Chpn hpna review week 3
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Chpn hpna review week 3
- 1. Clinical Review for the Hospice and Palliative Nurse Symptom Management
Hinweis der Redaktion
- There are numerous physical and psychological symptoms that complicate end-of-life care. Appropriate management of these symptoms is challenging and is an important quality-of-life issue. The symptoms addressed are common at the end of life, (anorexia/cachexia, dehydration, nausea/vomiting, bowel obstruction, constipation/diarrhea, anxiety, delirium/agitation, depression, dyspnea, noisy respirations, fatigue, pressure ulcers). Symptom management is necessary to meet patient needs & national guidelines. The definition, etiologies, physical/psychosocial aspects, pharmacological/non- pharmacological interventions and patient/family education are reviewed. √ Have participants volunteer or volunteer teams teach a Section of Symptom Management . Assign ahead of time to give the presenters time to prepare. The idea is to ‘show’ different ways to present information, making it different, interactive, creative. Utilize the skills and knowledge of experienced nurses √ Using acronyms, i.e., BREATHE AIR, from the BASICS product, to present the section on dyspnea. Patient/Family Teaching Sheets TIPS SHEETS www.hpna.org
- Symptom Management Objectives Define common symptoms present at the end of life. Identify possible etiologies of symptoms at the end of life. Assess for the physical and psychosocial aspects of the symptoms that are common at the end of life. Describe pharmacological and non-pharmacological interventions for common symptoms that can be included in the plan of care at the end of life. Describe the patient and family instructions needed for patients and families at the end of life.
- Clinical Practice Guidelines of Quality Palliative Care developed by the National Consensus Project. Update in 2009 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.
- Symptom Management Anorexia/cachexia - Definitions 1 Anorexia: loss of appetite resulting in the inability to eat Initially, will resolve with resolution of illness Weight loss can be replaced with supplements or increased intake Can potentially lead to protein calorie malnutrition if left unchecked Cachexia: a state of ill health & malnutrition marked by weakness & emaciation It isn’t just weight loss. It’s much worse Equal loss of fat and muscle Significant loss of bone mineral content Usually no response to nutritional supplements or increased intake Anorexia almost always a universal characteristic of cachexia May be in response to inflammatory response and metabolic imbalance of cachexia Anorexia/cachexia syndrome (ACS) Metabolic imbalances resulting from the action of tumor by-products and the catabolic state resulting in a functional disturbance, i.e., loss of appetite May have a mutually reinforcing aspect, i.e., anorexia leads to fatigue, fatigue increases anorexia, anorexia increases fatigue, and leading to weakness and emaciation 1
- Symptom Management Anorexia/cachexia Prevalence 1 Commonly for in patients with advanced disease Anorexia Almost universal in patients with advanced cancer and AIDS Common in cancers of digestive organs (stomach, pancreas, colon), lung cancer, non-Hodgkin’s lymphoma Cachexia Occurs in 80% of cancer patients Cause of death in 20% of such patients
- Anorexia/cachexia Causes 1 - Disease Related Chronic nausea and vomiting Infections – oral or systemic. Oral infections: mucositis, candidiasis, herpes simplex Dental pain or other problems, Dentures not fitting Delayed in gastric emptying or malabsorption Constipation caused by medications, inactivity, decreased fluid intake Metabolic alterations due to systemic inflammatory response and the stimulation of cytokines (tumor by products) Metabolic alterations cause anorexia and not vice versa Metabolic alterations may include: glucose intolerance, increased glucose turnover, insulin resistance, increased lipolysis, increased skeletal muscle catabolism, negative nitrogen balance Metabolic paraneoplastic syndromes Include hypercalcemia or hypernatremia -May cause anorexia or contribute to its symptoms Secondary to physical symptoms that contribute to anorexia Pain associated with certain disease states, i.e., pancreatitis Dysgeusia - abnormalities in taste (especially aversion to meat) Ageusia - loss of taste Hyperosmia - increased sensitivity to odor Hyposmia - decreased sensitivity to odor Anosmia - absence of sense of smell Stomatitis Delayed emptying or malabsorption Other symptoms seen in palliative care patients: dysphagia, dyspnea, nausea, vomiting, diarrhea, constipation, obstruction Alcoholism or substance abuse
- Anorexia/cachexia Causes - Medication side effects resulting in anorexia Prevalent in medications used to treat HIV infection (acyclovir, ethambutol, foscarnet, ganciclovir, isoniazid, interferon, pyrimethamine, zidovudine) Cytotoxic drugs that are highly emetic: cisplatin, dactinomycin, anthracyclines, dacarbazine, nitrosoureas, nitrogen mustard Other side effects of medications such as nausea, taste changes, diarrhea can lead to anorexia Chemotherapy Taste changes are often a result of treatments such as chemotherapy Radiation Radiation therapy effects, including bowel strictures/fistulas, can be problematic after the treatments has ended
- Psychological and/or spiritual distress Often overlooked as causes of anorexia May be seen alone or in combination with physical symptoms: anxiety, depression, feelings of hopelessness Results in decreased enthusiasm and/or energy expended toward eating Body image changes resulting from weight loss and subsequent self-image changes Appetite and ability to eat closely connected to aspects of quality of life
- Anorexia/cachexia - Assessment 1,2 Patient reports of anorexia or early satiety Presence of weakness and fatigue Mental status decline: decreased attention span, decreased ability to concentrate, possible depression Observation of progressive muscle wasting, loss of strength, decreased fat, increased total body water, possible edema Possible weight loss: does weight reflect nutritional status or fluid accumulation, if weight increased in presence of heart disease - maybe suggestive heart failure Decrease in triceps skin fold thickness in presence of protein calorie malnutrition Mid-arm circumference decreases in presence of protein calorie malnutrition Lab values associated with anorexia/cachexia syndrome: Anemia, increased triglycerides, decrease nitrogen balance, glucose intolerance Serum albumin concentrations decrease as nutritional status declines. Intake patterns Food likes and dislikes Determining meaning of food Is there pain associated with eating
- Anorexia/cachexia - Pharmacological interventions 1 Megestrol acetate (Megace ) 400-800 mg PO daily in liquid suspension – appetite stimulant Indications: decreased appetite, nausea/vomiting and taste alterations Most useful in patients with longer prognosis (weeks to months) Side effects: may cause fluid retention, menstrual irregularities, tumor flare in patients with breast cancer Contraindicated in patients with thrombophlebitis Do not discontinue abruptly: can cause hypertension, thromboembolism, vaginal bleeding, peripheral edema, hyperglycemia, Cushing’s syndrome, adrenal dysfunction Olanzapine or mirtazapine (antidepressant) may be helpful in increasing intake Metoclopramide (Reglan ) 10 mg PO TID – helpful in increase gastric emptying Indications: early satiety from delayed gastric emptying or gastric paresis Side effects: dystonic reactions, akathisia, tardive dyskinesia Dexamethasone (Decadron ) 4-8 mg PO every morning Indications: impaired sense of well-being, most useful in patients with limited life expectancy or when rapid effect is needed Side effects: euphoria, other mood changes, fluid retention, gastrointestinal irritation Dronabinol (Marinol ) 2.5-5 mg PO every 3-6 hours Indications: decrease appetite, nausea Side effects: sedation, euphoria, difficulty swallowing; older patients may have unpleasant feelings from cannabinoids
- Anorexia/cachexia - Non-pharmacological interventions 1 Treat underlying symptoms that may be contributing to anorexia: pain, nausea, fatigue, depression, taste disorder Emotional support for patient and family for irreversible anorexia or cachexia related to disease process Nutritional support Weight loss from cachexia does not respond well to nutritional interventions Increasing oral intake and/or maximizing nutritional content may be helpful in early phases of illness Encourage culturally appropriate or favored foods Provide small meals based on patient’s schedule; trials of different foods, tastes, textures, temperatures, seasonings, moistures, colors Room temperature foods, less spicy usually preferred; Encourage different liquids - cold, clear liquids usually well tolerated Maximize nutritional content as appropriate; consider protein and calorie supplements - monitor for “taste fatigue” from too frequent intake of supplements Assess for timing of meals and encourage patient to eat most nutritious part of meal first if experiencing early satiety Limit procedures, treatments, psychological upsets prior to eating
- Anorexia/cachexia - Non-pharmacological interventions 1 Enteral and parenteral nutrition May be indicated in small group of terminally ill individuals, if weight loss due to fistulas, mechanical bowel obstructions, dysphagia, adynophagia, vomiting, or malabsorption due to tumor or treatment Short term treatment (< 4 weeks) nasogastric feedings common Long-term enteral treatment (> 4 weeks) gastrostomy or jejunostomy is preferred Feeding formulas vary based on various body functions, but sources of nutrients usually Calories from carbohydrate Protein from casein or whey Fat from triglycerides or vegetable oils Various nutrients (fish oil and glutamine, arginine sometimes added) Total parenteral nutrition (TPN) May be indicated in early process of cancer Considered during treatment regimes, i.e., bone marrow transplantations Greater potential for complications than enteral nutrition, seldom improves outcomes Not indicated in terminally ill patients with advanced disease
- Anorexia/cachexia - Patient and Family Education 1,3 Support patient’s wishes Assist family to understand nutritional needs and limitations in terminal situations Educate family that loss of appetite is normal part of dying process Assure family if the patient is not hungry or thirsty Discuss discomfort experienced by patient associated with food and fluid intake during dying process Artificial fluids and hydration will not make the patient feel better and may lead to more discomfort Provide ongoing education about diminished appetite and intake especially for patients at the end of life Encourage family to provide desired foods at whim of patient and as tolerated Caution family not to barrage patient with constant assortment of foods Let family members know that if patient does not feel hungry, do not insist that the patient eat - may lead to anger, depression or withdrawal Explore the meaning with the patient/family of giving, taking, & refusing food Address emotional needs of family in providing food and fluids Assist family in finding ways to redirect their desire to be caring and teach them appropriate skills to demonstrate this ca Patient Teaching Sheet Managing Nausea and Vomiting (available in Spanish version)
- 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.
