pain%20management_merged.BDFGBSDFGDFH Hpdf
AmranOdeh
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Oct 02, 2024
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About This Presentation
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Slide Content
1
Pain
Management
Khalid Ali Alfaqih., RN, MSN, ONS.
Pain
Management
Khalid Ali Alfaqih., RN, MSN, ONS.
2
What is Pain?
•Highly personal.
•Highly subjective.
•Is the “Fifth Vital Sign”.
•“ Pain is whatever the client says it is,
existing whenever the client says it does”
What is Pain?
•Highly personal.
•Highly subjective.
•Is the “Fifth Vital Sign”.
•“ Pain is whatever the client says it is,
existing whenever the client says it does”
Pain
•Pain is the most feared consequence by
patients with cancer.
•"Pain is an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage."
TheInternational Association for the Study of Pain(IASP)
3
•Pain is the most feared consequence by
patients with cancer.
•"Pain is an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage."
TheInternational Association for the Study of Pain(IASP)
3
Epidemiology and Statistics of
cancer pain
•According to the International Association
for the Study of Pain (IASP), pain occurs
in as many as 50% of patients with cancer
undergoing treatment for their disease.
•30%-50% of those in active therapy
•75%-90% of those with advanced disease
•Cancer pain is highly prevalent
•more than 70% of patients experience
pain towards the end of life.
4
cancer pain
•According to the International Association
for the Study of Pain (IASP), pain occurs
in as many as 50% of patients with cancer
undergoing treatment for their disease.
•30%-50% of those in active therapy
•75%-90% of those with advanced disease
•Cancer pain is highly prevalent
•more than 70% of patients experience
pain towards the end of life.
4
•Pain is Multidimensional
•All of these dimensions of pain are important
in assessing and treating pain.
5
Dimension CharacterizedBy
Physiological Etiology of pain
Sensory Intensity, location, Quality
Affective Depression, Anxiety
Cognitive Manner in which pain influences an individual’s thought
processes, how the individual views self or the meaning of
pain
Behavioral Pain-related behaviors such as medication
intake and activity level
Sociocultural
dimensions
Which includes demographic, social, and cultural
characteristics that are related to the experience of pain
•All of these dimensions of pain are important
in assessing and treating pain.
5
Dimension CharacterizedBy
Physiological Etiology of pain
Sensory Intensity, location, Quality
Affective Depression, Anxiety
Cognitive Manner in which pain influences an individual’s thought
processes, how the individual views self or the meaning of
pain
Behavioral Pain-related behaviors such as medication
intake and activity level
Sociocultural
dimensions
Which includes demographic, social, and cultural
characteristics that are related to the experience of pain
6
Types of Pain
Categorized into:
•Acute Pain
•Chronic Pain
•Nonmalignant or
benign
•Cancer Pain
Pathophysiology:
•Nociceptive
–Somatic
–Visceral
•Neuropathic
Types of Pain
Categorized into:
•Acute Pain
•Chronic Pain
•Nonmalignant or
benign
•Cancer Pain
Pathophysiology:
•Nociceptive
–Somatic
–Visceral
•Neuropathic
7
Types of Pain: By Duration
•Acute pain is most frequently identified by suddenonset
and relative shortduration.
•Chronic Pain
–Long-term, (lasting 6 months or longer), persistent, nearly
constant, or recurrent pain
–Produces significant negative changes in client’s life
–May last long after the pathology is resolved
•Chronicnonmalignant pain occurs in persons who do not
have progressive tissue injury.
•Chronicmalignant pain occurs as a result of progressive
tissue injury as in Cancer.
Types of Pain: By Duration
•Acute pain is most frequently identified by suddenonset
and relative shortduration.
•Chronic Pain
–Long-term, (lasting 6 months or longer), persistent, nearly
constant, or recurrent pain
–Produces significant negative changes in client’s life
–May last long after the pathology is resolved
•Chronicnonmalignant pain occurs in persons who do not
have progressive tissue injury.
•Chronicmalignant pain occurs as a result of progressive
tissue injury as in Cancer.
8
Types of Pain: By Origin
•Nociceptive painis the process by which an
individual becomes consciously aware of pain.
–Somaticpain is nonlocalized and originates in
support structures. (i.e. pain in tendons, ligaments,
bone, blood vessels).
–Cutaneouspain is caused by stimulation of the
cutaneous nerve endings in the skin. (i.e. paper cut).
–Visceralpain is discomfort in the internal organs. (i.e.
bowel obstruction, throat pain)
Types of Pain: By Origin
•Nociceptive painis the process by which an
individual becomes consciously aware of pain.
–Somaticpain is nonlocalized and originates in
support structures. (i.e. pain in tendons, ligaments,
bone, blood vessels).
–Cutaneouspain is caused by stimulation of the
cutaneous nerve endings in the skin. (i.e. paper cut).
–Visceralpain is discomfort in the internal organs. (i.e.
bowel obstruction, throat pain)
9
Types of Pain: By Location
•Radiating Pain: perceived at the source of pain and
extends to nearby tissue
–Example: chest pain may radiates to arm and shoulder.
•Referred Pain: felt in part of the body that is not
causing the pain.
•Other Types of Pain:
1.Intractable Pain: highly resistant to relief like advanced cancer
pain.
2.Neuropathic Pain: results from damage to central or
peripheral nervous system and may not have stimulus. Like
nerve or tissue damage.
•Burning, numbness, radiating, shooting, stabbing, tingling, touch
sensitive, “like a fire”, electrical
3.Phantom pain: painful sensation perceived in body part that is
missing (example. Amputated leg).
Types of Pain: By Location
•Radiating Pain: perceived at the source of pain and
extends to nearby tissue
–Example: chest pain may radiates to arm and shoulder.
•Referred Pain: felt in part of the body that is not
causing the pain.
•Other Types of Pain:
1.Intractable Pain: highly resistant to relief like advanced cancer
pain.
2.Neuropathic Pain: results from damage to central or
peripheral nervous system and may not have stimulus. Like
nerve or tissue damage.
•Burning, numbness, radiating, shooting, stabbing, tingling, touch
sensitive, “like a fire”, electrical
3.Phantom pain: painful sensation perceived in body part that is
missing (example. Amputated leg).
Types of Pain
10
Type of
pain
Description Qualifiers Treatment
choice
Somati
c pain
caused by activation
of the nociceptorsin the periphery,
such as the skin, bone, muscles,
joints, or connective tissue.
•well localized
•aching, gnawing,
or throbbing pain.
•constant or
intermittent
opioids as well
as adjuvant
medications.
Viscera
l pain
caused by activation of nociceptors
in the abdominal or thoracic
cavities. It results from
compression, infiltration,
or distention of viscera
•poorly localized
pain
•dull, aching, or
cramping
opioids as well
as adjuvant
medications.
Neurop
athic
pain
pain arising as a direct
consequence of a lesion or disease
affecting the somatosensory
system
It is most.
commonly caused by compression
of a nerve by tumor or a
polyneuropathycaused by
shooting, burning,
pins and needles,
or hot or cold
sensation.
less responsive
to opioids
alone, requiring
adjuvant
Medications to
obtain adequate
control of pain
10
Type of
pain
Description Qualifiers Treatment
choice
Somati
c pain
caused by activation
of the nociceptorsin the periphery,
such as the skin, bone, muscles,
joints, or connective tissue.
•well localized
•aching, gnawing,
or throbbing pain.
•constant or
intermittent
opioids as well
as adjuvant
medications.
Viscera
l pain
caused by activation of nociceptors
in the abdominal or thoracic
cavities. It results from
compression, infiltration,
or distention of viscera
•poorly localized
pain
•dull, aching, or
cramping
opioids as well
as adjuvant
medications.
Neurop
athic
pain
pain arising as a direct
consequence of a lesion or disease
affecting the somatosensory
system
It is most.
commonly caused by compression
of a nerve by tumor or a
polyneuropathycaused by
shooting, burning,
pins and needles,
or hot or cold
sensation.
less responsive
to opioids
alone, requiring
adjuvant
Medications to
obtain adequate
control of pain
11
Nociceptive Pain
•Four principle processes are involved in nociception.
–Transduction
•involves the changing of noxious stimuli in sensory nerve endings to
energy impulses.
–Mechanical, Thermal, or Chemical
–Transmission
•involves the movement of impulses from site of origin to the brain.
–Reflex arc
–Perception
•occurs when the pain impulse has been transmitted to the cortex and the
person develops conscious awareness of the intensity, location, and
quality of pain.
–Recognition, Definition, Response
–Modulation
•refers to activation of descending neural pathways that inhibit
transmission of pain.
Nociceptive Pain
•Four principle processes are involved in nociception.
–Transduction
•involves the changing of noxious stimuli in sensory nerve endings to
energy impulses.
–Mechanical, Thermal, or Chemical
–Transmission
•involves the movement of impulses from site of origin to the brain.
–Reflex arc
–Perception
•occurs when the pain impulse has been transmitted to the cortex and the
person develops conscious awareness of the intensity, location, and
quality of pain.
–Recognition, Definition, Response
–Modulation
•refers to activation of descending neural pathways that inhibit
transmission of pain.
12
Four Processes Involved in
Nociception
•Transduction
•Transmission
•Perception
•Modulation
Four Processes Involved in
Nociception
•Transduction
•Transmission
•Perception
•Modulation
10/Jul/23 Dr. Suha Omran 13
Transmission of Pain
•Gate Control Theory of Pain
–Recognizes the psychological aspects of
pain.
–A gate control system serves to block the
individual’s perception of pain.
Transmission of Pain
•Gate Control Theory of Pain
–Recognizes the psychological aspects of
pain.
–A gate control system serves to block the
individual’s perception of pain.
14
Transmission of Pain
Transmission of Pain
15
Gate Control Theory
Gate Control Theory
16
Factors Affecting the Pain
Experience
•Cultural norms and attitudes
•Age (developmental stage) and gender
•Environment and support people
•Previous experience with pain
•Meaning of pain
•Stress, attention, and anxiety
•Fatigue
•Coping style
Factors Affecting the Pain
Experience
•Cultural norms and attitudes
•Age (developmental stage) and gender
•Environment and support people
•Previous experience with pain
•Meaning of pain
•Stress, attention, and anxiety
•Fatigue
•Coping style
17
Pain Assessment
Subjective Data
•Comprehensive pain history includes
COLDERR
–Character
–Onset
–Location
–Duration
–Exacerbation
–Relief
–Radiation
Pain Assessment
Subjective Data
•Comprehensive pain history includes
COLDERR
–Character
–Onset
–Location
–Duration
–Exacerbation
–Relief
–Radiation
18
Pain Assessment
•Data Collection: Pain
History:
–Intensity
–Location
–Quality (radiating, burning,
diffuse)
–Onset, Duration, Variations
–Type of Pain
–Associated manifestations
–Aggravating factors
–Alleviating factors
What relieves the pain?
What makes the pain
worse?
Patient’s perception of
pain
Patient’s goal for pain
relief
Analgesic history
Analgesics received in
last 24 hours
Pain Assessment
•Data Collection: Pain
History:
–Intensity
–Location
–Quality (radiating, burning,
diffuse)
–Onset, Duration, Variations
–Type of Pain
–Associated manifestations
–Aggravating factors
–Alleviating factors
What relieves the pain?
What makes the pain
worse?
Patient’s perception of
pain
Patient’s goal for pain
relief
Analgesic history
Analgesics received in
last 24 hours
Assessment of Pain
•The most common reasons for inadequate
treatment of pain:
1.lack of knowledge regarding pain.
2.lack of assessment.
19
•The most common reasons for inadequate
treatment of pain:
1.lack of knowledge regarding pain.
2.lack of assessment.
19
Barriers to Optimal Pain
Assessment
Health care system barriers
•System failure
•Lack of criteria culturally sensitive
instruments for pain assessment in health
care settings
•Lack of institutional policies for
performance and documentation of pain
assessment
20
Assessment
Health care system barriers
•System failure
•Lack of criteria culturally sensitive
instruments for pain assessment in health
care settings
•Lack of institutional policies for
performance and documentation of pain
assessment
20
Barriers to Optimal Pain
Assessment
Patient/family/societal barriers
•The highly subjective nature of the pain
experience
•Lack of patient and family awareness
•Lack of patient communication
–reluctance to report pain
–not wanting to bother staff
–fears of not being believed
–“nothing helps”
–Concern with curative therapy
–beliefs and myths about pain
21
Assessment
Patient/family/societal barriers
•The highly subjective nature of the pain
experience
•Lack of patient and family awareness
•Lack of patient communication
–reluctance to report pain
–not wanting to bother staff
–fears of not being believed
–“nothing helps”
–Concern with curative therapy
–beliefs and myths about pain
21
Barriers to Optimal Pain
Assessment
Health care professional barriers
•Lack of identification of pain assessment and relief
as a priority in patient care
•Inadequate knowledge
•Perceived lack of time
•Failure to use validated pain measurement tools
•Poor relationship with patients
•Lack of continuity of care
•Lack of communication among the health team
•Prejudice and bias in dealing with patients
22
Assessment
Health care professional barriers
•Lack of identification of pain assessment and relief
as a priority in patient care
•Inadequate knowledge
•Perceived lack of time
•Failure to use validated pain measurement tools
•Poor relationship with patients
•Lack of continuity of care
•Lack of communication among the health team
•Prejudice and bias in dealing with patients
22
23
Implementation
•Nurse-Client Relationship
–Trust
–Accept & acknowledge patient pain.
–Reduce misconception about pain and its treatment.
–Reduce fear & anxiety.
–Client Education (teach client about procedures,
anticipated discomfort)
•Individualized interventions
•Provide pre-emptive analgesia (treat pain before it
occurs).
•None-Pharmacological pain-Relief Interventions
Implementation
•Nurse-Client Relationship
–Trust
–Accept & acknowledge patient pain.
–Reduce misconception about pain and its treatment.
