درمان مراقبتی جسمی در بیماران مبتلا به سرطان پیشرفته دکتر راضیه قربانی پزشک عمومی همکار تیم طب تسکینی منابع ID: 785067
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Slide1
به نام خداوند یکتا
درمان مراقبتی جسمی در بیماران مبتلا به سرطان پیشرفتهدکتر راضیه قربانیپزشک عمومی همکار تیم طب تسکینی
Slide2منابع
GUIDELINES & PROTOCOLSADVISORY COMMITTEE 2011
Slide3تنگی نفسDyspnea
Slide4تعریف:
اشکال و ناراحتی هنگام تنفس که شدت متغیر دارد و می تواند همراه با هیپوکسمی ، تاکی پنه یا ارتوپنه باشد یا نباشد.در 80 درصد بیماران با سرطان پیشرفته اتفاق می افتد.
Slide5ارزیابی تنگی نفس
از بیمار بخواهید که شدت تنگی نفس خود را تعیین کند (نمره 1 تا 10)علل زمینه ای را مشخص کنید و در صورت نیاز درمان نمایید. (مثل آنمی ، آریتمی ، آمبولی ریه، اضطراب ...)در دو سوم موارد شرح حال و معاینه فیزیکی منجر به تشخیص درست می شود.آزمایشات : CBC/diff, electrolytes,
creatinine
,
oximetry
+/- ABGs and pulmonary function, ECG
تصویر برداری :
Chest X-ray and CT scan
Slide6استراتژی های درمانی
اثر اپیویید ها برای درمان علامتی تنگی نفس اثبات شده است.دوز درمانی استفاده شده در درمان تنگی نفس (morphine 2.5-5 mg PO (SC dose is half the PO dose) q4h) ریت تنفسی و میزان اکسیژن خون را کاهش نمی دهد.اکسیژن برای رفع هیپوکسمی مفید است.کنترل موفق تنگی نفس رنج بیمار را کاهش می دهد و کیفیت زندگی او را ارتقا می دهد.
درمانهای غیر دارویی شامل آموزش و اقدامات حمایتی همیشه مهم هستند.
درمانهای دارویی :
Opioids, +/- benzodiazepines or neuroleptics, +/-
steroids
Slide7درمانهای غیر دارویی و اقدامات حمایتی
جریان هوا (fan) / هوای مطبوعحالت خوابیدن بیمارکم کردن لباس ها و استفاده از لباس گشادآرام سازی (Relaxation)
کنترل تنفس
ذخیره انرژی
Slide8What can be done? Sit in a chair or
recliner
Elevate your head
on pillows when lying in
bed
Sit with your hands on your knees or on the side of the bed leaning over the bedside
table
Practice
pursed lip breathing technique
. Take slow, deep breaths, breathing in (inhale) through nose and then breathe out (exhale) slowly and gently through pursed lips (lips that are “puckered” as if you were going to whistle)
Increase air movement by
opening a window, using a fan or air conditioner
. Apply a
cool cloth to your head or neck
Use oxygen as directed by your healthcare provider
Take medication as directed by your doctor Keep your environment quiet to decrease feelings of anxiety Use relaxing activities such as prayer, medication, calming music, and massage Notify the team if your shortness of breath is not relieved or gets
Slide9اقدام آخر در موارد تنگی نفس که به درمان های دارویی وغیر دارویی پاسخ نمی دهند :
مشاوره با متخصص طب تسکینی
Palliative Sedation
Slide10یبوستConstipation
Slide11ارزیابی یبوست
عادات اجابت مزاج بیمار قبل از بیماری و در حال حاضر چگونه است.هدف راحتی دفع و تعداد دفعات دفع مناسب است.تا زمانی که ناراحتی برای بیمار وجود نداشته باشد کاهش دفعات دفع در بیمارانی که دریافت غذا و فعالیت کمتری دارند قابل قبول است.
Slide12Constipation Management Strategies
علل مختلفی وجود دارد مثل کاهش دریافت غذا ، مایعات و حرکت و عوارض داروهااز مداخلاتی مثل انما و شیاف بپرهیزید. این مداخلات در بیماران نوتروپنیک یا ترومبوسیتوپنیک یا هنگامی که بیماری رکتال وجود دارد کنتراندیکه هستند.
