癌症病人常見症狀之處理原則 廖幼婕

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  • 1. 元培科技大學護理系 廖幼媫 助理教授 2/9/2012 2013/1/2 1
  • 2.  Concept of symptom: Unpleasant Symptom Theory Dyspnea - Definition - Significance and Prevalence - Causes of cancer dyspnea - Management of dyspnea Cancer-related fatigue (CRF) - Definition - Significance and Prevalence - Causes of cancer CRF - Management of CRF Pain - Definition - Significance and Prevalence - Causes of cancer pain - Management of pain 2013/1/2 2
  • 3. Source: Lenz, E. R., Pugh, L. C., Miligan, R. A., Gift, A., & Suppe, F. (1997). The middle-range theory of unpleasant symptoms: An update. Advances in Nursing Science, 19(3), 14-27. 2013/1/2 3
  • 4. Dyspnea 2013/1/2 4
  • 5.  A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, social, and environmental factors, and may induce secondary physiological and behavioral responses A very common and most distressing symptom described by patients with life-limiting illnesses (Buckholz et al., 2009; DiSalvo etal., 2008) 2013/1/2 5
  • 6.  Dyspnea occurs in up to 60% of patients with cancer Estimated to occur in 15%–55% at diagnosis to 18%– 79% during the last week of life Up to 50% of solid tumors or hematologic malignancies who present to the emergency room with dyspnea die within 6 months of presentation Associated with poor prognosis Caused by the tumor burden and effects or anticancer therapy and/or lifestyle perturbations A difficult one for caregivers to manage (Beckles, Spiro, Colice, & Rudd, 2003; DiSalvo et al., 2008; Koelwyn et al., 2012; Ripamonti & Fusco, 2002). 2013/1/2 6
  • 7. Dyspnea Caused Directly by CancerPulmonary parenchymal HepatomegalyinvolvementAirway obstruction by tumor Phrenic nerve paralysisPleural tumor / effusion Pulmonary leukostasisAscites Superior vena cava syndrome Dudgeon et al. (2001) 2013/1/2 7
  • 8. Dyspnea Caused Indirectly by CancerCachexia Pulmonary emboliElectrolyte abnormalities SurgeryAnemia Radiation pneumonitis or fibrosisPneumonia Chemotherapy-induced pulmonary toxicityPulmonary aspiration Chemotherapy-induced cardiomyopathy Dudgeon et al. (2001) 2013/1/2 8
  • 9.  For those advanced cancer patients who have poor performance status and very short estimated life expectancy and who cannot tolerate further treatment, relief of dyspnea symptoms becomes the most important medical service. Dyspnea treatment can follow either a pharmacological or nonpharmacological approach or can draw from both types of intervention. 2013/1/2 9
  • 10. Cont’d The optimal treatment of dyspnea includes the use of specific therapies or palliative therapies as appropriate to reverse the causes of dyspnea Pharmacologic interventions  Oral and parenteral opioids - morphinel can reduce ventilatory demand by decreasing central respiratory drive for management of dyspnea in patients with terminal or advanced cancer  Chest tube drainage or chemical pleurodesis for pleural effusion Oxygen therapy  is beneficial for hypoxic patients with dyspnea at rest (DiSalvo et al., 2008; Qaseem et al., 2008) 2013/1/2 10
  • 11. Cont’d Nonpharmacologic Interventions Relatively few data suggesting the effect of other approach:  Cognitive-behavioral Approach  Breathing retraining combined with Psycho-educational strategies  Relaxation technique  Pulmonary rehabilitation  Exercise therapy (for postoperation) (Koelwyn et al., 2012; Xu & Abernethy , 2010) 2013/1/2 11
  • 12. Physiologic Emotional /Cognitive Approaches ApproachesMuscle strengthening (i.e. exercise, Counseling and supportneuromuscular electrical stimulation,respiratory muscle trainingSit up or lean forward position Relaxation (i.e. guided imagery, progressive muscle relaxation)Energy conservation Distraction (i.e. music)Breathing training (i.e. pursed lips, Psycho-educationdiaphragmatic breathing)Cool air/Moving airAcupuncture/acupressureNutritional supplementation (Buckholz & von Gunten, 2009; Koelwyn et al., 2012; Xu & Abernethy , 2010) 2013/1/2 12
  • 13. Cancer-Related Fatigue (CRF) 2013/1/2 13
  • 14.  A persistent, subjective sense of tiredness related to cancer and cancer treatment that interferes with usual functioning  tiredness  weakness  lack of energy  not relieved by rest or sleep  feelings of exhaustion  loss of drive and personal interests  impaired memory and concentration. (Horneber et al., 2012; NCCN, 2012a; Ryan et al., 2007) 2013/1/2 14
