CLINICAL REVIEW FOR THE

GENERALIST HOSPICE & PALLIATIVE NURSE

Symptom Management

WEEK 3

Nat’l. Consensus Project

Clinical Practice Guidelines of Qual. Pall. Care Domain 2—

Physical Aspect of Care Guideline 2.1—Pain,

other symptoms, and side effects are managed, based on the best available evidence, . . .

Common EOL Symptoms

1. Anorexia/Cachexia2. Dehydration3. Nausea/Vomiting4. Bowel Obstruction5. Constipation6. Diarrhea

8. Anxiety9. Depression10. Dyspnea11. Noisy Respirations12. Fatigue13. Pressure Ulcers

For each symptom, we will look at:

ETIOLOGY, ASSESSMENT, NON-PHARM. + PHARM. TREATMENTS, AND PT./FAM. TEACHING.

1. Anorexia/Cachexia

Anorexia—loss of appetite

Cachexia—wt. loss, wasting, loss of muscle, fat, bone minerals, marked by weakness, emaciation (occurs in 80% of Ca. pts., kills 20% of them)

2 May be a mutually re-inforcing cycle

ETIOLOGY (reason): Treatment-Related

Meds., chemo., XRT Disease-Related

Infxn., delayed gast. emptying, metabolic ch., N/V, dysphagia

P/S or spiritual distress Depression

Non-Pharm. Interventions for Anorexia/Cachexia

Encourage pts. to eat what they like

Refer to Dietician Encourage small, frequent

meals Avoid strong odors Encourage supplements Enteral/Parenteral

feedings may be appropriate

Class of drug Examples Comments

Gastrokinetic agents Metoclopramide (Reglan)

Useful w/ c/o nausea + early satiety (“I feel full”)

Corticosteroids Dexamethasone(Decadron)

Effective in short-term (w/side effects)

Progesterone Analogs (hormonal treatment)

Megestrol acetate(Megace)

Somewhat effective for some pts. (expensive)

Cannabinoids Dronabinol(Marinol)

Effective in low doses

Alcohol Beer or sherry May improve appetite + morale in some pts.

Vitamins Multivits., Vit. C Anecdotal evidence for improved appetite (placebo?)

Pharmacologic Interventions for Anorexia/Cachexia

Pt./Family Education

Support pt’s. wishes Discuss intake during dying process Explore the meaning of food to family

(love, health, togetherness) Address emotional needs Re-direct caring activities (tell stories,

use lotion for massage, look at photos together)

2. Dehydration

EtiologyNormal physiology at EOL

desire for fluids

Fasting/vomiting/ diarrhea

Fever

Over-use of diuretics

3rd spacing

Assessment Mental status ch. I/O (< 400ml/day) Poor skin turgor

(tenting) Wt. loss Skin/mouth Postural hypotension Lab Values (?)

Third-Spacing

Extracellular fluid is normally found in Interstitial or intravascular spaces.

Sometimes, with diseased states, it collects in “THIRD-SPACES” (ascites, pleural effusion, etc.

Pt. is often intravascularly dehydrated, while fluid collects in “third spaces”.

Treatments

Non-Pharm.

Oral Fluids/sports drinks

Review of disease trajectory

Facilitating discussion of benefits v. burdens

Pharm. Proctolysis (w/NGT) Hypodermoclysis IVF

Monitor for over-hydration (swelling, sob, etc.)

Good mouth care q2 (swab w/water or dilute mouthwash, lip balm)

Ice chips/popsicles

Family Teaching: Dehydration

Teaching about normal process of dehydration

Correcting misperceptions about dehydration Painful? Needs to be corrected? Should be corrected?

3. Nausea & Vomiting

Etiology

•Disease-Related

• GI (constip., B.O.)• Metabolic (uremia,

calcemia) • CNS (vertigo, brain mets.)

