c c e e n n l l e e end-of-life nursing education consortium international curriculum symptom...

CCEENNLLEEEnd-of-Life Nursing Education Consortium

International CurriculumInternational Curriculum

Symptom Management

Symptom Management

EE NN EE CCLL International CurriculumInternational Curriculum

Essential Elements of Symptom Management Essential Elements of

Symptom Management

• Ongoing assessment and evaluation

• Requires interdisciplinary teamwork

• Financial concerns (affordable options)

• Research is needed

Coyne et al., 2010

• Ongoing assessment and evaluation

• Requires interdisciplinary teamwork

• Financial concerns (affordable options)

• Research is needed

Coyne et al., 201022


Symptoms and SufferingSymptoms and Suffering

• Symptoms create suffering and distress

• Need for interdisciplinary care• Determine clinical intervention– Benefit (s)– Burden (s)– Risk (s)

• Symptoms create suffering and distress

• Need for interdisciplinary care• Determine clinical intervention– Benefit (s)– Burden (s)– Risk (s)

33


Common SymptomsCommon Symptoms• Respiratory– Dyspnea, cough

• GI– Anorexia/cachexia, constipation, diarrhea,

nausea/vomiting• Psychological– Depression, anxiety,

delirium/agitation/confusion• General/Systemic– Fatigue/weakness– Seizures– Fevers– Malaria

• Respiratory– Dyspnea, cough

• GI– Anorexia/cachexia, constipation, diarrhea,

nausea/vomiting• Psychological– Depression, anxiety,

delirium/agitation/confusion• General/Systemic– Fatigue/weakness– Seizures– Fevers– Malaria

44


DyspneaDyspnea

• Distressing shortness of breath• Associated diseases

Dudgeon, 2010

• Distressing shortness of breath• Associated diseases

Dudgeon, 2010

55


Causes of DyspneaCauses of Dyspnea

• Major pulmonary causes• Major cardiac causes• Major neuromuscular causes• Other causes

• Major pulmonary causes• Major cardiac causes• Major neuromuscular causes• Other causes

66


Assessment of DyspneaAssessment of Dyspnea

• Use subjective report• Clinical assessment– Physical exam– Diagnostic tests

Dudgeon, 2010

• Use subjective report• Clinical assessment– Physical exam– Diagnostic tests

Dudgeon, 2010

77


Treatment of DyspneaTreatment of Dyspnea

• Treating symptoms or underlying cause

• Pharmacologic treatments– Opioids– Bronchodilators– Diuretics– Other

Dudgeon, 2010; Jacobs, 2003

• Treating symptoms or underlying cause

• Pharmacologic treatments– Opioids– Bronchodilators– Diuretics– Other

Dudgeon, 2010; Jacobs, 2003

88


Treatment of DyspneaTreatment of Dyspnea

• Nonpharmacologic– Oxygen– Counseling– Pursed lip breathing– Energy conservation– Fans, elevation– Other

Dudgeon, 2010; Kravits & Berenson, 2010

• Nonpharmacologic– Oxygen– Counseling– Pursed lip breathing– Energy conservation– Fans, elevation– Other

Dudgeon, 2010; Kravits & Berenson, 2010

99


CoughCough

• Common symptom in advanced disease

• Causes pain, fatigue, insomnia

Dudgeon, 2010

• Common symptom in advanced disease

• Causes pain, fatigue, insomnia

Dudgeon, 2010

1010


Causes of CoughCauses of Cough

• Assess underlying cause (e.g. infection, sinusitis, reflux)

• Assess type of cough• Assess associated symptoms• Diagnostic tests may be needed

Dudgeon, 2010

• Assess underlying cause (e.g. infection, sinusitis, reflux)

• Assess type of cough• Assess associated symptoms• Diagnostic tests may be needed