–Reduce fear & anxiety.
–Client Education (teach client about procedures,
anticipated discomfort)
•Individualized interventions
•Provide pre-emptive analgesia (treat pain before it
occurs).
•None-Pharmacological pain-Relief Interventions
Patterns of the pain
1.Persistent Pain : pain that is present
most of the day (≥12 hours).
•Generally managed with sustained release
opioid medication administered around the
clock (ATC) on a scheduled basis.
•This method of medication administration
avoids the peaks and valleys associated
with short-acting medications.
24
1.Persistent Pain : pain that is present
most of the day (≥12 hours).
•Generally managed with sustained release
opioid medication administered around the
clock (ATC) on a scheduled basis.
•This method of medication administration
avoids the peaks and valleys associated
with short-acting medications.
24
Patterns of the pain
2 . Breakthrough pain: transient, moderate
to severe pain.
•It occurs in patients with persistent pain
even they are taking pain medicine
regularly for persistent pain.
•Generally treated with short-acting
medications
25
2 . Breakthrough pain: transient, moderate
to severe pain.
•It occurs in patients with persistent pain
even they are taking pain medicine
regularly for persistent pain.
•Generally treated with short-acting
medications
25
26
Principles of Cancer Pain Control
•There are five principles of cancer pain
management.
•The WHO approach to pain management
has been shown to be effective in relieving
pain in 90% of patients with cancer and
75% of terminally ill cancer patients .
27
•There are five principles of cancer pain
management.
•The WHO approach to pain management
has been shown to be effective in relieving
pain in 90% of patients with cancer and
75% of terminally ill cancer patients .
27
Principles of Cancer Pain Control
1-By the mouth : Oral administration is
convenient, non invasive, cost effective
and well tolerated in most patients.
2-By the Clock : Regular analgesia (4-6
hourly) with breakthrough doses when
needed provide a more constant level of
drug in the body and reduce pain
recurrence.
28
1-By the mouth : Oral administration is
convenient, non invasive, cost effective
and well tolerated in most patients.
2-By the Clock : Regular analgesia (4-6
hourly) with breakthrough doses when
needed provide a more constant level of
drug in the body and reduce pain
recurrence.
28
Principles of Cancer Pain Control
3-By the ladder : Patients should move up the
ladder as necessary, but may also move
down the ladder if pain decreases.
4-For the individual : Patients presenting with
moderate to severe pain can be started on a
higher step in the ladder.Some patients will
not be able to tolerate oral medication and
may need other preparations.There is no
standard dose of opioid -morphine
requirements can vary from 5mg to 1000mg
every four hours.
29
3-By the ladder : Patients should move up the
ladder as necessary, but may also move
down the ladder if pain decreases.
4-For the individual : Patients presenting with
moderate to severe pain can be started on a
higher step in the ladder.Some patients will
not be able to tolerate oral medication and
may need other preparations.There is no
standard dose of opioid -morphine
requirements can vary from 5mg to 1000mg
every four hours.
29
Principles of Cancer Pain Control
5-With attention to detail :
•Total analgesia usage should be monitored
every 24 hours, and the maintenance dose
adjusted accordingly.
•Breakthrough doses should be adjusted in line
with changes to regular medication.
•New pain should be assessed promptly to
ascertain the cause and to allow treatment.
•Patients should be informed of possible adverse
drug effects.
30
5-With attention to detail :
•Total analgesia usage should be monitored
every 24 hours, and the maintenance dose
adjusted accordingly.
•Breakthrough doses should be adjusted in line
with changes to regular medication.
•New pain should be assessed promptly to
ascertain the cause and to allow treatment.
•Patients should be informed of possible adverse
drug effects.
30
Other principle
•Do not delay use of analgesics
•Do NOT use placebos
–While 30% to 70% of patients will appear to experience some
response, there is no ethical or scientific basis for the use of
placebos to assess or treat pain.
•“Four A’sin Pain management
•Analgesia (pain relief),
•Activities of Daily Living(functioning at home &
work)
•Adverse Effects(medication side effects)
•“Aberrant Behaviors” (warning signs for addiction).
31
•Do not delay use of analgesics
•Do NOT use placebos
–While 30% to 70% of patients will appear to experience some
response, there is no ethical or scientific basis for the use of
placebos to assess or treat pain.
•“Four A’sin Pain management
•Analgesia (pain relief),
•Activities of Daily Living(functioning at home &
work)
•Adverse Effects(medication side effects)
•“Aberrant Behaviors” (warning signs for addiction).
31
33
Pharmacological Interventions
•Analgesia –Types (Box):
1.Narcotic analgesic or opioids (for moderate-sever
pain).
•Meperidine (Demerol), Methylmorphine (Codeine),
Fentanyl
2.Nonnarcotic, Nonopioid, NSAIDs analgesics (for
mild-moderate pain).
•i.e. (acetaminophen (Tylenol)
•NSAIDs: Ibuprofen, Naproxen, Indomethacin
•Most common side effect is gastrointestinal upset
(indigestion, heart burn)
3.Adjuvants/coanalgesics
•Diazepam (Valium) thorazine
Pharmacological Interventions
•Analgesia –Types (Box):
1.Narcotic analgesic or opioids (for moderate-sever
pain).
•Meperidine (Demerol), Methylmorphine (Codeine),
Fentanyl
2.Nonnarcotic, Nonopioid, NSAIDs analgesics (for
mild-moderate pain).
•i.e. (acetaminophen (Tylenol)
•NSAIDs: Ibuprofen, Naproxen, Indomethacin
•Most common side effect is gastrointestinal upset
(indigestion, heart burn)
3.Adjuvants/coanalgesics
•Diazepam (Valium) thorazine
Pharmacological Pain Relief
•There are three main classes of drugs used in
the pain ladder:
1. Non Opioids:
These include simple analgesics such
asParacetamolandAspirin, as well as Non-
Steroidal Anti Inflammatory Drugs (NSAIDS)
such asIbuprofen,
KetoprofenandDiclofenac.
34
•There are three main classes of drugs used in
the pain ladder:
1. Non Opioids:
These include simple analgesics such
asParacetamolandAspirin, as well as Non-
Steroidal Anti Inflammatory Drugs (NSAIDS)
such asIbuprofen,
KetoprofenandDiclofenac.
34
Pharmacological Pain Relief
2. Opioids:
The opioids are a large group of drugs that
include codeine,tramadol,morphine
andmethadone.They play an important
role in the management of pain in a large
proportion of cancer patients.
35
2. Opioids:
The opioids are a large group of drugs that
include codeine,tramadol,morphine
andmethadone.They play an important
role in the management of pain in a large
proportion of cancer patients.
35
Pharmacological Pain Relief
3.Adjuvants= coanalgesic.
•These include analgesics for specific types of pain
•drugs that enhance the effect of other analgesics,
•drugs that help treat concurrent symptoms that exacerbate
pain.,
•Drugs potentially useful for any type of pain (multipurpose
analgesics)
•Drugs used for treatment of neuropathic pain
•Drugs used for bone pain
•Drugs used for pain and other symptoms in the setting of
bowel obstruction
36
3.Adjuvants= coanalgesic.
•These include analgesics for specific types of pain
•drugs that enhance the effect of other analgesics,
•drugs that help treat concurrent symptoms that exacerbate
pain.,
•Drugs potentially useful for any type of pain (multipurpose
analgesics)
•Drugs used for treatment of neuropathic pain
•Drugs used for bone pain
•Drugs used for pain and other symptoms in the setting of
bowel obstruction
36
37
Pharmacological Pain Relief
Non Opioids
•A useful first line of treatment is often the use of
simple analgesics and NSAIDs.
38
Non Opioids
•A useful first line of treatment is often the use of
simple analgesics and NSAIDs.
38
COX-2 inhibitors indication
•used to decrease the need for opioids
postoperatively.
•delayed and decreased the need for
rescue analgesics without significant side
effects.
•may also be used for single dose
preoperative administration. [Preemptive
analgesia]
•used to decrease the need for opioids
postoperatively.
•delayed and decreased the need for
rescue analgesics without significant side
effects.
•may also be used for single dose
preoperative administration. [Preemptive
analgesia]
Opioids principle
•Opioids are the drugs of choice for moderate
to severe pain associated with advanced
illness.
•When the pain is only mild to moderate but
expected to worsen, starting a stronger opioid
may avoid another drug switch.
•There is no ceiling or maximal recommended
dose for strong opioids. Large doses may be
needed to manage pain associated with
advanced illness
40
•Opioids are the drugs of choice for moderate
to severe pain associated with advanced
illness.
•When the pain is only mild to moderate but
expected to worsen, starting a stronger opioid
may avoid another drug switch.
•There is no ceiling or maximal recommended
dose for strong opioids. Large doses may be
needed to manage pain associated with
advanced illness
40
Opioids principle
•Use oral route whenever possible. There is
no perfect route of administration; the plan
must be individualized to the patient and the
setting.
•When writing opioid orders, remember to
order medications to cover the 3 “B’s” –
Bowels, “Barfing” (vomiting) and
Breakthrough.
•It is not recommended to administer two
different opioids (e.g., regular morphine with
codeine or hydromorphonefor
breakthrough) at the same time
41
•Use oral route whenever possible. There is
no perfect route of administration; the plan
must be individualized to the patient and the
setting.
•When writing opioid orders, remember to
order medications to cover the 3 “B’s” –
Bowels, “Barfing” (vomiting) and
Breakthrough.
•It is not recommended to administer two
different opioids (e.g., regular morphine with
codeine or hydromorphonefor
breakthrough) at the same time
41
Pharmacological Pain Relief
Opioids
•If pain persists or increases, patients move up from step
1 to step 2.They will typically continue on any NSAID /
adjuvantsalready prescribed, but should also be
commenced on a weak opioid, such as:
Codeine,DihydrocodeineorTramadol.
42
Opioids
•If pain persists or increases, patients move up from step
1 to step 2.They will typically continue on any NSAID /
adjuvantsalready prescribed, but should also be
commenced on a weak opioid, such as:
Codeine,DihydrocodeineorTramadol.
42
43
Pharmacological Interventions
•Analgesia –Types (Box):
1.Narcotic analgesic or opioids (for moderate-sever
pain).
•Meperidine (Demerol), Methylmorphine (Codeine),
Fentanyl
2.Nonnarcotic, Nonopioid, NSAIDs analgesics (for
mild-moderate pain).
•i.e. (acetaminophen (Tylenol)
•NSAIDs: Ibuprofen, Naproxen, Indomethacin
•Most common side effect is gastrointestinal upset
(indigestion, heart burn)
3.Adjuvants/coanalgesics
•Diazepam (Valium) thorazine
Pharmacological Interventions
•Analgesia –Types (Box):
1.Narcotic analgesic or opioids (for moderate-sever
pain).
•Meperidine (Demerol), Methylmorphine (Codeine),
Fentanyl
2.Nonnarcotic, Nonopioid, NSAIDs analgesics (for
mild-moderate pain).
•i.e. (acetaminophen (Tylenol)
•NSAIDs: Ibuprofen, Naproxen, Indomethacin
•Most common side effect is gastrointestinal upset
(indigestion, heart burn)
3.Adjuvants/coanalgesics
•Diazepam (Valium) thorazine
44
Patient-Controlled Analgesia
(PCA)
•Allow client to self-administer pain medications without
risk for overdose.
–Maintains constant plasma level of analgesia so PRN meds are
avoided
–Use a portable infusion pump with a button the client pushes
when need the drug
–Deliver specific number of doses per hour or several hours
•To prevent drug overdose
•Has a lock system
–Prescription: Preset dose of medication
•Loading dose
•Low-dose (basal rate)
•On-demand dose/specific time (6 minutes)
•Total hourly limit
Patient-Controlled Analgesia
(PCA)
•Allow client to self-administer pain medications without
risk for overdose.
–Maintains constant plasma level of analgesia so PRN meds are
avoided
–Use a portable infusion pump with a button the client pushes
when need the drug
–Deliver specific number of doses per hour or several hours
•To prevent drug overdose
•Has a lock system
–Prescription: Preset dose of medication
•Loading dose
•Low-dose (basal rate)
•On-demand dose/specific time (6 minutes)
•Total hourly limit
45
Pharmacological Intervention
•Local Anesthesia
•Epidural Analgesia*
–Nursing Care for client with epidural analgesia:
•Secure catheter to prevent displacement
•Check catheter site for any sign of leak or discharge, use transparent
dressing.
•Use aseptic technique in handling the catheter, change tubing Q 24
hours, do not change dressing routinely.
•Monitor VS ( respiratory rate), apnea, puls oX.
•Assess for N/V, pruritis, give antiemetics if needed.
•Maintain I/O, assess for bowel & bladder distension, discomfort and
urgency.
•Principles of Pharmacologic Pain Management
–Combine analgesics
–Maintain therapeutic serum levels
–Choose appropriate routes of administration
Pharmacological Intervention
•Local Anesthesia
•Epidural Analgesia*
–Nursing Care for client with epidural analgesia:
•Secure catheter to prevent displacement
•Check catheter site for any sign of leak or discharge, use transparent
dressing.
•Use aseptic technique in handling the catheter, change tubing Q 24
hours, do not change dressing routinely.
•Monitor VS ( respiratory rate), apnea, puls oX.
•Assess for N/V, pruritis, give antiemetics if needed.
•Maintain I/O, assess for bowel & bladder distension, discomfort and
urgency.