•Treatment-Related

• Chemo (CTZ)• Opioids (slow gastric

emptying, may resolve-3days)

Assessment Pt’s subjective

report

Non-Pharmacological Treatments

Drink clear or ice-cold drinks

Eat light, bland foods

Avoid fried, greasy, or sweet foods

Eat small, frequent meals

Eat and drink slowly

Cool Cloth to face

Mouth Care

Fresh air/Fan

Pharmacological Treatments

Cause TreatmentSlow gastric emptying Prokinetic agent (Metoclopramide,

Domperidone)

Chemical (opioid side-effect) Haloperidol, Droperidol

Vestibular (vertigo, dizziness)

Antihistamine (Dimenhydrinate/dramamine)

Motion sickness Anticholinergic (scopolamine, hysoscyamine/Levsin)

Nausea w/anxiety Benzodiazepine (lorazepam)

Intestinal Obstruction Octreotide (sandostatin)

ICP Steroid (Dexamethasone/Decadron--in combination w/ other drugs)

Pt./Family Teaching: N/V

Assist with assessing cause

Problem-solving to treat

Family’s role

When to call provider (dehydration, not keeping anything down, pt is suffering)

4. Bowel Obstruction

Etiology

Occlusion of lumen (tumor v. fecal imp’n.)

Absence of propulsion

Metabolic disorders

Medications

Assessment

Bowel hx.

Pain on palpation

Rectal Exam

Consider location

Consider p.c. goals/disease trajectory

Treatments

Pharmacologic

OctreotideScopolamineOpioidsAnti-emeticsCorticosteroidsAnti-spasmodicLaxative/Antidiarrheal

Non-Pharmacologic

Prevention when poss.

Avoid big meals Avoid hot drinks Consider NGT/sxn.

Be Careful

DON’T give a stimulant laxative with a bowel obstruction—causes more pain

Don’t mistake liquid stool coming around an obstruction as evidence that there is not an obstruction.

Pt./Family Teaching: B.Obstruction

Review Causes Discuss Tx. Opts. Educate on prevent. Review meds. Review Diet Instruct when to call

provider

5. Constipation

Etiology Medication-related

(opiods, anticholin.)

Disease-related Cancer (tumors) Diabetes

(gastroparesis) Dehydration Inactivity/ intake

Assessment Bowel history Abdominal assessment Rectal assessment

Interventions

PharmacologicalLaxatives:

Detergent (softener/docusate) Lubricant (glycerine supp.) Stimulant (dulcolax/senna) Saline (Mag Citrate) Osmotic (latulose) Bulk-forming (miralax) Enemas (increase H2O

content Metoclopramide if indicated

Non-Pharm. Prevention! Treating med. side

effects pro-actively fluid + fiber Intervene only if

causing distress Cultural

considerations

Opioid-Induced Constipation (OIC)

Opioids bind to Mu-receptors in CNS to provide pain relief

Also bind to Mu-receptors in gut which stops peristalsis

Requires stimulant treatment (metaclopromide, dulcolax, oral erythro.)

New Drug: Relistor (methylnaltrexone)

Naloxone Relistor (naloxone w/ + charge on Nitrogen atom)

Methylnaltrexone: Treats Opioid-Induced Constipation

Binds to the same receptors as opioid analgesics (morphine, oxycodone, dilaudid, etc.)

Unable to cross blood/brain barrier due to the positive charge on its nitrogen atom.

Acts as an antagonist, blocking the GI effects of the opioid

Does not reverse the pain-killing properties

Does not cause withdrawal symptoms

Pt./Family Teaching: Constipation

Monitor bowel patterns

Encourage p.o. food/fluids

Encourage activity (oob)

Instruct when to call . . . .

6. Diarrhea

AssessmentAbdominal assessment

Blood in stool?

Dehydration?

