HOSPICE SHORT NOTES

By M.A. KAZMI; MD

 

side heading = new sentence/pointer n very imp point/paragraph p causes

E Rx signs/symptoms

 

 

 

Part I

HOSPICE: = Started in US in 1974 = Team work of nurses, doctors, pharmacists, social workers, chaplains, volunteers, caretakers & family members = Total care: Able to help patients medical, emotional, spiritual problems toward the end of life = Something can be done all of the time for the comfort of the terminally ill = Represent the best treatment plan for terminal patients = Palliative rather than curative treatment = Quality rather than quantity of life = Dying are comforted = Symptoms: relief provided = Discuss prognosis/issues surrounding death & dying = Give anticipatory guidance = Offer realistic goals = Give honest assessments = Discuss choices of care early = Family to take part in care = Affirm life & regard dying as a normal life process = Personalized services = All need compassionate, respectful Rx even if their life style was not conventional = Does not hasten, demise, nor prolong the inevitable = Inform patients regarding the choices of care = in 1990 WHO defined hospice as "the active total care of patients whose disease is not responsive to curative treatment." = use teamwork to help patient live actively & help family to cope & go through bereavement.

IDG: interdisciplinary group: = the team = Consider the views of others = discuss, negotiate, formulate the best course of treatment plan = interdisciplinary but medically directed

HOSPICE NURSING: = Takes care of symptoms to make patients comfortable with team work = Physical, spiritual, emotional, & social help to patients & family = Pain assessment & prompt treatment = Respect the dying = Prepare patient & family/friends for the terminal event = Speak to patient directly = Be courteous = Good symptom management = Routine vital signs not required = Brief history & physical examination are required = Get records (mainly path, labs, proceedures & biopsy results) = Conceptualize likely causes = Discuss treatment options = Provide ongoing patient, family education & support = Involve members of the entire interdisciplinary team = Reassess frequently & change Rx accordingly = Use "if it were me" = Continuous pain = continuous pain meds.

HOSPICE SERVICES: = Skilled nursing care = Services: 24 hours a day, 7 days a week = Pain and symptom management with consultation of Hospice medical director and consulting pharmacist = Home Health Aides and Homemakers = Inpatient care = Nutritional services = Provide prescription drugs = Medical equipment & supplies = Ambulance services = Physician services = Chaplainry services = Volunteer support = Bereavement counseling & group therapy = Sympathy letters & cards = Respite = Closure letter = Counseling services = Nurses can visit home without performing skilled care, even if the patient is going out of the house = Nurses provide in home, around the clock care for a medical crisis instead of hospital = Family Bereavement care = Able to shift from Hospice Benefits to other coverage at any time for a different medical problem = Patients do not have to stop seeing their primary care physician

ELIGIBILITY: = Diagnosis by physician that the patient has a limited life expectancy (<6 months) = Patient, family, attending physician, and Hospice team consent to the service = Requires terminal care only = Fix medical criteria

DYING: = Dying is a unique experience which needs respect = not a disease = patient should be center of attention = follow patients preferences = do not impose values = realistic treatment is good symptom control

 

 

Part II: PAIN MANAGEMENT

PAIN: subjective unpleasant physical & emotional experience = pain due to: disease process, fear, fatigue, frustration, depression = Pain by: Adequate sleep, Discussing worries and fears, Resolving emotional problems, controlling other symptoms, maintaining contact with family and friends, relaxation, Aroma therapy, Various activities: Yoga, Tai Chi

ANALGESIC LADDER: I. Mild pain: Non-Opioid Adjuvant II. Moderate pain: Opioid Non-Opioid Adjuvant III. Moderate to severe pain: morphine Non-Opioid + Adjuvant = control "total pain" which require physical, psychological, spiritual & social therapies n First line=NSAIDS, Tylenol n Mild Opioids: Vicodin, Codeine, Darvon n MILD TO MODERATE PAIN: E NSAIDS vicodin or Darvocet or Percocet n Moderate pain: Percocet, Oxycontin n Strong Opiods:for strong pain: Morphine, Methadone, Dilauded

ADJUVANT-ANALGESICS: = Elavil = Trazodone = Paxil = Prozac = Tegretol = Dilan-tin = Depakote = Neurontin = Lamictal = Mexitil = Dexamethasone = Prednisone = Calcitonin = Capsaicin = Baclofen = Clonidine = Dextro-methorphan = Neuroleptics = Bisphos-phonates (Fosamax & Miacalcin) = Scopolamine = Prazosin = Nonsteroidal Anti-inflammatory (NSAIDS) = Local applications (lidoderm patches or 4% local lidocaine) = Cox-2: Celebrex, Vioxx

ADEQUATE TREATMENT OF PAIN = Chronic pain in hospice: intractable, irreversible, requires special attention & skills = Cancer pain: Opioid therapy is the first-line approach for moderate to severe pain = > 95% of pain can be controlled = Severe pain is a medical emergency which should be treated promptly & adequately = Addiction is very rare when opiates are used for pain relief in hospice = Dont use Agonist / Antagonists with morphine: No to Stadol, Nubain, & Talwin = No Demerol: breakdown products are epileptogenic = Adequate analgesia = Control in-somnia = Radiation therapy: reduces a tumors mass, pathological fracture, painful localized bony metastases, Epidural met, Spinal Cord compression = Debulking a soft tissue tumor may not relieve pain = Immobilize fracture or joint = Estrogen E Lupron (gonadotropin inhibitor) in metastatic prostrate cancer = Co-analgesics E NSAIDS E Adjuvant analgesics E Anti-depressants E Muscle relaxants E Hypnotic E Anxiolytic = Neuroleptics = Corticosteroids = Explanation = Education = Counseling = Relaxation therapy = Imagery = family support

NON-OPIOID-ANALGESICS: = NSAIDS E Prostaglandin-synthesis inhibitor, no central effect = Side effects: bleeding under the skin, GI blood loss, renal dysfunction, liver (rare) = all have ceiling effect = GI side effects seem to be quite low with Tylenol, Arthrotec, Relafen, Lodine, Trillisate, Dolobid, Disalcid, Celebrex, Vioxx = 1st line: Ibuprofen or Naprosyn or Indocin with or without Cytotec (misoprostol) protect GI side effects = Avoid Tylenol in liver failure = uses: bony mets, pancreatic ca, head & neck tumor, in tissue damage, joint inflammation, arthralgia

OPIOID ANALGESICS: = For severe intractable pain drug of choice is Morphine sulfate = morphine has Mu1 Mu2 receptors = Safe = Effective = Pain should be anticipated, and treated with regular dosing not PRN = good dose: alert but pain free patient = no ceiling: dose= effectiveness = Anticipate constipation & Rx = Rx Nausea: Reglan, Haldol, Scopolamine = tolerance & addiction is rare = Morphine does not shorten life n Dilaudid (hydromorphone): E use in morphine intolerance, E potency, X6 morphine n Methadone (dolophine): use in Morphine allergy, drug accumulation, sedation, constipation = 1% of patients are intolerant to morphine (severe, persistent nausea, vomiting) use Dilauded if fails use Methadone (diff chemically) n Demerol, short acting, breakdown product that causes seizures (not used in hospice) n Duragesic (fentanyl) patch or lollipop

MORPHINE: = Morphine sulphate: can be used in tab/Elixer/SQ/IM/IV/Rectal forms = most commonly used in hospice = Poor pain control: MS by 50% & add TCA (may enhance MS effect) = Still in pain: Reevaluate, consider: Neuropathic pain, neuralgia, infection, muscle spasm, bony pain, vascular disorders, Stress, depression E Still no help: Radiation, hormonal therapy, counseling / psychotherapy, Co-analgesics, non drug measures, Antidepressants, Chemotherapy n SE: drowsiness, confusion, nausea, vomiting, constipation, bowel obstruction, urinary retention = Drowsiness for > 2-3 days, then decrease narcotics 10-25% &/or sedatives; switch meds, use long acting opiods Consider: Ritalin, Dexamphetamine = Nausea: Antiemetics: E Compazine E Haldol = Constip-ation: E Docusate E Senokot; E Pericolace, E Enema = Narcotic excess: miosis, sedation, hypo-ventilation, prolong confusion: dose by 50% or more = Morphine-intolerance change to Dilaudid = Allergic to Morphine: use Methadone (chemically different) = used in appropriate patients, Morphine does not cause addiction, or tolerance = when patient is on higher dosage the increments should be larger = Prior to death, do not stop, use 25-50% of the usual morphine dose to avoid withdrawal symptoms (restlessness, sweating, tremoulousness) = If pain lessened opioids = > 40% receive poor pain control (fear of addiction, lack of experience & knowledge) = No addiction to Morphine in chronic pain in hospice = Dosing Schedule: Fixed Schedule Dosing has replace PRN dosing in hospice = PRN= rescue dose in Hospice= 10% to 15% of the total daily dose = Otherwise PRN means pain relieve not enough = Do not wait for days to control the pain = Methadone: long-acting, should be avoided, cumulating effect = The myths of tolerance, addiction, and respiratory depression led to the poor management of cancer pain = Start with a low dose and adjust accordingly = Tolerance: does not occur = Respiratory depression does not occur when morphine is correctly used to control pain = Try to achieve full pain control = TCA may potentiate morphine n Physical Dependence: Withdrawal symptoms on abrupt dose reduction n Tolerance: Diminish drug effects n Substance abuse: Use of a drug illegally n Addiction: continuous compulsive use of drug despite harm

