(W5/6b) Common Symptoms Flashcards
What are the common symptoms of palliative patients?
1) Dyspnea
2) N&V
3) Constipation
4) Diarrhea
5) Delirium
Is dyspnea subjective?
yes, px can feel SOB even if SpO2 is high
- tf not a good indicator of EOL
What is Cheyne-Stokes breathing pattern?
Cycles of deep breathing followed by shallow breathing
What is death rattle breathing?
Noisy breathing caused by fluid accumulation in the throat and airways of someone near death
How to assess for dyspnea?
- Severity (using breathlessness scale)
- Pattern (alleviating and precipitating factors)
- Associated symptoms
- Associated anxiety
- Impact on function ability/QOL
What are the scales used to assess for breathlessness?
- Numeric rating scale
- Modified Borg scale
~ 0-10
What are the common comorbidities of dyspnea?
- COPD
- Interstitial lung disease
- Heart failure
- Anemia
What are the pharmacotherapeutic measures for dyspnea?
1) Opioids (eg morphine)
2) Steroids (eg dexamethasone)
- may reduce peri-tumoral edema
3) Anxiolytics (BZP and lorazepam)
4) Anticholinergics (eg Buscopan)
- To reduce secretions
What are the non-pharmacotherapeutic measures for dyspnea?
- Supplemental oxygen
- Blowing cool air on face (to stimulate trigeminal nerve)
- Breathing techniques
- Positioning
- Windows, environment
- Plan and pace activities
- Walking aids
What structures can be affected to caused N&V?
1) Cerebral cortex
- Fear, anxiety, smell, ^ ICP
2) Chemoreceptor trigger zone
- Drugs, toxins
- Metabolic disturbances (uremia, hypercalcemia)
3) GIT
- Stasis
- Squashed stomach (due to ascites, enlarged liver)
- Obstruction, constipation
- Irritation
- Drugs (NSAIDs, steroids, Abx, chemo)
4) Vestibular nuclei
- Motion, ear infx, tumor
How to assess for N&V?
- Hx taking
- Neurological system
- GIT (mouth, pharynx, abdomen and digital rectal exam to rule out constipation)
- Check for sepsis, drug toxicity, dehydration
What are the pharmacotherapeutic measures for N&V?
- Dexamethasone
- Haloperidol
- Metoclopromide
- Odansetron
- Cyclizine
- Prochlorperizine
What are some non-pharm measures for N&V?
- Ginger
- Regular mouth care
- Acupuncture and relaxation therapy
- Environment
What assessment is done for constipation?
- Last bowel movement
- Previous bowel pattern
- Stool consistency
- Presence of blood
- Any abdominal pain, N&V, excessive gas or rectal fullness
- On laxatives or any other medication
- General physical exam and digital rectal examination
What is the Bristol stool chart?
1: Separate hard lumps, like nuts
2: Sausage-shaped, but lumpy
3: Like a sausage but with cracks on the surface
4: Smooth and soft
5: Soft blobs with clear-cut edges
6: Fluffy pieces with ragged edges, mushy
7: Completely liquid
What is fecal impaction with overflow/spurious diarrhoea?
- Impacted stools in colon but softer stools leak around it
~ Can be mistaken as diarrhoea - Tf, important to do digital rectal exam to feel for impacted stools
What are the causes of constipation?
1) Drugs (eg opioids, antidepressants, calcium and iron supplements)
2) Metabolic conditions (eg dehydration, hypercalcemia, hypokalemia, uremia)
3) Neurological disorders
4) Structural (obstruction, adhesions)
5) Pain (anal fissures, hemorrhoids)
6) General (reduced mobility, decreased intake, weakess)
What are the pharmacotherapeutic measures for constipation?
1) Stimulant laxatives (eg Senna, Bisacodyl/Dulcolax)
2) Osmotic laxatives (eg Lactulose, Macrogol/Forlax, PEG)
3) Bulk-forming laxatives (eg Fybogel)
- Not often used in pall care as most px struggle to drink the req. 1.5L/day
What is the action of stimulant laxatives (eg Senna, Bisacodyl)?
- Stimulates peristalsis of the smooth muscle of intestine
What are precautions and adverse effects of stimulants laxatives?
- Px bowel obstruction or colic (localized pain in the abdomen or urinary tract that comes and goes)
Adverse effects:
- Dehydration
- Colic
What is the action of osmotic laxatives (eg Lactulose, macrologol, PEG)?
Draws fluid into bowel by osmosis
- Softens feces (to stimulate peristalsis)
What are the precautions and adverse effects of osmotic laxatives?
- Px must drinks lots of fluids
Adverse effects:
- Colic
- Flatulence
- Dehydration
- Electrolyte imbalance
What are non-pharm measures for constipation?
- Adequate fluid intake
- Increase intake of high-water content foods (eg soups, yoghurt, jelly)
- ^ Mobility
- Encourage toileting in the morning after breakfast
What defines diarhhoea and its severity?
> 3 episodes of unformed stools in a day
- Grade 0
- Grade 1: Increase in <4 stool episodes compared to pre-treatment
- Grade 2: Increase in 4-6 episodes
- Grade 3: Increase in >6 episodes
- Grade 4: Increase in >10 episodes
What are the causes of diarrhoea?
- Not to be confused with spurious/overflow diarrhoea
- General
~ GE
~ Broad-spectrum Abx
~ Enteral feeding (as it has high osmotic content, rapid and high volume feeding)
~ Tumor - Treatment-related
~ Chemo/radiotherapy
~ Post-surgical/procedural
IMPT:
What are the pharmacotherapeutic management for diarrhea?
- Loperamide 2-4mg tds, max 16mg/day)
- Buscopan
- Codeine phosphate
IMPT:
What drugs should be avoided in diarrhea?
- Lomotil (diphenoxylate/atropine)
~ Can cause delirium
What are the non-pharm measures for diarrhea?
- Non-milk diet
- Oral rehydration salts or isotonic drinks
~ Replace electrolytes lost due to hyponatremia or hypokalemia - Barrier cream
What is delirium and its subtypes?
- Acute deterioration in cognitive function
- Fluctuations in conscious level
- Disorientation and confusion
Subtypes:
1) Hypoactive - Confusion and somnolence
2) Hyperactive - Hypervigilance, restlessness, agitation
3) Mixed-alternating features
How to assess for delirium?
- Confusion assessment method (CAM)
~ Acute onset and fluctuates - Inattention
- Clouded consciousness
~ Ranges from hyper-awake to sleepy - Disorganized thinking
~ Rambling, irrelevant, incoherent conversation
What are the causes of delirium?
Acronym: DELIRIUM
- Drugs
- Electrolytes
- Lung/liver (Pneumonia, pulmonary embolism, hepatic encephalopathy)
- Infections
- Retention/Restraints (Urinary retention, fecal impaction, restraints)
- Intracranial (brain metastasis, stroke, seizures)
- Uremia
- Myocardial (MI)
IMPT:
What is the pharmacological measures for delirium?
- First line
~ Subcutaneous Haloperidol
~ Risperidone (for px with Parkinsons or EPS from haloperidol)
~ Subcutaneous Midazolam (if px is restless and uncooperative) - Second line (if px still agitated)
~ Oral/sublingual Olanzepine
~ Chlorpromazine
What are the non-pharm measures for delirium?
- Frequent reorientation
- Calm environment
- Emotional support and avoid confrontation
- Clear verbal instructions
- Promote a normal sleep-wake cycle
- Correct sensory deficits
- Minimise physical restraints
