Post on 18-Dec-2014
description
CLINICAL REVIEW FOR THE
GENERALIST HOSPICE & PALLIATIVE NURSE
Symptom Management
WEEK 3
Nat’l. Consensus Project
Clinical Practice Guidelines of Qual. Pall. Care Domain 2—
Physical Aspect of Care Guideline 2.1—Pain,
other symptoms, and side effects are managed, based on the best available evidence, . . .
Common EOL Symptoms
1. Anorexia/Cachexia2. Dehydration3. Nausea/Vomiting4. Bowel Obstruction5. Constipation6. Diarrhea
8. Anxiety9. Depression10. Dyspnea11. Noisy Respirations12. Fatigue13. Pressure Ulcers
For each symptom, we will look at:
ETIOLOGY, ASSESSMENT, NON-PHARM. + PHARM. TREATMENTS, AND PT./FAM. TEACHING.
1. Anorexia/Cachexia
Anorexia—loss of appetite
Cachexia—wt. loss, wasting, loss of muscle, fat, bone minerals, marked by weakness, emaciation (occurs in 80% of Ca. pts., kills 20% of them)
2 May be a mutually re-inforcing cycle
ETIOLOGY (reason): Treatment-Related
Meds., chemo., XRT Disease-Related
Infxn., delayed gast. emptying, metabolic ch., N/V, dysphagia
P/S or spiritual distress Depression
Non-Pharm. Interventions for Anorexia/Cachexia
Encourage pts. to eat what they like
Refer to Dietician Encourage small, frequent
meals Avoid strong odors Encourage supplements Enteral/Parenteral
feedings may be appropriate
Class of drug Examples Comments
Gastrokinetic agents Metoclopramide (Reglan)
Useful w/ c/o nausea + early satiety (“I feel full”)
Corticosteroids Dexamethasone(Decadron)
Effective in short-term (w/side effects)
Progesterone Analogs (hormonal treatment)
Megestrol acetate(Megace)
Somewhat effective for some pts. (expensive)
Cannabinoids Dronabinol(Marinol)
Effective in low doses
Alcohol Beer or sherry May improve appetite + morale in some pts.
Vitamins Multivits., Vit. C Anecdotal evidence for improved appetite (placebo?)
Pharmacologic Interventions for Anorexia/Cachexia
Pt./Family Education
Support pt’s. wishes Discuss intake during dying process Explore the meaning of food to family
(love, health, togetherness) Address emotional needs Re-direct caring activities (tell stories,
use lotion for massage, look at photos together)
2. Dehydration
EtiologyNormal physiology at EOL
desire for fluids
Fasting/vomiting/ diarrhea
Fever
Over-use of diuretics
3rd spacing
Assessment Mental status ch. I/O (< 400ml/day) Poor skin turgor
(tenting) Wt. loss Skin/mouth Postural hypotension Lab Values (?)
Third-Spacing
Extracellular fluid is normally found in Interstitial or intravascular spaces.
Sometimes, with diseased states, it collects in “THIRD-SPACES” (ascites, pleural effusion, etc.
Pt. is often intravascularly dehydrated, while fluid collects in “third spaces”.
Treatments
Non-Pharm.
Oral Fluids/sports drinks
Review of disease trajectory
Facilitating discussion of benefits v. burdens
Pharm. Proctolysis (w/NGT) Hypodermoclysis IVF
Monitor for over-hydration (swelling, sob, etc.)
Good mouth care q2 (swab w/water or dilute mouthwash, lip balm)
Ice chips/popsicles
Family Teaching: Dehydration
Teaching about normal process of dehydration
Correcting misperceptions about dehydration Painful? Needs to be corrected? Should be corrected?
3. Nausea & Vomiting
Etiology
•Disease-Related
• GI (constip., B.O.)• Metabolic (uremia,
calcemia) • CNS (vertigo, brain mets.)
