1簡淑慧_SymptomManagementII單元名稱：末期病患常見不適癥狀之評估及醫(yī)護處置(II)

整理者:簡淑慧老師(N棟1樓;分機:3136)單元時數(shù)：2小時2023/9/111簡淑慧_SymptomManagementII單元名稱簡淑慧_SymptomManagementII2Dyspnea-Physiology-1呼吸調(diào)節(jié)機轉(zhuǎn)※神經(jīng)性*呼吸道伸展接受體(Airwaystretchreceptors)*肺間質(zhì)接受體(Lungparenchymalreceptors):肺間質(zhì).肺泡與微血管之J-receptors,此被認為與呼吸困難產(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.2023/9/11簡淑慧_SymptomManagementII2Dysp簡淑慧_SymptomManagementII3Dyspnea-Physiology-2※化學性

：PaCO2&PaO2*周邊化學接受體(Peripheralchemo-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(Centralchemoreceptors):位於延腦呼吸中樞對血中PaCO2

及酸鹼度(PH)較敏感.2023/9/11簡淑慧_SymptomManagementII3Dysp簡淑慧_SymptomManagementII4Dyspnea-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；T11-12)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(jīng)呼吸道肌肉之控制Ref:Jantarakept,P.,&Porock,D.(2005).DyspneamanagementinLungcancer.ONF,32(4),785-795.2023/9/11簡淑慧_SymptomManagementII4Dysp簡淑慧_SymptomManagementII5PrevalenceofDyspneabyDisease

Disease

ChronicObstructive

PulmonaryDisease(COPD)CongestiveHeartDiseaseStrokeAmyotropicLateralSclerosisDementiaOutpatientCancerTerminalCancerLungCancerPrevalenceofDyspnea95%

61%37%47%to50%(漸凍人)70%(失智癥)50%45%to70%90%(Dudgeon,2001)Cancer2023/9/11簡淑慧_SymptomManagementII5Prev簡淑慧_SymptomManagementII6Dyspnea-causeDyspneaTreatment(化療/電療)PsychologicalSymptoms(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-肋膜積水現(xiàn)存疾病COPDCHF漸凍人末期失智癥腎衰竭肝疾病-腹水營養(yǎng)缺乏腫瘤壓迫Ref:Jantarakept,P.,&Porock,D.(2005).DyspneamanagementinLungcancer.ONF,32(4),785-795.2023/9/11簡淑慧_SymptomManagementII6Dysp簡淑慧_SymptomManagementII7Dyspnea-Etiology-2肋膜液之生成Mesothelialcellsofpleural(肋膜間皮細胞):5-10L/day

80-90%isreabsorbedbycapillaryofvisceralpleural10-20%isreabsorbedbylymphaticchannelsofvisceralpleural5-20ml

remainsinthepleuralspace

Regulatedby:Capillarypermeability,hydrostaticpressure,Colloidalosmoticpressure,negativeintralpleuralpressure,lymphaticdraining

2023/9/11簡淑慧_SymptomManagementII7Dysp簡淑慧_SymptomManagementII8Dyspnea-Etiology-3惡性肋膜積水*Malignantcellirritation&inflammation-Capillarypermeability

(微細血管通透性增加)-Obstructionofthepleurallymphaticsystems(淋巴細統(tǒng)阻塞)-Capillaryendothelialcellchangethehydrostaticpressure(微細血管改變其靜體滲透壓)proteinandfluidleaktopleuralspace(蛋白質(zhì)及水外流)Colloidosmoticpressure(膠體滲透壓增加)

absorption(再吸收能力)

2023/9/11簡淑慧_SymptomManagementII8Dysp簡淑慧_SymptomManagementII9Dyspnea-Etiology-2Treatment-relatedfactors

R/TorC/T：fibrosis(肺纖維化)(Bleomycin,MTX,Busulfex)

相關(guān)治療:CVPorPort-Ainsertion

Pneumothorax2023/9/11簡淑慧_SymptomManagementII9Dysp簡淑慧_SymptomManagementII10Dyspnea-Assessment-11.主觀性-主訴-呼吸短促(SOB),吸不到氣

(Airhunger),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(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)

精神及意識程度:清醒,專注度,記憶能力.2023/9/11簡淑慧_SymptomManagementII10Dys簡淑慧_SymptomManagementII11Dyspnea-Assessment-23.實驗室或診斷檢察-X-ray:pleuraleffusionorpneumonia.-CBC:Hb