NEUROPATHIC PAIN: Sharp, shooting, due to nerve involvement E TCA E Tegretol E Neurontin E Depakote E Dilantin

BONY PAIN: = Severe, constant, worse pain with movement, poorly correlate with site p 80% by breast, lungs, prostate, others 20% = w/u: X-rays, Bone Scan (2mm lesion); CT; MRI; Bone Biopsy

= Metastases (most common axial mainly lumbar or lower extremities), compression or pathological fractures E NSAIDs E corticosteroids E bisphos-phonates E calcitonin E radiation E Tamoxifen E opioids E chemotherapy n RADIATION: treatment of choice in uncontrolled bony pain, Hemoptysis, Tumor (pleura or chest wall), bleeding, Pleural effusion, bony mets = Pre-med: Steriods Hydrocortisone 100 mg & Antiemetic Reglan 10-20 mg IV= 4 800 RADS single dose 4 3000 RADS in ten divided doses as 300 RADS X 104 800 RADS upper body & 1-2 months later lower body

 

 

PART III: PSYCHIATRY

DELIRIUM: Mental status fluctuation, poor attention, hypervigilence, agitation, rage, visual / auditory hallucination, confusion, delusions, paranoia, disorganized thinking, disoriented to time/place/person, worse with darkness, marked startle response, apathy, depression, fear, tremors, anxiety p CAUSES: advanced disease & old age are high risk factors, CNS Metastases, metabolic, vital organ failure, Heart / Hepatic failure, electrolyte abnormalities, hypocalcemia, nutritional, infection, sepsis, drugs, fecal impaction, Opiates, steroids toxicity, sedatives / alcohol withdrawal, anti-nauseant, anticholinergics n Rx: E stop respon-sible meds E adjust narcotics E fluid & electrolyte balance E Quiet, well lit surroundings E frequent reassurance/reorientation E treat the cause E Haldol 1-2 mg PO TID, for severe 1-2 mg IM q to 1 hr X4 max 20 mg/d + Benadryl or Cogentin to prevent extrapyramidal s/s E Benzodiazepine may worsen the condition, use only for sedation, Valium suppository or Versed SQ E Benadry / Cogentin po/IM prn E Mellaril E Thorazine E Magnesium E Clonidine-PO/Patch E Neurontin E Change narcotic agent

ANXIETY (generalized): S/S: unable to relax, persistent motor hyperactivity, irritable, shaky, autonomic hyperactivity (sweating, epigastric discomfort, palpitations, shortness of breath); Numbness, Apprehension, Worry, Vigilance, Trouble Concentrating, Hyper-attentiveness, Insomnia, Distractibility p Causes: Unrealistic goals, fear, Impending death, Electrolyte imbalance, medical (hyperthyroidism, sympathomimetics, weight loss meds, decongestants, caffeine), withdrawal of sedatives, Medications, Fear n Rx: E Treat the cause E counseling E use ancillary hospice services: social, chaplainry E Buspar E Benzodiazepines: Ativan, Valium E Beta blockers: Inderol, Tenormin E Phenobarbital, Nembutal, E Mellaril

PHOBIA: Social phobias (social functions), simple phobia (claustrophobia), agoraphobia (public places) Rx: E Imipramine E SSR1s (Paxil, Zoloft, Prozac), E Xanax

PANIC ATTACK: 1-2%, F>M, afraid to go out because of the fear of attacks, sudden paroxysmal terror, somatisation (chest pain, dyspnea), n Rx E TCA E SSRIs (Paxil, Zoloft, Celexa, Prozac) E Benzodiazepine: Valium, Xanax (Xanax or Klonopin can be given SL.) E Haldol

OCD: obsessive compulsive disorder: E SSRIs: Paxil, Zoloft E Anafranil (clomipramine)

Depression: 20% = high suicide rate Persistent sadness; worthlessness; guilty; excessive self blame; loss of pleasure in any activity whatsoever; lack of energy; sleep disturbances; weight & appetite changes; crying; suicidal thoughts; p multiple risk factors, pancreatic ca, steroids, beta-blocker, Tagamet, pain, disability, fear, frustrations, personal or social problems n Rx: E use support system E active listening E relaxation E chaplain services E guided imagery E TCA antidepressants: Elavil (sedative); Pamelor (if no sleep disturbance) E SSRI: Prozac; Paxil; Zoloft; Celexa E Remeron: weight gain & sleep with smaller doses 15 mg 1/2 tab in evening to 45 mg/d; Adjust the dose = other antidepressants: E Trazodone (desyrel) sedative E to drowsiness & alertness, apathy: Ritalin; Dexedrine

Suicide: = Assess all depressed patients for risk = Discussion of thoughts of suicide may reduce the risk = Suicidal thoughts are a sign of depression = High risk if recurrent thoughts / plans = utilize all members of the team psychologist/psychiatric consultation = listen & encourage patient to talk about his worries & treat appropriately = Rx depression, pain & other s/s aggressively = advise caretakers to take weapons out of the house = Psychiatric consultation = Social worker = Psychologist = chaplain

Stress of dying: p death, interpersonal conflicts, guilt, unfinished work, religion, leaving survivors: spouse / children / friends E utilize the team members E occasionally use anxiolitics, antidepressants

GRIEF: normal emotional reaction to loss

BEREAVEMENT: Reaction to loss of a love one

MOURNING: the social expression of grief

INSOMNIA: up to 50% in advanced ca p CAUSES: crisis, fear, pain, dyspnea, phobias, anxiety, depression, nausea, dyspepsia, restless leg syndrome, cramps, urinary frequency, steroids, diurectics, stimulants, coffee, heavy smoking, Prozac, Wellbutrin, pruritis, check meds = RX: E Rx the cause E restore sleep cycle E Analgesic for pain: E Antihistamine: Benadryl E Antidepress-ants(if depressed): Doxepin, amitryptiline or Trazodone are the most sedating agents E Chloral Hydrate E Mellaril E Thorazine E Valium (very long acting) E Nembutal suppository/PO/IV/IM E Phenobarbital po hs E Restoril (8-25 hrs half life) E Dalmane, rapid absorption, sleep, but long acting E Ambien E Sonata E with anxiety: Ativan, Klonopin A with pruritis: Hydroxyzine (Vistaril), local applications, soothing skin prep E Combination of different classes (Benzo + Anxiolytic + Opiods + adjuvant analgesics) in adequate doses should help anybody sleep

TERMINAL RESTLESSNESS: causes: terminal event, Pain, fecal impaction, Urinary retention, Anxiety, severe Dyspnea, steroids, itching, uncomfortable position s/s: respiratory difficulties (dyspnea, death rattle, secretions); CNS (restless & agitation 40%, level of consciousness, myoclonus); pain: bladder distention n Rx: = prepare the family, make patient comfortable, do not prolong nor hasten the process E stop all meds except one for pain, vomiting, seizures, agitation, anticholinergics E keep the patient dry E stop IV, tube feeding n E morphine: dont stop, or dose depending on discomfort, change oral to Buccal or suppository or SQ E use 50% of previous 24 hrs dose of morphine E to avoid morphine withdrawl use 10-25% of the usual dose E if not on Morphine: Start 10mg SQ / buccal / PR and titrate up fast E If already on morphine the dose by 25-50% n E Valium per rectum E Lorazepam SL / IM / PO E Scopolamine patch E Atropine SC / IM / SL n If restlessness persists use: E Thorazine PR/IM E Haldol buccal / IM E Versed (midazolam) SQ/IM Phenorbital or Nembutal IM / PR E Catheterize for retention E Inapsine (for nausea) n Death rattles: A raise HOB 30 degrees A reassure family that patient not aware A to dry secretions use Atropine SL/IM or Scopolamine SL/ up to 3 patches at one given time A Lasix

