Palliative Management Of: Nausea And Vomiting Dyspnoea Oral
Health Anxiety Delirium Fatigue Seizures Terminal bleeding Pain
Constipation
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Nausea and vomiting Tiredness, trouble concentrating, slow
wound healing, weight loss, and loss of appetite. interferes with
your patients ability to take care of themselves. Causes
Chemotherapy & Radiation therapy, cancer medications bowel slow
down or blockage (obstruction) inner ear problems an imbalance of
minerals and salts (electrolytes) in the blood infections anxiety
the expectation of vomiting due to earlier experiences
(anticipatory vomiting) other diseases or illnesses
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Managing Nausea and vomiting Regular, small amounts of diet and
fluids at the time of day when you the patient is best able to eat.
(Many people find that breakfast time is best). Medication
Alternative therapies Guided imagery -mentally block the nausea and
vomiting. Music therapy Acupressure
(http://www.acupressure.com/articles/Applying_pressure_
to_acupressure_points.htm )
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Managing decreased intake Things you can do: Encourage favorite
foods and drinks Offer drinks or sips often at least every two
hours Clean the mouth often a pleasant tasting mouth may make food
taste better Help family members and friends understand why eating
and drinking may cause the patient to be uncomfortable- find other
ways besides food and drink to show the patient they care. For
example, offer the patient a massage or look through a picture
album together Support the patients decision not to eat or drink
Encourage the patient to rest before and after a meal Check
dentures fit comfortably Make mealtime a quiet and pleasant time
candles, flowers, soft music and good conversation all help Offer
small meals and use smaller dishes If nausea is a problem, serve
small portions of salty (not sweet), dry foods and clear
liquids
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Oral health affects and affected by other conditions It is
important to offer or provide regular mouth care. Lips should be
kept moist with an appropriate emollient. Dentures should be
checked for comfort and cleaned well every night. Report any
concerns or changes to the team.
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Shortness of breath (dyspnoea) An uncomfortable awareness of
breathing Patients may describe the feeling as not enough air or
suffocating. Management Position-sitting upright, chest stretched
Oxygen or concentrator Fan therapy Reduce anxiety and activity Open
space/open windows or doors Restrict visitors
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Anxiety -A feeling or deep sense that things are not right
Symptoms Fear Worrying Sleeplessness Confusion Rapid breathing
Tension Shaking Inability to relax or get comfortable Sweating
Problems paying attention or concentrating Feelings that may be
causing the anxiety worrying about money Concerns about the illness
or fear of dying Problems with relationships with family or friends
Spiritual concerns Signs and symptoms that the anxiety is getting
worse
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Managing anxiety Treat physical problems such as pain that can
cause anxiety Do relaxing activities Keep things calm Limit
visitors Play soothing music Massage arm, back, hand or foot
Communicate concerns
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Spirituality needs 1.Encourage story telling Life Review
2.Touch 3.Music 4.Reading poetry, meditations, prayers 5.Pictures
6.Ritual 7.Conversation 8.Writing letters to family/friends
9.Recording feelings
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Fatigue What is fatigue? Tiredness, exhaustion or lack of
energy A condition which impacts the ability to perform any
activity Seen frequently in hospice and palliative care patients A
complicated symptom which can have many causes Sometimes comes with
depressed feelings What are the signs that a patient is fatigued?
Unable to perform the normal activities for that patient every
person is different in their normal activity level, just too tired
Not participating in the normal routine Lack of appetite do not
have the energy to eat Sleepiness Not talking Depressed You should
report any of the behaviours listed above
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Managing Fatigue The team will work with the patient and family
to find the causes for the fatigue and discuss treatments. Plan,
schedule and prioritize activities at optimal times of the day
Assess and document which time of the day seems to be his/her best
time Eliminate or postpone activities that are not his/her priority
Assist with position changes - do not encourage staying in bed Use
sunlight/light source to cue his/her body to feel energized Try
activities that restore energy Assist with daily activities such as
eating, moving or bathing, plan activities ahead of time Encourage
him/her to rest as needed Establish and continue a regular bedtime
and awakening Avoid interrupted sleep time to get continuous hours
of sleep Plan rest times or naps during the day during late morning
and mid afternoon Avoid sleeping later in the day, which could
interrupt night time sleep Increase food intake Try nutritious,
high protein, nutrient dense food -Small frequent meals -Add
protein supplements to foods or drinks Frequent mouth care (before
and after meals)
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Constipation Constipation -defined as the difficult or
incomplete evacuation of hard infrequent stools (e.g. twice or less
per week) or stool less frequently than is usual for the
individual. too small too hard too infrequent too difficult to
expel unable to be expelled completely.
