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NORMAL PREGNANCY

NORMAL PREGNANCY

NORMAL PREGNANCY

Normal Pregnancy refers to growth and development of a fertilized ovum and begins from when the ovum is fertilized until the fetus is expelled from the uterus.

Normally the fetus is expelled at term or 9 months or 40 weeks or 280 days.
If the fetus is expelled before 28 weeks, it is called an abortion and if fetus is expelled after 28 weeks but before 37weeks it’s called premature labour and if born after 42 weeks, the post- mature is used.

Pregnancy is said to be normal when;

  • The fertilized ovum is growing in the cavity of the uterus.
  •  One fetus is forming, one placenta and two membranes.
  •  There is about 1000-1500ml of liquor amnii.
  •  There is vertex presentation.
  •  There is no bleeding until show in first stage of labour.
  •  The mother should remain healthy with no serious disorders of pregnancy.

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SIGNS AND SYMPTOMS OF PREGNANCY

When a woman misses one or two menstrual periods, she may begin to suspect that she is pregnant, and in most cases, her intuition is correct with an accuracy of about 98%, especially if she has been experiencing regular menstruation.

The signs of pregnancy can be classified into three groups:

  1. Presumptive
  2. Probable
  3. Positive.
Presumptive signs:

  1. Amenorrhea: This refers to the absence of menstruation. A woman may report missing one or two periods, which can be a strong indicator of pregnancy. However, amenorrhea can also be caused by factors such as contraceptive use, changes in environment, prolonged illness, or emotional disturbances.

  2. Breast changes: Many women experience tingling and prickling sensations, as well as breast enlargement and tenderness. These changes are commonly associated with pregnancy.

  3. Morning sickness (nausea and vomiting): Approximately 30-50% of pregnant women experience morning sickness, which typically occurs between the 4th and 14th weeks of pregnancy. While other conditions can also cause nausea and vomiting, the combination of these symptoms with amenorrhea strongly suggests pregnancy. Morning sickness often subsides by the end of the first trimester.

  4. Increased frequency of urination: The growing uterus puts pressure on the bladder, leading to more frequent trips to the bathroom. This symptom is usually experienced before 12 weeks of pregnancy and tends to decrease once the uterus rises out of the pelvis at around 12 weeks.

  5. Skin changes:

    • Striae gravidarum: These stretch marks appear around the 16th week of pregnancy on the abdomen, thighs, and breasts.
    • Chloasma (mask of pregnancy): Some women develop patches of darkened skin on the face.
    • Linea nigra: A dark line may darken and appear both above and below the umbilicus.
    • Darkening of areolas: The primary areolas become darker, and secondary areolas may form. The hormone responsible for these pigmentation changes is called melanin hormone and is produced by the anterior pituitary gland.

  6. Quickening: This refers to the first fetal movements felt by the mother, usually occurring around 18-20 weeks of pregnancy for primigravida (first-time pregnancies) and 16-18 weeks for multigravida (women who have been pregnant before). Quickening can assist a midwife or healthcare provider in estimating the gestational age of a mother who is unsure of her dates.

  7. Fatigue: Pregnant women often experience fatigue due to increased blood production, lower blood sugar levels, and decreased blood pressure influenced by progesterone. Sleep disturbances and nausea can also contribute to feelings of tiredness.

  8. Mood changes: Physical stress, metabolic changes, fatigue, and hormonal fluctuations, particularly progesterone and estrogen, can lead to mood swings in pregnant women.

Probable signs:

  1. Hagar\’s sign: This sign can be detected between the 6th and 12th week of pregnancy. It involves performing a vaginal examination where two fingers are inserted into the anterior fornix of the vagina while the other hand presses the uterus abdominally. When the fingers from both hands meet, a softening of the isthmus can be felt, indicating pregnancy.

  2. Jacquemier\’s sign: This sign refers to the bluish discoloration of the vaginal walls, which becomes noticeable from the 8th week onwards. It is caused by pelvic congestion, a common indication of pregnancy.

  3. Osiander\’s sign: Increased pulsation felt on the lateral vaginal fornices is known as Osiander\’s sign. This sign can be detected from the 8th week onwards and is a result of increased vascularity in the area.

  4. Softening of the cervix (Goodell\’s sign): Starting from the 8th week of pregnancy, the cervix of a pregnant woman becomes noticeably softer. It can be compared to the texture of the lower lip, whereas in a non-pregnant state, it is as firm as the tip of the nose.

  5. Uterine soufflé: This refers to a soft blowing sound heard on auscultation of the abdomen. It typically occurs from the 16th week of pregnancy due to increased vascularity in the uterus.

  6. Abdominal enlargement: The uterus undergoes rapid and progressive enlargement from the 16th week onwards. This enlargement can be observed and felt during abdominal palpation, helping to differentiate it from other causes such as gaseous distension, a full bladder, fibroids, or ascites.

  7. Braxton Hicks contractions: These are painless contractions that usually begin from the 16th week of pregnancy. They can be felt during abdominal palpation and occur approximately every 15 minutes.

  8. Internal ballottement: This technique involves giving the uterus a sharp tap just above the cervix, causing the fetus to float upward in the amniotic fluid. When the fetus sinks back down, the movement can be felt by fixed fingers within the vagina. Internal ballottement can be detected between the 16th and 28th weeks of pregnancy.

  9. Presence of hCG (Human chorionic gonadotropin): The hormone hCG can be detected in the blood as early as 9 days after conception and in urine approximately 14 days after conception. The presence of hCG is a reliable indicator of pregnancy and can also be detected in conditions like hydatidiform mole.

Positive signs:

Positive signs are those that definitively confirm the presence of pregnancy. These signs include:

  1. Fetal heart sounds: The fetal heart begins beating around the 24th week after conception. It can be heard using a Doppler device as early as 10 weeks and with a fetoscope by 24 weeks. It is important to distinguish the fetal heart sounds from the uterine soufflé caused by pulsating maternal arteries. The normal fetal heart rate ranges between 120 and 160 beats per minute.

  2. Ultrasound scanning of the fetus: Using ultrasound technology, the gestation sac can be visualized and photographed. As early as the 4th week, an embryo can be identified, and by the 10th week of gestation, fetal body parts begin to appear on the ultrasound images.

  3. Palpation of the entire fetus: A trained examiner can palpate and feel the various parts of the fetus, including the head, back, and upper and lower body parts. This allows for a comprehensive assessment of the baby\’s position and size.

  4. Palpation of fetal movement: Skilled healthcare providers can feel and detect fetal movements through palpation after the 24th week of gestation. This involves perceiving the baby\’s kicks, rolls, and other movements by gently applying pressure on the mother\’s abdomen.

  5. X-ray: While an X-ray can identify the complete fetal skeleton as early as the 12th week, it is not a recommended method for confirming pregnancy due to the potential risks associated with radiation exposure. Total body radiation from X-rays in utero can have harmful effects on the developing fetus, leading to genetic or gonadal alterations. Therefore, other non-invasive methods, such as ultrasound, are preferred for assessing pregnancy.

  6. Actual delivery of the baby: The ultimate confirmation of pregnancy occurs when the woman delivers the baby. The delivery of a live newborn is the conclusive evidence of pregnancy.

Differential Diagnosis:

Abdominal enlargement can be caused by conditions other than pregnancy, and it is important to consider these possibilities. Some of the potential differential diagnoses include:

  1. Ovarian cysts: Enlargement of the abdomen can occur due to the presence of ovarian cysts. When palpated, the swelling caused by ovarian cysts can be distinguished from the uterus, and pregnancy tests will yield negative results.

  2. Fibroids: Fibroids are noncancerous growths that can develop in the uterus. They can sometimes be mistaken for pregnancy, as they can cause a hard mass to be felt in the abdomen. However, pregnancy tests will be negative in the case of fibroids.

  3. Distended urinary bladder: Abdominal enlargement can also result from a distended urinary bladder due to urine retention. In such cases, a catheter can be inserted to relieve the urine retention, and there will be no other signs indicating pregnancy.

  4. Pseudocyesis: Pseudocyesis, also known as false pregnancy or phantom pregnancy, is a condition in which a woman experiences symptoms that mimic pregnancy, including amenorrhea (absence of menstruation) and other signs suggestive of pregnancy. However, upon examination, the typical signs of pregnancy are absent, and pregnancy tests will be negative. Pseudocyesis often occurs in women who have a strong desire to conceive or who experience high levels of anxiety related to pregnancy.

Multiple Choice Questions:

  1. Which of the following is a presumptive sign of pregnancy?
    a) Fetal heart sounds
    b) Softening of the cervix
    c) Palpation of fetal movement
    d) Morning sickness
  2. Hagar\’s sign is detected by:
    a) Auscultation of fetal heart sounds
    b) Palpation of fetal movement
    c) Vaginal examination
    d) Ultrasound scanning
  3. Which sign is a probable sign of pregnancy?
    a) Fetal heart sounds
    b) Ovarian cysts
    c) Presence of HCG
    d) Pseudocyesis
  4. What is the normal fetal heart rate?
    a) 60-80 beats per minute
    b) 90-120 beats per minute
    c) 120-160 beats per minute
    d) 180-200 beats per minute
  5. Which sign can help in determining the gestational age if the mother is unsure of her dates?
    a) Quickening
    b) Internal ballottement
    c) Jacquemier\’s sign
    d) Amenorrhea
  6. Which diagnostic tool can visualize the gestation sac and fetal parts?
    a) X-ray
    b) Ultrasound scanning
    c) Fetal palpation
    d) HCG test
  7. What is the most accurate method to confirm pregnancy?
    a) Palpation of fetal movement
    b) X-ray
    c) Actual delivery of the baby
    d) Ultrasonography
  8. Which condition can cause abdominal enlargement and yield negative pregnancy test results?
    a) Fibroids
    b) Ovarian cysts
    c) Pseudocyesis
    d) Morning sickness
  9. Osiander\’s sign is characterized by:
    a) Softening of the cervix
    b) Increased pulsation in the vaginal fornices
    c) Bluish discoloration of the vaginal walls
    d) Enlargement of the breasts
  10. Which sign can be detected by both Doppler and fetoscope?
    a) Fetal heart sounds
    b) Uterine soufflé
    c) Internal ballottement
    d) Quickening
  11. What differentiates fibroids from pregnancy?
    a) Positive pregnancy test results
    b) Palpable fetal movements
    c) Presence of uterine soufflé
    d) Hard mass felt on palpation
  12. What is the purpose of X-ray in pregnancy?
    a) To visualize the fetal heart rate
    b) To determine the gestational age
    c) To confirm pregnancy definitively
    d) It is not recommended due to radiation risks
  13. What differentiates pseudocyesis from a true pregnancy?
    a) Amenorrhea
    b) Fetal heart sounds
    c) Palpation of fetal movement
    d) Negative pregnancy test results
  14. What is the primary cause of morning sickness during pregnancy?
    a) Increased blood production
    b) Hormonal changes
    c) Bladder pressure
    d) Emotional upsets
  15. Which sign is considered a positive sign of pregnancy?
    a) Morning sickness
    b) Softening of the cervix
    c) Distended urinary bladder
    d) Palpation of fetal movement

Fill in the Blanks:

  1. ________ is the absence of menstruation and a presumptive sign of pregnancy.
  2. ________ can be detected by performing a vaginal examination and palpating the isthmus.
  3. Increased pulsation in the lateral vaginal fornices is known as ________.
  4. ________ is a condition in which a woman experiences symptoms resembling pregnancy, but pregnancy tests are negative.
  5. Fetal heart sounds can be detected by a ________ or a fetoscope.
  6. The normal fetal heart rate ranges between ________ beats per minute.
  7. Ultrasound scanning can visualize the ________ and identify the fetal parts.
  8. Palpation of ________ is necessary to assess the position and size of the fetus.
  9. X-ray is not recommended for pregnancy confirmation due to potential ________ risks.
  10. The delivery of a live newborn is the ________ evidence of pregnancy.

Multiple Choice Questions:

  1. Answer: d) Morning sickness
  2. Answer: c) Vaginal examination
  3. Answer: b) Ovarian cysts
  4. Answer: c) 120-160 beats per minute
  5. Answer: b) Internal ballottement
  6. Answer: b) Ultrasound scanning
  7. Answer: c) Actual delivery of the baby
  8. Answer: a) Fibroids
  9. Answer: b) Increased pulsation in the vaginal fornices
  10. Answer: a) Fetal heart sounds
  11. Answer: d) Hard mass felt on palpation
  12. Answer: d) It is not recommended due to radiation risks
  13. Answer: d) Negative pregnancy test results
  14. Answer: b) Hormonal changes
  15. Answer: d) Palpation of fetal movement

Fill in the Blanks:

  1. Amenorrhea is the absence of menstruation and a presumptive sign of pregnancy.
  2. Hagar\’s sign can be detected by performing a vaginal examination and palpating the isthmus.
  3. Increased pulsation in the lateral vaginal fornices is known as Osiander\’s sign.
  4. Pseudocyesis is a condition in which a woman experiences symptoms resembling pregnancy, but pregnancy tests are negative.
  5. Fetal heart sounds can be detected by a Doppler or a fetoscope.
  6. The normal fetal heart rate ranges between ________ beats per minute.
  7. Ultrasound scanning can visualize the gestation sac and identify the fetal parts.
  8. Palpation of the entire fetus is necessary to assess the position and size of the fetus.
  9. X-ray is not recommended for pregnancy confirmation due to potential radiation risks.
  10. The delivery of a live newborn is the ultimate evidence of pregnancy.

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Terminologies

Terminologies

Terminologies

TERMS USED IN MIDWIFERY

Midwifery: It is the profession of providing assistance and medical care to women undergoing labor and childbirth during the antenatal, prenatal, and postnatal periods.

Obstetrics: This is a branch of medicine dealing with pregnancy, labor, and the postpartum period.

Caesarian section: It is an incision made on the uterus through the anterior abdominal wall to remove products of gestation after 28 weeks of gestation.

Cephalic: Refers to the head.

Cervix: It is the neck of the uterus.

Colostrum: This is a fluid found in the breasts from the 16th week of pregnancy up to the 2nd and 3rd day after delivery.

Crowning: This is when the largest transverse diameter of the fetal skull emerges under the subpubic arch and does not recede back between contractions.

Gestation: Pregnancy or the maternal condition of having a developing fetus in the body.

Fetus: Refers to the human conceptus from the 9th week to delivery.

Viability: The capability of the fetus to live outside the womb, usually accepted between 24 and 28 weeks, although survival is rare.

Gravida: A woman who is or has been pregnant, regardless of pregnancy outcome.

Primigravida: A woman pregnant for the first time.

Multigravida: A woman who has been pregnant more than once.

Nullipara: A woman who is not currently pregnant and has never been pregnant.

Parity: The number of children born alive or dead after 28 weeks of gestation.

Vernix caseosa: A greasy substance that covers the baby\’s skin at birth.

Meconium: This is the stool of the neonate that is present in the lower bowel at 16 weeks of gestation and is passed within 3 days following birth. It is greenish-black in color.

Lightening: This refers to the descent of the baby into the pelvis, resulting in a drop in fundal height.

Show: The bloody stained mucoid discharge seen at the onset of labor.

Additional Midwifery Terms 

  1. Lochia: The vaginal discharge that occurs after childbirth, consisting of blood, mucus, and uterine tissue.

  2. Antenatal care: Medical care and monitoring provided to pregnant women before childbirth.

  3. Postpartum: The period following childbirth, typically lasting six weeks, during which the mother\’s body undergoes physical and hormonal changes.

  4. Perineum: The area between the vagina and anus in females, which may stretch or tear during childbirth.

  5. Amniotic fluid: The fluid surrounding the fetus within the amniotic sac, providing protection and cushioning.

  6. Placenta: A temporary organ that develops during pregnancy, providing oxygen and nutrients to the fetus and removing waste products.

  7. Episiotomy: A surgical incision made in the perineum during childbirth to enlarge the vaginal opening and facilitate delivery.

  8. Postpartum depression: A mood disorder characterized by feelings of sadness, anxiety, and exhaustion experienced by some women after giving birth.

  9. Lactation: The production and secretion of breast milk.

  10. Umbilical cord: The flexible cord connecting the fetus to the placenta, through which nutrients and oxygen are transferred.

  11. Neonate: A newborn baby, typically in the first 28 days after birth.

  12. Preterm birth: Delivery of a baby before completing 37 weeks of gestation.

  13. Ectopic pregnancy: A pregnancy that occurs outside the uterus, usually in the fallopian tube.

  14. Intrauterine growth restriction: A condition in which the fetus fails to grow at the expected rate inside the uterus.

  15. Preeclampsia: A pregnancy complication characterized by high blood pressure and damage to organs, usually occurring after 20 weeks of gestation.

  16. Fetal distress: A condition in which the fetus is not receiving adequate oxygen, typically detected through abnormal heart rate patterns.

  17. Postpartum hemorrhage: Excessive bleeding after childbirth, often caused by the uterus not contracting properly.

  18. Neonatal intensive care unit (NICU): A specialized medical unit providing care for newborns with serious health conditions or premature babies.

  19. Midwifery-led care: A model of care in which midwives are the primary providers for pregnant women, providing continuity of care throughout pregnancy, labor, and postpartum.

  20. Birth plan: A written document created by the pregnant woman outlining her preferences and expectations for labor, delivery, and postpartum care.

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Symptoms Control

Symptoms Control

Symptoms Control

Symptom control aims at the primary goal of providing comfort and improving the quality of life for individuals facing serious illness and end-of-life stages.

