CLINICAL REVIEW FOR THE GENERALIST  HOSPICE & PALLIATIVE NURSE  Symptom Management WEEK 3
Nat’l. Consensus Project <ul><li>Clinical Practice Guidelines of Qual. Pall. Care </li></ul><ul><ul><li>Domain 2—Physical ...
Common EOL Symptoms <ul><li>Anorexia/Cachexia </li></ul><ul><li>Dehydration </li></ul><ul><li>Nausea/Vomiting </li></ul><u...
1.  Anorexia/Cachexia  <ul><li>Anorexia —loss of appetite </li></ul><ul><li>Cachexia —wt. loss, wasting,  loss of muscle, ...
Non-Pharm. Interventions for Anorexia/Cachexia <ul><li>Encourage pts. to eat what they like </li></ul><ul><li>Refer to Die...
Pharmacologic Interventions for Anorexia/Cachexia Class of drug Examples Comments Gastrokinetic agents Metoclopramide (Reg...
Pt./Family Education <ul><li>Support pt’s. wishes </li></ul><ul><li>Discuss    intake during dying process </li></ul><ul>...
2.  Dehydration <ul><li>Etiology </li></ul><ul><li>Normal physiology  at EOL </li></ul><ul><li>   desire for fluids </li>...
Third-Spacing <ul><ul><li>Extracellular fluid is normally found in Interstitial or intravascular spaces. </li></ul></ul><u...
Treatments <ul><li>Non-Pharm. </li></ul><ul><ul><li>Oral Fluids/sports drinks </li></ul></ul><ul><ul><li>Review of disease...
Family Teaching: Dehydration <ul><ul><li>Teaching about normal process of dehydration </li></ul></ul><ul><ul><li>Correctin...
3.  Nausea & Vomiting <ul><li>Etiology </li></ul><ul><li>Disease-Related </li></ul><ul><ul><li>GI (constip., B.O.) </li></...
Non-Pharmacological Treatments <ul><li>Drink clear or ice-cold drinks </li></ul><ul><li>Eat light, bland foods  </li></ul>...
Pharmacological Treatments Cause Treatment Slow gastric emptying Prokinetic agent (Metoclopramide, Domperidone) Chemical (...
Pt./Family Teaching: N/V  <ul><li>Assist with assessing cause </li></ul><ul><li>Problem-solving to treat </li></ul><ul><li...
4.  Bowel Obstruction <ul><li>Etiology </li></ul><ul><li>Occlusion of lumen (tumor v. fecal imp’n.) </li></ul><ul><li>Abse...
Treatments <ul><li>Pharmacologic </li></ul><ul><li>Octreotide </li></ul><ul><li>Scopolamine </li></ul><ul><li>Opioids </li...
Be Careful <ul><li>DON’T give a stimulant laxative with a bowel obstruction—causes more pain </li></ul><ul><li>Don’t mista...
Pt./Family Teaching: B.Obstruction <ul><li>Review Causes </li></ul><ul><li>Discuss Tx. Opts. </li></ul><ul><li>Educate on ...
5.  Constipation <ul><li>Etiology </li></ul><ul><li>Medication-related (opiods, anticholin.) </li></ul><ul><li>Disease-rel...
Interventions <ul><li>Pharmacological </li></ul><ul><li>Laxatives: </li></ul><ul><ul><li>Detergent (softener/docusate) </l...
Opioid-Induced Constipation (OIC) <ul><li>Opioids bind to Mu-receptors in CNS to provide pain relief </li></ul><ul><li>Als...
New Drug:  Relistor  (methylnaltrexone ) Naloxone Relistor  (naloxone w/ + charge on Nitrogen  atom)
Methylnaltrexone:  Treats Opioid-Induced Constipation <ul><li>Binds to the same receptors as opioid analgesics (morphine, ...
Pt./Family Teaching:  Constipation <ul><li>Monitor bowel patterns </li></ul><ul><li>Encourage p.o. food/fluids </li></ul><...
6.  Diarrhea <ul><li>Assessment </li></ul><ul><li>Abdominal assessment </li></ul><ul><li>Blood in stool? </li></ul><ul><li...
Treatments <ul><li>Non-Pharmacologic </li></ul><ul><li>Clear liqs./advance </li></ul><ul><li>BRAT diet </li></ul><ul><li>L...
Pt./Family Teaching: Diarrhea <ul><li>Respect level of comfort with discussion </li></ul><ul><li>Monitor frequency + consi...
7.  Anxiety <ul><li>Assessment </li></ul><ul><li>Physical sx. </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li...
