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1
Clinical Review for the Hospice and Palliative Nurse
Symptom Management
2
Objectives
1. Define common symptoms present at the end of life.
2. Identify possible etiologies of symptoms at the end of life.
3. Assess for the physical and psychosocial aspects of the symptoms that are common at the end of life.
3
Objectives
4. Describe pharmacological and nonpharmacological interventions for common symptoms that can be included in the plan of care at the end of life.
5. Describe the patient and family instructions needed for patients and families at the end of life.
4
Domains of Quality Palliative Care
Clinical Practice Guidelines of Quality Palliative Care Domain 2: Physical Aspects of Care Guideline 2.1 Pain, other symptoms, and side
effects are managed based upon the best available evidence, with attention to disease-specific pain and symptom, which is skillfully and systematically applied.
5
Anorexia and Cachexia
Anorexia loss of appetite resulting in the inability to eat
Cachexia physical wasting and malnutrition usually associated with
chronic disease
6
Anorexia and Cachexia
Prevalence
Commonly found in patients with advanced disease 80% of cancer patients
7
Anorexia/Cachexia
Causes
Disease Related Infections Delayed gastric emptying Metabolic alterations Pain
8
Anorexia/Cachexia
Causes
Treatment Related Medications Chemotherapy Radiation
9
Anorexia/Cachexia
CausesPsychological and/or spiritual distress
Often overlooked Depression may exhibit somatic symptoms
10
Anorexia/Cachexia Assessment
Patient reports Muscle wasting Weight loss Lab values Intake patterns
11
Anorexia/Cachexia Pharmacological Interventions
Megestrol acetate (Megace®) Metoclopramide (Reglan®) Dexamethasone (Decadron®) Dronabinol (Marinol®)
12
Anorexia/Cachexia Non-pharmacological Interventions
Treat underlying symptoms Emotional support Nutritional support
13
Anorexia/Cachexia Non-pharmacological Interventions
Enteral and parenteral nutrition
14
Anorexia/Cachexia Patient & Family Education
Support patient’s wishes Discuss intake during dying process Explore meaning of food Address emotional needs Redirect caring
15
Anorexia/Cachexia References
1. Kemp C. Anorexia and cachexia, In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006:169-176.
2. Bednash G, Ferrell BR. End-of-life nursing education consortium (ELNEC). Washington, DC: Association of Colleges of Nursing; 2009.
3. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003.
16
Dehydration
Normal physiologic process at the end of life
Decreased desire for fluids
Symptoms vary
17
Causes of Dehydration
Loss of normal body water
Isotonic dehydration
Eunatremic dehydration
Hypotonic dehydration
18
Assessment for Dehydration
Mental status changes Confusion, restlessness
Intake and output Elderly may have decrease perception of thirst Urine output reduced
19
Assessment for Dehydration
Weight loss Reduced skin turgor
Skin and mouth assessment Postural hypotension Lab values
Increased hematocrit Serum sodium
20
Treatment of Dehydration
Ethical considerations Benefits vs. burdens
Review expected course of illness Artificial hydration Misperceptions
21
Treatment of Dehydration
Use least invasive approach possible Oral
Provide appropriate mouth care
Proctoclysis
22
Treatment of Dehydration
NG/GT NG uncomfortable
Hypodermoclysis Subcutaneous fluid administration
IV
23
Treatment of Dehydration
IV Monitor for over hydration
24
Dehydration Patient & Family Education
Oral/enteral/parenteral fluids Instruct more than one person Allow ample time for instruction and return
demonstration
25
Dehydration Patient & Family Education
Review benefits/burdens of artificial nutrition & dehydration
Address emotional needs Assist in redirecting ways of caring
26
Dehydration References
1. Emanuel L. von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003.
2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC). Washington, DC: Association of Colleges of Nursing; 2009.
3. Kedziera P, Coyle N. Hydration, thirst, and nutrition. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006: 239-248.
