PALIATIVE CARE  IN CERVICAL CASE<br />UPF  POSA RAWAT JALAN<br />RSU DR SOETOMO  SURABAYA<br />
KASUS  PASIEN  PALIATIVE<br />Namapasien  Mrs. X  (39 tahun)<br />Dx		: Ca Cervix stad III B<br />Terapi symptom : Relief ...
Cervix<br />Lower part of the uterus<br />Connects the body of the uterus to the vagina (birth canal)<br />Source: America...
What causes cervical cancer?<br />The central cause of cervical cancer is human papillomavirus or HPV:<br /><ul><li>HPV is...
The HPV detected today could have been acquired years ago
There are many different types of HPV that can infect the cervix, vagina and vulva</li></ul>‘Low-risk’ types may cause gen...
What are the symptoms of cervical cancer?<br />Abnormal bleeding<br />Between periods<br />With intercourse<br />After men...
Who is at risk?<br />Women who have ever had sex<br />Women who have had more than one partner<br />Women whose partner (s...
Signs and Symptoms<br />Vaginal bleeding<br />Menstrual bleeding is longer and heavier than usual<br />Bleeding after meno...
Risk Factors<br />Human papillomavirus infection (HPV) – Primary factor<br />HPV 16, HPV 18, HPV 31, HPV 33, HPV 45<br />5...
Treatment Ca Cervix<br />Surgery<br />Preinvasive cervical cancer<br />Cryosurgery<br />Laser surgery<br />Conization<br /...
3<br />By the<br />2<br />Clock<br />1<br />W.H.O.   ANALGESIC LADDER<br />Strong opioid<br />+/- adjuvant<br />Weak opioi...
Non-Pharmacological Pain Management<br />Acupuncture<br />Cognitive/behavioral therapy<br />Meditation/relaxation<br />Gui...
Massage– muscle tension, headaches, anxious patient<br />Heat & cold applications – muscle spasm<br />Distraction– periodi...
 Pain Relief<br />Neuropathic Pain<br />TCAD, Anticonvulsants, topicals (Capsaicin) , Baclofen<br />   Inflammatory Pain<b...
   Step I<br />Acetaminophen up to 4 gm/day,<br />ASA up to 4 gm/d<br />NSAID use cautiously for persistent pain<br />   S...
   Step III<br />Calculate 24 h opioid need and convert to long acting bid form<br />Use short acting for breakthrough<br ...
MSContin<br /><ul><li>15, 30, 60, 100, 200mg	</li></ul>OxyContin<br /><ul><li>10, 20, 40, 80mg</li></ul>Hydromorphone<br /...
STRONG  OPIOIDS<br /><ul><li>most commonly use:
morphine
Hydromorphone (Dilaudid ®)
transdermalfentanyl (Duragesic®)
oxycodone
Methadone
DO NOT use meperidine (Demerolâ) long-term
active metabolite normeperidine®seizures</li></li></ul><li>OPIOIDS   and<br />INCOMPLETE  CROSS-TOLERANCE<br /><ul><li>con...
cross-tolerance unpredictable, especially in:
high doses
long-term use
divide calculated dose in ½  and titrate</li></li></ul><li>Changing Route Of Administration <br />In Chronic Opioid Dosing...
Opioid Side Effects <br />Constipation – need proactive laxative use<br />Nausea/vomiting – consider treating with dopamin...
Management of Symptoms<br />Try to prevent symptoms if possible<br />use laxatives with opioids<br />give an anti-emetic w...