•Principles of Pharmacologic Pain Management
–Combine analgesics
–Maintain therapeutic serum levels
–Choose appropriate routes of administration
46
Addiction
•Primary, chronic, neurobiologic disease
•Genetic, psychosocial, and environment
are influential factors
•Behaviors can include:
–Impaired control over drug use
–Compulsive use
–Craving
–Continued use despite harm
Addiction
•Primary, chronic, neurobiologic disease
•Genetic, psychosocial, and environment
are influential factors
•Behaviors can include:
–Impaired control over drug use
–Compulsive use
–Craving
–Continued use despite harm
47
Dependence
•State of adaptation
•Manifested by withdrawal syndrome
•Produced by abrupt cessation, rapid dose
reduction, decreasing blood level of the
drug, and/or administration of an
antagonist
Dependence
•State of adaptation
•Manifested by withdrawal syndrome
•Produced by abrupt cessation, rapid dose
reduction, decreasing blood level of the
drug, and/or administration of an
antagonist
48
Tolerance
•State of adaptation
•Exposure to a drug induces changes
•Result in a diminution of one or more of
the drug’s effects over time
Tolerance
•State of adaptation
•Exposure to a drug induces changes
•Result in a diminution of one or more of
the drug’s effects over time
49
Surgical Management
•Resection of nerve endings/roots (Dorsal
Rhizotomy) as they enter the spinal cord.
–client loss sensation but maintain motor
•Chordotomy: resection of the spinothalamic tract.
–Can cause paralysis if motor nerves were accidentally
resected.
–Used to treat unrelieved pain.
•Risks of surgery: new pain from surgery, recurrence
of pain, neurologic impairment
Surgical Management
•Resection of nerve endings/roots (Dorsal
Rhizotomy) as they enter the spinal cord.
–client loss sensation but maintain motor
•Chordotomy: resection of the spinothalamic tract.
–Can cause paralysis if motor nerves were accidentally
resected.
–Used to treat unrelieved pain.
•Risks of surgery: new pain from surgery, recurrence
of pain, neurologic impairment
50
Nonpharmacologic Pain
Control Interventions
•Consists of variety of pain management
strategies
–Physical
–Cognitive-behavioral
–Lifestyle pain management
•Target body, mind, spirit, and social
interactions
Nonpharmacologic Pain
Control Interventions
•Consists of variety of pain management
strategies
–Physical
–Cognitive-behavioral
–Lifestyle pain management
•Target body, mind, spirit, and social
interactions
51
Physical Modalities
•Cutaneous
stimulation
•Immobilization or
therapeutic exercises
•Transcutaneous
electrical nerve
stimulation (TENS)
Physical Modalities
•Cutaneous
stimulation
•Immobilization or
therapeutic exercises
•Transcutaneous
electrical nerve
stimulation (TENS)
52
Cognitive-Behavioral
(Mind-Body)
•Providing comfort
•Eliciting relaxation
response
•Repatterning thinking
•Facilitating coping
with emotions
Cognitive-Behavioral
(Mind-Body)
•Providing comfort
•Eliciting relaxation
response
•Repatterning thinking
•Facilitating coping
with emotions
53
Lifestyle Management
•Stress management
•Exercise, nutrition
•Pacing activities
•Disability management
Lifestyle Management
•Stress management
•Exercise, nutrition
•Pacing activities
•Disability management
54
Spiritual
•Feel part of a community
•Bond with universe
•Religious activities
Spiritual
•Feel part of a community
•Bond with universe
•Religious activities
55
Body Interventions
•Reducing pain triggers
•Massage
•Applying heat or ice
•Electric stimulation (TENS)
•Positioning and bracing (selective immobilization)
•Acupressure
•Diet and nutritional supplements
•Exercise and pacing activities
•Invasive interventions (e.g. blocks)
•Sleep hygiene
Body Interventions
•Reducing pain triggers
•Massage
•Applying heat or ice
•Electric stimulation (TENS)
•Positioning and bracing (selective immobilization)
•Acupressure
•Diet and nutritional supplements
•Exercise and pacing activities
•Invasive interventions (e.g. blocks)
•Sleep hygiene
56
Mind Interventions
•Relaxation and imagery
•Self-hypnosis
•Pain diary and journal writing
•Distracting attention
•Re-pattern thinking
•Attitude adjustment
•Reducing fear, anxiety, stress, sadness, and
helplessness
•Providing information about pain
Mind Interventions
•Relaxation and imagery
•Self-hypnosis
•Pain diary and journal writing
•Distracting attention
•Re-pattern thinking
•Attitude adjustment
•Reducing fear, anxiety, stress, sadness, and
helplessness
•Providing information about pain
57
Spirit Interventions
•Prayer
•Meditation
•Self-reflection
•Meaningful rituals
•Energy work (therapeutic touch, Reiki)
•Spiritual healing
Spirit Interventions
•Prayer
•Meditation
•Self-reflection
•Meaningful rituals
•Energy work (therapeutic touch, Reiki)
•Spiritual healing
58
Social Interaction
•Functional restoration
•Improved communication
•Family therapy
•Problem-solving
•Vocational training
•Volunteering
•Support groups
Social Interaction
•Functional restoration
•Improved communication
•Family therapy
•Problem-solving
•Vocational training
•Volunteering
•Support groups
59
Evaluation
•Client’s facial expression and posture
•Presence (or absence) of restlessness
•Vital sign monitoring
•Ongoing use of pain assessment tool
Evaluation
•Client’s facial expression and posture
•Presence (or absence) of restlessness
•Vital sign monitoring
•Ongoing use of pain assessment tool
Khalid Ali Alfaqih, RN, MSN
Email: [email protected]
Email: [email protected]
Objectives
•To define the Palliative Care and its philosophy.
•To discuss:
- Elements, Global, & Nursing perspectives of
palliative care.
- Quality of issues, Communication skills, Home
care, & Hospice Care.
- Role of nursing in palliative care.
- Integrating of palliative care & End of life Care
into practice.
•To define the Palliative Care and its philosophy.
•To discuss:
- Elements, Global, & Nursing perspectives of
palliative care.
- Quality of issues, Communication skills, Home
care, & Hospice Care.
- Role of nursing in palliative care.
- Integrating of palliative care & End of life Care
into practice.
Reading Question
•Disease, … Poor Prognosis, … Pain,…
Suffering, … End of Life, …
(Palliative Care) )
Dying
What is Palliative care.. Its philosophy,
Principles, and Elements ??
•Disease, … Poor Prognosis, … Pain,…
Suffering, … End of Life, …
(Palliative Care) )
Dying
What is Palliative care.. Its philosophy,
Principles, and Elements ??
The spectrum of suffering in
patients with advanced disease
Symptoms Cancer % Chronic heart
failure %
COPD % AIDS %
Pain 30-94 14-78 21-77 30-98
Breathlessness 16-77 18-88 56-98 43-62
Anorexia 76-95
64-67 82
Constipation 4-64 12-42 12-44 9-35
Nausea/vomiting 2-78 2-48 4 41-57
Fatigue 23-100 42-82 32-96 43-95
Depression 4-80 56-57 17-77 17-83
Anxiety 3-74 2-49 23-53 13-76
patients with advanced disease
Symptoms Cancer % Chronic heart
failure %
COPD % AIDS %
Pain 30-94 14-78 21-77 30-98
Breathlessness 16-77 18-88 56-98 43-62
Anorexia 76-95
64-67 82
Constipation 4-64 12-42 12-44 9-35
Nausea/vomiting 2-78 2-48 4 41-57
Fatigue 23-100 42-82 32-96 43-95
Depression 4-80 56-57 17-77 17-83
Anxiety 3-74 2-49 23-53 13-76
• Palliative care interventions implemented
across a variety of settings ( out / in patient,
home and hospice ) have been shown to
significantly improve patient outcomes and
symptom control (especially pain and anxiety),
reduce acute hospital admission, and lead to
improvement in quality of life.
(Higginson and Evanse, 2010)
across a variety of settings ( out / in patient,
home and hospice ) have been shown to
significantly improve patient outcomes and
symptom control (especially pain and anxiety),
reduce acute hospital admission, and lead to
improvement in quality of life.
(Higginson and Evanse, 2010)
In health care, to palliate
the lessenmeans to
severity of pain or disease
or curingwithout
removing the underlying
cause.
To make less
severe
Palliative Care
the lessenmeans to
severity of pain or disease
or curingwithout
removing the underlying
cause.
To make less
severe
Palliative Care
•According to the WHO Palliative care is an
approach that improves the quality of life of
patients and their families facing the problem
associated with life-threatening illness,
through the prevention and relief of suffering
by means of early identification and
impeccable assessment and treatment of pain
and other problems, physical, psychosocial
and spiritual.
approach that improves the quality of life of
patients and their families facing the problem
associated with life-threatening illness,
through the prevention and relief of suffering
by means of early identification and
impeccable assessment and treatment of pain
and other problems, physical, psychosocial
and spiritual.
•The goal of Palliative Care is the
achievement of the best possible quality of
life for patients and families.
•Palliative care with curative care
•Palliative care alone, when curative care
is no longer helpful.
achievement of the best possible quality of
life for patients and families.
•Palliative care with curative care
•Palliative care alone, when curative care
is no longer helpful.
•Palliative care
requires a
multidisciplina
ry team,
doctors, nurses
and other
specialists who
work together
to provide the
best care.
requires a
multidisciplina
ry team,
doctors, nurses
and other
specialists who
work together
to provide the
best care.
Philosophy of Palliative Care
•Should be available to anybody with a life
threatening illness.
•Focus of care is quality of life, with the
autonomy and choice of the patient being
upheld.
•Care is extended to both the patient and
those who matter to him/her.
•A whole system approach is made when
planning care with the patient.
•Should be available to anybody with a life
threatening illness.
•Focus of care is quality of life, with the
autonomy and choice of the patient being
upheld.
•Care is extended to both the patient and
those who matter to him/her.
•A whole system approach is made when
planning care with the patient.
Philosophy of Palliative Care
•Palliative care should be delivered by any
health/social care professional in care setting of
patient’s choosing.
•Palliative care should begin at diagnosis of life
threatening condition, continuing through to
death/ bereavement.
•Specialist Palliative Care is defined in terms of
core services, delivered using multi-professional
team with skills, knowledge and experience in
palliative care.
•Specialist Palliative Care is needed by only a
minority of people with complex problems.
•Palliative care should be delivered by any
health/social care professional in care setting of
patient’s choosing.
•Palliative care should begin at diagnosis of life
threatening condition, continuing through to
death/ bereavement.
•Specialist Palliative Care is defined in terms of
core services, delivered using multi-professional
team with skills, knowledge and experience in
palliative care.
•Specialist Palliative Care is needed by only a
minority of people with complex problems.
Elements of Palliative Care
•Palliative care is delivered on a continuum involving a number of elements
depending on the status and needs of the patient. These include:
1- Pain management: Patients living with a life-threatening illness may
experience pain. Nurses work with patients and their families to identify the
source of the pain and ways to relieve it. Pain may be managed with drugs or
by other means such as massage therapy and relaxation techniques.
2- Symptom management: Often people have to deal with a variety of
symptoms that can include loss of appetite, nausea, weakness, breathing
difficulty, bowel and bladder problems and confusion. These symptoms can be
distressing for the patient and palliative care can help provide a relief.
•Palliative care is delivered on a continuum involving a number of elements
depending on the status and needs of the patient. These include:
1- Pain management: Patients living with a life-threatening illness may
experience pain. Nurses work with patients and their families to identify the
source of the pain and ways to relieve it. Pain may be managed with drugs or
by other means such as massage therapy and relaxation techniques.
2- Symptom management: Often people have to deal with a variety of
symptoms that can include loss of appetite, nausea, weakness, breathing
difficulty, bowel and bladder problems and confusion. These symptoms can be
distressing for the patient and palliative care can help provide a relief.
Elements of Palliative Care
3- Social, psychological, emotional and spiritual support:
Palliative care focuses on the person as a whole and offers a
wide range of support services to the ill person. It also offers
bereavement support and can help the family work through
emotions and grief regarding the illness and death of a loved
one.
4- Caregiver support: Family members and others are often
concerned about whether they will be able to cope, especially
when palliative care is provided at home.
3- Social, psychological, emotional and spiritual support:
Palliative care focuses on the person as a whole and offers a
wide range of support services to the ill person. It also offers
bereavement support and can help the family work through
emotions and grief regarding the illness and death of a loved
one.
4- Caregiver support: Family members and others are often
concerned about whether they will be able to cope, especially
when palliative care is provided at home.
PRINCIPLES
•Focus on quality rather than quantity of life.
•Life affirming but death accepting.
•Effective communication at all levels.
•Respect for autonomy and choice.
•Effective symptom management.
•Holistic, multi-professional approach.
•Caring about the person and those who
matter to that person.
•Focus on quality rather than quantity of life.
•Life affirming but death accepting.
•Effective communication at all levels.
•Respect for autonomy and choice.
•Effective symptom management.
•Holistic, multi-professional approach.
•Caring about the person and those who
matter to that person.
Global Perspective of Palliative care
• Worldwide, millions of patients are in
need of palliative care. Numerous
governments, including Australia, Canada,
Chile, Costa Rica, Cuba, France, Ireland,
Norway, Spain, Uganda, South Africa, and
the United Kingdom, have already adopted
national palliative care policies.
1 Sepúlveda C, Marlin A, Yoshida T, Ullrich A. Palliative care: the World Health Organization’s global perspective.
Jpainsymman 2002;24:2.
2 WHO Definition of Palliative Care. 2012 http://www.who.int/ cancer/palliative/definition/en/.
• Worldwide, millions of patients are in
need of palliative care. Numerous
governments, including Australia, Canada,
Chile, Costa Rica, Cuba, France, Ireland,
Norway, Spain, Uganda, South Africa, and
the United Kingdom, have already adopted
national palliative care policies.
1 Sepúlveda C, Marlin A, Yoshida T, Ullrich A. Palliative care: the World Health Organization’s global perspective.
Jpainsymman 2002;24:2.
2 WHO Definition of Palliative Care. 2012 http://www.who.int/ cancer/palliative/definition/en/.
Global Perspective
•It is the right of every person with a life-
threatening illness to receive appropriate
palliative care wherever they are.
•Palliative care is the responsibility of all health
and social care professionals delivering care.
•It is the right of every person with a life-
threatening illness to receive appropriate
palliative care wherever they are.