4. Kazanowski M. Symptom management in palliative care. In: Matzo, ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life. New York, NY: Springer; 2006: 319-344.
27
Nausea and Vomiting
Nausea Subjectively perceived Unpleasant sensation experienced in the back of the
throat and epigastrium, which may or may not result in vomiting
Vomiting expelling of stomach contents through the mouth
28
Nausea and Vomiting
PrevalenceCommon in patients with advanced disease 70% of patients experience nausea 30% of patients experience vomiting Patients under 65 and women Stomach, breast and gynecological cancer AIDS
29
Causes of Nausea and Vomiting
Physiological Causes Gastrointestinal Metabolic Central nervous system
Psychological Emotional
Disease related Treatment related
30
Nausea and Vomiting
Associated with Opioid therapy Uremia Hypercalcemia Constipation Bowel obstruction
31
Assessment of Nausea and Vomiting
History of disease Effectiveness of prior treatments Precipitating factors Self-reporting tools Physical Diagnostic testing
32
Nausea and Vomiting7 Steps for Antiemetics
1. Identify cause
2. Identify pathway of cause
3. Identify neurotransmitter receptor
4. Select potent antagonist for that receptor
5. Select a route
6. Titrate dose & administer ATC
7. If symptoms continue, additional treatment
33
Nausea and VomitingAntiemetics
Butyrophenones Indication: opioid-induced nausea, chemical and
mechanical nausea
Medications Haloperidol (Haldol) Droperidol (Inapsine)
34
Nausea and VomitingAntiemetics
Protokinetic agents Indication: gastric stasis, ileus
Medications Metoclopramide (Reglan) Domperidone (Motilium)
35
Nausea and VomitingAntiemetics
Cannabinoids Indication: second-line antiemetic
Medication Dronabinol (Marinol)
36
Nausea and VomitingAntiemetics
Phenothiazines Indications: general nausea and vomiting, not as
highly recommended for routine use in palliative care
Medications Prochlorperazine (Compazine) Thiethylperazine (Torecan) Trimethobenzamide (Tigan)
37
Nausea and Vomiting Antiemetics
Antihistamines Indications: intestinal obstruction, peritoneal
irritation, increased intracranial pressure, vestibular causes
Anticholinergics Indication: motion sickness, intractable
vomiting, or small bowel obstruction
38
Nausea and Vomiting Antiemetics
Steroids Appear to exert antiemetic effect as a result of
antiprostaglandin activity Most effective in combination with other agents
Benzodiazepines Indication: effective for nausea and vomiting as well
as anxiety
39
Nausea and VomitingAntiemetics
5-HT3 receptor antagonists Indicated for post-operative nausea and vomiting and
chemotherapy
ABHR Compounded antiemetics
40
Nausea and VomitingAntiemetics
Octreotide (Sandostatin®) Indications: nausea and vomiting associated with
intestinal obstruction
DimenhyDRINATE (Dramamine®) Indications: nausea, vomiting, dizziness, motion
sickness
41
Non-pharmacologicalTreatment of Nausea and Vomiting
Oral care Cool damp cloth Decrease noxious stimuli Loose-fitting clothes Fresh air or fan
42
Non-pharmacologicalTreatment of Nausea and Vomiting
Behavioral complementary therapies Interventions individually based
Cultural considerations
43
Nausea and VomitingPatient and Family Education
Assessment of nausea and vomiting Problem solving Family’s role Instruct when to call healthcare provider
44
Nausea and VomitingReferences
1. Berry PH, ed. Core Curriculum for the Generalist Hospice and Palliative Nurse. 2nd ed. Dubuque, IA: Kendal/Hunt; 2005.
2. King C. Nausea and vomiting. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006: 177-194.
3. Bednash G, Ferrell BR. End-of-life nursing education consortium (ELNEC - Geriatric). Washington, DC: Association of Colleges of Nursing; 20072005.
4. Kazanowski M. Symptom management in palliative care. In: Matzo ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life. New York, NY: Springer; 2006: 319-3442001:327-361.
