姑息關(guān)懷中的皮膚護(hù)理課件

1、姑息關(guān)懷中的皮膚護(hù)理Skin care in palliative care Dr. Z. ZyliczHospice in the WealdPembury, Tunbridge Wells, UK皮膚護(hù)理 Skin care 放射治療過(guò)程中的皮膚護(hù)理 skin care during radiotherapy 皮膚瘙癢 / 瘙癢癥 itchy skin / pruritus 蕈狀瘤，出血 fungating cancer, bleeding 患處疼痛 painful wounds某些因素可加劇放療后皮膚反應(yīng)，包括： There are some things that can make t

2、he skin reactions to radiotherapy more severe. These include: 在接受放療前曾行化療，或放化療同時(shí)進(jìn)行 having chemotherapy before or at the same time as radiotherapy 體重超重 being overweight 合并其它疾病 （如糖尿?。?having other health problems such as diabetes光敏感膚質(zhì) having sun-damaged skin 吸煙 Smoking化療期間的皮膚護(hù)理Skin care during radiothe

3、rapy有證據(jù)表明以下措施可以幫助減低皮膚反應(yīng)的嚴(yán)重程度 there is evidence that the following activities can help to reduce the severity of skin reactions: 選用溫和的皂性溶液或清潔劑清洗皮膚 Wash: with a mild soap or cleansing agent 使用溫和的的潤(rùn)膚霜增加皮膚濕度 Moisturise: with a light moisturising cream為了緩解癥狀病人能做些什么？ What can patient do to relieve symptom

4、s? 如果皮膚出現(xiàn)發(fā)紅，發(fā)癢，變干，起水皰，醫(yī)生（或護(hù)士）建議使用乳劑涂搽并加以敷料覆蓋患處，以緩解癥狀，使病人感覺(jué)更舒適。 if skin becomes red and dry, itchy, or develops blisters, the doctor or nurse can recommend creams and dressings to help reduce your symptoms and make the patient more comfortable.對(duì)照組Control patientsn= 25試驗(yàn)組Skin moistured with 3% urea lo

5、tion, n=6350%病人出現(xiàn)I度皮膚損害50 % of patients with grade I damage 22 Gy26 Gy50%病人出現(xiàn)II度皮膚損害50% of patients with grade II damage34 Gy51 Gy出現(xiàn)III度皮膚損傷的病人的百分比% of patients suffering grade III damage56%22%選用3%尿素洗液作為增濕劑用于皮膚保護(hù)Skin protection by moisturing with 3% urea lotionMomm F et al. 2003瘙 癢 癥Pruritus = itch癌

6、癥相關(guān)的瘙癢癥狀Pruritic syndromes associated with cancer 膽汁淤積（胰源性，膽管癌，轉(zhuǎn)移性肝癌） cholestasis (pancreatic, bile-duct cancer, liver mets)皮膚轉(zhuǎn)移癌（乳腺癌） cutaneous mets (breast cancer)副癌綜合征 Paraneoplastic合并皮膚病（類(lèi)天皰瘡） with dermatosis (parapemphigus) 不合并皮膚病 without dermatosis 瘙癢是全身性癌病罕見(jiàn)而重要的癥狀Pruritus, an uncommon but imp

7、ortant symptom of systemic carcinomaCormia FE. Arch Dermatol 1965;92:36-39. 肺癌 Lung乳腺癌 Breast 胃癌 Stomach 前列腺癌 Prostate 子宮腫瘤 Uterus 結(jié)腸癌 Colon 鼻咽癌 Nasopharynx 一名72歲的老年女性乳腺癌患者，7年前曾接受過(guò)乳癌手術(shù)治療。現(xiàn)因腫瘤皮內(nèi)擴(kuò)散，而飽受極度疼痛和瘙癢的折磨。 Woman, 72 years of age, intracutaneous spread of breast cancer. Originally treated with s

8、urgery 7 years earlier. She experienced extreme pain and pruritus. 疼痛Pain 瘙癢Itch_ H O Handwerker疼痛 Pain 瘙癢 Itch內(nèi)源性阿片類(lèi)endogeneousOpioids+_ H O Handwerker疼痛 Pain 瘙癢Itch內(nèi)源性阿片類(lèi)endogeneousOpioids+_ H O Handwerker椎管內(nèi)注射阿片類(lèi)藥物： Spinaopioids節(jié)段性或全身性； segmental or generalised;機(jī)理 ： mechanisms: 局部興奮（5-HT）或激活2受體 l