•Palliative care is the responsibility of all health
and social care professionals delivering care.
Quality of life Issues
To people living with cancer, life is precious.
When pain becomes part of each day, of one's
daily life, these days are diminished and
quality of life is eroded.
To people living with cancer, life is precious.
When pain becomes part of each day, of one's
daily life, these days are diminished and
quality of life is eroded.
Quality of life Issues
The list of damage that pain does to quality of life includes:
• sleep is disturbed
• ability to work is impaired
• exhaustion can become a constant companion
• sadness, depression and worry are commonly felt emotions
• appetite diminishes
• simple pleasures such as enjoying one's family are impaired
or given up
• trips and vacations are uncomfortable or impossible
• reluctance to move or exercise is experienced
• feelings of isolation from the world increase
• family and friends who are caregivers become exhausted.
)
The list of damage that pain does to quality of life includes:
• sleep is disturbed
• ability to work is impaired
• exhaustion can become a constant companion
• sadness, depression and worry are commonly felt emotions
• appetite diminishes
• simple pleasures such as enjoying one's family are impaired
or given up
• trips and vacations are uncomfortable or impossible
• reluctance to move or exercise is experienced
• feelings of isolation from the world increase
• family and friends who are caregivers become exhausted.
)
•Oncology nurses encounter a high rate of
stressful and difficult end-of-life conversations
with patients an families.
•Patient- and family-centered communication
skills training that places an emphasis on
palliative care would benefit oncology nurses.
• The COMFORT communication curriculum is a
resource that specifically provides nurses with
communication skills training on patient and
family needs at the end of life.
(Goldsmith, 2013)
stressful and difficult end-of-life conversations
with patients an families.
•Patient- and family-centered communication
skills training that places an emphasis on
palliative care would benefit oncology nurses.
• The COMFORT communication curriculum is a
resource that specifically provides nurses with
communication skills training on patient and
family needs at the end of life.
(Goldsmith, 2013)
Communication Skills
•communication skills are important while
providing care for patients and their
families/carers at the end-of-life, and the
families/carers progress beyond the patient's
death during their bereavement phase.
•communication skills are important while
providing care for patients and their
families/carers at the end-of-life, and the
families/carers progress beyond the patient's
death during their bereavement phase.
Communication Skills
•1- Establish and foster effective and empowering relationships with
patients and their families as partners in care decisions, as well as
with other healthcare professionals.
•2- Use good communication skills including active listening,
breaking bad news, dealing with difficult questions, discussing end-
of-life issues and crosscultural care at the end-of-life.
•3- Understand the experience and consequences of disease from
the perspective of the patient and their family.
•4- Help patients live as creatively and meaningfully as possible all
the way to the end-of-life.
•5- Be sensitive to differing perceptions and expectations of disease
and treatment among various family members.
•6- Be aware of spiritual, religious and cultural issues.
•7- Understand the normal process of grief, help prepare carers for
bereavement and offer support during this process.
•1- Establish and foster effective and empowering relationships with
patients and their families as partners in care decisions, as well as
with other healthcare professionals.
•2- Use good communication skills including active listening,
breaking bad news, dealing with difficult questions, discussing end-
of-life issues and crosscultural care at the end-of-life.
•3- Understand the experience and consequences of disease from
the perspective of the patient and their family.
•4- Help patients live as creatively and meaningfully as possible all
the way to the end-of-life.
•5- Be sensitive to differing perceptions and expectations of disease
and treatment among various family members.
•6- Be aware of spiritual, religious and cultural issues.
•7- Understand the normal process of grief, help prepare carers for
bereavement and offer support during this process.
• we should encourage and
focus on:
• 1- multidisciplinary
communication and
cooperation.
•2- professional development,
and empowerment of nurses,
Knowledge and practices
among palliative patients.
focus on:
• 1- multidisciplinary
communication and
cooperation.
•2- professional development,
and empowerment of nurses,
Knowledge and practices
among palliative patients.
Nursing Perspective of Palliative Care
•Palliative care presents a challenge for the nursing
team, as it involves an intersubjective meeting
between professionals and the patient in a terminal
condition.
( Silva, 2014)
• Nurses need the resources such as time, improved
methods of communication and cooperation as well as
more support in order to give quality palliative care
and achieve satisfaction with the outcome. The need
for discussion about the conditions for
giving palliative care outside the hospices and other
special palliative care settings is also elucidated.
(Wallerstedt & Andershed, 2006)
•Palliative care presents a challenge for the nursing
team, as it involves an intersubjective meeting
between professionals and the patient in a terminal
condition.
( Silva, 2014)
• Nurses need the resources such as time, improved
methods of communication and cooperation as well as
more support in order to give quality palliative care
and achieve satisfaction with the outcome. The need
for discussion about the conditions for
giving palliative care outside the hospices and other
special palliative care settings is also elucidated.
(Wallerstedt & Andershed, 2006)
Nursing Perspective of Palliative Care
• 70% of general ward nurses believe that
managing care of the dying is an integral part of
hospital care.
(McDonnell, Johnston , Gallagher, McGlade, 2000)
• 70% of general ward nurses believe that
managing care of the dying is an integral part of
hospital care.
(McDonnell, Johnston , Gallagher, McGlade, 2000)
Home Care
Home care is supportive care provided in
the home.
Palliative care is also available in residential care
homes. If someone is already in a residential
home, remaining there for palliative care may
be their choice, and it may make them more
comfortable and less distressed than having to
go into hospital unless it is really necessary.
Home care is supportive care provided in
the home.
Palliative care is also available in residential care
homes. If someone is already in a residential
home, remaining there for palliative care may
be their choice, and it may make them more
comfortable and less distressed than having to
go into hospital unless it is really necessary.
•A health service provided in the patient's plac
e of residence for the purpose of promoting,
maintaining, or restoring health or minimizing
the effects of illness and disability.
•Service mayinclude such elements as medical,
dental, and nursing care, speech and physical
therapy.
• Some hospitals have home care services that
include regular visits by a nurse and physician
to patients in the home.
e of residence for the purpose of promoting,
maintaining, or restoring health or minimizing
the effects of illness and disability.
•Service mayinclude such elements as medical,
dental, and nursing care, speech and physical
therapy.
• Some hospitals have home care services that
include regular visits by a nurse and physician
to patients in the home.
Types of Visits
•Initial visit.
•Routine visit.
•Crisis visit.
•Bereavement visit
•Initial visit.
•Routine visit.
•Crisis visit.
•Bereavement visit
Criteria for Home care
•Bed redden.
•Patient leave hospital with one or more of following:
•Foleys catheter.
•Nephrostomy.
•NG tube.
•PEG tube.
•Stoma.
•Pleura drains ( pleural& peritoneal).
•Pressure ulcer, malignant wound.
•The pt. under pain& or symptom management in
hospital to follow at their home.
•Bed redden.
•Patient leave hospital with one or more of following:
•Foleys catheter.
•Nephrostomy.
•NG tube.
•PEG tube.
•Stoma.
•Pleura drains ( pleural& peritoneal).
•Pressure ulcer, malignant wound.
•The pt. under pain& or symptom management in
hospital to follow at their home.
Hospice Care
•Hospice care: Care designed to give
supportive care to people in the final phase
of a terminal illness and focus on comfort
and quality of life, rather than cure.
• Hospice care is a type and philosophy of
care that focuses on the palliation of a
terminally or seriously ill patient's pain and
symptoms, and attending to their emotional
and spiritual needs.
•Hospice care: Care designed to give
supportive care to people in the final phase
of a terminal illness and focus on comfort
and quality of life, rather than cure.
• Hospice care is a type and philosophy of
care that focuses on the palliation of a
terminally or seriously ill patient's pain and
symptoms, and attending to their emotional
and spiritual needs.
•Hospice is a specialized form of palliative care
•hospice care and Palliative care are two
concepts close to each other in the definition .
•Discuss the difference between them.
•hospice care and Palliative care are two
concepts close to each other in the definition .
•Discuss the difference between them.
Palliative Vs. Hospice
Hospice Palliative
Life expectancy 6 months
or less
Any time during life
threatening of illness
Time
Hospice Care treatments
are limited and focus on
palliation of symptoms.
The goal is no longer to
cure, but to promote
comfort.
Treatments are not limited
with Palliative Care and can
range from conservative to
curative
Treatment
Hospice Care services are
more inclusive than
Palliative Care services.
Hospice Care includes
physician services, nursing
services, social worker,
spiritual care, bereavement
care and volunteers .
Palliative Care services are
typically provided through
regular physician and
nursing visits.
Differences in Types of
Services
National Hospice and Palliative Care Organization
Hospice Palliative
Life expectancy 6 months
or less
Any time during life
threatening of illness
Time
Hospice Care treatments
are limited and focus on
palliation of symptoms.
The goal is no longer to
cure, but to promote
comfort.
Treatments are not limited
with Palliative Care and can
range from conservative to
curative
Treatment
Hospice Care services are
more inclusive than
Palliative Care services.
Hospice Care includes
physician services, nursing
services, social worker,
spiritual care, bereavement
care and volunteers .
Palliative Care services are
typically provided through
regular physician and
nursing visits.
Differences in Types of
Services
National Hospice and Palliative Care Organization
Nursing Rule in Palliative care
•Communicating openly, honestly with patient
•Maintaining comfort
•Ensuring social support and care for caregivers
•Applying the principles of palliative care
•Ensuring that care is ethically, spiritually and
culturally appropriate.
•Communicating openly, honestly with patient
•Maintaining comfort
•Ensuring social support and care for caregivers
•Applying the principles of palliative care
•Ensuring that care is ethically, spiritually and
culturally appropriate.
Diagnostic of Cancer
•cancer is an invading disease that makes itself difficult to be discovered
easily.
•There is no single specific test that can discover or diagnose cancer.
•complete evaluation of a patient usually requires a thorough history and
physical examination along with diagnostic testing.
•Radiological and endoscopic diagnostic assessment are used to discover
cancer presence.
•cancer is an invading disease that makes itself difficult to be discovered
easily.
•There is no single specific test that can discover or diagnose cancer.
•complete evaluation of a patient usually requires a thorough history and
physical examination along with diagnostic testing.
•Radiological and endoscopic diagnostic assessment are used to discover
cancer presence.
Roadmap
Cancer
diagnosis
biopsy
Radiological
Diagnostics
Mammogram
X-Ray
Ultrasound
& CT Scan
MRI &
Nuclear
Medicine
Endoscopic
Procedures
Lab
chemistry,
genetic study
Cancer
diagnosis
biopsy
Radiological
Diagnostics
Mammogram
X-Ray
Ultrasound
& CT Scan
MRI &
Nuclear
Medicine
Endoscopic
Procedures
Lab
chemistry,
genetic study
Selecting the Appropriate Diagnostic
Procedure
•Type of tumor.
•Location of tumor.
•Risk and benefits of procedure.
•Cost of procedure.
•Urgency.
•Patient condition.
Procedure
•Type of tumor.
•Location of tumor.
•Risk and benefits of procedure.
•Cost of procedure.
•Urgency.
•Patient condition.
Histopathology
Refers to the microscopic examination of tissue in order to study
the manifestations of disease.
Specifically, in clinical medicine, histopathology refers to the
examination of a biopsy or surgical specimen by a pathologist.
Refers to the microscopic examination of tissue in order to study
the manifestations of disease.
Specifically, in clinical medicine, histopathology refers to the
examination of a biopsy or surgical specimen by a pathologist.
What is Biopsy?
-Biopsy is a sample of tissue taken from the body in order to
examine it more closely. A doctor should recommend a biopsy
when an initial test suggests an area of tissue in the body isn't
normal.
-Doctors may call an area of abnormal tissue a lesion, a tumour,
or a mass. These are general words used to emphasize the
unknown nature of the tissue. The suspicious area may be noticed
during a physical examination or internally on an imaging test.
-Biopsy is a sample of tissue taken from the body in order to
examine it more closely. A doctor should recommend a biopsy
when an initial test suggests an area of tissue in the body isn't
normal.
-Doctors may call an area of abnormal tissue a lesion, a tumour,
or a mass. These are general words used to emphasize the
unknown nature of the tissue. The suspicious area may be noticed
during a physical examination or internally on an imaging test.
Types of Biopsy
•Needle biopsy.
•CT-guided biopsy.
•Ultrasound-guided biopsy.
•Bone biopsy.
•Bone marrow biopsy: A large needle is used to enter the pelvis bone
to collect bone marrow.
•Surgical biopsy: Either open or laparoscopic surgery may be
necessary to obtain a biopsy of hard-to-reach tissue. Either a piece of
tissue or the whole lump of tissue may be removed.
•Aspiration biopsy. A needle withdraws material out of a mass. This
simple procedure is also called fine-needle aspiration.
•Needle biopsy.
•CT-guided biopsy.
•Ultrasound-guided biopsy.
•Bone biopsy.
•Bone marrow biopsy: A large needle is used to enter the pelvis bone
to collect bone marrow.
•Surgical biopsy: Either open or laparoscopic surgery may be
necessary to obtain a biopsy of hard-to-reach tissue. Either a piece of
tissue or the whole lump of tissue may be removed.
•Aspiration biopsy. A needle withdraws material out of a mass. This
simple procedure is also called fine-needle aspiration.
Nursing Role
•Help clients achieve their optimal level of function and
wellness after the biopsy.
•Simple gauze compression.
•The patient can eat and drink as normal.
•Advise to avoid hard physical activity for
24 hours after the biopsy.
•Help clients achieve their optimal level of function and
wellness after the biopsy.
•Simple gauze compression.
•The patient can eat and drink as normal.
•Advise to avoid hard physical activity for
24 hours after the biopsy.
The Need for Medical Imaging
oDetermine the presence of tumormass.
olocalize the mass for biopsy.
oProvide tissue characterization.
oAssess or stage the anatomical extent of disease.
oTumortreatment (either benign or malignant).