•Treatment-Related
• Chemo (CTZ)• Opioids (slow gastric
emptying, may resolve-3days)
Assessment Pt’s subjective
report
Non-Pharmacological Treatments
Drink clear or ice-cold drinks
Eat light, bland foods
Avoid fried, greasy, or sweet foods
Eat small, frequent meals
Eat and drink slowly
Cool Cloth to face
Mouth Care
Fresh air/Fan
Pharmacological Treatments
Cause TreatmentSlow gastric emptying Prokinetic agent (Metoclopramide,
Domperidone)
Chemical (opioid side-effect) Haloperidol, Droperidol
Vestibular (vertigo, dizziness)
Antihistamine (Dimenhydrinate/dramamine)
Motion sickness Anticholinergic (scopolamine, hysoscyamine/Levsin)
Nausea w/anxiety Benzodiazepine (lorazepam)
Intestinal Obstruction Octreotide (sandostatin)
ICP Steroid (Dexamethasone/Decadron--in combination w/ other drugs)
Pt./Family Teaching: N/V
Assist with assessing cause
Problem-solving to treat
Family’s role
When to call provider (dehydration, not keeping anything down, pt is suffering)
4. Bowel Obstruction
Etiology
Occlusion of lumen (tumor v. fecal imp’n.)
Absence of propulsion
Metabolic disorders
Medications
Assessment
Bowel hx.
Pain on palpation
Rectal Exam
Consider location
Consider p.c. goals/disease trajectory
Treatments
Pharmacologic
OctreotideScopolamineOpioidsAnti-emeticsCorticosteroidsAnti-spasmodicLaxative/Antidiarrheal
Non-Pharmacologic
Prevention when poss.
Avoid big meals Avoid hot drinks Consider NGT/sxn.
Be Careful
DON’T give a stimulant laxative with a bowel obstruction—causes more pain
Don’t mistake liquid stool coming around an obstruction as evidence that there is not an obstruction.
Pt./Family Teaching: B.Obstruction
Review Causes Discuss Tx. Opts. Educate on prevent. Review meds. Review Diet Instruct when to call
provider
5. Constipation
Etiology Medication-related
(opiods, anticholin.)
Disease-related Cancer (tumors) Diabetes
(gastroparesis) Dehydration Inactivity/ intake
Assessment Bowel history Abdominal assessment Rectal assessment
Interventions
PharmacologicalLaxatives:
Detergent (softener/docusate) Lubricant (glycerine supp.) Stimulant (dulcolax/senna) Saline (Mag Citrate) Osmotic (latulose) Bulk-forming (miralax) Enemas (increase H2O
content Metoclopramide if indicated
Non-Pharm. Prevention! Treating med. side
effects pro-actively fluid + fiber Intervene only if
causing distress Cultural
considerations
Opioid-Induced Constipation (OIC)
Opioids bind to Mu-receptors in CNS to provide pain relief
Also bind to Mu-receptors in gut which stops peristalsis
Requires stimulant treatment (metaclopromide, dulcolax, oral erythro.)
New Drug: Relistor (methylnaltrexone)
Naloxone Relistor (naloxone w/ + charge on Nitrogen atom)
Methylnaltrexone: Treats Opioid-Induced Constipation
Binds to the same receptors as opioid analgesics (morphine, oxycodone, dilaudid, etc.)
Unable to cross blood/brain barrier due to the positive charge on its nitrogen atom.
Acts as an antagonist, blocking the GI effects of the opioid
Does not reverse the pain-killing properties
Does not cause withdrawal symptoms
Pt./Family Teaching: Constipation
Monitor bowel patterns
Encourage p.o. food/fluids
Encourage activity (oob)
Instruct when to call . . . .
6. Diarrhea
AssessmentAbdominal assessment
Blood in stool?
Dehydration?