Fecal Impaction
با انجام معاینه و عکس ساده شکم بررسی می شود.
زمانی که ریسک فاکتورها وجود دارند از ملین ها به صورت مداوم استفاده کنید. اثر ملین ها زمانی که بر طبق پاسخ افزایش دوز داشته باشند بیشترین مقدار است (
Bowel Protocol
)
برای پیشگیری و درمان داروی
Sennosides
خط اول درمان است.
لاکتولوز که یک ملین اسموتیک است مزه ناخوشایندی دارد و نفخ ایجاد می کند.
برای بیماران با یبوست ناشی از اپیویید ، بعد از خط اول درمان و ملین های اسموتیک ، متیل نالتروکسان کمک کننده است.
Slide13Slide14What can be done?
Record when the bowel movements have occurred.Follow a regular bowel regimen, even if you are not constipated (many medications can cause constipation) Drink as much fluid (liquids) as is comfortable.
Drinking warm liquids
may promote bowel movement
Eat more
fruits and fruit juices
, including prunes and prune juice
Increase physical activity if possible.
Walking
can be beneficial
Take laxatives/stool softeners as ordered by healthcare provider
Sit upright
on toilet, commode or bedpan
Establish
routine times
for toileting
Avoid bulk laxatives if not taking enough fluids
Notify hospice/palliative care team if constipation continues
Slide15دلیریوم
Slide16What
is delirium?A sudden change in a person’s metal status over a period of hours to daysMental clouding with less awareness of one’s environmentConfusion about time, place and person
Slide17What are the signs and symptoms of delirium?
Reversal of sleep and awake cycles “Sundowning” or confusion that is worse at nightMood swings that may change over the course of a dayDifficulty focusing attention or shifting attention
Hallucinations
or seeing, hearing or feeling things which are not there
Agitation
and irritability
Drowsiness
and sluggishnessMay be restless and anxious
Slide18What can be done for delirium?
Delirium is common at the end-of-life.Keep the patient safeRemind the patient who you are when you assist with caregiving. Tell them what you are going to do. For example, “I am going to help you get out of bed now”Offering
support
such as “I am right here with you”
Try
to maintain a routine and structure
Avoid
asking a lot of questions
Provide a quiet, peaceful setting, without TV and loud noises
Play
the patient’s favorite music
Keep
a
nightlight on at night
If
starting a new medication, watch for improvement, worsening or side effects and report to healthcare provider
Slide19Pharmacological Treatments
in hypoactive patientsAVOID sedativesHaloperidol: minimum effective dose to control hallucinations
Slide20Pharmacological Treatmentsin Hyperactive (agitated) patient
Antipsychotic Start with least sedating most sedating until agitation controlledhaloperidol
risperidone
loxapine
olanzapine
quetiapine
methotrimeprazine
AVOID
benzodiazepines
Reassess
frequently
Slide21خستگی و ضعف
Although most cancer patients report that fatigue is a major obstacle to maintaining normal daily activities and quality of life, it is seldom assessed
and
treated
in clinical practice
.
Fatigue is
a highly prevalent condition among cancer
patients
.
Slide22What is fatigue?
Tiredness, exhaustion, or lack of energy not relieved by restA condition which impacts your ability to perform your usual or expected activitiesSeen frequently in hospice and palliative care patientsA complicated symptom which can have many causes including disease
,
emotional
state, and
treatments
Sometimes
comes with depressed feelings
Slide23What are the signs of fatigue?
“Just too tired” to perform your normal activities or routinesLack of appetite or not having energy to eatSleepinessNot
talking
Depression
Slide24Cancer-related fatigue can be an expression of (pre-existing) depression and
can also be a cause of depression.
The two-question test consists of the following questions:
“
In the last month, have you often felt
dejected, sad, depressed, or hopeless
?”
“
In the last month, have you gotten
much less pleasure than usual out of
the
things
that you normally like to do
?”