MRI
Ultrasound (US)Computerized Tomography (CT)
X-ray
Positron Emission Tomography
(PET) Scan
Contrast
•IV
•Oral
•Rectal
•Intrathecal
oDetermine the presence of tumormass.
olocalize the mass for biopsy.
oProvide tissue characterization.
oAssess or stage the anatomical extent of disease.
oTumortreatment (either benign or malignant).
MRI
Ultrasound (US)Computerized Tomography (CT)
X-ray
Positron Emission Tomography
(PET) Scan
Contrast
•IV
•Oral
•Rectal
•Intrathecal
Preparation for CT Scan and MRI
•If the patient has a history of allergyto contrast material
(such as iodine), the requesting physician and radiology staff
should be notified.
•If case patient has plain for CT scan with contrast, do not eat
anything (NPO) three hours prior to CT scan
•Large iv access.
•Kidney function test.
•Patient with Metal materials contraindicated for MRI
•If the patient has a history of allergyto contrast material
(such as iodine), the requesting physician and radiology staff
should be notified.
•If case patient has plain for CT scan with contrast, do not eat
anything (NPO) three hours prior to CT scan
•Large iv access.
•Kidney function test.
•Patient with Metal materials contraindicated for MRI
Mammogram
•Amammogram is an x-ray
examination of the breast.
It is used to detect and
diagnose breast disease in
women who either have
breast problems such as a
lump, pain, or nipple
discharge, as well as for
women who have no
breast complaints.
•Amammogram is an x-ray
examination of the breast.
It is used to detect and
diagnose breast disease in
women who either have
breast problems such as a
lump, pain, or nipple
discharge, as well as for
women who have no
breast complaints.
Mammogram
•The goal of mammography is the early detection ofbreast
cancer, typically through detection of characteristic of
masses.
•The National Cancer Institute recommends that women age
40 or older have screening mammograms every 1 to 2 years.
Women with family history of breast cancer should consider
yearly mammograms at young age.
•A normal mammogram does not exclude the presence of
cancer.
•The goal of mammography is the early detection ofbreast
cancer, typically through detection of characteristic of
masses.
•The National Cancer Institute recommends that women age
40 or older have screening mammograms every 1 to 2 years.
Women with family history of breast cancer should consider
yearly mammograms at young age.
•A normal mammogram does not exclude the presence of
cancer.
Before Mammogram
•Do notuse deodorant, perfume, powders, or ointments under
the arms or on the breasts on the day of the mammogram.
These substances may hide the images.
•Remove all jewellery from the neck and chest area.
•Asked the patient if she is pregnant or breastfeeding.
•Do notuse deodorant, perfume, powders, or ointments under
the arms or on the breasts on the day of the mammogram.
These substances may hide the images.
•Remove all jewellery from the neck and chest area.
•Asked the patient if she is pregnant or breastfeeding.
Positron Emission Tomography (PET)
Scan
•Diagnostic
procedure assess the
metabolic activity
levels of tissues in
an attempt to
pinpoint the location
of cancerous tissues,
so this type of scan
can show how body
tissues are working,
as well as what they
look like.
Scan
•Diagnostic
procedure assess the
metabolic activity
levels of tissues in
an attempt to
pinpoint the location
of cancerous tissues,
so this type of scan
can show how body
tissues are working,
as well as what they
look like.
How Does it Work?
•Inject patient by radioactive drug (tracer) one hour Before,
tracer known as (fluorodeoxy glucose), (FDG-18) This is a
radioactive version of glucose.
•FDG-18 travels to places where glucose is used for energy. It
shows up cancers because they use glucose in a different way
from normal tissue, in order to satisfy the energy required for
their rapid growth.
•Tracer create “hot” or “cold” spots on the computer image
depending on whether more or less of the tracer is taken up by
the tissue.
•Inject patient by radioactive drug (tracer) one hour Before,
tracer known as (fluorodeoxy glucose), (FDG-18) This is a
radioactive version of glucose.
•FDG-18 travels to places where glucose is used for energy. It
shows up cancers because they use glucose in a different way
from normal tissue, in order to satisfy the energy required for
their rapid growth.
•Tracer create “hot” or “cold” spots on the computer image
depending on whether more or less of the tracer is taken up by
the tissue.
Preparation for PET Scan
•Refrain from consuming caffeine for at least 24 hours prior to
the PET scan.
•A small quantity of radiotracer will either be injected into the
patient's arm or breathed in as a gas .
•Consume any food for at least four to six hours before the scan,
but to drink plenty of water.
•Some patients may be given some medication, such as
diazepam, to relax.
•Refrain from consuming caffeine for at least 24 hours prior to
the PET scan.
•A small quantity of radiotracer will either be injected into the
patient's arm or breathed in as a gas .
•Consume any food for at least four to six hours before the scan,
but to drink plenty of water.
•Some patients may be given some medication, such as
diazepam, to relax.
PET Scan Findings
•Show whether a lump is cancer or not.
•Show whether a cancer has spread to other parts of the body.
•Show the difference between scar tissue and active cancer
tissue.
•Find out the stage of a cancer.
•Show how well cancer drug treatment is working.
•Show whether a lump is cancer or not.
•Show whether a cancer has spread to other parts of the body.
•Show the difference between scar tissue and active cancer
tissue.
•Find out the stage of a cancer.
•Show how well cancer drug treatment is working.
RadiologicalDiagnostics Advantages Disadvantages
Plain X-ray
Quick, non-invasive and painless.
Can help diagnose various diseases and
injuries, including broken bones, some cancers
and infections.
Very small increased risk of cancer in future
from exposure to ionising radiation (X-rays).
Risk is greater for children
Ultrasound
Usually non-invasive, safe and relatively
painless.
Uses no ionising radiation.
Does not usually require injection of a contrast
medium (dye).
Can be used to check on the health of a baby
during pregnancy.
Quality and interpretation of the image highly
depends on the skill of the person doing the
scan
Other factors can affect image quality,
including the presence of air and calcified
areas in the body (e.g. bones, plaques and
hardened arteries), and a person's body size
Computed tomography
(CT scans)
Quick and painless
Can help diagnose and guide treatment for a
wider range of conditions than plain X-ray
Can detect or exclude the presence of more
serious problems
Can be used to check if a previously treated
disease has recurred
Uses higher doses of radiation than plain
X-ray, so the risks (while still small) are
generally greater than for other imaging
types.
Injection of a contrast medium (dye) can
cause kidney problems or result in allergic
or injection-site reactions in some people.
Some procedures require anaesthesia.
Plain X-ray
Quick, non-invasive and painless.
Can help diagnose various diseases and
injuries, including broken bones, some cancers
and infections.
Very small increased risk of cancer in future
from exposure to ionising radiation (X-rays).
Risk is greater for children
Ultrasound
Usually non-invasive, safe and relatively
painless.
Uses no ionising radiation.
Does not usually require injection of a contrast
medium (dye).
Can be used to check on the health of a baby
during pregnancy.
Quality and interpretation of the image highly
depends on the skill of the person doing the
scan
Other factors can affect image quality,
including the presence of air and calcified
areas in the body (e.g. bones, plaques and
hardened arteries), and a person's body size
Computed tomography
(CT scans)
Quick and painless
Can help diagnose and guide treatment for a
wider range of conditions than plain X-ray
Can detect or exclude the presence of more
serious problems
Can be used to check if a previously treated
disease has recurred
Uses higher doses of radiation than plain
X-ray, so the risks (while still small) are
generally greater than for other imaging
types.
Injection of a contrast medium (dye) can
cause kidney problems or result in allergic
or injection-site reactions in some people.
Some procedures require anaesthesia.
Magnetic resonance imaging
(MRI)
Usually non-invasive and painless
Uses no ionising radiation.
Can help diagnose and guide treatment for
a wide range of conditions.
Can provide similar information to CT in
some types of investigations.
Can be a lengthy and noisy procedure
Slight movement can ruin the image,
requiring retesting.
Can make some people feel claustrophobic
Sedation or anaesthesia may be required
for young children or others who can't
remain still.
Can't be undertaken in some situations
(e.g. when a heart pacemaker is present).
Mammogram
Screening mammograms are the most
effective test for finding breast cancer
early.
they are not 100% accurate. There is a
small chance that a screening
mammogram will look normal even if a
breast cancer is present.
Routine screening mammography is not
done during pregnancy or while
breastfeeding.
Nuclear medicine imaging
including positron-emission
tomography (PET)
Can help diagnose, treat, or predict the outcome
for a wide range of conditions.
Unlike most other imaging types, can show how
different parts of the body are working and can
detect problems much earlier.
Can check how far a cancer has spread and how
well treatment is working.
Involvesexposure to ionising radiation(gamma-
rays)
Radioactive material may cause allergic or
injection-site reactions in some people.
PET scanners cause some people to feel
claustrophobic, which may mean sedation is
required.
(MRI)
Usually non-invasive and painless
Uses no ionising radiation.
Can help diagnose and guide treatment for
a wide range of conditions.
Can provide similar information to CT in
some types of investigations.
Can be a lengthy and noisy procedure
Slight movement can ruin the image,
requiring retesting.
Can make some people feel claustrophobic
Sedation or anaesthesia may be required
for young children or others who can't
remain still.
Can't be undertaken in some situations
(e.g. when a heart pacemaker is present).
Mammogram
Screening mammograms are the most
effective test for finding breast cancer
early.
they are not 100% accurate. There is a
small chance that a screening
mammogram will look normal even if a
breast cancer is present.
Routine screening mammography is not
done during pregnancy or while
breastfeeding.
Nuclear medicine imaging
including positron-emission
tomography (PET)
Can help diagnose, treat, or predict the outcome
for a wide range of conditions.
Unlike most other imaging types, can show how
different parts of the body are working and can
detect problems much earlier.
Can check how far a cancer has spread and how
well treatment is working.
Involvesexposure to ionising radiation(gamma-
rays)
Radioactive material may cause allergic or
injection-site reactions in some people.
PET scanners cause some people to feel
claustrophobic, which may mean sedation is
required.
Endoscopies
•Endoscopy: is a procedure that allows to view the inside of a person's
body.
•During an endoscopy, inserts a tool into a person’s body.
Most endoscopes are thin tubes with a powerful light and tiny camera
at the end.
•There are several different
types of endoscopes.
•Endoscopy: is a procedure that allows to view the inside of a person's
body.
•During an endoscopy, inserts a tool into a person’s body.
Most endoscopes are thin tubes with a powerful light and tiny camera
at the end.
•There are several different
types of endoscopes.
Endoscopies Equipment
•An endoscope also often has a channel so the physician can
insert tools to collect tissue or provide treatment. Some of the
tools a doctor may use during an endoscopy include:
1.Flexible forceps, a tool that looks like tongs, for taking a
tissue sample
2.Biopsy forceps for removing a tissue sample or a suspicious
growth
3.Cytology brush for taking cell samples
4.Suture removal forceps for removing stitches inside the body
•An endoscope also often has a channel so the physician can
insert tools to collect tissue or provide treatment. Some of the
tools a doctor may use during an endoscopy include:
1.Flexible forceps, a tool that looks like tongs, for taking a
tissue sample
2.Biopsy forceps for removing a tissue sample or a suspicious
growth
3.Cytology brush for taking cell samples
4.Suture removal forceps for removing stitches inside the body
Reason for Endoscopies
•Endoscopy recommended to the patient for several different reasons.
•To screenfor and prevent cancer. the use of a colonoscopy to screen for
colorectal cancer. During a colonoscopy, the doctor can remove growths
called polyps that could develop into cancer.
•To diagnosea disease or find out the cause of symptoms. The type of
endoscopy it will recommend depends on the part of the body that needs
to be seen.
•To give treatment. Doctors can provide different treatments using
endoscopy
•Endoscopy recommended to the patient for several different reasons.
•To screenfor and prevent cancer. the use of a colonoscopy to screen for
colorectal cancer. During a colonoscopy, the doctor can remove growths
called polyps that could develop into cancer.
•To diagnosea disease or find out the cause of symptoms. The type of
endoscopy it will recommend depends on the part of the body that needs
to be seen.
•To give treatment. Doctors can provide different treatments using
endoscopy
The Most Common Types of Endoscopy
Laparoscopy: Laparoscope Stomach, liver, or other abdominal
organ, including female reproductive organs (uterus, ovaries,
fallopian tubes) Inserted through a small, surgical opening in the
abdomen
Colonoscopy: Colonoscopy Entire length of the colon and
large intestine Inserted through the anus.
Bronchoscopy: Bronchoscope Trachea (windpipe) and bronchi
of the lungs
Inserted through the mouth
Laparoscopy: Laparoscope Stomach, liver, or other abdominal
organ, including female reproductive organs (uterus, ovaries,
fallopian tubes) Inserted through a small, surgical opening in the
abdomen
Colonoscopy: Colonoscopy Entire length of the colon and
large intestine Inserted through the anus.
Bronchoscopy: Bronchoscope Trachea (windpipe) and bronchi
of the lungs
Inserted through the mouth
The Most Common Types of Endoscopy
•Cystoscopy: used for bladder
•Arthroscopy: use to joint.
•Esophagoscopy: Inserted to show Esophagus
•Laryngoscopy: Laryngoscope Larynx (voice box) Inserted through the
mouth
•Sigmoidoscopy: Sigmoid colon (bottom part of the colon) Inserted
through the anus.
•Thoracoscopy: Pleura covering the lungs and structures covering the
heart Inserted through a small surgical opening in chest.
•Gastroscopy: Stomach and duodenum (beginning of the small intestine)
Inserted through the mouth
•Cystoscopy: used for bladder
•Arthroscopy: use to joint.
•Esophagoscopy: Inserted to show Esophagus
•Laryngoscopy: Laryngoscope Larynx (voice box) Inserted through the
mouth
•Sigmoidoscopy: Sigmoid colon (bottom part of the colon) Inserted
through the anus.
