末期病患常見不適癥狀之及醫(yī)護(hù)處置i

1、1,簡(jiǎn)淑慧_Symptom Management II,單元名稱：末期病患常見不適癥狀之評(píng)估及醫(yī)護(hù)處置 (II),整理者: 簡(jiǎn)淑慧 老師(N棟 1樓; 分機(jī): 3136),單元時(shí)數(shù)：2 小時(shí),2024/3/21,簡(jiǎn)淑慧_Symptom Management II,2,Dyspnea-Physiology-1,呼吸調(diào)節(jié)機(jī)轉(zhuǎn)※神經(jīng)性*呼吸道伸展接受體 (Airway stretch receptors) *肺間質(zhì)接受體 (Lung

2、parenchymal receptors): 肺間質(zhì).肺泡與微血管之J-receptors, 此被認(rèn)為與呼吸困難產(chǎn)生有關(guān).*呼吸肌: 肋間肌與橫膈膜有接受體 .對(duì)呼吸肌之伸展及無力敏感.當(dāng)呼吸肌無力?呼吸效能下降?呼吸困難.,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,3,Dyspnea-Physiology-2,※化學(xué)性 ：PaCO2 & PaO2*周邊化學(xué)接受體 (Peripheral ch

3、emo-receptors): 位於主動(dòng)脈弓及頸動(dòng)脈體，對(duì)於 PaO2? 較敏感，但長(zhǎng)時(shí)間後就不敏感.*中樞化學(xué)接受體 (Central chemoreceptors):位於延腦呼吸中樞對(duì)血中 PaCO2? 及 酸鹼度(PH) 較敏感.,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,4,Dyspnea-Physiology-1,高度大腦中樞腦下垂體 大腦皮質(zhì),呼吸中樞延腦 橋腦,脊髓(C3-5；T11-

4、12),呼吸肌肉橫膈 肋間肌 輔助肌,機(jī)械接受器伸展接受體,化學(xué)接受器,上呼吸道運(yùn)動(dòng)神經(jīng),呼吸道肌肉之控制,,,,,,,,,Ref: Jantarakept, P., & Porock, D. (2005). Dyspnea management in Lung cancer. ONF, 32(4), 785-795.,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,5,Prevalence of D

5、yspnea by Disease,,,,,,,DiseaseChronic Obstructive Pulmonary Disease (COPD)Congestive Heart DiseaseStrokeAmyotropic Lateral SclerosisDementiaOutpatient CancerTerminal CancerLung Cancer,Prevalence of Dyspnea95

6、%61%37%47% to 50% (漸凍人)70% (失智癥)50%45% to 70%90%,(Dudgeon, 2001),Cancer,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,6,Dyspnea-cause,Dyspnea,Treatment (化療/電療),Psychological Symptoms(焦慮),肺泡失去結(jié)構(gòu),呼吸肌無力,氣道阻塞,氧氣流量減少,肺膜轉(zhuǎn)移-肋膜

7、積水,現(xiàn)存疾病COPD CHF漸凍人 末期失智癥腎衰竭 肝疾病-腹水,營(yíng)養(yǎng)缺乏,腫瘤壓迫,,,,,,,,,,,Ref: Jantarakept, P., & Porock, D. (2005). Dyspnea management in Lung cancer. ONF, 32(4), 785-795.,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,7,Dyspnea-Etiology-2,肋膜

8、液之生成Mesothelial cells of pleural (肋膜間皮細(xì)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

9、 by: Capillary permeability, hydrostatic pressure, Colloidal osmotic pressure, negative intralpleural pressure, lymphatic draining,,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,8,Dyspnea-Etiology-3,惡性肋膜積水*Malignant cell

10、 irritation & inflammation,,,- Capillary permeability ? (微細(xì)血管通透性增加)- Obstruction of the pleural lymphatic systems (淋巴細(xì)統(tǒng)阻塞)-Capillary endothelial cell change the hydrostatic pressure (微細(xì)血管改變其靜體滲透壓)? protein and f