Etiology Treatment-Related
Antibiotics Disease-Related
HIV, c. diff. Psychologically-
Related Anxiety
Treatments
Non-Pharmacologic
Clear liqs./advanceBRAT dietLow residue (fiber)diet fluidsSitz BathConsider homeopathic remedies
Pharmacologic Loperamide Opioids Bulk-forming agents
Psyllium (metamucil) Antibiotics (if
indicated) Steroids Octreotide (secretions,
slows transit time in bowel)
Pt./Family Teaching: Diarrhea
Respect level of comfort with discussion
Monitor frequency + consistency
Provide skin care
When to call . . . .
7. Anxiety
Assessment
Physical sx. Tachycardia Tremor Bowel/bladder
Cognitive Sx. Racing thoughts Insomnia
Etiology P/S, spiritual distress Uncontrolled pain Medications (steroids,
albuterol) Substance withdrawal Medical conditions
(copd)
TREATMENTS
Non-Pharmacological
Coping skills (breathing, cbt)
Reassurance/support
Counselling
Complementary Tx.
Pharmacological
Benzos (alprazolam, lorazepam)
Anti-depressants (SSRI)
Neuroleptics (haloperidol, prometh.)
Pt./Family Teaching: Anxiety
Review causes Monitor for sx. Avoid stimulation Discuss unresolved
issues Patient safety/when
to call
8. Delerium/Agitation
Infection Malignancy-related Renal/hepatic failure Metabolic causes Hypoxemia Medications (opioids,
etc.) Fecal impaction/Urinary
retention
Established Tools
Confusion Assessment Method (CAM)
Neecham Confusion Scale (NCS)
ETIOLOGY ASSESSMENT
Checklist for Assessing Checklist for Assessing Terminal AgitationTerminal Agitation
Thorough medication review (polypharm., toxicity, side effects?)
Hx/ of substance abuse Retention of urine/stool Signs of fever or sepsis Hypoxia Assess pain/suffering Assess LOC needed
(GIP/CC?)
Correcting the Causes of Delerium/Agitation
Constipation…………...
Urinary retention……...
Dehydration……………
UTI……………………..
Polypharm/ side effects
Hypoglycemia…………
Fever…………………..
Medicate/disimpact/aggressive bowel regimen
Catheterize
Consider 1L. IVF or SQ (if no overload)
Dipstick and treat if symptomatic
D/C or taper drug if appropriate
Consider glucose replacement
Consider anti-pyretics/cooling measures
Treatment
Correct underlying cause
Symptomatic/suppor-tive tx.
Consider trajectory/goals: may not be reversible—treat sx.
Neuroleptics Haloperidol
Benzos. Midazolam (Versed)
Anxiolytics Lorazepam
Atypical Antidepressants Risperidone
Non-Pharmacological Pharmacological
Pt./Family Teaching
Review medications Reassure pt./family Review symbolic
language (NDE) Careful sensory
stimulation, if indicated Instruct on re-orienting
pt.
9. DEPRESSION
Medical conditions (pain)
Treatment-related (meds.)
Psychological factors (financial, relationships)
Enduring sad mood
Hopelessness Fatigue Anhedonia Ability to make
decisions
Etiology Assessment
Screening for Depression
Tools Beck Depression Inventory Geriatric Depression Scale Hamilton Depression Scale
Ask about Mood Behavior (appetite/sleep) Cognition (slow thought, indecision)
Suicide Risk ETOH abuse Psychiatric disorder Depression
Treatments
Counseling Behavioral Cognitive Interpersonal Complementary
Tx.
SSRI’s (1st line) Tri-cyclics
(effective in 70% of pts.)
Stimulants (methylphenidate)
Steroids (appetite + mood)
Non-Pharmacologigal Interventions
Pharmacological
Pt./Family Teaching for Depression
Review signs and symptoms
Instruct on prevalence Review medications Review non-pharm.
Interventions Provide opportunity for
private conversations
10. Dyspnea
Diagnosis-related Treatment-related Pulmonary
congestion Broncho-
constriction Anemia Hyperventilation
Believe pt’s. report Not same as
tachypnea Functional status Past history Diagnostic tests
Etiology Assessment
Treatments
Fans Positioning ( HOB) Conserve energy Pursed-lip breathing Prayer Complementary tx.
