gi alterations fundamentals 9.27 white
TRANSCRIPT
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AngelaKnox,RN,BSN,OCNUniversityofWashingtonMedical
Center
SymptomManagement:GastrointesInalAlteraIons
• Describethe– incidence– riskfactors– assessment– intervenIons• forthemanagementofgastrointesInalsideeffectsfromcancer&cancertreatment
ObjecIve
Picturefrom:hRp://juicing-for-health.com/gastrointesInal-tract.html
• Nausea&VomiIng• MucosiIs• Diarrhea• ConsIpaIon• Anorexia/Cachexia
Whatwe’retalkingabout
• Nausea&vomiIngaresomeofthemostfearedsideeffectsofcancertreatment
• ProvidersoveresImatehowwellwecontrolnauseaandvomiIngcomparedtoreportedpaIentexperiences
• HeathcarecostsarehigherforpaIentswithuncontrollednausea&vomiIng
Nausea&vomiIng
– Nausea–unpleasant“wavelike”feeling,mayleadtovomiIng,subjecIve
– Retching(Akadryheaves)-rhythmiccontracIon– VomiIng-forcefulexpulsionofcontentsofthestomach
Nausea&vomiIng:defined
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• Nausea&vomiIngcanleadto:– Electrolyteimbalances– Poorqualityoflife– Treatmentdelays– HospitalizaIon– LossofappeIte– MalnutriIon– DehydraIon– Tornesophagus– Brokenbones– Reopeningofsurgicalwounds
Sowhat? Pathophysiology
• Serotonin(5-HT3)-releaseacIvatesvagusnerve• SubstanceP-foundinvagalafferentneurons-believedtobetriggerfordelayedn/v
• Dopamine-2• CorIcosteroid• Neurokinin-1• Muscarinic• Opioid• Acetylcholine• Cannabinoid• Histamine
Neuroreceptors
• AnIcipatory–before/during• Acute–within24hours• Delayed–happensmorethan24hoursager• Breakthrough–despitetreatment• Chronic-ongoing
PaRernsofNausea
Incidence• 18–57%ofpaIents
RiskFactors– Historyofpoorlycontrolled
n/v– Age<50– Female– Higheranxiety– Feelingwarm,hot,dizzy,
weakagerchemotherapy– HistoryofmoIonsickness,
pregnancy-inducedn/v
AnIcipatory
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Incidence• Determinedbytypeof
chemotherapy/treatment• CombinaIon=higher
incidence• EmetogenicpotenIal
(NCCN&ASCO)– Highrisk>90%– Moderaterisk30-90%– Low10-30%– Minimal<10%
Riskfactors• Female• Age<50• Alcoholuse(more=lessn/v)• Advancedstagedisease• FaIgue• Pain• Tumorburden• Tastedisturbances• Anxiety• SuscepIbilitytoGIdistress• Poorperformancestatus• MedicalcondiIons• N/vwithpregnancy
Acute
Incidence• Dependsonchemotherapy• Mostcommonagents:
– Cispla4n(upto6days)– CarboplaIn– Cyclophosphamide– Doxorubicin
RiskFactors• CisplaIn• Previouslypoorlycontrolled
nauseaandvomiIng
Delayed
• OccursdespitetreatmentfornauseaandvomiIng
• Ensureappropriateregimenisbeingused• IdenIfyfurtherriskfactors,issues• AddaddiIonalmedicaIons• Usearound-the-clockscheduling• Considernon-pharmacologicintervenIons
Breakthrough
• Ongoing,usuallyduetodiseaseortreatment• Coloncancer,braintumors• Stomachulcers• CertainmedicaIons,likeanIdepressantsoropiods
Chronic
• Francescaisa38yearoldwomanwithAMLandisgoingtoreceiveCyclophosphamideandBusulfanpriortoherallogenictransplant.SheisnervousabouthercondiIoningchemotherapybecausesheexperiencedseverenauseaandvomiIngwithpriorchemotherapyaswellasduringbothherpregnancies.
• Whatriskfactorsdoesshehave?• Whattypesofn/vissheatriskfor?