Symptom control and management play a crucial role in achieving this aim/goal. Palliative care focuses on addressing the physical, emotional, social, and spiritual needs of patients, with a particular emphasis on relieving distressing symptoms.

Common symptoms in Palliative Care

SystemSymptoms
GITDry mouth, painful mouth, nausea and vomiting, dysphagia, indigestion, constipation, diarrhea, intestinal obstruction, ascites
RespiratoryShortness of breath (SOB), cough, death rattle, hemoptysis
Genito-UrinaryDysuria, prostatism, spasms, urinary retention, urinary incontinence, hematuria
SkinFungating wound, pruritus, pressure sores
NeurologicalWeakness, seizures, headache
PsychiatricAdjustment disorders, depression, anxiety, delirium
OtherAnorexia, sleep disturbance

Principles of Symptom Assessment

  1. Accept the patient’s description: It is important to accept the patient’s description of their symptoms, considering the type and severity, as true and valid.
  2. Assess each symptom separately: Since most patients experience multiple symptoms, it is necessary to evaluate and analyze each symptom individually.
  3. Diagnose the possible cause: Determine the potential underlying cause of the symptom or problem through a comprehensive diagnostic process.
  4. Take a detailed history and examination, including:
    a. Onset of symptom: Gather information about when the symptom started, its severity, character, periodicity, precipitating and relieving factors, impact on sleep, mobility, quality of life, and its significance to the patient, particularly in the case of pain.
    b. Medication history: Explore the patient’s past medication usage, including the effectiveness of previous drugs and any failures, as well as the current medications and any complementary or alternative treatments being used for symptom management.
  5. Evaluate associated symptoms: Identify and assess any additional symptoms that may be related to the main symptom, such as constipation and abdominal distension in cases of intestinal obstruction.
  6. Perform a mandatory physical examination: Conduct a focused, thorough, and detailed physical examination that specifically targets the system associated with the presenting symptom.
  7. Proactively ask and observe: Don’t wait for the patient to complain; instead, actively inquire about their symptoms and carefully observe any visible signs or changes.
  8. Use appropriate investigations: Employ suitable investigations to guide clinical decision-making, ensuring that they are not performed unnecessarily or solely for the sake of doing them.
  9. Avoid delaying treatment: Initiate practical management and treatment without undue delay, even if investigation results are pending.
  10. Explain possible causes of symptoms: Provide explanations to the patient and their family regarding the potential reasons behind the symptoms, fostering open and regular communication that is essential for their understanding and involvement in the care process.

Principles of Symptom Management (Woodworth, 2004)

  1. Evaluation: Before initiating treatment, it is important to diagnose each symptom accurately.
  2. Explanation: Prior to treatment, provide clear explanations to the patient about the intended approach and set realistic goals for symptom management.
  3. Management: Tailor the treatment plan to each individual, considering their specific needs and preferences.
  4. Monitoring: Continuously assess and review the impact of the treatment on symptom control, making necessary adjustments as needed.
  5. Attention to details: Avoid making assumptions and ensure that all relevant details are taken into account when managing symptoms.
  6. Utilize both drug and non-drug measures: Incorporate a combination of pharmaceutical and non-pharmaceutical interventions to effectively control and manage symptoms.
  7. Allow sufficient time for interventions: Give interventions an appropriate amount of time to take effect before determining their success or failure.
  8. Adopt a multidisciplinary team approach: Collaborate with a diverse team of healthcare professionals to provide comprehensive symptom management.
  9. Seek consultation: When necessary, consult with a senior or more experienced clinician to gain insights and guidance in complex cases.
  10. Consider referral: In situations where specialized management is required, consider referring the patient to appropriate specialists or healthcare facilities.
  11. Implications of inaccurate assessment: Recognize that inaccurate assessment of the patient’s symptoms can have various implications on the overall management plan.
  12. Treat the underlying cause: Whenever possible, focus on treating the root cause of the symptoms to achieve optimal symptom control and management.

In Summary, Principles of Symptom Control are;

 Holistic assessment
1Careful and detailed history
2Relevant clinical examination
3Appropriate investigations
4Establish diagnosis
5Explain everything to the patient.
1Detailed history: First step in effective management of a patient’s symptoms is undertaking a detailed history.
This enables us to diagnose the possible cause of the symptoms.
We must remember the concept of “Total Care” and resist the temptation to focus on physical aspects of history.
2Physical examination: It should be focused, thorough, and detailed.
Direct examination towards the system of the presenting symptom.
3Investigations: Appropriate investigations to guide clinical decision making.
May not be a realistic option in terms of financial, location, and resources.
Do not delay starting treatment pending investigation results.
4Establish Diagnosis: Cause of symptoms may be due to the disease itself, the treatment for the disease, disease-related debility, or concurrent disorders.
What is the underlying mechanism? E.g., hypercalcemia, raised ICP.
16Explanation to patient: Explain the possible causes of symptoms to the patient and family. A simple explanation of the cause and nature of the symptoms to the patient may help to reduce fears or anxieties. Open and regular communication is essential.

Gastrointestinal Tract Symptoms

Nausea and Vomiting:

Causes:

  1. Pharmaceutical: opioids, digoxin, anti-convulsants, antibiotics.
  2. Toxic: infection, radiotherapy, chemotherapy.
  3. Metabolic: hypercalcemia, ketoacidosis, renal failure.
  4. Intracranial: cerebral tumors, cerebral infections, meningeal metastases, raised ICP, meningitis, cerebral malaria, ear infections.
  5. Gastrointestinal: gastric stasis, intestinal obstruction, constipation, candidiasis, abdominal and pelvic tumors, partial or complete bowel obstruction.

Assessment:

  1. Take a history, including the amount, content, and odor of vomit.
  2. Differentiate between vomiting, expectoration, or regurgitation.
    a. Determine the duration of the problem, including frequency, precipitating factors, type, and consistency.
    b. Review medication history, including antibiotics, ARVs, NSAIDs.
    c. Consider raised intracranial pressure.
    d. Examine the abdomen to rule out pancreatitis, gastritis, and peptic ulcers.

Pharmacological Management:

  1. Choose anti-emetics based on understanding different classes of medications and their mechanisms of action.
  2. Treat the underlying cause, if possible (e.g., constipation with bisacodyl – 5mg nocte, review and possibly change medication).
  3. Select appropriate anti-emetics based on the cause:
    • Depress vomiting center: hyoscine, cyclizine 50mg 6-hourly.
    • Depress chemoreceptors: prochlorperazine (Stemetil) 5-10mg tds, haloperidol 0.5-1mg bd.
    • Normalize upper bowel function: metoclopramide 5-10mg tds.
    • Delayed gastric emptying: metoclopramide 5-10mg tds (contraindicated in obstruction).
    • Vestibular disturbances: prochlorperazine 5-10mg tds, cyclizine 50mg 6-hourly, uraemia – haloperidol 0.5-1mg.

Non-Pharmacological Management:

  1. Provide psychological support, especially for anxiety-related or anticipatory symptoms.
  2. Recommend relaxation techniques.
  3. Suggest dietary modifications, such as increased fluid intake and small, regular meals.
  4. Create a calm environment away from food odors that may induce nausea.

Diarrhea:

Causes:

  1. Imbalance of laxative therapy.
  2. Drugs such as antibiotics, NSAIDs, ARVs.
  3. Fecal impaction – fluid stool leaks past a fecal plug or tumor mass.
  4. Abdominal or pelvic radiotherapy.
  5. Malabsorption.
  6. Colonic or rectal tumors.
  7. Concurrent disease.
  8. Odd dietary habits.
  9. HIV.
  10. Stress.

Assessment:

  1. Identify the cause of diarrhea.
  2. Differentiate between diarrhea and overflow.
  3. Gather history regarding duration, characteristics (volume, frequency, presence of blood), and associated symptoms (abdominal pain, fever).
  4. Review medications.
  5. Perform stool tests for culture and sensitivity.

Pharmacological Management:

  1. Advise increased fluid intake with oral rehydration solution after each episode of diarrhea.
  2. If symptoms persist, administer anti-diarrheal medication such as loperamide 2-4 capsules stat, then 2 capsules after every motion, codeine 30mg tds, or liquid morphine 5mg/5ml 4 hourly, 10ml at night.
  3. Administer antibiotics for infections, e.g., septrin 480mg bd if needed.
  4. Consider IV fluids for severe dehydration.
  5. Review and modify medications if necessary.
  6. Apply barrier cream (e.g., aqueous cream) to protect the skin when necessary.

Non-Pharmacological Management:

  1. Provide nutrition advice.
  2. Encourage plenty of oral fluids.
  3. Offer skin care to prevent breakdown.
  4. Provide appropriate advice for incontinence, including the use of a mackintosh/plastic under-sheet and regular changing/cleaning to prevent bedsores, etc.

Constipation:

Causes: Direct effects of disease:

  1. Intestinal obstruction from tumors in the bowel wall or external compression from abdominal masses.
  2. Damage to the lumbosacral spinal cord. Secondary effects of disease:
  3. Decreased food intake and low-fiber diet.
  4. Dehydration.
  5. General body weakness.
  6. Metabolic abnormalities – hypokalemia, hypercalcemia. Medications:
  7. Opioids such as codeine or morphine.
  8. Anticholinergic drugs such as tricyclic antidepressants.
  9. Diuretics. Concurrent disease:
  10. Diabetes mellitus, hypothyroidism.
  11. Hemorrhoids, anal fissures. (Note: The most common causes are related to the side effects of opioids and the effects of progressive disease.)

Assessment:

  1. Take a history to ascertain the cause of constipation.
  2. Establish the previous and present bowel pattern.
  3. Perform abdominal and rectal examinations.

Pharmacological Management:

  1. Prescribe appropriate laxatives, such as bisacodyl 5-15mg nocte.
  2. Consider the use of pawpaw seeds chewed or crushed in a fruit drink.
  3. Reduce or stop the dose of constipating drugs.

Non–Pharmacological Management:

  1. Use rectal interventions if required, such as enemas.
  2. Advise on increasing a high-fiber diet and fluid intake.
  3. Ensure privacy and adequate toilet facilities.

Management in Children:

 For children, an osmotically active laxative (e.g., lactulose) is preferable to a stimulant laxative (bisacodyl) as stimulants may cause severe abdominal pain in children. When starting opioids, prevent constipation by adding laxatives (e.g., bisacodyl).

Remember to adjust the dosage based on the child’s age:

  • 6-12 years: Bisacodyl 5-10mg once daily orally.
  • Step 1: Try lactulose, gradually increasing the dose over one week:
    • <1 year: 2.5ml twice daily.
    • 1-5 years: 5mls twice daily.
    • 6-12 years: 10mls twice daily.
  • Step 2: If no improvement, add Senna.
    • 2-6 years: 1 tablet twice daily orally.
    • 6-12 years: 1-2 tablets twice daily orally.
  • Step 3: If already on opioids, use step 2 drugs right away.

Additional Notes:

  • If rectal examination reveals hard stool, try a glycerine suppository. If the stool is soft but not moving, try a bisacodyl or senna suppository. If the rectum is empty, consider using a bisacodyl suppository to bring the stool down or a high-phosphate enema.
  • For severe constipation, consider using a phosphate enema or a bowel prep product (e.g., Movicol) if available.

Mouth Sores and Difficulty Swallowing (Dysphagia)

These sores are commonly caused by oral and esophageal candidiasis. It’s important to note that many mouth-related problems can be prevented by practicing good mouth care, keeping the mouth moist, and promptly treating any infections.

Causes of mouth sores and difficulty swallowing :

  1. Infections such as candidiasis or herpes.
  2. Mucositis resulting from radiotherapy or chemotherapy.
  3. Ulceration.
  4. Poor dental hygiene.
  5. Dry mouth caused by medications, salivary gland damage due to radiotherapy or tumors, or mouth breathing.
  6. Erosion of the buccal mucosa by tumors, possibly leading to fistula formation.
  7. Iron deficiency.
  8. Vitamin C deficiency.

Non-pharmacological management:

  1. Prevention through regular mouth cleaning, maintaining moisture, and promptly treating infections.
  2. Regularly checking the mouth, teeth, tongue, palate, and gums for dryness, inflammation, ulcers, or infection.
  3. Educating the patient and family on proper mouth care using available resources.
  4. Using a soft brush or soft cotton cloth for gentle brushing, avoiding harsh brushing.
  5. Rinsing the mouth with a simple mouthwash made from sodium bicarbonate or saline (a pinch in a glass of water is sufficient) can be effective.
  6. Relieving dry mouth by sucking on ice or pieces of fruit.
  7. Applying petroleum jelly on the lips after cleaning.

Assessment and pharmacological management:

  • Treating pain following the WHO analgesic ladder.
  • Considering oral morphine for severe pain caused by mucositis.
  • Treating oral candidiasis even in the absence of white patches but with inflammation:
    • Nystatin oral drops (1–2mls) every 6 hours after food and at night, holding the dose in the mouth for topical action.
    • Fluconazole (50mg daily for five days), increasing to higher doses (200mg daily for two weeks) if there is difficulty swallowing and suspicion of esophageal candidiasis. Ketoconazole (200mg daily) is an alternative, but caution must be exercised regarding drug interactions.
  • Treating other infections:
    • Applying Gentian Violet three times daily, which is useful for many types of sores.
    • Using metronidazole mouthwash, prepared by mixing crushed oral tablets or liquid for injection with fruit juice, to alleviate discomfort from foul-smelling mouth sores, especially in oral cancer cases. Consider acyclovir (200mg po for five days) for herpes infections. Severe infections may require oral or parenteral medications.
  • Treating inflammation:
    • Considering the use of steroids, such as oral dexamethasone (4–8mg) or prednisolone powder or solution, for ulceration and inflammation. However, it’s important to ensure that any infection is well treated, as steroids can exacerbate them.
Hiccup

 Hiccups are a common occurrence among many patients who are in the dying process. These hiccups can be quite distressing and exhausting for the patient, especially if they persist and do not resolve quickly.

Cause:

  1. The underlying cause of hiccups is typically irritation of the phrenic nerve in the neck of the mediastinum or irritation of the diaphragm from above.
  2. Commonly associated with hiccups are conditions such as tumors that cause stomach distension, lung tumors, esophageal cancer, renal failure, and hepatomegaly.
  3. Additionally, hiccups can also be of central origin, originating from the brain.

Management of hiccups:

Immediate measures:

  1. Pharyngeal stimulation: This can be achieved by having the patient swallow a piece of dry bread or two spoons of sugar.
  2. Correcting uremia if possible.
  3. Simple re-breathing from a paper bag to elevate the level of carbon dioxide (PCO2).
  4. Assisting the patient in a sitting up position.
  5. Medications such as Metoclopramide (10-20 mg every 8 hours), haloperidol (3 mg at night), or chlorpromazine (25-50 mg at night) may be prescribed.

Gastro-esophageal reflux

 Gastro-esophageal reflux commonly occurs when there is pressure on the diaphragm caused by an abdominal tumor or ascites, or in the presence of a neurological disorder.

Management:

  1. It is helpful to position the patient in an upright, sitting position.
  2. Administer medications after meals.
  3. Consider giving the patient milk.
  4. If the patient is currently taking NSAIDs, they may need to discontinue their use.
  5. Simple antacids such as Magnesium trisilicate (10 ml every 8 hours) may be prescribed. If the condition persists, cimetidine (200 mg every 12 hours), ranitidine (300 mg every 12 hours), or omeprazole (20-40 mg once daily) may be prescribed.

Dehydration

Dehydration is a common symptom often observed in patients, and there is a strong desire among both relatives and the medical or nursing team to ensure proper hydration for the patients.

Diagnosis:

The diagnosis and prognosis of dehydration can be influenced by several factors:

  1. Dehydration may occur when a patient experiences an intercurrent illness that is expected to resolve, such as an episode of diarrhea in a patient with lung cancer who has a prognosis of several months or severe diarrhea in an HIV/AIDS patient.
  2. Presence of other symptoms:

    a    . Dehydration can significantly impair drug excretion, leading to increased side effects, particularly for medications like morphine. It is advisable to discontinue unnecessary medications or reduce the dosage while maintaining symptom control.

    b    . Supplementary fluids may be administered for a short period to alleviate distressing symptoms like hallucinations or myoclonic jerks.
  3. Presence of a dry mouth rather than thirst:

    a    . Patients may report feeling thirsty, but they may appear well hydrated, and their symptom could be a dry mouth.

    b    . If the patient is excessively thirsty, and measures to keep their mouth moist are ineffective, considering supplementary fluids may be appropriate.

    c    . Assess the patient’s proximity to death:
    • Patients nearing death often struggle with managing oral fluids and may even experience coughing during swallowing.

Assessment and management of dehydration:

  1. A dilemma arises when a patient is critically ill and entering the terminal phase. In most patients approaching death, a reduction in fluid intake is natural and appropriate as they no longer require significant fluid intake. Explaining this to the family can help alleviate concerns and reduce requests for supplementary fluids.
  2. It is crucial to keep the mouth and lips clean and moist, as dry oral mucosa can be more distressing than thirst.
  3. In certain situations, considering artificial hydration may be appropriate. Whenever possible, oral hydration should be attempted, but if necessary, intravenous (IV) or subcutaneous (SC) infusions can be considered. SC infusions are the least invasive and can even be administered in a home setting.
  4. Excessive hydration can lead to fluid overload, requiring venous cannulation, which may become painful and challenging. When deciding to administer supplementary fluids, several factors should be taken into account.
  5. Offering more than sips of oral fluids in this situation risks the complication of aspiration and pneumonia.
  6. Families often worry that the patient will be uncomfortable without hydration. However, it’s important to note that anorexia and cachexia (severe weight loss) are common in advanced cancer, HIV/AIDS, and end-stage organ failure, and forced feeding or hydration will not improve these conditions.