- Dehydration Prevalence 1-4 Dehydration considered normal physiologic process at end of life Body has decreased desire for food and fluids as it prepares to die Prevalence of symptoms associated with dehydration vary
- Dehydration - Causes 3 Dehydration is loss of normal body water Isotonic dehydration: results from a balanced loss of water and sodium Occurs during episodes of complete fast, vomiting, diarrhea with loss of water and electrolytes in gastric contents Balanced loss of food and fluid intake seen in terminally ill Eunatremic dehydration: occurs if water loss is greater than sodium losses Can be caused by fever - loss of water through lungs and skin and limited ability to take in oral fluids Hypotonic dehydration: sodium loss exceeds water loss Occurs when water is consumed but food is not Overuse of diuretics Can also be caused from osmotic diuresis, salt-wasting renal conditions, third spacing, and adrenal insufficiency
- Dehydration - Assessment 1,3 Assessment techniques vary among practitioners Co-morbid conditions can also cause same symptoms associated with dehydration, particularly at the end of life Mental status changes Confusion and restlessness caused by dehydration May be exacerbated in terminally ill individuals Thirst, oral/parenteral intake Elderly may have decreased perception of thirst compared to healthy younger adults In hypernatremic dehydration, thirst is powerful stimulus to drink Patients who are confused, somnolent or at end-of-life may not be able to replace fluids by drinking At the end of life, decreased intake of food and fluid considered normal physiologic process Urine output Reduced intravascular volume caused by dehydration can result in renal failure Normal output at end of life: 300-500 cc/24 hours
- Dehydration - Assessment 1,3 Weight loss Weight loss of greater than 3% indicative of dehydration Obtaining patients weight may be impractical if at end of life Reduced skin turgor May be unreliable assessment in cachectic patient Dry mouth May also be associated with mouth breathing May also be associated with use of anticholinergic medications Dry tongue Postural hypotension May also be secondary to cardiac pathology Laboratory tests Increased hematocrit Elevated serum sodium Azotemia with disproportionate rise in blood urea nitrogen in relation to creatinine Concentrated urine Hyperosmolarity Fluid losses
- Dehydration - Ethical considerations 1-3 Dehydration may decrease suffering Improve physical care-giving for some patients Urinary catheters may be avoided Removes barriers of hydration equipment Less gastrointestinal fluid with dehydration - fewer episodes of vomiting Reduction in pulmonary secretions Less coughing, choking, and need for suctioning No needle sticks, increased mobility Dying process not prolonged May act as anesthetic Dehydration may increase suffering (thirst, dry mouth, fatigue, nausea/vomiting, confusion, muscle cramps May cause renal failure and accompanying accumulation of metabolites Emotional suffering of family with regards to provision of fluids Conflicting studies exist over benefits/burdens of hydration at end of life When considering treatment options 1 Review the goals of care Discuss general medical condition Review expected course of illness and establish an overall understanding of the situation Evaluate ability of artificial hydration in meeting the patient’s goals Address misperceptions Address true causes of poor appetite, fatigue, dry mouth, delirium within disease process
- Dehydration - Hydration options 3 Oral - Use least invasive approach possible Standard goal: 1500 to 3000 ml per day or 8-10 glasses of water per day Review medications and remove, if possible, those that contribute to dehydration Consider monitoring of intake/output, skin turgor, mucous membranes, mental status changes, blood pressure based on patient prognosis and goals of care If difficulty swallowing, small sips of favorite fluids - sports drinks are easily absorbed and can correct hypertonic dehydration Provide appropriate mouth care; Fine mist sprays can keep mucous membranes moist Consider use of air conditioners and fans to decrease hot, humid weather conditions Monitor for over-hydration: new orthopnea, shortness of breath, increased emotional distress or change in mental status Proctoclysis Usually used in situations where prognosis is greater - days to weeks Nasogastric tube placed rectally Tap water or saline is instilled starting at 100 cc/hour, increase to 400 ml/hour if no discomfort, leakage or spasm of anal sphincter; A liter of fluid can be instilled over 6-8 hours Side effects may include pain, edema, rectal leakage of fluids, during insertion Practicality in home setting if caregivers uncomfortable with rectal administration
- Dehydration - Hydration options 3 Nasogastric tube Often uncomfortable Patients frequently remove tube, especially if agitated or cognitively impaired Gastrostomy tube Usually placed for feeding alternatives, but also used for hydration Reliable alternative if permanent Consider goals of therapy, cost, and feasibility before placement May be inconvenient and cause complications Hypodermoclysis Subcutaneous fluid administration Alternative for those patients with poor venous access Easily started by any professional staff member who can perform SQ injection Does not require monitoring for clotting in line or letting line run dry Use hypotonic or isotonic solutions with/without hyaluronidase or corticosteroids Administration through needle in subcutaneous tissue of abdomen, anterior/lateral thigh Infusion usually tolerated at 100 ml/hour or more, up to 1500 ml into single site Adverse effects: pain, local irritation at site of infusion, sloughing of tissue possible with over-infusion and abscess formation may occur
- Dehydration - Hydration options 3 Intravenous hydration More technically complicated Must have access to competent vein Monitor carefully for over hydration - infusion pump may be necessary May have previously placed permanent access device or chose to have one placed Must have competent caregiver to monitor site and device Volume and type based on clinician preference - based on past experience and patient condition Some consider a liter per day - may assist with emotional burden of caregiver need to provide fluids, but only partially correct patient deficits; easily scheduled More aggressive replacement will require regular monitoring of labs: serum electrolytes, blood counts with subsequent adjustments every 24-48 hours
- Dehydration - Patient and Family Education 1,3 Instruct how to provide oral, enteral, or parenteral fluids depending on type patient is receiving Encourage family to offer fluids frequently - at least every 2 hours, as tolerated by patient Encourage family not to “insist” that the patient eat or drink - may cause more tension and feelings of anger, depression, or withdrawal by patient if he or she cannot comply If providing hydration in home setting, address all concerns about process and equipment Allow ample time for instruction and return demonstration; Provide instruction to more than one caregiver, if possible; Provide written materials, age and reading level appropriate, on education delivered; Follow up visits to assess level of functioning, give support, & reinforce teaching Offer patient mouth care every 2 hours including oral hygiene: Swab mouth with solution of diluted mouth wash or water; Lip lubrication; Ice chips or popsicles Review signs/symptoms associated with dehydration & the dying process Help family to understand that dehydration is normal part of dying process, if patient at EOL Patient / Family Teaching Sheet Food and Fluid Issues (available in Spanish version)
- Dehydration - Patient and Family Education 1,3 Review benefits & burdens of providing artificial hydration to actively dying patient Instruct family that artificial fluids may make edema, ascites, pulmonary and other secretions, and dyspnea worse Instruct family on dehydration benefits for dying patient: pulmonary secretions, vomiting, and urinary incontinence may be less Instruct family that dehydration may stimulate production of endorphins or other anesthetic compounds that help to contribute to a peaceful and comfortable death for many patients Address emotional needs of family in providing food and fluids Assist family in finding ways to redirect their desire to be caring and teach them appropriate skills to demonstrate this caring Assure family that if the patient is not hungry or thirsty, artificial fluids and hydration will not make the patient feel better
- Reference Emanuel L. von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum . Washington, DC: American Medical Association; 2003. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC - Geriatric) . 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.
- Nausea and Vomiting - Definition Nausea a subjectively perceived, stomach discomfort ranging from stomach awareness to the conscious recognition of the need to vomit. 1 An unpleasant sensation experienced in the back of the throat and epigastrium, which may or may not result in vomiting. 2 May be referred to as, sick in the stomach, butterflies Vomiting Expelling of stomach contents through the mouth 1 May be referred to as throwing up, “barfing”, upchucking
- Nausea and Vomiting Prevalence 2 Up to 70% of patients with advanced cancer experience nausea Vomiting occurs in approximately 30% of patients More common in patients under 65 years, women, and patients with stomach or breast cancer Also seen frequently in patients with gynecological cancers and in patients with AIDS
- Nausea and Vomiting Causes 3 Physiological: caused by visceral disturbances by stimulating vagal and sympathetic pathways: Gastric irritation, Constipation, Intestinal obstruction, Pancreatitis, Ascites, Hepatomegaly, Intractable cough, Radiation effects Metabolic causes: Hypercalcemia, Uremia, infection and drugs that stimulate chemoreceptor zone within the brain causing nausea (with or without vomiting) Central nervous system causes: Raised intracranial pressure, Pain Psychological Emotional factors that stimulate emetic receptors of brain Fear Anxiety Disease related Treatment related: Radiation, Chemotherapy Other: Vestibular disturbances (stimulate the vestibular apparatus causing nausea and vomiting), Motion sickness, Toxic action of certain drugs (ASA, opiates), Local tumors within the brain
- Nausea and Vomiting At the end of life, nausea and vomiting associated with 4 Initiation of opioid therapy Uremia Hypercalcemia Increased intracranial pressure secondary to brain metastasis Vagal stimulation secondary to oral candidiasis Stretching of the hepatic capsule Constipation or impaction Bowel obstruction
- Nausea and Vomiting - Assessment 2-4 History Well documented history of disease and its progression Prior treatments for disease Previous history of nausea and vomiting Effectiveness of prior treatments for nausea and vomiting Current treatments that may be leading to current episodes of nausea and vomiting Assess for precipitating factors: after taking medications, eating meals, movement, certain situations, or with certain smells Consider use of questionnaires, journals, diaries or other self-reporting tools Physical Assess frequency, consistency, volume of emesis Assess for constipation, impaction, obstruction Physical assessment of: Mouth (oral candidiasis), Abdomen (bowel sounds, distention, pain upon palpation), Rectum (impaction) Other considerations: Epigastric pain (gastritis), Pain on swallowing (oral thrush), Pain on standing (mesenteric traction), Thirst (hypercalcemia), Hiccups (uremia), Heartburn (small stomach syndrome) Diagnostic testing Lab values: Renal & liver function tests, Electrolytes, Calcium, Serum drug levels Radiologic testing: Abdominal x-rays, Head CT or MRI
- Nausea and Vomiting – Pharmacologic Consider these seven steps when choosing anti-emetic 5 Identify likely cause of symptom Try to identify the pathway by which each cause is triggering nausea & vomiting Identify the neurotransmitter receptor that may be involved in the pathway (e.g., 5-HT3) Select most potent antagonist for that receptor Select a route of administration that will ensure medication will reach site of action Titrate dose carefully and administer around the clock If symptoms continue, review likely causes, consider additional treatment for overlooked cause
- Nausea and Vomiting - Classes of antiemetics 2 Butyrophenones: dopamine antagonists Major tranquilizers whose mode of action in nausea and vomiting not well understood Generally less effective than other antiemetics Better in combination with other drugs, especially with the 5-HT3 receptor antagonists Effective when anxiety or other anticipatory symptoms aggravate nausea and vomiting Medications Haloperidol (Haldol ) Indication: opioid-induced nausea, chemical and mechanical nausea Side effects: dystonia, dyskinesia, akathisia Droperidol (Inapsine ) Indication: opioid-induced nausea, chemical and mechanical nausea Side effects: dystonia, dyskinesia, akathisia
- Nausea and Vomiting - Classes of antiemetics 2 Prokinetic agents: anti-dopaminergic activity at the CTZ and stimulates 5-HT3 receptors Help to bring normal peristalsis in the upper GI tract Block 5-HT3 receptors in CTZ and in gut Medications Metoclopramide (Reglan ) Indication: gastric stasis, ileus Side effects: dystonia, akathisia, esophageal spasm, colic if GI obstruction, headache, fatigue, abdominal cramps, diarrhea Considerations: infuse over 30 minutes to prevent agitation and dystonic reactions; use diphenhydrAMINE to decrease extrapyramidal symptoms Domperidone (Motilium ) Indication: gastric stasis, ileus Side effects: dystonia, akathisia, esophageal spasm, colic if GI obstruction, headache, fatigue, abdominal cramps, diarrhea Considerations: infuse over 30 minutes to prevent agitation and dystonic reactions; use diphenhydrAMINE to decrease extrapyramidal symptoms
- Nausea and Vomiting - Classes of antiemetics 2 Cannabinoids Usually use for patients as second line antiemetic Option for patients who are refractory to other antiemetics Site of action not completely understood - thought to be at cortical level May be helpful with younger adults with no previous cardiac or psychiatric illness Medications Dronabinol (Marinol ) Indication: second-line antiemetic Side effects CNS sedation Dizziness Disorientation Impaired concentration Dysphoria Hypotension Dry mouth Tachycardia