 

 

Part IV: GASTROENTEROLOGY

BAD TASTE: E less meat E dairy ok E fluids E Zinc sulphate E vit C chewable

HALITOSIS: = Poor oral hygiene, infection, Lung abscess, ENT ca Rx: E Routine oral hygiene, gentle mouth washes E Sodium bicarb-onate E hydrogen peroxide E antibiotics

SORE MOUTH: = Thrush = Dentures = coated tongue thrush Rx Nystatin = Gingivitis: Rx: E Flagyl = Ulcers: Vit C, Fresh pineapple, Mouthwash

ANOREXIA: = Decrease appetite, weight loss, emaciated, generalized weakness, fatigue, nausea p Cancer, meds, depression, practically any disease, not rejecting love, cancer cell may use most of the nutrients; n Rx: E sit up & rest before meals E Breakfast better tolerated E Alcohol & caffeine stimulates appetite E Small portion of attractive palatable meals E patients preference E Reglan E Decadron E Megace E Vit C

DYSPEPSIA: Heart burn, indigestion, burning epigastric discomfort, acid reflux, nausea n Rx: E eliminate predisposing factors E stop smoking E no spicy foods E frequent small meals E Antacids: magnesium containing antacids causes loose BM, aluminium causes constipation E H2 blockers E carafate E stop corticosteroids & NSAIDS E Reglan to increase motility E Prilosec

DYSPHAGIA: Difficulty in swallowing, regurgitation, aspiration, retrosternal pain p cancer of esophagus / nasopharynx, ALS, Parkinsons, CVA, MS, candida (esophagitis) = if needs w/u: Barium swallow; endoscopy n Rx: E oral hygiene E liquid / soft food, E carbonated drinks with meals E Nitroglycerine or isosorbide diniterate 10-20 mg or Procardia 10 mg hour before meals E feeding in sitting or Fowlers position E Candidiasis: no lesions but burning consider Rx with Nystatin swish & swallow; Nizoral; Diflucan E edema: neck cold compress hr AC or Decadron 4 mg QD / BID E no meat tenderizer

GERD: gastro-esophageal reflux: heart-burn, nausea p gastric contents / acid going into esophagus mucosal damage, heartburn, retro or substernal discomfort, increase s/s by recumbancy after meals or straining, clinical Dx, 50% abnormal endoscopy p ascites, smoking, obesity, alcohol, fatty/heavy meals, heavy caffeine use n Rx: E Eliminate the cause, E change lifestyle, E elevate the HOB, E antacid, E H2 blockers, E Reglan, E Prilosec

NAUSEA: = sick to stomach with desire to vomit = Vomiting: throwing up p Causes: Opioids, NSAIDs, Chemotherapy, Drugs, Mechanical obstruction, CNS or G.I. Cancer, ICP, systemic Infection, Enteritis, Radiotherapy, Electrolyte abnormalities, Anxiety Disorders, Gastroparesis n Rx of N/V: E frequent small palpatable meals E clear liquids E eliminate the cause E avoid recumbancy after meals, elevate the head of bed E Antihistamines: Benadryl, Phenergan E Pro-kinetics: Reglan E Corticosteriods: Pred-nisone, Decadron E Phenothiazines: Compazine, Thorazine E Anti-cholinergic drugs: scopolamine, atropine E Cannabinoids: Marinol E Butyrophenones: Haldol Inapsine E Benzodiazepines: Ativan E Opioids E Discontinue NSAIDS E Scopolamine E Chemo / rad : 5-HT3 antagonists: Zofran

CONSTIPATION: = Anticipate in hospice patients = 1 hard BM > 3 days difficult or no bowel movement p causes: opiates, poor bowel habits, advanced age, less fiber in diet, inactivity, impaction; structural, colon ca abnormalities, hypercalcemia, anticholinergic, phenothiazines, tricyclics, iron, calcium, aluminum containing antacids, calcium channel blockers & other pain meds n Rx E remove the cause E Initiate bowel program E stool softeners E laxatives: Bulk agents, Softeners (Docusate Sodium), Colonic stimulants (senna, bisacodyl) E Sorbital, lactulose, magnesium sulfate for severe constipation E mobilize the patient E Diet: roughage, fluids & fiber E Senna E Peri-Colace E Dulcolax suppositories E senakot E Prune JuiceE white grape juice & cranberry juice oz each/day E Reglan (not in parkinsons) = If no BM for > 3 days: intermittent use of mag citerate or phosphosoda, lubricants, Caster Oil, Milk of Magnesia, E Lactulose: not absorbed, side effects: cramping / flatulence (we prefer Sorbital) E Dulcolax supp E Enemas E disimpaction

HICCUPS: = Phrenic nerve irritation, CVA, post-operative, Irritation of nerves, psychiatric, Gastric distention, metabolic problems, Uremia = Rx: E keeping the tongue out for few seconds E supraorbital pressure E teaspoon of sugar on outstretched tongue E avoid recumbancy immediately after meals E hold breath for few seconds E Mylanta E Reglan PO / IV E Baclofen E Tegretol E Haldol E charcoal-tab E Adalat E IV-Lidocaine E Chlorpromazine (Thorazine) O / IM, 80% improvement E Peppermint water E lastly Phrenic nerve block

FECAL IMPACTION: p Prolong narcotic use; chronic Constipation, debility, prolong bed rest Overflow diarrhea, firm mass in rectum, leakage around impaction, abdominal pain, Nausea / vomiting / anorexia, abdominal distention n Rx: E Dulcolax or Glycerin suppository E warm water or mineral oil retention enema E soap suds or Fleets enema E Reglan 60mg/day SQ continuously for 1day followed by oral once symptoms improve E longterm care: diet, regular BM, stool softener E Vaseline balls

DIARRHEA: increase frequency > 3 stools/d, decrease consistency, watery stool p laxative overuse, maldigestion, malabsorption, Partial bowel obstruction, GI Tumor, Magnesium, antibiotics, Clostridium difficile and pseduo membranous-colitis, chemotherapy, NSAIDS, Caffeine, Estrogen, Sulfonylureas, Reglan, Radiation, Infection (particularly in AIDS), bacterial, Viral, parasitic: giardia, AIDS, Colitis, irritable bowel syndrome, Malapsorbtion, Pancreatic insufficiency, sorbitol, Lactose, diet, tube feedings n Treatment: E avoid offending agent E Disimpaction E bland low residue diet E watch dairy products E less carbohydrates E Gatorade E Stop offending meds if possible E Kaopectate E Pepto-Bismol E Imodium (Loperamide) E Lomotil (diphenoxylate / Atropine) E Anticholinergic E Tricyclics E codeine E Morphine sulphate E Pancreatin for pancreatic insufficiency E Questran provided no biliary obstruction E Steroid enemas for Colitis, infiltrating tumor or Inflammatory E Infection: Cipro + Flagyl E Clostridium difficile: Flagyl or Vancomycin E Desitin or A&D or Vaseline for local irritation E discontinue Penicillin, Cephalosporin; Sulpha E Steroids: Ulcerative colitis E Sandostatin (octreotide) in AIDS diarrhea

to induce CONSTIPATION: E Codeine phosphate E Opiods E Tricyclic antidepressants

BOWEL-OBSTRUCTION:= Abdominal pain / tenderness, abdominal distention, Overflow diarrhea, Air-fluid levels on x-ray p colon ca, fecal impaction, ileus, meds n Rx: E IV fluids, E NG suction for 7-10 days E Small meals preferably liquid/low residue E all meals timed long before bedtime E dont force feed E Vaseline ball-for-high-impaction E Benadryl-PO-BID/QID E Haloperidol E Scopolamine (antispasmodic) E Robinol po TID or SQ / IV E Atropine (antispasmodic) SC / PO / sublingual = Droperidol (Inapsine) IM-TID E Opiates for severe pain SL/PR E Probanthine POQID E Phosphate enema E Ducolax or Senokot for small bowel obs avoid if possible E Trial Decadron 4mg po QID or Prednisone 30mg po QID for 5-7 days E Solumedrol 50mg IM TID x 3 days (50% response) E Thorazine E NG p.r.n.; E sedation, E control pain E needle decompression for severe gaseous distension E steroid retension enema E Pepcid 20 mg POBID E 1 wk to allow spontaneous resolution before surgery, avoid surgery, 30% perioperative mortality with surgery = Avoid Tubes

ABDOMINAL DISTENSION: p Tumor, ascites, Perforation, Intestinal Obstruction, Gaseous Distention (Lactulose) n Rx: E Treat the Cause E No NG Tube or No flatus tube in Perforation E Treat symptoms E Control Pain E Needle decompression!

