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Palliative Care + Oncology > Agitation / Secretions / Hiccups / N+V / Nutrition > Flashcards

Agitation / Secretions / Hiccups / N+V / Nutrition Flashcards

(58 cards)

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1
Q

What should you look for if confusion / agiation

A 
Underlying cause to treat
Infection
Pain 
Dehydration 
Retention / constipation 
Medication
Hypercalcaemia
Uraemia 
Electrolyte imbalance
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2
Q

Where are sources of information for reasons for confusion

A 
Nurse
Relative
NEWS
Drug cardex
Blood results 
4AT + TIME
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3
Q

What examination can you do

A

Chest
ABdo
Neuro
PEARL

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4
Q

What can you use if specific Rx fails

A

Side room, regular staff and possible 1:1 nursing
Haloperidol = 1st line
Chloropromazine
Lorazepam if can’t have anti-psychotic

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5
Q

What is used in terminal phase of agitation / restless

A

Midazolam 2.5-5 SC

Levomepromazine 12.5mg SC 2 hourly PRN

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6
Q

What is licensed for intractable hiccups

A

Chloropromazine

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7
Q

What is also used if unresponsive

A

Haloperidol
Gabapentin
Dexamethasone - hepatic

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8
Q

What are common in final days of life

A 
Secretions
Due to inability to cough or swallow 
Rattling sounds in expiration as air passes through 
More troubling for family
Suggests death in next few days
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9
Q

What is conservative Rx for secretions

A 
Consider reversible cause e.g. HF, chest infection, aspiration pneumonia 
Avoid overload - stop IV or SC fluid
Reposition patient
Consider suction 
Educate family that patient not troubled
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10
Q

What is medical management of secretions

A

Hyoscine hydrobromide - 20mg SC hourly PRN (120max in 24 hours)
- Reduce production

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11
Q

What is used for bowel colic

A

Hyoscine butyl bromide (Buscopan)

- Oesophageal spasm / crampy abdo pain

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12
Q

What can cause sickness in palliative care / broad spectrums of N+V

A 
Severe pain 
Metabolic
Drugs / chemical e.g. chemo SE 
Infection
Intra-cranial causing raised ICP 
Vestibular
Abdominal  / reduced gastro-mobility 
Psychological
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13
Q

What metabolic

A

Uraemia from renal failure
Hypercalcaemia
Circulating Ig
Renal failure

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14
Q

What drugs

A 
Opioids 
Chemo
AX
SSRI 
Iron 
Digoxin
NSAID
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15
Q

What abdominal causes

A

Gastric outlet obstruction
Severe constipation
Mass
Hepatic mets

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16
Q

What is useful if intra-cranial / raised ICP lesion causing N+V

A

Dexamethasone = 1st line
Cyclizine
Haloperidol - anti-psychotic (D2 antagonist)

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17
Q

What are RF of chemo related N+V

A

Anxiety
<50
Concurrent use of opioids
Type of chemo

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18
Q

What is used if low risk of N+V Sx in chemo

A

Metoclopramide

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19
Q

What is added if doesn’t work or if high risk

A

5HT3 receptor antagonist - ondansetron

Dexamethasone

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20
Q

What are used as anti-emetics

A 
H1 antagonist (anti-histamine) 
D2 antagonist (pro kinetic) 
5HT3 antagonist 
Anti-psychotics 
Anti-cholinergic - hyoscine hydrobromide
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21
Q

What are dopamine antagonist and what are they useful for

A

Metoclopramide 10mg - gut peristalsis - used for GI causes
Domperidone 10-20mg - gut peristalsis
- Useful in gastric stasis, hiccups in palliative, RT induced 2nd line, delayed chemo induced, gastroenteritis, uraemia
Avoid in mechanical bowel obstruction, Parkinson and prolactinoma

Haloperidol- N+V in palliative care / raised ICP

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22
Q

What antihistamine and what useful for and what others

A

Cyclizine 50mg TDS PO / SC / IV / IM
Useful for inner ear induced nausea / intra-cranial / mechanical bowel
Risk of urinarry retention
Chloropromazine also useful / levomepromazine