Cachexia and Anorexia

Cachexia refers to weakness, profound weight loss, and poor appetite commonly observed in advanced stages of cancer, HIV/AIDS, and end-stage organ failure. 

It is important to understand that cachexia is not associated with hunger or thirst and cannot be improved by forced feeding or hydration. The underlying mechanisms of cachexia differ among different diseases but involve the release of inflammatory mediators and metabolic alterations that induce a catabolic state, resulting in significant weight loss affecting both fat and skeletal muscle.

General measures for managing cachexia:

  • Ensuring that reversible causes of anorexia or malnutrition are addressed, such as:
    • Lack of available or digestible food.
    • Dysphagia.
    • Sore mouth or altered taste.
    • Dyspepsia, nausea and vomiting, or constipation.
    • Pain.

Management in Children:

  • Corticosteroids should not be used in children if anorexia/cachexia is the sole symptom that may benefit from treatment.
  • A short trial of corticosteroids may be considered in children with associated symptoms like nausea, pain, asthenia, or depressed mood. Dexamethasone is the most appropriate corticosteroid dose in children. Alternatively, prednisone can be used at a dosage of 0.05-2mg/kg divided 1-4 times a day.

Faecal Incontinence

Faecal incontinence is a distressing symptom for the patient and presents a challenging problem for their relatives to manage at home. The causes of faecal incontinence can vary and may include:

  1. Faecal impaction: A blockage in the rectum can lead to involuntary leakage of stool.
  2. Excessive use of laxatives: Overuse of laxatives can cause loose stools and contribute to incontinence.
  3. Frequent and severe diarrhoea in debilitated patients.
  4. Paraplegic patients: Those with paralysis or impaired control of the lower body may experience difficulties in controlling bowel movements.
  5. Relaxed anal sphincters, especially in the elderly: Weakening of the muscles that control bowel movements can result in incontinence.
  6. Ano-rectal tumors: Tumors in the anal or rectal region can disrupt normal bowel function and contribute to incontinence.

Management strategies for faecal incontinence:

  1. Thorough rectal examination: A comprehensive examination should be performed to identify the underlying cause of the incontinence.
  2. Patients with relaxed anal sphincters may benefit from the use of constipating agents such as loperamide or codeine phosphate.
  3. Paraplegic or constipated patients can benefit from regular rectal evacuation and the use of faecal softeners to maintain regular bowel movements.
  4. Patients with ano-rectal carcinoma may find relief through the following measures:
    • Radiotherapy (RT) may be recommended.
    • Rectal steroids, such as prednisolone suppositories twice daily or betamethasone foam twice daily, can provide relief.
    • Metronidazole can be used rectally if there is an offensive discharge.
  5. Practical measures to manage faecal incontinence at home include:
    • Using plastic under sheets, diapers, and promptly changing and washing/drying the patient after each episode.
    • Applying barrier cream to protect the skin.
    • Regularly turning immobile patients to prevent pressure sores.

Neurological Symptoms

Fatigue:

Chronic fatigue is a common symptom in people with advanced disease. It can have multiple causes that are often overshadowed by coexisting disease processes. 

Causes of fatigue:

  1. Anaemia
  2. Pain
  3. Emotional distress
  4. Sleep disturbances
  5. Poor nutrition

General care for managing fatigue:

  •  Adapting lifestyle around periods of greater energy or fatigue. 
  • To address fatigue, it is important to treat the underlying cause if possible. For example, if anaemia is contributing to fatigue, a blood transfusion may be appropriate.
  •  Low doses of psycho-stimulants such as methylphenidate (Ritalin) or antidepressants can also be considered.
  •  Non-pharmacological interventions include energy conservation, physical exercise, stress reduction through relaxation techniques, and meditation.

Insomnia:

Insomnia refers to difficulty initiating or maintaining sleep, early-morning awakening, non-restful sleep, or a combination of these symptoms. It is common in individuals with advanced disease and can be transient or chronic. 

The causes of insomnia:

  1. Transient: Often related to life crises, bereavement, or illness.
  2. Chronic: Associated with medical or psychiatric disorders, drug intake, or maladaptive behavioral patterns. In advanced disease, it can emerge as a psychological or physiological side effect of diagnosis or treatment.

General care for managing insomnia 

  •  Reducing intake of nicotine, caffeine, and other stimulants, as well as avoiding alcohol near bedtime. 
  • Regular exercise earlier in the day can also be helpful. 
  • Benzodiazepines are commonly used hypnotic medications for sleep, offering prompt relief by decreasing time to sleep onset, improving sleep efficiency, and promoting a sense of restful sleep. 
  • Long-acting benzodiazepines like lorazepam and diazepam can be considered, but they are not recommended for long-term treatment due to the risk of tolerance, dependency, and other side effects.

Confusion:

Confusion is a distressing symptom and can be difficult to manage.

 Causes:

  1. Uncontrolled pain
  2. Urinary retention or severe constipation
  3. Changes in environment or transfer from one ward to another
  4. Metabolic disturbances (e.g., uraemia, hypercalcaemia, hyponatraemia)
  5. Infections (e.g., urinary tract infection, cryptococcal meningitis, other opportunistic infections)
  6. Hypoxia
  7. Raised intracranial pressure, strokes
  8. Medication-induced (e.g., opioids, antimuscarinics, corticosteroids)
  9. Withdrawal states (e.g., alcohol, benzodiazepines, opioids)
  10. Dementia, delirium, HIV encephalopathy
  11. Sudden sensory deprivation (blindness, deafness)

General care for managing confusion

  •  Creating a calm and reassuring environment that is as familiar as possible. 
  • Reminding the patient of their surroundings and orientation in time can be helpful. 
  • Physical restraint should be avoided unless necessary for the patient’s safety. 
  • Supporting family members to stay with the patient and express their concerns is important. 

The management of confusion

  •  Addressing underlying causes such as pain, urinary retention, constipation, infections, and organ failure. 
  • Medications can be used to relieve symptoms, but caution should be exercised to avoid excessive sedation. 
  • For mild agitation, diazepam or lorazepam can be given. For severe delirium, haloperidol or chlorpromazine can be considered along with diazepam, but not as a sole treatment for severe delirium as it may worsen confusion.

Depression:

Depression is often misunderstood, under-diagnosed, and under-treated. Assessing and managing depression involves considering key factors such as low mood for more than 50% of each day, loss of enjoyment or interest, excessive or inappropriate guilt, and thoughts of suicide.

 Ongoing support and counseling may be necessary, and antidepressant medications can be considered if depression does not respond to counseling. Amitriptyline and imipramine are examples of antidepressants that may be prescribed.

Anxiety:

Anxiety may be a symptom of depression or can occur independently. Assessment and management of anxiety involve recognizing symptoms such as feelings of panic, irritability, tremor, sweating, sleep disturbances, and lack of concentration. Providing opportunities for the patient to talk about their fears and anxieties can be beneficial. Non-pharmacological interventions like massage, relaxation techniques, and counseling may help. If persistent symptoms significantly affect the patient’s quality of life, medication with benzodiazepines such as diazepam can be considered.

Respiratory Symptoms

Breathlessness:

Difficulty in breathing can be a frightening experience for patients. They often use words such as “suffocating,” “choking,” “could not get enough air,” or “it felt like I was about to die” to describe their experience.

 Causes of breathlessness:

  1. Respiratory causes: Primary or secondary lung cancers, pleural effusion, pulmonary embolism, tracheal tumors, airway collapse, infections, lymphangitis carcinomatosa, and chronic obstructive pulmonary disease (COPD), weak respiratory muscles.

  2. Cardiac causes: Superior vena cava obstruction, anemia, cardiac failure, cardiomyopathy, pericardial effusion.

  3. Other causes: Ascites, and breathlessness secondary to treatments like radiotherapy, chemotherapy, or pneumonectomy.

General care for managing breathlessness:

  1. Adjusting the patient’s position: It is usually best for the patient to sit up. However, in patients with pleural effusion, lying on the affected side with the good lung upwards can help maximize ventilation.
  2. Ensuring good ventilation: This can be achieved by opening windows, using a fan, or even fanning with a newspaper.
  3. Assisting with slow, deep breathing and adjusting activity accordingly.
  4. Gently suctioning any excessive secretions.

Assessment and management of breathlessness:

  1. Taking a careful history: Inquire about the severity, duration, and associated features such as breathlessness worsening when lying down or on exertion, pleuritic chest pain, or hemoptysis.
  2. Treating reversible conditions if possible: This may include addressing anemia, heart failure, infection, pulmonary embolism, or pleural effusion.
  3. Addressing underlying anxiety and panic.

  4. Using medications to relieve symptoms:

  • a. Morphine: 2.5-5mg orally every four hours. If the patient is already taking oral morphine for pain, adjust the dose and advise on taking extra doses as required.
  • b. Diazepam: 2-5mg at night, especially for anxiety and panic.
  • c. Dexamethasone: 8-12mg daily for specific causes such as superior vena cava obstruction or lymphangitis carcinomatosa.
  • d. Consider other medications such as bronchodilators, diuretics, or oxygen, depending on their availability and the cause of breathlessness.

Cough

The incidence of cough in all cancer patients is around 30%, while in patients with lung or bronchus cancer, it is as high as 80%. In patients living with HIV/AIDS, any duration of cough should raise a high suspicion of tuberculosis (TB), and the patient should be referred for investigations such as Gene X-pert.

Causes of cough:

  1. Bronchial obstruction from a primary tumor or enlarged medial sternal glands, which is the most common cause.
  2. TB or pneumonia in immunosuppressed patients.
  3. Left ventricular failure, characterized by dyspnea and cough that wakes the patient.
  4. Vocal cord paralysis due to hilar tumor or lymphadenopathy.
  5. Unrelated causes to cancer, such as smoking, common colds, asthma, or congestive heart failure.

During the assessment, consider the following:

  • Type of cough: Determine if the cough is productive (with phlegm) or dry, and whether the patient is able to cough effectively.
  • Identify factors that precipitate, worsen, or relieve the cough.

Perform a physical examination of the mouth, throat, lungs, and heart.

Management of cough:

  1. Productive cough: Perform gentle postural drainage to aid expectoration and drainage if the patient’s condition allows. Steam inhalations can be helpful if the sputum is thick. Antibiotics are often prescribed to clear infections and facilitate easier expectoration. Bronchodilators, such as salbutamol, can be included in cough mixtures if bronchospasms are present.

  2. Non-productive cough: Sedation at night can be achieved with codeine linctus (1mg/ml, 10mls every 4 hours) or morphine (2.5mg, with an increase in the usual dose by 2.5mg every 4 hours).

Nursing management:

  • Positioning the patient in bed, propped up with 2 or 3 pillows in the most comfortable position.
  • If there is a pleural effusion, the patient should lie on the side of the effusion in a semi-recumbent position.

Urinary Symptoms

Urinary Retention

Urinary retention in terminally ill patients can have various causes, including:

  1. Drug-induced retention, particularly from anti-cholinergic medications, tricyclic antidepressants, and opioids. This is usually temporary and initially only.
  2. Neurological causes, especially spinal cord compression.
  3. Faecal impaction of the rectum, which can be resolved by evacuating the rectum.
  4. Prostatic carcinoma obstructing the bladder neck, which requires managing the underlying cause.

In all of the above causes, catheterization of the patient should be performed while managing the underlying cause.

Dysuria

Causes:

  1. Urinary tract infections (UTIs).
  2. Bladder or prostatic carcinoma, particularly affecting the bladder neck.
  3. Calculi (stones) or retained blood clots in the urinary system.
  4. Infiltration of the bladder by a tumor from adjacent organs such as the rectum, vagina, or cervix.

Management:

Except for UTIs, catheterization is crucial to perform bladder washouts and address incontinence or partial retention.

  1. Generalized bladder pain from bladder carcinoma may be relieved by prostaglandin inhibitors such as Ibuprofen (400mg four times a day), but strong analgesics like opioids are usually necessary and should not be withheld.
  2. If the above measures fail, permanent catheterization may be considered as an option.

Urinary catheterization is very useful for ill patients to prevent dribbling incontinence or recurring retention. When performing catheter care, the following tips are helpful:

  1. Use Foley catheters.
  2. Avoid inflating/deflating the bulb or inserting different sizes of catheters repeatedly.
  3. Bladder washouts are beneficial. Use Chlorhexidine 0.05% daily for infection prevention and weekly for maintenance, and saline for removing debris, deposits, and clots. Carers should be trained to perform bladder washouts using boiled, cooled water at home to remove debris.
  4. To minimize discomfort during catheterization for anxious patients, administer oral or rectal diazepam (2-5mg) or morphine (5mg) 30 minutes before the procedure.
  5. In about 10% of patients nearing the end of life, hematuria (blood in urine) may occur. In severe cases, a bladder washout using a silver nitrate solution can help reduce bleeding.
  6. Reassurance and explanation to family members are crucial.

Skin Related Conditions

Skin disorders can cause significant discomfort and distress to patients, especially as end-of-life approaches. Lack of activity and excessive weight loss can contribute to the development of skin breakdown. Recognizing the potential causes of skin and mucous membrane disorders is crucial because terminally ill patients cannot afford to wait for diagnostic test results before initiating therapy. Treatment planning is based on clinical identification of the most likely diagnosis, and therapy should be started as soon as possible to alleviate discomfort.

Pruritus (Itching)

Near the end of life, the cause of pruritus may be related to the patient’s primary illness, co-morbid conditions, allergies, and infections. 

The causes of pruritus;

  1. HIV/AIDS
  2. Pre-existing skin diseases (such as eczema, psoriasis, or infestations)
  3. Dry skin, particularly senile pruritus
  4. Obstructive jaundice
  5. Anxiety
  6. Allergic reactions

Management:

  1. For HIV/AIDS-related pruritus due to drug eruptions, apply 1% hydrocortisone cream.
  2. In cases of multiple opportunistic skin infections, rinse the skin after bathing with a 0.05% Chlorhexidine solution. This usually provides results within 10 days.
  3. In cases of obstructive jaundice where biliary stenting is unavailable, the following measures can be taken:
    • Administer steroids such as Dexamethasone (2mg twice daily, reducing to 1mg/day) or Prednisolone (15mg reducing to 10mg daily in the morning).
    • Use an antihistamine, such as Chlorpheniramine (4mg three times daily).

Other measures to alleviate pruritus include:

  1. Advising the patient to keep their nails short and to gently rub itching skin to prevent damage.
  2. Using a cold fan on exposed skin.

Hyperhidrosis (Excessive Sweating)

Hyperhidrosis, or excessive sweating, can cause discomfort and anxiety in patients.

Caused by various factors, including:

  1. Intercurrent infections, including tuberculosis (TB)
  2. Toxemia associated with liver metastases
  3. Lymphomas
  4. High doses of morphine

Management:

  • Identify and treat the underlying cause. 
  • If fever is present, administer antipyretics such as Paracetamol, Ibuprofen, or Diclofenac, which may initially increase sweating but eventually bring down the temperature and provide cooling effects. 
  • Steroids like Dexamethasone (2-4mg/day) can also be given. 
  • Frequent sponging and appropriate advice regarding clothing and bedding can help alleviate discomfort.

Oedema and Swelling

Kaposi’s Sarcoma is a common cause of swelling in various parts of the body, particularly the legs and face. The woody hard infiltration of the skin by the tumor leads to areas of distension, blockage of small vessels and lymphatics, and fluid retention.

Management:

  1. Considering starting antiretroviral therapy (ART) to improve the condition.
  2. Chemotherapy, if available.
  3. Pain relief with analgesics.
  4. Managing the underlying cause, if identified.

Bilateral Upper Limb Oedema

Bilateral upper limb edema is mainly caused by superior vena cava obstruction, resulting in venous distension in the area drained by the superior vena cava. Management involves:

  • Prompt radiotherapy (RT)
  • Chemotherapy
  • High-dose Dexamethasone

Unilateral Lower Limb Oedema

The three principal causes of unilateral lower limb edema in terminal care are:

  • Venous and/or lymphatic obstruction caused by a pelvic tumor. Consider radiotherapy (RT) and chemotherapy to shrink the tumor.
  • Deep venous obstruction. Avoid anticoagulants due to the bleeding tendency in terminal diseases.
  • Infection, which can manifest as cellulitis, lymphangitis, or deep tissue infection from a nearby tumor.

Management:

  • Use appropriate antibiotics, specifically broad-spectrum or according to culture and sensitivity results.
  • Advise bed rest.
  • Administer analgesics to control pain.

Bilateral Lower Limb Oedema

The three principal causes of bilateral lower limb edema in terminal care are:

Lymphatic and venous obstruction caused by a pelvic tumor. Management:

  • High-dose Dexamethasone
  • Diuretics, preferably Spironolactone (75-400mg daily) together with Frusemide (40-200mg daily)

Cardiac failure, which should be treated using routine methods.

 

Lypoalbuminemia resulting from dietary deficiency or loss in ascitic fluids. Prolonged periods of sitting with dependent feet can also cause lower limb edema, but it is not an indication for diuretics. Management:
  • Elevate the feet
  • Encourage leg movement through walking or passive movements
  • Treat the contributing factor
  • Provide reassurance to the patient and family members

Ascites

Ascites is the accumulation of excessive fluid in the peritoneal cavity, which is the space within the abdomen. Malignancy, or cancer, accounts for around 10% of all adult cases of ascites.