ASCITES: fluid in the abdominal cavity Abdominal distention, pain, discomfort, fluid thrills, Dyspnea, orthopnea, nausea, Lower Extremity edema p Any cancer primary or metastatic, cirrhosis, CHF, infection, nephrotic synd. n Rx: E Elevate HOB 30 E sodium restriction E Pain Control E Diuretics E Para-centesis E Peritoneovenous Shunt E treat the cause E symptomatic

RETROPERITONEAL METASTASES: = Cancer of: Pancreas, breast, cervix, endomet-rium, kidney, colon, or prostate = Retroperitoneal: sarcomas, germ cell tumors, lymphomas S/S: = Backache, palpable abdominal mass, urinary frequency, venous thrombosis, pain, impotence, lymphedema n Rx: symptomatically, radiation

 

 

Part V: GENITOURINARY

 

 

URINARY-FREQUENCY/INCONTINENCE: (urge incontinence) >7 daytime, > 2-3 times/night p with age, Diuretics & Hypercalcemia (large volume, urine), Infection (cystitis, prostitis), Diabetes, tumor, debility, Diabetes, Bladder spasm / cancer, Fecal impaction, Retention with overflow, Anxiety, Detrusor weakness, coffee n Rx: E Ditropan (oxybutynin) E Detrol E Elavil E Catheter E Bladder Training E Flomax = Dysuria E Phenazopyridine (Pyridium): for dysuria E Septra DS bid if not allergic E antispamodics: levsin SL, Scopolamine E TCA: Elavil, Tofranil

HESITANCY / RETENTION: frequent small volume, large postvoid, overflow incontinence, Urinary Retention n Rx: bedpan, schedule urination E Minipres E Hytrin E Urecholine (bethanecol), E Flomax, E Cardura A stop anticholinergics A catheter E suprapubic catheter

BLADDER SPASM: p infection, tumor, radiation, fecal impaction n Rx: E Ditropan

E Urispas E Probanthine E Tofranil E Flomax E Benzodiazepines E levsin SL E Scopolamine E Aropine E Naprosyn E TCA: Elavil, Tofranil E Belladonna

URINARY TRACT INFECTIONS: dysuria, fever n treat if symptomatic, not near death, dont treat if asymtomatic bacteriuria E Pyridium (pink urine) E Septra E Floxin E Cipro

MESTASTATIC PROSTRATE CANCER: = bone pain, anorexia, weakness, malaise, anemia, hematuria, obstructive uropathy E Lupron (leuprolide) / month (Less side effects than estrogens) E Antiandrogens Eulexin (flutamide) (Prevents testosterone receptor binding, less side effects E Orchiectomy instead of Lupron (less expensive) E Corticosteroids: for painful bony mets E Radiation E Didronel E Calcitonin

HEMATURIA: Bloody urine p tumor, infection, chemotherapy, radiation, coagulopathy = RX: E Antibiotics E Continuous irrigation with 1% Alum solution at 5cc/min E Radiation E Amicar 5gm po followed by 1 gm po q1-4h as needed E Transfusion (benefits lasts 2 days)

URETHAL CATHETER OBSTRUCTION: = Cause: clot, sediment, tumor, infection n Irrigation E Larger catheter E Larger balloon E Emmett catheter multiple holes

CATHETER: catheter better than pads or diapers, drained to gravity, if ambulatory use leg bag

 

 

Part VI: BEDSORES & SKIN

 

PRESSURE SORES = Turn in bed Q2-4 hrs = Avoid pressure/friction except in last few days = Use skin prep (Sween, Hollister, Bard) = Egg crate, thick foam, air-mattress = Do not massage = Clean, rinse, & dry n Open wounds: kept moist to heal; Protein supplement, multivitamins, Vit C 500mg TID, and Zinc 220 BID; Foley catheter n BEDSORE with INTACT skin (reddish): Ointments: A&D, Vaseline, zinc oxide, Desitin = (Op-site, Tegaderm), change every 5-7 days or PRN = Granulex spray BID or prn = Blister (skin break partially): Irrigate well with saline = Use saline = Carington wound gel = Duoderm, Tegosorb, Change each week n Sore with exposed Bone / muscle exposed: Bedside surgical debridement; Travase or Elase; Carrington wound gel; Wet to dry gauze; if granulating n Infected bedsore: Wet to dry; Carrington wound gel; Silvadene; no semi-permeable or occlusive dressing when infected = Granular (clean pinkish): Moisturizing ointments; MVP film; Granulex

PERISTOMAL CARE: = Cleanse, rinse and dry = use skin Prep = device fit & sealed = Rapid attention to skin breakdown

MALIGNANT ULCERATIONS: A radiation E Anti-inflammatory E steroids E Odor/drainage: Dakins soaked dressings, Benzoyl peroxide 10% solution packing (protect surrounding tissue) E Air freshener E Flagyl PO/gel E Bleeding lesion: Alum in 1% solution; 1:1000 epinephrine soaked gauze; Gel foam

SKIN INFECTIONS: = Infected sores, Erythema, purulence, foul odor, pain = Culture n Rx E Dakins dressings E use Acetic acid if green (Pseudomonas) E Metrogel topical BID E Flagyl po QID E Silvadane E Cipro n Impetigo-superficial-infections: Bactroban (mupirocin) topical, Eryth-romycin, Dicloxacillin, Velosef, n Cellulitis: Penicillin, Erythromycin, Velosef or cipro n Candidiasis: Nizoral, Lortrisone, or Mycolog topically, Nizoral for 2 wks

DRY SKIN: = After bathing apply Lanolin, Vaseline Intensive Care, Vaseline, Bag balm E Atarax (hydroxyzine) E Steroids: 1% hydro-cortisoneoint/0.1% Triamcinolone oint / Prednisone 20-40 mg po daily E Phenergan only if allergies E Benzodiazepines

WET SKIN: E Wash & dry E Special cleansers E Zinc oxide E No ointments or creams E Calamine lotion E Starch E zincoxide E talc E Lotrimin E Burrows solution

MOUTH CARE: n Dry mouth Rx: E avoid anticholinergic drugs E Lip balm E Frozen tonic water, fruit juices, pineapple chunks E Sugarless lemon drops E Chewing gum E Artificial saliva E brush E rinse (H2O2) E Soda water E Cepacol n Ulcerations: = Herpes: E Zovirax (acyclovir) 200mg q4h 5 days = Aphthous ulcers: E Glyoxide rinse n Periodontal infections: E Peridex wash, oral Pen VK, Flagyl, Velosef E Kenalog, Lidex or benzocaine in Orabase n Foul, fungating lesion: E Flagyl n Yeast E Mycelex troches 5x/day are very effective E Nizoral (Hepatotoxic) E Nystatin suspension 1 tsp q4h n Painful mouth: E Xylocaine 2% viscous solution 1-2 tsp or 10% oral spray q3h E Antacid E Glyoxide rinse E Tessalon perles, 1 or 2 dissolved orally q8h Anesthesized Throat

Taste Alteration: E Zinc, Vit C

URTICARIA: E Rx: E Antihistamine E H2 blockers (Pepcid) E TCA (Elavil) E Benzodiazepine E Local application

PRURITIS: = Dry skin: E NO hot baths E avoid irritants E lubricants E cornstarch & bak-ing soda tepid bath E cotton dressing E 1% Hydrocortisone cream E Antihistamine E Decadron

CANDIDIASIS: 70% = Sore mouth = Painful Dysphagia = risk with: Steroids, antibiotics, radiotherapy, chemo, dentures n Rx E Nystatin oral susp / Popsicle E Ketoconazole E Diflucan E prophylactic Mycelex troches

 

 

PART VII: SPECIAL PROCEEDURES:

 

Needs pain management specialist or physician who is experienced

SUBCUTANEOUS INFUSION: = change needle site weekly = use: Intractable pain, Nausea, Bowel obstruction, coma, debility, poor compliance n Rx: E Fluids 500-1500 ml / 24hrs E Morphine E Antiemetics E Haldol E Reglan E Dilaudid = contraindication: severe Thrombocytopenia

Enteral tube feeding: Patient, family & team prefernce, not helpful in last few days