TREATMENTS <ul><li>Non-Pharmacological </li></ul><ul><li>Coping skills (breathing, cbt) </li></ul><ul><li>Reassurance/supp...
Pt./Family Teaching:  Anxiety <ul><li>Review causes </li></ul><ul><li>Monitor for sx. </li></ul><ul><li>Avoid stimulation ...
8.  Delerium/Agitation <ul><li>Infection </li></ul><ul><li>Malignancy-related </li></ul><ul><li>Renal/hepatic failure </li...
Checklist for  Assessing  Terminal Agitation <ul><li>Thorough medication review (polypharm., toxicity, side effects?) </li...
Correcting the Causes of Delerium/Agitation <ul><li>Constipation…………... </li></ul><ul><li>Urinary retention……... </li></ul...
Treatment <ul><li>Correct underlying cause </li></ul><ul><li>Symptomatic/suppor-tive tx. </li></ul><ul><li>Consider trajec...
Pt./Family Teaching <ul><li>Review medications </li></ul><ul><li>Reassure pt./family </li></ul><ul><li>Review symbolic lan...
9.  DEPRESSION <ul><li>Medical conditions (pain) </li></ul><ul><li>Treatment-related (meds.) </li></ul><ul><li>Psychologic...
Screening for Depression <ul><li>Tools </li></ul><ul><ul><li>Beck Depression Inventory </li></ul></ul><ul><ul><li>Geriatri...
Treatments <ul><li>Counseling </li></ul><ul><li>Behavioral </li></ul><ul><li>Cognitive </li></ul><ul><li>Interpersonal </l...
Pt./Family Teaching for Depression <ul><li>Review signs and symptoms </li></ul><ul><li>Instruct on prevalence </li></ul><u...
10.  Dyspnea <ul><li>Diagnosis-related </li></ul><ul><li>Treatment-related </li></ul><ul><li>Pulmonary congestion </li></u...
Treatments <ul><li>Fans </li></ul><ul><li>Positioning (   HOB) </li></ul><ul><li>Conserve energy </li></ul><ul><li>Pursed...
Pt./Family Teaching for Dyspnea <ul><li>Instruct on breathing techniques </li></ul><ul><li>Minimize aggravation </li></ul>...
11.  Noisy Respirations/Secretions <ul><li>Caused by turbulent air passing over pooled secretions or through relaxed oroph...
Treatments <ul><li>Repositioning </li></ul><ul><li>Suctioning not recommended at EOL </li></ul><ul><li>Anticholinergics </...
Pt. /Family Teaching on Secretions  <ul><li>Explain process/demonstrate lack of pt. distress, air moving </li></ul><ul><li...
12.  Fatigue <ul><li>Accumulation  theory-metabolites affect cells </li></ul><ul><li>Depletion theory-  muscles lack fuel ...
Treatments <ul><li>Active exercise </li></ul><ul><li>Preparatory education  (conserve energy) </li></ul><ul><li>Psychosoci...
PT./Family Teaching on Fatigue <ul><li>Explain prevalence + nature of fatigue </li></ul><ul><li>Plan, schedule, and priori...
13.  Pressure Ulcers <ul><li>Poor nutrition/wt. loss </li></ul><ul><li>Impaired circulation (vascular and lymphatic) </li>...
SHEAR <ul><li>Shear** —Pressure + Friction--When tissue and bone move in opposite directions (↑ HOB, sliding down in chair...
Shearing is Caused by: <ul><li>Gravity & friction  </li></ul><ul><li>Elevation of Head of Bed </li></ul><ul><li>Sliding do...
Wound Assessment <ul><li>Pressure Ulcer Scale for Healing (PUSH) </li></ul><ul><li>Pressure Sore Status Tool (PSST) </li><...
Unstageable wound— cannot see base of wound – Black eschar in wound bed-needs debriding Dry, Black eschar on heel—do not r...
Treatment <ul><li>Nutritional support (increase protein) </li></ul><ul><li>Pressure-reducing mattress </li></ul><ul><li>Fr...
Pt./Family Teaching <ul><li>Prevention and early signs </li></ul><ul><li>Positioning to protect bony prominences </li></ul...
