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3. Symptoms Psychological.pdf
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- 2. Objectives 1. Describe delirium, fatigue, anxiety and depression symptoms experienced by children at the end of life 2. Review essential assessment strategies used to diagnose these symptoms as part of paediatric palliative care 3.Present an approach to symptom management for psychologic symptoms
- 3. Delirium Definition • Disturbance of consciousness (attention and awareness) and cognition (memory, orientation, language, perception) • Acute onset, fluctuating course •Cause ‐ Underlying disease process ‐ Side effects of treatment ‐ Highly abnormal environment
- 4. Assessment of Delirium Assessment • Often under recognized • Cornell Assessment of Pediatric Delirium (CAP‐D)‐pediatric screening tool • Consult psychiatry unit to assist with diagnosis Risk factors • Significant developmental delay • Supplemental oxygen/mechanical ventilation • Preschool children
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- 6. Treatment of Delirium Treatment • Treat the underlying cause for the delirium (i.e., electrolytes, infection, pain, dyspnea) • Reduce iatrogenic factors (i.e. avoiding anticholinergics or restraints, encourage mobilization) •Optimize environment – adjust sleep/wake cycle, redirection/re‐orientation • Medication (quetiapine, haloperidol, risperidone, olanzapine) Joyce, C., Witcher, R., Herrup, E., Kaur, S., Mendez‐Rico, E., Silver, G., Greenwald, B.M., & Traube, C. (2015). Evaluation of the safety of quetiapine in treating delirium in critically ill children: a retrospective review. Journal of Child & Adolescent Psychopharmacology, 25(9), 666‐670.
- 7. Fatigue Definition • Subjective, multidimensional experience of exhaustion • Fatigue has been reported in 50‐75% of children undergoing cancer treatments •Commonly associated with many diseases • Impacts quality of life at all dimensions Erickson, J.M., Beck, S.L., Christian, B.R., Dudley, W., Hollen, P.J., Albritton, K.A. et al. (2011). Fatigue, sleep‐wake disturbances, and quality of life in adolescents receiving chemotherapy. Journal of Pediatric Hematology/Oncology, 33(1), e17‐e25. Miller, E., Jacob, E., & Hockenberry, M.J. (2011). Nausea, pain, fatigue, and multiple symptoms in hospitalized children with cancer. Oncology Nursing Forum, 38(5), E382‐E393.
- 8. Disease related • Anemia • Electrolyte imbalances, hyperglycemia •Malnutrition (however, improving intake has not been shown to alleviate this symptom) • Infection, fever • Pain • Organ failure (heart/lungs/kidneys/liver) • Adverse environment (heat or cold extremes) Causes of Fatigue
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- 10. Assessment of Fatigue Subjective • Symptom assessment scale Objective • Test muscle strength, symmetry, and endurance of upper and lower extremities •Cognitive status – difficulty concentrating, forgetfulness, orientation • Nutritional assessment – weight gain/loss, caloric intake and appetite • Review medications that may cause or worsen fatigue Laboratory data • Oxygenation status, FBC and differential, and Thyroid tests
- 11. Treatment of Fatigue Multifactorial • Evaluate possible causes and treat contributing factors (e.g. treat sleep disturbances, depression, nausea) Pharmacologic • Short term corticosteroids •Megestrol acetate can improve energy levels • Ritalin or amantadine Non‐pharmacologic • Rest • Energy conservation • PT/OT • Scheduled exercise routine O’Neil‐Page, E., Anderson, P., & Dean, G. (2015). Fatigue. In: B.R. Ferrell, N. Coyle & J. Paice (Eds.), Textbook of Palliative Nursing, 4th edition (Chapter 8, pp. 154‐166). New York, NY: Oxford University Press.
- 12. Sleep Disturbances • Often due to uncontrolled symptoms, most commonly pain ‐ Assess for adequate pain management and treat accordingly •Behavioral modification • Environment modification and sleep hygiene • Melatonin • Short term sleep aids ‐ i.e benzodiazepines
- 13. Depression • Depressed or irritable mood • Diminished interest or pleasure •Change in appetite or weight • Sleep disturbance • Physical symptoms (e.g. pain, GI, fatigue) • Psychomotor agitation or retardation • Feelings of worthlessness or guilt • Impaired concentration and decision making • Recurring thoughts of death or suicide
- 14. Depression Common in children and adolescents • Does not always manifest same as adult depression • Often unrecognized and undertreated Chronic and terminally ill children are at risk Age risk •Adolescent females are at greater risk than males • Prepubertal males are at greater risk than females
- 15. Depression Causes of Depression • Disease related • Psychological •Treatment related Risk Factors • Family history of depression and anxiety • Chronic illness • Traumatic brain injury • Poor coping skills • Caregiver/child conflict • Academic difficulties • History of anxiety disorders, substance use disorder
- 16. Treatment of Depression • Collaborative effort • Pharmacotherapy ‐SSRI ‐ Psychostimulants • Psychotherapy ‐ Grief/psychiatric counseling/therapy ‐ Draw on strengths • Combination therapy ‐ Pharmacotherapy plus psychotherapy
- 17. Anxiety Anxiety can come from different sources • Separation anxiety • Procedure related •Death anxiety • Inpatient admission (Abandonment) • Receiving bad news Assessment • Physical symptoms • Psychological symptoms • Behavioral symptoms • Assess for presence of uncontrolled symptoms/fears
- 18. Treatment of Anxiety • Optimize symptom management • Empathetic listening •Assurance and support • Relaxation/imagery • Medications – SSRI, benzodiazepines
- 19. Resources • Princess Marina Hospital Treatment Guidelines. Gaborone, Botswana. • Malawi Ministry of Health. (2015). Introduction to Children Palliative Care; Manual for service providers, Malawi Government. •Hospice Africa Uganda. (2015). Palliative Care Manual for Initiator of Palliative Care in Africa, 3rd Ed. Kampala, Uganda. • End‐of‐Life Nursing Education Consortium (ELNEC), based at the City of Hope in Duarte, California, initially established the pediatric end‐of‐life curriculum to train nurses throughout the United States. The authors of ELNEC have given Global HOPE permission to use their materials in this course for health care providers in Sub‐Saharan Africa.
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