCA)
Electrolytes
- hypercalcemia
- hypoglycaemia
- hypernatremia
- hyponatremia
Lung/liver
- pneumoia
- pulmonary embolism
- hepatic encephalopathy
Infection
- consider possible infection sites
Retention/restrain
- urinary retention
- fecal impaction
- use of restraint
Intracranial
- brain metastasis
- stroke
- seizures
Uremia
Myocardia
- MI
Assessment for delirium
Confusion Assessment Method (CAM): 4 features
Feature 1: Acute onset and fluctuating course
Feature 2: Inattention (difficulty focusing attention)
Feature 3: Clouded consciousness (ranging from hyper-awake to sleepy)
Feature 4: Disorganised thinking (rambling/irrelevant/incoherent conversation)
General management of delirium
- Treat any potentially reversible causes
- Optimise pain control
- Pharmaco management
- Non-phamaco management
Pharmaco-management of delirium
First line:
- Haloperidol
- Risperidone (for pts with Parkinson’s or those who developed EPSE with haloperidol)
Second line (if pt is still agitated despite above):
- switch from haloperidol to sublingual Olanzepine
- Chlorpromazine
Non-pharmaco management of delirium
- frequent reorientation
- calm environment (avoid sensory deprivation and overstimulation)
- clear verbal instructions
- emotional support (avoid 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 IV or urinary catheters)
- minimise room and staff changes
- request family bring familiar items and sit w patient