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Paliative care in cervical case

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Palliative Crae in Cervical Cancer and How do Pharmacist must know

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Paliative care in cervical case

  1. 1. PALIATIVE CARE IN CERVICAL CASE<br />UPF POSA RAWAT JALAN<br />RSU DR SOETOMO SURABAYA<br />
  2. 2. KASUS PASIEN PALIATIVE<br />Namapasien Mrs. X (39 tahun)<br />Dx : Ca Cervix stad III B<br />Terapi symptom : Relief Nyeri<br />R/Codifam<br />Codein<br />Amitrip<br />
  3. 3. Cervix<br />Lower part of the uterus<br />Connects the body of the uterus to the vagina (birth canal)<br />Source: American Cancer Society<br />
  4. 4. What causes cervical cancer?<br />The central cause of cervical cancer is human papillomavirus or HPV:<br /><ul><li>HPV is transmitted through sexual contact
  5. 5. The HPV detected today could have been acquired years ago
  6. 6. There are many different types of HPV that can infect the cervix, vagina and vulva</li></ul>‘Low-risk’ types may cause genital warts <br />‘High-risk’ types may cause precancer and cancer of the cervix<br /><ul><li>Most women who are infected with HPV will never have any symptoms</li></li></ul><li>How do I lower my risk?<br />Delay onset of sexual activity or remain abstinent<br />Know your sexual partner<br />Do not smoke<br />Maintain a healthy diet and lifestyle <br />Practice safe sex. Condoms decrease the chance of HPV exposure.<br />If eligible, consider getting the vaccine that prevents most cervical cancers.<br />Get your Pap test and HPV testing as recommended by your health care provider.<br />
  7. 7. What are the symptoms of cervical cancer?<br />Abnormal bleeding<br />Between periods<br />With intercourse<br />After menopause<br />Unusual vaginal discharge<br />Other symptoms<br />Leg pain<br />Pelvic pain<br />Bleeding from the rectum or bladder<br />Some women have no symptoms<br />
  8. 8. Who is at risk?<br />Women who have ever had sex<br />Women who have had more than one partner<br />Women whose partner (s) has had more than one sexual partner<br />Women who have had a sexually-transmitted disease<br />
  9. 9. Signs and Symptoms<br />Vaginal bleeding<br />Menstrual bleeding is longer and heavier than usual<br />Bleeding after menopause or increased vaginal discharge<br />Bleeding following intercourse or pelvic exam<br />Pain during intercourse<br />Source: American Cancer Society<br />
  10. 10. Risk Factors<br />Human papillomavirus infection (HPV) – Primary factor<br />HPV 16, HPV 18, HPV 31, HPV 33, HPV 45<br />50% are caused by HPV 16 AND 18<br />Sexual behavior<br />Smoking<br />HIV infection<br />Chlamydia infection<br />Diet<br />Oral contraceptives<br />Multiple pregnancies<br />Low socioeconomic status<br />Diethylstilbestrol (DES)<br />Family history<br />Source: American Cancer Society<br />
  11. 11. Treatment Ca Cervix<br />Surgery<br />Preinvasive cervical cancer<br />Cryosurgery<br />Laser surgery<br />Conization<br />Invasive cervical cancer<br />Simple hysterectomy<br />Removal of the body of the uterus and cervix.<br />Radical hysterectomy and pelvic lymph node dissection<br />Removal of entire uterus, surrounding tissue, upper part of the vagina, and lymph nodes from the cervix.<br />Radiation<br />Chemotherapy<br />Paliative Care<br />Source: American Cancer Society<br />
  12. 12. 3<br />By the<br />2<br />Clock<br />1<br />W.H.O. ANALGESIC LADDER<br />Strong opioid<br />+/- adjuvant<br />Weak opioid<br />+/- adjuvant<br />Pain persists or increases<br />Non-opioid<br />+/- adjuvant<br />
  13. 13. Non-Pharmacological Pain Management<br />Acupuncture<br />Cognitive/behavioral therapy<br />Meditation/relaxation<br />Guided imagery<br />TENS<br />Therapeutic massage<br />Others…<br />
  14. 14. Massage– muscle tension, headaches, anxious patient<br />Heat & cold applications – muscle spasm<br />Distraction– periodic or procedural pain<br />Transcutaneous Electrical NerveStimulation (TENs) – musculosketal problems<br />Aromatherapy<br />Complimentary and Alternative therapies<br />Nerve block <br />Non-pharmacological methods of pain relief<br />
  15. 15. Pain Relief<br />Neuropathic Pain<br />TCAD, Anticonvulsants, topicals (Capsaicin) , Baclofen<br /> Inflammatory Pain<br />Steroids, NSAIDS use cautiously, opioids<br /> Bone Metastasis<br />Pamidronate, Calicitonin, opioids<br /> Muscle Spasms<br />Baclofen, Benzodiazepines<br />
  16. 16. Step I<br />Acetaminophen up to 4 gm/day,<br />ASA up to 4 gm/d<br />NSAID use cautiously for persistent pain<br /> Step II <br />Tramadol 50 mg max 8 tabs divided q 6h<br />Oxycodone 5 mg max 12 tabs divided q 6h<br />Morphine 5 mg no maximum dose q 4 hour<br />Persistent Pain <br />
  17. 17. Step III<br />Calculate 24 h opioid need and convert to long acting bid form<br />Use short acting for breakthrough<br />Barriers to maximal pain relief from doctors and patients<br />Ethical precedent for using as much as needed to alleviate suffering<br />Persistent Pain<br />
  18. 18. MSContin<br /><ul><li>15, 30, 60, 100, 200mg </li></ul>OxyContin<br /><ul><li>10, 20, 40, 80mg</li></ul>Hydromorphone<br /><ul><li>1, 2, 3, 4, 8mg</li></ul>Methadone<br /><ul><li>5,10,40mg</li></ul>Fentanyl<br /><ul><li>25, 50, 75, 100 microgram patch</li></ul>Persistent Pain<br />
  19. 19. STRONG OPIOIDS<br /><ul><li>most commonly use:
  20. 20. morphine
  21. 21. Hydromorphone (Dilaudid ®)
  22. 22. transdermalfentanyl (Duragesic®)
  23. 23. oxycodone
  24. 24. Methadone
  25. 25. DO NOT use meperidine (Demerolâ) long-term
  26. 26. active metabolite normeperidine®seizures</li></li></ul><li>OPIOIDS and<br />INCOMPLETE CROSS-TOLERANCE<br /><ul><li>conversion tables assume that tolerance to a specific opioid is fully “crossed over” to other opioids.