  • 15.  CRF is extremely common with 60% -90% of prevalence rate Persists for months in treatment or even years after the completion of cancer treatment, end-of-life and survivorship 98% of patients considered fatigue to be the most distressing symptom, impacts patients’ physical, psychological, social and spiritual well-being and quality of life considerably Under-reported, under-diagnosed and under-treated (NCCN, 2012a; Ryan et al., 2007) 2013/1/2 15
  • 16.  NCCN guideline suggests screen every patient for fatigue as vital sign at regular intervals on a scale of 0 - 10  None (0)  Mild (1-3)  Moderate (4-6)  Severe (7-10) Fatigue severity Inventory (severity and interference) (NCCN, 2012a) 2013/1/2 16
  • 17.  The etiology of CRF is multifactorial and most likely involves the dysregulation of several interrelated physiological, biochemical, and psychological systems 2013/1/2 17
  • 18. Cont’dMedication effect Pain AnemiaEmotional distress Diminished physical - depression performance - anxiety Cancer-related - reduced fitness - adaptive Fatigue - lack of exercise disorder -myopathy/sarcopenia - stress reaction Comorbidities - infection Sleep disturbance - cardiac and - insomnia Malnutrition respiratory disease - hypersomnia -anorexia/cachexia - renal, hepatic, - OBSA -dehydration - endocrine…disorder - narcolepsy electrolyte - paraneoplasty disturbance syndrome 2013/1/2 18
  • 19.  Serotonin (5-HT) dysregulation Increased proinflammatory cytokines (TNF-α interleukin (IL)-1β, IL-6, interferon (IFN)-α, IFN-γ) Neuroendocrine dysfunctions of the hypothalamic pituitary adrenal axis Circadian rhythm desynchronization Skeletal muscle wasting Genetic dysregulation Anemia (Ryan et al., 2007) 2013/1/2 19
  • 20.  All patients/families need to receive education, counseling, and general strategies for managing CRF General strategies Nonpharmacologic Pharmacologic (NCCN guideline, 2012) (NCCN, 2012a) 2013/1/2 20
  • 21.  Self-monitoring of fatigue levels Energy conservation  Set priorities  Pace  Delegate  Schedule activity at times of peak energy  Postpone nonessential activities  Limit naps to < 1 hr  Structure daily routine  Attend to one activity at a time Use distraction (eg, games, music, reading, socializing) (NCCN, 2012a) 2013/1/2 21
  • 22.  Activity enhancement  Maintain optimal level of activity Energy management  Rational apportionment of physical effort, task planning, taking of breaks and rest periods Exercise  Endurance and strength training at moderate intensity several times a week for 30 to 45 minutes,  Gradually increasing intensity supervision by physician or physical therapist desirable (necessary for strength training) Physical-based therapy (eg, massage therapy) (Horneber et al., 2012; NCCN, 2012a) 2013/1/2 22
  • 23. Cont’d Cautions for activity enhancement Patients with following conditions should be constrained  Bone metastases  Thrombocytopenia  Anemia  Fever or active infection  Assessment of safety issue (risk of falls, stability) (NCCN, 2012a) 2013/1/2 23
  • 24. Cont’d Psychoeducation therapy & CBT  Targeted information and counseling about CRF  stress reduction  identification of adaptive and maladaptive attitudes  relief of anxiety  assistance in coping with stress  promotion of active problem-centered coping strategies  learning of control techniques  sleep management (stimulus control, sleep restriction, sleep hygiene) (Horneber et al., 2012; NCCN, 2012a) 2013/1/2 24
  • 25. Cont’d Psychotherapy for depression Relaxation techniques and mindfulness 2013/1/2 25
  • 26.  Psychostimulated (eg, methylphenidate, modafanil) Treatment for anemia during chemotherapy with erythropoietin Treatment for pain, emotional distress as indicated Treatment for sleep dysfunction, nutritional deficit/imbalance, and comorbidity (NCCN, 2012a) 2013/1/2 26
  • 27. Pain 2013/1/2 27
  • 28.  One of the most common symptoms associated with cancer An unpleasant multidimensional, sensory and emotional experience associated with actual or potential tissue damage, or described in relation to such damage. One of the symptoms patients fear most To maximize patient outcomes, pain is an essential part of oncologic management Encouraging patients to communicate with the physician and/or the nurse about their suffering (NCCN, 2012b; Ripamonti et al., 2011) 2013/1/2 28