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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 of "Sg chpn hpna week 3 symptom management"

    1. 1. CLINICAL REVIEW FOR THE GENERALIST HOSPICE & PALLIATIVE NURSE Symptom Management WEEK 3
    2. 2. Nat’l. Consensus Project <ul><li>Clinical Practice Guidelines of Qual. Pall. Care </li></ul><ul><ul><li>Domain 2—Physical Aspect of Care </li></ul></ul><ul><ul><ul><li>Guideline 2.1—Pain, other symptoms, and side effects are managed, based on the best available evidence, . . . </li></ul></ul></ul>
    3. 3. Common EOL Symptoms <ul><li>Anorexia/Cachexia </li></ul><ul><li>Dehydration </li></ul><ul><li>Nausea/Vomiting </li></ul><ul><li>Bowel Obstruction </li></ul><ul><li>Constipation </li></ul><ul><li>Diarrhea </li></ul><ul><li>Anxiety </li></ul><ul><li>Depression </li></ul><ul><li>Dyspnea </li></ul><ul><li>Noisy Respirations </li></ul><ul><li>Fatigue </li></ul><ul><li>Pressure Ulcers </li></ul>For each symptom, we will look at: ETIOLOGY, ASSESSMENT, NON-PHARM. + PHARM. TREATMENTS, AND PT./FAM. TEACHING.
    4. 4. 1. Anorexia/Cachexia <ul><li>Anorexia —loss of appetite </li></ul><ul><li>Cachexia —wt. loss, wasting, loss of muscle, fat, bone minerals, marked by weakness, emaciation (occurs in 80% of Ca. pts., kills 20% of them) </li></ul><ul><li>2 May be a mutually re-inforcing cycle </li></ul><ul><li>ETIOLOGY (reason): </li></ul><ul><li>Treatment-Related </li></ul><ul><ul><li>Meds., chemo., XRT </li></ul></ul><ul><li>Disease-Related </li></ul><ul><ul><li>Infxn., delayed gast. emptying, metabolic ch., N/V, dysphagia </li></ul></ul><ul><li>P/S or spiritual distress </li></ul><ul><ul><li>Depression </li></ul></ul>
    5. 5. Non-Pharm. Interventions for Anorexia/Cachexia <ul><li>Encourage pts. to eat what they like </li></ul><ul><li>Refer to Dietician </li></ul><ul><li>Encourage small, frequent meals </li></ul><ul><li>Avoid strong odors </li></ul><ul><li>Encourage supplements </li></ul><ul><li>Enteral/Parenteral feedings may be appropriate </li></ul>
    6. 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. 7. Pt./Family Education <ul><li>Support pt’s. wishes </li></ul><ul><li>Discuss  intake during dying process </li></ul><ul><li>Explore the meaning of food to family (love, health, togetherness) </li></ul><ul><li>Address emotional needs </li></ul><ul><li>Re-direct caring activities (tell stories, use lotion for massage, look at photos together) </li></ul>
    8. 8. 2. Dehydration <ul><li>Etiology </li></ul><ul><li>Normal physiology at EOL </li></ul><ul><li> desire for fluids </li></ul><ul><li>Fasting/vomiting/ diarrhea </li></ul><ul><li>Fever </li></ul><ul><li>Over-use of diuretics </li></ul><ul><li>3 rd spacing </li></ul><ul><li>Assessment </li></ul><ul><ul><li>Mental status ch. </li></ul></ul><ul><ul><li>I/O (< 400ml/day) </li></ul></ul><ul><ul><li>Poor skin turgor (tenting) </li></ul></ul><ul><ul><li>Wt. loss </li></ul></ul><ul><ul><li>Skin/mouth </li></ul></ul><ul><ul><li>Postural hypotension </li></ul></ul><ul><ul><li>Lab Values (?) </li></ul></ul>
    9. 9. Third-Spacing <ul><ul><li>Extracellular fluid is normally found in Interstitial or intravascular spaces. </li></ul></ul><ul><ul><li>Sometimes, with diseased states, it collects in “THIRD-SPACES” (ascites, pleural effusion, etc. </li></ul></ul><ul><ul><li>Pt. is often intravascularly dehydrated, while fluid collects in “third spaces”. </li></ul></ul>