- Nausea and Vomiting - Classes of antiemetics 2 Phenothiazines Once considered first line antiemetic in palliative care Primarily dopamine antagonists Advantages: available in several routes Effective for acute or delayed nausea May be used in combination with 5-HT3 receptor antagonists and dexamethasone (Decadron ) Medications Prochlorperazine (Compazine ) Thiethylperazine (Torecan ) Trimethobenzamide (Tigan ) Indications: general nausea and vomiting, not as highly recommended for routine use in palliative care Side effects: drowsiness, irritation, dry mouth, anxiety, hypotension, extrapyramidal side effects Considerations: may cause excessive drowsiness in elderly; IM route painful
- Nausea and Vomiting - Adjuvant Antihistamines Act on histamine receptors in the vomiting center and the vestibular afferents Rarely used as single antiemetic agent in palliative care Medications DiphenhydrAMINE (Benadryl ) Indications: intestinal obstruction, peritoneal irritation, increased intracranial pressure, vestibular causes Side effects: dry mouth, blurred vision, sedation Note: often used in combination antiemetic therapy to minimize extrapyramidal side effects Cyclizine (Marezine ) - least sedating and considered better choice Anticholinergics Not used as frequently in antiemetic therapy Anticholinergic effects at or near vomiting center Effective at reducing peristalsis and inhibiting exocrine secretions therefore providing palliation of nausea and colic Route advantages: subcutaneous, sublingual, transdermal Medications Scopolamine (Transderm-Scop ) Indication: motion sickness, intractable vomiting, or small bowel obstruction Side effects: dry mouth, ileus, urinary retention, blurred vision, possible agitation Note: useful if nausea and vomiting co-exist with colic
- Nausea and Vomiting - Adjuvants Steroids Appear to exert antiemetic effect as a result of antiprostaglandin activity Most effective in combination with other agents Enhances efficacy of ondansetron, granisetron and metoclopramide Use over 4 to 5 days can prevent delayed nausea and vomiting Taper after several days to decrease side effects High dose steroids should be considered if there is increased ICP, hypercalcemia, or malignant pyloric stenosis Consider in advanced cancer if nausea resistant to other antiemetics Medications Dexamethasone (Decadron ) Indications: given alone or with other agents for nausea and vomiting Side effects: insomnia, anxiety, euphoria, peri-rectal burning Note: compatible with 5-HT3 receptor antagonists or metoclopramide; taper dose to prevent side effects Benzodiazepines Site of action is central nervous system Used alone or in combination with other antiemetics May decrease anticipatory nausea and vomiting due to amnesic effect Medication Lorazepam (Ativan ) Indication: effective for nausea and vomiting as well as anxiety Side effects: sedation, amnesia, pleasant hallucinations Note: use with caution in patients with hepatic or renal dysfunction, or debilitated patients
- Nausea and Vomiting - Other medications may be helpful for nausea and vomiting in palliative care 5-HT3 receptor antagonists 5-HT3 receptors discovered in CTZ, vomiting center (central) 5-HT3 receptors found in the terminals of the vagal afferents in the gut (peripheral) Appear to limit serotonin inhibition - leads to limited extrapyramidal side effects Limited testing for advanced cancer and use in palliative care Indicated for post-operative nausea and vomiting and chemotherapy Ideal for pediatric and elderly patients Effectiveness is increased if used with dexamethasone Medications Ondansetron (Zofran ) Granisetron (Kytril ) Indications: chemotherapy, abdominal radiotherapy, postoperative nausea and vomiting Side effects: headache, constipation, diarrhea, minimal sedation Note: granisetron has highest potency with longer duration of action than ondansetron ABHR ABHR: Compounded antiemetics: commonly used by palliative care providers 4 ABHR: Ativan (1 mg), Benadryl (25 mg), Haldol (1 mg), Reglan (10 mg) Note: doses and agents may vary Available in multiple routes: troches, transdermal gel Limited by need for compounding pharmacist May cause excessive sedation that is unacceptable to patient and/or family
- Nausea and Vomiting - Other medications may be helpful for nausea and vomiting in palliative care Octreotide acetate (Sandostatin ) Action: mimics the actions of the natural hormone somatostatin and is long acting Inhibits gastric, pancreatic, and intestinal secretions; reduces gastrointestinal motility Indications: nausea and vomiting associated with intestinal obstruction Side effects: diarrhea, loose stools, anorexia, headache, dizziness, seizures, anaphylactic shock Note: may interfere as others with insulin and beta-adrenergic blocking agents; watch liver enzymes DimenhyDRINATE (Dramamine ) Action: unknown mechanism for inhibiting nausea and vomiting Indications: nausea, vomiting, dizziness, motion sickness Side effects: dry mouth, blurred vision, sedation Note: geriatric clients may be more sensitive to dose
- Nausea and Vomiting - Non-pharmacologic Interventions 2 Self care activities Oral care after each episode of emesis Apply a cool damp cloth to forehead, neck, wrists Decrease noxious stimuli like odor and pain Restrict fluids with meals Eat frequent small meals Eat bland, cold or room-temperature food Lie flat for 2 hours after eating unless patient has hiatal hernia Wear loose-fitting clothes Have fresh air with a fan or open window Avoid sweet, salty, fatty, and spicy food Limit sounds, sights, and smells that precipitate nausea and vomiting
- Nausea and Vomiting - Non-pharmacologic Interventions 2 Behavioral interventions Used alone or in combination with antiemetics Produce relaxation which decreases nausea and vomiting Serve as distraction from noxious stimuli Enhance feelings of control and decrease feelings of helplessness No side effects, easily self administered Intervention is individually based and may include: Self hypnosis, Relaxation, Biofeedback, Imagery, Distraction, Desensitization Other non-pharmacological interventions Acupressure: wrist bands may decrease nausea and vomiting Music therapy: used with other techniques; decreases nausea during and after chemotherapy; decreases perception of degree of vomiting Nasogastric tube to relieve pressure for comfort Draining PEG tube (rare, such as in unresectable obstruction) Consider IV hydration based on patient prognosis and goals of care Cultural Considerations, examples Be observant, American Indians/Alaskan natives may be embarrassed to report signs and/or symptoms Asian/Pacific Islander may believe nausea and/or vomiting caused by too much “yin” - treat with hot soups, warm clothing Generally, Hispanics will freely discuss symptom
- Nausea and Vomiting - Patient and Family Education 2 Instruct family on how to assess nausea and vomiting rate distress caused by nausea and vomiting based on 0-10 scale problem solving skills (e.g., when to give additional antiemetic; when to incorporate non-pharmacological interventions) their role in ensuring self care activities associated with nausea and vomiting - include written instructions when to call healthcare provider non-pharmacological methods for decreasing nausea and vomiting (e.g., music therapy, progressive relaxation) Patient Teaching Sheet (Spanish version available) Managing Nausea and Vomiting
- References Berry PH, ed. Core Curriculum for the Generalist Hospice and Palliative Nurse . 2nd ed. Dubuque, IA: Kendal/Hunt; 2005. 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. Bednash G, Ferrell BR. End-of-life nursing education consortium (ELNEC) . Washington, DC: Association of Colleges of Nursing; 2009. 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. Mannix K. Gastrointestinal symptoms. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 3rd New York, NY: Oxford University Press: 2005:464-468.
- Bowel Obstruction Prevalence 1 Obstruction related to site of disease Tumors of splenic flexure obstruct 49% of time Rectum or rectosigmoid junction obstruct 6% of time
- Bowel Obstruction - Causes 1 Occlusion of the lumen or absence of the normal propulsion which affects elimination from the gastrointestinal tract Intralumen obstruction related to primary tumors of colon and consists of tumor in the muscular wall of the intestine flexure Extramural obstruction related to mesenteric and omental masses and malignant adhesions Mechanical obstruction impaired or absent motility without the luminal occlusion; results in the accumulation of fluids and gas proximal to the obstruction leading to distention Metabolic disorders Crohn’s disease, hypokalemia Medications Diuretics can cause hypokalemia, which decrease peristalsis; opioids; chemotherapy As distention increases, intestinal secretion of water and electrolytes increases Small bowel obstruction associated with large amounts of diarrhea Increased fluid in the bowel leads to increased peristalsis with large quantities of bacteria growing in the intestinal fluid of the small bowel Additional factors include multiple sites of obstruction along the intestine to constipating medications, fecal impaction, fibrosis, or change in normal flora of bowel 1
- Bowel Obstruction - Assessment 1 Usually slow and insidious process - May progress from partial to complete Consider assessment within context of palliative care goals Consider x-ray if surgical intervention realistic option Consider barium enema to identify cause of obstruction within context of palliative care goals (or prognosis greater than 3 months) Obtain bowel history: Last bowel movement; Consistency; Complaint of constipation Palpation of abdomen for masses or distention Rectal exam for presence of stool in rectum - distinguish between stool and tumor mass Empty or “ballooned” rectum indicates higher obstruction Location of obstruction Duodenal obstruction: Severe vomiting with large amounts of undigested food; Abdominal sounds: succussion splash (sloshing of liquid within the intestinal tract) may be present; No pain or distention noted Small intestine obstruction: Moderate to severe vomiting; Usually hyperactive bowel sounds with borborygmi (rumbling or growling sound); Colic-type pain in upper and central abdomen; Moderate distention Large intestine obstruction: Vomiting is late sign; Borborygmi bowel sounds; Severe distention Colic-type pain in central to lower abdomen
- Bowel Obstruction - Treatment 1-3 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
- Bowel Obstruction - Pharmacological interventions 1-3 Octreotide (Sandostatin ) 0.3 mg to 0.6 mg IV/SQ injection or IV/SQ infusion, convert to octreotide depot before going home Useful in early treatment to prevent complete obstruction Slows irregular and ineffective peristalsis associated with obstruction Reduces vomiting (70% effective) by inhibiting secretion of gastrin, secretin, vasoactive peptide, pancreatic polypeptide, insulin & glucagon Blocks secretion of gastric acids Scopolamine patch 1.5 mg behind the ear every 4 days May increase to 2 patches Anticholinergic effects decreases peristalsis and decreases fluid build up above obstruction Can cause dilation of pupils Opioid medications Used for pain relief associated with obstruction SQ infusion route may be preferred (PCA) Improved absorption over oral route PCA provides patient control over analgesia Antiemetic medications Haloperidol (Haldol ) 5-15 mg/day Is first line antiemetic for complete obstruction Promethazine, prochlorperazine can also be used
- Bowel Obstruction - Pharmacological interventions 1-3 Corticosteroids – decrease inflammatory response, helpful antiemetic properties Dexamethasone (Decadron ) 8 to 20 mg/day Consider 4 mg/day twice a day for five days then decrease to 4 mg/day Possible side effect is oral candidiasis Prednisolone 50 mg/day injection or SQ infusion Antispasmodic medications Hyoscine butylbromide 60 mg/day increased to up to 380 mg/day SQ infusion 1 Used to relieve spasm-like pain associated with increased peristalsis against the resistance of a mechanical obstruction Anticholinergic side effects: tachycardia, dry mouth, sedation, hypotension Laxative medications Stimulant laxatives contraindicated due to increased peristalsis against obstruction If only single obstruction in colon or rectum, stool softeners may be helpful If obstruction in small bowel, laxatives will not be of benefit Metoclopramide (Reglan ) 10 mg every 4 hours Drug of choice for incomplete bowel obstruction Stimulates the stomach to empty its contents into the reservoir of the bowel Discontinue if becomes complete obstruction and use haloperidol Antidiarrheal medications Diarrhea may be associated with subacute obstruction or a fecal fistula Codeine or loperamide (Imodium ) may be helpful to relieve both diarrhea and pain
- Bowel Obstruction - Surgical interventions 1 Considered within context of established palliative care goals Verification that obstruction may or may not be related to worsening tumor Probability of reoccurrence is high with lowered survival rates with subsequent surgeries Mortality is possible Consider poor prognosis factors General medical condition Poor nutritional status Ascites Palpable abdominal masses Distant metastasis Previous radiation to abdomen or pelvis Combination chemotherapy Multiple small bowel obstruction Consider possible success factors in palliative surgery Absence of palpable abdominal or pelvic masses Volume of ascites less than 3 liters Unifocal obstruction Preoperative weight loss less than 9 kg Placement of draining nasogastric tube or venting gastrostomy
- Bowel Obstruction - Non-Pharmacological interventions Modified diet or nothing by mouth (NPO) Low impactions may require patient to lay down to decrease pressure on the rectal area, avoid hot drinks, avoid eating big meals as these may increase peristalsis Consider nasogastric or nasointestinal tubes to decompress bowel or stomach if intractable vomiting (> 2 episodes/8 hours) not relieved with pharmacological interventions
- Bowel Obstruction - Patient and Family Education Review possible causes of bowel obstruction Discuss all treatment options within context of palliative care goals Educate to prevent bowel obstructions Review signs and symptoms of bowel obstruction with patients who are at increased risk: GI cancers, ovarian cancer Instruct patient and family on when to contact healthcare provider: fullness in stomach, constipation, vomiting, vomiting bright red blood, abdominal pain, belly hard and tender, bright red blood in stools Review medication regime and report effectiveness to healthcare provider Review dietary recommendations Encourage patient to eat and drink as tolerated
- References 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. 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. Emanuel L. von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC - Geriatric) Curriculum . Washington, DC: American Medical Association; 2003.
