Palliative Care in Gynaecological Malignancies Flashcards

1
Q

what physical symptoms do patients usually experience in gynaecological malignancies?

A
pain 
nausea and vomiting 
constipation 
bleeding 
treatment related (eg chemotherapy)
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2
Q

what emotional and psycho-social symptoms may patients experience in relation to gynaecological malignancy?

A

fear
worry about future
why me?
what will happen to my family?

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3
Q

what is the difference between nausea and vomiting?

A

nausea = unpleasant feeling of the need to be sick, often with autonomic features

vomiting = forceful expulsion of gastric contents through the mouth

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4
Q

what do you need to ask in order to take an adequate nausea and vomiting history?

A
triggers 
volume 
pattern 
exacerbation and relieving factors 
drug tried + route 
bowel habit 
medication - contributing to the nausea and vomiting cause harm
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5
Q

what must you be aware of if a patient is already on medication and is experiencing nausea and vomiting?

A

is the drug contributing to nausea and vomiting

is the drug being absorbed if patient is vomiting

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6
Q

what are the 4 main reasons that a patient experiences nausea and vomiting?

A

cerebral cortex = emotions, sight, smell, raised ICP, anxiety

vestibular centre = motion sickness

GI tract = distension, stasis, tumour mass, constipation

chemoreceptor trigger zone = metabolic (uraemia, Ca), drugs

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7
Q

what drugs work to combat nausea and vomiting from the cerebral cortex and what receptors do these act on?

A

dexamethasone
benzodiazepines

NK1, 5HT, ?GABA

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8
Q

what drugs work to combat nausea and vomiting from the vestibular centre and what receptors do these act on?

A

cyclizine, hyoscine

H1, ACh

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9
Q

what drugs work to combat nausea and vomiting from the GI tract and what receptors do these act on?

A

metoclopramide
levomepromazine
ondansetron

5HT, D2, ACh

*use with caution in obstruction

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10
Q

what drugs work to combat nausea and vomiting from the chemoreceptor trigger zone and what receptors do these act on?

A

haloperidol, ondansetron

D2, 5HT, ACh

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11
Q

how would you identify from a nausea and vomiting history that the patients symptoms are due to cerebral cortex cause?

A

vomiting worse in morning then gets better throughout day

assoc headache

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12
Q

what would cause impaired gastric emptying?

A

locally advanced cancer
drugs
radiotherapy damage to gut
autonomic neuropathy

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13
Q

how would impaired gastric emptying present?

A

not usually nauseated until patient eats and then very nauseated
large volume vomits
feels better after being sick

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14
Q

what clinical picture would indicate a chemical or metabolic cause of nausea and vomiting?

A

persistent nausea

little relief from vomiting

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15
Q

what would cause a chemical or metabolic abnormality that stimulates nausea or vomiting?

A

medication
advanced cancer
sepsis
kidney or liver impairment

think: Ca, Na, Mg, Urea

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16
Q

what non-pharmacological palliative care is provided to counteract nausea and vomiting in patients with gynaecological malignancies?

A
mouth care
keep bowels moving 
small meals 
avoid cooking or preparing food (due to smell)
acupressure bands (eg seaband)
acupuncture
17
Q

what is meant by malignant bowel obstruction?

A

clinical evidence of bowel obstruction in the setting of a diagnosis of intra-abdominal cancer OR non intra-abdominal cancer with clear intraperitoneal disease

18
Q

bowel obstruction in advanced cancer may not always be directly due to malignancy - what other causes are possible?

A

benign causes eg adhesions post-radiotherapy

19
Q

why do patients with malignant bowel obstruction vomit?

A

proximal accumulation of secretions - these need to be removed

20
Q

how do patients with malignant bowel obstruction usually present?

A
nausea and vomiting 
pain (continuous or cockily)
anorexia 
systemic symptoms from cancer
reduced then absent bowel motions
21
Q

how is malignant bowel obstruction managed?

A

“drip and suck” before surgery
bowel rest
nil by mouth

surgical resection

  • palliative colostomy or ileostomy
  • or self expending metallic stent
22
Q

what are the main aims of medical management of malignant bowel obstruction?

A
if partial - promote resolution with prokinetics 
relieve pain and colic 
reduce vomiting without use of NG tube 
relieve nausea 
relieve thirst
23
Q

what pharmacological options can be given for malignant bowel obstruction?

A

analgesics = opioids / hyoscine butylbromide (buscopan)

anti-emetics = metoclopramide if not contraindicated and partial / subtle obstruction

steroids = dexamethasone to reduce inflammation

anti-secretory agents = buscopan, octreotide (CSCI)

laxatives = docusate or movicol to soften stool

fluids

24
Q

why is it important to remember to not give nauseated / vomiting patients oral medication?

A

must be absorbed

- IV subcutaneous, transdermal or IM