    10. 10. Treatments <ul><li>Non-Pharm. </li></ul><ul><ul><li>Oral Fluids/sports drinks </li></ul></ul><ul><ul><li>Review of disease trajectory </li></ul></ul><ul><ul><li>Facilitating discussion of benefits v. burdens </li></ul></ul><ul><li>Pharm. </li></ul><ul><ul><li>Proctolysis (w/NGT) </li></ul></ul><ul><ul><li>Hypodermoclysis </li></ul></ul><ul><ul><li>IVF </li></ul></ul><ul><ul><ul><li>Monitor for over-hydration (swelling, sob, etc.) </li></ul></ul></ul><ul><ul><li>Good mouth care q2 (swab w/water or dilute mouthwash, lip balm) </li></ul></ul><ul><ul><li>Ice chips/popsicles </li></ul></ul>
    11. 11. Family Teaching: Dehydration <ul><ul><li>Teaching about normal process of dehydration </li></ul></ul><ul><ul><li>Correcting misperceptions about dehydration </li></ul></ul><ul><ul><ul><li>Painful? </li></ul></ul></ul><ul><ul><ul><li>Needs to be corrected? </li></ul></ul></ul><ul><ul><ul><li>Should be corrected? </li></ul></ul></ul>
    12. 12. 3. Nausea & Vomiting <ul><li>Etiology </li></ul><ul><li>Disease-Related </li></ul><ul><ul><li>GI (constip., B.O.) </li></ul></ul><ul><ul><li>Metabolic (uremia,  calcemia) </li></ul></ul><ul><ul><li>CNS (vertigo, brain mets.) </li></ul></ul><ul><li>Treatment-Related </li></ul><ul><ul><li>Chemo (CTZ) </li></ul></ul><ul><ul><li>Opioids (slow gastric emptying, may resolve-3days) </li></ul></ul><ul><li>Assessment </li></ul><ul><ul><li>Pt’s subjective report </li></ul></ul>
    13. 13. Non-Pharmacological Treatments <ul><li>Drink clear or ice-cold drinks </li></ul><ul><li>Eat light, bland foods </li></ul><ul><li>Avoid fried, greasy, or sweet foods </li></ul><ul><li>Eat small, frequent meals </li></ul><ul><li>Eat and drink slowly </li></ul><ul><li>Cool Cloth to face </li></ul><ul><li>Mouth Care </li></ul><ul><li>Fresh air/Fan </li></ul>
    14. 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) <ul><li>ICP </li></ul>Steroid (Dexamethasone/Decadron--in combination w/ other drugs)
    15. 15. Pt./Family Teaching: N/V <ul><li>Assist with assessing cause </li></ul><ul><li>Problem-solving to treat </li></ul><ul><li>Family’s role </li></ul><ul><li>When to call provider (dehydration, not keeping anything down, pt is suffering) </li></ul>
    16. 16. 4. Bowel Obstruction <ul><li>Etiology </li></ul><ul><li>Occlusion of lumen (tumor v. fecal imp’n.) </li></ul><ul><li>Absence of propulsion </li></ul><ul><li>Metabolic disorders </li></ul><ul><li>Medications </li></ul><ul><li>Assessmen t </li></ul><ul><ul><li>Bowel hx. </li></ul></ul><ul><ul><li>Pain on palpation </li></ul></ul><ul><ul><li>Rectal Exam </li></ul></ul><ul><ul><li>Consider location </li></ul></ul><ul><ul><li>Consider p.c. goals/disease trajectory </li></ul></ul>
    17. 17. Treatments <ul><li>Pharmacologic </li></ul><ul><li>Octreotide </li></ul><ul><li>Scopolamine </li></ul><ul><li>Opioids </li></ul><ul><li>Anti-emetics </li></ul><ul><li>Corticosteroids </li></ul><ul><li>Anti-spasmodic </li></ul><ul><li>Laxative/Antidiarrheal </li></ul><ul><li>Non-Pharmacologic </li></ul><ul><li>Prevention when poss. </li></ul><ul><li>Avoid big meals </li></ul><ul><li>Avoid hot drinks </li></ul><ul><li>Consider NGT/sxn. </li></ul>
    18. 18. Be Careful <ul><li>DON’T give a stimulant laxative with a bowel obstruction—causes more pain </li></ul><ul><li>Don’t mistake liquid stool coming around an obstruction as evidence that there is not an obstruction. </li></ul>
    19. 19. Pt./Family Teaching: B.Obstruction <ul><li>Review Causes </li></ul><ul><li>Discuss Tx. Opts. </li></ul><ul><li>Educate on prevent. </li></ul><ul><li>Review meds. </li></ul><ul><li>Review Diet </li></ul><ul><li>Instruct when to call provider </li></ul>
    20. 20. 5. Constipation <ul><li>Etiology </li></ul><ul><li>Medication-related (opiods, anticholin.) </li></ul><ul><li>Disease-related </li></ul><ul><ul><li>Cancer (tumors) </li></ul></ul><ul><ul><li>Diabetes (gastroparesis) </li></ul></ul><ul><li>Dehydration </li></ul><ul><li>Inactivity/  intake </li></ul><ul><li>Assessment </li></ul><ul><li>Bowel history </li></ul><ul><li>Abdominal assessment </li></ul><ul><li>Rectal assessment </li></ul>
