Suppportive Care in Oncology Flashcards
(71 cards)
1
Q
Common symptoms in advanced cancer (9)
A
- Constipation
- Intestinal obstruction
- Diarrhoea
- Dyspnoea
- Nausea & Vomiting
- Depression
- Xerostomia
- Delirium
- Pruritis
2
Q
Constipation symptoms
A
- unable to move bowels
- having to push harder to move bowels (straining)
- moving them less often than usual
- faeces small, dry and hard
3
Q
Constipation causes (3)
A
- Disease-related
- immobility
- tumour invasion leading to obstruction - Fluid depletion
- Medication
- opioids
- calcium
- iron
4
Q
Constipation complications (3)
A
- Colic or constant abdominal discomfort
- Intestinal obstruction
- Confusion or restlessness if severe
5
Q
Before prescribing laxatives for constipation,
2
A
- Rule out obstruction
- Consider underlying causes
eg drugs
6
Q
Laxatives for constipation (3)
A
- Bulk forming
- fybogel
- not usually in palliative care - Stimulant laxatives
- senna
- bisacodyl - Osmotic laxatives
- lactulose
- phosphate enema
- forlax
7
Q
Precaution/advice for patients taking bulk forming & osmotic laxatives
A
Drink extra fluids
8
Q
Laxatives not suitable for intestinal obstruction (2)
A
- Bulk forming
- Stimulant laxatives
- esp complete obstruction cos increase cramping pains
9
Q
Rectal examination
A
Is rectum impacted or empty?
- If rectum is impacted, is stool hard or soft?
- If rectum is empty, is it “ballooned”/dilated or non-dilated?
10
Q
Treatment for
- Impacted rectum
- Soft stool
A
- Use rectal stimulant
- biscodyl suppositories
- phosphate enema - If still no defecation, increase oral stimulant or softener
11
Q
Treatment for
- Impacted rectum
- Hard stool
A
- Lubricate with glycerin suppositories or soften with olive oil enema
- If still no defecation, increase oral stimulant or softener
12
Q
Treatment for
- Empty rectum
- non-dilated
A
- exclude intestinal obstruction
- ensure patient is on regular laxatives
- consider additional laxatives when necessary
13
Q
Treatment for
- Empty rectum
- dilated / “ballooned”
A
- suggests constipation higher up
- give high fleet enema over several days until constipation resolves
- if colic present, reduce any stimulant laxatives & add softener or osmotic agents
- if colic absent, increase stimulant laxatives
14
Q
Why reduce dose of stimulant laxatives when colic present?
A
- reduce cramping pains for the patient
15
Q
Should preventive treatment for constipation be use before symptoms present?
A
Yes
Check for any possible risk of constipation, if present then introduce laxatives to patient’s regimen
eg opioids use
16
Q
Intestinal Obstruction classifications (I/O) (3)
A
- upper vs lower GI I/O
- mechanical vs functional (ileus)
- complete vs incomplete
17
Q
Upper GI I/O symptoms
- vomiting
- abdominal distension
- constipation
- anorexia
A
Vomiting : large volume, bilious
Abdominal distension : may be absent
Constipation : late feature
Anorexia : early feature
18
Q
Lower GI I/O symptoms
- vomiting
- abdominal distension
- constipation
- anorexia
A
Vomiting : small volume, faeculent
Abdominal distension : present
Constipation : early feature
Anorexia : late feature
19
Q
General treatment for I/O (3)
A
Reversing obstruction if possible & relief symptoms
- Gut rest
- NBM (nth by mouth)
- IV hydration
20
Q
Management of I/O (operable)
A
- consider surgery to remove the hard stools
21
Q
Management of I/O (not operable)
A
- stenting
- trial of steroids (reduce peritumoral oedema & improve intestinal transit)
22
Q
Contraindications for stenting (2)
A
- Multiple levels of obstruction
2. Rectal tumours (risk of stent migration)