•Thoracoscopy: Pleura covering the lungs and structures covering the
heart Inserted through a small surgical opening in chest.
•Gastroscopy: Stomach and duodenum (beginning of the small intestine)
Inserted through the mouth
Instructions Before
Endoscopy
•NPO for several hours
before the procedure.
•Stop anticoagulation
drug several days
before the procedure to
reduce the risk of
bleeding.
•Take a laxative to clean
bowels, depending on
the type of endoscopy.
During the Procedure
•If anesthesia or sedative
received depending on the
type of endoscopy.
Checked patient alert,
drowsy, or asleep during
the procedure.
•monitor vital sign
•collecting tissue sample
for testing.
After the Procedure
•the patient will rest in
a recovery area. may
have mild side effects
afterwards. This
depends on the type
of endoscopy but can
include a sore, dry
throat or bloating and
gas.
Endoscopy
•NPO for several hours
before the procedure.
•Stop anticoagulation
drug several days
before the procedure to
reduce the risk of
bleeding.
•Take a laxative to clean
bowels, depending on
the type of endoscopy.
During the Procedure
•If anesthesia or sedative
received depending on the
type of endoscopy.
Checked patient alert,
drowsy, or asleep during
the procedure.
•monitor vital sign
•collecting tissue sample
for testing.
After the Procedure
•the patient will rest in
a recovery area. may
have mild side effects
afterwards. This
depends on the type
of endoscopy but can
include a sore, dry
throat or bloating and
gas.
Nursing Responsibilities in Diagnostic
Measures
Measures
Oncological Emergency
Khalid Ali Alfaqih., RN, MSN, ONS.
Khalid Ali Alfaqih., RN, MSN, ONS.
Oncological Emergency
•Oncological emergencies are a group of conditions that occur as a direct or indirect
result of cancer or its treatment that are potentially life-threatening[1]
•These include:
•Hypercalcaemia
•Neutropaenicsepsis
•Tumourlysissyndrome
•Leukostasis
•Raised intracranial pressure
•Spinal cord compression
•Caudaequinasyndrome
•Superior vena cava obstruction
•Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
•Disseminated intravascular coagulation
•Oncological emergencies are a group of conditions that occur as a direct or indirect
result of cancer or its treatment that are potentially life-threatening[1]
•These include:
•Hypercalcaemia
•Neutropaenicsepsis
•Tumourlysissyndrome
•Leukostasis
•Raised intracranial pressure
•Spinal cord compression
•Caudaequinasyndrome
•Superior vena cava obstruction
•Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
•Disseminated intravascular coagulation
Malignant Spinal cord compression
(MSCC)
•5% incidence in known cancer pts20% -MSCC is
the first presentation of cancer Metastatic –
Breast, Lung, Prostate, Kidney Primary –
Myeloma, Lymphoma Sites –60% Thoracic, 30%
Lumbosacral, 10% cervical >100 confirmed cases
of MSCC at UHL in 2014
•MSCC –Red Flags Pain –almost universal,
precedes neurology by several weeks Motor –
depends on location, weakness, abnormal
reflexes Sensory –Numbness, parasthesias,
unsteadiness Bladder & bowel
(MSCC)
•5% incidence in known cancer pts20% -MSCC is
the first presentation of cancer Metastatic –
Breast, Lung, Prostate, Kidney Primary –
Myeloma, Lymphoma Sites –60% Thoracic, 30%
Lumbosacral, 10% cervical >100 confirmed cases
of MSCC at UHL in 2014
•MSCC –Red Flags Pain –almost universal,
precedes neurology by several weeks Motor –
depends on location, weakness, abnormal
reflexes Sensory –Numbness, parasthesias,
unsteadiness Bladder & bowel
MSCC –Red Flags
•Pain –almost universal, precedes neurology
by several weeks
•Motor –depends on location, weakness,
abnormal reflexes
•Sensory –Numbness, parasthesias,
unsteadiness
•Bladder & bowel
•Pain –almost universal, precedes neurology
by several weeks
•Motor –depends on location, weakness,
abnormal reflexes
•Sensory –Numbness, parasthesias,
unsteadiness
•Bladder & bowel
Management -MSCC
•Steroids & gastric protection
•Analgesia
•Urgent MRI of whole spine
•Surgery –decompression & stabilisationof the
spine
•Radiotherapy
•Chemotherapy e.g. lymphoma
•Hormonal manipulation e.g. prostate Ca
•Steroids & gastric protection
•Analgesia
•Urgent MRI of whole spine
•Surgery –decompression & stabilisationof the
spine
•Radiotherapy
•Chemotherapy e.g. lymphoma
•Hormonal manipulation e.g. prostate Ca
Thrombocytopenia
•Description
–defined as a platelet count less than
140,000/mm
3
.
•Idiopathic thrombocytopenia purpura(ITP)
–Caused by autoimmune response resulting in
destruction of existing platelets
–Medical management: administration of
glucocorticoids, immunoglobulin, and platelets
–Nursing management: initiating bleeding precautions,
providing comfort and emotional support, and
watching for complications
33
•Description
–defined as a platelet count less than
140,000/mm
3
.
•Idiopathic thrombocytopenia purpura(ITP)
–Caused by autoimmune response resulting in
destruction of existing platelets
–Medical management: administration of
glucocorticoids, immunoglobulin, and platelets
–Nursing management: initiating bleeding precautions,
providing comfort and emotional support, and
watching for complications
33
Tumor Lysis Syndrome
•Description
–Occurs when a large number of neoplastic cells
are rapidly killed
•Etiology
–Associated with the use of cancer treatment
agents (often first time)
–May rarely occur spontaneously
34
•Description
–Occurs when a large number of neoplastic cells
are rapidly killed
•Etiology
–Associated with the use of cancer treatment
agents (often first time)
–May rarely occur spontaneously
34
Tumor Lysis Syndrome (Cont.)
•Pathophysiology
–Hyperuricemia
–Hyperkalemia
–Hyperphosphatemiaand hypocalecmia
Copyright © 2014, 2010 by
Mosby, an imprint of Elsevier
Inc.
35
•Pathophysiology
–Hyperuricemia
–Hyperkalemia
–Hyperphosphatemiaand hypocalecmia
Copyright © 2014, 2010 by
Mosby, an imprint of Elsevier
Inc.
35
Tumor Lysis Syndrome (Cont.)
Copyright © 2014, 2010 by
Mosby, an imprint of Elsevier
Inc.
36
Copyright © 2014, 2010 by
Mosby, an imprint of Elsevier
Inc.
36
Tumor Lysis Syndrome (Cont.)
•Assessment and diagnosis
–Clinical manifestations
–Laboratory findings
–Other diagnostic tests
Copyright © 2014, 2010 by
Mosby, an imprint of Elsevier
Inc.
37
•Assessment and diagnosis
–Clinical manifestations
–Laboratory findings
–Other diagnostic tests
Copyright © 2014, 2010 by
Mosby, an imprint of Elsevier
Inc.
37
Tumor Lysis Syndrome (Cont.)
•Medical management
–Adequate hydration
–Metabolic imbalances
–Life-threatening complications
Copyright © 2014, 2010 by
Mosby, an imprint of Elsevier
Inc.
38
•Medical management
–Adequate hydration
–Metabolic imbalances
–Life-threatening complications
Copyright © 2014, 2010 by
Mosby, an imprint of Elsevier
Inc.
38
Tumor Lysis Syndrome (Cont.)
•Nursing management
–Monitoring fluid and electrolytes
–Maintaining surveillance for complications
–Educating the patient and family
Copyright © 2014, 2010 by
Mosby, an imprint of Elsevier
Inc.
39
•Nursing management
–Monitoring fluid and electrolytes
–Maintaining surveillance for complications
–Educating the patient and family
Copyright © 2014, 2010 by
Mosby, an imprint of Elsevier
Inc.
39
Neutropenicfever
•Neutropenia is defined as an absolute
neutrophil count (ANC) of less than 500/µL, or
less than 1000/µL with an anticipated decline
to less than 500/µL in the next 48-hour
period.
•Neutropenicfever is a single oral temperature
of 38.3º C (101º F) or a temperature of greater
than 38.0º C (100.4º F) sustained for more
than 1 hour in a patient with neutropenia.
•Neutropenia is defined as an absolute
neutrophil count (ANC) of less than 500/µL, or
less than 1000/µL with an anticipated decline
to less than 500/µL in the next 48-hour
period.
•Neutropenicfever is a single oral temperature
of 38.3º C (101º F) or a temperature of greater
than 38.0º C (100.4º F) sustained for more
than 1 hour in a patient with neutropenia.
Signs and symptoms of neutropenia
•A fever, which is a temperature of 100.5°F (38°C)
or higher.
•Chills or sweating.
•Sore throat, sores in the mouth, or a toothache.
•Abdominal pain.
•Pain near the anus.
•Pain or burning when urinating, or urinating
often.
•Diarrhea or sores around the anus.
•A cough or shortness of breath.
•A fever, which is a temperature of 100.5°F (38°C)
or higher.
•Chills or sweating.
•Sore throat, sores in the mouth, or a toothache.
•Abdominal pain.
•Pain near the anus.
•Pain or burning when urinating, or urinating
often.
•Diarrhea or sores around the anus.
•A cough or shortness of breath.
Mangement
•IVF
•Septic wourkup
•CXR
•Antibiotics
•GCSF
•Observe vital sign
•IVF
•Septic wourkup
•CXR
•Antibiotics
•GCSF
•Observe vital sign
SUPERIOR VENA CAVA SYNDROME
In a patient on treatment consider:
•relapse
•effusion
•infection
•thrombosis (especially if a CVL is present)
In a patient on treatment consider:
•relapse
•effusion
•infection
•thrombosis (especially if a CVL is present)
SVC SYNDROME: evaluation
Pulse oximetry
Chest XR: the trachea is a 3-dimensional
structure. It must be evaluated with both PA
and lateral views. The latter often requires a
high-KV film.
Echocardiogram: if any question re size, motion
Pulmonary function: if considering anesthesia.
Should be performed in both upright and
recumbent positions.
Pulse oximetry
Chest XR: the trachea is a 3-dimensional
structure. It must be evaluated with both PA
and lateral views. The latter often requires a
high-KV film.
Echocardiogram: if any question re size, motion
Pulmonary function: if considering anesthesia.
Should be performed in both upright and
recumbent positions.
SVC SYNDROME: TREATMENT
•CONSULTS
–ENT/ANESTHESIA
–SURGERY
•TREATMENT
–O2, IV ACCESS, IVF
–SURGERY
–IRRADIATION
–CHEMOTHERAPY
•CORTICOSTEROIDS
•OTHER
DIAGNOSIS
•LOCAL ANESTHESIA
•ALTERNATE SITE
•DELAY OF 48 HOURS
DOES NOT USUALLY
PREVENT ACCURATE
DIAGNOSIS
•CONSULTS
–ENT/ANESTHESIA
–SURGERY
•TREATMENT
–O2, IV ACCESS, IVF
–SURGERY
–IRRADIATION
–CHEMOTHERAPY
•CORTICOSTEROIDS
•OTHER
DIAGNOSIS
•LOCAL ANESTHESIA
•ALTERNATE SITE
•DELAY OF 48 HOURS
DOES NOT USUALLY
PREVENT ACCURATE
DIAGNOSIS
Symptom Managements
Khalid Ali Alfaqih., RN, MSN, ONS.
Khalid Ali Alfaqih., RN, MSN, ONS.
Symptom Managements
•There are certain symptom may appeared in
patient with cancer
•The goal of symptom management is to prevent
or treat as early as possible the symptoms that
can be arise in patient with cancer, side effects
caused by treatment of a cancer, and
psychological, social, and spiritual problems
related to a cancer or its treatment.
•Also the achieved comfort care, reduced
suffering, and supportive care
•There are certain symptom may appeared in
patient with cancer
•The goal of symptom management is to prevent
or treat as early as possible the symptoms that
can be arise in patient with cancer, side effects
caused by treatment of a cancer, and
psychological, social, and spiritual problems
related to a cancer or its treatment.
•Also the achieved comfort care, reduced
suffering, and supportive care
Symptoms at Advanced Stage of the
cancer and End of Life
•Current literature emphasizes that too many people still die in pain
•Equally or even more distressing are:
-Fatigue (asthenia)
-Anorexia/Cachexia
-Drowsiness or Insomnia
-Confusion, Anxiety, and Depression
-Dyspnea
-Dyspepsia
-Hiccup
-Intestinal obstruction
-Nausea and Vomiting
-Constipation & Diarrhea
-Edema
-Skin Problem
cancer and End of Life
•Current literature emphasizes that too many people still die in pain
•Equally or even more distressing are:
-Fatigue (asthenia)
-Anorexia/Cachexia
-Drowsiness or Insomnia
-Confusion, Anxiety, and Depression
-Dyspnea
-Dyspepsia
-Hiccup
-Intestinal obstruction
-Nausea and Vomiting
-Constipation & Diarrhea
-Edema
-Skin Problem
Effects on Quality of Life
Physical suffering Inability to enjoy remaining
life:
•Simple tasks become a challenge
•Isolated from loved ones
•Unable to fulfill remaining life goals
•Worst fears about dying become realized
•Destruction of hope for any quality of life
Physical suffering Inability to enjoy remaining
life:
•Simple tasks become a challenge
•Isolated from loved ones
•Unable to fulfill remaining life goals
•Worst fears about dying become realized
•Destruction of hope for any quality of life
Quality of End-of-Life Care
•The Patients’ View: FIVE Components of
Quality End-of-Life Care
1)Adequate pain and symptom management
2) Avoiding inappropriate prolongation of dying
3) Achieving a sense of control
4) Relieving burden
5) Strengthening relationships with loved ones
•The Patients’ View: FIVE Components of
Quality End-of-Life Care
1)Adequate pain and symptom management
2) Avoiding inappropriate prolongation of dying
3) Achieving a sense of control
4) Relieving burden
5) Strengthening relationships with loved ones
Patient & Family Education
Education on likely course of illness, symptoms &
possible complications :
1. Decreases natural fear & anxiety of the
“unknown”
2. Develops a plan to alleviate/control symptoms
3. Facilitates decision-making & helps plan for
future
4. Helps patients and families to know when to seek
prompt medical attention
5. Dispels myth that dying = unavoidable suffering
Education on likely course of illness, symptoms &
possible complications :
1. Decreases natural fear & anxiety of the
“unknown”
2. Develops a plan to alleviate/control symptoms
3. Facilitates decision-making & helps plan for
future
4. Helps patients and families to know when to seek
prompt medical attention
5. Dispels myth that dying = unavoidable suffering
Approach to Symptom Management
•„Multidisciplinary team approach
•„“Around the clock” medication for continuous
symptoms „
•Breakthrough medication „
•Symptom diary „
•Rating symptoms on a scale (ESAS/PPS/KPS)
•„Frequent re-assessments „
•Palliative care consult if uncertain, not
responding or difficult to control
•„Multidisciplinary team approach
•„“Around the clock” medication for continuous
symptoms „
•Breakthrough medication „
•Symptom diary „
•Rating symptoms on a scale (ESAS/PPS/KPS)
•„Frequent re-assessments „
•Palliative care consult if uncertain, not
responding or difficult to control
Asthenia
•„Most distressing symptom in patients „with CA
Easy tiring, generalized weakness, or mental
tiredness „May be seen as sign of “failure” or
“giving up” by dying person and loved ones „
Difficult to assess.
