Symptom management

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  • Medications: opioids, phenothiazines, benzodiazepines, anticholinergics, beta-blockers, diuretics, dopaminergics, steroids, phenytoin, H2 antagonists, dig toxicity. H2 antagonists: Pepcid, Zantac, Tagamet
  • Excessive restlessness, increased mental and physical activity Frequent, non-purposeful motor activity, inability to concentrate or relax, sleep disturbances, may progress to agitation
  • Portal hypertension: cirrhosis, cancer (ovarian, color, edometrial, breast, pancreatic gastric lymphoma, liver) Decreased plasma oncotic pressure: decrease in plasma albumin levels, causing fluid to leave plasma and accumulate in abdomen: cirrhosis, nephrotic syndrome, malnutrition
  • Comtan
  • Tumor necrosis –potential for hemorrhage or obstruction of blood vessel Nutritional assessment – involve dietician
  • Cleanse wound: low pressure for granulation tissue; high pressure (35 ml syringe with 19 ga angiocath) if wound has debris, eschar, or exudate.
  • Drugs: Anticholinergics, antihistamines, phenothiazines, 5FU (chemo) Oral mucosa: dry cracked lips, sores / white patches in mouth, bleeding of gums, lips, tongue
  • Lemon contributes to dryness / irritation Pilocarpine is cholinergic drug.
  • Sarna
  • Symptom management

    1. 1. (Or how to make your patients comfortable without distressing their families or yourself)
    2. 2. <ul><li>Identify steps in assessing the hospice patient to develop the plan of care. </li></ul><ul><li>Identify common symptoms found in Hospice and Palliative Care patients. </li></ul><ul><li>Identify interventions for these common symptoms </li></ul>
    3. 3. <ul><li>Identify etiologies </li></ul><ul><li>Assess symptoms </li></ul><ul><li>Identify diagnoses </li></ul><ul><li>Identify interventions </li></ul><ul><li>Provide education to patient & family </li></ul><ul><li>Evaluate effectiveness of interventions </li></ul><ul><li>Revise plan, according </li></ul>
    4. 4. <ul><li>Terminal Diagnosis </li></ul><ul><li>Secondary Diagnosis </li></ul><ul><li>Treatment (Medications, Chemotherapy, Radiation) </li></ul><ul><li>Altered Immune System (Corticosteroids, Disease progression) </li></ul>
    5. 5. <ul><li>Head to toe assessment </li></ul><ul><li>Ask the patient and family </li></ul><ul><ul><li>What has helped in the past? </li></ul></ul><ul><li>Review medications </li></ul>
    6. 6. <ul><li>Alteration in . . . </li></ul><ul><li>Impaired . . . </li></ul><ul><li>Patient / family knowledge deficit related to . . . </li></ul><ul><li>Pain related to . . . </li></ul><ul><li>Anxiety related to . . . </li></ul><ul><li>Potential for . . . </li></ul><ul><li>Risk for . . . </li></ul><ul><li>(Symptom) related to (underlying condition) . . . </li></ul>
    7. 7. <ul><li>Review list of possible interventions with patient and family </li></ul><ul><li>Consult with pharmacist </li></ul><ul><li>Consult with other team members </li></ul><ul><li>Contact physician </li></ul>
    8. 8. <ul><li>Treatment </li></ul><ul><ul><li>Involve Team members </li></ul></ul><ul><li>Prevention </li></ul><ul><li>Demonstration of new procedures </li></ul><ul><li>Observation of family providing care </li></ul>
    9. 9. <ul><li>Are things better? </li></ul><ul><li>If not, why not? </li></ul><ul><ul><li>What does patient / family think? </li></ul></ul><ul><ul><li>Patient / family understanding of treatment / prevention </li></ul></ul>
    10. 12. <ul><li>The great majority of the information in this presentation was taken from Core Curriculum for the Generalist Hospice and Palliative Care Nurse. </li></ul><ul><li>To present ALL the information from pages 79 to 144 would take much more than 2 hours. </li></ul><ul><li>Therefore, I have decided to “hit the highlights” only. I would recommend that you read the entire section on Symptom Management to get ALL the information you need. </li></ul>
    11. 14. <ul><li>Confusion – gradual onset </li></ul><ul><li>Delirium – sudden onset </li></ul><ul><ul><li>Hyperactive – may be misdiagnosed as anxiety </li></ul></ul><ul><ul><li>Hypoactive – may be misdiagnosed as depressed </li></ul></ul><ul><li>Agitation – includes verbal/physical aggressive behaviors. </li></ul>
    12. 15. <ul><li>Medications: opioids, phenothiazines, benzodiazepines, anticholinergics, beta-blockers, diuretics, dopaminergics, steroids, atropine, phenytoin, H2 antagonists, digoxin toxicity </li></ul><ul><li>Pain </li></ul><ul><li>Full bladder or bowel </li></ul><ul><li>Infection </li></ul><ul><li>Brain tumor </li></ul><ul><li>Cardiac / respiratory failure </li></ul><ul><li>Metabolic imbalance (Ca, BUN, Glucose, Na) </li></ul><ul><li>Drug withdrawal </li></ul><ul><li>Extreme anxiety </li></ul><ul><li>Fever, heart failure, sleep disturbance </li></ul>
    13. 16. <ul><li>Confusion vs. Delirium vs. Depression </li></ul><ul><li>Hyperactive vs. hypoactive </li></ul><ul><li>Patient’s personality / coping abilities </li></ul><ul><li>Alcohol / drug use </li></ul><ul><li>Signs of infection </li></ul><ul><li>Abdominal exam / bowel history </li></ul><ul><li>If diabetic – blood sugar </li></ul><ul><li>BUN, creatinine, electrolytes, glucose, calcium </li></ul><ul><li>Neuro status </li></ul><ul><li>Pt / family coping </li></ul><ul><li>Is this distressing to pt / family? </li></ul>