23
Q
Complete I/O treatment
- pain (2)
- n/v (3)
A
- pain relief with morphine +/- anticholinergics (eg hyoscine)
- n/v relief with haloperidol, octreotide or NGT suction
- avoid prokinetics eg metocleopramide
24
Q
Incomplete I/O treatment (4)
- pain
- n/v
- bowel
A
- pain relief with fentanyl (less constipation)
- buscopan if pain not relief (laxative > stimulant to reduce pain)
- n/v relief with metocleopramide
- clear bowels using high fleet/lactulose
25
Dietary advice for patients prone to I/O or gastric outlet obstruction (3)
- low residue & fibre diet
- limit fat intake (fat increase stool bulk)
- avoid tough fibrous meats
Reduce potential obstruction which can aggravate I/O
26
Bristol Stool Form Scale
Type 1-7
| - increasing watery & looseness
27
Diarrhoea symptoms (2)
- loose or watery stools
| - more than 3 unformed stools within 24h
28
Diarrhoea causes (3)
1. Medications (eg irinotecan, laxatives)
2. Diets
- spicy
- alcohol
- fruits (fibrous)
3. Treatment (RT & chemotherapy)
29
Before prescribing for diarrhoea, (2)
1. Rule out fecal impaction, intestinal obstruction & infective causes
2. Consider underlying causes
eg medications, diets
30
Diarrhoea management (4)
1. Diphenoxylate/atropine
- not to use if liver impairment
2. Loperamide HCl
3. Codeine phosphate
- with pain
4. Octreotide
- tumour secretions
31
CI for codeine phosphates (3)
- Asthma
- COPD
- hepatic/renal disease
32
CI for diphenoxylate/atropine
Liver diseases
33
Dietary advice for patients with diarrhoea (6)
- eat small but frequent meals
- eat low fibre diets
- maintain sufficient fluid intake (2L)
- avoid coffee, tea, milk, alcohol & sweets
- avoid greasy foods
- gradually reintroduce proteins then fats as diarrhoea resolves
34
Dyspnoa
- subjective experience of breathing discomfort
35
Principles of management of dyspnoea (2)
- treat reversible
| - non-drug measures are essential but as illness progress, medication become alot more necessary
36
Management of dyspnoea (5)
1. Oxygen therapy
- SpO2 <90% (hypoxic)
2. Opioids
- SOB at rest/minimal exertion
eg morphine, fentanyl (if patient have renal impairment)
3. Steroids
- reduce peri-tumoral edema
eg dexamethasone
4. Anxiolytics
eg lorazepam & midazolam
eg escitalopram (antidepressants if longer prognosis)
5. Secretions treatment
- nebulised NaCl 0.9% (loosen secretion)
- anticholinergics (buscopan)
- suction (distressing)
37
Advice for patients with dyspnoea (5)
1. Break tasks into smaller bits & use aid when necessary
2. Breathing techniques
3. Find comfortable positions
4. Open windows to allow ventilation/fans for non-hypoxic patients
5. Use of opioids prior to major movements/tasks for prevention
38
Nausea definition
- subjectively unpleasant sensation associated with flushing, tachycardia and an awareness of the urge to vomit
39
Retching definition
- involves spasmodic contractions of the diaphragm, thoracic & abdominal walls muscles without expulsion of gastric contents
40
Vomiting/emesis
- expulsion of stomach contents from mouth
41
Before prescribing for n/v,
- exclude regurgitation (different approach)
42
Management of n/v (7)
1. Domperidone (prokinetic)
2. Metoclopramide (prokinetic)
3. Haloperidol
4. Olanzapine
5. Ondansetron (5-HT antagonist)
6. Buclizine (antihistamine)
7. Mirtazapine (NaSSAntagonist)
43
Advice for n/v (5)
- eat small but frequent meals
- rinse mouth before eating (1 tsp of baking soda/sodium bicarb) to remove bad taste
- candies (lemon & peppermints)
- drink clear liquids as often as possible to prevent dehydration
- ensure nutritional status