Clinical features of ascites :

  1. Increasing distension of the abdomen
  2. Abdominal pain
  3. Early satiety (feeling full quickly after eating)
  4. Nausea and vomiting
  5. Shortness of breath
  6. Leg edema (swelling)

Pathogenesis

The pathogenesis of ascites involves an imbalance between fluid influx and efflux in the peritoneal cavity. Increased fluid influx is associated with peritoneal metastasis (spread of cancer to the peritoneum) and increased peritoneal permeability. Reduced efflux is associated with lymphatic vessels blocked by tumor infiltration and liver metastasis causing low albumin levels.

Causes of ascites can include 

  • ovarian carcinoma, 
  • colorectal carcinoma, 
  • pancreatic carcinoma, 
  • gastric carcinoma, 
  • cardiac failure, 
  • renal failure, and liver failure.

Management

  •  Correcting the underlying cause if possible, as successful treatment of the underlying condition can often control ascites. 
  • Non-drug treatment options include paracentesis, which involves the removal of fluid from the peritoneal cavity. However, ascites is likely to reaccumulate after paracentesis.
  • Drug treatment options for ascites include the use of spironolactone, which is a diuretic that helps reduce fluid accumulation, and frusemide may be added if necessary.

Fungating Tumors and Odors

Fungating tumors can cause distress to patients due to embarrassment and isolation from relatives and friends. 

Management:

  1. Regular cleaning of the fungating tumor with saline.
  2. Radiotherapy (RT) may be a good option.
  3. Crushed Metronidazole tablets applied to the fungating area can remove odor and dry up the discharge.
  4. Metronidazole tablets can be inserted into sinuses or orifices leading to smelly growth, particularly in rectal or cervical cancers. It helps with pain relief, hemostasis, and clearing infections caused by anaerobic organisms.
Wound Care

Causes of wounds:

  1. Fungating skin cancers (primary or secondary), such as breast, sarcoma, squamous tumors, or melanoma.
  2. Poor wound healing due to debility, poor nutrition, and illness.
  3. Pressure sores due to debility and immobility.

General Care:

Cleaning wounds:

  1. Use a simple saline solution made by boiling water and adding salt (a pinch for a glass or one teaspoon for 500mls).
  2. Use saltwater baths for perineal wounds.
  3. Avoid caustic cleaning agents like hydrogen peroxide.
  4. Consider leaving a wound exposed to air (while monitoring for maggots).
  5. If necessary, apply clean dressings daily or more frequently if there is discharge.
  6. Consider using locally available materials, such as old cotton cloths washed and cut to size, for simple dressings.
  7. Educate the patient’s family on how to perform daily dressing changes.
  8. Prevent pressure sores by regularly changing the patient’s position.
  9. Keep the skin dry and clean.
  10. Consider using a water-filled surgical glove for pressure relief in critical areas.

Assessment and Management:

Is there pain?

  • Use non-adherent dressings and soak them off before changing.
  • Administer analgesia 30 minutes before changing the dressing.

Is there an unpleasant smell?

  • Sprinkle crushed metronidazole tablets directly onto the wound (avoid enteric-coated tablets) or use metronidazole gel if affordable.
  • Consider using locally available remedies such as natural yogurt, papaya, or tried-and-tested local herbs.
  • Honey or sugar can be temporarily used on a dressing for de-sloughing necrotic wounds. Dressings should be changed twice a day as they become moist, but within a few days, you can revert to dry dressings or metronidazole.

Is there discharge?

  • Use absorbent dressings and change them frequently.

Is there bleeding?

  • In cases of severe bleeding, consider radiotherapy or surgery. Use dark cloths to soak up the blood.
  • Clean the wound carefully to avoid trauma during dressing changes.
  • Consider using crushed topical tranexamic acid (500mg).

Symptoms Control Read More »

Pain Management

Pain Management

Pain Management in Palliative Care

The WHO states that freedom from cancer pain and pain caused by other diseases like HIV/AIDS should be a Basic Human Right. Pain is managed after Assessment, therefore understand Assessment of Pain by clicking here.

Principal of effective pain management

The WHO set out some basic principles for pain management::

PrincipleDescription
By the mouth
  • Always give treatment orally when possible.
By the clock
  • Persistent pain requires regular round the clock dosages (i.e. 4 hourly oral morphine).
  • Give analgesics at regular intervals.
  • Give the net dose of analgesia before the previous one has worn off
  • Titrate the dose against pain.
By the ladder
  • Use the WHO analgesic ladder as a guide to management, you can move stepwise up or down the ladder.
By the patient
  • Dosage is determined on an individual basis as no two patients are the same.
  • The choice of drug for managing pain should be appropriate for the type and severity of pain and a combination of medication should be used as appropriate.
Attention to Detail/Adjuvants
  • Regular laxatives are needed in all patients who receive opiates except those suffering from persistent diarrhea.
  • Antiemetics are usually required with initial morphine use in African patients.
  • Not all pain responds to opiates and the ladder.
  • Opiate semi-responsive: Bone pain-NSAID+/- opiates;
  • Nerve compression-steroid;
  • Increased edema-ICP-steroid;
  • Inflammation-steroid.
  • Opiate resistant:
  • Muscle pain/spasm-muscle relaxant;
  • Neuropathic pain-tricyclic antidepressants e.g. amitriptyline and anticonvulsants.

Types of Pain Management

Non-pharmacological Pain Management

  • Physical: Includes methods like massage, exercise, physiotherapy, and surgery.
  • Psychological: Involves strengthening the patient’s coping mechanisms through counseling and relaxation therapies.
  • Social: Assists the patient in resolving social or cultural problems through community resources, financial and legal support, etc.
  • Spiritual: Includes religious counseling and prayer.

Pharmacological Pain Management

  • Nociceptive Pain (normal) Management:
    • Follow WHO guidelines.
    • Utilize the oral route whenever possible.
    • Administer analgesia at fixed time intervals, giving the next dose before pain recurs.
    • Involve adults and children fully in their care and link doses to their daily routine.
    • Choose analgesics based on the WHO analgesic ladder, which covers mild, moderate, and severe pain.

WHO Analgesic Ladder

The World Health Organization (WHO) created an analgesic ladder as a method for effectively managing pain in cancer patients (WHO, 1996).

The ladder consists of three steps.

  • If a particular drug becomes ineffective, a stronger drug should be prescribed, and the treatment should progress to the next step on the ladder.
  • The management of pain should follow a step-wise approach, moving both upward and downward on the ladder as necessary.

The WHO Analgesic Ladder has proven successful in providing pain relief to approximately 90% of cancer patients.

WHO Analgesic Ladder

Step 1: Mild Pain(Non-Opioids)

  • Paracetamol:
    • Adult dose: 500mg-1g orally every 6 hours, with a maximum daily dose of 4g.
    • Can be combined with a non-steroidal anti-inflammatory drug (NSAID).
  • Ibuprofen (NSAID):
    • Adult dose: 400mg orally every 6-8 hours, with a maximum daily dose of 1.2g.
    • Give with food and avoid in asthmatic patients.
    • Effective for bone and soft tissue pains.

Step 2: Moderate Pain (Weak opioids)

  • Codeine:
    • Adult dose: 30-60mg orally every 4 hours, with a maximum daily dose of 180-240mg.
    • Often combined with Step 1 analgesics.
    • Laxatives should be given to prevent constipation, unless the patient has diarrhea.
  • Tramadol:
    • Adult dose: 50-100mg orally every 4-6 hours.
    • Start with a small dose and increase if needed, with a maximum daily dose of 400mg.
    • Use with caution in epileptic cases.

Step 3: Severe Pain (Strong analgesics)

  • Morphine:
    • Considered the “gold standard” of opioid analgesics.
    • No maximum dose; the right dose is the one that provides pain relief without side effects.  (In Uganda 30mg /24hrs is most common dose)
    • Starting dose varies based on factors such as age and previous use of opioids.
    • Starting dose: 5—10mg orally 4hrly depending on age, previous use of opiates, etc.
    • Gradually increase the dose as needed.
    • Frail/elderly patients may start with a lower dose( 2.5mg orally 6—8hrly,) due to impaired renal function.

Pharmacology of the Drugs used in the WHO Analgesic Ladder

MORPHINE

Morphine is a commonly used analgesic medication available in liquid form. It comes in different strengths, including weak (green) with a concentration of 5mg/5ml, strong (red) with a concentration of 50mg/5ml, and very strong (blue) with a concentration of 100mg/5ml. Liquid morphine is widely accessible and used for pain management purposes.  

Mode of Action
  • Morphine exerts its action by binding to opioid receptors in the brain and spinal cord, resulting in pain relief. (Morphine binds to both mu and kappa receptor sites, resulting in profound analgesia.)
  • It acts on the spinal cord to modify the transmission of pain signals and activates inhibitory pathways from the brain stem and basal ganglia.
  • Morphine also affects the limbic system and higher brain centers, influencing the emotional response to pain.
  • Additionally, its effects on the gastrointestinal and respiratory systems are partly mediated by the autonomic nervous system and direct interaction with opioid receptors in peripheral tissues.
Indications of Morphine
  •  Primarily indicated for moderate to severe pain
  • It is also employed in the treatment of acute myocardial infarction (heart attack) to alleviate chest pain and reduce anxiety.
  • It is used for the symptomatic relief of severe acute and chronic pain when nonnarcotic analgesics have proven ineffective.
  • Morphine is administered as preanesthetic medication.
  • It helps relieve shortness of breath associated with heart failure and pulmonary edema.
  • Morphine is employed for the management of acute chest pain associated with myocardial infarction (MI).
  • Morphine can be utilized to treat symptoms such as diarrhea, cough, and dyspnea.
Common Side Effects
  1. Constipation: Laxatives should be administered alongside morphine, unless the individual has diarrhea. For example, Bisacodyl 5mg at night, increasing the dose to 15mg if necessary.
  2. Nausea and Vomiting: If these symptoms occur, anti-emetics can be given. For instance, Plasil 10mg every 8 hours or Haloperidol 0.5mg once a day.
  3. Drowsiness: Some individuals may experience drowsiness during the initial days of morphine treatment. If drowsiness persists beyond three days, reducing the morphine dose is recommended.
  4. Itching: Although uncommon, itching may occur as a side effect of morphine. In such cases, reducing the morphine dose can help alleviate the itching sensation.
Contraindications
  • Acute or Severe Asthma: Morphine should be avoided in patients with acute or severe asthma due to the potential risk of exacerbating respiratory symptoms.
  • Gallbladder Disease: Morphine may intensify or mask the pain associated with gallbladder disease, specifically due to biliary tract spasms. Caution should be exercised when considering morphine use in these cases.
  • Gastrointestinal (GI) Obstruction: Morphine should be avoided in patients with known or suspected GI obstruction as it may worsen the condition or lead to complications.
  • Severe Hepatic Impairment: Morphine should be used with caution in patients with severe hepatic impairment, as the metabolism and elimination of the drug may be altered.
  • Severe Renal Impairment: Morphine should be used with caution in patients with severe renal impairment, as clearance of the drug may be reduced, potentially leading to drug accumulation and increased risk of adverse effects.
  • Caution: Elderly patients and those who are debilitated or cachectic should be initially treated with reduced doses of morphine.
Adverse Effects of Morphine
  • Dysphoria: Morphine can lead to feelings of restlessness, depression, and anxiety.
  • Hallucinations: Some individuals may experience hallucinations while taking morphine.
  • Nausea: Morphine can cause nausea.
  • Constipation: One of the common side effects of morphine is constipation.
  • Dizziness: Morphine may cause dizziness.
  • Itching: Some individuals may experience an itching sensation.
  • Overdose: Taking an excessive amount of morphine can result in severe respiratory depression or cardiac arrest.
  • Tolerance: Tolerance can develop to the sedative, nausea-producing, and euphoric effects of morphine.
Drug Interactions of Morphine
  1. CNS Depressants: Concurrent use of morphine with other central nervous system (CNS) depressants, such as alcohol, other opioids, general anesthetics, sedatives, and certain antidepressants (e.g., monoamine oxidase inhibitors and tricyclics), can potentiate the effects of opiates. This increases the risk of severe respiratory depression and the potential for life-threatening complications.
  2. Monoamine Oxidase (MAO) Inhibitors: Combining morphine with MAO inhibitors, a type of antidepressant medication, can lead to increased opioid effects and the risk of serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition characterized by symptoms such as agitation, hallucinations, rapid heartbeat, elevated body temperature, and changes in blood pressure.
  3. Tricyclic Antidepressants: Concurrent use of morphine with tricyclic antidepressants can enhance the analgesic effects of morphine but also increase the risk of adverse effects, such as sedation and respiratory depression.
Black Box Warning:
  • When morphine is administered as an epidural drug, patients must be closely monitored in a fully equipped and staffed environment for at least 24 hours due to the risk of adverse effects.
  • Extended-release tablets of morphine have a potential for abuse similar to other opioid analgesics.
  • Morphine is classified as a Schedule II controlled substance and should be used strictly according to dispensing instructions. Tablets or capsules should be taken whole and should not be broken, chewed, dissolved, or crushed.
  • Alcohol consumption should be avoided when taking morphine products.
  • Failure to adhere to these warnings could result in fatal respiratory depression.
Morphine prescription
Date25/3/2014
PatientBaluku John
IP No123/14
Age68 years
SexMale
DiagnosisCa penis
MedicationLiquid morphine 5mg in 5ml
InstructionsTake 5ml every 4 hours and 10ml at night
Supply250ml
Signature…………………………..
Treatment of Morphine Overdose
  1. Naloxone Administration: Naloxone is an opioid receptor antagonist that can reverse the effects of morphine overdose. It is typically administered intravenously (IV) and acts quickly to restore normal respiration and consciousness. Multiple doses of naloxone may be required depending on the severity of the overdose.
  2. Activated Charcoal: Activated charcoal may be given orally or through a nasogastric tube to help prevent further absorption of morphine from the gastrointestinal tract. It works by binding to the drug and reducing its availability for systemic circulation.
  3. Laxative: A laxative may be administered to promote bowel movement and eliminate the morphine from the digestive system. This helps to reduce the absorption of the drug and enhance its elimination.
  4. Narcotic Antagonist: Along with naloxone, other narcotic antagonists such as naltrexone may be used to counteract the effects of morphine overdose. These medications compete with morphine for opioid receptors and can help reverse respiratory depression and other opioid-related symptoms.
About Naloxone.

Actions and Uses of Naloxone

  • Naloxone is a pure opioid antagonist
  • Blocks both mu and kappa receptors I.

Used for:

  • Reversal of opioid effects in emergency situations of suspected opioid overdose
  • Postoperative opioid depression treatment
  • Adjunctive therapy to reverse hypotension caused by septic shock

II. Administration Alerts

  • Administer for a respiratory rate of fewer than 10 breaths/minute
  • Keep resuscitative equipment accessible
  • Pregnancy category B

III. Adverse Effects of Naloxone

  • Minimal toxicity
  • Reversal of opioid effects may result in: 1. Rapid loss of analgesia 2. Increased blood pressure 3. Tremors 4. Hyperventilation 5. Nausea and vomiting 6. Drowsiness

IV. Contraindications

  • Naloxone should not be used for respiratory depression caused by nonopioid medications

About Dependence

I. Opioid Dependence

Dependence refers to the state where a patient feels that they cannot function without the drug.

  1. Psychological dependence (addiction):

    • Involves experiencing cravings and engaging in compulsive drug-seeking behavior.

  2. Physiological dependence:

    • If the drug is abruptly discontinued, patients may develop withdrawal symptoms.
    • The likelihood of physiological dependence is reduced due to the use of low doses and the shorter lifespan of cancer patients.

  3. Therapeutic dependence:

    • Occurs when the underlying cause of pain is not resolved, leading to ongoing reliance on morphine.
    • If the cause of pain is resolved, the dosage of morphine needs to be adjusted accordingly.
  • Opioids have a high risk for dependence
  • Tolerance develops quickly, leading to escalated doses and increased frequency of drug use
  • Physical dependence occurs with higher and more frequent doses
  • Discontinuation of drug use leads to uncomfortable withdrawal symptoms
  • Psychological dependence and intense craving may persist even after overcoming physical dependence
  • Support groups are important to prevent relapse

II. Treatment Options for Opioid Dependence

Methadone Maintenance

  • Switching from illegal IV and inhalation drugs to oral methadone
  • Methadone does not cause euphoria and allows patients to function normally
  • Methadone maintenance requires continued drug use to avoid withdrawal symptoms
  • Provides physical, emotional, and legal benefits compared to illegal drug use

Buprenorphine Therapy

  • Administered sublingually or transdermally
  • Used early in opioid abuse therapy to prevent withdrawal symptoms
  • Suboxone (buprenorphine and naloxone) used for maintenance of opioid addiction

Adjuvant Medication

Adjuvant medications are drugs that are typically used for other purposes but can be effective in relieving pain under certain circumstances. They can be used alone or in combination with other medications on the analgesic ladder. Adjuvant medication plays a crucial role in pain management, especially for non-opioid responsive pain.