- Constipation - Definitions 1 Infrequent passage of stool Primary constipation: caused by reduced fluid and fiber intake, decreased activity, lack of privacy Secondary constipation: related to pathologic changes such as tumor, partial intestinal obstruction, hypercalcemia, hypothyroidism Iatrogenic constipation: due to pharmacologic interventions, such as opioids , chemotherapeutic agents, tricyclic antidepressants
- Constipation - Prevalence 2,3 10% of general population in the United States report constipation Constipation and laxative use increase with age Incidence as high as 50-78% in older or ill adults 1 Constipation effects more than 50% of patients in a palliative care unit or in hospice Frequently seen symptom at the end of life 2 Constipation is a major problem with cancer patients with as many as 70-100% reporting this distressing symptom Constipation is common yet undertreated by both nurses and physicians Can be very embarrassing for some patients thus can evolve into a severe problem Prevention is the key!
- Constipation - Causes 1 Disease Related Cancer related Directly related to tumor site: bowel cancers, secondary bowel cancers, pelvic cancers, hypercalcemia, surgical interruption of bowel integrity (adhesions) Intestinal obstruction Diabetes – affects neurological stimulation of gastrointestinal mobility hypothyroidism, hypokalemia, diverticular disease, hemorrhoids, colitis, chronic neurological diseases, spinal cord compression Medication related Opioids, anticholinergic effects, tricyclic antidepressants, antiparkinsonian drugs, iron, antihypertensives, antihistamines, antacids, diuretics, vinca alkaloids Other factors Not enough fluids or fiber, lack of privacy, weakness, inactivity, decreased abdominal tone depression
- Constipation - Assessment 1,2 Bowel history Characteristics and frequency of stool Stools that are hard and pellet-like indicate constipation due to slow transit time; ribbon-like stools indicates hemorrhoids; blood or mucous in stools indicate tumor, hemorrhoids or possible preexisting colitis History of use of bowel medication Presence of concurrent medical conditions Prior constipation problems Patterns of alternating constipation and diarrhea Patterns of oozing stools - see “Obstruction” Complaints of colic pain or nausea and vomiting Recognize that individuals define constipation differently and establish what is normal bowel pattern for individual patient Consider use of Constipation Assessment Scale 4 which includes Abdominal distention or bloating Change in amount of gas passed rectally Less frequent bowel movements Oozing liquid stools Rectal fullness or pressure Rectal pain with bowel movement Smaller stool size Urge but inability to pass stool Fluid and food intake
- Constipation - Assessment 1,2 Physical Assessment Assess oral cavity for tumor or lesions that interfere with eating Have patient empty bladder before abdominal assessment Assess for bloating, tenderness, distention, bulges Bowel sounds: hyperactive, hypoactive, absent Listen continuously for 5 minutes if bowel sounds absent - could indicate paralytic ileus Percussion: tympany related to gas; dull sound related to intestinal fluids and feces Palpation: look for muscular resistance, abdominal tenderness; rebound tenderness associated with peritoneal inflammation; deep palpation may reveal stool in left colon Digital examination of rectum for stool, tumor or rectocele; assess for hemorrhoids, ulcerations, rectal fissures Diagnostic tests Consider x-rays within context of palliative care goals May be useful to rule out obstruction vs. constipation Consider blood work if hypercalcemia or hyperkalemia suspected and is reversible Medication review Current medications that can cause constipation Use of over the counter laxatives Use of herbal remedies (flax, rhubarb, mulberry have laxative properties)
- Constipation - Pharmacologic - Treatment 1,5,6 Lubricant laxatives Lubricates the stool surface/softens the stool leading to easier bowel movement Mineral oil most common - Dosing: 10-30 ml/day (may see action in 1-3 days) Complications Overuse can cause seepage from rectum and peri-anal irritation With chronic use, may lead to malabsorption of fat-soluble vitamins Avoid giving at bedtime to frail patients - potential for aspiration pneumonitis Avoid concurrent use with daily docusate (Colace ) - increased absorption of mineral oil may lead to lipoid granuloma on intestinal wall Surfactant/detergent laxatives Reduce surface tension, increase absorption of fluids and fats into stool which soften it At higher doses, can stimulate peristalsis Dosing Sodium docusate (Colace ): 1-2 tablets PO daily to twice a day, titrate to effect Calcium docusate (Surfak ): 1-2 tablets PO daily to twice a day, titrate to effect (may take 1-3 days for effect) Sodium phosphate (Fleet ) enema PRN Avoid use of castor oil in cancer-related constipation, results are difficult to control
- Constipation - Treatment 1,5,6 Combination medications - Combine mild stimulant laxatives, casanthranol, and stool softener (docusate) Dosing Docusate with senna (Senokot S ): 2 tablets PO BID, titrate to effect (results occur in 6 to 12 hours) Docusate with casanthranol (Peri-Colace ): 1-2 tablets PO bid, titrate to effect Osmotic laxatives - Non-absorbable sugars that exert an osmotic effect in primarily the small intestine (lesser extent in large intestine) Also lower ammonia levels - improves confusion in patients in hepatic failure Dosing Lactulose (Chronulac ),Cephulac ) sorbitol: 30 to 60 ml initially every 4 hours until BM occurs; then calculate amount needed to achieve initial BM and divide in half for daily dosing (action can occur in 4 hours) Complications: Effectiveness is dose related; Taste may be intolerable to some patients - may be placed in juice or other liquid; With higher doses, bloating and gas may be uncomfortable or distressing; Lactulose is more costly and has higher incidence of nausea than sorbitol Osmotic suppositories Glycerine suppositories: Soften stool by osmosis and act as lubricant Bisacodyl (Dulcolax ) suppositories: Acts directly on mucous membrane of the large intestine causing reflex stimulation; Less side effects as it is not absorbed in small intestine Avoid suppositories in patients with severely reduced white cell or platelet counts due to risk of bleeding or infection
- Constipation - Treatment 1,5,6 Saline laxatives Increase gastric, pancreatic, & small intestinal secretions, & motor activity throughout the intestine Recommended as last resort in chronically ill patients Dosing Milk of Magnesia: 30 cc PO to initiate a BM or 1-2 tablespoons 1-3 times per day. For opioid induced constipation 15 ml of Milk of Magnesia may be added to baseline bowel medications either daily or every other day Magnesium citrate: 1-2 bottles PRN (recommended as one time initial therapy in severe constipation, or obstipation) With abdominal discomfort or pain it is recommended to rule out obstruction before administrating not to cause discomfort or lead to perforation Complications Aluminum salts from antacids counteract laxative effect of magnesium May cause severe cramping and discomfort Should be avoided if patient has renal disease
- Constipation - Pharmacological - Treatment 1,5,6 Bowel stimulants - Work directly to irritate bowel & stimulate peristalsis; Reduces the amount of water & electrolytes in colon Diphenylmethanes Phenolphthalein (Ex-Lax , Fen-a-ment , Correctol , Doxidan ) Must be metabolized in liver not in colon - Use with caution when liver disease present May not be appropriate for cancer-related constipation as effects are difficult to control Anthraquinones Bowel stimulants such as senna, cascara, bisacodyl – may be effective for opioid-induced constipation Dosing Bisacodyl (Dulcolax ): 5-10 mg PO, PR at bedtime, titrate to effect Casanthranol: 2(15 mg) PO every at bedtime, titrate to effect Senna: 2 PO at bedtime, titrate to effect (up to 9 or more per day) Complications Take Bisacodyl with food, milk or antacid to avoid gastric irritation
- Constipation - Pharmacological - Treatment 1,5,6 Bulk laxatives Provide bulk to the intestines to increase mass - stimulates bowel to move Most helpful in mild constipation Must increase fluid intake by 200-300 ml if using bulk laxatives If unable to tolerate increase fluid, may lead to bowel obstruction May not be appropriate at end of life if patient fluid intake inadequate Not recommended in debilitated patients due to decreased fluid intake Types: dietary fiber, bran, psyllium (Metamucil ), carboxymethylcellulose, methylcellulose Dosing 8 g daily then stabilize to 3-4 g for maintenance Psyllium: 2-4 teaspoons daily (make take 2-3 days for results) Complications: allergic reactions, fluid retention, hyperglycemia
- Constipation - Pharmacological - Treatment 1,5,6 Enemas Soften stool by increasing water content Large volume enemas distend colon and stimulate peristalsis Recommended for infrequent use and for severely constipated patients Repeated use can cause hypocalcemia and hyperphosphatemia The longer the enema retained, the better the outcome Oil retention enema Useful when disimpaction may be necessary Work best when given overnight - if patient able to retain Fleet enema ® Should not be used in presence of abdominal pain, nausea, fever or vomiting (may be signs of appendicitis or inflamed bowel) cardiac disease, severe dehydration or debility Do not administer to children under the age of 2 years Combination enemas Enema with saline-type laxative lactulose (Chronulac , Cephulac ) Useful if large amount of stool present Narcan ® studied for used of opioid induced constipation that does not respond to other treatment
- Opioid Induced Constipation Opioids bind to mu–opioid receptors in the central nervous system (CNS), providing analgesia, but they also bind to peripheral mu–opioid receptors in the gastrointestinal tract, inhibiting bowel function. Treatment of OIC involves both nonpharmacologic and pharmacologic management. Nonpharmacologic management may include increasing fluid intake and activity as patient able. Oral erythromycim is being studied as an effective medication for OIC Metoclopramide, when given PO, may be effective in increasing gastric motility and intestinal transit time.
- Methylnaltraxone (Relistor ® ) 7 first selective peripherally acting mu–opioid receptor antagonist displacing opioid binding in tissues such as the gastrointestinal tract unique molecular structure that restricts it from crossing the blood-brain barrier inhibits opioid induced decreased gastrointestinal motility and delay in gastrointestinal transit time, thereby decreasing opioid induces constipation. Does not affect opioid analgesic effects or induce opioid withdrawal symptoms. It blocks the effects of opioids in peripheral tissues, including the GI tract, mitigating their constipating effects without interfering with their centrally-mediated analgesia. Effects of opioids on the gastrointestinal tract include: Small intestine Decreased propulsive contractions / Increased water absorption Large intestine Decreased propulsive peristalsis / Decreased reflex relaxation response Increased nonpropulsive contractions / Increased anal sphincter tone Increased transit time / Increased desiccation of feces 50% of patients treated had a bowel movement within 30 minutes - 4 hours of the first injection contraindicated in patients with known or suspected mechanical gastrointestinal obstruction Doses: dosing according to weight subcutaneous injection • No dose adjustment required in elderly patients • No dose adjustment required in patients with mild or moderate renal or hepatic impairment • Dose reduction by one half is recommended in patients with severe renal impairment (creatinine clearance less than 30 mL/min) 1 Adverse reactions: Abdominal pain, flatulence, nausea, dizziness, diarrhea.
