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Session 3b Flashcards

1
Q

Assessmeent of dyspnea

A

Severity

Pattern (alleviating and precipitating factors)

Associated symptoms

Associated anxiety

Impact on functional ability/quality of life

Look for reversible causes

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2
Q

Numeric rating scale/ Modified borg scale dyspnea

A
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3
Q

Causes of dyspnea

A

Cancer related:
* Lung: tumour obstruction, pleural effusion or post-obstructive
pneumonia
* Heart: Pulmonary embolism, SVCO
* Lymphatics: Lymphangitis Carcinomatosis
* Extrinsic compression: Mediastinal Lymphadenopathy, diaphragmatic
splinting (ascites/hepatomegaly)

  • Treatment related:
  • Chemotherapy induced pneumonitis
  • Radiation induced pneumonitis
  • Co-morbidities:
  • COPD, interstitial lung disease
  • Heart failure
  • Anaemia
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4
Q

Management of dyspnea

A

Treat reversible causes, if possible

Treat underlying disease, if possible

Pharmacotherapeutic

Non-pharmacotherapeutic measures that optimize coping

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5
Q

Pharmacotherapeutic measures for dyspnea

A

Opioids
* Usual starting dose of Morphine for opioid naive patients is 2.5-
5mg q4h, dose can be titrated according to response.

Steroids
* May reduce peri-tumoural oedema
(e.g. Dexamethasone)

  • Anxiolytics
  • Benzodiazepines -for patient who is anxious
  • Lorazepam – for patient who does not respond to opioid alone
  • Anticholinergics
  • To reduce secretions-in frail patients who are unable to
    expectorate (e.g. Buscopan)
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6
Q

Non-pharmacotherapeutic measures
for dyspnea

A

Supplemental oxygen is beneficial for hypoxic patients

Blowing cool air (using fan)on the face maybe useful by stimulating the trigeminal nerve

Breathing techniques – Pursed lip breathing, anxiety
management techniques

Position – Find the most efficient position for the patient

Environment – Open windows to allow airflow

Plan and pace activities – Break tasks into smaller bits, walking
aids to decrease breathing effort

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7
Q

Management (prepare for future) dyspnea

A

Conversation:
* Advance Care Planning
* Advance Medical Directive
* End-of-life care

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8
Q

Causes of nausea and vomiting

cerebral cortex

A

Fear, anxiety, smell, taste, increased intracranial pressure,
tumor of central nervous system

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9
Q

Causes of nausea and vomiting

Chemoreceptor Trigger
Zone (CTZ)

A

Drugs-Chemotherapy.
Toxin –Infections, radiotherapy.
Metabolic –Uremia, hypercalcemia

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10
Q

Causes of nausea and vomiting

Visceral – GI tract

A

Stasis – Drugs, disease.

Squashed stomach – enlarged liver, ascites

Obstruction – tumour
Irritation, NSAIDs, steroids, antibiotics, chemotherapy,
radiotherapy.

Constipation

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11
Q

Causes of nausea and vomiting

Vestibular nuclei

A

Motion, ear infection, tumor.

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12
Q

Assessment of nausea and vomiting

A

Physical examination:

  • Neurological system
  • Abdominal/GI system
  • Mouth, pharynx, abdomen (including digital rectal
    examination to rule out constipation).
  • History taking
  • Others
    -Sepsis, drug toxicity, hydration status
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13
Q

Management of nausea and vomiting

A
  • Treat the treatable
  • Pharmacotherapeutic
  • Non-pharmacotherapeutic
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14
Q

Pharmacotherapeutic management of nausea and vomiting

A

Appropriate anti-emetics for affected structure that causing
nausea and vomiting:
* Dexamethasone
* Haloperidol
* Metoclopramide
* Prochlorperazine
* Ondansetron
* Cyclizine