Etiology Treatment-Related

Antibiotics Disease-Related

HIV, c. diff. Psychologically-

Related Anxiety

Treatments

Non-Pharmacologic

Clear liqs./advanceBRAT dietLow residue (fiber)diet fluidsSitz BathConsider homeopathic remedies

Pharmacologic Loperamide Opioids Bulk-forming agents

Psyllium (metamucil) Antibiotics (if

indicated) Steroids Octreotide (secretions,

slows transit time in bowel)

Pt./Family Teaching: Diarrhea

Respect level of comfort with discussion

Monitor frequency + consistency

Provide skin care

When to call . . . .

7. Anxiety

Assessment

Physical sx. Tachycardia Tremor Bowel/bladder

Cognitive Sx. Racing thoughts Insomnia

Etiology P/S, spiritual distress Uncontrolled pain Medications (steroids,

albuterol) Substance withdrawal Medical conditions

(copd)

TREATMENTS

Non-Pharmacological

Coping skills (breathing, cbt)

Reassurance/support

Counselling

Complementary Tx.

Pharmacological

Benzos (alprazolam, lorazepam)

Anti-depressants (SSRI)

Neuroleptics (haloperidol, prometh.)

Pt./Family Teaching: Anxiety

Review causes Monitor for sx. Avoid stimulation Discuss unresolved

issues Patient safety/when

to call

8. Delerium/Agitation

Infection Malignancy-related Renal/hepatic failure Metabolic causes Hypoxemia Medications (opioids,

etc.) Fecal impaction/Urinary

retention

Established Tools

Confusion Assessment Method (CAM)

Neecham Confusion Scale (NCS)

ETIOLOGY ASSESSMENT

Checklist for Assessing Checklist for Assessing Terminal AgitationTerminal Agitation

Thorough medication review (polypharm., toxicity, side effects?)

Hx/ of substance abuse Retention of urine/stool Signs of fever or sepsis Hypoxia Assess pain/suffering Assess LOC needed

(GIP/CC?)

Correcting the Causes of Delerium/Agitation

Constipation…………...

Urinary retention……...

Dehydration……………

UTI……………………..

Polypharm/ side effects

Hypoglycemia…………

Fever…………………..

Medicate/disimpact/aggressive bowel regimen

Catheterize

Consider 1L. IVF or SQ (if no overload)

Dipstick and treat if symptomatic

D/C or taper drug if appropriate

Consider glucose replacement

Consider anti-pyretics/cooling measures

Treatment

Correct underlying cause

Symptomatic/suppor-tive tx.

Consider trajectory/goals: may not be reversible—treat sx.

Neuroleptics Haloperidol

Benzos. Midazolam (Versed)

Anxiolytics Lorazepam

Atypical Antidepressants Risperidone

Non-Pharmacological Pharmacological

Pt./Family Teaching

Review medications Reassure pt./family Review symbolic

language (NDE) Careful sensory

stimulation, if indicated Instruct on re-orienting

pt.

9. DEPRESSION

Medical conditions (pain)

Treatment-related (meds.)

Psychological factors (financial, relationships)

Enduring sad mood

Hopelessness Fatigue Anhedonia Ability to make

decisions

Etiology Assessment

Screening for Depression

Tools Beck Depression Inventory Geriatric Depression Scale Hamilton Depression Scale

Ask about Mood Behavior (appetite/sleep) Cognition (slow thought, indecision)

Suicide Risk ETOH abuse Psychiatric disorder Depression

Treatments

Counseling Behavioral Cognitive Interpersonal Complementary

Tx.

SSRI’s (1st line) Tri-cyclics

(effective in 70% of pts.)

Stimulants (methylphenidate)

Steroids (appetite + mood)

Non-Pharmacologigal Interventions

Pharmacological

Pt./Family Teaching for Depression

Review signs and symptoms

Instruct on prevalence Review medications Review non-pharm.