9、ocal excitation (5-HT) or stimulation of 2receptors PGE ?治療 ： treatment: 5-HT3 拮抗劑 5-HT3 antagonists 異丙酚 Propofol 2受體拮抗劑 2 antagonism ?雙氯芬酸 diclofenac全身性應(yīng)用阿片類(lèi)藥物 Systemic opioids:全身性 ； generalised; 機(jī)理 ： mechanisms: 非阿片類(lèi)藥物依賴(lài)的組胺釋放，特異質(zhì)反應(yīng)，或阿片類(lèi)藥物介導(dǎo)的 opioid-independent histamine release, idiosyncratic reac

10、tion or opioid-mediated 治療： treatment: H 1受體拮抗劑 H1 receptor antagonist 阿片類(lèi)受體通道調(diào)節(jié)劑 opioid switch ?5-HT3 拮抗劑 5-HT3 antagonists,SSRI阿片類(lèi)藥物誘發(fā)的瘙癢 Opioid induced pruritus帕羅西汀治療瘙癢癥Paroxetine for pruritus初始劑量 5 -10 mg, 可增加到20mg qd, 與早飯同服 start with 5 or 10 mg, increase to 20 mg o.d. with breakfast如服藥后出現(xiàn)惡心，可加

11、服恩丹西酮4mg，連用數(shù)天 for early nausea add ondansetron 4 mg for few days瘙癢癥病人服用帕羅西汀后更容易出現(xiàn)惡心、鎮(zhèn)靜等副作用 in pruritic patients side effects of paroxetine appear more often (nausea, sedation)即使疾病進(jìn)展或停止病因性治療，作用仍可持續(xù)幾個(gè)星期 The effect may last for a few weeks if disease will progress or causal treatment will be discontinu

12、ed. Zylicz et al. 2003帕羅西汀治療瘙癢癥的臨床證據(jù)（1） Clinical evidence on paroxetine (i) 對(duì)抗瘙癢癥狀起效迅速 Works rapidly against pruritus藥效可持續(xù)到停藥4-8周以后 effect weans after 4-8 weeks服藥后患者多出現(xiàn)精神性惡心和嘔吐 more nausea and vomiting seen then in psychiatry部分副反應(yīng)類(lèi)似于阿片類(lèi)藥物撤藥綜合征的表現(xiàn) part of the side effects similar to opioid abstinence

13、 syndrome對(duì)各種類(lèi)型的瘙癢癥均有效 effect not selective to one type of pruritus帕羅西汀治療瘙癢癥的臨床證據(jù)（2） Clinical evidence on paroxetine (ii)帕羅西汀的治療反應(yīng)和其所致副反應(yīng)是相伴出現(xiàn)的 Patients without adverse effects do not show antipruritic effect5羥色氨3受體拮抗劑可以迅速中止惡心和嘔吐癥狀 5-HT3 antagonists able immediatly to block nausea and vomiting米氮平和帕羅西

14、汀聯(lián)用對(duì)治療有協(xié)同作用 combination of mirtazapine and paroxetine has positive effect瘙癢癥治療中的一般處理General measures in pruritus第一步Step 1第二步Step 2第三步Step 3糾正可逆因素例如：治療皮膚病變Correct the correctable, e.g. treat skin disorders使用潤(rùn)膚劑q.d. t.i.d.Emollient cream o.d. t.id.口服鎮(zhèn)靜劑每天兩次 如：苯唑安定或服用具有鎮(zhèn)靜作用的H1受體拮抗劑 如：撲爾敏 4mg 每天三次 Cb.d.

15、Sedative, e.g. benzodiazepine or sedative H1antihistamine e.g. chlorphenamine 4mg t.d.s. C尿毒癥性瘙癢的治療Uraemic pruritus第一步Step 1第二步Step 2第三步Step 3行紫外光療 A 或 （如為 局限性）予0.025-0.075%辣椒堿軟膏局部使用 q.d.b.i.d. AUVB phototherapy A or (if localised) capsaicin cream 0.025-0.075% o.d.-b.d. A納曲酮 50mg q.d. ANaltrexone 50

16、mg o.d. A反應(yīng)停 100mg q.n. AThalidomide 100mg o.n. A膽汁淤積性瘙癢的治療Pruritus of cholestasis第一步Step 1第二步Step 2第三步Step 3納曲酮 12.5-250mg q.d. ANaltrexone 12.5-250mg o.d. A利福平 75-300mg q.d. A或 帕羅西汀5-20mg q.d. ARifampicin 75-300mg o.d. A or paroxetine 5-20mg o.d. A 甲基睪丸酮 25mg 含化 q.d. C或其它同類(lèi)藥物 如：達(dá)那唑 200mg q.d. t.i.