  • 29.  About 25% of newly diagnosed and 75% of advanced cancer patients suffered from pain Pain was present in all phases of cancer disease (early and metastatic) and was not adequately treated in a significant percentage of patients, ranging from 56 to 82.3%. The pathophysiology of cancer pain may involve nociceptive (somatic and visceral) or neuropathic mechanisms, or both 2013/1/2 29
  • 30. Nociceptive Neuropathic pain pain PeripheralSomatic pain Visceral pain Central nervous nervous Compression, treatment-Bone meta Tumor related infiltration, Surgical involvement Surgical distension of process process viscera Sharp, well- Burning, sharp, shooting, localized, Diffused, aching, dysesthesia ,allodynia, hyperesthesia, throbbing, cramping hypalgesispressure-like 2013/1/2 30
  • 31.  Caner treatment  Diagnostic procedure - venepuncture, lumbar puncture, angiography, endoscopy, biopsy  Chemotherapy - arthralgia, cardiomyopathy, gastrointestinal distress, mucositis, myalgia  Radiation therapy - esophagitis, mucositis, pharyngitis, skin burns  Surgical therapy - postoperative pain, ileus, urinary retention 2013/1/2 31
  • 32. Cont’d Tumor invasion of bone  vertebral body metastases, base of the skull metastases, pelvis, long bone Tumor involvement of nerves, plexus, or spinal cord  peripheral, cranial, or spinal neuropathy; brachial plexus; epidural spinal cord compression Tumor Involvement of Viscera  obstruction of hollow viscus or of ductal system of solid viscus; rapid tumor growth in solid viscus 2013/1/2 32
  • 33. Cont’d Tumor involvement of blood vessels  Infiltration; obstruction of large vein/artery Postsurgical syndromes  Post-thoracotomy; postmastectomy Postchemotherapy pain  Peripheral neuropathy; aromatase inhibitors; steroid Postradiation therapy pain  Radiation fibrosis of brachial or lumbosacral plexus; radiation myelopathy; painful peripheral nerve tumors 2013/1/2 33
  • 34.  All patients must be screened for pain at each contact Comprehensive assessment and managemenmust be performed as most patients have multiple pathophysiologies Analgesic therapy is done with management of multiple symptoms Pain intensity must be quantified by patients Determine patient goals for comfort and function Reassessment of pain intensity to ensure benefits from analgesic therapy with as few adverse effects as possible A multidisciplinary team may be needed Psychosocial support must be available Specific education material must be provided (NCCN, 2012b) 2013/1/2 34
  • 35. 2013/1/2 35
  • 36. Cont’d2013/1/2 36
  • 37. Cont’d For cognitive impairment, older or limited communication skills patients:  Observation of pain-related behaviors and discomfort - facial expression - body movements - verbalization or vocalizations - changes in interpersonal interactions - changes in routine activity 2013/1/2 37
  • 38.  Pain related to a oncologic emergency should be directly treated the underline conditions  Bone fracture  Brain/epidural/ leptomeningeal metastases  Infection,  Obstructive or perforated viscus 2013/1/2 38
  • 39. Cont’d Pharmacologic approaches  Non-opioids  Opioids  Adjuvant analgesics Psychological approaches Physical modalities Cognitive modalities Spiritual care (NCCN, 2012b; Ripamonti et al., 2011) 2013/1/2 39
  • 40. Cont’d WHO analgesic ladder By Mouth By the Clock By the Ladder For the individual Attention to detail (WHO, 1986) 2013/1/2 40
  • 41.  Mild pain (1-3) paracetamol and/or a non-steroidal anti-inflammatory Moderate pain (4-6)  codeine, tramadol and dihydrocodeine  low doses of strong opiods in combination with non-opioid analgesics Severe pain (7-10)  oral morphine The average relative potency ratio of oral to subcutaneous/intravenous morphine is between 1:2 and 1:3 (NCCN, 2012b; Ripamonti et al., 2011) 2013/1/2 41
  • 42. Cont’d Patients with pain from bone metastases  external beam radiotherapy or radioisotope treatment  bisphosphonates Patients with resistant and neuropathic pain  non-opioid and opioid analgesics may be combined with tricyclic antidepressant or a anticonvulsant Patients with refractory pain at the end of life  sedative drugs 2013/1/2 42