Dudgeon, 2010

1111


Pharmacologic Interventions for Cough

Pharmacologic Interventions for Cough

• Suppressants/expectorants• Antibiotics• Steroids• Anticholinergics

• Suppressants/expectorants• Antibiotics• Steroids• Anticholinergics

1212


Non-Pharmacologic Interventions for Cough

Non-Pharmacologic Interventions for Cough

• Chest PT• Humidifier• Positioning

• Chest PT• Humidifier• Positioning

1313


Anorexia and CachexiaAnorexia and Cachexia

• Anorexia - loss of appetite, usually with decreased intake

• Cachexia - lack of nutrition and wasting

Wholihan & Kemp, 2010

• Anorexia - loss of appetite, usually with decreased intake

• Cachexia - lack of nutrition and wasting


1414


Causes of Anorexia and Cachexia

Causes of Anorexia and Cachexia

• Disease related• Psychological• Treatment related

Fearon et al., 2010; Wholihan & Kemp, 2010


Fearon et al., 2010; Wholihan & Kemp, 2010

1515


Assessment of Anorexia and Cachexia

Assessment of Anorexia and Cachexia

• Physical findings• Impact on function and quality of life• Calorie counts/daily weights• Lab tests• Skin breakdown


• Physical findings• Impact on function and quality of life• Calorie counts/daily weights• Lab tests• Skin breakdown


1616


Treatment of Anorexia and Cachexia

Treatment of Anorexia and Cachexia

• Dietary consultation• Medications• Parenteral/enteral nutrition• Odor control• Counseling

Earthman, 2002; MacDonald, 2003; Wholihan & Kemp, 2010

• Dietary consultation• Medications• Parenteral/enteral nutrition• Odor control• Counseling

Earthman, 2002; MacDonald, 2003; Wholihan & Kemp, 2010

1717


ConstipationConstipation

• Infrequent passage of stool• Frequent symptom in palliative

care• Prevention is key

• Infrequent passage of stool• Frequent symptom in palliative

care• Prevention is key

1818


Causes of ConstipationCauses of Constipation

• Disease related (e.g. obstruction, hypercalcemia, neurologic, inactivity)

• Treatment related (e.g. opioids, other meds)

• Disease related (e.g. obstruction, hypercalcemia, neurologic, inactivity)

• Treatment related (e.g. opioids, other meds)

1919


Assessment of ConstipationAssessment of Constipation

• Bowel history• Abdominal assessment• Rectal assessment• Medication review

Economou, 2010

• Bowel history• Abdominal assessment• Rectal assessment• Medication review

Economou, 2010

2020


Treatment of ConstipationTreatment of Constipation

• Medications• Dietary/fluids• Other approaches

Economou, 2010

• Medications• Dietary/fluids• Other approaches

Economou, 2010

2121


DiarrheaDiarrhea

• Frequent passage of loose, nonformed stool

• Effects (e.g. fatigue, caregiver burden, skin breakdown)

• Frequent passage of loose, nonformed stool

• Effects (e.g. fatigue, caregiver burden, skin breakdown)

2222


Causes of DiarrheaCauses of Diarrhea

• Disease related• Malabsorption• Concurrent diseases• Psychological• Treatment related

• Disease related• Malabsorption• Concurrent diseases• Psychological• Treatment related

2323


Assessment of DiarrheaAssessment of Diarrhea

• Bowel history• Medication review• Infectious processes

• Bowel history• Medication review• Infectious processes

2424


Treatment of DiarrheaTreatment of Diarrhea

• Treat underlying cause• Dietary modifications• Hydration• Pharmacologic agents

• Treat underlying cause• Dietary modifications• Hydration• Pharmacologic agents

2525


Nausea and VomitingNausea and Vomiting

• Common in advanced disease• Assessment of etiology is

important• Acute, anticipatory or delayed

Mannix, 2010

• Common in advanced disease• Assessment of etiology is

important• Acute, anticipatory or delayed

Mannix, 2010

2626


Causes of Nausea and Vomiting

Causes of Nausea and Vomiting

• Physiological (gastrointestinal, metabolic, central nervous system)

• Psychological• Disease related• Treatment related• Other

• Physiological (gastrointestinal, metabolic, central nervous system)