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! - Constipation Facts Regular Bowel movements does not
necessarily mean that a patient is not constipated. Whenever a
Palliative Patient presents with diarrhoea it is a good idea for
you to suspect faecal impaction with overflow. Even patients with
little or no oral intake need to have regular bowel movements.
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What are the Symptoms of Constipation? Confusion- delirium
anxiety restlessness abdominal bloating or pain loss of appetite
nausea urine retention and incontinence urge to defecate but
inability to do so - suggests hard stool or rectal obstruction
overflow diarrhea - occurs when liquid faeces leaks around a hard
blockage or when unaware of stool passage
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Causes Decreased mobility Poor dietary or liquid intake
Medications (iron, opioids, anti-emetics) Weakness Dehydration
Confusion Discomfort with unfamiliar toilet facilities. Directly
related to malignancy haemorrhoids
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Management of Constipation It is so much easier to avoid
constipation in the first place than it is to treat it once it
happens. Your patient might need your help to create a bowel
routine aimed at the prevention of constipation. If a patient does
develop constipation, interventions are aimed at: Identifying and
treating underlying causes. Using a laxative and supportive regime
to maintain soft, regular stool Overall be aggressive toward
resolving constipation unless imminent death is apparent.
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Other management strategies Fluid and Food Intake Encourage
generous fluid intake with diet as tolerated Mobilization Encourage
mobilisation and exercise as tolerated. Ensure pain/symptom control
is maximised Toileting- 1. Sit upright when toileting if possible.
2. Enhance comfort by using raised toilet seat 3. Consider local
anaesthetic creams or ointments. 4. Provide privacy and time 5.
Time toileting events 30-60 minutes following ingestion of a meal,
especially morning or lunchtime
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Seizures Seeing someone have a seizure can be a frightening
experience. Try to remain calm. Signs and Symptoms The person
having a seizure may have some or none of these signs: Muscle
jerking / Twitching (convulsion) Stiffening of the body Unable to
awaken for a period of time Loss of bladder control Blurred vision
Inability to speak / Difficulty talking Eyes rolling back Sudden
confusion or memory loss Recurring movements chewing, lip smacking,
clapping Blank staring or blinking
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Managing Seizures Safety is the first concern. Stay with the
patient and call for help. Keep the person free from injury remove
any objects that the person may fall on or bump into Turn the
person on his/her side if vomiting occurs, or when the seizure ends
It is important not to restrain the person. Do not attempt to place
any objects in the mouth. Do not feed him/her until he/she is fully
awake/alert If possible, gently support the head by placing a
pillow under the head
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Confusion, agitation & Delirium Delirium is one of the most
frequent and serious complication -acute onset and fluctuating
course Supportive treatment Explanation of delirium, communication
with relatives. Calm, quite environment Clear and simple
communication Reorientation Glasses, hearing aids, dentures Good
light Visible clock Uninterrupted sleep
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Characteristics Abrupt onset Disorientation, fluctuation of
symptoms Hypoactive or hyperactive (restlessness, agitation,
aggression) or mixed Changes in sleeping patterns Incoherent,
rambling speech Fluctuating emotions Activity that is disorganized
and without purpose
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The Management Of Irreversible Delirium In The Imminently
Dying
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24 Agitated EOL Delirium Is A Medical Emergency Imagine in the
last few hours of life being: agitated, combative, striking out at
caregivers paranoid, saying hurtful things to family children /
grandchildren afraid to visit Loss of self / personhood / dignity
Lifelong difficult memories for family No chance for a do-over if
poorly managed An overarching goal of care becomes the effective,
consistent sedation of the patient until the condition's natural
course unfolds, and the patient dies as expected from the
underlying condition i.e. the goal is to ensure that the patient
does not waken again before dying
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25 Supporting Families At minimum, effective sedation changes
the beside dynamics from one in which people are afraid to visit
and there is no meaningful interaction to one in which people can
talk, read, sing, play favourite music, pray, tell stories, touch.
Health care team has a role in facilitating meaningful visits
family/friends may not know the right things to do Individuals may
want time alone but be reluctant to ask others (friends/family) to
leave the room. The health care team can suggest that this might be
something that the family can explore with each other
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26 Supporting Families Hearing is a resilient sense, as
evidenced by its potential to endure into the early phase of
general anesthesia If not true hearing, the comforting/settling
effect of the awareness of the presence of family can be remarkable
The approach is that some nature of hearing/awareness/spiritual
connection is maintained this therefore must be considered when
speaking about the patient in his/her presence. The question of can
they still hear us? arises frequently of course its not possible to
know this, however:
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Terminal bleeding clotting disorders, tumors that erode (or
wear away) blood vessels, and ulcers. Patients who have had
previous bleeding are at increased risk. Anticipate bleeding and
plan in place to respond should bleeding occur. The primary goal is
patient comfort and lessening patient and family anxiety and fear.