11、luid leak to pleural space (蛋白質(zhì)及水外流)Colloid osmotic pressure (膠體滲透壓增加) ? absorption (再吸收能力) ?,,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,9,Dyspnea-Etiology-2,Treatment-related factors? R/T or C/T ：fibrosis (肺纖維化) (Bleomycin

12、, MTX, Busulfex)?相關(guān)治療: CVP or Port-A insertion? Pneumothorax,2024/3/21,簡(jiǎn)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(píng)估

13、? PQRST?呼吸次數(shù)及深度,呼吸肌或輔助肌使用,臉色及周邊膚色 ( 發(fā)紺或蒼白)?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(shí)程度: 清醒,專注度,記憶能力.,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,11,Dyspnea-Assessment-2,3. 實(shí)驗(yàn)室或診斷檢察-X-ray: pleural effusion or pneumonia.-CBC: Hb?

14、.-ABG or Pulse oximetry: PaO2 ?. PaCO2?.-Thoracentesis (胸腔穿刺術(shù)) & Pleural Fluid Analysis (肋膜液分析)-以檢查是否有惡性細(xì)胞或感染情形,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,12,http://www.nlm.nih.gov/medlineplus/ency/article/000086.htm,202

15、4/3/21,Dyspnea-Assessment-3,簡(jiǎn)淑慧_Symptom Management II,13,處置-1,Treat the underlying disease: C/T, R/T, Thoracentesis (胸腔穿刺術(shù))-**Pigtail draining (4-5-6 ICS ) , Antimicrobial agents (抗生素)Pleurodesis (肋膜硬化):引流管內(nèi)打入Tetracycli

16、n, Bleomycin, 使局部炎癥及沾粘硬化肋膜，以預(yù)防肋膜液產(chǎn)生? Bronchodilators (200-400mg/day theophylline)- 增加到肺部之氣流量,2024/3/21,簡(jiǎn)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 De

17、xan - 減少局部炎癥反應(yīng)、水腫情形 Diuretics- 減少體內(nèi)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%),2024/3/21,簡(jiǎn)淑慧_Symptom Management II,15,處置-3,? Opioids-Mor

18、phine (Oral, IV, Inhalation) -延腦對(duì) CO2 敏感性 ? -大腦皮質(zhì)對(duì)呼吸困難認(rèn)知 ? -延腦到呼吸肌刺激 ? -中樞性鎮(zhèn)靜功能 ?,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,16,處置-4,Opioids-Morphine ?oral: 5-15mg q4h (duration is shorter than pain control)

19、 ； old patient/renal failure：2.5mg q4h ? IV: 2.5-5mg q4h (bedtime 2times) ? Nebulizer: 20mg q4h (with 2ml of N/S),2024/3/21,※ 胸腔復(fù)健運(yùn)動(dòng)擺位:身體前傾方式，採坐姿或站姿，以增加橫膈長(zhǎng)度呼吸運(yùn)動(dòng): -噘嘴式呼吸：以增加吐氣末端之正壓及預(yù) 防胸內(nèi)過早關(guān)閉 -腹式(

20、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(yōu)先需要，避免很急促活動(dòng),簡(jiǎn)淑慧_Symptom Management II,17,處置-5,2024/3/21,※ 輔助治療肌肉放鬆技巧按摩或芳香療法轉(zhuǎn)移注意力/音樂治療使用電風(fēng)扇吹冰涼空氣穴位按摩或針灸,簡(jiǎn)淑慧_Symptom Management II,18,處置-6,2024/3/21,簡(jiǎn)淑慧_Symptom Manage

21、ment II,19,不適癥狀之評(píng)估-CACS,Cancer Anorexia Cachexia Syndrome (CACS)-癌癥惡病質(zhì)癥候群 導(dǎo)因生理機(jī)轉(zhuǎn)評(píng)估處置,http://www.dwdv.org.au/images/SteveGuestLosesHalfHisWeightThumb.jpg,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,20,惡病質(zhì)癥候群,http://www.medic