5. Mannix K. Gastrointestinal symptoms. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 3rd New York, NY: Oxford University Press: 2005:1998464-468: 489-499.
45
Bowel Obstruction
Prevalence Related to site of disease Tumors of splenic flexure obstruct 49% of the time Rectum or rectosigmoid obstruct 6% of the time
46
Bowel Obstruction
Occlusion of the lumen or absence of the normal propulsion
Intralumen obstruction Extramural obstruction Mechanical obstruction Metabolic disorders Medications
47
Assessment of Bowel Obstruction
Assess within palliative care goals Bowel history Pain Palpate abdomen Rectal exam Location of obstruction
48
Treatment of Bowel Obstruction
Prevention Principles
Goal of treatment is prevention whenever possible Verify cause of obstruction: tumor vs. fecal
impaction If stool, goal is to move the stool down through the
intestinal tract Avoid stimulant laxatives - usually increase
discomfort and may cause intestinal wall rupture
49
Treatment Bowel Obstruction
Pharmacolologic Octreotide (Sandostatin®) Scopolamine Opioids Antiemetics
50
Treatment of Bowel Obstruction
Pharmacolologic Corticosteroids Antispasmodic Laxative / Antidiarrheal
51
Treatment of Bowel Obstruction
Surgical Considered within context of established palliative care
goals
52
Treatment of Bowel Obstruction
Non-pharmacological Avoid hot drinks Avoid big meals Consider NG
53
Bowel Obstruction Patient & Family Education
Review causes Discuss treatment options Educate to prevent Instruct when to call healthcare provider Review medications Review dietary recommendations
54
Bowel Obstruction References
1. Economou DC. Bowel management: constipation, diarrhea, obstruction, and ascites. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006: 219-238.
2. Kazanowski M. Symptom management in palliative care. In: Matzo ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life. New York, NY: Springer; 2006:319-344.
3. Emanuel L. von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003
55
Constipation
Infrequent passage of stool Increases with age Frequent with illness and at the end of life Results from some medications
Opioids!
56
Constipation
Prevalence 10% of general population Increases with age Effects more than 50% of patients in a palliative care
unit or in hospice Frequently seen symptom at the end of life Undertreated by nurses and doctors Can be very embarrassing for some patients Prevention is the key!
57
Causes of Constipation
Disease Related Cancer Diabetes Hypercalcemia
Medication Related Other
Dehydration Inactivity Depression
58
Assessment for Constipation
Bowel history Abdominal assessment Rectal Assessment
59
Assessment for Constipation
Physical assessment Diagnostic tests Medication review
Prescription Over the counter Herbals
60
Pharmacological Treatment of Constipation
Laxatives Lubricant laxatives - lubricate the stool surface & soften
the stool leading to easier bowel movement
Surfactant/detergent laxatives Reduce surface tension, increase absorption of fluids and
fats into stool which soften it can increase peristalsis
61
Pharmacological Treatment of Constipation
Combination medications Osmotic laxatives
non-absorbable sugars that exert an osmotic effect in primarily the small intestine
Osmotic suppositories Glycerine suppositories: Soften stool by osmosis and act
as lubricant
62
Pharmacological Treatment of Constipation
Laxatives Saline laxatives - increase gastric, pancreatic, & small
intestinal secretions, & motor activity throughout the intestine
63
Pharmacological Treatment of Constipation
Bowel stimulants Bowel stimulants - Work directly to irritate bowel &
stimulate peristalsis; Use with caution when liver disease present
64
Pharmacological Treatment of Constipation
Bulk Laxatives Provide bulk to the intestines to increase mass -
stimulates bowel to move
65
Pharmacological Treatment of Constipation
Enemas Soften stool by increasing water content
66
Opioid Induced Constipation
Opioid Induced Constipation Opioids
bind to mu–opioid receptors in the central nervous system – provide analgesia
also bind to peripheral mu–opioid receptors in the gastrointestinal tract, inhibiting bowel function – opioid induced constipation (OIC).