Examples of adjuvant medications include:

  1. Antidepressants (e.g., Amitriptyline):
    • Used to treat pain caused by nerve damage.
    • Cancer pain may require the addition of opioids as well.
    • Full benefits may take several weeks to achieve, although some effects may be noticed within one week.
    • Commonly used antidepressants are Amitriptyline (12.5-50mg at night) and Imipramine (10-50mg at night).
    • Given at night to potentially aid in sleep.
    • Side effects may include drowsiness, dry mouth, and urinary retention.
  2. Anticonvulsants (e.g., Phenytoin, Carbamazepine):
    • Used to treat neuropathic pain.
    • Can be used as an alternative or in combination with antidepressants or opioids.
    • Mechanism of action involves blocking sodium channels and enhancing GABA-mediated synaptic inhibition.
    • Examples of anticonvulsants include Phenytoin, Sodium valproate, Clonazepam, and Gabapentin.
  3. Corticosteroids (e.g., Dexamethasone):
    • Have various uses in palliative care.
    • Useful for pain caused by tumor pressure and inflammation.
    • Best used as a short-term measure due to potential side effects with long-term use.
    • Indicated for conditions such as nerve compression, superior vena caval obstruction, raised intracranial pressure (headache), and bone pain.
    • Side effects may include gastric irritation, oral candidiasis, fluid retention (ankle edema), proximal myopathy, steroid-induced diabetes mellitus, and psychosis.

  4. Smooth Muscle Relaxants (e.g., Buscopan, Diazepam):

    • Used for specific types of pain, such as biliary colic, bowel obstruction, ureteric colic, contractures, or spastic paraparesis.
    • Examples include Hyoscine butylbromide (Buscopan), Oxybutynin, Diazepam, and Clonazepam.
    • Side effects may include drowsiness.

Other interventions in pain management

  • Antibiotics for fungating wounds
  • Use of frangipani petals for post-herpetic neuralgia (neuropathic pain)
  • Capsaicin cream for neuropathic pain
  • Massage therapy, and reflexology.

Myths surrounding the use of opioids:

Morphine is offered to patients only when death is imminent:

  • The degree of pain, not the stage of a life-threatening illness, determines the need for medication.
  • Morphine is prescribed based on pain levels, and some patients may require it for an extended period.
  • Patients can lead active lives while managing pain with morphine.

Healthcare providers do an adequate job of providing pain control:

  • Barriers exist for healthcare providers in achieving optimal pain control.
  • Doctors may overlook assessing pain and assume disease-oriented treatment will suffice.
  • Nurses may administer lower doses than prescribed, resulting in under-treatment of acute pain.

Pain medications always lead to addiction:

  • Appropriate use of opioids for short-term acute pain management does not lead to addiction.
  • Reluctance to prescribe opioids due to addiction fears can deny patients freedom from pain.

People on morphine die sooner because of respiratory depression:

  • Respiratory depression is rare, especially in patients started on oral morphine with careful titration.
  • Low doses of morphine can safely relieve dyspnea in patients with COPD or lung cancer.

Pain medications always cause heavy sedation:

  • Initial sedation may occur due to chronic pain-induced sleep deprivation.
  • Adequate opioid doses allow patients to regain normal mental alertness and orientation.

People should not take morphine before their pain is severe, lest it lose its effect:

  • There is no upper dose limit for morphine. The dose can be increased as pain increases.
  • Early use of opioids does not diminish their effectiveness later in a terminal illness.

Some kinds of pain cannot be relieved:

  • Different pain medications have varying effects, and a combination approach may be necessary.
  • Thorough pain assessment helps in prescribing a regimen to manage pain effectively.

Effective pain management can be achieved on an ‘as needed’ basis:

  • Prophylactic, around-the-clock medication administration is necessary for effective pain management.
  • Scheduled opioid administration reduces side effects and provides continuous pain relief.

Opioid analgesics should be avoided in older patients:

  • Elderly patients with chronic moderate-to-severe pain may require strong opioids.
  • Caution is needed in dosing and titration due to pharmacokinetic and physiological changes.

Other myths about managing pain:

  1. Morphine does not hasten death in terminally ill patients.
  2. Injectable morphine is not necessarily more effective than other routes.
  3. Strong analgesics should not be withheld until death is imminent.
  4. Patients can experience pain even while sleeping.
  5. Pain can be present in patients who are engaged in activities like watching television or laughing.
  6. Infants and children experience pain similarly to adults.
  7. The dose of pain medications does not always need to be increased continuously.
  8. Vital signs alone are not reliable indicators of pain in patients.

Myths and Fears about Morphine:

Myths:

  1. Tolerance (Myth):

    • Some patients and physicians believe that increasing the dose of morphine to control pain indicates tolerance.
    • In palliative care, the ceiling dose of morphine is the dose that effectively controls the pain for each individual patient.
    • The need for an increased dose of morphine does not mean the patient is developing an addiction.

  2. Physical dependence (Myth):

    • Abrupt discontinuation of an opioid typically leads to withdrawal symptoms.
    • Gradual withdrawal over 2-3 days can alleviate these symptoms.
    • This is not physical dependence.

  3. Addiction (Psychological dependence) (Myth):

    • Addiction to morphine is very rare and primarily associated with non-medical use of opioids.
    • It is not a common problem in medical settings.

  4. Cognitive impairment (Myth):

    • When initiating morphine therapy, some sedation and temporary attention deficits may occur, including reduced recent memory.
    • These effects generally disappear after three to five days.
    • This is not addiction.

  5. Lethality (Myth):

    • Properly prescribed morphine, with gradual dose adjustments based on need, does not cause death.
    • In the event of an overdose, Naloxone can help control the situation.
Fears:

  1. A last resort before death? (Fear):

    • Some people fear that morphine is only prescribed as a last resort when the patient is close to death.
    • In reality, morphine is used to relieve pain at various stages of illness, not solely in end-of-life care.

  2. Hastening death (Fear):

    • There is a fear that morphine might speed up the dying process.
    • When used appropriately, morphine does not affect the timing of death.
    • Patients pass away due to the effects of advanced cancer or AIDS, not as a direct result of morphine.
    • Morphine allows pain relief, enabling patients to function more effectively.

  3. Morphine is reserved until the end (Fear):

    • Some individuals mistakenly believe that morphine should only be used as a last resort.
    • They fear that if morphine is taken early in the illness, it may not be effective when pain becomes more severe.
    • However, morphine can be used at various stages of illness to alleviate pain.

  4. Respiratory distress (Fear):

    • Some people believe that morphine can cause breathing problems, especially if the person has a lung condition.
    • Breathing difficulties can occur due to morphine overdose.
    • Starting with low doses and gradually increasing can help avoid this issue.
    • Morphine can actually be used to reduce distress caused by severe cough or breathlessness.

  5. The elderly should not be given morphine (Fear):

    • Elderly patients with cancer pain respond as well to morphine as younger patients.
    • However, they may be more prone to side effects.
    • Smaller doses and gradual increments are recommended for the elderly.

  6. Injection morphine is better than oral morphine (Fear):

    • Morphine is well absorbed when taken orally.
    • Oral (liquid) morphine is cost-effective compared to tablets or injectable forms.
    • Injection morphine should only be used when oral administration is not possible, such as in cases of severe vomiting.

Laws governing narcotics

International Regulation:

  • Opioids are regulated under the 1961 convention, amended by the 1972 protocol.
  • Uganda is a party to this convention, aiming to ensure the availability of opioids for medical and research purposes while preventing abuse.
  • The following aspects are considered under the enacted laws:
    • Production (cultivation)
    • Manufacturers
    • Distribution
    • Registration of all handlers
  • The international board oversees countries’ compliance with the convention.
  • The government estimates the annual quantity of opioids needed, which is confirmed by the International Board before manufacturing or importation.
  • Quarterly reports on imported, manufactured, and distributed opioids are required, necessitating accurate record-keeping.
  • Communication regarding regulations is done through the Ministry of Health (MOH) and the National Drug Authority (NDA), with the NDA regulating drug handling.

Restricted or Class A Drugs:

  • Class A drugs include opioids like morphine and pethidine.
  • Specific procedures, storage requirements, and records are in place to prevent diversion.
  • Records must be kept for two years for inspection purposes.
  • Loss of class A drugs must be reported to the Chief Inspector of Drugs (NDA) within seven days.

Expired, Rejected, or Returned Class A Drugs:

  • Unused drugs should be returned to the prescriber or dispenser.
  • Expired or rejected drugs should be returned to the pharmacy in charge, who contacts the drug inspector.
  • Expired drugs should be destroyed by the pharmacy in charge, witnessed by the drug inspector, following WHO guidelines.
  • Details of the quantity destroyed and the reason must be recorded in the Class A register.

Importation of Class A Drugs:

  • Manufacturing and wholesale of class A drugs require an annual import license.
  • Currently, only the National Medical Stores (government) and Joint Medical Stores (NGO) are allowed to import narcotics.
  • Private retail pharmacies and hospitals can access narcotics through these licensed agencies.

Storage:

  • Powdered morphine and finished morphine should be stored in a separate, immovable cupboard.
  • The cupboard should be double-locked and restricted from public access.
  • The key should be kept by the pharmacist or dispenser.

Disposal:

  • Drug disposal follows WI-TO guidelines (NDA).
  • Details of the quantity destroyed and the reason for destruction must be recorded in the Class A register.

Transport:

  • All individuals and enterprises involved in the distribution system should be licensed and authorized.
  • An anti-narcotic drug squad ensures drugs do not fall into the hands of drug traffickers.

Prescription:

  • Only registered medical doctors, dentists, veterinary doctors, specialized palliative care nurses or clinical officers, and midwives are allowed to prescribe class A drugs.
  • Prescription forms must contain all necessary details as it is a legal document.
  • Prescription is valid for 14 days, and supply must not exceed one month. Duplicate copies are required.

Prescription Requirements:

  • The prescription must include:
    • Name, age, sex, and address of the patient
    • Total dose of drugs prescribed in words and figures
    • Specific form of drug (e.g., tablets, injections, oral solution)
    • Specific strength where possible (e.g., 5mg/5ml or 50mg/5ml of oral morphine)

Penalties:

  • Unlawful possession of classified drugs can result in:
    • A fine not exceeding 2 million Ugandan shillings
    • Imprisonment for a term not exceeding 2 years
    • Both penalties may be applied.

Pain Management Read More »

Assessment OF Pain

Assessment OF Pain

Assessment OF Pain

Assessment Introduction.

To effectively manage pain, it is important to begin with a thorough assessment. This includes conducting a comprehensive physical examination and considering other factors that may influence the pain, such as psychological, social, cultural, and spiritual aspects. We covered Pain already, incase you want to view Pain Introduction, Click Here.

Here are some key points to keep in mind during the pain assessment process:

Physical Assessment: Perform a detailed physical examination and document the findings in writing and on a body chart. Limit further investigations to those that will significantly impact treatment decisions. Also, evaluate the extent of the patient’s disease.

Assessment of Influencing Factors: In addition to the physical assessment, assess other factors that may contribute to the pain experience, such as psychological, social, cultural, and spiritual aspects.

Specific Questions to Ask: To gather important information about the pain, ask specific questions, including:

  1. Onset of Pain: When did the pain start?
  2. Nature of Pain: What does the pain feel like?
  3. Site and Radiation of Pain: Where is the pain located and does it spread to other areas?
  4. Type of Pain: What type of pain is it?
  5. Duration of Pain and Changes: How long has the pain been present and has it changed over time?
  6. Precipitating/Aggravating or Relieving Factors: What triggers or worsens the pain? Are there any factors that provide relief? Also, consider how the pain affects the patient’s functional ability, mood, and sleep.
  7. Effect of Previous Medications: Assess the effectiveness and any side effects of previous pain medications.
  8. Meaning of Pain to the Patient: Understand the patient’s perspective on the pain and its significance, especially if it relates to their deterioration or end-of-life concerns.

PQRST Pain Assessment 

  1. Precipitating and relieving factors: What makes your pain better or worse?
  2. Quality of pain: How would you describe your pain? What does it feel like?
  3. Radiation of pain: Does the pain stay in one place or move around your body?
  4. Site and severity of pain: Where is your pain? (Use a body chart) How bad is it? (Use a pain rating scale)
  5. Timing and previous treatment for pain: How often do you experience the pain? Does it occur at specific times? Have you received any previous pain treatments?

PQRST Pain Assessment

PQRSTQuestions
P – Position
  • – Where is the pain?
  • – Can you point to where the pain is?
  • – Does the pain spread?
  • – Put an X where it hurts the most.
P – Precipitating Factors
  • – Does anything worsen the pain, such as eating, bowel movements, or movement in general?
  • – Does anything alleviate or improve the pain?
  • – Does the pain get better when staying still?
  • – Does it improve after having a bowel movement?
  • – Does it improve after wound discharge?
  • – Does using hot or cold compresses help?
  • – Does praying or being with friends provide relief?
  • – Have you tried any medications, painkillers, or herbs? Do they help?
  • – Did any treatment reduce or eliminate the pain?
  
Q – Quality
  • – What does the pain feel like to you?
  • – How would you describe your pain using words like nociceptive, somatic pain, etc.?
R – Radiation
  • – Where does the pain start?
  • – Does the pain radiate to any other areas?
S – Severity
  • – On a scale of 0 to 5, how severe is the pain?
  • – How does the pain affect your daily life?
  • – Does it prevent you from engaging in normal activities, sleeping, moving, sitting, or eating?
T – Timing
  • – How long have you had the pain?
  • – Is the pain constant or does it come and go?
  • – Does the pain worsen at a specific time of day or night?
Meaning of Pain, this is to help to understand the patient’s thinking about the pain.
  1. – What are your fears about the pain?
  2. – What do you think is causing the pain?
  3. – What does the pain mean to you?
  4. Some possible answers: “I’m being punished,”
  5. “I’m going to die,”
  6. “There is no hope,”
  7. “I have to suffer; it is my destiny,”
  8. “I’m being eaten away.”

In a PQRST pain assessment, these questions help gather important information about the pain, its location, factors that worsen or alleviate it, the quality of the pain, any radiation or spread, its severity and impact on daily life, timing patterns, and the patient’s thoughts and fears related to the pain.

Pain Assessment Tools

Pain assessment tools are helpful in evaluating and monitoring a patient’s pain. These tools provide a way to measure and track the severity of pain over time. They are particularly useful for:

  • Determining the intensity of the patient’s pain.
  • Monitoring changes in pain levels as treatment progresses.
  • Assessing the effectiveness of interventions.

It is important to use simple techniques during pain assessment. 

Initially, 

  • Identifying the location of the pain and whether it is present in multiple areas of the body is crucial
  • Regular pain measurements should be conducted, typically every 6 or 4 hours, or more frequently in severe cases.
  •  It is important to note that most measurement tools do not consider the presence of anxiety, which can lead to inaccurate high or low pain scores. Anxiety and pain can exhibit similar behavioral indicators, so it is possible to measure anxiety instead of pain.

There are various pain measurement tools available for both adults and children. One useful tool is a body chart, where individuals can mark the areas where they experience pain.

Types of pain assessment tools.

The Numerical Rating Scale

 

  • The Numerical Rating Scale

One common type of pain assessment tool is the Numerical Rating Scale. The patient is asked to rate their pain intensity on a numerical scale, typically ranging from 0 (indicating no pain) to 10 (indicating the worst pain imaginable). Alternatively, a simplified version of the scale may use a range of 0-5. Another variation is the verbal-descriptor scale, which includes descriptive terms such as “mild pain,” “mild-to-moderate pain,” and “moderate pain.”

hand scale for pain assessment
  • Hand Scale

This scale uses a hand gesture to represent the level of pain. A clenched hand indicates no pain or “no hurt,” while fully extended fingers represent the worst possible pain or “hurts worst.”

 It’s important to note that cultural interpretations may vary, so it’s necessary to explain the scale clearly to the patient. For example, you can ask the patient to rate their pain on a scale of 0 to 5, where 0 means no pain at all, 1 is a little pain, 2 is a bit more pain, 3 is quite some pain, 4 is a significant amount of pain, and 5 is overwhelming pain—the worst pain imaginable

  • The Faces Pain Scale  (Wong-Baker Faces Pain Rating Scale)

This scale consists of six cartoon faces, each depicting a different expression. The faces range from a broad smile, representing “no hurt,” to a very sad face, representing “hurts worst.”

 It’s important to provide proper training to the patient on how to use this tool accurately. Make sure they understand that they are rating their pain level and not their emotions. It’s worth noting that experiences with the Faces Scale in Africa have varied, with many individuals preferring the hand scale for pain assessment.

Pain assessment in children 

Pain management in children is complex. Although there are similarities with pain management in adults, there are specific considerations for children.

Myths and Facts about Pain in Children
MythsFacts
Newborns do not feel painNewborns have the ability to perceive pain
Young children cannot process or remember painChildren of all ages can experience and remember pain
Children become accustomed to repeated painful proceduresRepeated painful procedures can still cause distress and pain
Children are unable to tell where it hurtsChildren can indicate the location of their pain
Opioids should be avoided due to addiction riskPsychological addiction to opioids is rare in children
Incomplete myelination or immature pain cortex means children don’t feel painProper nociception (pain perception) is possible without complete myelination
Younger children have higher pain sensitivityPain tolerance generally increases with age
Children always communicate when they have painChildren may not always express pain due to fear or inadequate communication skills
Children are not aware they have chronic painChildren may not recognize or understand chronic pain

Goals of pain measurement in children:

  1. Assess the intensity/severity of pain.
  2. Identify the location of pain.
  3. Evaluate the effectiveness of treatment.