.-ABGorPulseoximetry:PaO2.PaCO2.-Thoracentesis(胸腔穿刺術(shù))&PleuralFluidAnalysis(肋膜液分析)-以檢查是否有惡性細胞或感染情形2023/9/11簡淑慧_SymptomManagementII11Dys簡淑慧_SymptomManagementII12/medlineplus/ency/article/000086.htm2023/9/11Dyspnea-Assessment-3簡淑慧_SymptomManagementII12htt簡淑慧_SymptomManagementII13處置-1Treattheunderlyingdisease:C/T,R/T,Thoracentesis(胸腔穿刺術(shù))-**Pigtaildraining(4-5-6ICS),Antimicrobialagents(抗生素)Pleurodesis(肋膜硬化):引流管內(nèi)打入Tetracyclin,Bleomycin,使局部炎癥及沾粘硬化肋膜，以預防肋膜液產(chǎn)生

Bronchodilators(200-400mg/daytheophylline)-增加到肺部之氣流量2023/9/11簡淑慧_SymptomManagementII13處置-簡淑慧_SymptomManagementII14處置-2Mucolytic(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.dDexan-減少局部炎癥反應、水腫情形

Diuretics-減少體內(nèi)組織液過多

Anxiolytics-減少緊張情緒

Oxygen&airtherapy:lowflowrateofO2,coldair

Ventilator???(COPD70%vs.LungCa.20%)2023/9/11簡淑慧_SymptomManagementII14處置-簡淑慧_SymptomManagementII15處置-3

Opioids-Morphine(Oral,IV,Inhalation)-延腦對CO2敏感性

-大腦皮質(zhì)對呼吸困難認知

-延腦到呼吸肌刺激

-中樞性鎮(zhèn)靜功能2023/9/11簡淑慧_SymptomManagementII15處置-簡淑慧_SymptomManagementII16處置-4Opioids-Morphineoral:5-15mgq4h(durationisshorterthanpaincontrol)；

oldpatient/renalfailure：2.5mgq4h

IV:2.5-5mgq4h(bedtime2times)

Nebulizer:20mgq4h(with2mlofN/S)2023/9/11簡淑慧_SymptomManagementII16處置-※

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(nèi)過早關(guān)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(yōu)先需要，避免很急促活動簡淑慧_SymptomManagementII17處置-52023/9/11※胸腔復健運動簡淑慧_SymptomManagement※

輔助治療肌肉放鬆技巧按摩或芳香療法轉(zhuǎn)移注意力/音樂治療使用電風扇吹冰涼空氣穴位按摩或針灸簡淑慧_SymptomManagementII18處置-62023/9/11※輔助治療簡淑慧_SymptomManagementI簡淑慧_SymptomManagementII19不適癥狀之評估-CACSCancerAnorexiaCachexiaSyndrome(CACS)-癌癥惡病質(zhì)癥候群

導因生理機轉(zhuǎn)評估處置.au/images/SteveGuestLosesHalfHisWeightThumb.jpg2023/9/11簡淑慧_SymptomManagementII19不適癥簡淑慧_SymptomManagementII20惡病質(zhì)癥候群/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)對抗腫瘤2023/9/11簡淑慧_SymptomManagementII20惡病質(zhì)簡淑慧_SymptomManagementII21癌癥惡病質(zhì)癥候群(CACS)~導因

Disease-relatedfactors~aHallmarkofterminalillness(80%end-stagepatients)Cancer(80%GICancer;60%lungcancer),GIobstruction(腸道阻塞或吸收障礙),Infection,Septicstates.

Treatment-relatedfactorsC/T,R/T,OP(Stomach,pancreasorbowel).

Psychologicalfactors“Giveup”

(cancermeansterminalillness)Depression,inactivity,lossofappetite.2023/9/11簡淑慧_SymptomManagementII21癌癥惡簡淑慧_SymptomManagementII22CACS

~Mechanism-1

【宿主】與【腫瘤進展】間的一種負向代謝結(jié)果，其涉及:食慾不振、新陳代謝改變、前趨發(fā)炎細胞激素之釋放(Pro-inflammatorycytokines).

當【腫瘤細胞】或【個體對抗腫瘤細胞之免疫反應】時會產(chǎn)生【前趨發(fā)炎細胞激素-TumorNecroticFactor(TNF),IL-1&IL-6,IFN-&IFN-γ】

【新陳代謝增加】2023/9/11簡淑慧_SymptomManagementII22CAC簡淑慧_SymptomManagementII23CACS

~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(zhì)新生、蛋白質(zhì)分解(耗損肌肉塊)2023/9/11簡淑慧_SymptomManagementII23CAC簡淑慧_SymptomManagementII24CACS~Assessment-11.PQRST:評估食慾(營養(yǎng)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(xiàn)水腫.3.實驗室檢查-內(nèi)臟蛋白質(zhì):Albumin,TotalIron-BindingCapacity,Transferrin,NitrogenBalance.-肌肉塊:24hCCR2023/9/11簡淑慧_SymptomManagementII24CAC簡淑慧_SymptomManagementII25處置

Steroid(20-40mgPrednisone