TPN (total parenteral nutrition): does not improve nutritional status, may be inappropriate in hospice

TRIGGER POINT: Rx: E Local injection of Bupivacaine & Methylprednisolone E Ethyl chloride spray E Lidoderm patches 12 hrs on 12 off EPIDURAL OPIOID THERAPY: = Analgesia = less sedation = less side effects = Titratable

NERVE BLOCKS: blocking the nerve= Marcaine + Depomedrol

SYMPATHETIC BLOCKS: = Local anesthetics + 50% alcohol or phenol 5-10% in water

CELIAC PLEXIS BLOCK:= pancreatic ca = upper abdominal cancers

STELLATE GANGLION BLOCK: = For pain in the head, neck and arm, Complications: Pneumothorax, infection, Horners syndrome, laryngeal nerve, phrenic nerve & Brachial plexis injury

NEUROABLATION: = Cordotomy, for sev-ere pain below that level = Partial posterior rhizotomy

RADIATION: = Shortest treatment = Bone Pain = Spinal cord compression = Fungating ulcer = Control of hemorrhage = Obstruction (SVC, airway, esophagus) = Brain metastases = Reduce tumor bulk = SE: Nausea and vomiting; = skin reactions: starts in 21 days; lasts 1 or 2 weeks after the last Rx

 

 

Part VIII: CARDIORESPITORY

 

ANGINA: = Chest pain, increases on exertion, relieved by rest/nitro = Rx: E sublingual nitroglycerine 0.4 mg q 5 min x3 or pain free E O2 E rest

ACUTE MI: = Chest pain > 30 min, shortness of breath, left arm/neck pain, diaphoresis, hypotension = Rx: E O2= 2-4 L/min E Nitro-glycerine 0.4 mg SL q 5 min x 3 E Morphine liq sublingual

HYPERTENSIVE CRISIS: = BP > 200/120 = Headache = Epistaxis = Blurred Vision E Rx Catapress (clonidine) 0.1 mg q 1hr until DBP < 115 (total dose 0.8 mg) E Procardia (Nifedipine) 5-10 mg bite & swallow q 1 hr (x 3), no sublingual may drop BP rapidly E Nitroglycerine SL

HYPERTENSION: = Diuretics: elderly, African-American, smokers = Beta-blockers: whites, non-smoker, younger, no asthma/CHF = ACE inhibitors: whites, young, total chol > 240, diabetics = Calcium channel blockers: elderly, African, hypercholesterolemia = Alpha 1 blocker: men with prostatic hypertrophy

DYSPNEA: Breathlessness, severe shortness of breath, 70% in cancer p lung-ca, CHF, COPD/Emphysema, CNS metastases, pain, anxiety, Anemia, Infection, terminal event, SVC= superior vena cava synd (edema above neck & upper extremity) = hrs or days infectioin = weeks tumor or chronic diseases n Rx: E Treat the cause if possible E relaxation E reassurance E breathing exercises E fan E cold humidified air E Fowlers position E pursed lip breathing E Bronchodilators E Prednisone, control pain = Asthma / COPD: Albuterol, Atrovent inhaler, Beclovent inhaler, E Theophylline for COPD, = CHF: raise head of bed, Diuretics, Digoxin, ACE inhibitors = Infections: antibiotics unless near and symptomatic death = Death rattle: E turn patient on side; Scopolamine Patch; Atropine 1% 1-2 drops SL/PO Q 4 hrs E Small doses of Ativan or Valium as anxiolytics = Anemia: Transfusion (affects lasts 2 days) = SVC or TUMOR: Radiotherapy +/- Corticosteroids = O2 = Morphine

COUGH: p Pneumonia, bronchitis, lung abscess, COPD, Cancer, Smoking, CHF, LVH, ACE inhibitors, GERD n Rx: E remove irritants E oral hydration E steam E antibiotics for infections except actively dying E expectorants = Bronchospasm: Bronchodilator; Atrovent; Proventil inhalers = Post nasal drip: Anti-histamines / decongestants; Pseudoephedrine (Sudafed= decongestant) = CHF: Diuretics, Digox-in, raise head of bed, (ACE inhibitors may induce cough) = Dry cough: E hydration, humidity and or steam, Bronchodilators, terpin hydrate = Productive cough: E Antitussive, Dextrometh-orphan, Codeine PO; Scopolamine sublingual / patch E Atropine PO or SL E Corticosteroids = Cancer: radiation or chemotherapy = Dying with ineffective cough: E morphine E atropine drops E Scopolamine patch

LYMPHEDEMA: unilateral painless non-pitting edema p post-mastectomy: immediately or yrs later; radiotherapy; Pelvic malignancy = document limb circumference n Rx: E elevate the extremity E avoid infection E Compression stockings E lymphatic compression pump E light massage E exercise E no Diuretics A physical therapy (Home?) pneumatic compression 1 hr/d for 1 month E TENS proximal & distal to the swelling E short course of decaderon E if very painful consider infection or tumor invasion

PERIPHERAL EDEMA: failure of heart, liver & kidney p Fluid retention, Immobility, Hepatomegaly, Low serum albumin, CHF, Pelvic tumors, nephrotic syndrome n Rx: E Elevate extremities E Exercise E Ted Hose E Start Diuretics E Reduce the dose or D/C Steroids

DVT: E Elevate leg E moist heat E Heparin E Coumadin

Bronchospasm: n Rx: E Albuterol E amino-phyline E steroids E Radiotherapy: large carc-inoma E Opiods: the most powerful central cough suppressants E Nebulized Lidocaine: 2% can bring dramatic relief

DIABETES: p carcinoma of the pancreas, steroids Thirst, Drowsiness, increasing weakness = keep pre-prandial blood glucose levels below 170 mg/dL = Oral hypoglycemic E Diet = Warned about hypoglycemia = Insulin requirements in advancing disease may decrease = During the terminal phase, insulin may still be needed = Basal requirement of insulin Novolin 70/30=10 units BID = If unconscious insulin should be stopped but follow blood sugars unless near death

Superior Vena Cava syndrome (SVC): p right apical lung ca; breast; lymphoma; mets Headache, swelling of the face & right arm, swollen eyes, pain, dilated neck veins n Rx: E Decaderon 8-12 mg per day E Radiation E Chemotherapy

 

 

Part IX: CNS

 

SEIZURES: 1% p CNS tumor & metastases, CVA, electrolyte abnormality, hypocalcema, hypoglycemia, drug, stopping anticonvulsants abruptly, sedative withdrawal, alcohol n Rx: E Valium 5-10mg by slow IV/rectal stat E Dilantin 1,000mg po in first 24 hours in 3-5 doses, followed by 300- po/day E Dilantin, phenobarbital 100-200 IM E Phenobarbital 30-60mg po BID-TID E Dysphagic: Phenobarbital, Ativan, Valium IV/Rectal. E Versed 0.25-2mg/hr by SQ pump C Diastat: Rectal valium pre-filled syringe = control seizures even in dying patients

ALS: = Respite care = Mentally alert until death = Choking is a rare cause of death <1% = Occupational therapy = Aids: walking, talking, eating, etc. = Dysphagia: ice to neck before meals = Suck ice before meals = eat slow = place food at the back of throat = Avoid dehydration = Repeated chocking: PEG = Drooling: E Atropine, Scop-olamine, TCA (Elavil) = NO artificial ventilation = Good symptom management = Rilutek: very expensive, not a cure.