Signs and Symptoms of bleeding? Previous bleeding from any site of
the body including gums Blood-tinged coughing or vomiting Blood in
urine or stool Nose bleeds Skin with excessive bruising or many
pinpoint sized red areas on the skin What to Report to the RN Any
change in frequency or quantity of the above stated signs or
symptoms Keep air humidified Keep dark colored towels or blankets
and waterproof underpads on hand in the event that bleeding occurs
Do relaxing activities Keep things calm Limit visitors Play
soothing music
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Pain management Pain is not exclusively physiological but also
includes spiritual, emotional and psychosocial dimensions. The goal
of pain management is to provide maximum pain relief with minimal
side effects. A wide variety of factors including inaccurate
information, myths, rumors. fear and cultural issues contribute to
inadequate pain management. Since pain is identified and reported
primarily through patient self- reporting, difficulty in
communicating increases the patients risk for under-treatment.
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A fundamental Human Right (WHO) Seniors are among the biggest
group that suffers from inadequate pain control. The elderly tend
to minimize the expression of pain. They may also have underlying
depression or dementia, which may affect their ability to
communicate pain effectively. They may have impaired kidney or
liver function that affect the absorption and metabolism of pain
medications.
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Describing pain only in terms of its intensity is like
describing music only in terms of its loudness von Baeyer CL; Pain
Research and Management 11(3) 2006; p.157-162
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PAIN HISTORY How to report Description: severity, quality,
location, frequency, aggravating & alleviating factors Previous
history Context: social, cultural, emotional, spiritual factors
Interventions: what has been tried?
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Non-Pharmacological Pain Management Distraction Aromatherapy
Meditation/relaxation Guided imagery Therapeutic massage or
reflexology Music therapy Art Therapy Pet therapy
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Common myths -True or False? 1. Too much pain medication too
frequently constitutes substance abuse, causes addiction, will
result in respiratory depression or will hasten death; 2. Pain
should be treated, not prevented; 3. People in pain always report
their pain to their health care provider; 4. People in pain
demonstrate or show that they have pain - pain can be seen in the
patients behavior; 5. The level of pain is often exaggerated by the
patient; 6. Generally a patient cannot be relieved of all pain; 7.
Some pain is good so that the patients symptoms are not masked 8.
It is expected that the elderly, especially the frail elderly,
always have some pain.
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TOLERANCE A normal physiological phenomenon in which increasing
doses are required to produce the same effect Inturrisi C, Hanks G.
Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3
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PHYSICAL DEPENDENCE A normal physiological phenomenon in which
a withdrawal syndrome occurs when an opioid is abruptly
discontinued or an opioid antagonist is administered Inturrisi C,
Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter
4.2.3
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Opioid Side Effects Constipation need proactive laxative use
Nausea/vomiting Urinary retention Itch/rash Dry mouth Respiratory
depression uncommon when titrated in response to symptom Drug
interactions Neurotoxicity (OIN): delirium, myoclonus seizures Any
of the above should be reported to the RN
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Constipation risk There's an old saying: "The hand that writes
the opioid order also writes the laxative order". In other words, a
patient should be started on a laxative regime AT THE SAME TIME
that an opioid is started.
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Subcutaneous Medication Administration Infusions Unable to take
medications orally. Subcutaneous is frequently referred to as SubQ.
The SubQ insertion site may be on the abdomen, chest wall, upper
outer thigh, or the upper outer arm Care of SQ sites Avoid sudden
twisting or turning of the body area where the site is located to
avoid stretching the tubing During SQ administration or infusion,
slight redness or swelling at the site is common but should
decrease soon after the infusion is complete and should disappear
within 2-4 hours Check the site whenever you are caring for the
patient. If you notice leaking, pain, redness, bruising, burning,
or swelling at the site, report it to the nurse If the site becomes
painful or redness and swelling persist for several hours, report
it to the nurse
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Oh, how to place a value on the things that cannot be measured?
(Jones, 2009) What is it worth, when you receive a look that says I
feel your pain? What is it worth, when a hand reaches out to you in
comfort? What is it worth, to sit together in silence and know that
even without words, you have been heard? And what is the cost, if
these things had never occurred? Oh, how to place a value on the
things that cannot be measured?