Barriers to pain assessment and measurement in children::

  1. Limited availability of age-appropriate and validated pain assessment tools.
  2. Lack of knowledge regarding appropriate tools for different age groups in children.
  3. Insufficient training in the use and implementation of pain assessment tools.
  4. Difficulty in interpreting pain scores.
  5. Challenges in distinguishing between anxiety and psychological pain.
  6. Limited understanding of children’s pain experiences.
  7. Factors that may inhibit children from reporting their pain, such as fear of doctors or nurses, fear of illness, reluctance to bother caregivers, avoidance of injections, and eagerness to leave the hospital

Assessment Process of Pain in Children

To effectively assess pain in children, a standardized tool or guideline can be valuable in tracking changes in pain over time. One such tool is the QUESTT tool, which stands for:

  • Q – Question the child (if able to respond) or the parent/caregiver (if the child is unable to communicate).
  • U – Use pain rating scales, if appropriate, to quantify the child’s pain.
  • E – Evaluate the child’s behavior and physiological changes that may indicate pain.
  • S – Secure the involvement of parents in assessing and managing the child’s pain.
  • T – Take into account the cause or source of the pain.
  • T – Take necessary action based on the assessment findings and continuously evaluate the effectiveness of interventions.
StepQuestions/Tools
Question the child1. Do you have any hurt/pain?
 2. Can you show me where it hurts?
 3. Does it hurt anywhere else?
 4. When did the pain/hurt start?
 5. Do you know what might have caused the pain?
 6. How much does it hurt? (Use a pain rating scale)
 7. What helps to take away the pain or make it better?
U – Use of pain rating scales– Eland Body scale: This tool helps to assess multiple sites and differing intensities. Get the child to assign colors to the different categories e.g. no pain – green. Little pain – yellow, moderate pain – orange and severe pain – red. Ask them to colour in the bodies where their pain is, using the different colors to depict different levels of pain in different areas.
 – Faces Scale
 – Hand Scale
Evaluate behavior and physiological changesObserve behavioral and physiological responses to pain
Secure the caregivers involvement1. Listen to mothers, fathers, and caregivers
 2. Include them in decision-making
 3. Consider their insights into subtle changes in behavior
 4. Seek their input on comforting strategies for the child
Take the cause of pain into account1. Consider the underlying problem/pathophysiology
 2. Obtain descriptions of the type of pain to determine its cause
Take action and evaluate results1. Assess pain, develop a treatment plan
 2. Reassess using pain rating scales
 3. Adjust the treatment plan accordingly
 4. Utilize pain diaries for continuous re-evaluation in chronic pain cases

Assessment OF Pain Read More »

Pain assessment

Pain assessment

Pain assessment

We cannot assess pain without understanding what pain is, right? Let us first explore pain!

Pain

Pain is an unpleasant experience that involves both physical sensations and emotions, often connected to actual or possible harm to body tissues.

Pain is defined by the person experiencing it and exists as they perceive it. “Pain is what the patient says hurts.”

Pain is subjective, as individuals shape their own understanding of pain based on their personal experiences.

Pain is the most common and feared symptom among those nearing the end of life. It affects around 98% of cancer and HIV/AIDS patients.

Cancer pain is typically constant and worsens as the disease progresses.

In developing countries where less than 5% of cancer patients have access to chemotherapy or radiotherapy, pain tends to worsen gradually until death.

A study conducted in Africa involving stage IV AIDS patients identified the most common pains reported:

  • Lower limb pain (66%) caused by peripheral neuropathy
  • Mouth pain (50.5%)
  • Headache (42.3%)
  • Throat pain (39.8%)
  • Chest pain (17.5%)

The Purpose of Acute Pain: Acute pain serves as a useful mechanism that alerts organisms to the presence of harmful or potentially harmful stimuli in their environment, such as extreme heat or cold.

Acute Pain in Cancer: Cancer patients may experience pain due to different factors, including:

  • Direct effects of the disease, such as tumors infiltrating sensitive structures that cause pain
  • Treatment-related effects, like radiotherapy that can harm visceral, musculoskeletal, and nervous tissues.
  • Surgery, chemotherapy, and radiotherapy are all associated with potential side effects that may cause pain.
pain classification of pain

Classification of Pain

Pain comes in various forms and can be categorized based on its duration (acute or chronic) and its underlying physiological mechanism (nociceptive or neuropathic). 

It is common for multiple types of pain to coexist. To effectively assess and treat pain, it is important to identify the specific type(s) of pain being experienced

TypeCauseDescriptionTreatment 
NociceptiveActivation of intact nerve pathwaysNormal response to a stimulusAddress underlying cause 
     
  • Somatic pain
Tissue injury to skin, muscle, boneNagging, throbbing, aching sensationStandard pain medication (according to WHO ladder) 
  (e.g., toothache, burns)  
     
  • Visceral pain
Pain originating from organsCrampy, nagging sensation (e.g., crampy bowel pain)Additional medication 
     
     
Neuropathic painNerve pathway damage resulting in abnormal response to stimulusBurning, shooting, pricking, electric shock, numb sensations (e.g., neuropathy, herpes zoster)Antidepressants, anticonvulsants, +/- Opiates 
     
     
  • Peripheral pain
Damage to peripheral nervesPain originating from peripheral nerves (e.g., nerve compression, chemotherapy-induced damage)Targeted nerve pain medications 
     
     
  • Central pain
Damage to the central nervous systemPain originating from the central nervous system (e.g., stroke, spinal cord injury)Neuropathic pain medications–
     
Duration of Pain    
  • Acute Pain
Definite injury or illnessCharacterized by definite onset, limited duration, and clinical signs of sympathetic overactivity (e.g., tachycardia, pallor)Address underlying cause 
     
     
  • Chronic Pain
Chronic pathological processGradual or ill-defined onset, continues unabated(increase in intensity, and strength) may become severe
No typical signs of sympathetic overactivity		Address underlying cause 
     
Pain according to Situation    
  • Breakthrough
Transitory exacerbation of pain on a controlled pain backgroundOccurs on a background of otherwise controlled painAdjust pain management plan as needed 
     
     
  • Incident Pain
Occurs in specific circumstances (e.g., after a particular movement)Occurs only in certain circumstances (e.g., after a particular movement)Address specific triggers or interventions 
     
     
  • Procedural Pain
Related to procedures or interventions Appropriate pain management during procedures 

Factors that influence pain

  • The patient’s mood
  • The patient’s morale
  • The meaning of the pain for the patient e.g. the meaning of pain in advanced cancer is 
  • “I ‘m incurable”: I ‘m going to die.
  • Psychological and Spiritual Factors: Pain can be influenced by psychological factors, such as mood, morale, and the meaning of pain for the individual. Spiritual beliefs and practices may also impact pain perception.
  • Social Circumstances: Social factors, including support systems, relationships, and cultural influences, can affect the experience and management of pain.
  • Emotional Component of Pain: Pain is not purely a physical sensation but also involves an emotional component. Individuals may describe their pain using terms like agonizing, cruel, or terrible.
  • Integrated Multi-disciplinary Teams: Managing chronic pain often requires the involvement of various healthcare professionals working together as a team. This interdisciplinary approach ensures comprehensive care and improved outcomes.
  • Holistic Support: Providing holistic support to patients with chronic pain can greatly impact their quality of life. This support focuses on addressing feelings of helplessness, building resilience, and addressing the physical, emotional, and social aspects of pain.
  • Gender Differences: Biological, psychological, and social factors contribute to differences in how men and women experience pain. This includes variations in pain perception, response to treatment, and effectiveness of different pain management approaches.
Factors Increasing PainFactors Decreasing Pain
DiscomfortRelief of other symptoms
InsomniaUnderstanding
FatigueCompanionship
AnxietyCreative activity
FearRelaxation
AngerReduction in anxiety
SadnessElevation in mood
DepressionAnalgesics
BoredomAnxiolytics
 Antidepressants

Total pain

  • The concept of total pain was developed by Cicely Saunders in 1960s.

She acknowledges that pain is not just a physical phenomenon. It encompasses physical, psychological, social and spiritual aspects of suffering.

  • Physical: undesirable effects of treatment, insomnia, chronic fatigue
  • Psychological: anger at delays in diagnosis, anger in treatment failure, disfigurement, fear of pain/death, feelings of helplessness, anger at friends who do not visit.
  • Social: worry about family, Worry about finance, loss of job, loss of income, loss of social position.
  • Spiritual: Why has this happened to me? Why does God allow me to suffer like this? Is there any meaning or purpose in life? 
The impact of pain
  • Severe pain in advanced cancer patients has negative physiological and psychological complications that may worsen an already bad situation.
  • Interaction of pain with other symptoms (e.g. nausea, constipation, shortness of breath, depression, anxiety, insomnia) may worsen the patient’s condition.
  • The patient’s functional status is further impaired.
  • The patient’s autonomy is challenged.
  • The patient’s dignity is challenged.
  • The patient and family may interpret pain as impending death.
Barriers to pain management
  • Inadequate pain assessment
  • Inadequate knowledge about pain and its management
  • Concerns about possible side effects of pain medications
  • Patient and doctor’s attitudes, fears and misconceptions about pain and opioids.
  • Poorly accessible or unavailable pain management services.

Principles for Assessing and Managing Pain

  1. Comprehensive Approach: All aspects of total pain, including psychological, spiritual, social, cultural, and physical dimensions, should be addressed during pain assessment and management.

  2. Multiple Causes of Pain: Pain can stem from various sources such as diseases (e.g., HIV), their consequences (e.g., opportunistic infections), treatments (e.g., chemotherapy), or concurrent disorders (e.g., arthritis).

  3. Goal of Palliative Care: The aim of palliative care is to alleviate pain effectively, ensuring it does not significantly impact the patient’s quality of life.

  4. Subjectivity of Pain: Pain is a subjective experience, relying on what the patient communicates and describes.

  5. Guideline-based Management: Pain should be managed according to the guidelines provided by the World Health Organization (WHO) and the analgesic ladder.

  6. Considerations in Pediatric Pain: Incident and procedural pain are particularly significant in children and should be addressed appropriately.

Clinical Presentation of Pain

Different types and causes of pain manifest with distinct clinical presentations:

  1. Visceral Pain: This type of pain is not well localized and presents as a constant, aching sensation.

  2. Bone Pain: Bone pain is well localized with local tenderness. It resembles a nagging toothache, worsens with movement and weight bearing, and is often caused by the release of prostaglandins.

  3. Colic: Colic refers to gripping pain associated with spasms, typically occurring in the middle or upper abdomen (bowel) or related to micturition (bladder).

  4. Raised Intracranial Pressure: Increased pressure within the skull results in a generalized headache that worsens in the mornings, when lying down, and during coughing. This type of pain may be accompanied by symptoms like nausea, projectile vomiting, and blurred vision.

  5. Neuropathic Pain: Neuropathic pain is constant or aggravated by movement. It is described as burning, sharp, stabbing, shooting, or a nagging ache. It may be associated with altered sensation and can follow a dermatomal distribution.

  6. Spiritual Pain: Spiritual pain is an emotional form of suffering, often expressed through dreams or nightmares.

  7. Other Forms of Pain: Patients may exhibit refusal to take medication or engage in self-harming behaviors as active manifestations of pain.

Pain Assessment

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Hemorrhage

Hemorrhage

Hemorrhage

Hemorrhage, or profuse bleeding, can occur from major blood vessels and can be a frightening event for patients and their caregivers.

However, hemorrhage is often predictable and requires proactive management, such as ensuring necessary medicines are available in the home care setting for emergencies.

Causes of Hemorrhage.

  1. Catastrophic bleeding from tumor erosion: Hemorrhage can occur when tumors erode into nearby blood vessels, especially in areas such as the head and neck, stomach, pelvis, bladder, or lungs. Tumors infiltrating blood vessels can lead to significant bleeding.

  2. Bleeding from oesophageal varices in cirrhosis: Patients with advanced liver disease, particularly cirrhosis, may develop oesophageal varices. These are enlarged veins in the esophagus that can rupture and cause torrential bleeding.

  3. Blood-clotting disorders: Palliative patients may have underlying bleeding disorders, such as abnormalities in platelet number and function or reduced clotting factors. These conditions can impair the blood’s ability to clot properly and increase the risk of hemorrhage.

  4. Low platelet levels in malignancies and HIV: Certain malignancies, such as bone marrow infiltration by cancer cells, can result in decreased platelet production or destruction, leading to low platelet levels (thrombocytopenia). HIV infection can also cause thrombocytopenia, further increasing the risk of bleeding.

Assessment and management of hemorrhage in palliative care patients

  1. The first rule of management is to ensure that the patient is never left alone until the bleeding is under control. Immediate attention and support are crucial during a hemorrhagic episode.
  2. If there is a risk of bleeding, anticoagulants such as warfarin should be either stopped or maintained at the lowest effective doses to minimize the potential for excessive bleeding.
  3. Review and reassess other medications that could contribute to bleeding. If these medications are not essential for symptom control, they should be discontinued to reduce the risk of hemorrhage.
  4. Consider referring the patient for radiotherapy in specific cases:
    a. Hemoptysis (coughing up blood) from lung tumors.
    b. Bleeding from Kaposi’s sarcoma (KS) and fungating tumors.
    c. Bleeding from head and neck tumors.
    d. Hematuria (blood in urine) due to bladder cancer.
    e. Rapidly growing erosive tumors.
  5. If the patient has a history of smaller bleeds, consider administering tranexamic acid in a dose of 0.5mg to 1g, given two to three times a day (bd/tds), if it is available. Tranexamic acid helps in reducing bleeding.
  6. For surface bleeding from tumor areas, the use of gauze soaked in adrenaline (1ml) or crushed tranexamic acid applied topically can be considered to control bleeding.
  7. Isolated bleeding vessels may be amenable to surgical ligation, which involves tying off or closing the bleeding blood vessels surgically.
  8. In severe cases where hemorrhage may lead to a terminal event, various measures can be implemented:
    a. Keep dark towels nearby for the family, as blood can appear to be of a much larger volume on white or pale surfaces. This helps manage the emotional impact of the bleeding event.
    b. Sedation with benzodiazepines, such as diazepam (10 mg orally or rectally), may be administered to alleviate anxiety and fear during catastrophic bleeding events. However, it is essential to note that the rapid progression of bleeding may limit the effectiveness of sedation.
For Children

When managing hemorrhage in children, particularly those with hematological malignancies, the following approaches should be considered:

  1. Aim for rapid and complete sedation using benzodiazepines and/or opioids, if available, administered through parenteral routes. This helps ensure the child remains calm and comfortable during the episode.

  2. If the child is able to swallow, administer double the usual dose of morphine, with or without diazepam, as prescribed. This helps manage pain and anxiety associated with severe nose bleeds (epistaxis).

  3. In cases where the child is unable to swallow, administer large doses of morphine and diazepam rectally. The recommended rectal valium dose is as follows:

    • If the child’s weight is unknown: 5mg for children below 3 years, and up to 10mg for children older than 3 years.
    • If the child’s weight is known: Administer a dose of 0.5–1mg/kg up to a maximum of 10kg.
Superior Vena Cava Obstruction (SVCO)

Superior Vena Cava Obstruction (SVCO)

SVCO refers to the partial or complete blockage of blood flow through the superior vena cava, leading to impaired venous return into the right atrium.

Superior vena cava syndrome (SVCS) is a condition where the superior vena cava, which carries blood from the head, neck, and upper thorax to the right atrium, becomes obstructed. 

This obstruction can be caused by external compression from a tumor or lymph node, direct invasion of the vessel wall by a tumor, or thrombosis of the vein due to a blood clot. When the vein is obstructed, it impairs blood flow to the right atrium and the upper drainage above the thorax.

SVCS is most commonly seen in lung cancers, particularly small cell carcinoma, accounting for about 75% of cases. Lymphoma accounts for about 15% of cases, and other cancers such as breast, colon, esophagus, and testicular cancer can also cause SVCS. If left untreated, SVCS can progress rapidly, leading to complications such as thrombosis, cerebral edema, and even death within a few days. The respiratory, cardiac, and central nervous systems are always affected by this condition.

Signs and symptoms of SVCS 

  1. Respiratory system: Shortness of breath, dyspnea, cyanosis, cough, hoarseness, stridor, and dysphagia.
  2. Central nervous system: Mental status changes, headache, dizziness, blurred vision, syncope, and seizures.
  3. Cardiac system: Tachycardia, chest pain, and hypotension.
  4. Swelling of the face, upper body, and arms
  5. Dysphagia (difficulty swallowing) Some patients may describe a sensation of drowning. SVCO is commonly seen in patients with tumors in the mediastinum, such as bronchial carcinoma, breast cancer, and lymphoma.
  • Physical examination may reveal signs such as edema of the face, arm, and upper chest, dilated veins in the upper part of the thorax, shoulders, and arm, jugular venous distension, and engorged conjunctiva.
  • Late signs may include pleural effusion, pericardial effusion, and stridor.

Assessment and Management.

Assessment

  • Physical examination may reveal engorged conjunctivae, periorbital edema, dilated neck veins, and collateral veins on the arms and chest wall.
  • Late signs may include pleural effusions, pericardial effusion, and stridor.

Management of Superior Vena Cava Obstruction (SVCO):

Aim

In advanced cases, the primary goal is to provide relief from acute symptoms.

  1. Relief of Acute Symptoms:

    • High-dose Corticosteroids: Administer corticosteroids, such as dexamethasone, in high doses (e.g., 16mg PO/IV). These help reduce inflammation and alleviate symptoms.
    • Radiotherapy: If available, consider urgent radiotherapy to target the underlying cause of SVCO, such as tumors or lymph nodes causing compression. This can help alleviate the obstruction and improve blood flow.