- Constipation - Non-Pharmacological -Treatment 1,5,6 Prevention of constipation is primary strategy Patients respond individually to established therapies Patient should have BM at least once every 3 days regardless of intake Awareness of disease processes and medications that can cause constipation Manage side effects of pain management Encourage fluid intake - prune juice, coffee to stimulant bowel movement Increase dietary intake as possible - Caution use of high fiber diet or fiber supplements if patient unable to tolerate adequate fluids - may worsen problem Encourage activity to increase peristalsis & improve mood - even at the end of life; may include active or passive range of motion exercises Consider intervening at end of life only if signs of constipation or impaction causing distress (abdominal pain, escalation of usual pain, anxiety, agitation, nausea, vomiting) Disimpaction Administer oil retention enema (120 cc) several hours prior or night before. Recommended to premedicate with opioid and/or anxiolytic - 10 minutes prior, instill rectum with 10 ml of 1% lidocaine jelly. Lubricate surface of anus with lidocaine jelly and tip of gloved finger used for digital disimpaction Cultural Considerations Examples American Indians/Alaskan Natives are generally modest, but will report Asian/Pacific Islanders may believe caused by too much “yang” (warm), may treat with “yin” (cool) foods African American may report being “backed up”
- Constipation - Patient and Family Education 1,6 Advise patient and/or family to monitor frequency of BM patterns Educate that patient should have at least 1 bowel movement every 3 days regardless of intake Bowel movement should be ‘full and satisfying’ Advise patient/family to monitor character of stool: quantity, color, consistency Encourage fluid intake of 1800-2000 cc per day if possible Encourage intake of dietary fiber within restrictions of disease process Encourage activity and exercise as much as possible - consider physical therapy consult to maximize exercise regime Educate patient and family on use of laxatives and possible side effects, as well as medications that can lead to constipation Advise patient and family to call healthcare provider if signs of constipation present No BM in 3 days or more; Bloated feelings Cramping and/or abdominal discomfort; Abdominal distention Change in amount of gas passed rectally Less frequent bowel movements; Urge but inability to pass stool Oozing liquid stools Rectal fullness or pressure; Rectal pain with bowel movement Smaller stool size Patient / Family teaching Sheet (available in Spanish version) Managing Constipation
- References 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. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC). Washington, DC: Association of Colleges of Nursing, 2009. 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. McMillan S, Williams F. Validity and reliability of the constipation assessment scale. Cancer Nursing 1989;12:183-188. Emanuel L, von Gunten C, Ferris F. The education for Physicians on End of Life Care (EPEC) Curriculum . Washington, DC: American Medical Association, 2003. 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. RELISTOR® (methylnaltrexone bromide) Prescribing Information, Wyeth Pharmaceuticals Inc.
- Diarrhea - Definition 1,2 Frequent passing of loose, non-formed stool Increase in stool volume and liquidity resulting in three or more bowel movements per day Secondary effects can include abdominal cramps, anxiety, lethargy, weakness, dehydration, dizziness, loss of electrolytes, skin breakdown and associated pain, dry mouth, weight loss Potential to have a significant negative impact on patient quality of life leading to exhaustion, depression, caregiver burden
- Diarrhea - Prevalence 2 Considered a main symptom of 7-10% of hospice patients Considered especially prevalent and severe in the HIV-infected patients 43% of bone marrow transplant patients develop diarrhea related to radiation or graft-versus-host disease
- Diarrhea - Causes 1 Disease related AIDS patients: multiple bacterial and parasitic infections Partial bowel obstruction or fecal impaction - diarrhea may alternate with constipation Certain tumors (rectal) may cause increase in mucous secretions Malabsorption: related to pancreatic tumors or post gastrectomy Excessive dietary fiber Concurrent diseases: hyperthyroidism, irritable bowel syndrome, colitis Psychologically related Source of anxiety for patient, particularly in public places May lead to homebound, isolated patient Use of adult incontinent briefs (avoid the term adult diapers ) may increase participation, but patient may feel use is degrading to self image Treatment related Chemotherapy-related mucositis and infections secondary to immunosuppression Radiation to abdomen, pelvis, spine leading to intestinal mucosa damage Graft-Versus-Host Disease caused by immunosuppression, may lead to dumping syndrome. Dumping syndrome can also occur after surgery - bowel has a decreased ability to absorb and secrete fluids C-difficile infection after course of antibiotics - stemming from overgrowth of bacteria in the gut Drugs such as chemotherapeutic agents, antibiotics, bulk-laxatives, magnesium-containing medications; herbal remedies such as milk thistle, aloe, cayenne, saw palmetto, siberian ginseng, and over-the-counter medications may also cause diarrhea Foods, such as milk and other dairy products, caffeine-containing products, carbonated and high-sugar or high-sorbitol juices (prune, pear, sweet cherry, apple), high-fiber, gas-forming legumes, high-fat foods, spicy foods
- Diarrhea - Assessment 1,2 Bowel history Assess frequency and nature of diarrhea in last 2 weeks Consider use of National Cancer Institute Scale of Severity of Diarrhea Assess for onset and/or suddenness of bowel movement Complaints of pain or abdominal cramping Rapid onset may indicate fecal impaction with overflow If liquid stools occur 1-2 times per day, may indicate anal incontinence Colonic diarrhea: watery stools in large amounts Malabsorption: foul smelling, fatty, pale stools Dietary history Assess fluid intake (normal 2 quarts per day) Assess fiber intake (normal 20-40 gm/day) Appetite, presence of nausea or vomiting; spicy food intake, enteral nutritional supplements Treatment history Recent surgery (gastrectomy, pancreatectomy, bypass or ileal diversion) Chemotherapy Radiation therapy to abdomen, pelvis, lower spine Medication review Assess for laxative overuse: cramping, urgency, fecal leakage Inquire about over-the-counter and herbal remedy use Assess for recent antibiotic therapy Assess for NSAID use
- Diarrhea - Assessment 1,2 Evaluate for infectious processes Lab analysis of stool: blood, fat, mucous and pus, culture and sensitivity, ova and parasites Immunosuppression: bacterial, protozoan, viral disease Physical assessment Perform digital exam to rule out impaction Abdominal assessment for distention or palpable stool in large bowel Examine stools for signs of bleeding: color, odor, guaiac testing Evaluate for signs of dehydration Examine perineum or ostomy site for integrity: breakdown, fissures, external hemorrhoids
- Diarrhea - Pharmacological interventions 1,2,3 Treat underlying cause as appropriate Opioids Suppress forward peristalsis and increase sphincter tone Diphenoxylate hydrochloride (Lomotil ) and atropine sulfate 5 mg PO twice a day Not recommended for patients with advanced liver disease as it may precipitate hepatic coma in patients with cirrhosis Not recommended for children under 12 years Loperamide hydrochloride (Imodium ® ) 4 mg PO, then 2 mg after each loose stool, not to exceed 16 mg/24 hours Drug of choice for treatment of non-specific diarrhea Not recommended for children under 12 years Tincture of opium 0.7 ml PO every 4 hours, and titrate Bulk forming agents - Promote absorption of liquid and increase thickness of stool Psyllium (Metamucil ® - many available) 1-3 times per day Patient must be able to drink at least 8 oz of water with each dose Antibiotics Metronidazole (Flagyl ) for example, to eliminate infectious process Steroids - Decrease inflammation in the gut and provides some relief in partial bowel obstruction and ulcerative colitis Dexamethasone (Decadron ) Dosing based on clinician assessment Somatostatins - Slows transit time by decreasing secretions; Suppresses diarrhea associated with carcinoid tumors and AIDS Octreotide (Sandostatin ) 50 mcg to 200 mcg SQ 2-3 times per day or 10-80 mcg every 1 hour by continuous SQ or IV infusion Usually used for persistent, severe secretory diarrhea Lactaid ® may help if diarrhea related to lactose intolerance
- Diarrhea - Non-Pharmacological interventions Dietary management 1,2 Systematically eliminating foods certain foods may reveal a diarrhea causing food for the individual Consider consult from registered dietician Initiate a clear liquid diet Eat small, frequent, bland meals – BRAT diet which is Bananas, Rice, Applesauce and Toast Avoid milk, proteins, fats, alcohol, hot spices, caffeinated beverages, chocolate Avoid gas-forming foods - broccoli, cauliflower, cabbage, sauerkraut, corn, beans Avoid intake of hyperosmotic supplements (e.g., Ensure ® , Sustacal ® ) Low residue diet - potassium rich (bananas, rice, peeled apples, dry toast) Increase fluids in diet - approximately 3 liters of fluid per day if possible Consider IV hydration, if appropriate Consider electrolyte fluids, i.e., Pedialyte ® Consider homeopathic remedies for diarrhea: ginger, tea, glutamine, peeled apples
- Diarrhea - Non-Pharmacological interventions Psychosocial interventions 2 Provide support to patient and family Recognize negative effects of diarrhea on quality of life Fatigue Malnutrition Alteration in skin integrity Pain and discomfort Sleep disturbances Limited ability to travel Compromised role within family Decreased sexual activity Caregiver burden Sitz baths Odor Control Cultural considerations examples American Indian/Alaskan Native generally are modest but will report May self treat with elderberry flowers Asian/Pacific Islanders may believe diarrhea is caused by too much “yang” (warm), may treat with “yin” (cool) Generally, African Americans will disclose if asked. They believe diarrhea is beneficial and may not want drug therapy
- Diarrhea - Patient and Family Education 2 Respect levels of comfort during discussions about diarrhea with patient/family Instruct patient and family on monitoring frequency and consistency of stools per comfort level Instruct patient and family on dietary modifications as described Instruct patient and family on signs and symptoms to report to healthcare provider: excessive thirst, dizziness, fever, palpitations, rectal spasms, excessive cramping, watery or bloody stools Advise family to contact healthcare provider if medications not effective in managing diarrhea Instruct patient and family on importance of cleansing the perineum gently after each stool to prevent skin breakdown Instruct family to monitor stoma site if applicable Use protective skin barrier (i.e., Desitin ® ) to protect area from breakdown (skin care and soothing interventions) Recommend a bedside commode for easy access and timing needs Suggest adult incontinent products, avoid using the term “adult diapers”
- References Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC) . Washington, DC: Association of Colleges of Nursing, 2009. 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. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum . Washington, DC: American Medical Association, 2003.
