یکتا خداوند نام بهپیشرفته سرطان به مبتال بیماران در جسمی مراقبتی درمان

قربانی راضیه دکتر

تسکینی طب تیم همکار عمومی پزشک

منابع GUIDELINES & PROTOCOLSADVISORY COMMITTEE 2011

نفس تنگیDyspnea

تعریف:می و دارد متغیر شدت که تنفس هنگام ناراحتی و اشکال

یا باشد ارتوپنه یا پنه تاکی ، هیپوکسمی با همراه تواند.نباشد

افتد 80در می اتفاق پیشرفته سرطان با بیماران درصد .

نفس تنگی ارزیابی ( نمره کند تعیین را خود نفس تنگی شدت که بخواهید بیمار 1از

(10تا . نمایید درمان نیاز صورت در و کنید مشخص را ای زمینه علل

اضطراب) ...( ریه، آمبولی ، آریتمی ، آنمی مثل تشخیص به منجر فیزیکی معاینه و حال شرح موارد سوم دو در

. شود می درست : آزمایشاتCBC/diff, electrolytes, creatinine,

oximetry +/- ABGs and pulmonary function, ECG : برداری Chest X-ray and CT scanتصویر

درمانی های استراتژی. است شده اثبات نفس تنگی عالمتی درمان برای ها اپیویید اثر( نفس تنگی درمان در شده استفاده درمانی morphineدوز

2.5-5 mg PO (SC dose is half the PO dose) q4h ). دهد نمی کاهش را خون اکسیژن میزان و تنفسی ریت

. است مفید هیپوکسمی رفع برای اکسیژن کیفیت و دهد می کاهش را بیمار رنج نفس تنگی موفق کنترل

. دهد می ارتقا را او زندگی همیشه حمایتی اقدامات و آموزش شامل دارویی غیر درمانهای

. هستند مهم : دارویی Opioids, +/- benzodiazepines orدرمانهای

neuroleptics, +/- steroids

اقدامات و دارویی غیر درمانهایحمایتی

( هوا مطبوع( / fanجریان هوای بیمار خوابیدن حالت گشاد لباس از استفاده و ها لباس کردن کم( سازی (Relaxationآرام تنفس کنترل انرژی ذخیره

What can be done? Sit in a chair or recliner Elevate your head on pillows when lying in bed Sit with your hands on your knees or on the side of the

bed leaning over the bedside table Practice pursed lip breathing technique. Take slow, deep

breaths, breathing in (inhale) through nose and then breathe out (exhale) slowly and gently through pursed lips (lips that are “puckered” as if you were going to whistle)

Increase air movement by opening a window, using a fan or air conditioner. Apply a cool cloth to your head or neck

Use oxygen as directed by your healthcare provider Take medication as directed by your doctor Keep your environment quiet to decrease feelings of

anxiety Use relaxing activities such as prayer, medication,

calming music, and massage Notify the team if your shortness of breath is not relieved

or gets

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

تسکینی طب متخصص با مشاوره

Palliative Sedation

یبوستConstipation

یبوست ارزیابی. است چگونه حاضر حال در و بیماری از قبل بیمار مزاج اجابت عادات. است مناسب دفع دفعات تعداد و دفع راحتی هدف در دفع دفعات کاهش باشد نداشته وجود بیمار برای ناراحتی که زمانی تا

. است قبول قابل دارند کمتری فع�الیت و غذا دریافت که بیمارانی

Constipation Management Strategies عوارض و حرکت و مایعات ، غذا دریافت کاهش مثل دارد وجود مختلفی علل

داروها . یا نوتروپنیک بیماران در مداخالت این بپرهیزید شیاف و انما مثل مداخالتی از

. هستند کنتراندیکه دارد وجود رکتال بیماری که هنگامی یا ترومبوسیتوپنیکFecal Impaction. شود می بررسی شکم ساده عکس و معاینه انجام با . کنید استفاده مداوم صورت به ها ملین از دارند وجود فاکتورها ریسک که زمانی

مقدار بیشترین باشند داشته دوز افزایش پاسخ طبق بر که زمانی ها ملین اثر(Bowel Protocolاست )

داروی درمان و پیشگیری .Sennosidesبرای است درمان اول خط

. کند می ایجاد نفخ و دارد ناخوشایندی مزه است اسموتیک ملین یک که الکتولوز های ملین و درمان اول خط از بعد ، اپیویید از ناشی یبوست با بیماران برای

. است کننده کمک نالتروکسان متیل ، اسموتیک

What can be done? Record when the bowel movements have occurred. Follow a regular bowel regimen, even if you are not

constipated (many medications can cause constipation) Drink as much fluid (liquids) as is comfortable. Drinking

warm liquids may promote bowel movement Eat more fruits and fruit juices, including prunes and

prune juice Increase physical activity if possible. Walking can be

beneficial Take laxatives/stool softeners as ordered by healthcare

provider Sit upright on toilet, commode or bedpan Establish routine times for toileting Avoid bulk laxatives if not taking enough fluids Notify hospice/palliative care team if constipation

continues

دلیریوم

What is delirium? A sudden change in a person’s metal

status over a period of hours to days Mental clouding with less awareness of

one’s environment Confusion about time, place and

person

What are the signs and symptoms of delirium?