Pharmacologic / non-pharmacologic treatment Oral erythromycin Metoclopramide
67
Pharmacological Treatment of Constipation
Methylnaltraxone / (Relistor®) Inhibits opioid induced decreased gastrointestinal
motility and delay in gastrointestinal transit time Does not affect opioid analgesic effect Subcutaneous route / Dose according to weight
Decrease dose with renal impairment 50% of patients had a bowel movement within 30
minutes to 4 hours of the first injection
68
Non-pharmacological Treatment of Constipation
Prevention Manage side effects of pain medication Encourage fluid and fiber intake Encourage activities Intervene only if causing distress Cultural Considerations
69
Constipation Patient & Family Education
Monitor bowel patterns Encourage fluid intake Encourage dietary intake Encourage activity Instruct when to call healthcare provider
70
Constipation References
1. Economou DC. Bowel management: Constipation, diarrhea, obstruction, and ascites. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006: 219-238.
2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC ). Washington, DC: Association of Colleges of Nursing, 2009.
3. Sykes N. Constipation and diarrhea. In: Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York, NY: Oxford, 2005: 483-490.
71
Constipation References
4. McMillan S, Williams F. Validity and reliability of the constipation assessment scale. Cancer Nursing 1989;12:183-188.
5. Emanuel L, von Gunten C, Ferris F. The education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association, 2003.
6. Kazanowski M. Symptom management in palliative care. In: Matzo ML, Sherman D W, eds. Palliative care nursing: Quality care to the end of life. New York, NY: Springer, 2006: 319-344.
72
Diarrhea
Frequent passing of loose, non-formed stool More severe in HIV-infected patients and bone
marrow transplant patients
73
Diarrhea
Prevalence Considered a main symptom in 7-10% of hospice patients Especially prevalent in the HIV patient 43% of bone marrow transplant patients develop diarrhea
related to radiation Occurs in 10% of cancer patients
74
Causes of Diarrhea
Disease related Psychologically related Treatment related
75
Assessment of Diarrhea
Bowel history Assess frequency and nature of diarrhea in last 2 weeks Complaints of pain or abdominal cramping Rapid onset may indicate fecal impaction with overflow Colonic diarrhea: watery stools in large amounts Malabsorption: foul smelling, fatty, pale stools
Diet history Treatment history Medication review
76
Assessment of Diarrhea
Physical assessment Abdominal assessment Examine stools for signs of bleeding Evaluate for signs of dehydration
77
PharmacologicalTreatment for Diarrhea
Opioids Suppress forward peristalsis and increase sphincter tone Loperamide (Imodium®)
Bulk forming agents Promote absorption of liquid / increase thickness of stool Psyllium (Metamucil®
Antibiotics Steroids Somatostatins
Slows transit time by decreasing secretions Octreotide (Sandostatin)
78
Non-pharmacological Treatment for Diarrhea
Dietary management Initiate a clear liquid diet Eat small, frequent, bland meals
BRAT diet Low residue diet Increase fluids in diet Consider homeopathic remedies
79
Non-pharmacological Treatment for Diarrhea
Psychosocial interventions Provide support to patient and family Recognize negative effects of diarrhea on quality of life
Sitz baths Cultural Considerations
Many cultures modest – may prevent reporting
80
Diarrhea Patient & Family Education
Respect level of comfort during discussions Monitor frequency and consistency Instruct when to contact healthcare provider Provide skin care
81
Diarrhea References
1. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC - Geriatric). Washington, DC: Association of Colleges of Nursing, 2007.
2. Economou DC. Bowel management: Constipation, diarrhea, obstruction, and ascites. In: Ferrell BR, Coyle N, eds. Textbook of palliative nursing. 2nd ed. New York, NY: Oxford, 2006: 219-238.
3. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association, 2003.