    21. 21. Interventions <ul><li>Pharmacological </li></ul><ul><li>Laxatives: </li></ul><ul><ul><li>Detergent (softener/docusate) </li></ul></ul><ul><ul><li>Lubricant (glycerine supp.) </li></ul></ul><ul><ul><li>Stimulant (dulcolax/senna) </li></ul></ul><ul><ul><li>Saline (Mag Citrate) </li></ul></ul><ul><ul><li>Osmotic (latulose) </li></ul></ul><ul><ul><li>Bulk-forming (miralax) </li></ul></ul><ul><ul><li>Enemas (increase H2O content </li></ul></ul><ul><ul><li>Metoclopramide if indicated </li></ul></ul><ul><li>Non-Pharm. </li></ul><ul><li>Prevention! </li></ul><ul><li>Treating med. side effects pro-actively </li></ul><ul><li> fluid + fiber </li></ul><ul><li>Intervene only if causing distress </li></ul><ul><li>Cultural considerations </li></ul>
    22. 22. Opioid-Induced Constipation (OIC) <ul><li>Opioids bind to Mu-receptors in CNS to provide pain relief </li></ul><ul><li>Also bind to Mu-receptors in gut which stops peristalsis </li></ul><ul><li>Requires stimulant treatment (metaclopromide, dulcolax, oral erythro.) </li></ul>
    23. 23. New Drug: Relistor (methylnaltrexone ) Naloxone Relistor (naloxone w/ + charge on Nitrogen atom)
    24. 24. Methylnaltrexone: Treats Opioid-Induced Constipation <ul><li>Binds to the same receptors as opioid analgesics (morphine, oxycodone, dilaudid, etc.) </li></ul><ul><li>Unable to cross blood/brain barrier due to the positive charge on its nitrogen atom. </li></ul><ul><li>Acts as an antagonist, blocking the GI effects of the opioid </li></ul><ul><li>Does not reverse the pain-killing properties </li></ul><ul><li>Does not cause withdrawal symptoms </li></ul>
    25. 25. Pt./Family Teaching: Constipation <ul><li>Monitor bowel patterns </li></ul><ul><li>Encourage p.o. food/fluids </li></ul><ul><li>Encourage activity (oob) </li></ul><ul><li>Instruct when to call . . . . </li></ul>
    26. 26. 6. Diarrhea <ul><li>Assessment </li></ul><ul><li>Abdominal assessment </li></ul><ul><li>Blood in stool? </li></ul><ul><li>Dehydration? </li></ul><ul><li>Etiology </li></ul><ul><li>Treatment-Related </li></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><li>Disease-Related </li></ul><ul><ul><li>HIV, c. diff. </li></ul></ul><ul><li>Psychologically-Related </li></ul><ul><ul><li>Anxiety </li></ul></ul>
    27. 27. Treatments <ul><li>Non-Pharmacologic </li></ul><ul><li>Clear liqs./advance </li></ul><ul><li>BRAT diet </li></ul><ul><li>Low residue (fiber)diet </li></ul><ul><li> fluids </li></ul><ul><li>Sitz Bath </li></ul><ul><li>Consider homeopathic remedies </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Loperamide </li></ul><ul><li>Opioids </li></ul><ul><li>Bulk-forming agents </li></ul><ul><ul><li>Psyllium (metamucil) </li></ul></ul><ul><li>Antibiotics (if indicated) </li></ul><ul><li>Steroids </li></ul><ul><li>Octreotide (  secretions, slows transit time in bowel) </li></ul>
    28. 28. Pt./Family Teaching: Diarrhea <ul><li>Respect level of comfort with discussion </li></ul><ul><li>Monitor frequency + consistency </li></ul><ul><li>Provide skin care </li></ul><ul><li>When to call . . . . </li></ul>
    29. 29. 7. Anxiety <ul><li>Assessment </li></ul><ul><li>Physical sx. </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Tremor </li></ul></ul><ul><ul><li>Bowel/bladder </li></ul></ul><ul><li>Cognitive Sx. </li></ul><ul><ul><li>Racing thoughts </li></ul></ul><ul><ul><li>Insomnia </li></ul></ul><ul><li>Etiology </li></ul><ul><li>P/S, spiritual distress </li></ul><ul><li>Uncontrolled pain </li></ul><ul><li>Medications (steroids, albuterol) </li></ul><ul><li>Substance withdrawal </li></ul><ul><li>Medical conditions (copd) </li></ul>