Reversal of sleep and awake cycles “Sundowning” or confusion that is worse at night Mood swings that may change over the course of

a day Difficulty focusing attention or shifting attention Hallucinations or seeing, hearing or feeling things

which are not there Agitation and irritability Drowsiness and sluggishness May be restless and anxious

What can be done for delirium?

Delirium is common at the end-of-life. Keep the patient safe Remind the patient who you are when you assist with

caregiving. Tell them what you are going to do. For example, “I am going to help you get out of bed now”

Offering support such as “I am right here with you” Try to maintain a routine and structure Avoid asking a lot of questions Provide a quiet, peaceful setting, without TV and loud noises Play the patient’s favorite music Keep a nightlight on at night If starting a new medication, watch for improvement,

worsening or side effects and report to healthcare provider

Pharmacological Treatmentsin hypoactive patients

AVOID sedatives Haloperidol: minimum effective dose to

control hallucinations

Pharmacological Treatmentsin Hyperactive (agitated) patient

Antipsychotic Start with least sedating most sedating until agitation controlled haloperidol risperidone loxapine olanzapine quetiapine methotrimeprazine AVOID benzodiazepines Reassess frequently

ضعف و خستگی

Although most cancer patients report that fatigue is a major obstacle to maintaining normal daily activities and quality of life, it is seldom assessed and treated in clinical practice.

Fatigue is a highly prevalent condition among cancer patients.

What is fatigue? Tiredness, exhaustion, or lack of energy not

relieved by rest A condition which impacts your ability to

perform your usual or expected activities Seen frequently in hospice and palliative

care patients A complicated symptom which can have

many causes including disease, emotional state, and treatments

Sometimes comes with depressed feelings

What are the signs of fatigue?

“Just too tired” to perform your normal activities or routines

Lack of appetite or not having energy to eat

Sleepiness Not talking Depression

Cancer-related fatigue can be an expression of (pre-existing) depression and can also be a cause of depression.The two-question test consists of the following questions: “In the last month, have you often felt dejected, sad,

depressed, or hopeless?” “In the last month, have you gotten much less pleasure

than usual out of the things that you normally like to do?”

Fatigue Assessment خستگی پذیر برگشت علل درمان

Anemia Dehydration Hypokalemia Hyponatremia Hypomagnesemia Hypo/Hypercalcemia Hypothyroidism Medication induced Alcohol/drug abuse Infection Sleep disorder Obstructive Sleep Apnea Chronic Fatigue Syndrome

Non-pharmacological Treatments

Gradually increase your activity. Do so gradually in order to conserve energy

Keep a log of which time of day seems to be your best time Plan, schedule and prioritize activities at optimal times of the day Eliminate or postpone activities that are not your priority Change your position and do not just stay in bed Use sunlight or a light source to cue the body to feel energized Try activities that restore your energy, such as music, or

spending time outdoors in nature or meditation Allow caregivers to assist you with daily activities such as eating,

moving or bathing if necessary. Plan activities ahead of time Encourage your family to be accepting of your new energy pace

Rest and sleep better Listen to your body – rest as needed Establish and continue a regular bedtime and

awakening Avoid interrupted sleep time and try to get

continuous hours of sleep Plan rest times or naps during the day late

morning and mid afternoon Avoid sleeping later in the afternoon which could

interrupt your night time sleep Ask if using oxygen when you sleep will help you

to sleep better

Increase food intake Try nutritious, high protein food Small frequent meals Add protein supplements to foods or

drinks Frequent mouth care (before and after

meals) Ask about possible use of medications

to stimulate your appetite or relieve fatigue

Contraindications to exercise in patients with cancer

Absolute contraindications– acute illnesses– acute worsening or decompensation of chronic illness– fever above 38°C– pain– inadequately controlled arterial hypertension Relative contraindications

– anemia (hemoglobin below 8 g/dL)– thrombocytopenia, coagulopathy– bone metastases– accompanying illnesses such as coronary heart disease, occlusive peripheral arterial disease, arterial hypertension, diabetes mellitus, arthrosis– administration of cytostatic agents on the same day– mediastinal/cardiac radiation therapy– flu-like symptoms under immunotherapy– epilepsy

دارویی های درمانHematopoietic growth factorsPsychostimulants : فنیدیت متیلCorticosteroidsThyreoliberin (TRH)Phytotherapeutic agents (Ginseng)

عالئم در بهبودی بالینی مطالعات در ها دپرسانت آنتی از استفاده. است نداده نشان سرطان از ناشی خستگی

افسردگی

Depression occurs in 13-26% of patients with terminal illness

Patients are at high risk of suicide and have an increased desire for hastened death

A useful depression screening question is, “Have you been depressed most of the time for the past two weeks?”