  2. Symptomatic Management:

    • Dyspnea: Provide symptomatic relief for dyspnea (shortness of breath) using medications like morphine (e.g., 5mg every 4 hours) and/or benzodiazepines. These medications help alleviate anxiety and improve breathing comfort.
    • Cough: Address the cough by using appropriate medications, such as cough suppressants or expectorants, as recommended by a healthcare professional.
    • Dysphagia: If dysphagia (difficulty swallowing) is present, work with a speech therapist to develop strategies and exercises to improve swallowing function.

  3. Supportive Care:

    • Patient Positioning: Keep the patient in an elevated or sitting position, as this can help improve venous return and reduce symptoms.
    • Oxygen Therapy: Administer supplemental oxygen if needed to alleviate dyspnea and improve oxygenation.
    • Calm Environment: Create a calm and soothing environment for the patient, which can help reduce anxiety and improve overall comfort.

  4. Multidisciplinary Approach:

    • Collaborate with a multidisciplinary team, including oncologists, palliative care specialists, and supportive care professionals, to provide comprehensive management and support for the patient’s physical, emotional, and psychosocial needs.
    • Psychological Support: Offer emotional support to the patient and their family, addressing their concerns and providing guidance throughout the treatment process.

  5. Close Monitoring and Follow-up:

    • Regularly monitor the patient’s clinical status, including vital signs, symptom progression, and response to treatment.
    • Schedule follow-up appointments to assess treatment efficacy, manage symptoms, and make any necessary adjustments to the management plan.

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Hypercalcemia

Hypercalcemia

Hypercalcemia

Hypercalcemia is a threatening metabolic disorder associated with cancer. It commonly occurs in patients with breast cancer, multiple myeloma, and head, neck, and renal tumors. 

This is when the serum level of calcium is >10.4 mg/dl(greater than 2.60 mmol/dL).

Hypercalcemia associated with malignancy is referred to as Hypercalcemia of Malignancy (HCM) and is commonly associated with primary cancers of the 

  • breast
  • lungs
  • neck
  • kidney
  • esophagus
  • gastrointestinal tract
  • cervix, leukemia
  • multiple myeloma, and melanomas.

 HCM most often results from bone metastasis. There is a release of calcium from the bones, which causes hypercalcemia. Additionally, cancer treatment modalities such as estrogen and anti-estrogen agents are associated with the development of HCM.

Non-cancer related factors associated with the development of hypercalcemia include

  • immobility
  • dehydration
  • excessive intake of calcium and Vitamin D
  • decreased parathyroid hormone levels, and vitamin A intoxication.

Causes:

  1. Specific cancers: Certain types of cancer, such as breast cancer, lung cancer, kidney cancer, leukemia, multiple myeloma, and melanomas, are commonly associated with hypercalcemia. The presence of these cancers can lead to the release of calcium from the bones, contributing to elevated calcium levels in the bloodstream.

  2. Treatment modalities: Cancer treatment methods, including the use of estrogen and anti-estrogen agents, can be associated with the development of hypercalcemia. These treatment modalities may impact calcium regulation in the body and contribute to increased levels of calcium in the blood.

  3. Non-malignant causes: Hypercalcemia can also occur due to non-cancer-related factors. These may include immobility, dehydration, excessive intake of calcium and Vitamin D, decreased levels of parathyroid hormone, and vitamin A intoxication. These factors can disrupt the normal balance of calcium in the body and lead to elevated levels.

  4. Lytic bone lesions: In some cases, hypercalcemia can be caused by lytic bone lesions. These are bone abnormalities characterized by the destruction of bone tissue. When bone lesions are present, calcium is released from the bones into the bloodstream, contributing to hypercalcemia. Additionally, there may be a decrease in the excretion of urinary calcium, further elevating calcium levels.

Signs and symptoms:

  1. General malaise: Patients with hypercalcemia may experience a general sense of discomfort, uneasiness, or fatigue.
  2. Nausea and vomiting: Hypercalcemia can cause nausea and vomiting, leading to gastrointestinal disturbances.
  3. Anorexia: Loss of appetite or decreased desire to eat can occur in individuals with hypercalcemia.
  4. Constipation: Elevated calcium levels can affect the smooth muscle contractions in the gastrointestinal tract, leading to constipation and difficulty passing stool.
  5. Bone pain: Hypercalcemia can cause bone pain, which may be localized or generalized throughout the body. This pain is often a result of the underlying bone abnormalities or metastasis.
  6. Thirst and polyuria: Increased thirst and excessive urination (polyuria) can be signs of hypercalcemia, as the body tries to eliminate excess calcium through increased fluid intake and urine output.
  7. Polydipsia: Polydipsia refers to excessive thirst, which can be experienced by individuals with hypercalcemia.
  8. Severe dehydration: Hypercalcemia can lead to dehydration due to increased fluid loss through urine and other symptoms like vomiting and decreased oral intake.
  9. Drowsiness: Excess calcium in the bloodstream can affect the central nervous system, leading to drowsiness and excessive sleepiness.
  10. Confusion and coma: Severe hypercalcemia can cause neurological symptoms, including confusion and, in extreme cases, coma.
  11. Cardiac arrhythmias: Elevated calcium levels can disrupt the normal electrical activity of the heart, leading to irregular heart rhythms or arrhythmias.
  12. Mental state changes: Hypercalcemia can affect mental functioning, leading to changes in concentration, memory, mood, and irritability.
  13. Hallucinations: In some cases, hypercalcemia can cause hallucinations, which are perceptual distortions or false sensory experiences.
  14. Jumbled speech: Speech abnormalities, such as slurred speech or difficulty finding the right words, can occur in individuals with hypercalcemia.
  15. Depression and fatigue: Hypercalcemia can contribute to feelings of depression and persistent fatigue.
  16. Patients may report visual changes: Some individuals with hypercalcemia may experience visual changes, such as blurring, double vision, or sensitivity to light.

Diagnosis and Investigations:

  1. Medical History and Physical Examination: A thorough medical history and physical examination are important in identifying potential risk factors and assessing the symptoms associated with hypercalcemia.
  2. Serum Calcium Level: Measurement of serum calcium levels is a primary diagnostic tool for hypercalcemia. A serum calcium level greater than 2.60 mmol/dL is indicative of hypercalcemia.
  3. Ionized Calcium: In some cases, measuring ionized calcium levels may provide a more accurate assessment of calcium abnormalities.
  4. Parathyroid Hormone (PTH) Level: Measuring PTH levels can help differentiate between different causes of hypercalcemia. In primary hyperparathyroidism, PTH levels are typically elevated, while in malignancy-associated hypercalcemia, PTH levels are usually suppressed.
  5. Kidney Function Tests: Assessing kidney function is important as hypercalcemia can affect renal function. Tests such as blood urea nitrogen (BUN) and creatinine levels help evaluate renal function.
  6. Serum Phosphate and Magnesium Levels: Measuring phosphate and magnesium levels can provide additional information about the underlying causes of hypercalcemia.
  7. 24-Hour Urine Calcium: Collecting a 24-hour urine sample for calcium measurement helps evaluate urinary calcium excretion and can assist in determining the cause of hypercalcemia.
  8. Imaging Studies: Imaging techniques such as X-rays, bone scans, computed tomography (CT), or magnetic resonance imaging (MRI) may be conducted to identify any bone abnormalities or metastases.
  9. Additional Investigations: Depending on the clinical presentation and suspected underlying cause, additional investigations such as complete blood count (CBC), liver function tests, measurement of serum protein electrophoresis, and assessment of vitamin D levels may be performed.

Management 

  1. Hydration: Intravenous rehydration and close monitoring are key aspects of treating hypercalcemia. Hydration helps to reverse the decrease in intravascular volume. In cases of mild hypercalcemia, rehydration with normal saline at a rate of 100-120 ml/hr is often sufficient.
  2. Medications: Bisphosphonates are commonly used to inhibit osteoclastic bone reabsorption and lower calcium levels. In cases of moderate to severe hypercalcemia, the treatment approach includes rehydration as mentioned above, followed by the administration of bisphosphonates. One example of a bisphosphonate is Pamidronate. It’s important to ensure adequate hydration before giving bisphosphonates, and the dose may need to be repeated every 3-4 weeks. However, it’s worth noting that bisphosphonates may not be readily available in resource-poor countries due to their cost.

Mild hypercalcemia

  • Step 1: Rehydrate with normal saline 100-120ml/hr.; this alone is sufficient in small number of cases.

Moderate to severe hypercalcemia

  • Step 1: as above
  • Step 2: bisphosphonates; e.g. Pamidronate, (not usually available in resource poor countries because they are expensive) Reduce calcium if given IV. Care must be taken to rehydrate the well prior to administration of bisphosphonates. The dose may need repeating 3-4 weekly.
  • Corticosteroids may lower the calcium in hematological malignancies but less effective in solid tumor. 
  • End-of-life care: In cases where bisphosphonates are not available or hypercalcemia indicates the terminal phase of the disease, the focus shifts to providing comfort and dignity to the patient.
  • Simple measures like
  • regular mouth care,
  • bowel care,
  • regular turning of the patient, 
  • effective pain and symptom control are important in ensuring a dignified and comfortable end-of-life experience.

For HCM;

Management and Care:

  1. The management of Hypercalcemia of Malignancy (HCM) may involve treating the underlying malignancy. This could include chemotherapy, radiation therapy, and/or surgery, depending on the specific cancer.
  2. Hydration: Patients should aim to consume 1 to 2 liters of fluids per day, if they can tolerate oral fluids.
  3. Fluid Replacement: For patients with moderate to severe HCM (calcium levels above 13 mg/dL), fluid replacement may be necessary to restore extracellular fluid balance. This typically involves administering 5 to 10 liters of fluid.
  4. Saline Administration: In cases of dehydration or severe hypercalcemia, the administration of saline may be required to restore volume and correct electrolyte imbalances.
  5. Corticosteroid Therapy: Patients with HCM caused by steroid-responsive tumors may benefit from corticosteroid treatment. Corticosteroids can help lower calcium levels in these cases.
  6. Symptom Management and Mobility: Management of HCM also involves addressing symptoms associated with hypercalcemia and promoting mobility. This may include medications to alleviate bone pain, such as nonsteroidal anti-inflammatory drugs (NSAIDs), and implementing strategies to improve patient comfort and mobility.
  7. Constipation Assessment and Treatment: Patients should be assessed for constipation, as it can be a common symptom of hypercalcemia. If constipation is present, appropriate measures should be taken to alleviate it.

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PALLIATIVE CARE EMERGENCIES

PALLIATIVE CARE EMERGENCIES

PALLIATIVE CARE EMERGENCIES

Palliative care emergencies refer to any sudden change in a patient’s condition that necessitates immediate and urgent intervention.

The timely and comprehensive assessment is crucial to achieve positive outcomes.

Considerations for Managing Palliative Care Emergencies:

  1. The nature of the emergency: Understanding the specific emergency at hand is essential.
  2. The general condition of the patient: Assessing the overall well-being of the patient.
  3. The stage of the disease and prognosis: Considering the patient’s disease progression and future outlook.
  4. The availability of possible treatments: Determining the treatment options accessible.
  5. The affordability of possible treatments: Considering the financial feasibility of available treatments.
  6. The likely effectiveness and toxicity of available treatments: Evaluating the potential outcomes and side effects.
  7. The patient’s wishes: Taking into account the preferences of the patient.
  8. The carer’s wishes: Considering the desires of the caregiver.

Assessment of the Emergency:

  1. Identifying the problem: It is crucial to establish an accurate diagnosis.
  2. Reversibility of the problem: Assessing if the issue can be reversed.
  3. Impact on the patient’s overall condition: Determining how resolving the problem will affect the patient’s well-being.
  4. Maintaining or improving the patient’s quality of life through active intervention: Evaluating if intervention can enhance the patient’s quality of life.
  5. Availability and affordability of the chosen treatment option: Ensuring that the desired treatment is accessible and financially viable.
  6. Patient’s preferences: Taking into account the patient’s wishes.
  7. Caregiver’s preferences: Considering the preferences of the caregiver.

Types of Palliative Care Emergencies

  1. Severe uncontrolled pain
  2. Spinal cord compression (SCC)
  3. Hypercalcaemia
  4. Haemorrhage
  5. Superior vena cava obstruction (SVCO).

Severe Uncontrolled Pain

Pain management in palliative care is of utmost importance to ensure the comfort and well-being of patients. Severe uncontrolled pain, whether it is acute or chronic( is that pain which is present for more than 3 months.), requires immediate attention and intervention. 

Understanding Acute Pain

Acute pain can be anticipatory, procedural, acute-on-chronic, or breakthrough pain. It is often associated with cancer complications and can evolve into chronic pain if left uncontrolled. Prompt management of acute pain is crucial to prevent the progression of pain and alleviate distress.

Assessment:

  1. Establishing the Possible Cause: It is essential to rapidly identify the underlying cause of the pain to determine the most appropriate analgesic intervention.
  2. Using the PQRST Approach: Assess the pain using the PQRST method, considering its location, severity, aggravating and palliative factors, and referral pattern. Numerical rating scales (NRS), visual analogue scales (VAS), or face scales (for children under 8 years) can be used to measure pain severity.
  3. Assessing Pain at Rest and During Movement: Recognize that pain intensity can vary during different activities, so evaluate pain levels independently during rest and movement.

Management:

Severe uncontrolled pain (on initial presentation or a sudden escalation of pain) is an emergency; the patient needs constant attention until pain is controlled. It is important to establish rapidly the possible cause of the pain to ensure they give the most appropriate analgesia.

Immediate goal

  • To reduce the pain and allow the patient to rest. The patient will settle enough to facilitate assessment.

Pharmacological Approach:

  1.  Initial Dose: Administer a stat dose of oral morphine, usually between 5-10mg. If the patient is already on morphine, provide a breakthrough/rescue dose equivalent to their 4-hourly dose immediately.
  2.  Assess Response: Evaluate the patient’s response to the initial dose after 30 minutes.
  3. Repeat Dose if Needed: If the pain is not relieved, repeat the same dose of morphine. 
  4. Alternative Routes: Consider subcutaneous or intravenous administration if the oral route is unavailable or ineffective.
  5.  Titration of Regular Morphine Dose: Adjust the regular morphine dose based on the patient’s response. Be prepared to increase the dose by 100% or more if necessary. 
  6. Continuous Review: Ensure regular review and consider modifying the management plan if the current intervention is not effective.

Addressing Specific Causes

Severe uncontrolled pain may arise from various sources, including:

    • Bone metastases
    • Visceral cancer
    • Thoracic cancer
    • Soft tissue and bone cancer
    • Central or peripheral nervous system involvement
    • Procedure or treatment-related factors
    • Cancer complications

Evaluate and address any specific causes contributing to the sudden escalation or exacerbation of pain.

Spinal Cord Compression

Spinal Cord Compression 

Spinal cord compression (SCC) is an emergency condition where the spinal cord is compressed, leading to neurological symptoms.

The most common cause of SCC is vertebral metastases invading the epidural space and compressing the spinal cord. It is frequently observed in advanced carcinoma, particularly in breast, lung, prostate, kidney, lymphoma, myeloma, and sarcoma cancers.

In 20% of cases, compression of the cord occurs at more than one level. The commonest site for compression is in the thoracic spine (70%), followed by the lumbar spine (20%), and cervical spine (10%). Below the level of L2 compression is the CAUDA EQUINA not the spinal cord.

Presentation

  • SCC usually presents with back pain (<90%). Typically pain is the earliest sign. It may be a bony pain due to vertebral metastases, radicular or nerve root compression, a diffuse band-like pain, or an unpleasant sensation below the level of compression. Pain is often exacerbated by straining, coughing, or sneezing.
  • Sensation of sharp shooting pains, electric shock-like sensations down the legs may also indicate spinal cord compression. Pain can usually be elicited by percussion of the vertebra within one or two vertebrae of the compression, but absence of tenderness in the presence of suggestive history doesn’t rule out the diagnosis.
  • Escalating back pains (i.e. increasing in severity rapidly) that is difficult to relieve should always raise high suspicion of SCC.
  • Following escalating back pain, weakness of the limbs tends to occur in continuing SCC. Patients often initially describe their legs as HEAVY or uncoordinated. A history of escalating back pain and heavy legs is sufficient to consider treating for SCC.

On examination

  • Tenderness over spine
  • motor weakness
  • reduced muscle tone
  • decreased rectal tone
  • decreased reflexes (early stage) and sensory loss with a level.

Investigations

  • Plain x-ray to show vertebral metastases or collapse at the appropriate level in 80% of cases. Normal x-ray doesn’t rule out the diagnosis
  • MRI (magnetic resonance imaging) is the investigation of choice when available
  • CT scan or myelograms can also be useful.
  • The single most important prognostic indicator with SCC is neurological status before initiation of treatment, i.e. the less damage the better the potential for recovery.
  • Patients with paraparesis do better than those with paraplegia, loss of sphincter control/ function is a bad prognostic sign. Recovery is more likely after lesions of cauda equine.