• Psychological• Disease related• Treatment related• Other

2727


Assessment of Nausea and Vomiting

Assessment of Nausea and Vomiting

• Physical exam• History• Lab values

• Physical exam• History• Lab values

2828


Pharmacologic Treatment of Nausea and Vomiting

Pharmacologic Treatment of Nausea and Vomiting

• Anticholinergics• Antihistamines• Steroids• Prokinetic agents• Other

• Anticholinergics• Antihistamines• Steroids• Prokinetic agents• Other

2929


Non-Drug Treatment of Nausea and Vomiting

Non-Drug Treatment of Nausea and Vomiting

• Distraction/relaxation• Dietary• Small/slow feeding• Invasive therapies

• Distraction/relaxation• Dietary• Small/slow feeding• Invasive therapies

3030


FatigueFatigue

• Subjective, multidimensional experience of exhaustion

• Commonly associated with many diseases

• Impacts all dimensions of quality of life

Anderson et al., 2010; Ferrell et al., 1996

• Subjective, multidimensional experience of exhaustion

• Commonly associated with many diseases

• Impacts all dimensions of quality of life

Anderson et al., 2010; Ferrell et al., 1996

3131


Causes of FatigueCauses of Fatigue



3232


Assessment of FatigueAssessment of Fatigue

• Subjective• Objective• Laboratory data

• Subjective• Objective• Laboratory data

3333


Treatment of FatigueTreatment of Fatigue

• Pharmacologic• Nonpharmacologic (rest, energy

conservation, involve physical therapy/occupational therapy)

Anderson et al., 2010

• Pharmacologic• Nonpharmacologic (rest, energy

conservation, involve physical therapy/occupational therapy)

Anderson et al., 2010

3434


DepressionDepression

• Ranges from sadness to suicidal• Often unrecognized and

undertreated• Distinguish normal vs. abnormal• Should not be dismissed

Pasacreta et al., 2010

• Ranges from sadness to suicidal• Often unrecognized and

undertreated• Distinguish normal vs. abnormal• Should not be dismissed


3535


Causes of DepressionCauses of Depression

• Disease related• Psychological• Medication related• Treatment related

• Disease related• Psychological• Medication related• Treatment related

3636


Assessment of DepressionAssessment of Depression

• Situational factors/symptoms• Previous psychiatric history• Other factors (e.g. lack of

support system, pain)


• Situational factors/symptoms• Previous psychiatric history• Other factors (e.g. lack of

support system, pain)


3737


Example Questions for Depression AssessmentExample Questions for

Depression Assessment

• How have your spirits been lately?

• What do you see in your future?• What is the biggest problem you

are facing?


• How have your spirits been lately?

• What do you see in your future?• What is the biggest problem you

are facing?


3838


Suicide AssessmentSuicide Assessment

• Do you think life isn’t worth living?

• Have you thought about how you would kill yourself?

• Do you think life isn’t worth living?

• Have you thought about how you would kill yourself?

3939


Pharmacologic Interventions for Depression

Pharmacologic Interventions for Depression

• Antidepressants• Stimulants• Non-benzodiazepines• Steroids

• Antidepressants• Stimulants• Non-benzodiazepines• Steroids

4040


Non-Pharmacologic Interventions for Depression

Non-Pharmacologic Interventions for Depression

• Promote autonomy• Grief counseling• Draw on strengths• Use cognitive strategies

• Promote autonomy• Grief counseling• Draw on strengths• Use cognitive strategies

4141


AnxietyAnxiety

• Subjective feeling of apprehension• Often without specific cause• Categories of mild, moderate,

severe

• Subjective feeling of apprehension• Often without specific cause• Categories of mild, moderate,

severe

4242


Causes of AnxietyCauses of Anxiety

• Medications and substances• Uncertainty


• Medications and substances• Uncertainty


4343


Assessment of AnxietyAssessment of Anxiety

• Physical symptoms• Cognitive symptoms• Questions for assessment

APA, 2000

• Physical symptoms• Cognitive symptoms• Questions for assessment

APA, 2000

4444


Pharmacologic Interventions for Anxiety

Pharmacologic Interventions for Anxiety

• Antidepressants• Benzodiazepines/anticonvulsants• Neuroleptics• Non-benzodiazepines

• Antidepressants• Benzodiazepines/anticonvulsants• Neuroleptics• Non-benzodiazepines

4545


Non-pharmacologic Interventions for Anxiety

Non-pharmacologic Interventions for Anxiety

• Empathetic listening• Assurance and support• Concrete information/warning• Relaxation/imagery

• Empathetic listening• Assurance and support• Concrete information/warning• Relaxation/imagery