82
Anxiety
Feeling of deep sense of unease without an identifiable cause
Prevalence - varies
83
Causes of Anxiety
Poorly controlled pain Altered physiologic states Medications Withdrawal from alcohol/medications Medical conditions Physiological/Emotional/Spiritual distress
84
Assessment of Anxiety
Physical symptoms Cognitive symptoms Pain Bowel/bladder Familiarity with environment Interview questions
Explore psychological and emotional dimensions
85
Pharmacological Treatment of Anxiety
Antidepressants Blocks serotonin reuptake
Benzodiazepines acts on limbic-thalmic-hypothalmic area of the CNS
producing anxiolytic, sedative, hypnotic, skeletal muscle relaxation
Neuroleptics blocks dopamine reuptake
86
Non-pharmacological Treatment of Anxiety
Coping skills Reassurance and support Manage stress and decrease stimulation Symptom management Complementary therapies Counseling
87
Anxiety Patient & Family Education
Review causes Monitor for signs and symptoms Avoid stimulation Patient safety Discuss unresolved issues
88
Anxiety References
1. Kazanowski M. Symptom management in palliative care. In: Matzo ML, Sherman D W, eds. Palliative care nursing: Quality Care to the End of Life. New York, NY: Springer, 2006: 319-344.
2. Pasacreta JV, Minarik PA, Nield-Anderson L. Anxiety and depression. In: Ferrell B R, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006: 375-399.
3. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC – Geriatric ). Washington, DC: Association of Colleges of Nursing, 2007.
4. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York, NY: Oxford, 2003.
5. Berry PH, ed. Core Curriculum for the Hospice and Palliative Nurse 2nd ed. Dubuque, IA:Kendal/Hunt; 2005.
89
Delirium/Agitation
Delirium – a global, potentially reversible change in cognition and consciousness that is relatively acute in onset Common in patient near death (approx 88%)
Agitation - excessive restlessness accompanied by increased mental and physical activity
90
Delirium/Agitation
Prevalence Almost half of patients experience
delirium/agitation in last 48 hours Experienced by 77-85% of terminally ill cancer
patients
91
Causes of Delirium/Agitation
Infection Malignancies / Tumor burden and secretions Renal or hepatic failure Metabolic abnormalities (low/hi Na, low K, hi Ca,
low/hi glucose, hypothyroid, renal/liver failure) Hypoxemia Sensory deprivation Medications Fecal impaction / Urinary retention Vitamin deficiencies
92
Assessment of Delirium/Agitation
Distinguish from other related symptoms Physical assessment History Spiritual distress Consider medical etiologies
93
Assessment of Delirium/Agitation
Established tools Mini-Mental Status Examination (MMSE)
www.chcr.brown.edu/MMSE.pdf Memorial Delirium Assessment Scale (MDAS)
www.painconsortium.gov Delirium Rating Scale (DRS)
94
Assessment of Delirium/Agitation
Established tools Confusion Assessment Method (CAM)
www.hartfordign.org/publications/trythis/issue13.pdf Neecham Confusion Scale (NCS)
www.unc.edu/courses/2005fall/nurs/213/001/neuropsychiatric/neecham.html
95
Treatment of Delirium/Agitation
Correct underlying cause Consider symptomatic and supportive therapies At end of life, causes may not be reversible and
medications are indicated
96
Treatment of Delirium/Agitation
Pharmacological interventions Neuroleptics
blocks dopamine uptake; metabolized by the liver Haloperidol (Haldol)
Severe agiation
97
Treatment of Delirium/Agitation
Benzodiapines Midazolam (Versed)
Anxiolytics Lorazepam (Ativan)
Atypical Antidepressants – blocks dopamine uptake selectively, but with less anticholingeric effects Risperidone
98
Non-pharmacological Treatment of Delirium/Agitation
Encourage presence of family Avoid excessive stimulation Reorient if indicated Familiar people and items Acknowledge visions Complementary therapies
99
Delirium/Agitation Patient & Family Education
Reassure patient and family Review symbolic language Review medications Sensory stimulation if indicated Instruct how to reorient
100
Delirium/Agitation References
1. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association, 2003.
2. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford textbook of palliative medicine. New York, NY: Oxford, 2005.
3. Lichter I, Hunt E. The last 48 hours of life. Journal of Palliative Care 1990;6:7-15.
4. Pereira J, Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer 1997;79:835-842.
5. Caraceni A. Delirium in palliative medicine. European Journal of Palliative Care 1995;2:62-67.
6. Kuebler KK, Heidrich D, Vena C, English N. Delirium, confusion, and agitation. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006:401-420.
101
Delirium/Agitation Additional References
Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium
(ELNEC). Washington, DC: Association of Colleges of Nursing, 2009.
102
Depression
Intense and often prolonged feelings of sadness, hopelessness and despair
103
Depression
Prevalence 25–77% terminally ill population 22% of nursing home residents Often not recognized at end-of-life
104
Causes of Depression
Medical conditions Pain
Treatment-related factors Medications
Psychological factors Financial issues
105
Assessment of Depression
Symptoms associated with medically ill Enduring sad mood Hopelessness Fatigue Diminished ability to make decisions
106
Assessment of Depression
Risk factors Medical co morbidity Male > age 45 Stressful life events Uncontrolled pain
107
Assessment of Depression
Screening tools Mini-Mental Status Examination (MMSE) Beck Depression Inventory Geriatric Depression Scale
Cultural influences Cultures may judge severity of depressive symptoms
differently Symptoms should not be dismissed because it is seen as a
characteristic of a particular culture Chinese may use the term ‘imbalance’ Latino/Mediterrean may say ‘nerves’, ‘headaches’
108
Assessment of Depression
Ask questions regarding Mood Behavior Cognition
Suicide assessment risk factors Psychiatric disorder Depression Alcohol abuse
109
Treatment of Depression
Optimal Pharmacological Non-pharmacological Interpersonal interventions Complementary
110
PharmacologicalTreatment of Depression
Antidepressants Blocks serotonin, (5HT) reuptake SSRIs
Considered as first line treatment For debilitated patients start at 1/3 dose
111
PharmacologicalTreatment of Depression
Tricyclics Blocks reuptake of various neurotransmitters at the
neuronal membrane Improves sleep Effective on 70% of patients treated
112
PharmacologicalTreatment of Depression
Stimulants Stimulates CNS and respiratory centers Increases appetite and energy levels Improves mood Reduces sedation
113
PharmacologicalTreatment of Depression
Other Steroids
Improves appetite Elevates mood
Non-benzodiazepines Useful in patients wit mixed anxiety/depressive
symptoms
114
Non-pharmacological Treatment of Depression
Counseling reinforce goals and interventions of care plan established by
interdisciplinary team
Behavioral interventions Provide directed / structured activities Focus on goal attainment / prepare for future adaptive coping
115
Non-pharmacological Treatment of Depression
Cognitive interventions Assist patient to reframe negative thoughts into positive
thoughts
Interpersonal interventions Build rapport with frequent, short visits Mobilize family and social support systems
Complementary therapies Guided imagery Art and music therapy
116
Non-pharmacological Treatment of Depression
Specific Behavioral Strategies Negotiate structured schedule Realistic goals Positively reinforce
117
Depression Patient & Family Education
Review signs and symptoms Instruct on prevalence Review medications Review non-pharmacological interventions Provide private opportunity to talk
118
Depression References
1. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC ). Washington, DC: Association of Colleges of Nursing, 2009.
2. Pasacreta JV, Minarik PA, Nield-Anderson L. Anxiety and depression. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006:375-399.
3. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York, NY: Oxford, 2005.