Francesca
• DetermineemetogenicpotenIal
• Determinecauses• ConsidertheduraIonandpaRernofemesis
• EnsureanI-emeIcprotocolisappropriate
• EvaluatepaIentresponse
Assessment
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• Prevent!• Medicate!• Dosomethingelse!(Non-pharmacologic)
Treatment PharmacologicManagement
• Benzodiazepine• Olanzapine• Cannabinoid• CorIcosteroid• Dopamineantagonist
• NK1antagonist• Serotoninantagonist
Polovich,p.199-203
Serotoninantagonist• Examples:Ondansetron,Dolasetron,Palonosetron,NEPA(Netupitant&Palosetron)• Mechanism:Serotoninreceptorantagonist(5HT3)• Route:PO,IV,oraldisintegraIngtablet,transdermalpatch• IndicaIons:PrevenIonofCINV• Sideeffects:Headache,diarrhea,consIpaIon,faIgue• NursingconsideraIons:EnsurecompaIbilitywithconcurrent
drugadministraIon
Polovich,p.201Eisai,packageinsert,2014
CorIcosteroid
• Example:Dexamethasone• Mechanism:AnIprostaglandinsynthesis• Route:POorIV• IndicaIon:PrevenIonofn/vincludingdelayedn/v• Sideeffects:insomnia,anxiety,acne• NursingconsideraIons:AdministerIVdosesslowlytopreventperianalorvaginalburning
Polovich,p.199
AnxiolyIc
• Example:Lorazepam• Mechanism:CNSdepressant• Route:POorIV• IndicaIons:AnIcipatoryN/Vandasneededforacuteanddelayed
• Sideeffects:sedaIon,confusion,agitaIon,hallucinaIons
• NursingconsideraIons:UsewithcauIoninelderlypaIents;givefirstdoseatnight
Polovich,p.199
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Dopamineantagonist
• Examples:Haloperidol,Metoclopramide,Prochlorperazine
• Mechanism:Blocksdopaminereceptors• Route:POorIV• IndicaIons:Delayedorbreakthrough• Sideeffects:sedaIon,extrapyramidalsymptoms,dizziness,orthostasis
• NursingconsideraIons:monitorsedaIon
Polovich,p.199
AnIpsychoIc
• Example:Olanzapine• Mechanism:mulIpleCINVreceptors• Route:PO• IndicaIons:BreakthroughN/V• Sideeffects:Drymouth,weightgain,dizziness,sedaIon
• NursingconsideraIons:ContraindicatedinolderadultpaIentswithdemenIa
Polovich,p.199
Cannabinoid• Example:Dronabinol• Mechanism:Interactswithcannabinoidreceptors• Route:PO• IndicaIons:TreatmentagerstandardanIemeIcfailure• Sideeffects:verIgo,euphoria,dysphoria,drymouth,
tachycardia,orthostasis• NursingconsideraIons:IncidenceofparanoidreacIons;use
withcauIoninpaIentswithhistoryofpsychiatricillness
Polovich,p.199
Neurokinin-1antagonist
• Example:Aprepitant• Mechanism:Neurokinin-1receptorantagonist• Route:predominantlyPO.IVformalsoavailable• IndicaIon:AcuteanddelayedCINV• Sideeffects:ConsIpaIon,hiccups,diarrhea,faIgue• NursingConsideraIons:Drugisdosedfor3days.AssessfordruginteracIons
Polovich,p.200-1
Non-pharmacologicIntervenIons• Acupuncture• Behavioral• Dietary– Small,frequentmeals– AvoidovereaIng– AvoidfaRy,spicy,saltyfood– Encouragecoldorroom-temperaturefoods– Dietaryconsult– Avoidyourfavoritefoods
Polovich,pp.204-5
PaIentandFamilyEducaIon
• NoIfyteamifitlasts>24hoursorunabletomaintainfluidintake
• EnsureanI-emeIcsaretakenasprescribed• Follow-upwithpaIents24-48hoursagertreatmenttoevaluateeffecIveness(orsooner)
• Provideresources
Polovich,pp.205-6
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Now,she’stwodayspostchemo,callsyouintoherroombeforetheendofyourshigandtellsyoushethrewup.• Howwouldyouassesshernausea?
• WhatkindofmedicaIonswouldyouexpecthertobeon?
