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by tbruno


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Componants of Pallative care
Pain
Physical Symptoms
Psychological problems
Social difficulties
Cultural Concerns
Spiritual existential concerns
Hospice important points
Hospice is not a place

Provides relief from pain and other distressing symptoms

Support
Pharmacist role in hospice
All things releated to dispencing and counselling of medication

Adressing financial concerns

Ensuring safe and legal disposal of all uneeded medications

Establishing and maintaining effective communication with regulatory and licensing agencies
Pharmacist role in medications
Chemo induced N/V
Pain managment
Constipation
Dyspnea
Fatigue
Deprssion
Anxiety
Delirium
Chemo Induced NV (CINV)
Acute CINV-N/V within 24 hours

Delayed CINV-N/V 24 hours after administration

Anticipatory CINV-N/V conditioned CINV response that can happen before
Prevelance of CINV
70%-80%

80% of pts on Cisplatin

Anticipitory N/V 14%-63%
Pathophysology of CINV
Central- Chemoreceptor trigger zone (CTZ) in area postrema in the brainstem

Peripheral Mechanisim- GI irritation, Damage to GI mucosa, release of neruotransmitters.  Mediated by Vagal afferents
High Emetic Risk
Start before Chemo

Aprepitant or Fosaprepitant

Dexamethason

5-HT3 atagonist (-setron's)

+/- Lorazepam
Moderate Emetic Risk
5-HT3 antagonist (-sentron)
Dexamethasone
+/- Aprepitant or Fosapripitant
+/- Lorazepam
Low Emetic risk
Dexamethason
Prochloperazien
Metoclopramide
+/- Diphenhydramine
+/- Lorazepam
Serotonin Antagonists
-setron's

Dosing IV=PO equivalent doses

Toxicies
-Headache
-Constipation
Dopamine Agents
Phenothiazines (-azines's)
Butyrphenones (Droperidol, Haloperidol)
Substituted Bezamines (Metohloprimide)

Toxicites
-Extrapyramidal symptoms
-Anticholinergic effets
-Sedation
Other Antiemetics
P/NKI antagonists
-Fox/aprepitant
Corticostroids
Benzodiazepines
Cannabinodes
Atnicholinergics
-Scopolamine
Factors that may increase pain perception
Anxiety
Depression
Insomnia
Fatigue
Stress
Anger
Cancer Pain Managment Perarls
Optimum Dose= No pain and no adverse effects

Chronic pain should have around the clock plus break thru

Breakthrough does about 10% of total piate daily dose

If pt using >5 breakthrough doses/day

Neruopathic Vs Somatic
Constipations
Co-administer laxitives

Titrate bowel reginim to produce 1-2 BMS a day

Proper hydration

Fentanyl
Suggested Initial Constipation Prohylaxis Regimins
Stimulat laxative + softener (Senna + Docusate) PO BID

Milk of magnesia 30 mL PO BID-TID

Bisacodyl (Dulcolax) 5-10 mg QD
Refractory Constipation
Sorbitol 70% 30 mL PO Q4 h until BM

Lactulose 30 mL (20grams) PO 3-4h until BM

Magnesium Citrate 1 bottle (300 mL) PO X 1, may repeat X 1
Dyspnea Non-pharmacologic
Pursed lip breathing
Upright position
Relaxation
Meditation
Use a fan or open widow to air over the face
Temporary oxygen (only if hypoxic)
Dyspnea Pharmacologic
Systemic opioids (short and long)

Inhaled opioids
Deliver drug directly to airway

Benzodiazepines
Useful for relieving anxiety associated with breathlessnes
Opioids for Dyspnea
Small doeses

MOA: Vasodilation, inhibit baroreceptor response/reflex, Reduction of brain stem responsivness to CO2
Lessened reflex vasoconstriction caused by increased PCO2 levels

Lower anxiety
Fatigue Non Pharm
Education

Mild exerscise

Aerobic exersicse
Fatigue Pharm
Epoetin-alfa (only with anemia)

ESA apprise

Psychoostimulates
-Methlphenidate/dextroampetamine
-Modafinil
-Corticosteroids
Non-pharm anxiety
Chaplain involvment
Progressive relazation
Bio-feedback
Guided imagery
Meditation
BZDs and Delirium
BZDs can worsen Delirium
Delirium Pharmacologic
Neuroleptics

Haloperidol is drug of choice

Monitor extrapyramidal side effects
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