44
Colicky pain after prokinetics
Suggests intestinal obstruction
45
Depression symptoms
InSADCAGES
- interest
- sleep
- appetite
- depressed
- concentration
- activity
- guilt
- energy
- suicidal
In & D
46
What type of antidepressant to use? (2)
- all antidepressants have similar efficacy
| - consider side effect profile & any comorbidity to indicate what type of antidepressant to use
47
Bupropion
- CI
- benefit
CI :
- seizures
- eating disorders
- psychosis
Benefit :
- no sexual dysfunction
48
Mirtazapine
- disadvantages
- benefit
Disadvantages :
- weight gain (due to increased appetite)
- sedation
Benefit :
- no sexual dysfunction
49
Duloxetine
SNRI
Benefit :
- diabetic neuropathic pain
- fibromyalgia
- chronic musculoskeletal pain
50
Venlafaxine
Disadvantage :
| - worsens HTN
51
Xerostomia symptoms
- dryness of the mouth
- altered salivation
- need to expectorate frequently or manually remove thick saliva
52
Management of xerostomia (8)
1. Frequent oral rinses or sips of water/juices
2. Mouth care before & after meals & at bedtimes
3. Soft & moist foods > dry & sticky foods
4. Increase fluid intake during meals
- avoid alcohol & carbonated drinks
5. Suck on sugarless candies
6. Lubricate oral cavity
- olive oil
- butter
7. Apply lip moisturiser to prevent drying/chapping of lips
8. Medications to promote saliva production
- pilocarpine
53
Delirium symptoms (4)
- disturbed consciousness
- inattention / terminal restlessness
- cognitive impairment / confusional state
- agitation
54
Assessment tools for delirium (2)
1. Mini Mental State Examinations (MMSE)
| 2. Confusional Assessment Method (CAM)
55
Causes of delirium (5)
```
1. Infection
eg UTI
2. Drug induced
eg opioid toxicity, corticosteroids
3. Constipation, urinary retention or catheter problems
4. Sensory impairment
5. Dehydration
```
56
Management of delirium (3)
```
First line : Haloperidol
Second line : Benzodiazepines
- lorazepam
- midazolam
- does not improve cognition but help with anxiety to calm patient down
```
Increase fluid intakes
57
Pruritis symptoms (2)
- persistent scratching leading to skin damage, excoriation & thickening
- dry skin
58
Management of pruritis (4)
1. Emollients
- ointments > creams for dry skin
- use emollient to bath water & soap substitute
2. Avoid topical antihistamines
- cause allergic dermatitis
3. Reserve systemic medication if topical therapy (skin care) doesn't improve symptoms
4. Avoid caffeine, alcohol, spices & hot water
59
Cholestasis pruritis treatment (3)
RSC
1. Rifampicin
2. Sertraline
3. Cholestyramine
60
Uremia pruritis treatment (1)
UG
Gabapentin
- renal dose adjustment req
61
Lymphoma pruritis treatment (1)
Prednisolone
62
Systemic opioids-induced pruritis (1)
Chlorpheniramine
63
Paraneoplastic pruritis treatment (1)
PP
Paroxetine
64
Unknown reason for pruritis
Chlorpheniramine
65
Buscospan uses (2)
- relieve pain from intestinal cramps
| - decrease respiratory secretions
66
Treatment of N/V from drugs (2)
- metoclopramide
| - haloperidol
67
N/V from motility disorder (2)
- metoclopramide
| - domperidone
68
N/V from :
- intracranial disorders
eg vestibular dysfunction
- oral pharyngeal irritation
(2)
1. Anticholinergics
- hyoscine
2. Antihistamines
- buclizine
69
Assessing patients with depression
- rule out medical / drug-induced cause
70
Advice for patients taking anti-depressants (3)
- adverse effect can occur immediately
- anti-depressant effect may take place 2-4 weeks or even longer
- need to adhere to treatment plan
71
Drugs that can cause delirium (2)
- opioids toxicity
| - corticosteroids
