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به نام خداوند یکتا به نام خداوند یکتا

به نام خداوند یکتا - PowerPoint Presentation

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به نام خداوند یکتا - PPT Presentation

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

Slide2

منابع

GUIDELINES & PROTOCOLSADVISORY COMMITTEE 2011

Slide3

تنگی نفسDyspnea

Slide4

تعریف:

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.

Slide5

ارزیابی 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

Slide6

استراتژی 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

Slide7

درمانهای 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

Slide8

What 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

Slide9

اقدام آخر در موارد تنگی نفس که به درمان های دارویی وغیر دارویی پاسخ نمی دهند :

مشاوره با متخصص طب تسکینی

Palliative Sedation

Slide10

یبوستConstipation

Slide11

ارزیابی 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.

Slide12

Constipation 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.

Slide13

Slide14

What 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

Slide15

دلیریوم

Slide16

What

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

Slide17

What 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

Slide18

What 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

Slide19

Pharmacological Treatments

in hypoactive patientsAVOID sedativesHaloperidol: minimum effective dose to control hallucinations

Slide20

Pharmacological Treatmentsin Hyperactive (agitated) patient

Antipsychotic Start with least sedating most sedating until agitation controlledhaloperidol

risperidone

loxapine

olanzapine

quetiapine

methotrimeprazine

AVOID

benzodiazepines

Reassess

frequently

Slide21

خستگی 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

.

Slide22

What 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

Slide23

What 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

Slide24

Cancer-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

?”

Slide25

Fatigue Assessment

درمان علل برگشت پذیر خستگیAnemiaDehydrationHypokalemiaHyponatremiaHypomagnesemiaHypo/HypercalcemiaHypothyroidismMedication induced

Alcohol/drug abuse

Infection

Sleep disorder

Obstructive Sleep Apnea

Chronic Fatigue Syndrome

Slide26

Non-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

Slide27

Rest 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

Slide28

Increase 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

Slide29

Contraindications 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

Slide30

درمان 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.

Slide31

افسردگی

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

Slide32

Risk 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).

Slide33

Management 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.

Slide34

Non-pharmacological Treatment for Depression

• Exercise, rest, nutrition, social and spiritual support• Psychotherapy• Cognitive Behavioural Therapy

Slide35

What 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

Slide36

Edema (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

Slide37

What 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

Slide38

How 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

Slide39

Seizures

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

Slide40

What 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

Slide41

How 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

Slide42

Self-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.

Slide43

Communication 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

Slide44

Emotional/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