4. Wrede-Seaman L. Symptom management algorithms: A handbook for palliative care. Yakima, WA: Intellicard, 1999.
119
Dyspnea
Difficult or distressing shortness of breath Prevalence
Experienced in 50-70% of dying patients Marker for terminal phase of life Varies according to disease
Higher in pulmonary patients
120
Causes of Dyspnea
Related to primary or secondary diagnosis Related to treatment Pulmonary congestion Bronchoconstriction Anemia Hyperventilation
121
Assessment of Dyspnea
Acknowledge the subjective report Not tachypnea Functional Status Past history of related factors Diagnostic tests
122
PharmacologicalTreatment of Dyspnea
Opioids Reduce respiratory drive Reduce oxygenation consumption
Bemzodiazepines Lorazepam
Conflicting reports of efficacy for dyspnea – should not be first line treatment
123
PharmacologicalTreatment of Dyspnea
Diuretics Used in patients with signs of fluid volume excess
Bronchodilators Relax smooth muscles of respiratory tract
Corticosteroids Appears to decrease inflammation
124
PharmacologicalTreatment of Dyspnea
Antibiotics Useful if dyspnea secondary to infection
Anticoagulants Prevents clot formation which may prevent future
incidence of pulmonary emboli
Oxygen therapy
125
Non-pharmacological Treatment of Dyspnea
Fans, circulate air Positioning Conserve energy Rest Pursed lip breathing Prayer Complementary therapies
126
Dyspnea Patient & Family Education
Instruct breathing techniques Minimize aggravation Prevent panic Conserve energy Use of fans Don’t leave patient in distress alone
127
Noisy Respirations
Noisy, moist breathing Median time - 23 hrs before death May be very disturbing to family members
128
Noisy Respirations
Causes Turbulent air passes over pooled secretions or
through relaxed muscles of oropharynx
129
Assessment of Noisy Respirations
Onset Contributing causes Pulmonary embolism Fluid overload or CHF
130
PharmacologicalTreatment of Noisy Respirations
Treat underlying disorder Anticholinergics Hyoscine hydrobromide (Scopolamine®) Atropine
131
Non-pharmacologicalTreatment of Noisy Respirations
Repositioning
132
Noisy Respirations Patient & Family Education
More distressing to family than patient - reassure
Explain process Teach as a sign of impending death
133
Dyspnea & Noisy Respirations References
1. Dudgeon D. Dyspnea, death rattle and cough. In: Ferrell B R, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006: 249-264.
2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC - Geriatric). Washington, DC: Association of Colleges of Nursing, 2007.
134
Fatigue
A complex phenomenon, extreme tiredness, lack of energy, weariness
Subjective perception
135
Fatigue
Prevalence Reported in
78-96% of cancer patients 51% of patients in international palliative care centers 50% of school-aged children receiving chemotherapy
Effects Activities of Daily Living
136
Causes of Fatigue
Accumulation Theory Depletion Theory Central Nervous System Control Predisposing factors
137
Assessment of Fatigue
Subjective Data Location, severity, intensity and duration Aggravating & alleviating factors
Objective Strength Vital signs
Lab values Oxygenation status, CBC and Diff, Hgb
138
PharmacologicalTreatment of Fatigue
Steroids Methylphenidate (Ritalin®)
stimulates CNS and respiratory center increases appetite and energy levels, improves
mood, reduces sedation
139
PharmacologicalTreatment of Fatigue
Antidepressants Reduces depressive symptoms associated with fatigue Can improve sleep
SSRIs Inhibits serotonin reuptake
Tricyclics Monitor blood levels
Epoetin (Epogen®) Increases hemoglobin with effects on energy
140
Non-pharmacological Treatment of Fatigue
Active exercise Attention-restoring interventions Preparatory education Psychosocial support
141
Fatigue Patient & Family Education
Explain nature of fatigue Plan, schedule & prioritize activities Rest Instruct on nutrition Control contributing symptoms
142
Fatigue References
1. Anderson PR, Dean G. Fatigue. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006:155-168.
2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC - Geriatric). Washington, DC: Association of Colleges of Nursing, 2007.
3. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association, 2003.
4. Kazanowski M. Symptom management in palliative care. In: Matzo M L, Sherman D W, eds. Palliative Care Nursing: Quality Care to the End of Life. New York, NY: Springer, 2006.
143
Pressure Ulcers
A Pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence as a s result of pressure, or pressure in combination with shear and/or friction
144
Pressure Ulcers
Prevalence Reported in up to 17% of hospitalized patients 70% of pressure sores in hospitalized occur within 2
weeks Incidence higher with conditions that impair wound
healing
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Causes of Pressure Ulcers
Intrinsic factors Extrinsic factors
146
Causes of Pressure Ulcers
Impaired vascular and lymphatic system of skin and deep tissue
Impaired nutritional status and weight loss increases risk
Compressed tissue may continue to suffer ischemic damage even after relief
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Assessment of Pressure Ulcers
Clinical Physical Lab values National Pressure Ulcer Advisory Panel Staging
Criteria www.npuap.org
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Assessment for Pressure Ulcers
Pressure Ulcer Staging Criteria Stage l Stage ll Stage lll Stage lV Unstageable
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Assessment for Pressure Ulcers
Wound Status Pressure Ulcer Scale for Healing (PUSH) Pressure Sore Status Tool (PSST)
150
Assessment for Pressure Ulcers
Wound Characteristics Edges / margins
Assess through visual inspection and palpation
Undermining and tunneling Loss of tissue underneath an intact skin surface
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Assessment for Pressure Ulcers
Wound Characteristics Necrotic tissue
indicate the degree of severity or involvement
Exudate Assists in assessment of potential infection, evaluation
of therapy, and monitoring of healing Healthy wound will have some degree of moisture as
part of healing
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Assessment for Pressure Ulcers
Wound Characteristics Surrounding tissue conditions
Assess surrounding tissue for color, induration, edema May be first warning of potential further damage
Induration Abnormal firmness of tissues with margins is a sign of
impending damage to tissue Assess tissues within 4 cm of wound
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Assessment for Pressure Ulcers
Wound Characteristics
Edema will impede healing of pressure ulcer
Granulation & Epithelialization markers of wound health
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Treatment of Pressure Ulcers
Nutritional support Maintain nutritional status
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Treatment of Pressure Ulcers
Management of tissue load Pressure reduction surfaces Alternating airflow mattresses
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Treatment of Pressure Ulcers
Debridement Necrotic tissue impedes healing and provides bacterial
growth medium Important for decreasing odor
Bacterial colonization and infection Most open pressure ulcers often colonized by bacteria
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Treatment of Pressure Ulcers
Wound cleansing Decreases potential for wound infection
Dressings Goal of dressing is to provide an environment that keeps the
wound bed tissue moist and the surrounding intact skin dry
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Patient & Family Education for Pressure Ulcers
Teach prevention and early signs Repositioning Protecting bony prominences Keep heels off bed surface Skin care Nutrition Mobility
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Patient & Family Education for Pressure Ulcers
Nutrition Supplements Protein Fluids Dietitian
Mobility Review importance of pressure ulcer prevention by
maximizing activity and/or mobility
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Pressure UlcersReferences
1. Bates-Jensen BM. Skin disorders: pressure ulcers-assessment and management. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006: 301-328.
2. Miller C. Management of skin problems: nursing aspects. In: Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York, NY: Oxford, 2005: 629-640.
3. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association, 2003.
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Pressure UlcersReferences
4.. Agency for Health Care Policy and Research (AHCPR). Treatment of pressure ulcers. Clinical practice guideline number 15. Rockville, MD: Public Health Services, U.S. Department of Health and Human Services, 1994
5. Wrede-Seaman L. Symptom management algorithms: A handbook for palliative care. Yakima, WA: Intellicard, 1999
6. National Pressure Ulcer Advisory Panel Staging Criteria, 2007. Available at www.npuap.org/pr2.htm. Accessed October 21, 2009