chpn hpna review week 3

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


Use least invasive approach possible Oral

Provide appropriate mouth care

Proctoclysis

22


NG/GT NG uncomfortable

Hypodermoclysis Subcutaneous fluid administration

IV

23


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


Protokinetic agents Indication: gastric stasis, ileus

Medications Metoclopramide (Reglan) Domperidone (Motilium)

35


Cannabinoids Indication: second-line antiemetic

Medication Dronabinol (Marinol)

36


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


5-HT3 receptor antagonists Indicated for post-operative nausea and vomiting and

chemotherapy

ABHR Compounded antiemetics

40


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


Pharmacolologic Corticosteroids Antispasmodic Laxative / Antidiarrheal

51


Surgical Considered within context of established palliative care

goals

52


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


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


Laxatives Saline laxatives - increase gastric, pancreatic, & small

intestinal secretions, & motor activity throughout the intestine

63


Bowel stimulants Bowel stimulants - Work directly to irritate bowel &

stimulate peristalsis; Use with caution when liver disease present

64


Bulk Laxatives Provide bulk to the intestines to increase mass -

stimulates bowel to move

65


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


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


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


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


Pharmacological interventions Neuroleptics

blocks dopamine uptake; metabolized by the liver Haloperidol (Haldol)

Severe agiation

97


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


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


Risk factors Medical co morbidity Male > age 45 Stressful life events Uncontrolled pain

107


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


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


Tricyclics Blocks reuptake of various neurotransmitters at the

neuronal membrane Improves sleep Effective on 70% of patients treated

112


Stimulants Stimulates CNS and respiratory centers Increases appetite and energy levels Improves mood Reduces sedation

113


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


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


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


Diuretics Used in patients with signs of fluid volume excess

Bronchodilators Relax smooth muscles of respiratory tract

Corticosteroids Appears to decrease inflammation

124


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.


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.



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

145

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

147

Assessment of Pressure Ulcers

Clinical Physical Lab values National Pressure Ulcer Advisory Panel Staging

Criteria www.npuap.org

148

Assessment for Pressure Ulcers

Pressure Ulcer Staging Criteria Stage l Stage ll Stage lll Stage lV Unstageable

149


Wound Status Pressure Ulcer Scale for Healing (PUSH) Pressure Sore Status Tool (PSST)

150


Wound Characteristics Edges / margins

Assess through visual inspection and palpation

Undermining and tunneling Loss of tissue underneath an intact skin surface

151


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

152


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

153


Wound Characteristics

Edema will impede healing of pressure ulcer

Granulation & Epithelialization markers of wound health

154

Treatment of Pressure Ulcers

Nutritional support Maintain nutritional status

155


Management of tissue load Pressure reduction surfaces Alternating airflow mattresses

156


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

157


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

159

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.


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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

chpn hpna review week 3

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