- Anxiety - Definitions Anxiety: a feeling of deep sense of unease without an identifiable cause May be assessed as mild, moderate or severe based on severity of accompanying symptoms Symptoms include: chronic apprehension, worry, inability to relax, difficulty concentrating, sleep disturbances. May be accompanied by physical signs; palpations, abdominal distress Prevalence Varies based on study and definition of anxiety
- Anxiety - Causes 1 Poorly controlled pain, urinary retention, fecal impaction Altered physiologic states: hypoxia, septicemia, hypoglycemia, hypocalcemia Medications: stimulants, corticosteroids, metoclopramide in high doses, neuroleptic medications, thyroid replacements, digitalis, antihypertensives, antihistamines, antiparkinsonian medications, anticholinergics, analgesics Withdrawal from alcohol and medications: sedatives, narcotics Medical conditions: endocrine disorders, metabolic conditions, respiratory conditions, neoplasms, neurological conditions Psychological distress, Emotional distress, Spiritual distress Lifestyle changes, financial concerns, dealing with difficulty, exhausting treatment regimens and the side effects
- Anxiety - Assessment 1,2 Physical assessment Initial focus on finding physical cause and assess if reversible Assess physical symptoms: sweating, tachycardia, restlessness, agitation, trembling, chest pain, hyperventilation, tension Assess cognitive symptoms: recurrent and persistent thoughts, ideas, or impulses; fear of “going crazy”; fear of dying Assess for: pain, bowel/bladder causes: urinary retention and constipation Assess medication regime for anxiety-inducing drugs including recent changes in medications Consider metabolic changes: hyperkalemia, hypernatremia, hyponatremia, hypoglycemia, anemia Note: work up for metabolic causes may not be appropriate at the end of life. Consider prognosis and patient goals before implementing invasive laboratory analysis Distinguish between movement associated with anxiety and physical causes such as myoclonus or extrapyramidal movements Assess familiarity with environment - especially if recent move from familiar home environment of elderly patient Interview Explore psychological and emotional dimensions that may be causing anxiety: readiness to die, unresolved conflicts, family dynamics, etc. Explore spiritual concerns that may cause anxiety: fear, relationship with God and afterlife, meaningfulness Questions to explore 3 Have you experienced any of the following symptoms since your diagnosis or treatment? When do they occur and how long do they last? Do you feel nervous, shaky, or jittery? Have you had a sudden onset of feeling you might be, losing control, or dying? Do you worry about when your pain will return and how bad it will get? Do you worry if you’ll be able to get your next dose of medication on schedule? Consider standard evaluation tools (i.e., Mini Mental Status Exam) to evaluate patient’s ability to respond to questions
- Pharmacological Interventions 1 Antidepressants - Blocks serotonin reuptake useful in treating panic attacks and transient anxiety / Use cautiously with terminally ill SSRI’s – Fluoxetine, Paroxetine Benzodiazepines/anticonvulsants – acts on limbic-thalmic-hypothalmic area of the CNS producing anxiolytic, sedative, hypnotic, skeletal muscle relaxation Lorazepam (Ativan ) 0.5-2 mg every 6-8 hours around the clock May be give sublingually with few drops of water if patient unable to swallow Consider IM route as last resort Alprazolam (Xanax ) 0.5-2 mg PO or SL every 6-8 hours around the clock if patient experiences paroxysmal agitation from lorazepam Consider long acting benzodiazepine for agitation near death Diazepam (Valium ) 10-20 mg PR at first sign of restlessness followed by 5-10 mg every 6-12 hours around the clock Clonazepam (Klonopin ) 0.3-0.5 mg SC every 12 hours or 0.5-2 mg every 6-12 hours Barbiturates - Considered when benzodiazepines not effective in relief of anxiety Phenobarbital 60 mg PR every 4-12 hours as needed - Rapid onset; very sedating May be useful for treating myoclonus and seizures Neuroleptics – blocks dopamine reuptake. Atypical antipsychotics have less anticholinergic effects when used at lower doses Given with occurrence of hallucinations or paranoia in terminal anxiety or in the presence of agitation delirium Haloperidol (Haldol ) starting dose of 1-2 mg PO or SC every 1 hour as necessary Do not exceed more than 5 mg in 4 hour period due to risk of myoclonus Chlorpromazine (Thorazine ) 25-50 mg PR every 4-12 hours, or 12.5 mg IV every 4-8 hours Terminal restlessness: starting dose of 100 mg PR or PO followed by 25-50 mg every 4–12 hours More sedating than haloperidol / Can be given PO, PR, IV Tricyclic antidepressants 4 Useful when anxiety accompanies depression Use cautiously with terminal ill due to anticholinergic effects and sedative side effects Often require weeks for therapeutic effect to be achieved Imipramine (Tofranil ) 75-150 mg PO, IM daily in divided doses ClomiPRAMINE (Anafranil )10-150 mg PO daily in divided doses
- Anxiety - Non-pharmacologic Interventions 3 Non-pharmacologic interventions may vary depending on the severity of the anxiety experienced by the patient Assist patient to identify past effective coping skills and to learn new coping skills Provide reassurance and support Use open ended questions, reflect, clarify, empathic listening skills Consider interdisciplinary team consult with counselor and/or spiritual care provider Acknowledge patient fears and provide concrete information to eliminate fear of the unknown Provide warning of stressful event when appropriate Encourage use of a stress diary to assist patient in understanding relationships between situation, thoughts and feelings Explore past traumatic stressors of patient and family such as during treatment or illness, death of a loved one, near-death experiences Maximize symptom management to decrease physical stressors that can exacerbate anxiety Consider use of relaxation techniques, guided imagery, music therapy, therapeutic touch and other complementary therapies Consider psychiatric counseling for those experiencing significant inability to cope with the experience of their medical illness
- Anxiety - Patient and Family Education 5 Review causes of anxiety with patient and family Instruct family to monitor for signs and symptoms of anxiety and when to notify physician or nurse Instruct family to avoid excessive stimulation of patient: calm environment, maintain quiet room, limit visitors as needed, monitor noise level Instruct family in their participation in non-drug therapies, such as playing soothing music Encourage family to reassure patient with their presence: encourage hand-holding, stroking, massage - all as tolerated by patient Encourage family to maintain patient safety Teach patient and family the significance of unresolved fears, concerns, issues and encourage patient and family to resolve these issues, whenever possible Encourage family to talk with the patient about activities occurring in the patient’s room and home even when patient does not appear to be aware of the environment As patient is nearing death, encourage family to say good-bye to patient and to reassure patient the survivors will be okay Patient/Family Teaching Sheet (available on Spanish version) Managing Anxiety
- References 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. 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. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC) . Washington, DC: Association of Colleges of Nursing, 2009. 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. Berry PH, ed. Core Curriculum for the Hospice and Palliative Nurse 2nd ed. Dubuque, IA:Kendal/Hunt; 2005.
- Definition 1 Delirium - a global, potentially reversible change in cognition and consciousness that is relatively acute in onset Common in patient near death (approx 88%) Often exhibit disorientation, a fluctuating level of consciousness, or other signs of cognitive impairment Distinguished from dementia which progresses slower, is irreversible, and generally associated with unaltered consciousness until late in course of illness At the end of life may be accompanied by distressing hallucinations, nightmares, or paranoid ideation May not be reversible in last 48 hours of life due to accompanying organ failure Also referred to as terminal restlessness/terminal agitation at the end of life Agitation - excessive restlessness accompanied by increased mental and physical activity such as Frequent, non-purposeful motor activity Inability to concentrate or relax Disturbances in sleep/rest patterns Fluctuating levels of consciousness, cognitive failure and/or anxiety Components of agitation and delirium may cross
- Delirium/Agitation - Prevalence 2 Restlessness and agitation occurred in 42% of patients during the last 48 hours of life 3 Between 15 and 20% of hospitalized cancer patients have organic mental disorders Found in 77% to 85% of terminally ill cancer patients 4 In terminally ill AIDS patients, 57% experienced delirium 5
- Delirium/Agitation - Causes 1 Causes Infection Malignancies / Tumor burden and secretions HIV Renal or hepatic failure Metabolic abnormalities (low/hi Na, low K, hi Ca, low/hi glucose, hypothyroid, renal/liver failure) Hypoxemia Sensory deprivation Changes in environment Medications (including opioids, chemotherapeutic agents, steroids) Street drugs (including withdrawal) Fecal impaction / Urinary retention Vitamin deficiencies Risk factors for delirium: Pre-existing dementia due to Alzheimer’s disease, AIDS, or age; Brain neoplasms; Thyroid and adrenal gland dysfunction; Hepatic encephalopathy; Schizophrenia; Korsakoff’s syndrome; Neurosyphilis; Trauma
- Delirium/Agitation - Assessment 6 Important to be able to distinguish delirium from anxiety, depression, agitation, Physical Assessment Common signs - disturbed sleep/wake cycle, agitation, restlessness, moaning Assess for underlining cause History – onset, s/s, Spiritual distress Consider the following precipitating factors of delirium Medication intoxication: anticholinergic agents, anticonvulsants, anti-Parkinsonism agents, corticosteroids, cimetidine opioids, sedatives, alcohol, sedatives, benzodiazepines, or barbiturates causing nystagmus, ataxia, extreme lethargy Metabolic abnormities; hypoglycemia, organ failure, fluid and electrolyte imbalances, endocrinopathies (hypothyroidism, hyperparathyroidism) Renal/hepatic insufficiency: asterixis - sustained contraction of muscle groups, “liver flap” Hypoxia: restlessness, agitation, poor judgment, inattentiveness COPD (carbon dioxide narcosis and hypoxia): intermittent drowsiness, indifference to environment, inattention, forgetfulness, inability to follow sequence of events Hepatic encephalopathy: hypo-alert behaviors Systemic infections Head trauma Neoplastic disease Vascular disorders, TIA, thrombosis, MI, cardiac failure
- Delirium/Agitation - Assessment 6 Instruments that distinguish delirium from dementia correlating with DSM-IV criteria for dementia. Mini-Mental Status Examination (MMSE) www.chcr.brown.edu/MMSE.pdf. Center for Gerontology and Health Care Research Assists in evaluating cognitive function Assess five areas of cognition: Orientation; Registration; Attention and calculation; Recall; Language May not be able to definitively identify delirium May be more appropriate for gradual changes in cognition vs. abrupt onset that characterizes delirium Memorial Delirium Assessment Scale (MDAS), www.painconsortium.nih.gov Designed to quantify the severity of delirium in medically ill Assessments include: Reduced level of consciousness (awareness), Disorientation, Short-term memory impairment, Impaired digit span, Reduced ability to maintain and shift attention, Disorganized thinking, Perceptual disturbances, Delusions, Decreased or increased psychomotor activity, Sleep-wake cycle disturbance (disorder or arousal), Integrates both behavioral observations & operationalized descriptions of specific behaviors Easily administered and requires minimal training to utilize Delirium Rating Scale (DRS) Discerns between delirious and non-delirious patient Assess 10 items: Temporal onset of symptoms, Perceptual disturbances, Hallucination type, Delusions, Psychomotor behavior, Cognitive status during formal testing, Underlying physical disorder, Sleep-wake cycle disturbance, Lability of mood, Variability of symptoms Usefulness may be limited to research settings
- Delirium/Agitation - Assessment 6 Confusion Assessment Method (CAM) www.hartfordign.org/publications/trythis/issue13.pdf Trained interviewer assesses cognitive function on a daily scheduled basis Reflects patients level of consciousness and clarity of thought Assesses 10 domains based on interview and clinical observations; Acute onset, Inattention, Disorganized thinking, Altered LOC, Disorientation, Memory impairment, Perceptual disturbances, Psychomotor agitation, Psychomotor retardation, Altered sleep-wake cycle Is complex to use and requires extensive instruction Specifies that patient must have abrupt onset of symptoms corresponding with disorganized thought and inattentions Neecham Confusion Scale (NCS) www.unc.edu/courses/2005fall/nurs/213/001/neuropsychiatric/neecham.html Designed to be used by nurses to assess confusion in elderly 3 subscales to measure information processing, psychomotor behavior, select vital functions Level l – Processing - Attention, Command, Orientation Level ll - Behavior - Motor, Verbal Level lll - Physiologic control - Physiological measurements; vital signs, oxygen saturation, urinary continence
- Delirium/Agitation - Treatment 3,6 Principles Goal: diagnose and correct the underlying cause Consider symptomatic and supportive therapies At end of life, causes may not be reversible and medications are indicated Evaluate hydration status and consider artificial hydration within context of patient and family palliative care goals; consider hypodermoclysis or proctoclysis if IV hydration not desired due to complexity or discomfort
