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Sg chpn hpna week 3 symptom management

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  • Shear is caused by gravity pushing down on the body and resistance (friction) between the patient and a surface, such as the bed or chair. E.g. elevation of head of bed, and sliding down in chair.
  • Transcript

    • 1. CLINICAL REVIEW FOR THE GENERALIST HOSPICE & PALLIATIVE NURSE Symptom Management WEEK 3
    • 2. 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, . . .
    • 3. Common EOL Symptoms
      • Anorexia/Cachexia
      • Dehydration
      • Nausea/Vomiting
      • Bowel Obstruction
      • Constipation
      • Diarrhea
      • Anxiety
      • Depression
      • Dyspnea
      • Noisy Respirations
      • Fatigue
      • Pressure Ulcers
      For each symptom, we will look at: ETIOLOGY, ASSESSMENT, NON-PHARM. + PHARM. TREATMENTS, AND PT./FAM. TEACHING.
    • 4. 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
    • 5. 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
    • 6. Pharmacologic Interventions for Anorexia/Cachexia 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?)
    • 7. 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)
    • 8. 2. Dehydration
      • Etiology
      • Normal physiology at EOL
      •  desire for fluids
      • Fasting/vomiting/ diarrhea
      • Fever
      • Over-use of diuretics
      • 3 rd spacing
      • Assessment
        • Mental status ch.
        • I/O (< 400ml/day)
        • Poor skin turgor (tenting)
        • Wt. loss
        • Skin/mouth
        • Postural hypotension
        • Lab Values (?)
    • 9. 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”.
    • 10. 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
    • 11. Family Teaching: Dehydration
        • Teaching about normal process of dehydration
        • Correcting misperceptions about dehydration
          • Painful?
          • Needs to be corrected?
          • Should be corrected?
    • 12. 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
    • 13. 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
    • 14. Pharmacological Treatments Cause Treatment Slow 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)
    • 15. 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)
    • 16. 4. Bowel Obstruction
      • Etiology
      • Occlusion of lumen (tumor v. fecal imp’n.)
      • Absence of propulsion
      • Metabolic disorders
      • Medications
      • Assessmen t
        • Bowel hx.
        • Pain on palpation
        • Rectal Exam
        • Consider location
        • Consider p.c. goals/disease trajectory
    • 17. Treatments
      • Pharmacologic
      • Octreotide
      • Scopolamine
      • Opioids
      • Anti-emetics
      • Corticosteroids
      • Anti-spasmodic
      • Laxative/Antidiarrheal
      • Non-Pharmacologic
      • Prevention when poss.
      • Avoid big meals
      • Avoid hot drinks
      • Consider NGT/sxn.
    • 18. 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.
    • 19. Pt./Family Teaching: B.Obstruction
      • Review Causes
      • Discuss Tx. Opts.
      • Educate on prevent.
      • Review meds.
      • Review Diet
      • Instruct when to call provider
    • 20. 5. Constipation
      • Etiology
      • Medication-related (opiods, anticholin.)
      • Disease-related
        • Cancer (tumors)
        • Diabetes (gastroparesis)
      • Dehydration
      • Inactivity/  intake
      • Assessment
      • Bowel history
      • Abdominal assessment
      • Rectal assessment
    • 21. Interventions
      • Pharmacological
      • Laxatives:
        • 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
    • 22. 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.)
    • 23. New Drug: Relistor (methylnaltrexone ) Naloxone Relistor (naloxone w/ + charge on Nitrogen atom)
    • 24. 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
    • 25. Pt./Family Teaching: Constipation
      • Monitor bowel patterns
      • Encourage p.o. food/fluids
      • Encourage activity (oob)
      • Instruct when to call . . . .
    • 26. 6. Diarrhea
      • Assessment
      • Abdominal assessment
      • Blood in stool?
      • Dehydration?
      • Etiology
      • Treatment-Related
        • Antibiotics
      • Disease-Related
        • HIV, c. diff.
      • Psychologically-Related
        • Anxiety
    • 27. Treatments