•Some tools available:
1. Edmonton Functional Assessment Tool (EFAT)
2. Fatigue self-report scale
3. Fatigue symptom checklist
•„Most distressing symptom in patients „with CA
Easy tiring, generalized weakness, or mental
tiredness „May be seen as sign of “failure” or
“giving up” by dying person and loved ones „
Difficult to assess.
•Some tools available:
1. Edmonton Functional Assessment Tool (EFAT)
2. Fatigue self-report scale
3. Fatigue symptom checklist
Etiology of Asthenia
•Likely multifactorial: ƒ
•Direct tumor effects on energy ƒ
•Paraneoplasticsyndromes ƒ
•Humoraland hormonal influences ƒ
•Anemia ƒ
•Chronic infections ƒ
•Sleep disturbances ƒ
•Fluid & electrolyte disturbances ƒ
•Drugs ƒOver-exertion
•Likely multifactorial: ƒ
•Direct tumor effects on energy ƒ
•Paraneoplasticsyndromes ƒ
•Humoraland hormonal influences ƒ
•Anemia ƒ
•Chronic infections ƒ
•Sleep disturbances ƒ
•Fluid & electrolyte disturbances ƒ
•Drugs ƒOver-exertion
Anorexia/Cachexia Syndrome
•„Weight loss, anorexia, fatigue, chronic nausea „
•Inflammatory process, loss of fat and muscle
tissue „
•Very common in advanced illness „
•Frequently associated with asthenia „
•May be seen as sign of “failure” or “giving up” „
•Increased nutrition often does NOT reverse or
improve cachexia „
•Increased nutrition will not halt disease
progression
•„Weight loss, anorexia, fatigue, chronic nausea „
•Inflammatory process, loss of fat and muscle
tissue „
•Very common in advanced illness „
•Frequently associated with asthenia „
•May be seen as sign of “failure” or “giving up” „
•Increased nutrition often does NOT reverse or
improve cachexia „
•Increased nutrition will not halt disease
progression
Anorexia/Cachexia
•„Etiologies not well understood:
•1. Hormonal mediators
•2. Humoralmediators: IL-1, IL-6, TNF, leukemia
inhibitory factor, D factor
•3. Host-tumor factors
•4. Alterations in metabolism
•5. Greater energy expenditure than supply
•„Etiologies not well understood:
•1. Hormonal mediators
•2. Humoralmediators: IL-1, IL-6, TNF, leukemia
inhibitory factor, D factor
•3. Host-tumor factors
•4. Alterations in metabolism
•5. Greater energy expenditure than supply
Anorexia/Cachexia-Treatment
•Search for and treat specific causes
contributing to secondary cachexia: 1.
Nausea/vomiting 2. Anxiety 3. Pain 4.
Constipation/diarrhea „
•If no specific cause found, treat anorexia if: 1.
Quality of life = enjoyment of food 2. To give
sense of normalcy in daily living
•Search for and treat specific causes
contributing to secondary cachexia: 1.
Nausea/vomiting 2. Anxiety 3. Pain 4.
Constipation/diarrhea „
•If no specific cause found, treat anorexia if: 1.
Quality of life = enjoyment of food 2. To give
sense of normalcy in daily living
Non-Pharmacological Interventions
•„Educate:
1. Common part of dying process
2. Natural endorphins prevent hunger „
•Encourage trials of favorite foods „
•Avoid gastric irritants: e.g. spicy foods, milk „
•Small frequent meals „
•Avoid disagreeable or nauseating smells „
•Nutritional supplements
•„Educate:
1. Common part of dying process
2. Natural endorphins prevent hunger „
•Encourage trials of favorite foods „
•Avoid gastric irritants: e.g. spicy foods, milk „
•Small frequent meals „
•Avoid disagreeable or nauseating smells „
•Nutritional supplements
Pharmacological Interventions
(Appetite Stimulation)
•Steroids: mechanism not clear–? Euphoria/ PG
inhibition dexamethasone 2-4 pomg BID
benefit may decrease after 4-6 weeks „
•Progesterone Drugs: mechanism not clear –
inhibits production of cachexin/TNF ? appetite
stimulant SE: nausea/edema/hypercalcemia
cushingnoid/decreased survival
-megestrolacetate: 200 mg q6-8h range 480-
1600 mg/day
(Appetite Stimulation)
•Steroids: mechanism not clear–? Euphoria/ PG
inhibition dexamethasone 2-4 pomg BID
benefit may decrease after 4-6 weeks „
•Progesterone Drugs: mechanism not clear –
inhibits production of cachexin/TNF ? appetite
stimulant SE: nausea/edema/hypercalcemia
cushingnoid/decreased survival
-megestrolacetate: 200 mg q6-8h range 480-
1600 mg/day
Dyspnea
oIt is subjective uncomfortable difficulty of
breathing sensation associated with…
Breathlessness
Shortness of breathing
Air hunger
oA complex experience of
mind and body that is likely
to progress with disease severity
oIt is subjective uncomfortable difficulty of
breathing sensation associated with…
Breathlessness
Shortness of breathing
Air hunger
oA complex experience of
mind and body that is likely
to progress with disease severity
Prevalence of dyspneawith cancer
patients
•The prevalence of dyspneavaries with the primary tumorsite.
•dyspneaoccurs as a symptom most frequently in lung cancer,
-it may be affected 75% of people with primary disease of the
lung, bronchus and trachea.
•Significant correlation with impaired quality of life and poor
survival.
•Effects Patients and Carers.
•A common complex distressing symptom at the end of life
patients
•The prevalence of dyspneavaries with the primary tumorsite.
•dyspneaoccurs as a symptom most frequently in lung cancer,
-it may be affected 75% of people with primary disease of the
lung, bronchus and trachea.
•Significant correlation with impaired quality of life and poor
survival.
•Effects Patients and Carers.
•A common complex distressing symptom at the end of life
Causes of dyspneain patient with cancer
1.Direct tumoreffects
2.Indirect tumor effects
3.Treatment-related
4.Unrelated to cancer
1.Direct tumoreffects
2.Indirect tumor effects
3.Treatment-related
4.Unrelated to cancer
Management
•Treatment of underlying disease with RTx, CTx,
antimicrobial
•Pharmacological agents
1.Steroids –to decrease local inflammation
2.Opioids and anxiolytics –decrease pain & anxiety
3.Bronchodilators –increase air flow to lungs
4.Diuretics –decrease fluid overload
•Supplements O2, as indicated
•Treatment of underlying disease with RTx, CTx,
antimicrobial
•Pharmacological agents
1.Steroids –to decrease local inflammation
2.Opioids and anxiolytics –decrease pain & anxiety
3.Bronchodilators –increase air flow to lungs
4.Diuretics –decrease fluid overload
•Supplements O2, as indicated
Non Pharmacological Management
•Positioning
•Airflow -use of fan /window
•Relaxation / Distraction/ Reassurance
•Energy conservation / rest
•Controlled Breathing techniques /physiotherapy
•Loose clothing
•Mouth Care
•Positioning
•Airflow -use of fan /window
•Relaxation / Distraction/ Reassurance
•Energy conservation / rest
•Controlled Breathing techniques /physiotherapy
•Loose clothing
•Mouth Care
Hemoptysis
•„Ranges from streaking of sputum to massive
bleeding > 200 cc/24 hrs„Frightening „Thankfully
rare! „
•Etiologies: tumor, bronchitis, pneumonia,
pulmonary embolism, low platelets,
coagulopathy „
•If massive :
-MD at bedside Opioids/ Benzodiazepines iv/sc
push „
-Hide with dark towels
•„Ranges from streaking of sputum to massive
bleeding > 200 cc/24 hrs„Frightening „Thankfully
rare! „
•Etiologies: tumor, bronchitis, pneumonia,
pulmonary embolism, low platelets,
coagulopathy „
•If massive :
-MD at bedside Opioids/ Benzodiazepines iv/sc
push „
-Hide with dark towels
Nausea/Vomiting
•„Nausea: caused by stimulation of GI lining,
chemoreceptor trigger zone in base of fourth
ventricle, vestibular apparatus or cerebral cortex „
•Vomiting: a neuromuscular reflex centered in the
medulla oblongata „
•Mediators: serotonin, dopamine, acetylcholine,
histamine „
•Origin in cerebral cortex = learned response
(anticipatory nausea)
•„Nausea: caused by stimulation of GI lining,
chemoreceptor trigger zone in base of fourth
ventricle, vestibular apparatus or cerebral cortex „
•Vomiting: a neuromuscular reflex centered in the
medulla oblongata „
•Mediators: serotonin, dopamine, acetylcholine,
histamine „
•Origin in cerebral cortex = learned response
(anticipatory nausea)
Constipation
•Constipation Presents as: „pain, „bloating „
nausea, vomiting,„overflow incontinence ,
fecal impaction,„bowel obstruction.
•Etiologies of Constipation „Drugs „Metabolic „
Diet „Motility „Spinal cord compression „
Mechanical obstruction „Dehydration „
Autonomic dysfunction „Ileus.
•Constipation Presents as: „pain, „bloating „
nausea, vomiting,„overflow incontinence ,
fecal impaction,„bowel obstruction.
•Etiologies of Constipation „Drugs „Metabolic „
Diet „Motility „Spinal cord compression „
Mechanical obstruction „Dehydration „
Autonomic dysfunction „Ileus.
Constipation —Treatment
•Non-Pharmacological: „
-Scheduled toileting „
-Position: sit up „
-Encourage fluid intake if not in advanced stages of illness „
-Avoid bulk agents e.gbran Æ may precipitate obstruction
•Pharmacological „
-Stimulant laxatives „
-Osmotic laxatives „
-Detergent laxatives (stool softener) „
-Prokineticagents „
-Enemas: lubricant stimulants large volume enemas „
-Opioid antagonist
•Non-Pharmacological: „
-Scheduled toileting „
-Position: sit up „
-Encourage fluid intake if not in advanced stages of illness „
-Avoid bulk agents e.gbran Æ may precipitate obstruction
•Pharmacological „
-Stimulant laxatives „
-Osmotic laxatives „
-Detergent laxatives (stool softener) „
-Prokineticagents „
-Enemas: lubricant stimulants large volume enemas „
-Opioid antagonist
Diarrhea
•„More than 3 loose stools/ 24-hour period „
•„If occurs > 3 weeks = chronic „
•At EOL commonly due to overuse of laxatives
or infection/bacteria or Candida overgrowth
•„May lead to: dehydration malabsorption
fatigue hemorrhoids perianal skin breakdown
electrolyte imbalance
•„More than 3 loose stools/ 24-hour period „
•„If occurs > 3 weeks = chronic „
•At EOL commonly due to overuse of laxatives
or infection/bacteria or Candida overgrowth
•„May lead to: dehydration malabsorption
fatigue hemorrhoids perianal skin breakdown
electrolyte imbalance
Diarrhea
•„Non-Pharmacological Interventions: „
Rehydration, electrolyte correction „Avoid
milk, gas forming foods „Hold laxatives „
Consider bulk agents such as bran but use
with caution.
•Pharmacological Interventions:
„-„Mucosal prostaglandin inhibitors
-Opioids –codeine, loperamide.
•„Non-Pharmacological Interventions: „
Rehydration, electrolyte correction „Avoid
milk, gas forming foods „Hold laxatives „
Consider bulk agents such as bran but use
with caution.
•Pharmacological Interventions:
„-„Mucosal prostaglandin inhibitors
-Opioids –codeine, loperamide.
Dyspepsia
•Dyspepsia is a common condition and usually describes
a group of symptoms rather than one predominant
symptom. These symptoms include:
•Belly pain or discomfort.
•Bloating.
•Feeling uncomfortably full after eating.
•Nausea.
•Loss of appetite.
•Heartburn.
•Burping up food or liquid (regurgitation).
•Dyspepsia is a common condition and usually describes
a group of symptoms rather than one predominant
symptom. These symptoms include:
•Belly pain or discomfort.
•Bloating.
•Feeling uncomfortably full after eating.
•Nausea.
•Loss of appetite.
•Heartburn.
•Burping up food or liquid (regurgitation).
Management
●Clarification; Explanation:
–Nature of the problem.
–What is ulcer & non-ulcer dyspepsia.
–Prognosis:
•Ulcer dyspepsia can be treated effectively.
•Non-ulcer remains recurrent since the cause is
unclear.
