姑息关怀中的皮肤护理.ppt

姑息关怀中的皮肤护理Skincareinpalliativecare,Dr.Z.ZyliczHospiceintheWealdPembury,TunbridgeWells,UK,皮肤护理Skincare,放射治疗过程中的皮肤护理skincareduringradiotherapy皮肤瘙痒/瘙痒症itchyskin/pruritus蕈状瘤，出血fungatingcancer,bleeding患处疼痛painfulwounds,某些因素可加剧放疗后皮肤反应，包括：Therearesomethingsthatcanmaketheskinreactionstoradiotherapymoresevere.Theseinclude:,在接受放疗前曾行化疗，或放化疗同时进行havingchemotherapybeforeoratthesametimeasradiotherapy体重超重beingoverweight合并其它疾病（如糖尿病）havingotherhealthproblemssuchasdiabetes光敏感肤质havingsun-damagedskin吸烟Smoking,化疗期间的皮肤护理Skincareduringradiotherapy,有证据表明以下措施可以帮助减低皮肤反应的严重程度thereisevidencethatthefollowingactivitiescanhelptoreducetheseverityofskinreactions:选用温和的皂性溶液或清洁剂清洗皮肤Wash:withamildsoaporcleansingagent使用温和的的润肤霜增加皮肤湿度Moisturise:withalightmoisturisingcream,为了缓解症状病人能做些什么？Whatcanpatientdotorelievesymptoms?,如果皮肤出现发红，发痒，变干，起水疱，医生（或护士）建议使用乳剂涂搽并加以敷料覆盖患处，以缓解症状，使病人感觉更舒适。ifskinbecomesredanddry,itchy,ordevelopsblisters,thedoctorornursecanrecommendcreamsanddressingstohelpreduceyoursymptomsandmakethepatientmorecomfortable.,选用3%尿素洗液作为增湿剂用于皮肤保护Skinprotectionbymoisturingwith3%urealotionMommFetal.2003,瘙痒症Pruritus=itch,瘙痒症的分类ClassificationofItch,周围性Peripheral皮肤性（瘙痒感受性的）cutaneous(pruritoceptive)神经病性，例如多发性硬化，神经损伤neuropathic,e.g.MS,nervedamage中枢性Central神经病性，例如脑脓肿/脑肿瘤neuropathic,e.g.brainabscess/tumour神经源性，例如服用阿片类药物，胆汁淤积neurogenic,e.g.opioid,cholestasis精神性Psychogenic混合性Mixed尿毒症性Uraemic,Twycrossetal.2003,术语Terminology,神经病性瘙痒：指瘙痒感源于皮肤感受性发生改变的区域，通常是由于局部神经结构遭破坏而引起。neuropathicpruritus:pruritusexperiencedintheareaofchangedsensitivity,usuallybydamageoftheneuralstructure神经源性瘙痒症：指由能够干扰痒觉传导及神经系统功能的瘙痒介质所致瘙痒症neurogenicpruritus:prurituscausedbypruriticmediatorsinterferingwithitchtransmissionandthefunctioningofthenervoussystem,癌症相关的瘙痒症状Pruriticsyndromesassociatedwithcancer,胆汁淤积（胰源性，胆管癌，转移性肝癌）cholestasis(pancreatic,bile-ductcancer,livermets)皮肤转移癌（乳腺癌）cutaneousmets(breastcancer)副癌综合征Paraneoplastic合并皮肤病（类天疱疮）withdermatosis(parapemphigus)不合并皮肤病withoutdermatosis,瘙痒是全身性癌病罕见而重要的症状Pruritus,anuncommonbutimportantsymptomofsystemiccarcinomaCormiaFE.ArchDermatol1965;92:36-39.,肺癌Lung乳腺癌Breast胃癌Stomach前列腺癌Prostate子宫肿瘤Uterus结肠癌Colon鼻咽癌Nasopharynx,一名72岁的老年女性乳腺癌患者，7年前曾接受过乳癌手术治疗。现因肿瘤皮内扩散，而饱受极度疼痛和瘙痒的折磨。Woman,72yearsofage,intracutaneousspreadofbreastcancer.Originallytreatedwithsurgery7yearsearlier.Sheexperiencedextremepainandpruritus.,恶性肿瘤引起的神经源性瘙痒(1)Neurogenicpruritusinmalignancy(i),疱疹后瘙痒症LiddellK.Post-herpeticpruritus.BrMedJ1974;4:165.