RAISED INTRA CRANIAL PRESSURE: Wakes up with HA, nausea, projectile vomiting, papilloedema, focal neurologic deficit, mental status change (seizure) Tumor, metastasis n Rx: E High dose Decadron 16mg/d as 4 mg PO QID E diuretics E Head of bed elevated to 30-45

BRAIN METS: 10% of Cancers Focal Neuro deficit, Seizures, ICP, wakes up with HA, Vomiting, Papilloedema, Personality changes n Rx: E High dose Decadron E Radiation E Anticonvuls-ants E Surgery: Solitary accessible lesion, no other mets, healthier pt, not dying, good prognosis

SIADH: 1% ca of lung small cell, water, decreased sodium HA, fatigue, cramps, confusion, seizures, coma E Fluid Restriction 500-900 cc/day E Demeclocycline 300 mg PO BID A lasix E Rx the cause A monitor electrolytes A consider hypertonic saline infusion but avoid rapid correction

ALZHEIMERS: = Most common cause of dementia = Cause: not known = Gradual decline in intellectual functioning, memory, concentration, behavior, language = Early Stages: Treatment is available = Late Stages: Symptomatic Care, control behavior, support caretakers

CONFUSION: p Drugs, metabolic & electrolyte abnormalities, Pain, Impaction, Brain Metastases, CVA, Infection, Alcohol, bladder distension j family members are worried more than the patient confusion, disorientation, agitation n Rx: E correct the cause = agitation / hallucin-ation: E Haloperidol E Chlorpromazine, Risper-idol, Zyprexa E Symptomatic care

DROWSINESS: p Morphine, Pyschotropic drugs, Hypercalcemia, Uremia, Electrolyte imbalance, Hyponatremia, Infection n Rx: E Treat cause = pain free but drowsy: A morphine A Ritalin

CAUDA EQUINA SYND: p Involvement b/wL1 to the end = Lumbosacral nerves supply the lower extremities, bladder, rectum. = Interruption of S2, 3, 4 the bladder-emptying reflex causes retention bilateral Sciatica = Perianal numbness ("saddle anesthesia"), Urinary hesitancy or retention, Weak, flaccid legs = Rx: E Radio-therapy, E high dose steroids E Tricyclic E Phenothiazine E Pain control E Urinary Catheter

SPINAL CORD COMPRESSION: 5% pain, weakness / paralysis / decrease sensation / increased DTR below the compression; incontinence of bowel / bladder = W/U: x-ray, MRI, Myelogram (if needed), CT n Rx: E immediate Rx within 48 hours may restore the deficit E High dose steroids E Radiation A decompression

FECAL INCONTINENCE: p weak to get the bathroom, Diarrhea, Impacted feces, Rectal carcinoma, spinal cord compression n Rx: E treat the cause

TREMORS: E Mysolin E Beta-Blockers E Benzo: Klonopin E Neurontin

MUSCULAR SPASMS: n Rx: E Diazepam E Baclofen E Physical therapy E Replace magnes-ium & calcium

 

(Part X) MISCELLNEOUS

ANEMIA: = Hemoglobin < 7, or sudden blood loss Light headedness, dizziness, palp-itation, dyspnea, fatigue, generalized weakness = 1 unit of blood raises HG 1 g/dl = Benefits lasts 1-2 days = Transfuse for special occasion or good prog!

NOT RECOMMENDED: = Mixed agonist-antagonists: Pentazocine (Talwin), Butorphanol (Stadol), Nalbuphine (Nubain), Dezocine (dalgan), compete with agonists withdrawal = Demoral: breakdown product epiletogenic

PRECHEMOTHERAPY TREATMENT: = Vomiting Central mechanism E Antiemetic before chemotherapy; Zofran IV, benadryl, Compazine E Dexamethasone: 6-10 mg oral / parental starting before therapy then Q 6 hrs x4 E Reglan 1-2mg / kg IM / IV / 30 minutes before & after E combination= Reglan + Ativan + Dexamethazone E Dronabinol (tetrahydrocanna-binol)

HIV: = > 60% experience pain = intense pain is associated with fear, anxiety, depression, poor quality of life = Neuropathy, CNS involvement = Opportunistic infection are common, treat if not terminal = Headache: Cryptococcus, Toxoplasmosis, Lymphoma = Poor Nutrition = Pain = Painful peripheral Neuropathy = Wt. Loss = Fever = Diarrhea = Dementia = Retrosternal discomfort: Esophagitis due to candida, Herpes virus, CMV, GERD = Rectal pain: Herpes until proven otherwise E Acyclovir 200-800mg 5x/day for 5 days, remain on 200mg 3x/day = Gonorrhea and Chlamydia E Amoxicillin 3 grams orally and Tetracycline = Herpes Zoster; Acute: E Acyclovir 800mg 5x/day for 5 days, Tegretol, TCA = Kaposis (KS): E Radiation therapy = FEVER: T cells are under 100, PCP, Myrobacterium Avium lymphoma, include Cryptococcus, CMV, toxo, candidiasis, KS, drug reaction to sulfa. n Octreotide (Sandostatin) in AIDS- related diarrhea 100-500mcg Sq tid = good symptom management = Total care

Fever: p U.T.I, URI, infection, Dehydration, wound n Rx: E Fluids E Cooling: ice packs, axial, groin or cooling blanket E Tylenol E Aspirin E Water Sponging E Antibiotics in appropriate patients, avoid close to death

HYPERCALCEMIA: > 12 mg/dl = 80% die within one year p Cancer of lung, prostate, breast, head & neck; hypernephroma p presenting s/s in MM = Multiple Myeloma, T cell Lymphoma, Hyperparathyroidism drowsiness, Confusion, lethargy, fatigue, Polyuria, Polydipsia, anorexia, dry mouth, nausea, vomiting, severe weakness, constipation, coma, S/S resemble OD of morphine & typical worsening hospice pt., hyporeflexia, alkaline phosphatase (not in MM) n Rx: E Fluid intake, mobilize pt E D/C Dyazide (Thiazides) E Decadron E Lasix E 1.V.F NS>3L/d E Calcitonin: 200-400 1 U SQ q 12 hrs. E Aredia 60 mg / 250 cc 1.V. over 4-8 hrs E Calcitonin 200 units QD nasal spray E Oral phosphate E Oral steroids E Hormone = Chronic Hypercalcemia: E exercise E fluids E Didronel 200 400 mg PO / day E no vit A&D A no extra calcium E Prednisone = Levels above 14.0 mg/dL require IV re-hydration with 2 to 3 liters normal saline per day with potassium supplements (monitor serum electrolytes) combined with Didronel (etidronate) 7.5 mg/kg/day in 250 cc over 2 hrs for 3 days or Aredia

ODOR: = Wound: Yogurt, Dakins Solution chemical or surgical debridement = Ostomy: activated charcoal, Aspirin crushed in bag = Incontinence: Rx appropriately = ionizer = infection: Antibiotics = Flagyl or Clindamycin = Topical: E Bacitracin, E Neosporin E Bactroban = Topical Antifungal: E Clotrimazote (Lotrimin), E Miconazole (Monistat) = Tea Tree Oil

PHYSICIAN ASSISTED SUICIDE: NO-NO-NO = no right to PAS by US Supreme Court = Oregon is the only state where PAS is legal (as of 1999) = their intent is to shorten life = Hospice intends to comfort, do not shorten or prolong the inevitable in dying = dont give license to kill to those who were trained to save & cure

ANTI COAGULATION: = May be ok in DVT/PE to control symptoms E Coumadin: decrease the dose by 50% or stop = to reverse: vit K po/IM effective in 4 hrs.

BLEEDING: Local measure = 1:1000 adrenaline soaked dressing = Reverse Coumadin by Vit K, oral/I.M. = No blood transfusion = Heavy Sedation in terminal event = Radiation = 1% alum for hematuria / Skin Bleed / Rectal bleed = nasal pack = ICE = keep towels wet

CANDIDIASIS: Sore white plaques, Painful Dysphagia, p following antibiotic or steroids or radiation E Rx: E Nystatin, E Ketoconazole


= Candidiasis

TERMINAL DEHYDRATION: benefit = keeps pt dry, No IVF, comfort family, educate, chaplain, involve team

EXCESSIVE SWEATING: E Prednisone 20mg/day QD or divided dosage = Anticholinergic

SURGICAL OPTIONS IN HOSPICE: = Paracentesis = colonic tumor resection for obstruction in appropriate = Tracheostomy = PEG tube for feeding = Colostomy = central line = Pick line = Fractures

STRENGTH: E no med will restore E vitamin may help E blood: no help E depressed: anti-depression

 

 

Part XI: MEDS

 

ANTICHOLINERGIC: Uses: secretions, Death Rattle, colic, bladder spasms, sleep, to produce urinary retention, to prevent EPS (extra pyramidal SE) E Atropine E Scopolamine E Benadryl E Cogentin = SE: dry mouth, confusion, agitation, ataxia, dizziness, delirium, bradycardia, photophobia, constipation, urinary retension

HALDOL: non-sedating anti-emetic or anxiolytic = calm a severely agitated person Haldol: Uses: psychosis, agitation, combative-ness, pain, nausea, intractable vomiting, pelvic-abdominal radiation induced pain & discomfort = Haldol: available in tabs / concentrated liquid/IM, absorbed sublingually, less sedative, less anticholinergic, minimal cardiac/CNS side effects, long acting