●Clarification; Explanation:
–Nature of the problem.
–What is ulcer & non-ulcer dyspepsia.
–Prognosis:
•Ulcer dyspepsia can be treated effectively.
•Non-ulcer remains recurrent since the cause is
unclear.
Hiccups
•Are involuntary contractions of the diaphragm
muscle.
•thediaphragmmuscle is separated chest from
abdomen and plays an important role in breathing.
•Each contraction is following by a sudden
closure of vocal cords,
which produces
the characteristic "hic" sound.
•Are involuntary contractions of the diaphragm
muscle.
•thediaphragmmuscle is separated chest from
abdomen and plays an important role in breathing.
•Each contraction is following by a sudden
closure of vocal cords,
which produces
the characteristic "hic" sound.
Management
•Most cases of hiccups go away on their own without
medical treatment.
•If an underlying medical condition is causing a hiccups,
treatment of that illness may eliminate the hiccups.
•Drugs that may be used to treat long-term hiccups
include:
-Baclofen
-Chlorpromazine
-Metoclopramide
•Surgical phrenicnerve ablation
•Most cases of hiccups go away on their own without
medical treatment.
•If an underlying medical condition is causing a hiccups,
treatment of that illness may eliminate the hiccups.
•Drugs that may be used to treat long-term hiccups
include:
-Baclofen
-Chlorpromazine
-Metoclopramide
•Surgical phrenicnerve ablation
Bowel Obstruction
•Bowel obstruction any process preventing
forward movement of bowel contents
•Mechanical obstruction (partial or complete)
–most common in end stage of cancer.
•Functional obstruction –caused by changes in
peristalsis.
•Location (small bowel
or large bowel)
•Bowel obstruction any process preventing
forward movement of bowel contents
•Mechanical obstruction (partial or complete)
–most common in end stage of cancer.
•Functional obstruction –caused by changes in
peristalsis.
•Location (small bowel
or large bowel)
Large Bowel
•Colon Cancer
•Diverticulitis
•Extrinsic Cancer
•Fecal Impaction
•Intussusception
•Volvulus
•Incarcerated Hernias
Small Bowel
•Adhesions
•Malignancy
•External or Internal Hernia
•Volvulus
•Crohn’sDisease
•Intra-abdominal Abscess
•Colon Cancer
•Diverticulitis
•Extrinsic Cancer
•Fecal Impaction
•Intussusception
•Volvulus
•Incarcerated Hernias
Small Bowel
•Adhesions
•Malignancy
•External or Internal Hernia
•Volvulus
•Crohn’sDisease
•Intra-abdominal Abscess
Management
oFluid and TPN
oNG tube:
–Could be useful for a quick relief of gastric distension and
improve nausea and vomiting
oSurgery
–Resection/debulking….primary anastomosis
–Bypass surgery
–Defunctioningcolostomy/ileostomy
–Gastric & colonic stenting
oFluid and TPN
oNG tube:
–Could be useful for a quick relief of gastric distension and
improve nausea and vomiting
oSurgery
–Resection/debulking….primary anastomosis
–Bypass surgery
–Defunctioningcolostomy/ileostomy
–Gastric & colonic stenting
Lymphedema
•Excessive and persistent
accumulation of
extravascularand
extracellular
fluid and proteins
in tissue spaces
due to obstruction in
lymphatic system
•Excessive and persistent
accumulation of
extravascularand
extracellular
fluid and proteins
in tissue spaces
due to obstruction in
lymphatic system
Pathophysiology
•Occlusion or damage to capillary or
•Decrees reabsorptionof Lf ( water, proteins,
fat and waste from cells)
•Thereby causing of swelling and edema.
•Also develops when lymph vessels or lymph
nodes are missing, impaired, damaged or
removed
•Occlusion or damage to capillary or
•Decrees reabsorptionof Lf ( water, proteins,
fat and waste from cells)
•Thereby causing of swelling and edema.
•Also develops when lymph vessels or lymph
nodes are missing, impaired, damaged or
removed
Pathophysiology
•Primary lymphedema–rare, caused by absent lymph
vessels at birth, or caused by abnormal lymphatic
vessels.
•Secondary lymphedema
-Due to blockage or interruption that alters the
lymphatic system.
-can develop from infection, malignancy, surgery, scar
tissue formation, trauma, deep vein thrombosis (DVT),
radiation or other cancer treatment.
•Primary lymphedema–rare, caused by absent lymph
vessels at birth, or caused by abnormal lymphatic
vessels.
•Secondary lymphedema
-Due to blockage or interruption that alters the
lymphatic system.
-can develop from infection, malignancy, surgery, scar
tissue formation, trauma, deep vein thrombosis (DVT),
radiation or other cancer treatment.
Lymphedema Location
Components of a Decongestive
Lymphatic Therapy Program
•Elevation
•Manual lymphatic drainage
•Compression
•Exercise
•Skin care
•Daily living precautions
•„Limit fluid intake „
•Increase intake of salty foods „„
•TEDS stockings to improve venous return
•Diuretics
Lymphatic Therapy Program
•Elevation
•Manual lymphatic drainage
•Compression
•Exercise
•Skin care
•Daily living precautions
•„Limit fluid intake „
•Increase intake of salty foods „„
•TEDS stockings to improve venous return
•Diuretics
Skin Ulcers
•„Skin care is poorly taught „
•Often related to nursing staff „
•Can cause: significant pain isolation odors infections „
•Management is preventive „Team approach
•Skin protection:
•Keep skin clean and dry „
-Avoid iodine containing solutions „
-Protect pressure points with dressings „
-Use draw sheets to move/turn patient „
-Use foam pads (not donuts) „
-Special mattresses –air or air flotation
•„Skin care is poorly taught „
•Often related to nursing staff „
•Can cause: significant pain isolation odors infections „
•Management is preventive „Team approach
•Skin protection:
•Keep skin clean and dry „
-Avoid iodine containing solutions „
-Protect pressure points with dressings „
-Use draw sheets to move/turn patient „
-Use foam pads (not donuts) „
-Special mattresses –air or air flotation
Pressure Ulcers
•Stage I: precursor stage –red, blanches with
pressure „
Stage II: does not blanch, excoriated,
vesiculation, epidermal breakdown „
Stage III: full thickness skin loss, not extending
into subcutaneous tissue, serosanguinous
drainage „
Stage IV: ulcer into subcutaneous fat, deep
fascia, destruction of muscle, osteomyelitis
•Stage I: precursor stage –red, blanches with
pressure „
Stage II: does not blanch, excoriated,
vesiculation, epidermal breakdown „
Stage III: full thickness skin loss, not extending
into subcutaneous tissue, serosanguinous
drainage „
Stage IV: ulcer into subcutaneous fat, deep
fascia, destruction of muscle, osteomyelitis
Odors
•„Result of infection, poor hygiene „
•Treat superficial infections with topical
metronidazole or silver sulfadiazine „
•If spread to soft tissue consider systemic
metronidazole „
•Non-pharmacological Rx:
1. open windows/doors
2. kitty litter/activated charcoal in pan under bed
3. burning candles „
4. cup of vinegar in room
•„Result of infection, poor hygiene „
•Treat superficial infections with topical
metronidazole or silver sulfadiazine „
•If spread to soft tissue consider systemic
metronidazole „
•Non-pharmacological Rx:
1. open windows/doors
2. kitty litter/activated charcoal in pan under bed
3. burning candles „
4. cup of vinegar in room
FungatingWounds
•Definition
•“Fungatingwounds are products of cancerous
infiltration of the epithelium . . . which
develop into a FUNGATING mass or
ULCERATIVE lesion with subsequent
infection, pain, bleeding and maloderous
exudate.”
•Definition
•“Fungatingwounds are products of cancerous
infiltration of the epithelium . . . which
develop into a FUNGATING mass or
ULCERATIVE lesion with subsequent
infection, pain, bleeding and maloderous
exudate.”
A fungatingwound may develop in the
following ways:
•As a result of a primary skin tumor such as
squamouscell carcinoma or melanoma.
-most common basal cell ca
•Through direct invasion of the structures of the
skin by an underlying tumor, for example
breast cancer.
•From metastatic spread of a distant tumor.
following ways:
•As a result of a primary skin tumor such as
squamouscell carcinoma or melanoma.
-most common basal cell ca
•Through direct invasion of the structures of the
skin by an underlying tumor, for example
breast cancer.
•From metastatic spread of a distant tumor.
•A Primary Tumor invading up into and through
the skin like Breast tumor.
•As malignant cells
grow and divide,
the nodules enlarge
–interfere with skin
capillaries and lymph vessels
the skin like Breast tumor.
•As malignant cells
grow and divide,
the nodules enlarge
–interfere with skin
capillaries and lymph vessels
Treatments
•Surgery
-Used occasionally to reduce tumor mass but may not always
be possible due to bleeding, infection, etc.
•Chemotherapy
-Can decrease tumor mass
-Depends on tumor response
•Radiotherapy
-Can reduce the size of mass –controlling exudate, bleeding
and pain
-Adding radiotherapy reactions to wound
•Surgery
-Used occasionally to reduce tumor mass but may not always
be possible due to bleeding, infection, etc.
•Chemotherapy
-Can decrease tumor mass
-Depends on tumor response
•Radiotherapy
-Can reduce the size of mass –controlling exudate, bleeding
and pain
-Adding radiotherapy reactions to wound
Local treatments at wound interface
Control of pain
Control of Bleeding
-Oral/topical anti-fribrinolytics–Tranexamicacid.
Control of Infection
Metronidazole
Topical –(Anabact0.8% gel) and/or systemic 400 mg x BD
Control of Odour
Metronidazoleand charcoal +/-silver dressings
Sugarpasteand honey
Control of Exudates and necrosis
debridement, moist
Control of pain
Control of Bleeding
-Oral/topical anti-fribrinolytics–Tranexamicacid.
Control of Infection
Metronidazole
Topical –(Anabact0.8% gel) and/or systemic 400 mg x BD
Control of Odour
Metronidazoleand charcoal +/-silver dressings
Sugarpasteand honey
Control of Exudates and necrosis
debridement, moist
Anxiety and Depression
Anxiety
•Is mood state characterized by apprehension
and somatic symptoms of tension in which an
individual anticipates impending danger,
catastrophe, misfortune
•The future threat may be real, imagined,
internal, external, identifiable, more vague.
•It’s commonly with cancer
•Is mood state characterized by apprehension
and somatic symptoms of tension in which an
individual anticipates impending danger,
catastrophe, misfortune
•The future threat may be real, imagined,
internal, external, identifiable, more vague.
•It’s commonly with cancer
Management approach
•Physical symptoms treated
•Psycheducationalintervention
•Pharmacological management
•Complementary management
•Family education
•Supportive group
•Referral to licensed psychiatric
•Physical symptoms treated
•Psycheducationalintervention
•Pharmacological management
•Complementary management
•Family education
•Supportive group
•Referral to licensed psychiatric
Depression
•Mood state of feeling sadness, discouraged,
hapless and worthless
•Rangedfrom sadness and transitions to
majors psychotic disorder
•It’s affecton physical, cognitive, social well-
being
•Reactive dpression
•Mood state of feeling sadness, discouraged,
hapless and worthless
•Rangedfrom sadness and transitions to
majors psychotic disorder
•It’s affecton physical, cognitive, social well-
being
•Reactive dpression
Symptoms
•Appetite or weight change
•Insomnia
•Psychomotor agitation
•Loss of energy
•Feeling of worthlessness or guilt
•Difficulty of concentration or decision making
•Thought of death ( suicidal attempt)
•Appetite or weight change
•Insomnia
•Psychomotor agitation
•Loss of energy
•Feeling of worthlessness or guilt
•Difficulty of concentration or decision making
•Thought of death ( suicidal attempt)
Consequences of Depression in Cancer
•Maladaptive coping and abnormal illness behavior
•Poor Quality of Life
•Higher perception of pain
•Higher risk of suicide (and request for hastened
death)
•Possible action in reducing the efficacy of
chemotherapy
•Possible association with shorter survival time
•Reverberation on the family with risk of emotional
disorders in family members
•Maladaptive coping and abnormal illness behavior
•Poor Quality of Life
•Higher perception of pain
•Higher risk of suicide (and request for hastened
death)
•Possible action in reducing the efficacy of
chemotherapy
•Possible association with shorter survival time
•Reverberation on the family with risk of emotional
disorders in family members
Insomnia
•Insomnia or Sleep-wake disturbances are actual or
perceived changes in night sleep with resulting daytime
impairment.
•Sleep-wake disturbances have been reported in 30%–
75% of people with cancer.
•There are a number of demographic, lifestyle,
environment, disease, and treatment-related factors that
can increase the risk of sleeping problems in patients
with cancer
•including symptoms such as pain, nausea, anxiety,
depression, and hot flashes
•Insomnia or Sleep-wake disturbances are actual or
perceived changes in night sleep with resulting daytime
impairment.
•Sleep-wake disturbances have been reported in 30%–
75% of people with cancer.
•There are a number of demographic, lifestyle,
environment, disease, and treatment-related factors that
can increase the risk of sleeping problems in patients
with cancer
•including symptoms such as pain, nausea, anxiety,
depression, and hot flashes
Non-Pharmacological Interventions
•Regular schedule „
•Naps OK but avoid sleeping all day „
•Control symptoms „
•Avoid mental stimulation AND distress at night „
•Increase daytime physical activity „
•Relaxation therapy, music, imagery „
•Avoid stimulants, alcohol, steroids,
metamphetaminesat night „
•Extra bedding in case of cold
•Regular schedule „
•Naps OK but avoid sleeping all day „
•Control symptoms „
•Avoid mental stimulation AND distress at night „
•Increase daytime physical activity „
•Relaxation therapy, music, imagery „
•Avoid stimulants, alcohol, steroids,
metamphetaminesat night „
•Extra bedding in case of cold
Questions
Thank you
Thank you
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