Interventions Provide opportunity for

private conversations

10. Dyspnea

Diagnosis-related Treatment-related Pulmonary

congestion Broncho-

constriction Anemia Hyperventilation

Believe pt’s. report Not same as

tachypnea Functional status Past history Diagnostic tests

Etiology Assessment

Treatments

Fans Positioning ( HOB) Conserve energy Pursed-lip breathing Prayer Complementary tx.

Opioids Benzodiazepines (not

first-line) Diuretics, if indicated Bronchodilators, if

indicated Cortico-steroids if

indicated

Non-Pharmacological Pharmacological

Pt./Family Teaching for Dyspnea

Instruct on breathing techniques

Minimize aggravation Prevent panic Conserve energy Use fans Don’t leave pt. in distress

alone

11. Noisy Respirations/Secretions

Caused by turbulent air passing over pooled secretions or through relaxed oropharynx

Median time=8-23 hrs. before death

Onset/? Trajectory

?Pulmonary embolism

CHF/fluid overload

Etiology Assessment

Treatments

Repositioning Suctioning not

recommended at EOL

Anticholinergics Hyoscyamine Scopolamine Atropine Glycopyrrolate Treat underlying

disorder, if appropriate (pneumonia, CHF, PE)

Non-Pharm Pharm

Pt. /Family Teaching on Secretions

Explain process/demonstrate lack of pt. distress, air moving

More distressing to family than pt.

Teach as a sign of impending death

12. Fatigue

Accumulation theory-metabolites affect cells

Depletion theory- muscles lack fuel (anemia)

CNS Control (RAS/Inhibiting systems imbalance

Predisposing factors (sleep,nutrition, age, wt. loss)

Subjective Location, severity,

duration Aggravating/

alleviating factors Objective

Strength VS

Labs (O2 sat., hgb.)

Etiology Assessment

Treatments

Active exercise Preparatory

education (conserve energy)

Psychosocial support

Steroids Methylphenidate

(CNS stim., inc. appetite and energy, improved mood, reduces sedation)

SSRIs Tricyclics Epoetin (if anemic)

Non-Pharm Pharmacological

PT./Family Teaching on Fatigue

Explain prevalence + nature of fatigue

Plan, schedule, and prioritize

Rest Instruct on nutrition

(protein) Control contributing

sx. (ex. Use O2)

13. Pressure Ulcers

Poor nutrition/wt. loss

Impaired circulation (vascular and lymphatic)

Poor mobility/tissue compression

Pressure over bony prominence/friction/shear

Clinical Physicial Labs (alb., Hbg., BG, O2 sat. NPUAP.org staging criteria

I (intact redness) II (broken skin, shallow) III (sub-Q tissue exposed) IV (bones, tendon, muscle exposed) Unstageable (stable, dry eschar on

heels-do not remove)

Etiology Assessment

SHEARShear**—Pressure + Friction--When tissue and bone move in opposite directions (↑ HOB, sliding down in chair).

**Causes undermining & tunneling beneath surface.

Shearing is Caused by:

Gravity & friction

Elevation of Head of Bed

Sliding down in chair

Wound Assessment

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

Margins (palpate for induration) Undermining/tunneling (tissue loss under

intact surface) Necrotic tissue (type?) Exudate ? Surrounding tissue (induration, edema?) Granulation? Epithelialization?

Unstageable wound— cannot see base of wound –

Black eschar in wound bed-needs debriding

Dry, Black eschar on heel—do not remove

Do not “reverse stage”—As a wound heals, it remains the same stage—a stage 3 is “a healing stage 3”, not a stage 2.

Treatment

Nutritional support (increase protein)

Pressure-reducing mattress

Frequent turning (q 1h)

Debridement Cleansing/Anti-

bacterial tx. Dressing (keep

wound moist and skin dry)

Non-Pharmacological Pharmacological

Pt./Family Teaching

Prevention and early signs Positioning to protect bony prominences Off-loading heels Skin care Nutrition (protein supps., fluids) Mobility

QUESTIONS?