前列腺癌可表现为阴囊及会阴区的持续性瘙痒Canceroftheprostatemaymanifestbypersistentitchingatthescrotalandperinealregion大脑肿瘤可引起鼻孔区的瘙痒Pruritusofthenostrilsisassociatedwithbraintumours.,恶性肿瘤引起的神经源性瘙痒(2)Neurogenicpruritusinmalignancy(ii),有报道表明宫颈癌患者可出现外阴瘙痒Pruritusvulvaehavebeenreportedinpatientswithcarcinomaofthecervix直肠，乙状结肠，结肠癌可以伴发肛门区瘙痒pruritusanimayaccompanyrectal,sigmoidorcoloncancer,造血系统疾病Hematopoieticdisorders,（真性红细胞增多症）Policythemiavera58%（何杰金氏病）Hodgkinsdisease5-10%（蕈样真菌病）mycosisfungoides100%（塞扎里综合征）Sezarysyndrome100%（多发性骨髓瘤偶尔发生瘙痒）myelomamultiplexoccasionally（瓦氏巨球蛋白血症）Waldenstrommacroglobulinaemia（良性r球蛋白病偶尔发生）benigngammopathy,occasionally（肥大细胞增多症偶尔发生）Mastocytosis,occasionally（缺铁偶尔发生）irondefficiency,occasionally,疼痛Pain,瘙痒Itch,HOHandwerker,疼痛Pain,瘙痒Itch,内源性阿片类endogeneousOpioids,HOHandwerker,疼痛Pain,瘙痒Itch,内源性阿片类endogeneousOpioids,HOHandwerker,椎管内注射阿片类药物：Spinaopioids节段性或全身性；segmentalorgeneralised;机理：mechanisms:局部兴奋（5-HT）或激活2受体localexcitation(5-HT)orstimulationof2receptorsPGE?治疗：treatment:5-HT3拮抗剂5-HT3antagonists异丙酚Propofol2受体拮抗剂2antagonism?双氯芬酸diclofenac,全身性应用阿片类药物Systemicopioids:全身性；generalised;机理：mechanisms:非阿片类药物依赖的组胺释放，特异质反应，或阿片类药物介导的opioid-independenthistaminerelease,idiosyncraticreactionoropioid-mediated治疗：treatment:H1受体拮抗剂H1receptorantagonist阿片类受体通道调节剂opioidswitch?5-HT3拮抗剂5-HT3antagonists,SSRI,阿片类药物诱发的瘙痒Opioidinducedpruritus,瘙痒的潜在化学介质（1）Potentialchemicalmediatorsofpruritus(i),氨类：组胺，五羟色氨，多巴胺，肾上腺素，去甲肾上腺素，N-乙酰-5-氧基色胺Amines:histamine,serotonin,dopamine,adrenaline,noradrenaline,melatonin蛋白酶类：纤维蛋白溶酶，糜蛋白酶，羟肽酶，木瓜蛋白酶，激肽释放酶Proteases:tryptases,chymases,carboxypeptidases,papain,kallikrein神经肽类：降钙素基因相关蛋白，缓激肽，内皮素，神经激肽A&B，生长抑素，血管活性肠肽，胆囊收缩素，-&-促黑色素，神经降压素，蛙皮素等Neuropeptides:SP,CGRP,bradykinin,endothelin,neurokininA&B,somatostatin,CRF,VIP,CCK,-&-MSH,neurotensin,bombesin,others,瘙痒的潜在化学介质（2）Potentialchemicalmediatorsofpruritus(ii),阿片类药物：蛋氨酸脑啡肽，亮氨酸脑啡肽，-内啡肽，吗啡Opioids:met-enkephalin,leu-enkephalin,-endorphin,morphine二十烷类：前列腺素E2,H2，和其他前列腺素家族成员，白三烯B4，及其他白三烯家族成员Eicosanoids:PGE2,PGH2,otherPGs,LTB4,otherLTs生长因子类Growthfactors细胞因子：白细胞介素-1到-10，肿瘤坏死因子-，-，嗜酸性粒细胞产物Cytokines:Il-1toIL-11,TNF-&TNF-,eosinophilproducts,润滑剂Emolients,无活性成分Noactiveingredients减轻皮肤干燥的一系列产品Groupofproductsreducingskindryness皮肤湿化剂-主动将水分转运入表皮（1950年初）Hydrationpreparationsactivetransportofwaterintotheepidermis(early1950)最大疗效持续时间0.5-1小时Maximaleffect0.5-1h疗效短于4小时Effectnolongerthan4hours,帕罗西汀治疗瘙痒症Paroxetineforpruritus,初始剂量5-10mg,可增加到20mgqd,与早饭同服startwith5or10mg,increaseto20mgo.d.withbreakfast如服药后出现恶心，可加服恩丹西酮4mg，连用数天forearlynauseaaddondansetron4mgforfewdays瘙痒症病人服用帕罗西汀后更容易出现恶心、镇静等副作用inpruriticpatientssideeffectsofparoxetineappearmoreoften(nausea,sedation)即使疾病进展或停止病因性治疗，作用仍可持续几个星期Theeffectmaylastforafewweeksifdiseasewillprogressorcausaltreatmentwillbediscontinued.,Zyliczetal.2003,帕罗西汀治疗瘙痒症的临床证据（1）Clinicalevidenceonparoxetine(i),对抗瘙痒症状起效迅速Worksrapidlyagainstpruritus药效可持续到停药4-8周以后effectweansafter4-8weeks服药后患者多出现精神性恶心和呕吐morenauseaandvomitingseentheninpsychiatry部分副反应类似于阿片类药物撤药综合征的表现partofthesideeffectssimilartoopioidabstinencesyndrome对各种类型的瘙痒症均有效effectnotselectivetoonetypeofpruritus,帕罗西汀治疗瘙痒症的临床证据（2）Clinicalevidenceonparoxetine(ii),帕罗西汀的治疗反应和其所致副反应是相伴出现的Patientswithoutadverseeffectsdonotshowantipruriticeffect5羟色氨3受体拮抗剂可以迅速中止恶心和呕吐症状5-HT3antagonistsableimmediatlytoblocknauseaandvomiting米氮平和帕罗西汀联用对治疗有协同作用combinationofmirtazapineandparoxetinehaspositiveeffect,瘙痒症治疗中的一般处理Generalmeasuresinpruritus,尿毒症性瘙痒的治疗Uraemicpruritus,胆汁淤积性瘙痒的治疗Pruritusofcholestasis,何杰金病所致瘙痒的治疗Hodgkinlymphoma,真性红细胞增多症所致瘙痒的治疗Polycythaemiavera,椎管内注射阿片类药物所致瘙痒的治疗Spinalopioid-inducedpruritus,全身性阿片类药物应用所致瘙痒的治疗Systemicopioid-inducedpruritus,副癌性瘙痒的治疗Paraneoplasticpruritus,痛性伤口的治疗Painfulwounds,C型纤维上可能存在阿片类受体C-fibresmaycontainopioidreceptors,C.Stein1995,一位82岁的老年患者，因动脉血供不足，导致多处皮损，出现局部缺血性疼痛82yearsold,poorarterialsupply.Multiplewounds,ischaemicpain,经过0.1%吗啡的局部治疗，她的疼痛得到缓解，以上治疗同时也促进了她皮损的愈合。在我们拍下上面第二张照片的两周后，她不幸因败血症去逝。Thispatientwastreatedwithtopicalmorphine,0,1%.Thiseasedherpainandeasedwoundhealing.Unfortunatelyshediedofsepsistwoweeksafterthesecondphoto.,痛性伤口的其他治疗方案Otheroptionsforthetreatmentofwoundpain,1-2%利多卡因局部治疗Topicallignocaine1-2%如皮损处并发感染，应全身性使用抗生素抗感染Systemicantibioticsifwoundinfected如皮损处并发厌氧菌感染，需采用0.75%灭滴灵局部治疗Topicalmetronidazol0,75%ifwoundinfectedwithanaerobicbacteria,皮损出血的处理Woundbleeding,局部按压止血Compression抗感染治疗（抗生素应用）Treatinginfection(antibiotics)患者需行凝血功能检查Checkbloodcoagulation寻找皮损的原因Isthereanythingdamagingskin?在皮损周围健康的皮肤上涂抹氧化锌Usezincoxideonthehealthyskinaroundthewound皮损处可行环卡普隆酸局部治疗Topicalcyclocaproneacidcanbeused,异味皮损的处理Smellingwound,必要时全身性使用抗生素抗感染治疗Usesystemicalantibioticsifnecessary全身性应用灭滴灵250mgt.i.d.Systemicmetronidazol250mgt.d.s.0.75%灭滴灵局部治疗Topicalmetronidazol0,75%用自来水清洗患处（淋浴）Cleaningwoundswithtapwater(shower)对房间内异味的处理Takecareofthesmel