Slide25Fatigue Assessment
درمان علل برگشت پذیر خستگیAnemiaDehydrationHypokalemiaHyponatremiaHypomagnesemiaHypo/HypercalcemiaHypothyroidismMedication induced
Alcohol/drug abuse
Infection
Sleep disorder
Obstructive Sleep Apnea
Chronic Fatigue Syndrome
Slide26Non-pharmacological Treatments
Gradually increase your activity. Do so gradually in order to conserve energyKeep a log of which time of day seems to be your best timePlan, schedule and
prioritize activities
at optimal times of the day
Eliminate
or postpone activities that are not your priority
Change
your position and
do not just stay in bedUse sunlight
or a light source to cue the body to feel energized
Try
activities that
restore your energy
, such as music, or spending time outdoors in nature or meditation
Allow
caregivers to assist you
with daily activities such as eating, moving or bathing if necessary. Plan activities ahead of time
Encourage
your family to be
accepting
of your new energy pace
Slide27Rest and sleep better
Listen to your body – rest as neededEstablish and continue a regular bedtime and awakeningAvoid interrupted sleep time and try to get continuous hours of sleepPlan
rest times or
naps during the day
late morning and mid afternoon
Avoid
sleeping later in the afternoon which could interrupt your night time sleep
Ask
if using oxygen when you sleep will help you to sleep better
Slide28Increase food intake
Try nutritious, high protein foodSmall frequent mealsAdd protein supplements to foods or drinksFrequent mouth care (before and after meals)Ask about possible use of medications to stimulate your appetite or relieve
fatigue
Slide29Contraindications to exercise in
patients with cancerAbsolute contraindications
– acute illnesses
– acute worsening or decompensation of
chronic
illness
– fever above 38°C
– pain
– inadequately controlled arterial hypertension
Relative
contraindications
– anemia (hemoglobin below 8 g/
dL
)
– thrombocytopenia, coagulopathy
– bone metastases
– accompanying illnesses such as coronary
heart
disease
, occlusive peripheral arterial disease,
arterial
hypertension, diabetes mellitus, arthrosis
– administration of cytostatic agents on the same day– mediastinal/cardiac radiation therapy– flu-like symptoms under immunotherapy– epilepsy
Slide30درمان های دارویی
Hematopoietic growth factorsPsychostimulants : متیل فنیدیت CorticosteroidsThyreoliberin (TRH
)
Phytotherapeutic
agents
(
Ginseng
)
استفاده از آنتی دپرسانت ها در مطالعات بالینی بهبودی در علائم خستگی ناشی از سرطان نشان نداده است.
Slide31افسردگی
Depression occurs in 13-26% of patients with terminal illnessPatients are at high risk of suicide and have an increased desire for hastened deathA useful depression screening question is, “
Have you been depressed most of the time for the past two weeks
?”
A diagnosis of depression in the terminally ill may be made when at least two weeks of depressed mood is accompanied by symptoms of hopelessness, helplessness, worthlessness, guilt, lack of reactivity, or suicidal
ideation
Slide32Risk factors
personal or family history of depression, social isolation, concurrent illnesses (e.g., COPD, CHF), alcohol or substance abuse, poorly controlled pain,
advanced
stage of illness, certain cancers (head and neck, pancreas, primary or metastatic brain cancers),
chemotherapy
agents (vincristine, vinblastine, asparagines, intrathecal methotrexate, interferon, interleukin),
corticosteroids
(especially after withdrawal),
abrupt
onset of menopause (e.g. withdrawal of hormone replacement therapy, use of tamoxifen).
Slide33Management Strategies
Non-pharmacological treatments are the mainstay of treatment for the symptom of depression without a diagnosis of primary affective disorderTreatment of pain and other reversible physical symptoms should occur before initiating antidepressant medication.
Slide34Non-pharmacological Treatment for Depression
• Exercise, rest, nutrition, social and spiritual support• Psychotherapy• Cognitive Behavioural Therapy
Slide35What can be done for depression?