A diagnosis of depression in the terminally ill may be made when at least two weeks of depressed mood is accompanied by symptoms of hopelessness, helplessness, worthlessness, guilt, lack of reactivity, or suicidal ideation

Risk factors personal or family history of depression, social isolation, concurrent illnesses (e.g., COPD, CHF), alcohol or substance abuse, poorly controlled pain, advanced stage of illness, certain cancers (head and

neck, pancreas, primary or metastatic brain cancers), chemotherapy agents (vincristine, vinblastine,

asparagines, intrathecal methotrexate, interferon, interleukin),

corticosteroids (especially after withdrawal), abrupt onset of menopause (e.g. withdrawal of

hormone replacement therapy, use of tamoxifen).

Management Strategies Non-pharmacological treatments are

the mainstay of treatment for the symptom of depression without a diagnosis of primary affective disorder

Treatment of pain and other reversible physical symptoms should occur before initiating antidepressant medication.

Non-pharmacological Treatment for Depression

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

What can be done for depression?

You may: Optimize physical status with rest and nutrition Set small, realistic, achievable goals Utilize relaxation techniques Consider complementary therapies such as

aromatherapy, art and music therapyYour caregiver may: Keep you and your area safe Let you know that they will be there Allow you to express feelings Allow you to control as much as possible

related to treatment decisions and activities

Edema (Swelling) Puffiness or swelling of legs, ankles,

feet, arms, face, or hands Clothes, shoes, rings, or watches that

feel too tight Skin that is shiny, feels tight, indents or

dimples when pressed Sudden weight gain

What can you do for the patient to prevent and treat edema?

Elevate the affected area when sitting or lying down

Remind them to avoid crossing legs when sitting, and avoid standing for long periods

Teach correct application and care if compression stockings (support stockings) are worn

Encourage limiting their intake of salt and sodium

How you can support the family Inform the family that they play an

important role in managing the edema Reinforce that sometimes edema may

not go away Reinforce that the goal is patient

comfort and edema may not be painful Teach them how to elevate affected

area (For example: use of pillows, recliner, and/or propping feet on a stool)

Let the family know that if moving the affected area appears to cause pain, tell the interdisciplinary team

SeizuresThe person having a seizure may have some or none of these signs. Muscle jerking/twitching (convulsion) Stiffening of the body Unable to awaken for a period of time Loss of bladder control Blurred vision, eyes rolling back, blank staring or

blinking Inability to speak, difficulty talking Sudden confusion or memory loss Recurring movements – chewing, lip smacking, clapping

What can you do for the patient?

If you are with a patient who is having a seizure it is important to keep in mind that

safety is the first concern

How can you support the family?

Remain with the patient throughout the seizure Encourage the family to remain calm Family members may believe the patient will “swallow” his/her

tongue. This is not possible, though the tongue may “relax” in the pack of the throat causing the airway to be obstructed. If it is determined the patient is not breathing after a seizure, reposition his/her head to open the airway and administer breaths if necessary

Discourage the family from restraining the patient or placing anything in his/her mouth, which could cause injury to the patient or family member

Family members may have been instructed by a nurse or doctor to administrate certain anti-seizure or sedating drugs during the seizure

Contact the hospice or palliative care nurse if you have any questions or concerns

Self-Care for the CaregiverPhysical needs Remember to take care of your own health Keep your own doctor appointments Schedule time to eat. Have at least 3 healthy but simple meals a

day Learn to make meals in advance. Ask friends/family if they could

help with making meals Ask how best to provide care to your loved one and prevent

injuring yourself Take time to rest, especially if sleeping has become hard for your Avoid/limit the use of tobacco and alcohol as they make it difficult

to fall asleep Try to get some form of exercise in the day Take time alone. This can include walking, reading, listening to

music, baths, praying, gardening, etc.

Communication needs Tell people about your worries. These people

may be family, friends, or some of the healthcare providers working with you to help care for your loved one

Be informed! Ask what signs and symptoms to expect from the patient so that you are prepared to deal with them

Get organized and set realistic goals for your day. Keep it real and be flexible. Set limits

Ask others to help with whatever you or your loved one needs

Emotional/spiritual needs Keep relationships with family and friends to avoid feeling alone. If it is

difficult for you to get out, ask people to come visit. Let people take care of you and allow your loved one to say thank you for all you do

Work with your team to provide time to get out of the home to enjoy social activities or attend support groups. When possible, keep doing favorite activities. Try to keep things simple

Talk about your fears about what is happening to your loved one. Also, talk about any concerns or frustrations you may have

Even though you are feeling stressed, tell yourself every day you are doing a great job

Let your hospice/palliative staff know if you are feeling overwhelmed. Your team has ways to help, including nursing assistants and other resources

Attend to your spiritual needs by calling or visiting your clergy, church or synagogue

Have your own “special space.” This can be your room, a chair, a table, etc. Someplace that is yours where you can go unwind

Seek additional professional help if you are feeling scared, helpless, lost, or depressed

Breathe and laugh