      • Non-Pharmacologic
      • Clear liqs./advance
      • BRAT diet
      • Low residue (fiber)diet
      •  fluids
      • Sitz Bath
      • Consider homeopathic remedies
      • Pharmacologic
      • Loperamide
      • Opioids
      • Bulk-forming agents
        • Psyllium (metamucil)
      • Antibiotics (if indicated)
      • Steroids
      • Octreotide (  secretions, slows transit time in bowel)
    • 28. Pt./Family Teaching: Diarrhea
      • Respect level of comfort with discussion
      • Monitor frequency + consistency
      • Provide skin care
      • When to call . . . .
    • 29. 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)
    • 30. TREATMENTS
      • Non-Pharmacological
      • Coping skills (breathing, cbt)
      • Reassurance/support
      • Counselling
      • Complementary Tx.
      • Pharmacological
      • Benzos (alprazolam, lorazepam)
      • Anti-depressants (SSRI)
      • Neuroleptics (haloperidol, prometh.)
    • 31. Pt./Family Teaching: Anxiety
      • Review causes
      • Monitor for sx.
      • Avoid stimulation
      • Discuss unresolved issues
      • Patient safety/when to call
    • 32. 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
    • 33. Checklist for Assessing Terminal 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?)
    • 34. 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
    • 35. 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
    • 36. Pt./Family Teaching
      • Review medications
      • Reassure pt./family
      • Review symbolic language (NDE)
      • Careful sensory stimulation, if indicated
      • Instruct on re-orienting pt.
    • 37. 9. DEPRESSION
      • Medical conditions (pain)
      • Treatment-related (meds.)
      • Psychological factors (financial, relationships)
      • Enduring sad mood
      • Hopelessness
      • Fatigue
      • Anhedonia
      •  Ability to make decisions
      • Etiology
      • Assessment
    • 38. 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
    • 39. Treatments
      • Counseling
      • Behavioral
      • Cognitive
      • Interpersonal
      • Complementary Tx.
      • SSRI’s (1 st line)
      • Tri-cyclics (effective in 70% of pts.)
      • Stimulants (methylphenidate)
      • Steroids (  appetite + mood)
      • Non-Pharmacologigal Interventions
      • Pharmacological
    • 40. Pt./Family Teaching for Depression
      • Review signs and symptoms
      • Instruct on prevalence
      • Review medications
      • Review non-pharm. Interventions
      • Provide opportunity for private conversations
    • 41. 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
    • 42. 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
    • 43. Pt./Family Teaching for Dyspnea
      • Instruct on breathing techniques
      • Minimize aggravation
      • Prevent panic
      • Conserve energy
      • Use fans
      • Don’t leave pt. in distress alone
    • 44. 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
    • 45. Treatments
      • Repositioning
      • Suctioning not recommended at EOL
      • Anticholinergics
        • Hyoscyamine
        • Scopolamine
        • Atropine
        • Glycopyrrolate
        • Treat underlying disorder, if appropriate (pneumonia, CHF, PE)
      • Non-Pharm
      • Pharm
    • 46. 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
    • 47. 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
    • 48. 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
    • 49. 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)
    • 50. 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
    • 51. SHEAR
      • Shear** —Pressure + Friction--When tissue and bone move in opposite directions (↑ HOB, sliding down in chair).
      • **Causes undermining & tunneling beneath surface.
    • 52. Shearing is Caused by:
      • Gravity & friction
      • Elevation of Head of Bed
      • Sliding down in chair
    • 53. 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?
    • 54. 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 .
    • 55. 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
    • 56. Pt./Family Teaching
      • Prevention and early signs
      • Positioning to protect bony prominences
      • Off-loading heels
      • Skin care
      • Nutrition (protein supps., fluids)
      • Mobility
    • 57. QUESTIONS?

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