- Delirium/Agitation - Treatment 3,6 - Pharmacological interventions Medication treatment is based on case by case assessment Neuroleptics – blocks dopamine uptake; metabolized by the liver Haloperidol (Haldol ) 1-2 mg every 2-4 hours as needed, (not to exceed 20mg/24 hours), IV and SQ dose not FDA approved in the United States or United Kingdom) 6 Short half life, no active metabolites, minimal anticholinergic and cardiovascular side effects make it preferred by palliative care clinicians Can prolong QT interval Parenteral doses usually twice as effective as oral / Subcutaneous route frequently used in palliative care Consider combination of Haloperidol (Haldol ) with lorazepam (Ativan ) (0.5-1 mg every 1-2 hr PO or IV) if needed for rapid sedation of agitated, delirious pt. Monitor for extrapyramidal side effects - may be less severe if given IV vs. PO Not to be used with alcohol or benzodiazepine withdrawal May be tapered over several days as delirium resolves Chlorpromazine (Thorazine ) 12.5-50 mg every 4 -12 hr PO, IV, IM, PR Thioridazine (Mellaril ) 10-75 mg every 4-8 hr PO Used when symptoms severe and sedation needed May be helpful for signs of terminal anguish Side effects may complicate delirium: sedation, anticholinergic effects, alpha-adrenergic blocking effects May be tapered over several days as delirium resolves
- Delirium/Agitation - Treatment 3,6 - Pharmacological interventions Benzodiazepines Midazolam (Versed ) 30-100 per 24 hours IV, SC Phenobarbital Frequently used for palliative sedation Consider when distressing symptoms cannot be controlled by other medications and interventions: severe anxiety, disorientation, restlessness, agitation, hallucinations, illusions, and sleep disturbances associated with unresolved or unmanageable cognitive disorders Consider use in combination with haloperidol (Haldol up to 20-40 mg in 24 hours) May increase dose to achieve sedation Anxiolytics Useful in elderly – may worsen delirium / Not indicated if dementia present – may have paradoxical response May be used alternately with neuroleptics Lorazepam (Ativan ) 0.5-2 mg every 1-4 hours PO, IV, IM, Drug of choice in this drug class for restlessness and agitation palliative care May be repeated or doubled every 30-60 minutes, depending on level of sedation Atypical Antidepressants – blocks dopamine uptake selectively, but with less anticholingeric effects Risperidone Low doses tolerated better by the elderly Should not be considered as first line ttreatment
- Delirium/Agitation - Non-pharmacological interventions 1,6 If hospitalized, encourage family or caregivers to be present as much as possible Provide quiet restful environment Regularly orient patient and assure them of his/her safety, though reorientation to time at end of life may be meaningless Attempt to manage patient in familiar environment, such as home Encourage familiar sounds, smells and textures as visual perspectives may be distorted Offer frequent verbal reassurance Encourage family to talk to patient, a familiar voice is often reassuring Repeat family names, pets, grandchildren Reduce extraneous noise and television Consider familiar music Consider use of spiritual readings within patient’s belief system Review potential unresolved conflicts within patient and family structure Utilize interdisciplinary team resources: counseling, spiritual support, as appropriate Acknowledge patient’s experience of nearing death visions or “hallucinations” Consider use of aromatherapy for reduction of anxiety, i.e., a faint scent of freshly baked bread Consider hand massage with scented (lavender) oil Consider use of therapeutic touch
- Delirium/Agitation - Patient and family education 6 Reassure patient and family, Assure family that delirium is part of medical condition, Review potential temporary nature of delirium Review potential behaviors family may see associated with delirium; fear, anger, incontinence, resistance to care Explain all procedures to patient using simple clear instructions Review symbolic language of dying patient and appropriate responses, educate family on nearing death visions & encourage them to validate visions or experiences, encourage family to talk to patient reassuringly, encourage patient/family to identify & address problems/unresolved issues Review proper dosing and schedule of all medications to prevent drug-induced delirium Review symptom management plans (pain, nausea, constipation, insomnia) with patient and family to prevent delirium Encourage sensory stimulation appropriate to patient’s tolerance: friendly visits, appropriate noise levels of TV or radio, ability to see out window, touch, massage, use of sensory aids such as eyeglasses and hearing aids Monitor for sensory overload such as combination of noises from vacuums, mixers, dishwashers, televisions, radios, oxygen concentrators If in acute care setting, bring in familiar photographs or objects, encourage family to visit regularly or even scheduled Encourage family to report any new feelings of uneasiness, anxiety, restlessness, or mood changes to healthcare provider Teach family reorientation strategies to use during interactions with patient Patient Teaching Sheet (available in Spanish version) Managing Delirium
- References Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum . Washington, DC: American Medical Association, 2003. 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. Lichter I, Hunt E. The last 48 hours of life . Journal of Palliative Care 1990;6:7-15. Pereira J, Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer . Cancer 1997;79:835-842. Caraceni A. Delirium in palliative medicine . European Journal of Palliative Care 1995;2:62-67. 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.
- Additional References Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC) . Washington, DC: Association of Colleges of Nursing, 2009.
- Depression - Definition 1,2 Described as intense and often prolonged feelings of sadness, hopelessness and despair
- Depression - Prevalence 1 Feelings of depression in 10-25% of patients with cancer Occurs in 22% of nursing home residents and 25-77% of terminally ill patients1 Frequent depression and anxiety are co-morbid factors in medical illness Depression at the end-of-life is often not recognized Incidence increases with higher levels of disability, advanced illness, and pain Persistent feelings of helplessness, hopelessness, inadequacy, depression and suicidal ideation are not normal at the end of life. These symptoms should be aggressively evaluated and treated
- Depression - Causes 1,2 Medical conditions associated with depression Uncontrolled pain and associated symptoms: constipation, nausea, anorexia Cardiovascular: CHF, MI, arrhythmias Central nervous system: CVA, Alzheimer’s, subdural hematoma, HIV infection, MS, Huntington’s disease, dementia Autoimmune: rheumatoid arthritis Endocrine: parathyroiditis, Diabetes, Cushing's disease, Addison’s disease Other: alcoholism, anemia, systemic lupus erythematosus, Epstein-Barr virus, hepatitis, malignancies, pancreatic and liver diseases, malnutrition, pulmonary insufficiency Treatment-related factors associated with depression Medications: antihypertensives, analgesics, antiparkinsonian agents, steroids, hypoglycemic agents, chemotherapeutic agents, hormones, antimicrobials, alcohol, lithium carbonate, L-Dopa, benzodiazepines, Brain radiation Metabolic and endocrine abnormalities Inherited genetic predisposition Psychological factors associated with depression Existential factors related to impending death such as fear, loss of independence or control, changes in body image Family and personal history of preexisting psychological disorders Financial, social, safety issues may exacerbate distress and contribute to depression Social factors such as isolation and conflicted relationships
- Depression - Assessment 1,2 Assess for symptoms of depression associated with medically ill 2 Enduring depression or sad mood, tearful Marked disinterest or lack of pleasure in social activities, family, and friends Feelings of worthlessness and hopelessness Excessive enduring guilt that illness is a punishment Significant weight loss or gain not explained by dieting, illness, or treatments Hopelessness about the future Enduring fatigue Increase or decrease in sleep not explained by illness or treatment Recurring thoughts of death or suicidal thoughts or acts Diminished ability to think or make decisions
- Depression - Assessment 1,2 – Assess for symptoms of depression associated with risk factors Medical comorbidity Cancer patients at highest risk (oral, pharyngeal, or lung cancers) Chronic deteriorating medical illness with perceived poor health, recent diagnosis of life threatening illness, recent conflict/loss of significant relationship are also predictors Prior episodes of depression, Family history of depression, suicide attempt Male gender, age over 45, living alone, lacking a support system Age of onset under 40 Postpartum period Lack of social support Stressful life events Personal history of sexual abuse Current substance abuse Uncontrolled pain Presence of multiple deficits: inability to walk, loss of bowel and bladder control, amputation, inability to eat or swallow, sensory loss, exhaustion Presence of chronic or life threatening illness may cause increased dependence, helplessness, uncertainty, negative self-critical view Cognitive distortions may develop leading to negative interpretations of benign events Diminished motivation leading to withdrawal Feelings of being burden to family Family may become immobilized, impatient or angry with patient who has become withdrawn and non-communicative
- Depression - Assessment 1,2 - Screening Tools Consider use of depression screening instruments Mini-Mental Status Examination (MMSE), www.chcr.brown.edu/MMSE.pdf Beck Depression Inventory www.fpnotebook.com/PSY99.htm Geriatric Depression Scale www.hartfordign.org/publications/trythis/issue04.pdf Hamilton Depression Scale www.healthnet.umassmed.edu/mhealth/HAMD.pdf Hospital Anxiety and Depression Scale Distress Thermometer 2 Cultural influences in depression, examples May be mixed with somatic complaints instead of feelings of sadness or guilt Latino and Mediterranean: may complaint of “nerves” and headaches Chinese or Asian: may have weakness, tiredness, or “imbalance” Middle Eastern: refer to “problems of the heart” Hopi: may refer to being “heartbroken” Cultures may judge severity of depressive symptoms differently Symptoms should not be dismissed because it is seen as a characteristic of a particular culture
- Depression - Assessment 1,2 Observation and interviewing on mood, behavior and cognition Direct questioning of mood How have your spirits been lately? How would you describe your mood now? Have you felt sad or blue? Questions relating to behavior How are you sleeping lately? How much energy do you have compared to 1 month ago? 6 months ago? Have you experienced recent changes in appetite? Have you lost or gained weight? What do you usually do to cope with stress? Are you feeling guilt, remorse, worthlessness? Questions related to cognition What do you see in your future? What are the biggest problems facing you now? Are you as interested as usual in your family and friends? Work? Hobbies? Have you felt satisfied with yourself and your life? Can you concentrate as well as you usually do? Do you have family or close friends to help you now? Do you feel able to call on them? Note: disturbances in appetite, sleep, energy, or cognition may be related to the medical condition - not necessarily related to depression Suicide Assessment Three greatest risk factors are presence of psychiatric disorder, depression, and alcohol abuse Palliative care risk for suicide: severe, rapidly progressing disease producing a rapid functional decline, intractable pain, and/or those with a history of depression, suicide attempts, or substance abuse Assess suicide lethality: presence of plan, method to carry out plan, availability of resources to carry out plan, ability to communicate intent, intended outcome
- Depression - Treatment Optimal treatment as combination of supportive psychotherapy, cognitive-behavioral techniques, and antidepressant medications Evaluate role of medical condition in causing depression Address potential medical or treatment related causes when possible Pharmacological Interventions 3,4 Pharmacotherapy is mainstay of treatment for palliative care patients with major depressive illness Prognosis and time-frame of treatment must be addressed when considering antidepressant therapy When considering medications, use medication with least potential for drug interaction and side effects, start at low does and increase to effectiveness, reassess dosage requirements regularly
- Depression - Pharmacological Interventions 3,4 Selective Serotonin Reuptake Inhibitors (SSRI) 3 Considered by many to be first line treatment for depression in palliative care Lower side effect profile than tricyclic antidepressants: negligible orthostatic hypotension, urinary retention, memory impairment, sedation, or reduced awareness No clinically significant cardiac conduction problems May not need to have therapeutic drug level monitoring Side effects: loose stools, nausea, vomiting, insomnia, headaches, sexual dysfunction; Side effects generally dose related & may be problematic for patients with advanced illness Response time must be considered when selecting SSRI Paroxetine (Paxil ), fluvoxamine (Luvox ), sertraline (Zoloft ) may reach steady state in 4 to 14 days Fluoxetine (Prozac ) does not reach steady state for 5 to 6 weeks For debilitated patients start at 1/3 dose Daily dosing ranges, Start at minimally effective doses Paroxetine (Paxil ) 10-60 mg PO, Fluoxetine (Prozac ) 10-60 mg PO Sertraline (Zoloft ) 50-200 mg PO Citalopram (Celexa ) 10-60 mg PO
