末期病患常见不适症状之及医护处置I.ppt

1,簡淑慧_Symptom Management II,單元名稱：末期病患常見不適症狀之評估及醫護處置 (II),整理者: 簡淑慧 老師 (N棟 1樓; 分機: 3136),單元時數：2 小時,2019/10/5,簡淑慧_Symptom Management II,2,Dyspnea-Physiology-1,呼吸調節機轉 神經性 *呼吸道伸展接受體 (Airway stretch receptors) *肺間質接受體 (Lung parenchymal receptors): 肺間質.肺泡與微血管之J-receptors, 此被認為與呼吸困難產生有關. *呼吸肌: 肋間肌與橫膈膜有接受體 .對呼吸肌之伸展及無力敏感.當呼吸肌無力呼吸效能下降呼吸困難.,2019/10/5,簡淑慧_Symptom Management II,3,Dyspnea-Physiology-2,化學性 ：PaCO2 & PaO2 *周邊化學接受體 (Peripheral chemo-receptors): 位於主動脈弓及頸動脈體，對於 PaO2 較敏感，但長時間後就不敏感. *中樞化學接受體 (Central chemoreceptors):位於延腦呼吸中樞對血中 PaCO2 及 酸鹼度(PH) 較敏感.,2019/10/5,簡淑慧_Symptom Management II,4,Dyspnea-Physiology-1,高度大腦中樞 腦下垂體 大腦皮質,呼吸中樞 延腦 橋腦,脊髓 (C3-5；T11-12),呼吸肌肉 橫膈 肋間肌 輔助肌,機械接受器 伸展接受體,化學接受器,上呼吸道運動神經,呼吸道肌肉之控制,Ref: Jantarakept, P., & Porock, D. (2005). Dyspnea management in Lung cancer. ONF, 32(4), 785-795.,2019/10/5,簡淑慧_Symptom Management II,5,Prevalence of Dyspnea by Disease,Disease Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Disease Stroke Amyotropic Lateral Sclerosis Dementia Outpatient Cancer Terminal Cancer Lung Cancer,Prevalence of Dyspnea 95% 61% 37% 47% to 50% (漸凍人) 70% (失智症) 50% 45% to 70% 90%,(Dudgeon, 2001),Cancer,2019/10/5,簡淑慧_Symptom Management II,6,Dyspnea-cause,Dyspnea,Treatment (化療/電療),Psychological Symptoms (焦慮),肺泡失去結構,呼吸肌無力,氣道阻塞,氧氣流量減少,肺膜轉移- 肋膜積水,現存疾病 COPD CHF 漸凍人 末期失智症 腎衰竭 肝疾病-腹水,營養缺乏,腫瘤壓迫,Ref: Jantarakept, P., & Porock, D. (2005). Dyspnea management in Lung cancer. ONF, 32(4), 785-795.,2019/10/5,簡淑慧_Symptom Management II,7,Dyspnea-Etiology-2,肋膜液之生成 Mesothelial cells of pleural (肋膜間皮細胞): 5-10L/day,80-90% is reabsorbed by capillary of visceral pleural 10-20% is reabsorbed by lymphatic channels of visceral pleural,5-20ml remains in the pleural space,Regulated by: Capillary permeability, hydrostatic pressure, Colloidal osmotic pressure, negative intralpleural pressure, lymphatic draining,2019/10/5,簡淑慧_Symptom Management II,8,Dyspnea-Etiology-3,惡性肋膜積水 *Malignant cell irritation & inflammation,- Capillary permeability (微細血管通透性增加) - Obstruction of the pleural lymphatic systems (淋巴細統阻塞) -Capillary endothelial cell change the hydrostatic pressure (微細血管改變其靜體滲透壓) protein and fluid leak to pleural space (蛋白質及水外流) Colloid osmotic pressure (膠體滲透壓增加) absorption (再吸收能力) ,2019/10/5,簡淑慧_Symptom Management II,9,Dyspnea-Etiology-2,Treatment-related factors R/T or C/T ：fibrosis (肺纖維化) (Bleomycin, MTX, Busulfex) 相關治療: CVP or Port-A insertion Pneumothorax,2019/10/5,簡淑慧_Symptom Management II,10,Dyspnea-Assessment-1,1. 主觀性-主訴 -呼吸短促 (SOB), 吸不到氣 (Air hunger) ,malaise (不安),乾咳或無痰性咳嗽,胸部壓迫感或疼痛感,焦慮 或害怕. 2. 客觀徵象-身體評估 PQRST 呼吸次數及深度,呼吸肌或輔助肌使用,臉色及周邊膚色 ( 發绀或蒼白) 胸腔括張情形,呼吸音(是否減少,磨擦音) ,局部扣診(濁音) 精神及意識程度: 清醒,專注度,記憶能力.,2019/10/5,簡淑慧_Symptom Management II,11,Dyspnea-Assessment-2,3. 