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23
Q

What anti-psychotic

A

Levomepromazine

  • Only used in pallaitiv care
  • Also provide analgesia
  • Avoid in myasthenia graves + Parkinson
  • Decreases seizure threshold
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24
Q

What 5HT3 antagonist and what is it useful for

Study These Flashcards
A

Ondanstron
1st line for chemo induced + RT induced + post-op
Gastroenteritis
Avoid in long QT

25
What is downside
Very constipation | Expensive
26
What happens to calcium in a sick person
Albumin is low | Ca levels may be normal but ionised Ca will be too high
27
What should you do if risk
``` Add the mission albumin to calcium If Ca 2.6 and albumin 16 (36-52) Missing = 36-16 = 20g Each g carried 0.2m of calcium So if albumin was normal there would be additional 0.4 moll of Ca Corrected calcium = 3 ```
28
What are consequences of malnutrition
``` Impaired immune Poor wound healing Muscle wasting and weakness Impaired organ function Altered drug Poor response to Rx ```
29
What is cancer cachexia
Unintential body and lean tissue wasting | Metabolic abnormality results in increased energy, fab and oxidation
30
What does it lead too
GI disturbance Anorexia Undernutriton
31
How do you treat
Adequate replacement and supplements Appetite stimulates MUST screening on admission and weekly
32
What replacement
``` Energy and protein dense diet Food fortification Oral supplement NGT PEG TPN ```
33
What stimulates appetite
Megace Dexamethasone Alcohol
34
What causes constipation in palliative
``` SE of opioid Hypercalcaemia Dehydration Drugs INtra-abdominal disease ```
35
What are causes of breathlessness
``` Infection Pleural effusion Anaemia Arrhythmia VTE SVC = urgent Rx ```
36
How do you Rx
Treat cause If patient distressed consider low dose morphine as suppress resp drive Benzo may help if associated anxiety
37
What are common medications in anticipatory care pan
``` Morphine for pain Haloperidol for agitation / N+V Midazolam for agitation and anxiety Anti-emetic for N+V Glycopyronium for resp secretion ```
38
What is breathlessness in palliative care
A subjective experience of chest discomfort - Tachypnoea - Examination - Hypoxia in patient with no known resp
39
What can cause
Most common Sx - Heart - Lung - End stage cancer
40
What investigation
CXR = 1st line for cause
41
What category
On exertion At rest Terminal
42
What 3 things are involved in perception of breathlessness
Thinking Breathing Function
43
Thinking
Anxiety / distress Thoughts about dying Attention to sensation
44
Breathing
Increased RR Use of accessory Increased work of breathing
45
Function
Reduced activity More help from others Deconditioning of chest
46
How do you treat thinking non-pharmalogically
Distractive stimuli Relaxation Cold air
47
How do you treat breathing non-pharmacologically
Sit upright | Breathing exercise
48
How do you treat function non
Walking aid | Chest wall vibration and muscle stimulation
49
What are pharmacological therapy
Opaites - Reduce response to hypercapnia - Reduces RR and drive and therefore breathlessness - Morphine 2mg SC PRN Benzo - Used for anxiety - Midazolam 2mg SC PRN (larger dose may be needed if on background of opiates)
50
Use of anti-cholinergic in palliative
Bowel colic Resp secretion N+V Hyoscine hydrobromide and butylbromide
51
When do you have caution
Mechanical bowel Angle closure glaucoma Risk of retention an arrhythmia
52
If opiate naive what should you start morphine at for end of life
Morphine 2mg SC hourly PRN for pain or breathlessness | If on background = 1/6 of total SC dose
53
Breathless
Morphine 2mg SC hourly PRN | Midazolam 2mg SC PRN
54
Agitation / anxiety
Midazolam 2mg SC PRN
55
Secretions
Hyoscine butyl bromide 20mg SC hourly
56
N+V
Levomepromazine 2.5-5mg SC12 hourly
57
If patient was of life what should you do
``` Look for reversible causes Dehydration? Glucose? AKI? Delerium? ```
58
What are risks of fluid in end of life
Secretions SOB Overload

Palliative Care + Oncology (6 decks)

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