    14. 17. <ul><li>Etiology: full bladder, constipation / impaction, hypoxia, dyspnea, left ventricular failure, decreased cardiac output, pain, emotional / spiritual issues, as well as etiologies for confusion/delirium/agitation. </li></ul><ul><li>Interventions: Address symptoms listed above, </li></ul><ul><ul><li>Antipsychotics </li></ul></ul><ul><ul><li>Benzodiazepines </li></ul></ul><ul><ul><li>Barbiturates </li></ul></ul><ul><ul><li>Psychosocial support </li></ul></ul><ul><ul><li>Non-pharmacologic interventions </li></ul></ul><ul><ul><li>Family education </li></ul></ul>
    15. 18. <ul><li>Tumor </li></ul><ul><li>Abscess </li></ul><ul><li>Infection in HIV / AIDS </li></ul><ul><li>ICP </li></ul><ul><li>Pre-existing seizure disorder </li></ul><ul><li>Medications (normeperidine, propoxyphene metabolites), medications that lower seizure threshhold (phenothiazines, butyrophenones, tricyclin antidepressants, tramodol) </li></ul><ul><li>Infection </li></ul><ul><li>Stroke </li></ul><ul><li>Hemorrhage </li></ul><ul><li>O2 deprivation </li></ul><ul><li>Paraneoplastic syndromes (↑ Ca, SIADH) </li></ul><ul><li>↓ Na, ↑ Ca, ↓ Magnesium, ↓ O2, ↓ Glucose </li></ul><ul><li>Drug toxicity, drug withdrawal </li></ul>
    16. 19. <ul><li>Actively seizing patients </li></ul><ul><ul><li>ABC </li></ul></ul><ul><ul><li>Calm </li></ul></ul><ul><ul><li>Medications: </li></ul></ul><ul><ul><ul><li>Lorazepam, Diazepam, Clonazepam </li></ul></ul></ul><ul><ul><ul><li>Other anticonvulsants </li></ul></ul></ul><ul><li>Treatable etiologies </li></ul><ul><li>History of seizure </li></ul><ul><li>Drug levels </li></ul><ul><li>Caution: Dexamethasone inhibits metabolism of Phenytoin and Phenytoin decreases bioavailability of Dexamethasone </li></ul>
    17. 20. <ul><li>Paresthesia: sensation of numbness, prickling or tingling; heightened sensitivity </li></ul><ul><li>Neuropathy: an disease of the nerves; may include sensory loss, muscle weakness and atrophy and decreased deep tendon reflexes </li></ul>
    18. 21. <ul><li>Etiology </li></ul><ul><ul><li>Central & peripheral nerve lesions </li></ul></ul><ul><ul><li>Direct damage to peripheral and autonomic nerves </li></ul></ul><ul><ul><li>Metabolic and vascular changes of DM </li></ul></ul><ul><ul><li>Chemical or dug-induced: chemotherapy, isoniazid, alcohol </li></ul></ul><ul><ul><li>Amputation, AIDS, Vit B12 deficiency </li></ul></ul><ul><ul><li>Tumor invasion with pressure on nerves or plexuses </li></ul></ul><ul><ul><li>Spinal cord compression (an oncologic emergency) </li></ul></ul>
    19. 22. <ul><li>Interventions: </li></ul><ul><ul><li>If in advanced stage, treat with steroids, manage pain </li></ul></ul><ul><ul><li>Treat neuropathic pain with adjuvant TCA, anticonvulsants </li></ul></ul><ul><ul><ul><li>Max dose Gabapentin 3600 mg/day </li></ul></ul></ul><ul><ul><ul><li>Carbamazepine / Phenytoin: monitor for drug interactions, monitor CBC </li></ul></ul></ul>
    20. 23. <ul><li>Sudden loss of sensation, motor function of lower extremities. </li></ul><ul><li>Bowel / bladder incontinence may or may not occur </li></ul><ul><li>Escalating back pain, worse when lying down, improved when standing. </li></ul><ul><li>Is an oncologic emergency </li></ul><ul><li>Interventions: </li></ul><ul><ul><li>Palliative radiation </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Bowel regime </li></ul></ul><ul><ul><li>Catheter </li></ul></ul>
    21. 24. <ul><li>Etiology: </li></ul><ul><ul><li>Drug induced </li></ul></ul><ul><ul><ul><li>Neuroleptics </li></ul></ul></ul><ul><ul><ul><li>Phenothiazines (chlorpromazine) </li></ul></ul></ul><ul><ul><ul><li>Butyrophenones (haloperidol) </li></ul></ul></ul><ul><ul><ul><li>Clozapine </li></ul></ul></ul><ul><ul><ul><li>Metoclopramide </li></ul></ul></ul><ul><ul><ul><li>Opioids (myoclonus) </li></ul></ul></ul><ul><ul><li>Parkinson’s, chorea </li></ul></ul><ul><ul><li>Cerebral lesions </li></ul></ul>
    22. 25. <ul><li>Interventions </li></ul><ul><ul><li>Phenothiazine toxicity </li></ul></ul><ul><ul><ul><li>Stop phenothiazine </li></ul></ul></ul><ul><ul><ul><li>diphenhydrAMINE, benztropine (Cogentin), trihexyphenidyl (Artane) </li></ul></ul></ul><ul><ul><li>Akathisia (inability to sit still) </li></ul></ul><ul><ul><ul><li>Benzodiazepines </li></ul></ul></ul><ul><ul><ul><li>Beta-blockers </li></ul></ul></ul><ul><ul><li>Dystonia, slow retarded movements </li></ul></ul><ul><ul><ul><li>Physical therapy </li></ul></ul></ul><ul><ul><li>If sensitive to anticholinergics </li></ul></ul><ul><ul><ul><li>Amantadine </li></ul></ul></ul>
    23. 26. <ul><li>Etiology </li></ul><ul><ul><li>Tumor </li></ul></ul><ul><ul><li>Intracranial hemorrhage </li></ul></ul><ul><ul><li>Abscess, encephalitis, meningitis </li></ul></ul><ul><ul><li>Obstruction of CSF flow </li></ul></ul><ul><li>Assess for: </li></ul><ul><ul><li>Headache, vomiting, change in respiratory pattern, ↓motor function, lethargy, restlessness, agitation, blurred vision </li></ul></ul>