22、al-look.com/diseases_images/cachexia.jpg,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(tǒng)對(duì)抗腫瘤,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,21,癌癥惡病質(zhì)癥候群 (CACS)~導(dǎo)因,?Disease-related factors~ a Hallmark of terminal illness (80% end-stage patient

23、s)Cancer (80% GI Cancer; 60% lung cancer), GI obstruction (腸道阻塞或吸收障礙), Infection, Septic states.?Treatment-related factorsC/T, R/T, OP (Stomach, pancreas or bowel).?Psychological factors“Give up” (cancer means termi

24、nal illness)Depression, inactivity, loss of appetite.,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,22,CACS ~Mechanism-1,?【宿主】與【腫瘤進(jìn)展】間的一種負(fù)向代謝結(jié)果，其涉及:食慾不振、新陳代謝改變、前趨發(fā)炎細(xì)胞激素之釋放(Pro-inflammatory cytokines).? 當(dāng)【腫瘤細(xì)胞】或【個(gè)體對(duì)抗腫瘤細(xì)胞之免疫反應(yīng)】時(shí)會(huì)

25、產(chǎn)生【前趨發(fā)炎細(xì)胞激素-Tumor Necrotic Factor (TNF), IL-1 & IL-6, IFN-? & IFN-γ】 【新陳代謝增加】,,2024/3/21,簡(jiǎn)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

26、白質(zhì)新生? 、蛋白質(zhì)分解? (耗損肌肉塊),,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,24,CACS ~Assessment-1,1.PQRST: 評(píng)估食慾 (營(yíng)養(yǎng)替代品)、疲倦或無力狀 況、功能性評(píng)估 ADL.2.身體評(píng)估-目前體重、近日體重變化 (3個(gè)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(xiàn)水腫.3.實(shí)驗(yàn)室檢查-內(nèi)臟蛋白質(zhì):A

27、lbumin, Total Iron-Binding Capacity, Transferrin,Nitrogen Balance.-肌肉塊: 24h CCR,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,25,處置,?Steroid (20-40mg Prednisone)-刺激食慾及增加愉悅感Megestrol acetate (160mg/day Megace)-抑制TNF，刺激食慾、增加體重 (促進(jìn)

28、代謝合成)及增加愉悅感Metoclopramide (Raglan)-促進(jìn)腸蠕動(dòng)、減少飽足感NG feeding & TPN (???),2024/3/21,簡(jiǎn)淑慧_Symptom Management II,26,學(xué)習(xí)目標(biāo),1.瞭解癌末病患常見之不適癥狀(呼吸困難、癌癥惡病質(zhì))。2.說出引起癌末病患不適癥狀之相關(guān)導(dǎo)因 (呼吸困難、癌癥惡病質(zhì))。3. 分析引起 疼痛、呼吸困難、癌癥惡病質(zhì)之相關(guān)生理病理機(jī)轉(zhuǎn)。4.列舉癌末

29、病患不適癥狀之評(píng)估重點(diǎn) (呼吸困難、癌癥惡病質(zhì))。5.能說出呼吸困難、癌癥惡病質(zhì)之處置原則及其機(jī)轉(zhuǎn)。,2024/3/21,簡(jiǎn)淑慧_Symptom Management II,27,教學(xué)活動(dòng),?課前準(zhǔn)備 ：複習(xí)內(nèi)外科護(hù)理~癌癥單元 (疾病及治療所出現(xiàn)之癥狀不適) ?課室準(zhǔn)備 ：小組分享 (15-20”)-列舉引起癌癥病人不適癥狀(癌癥惡病質(zhì)、呼吸困難) 之導(dǎo)因、-列舉引起癌癥病人不適癥狀(癌癥惡病質(zhì)、呼吸困難) 之癥狀、- 列