Management of SCC

  1. Referral for urgent radiotherapy should be made. It is usually given to a field that includes 1 or 2 vertebrae above, and below the compression.
  2. Rule out infections e.g. TB, this may delay treatment.
  3. Urgent treatment may require high dose steroids. Dexamethasone 16-24 mgs oral or IV, this will reduce the inflammation around the tumor (peri tumor edema) and the spinal cord and may improve leg weakness and will buy time before other treatments are commenced.
  4. If there is a good response to concurrent radiotherapy, dexa can be tapered down every 3 days to the smallest maintenance dose possible, lowest dose at which there is no neurological deterioration in pain control.
  5. Sometimes after RT, it’s possible to stop the steroids completely without worsening/recurrence of SCC.
  6. Titrate analgesia and if on, morphine, the dose is likely to need a substantial increase in the early stages of SCC, it should happen at the same time as using steroids and RT.
  7. Particular attention should be paid to incontinence, bowel care, and pressure areas. Patients with urine retention will require catheterization.
  8. Those with complete cord compression unresponsive to treatment and compression are likely to require enemas or manual evacuation of the rectum regularly.
  9. Helping the patient to sit up for periods and regular changing of position will prevent pressure sores/areas.
  10. Family members should be taught to care for their relative in this way.
  11. Advising both the patient and family about SCC and its effect, including a realistic assessment of the prospect of recovery, is very important.
  12. In practice, recovery will usually occur early if it is going to do so, i.e. Improvement in condition occurring within days/weeks.
  13. After weeks of immobility, recovery is increasingly unlikely, and a difficult prospect for anybody to face, it is kinder to be truthful with the patient at this stage than to suggest future recovery.
  14. Creating false hope, even when well-intended, is unfair to the patient and it often leads to huge efforts, expense (often paying for expensive physiotherapy, urging patients to try harder, etc.) and ultimately to huge frustration and disappointment when there is no improvement, despite all their efforts and promises. This may damage the relationship between you and the patient if he/she realizes hasn’t been told the truth.

PALLIATIVE CARE EMERGENCIES Read More »

ARTIFICIAL DISASTER PREVENTION PREVENTION AND CONTROL OF DISASTERS

ARTIFICIAL DISASTER PREVENTION

ARTIFICIAL DISASTER PREVENTION

Transport-Related Accidents

  1. Enforcement of Road Traffic Regulations: Strictly enforce the Road Traffic Act 1998, as amended, to ensure compliance with traffic laws. This includes monitoring speed limits, seatbelt usage, and other safety regulations to prevent accidents.

  2. Education on Safe Road Usage: Conduct comprehensive awareness campaigns to educate drivers and passengers on safe road usage. Promote responsible driving behavior, adherence to traffic rules, and the importance of defensive driving techniques.

  3. Introduction of Urban Bus Transport: Introduce efficient and reliable bus transport systems in urban centers. This encourages the use of public transportation, reducing the number of private vehicles on the roads and minimizing traffic congestion and accidents.

  4. Improved Road Infrastructure: Enhance road quality by investing in infrastructure development. Construct additional entry and exit roads for major urban centers like Kampala and improve existing road networks to accommodate increasing traffic flow and ensure safer journeys.

  5. Establishment of Emergency Facilities: Set up well-equipped hospital emergency facilities along major highways to provide immediate medical assistance in the event of accidents. This helps to reduce response time and save lives.

  6. Public/Private Partnership for Road Improvement: Encourage public/private partnerships to invest in road quality improvement and network expansion projects. This collaboration enhances the resources and expertise available for infrastructure development, leading to safer and more efficient transportation.

  7. Water Transport Safety Standards: Establish and enforce safety standards for water transport on Uganda’s major lakes. This includes implementing regulations on vessel maintenance, equipment standards, and crew training to ensure safe and secure water transportation.

  8. Supervision and Monitoring of Water Transport: Intensify supervision and monitoring of water transport systems to ensure compliance with safety regulations. Regular inspections, enforcement of licensing requirements, and training programs for boat operators contribute to safer water transport operations.

  9. Enforcement of Codes of Conduct: Enforce strict codes of conduct among staff responsible for checking and regulating transport systems. This ensures accountability, discourages corruption, and promotes a culture of safety and professionalism.

Fires
  • Institute severe measures and regulations to halt bush burning practices, imposing strict punishment through bye-laws and ordinances.
  • Ensure the installation of firefighting equipment in key locations to enable swift response in case of fire outbreaks.
  • Establish building codes that specify fire escape routes, the use of fire-resistant materials, and the implementation of fire detection systems.
  • Raise awareness among the public about the causes of fires and educate them on preventive actions to mitigate the risk of fire outbreaks.
  • Regularly inspect electrical installations to identify and rectify potential hazards that may lead to fires.
  • Conduct regular fire drills in public places and educational institutions to prepare individuals for emergency situations and ensure a prompt and efficient response.
  • Equip fire brigade institutions with the necessary resources, including training, equipment, and personnel, to effectively combat fires.
  • Establish regional fire facilities strategically located to address emerging fire-related challenges in different areas.
  • Develop partnerships with companies, organizations, and institutions that possess relevant firefighting equipment and rescue facilities to enhance the firefighting capabilities across the country.
Fire Safety Measures

Before a Fire:

  1. Install smoke alarms throughout your residence. These devices significantly reduce the likelihood of fatalities in fires. Place them on every level, outside bedrooms, at the top of stairways, and near the kitchen.
  2. Regularly test and clean smoke alarms, replacing batteries at least once a year. It’s also important to replace smoke alarms every 10 years.
  3. Maintain a record of the fire brigade’s contact information, keeping it safe and accessible to all family members.
  4. Educate people about fire prevention and escape mechanisms to ensure they are well-informed and prepared.

Escaping the Fire:

  1. Review escape routes with your family and practice evacuation drills from each room.
  2. Ensure windows are easily opened and not obstructed. Install security gratings with fire safety openings to allow for easy escape.
  3. Consider using escape ladders for multi-level residences and ensure that burglar bars and other security features can be quickly opened from the inside.
  4. Teach family members to stay low to the floor, where the air is safer, when escaping a fire.
  5. Avoid accumulating flammable materials in storage areas, regularly disposing of trash, newspapers, and other combustible items.

Dealing with Flammable Items:

  1. Never use gasoline, benzene, or similar flammable liquids indoors.
  2. Store flammable liquids in approved containers within well-ventilated storage areas.
  3. Avoid smoking near flammable liquids and properly dispose of materials soaked in these liquids in outdoor metal containers.
  4. Insulate chimneys and install spark arresters to minimize the risk of fire. Clear branches hanging above and surrounding the chimney.

Heating Sources:

  1. Exercise caution when using alternative heating sources and maintain a safe distance (at least three feet) from flammable materials.
  2. Ensure heaters are properly insulated on the floor and nearby walls. Adhere to the manufacturer’s instructions and use only designated fuel.
  3. Store ashes in a metal container away from the residence.
  4. Keep open flames away from walls, furniture, drapery, and other flammable items. Install a screen in front of fireplaces.
  5. Regularly inspect and clean heating units with the assistance of certified specialists.

Matches and Smoking:

  • Store matches and lighters out of children’s reach, preferably in a locked cabinet.
  • Avoid smoking in bed, when drowsy, or under the influence of medication. Provide smokers with deep, sturdy ashtrays and extinguish cigarette butts with water before disposal.

Electrical Wiring:

  1. Have the electrical wiring in your residence inspected by a professional electrician.
  2. Regularly check extension cords for frayed or exposed wires and loose plugs.
  3. Ensure outlets have cover plates and no exposed wiring. Avoid running wires under rugs or across high-traffic areas.
  4. Avoid overloading extension cords or outlets, and use UL-approved units with built-in circuit breakers. Ensure insulation does not come into contact with bare electrical wiring.

Additional Safety Measures:

  1. Sleep with your door closed to slow down the spread of fire and smoke.
  2. Install fire extinguishers in your residence and educate family members on their usage.
  3. Consider installing an automatic fire sprinkler system for added safety.
  4. Request a fire safety inspection from your local fire department to identify potential risks and preventive measures.
  5. Ensure buildings have access to a nearby water source.

During a Fire:

  1. If your clothes catch fire, remember to “Stop, Drop, and Roll” until the fire is extinguished. Avoid running, as it can intensify the flames.
  2. Check closed doors for heat before opening them. Use the back of your hand to assess the temperature of the door, doorknob, and cracks.
  3. Crawl low under smoke to escape, as heavy smoke and toxic gases rise to the ceiling first.
  4. Close doors behind you to slow down the spread of fire.
  5. Once you have safely exited a burning building, do not reenter.

After a Fire:

  1. If there are burn victims, promptly cool and cover their burns to prevent further injury or infection.
  2. If heat or smoke is detected when entering a damaged building, evacuate immediately.
  3. Contact your landlord if you are a tenant affected by the fire.
  4. Avoid attempting to open a safe or strongbox as they can retain intense heat. Seek professional assistance.
  5. If you need to vacate your home due to safety concerns, ask a trusted individual to watch over the property during your absence.
Environmental Pollution
Government Efforts to address Environmental Pollution.
  1. The government is actively involved in raising public awareness about the various types of environmental pollution, their effects, and the potential outcomes.
  2. Local governments have implemented plans to reduce air pollution, which include measures to restrict the use of private motor vehicles and promote the use of mass transportation systems.
  3. Local governments can also pass recycling laws to encourage the reuse of materials instead of disposing of them. For instance, in Uganda, there is a deposit-refund system for plastic bottles, incentivizing their return for reuse.
  4. National governments have enacted legislation to regulate the disposal of solid and hazardous wastes, ensuring that proper protocols are followed based on the level of hazard potential.
  5. Governments have banned the use of the dangerous pesticide DDT, except for essential purposes. Farmers have adopted alternative, less harmful pesticides to replace DDT.
  6. To control water pollution, the government has prohibited the use of lead oxide to seal water pipes.
  7. Environmental concerns have led to the formation of political parties representing these issues in many industrial nations.
  8. Governments may impose taxes on products that contribute to pollution, such as non-returnable bottles, encouraging companies to reduce pollution to maintain a positive image and consumer demand.
Scientific Efforts to Address Environmental Pollution:
  1. Scientists have developed new car engines that burn petrol more cleanly and efficiently than older engines. Additionally, researchers have created vehicles that run on clean-burning fuels like methanol and natural gas.
Agricultural Efforts to Address Environmental Pollution:
  1. Scientists are working on developing agricultural methods that require fewer fertilizers and pesticides.
  2. Many farmers practice crop rotation, alternating crops such as maize, wheat, and legumes like alfalfa and soybeans, to reduce the need for chemical fertilizers and control pests and diseases.
  3. Some farmers utilize compost and other environmentally friendly fertilizers, while others employ natural pest control methods, releasing beneficial insects or bacteria that prey upon pests.
  4. Genetically engineered plants resistant to specific pests are being developed. This approach, along with the use of natural controls, is known as integrated pest management (IPM), where chemical pesticides are used in smaller amounts and selectively.
Individual Efforts to Address Environmental Pollution:
  1. Conserving energy is crucial in reducing pollution. One effective way is to drive less, reducing air pollution and energy consumption.
  2. People can save electricity by purchasing energy-efficient light bulbs and home appliances. Additionally, alternative fuels like ethanol can be used in vehicles.
  3. Buildings with specially treated windows and good insulation require less fuel or electricity for heating and cooling, reducing energy consumption.
  4. Using fewer toxic cleaning products and properly disposing of any toxic substances can help reduce water pollution.
  5. Reducing meat consumption can contribute to decreasing pollution, as intensive farming practices associated with livestock production require large amounts of fertilizer and pesticides.
  6. Reusing products is a simple yet effective way to prevent pollution. This includes using refillable glass bottles, reusing paper or plastic bags, and engaging in recycling initiatives.
  7. Many cities and towns organize waste collection programs for recycling. Recycling materials like metal cans, glass, paper, plastic containers, and old tires saves energy, raw materials, and prevents pollution.
Internal Armed Conflicts and Internal Displacement of Persons:
  1. Maintain good governance principles and practices to ensure stability and promote peaceful coexistence within the country.
  2. Develop mechanisms for peace building and conflict management/resolution, fostering dialogue and reconciliation among conflicting parties.
  3. Implement the National IDP Policy comprehensively, providing protection, assistance, and support to internally displaced persons (IDPs) in line with established guidelines.
  4. Implement the Kampala Convention on IDPs, Refugees, and Returnees in Africa (2009), adhering to its provisions and promoting cooperation among African nations to address internal displacement.
  5. Implement other relevant conventions and treaties on forced displacement, integrating their principles and recommendations into national policies and practices.
  6. Establish and enhance conflict early warning systems, utilizing technology and intelligence to identify potential conflicts and intervene proactively to prevent escalation.
  7. Control the movement and proliferation of small arms and light weapons, implementing effective regulations and enforcement measures to minimize their availability and use in conflicts.
  8. Conduct disarmament programs and ensure the safe destruction of illegal ammunition, reducing the arsenal of weapons that can fuel internal armed conflicts.
  9. Strengthen community policing initiatives, empowering local law enforcement to maintain peace, protect communities, and prevent and address conflicts at the grassroots level.
  10. Integrate and provide vocational skills training to veteran warriors, offering them alternative livelihood opportunities and reintegrating them into society as productive members, reducing the likelihood of renewed conflict.
Mines and Unexploded Ordnances (UXOs):
  1. Map out mine/UXO contaminated areas to identify the extent and locations of these hazardous devices, enabling effective planning and targeted action.
  2. De-mine contaminated areas through systematic removal and disposal of mines and UXOs, ensuring the safety of communities and enabling the return of affected areas to productive use.
  3. Undertake risk education for the affected communities, raising awareness about the dangers of mines and UXOs, educating people on how to identify and avoid them, and promoting safe behavior to prevent accidents.
  4. Develop and implement victim support systems, providing medical, psychological, and social assistance to individuals who have been affected by mines and UXOs, including survivors, their families, and communities.
  5. Conduct the destruction of stockpiles of dangerous arms and ammunitions, ensuring that obsolete, unstable, or surplus devices are safely disposed of to eliminate the risk of accidental explosions or misuse.
  6. Advocate for and maintain the ban on the use, manufacture, and transfer of mines, actively supporting international agreements and conventions aimed at reducing the proliferation and impact of these deadly weapons.
  7. Develop mine/UXO information and teaching manuals, providing comprehensive guidance and resources for mine clearance operations, risk education campaigns, and victim support initiatives, facilitating effective knowledge sharing and capacity building.
Land Conflicts:

Land conflicts, which result in loss of life, displacement, and property loss, require concerted efforts to promote peace and resolve disputes. The following policy actions can help mitigate the impact of land conflicts:

  1. Undertake awareness creation to educate communities about land rights, legal procedures, and peaceful resolution of disputes, fostering a culture of dialogue and understanding.
  2. Develop a comprehensive land use policy that clearly outlines land ownership, allocation, and utilization guidelines, ensuring transparency and fairness in land management.
  3. Promote peace building and conflict management mechanisms that facilitate dialogue, mediation, and negotiation among conflicting parties, aiming to find mutually beneficial solutions and prevent violence.
  4. Build the capacity of land actors, including government officials, community leaders, and legal professionals, by providing training and resources on land governance, conflict resolution, and the application of relevant laws.
Terrorism:

To counter the risks associated with terrorism and ensure the safety and security of communities, the following policy actions can be implemented:

  1. Create community awareness on the risk of terrorism by conducting education campaigns, disseminating information about potential threats, and promoting vigilance and reporting suspicious activities.
  2. Strengthen community policing by enhancing collaboration and communication between law enforcement agencies and local communities, fostering a sense of shared responsibility and proactive engagement in maintaining security.
  3. Conduct regular inspection and monitoring of borders and entry points into the country to prevent illegal activities and unauthorized entry of potential threats, employing technology and intelligence-sharing to enhance border security.
  4. Develop anti-terrorist media campaigns to counter extremist ideologies, promote tolerance, and debunk misinformation, utilizing various media platforms to reach a wide audience and promote community resilience against terrorism.
  5. Implement a national identity card policy to enhance identity verification, facilitate law enforcement efforts, and improve border control measures.
Industrial and Technological Hazards:

As Uganda pursues agricultural modernization and industrialization, it is crucial to prioritize awareness and preparedness for industrial and technological hazards. The following policy actions can be taken:

  1. Develop a comprehensive policy framework and monitoring system for the location of industrial parks, fuel stations, factories handling hazardous materials, and waste disposal facilities, ensuring adherence to safety standards and minimizing risks.
  2. Enforce proper urban planning standards to ensure the safe integration of industrial installations and residential areas, minimizing the exposure of communities to potential hazards.
  3. Address air polluting emissions by implementing regulations, monitoring mechanisms, and emission control technologies to reduce pollution from industrial activities.
  4. Enforce standards on the age and number of vehicles and machinery used in industrial operations to ensure their safety and minimize the risk of accidents.
  5. Establish and enforce standards on the age and quality of food processing machinery, promoting safe food production practices and minimizing contamination risks.
  6. Enforce standards on the importation, storage, and handling of human and animal drugs, as well as medical equipment, to ensure their quality, safety, and proper disposal.
  7. Strengthen supervision and monitoring of mechanical facilities, including factories, construction sites, and processing plants, to identify and address potential hazards in a timely manner.
  8. Enforce safety standards and codes in mechanical facilities, including the use of personal protective equipment, regular equipment maintenance, and adherence to safety protocols, to prevent accidents and protect workers’ well-being.
  9. Enforce laws on inspection and licensing of industrial plants, ensuring compliance with safety regulations and standards.
  10. Implement a screening process to assess the competence of engineering firms and personnel involved in engineering industries, promoting professionalism and adherence to safety practices.

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