    30. 30. TREATMENTS <ul><li>Non-Pharmacological </li></ul><ul><li>Coping skills (breathing, cbt) </li></ul><ul><li>Reassurance/support </li></ul><ul><li>Counselling </li></ul><ul><li>Complementary Tx. </li></ul><ul><li>Pharmacological </li></ul><ul><li>Benzos (alprazolam, lorazepam) </li></ul><ul><li>Anti-depressants (SSRI) </li></ul><ul><li>Neuroleptics (haloperidol, prometh.) </li></ul>
    31. 31. Pt./Family Teaching: Anxiety <ul><li>Review causes </li></ul><ul><li>Monitor for sx. </li></ul><ul><li>Avoid stimulation </li></ul><ul><li>Discuss unresolved issues </li></ul><ul><li>Patient safety/when to call </li></ul>
    32. 32. 8. Delerium/Agitation <ul><li>Infection </li></ul><ul><li>Malignancy-related </li></ul><ul><li>Renal/hepatic failure </li></ul><ul><li>Metabolic causes </li></ul><ul><li>Hypoxemia </li></ul><ul><li>Medications (opioids, etc.) </li></ul><ul><li>Fecal impaction/Urinary retention </li></ul><ul><li>Established Tools </li></ul><ul><ul><li>Confusion Assessment Method (CAM) </li></ul></ul><ul><ul><li>Neecham Confusion Scale (NCS) </li></ul></ul><ul><li>ETIOLOGY </li></ul><ul><li>ASSESSMENT </li></ul>
    33. 33. Checklist for Assessing Terminal Agitation <ul><li>Thorough medication review (polypharm., toxicity, side effects?) </li></ul><ul><li>Hx/ of substance abuse </li></ul><ul><li>Retention of urine/stool </li></ul><ul><li>Signs of fever or sepsis </li></ul><ul><li>Hypoxia </li></ul><ul><li>Assess pain/suffering </li></ul><ul><li>Assess LOC needed (GIP/CC?) </li></ul>
    34. 34. Correcting the Causes of Delerium/Agitation <ul><li>Constipation…………... </li></ul><ul><li>Urinary retention……... </li></ul><ul><li>Dehydration…………… </li></ul><ul><li>UTI…………………….. </li></ul><ul><li>Polypharm/ side effects </li></ul><ul><li>Hypoglycemia………… </li></ul><ul><li>Fever………………….. </li></ul><ul><li>Medicate/disimpact/aggressive bowel regimen </li></ul><ul><li>Catheterize </li></ul><ul><li>Consider 1L. IVF or SQ (if no overload) </li></ul><ul><li>Dipstick and treat if symptomatic </li></ul><ul><li>D/C or taper drug if appropriate </li></ul><ul><li>Consider glucose replacement </li></ul><ul><li>Consider anti-pyretics/cooling measures </li></ul>
    35. 35. Treatment <ul><li>Correct underlying cause </li></ul><ul><li>Symptomatic/suppor-tive tx. </li></ul><ul><li>Consider trajectory/goals: may not be reversible—treat sx. </li></ul><ul><li>Neuroleptics </li></ul><ul><ul><li>Haloperidol </li></ul></ul><ul><li>Benzos. </li></ul><ul><ul><li>Midazolam (Versed) </li></ul></ul><ul><li>Anxiolytics </li></ul><ul><ul><li>Lorazepam </li></ul></ul><ul><li>Atypical Antidepressants </li></ul><ul><ul><li>Risperidone </li></ul></ul><ul><li>Non-Pharmacological </li></ul><ul><li>Pharmacological </li></ul>
    36. 36. Pt./Family Teaching <ul><li>Review medications </li></ul><ul><li>Reassure pt./family </li></ul><ul><li>Review symbolic language (NDE) </li></ul><ul><li>Careful sensory stimulation, if indicated </li></ul><ul><li>Instruct on re-orienting pt. </li></ul>
    37. 37. 9. DEPRESSION <ul><li>Medical conditions (pain) </li></ul><ul><li>Treatment-related (meds.) </li></ul><ul><li>Psychological factors (financial, relationships) </li></ul><ul><li>Enduring sad mood </li></ul><ul><li>Hopelessness </li></ul><ul><li>Fatigue </li></ul><ul><li>Anhedonia </li></ul><ul><li> Ability to make decisions </li></ul><ul><li>Etiology </li></ul><ul><li>Assessment </li></ul>