Opioids Benzodiazepines (not
first-line) Diuretics, if indicated Bronchodilators, if
indicated Cortico-steroids if
indicated
Non-Pharmacological Pharmacological
Pt./Family Teaching for Dyspnea
Instruct on breathing techniques
Minimize aggravation Prevent panic Conserve energy Use fans Don’t leave pt. in distress
alone
11. Noisy Respirations/Secretions
Caused by turbulent air passing over pooled secretions or through relaxed oropharynx
Median time=8-23 hrs. before death
Onset/? Trajectory
?Pulmonary embolism
CHF/fluid overload
Etiology Assessment
Treatments
Repositioning Suctioning not
recommended at EOL
Anticholinergics Hyoscyamine Scopolamine Atropine Glycopyrrolate Treat underlying
disorder, if appropriate (pneumonia, CHF, PE)
Non-Pharm Pharm
Pt. /Family Teaching on Secretions
Explain process/demonstrate lack of pt. distress, air moving
More distressing to family than pt.
Teach as a sign of impending death
12. Fatigue
Accumulation theory-metabolites affect cells
Depletion theory- muscles lack fuel (anemia)
CNS Control (RAS/Inhibiting systems imbalance
Predisposing factors (sleep,nutrition, age, wt. loss)
Subjective Location, severity,
duration Aggravating/
alleviating factors Objective
Strength VS
Labs (O2 sat., hgb.)
Etiology Assessment
Treatments
Active exercise Preparatory
education (conserve energy)
Psychosocial support
Steroids Methylphenidate
(CNS stim., inc. appetite and energy, improved mood, reduces sedation)
SSRIs Tricyclics Epoetin (if anemic)
Non-Pharm Pharmacological
PT./Family Teaching on Fatigue
Explain prevalence + nature of fatigue
Plan, schedule, and prioritize
Rest Instruct on nutrition
(protein) Control contributing
sx. (ex. Use O2)
13. Pressure Ulcers
Poor nutrition/wt. loss
Impaired circulation (vascular and lymphatic)
Poor mobility/tissue compression
Pressure over bony prominence/friction/shear
Clinical Physicial Labs (alb., Hbg., BG, O2 sat. NPUAP.org staging criteria
I (intact redness) II (broken skin, shallow) III (sub-Q tissue exposed) IV (bones, tendon, muscle exposed) Unstageable (stable, dry eschar on
heels-do not remove)
Etiology Assessment
SHEARShear**—Pressure + Friction--When tissue and bone move in opposite directions (↑ HOB, sliding down in chair).
**Causes undermining & tunneling beneath surface.
Shearing is Caused by:
Gravity & friction
Elevation of Head of Bed
Sliding down in chair
Wound Assessment
Pressure Ulcer Scale for Healing (PUSH) Pressure Sore Status Tool (PSST) Wound Characteristics
Margins (palpate for induration) Undermining/tunneling (tissue loss under
intact surface) Necrotic tissue (type?) Exudate ? Surrounding tissue (induration, edema?) Granulation? Epithelialization?
Unstageable wound— cannot see base of wound –
Black eschar in wound bed-needs debriding
Dry, Black eschar on heel—do not remove
Do not “reverse stage”—As a wound heals, it remains the same stage—a stage 3 is “a healing stage 3”, not a stage 2.
Treatment
Nutritional support (increase protein)
Pressure-reducing mattress
Frequent turning (q 1h)
Debridement Cleansing/Anti-
bacterial tx. Dressing (keep
wound moist and skin dry)
Non-Pharmacological Pharmacological
Pt./Family Teaching
Prevention and early signs Positioning to protect bony prominences Off-loading heels Skin care Nutrition (protein supps., fluids) Mobility
QUESTIONS?