Francesca
• PutngevidenceintopracIce(ONS)
• QuesIons?
PEPResources
• YoucomeinathreedaysagerFrancescareceivedhertransplant.Inthemorningshetellsyouherlipsarereallydry,shehasanawfultasteinhermouth,andherthroathurts.What’shappening?
Francesca
– InflammaIonofanymucosalmembranes,oraltoanus– OralmucosiIs-inflammaIonofanyoralIssue– StomaIIsincludesoralinfecIons-inflammatorydiseasesoftheoralcavity– AlimentarytractmucosiIs-mucosaldamagethroughoutthedigesIvetract
MucosiIs
PathophysiologyandTimeline
(Sonis,S.2004)
• Pain• Limitedoralintake,poornutriIon• InfecIons• Decreasedqualityoflife• TreatmentdelaysordosereducIon• AspiraIon• LossofairwayprotecIon
Sowhat?
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• Overall30-100%• Transplantrecipientsup
to100%• HeadandneckradiaIon
65-90%
– AnImetabolites(bolus5-FU)– AnItumoranIbioIcs– AlkylaIngagents(highdosemelphalan)
– IL-2,Interferon– Neutropenia– Oxygentherapy,anIcholinergics,phenytoin,steroids
– TBI,headandneckradiaIon– MethotrexateforGVHDprophylaxispostHSCT
)
Incidence&RiskFactors PersonalRiskFactors
• Dentaldisease,poororalhygiene• Ill-fitngdentures• Advancedageandyouth• Historyofalcoholandtobaccouse• PoornutriIon• ConsumpIonofirritaIngfoods• DehydraIon• HepaIcorrenaldysfuncIon
Assessment:GradingScales
hRps://www.uspharmacist.com/arIcle/mucosiIs-in-cancer-paIents-a-review
hRp://chicagocancer.com/wp-content/uploads/2014/02/February-2014-EdiIon-The-Use-of-GabapenIn-for-RadiaIon-Induced-MucosiIs-in-Head-and-Neck-Cancer-PaIents.pdf
• Scalloping• SecreIons• Redness• Ulcers• Bloodblisters• Thrush• Dryness• Crackedlips
Whattolookfor PrevenIon• Nostandardofcare• Treatpre-exisIngdentalissues• Goodoralcarebeforetreatment• Oralcareprotocols– PaIenteducaIon– Blandrinses
• Cryotherapy• Bolus5-FU,bolusedatrexate,highdosemelphalan
• Palifermin• AutologousHSCT
• LowLevelLaserTherapy(LLLT)
)
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Management
• Nostandardofcare• SymptomManagement• NutriIon• PainManagement– PCA
• SucIoning• Oralcare– Frequentrinses,hydraIon(>1500ml)– Sodiumbicarb
PaIentandFamilyEducaIon
• Managetheirexpecta0ons!• Keeporalcavityclean,moist,intact• DailyoralselfexaminaIon• Oralhygiene• Moisturizelips• MaintainhydraIon• AvoidirritaIngfood• Proteinrichdiet
• Francesa’smucosiIsisworsening.Yesterdayshesaidshehadafewbitesofapplesaucebuthasn’teatensincethen.YoucheckherI&OsandnoIcethatshe’snegaIve1Lwithnochartedintake.Shealsoratesherpainata9/10whensheswallows,a6/10whenresIng.Shehas6hugepillstoswallowwithhermorningmeds.
Whatorderswouldyouexpectonceyoutalktoherdoctor?WhateducaIondoyouprovide?
Francesca
• LooseorwaterystoolsabovethepaIent’sbaseline
• Incidencedependsondisease,treatment– Chemo– RadiaIon
Diarrhea
Pathophysiology
– OsmoIc• Gutinjury• Largevolumesofstool• ImprovedwithfasIngoreliminaIvecausaIvefactor(lactose)
– Secretory• IntesInessecretemorefluidsandelectrolytesthancanbeabsorbed• Chemo,radiaIon,GVHD• ImprovedwithparenteralnutriIonfollowedbyslowdietprogression
– ExudaIve• AlteraIonsinmucosalintegrity,epithelialloss,defecIveabsorpIon• InflammaIon• Morethan6stools/day• Rehydrate,BRATdiet
Polovich,p.206
Sowhat?