    24. 27. <ul><li>Interventions </li></ul><ul><ul><li>Treat underlying etiology </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Anticonvulsants </li></ul></ul><ul><ul><li>Palliative radiation </li></ul></ul><ul><ul><li>Analgesia (headache) </li></ul></ul><ul><ul><ul><li>Do not use Tramadol (↓ seizure threshhold) </li></ul></ul></ul><ul><ul><ul><li>Opioids can ↑ ICP, due to vasodilation </li></ul></ul></ul><ul><ul><li>HOB ↑ 45 – 60 degrees, dark room, ↓ stimuli, calm presence </li></ul></ul>
    25. 28. <ul><li>Etiology </li></ul><ul><ul><li>Left cerebral hemisphere infarct, hemorrhage, tumor, trauma, degeneration </li></ul></ul><ul><ul><li>Advanced dementia, cerebral vascular disease </li></ul></ul><ul><li>Assessment: </li></ul><ul><ul><li>Sensory: Inability to comprehend spoken/written words </li></ul></ul><ul><ul><li>Motor: Comprehends, but unable to speak </li></ul></ul><ul><ul><li>Global: failure of all forms of communication </li></ul></ul><ul><ul><li>Caregiver’s abilities, willingness to interpret </li></ul></ul><ul><ul><li>Pt / family frustration </li></ul></ul>
    26. 29. <ul><li>Interventions </li></ul><ul><ul><li>Staff to model acceptance, patience in communication </li></ul></ul><ul><ul><li>Speech therapy </li></ul></ul><ul><ul><li>Picture boards </li></ul></ul><ul><ul><li>Monitor non-verbal behaviors for pain, anxiety, discomfort </li></ul></ul><ul><ul><li>Consistency in communication from staff, family </li></ul></ul><ul><ul><li>Decrease excessive stimuli </li></ul></ul>
    27. 30. <ul><li>Etiology </li></ul><ul><ul><li>High dose opioids </li></ul></ul><ul><ul><ul><li>↑ levels 3-glucuronide opioid metabolites. </li></ul></ul></ul><ul><ul><ul><li>Co-morbid factors </li></ul></ul></ul><ul><ul><ul><ul><li>Renal failure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Electrolyte disturbances </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dehydration </li></ul></ul></ul></ul><ul><ul><li>Uremia </li></ul></ul><ul><ul><li>Inflammatory / degenerative CNS diseases </li></ul></ul><ul><ul><ul><li>Jakob-Creutzfeldt </li></ul></ul></ul><ul><ul><ul><li>Subacute sclerosing panencephalitis </li></ul></ul></ul><ul><ul><ul><li>E S Alzheimer </li></ul></ul></ul><ul><ul><li>Hypercalcemia (Bone metastasis) </li></ul></ul>
    28. 31. <ul><li>Interventions </li></ul><ul><ul><li>Hypercalcemia </li></ul></ul><ul><ul><ul><li>Palliative care: Pamidronate </li></ul></ul></ul><ul><ul><ul><li>Hospice: Hydration (IV or PO) may ↓ serum Ca </li></ul></ul></ul><ul><ul><li>Opioid induced </li></ul></ul><ul><ul><ul><li>Adjuvant medications </li></ul></ul></ul><ul><ul><ul><li>Opioid rotation </li></ul></ul></ul><ul><ul><li>Muscle relaxants – Diazepam, Baclofen, Lorazepam </li></ul></ul><ul><ul><ul><li>Cyclobenzaprine – use in caution in elderly / debilitated </li></ul></ul></ul><ul><ul><li>Gabapentin for restless leg syndrom </li></ul></ul><ul><ul><li>Quinine sulfate at HS for night leg cramp </li></ul></ul>
    29. 33. <ul><li>Etiology: Portal hypertension, decreased plasma oncotic pressure, lymphatic obstruction, pancreatitis, TB, bowel perforation </li></ul><ul><li>Assess: History, weight gain, discomfort, tachycardia, dyspnea, mobility, edema, girth, dehydration, anorexia </li></ul><ul><li>Diagnoses </li></ul><ul><li>Intervention: Analgesics, fluid/sodium restriction, diuretics, paracentesis, palliative chemo </li></ul><ul><li>Pt / family education </li></ul>
    30. 34. <ul><li>Etiology: Protein deficiency, tumor, DVT, CHF, SVCS, renal failure, lymphedema, ascites </li></ul><ul><li>Assess: Extremities for warmth, weeping, pitting, SVCS is oncologic emergency, ascites, </li></ul><ul><li>Interventions: elevation, compression hose, diuretics, skin care </li></ul><ul><li>Lymphedema does not respond to diuretics, may not respond to elevation. Manual lymph drainage for palliative care pts </li></ul>
    31. 35. <ul><li>Etiology: DVT, PE, Tumor erosion, chemo / radiation /disorders of spleen, AIDS, DIC, prosthetic heart valves </li></ul><ul><li>Assess: history, medications, DIC, DVT, PE, thrombocytopenia </li></ul><ul><li>Diagnoses </li></ul><ul><li>Intervention: </li></ul><ul><ul><li>DVT – anticoagulant. Monitor for interactions (Vit E, theophylline, carbamazepine, phenytoin, dark green vegetables, </li></ul></ul><ul><ul><li>PE – anticoagulant, treat dyspnea, pain, antiembolic stockings </li></ul></ul><ul><ul><li>DIC – replenish clotting factors. Palliative care patient should be in acute care </li></ul></ul><ul><ul><li>Neutropenia – precautions </li></ul></ul><ul><ul><li>Bleeding precautions </li></ul></ul><ul><ul><li>Dark towels </li></ul></ul><ul><li>Pt / family education </li></ul>
    32. 37. <ul><li>Dyspnea: </li></ul><ul><ul><li>Lung tumor or metastasis </li></ul></ul><ul><ul><li>Pleural effusion </li></ul></ul><ul><ul><li>COPD </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>Ascites </li></ul></ul><ul><ul><li>Pneumothorax </li></ul></ul><ul><ul><li>PE </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Neurologic insult </li></ul></ul>
