Sg chpn hpna week 3 symptom management
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Transcript of Sg chpn hpna week 3 symptom management
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CLINICAL REVIEW FOR THE
GENERALIST HOSPICE & PALLIATIVE NURSE
Symptom Management
WEEK 3
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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, . . .
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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.
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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
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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
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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
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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)
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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 (?)
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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”.
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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
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Family Teaching: Dehydration
Teaching about normal process of dehydration
Correcting misperceptions about dehydration Painful? Needs to be corrected? Should be corrected?
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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
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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
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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)
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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)
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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
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Treatments
Pharmacologic
OctreotideScopolamineOpioidsAnti-emeticsCorticosteroidsAnti-spasmodicLaxative/Antidiarrheal
Non-Pharmacologic
Prevention when poss.
Avoid big meals Avoid hot drinks Consider NGT/sxn.
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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.
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Pt./Family Teaching: B.Obstruction
Review Causes Discuss Tx. Opts. Educate on prevent. Review meds. Review Diet Instruct when to call
provider
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5. Constipation
Etiology Medication-related
(opiods, anticholin.)
Disease-related Cancer (tumors) Diabetes
(gastroparesis) Dehydration Inactivity/ intake
Assessment Bowel history Abdominal assessment Rectal assessment
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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
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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.)
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New Drug: Relistor (methylnaltrexone)
Naloxone Relistor (naloxone w/ + charge on Nitrogen atom)
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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
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Pt./Family Teaching: Constipation
Monitor bowel patterns
Encourage p.o. food/fluids
Encourage activity (oob)
Instruct when to call . . . .
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6. Diarrhea
AssessmentAbdominal assessment
Blood in stool?
Dehydration?
Etiology Treatment-Related
Antibiotics Disease-Related
HIV, c. diff. Psychologically-
Related Anxiety
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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)
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Pt./Family Teaching: Diarrhea
Respect level of comfort with discussion
Monitor frequency + consistency
Provide skin care
When to call . . . .
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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)
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TREATMENTS
Non-Pharmacological
Coping skills (breathing, cbt)
Reassurance/support
Counselling
Complementary Tx.
Pharmacological
Benzos (alprazolam, lorazepam)
Anti-depressants (SSRI)
Neuroleptics (haloperidol, prometh.)
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Pt./Family Teaching: Anxiety
Review causes Monitor for sx. Avoid stimulation Discuss unresolved
issues Patient safety/when
to call
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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
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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?)
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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
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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
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Pt./Family Teaching
Review medications Reassure pt./family Review symbolic
language (NDE) Careful sensory
stimulation, if indicated Instruct on re-orienting
pt.
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9. DEPRESSION
Medical conditions (pain)
Treatment-related (meds.)
Psychological factors (financial, relationships)
Enduring sad mood
Hopelessness Fatigue Anhedonia Ability to make
decisions
Etiology Assessment
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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
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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
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Pt./Family Teaching for Depression
Review signs and symptoms
Instruct on prevalence Review medications Review non-pharm.
Interventions Provide opportunity for
private conversations
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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
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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
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Pt./Family Teaching for Dyspnea
Instruct on breathing techniques
Minimize aggravation Prevent panic Conserve energy Use fans Don’t leave pt. in distress
alone
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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
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Treatments
Repositioning Suctioning not
recommended at EOL
Anticholinergics Hyoscyamine Scopolamine Atropine Glycopyrrolate Treat underlying
disorder, if appropriate (pneumonia, CHF, PE)
Non-Pharm Pharm
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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
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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
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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
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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)
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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
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SHEARShear**—Pressure + Friction--When tissue and bone move in opposite directions (↑ HOB, sliding down in chair).
**Causes undermining & tunneling beneath surface.
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Shearing is Caused by:
Gravity & friction
Elevation of Head of Bed
Sliding down in chair
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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?
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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.
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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
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Pt./Family Teaching
Prevention and early signs Positioning to protect bony prominences Off-loading heels Skin care Nutrition (protein supps., fluids) Mobility
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QUESTIONS?