    38. 38. Screening for Depression <ul><li>Tools </li></ul><ul><ul><li>Beck Depression Inventory </li></ul></ul><ul><ul><li>Geriatric Depression Scale </li></ul></ul><ul><ul><li>Hamilton Depression Scale </li></ul></ul><ul><li>Ask about </li></ul><ul><ul><li>Mood </li></ul></ul><ul><ul><li>Behavior (appetite/sleep) </li></ul></ul><ul><ul><li>Cognition (slow thought, indecision) </li></ul></ul><ul><li>Suicide Risk </li></ul><ul><ul><li>ETOH abuse </li></ul></ul><ul><ul><li>Psychiatric disorder </li></ul></ul><ul><ul><li>Depression </li></ul></ul>
    39. 39. Treatments <ul><li>Counseling </li></ul><ul><li>Behavioral </li></ul><ul><li>Cognitive </li></ul><ul><li>Interpersonal </li></ul><ul><li>Complementary Tx. </li></ul><ul><li>SSRI’s (1 st line) </li></ul><ul><li>Tri-cyclics (effective in 70% of pts.) </li></ul><ul><li>Stimulants (methylphenidate) </li></ul><ul><li>Steroids (  appetite + mood) </li></ul><ul><li>Non-Pharmacologigal Interventions </li></ul><ul><li>Pharmacological </li></ul>
    40. 40. Pt./Family Teaching for Depression <ul><li>Review signs and symptoms </li></ul><ul><li>Instruct on prevalence </li></ul><ul><li>Review medications </li></ul><ul><li>Review non-pharm. Interventions </li></ul><ul><li>Provide opportunity for private conversations </li></ul>
    41. 41. 10. Dyspnea <ul><li>Diagnosis-related </li></ul><ul><li>Treatment-related </li></ul><ul><li>Pulmonary congestion </li></ul><ul><li>Broncho-constriction </li></ul><ul><li>Anemia </li></ul><ul><li>Hyperventilation </li></ul><ul><li>Believe pt’s. report </li></ul><ul><li>Not same as tachypnea </li></ul><ul><li>Functional status </li></ul><ul><li>Past history </li></ul><ul><li>Diagnostic tests </li></ul><ul><li>Etiology </li></ul><ul><li>Assessment </li></ul>
    42. 42. Treatments <ul><li>Fans </li></ul><ul><li>Positioning (  HOB) </li></ul><ul><li>Conserve energy </li></ul><ul><li>Pursed-lip breathing </li></ul><ul><li>Prayer </li></ul><ul><li>Complementary tx. </li></ul><ul><li>Opioids </li></ul><ul><li>Benzodiazepines (not first-line) </li></ul><ul><li>Diuretics, if indicated </li></ul><ul><li>Bronchodilators, if indicated </li></ul><ul><li>Cortico-steroids if indicated </li></ul><ul><li>Non-Pharmacological </li></ul><ul><li>Pharmacological </li></ul>
    43. 43. Pt./Family Teaching for Dyspnea <ul><li>Instruct on breathing techniques </li></ul><ul><li>Minimize aggravation </li></ul><ul><li>Prevent panic </li></ul><ul><li>Conserve energy </li></ul><ul><li>Use fans </li></ul><ul><li>Don’t leave pt. in distress alone </li></ul>
    44. 44. 11. Noisy Respirations/Secretions <ul><li>Caused by turbulent air passing over pooled secretions or through relaxed oropharynx </li></ul><ul><li>Median time=8-23 hrs. before death </li></ul><ul><li>Onset/? Trajectory </li></ul><ul><li>?Pulmonary embolism </li></ul><ul><li>CHF/fluid overload </li></ul><ul><li>Etiology </li></ul><ul><li>Assessment </li></ul>
    45. 45. Treatments <ul><li>Repositioning </li></ul><ul><li>Suctioning not recommended at EOL </li></ul><ul><li>Anticholinergics </li></ul><ul><ul><li>Hyoscyamine </li></ul></ul><ul><ul><li>Scopolamine </li></ul></ul><ul><ul><li>Atropine </li></ul></ul><ul><ul><li>Glycopyrrolate </li></ul></ul><ul><ul><li>Treat underlying disorder, if appropriate (pneumonia, CHF, PE) </li></ul></ul><ul><li>Non-Pharm </li></ul><ul><li>Pharm </li></ul>
    46. 46. Pt. /Family Teaching on Secretions <ul><li>Explain process/demonstrate lack of pt. distress, air moving </li></ul><ul><li>More distressing to family than pt. </li></ul><ul><li>Teach as a sign of impending death </li></ul>