    33. 38. <ul><li>Cough: </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Inflammation </li></ul></ul><ul><ul><li>Cardiac (left ventricular failure) </li></ul></ul><ul><ul><li>Pulmonary disease </li></ul></ul><ul><ul><ul><li>Pleural effusion, bronchospasm, bronchogenic cancer </li></ul></ul></ul><ul><ul><li>ACE inhibitors </li></ul></ul><ul><ul><li>Smoke, tobacco abuse, </li></ul></ul><ul><ul><li>Allergic conditions </li></ul></ul><ul><ul><li>GERD </li></ul></ul>
    34. 39. <ul><li>KISS – O2 on? Kinked? Fluid overload? Anxiety? Pain? Constipation </li></ul><ul><li>Onset, rate/depth/quality of respirations, breath sounds, accessory muscles, stridor </li></ul><ul><li>Past interventions? </li></ul><ul><li>Current medications </li></ul><ul><li>CO 2 retainer? </li></ul><ul><li>Pt / family anxiety </li></ul>
    35. 40. <ul><li>Productive vs non-productive cough </li></ul><ul><li>Sputum quantity, appearance </li></ul><ul><li>Appropriate diagnostic studies </li></ul><ul><li>Effect of cough on pt / family </li></ul><ul><li>Need for cough suppressant vs. cough expectorant </li></ul><ul><li>Fever </li></ul>
    36. 41. <ul><li>Non-pharmacologic </li></ul><ul><ul><li>High Fowler’s </li></ul></ul><ul><ul><li>Pursed lip breathing </li></ul></ul><ul><ul><li>Thoracentesis or paracentesis </li></ul></ul><ul><ul><li>Calm reassurance </li></ul></ul><ul><ul><li>If dyspnea ↓ intake, use liquid supplements </li></ul></ul><ul><ul><li>Fan </li></ul></ul><ul><ul><li>Relaxation, imagery, therapeutic touch </li></ul></ul><ul><ul><li>O2 if helpful. Base on symptom relief, not oximetry </li></ul></ul><ul><ul><li>Throat lozenges </li></ul></ul><ul><ul><li>Suctioning rarely effective; irritates mucous membranes </li></ul></ul>
    37. 42. <ul><li>Pharmacologic </li></ul><ul><ul><li>Opioids PO, SL, SQ, IV, nebulized </li></ul></ul><ul><ul><ul><li>Start low / go slow if opioid naïve </li></ul></ul></ul><ul><ul><ul><li>If opioid tolerant, dose = breakthrough pain dose </li></ul></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Bronchodilators </li></ul></ul><ul><ul><li>Anticholinergic </li></ul></ul><ul><ul><li>Expectorant </li></ul></ul><ul><ul><li>Antibiotics, if appropriate </li></ul></ul><ul><ul><li>Anxiolytic medications </li></ul></ul><ul><ul><li>Continuous Care / Hospice Inpatient </li></ul></ul><ul><ul><li>Sedation at end of life </li></ul></ul><ul><ul><li>Opioids vs resp depression – do not withhold from dying patient </li></ul></ul>
    38. 43. <ul><li>Non-opioid (dextromethorphan, benzonatate) or opioid cough suppressants </li></ul><ul><li>Nebulized lidocaine </li></ul><ul><li>Cough r/t CHF </li></ul><ul><ul><li>Diuretic </li></ul></ul><ul><ul><li>Beta-Blocker </li></ul></ul><ul><ul><li>ACE Inhibitor </li></ul></ul>
    39. 45. <ul><li>Medications </li></ul><ul><ul><li>Opioids, TCA, phenothiazines, antacids, diuretics, iron, vincristine, antihypertensives, anticonvulsants, anticholinergics, NSAIDs </li></ul></ul><ul><li>Obstruction </li></ul><ul><li>Metabolic disorders: ↑ Ca, ↓ K, ↓ Thyroid. </li></ul><ul><li>Colitis, diverticular disease, DM </li></ul><ul><li>Dietary: low fiber, inadequate fluid, dehydration </li></ul><ul><li>Neuro: confusion, depression, sedation </li></ul><ul><li>Weakness, inactivity, immobility </li></ul><ul><li>Pain r/t constipation </li></ul><ul><li>Privacy </li></ul>
    40. 46. <ul><li>Bowel history </li></ul><ul><li>Food / fluid intake </li></ul><ul><li>Medications </li></ul><ul><li>Mobility </li></ul><ul><li>Abdominal assessment </li></ul><ul><li>↑ flatus </li></ul><ul><li>Nausea, vomiting </li></ul><ul><li>Rectal exam </li></ul><ul><li>Pt / family understanding of causes </li></ul>
    41. 47. <ul><li>PREVENTION PREVENTION PREVENTION </li></ul><ul><li>R/O Bowel obstruction </li></ul><ul><ul><li>Disimpaction – premedicate </li></ul></ul><ul><ul><ul><li>Contraindicated in neutropenic / thrombocytopenic pts, as well as cardiac pts </li></ul></ul></ul><ul><li>Non-pharmacologic therapy </li></ul><ul><ul><li>↑ fluid, ↑ fiber intake, ↑ activity, what has worked before? </li></ul></ul><ul><li>Pharmacologic therapy </li></ul><ul><ul><li>Softener, stimulant laxatives </li></ul></ul><ul><ul><li>Routine use </li></ul></ul><ul><ul><li>Titrate meds to changes in opioids </li></ul></ul><ul><ul><li>If no BM in 3 days, ↑ fluid & add osmotic laxative (Lactulose or Sorbitol) </li></ul></ul><ul><ul><li>Dulcolax or Glycerin suppository or biphosphate enema </li></ul></ul><ul><ul><li>Stop medications (Calcium, Iron) if not medically necessary </li></ul></ul><ul><li>Rectal pain: hemorrhoid preparations or warm sitz bath (r/o herpes in case of pt with HIV) </li></ul><ul><li>Algorithm on page 108 of Core Curriculum </li></ul>
    42. 48. <ul><li>Laxative overuse </li></ul><ul><li>S.E. other drugs (NSAIDs, antibiotics) </li></ul><ul><li>Radiation, chemotherapy </li></ul><ul><li>Food intolerance, tube feeding </li></ul><ul><li>Malnutrition (cachexia r/t cancer or AIDS) </li></ul><ul><li>Surgery: gastrectomy, colectomy </li></ul><ul><li>Fecal impaction </li></ul><ul><li>Infection </li></ul><ul><li>Partial intestinal obstruction </li></ul><ul><li>Tumors: GI, carcinoid, pancreatic, SCLC </li></ul><ul><li>GI disorders: inflammatory bowel disease, pancreatic insufficiency, diverticulitis, ulcerative colitis, Crohn’s disease </li></ul><ul><li>DM, hyperthyroidism </li></ul>