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15
Q

Non-pharmacotherapeutic management of nausea and vomitting

A

Management
Non-pharmacotherapeutic

  • Calm, peaceful and fresh every environment if possible.
  • Explain examination, diagnosis and treatment.
  • Emotional support and attention to patients to allay fear and anxiety.
  • Relaxation therapy
  • Appropriate preparation and presentation of food (if patient is able to eat).
  • Foot prepare away from patient to prevent smell stimulating nausea or
    vomiting response.
  • Small meals as tolerated.
  • Upright position during and after meals.
  • Ginger is a good anti emetics-drinks, biscuits or crystallize.
  • Regular mouth care to keep mouth clean and fresh.
  • Acupuncture or acupressure- sea bands
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16
Q

What is constipation?

A

Infrequent or difficult passage of stools, which may be (but not always)
small and; hard

May be associated with inability to defecate, discomfort when defecating, unproductive urges and straining, sensation of incomplete evacuation.

Present with pain, bloating, nausea, vomiting, overflow/spurious
diarrhoea, urinary incontinence.

Constipation can be more distressing than pain, and cause patient to
decline opioids.

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17
Q

Assessment of constipation

A

History taking
* Last bowel movement, when was the last ‘normal’
* Previous bowel pattern
* Stool consistency, any blood
* Any abdominal pain, nausea/vomiting, excessive gas, rectal fullness
* Is patient on laxatives
* Types of current medication taking

Physical examination
* General
* Abdomen, digital rectal examination

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18
Q

Drugs examples

Constipation

A

Opioids, tricyclic antidepressants, 5HT3 antagonists, calcium,
iron supplements

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19
Q

Metabolic examples

Constipation

A

Dehydration, hypercalcaemia, hypokalaemia, uraemia,
hypothyroidism, diabetes mellitus

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20
Q

Structural examples

Constipation

A

Intestinal obstruction secondary to extrinsic/intrinsic
tumours/peritoneal disease/adhesions

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21
Q

Neurological examples

Constipation

A

Parkinson’s disease, brain tumours, spinal cord compression,
autonomic dysfunction, sacral nerve infiltration