CORTICOSTEROID: USE: = Superior vena caval syndrome (Decadrone 8mg/d) = Upper Airway obstruction = With radiation or chemo-therapy = Bowel obstruction = Carcinomatous lymphangitis = lymphadema = Malignant effusion = Hemoptysis = Discharge from a rectal tumor = Raised intra cranial pressure secondary to tumor (high dose Decadrone 16mg/d) = Painful compressive Neuropathy = Bony metastases = Spinal cord compression = Hepatomegaly = vomiting due to Pyloric stenosis resistance to other meds = to improve appetite = Hypercalcemia = Excessive sweating: Prednisone upto 20mg/day in divided doses = Prednisone 7:1 ratio to Decadron (prednisone 30mg = Decadrone 4mg) = If no benefit after 7-10 days, then discontinue = after prolong use decrease steroids slowly (Decadron 2mg/week) = Dysphagia (esophageal cancer) = Dyspnea n SE: = Peptic ulcer disease and hemorrhage rare = Infections = Tuberculosis: no difference in incidence = Oral candidiasis Rx: E nystatin, E Mycelex E ketoconazole: = Hyper-glycemia = Euphoria and restlessness = manic depression = increased appetite = insomnia = psychosis: E Rx symptomatically = Avascular necrosis (femoral or humeral head) in 6 months = Adrenocortical atrophy in 16 months = gastric irritation = facial swelling = easy bruising = edema = weakness (potassium depletion, proximal myopathy) = hair growth = acne

 

 

XII: FORMULARY

Familiar and trade names are used PO unless mentioned

 

 

 

I. Pain

8 Ansaid: 50-100 mg tid (50,100)

8 Codeine: 15-60 mg /IM q4-6h(15,30,60)

8 Darvocet (propoxy/Tylenol): 1tab q4h

8 Darvon Comp (propoxy / ASA / caf): 1 q4h 8 Daypro: 600 mg 2 tabs/d

8 Dilaudid (hydromorphone) 2mg q4-6h; 3mg PR q6-8h(tab1,2,3,4, supposit 3)

8 Dolobid: 100 mg 500 mg bid (250,500)

8 Duragesic-25mcg-q3-d (patches 25, 50, 75, 100)

8 Empirin with Codiene=30,60 mg: 1-2tabs q4h 8 Feldene: 20 mg qd (10,20)

8 Fioricet (Tylenol + butal + caf): 1-2 tabs q4h

8 Fiorinal (ASA/butal/caf) 1-2 tabs q4h

8 Indocin: 25-50 mg tid or SR: 75 mg qd/bid.

8 Lodine: 200-400 mg tid/qid (200,300,400)

8 Lorcet (hydrocodone/Tyl 5/500): 1-2 q4-6h

8 Lortab (hydrocodone/Tylenol) 2. 5, 5,7.5, 10 =1-2 tab, or 2. 5/167 per5ml : 10-15ml PO q4-6h.

8 Methadone (Dolophine): 2. 5-10 mg PO / IM / SC q4h (tabs 5, 10) cumulative effect

8 Motrin: 200-800 mg PO qid. [200, 300, 400, 600, 800]

8 MS-contin: 15, 30, 60, 100, 120 mg q8-12hrs; morphine Elixir 10-30mgPOq4h short act (10,20,100 mg/5ml)

8 Narcan: 0.01 mg / kg IV / IM / SC / ET; opiod antagonist

8 Naproxen: 250-500 mg PO bid

8 Orudis: 50-75 mg PO tid. (12. 5, 25, 50,75) (Oruvail): 200 mg PO qd. [200]

8 Oxycodone: 5 mg PO tab or syrup q6h

8 Oxycontin: 1 tab PO q12h (10,20,40,80,160)

8 Percocet (oxycodone 5mg+Tylenol): 1tab POqid

8 Percodan (oxycodone 5mg+ASA): 1tab PO q6h

8 (Propoxyphene) Darvon :65mg PO q4h

8 Pyridium: Dysuria 200 mg po tid x 2d [100,200]

8 Relafen: 500-750 mg bid

8 Salsalate=Disalcid: 500-750 mg po qid

8 Soma compound (+ASA )1- 2 tabs PO qid.

8 Toradol: 10 mg PO q4-6h (10) 30 mg I/M

8 Trilisate 1tab poq4-8h(tab500,750,1000,liq 500 /5

8 Tylenol 650 mg po q4h

8 Tylenol w / codeine #2;3;4 =1-2 tabs PO q4h

8 Tylox (oxycodone +Tylenol): 1tab PO q6h

8 Ultram: 50-100 mg po q6h max 400 mg/day(50)

8 Vicodin 5/500: 1-2 q4-6h, or ES 7.5/750: 1q4-6h

8 Voltaren: 50-75mgbid; XR: 100 mg POqd.[100]

8 Xylocaine= viscous Lidocaine 2%=15ml po q3h

 

 

 

II. Muscle Relaxant

 

8 Baclofen: (10,20) 5mgPO tid max 80 mg/day.

8 Bethanechol: (5,10,25.50) 10-50 mg PO qid

8 Ditropan (5,10XL/d, (5mg / 5ml short act)

8 Flexeril: (10) start 10 mg PO tid max 60 mg/day

8 Robaxin: (500,750)1000 1500 mg PO qid

8 Soma: (350) 350mg PO tid/qid

8 Urispas: (100) 100-200 mg PO qid

8 Valium: (2,5,10)2-10 mg PO tid/qid; for seizures

5-10 mg slow IV push, Diastat rectal inj

 

 

III. GI

 

8 Axid: 150-300 mg PO qhs

8 Atropine 0.4-.6 mg IV/IM/PO prn (.4; 0.6)

8 Bellergal-S=belladonna, phenobarb, ergota 1 bid.

8 Carafate: 1 g PO 1h ac & qhs

8 Colace: 100mg bid(tab 50,100,250;liq available)

8 Citrucel: 1 tablespoon in water 1-3 times/d

8 Cytotec: 200 g PO qid

8 Doc (Surfak): 240 mg PO qd. [50,240]

8 Dulcolax: 10 mg PO/PR prn(5, supp 10)

8 Fleet enema: 1 enema PR prn; avoid in feeble pt.

8 Gl cocktail mixture: Mylanta 15 ml, lidocaine 15 ml, Donnatal 5 ml PO one dose.

8 Glycerin suppository 1 rectal prn

8 Inapsine: 2. 5-5mgIMq3-6h vomiting, short term 8 Lactulose 30-45 ml PO up to 1-3/d or 300 ml retention enema, gas, GI-SE

8 Levsin: 0.125-0.25 mg PO/SL qid; Levsinex long acting: 0.375 mg PO q12h .

8 Librax 1 tab PO qid.

8 Magnesium citrate: up to 300 ml PO.

8 Milk of Magnesia: 5-15 ml Poqid(400 mg/5ml)

8 Mylanta (alum & mag ): 1tab or 15-30 ml PO qid

8 Pancreatin 1-2 tabs PO with meals.

8 Pepcid: 20-40 mg PO qhs

8 Peri-Colace: 1-2 tabs PO hs,

8 Prevacid: 15-30 mg qd (15,30)

8 Prilosec: 20-40mg qd

8 Senokot: 10-15 ml PO hs, 1-2 tab q 6 hrs

8 Sorbitol: up to 50 ml po qd for constipation

8 Tagamet: 400-800 mg PO qhs; liquid avail

8 Zantac: 150 mg PO bid or 300 qhs

8 Zinc So 4

IV. Antibiotics

 

8 Amoxicillin 250-500mg PO tid

8 Ampicillin 250-500 mg PO qid

8 Augmentin: 500-875 mg PO bid

8 Biaxin: 250-500 mg PO bid

8 Bactrim, Septra DS, 1 tab PO bid

8 Ceclor: 250-500 mg PO tid

8 Cipro: 250-750 mg PO bid. (250,500,750)

8 Cleocin: 2% vaginal cream qhs x7 d

8 Diflucan: for candida: 100-200 mg po qd

8 Erythromycin base: 250-500 mg PO qid

8 Erythromycin (EES): 400 mg PO qid

8 Flagyl: 1g then 500 mg q6h 250-750 mg PO tid (250,500)

8 Floxin: 200-400 mg PO q12h. (200,400)

8 Flumadine: fluA:100mg PO bid x 5d (tab/syp)

8 Keflex: 250-500 mg PO qid.

8 Ketoconazole:200-400 mg po qd [200] hepatotoxic

8 Macrodatin: 50-100mg qid

8 MetroGel-Vaginal : 0.75% gel bid x 5 days.

8 Monistat: Vag 2% cream qhs 7d, or 100 mg suppository qhs 7 days (supp 100,200)

8 Mycelex: 1% cream bid, or supp 100 mg qhs x 7d

8 Mycelex: oral troches 5 times/day x 14 days

8 Nystatin 1 suppository qhs for 14 d(100,000 U)

8 Nystatin: 4-6ml swish & swallow qid.(100,000 u) 8 Pencillin V(Pen-VK), 250, 500 mg PO qid

8 Tetracycline 250-500 mg PO qid.

8 Vibramycin 200 mg load, then 50-100 bid

8 Zithromax: 500 mg load ,250 mg Po qd x5d 8 Zovirax: 400 mg PO tid x 7d ; for Zoster: 800 mg PO 5x/day x 10 days.

 