    43. 49. <ul><li>History </li></ul><ul><li>Review Diet </li></ul><ul><li>Physical exam </li></ul><ul><ul><li>Abdominal assessment </li></ul></ul><ul><ul><li>Nature / consistency of stool </li></ul></ul><ul><li>Signs of dehydration </li></ul><ul><li>Skin integrity </li></ul>
    44. 50. <ul><li>↑ fluid, electrolyte replacement drinks </li></ul><ul><li>Clear liquids x 24 hrs, advance as tolerated </li></ul><ul><ul><li>Avoid spicy, greasy, high-fiber foods </li></ul></ul><ul><ul><li>Avoid foods high in caffeine and lactose </li></ul></ul><ul><ul><li>Small frequent meals </li></ul></ul><ul><ul><li>B R A T diet </li></ul></ul><ul><li>Disimpact. Premedicate </li></ul><ul><li>Stop laxatives if no impaction </li></ul><ul><li>Antidiarrheals: Loperamide, Lomotil, opioids </li></ul><ul><li>Panreatic enzymes with Loperamide </li></ul><ul><li>Skin integrity </li></ul><ul><li>Table 3 on page 111. Caution re: Bulk forming agents </li></ul>
    45. 51. <ul><li>May be more distressing to family than patient </li></ul><ul><li>Etiology: pain, constipation, n/v, mucositis, gastroparesis, dysgeusia, dentures, depression, fatigue, medications, radiation, chemotherapy, disease progression, malabsorption, change in fluid/electrolyte balance. </li></ul><ul><li>Diagnoses </li></ul><ul><li>Interventions: Dietician, small frequent meals, cool food, treat GI symptoms, supplements, enteral feedings if appropriate, TPN/PPN if appropriate (rare in hospice), emotional needs, Table 2 shows pharmacologic interventions. </li></ul><ul><li>Pt / family education </li></ul>
    46. 52. <ul><li>Dysphagia = difficulty swallowing </li></ul><ul><ul><li>Obstructive: Ca esophagus / head & neck, benign peptic stricture and lower esophageal ring (hx of GERD) </li></ul></ul><ul><ul><ul><li>Occurs with eating/drinking: meat/ bread most difficult </li></ul></ul></ul><ul><ul><li>Motor: neuromuscular, esophageal dysfunction (stasis) r/t smooth muscle spasm (GERD), ALS, scleroderma </li></ul></ul><ul><ul><ul><li>Both liquids and solids </li></ul></ul></ul>
    47. 53. <ul><li>Odynophagia = painful swallowing </li></ul><ul><ul><li>Inflammatory process: candidiasis, (antibiotics, DM, compromised immunity [AIDS, leukemia, chemotherapy]) </li></ul></ul><ul><ul><li>Dry mucous membranes r/t xerostomia (↓ saliva) from radiation, anticholinergics, other meds </li></ul></ul><ul><ul><li>Corrosive esophagitis </li></ul></ul><ul><ul><li>Bronchoesophageal fistula: “coughing after ingesting fluids” </li></ul></ul>
    48. 54. <ul><li>Etiology will guide intervention </li></ul><ul><li>Common complaints: choking on fluids, long meal times, nasal regurgitation of fluids, difficulty starting to swallow, dry mouth, solids caught in throat, regurgitation / emesis after swallowing, sour taste in mouth, after eating, pain on swallowing </li></ul><ul><li>For odynophagia, treat underlying cause to relieve symptom: </li></ul><ul><ul><li>Assess oral cavity </li></ul></ul><ul><ul><li>Onset, duration </li></ul></ul><ul><ul><li>Voice quality, swallowing ability, oral hygiene </li></ul></ul><ul><ul><li>Oral intake history </li></ul></ul><ul><ul><li>Review history for AIDS, DM, chemotherapy, radiation </li></ul></ul><ul><ul><li>Contributing agents: steroid inhalers, steroids, antibiotics </li></ul></ul><ul><ul><li>Candidiasis in throat may not be seen in mouth </li></ul></ul>
    49. 55. <ul><li>Candidiasis: Nystatin, Fluconozole </li></ul><ul><li>Mucositis / Esophagitis from radiation: Magic M/W, Banhurt </li></ul><ul><li>Obstruction from tumor / nodes: Steroids </li></ul><ul><li>↓ Esophageal motility: Prokinetic (Metoclopromide) </li></ul><ul><li>GERD: Omeprazole, ranitidine </li></ul><ul><li>Neuromotor: ST consult </li></ul><ul><li>Dry mucosa: Artificial saliva </li></ul><ul><li>Food consistency (thickened liquids) </li></ul><ul><li>Artificial feeding if appropriate </li></ul>
    50. 56. <ul><li>Etiology </li></ul><ul><ul><li>External compression of lumen </li></ul></ul><ul><ul><li>Internal occlusion of lumen </li></ul></ul><ul><ul><li>Ischemic or inflammatory precesses </li></ul></ul><ul><ul><li>Fecal blockage </li></ul></ul><ul><ul><li>Adynamic ileus (pneumonia, metabolic/electrolyte problems) </li></ul></ul><ul><ul><li>Metabolic disorders (Crohn’s, ↓ K) </li></ul></ul><ul><ul><li>Drugs (diuretics ->↓ K, which ↓ peristalsis, opioids, chemotherapy) </li></ul></ul><ul><li>May be more than one etiology </li></ul>
    51. 57. <ul><li>Assessment </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><ul><li>Crampy colicky pain in middle to upper abdomen, relieved with vomiting, suggests SBO </li></ul></ul></ul><ul><ul><ul><li>Crampy pain in lower abdomen, ↑ over time, suggests LBO </li></ul></ul></ul><ul><ul><ul><li>Severe, steady pain is sign of bowel strangulation </li></ul></ul></ul><ul><ul><li>Distention: may be severe in LBO, visible peristalsis, constipation / bloating </li></ul></ul><ul><ul><li>Nausea / Vomiting: moderate to severe in SBO; can relieve pain. May develop later in LBO </li></ul></ul><ul><ul><li>Bowel sounds: hyperactive or hypoactive </li></ul></ul><ul><ul><li>Constipation or diarrhea </li></ul></ul><ul><ul><li>Fever / chills in bowel ischemia / strangulation </li></ul></ul>