You may: Optimize physical status with rest and nutrition Set small, realistic, achievable goals
Utilize
relaxation techniques
Consider
complementary therapies
such as aromatherapy, art and music therapy
Your caregiver may:
Keep you and your area
safe
Let you know that they will be there
Allow you to
express feelings
Allow you to control as much as possible related to treatment decisions and activities
Slide36Edema (Swelling)
Puffiness or swelling of legs, ankles, feet, arms, face, or handsClothes, shoes, rings, or watches that feel too tightSkin that is shiny, feels tight, indents or dimples when pressedSudden weight gain
Slide37What can you do for the patient to prevent and treat edema?
Elevate the affected area when sitting or lying downRemind them to avoid crossing legs when sitting, and avoid standing for long periodsTeach correct application and care if compression stockings
(support stockings) are worn
Encourage
limiting their intake of salt and sodium
Slide38How you can support the family
Inform the family that they play an important role in managing the edemaReinforce that sometimes edema may not go awayReinforce that the goal is patient comfort and edema may not be painful
Teach
them how to elevate affected area (For example:
use of pillows
, recliner, and/or
propping feet on a stool
)
Let the family know that if moving the affected area appears to
cause pain
, tell the interdisciplinary team
Slide39Seizures
The person having a seizure may have some or none of these signs.Muscle jerking/twitching (convulsion)Stiffening of the bodyUnable to awaken for a period of timeLoss of bladder controlBlurred
vision, eyes rolling back, blank staring or blinking
Inability
to speak, difficulty talking
Sudden
confusion or memory loss
Recurring
movements – chewing, lip smacking, clapping
Slide40What can you do for the patient?
If you are with a patient who is having a seizure it is important to keep in mind that safety is the first concern
Slide41How can you support the family?
Remain with the patient throughout the seizureEncourage the family to remain calmFamily members may believe the patient will “swallow” his/her tongue. This is not possible, though the tongue may “relax” in the pack of the throat causing the airway to be obstructed. If it is determined the patient is not breathing after a seizure, reposition his/her head to open the airway and administer breaths if necessaryDiscourage
the family from restraining the patient or placing anything in his/her mouth, which could cause injury to the patient or family member
Family
members may have been instructed by a nurse or doctor to administrate certain
anti-seizure or sedating drugs
during the seizure
Contact
the hospice or palliative care nurse if you have any questions or concerns
Slide42Self-Care for the Caregiver
Physical needsRemember to take care of your own healthKeep your own doctor appointmentsSchedule time to eat. Have at least 3 healthy but simple meals a dayLearn
to make meals in advance. Ask friends/family if they could help with making meals
Ask
how best to provide care to your loved one and prevent injuring yourself
Take
time to rest
, especially if sleeping has become hard for your
Avoid/limit
the use of tobacco and alcohol
as they make it difficult to fall asleep
Try
to get
some form of exercise in the day
Take
time alone
. This can include walking, reading, listening to music, baths, praying, gardening,
etc.
Slide43Communication needs
Tell people about your worries. These people may be family, friends, or some of the healthcare providers working with you to help care for your loved oneBe informed! Ask what signs and symptoms to expect from the patient so that you are prepared to deal with themGet
organized and set realistic goals for your day
. Keep it real and be flexible. Set limits
Ask
others to help
with whatever you or your loved one
needs
Slide44Emotional/spiritual needs
Keep relationships with family and friends to avoid feeling alone. If it is difficult for you to get out, ask people to come visit. Let people take care of you and allow your loved one to say thank you for all you doWork with your team to provide time to get out of the home to enjoy social activities or attend support groups
. When possible, keep doing favorite activities. Try to keep things simple
Talk
about your fears about what is happening to your loved one. Also,
talk about any concerns or frustrations you may have
Even
though you are feeling stressed
, tell yourself every day you are doing a great job
Let
your hospice/palliative staff know if you are feeling overwhelmed. Your team has ways to help, including nursing assistants and other resources
Attend
to your spiritual needs by calling or visiting your clergy, church or synagogue
Have
your own “special space.” This can be your room, a chair, a table, etc. Someplace that is yours where you can go unwind
Seek
additional professional help if you are feeling scared, helpless, lost, or depressed
Breathe
and laugh