• DehydraIon• Orthostasis• Electrolyteimbalances• malnutriIon• Cardiovascularorrenalcompromise
• ImpairedimmunefuncIon
• Perianalskinbreakdown
• ReducedabsorpIonoforalmedicaIons
• Pain• Anxiety• ExhausIon• DecreasedQOL
Polovich,p.207
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RiskFactors
Treatmentrelated• RadiaIontopelvis,
abdomen,orspine• 5-FUincombinaIonwith
high-doseleucovorin• Irinotecan• EGFR-targetedtherapies• MulI-targetedtyrosine
kinaseinhibitors• Immunosuppression
Physical&ClinicalFactors• IntesInalresecIonor
gastrectomy• ManipulaIonofbowel
duringsurgery• IntesInalinfecIon• GVHD• Dietarycauses• InflammaIon,IBS• ObstrucIon• Anxietyandstress
Polovich,p.208
Assessment
• StoolpaRern• PhysicalAssessment• Diethistory• MedicaIonhistory• ContribuIngfactors• ObjecIvemeasurement
• 7daysin,Francescahasbeentothebathroom4Imesinthefirst4hoursofyourshig.
• HowwouldyouobjecIvelymeasureFrancesca’sdiarrhea?
Francesca CollaboraIveManagement
• Monitorstooloutput• Replacefluidsandelectrolytes• Ruleout/treatinfecIouscause• AdministeranIdiarrheal• ProbioIcs-underinvesIgaIon• Assess&treatothercauses(GVHD)
PharmaceuIcalManagement
• AnImoIlityagents– LomoIl,Imodium
• SomostaInanalog– OctreoIde
• AnIcholinergic– Atropine
• Irinotecancommonprotocol– atropinesubcutaneous0.5-1mgpre-infusion
– loperamidefordelayeddiarrhea
PaIent&FamilyEducaIon
• TakemedicaIonsasprescribed• Avoidfoodshighininsolublefiber• Includefoodshighinsolublefiber• Limitoravoidmilkanddairyproducts• AvoidhyperosmoIcsupplements• Cleanrectalareawithmildsoapandwater• Applymoisturebarrierointment• Takewarmsitzbaths• Reportseveresymptoms
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• Infrequentbowelmovements&stoolthatisdifficulttopass
• Incidencedependsontreatment,riskfactors– 50-95%ofpaIents– Morecommoninthosetakingopioids
ConsIpaIon SoWhat?
• Abdominalorrectaldiscomfort• Nausea/vomiIng• Anorexia• ImpacIon• Ileus• Analfissures• Hemorrhoids• Rupturedbowelandlife-threateningsepsis
RiskFactors• Opioids• Vincaalkaloids(decrease
moIlity)• Thalidomide,lenalidomide,
bortezomib• 5HT3antagonists
ConsIpaIon
• Advancedage• Autonomicnervoussystem
dysfuncIon• Spinalcordcompression• Metaboliceffects• DehydraIon• Immobility
Assessment
ü PaRernsofeliminaIonü Dietaryintakeü Mobility,acIvitylevelü Abdominalpain,distension,bowelsoundsü CharacterisIcsoflastBMü CurrentmedicaIonsü Laboratoryvalues-metabolicevaluaIonü Abdominal/rectalexamifappropriateü Radiographicstudies
Non-PharmacologicTreatment
ü IncreasephysicalacIvityorpassiveexerciseü MaintainusualbowelhabitsduringhospitalizaIonü Increasefluidandfiberintakeü ObtainnutriIonalconsult
CollaboraIveManagementType Example Considera4ons
Bulkforming Psyllium Takewithwater
Lubricant Mineraloil CanleadtomalabsorpIonofvitamins
Saline Magnesiumsalts AcuteevacuaIon
OsmoIc Polyethyleneglycol(PEG) RecommendedforpersistentconsIpaIon
Detergent Docusatesodium Shorttermuse
SImulant Bisacodyl,senna ProphylacIcplan
ProkineIcagents Metoclopramide PromotemoIlity;anIemeIcproperIes
Methylnaltrexone Relistor® Opioid-induced
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CaseStudy
BobJonesisa69yearoldpaIentwithmetastaIcprostatecanceradmiRed3daysagowithseverebony,deeppelvicandbackpain.HehasbeenimmobilizedwithpainandtakingnarcoIcopioidsforanalgesia.Hehasbeenonstoolsogeners.TodayyouhavegavehimMagnesiumcitrate.Duetopainandweakness,youassistedhimseveralImestothebedsidecommodewithunsuccessfulbowelresultstoday.