    52. 58. <ul><li>Interventions </li></ul><ul><ul><li>PREVENTION </li></ul></ul><ul><ul><li>Disimpact </li></ul></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>Medication: loperamide or scopolamine, atropine, glycopyrrolate, opioids </li></ul></ul><ul><ul><li>Ocreotide: lacks adverse effects of anticholinergics </li></ul></ul><ul><ul><ul><li>Give SC or IV </li></ul></ul></ul><ul><ul><li>Corticosteroids </li></ul></ul><ul><ul><li>Stop stimulant laxatives (Senna & Bisacodyl)and prokinetics (Metoclopromide) if pt having colicky pain </li></ul></ul><ul><ul><li>Medication for N/V: promethazine, prochlorperazine, haloperidol, lorazepam </li></ul></ul><ul><ul><li>Gastric decompression </li></ul></ul><ul><ul><li>Oral fluids if N/V can be controlled. Parenteral fluids if vomiting not controlled and pt at risk for dehydration </li></ul></ul>
    53. 59. <ul><li>Etiology: </li></ul><ul><ul><li>Distention </li></ul></ul><ul><ul><li>CNS: neoplasm, stroke, MS, shunts, AV malformations, hydrocephalus, head trauma </li></ul></ul><ul><ul><li>Irritation of phrenic / vagus nerve </li></ul></ul><ul><ul><li>Tumors of neck, lung, mediastinum </li></ul></ul><ul><ul><li>Chest surgery / trauma </li></ul></ul><ul><ul><li>Pulmonary edema, pneumonia, bronchitis, asthma, COPD </li></ul></ul><ul><ul><li>GI: esophagitis / esophageal obstruction, gastritis, peptic ulcer disease, gastric cancer, pancreatitis, pancreatic cancer, bowel obstruction, cholelithiasis / cholecystitis </li></ul></ul><ul><ul><li>Renal/hepatic disorders </li></ul></ul><ul><ul><li>Metabolic disorders: uremia, hypocalcemia, hyponatremia </li></ul></ul><ul><ul><li>Infection disease: sepsis, influenza, herpes zoster, malaria, tuberculosis </li></ul></ul><ul><ul><li>Pharmacologic agents: general anesthesia, IV corticosteroids, barbiturates, benzodiazepines, diazepam, chlordiazepoxide </li></ul></ul><ul><ul><li>Psychogenic: stress, excitement, greif reaction, anorexia, personality disorder </li></ul></ul>
    54. 60. <ul><li>Assess: </li></ul><ul><ul><li>How much distress? </li></ul></ul><ul><ul><li>Which etiology? </li></ul></ul><ul><ul><li>Underlying disease process </li></ul></ul><ul><ul><li>Severity / duration </li></ul></ul><ul><ul><li>What helps? </li></ul></ul><ul><ul><li>Hiccoughs that stop during sleep may be psychogenic. </li></ul></ul>
    55. 61. <ul><li>Interventions: </li></ul><ul><ul><li>Non-pharmacologic </li></ul></ul><ul><ul><ul><li>Nasopharyngeal stimulation </li></ul></ul></ul><ul><ul><ul><li>Interference with normal respiratory function </li></ul></ul></ul><ul><ul><ul><li>If related to gastric distention </li></ul></ul></ul><ul><ul><ul><li>Complimentary therapies </li></ul></ul></ul><ul><ul><li>Pharmacologic </li></ul></ul><ul><ul><ul><li>Distention: Simethicone, Metoclopramide, Baclofen </li></ul></ul></ul><ul><ul><ul><li>Peppermint oil </li></ul></ul></ul><ul><ul><ul><li>Calcium Channel blockers </li></ul></ul></ul><ul><ul><ul><li>Clorpromazine </li></ul></ul></ul><ul><ul><ul><li>Anticonvulsants if CNS etiology (carbamazepin, phenytoin, valproic acid) </li></ul></ul></ul><ul><ul><ul><li>Nebulized lidocaid </li></ul></ul></ul><ul><ul><li>Invasive techniques </li></ul></ul><ul><ul><ul><li>Phrenic nerve interruption (bupivacaine or surgery) </li></ul></ul></ul><ul><ul><ul><li>Pacing electrodes for diaphragmatic or phrenic nerve stimulation </li></ul></ul></ul>
    56. 62. <ul><li>Fluid / electrolyte imbalance </li></ul><ul><ul><li>↑ Ca, ↓ Na, uremia, dehydration </li></ul></ul><ul><li>GI disorders </li></ul><ul><li>Other disorders (thrush, cough, pain, fever) </li></ul><ul><li>Neuro disorders (CNS tumors, ↑ ICP) </li></ul><ul><li>Renal failure </li></ul><ul><li>Vestibular </li></ul><ul><li>Chemical (radiation, chemotherapy, antibiotics, aspirin, iron, steroids, digoxin, expectorants, NSAIDs, opioids, theophylline) </li></ul><ul><li>Psychogenic (anxiety, anticipatory n/v, fear) </li></ul><ul><li>↑ fat foods </li></ul>
    57. 63. <ul><li>History: heartburn? Constipation? Thirst? </li></ul><ul><li>Pattern of nausea </li></ul><ul><li>Assess emesis for volume, color, odor, blood </li></ul><ul><li>Abdominal assessment </li></ul><ul><li>Oropharynx for thrush or presence of tenacious sputum </li></ul><ul><li>Signs of ↑ICP </li></ul><ul><li>Wounds, anxiety, pain, fear </li></ul>
    58. 64. <ul><li>Modify diet </li></ul><ul><li>Reversible causes (cough, ↑ ICP, ↑ Ca) </li></ul><ul><li>Keep cool </li></ul><ul><li>HOB ↑ </li></ul><ul><li>Medication </li></ul><ul><ul><li>Prokinetic </li></ul></ul><ul><ul><li>Butyrophenones (haloperidol) for opioid induced </li></ul></ul><ul><ul><li>Antihistamine for visceral irritation, bowel obstruction, vestibular, pharyngeal stimulation, ↑ICP, </li></ul></ul><ul><ul><li>Anticholinergics for ↑ ICP, vestibular disturbance </li></ul></ul><ul><ul><li>Chemoreceptor Trigger Zone – metabolic disorders, toxins from GI tumors, infection – haloperidol, metoclopramide, phenothiazines </li></ul></ul><ul><ul><li>Chemotherapy – 5HT serotonin receptor antagonists (ondansetron, granisetron) </li></ul></ul><ul><ul><li>Opioid rotation </li></ul></ul><ul><ul><li>Treat constipation </li></ul></ul><ul><li>Oral hygiene </li></ul><ul><li>Table 7 on page 137 </li></ul>