    47. 47. 12. Fatigue <ul><li>Accumulation theory-metabolites affect cells </li></ul><ul><li>Depletion theory- muscles lack fuel (anemia) </li></ul><ul><li>CNS Control (RAS/Inhibiting systems imbalance </li></ul><ul><li>Predisposing factors (sleep,nutrition, age, wt. loss) </li></ul><ul><li>Subjective </li></ul><ul><ul><li>Location, severity, duration </li></ul></ul><ul><ul><li>Aggravating/ alleviating factors </li></ul></ul><ul><li>Objective </li></ul><ul><ul><li>Strength </li></ul></ul><ul><ul><li>VS </li></ul></ul><ul><li>Labs (O2 sat., hgb.) </li></ul><ul><li>Etiology </li></ul><ul><li>Assessment </li></ul>
    48. 48. Treatments <ul><li>Active exercise </li></ul><ul><li>Preparatory education (conserve energy) </li></ul><ul><li>Psychosocial support </li></ul><ul><li>Steroids </li></ul><ul><li>Methylphenidate (CNS stim., inc. appetite and energy, improved mood, reduces sedation) </li></ul><ul><li>SSRIs </li></ul><ul><li>Tricyclics </li></ul><ul><li>Epoetin (if anemic) </li></ul><ul><li>Non-Pharm </li></ul><ul><li>Pharmacological </li></ul>
    49. 49. PT./Family Teaching on Fatigue <ul><li>Explain prevalence + nature of fatigue </li></ul><ul><li>Plan, schedule, and prioritize </li></ul><ul><li>Rest </li></ul><ul><li>Instruct on nutrition (protein) </li></ul><ul><li>Control contributing sx. (ex. Use O2) </li></ul>
    50. 50. 13. Pressure Ulcers <ul><li>Poor nutrition/wt. loss </li></ul><ul><li>Impaired circulation (vascular and lymphatic) </li></ul><ul><li>Poor mobility/tissue compression </li></ul><ul><li>Pressure over bony prominence/friction/shear </li></ul><ul><li>Clinical </li></ul><ul><li>Physicial </li></ul><ul><li>Labs (alb., Hbg., BG, O2 sat. </li></ul><ul><li>NPUAP.org staging criteria </li></ul><ul><ul><li>I (intact redness) </li></ul></ul><ul><ul><li>II (broken skin, shallow) </li></ul></ul><ul><ul><li>III (sub-Q tissue exposed) </li></ul></ul><ul><ul><li>IV (bones, tendon, muscle exposed) </li></ul></ul><ul><ul><li>Unstageable (stable, dry eschar on heels-do not remove) </li></ul></ul><ul><li>Etiology </li></ul><ul><li>Assessment </li></ul>
    51. 51. SHEAR <ul><li>Shear** —Pressure + Friction--When tissue and bone move in opposite directions (↑ HOB, sliding down in chair). </li></ul><ul><li>**Causes undermining & tunneling beneath surface. </li></ul>
    52. 52. Shearing is Caused by: <ul><li>Gravity & friction </li></ul><ul><li>Elevation of Head of Bed </li></ul><ul><li>Sliding down in chair </li></ul>
    53. 53. Wound Assessment <ul><li>Pressure Ulcer Scale for Healing (PUSH) </li></ul><ul><li>Pressure Sore Status Tool (PSST) </li></ul><ul><li>Wound Characteristics </li></ul><ul><ul><li>Margins (palpate for induration) </li></ul></ul><ul><ul><li>Undermining/tunneling (tissue loss under intact surface) </li></ul></ul><ul><ul><li>Necrotic tissue (type?) </li></ul></ul><ul><ul><li>Exudate ? </li></ul></ul><ul><ul><li>Surrounding tissue (induration, edema?) </li></ul></ul><ul><ul><li>Granulation? Epithelialization? </li></ul></ul>
    54. 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. 55. Treatment <ul><li>Nutritional support (increase protein) </li></ul><ul><li>Pressure-reducing mattress </li></ul><ul><li>Frequent turning (q 1h) </li></ul><ul><li>Debridement </li></ul><ul><li>Cleansing/Anti-bacterial tx. </li></ul><ul><li>Dressing (keep wound moist and skin dry) </li></ul><ul><li>Non-Pharmacological </li></ul><ul><li>Pharmacological </li></ul>
    56. 56. Pt./Family Teaching <ul><li>Prevention and early signs </li></ul><ul><li>Positioning to protect bony prominences </li></ul><ul><li>Off-loading heels </li></ul><ul><li>Skin care </li></ul><ul><li>Nutrition (protein supps., fluids) </li></ul><ul><li>Mobility </li></ul>
    57. 57. QUESTIONS?

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