17、d. UMethyltestosterone 25mg SL o.d. C oralternative, e.g. danazol 200mg o.d.-t.d.s. U何杰金病所致瘙癢的治療Hodgkin lymphoma第一步Step 1第二步Step 2第三步Step 3甲基強(qiáng)的松龍 10-20mg t.i.d. CPrednisolone 10-20mg t.d.s. C西米替丁 800mg/24h BCimetidine 800mg/24h B米氮平 15-30mg q.n. UMirtazapine 15-30mg o.n. U真性紅細(xì)胞增多癥所致瘙癢的治療Polycythaemi

18、a vera第一步Step 1第二步Step 2第三步Step 3阿司匹林 100-300mg q.d. AAspirin 100-300mg o.d. A帕羅西汀 5-20mg q.d. AParoxetine 5-20mg o.d. A鎮(zhèn)靜劑 如 苯唑安定 CSedative, e.g. benzodiazepine C椎管內(nèi)注射阿片類(lèi)藥物所致瘙癢的治療Spinal opioid-induced pruritus第一步Step 1第二步Step 2第三步Step 3鞘內(nèi)注射布比卡因 ABupivacaine intrathecal A NSAID: 雙氯芬酸 100mg 直腸給藥或替諾昔康

19、 20mg 靜脈用藥 ANSAID: diclofenac 100mg PR A or tenoxicam 20mg IV A 恩丹西酮 8mg 靜脈立即用藥 AOndansetron 8mg IV stat A 痛性傷口的治療Painful woundsC型纖維上可能存在阿片類(lèi)受體C-fibres may contain opioid receptorsC. Stein 1995一位82歲的老年患者，因動(dòng)脈血供不足，導(dǎo)致多處皮損，出現(xiàn)局部缺血性疼痛82 years old, poor arterial supply. Multiple wounds, ischaemic pain經(jīng)過(guò)0.1%

20、嗎啡的局部治療，她的疼痛得到緩解，以上治療同時(shí)也促進(jìn)了她皮損的愈合。在我們拍下上面第二張照片的兩周后，她不幸因敗血癥去逝。This patient was treated with topical morphine, 0,1%. This eased her pain and eased wound healing. Unfortunately she died of sepsis two weeks after the second photo. 痛性傷口的其他治療方案Other options for the treatment of wound pain1-2%利多卡因局部治療 Topi

21、cal lignocaine 1-2%如皮損處并發(fā)感染，應(yīng)全身性使用抗生素抗感染 Systemic antibiotics if wound infected如皮損處并發(fā)厭氧菌感染，需采用0.75%滅滴靈局部治療 Topical metronidazol 0,75% if wound infected with anaerobic bacteria皮損出血的處理Wound bleeding局部按壓止血 Compression抗感染治療（抗生素應(yīng)用） Treating infection (antibiotics)患者需行凝血功能檢查 Check blood coagulation尋找皮損的原因

22、 Is there anything damaging skin?在皮損周?chē)】档钠つw上涂抹氧化鋅 Use zinc oxide on the healthy skin around the wound皮損處可行環(huán)卡普隆酸局部治療 Topical cyclocaprone acid can be used 異味皮損的處理Smelling wound必要時(shí)全身性使用抗生素抗感染治療 Use systemical antibiotics if necessary全身性應(yīng)用滅滴靈 250mg t.i.d. Systemic metronidazol 250 mg t.d.s.0.75%滅滴靈局部治療 Topical metronidazol 0,75%用自來(lái)水清洗患處（淋?。?Cleaning wounds with tapwater (shower)對(duì)房間內(nèi)異味的處理 Take care of the smell in the room:除臭劑使用 Deodorants咖啡 Coffee保持房間通風(fēng)良好 Ventilation結(jié)論（1） Conclusions (i)對(duì)放療病人進(jìn)行良好的護(hù)理對(duì)提高患者的生活質(zhì)量是至關(guān)重要的，可使更多的患者能順利完成整個(gè)治療期。