    59. 65. <ul><li>Etiology </li></ul><ul><ul><li>Obstruction: impaction or tumor </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Sphincter damage r/t rectal ca, recto-vaginal fistula, inflammatory bowel disease </li></ul></ul><ul><ul><li>Spinal cord lesion or compression, MS, DM </li></ul></ul><ul><ul><ul><li>Causes sensory or motor dysfunction </li></ul></ul></ul><ul><ul><li>Change in sphincter tone r/t age, SCC </li></ul></ul><ul><ul><li>Dementia or mobility related </li></ul></ul>
    60. 66. <ul><li>Intervention </li></ul><ul><ul><li>Bowel regimen, adjust laxative dose </li></ul></ul><ul><ul><li>Use opioids for constipating effect (codeine most effective) </li></ul></ul><ul><ul><li>Disimpact </li></ul></ul><ul><ul><li>Modify diet </li></ul></ul><ul><ul><ul><li>↓ fiber, ↑fluid, avoid very cold or hot liquids, avoid spicy, greasy, rich, fried foods </li></ul></ul></ul><ul><ul><ul><li>Avoid caffeine and milk products </li></ul></ul></ul><ul><ul><ul><li>B R A T diet </li></ul></ul></ul><ul><ul><li>Toileting routine </li></ul></ul>
    61. 68. <ul><li>Etiology </li></ul><ul><ul><li>Catheter obstruction, size too large, balloon too large </li></ul></ul><ul><ul><li>UTI </li></ul></ul><ul><ul><li>Fecal impaction </li></ul></ul><ul><ul><li>Radiation or chemotherapy cystitis </li></ul></ul><ul><ul><li>Urethral obstruction (tumors or blood clots) </li></ul></ul><ul><ul><li>Neurologic (CVA, MS, Spinal cord lesion) </li></ul></ul><ul><li>Etiology will guide interventions </li></ul><ul><li>Pharmacologic interventions: </li></ul><ul><ul><li>Oxybutynin, NSAIDs, B & O suppositories </li></ul></ul>
    62. 69. <ul><li>Urge Incontinence </li></ul><ul><ul><li>Irritation: infection, tumor, radiation, chemotherapy </li></ul></ul><ul><ul><li>Spinal cord damage, stroke, MS, Parkinson’s, Alzheimer’s </li></ul></ul><ul><ul><li>↓ mobility </li></ul></ul><ul><li>Stress Incontinence </li></ul><ul><ul><li>Tumor infiltration or spinal cord lesion </li></ul></ul><ul><ul><li>Multiparity or post-menopausal changes </li></ul></ul><ul><li>Overflow </li></ul><ul><ul><li>Bladder outlet obstruction </li></ul></ul><ul><ul><li>Detrusor muscle failure (anticholinergic drugs, CNS lesions, debility, confusion) </li></ul></ul>
    63. 70. <ul><li>Functional incontinence (no impairment of GU tract) </li></ul><ul><li>Drugs </li></ul><ul><ul><li>Diuretics ↑ volume / frequency </li></ul></ul><ul><ul><li>Anticholinergics ↓ bladder contraction </li></ul></ul><ul><ul><li>Sedatives ↓ awareness, ↓ bladder contraction </li></ul></ul><ul><ul><li>Antiparkinson drugs ↑ outlet resistance </li></ul></ul><ul><li>Hypercalcemia </li></ul><ul><li>Atonic Bladder </li></ul><ul><ul><li>Diabetic neuropathy </li></ul></ul><ul><ul><li>Spinal cord lesions </li></ul></ul><ul><ul><li>Neurologic dysfunction </li></ul></ul>
    64. 71. <ul><li>Interventions </li></ul><ul><ul><li>Review medications </li></ul></ul><ul><ul><li>Voiding schedule, proximity to toilet, privacy </li></ul></ul><ul><ul><li>↓ fluid at night, limit caffeine </li></ul></ul><ul><ul><li>Check for fecal impaction / bowel regime </li></ul></ul><ul><ul><li>Urge incontinence: treat UTI, urinary tract analgesics </li></ul></ul><ul><ul><li>Stress incontinence: pelvic floor muscle exercizes, voiding schedule, imipramine at HS </li></ul></ul><ul><ul><li>Overflow incontinence: stop anticholinergics, disimpact, Bethanechol (Urecholine), catheter </li></ul></ul><ul><ul><li>Fistulas: Urinary diversion (if life expectancy is not short) </li></ul></ul>
    65. 73. <ul><li>Pressure Ulcers </li></ul><ul><li>Oral Mucous Membranes </li></ul><ul><ul><li>Dry Mouth (Xerostomia) </li></ul></ul><ul><ul><li>Candidiasis </li></ul></ul><ul><ul><li>Herpes Simplex </li></ul></ul><ul><ul><li>Mucositis </li></ul></ul><ul><li>Pruritis </li></ul>
    66. 74. <ul><li>Pressure </li></ul><ul><li>Shearing or Friction </li></ul><ul><li>Moisture </li></ul><ul><li>Obesity, Malnutrition, Cachexia </li></ul><ul><li>Immobility </li></ul><ul><li>Impaired Circulation </li></ul>
    67. 75. <ul><li>Stage I – Non-blanchable erythema of intact skin </li></ul><ul><li>Stage II – Partial thickness skin loss involving epidermis, dermis or both. </li></ul><ul><li>Stage III – Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia </li></ul><ul><li>Stage IV – Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures; undermining and sinus tracts also may be present. </li></ul>
    68. 76. <ul><li>Braden Scale </li></ul><ul><li>Pressure Ulcer Scale for Healing (PUSH) </li></ul><ul><li>Pain? </li></ul><ul><li>Tumor necrosis? </li></ul><ul><li>Malodorous? Fungating? </li></ul><ul><li>Nutritional Assessment </li></ul>
    69. 77. <ul><li>Relieve pressure, reduce friction & shearing </li></ul><ul><li>Consult dietician </li></ul><ul><li>Consult ET nurse </li></ul><ul><li>AHRQ guidelines </li></ul><ul><li>Cleanse wounds with normal saline </li></ul><ul><li>Dressing selection: </li></ul><ul><ul><li>Moist wound bed, dry surrounding skin, control exudate, consider caregiver time (see page 87) </li></ul></ul><ul><li>Pain control with dressing changes </li></ul>