  27. 27. cross-tolerance unpredictable, especially in:
  28. 28. high doses
  29. 29. long-term use
  30. 30. divide calculated dose in ½ and titrate</li></li></ul><li>Changing Route Of Administration <br />In Chronic Opioid Dosing<br />po / sublingual / rectal routes <br />SQ / IV / IM routes<br />reduce by ½<br />
  31. 31. Opioid Side Effects <br />Constipation – need proactive laxative use<br />Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol) <br />Urinary retention<br />Itch/rash – worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great success<br />Dry mouth<br />Respiratory depression – uncommon when titrated in response to symptom<br />Drug interactions<br />Neurotoxicity (OIN):delirium, myoclonus® seizures<br />
  32. 32. Management of Symptoms<br />Try to prevent symptoms if possible<br />use laxatives with opioids<br />give an anti-emetic when starting morphine<br />review and often stop after 3-4 days<br />give anti-emetics before and during chemotherapy<br />encourage good mouth care, especially in dying patients<br />sips of water, moisten mouth, anti-fungal agent<br />
  33. 33. Match cause of nausea to treatment<br /><ul><li>Increased ICP Dexamethasone
  34. 34. Vestibular Antihistamines
  35. 35. Chemoreceptor Dopamine Antagonist
  36. 36. Gastric Irritation Feeds, stop NSAIDS
  37. 37. Gut Motility Metaclopromide
  38. 38. Ascites Diuretics
  39. 39. Pain or anxiety Treat accordingly </li></ul>Nausea and Vomiting<br />
  40. 40. Physical and/or psychological<br />Morphine<br />Oxygen<br />Fan in Room, Fresh Air<br />Secretions Control with anticholinergics and suctioning<br />Address fears, anxiety, spiritual needs<br />Relaxation, distraction, <br />Dyspnea<br />
  41. 41. Sources include:<br /> fear, pain, psychological and spiritual distress<br />Treatment :<br />Anxiolytics<br />Human Contact<br />Address fears<br />Setting affairs into order<br />Anxiety<br />
  42. 42. Target behavior and seek causes if possible<br />Decrease external stimuli<br />Use Music, Prayer<br /> Agitation as a form of communication<br /> As part of delirium very near end of life<br /> Haldol, Anxiolytics <br />Agitation<br />
  43. 43. Target behavior and seek causes if possible<br />Decrease external stimuli<br />Use Music, Prayer<br /> Agitation as a form of communication<br /> As part of delirium very near end of life<br /> Haldol, Anxiolytics <br />Agitation<br />
  44. 44. Combat constipation of narcotics, avoid impaction<br />Careful skin care, positioning<br />If diarrhea use anticholinergics<br />Scheduled voids , disposable pads, Foley’s urine catheter?<br />Manage odors <br />Bowel and Bladder<br />
  45. 45. Sips, Chips, mouth care<br /> Anorexia/Cachexia<br /><ul><li>Consider steroids, TCAD, Cannabinoids, Remeron (Mirtazepine – anti depressant ) </li></ul>Artificial Assistance<br /><ul><li>Values Based Decisions
  46. 46. Delays the inevitable
  47. 47. Consider limited trial and withdrawal if no evident benefit</li></ul>Nutrition and Hydration<br />
  48. 48. Skin Care and Pruritis<br />Pruritis<br />Consider xerosis, uremia, hypercalcemia, medication side effects, delirium<br /> Hygiene and positioning<br /> Lotions<br /> Cool moist compresses<br /> Antihistamines<br />
  49. 49. Shock and denial<br />Anger<br />Bargaining<br />Depression<br />Acceptance<br />Reaction to death or Impending death <br />
  50. 50. maturnuwun<br />

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