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22
Q

Pain examples

Constipation

A

Anal fissures, haemorrhoids

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23
Q

General examples

Constipation

A

Reduced mobility, decreased food intake, general weakness

24
Q

General examples

Environmental

A

Lack of privacy or assistance with toileting

25
Consstipation Management Pharmacotherapeutic
Stimulant laxatives (e.g. Senna, Bisacodyl[Dulcolax]) Osmotic laxatives (e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG) Bulk-forming laxatives (e.g. Fybogel)
26
Stimulant laxatives (e.g. Senna, Bisacodyl[Dulcolax]) Action
Stimulates peristalsis by directly stimulating the smooth muscle of the intestine
27
Stimulant laxatives (e.g. Senna, Bisacodyl[Dulcolax]) Precautions
Unsuitable for patients with complete bowel obstruction or with colic
28
Stimulant laxatives (e.g. Senna, Bisacodyl[Dulcolax]) Adverse effects
Dehydration, colic
29
Osmotic laxatives (e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG) Action
Draws fluid into bowel by osmosis, softens faeces and stimulates peristalsis
30
Osmotic laxatives (e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG) Precaution
Patient must drink fluids
31
Osmotic laxatives (e.g. Lactulose, Macrogol (Forlax), Polyethylene glycol (PEG) Adverse effects
Colic, flatulence, dehydration and electrolyte imbalance in debilitated patients
32
Constipation Management Non-pharmacotherapeutic
* Ensure adequate fluid intake – Increase intake of high-water content foods such as soups, yoghurt and jelly * Encourage mobility * Encourage toileting in the morning after breakfast * Maintain privacy and avoid bedpans, if possible
33
Diarrhea
Definition Passage of > 3 episodes of unformed stools in a day.
33
Grade 1 Diarrhea
Increase < 4 stool episodes compared to pre-treatment
33
Grade 2 Diarrhea
Increase in 4-6 episodes
34
Grade 3 Diarrhea
Increase in >6 episodes
35
Grade 4 Diarrhea
Increase in >10 episodes
36
Causes of diarrhea
First step is to exclude “Spurious/Overflow Diarrhea”, either from laxative over-use, constipation of fecal impaction.
37
General Causes of diarrhea
Gastroenteritis Immunocompromised, receive multiple broad-spectrum antibiotics Enteral feeding - Due to high osmotic content, rapid or high-volume feeding, hypoalbuminaemia * Tumour related - Rectal, pancreatic cancer
38
Treatment-related causes
Chemotherapy Radiotherapy Post surgical/post procedural
39
Management Pharmacotherapeutic Diarrhea
Loperamide 2-4mg tds (maximum 16mg/day) Hyoscine Butylbromide (Buscopan) Codeine Phosphate * Avoid Lomotil (Diphenoxylate/ Atropine) in elderly as Atropine can cause delirium.
40
Management Non-pharmacotherapeutic Diarrhea
Exclude spurious diarrhea Non-milk diet Oral rehydration salt or isotonic drinks Replace electrolytes lost due to hyponatremia or hypokalemia Prevent pressure injury with barrier cream, pressure relief mattresses and regular turning
41
Delirium definition
Acute deterioration in cognitive function accompanied by fluctuations in conscious level leading to disorientation and confusion * 3 clinical subtypes: * Hypoactive- characterized by confusion and somnolence. * Hyperactive- associated with hypervigilance, restlessness and agitation. * Mixed-alternating features of hypoactive and hyperactive delirium
42
Hypoactive delirium
* Hypoactive- characterized by confusion and somnolence.
43
Hyperactive delirium
* Hyperactive- associated with hypervigilance, restlessness and agitation.
44
Assessment of delirium
Confusion assessment method (CAM) * Acute onset and fluctuating course * Inattention - Difficulty focusing attention * Clouded consciousness - Ranging from hyper-awake to sleepy * Disorganised thinking - Rambling/irrelevant/incoherent conversation
45
Causes of delirium Drug
Anti-cholinergic drugs Steroids Opioids Tricyclic Antidepressants (TCA)
46
Causes of delirium Electrolytes
* Hypercalcemia * Hypoglycaemia * Hypernatremia * Hyponatremia
47
Causes of delirium Lung/Liver
Pneumonia Pulmonary embolism Hepatic Encephalopathy
48
Causes of delirium Infections
Consider possible infection sites
49
Causes of delirium Retention/Restraint
Urinary retention Fecal impaction Use of restraint
50
Causes of delirium Intracranial
Brain metastasis Stroke Seizures
51
Causes of delirium U
Uraemia
52
Management of delirium
Treat any potentially reversible cause(s), if appropriate Optimise pain control Pharmacotherapeutic management Non- pharmacotherapeutic management
53
Pharmacotherapeutic management of Delirium
First Line * Haloperidol (drops/tablets) 0.5-1.5mg tds * Risperidone (drops/tablets) 0.5-1.0mg tds (for patients with Parkinson’s disease or those developed extra-pyramidal side effects with Haloperidol) Second Line * If patient is still agitated despite the above, consider: * Switching from Haloperidol to oral or sublingual Olanzepine 2.5mg od- tds * Chlorpromazine 12.5-50mg on
54
Management of the confused and agitated patient
- Subcutaneous Haloperidol 1.0-2.5mg stat. - May need subcutaneous Midazolam 1.0-2.5mg p.r.n., if patient is very restless and uncooperative
55
Management of the confused and agitated patient Non-pharmacotherapeutic management
Frequent reorientation Providing a calm environment that avoids both sensory deprivation and overstimulation Using clear verbal instructions Providing emotional support Avoiding 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 or avoiding intravenous or urinary catheters Minimise room and staff changes Request that family members bring in familiar items and sit with the patient

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