    70. 78. <ul><li>Etiologies: </li></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><li>Radiation, chemotherapy </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Mucositis </li></ul></ul><ul><ul><li>Mouth breathing </li></ul></ul><ul><ul><li>Hypercalcemia, hyperglycemia </li></ul></ul><ul><li>Assessment of internal / external oral mucosa </li></ul>
    71. 79. <ul><li>Stimulate salivation </li></ul><ul><ul><li>Peppermint water, gum, hard candy </li></ul></ul><ul><ul><li>Avoid lemon preparations </li></ul></ul><ul><ul><li>Ice chips / sips water </li></ul></ul><ul><ul><li>Pilocarpine (not for COPD or bowel obstruction) </li></ul></ul><ul><li>Saliva substitutes </li></ul><ul><ul><li>Ice chips / sips water </li></ul></ul><ul><ul><li>Artificial saliva </li></ul></ul>
    72. 80. <ul><li>Etiologies: </li></ul><ul><ul><li>Radiation, chemotherapy </li></ul></ul><ul><ul><li>Medications (corticosteroids, antibiotics) </li></ul></ul><ul><ul><li>Altered immune system </li></ul></ul>
    73. 81. <ul><li>Candida: Nystatin, Fluconozole </li></ul><ul><li>ATC Mouth care q 2 to 4 hours </li></ul><ul><li>1:4 H2O2 / H2O rinse </li></ul><ul><li>Soft moist bland foods </li></ul><ul><li>Magic Mouthwash, Banhurt </li></ul>
    74. 82. <ul><li>Etiology: Chemotherapy / Radiation </li></ul><ul><li>Banhurt 15 ml contains: </li></ul><ul><ul><li>Prednisone 2.5 mg (anti-inflammatory) </li></ul></ul><ul><ul><li>Tetracycline 125mg (antibacterial) </li></ul></ul><ul><ul><li>Nystatin 250,000 units (antifungal) </li></ul></ul><ul><ul><li>DiphenhydrAMINE 12.5mg (anesthetic) </li></ul></ul>
    75. 83. <ul><li>Etiologies: </li></ul><ul><ul><li>Dry, flaky skin </li></ul></ul><ul><ul><li>Wet, macerated skin </li></ul></ul><ul><ul><li>Contact dermatitis </li></ul></ul><ul><ul><li>Scabies, lice, fleas </li></ul></ul><ul><ul><li>Drugs (antibiotics, morphine, phenothiazines) </li></ul></ul><ul><ul><li>Systemic disease (renal failure, hepatobiliary disease, tumor infiltration into SC tissue) </li></ul></ul><ul><ul><li>Fungal infections </li></ul></ul>
    76. 84. <ul><li>Assessment </li></ul><ul><ul><li>Location </li></ul></ul><ul><ul><li>Rash / Lesions </li></ul></ul><ul><ul><li>Skin integrity </li></ul></ul><ul><ul><li>Aggravating / alleviating factors </li></ul></ul><ul><li>Interventions </li></ul><ul><ul><li>Avoid skin irritation </li></ul></ul><ul><ul><li>Maintain cool room </li></ul></ul><ul><ul><li>Cool (starch) baths, compresses </li></ul></ul><ul><ul><li>Ointments / cream / antihistamines / topical corticosteroid / antifungal </li></ul></ul><ul><ul><li>Cholestyramine for E. S. Liver itching </li></ul></ul>
    77. 85. <ul><li>Wound care, turning/positioning, mobility </li></ul><ul><li>Frequent oral care </li></ul><ul><li>Nutritional concerns </li></ul><ul><li>Prevention / treatment of Pruritis </li></ul>
    78. 87. <ul><li>Etiology: </li></ul><ul><ul><li>Sudden onset: SCC, CNS tumor </li></ul></ul><ul><ul><li>COPD, CHF </li></ul></ul><ul><ul><li>Tumor infiltration of bone marrow </li></ul></ul><ul><ul><li>Liver disease with coagulopathy </li></ul></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><li>Uremia t/t renal failure, tumor or nephrotoxic drugs </li></ul></ul><ul><ul><li>Metabolic: hypercalcemia </li></ul></ul><ul><ul><li>Medications: beta-blockers, antihistamines, benzodiazepines, phenothiazines, zidovudine, myelosuppressive chemotherapy, radiation </li></ul></ul><ul><ul><li>Nutritional deficiency: </li></ul></ul><ul><ul><ul><li>Iron, B12, folate </li></ul></ul></ul><ul><ul><ul><li>Anorexia, n/v, weight loss </li></ul></ul></ul><ul><ul><ul><li>GI malabsorption </li></ul></ul></ul><ul><ul><li>Infection: </li></ul></ul><ul><ul><ul><li>AIDS-related </li></ul></ul></ul><ul><ul><ul><li>Pneumonia </li></ul></ul></ul><ul><ul><ul><li>UTI </li></ul></ul></ul><ul><ul><li>Emotional factors </li></ul></ul><ul><ul><li>Environmental factors </li></ul></ul>
    79. 88. <ul><li>Prognosis, wishes & advance directives </li></ul><ul><li>Treat underlying causes </li></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Endocrine disorder </li></ul></ul><ul><ul><li>Medication induced </li></ul></ul><ul><ul><ul><li>Taper / discontinue </li></ul></ul></ul><ul><ul><ul><li>Tolerance to opioids usually occurs 48 – 72 hrs </li></ul></ul></ul><ul><ul><ul><li>Methulphenidate in am & noon. </li></ul></ul></ul><ul><li>Treat depression & anxiety </li></ul><ul><li>Non-pharmacologic </li></ul><ul><ul><li>Pace activities </li></ul></ul><ul><ul><li>DME </li></ul></ul><ul><ul><li>Realistic goals </li></ul></ul><ul><ul><li>PT / OT, if appropriate </li></ul></ul><ul><ul><li>Hospice Aide </li></ul></ul><ul><li>Table 6 on page 130 </li></ul>
    80. 90. <ul><li>Core Curriculum for the Generalist Hospice and Palliative Nurse, 2 nd Edition, Kendall Hunt Publishing Company, 2005 </li></ul><ul><li>Study Guide for the Generalist Hospice and Palliative Nurse, 3 rd Edition, Kendall Hunt Professional, 2009. </li></ul><ul><li>Ferrell, Betty R, Coyle, Nessa, eds. Textbook of Palliative Nursing. New York, N.Y.: Oxford University Press; 2001. </li></ul><ul><li>Fast Facts, http ://www.eperc.mcw.edu/ </li></ul>

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