4646


Delirium/Agitation/Confusion

Delirium/Agitation/Confusion

• Delirium - Acute change in cognition/awareness

• Agitation - accompanies delirium

• Confusion - disorientation, inappropriate behavior, hallucinations

Heidrich & English, 2010

• Delirium - Acute change in cognition/awareness

• Agitation - accompanies delirium

• Confusion - disorientation, inappropriate behavior, hallucinations


4747


CausesCauses

• Infection• Medications• Hypoxemia• Bladder distention

• Infection• Medications• Hypoxemia• Bladder distention

Examples:Examples:

4848


AssessmentAssessment

• Physical exam• History• Spiritual distress• Other symptoms


• Physical exam• History• Spiritual distress• Other symptoms


4949


TreatmentTreatment

• Pharmacologic• Evaluate medications• Reorientation• Relaxation/distraction• Hydration

• Pharmacologic• Evaluate medications• Reorientation• Relaxation/distraction• Hydration

5050


WoundsWounds

• Patients at risk• Prevention as key• Patients at risk• Prevention as key

5151


Assessment of WoundsAssessment of Wounds

• Characteristics• Pain• Psychosocial• Caregivers

• Characteristics• Pain• Psychosocial• Caregivers

5252


Treatment of WoundsTreatment of Wounds

• Wound cleaning• Dressings• Provide analgesia• Seek consultation

• Wound cleaning• Dressings• Provide analgesia• Seek consultation

5353


SeizuresSeizures

• Definition• Causes– Infections– Trauma– HIV– Tumors– Medications– Metabolic imbalances

• Definition• Causes– Infections– Trauma– HIV– Tumors– Medications– Metabolic imbalances

5454


Assessment for SeizuresAssessment for Seizures

• Manifestations– Aura– Mental status changes– Sensory changes

• Physical exam• Labs

• Manifestations– Aura– Mental status changes– Sensory changes

• Physical exam• Labs

5555


Treatment for SeizuresTreatment for Seizures

• Limit trauma• Anticonvulsant treatments– Phenytoin– Phenobarbital– Lorazepam, diazepam

• Limit trauma• Anticonvulsant treatments– Phenytoin– Phenobarbital– Lorazepam, diazepam

5656


FeversFevers

• Definition• Causes– Infection– Tissue injury– Altered thermoregulation

• Definition• Causes– Infection– Tissue injury– Altered thermoregulation

5757


Assessment/Treatment of FeversAssessment/Treatment of Fevers

• Clinical– Flushing– Malaise/fatigue

• Rigors/shaking• Treatment– Antibiotics– Antipyretics– Cooling measures

• Clinical– Flushing– Malaise/fatigue

• Rigors/shaking• Treatment– Antibiotics– Antipyretics– Cooling measures

5858


MalariaMalaria

• High morbidity/mortality• Caused by a parasite• Use of prompt and effective

treatment WHO, 2010

• High morbidity/mortality• Caused by a parasite• Use of prompt and effective

treatment WHO, 2010

5959


Symptoms/Treatment of MalariaSymptoms/Treatment of Malaria

• Fever• Chills• Headache• Nausea/vomiting

• Fever• Chills• Headache• Nausea/vomiting

6060


Key RolesKey Roles

• Patient advocacy• Assessment• Pharmacologic treatments• Non-pharmacologic treatments• Patient/family teaching

• Patient advocacy• Assessment• Pharmacologic treatments• Non-pharmacologic treatments• Patient/family teaching

6161


ConclusionConclusion

• Multiple symptoms common• Coordination of care with

physicians and others• Use drug and nondrug treatment• Patient/family teaching and support

• Multiple symptoms common• Coordination of care with

physicians and others• Use drug and nondrug treatment• Patient/family teaching and support

6262

EE NN EE CCLL International CurriculumInternational CurriculumA Nurse's Touch 6363


Give the answers to the following questions please

Give the answers to the following questions please

1. List the respiratory symptoms that occur in palliative care patients?

2. What Non-pharmacologic Interventions for Anxiety do you know?

3. What are the causes of Delirium?

1. List the respiratory symptoms that occur in palliative care patients?

2. What Non-pharmacologic Interventions for Anxiety do you know?

3. What are the causes of Delirium?

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