Whatriskfactorsdoeshehave?Whatelsemightbedoneforhim?
PaIent&FamilyEducaIon
• Increasefluid• Increasefiberindiet• Fruits,vegetables,wholegrains• Consume25-30g/dayiftolerated
• Exerciseregularly• UsediaphragmaIcbreathingtoincreasemuscletone• CallMDifnoBMfor3days• PrevenIveplanforallpaIentsonopioids
Anorexia&Cachexia
• Anorexia-Lossofadesiretoeat• Cachexia– MulIfactorialsyndrome– Lossofmusclemass– CannotbereversedwithnutriIonalsupport– NegaIveproteinandenergybalance
• Decreasedadherencetochemotherapy• Increaseintreatmenttoxicity• MorefrequenthospitalizaIons• Decreaseintreatmentresponse• Decreasedqualityoflife• Decreaseinsurvival
Sowhat?
Pathophysiology• Tumoreffect
– ObstrucIonleadstomalabsorpIon,N/V,pain– Pro-inflammatorycytokinescausesaIetyandmetabolicabnormaliIes
• Treatmenteffects– SurgerymaycausemalabsorpIon,obstrucIon,fluid&electrolyteabnormaliIes
– Chemotherapy/radiaIonsideeffects:N/V,mucosiIs,consIpaIon,etc.
• Psychosocialeffects– Depression,anxiety,grief– Bodyimagechanges
RiskFactors
• Advancedcancer• Head&Neck,GI,lungcancer• Chronicillness-pulmonarydisease,CHF• Veryyoungorolderadults• MulImodalitytherapy
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ClinicalManifestaIons
• Involuntaryweightlossof>5%
• ChangesinappeIte– Changesintasteandsmell
– EarlysaIety• ChangesinGItractfuncIon
• Lossofmusclemass
• LossofadiposeIssue• FaIgue/weakness• Immunesystemimpairment
• MetabolicdysfuncIon• Hypoalbuminemia
Assessment
• Monitorweight• Obtaindiethistory-usefooddiary• MeasurebodycomposiIon• Labtests-endocrineabnormaliIes• AssessfuncIonalstatus
CollaboraIveManagement
• AssesspaIent’sgoals• Treatunderlyingcancer• ProgesInsandcorIcosteroids– Megace– ImprovesappeIteandweightgain;doesnotimproveQOL– Sideeffects:DVT,edema,impotenceinmen,GIdisturbances
PaIentEducaIon&Strategies• Focusonqualityoflife• RefertodieIIan-highproteinrecommendaIons• Providehigh-calorie/highproteinsupplementsastolerated• EnteralorparenteralnutriIon• Smallfrequentmeals• ARracIvesetngformeals• EncouragephysicalacIvity• Controlothersymptoms(mucosiIs,n/v,drymouth,etc.)• IncludepaIentinfamilyacIviIes• Refertocommunityresources• ReferforpsychosocialintervenIonsandemoIonalsupport
• Cancer.gov• SideeffecttrackersfromtheAmericanCancerSociety
• InsItuIonalHandouts• PEPGuidelines• ONSPublicaIons:hRps://www.ons.org/pracIce-resources/books
Resources
• hRp://www.slideshare.net/RIPS-14/vomiIng• hRp://alltaskstraducoes.com.br/vdisk/29/vomiIng-center-hypothalamus
• NaIonalCancerInsItute(2015).Sideeffects:Nausea.RetrievedfromhRps://www.cancer.gov/about-cancer/treatment/side-effects/nausea/nausea-pdq
• Polovich,M.,Olsen,M.,LeFebvre(2014).ChemotherapyandBiotherapyGuidelinesandRecommendaIonsforPracIce(4thEdiIon).OncologyNursingSociety
references