實驗室或診斷檢察 -X-ray: pleural effusion or pneumonia. -CBC: Hb. -ABG or Pulse oximetry: PaO2 . PaCO2. -Thoracentesis (胸腔穿刺術) & Pleural Fluid Analysis (肋膜液分析)-以檢查是否有惡性細胞或感染情形,2019/10/5,簡淑慧_Symptom Management II,12,/medlineplus/ency/article/000086.htm,2019/10/5,Dyspnea-Assessment-3,簡淑慧_Symptom Management II,13,處置-1,Treat the underlying disease: C/T, R/T, Thoracentesis (胸腔穿刺術)-*Pigtail draining (4-5-6 ICS ) , Antimicrobial agents (抗生素) Pleurodesis (肋膜硬化):引流管內打入Tetracyclin, Bleomycin, 使局部炎症及沾粘硬化肋膜，以預防肋膜液產生 Bronchodilators (200-400mg/day theophylline)- 增加到肺部之氣流量,2019/10/5,簡淑慧_Symptom Management II,14,處置-2,Mucolytic (化痰劑)- 減少痰液量 Anticholinergic (抗乙醯膽鹼)- 減少呼吸道分泌量 Steroid (4-8mg/b.i.d Dexan - 減少局部炎症反應、水腫情形 Diuretics- 減少體內組織液過多 Anxiolytics- 減少緊張情緒 Oxygen & air therapy: low flow rate of O2, cold air Ventilator ? (COPD 70% vs. Lung Ca.20%),2019/10/5,簡淑慧_Symptom Management II,15,處置-3, Opioids-Morphine (Oral, IV, Inhalation) -延腦對 CO2 敏感性 -大腦皮質對呼吸困難認知 -延腦到呼吸肌刺激 -中樞性鎮靜功能 ,2019/10/5,簡淑慧_Symptom Management II,16,處置-4,Opioids-Morphine oral: 5-15mg q4h (duration is shorter than pain control) ； old patient/renal failure：2.5mg q4h IV: 2.5-5mg q4h (bedtime 2times) Nebulizer: 20mg q4h (with 2ml of N/S),2019/10/5, 胸腔復健運動 擺位:身體前傾方式，採坐姿或站姿，以增加橫膈長度 呼吸運動: -噘嘴式呼吸：以增加吐氣末端之正壓及預 防胸內過早關閉 -腹式(或橫膈式)呼吸:以增加潮氣容積，減少 功能性肺餘量及耗氧量 3. 體能保存法: 安排生活優先需要，避免很急促活動,簡淑慧_Symptom Management II,17,處置-5,2019/10/5, 輔助治療 肌肉放鬆技巧 按摩或芳香療法 轉移注意力/音樂治療 使用電風扇吹冰涼空氣 穴位按摩或針灸,簡淑慧_Symptom Management II,18,處置-6,2019/10/5,簡淑慧_Symptom Management II,19,不適症狀之評估-CACS,Cancer Anorexia Cachexia Syndrome (CACS)-癌症惡病質症候群 導因 生理機轉 評估 處置,.au/images/SteveGuestLosesHalfHisWeightThumb.jpg,2019/10/5,簡淑慧_Symptom Management II,20,惡病質症候群,http:/www.medical-,情緒低落,便秘,腸阻塞,吸收不良,味覺改變,化療/電療,腹痛,免疫系統 對抗腫瘤,2019/10/5,簡淑慧_Symptom Management II,21,癌症惡病質症候群 (CACS)導因,Disease-related factors a Hallmark of terminal illness (80% end-stage patients) Cancer (80% GI Cancer; 60% lung cancer), GI obstruction (腸道阻塞或吸收障礙), Infection, Septic states. Treatment-related factors C/T, R/T, OP (Stomach, pancreas or bowel). Psychological factors “Give up” (cancer means terminal illness) Depression, inactivity, loss of appetite.,2019/10/5,簡淑慧_Symptom Management II,22,CACS Mechanism-1,【宿主】與【腫瘤進展】間的一種負向代謝結果，其涉及:食慾不振、新陳代謝改變、前趨發炎細胞激素之釋放(Pro-inflammatory cytokines). 當【腫瘤細胞】或【個體對抗腫瘤細胞之免疫反應】時會產生【前趨發炎細胞激素-Tumor Necrotic Factor (TNF), IL-1 & IL-6, IFN- & IFN-】 【新陳代謝增加】,2019/10/5,簡淑慧_Symptom Management II,23,CACS Mechanism-2, 【新陳代謝速率增加 】 -醣類新生 、醣類分解代謝 -脂肪新生 、脂肪分解 -蛋白質新生 、蛋白質分解 (耗損肌肉塊),2019/10/5,簡淑慧_Symptom Management II,24,CACS Assessment-1,1.PQRST: 評估食慾 (營養替代品)、疲倦或無力狀 況、功能性評估 ADL. 2.身體評估 -目前體重、近日體重變化 (3個月體重下降10%) 、三頭肌及上臂中段臂圍. -脫水或體電不平衡情形. -有肌肉塊萎縮、失去脂肪、出現水腫. 3.實驗室檢查 -內臟蛋白質:Albumin, Total Iron-Binding Capacity, Transferrin,Nitrogen Balance. -肌肉塊: 24h CCR,2019/10/5,簡淑慧_Symptom Management II,25,處置,Steroid (20