 

V. CNS

8 Ambien: 5-10 mg PO hs (5,10)

8 Ativan: 0.5-2 mg IV/IM/PO q6h (0. 5, 1, 2) 8 Atarax, vistaril:10-25 qid(tab/susp 10,25 mg/5ml)

8 Benadryl: 25-50 mg IV/IM/PO q6h

8 BuSpar: 5-20mg PO tid (5,10,15,30)

8 Chloral hydrate: 10-50mg/kg tab 250,500; syrup 250 & 500 mg/5ml; suppository 324,500

8 Cylert: 37. 5 mg q am, [18.75,37.5,75]

8 Dalmane: 15-30 mg PO qhs. 90 hrs HL (15,30)

8 DDAVP: 150-300ug nasal; bleeding for 3 d

8 Desyerl: 50 300mg qhs. [50,100,150,300]

8 Dexedrine: 5-10 mg PO qam/bid. [tabs 5,10 elixir 5mg/5ml]. LA10-15 mg qam (5,10,15)

8 Doxepin=Sinequan: 150-300 mg/day(tabs 10,25,50,75,100; liquid 10 mg/ml)

8 Effexor: 37. 5qam up to 200 mg / d [ 37, 5, 75,]

8 Elavil: 10-75 mg qhs150-300 mg/day

8 Famvir: for Zoster-500 mg PO tid x7 d

8 Haldol: 1-5 mg PO tid, 6-20 mg/day. (tabs 0. 5, 1,2,5,10; liquid 2mg/ml

8 Klonopin: 0. 5 mg Poqd/tid, max 20/day. [0. 5,1,2,]

8 Librium: 5-25 mg PO tid. [5,10,25]

8 Limbitrol 5/12.5, 10/25): 1 PO tid/qid.

8 Mellaril: 50-100 mg POtid, max 800mg/d

8 Norpramin: 50-300 mg/d (10,25,50,75,100,150)

8 Pentobarbital: 30-120 mg PO/IV/IM/PR tid/qid. (tabs 50,100,supp 30,60,120,200)

8 Prolixin: 1-2 mg PO tid-qid.

8 Prozac 20-40 mg/d( tab10,20, liq 20 mg/5 ml)

8 Paxil: 20-40 mg/day (10,20,30)

8 Remeron: 15 mg PO1/2 qhs;15-45 mg/day(15,30)

8 Restoril: 15-30 mg PO q hs (15,30)

8 Risperdal: 1 mg 1/2bid, total 16 mg/day(1,2,3,4)

8 Ritalin: 5-10 mg PO bid[5,10,20]not past 4 pm 8 Romazicon: 0.2 mg IV over 20sec; 1 mg total

8 Symmetrel: flu 100mg PO bid x 5 d

8 Thorazine: 10-50 mg PO/IM bid/tid , 800 mg/d. (tabs 10,25,50,100;supp 25;syrup 10 mg/5ml)

8 Tofranil: 10-300 mg hs (10,25,50)

8 Tranxene: 7. 5-15 mg bid. (3.75,7. 5) long HL

8 Triavil 2/10, 2/25/ 4/10,4/25, 4/50: 1 tab Potid/qid

8 Valtrex: Herpes: 500 mg PO bid x 5d; Zoster:

1,000 mg PO tid x 7d for Zoster(500mg)

8 Versed: Conscious sedation: 1 mg IV slowly q2-3 8 Xanax: 0.25-0.5 mg tid. (0.25,0. 5,1,2)

8 Zoloft: 50-200 mg/day, (25,50,100)

min up to 5 mg; 2-2. 5 hr half life

 

 

 

VI. Neurology

8 Antivert: 25 mg PO q6h prn. [12.5,25,50]

8 Artane: 2 mg/day, total 15 mg/day

8 Cogentin: 1-2 mg IM/PO bid (0.5,1,2)

8 Depakote: 250-500 mg tid(125,250,500)

8 Dilantin: 1000 mg IV 50 mg /min. 300 mg PO qd 8 Tegretol: 200-600 mg PO bid(tabs 100,200)

8 Klonopin: 0.5 mg PO tid, total 20/day(0.5,1, 2 )

8 Lamictal: 25 mg PO qd x 14d, then 150-250 bid

8 Midrin 2 tabs stat 1 per hour up to 5 per/d

8 Mestinon: 60-120 mg PO tid; LA 180 mg bid

8 Methylprednisolone: spinal cord injury =30 mg/kg bolus followed by 5.4 mg/kg/h IV

8 Mysoline: 100-125 mg qid (50,250;liq 250 mg/5ml]

8 Neurontin: 300-600 mg PO tid, max 4800 mg/day (100,300,400,600,800)

8 Phenobarbital: 60 mg PO tid(tab15,16,30,60; suspension 20 mg/5ml]

8 Sansert: 4-8 mg PO qd.

8 Sinemet: 1 tab PO tid [25/100,25/250]

8 Symmetrel: 100 mgbid (tab 100, syrup 50 mg/5ml)

 

 

VII. Cardiovascular

8 Altace: 2.5 mg qd, max20 mg/day (1.25,2.5,5,10)

8 Cozaar: 25mg PO qd, total 100 mg/day(25,50)

8 Cardura: 1mg po qd, total 16 mg/day. (1,2,4,8)

8 Catapres: 0.1 mg PO bid, max 2.4 same as patch

8 Catapres TTS): 1 patch q wk (0.1, 0.2, 0.3 mg/day)

8 Digoxin=Lanoxin:0.125-po qd. tab0.125,0.25; elix

8 Dyazid:37.5/25 1 qam or 1 am+noon

8 Hytrin:1 mg po qhs, total 20 mg/d (1, 2, 5,10)

8 Hyzaar=Losartan / HCTZ 50/12.5: 1 tab po am.

8 Maxzide=HCTZ / triam 37.5/25 1 tab po am.

8 Moduretic (HCTZ / amil 50/5): 1-2 tabs po am.

8 Vasotec:1.25 mg IV q6h; 5mg POqd,max 40 mg

8 Zestril: 10mg qd, max 40mg/day(2. 5,5,10,20,40)

 

 

VIII. Hematology

8 Coumadin: 2-10 mg PO qd (1, 2, 2. 5, 5,7. 5, 10]

8 Heparin:DVT prophylax: 5000 units SC q8-12hr

8 Lovenox: 30 mg SC q12h.

8 Procrit=Epogen: 1 inj IV/Sc 3 times /wk

8 Trental: 400 mg PO tid (400)

 

 

 

IX. Eye

8 Artificial tears 1 drop prn.

8 Atropine1drop qid-buccal secretion(0. 5,1,2%)

8 Bacitracin: oint qid.

8 Chloramphenicol: 0.5% -1% oint qid

8 Cortisporin oint or 1 drop bid-tid

8 Decadron oint 0.05% bid or 1 drop 0.1% q1-6h 8 Erythromycin 0.5 oint qid

8 Gentamicin 0. 3% oint qid. 0. 3% drops q 6h.

8 Neosporin ointment qid; 1 drop qid better than lactulose, no absorption

8 Vidarabine 0.5 inch oint five times/d (3%)

8 Voltaren eye drops: 1 drop qid.

8 Ventolin 2 puffs q 4-6 hours; 2-4 tabs

 

X. Respiratory

8 Alupent: 2-3 puffs 3-4h,tab10,20,syrup10mg/5ml

8 Atrovent: 2-3 puffs or 1 vial nebulizer qid

8 Azmacort: 2 puffs tid/qid

8 Brethine: 0.25 mg SC/ 2 puffs q4-6h 5 mg PO tid.

8 Intal: 2-4 puffs qid

8 Serevent: 2 puffs bid

8 Theo-24: 100-400 mg PO qd; (Theo-Dur bid)

8 Vanceril: 2-4 puffs bid-qid

 

Comments/Suggestions email us at: pdrtv@msn.com

 

 

Notes: