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END-OF-LIFE CARE: Module 5 Non-Pain Symptom Management Module #5

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Case Imagine you have progressed pancreatic growth. You've lost 30 pounds in the course of recent months. There is no proof of GI obstacle and you are not sickened. You are exceptionally powerless, and are presently laid up, with no hunger. Your mouth is dry. Your mate continues attempting to inspire you to eat and you attempt, yet you can't do it. You continue asking why this is occurring, and your life partner is extremely disturbed. You are admitted to the doctor's facility and lab tests uncover that you are got dried out. The assistant comes to embed an IV. Module #5

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Learning Objectives Increase comprehension of how physical and mental elements influence symptomatology Be ready to utilize this comprehension in the treatment of patients experiencing sickness and heaving, dyspnea, and cachexia/anorexia/asthenia Incorporate this substance into your clinical showing Module #5

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Outline of Module Non-torment side effects at EOL Symptom investigation agenda Nausea and spewing Break Dyspnea 'Terminal Syndrome Characterized by Retained Secretions' Cachexia/anorexia/asthenia Module #5

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Symptoms as Clues A physical or mental marvel, situation or change of condition emerging from and going with a confusion and constituting proof for it … particularly a subjective marker distinguishable to the patient and rather than a goal one (contrast and sign). The New Shorter Oxford English Dictionary Module #5

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Disease as a Clue to the Symptom Questions to ask: How does the infection offer ascent to the manifestation? What subjective, full of feeling, and profound segments are included? Module #5

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From the Patient's Perspective A side effect is what is irksome Module #5

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Physiological Factors Local Central Mental Factors Cognitive Affective Spiritual Symptom Analysis Checklist Module #5

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Physiological components Local: Central: Mental Factors Cognitive: Affective: Spiritual: Skills Practice: Patient with agony side effects because of metastatic bone malignancy Module #5

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Non-Pain Symptoms at the EOL Akathesia Anhedonia Anorexia Anxiety Colic Confusion Constipation Cough Crying Death shake/discharges Diarrhea Dizziness Drooling Dry skin Dysarthria Dysgeusia Dyspepsia Dysphagia Dysphoria Dyspnea Dysuria Failure to flourish Fatigue Fear Fecal incontinence Fever Flatulence Halitosis Hallucinations Hearing misfortune Hiccups Impotence Irritability Memory misfortune Mucositis Muscle fits Nausea Odor Panic assaults Peripheral edema Photosensitivity Polydipsia Polyuria Pruritus Restlessness Sexual brokenness Sleep issue Stomatitis Taste changes Urinary recurrence Urinary incontinence Visual issues Vomiting Xerostomia Index, Oxford Textbook of Palliative Medicine, 1998 Module #5

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Nausea & Vomiting When you were an inhabitant (or in the event that you are an occupant now: when you were in restorative school), what were you educated about antiemetics? Module #5

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Nausea & Vomiting As Protective Mechanisms Serial hindrances: 1. Locate, notice, taste 2. Chemoreceptors and mechanoreceptors 3. Mind receptors 4. Message to regurgitation leftover gut substance Module #5

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A Central Final Pathway for Nausea (Dopamine, Serotonin) (???) CNS CTZ VOMIT CENTER (Acetylcholine, Histamine) Vestibular Apparatus GI Tract (Acetylcholine, Histamine) (Acetylcholine, Histamine, Serotonin + mechanoreceptors) Module #5

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Receptor Affinity Common Antiemetics Drug Receptors Dopamine Musc. Chol. Histamine Scopalomine >10,000 .08 >10,000 Promethazine 240 21 2.9 Prochlorperazine 15 2100 100 Chlorpromazine 25 130 28 Metoclopramide 270 >10,000 1,000 Haloperidol 4.2 >10,000 1,600 Potency: K1 (nanomolar) The lower the number, the more grounded this specialist is at hindering this receptor Adapted from Peroutka and Snyder, 1982 Module #5

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Causes of Nausea & Vomiting V estibular O bstruction M ind Dys m otility I nfection ( i rritation) T oxins ( t aste and different faculties) Module #5

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Vestibular Apparatus Nausea with head development Medicated by acetylcholine and histamine receptors Most anticholinergic, antihistamine medications will help Module #5

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Obstruction/Opioids Constipation = most normal cause External or inward hindrance Mediated by mechanoreceptors as well as chemoreceptors Controversy as to best drug for genuine inside obstacle Anti-clogging meds for blockage Module #5

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Mind Memory, which means, and feelings can be capable Manipulate taste and different faculties Module #5

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Dysmotility Multiple causes Upper intestinal dysmotility is extremely basic Prokinetics : Metoclopramide (upper just) Senna (bring down just) Module #5

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Infection/Irritation Mediated through chemoreceptors Gut and adjoining organ aggravation can trigger Anticholinergic/antihistaminic solutions can help Module #5

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Toxins Most essential source: meds Various components of prompting queasiness Treatment relies on upon system of activity Module #5

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Opioid-Related Nausea Incidence of dysmotility brought about by opioids might be thought little of Haloperidol prescribed for sickness identified with chemoreceptor trigger zone (CTZ) Module #5

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5HT3 Antagonists May have an assortment of employments Minimally tried outside of their utilization in chemotherapy-related queasiness Expensive Module #5

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Symptom Analysis Checklist Physiological Factors Local Central Mental Cognitive Affective Spiritual Module #5

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Exercise 1: The Runner Are you dyspneic? Shy of breath? What is your O 2 immersion level? What is going on locally in you mid-section? What do you think about your run? Any otherworldly significance? It is safe to say that you are enduring? Module #5

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Exercise 2: Being Held Under Water Are you dyspneic? Shy of breath? What is your O 2 immersion level? What is going on locally in you mid-section? What do you think about your run? Any profound significance? Is it true that you are enduring? Module #5

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Exercise 3: Lung Cancer Imagine that you have lung growth, on top of prior COPD You are getting winded with the slightest conceivable work out. Returning from the washroom to the bed you are currently extremely dyspneic You wish there was a window you could open The medical caretaker measures your O 2 Sat There is a low-pitched beeping sound, which you know is bad The attendant looks troubled and surges from the room Module #5

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Treating Dyspnea Physiological Factors Local: Fan, cool wind Central: WOB might be especially receptive to low dosage opioids Mental elements Cognitive: Education, reframing Affective: Emotional support, benzodiazepines for frenzy sensation Module #5

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Dyspnea in the Dying Common -70% of patients in most recent 6 weeks of life Reuben & Mor, 1986 Care has generally concentrated more on lung physiology than focal procedures Not generally connected with oxygen level Module #5

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'Terminal Syndrome Characterized by Retained Secretions' Relative absence of hack Not generally connected with dyspnea Deep suctioning insufficient Hydration may surge lungs Because patient can't hack Use of anti-microbials, IV liquids dubious Module #5

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Treatment of this Terminal Syndrome Peaceful environment For dyspnea Opioid-gullible: 2-4 mg SC morphine or equal q1-2 hours On opioid: increment measurements by 25% Lorazepam or chlorpromazine for fomentation For discharges Oxygen, fan Module #5

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Case Exercise Imagine you have progressed pancreatic disease. You've lost 30 pounds in the course of recent months. There is no confirmation of GI hindrance and you are not disgusted. You are exceptionally frail, and are presently confined to bed, with no craving. Your mouth is dry. Your companion continues attempting to motivate you to eat and you attempt, however you can't do it. You continue asking why this is going on, and your life partner is extremely disturbed. You are admitted to the healing facility and lab tests uncover that you are got dried out. The understudy comes to embed an IV. Module #5

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Definitions Cachexia = physical squandering Anorexia = absence of craving Asthenia = shortcoming, exhaustion Module #5

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Physiological Mechanisms Complex physiology Best concentrated on in malignancy Key finding: Not the same as starvation Significant physiological contrasts Often not switched by simulated sustaining Module #5

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Cachexia/Anorexia/Asthenia Strongly related with diminished utilitarian status Associated with various misfortunes -Appetite and joy in eating -Energy level -Independence -Activities of day by day living Module #5

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Medical Interventions Treat basic sickness, torment, misery Artificial encouraging might be suitable To expand hunger Megestrol acetic acid derivation Steroids Cannabinoids Transfusion for weakness May or may not enhance asthenia Module #5

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Psychological Interventions Treat fundamental wretchedness Address misfortune in patient and family Reflect back misfortunes of supporting, practical status and freedom Help quiet/family reclassify these misfortunes Coach in better approaches to sustain Consider treatments to make up for useful misfortune Module #5

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Artificial Hydration toward the End of Life is Controversial Module #5

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Brainstorm What are a few contentions on both sides of the EOL fake hydration discussion? Module #5

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In Favor: Minimum standard of care ? More noteworthy solace ? Less disarray, eagerness Against: Not clear that it draws out life Increases pee yield, GI emissions/queasiness, & aspiratory discharges with pneumonia Not clear that it mitigates thirst Decreasing liquids goes about as normal anesthesia Some Arguments... Module #5

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Medical Issues Aside… Some favor a more 'normal demise' without counterfeit hydration Others may consider hydration to be insignificant, accommodating (if specialized) bolster Important to take tolerant objectives and situ