  • 43. Side effects Frequency with oral opioidsConstipation Very commonSedation CommonNausea CommonCognitive impairment OccasionalPruritus OccasionalDysphoria OccasionalHypnogogic imagery RareMyoclonus Rare with oral routeRespiratory depression Very rare 2013/1/2 43
  • 44.  Psychosocial support  Ensure patients encountering common barriers to appropriate pain control  Provide patient and family education and support  Work together to address the pain problem  Inform patient and family there is always something that can be done to relief pain 2013/1/2 44
  • 45. Cont’d Physical modalities  Bed, bath, and walking supports  Position instruction  physical therapy  Energy conservation, pacing of activites  Massage  Heat and /or ice  TENS  Acupunture or acuperssure  Ultrasonic stimulation 2013/1/2 45
  • 46. Cont’d Cognitive modalities  Imagery/hypnosis  Distraction training  Relaxation training  Active coping training  Graded task assignments, setting goals, pacing and prioritizing  Cognitive behavioral training Spiritual care  Determine importance to patient/family and current availability of support  Management of spiritual, existential concerns (NCCN, 2012b) 2013/1/2 46
  • 47.  Dyspnea, fatigue and pain are distressing and debilitating symptoms for patients with cancer Multidisciplinary cancer care team pay more efforts to identify evidence-based interventions to reduce the symptoms and improve quality of life are essential Both pharmacologic agents and nonpharmacologic approaches are necessary to impede effective symptom management for patients with cancer 2013/1/2 47
  • 48.  臺灣癌症臨床研究合作組織 (2007)‧癌症疼痛處理指引‧國家衛生研究院 Beckles, M.A., Spiro, S.G., Colice, G.L., & Rudd, R.M. (2003). Initial evaluation of the patient with lung cancer: Symptoms, signs, laboratory tests, and paraneoplastic syndromes. Chest, 123(1, Suppl.), 97S-104S. Buckholz, G. T., & von Gunten, C. F. (2009). Nonpharmacological management of dyspnea. Current Opinion in Supportive and Palliative Care, 3(1), 98-102. DiSalvo, W. M., Joyce, M. M., Tyson, L. B., Culkin, A. E., & Mackay, K. (2008). Putting evidence into practice: Evidence-based interventions for cancer-related dyspnea. Clinical Journal of Oncology Nursing, 12 (2), 341- 352. Dudgeon, D.J., Kristjanson, L., Sloan, J.A., Lertzman, M, & Clement, K (2001). Dyspnea in cancer patients: Prevalence and associated factors. Journal of Pain and Symptom Management, 21(2), 95-102. Horneber, M., Fischer, I., Dimeo, F., Rü ffer, J. U., & Weis, J. (2012). Deutsches Ä rzteblatt International, 109(9), 161-172. Koelwyn, G. J., Jones, L. W., Hornsby, W., & Eves, N. D. (2012). Exercise therapy in the management of dyspnea in patients with cancer. Current Opinion in Supportive and Palliative Care, 6(2), 129-137. Lenz, E. R., Pugh, L. C., Miligan, R. A., Gift, A., & Suppe, F. (1997). The middle-range theory of unpleasant symptoms: An update. Advances in Nursing Science, 19(3), 14-27. National Comprehensive Cancer Network. (2012). NCCN clinical practice guideline in Oncology: Cancer-related fatigue (versin I. 2012). Qaseem, A., Snow, V., Shekelle, P., Casey Jr, D. E., Cross Jr, J. T. et al. (2008). Evidence-based intervention to improve the palliative care of pain, dyspnea, and depression, at the end of life : A clinical practice guideline from the America College of Physicians. Annals of Internal Medicine, 148 (2), 141-146. Ripamonti, C. I., Bandieri, E., & Roila, F. (2011). Management of cancer pain: ESMO clinical practice guideline. Annals of Oncology, 22 (Suppl 6), vi69-vi77. Ryan, J. L., Carroll, J. K., Ryan, E., Mustain K. M., Fiscella, K., & Morrow, G. R. (2007). Mechanisms of cancer- related fatigue. The Oncologist, 12 (Suppl 1), 22-34. Ripamonti, C., & Fusco, F. (2002). Respiratory problems in advanced cancer. Supportive Care in Cancer, 10(3), 204–216. World Health Organization (2012). WHO’s pain ladder. http://www.who.int/cancer/palliative/painladder/en/ Xu, D., & Abernethy, A. P. (2010). Management of dyspnea in advanced lung cancer: recent data and emerging concepts. Current Opinion in Supportive and Palliative Care, 4(1), 85-91. 2013/1/2 48