Assessment and management of these symptoms commonly experienced Flashcards
1
Q
Intractable breathlessness:
- Definition
- DD
- Assessment
- Management
A
Intractable breathlessness
- Definition: common in advanced cancer or lung cancer. Short prognosis
-
DD:
1. Tumour involving the lung parenchyma or causing airway obstruction or advanced cancer
2. Lung conditions - pleural effusion, pneumonia, SVCO, radiation induced fibrosis, COPD, PE, pneumothorax
3. Systemic conditions: anaemia, anxiety, HF, pericardial effusion -
Assessment:
1. History: other symptoms
2. Examination: anaemia? Engorged veins? Resp/cardio systems? Panic? Oxy sats?
3. Other investigations: bloods (fbc - anaemia?), ecg, cxr, spirometry, ct chest/ ctpa -
Management
Air flow across face such as window or fan, trial oxy if hypoxic, position pt upright, encourage exercise
Only meds if necessary: oromorph 1-2mg orally prn (hence also antiemetics!!), morphine 1-2mg sc prn, benzodiazepines lorazepam 0.5-1mg SL prn if anxiety, if emergency corticosteroids, oxy if <92%
- Anaemia: transfusion
- PE: lmwh, doac
- CHF: diuretics, acei
- COPD: bronchodilators
- Pleural effusion: aspiration, pleurodesis
- Pericardial effusion: paracentesis, corticosteroids
- SVCO: stent, steroids
- Anxiety: CBT, benzodiazepines, SSRIs
- Pneumonia - abx
2
Q
Confusion and delirium:
- Definition delirium
- Assessment
- Causes
- Management
A
Confusion and delirium:
- Definition delirium: Acute fluctuating syndrome of disturbed consciousness, attention, cognition and perception. Can be hyperactive or hypoactive
- Assessment: 4AT assessment
-
Causes:
1. Drug related: opioids, steroids, sedatives, antimuscarinics
2. Withdrawal: opioids, benzodiazepines, alc/nicotine
3. Metabolic: resp, liver, renal failure, glucose, hypercalcaemia, infection, nutrition
4. Raised ICP
5. Other: dehydration, pain, constipation, urinary retention, poor sleep - Management: make sure family there, hydration, reassure
- Drugs: reduce/stop
- Withdrawal: continue agent responsible or nicotine patches
- Metabolic: treat reversible causes
- ICP: dexamethasone 8-16mg daily for one week and slowly reduce
3
Q
Nausea and vomiting:
- Definition
- Assessment
- Causes
- Management
- N+V due to chemo
A
Nausea and vomiting:
- Definition: 30-40% with advanced cancer
- Assessment:
- Review history + recent invest + meds
- Examination
- Investigations if it affects management only
- Causes:
- Drugs opioids, PPIs, nsaids, ssris, abx, iron, digoxin, chemo
- Uncontrolled pain
- Anxiety
- Cough
- Urin retention
- Gastric stasis - tumour, opioids, antichol (fullness/regurg, reduce appetite, vomm relieves, abdo pain)
- Liver mets
- Raised ICP (worse in morning, projectile, headache)
- Infection - uti, pneumonia, gastroenteritis, thrush
- GI disturbance - Gastritis, constip, ulcer, obstruction
- Electrolyte/metabolic disturbances - renal/liver impairment, low na, high ca (persistent, worse with sight/smell, relieved by vom, confusion)
- Management: avoid triggers, small freq meals, acupuncture, if more severe use non oral route, antiemetics regularly and can combine, switch or oral if improving
- Drugs - stop, haloperidol if opioid
- Uncontrolled pain - analgesia
- Anxiety - lorazepam
- Cough - cough suppressant
- Urin retention - catheter
- Gastric stasis - metoclopramide
- Liver mets - steroids, cancer treatment
- Raised ICP - dexmethasone, cyclizine
- Infection - abx
- Gastritis - stop irritant, ppi, metaclopramide
- Electrolyte disturbances - correct, haloperidol
- Mech bowel obstruction + colic: cyclizine + maybe hyoscine butylbromide
unknown cause = levomepromazine
vestibular symptoms = cyclizine
DO NOT COMBINE CYCLIZINE + METOCLOPRAMIDE
- N+V due to chemo: in 75% pts. Acute, delayed, anticipatory.
Increased risk if a specific chemo, female, <50, past hx of n+v in preg/chemo/motion sickness
Give ondanestron, dexamethasone and aprepitant (augments other 2 drugs)
4
Q
Constipation:
- Causes
- Assessment
- Management
A
Constipation:
- Causes:
- Drug induced (opioids, diuretics)
- Dehydration - reduced intake or vomiting/sweating
- Reduced mobility
- Altered diet
- Hypercalcaemia
- GI obstruction - disease, adhesions, surgery
- Neurolog - sc compression
- Assessment:
- History - bowel habits past + present, laxatives, last bowel opened, current meds
- Abdo palpate + ausc, DRE
- Investigations - axr, ca
- Management: prevent, encourage oral intake, oral laxatives.
If soft stools stimulant which reduces bowel transit time like bisacodyl start 5mg, or senna 15mg.
If dry hard faces softening agents increase water penetration into stool like docusate sodium 500mg - if full rectum on top then also stimulant bisacodyl.
If full colon and pain then osmotic macrogels like laxido (not lactulose as too sweet) (but bloating, flatulance). If impaction enema or
5
Q
Antiemetic drugs
A
6
Q
Depression:
- Definition
- Assessment
- Management
A
Depression:
- Definition: in 25% with advanced illness which may increase impact of existing symptoms and reduce effectiveness
- Assessment: screening via history
- Management: explore their understanding of illness, address distresses, if >4 weeks prognosis then - sleep management, CBT, exercise, hospice day therapy and pharmacological - SSRIs selective serotonin like sertraline 50-200mg, citalopram 10-40mg daily if mixed anxiety/depression but note it may cause anxiety flare (but lots med interactions!!), mirtazapine which is rapid onset but may inc appetite/sedation, duloxetine 60mg if also neuropathic pain
7
Q
Anxiety:
- Causes
- Management
A
Anxiety:
- Causes: uncertainty about future, seperated from loved ones, financial, work, unrelieved pain/symptoms. Or may be due to another problem: hypoxia, meds (ssris, steroids, opioid/benzodiazepine withdrawal), hyperthyroid, hypoglycaemia, dementia, sepsis
- Management: treat contributing factors. If >4 weeks non pharmacological relaxation, counselling, cbt, psychiatric services, ssri sertraline. If <4 weeks can also consider benzodiazepines - 500mg lorazepam, diazepam 2mg (remember older patients more sensitive so 2-4 weeks only)