- Depression - Pharmacological Interventions 3,4 Tricyclic antidepressants 3 Blocks reuptake of various neurotransmitters at the neuronal membrane. Improves sleep Effective in 70% of patients treated: side effects can be particularly troublesome for palliative patients: Anticholinergic effects: constipation, dry mouth, urinary retention, tachycardia, potential cardiac arrhythmia, postural hypotension, dizziness (fall concern in elderly) Choice of antidepressant should be based on nature of terminal illness, side effect profile, characteristic of depressive episode, past response to tricyclics: consider tricyclics if sleep disturbance is a significant component of depression Response time is generally 2-4 weeks - consider psychostimulants, sedatives or opioids if prognosis less than 4 weeks Start at low doses (10-25 mg at bedtime) and titrate up in 10-25 mg increments until therapeutic dose is obtained or limiting side effects occur Depressed cancer patients may achieve therapeutic response at lower doses (25-125 mg) compared to the medically-well depressed (150-300 mg) Desipramine & nortriptyline are better tolerated by terminally ill Daily dosing ranges Amitriptyline (Elavil ) 10-150 mg PO, IM, PR – not usually recommended because of the side effect profile Nortriptyline (Pamelor ) 10-125 mg PO Clomipramine (Anafranil ) 10-150 mg PO Doxepin (Sinequan ) 12.5-150 mg PO, IM Imipramine (Tofranil ) 12.5-150 mg PO, IM Desipramine (Norpramin ) 12.5-150 mg PO
- Depression - Pharmacological Interventions 3,4 Psychostimulants 3 Stimulates CNS and respiratory centers / Increases appetite and energy levels / Improves mood / Reduces sedation More rapid onset of action and stimulating effects make it attractive in palliative care setting - especially for prognosis less than 4 weeks Helpful in patients where depression accompanied by psychomotor slowing and possibly mild cognitive impairment Low doses also increase appetite, promote a sense of well being, improve feelings of weakness & fatigue in cancer patients, used to counter sedating effects of opioids Many clinicians give in combination with SSRI Start SSRI at low dose & withdraw psychostimulant as titration of SSRI continues to effectiveness Psychostimulant provides immediate antidepressant effects while SSRI reaches therapeutic level Use cautiously and monitor side effects Side effects: over stimulation, anxiety, insomnia, paranoia, confusion, mild increase in blood pressure Initial dosing administered BID; increase dose slowly over several days until desired effect achieved or side effects intervene; tolerance may develop with long-term use and dose will need to be adjusted Patients taking pemoline (Cylert ® ) long term must have liver function tests monitored periodically Dosing ranges Dextroamphetamine (Dexedrine ) 2.5-20 mg BID PO Methylphenidate (Ritalin , Concerta ) 2.5-20 mg BID PO Pemoline (Cylert ) 37.5-75 mg PO (chewable form can be used sublingually) Use with caution with liver impairment
- Depression - Pharmacological Interventions 3,4 Steroids (Dexamethasone) Improves appetite / Elevates mood / Improving sense of well being May increase risk of mood disturbance, depression, sleeplessness and hallucinations Non-benzodiazepines (Buspirone Hydrochloride) Acts on multiple CNS sites to produce anxiolytic activity Useful in patients with mixed anxiety and depressive symptoms Slow onset
- Depression - Non-pharmacological interventions for depression 2 Counseling Seek assistance of interdisciplinary resources: counseling, spiritual care, dietician All caregivers routinely reinforce goals and interventions of care plan established by interdisciplinary team Goals of interventions Ensure safe environment Assist patient in reducing depressive symptoms and maladaptive coping responses Restore or increase patient’s functional level Prevent future relapse and recurrence of depression Behavioral interventions Provide directed activities Develop a hierarchy of behaviors with the patient & use graded task assignment Develop structured daily activity schedules Encourage at home use of diary or journal to monitor automatic thoughts, behaviors, and emotions; review this with patient Use systematic application of reinforcement Encourage self-monitoring of predetermined behaviors, i.e., sleep pattern, diet, physical exercise Focus on goal attainment and preparation for future adaptive coping
- Depression - Non-pharmacological interventions for depression 2 Cognitive interventions Review and reinforce realistic ideas and expectations Review and reinforce patient’s strengths Assist patient to reframe negative thoughts into positive thoughts Set realistic, achievable goals Explain all actions and plans, seek feedback and participation in decision making Provide choices Encourage exploration of feelings only for a specific purpose - only if the patient is not ruminating (constant repeating of failures, problems) Listen and take action on physical complaints Avoid chastising the patient for feeling sad Interpersonal interventions Educate the patient about the physical and biochemical causes of depression Enhance social skills through modeling, role playing, rehearsal, feedback, reinforcement Build rapport with frequent, short visits / Engage in normal social conversation with the patient as often as possible Direct comments and questions to the patient rather than to significant others Allow adequate time for the patient to prepare a response Mobilize family and social support systems Encourage the patient to maintain open communication/ share feelings with significant others Supportively involve family and friends and teach them how to help Avoid medical jargon, advice giving, sharing personal experiences, or making value judgments Avoid false reassurance Complementary therapies ; Guided imagery and visualization, Art and music therapy, Humor, Aerobic exercise, Photo therapy, Aromatherapy and massage
- Depression - Non-pharmacological interventions for depression 2 Specific behavioral strategies Observe the patient’s self patterns, negotiate with patient to develop a structured, daily schedule Develop realistic daily self-care goals with the patient to increase sense of control Upgrade goals gradually to provide increased opportunity for positive reinforcement and goal attainment Utilize a chart for monitoring daily progress for communication and consistency among caregivers Provide sufficient time & reassurance to encourage patients to accomplish self-care actions Positively reinforce even small achievements Provide physical assistance with self-care activities, especially those related to appearance and hygiene, that the patient is unable to do Adjust physical assistance, verbal direction, reminders and teaching to the actual needs/abilities of the patient Avoid increasing unnecessary dependency by overdoing Teach deep breathing or relaxation techniques for anxiety management
- Depression - Patient and Family Education Review signs and symptoms of depression with patient and family Educate patient and family on prevalence of depression in all phases of serious illness trajectory Review medication regime with patient and family - dosing, schedule, side effects Review non-pharmacological interventions with family and seek their participation in approaches discussed above Provide private opportunity for family and caregiver to discuss effects of depression on family dynamics Patient Teaching Sheets (available in Spanish version) Managing Depression
- References Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC) . Washington, DC: Association of Colleges of Nursing, 2009. 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. 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. Wrede-Seaman L. Symptom management algorithms: A handbook for palliative care . Yakima, WA: Intellicard, 1999.
- Dyspnea 1 Definition Difficult or labored breathing Prevalence Experienced in 50-70% of dying patients Marker for terminal phase of life Varies according to disease Chronic obstructive pulmonary disease (COPD) - 95% higher in pulmonary patients 1 Congestive heart failure - 61% Cardiovascular accident (CVA, stroke - 37% Amyotrophic lateral sclerosis (ALS) - 47-50% Dementia - 70% Cancer - 50% (outpatient) Cancer - 45-70% (terminal phase) Lung cancer - 90% (terminal phase)
- Dyspnea 1 - Causes Related to primary diagnosis Lung cancer, breast cancer, coronary artery disease Secondary to the primary diagnosis Pleural effusions, metastasis to lung or pleura Related to treatment of primary disease Congestive heart failure related to chemotherapy or constrictive pericarditis related to radiation therapy, anemia secondary to chemotherapy Etiology unrelated to primary diagnosis Pneumonia Pathophysiology Obstructive, restrictive or vascular disturbances in the airways with tumor or nodal involvement Pulmonary congestion secondary to fluid overload and/or cardiac dysfunction Bronchoconstriction and bronchospasm as seen with respiratory infection, COPD or airway encroachment by a tumor Decreased hemoglobin carrying capacity as seen in anemia Hyperventilation secondary to neuromuscular disease with limited movement of diaphragm
- Dyspnea 1 - Assessment Acknowledge the subjective experience of dyspnea Clinical signs and symptoms may not manifest, but does not mean dyspnea not being experienced Do not confuse dyspnea with tachypnea Functional status Ask about shortness of breath in relation to activities: ability to walk at the same speed as someone of their age; stopping to catch your breath when climbing stairs or other exertion; eating Clinical assessment Complete history of the symptom / Qualities or descriptive words of experience Associated symptoms Precipitating, relieving events or activities / Affected by positions Respiratory rate / Diminished breath sounds Use of accessory muscles / Distended neck veins Auscultation of adventitious breath sounds (e.g., rhonchi or rales) Prior response to medications Past history Smoking / Underlying lung or cardiac disease / Concurrent medical conditions / Allergy history Diagnostic tests to determine etiology of dyspnea Chest radiography / ECG / Pulmonary function test / O2 saturation / ABGs / CBC, serum K, Mg, and phosphate levels Cardiopulmonary exercise testing NOTE: Appropriate diagnostic testing should be guided by stage of disease, prognosis, patient goals, prognosis, risk benefit ratio
- Dyspnea 1 - Treatment - Pharmacologic Opioids 2 Morphine considered standard treatment for relief of dyspnea Alter individual’s perception of breathlessness Reduce respiratory drive / Reduce oxygen consumption May be administered by multiple routes Opioid naïve: start on low doses Morphine sulfate: 5-15 mg PO (pill or liquid) every 1-4 hours; 1-4 mg IV every 15 minutes-4 hours; 1-4 mg every 30 minutes-4 hours SQ; 5-15 mg every 1-4 hour PR (suppository) 2 Patients already taking opioid: increase breakthrough by 50% of their usual dose for effective treatment of dyspnea Benzodiazepines can be used for their effect on anxiety, fear and autonomic responses that accompany dyspnea Lorazepam (Ativan ) 0.5-2mg PO every 8-12 hours Not considered first line treatment Dosages mat vary significantly and should e adjusted to patients requirement and response Benzodiazepines more commonly used as phenothiazines can cause extrapyramidal side effects Chlorpromazine hydrochloride (Thorazine ) has been used to decrease breathlessness, especially in advanced cancer
- Dyspnea 1 - Treatment - Pharmacologic Diuretics Inhibits reabsorption of electrolytes in ascending loop of Henle enhancing excretion of sodium chloride, K, calcium and other electrolytes Furosemide (Lasix ) 20-40 mg IV, 20-80 mg PO Used in patients with signs of fluid volume excess: dyspnea, crackles/rales on auscultation, peripheral edema Decreases blood volume, reduces vascular congestion, reduces workload of heart Dosages may vary significantly and should be adjusted to patients requirement & response Bronchodilators Relax smooth muscles of respiratory tract relieving bronchospasm Albuterol (Proventil ) or Ipratropium bromide (Atrovent ) Metered dose inhaler or nebulizer Used for symptoms of bronchospasm (wheezing on auscultation), relaxes smooth muscles of respiratory tract May cause nervousness and cough Steroids Mechanism not fully understood. Decreases inflammation, esp. associated with vena cava syndrome. Decreases bronchospasm of asthma and COPD Dexamethasone (Decadron )
- Dyspnea 1 - Treatment - Pharmacologic Antibiotics Erythromycin PO Useful if dyspnea secondary to infection Monitor dyspnea with elevated temperature, adventitious breath sounds, congested cough – signs of upper respiratory infection Consider antibiotics for comfort based on patient goals and desires Anticoagulants Prevents clot formation which may prevent future incidence of pulmonary emboli Warfarin Heparin Anxiolytics No effect on pulmonary function tests or ABG’s but improves exercise tolerance and decreases sensation of breathlessness in patients with COPD Oxygen Use in non-hypoxemic patients may have limited benefit. A trial of oxygen should be considered Primary usefulness based on patient’s report of relief Efficacy in dyspnea not well established. May be useful in patients with hypoxemia If patient does not respond to morphine, a trial of oxygen, regardless of hypoxemia, is mandated Attempt to achieve and maintain oxygen saturation of 88-90% Continuous oxygen guidelines 1 PaO 2 55 HG or oxygen saturation 88% at rest PaO 2 of 56 to 59 mm Hg or oxygen saturation of 89% in presence of Dependent edema (suggesting CHF), Cor pulmonale, Polycythemia (hematocrit > 56%), Pulmonary hypertension Non-continuous oxygen during exercise 1 PO 2 55 Hg or oxygen saturation 88% with a low level of exertion or during sleep PaO 2 of 55 Hg or oxygen saturation 88% associated with pulmonary hypertension, daytime somnolence, and cardiac arrhythmias
- Dyspnea 1 - Treatment - Non-pharmacological interventions Used in conjunction with medications - not in place of Alternating environment to facilitate circulation of air - electric fans or air-conditioned room to decrease impact of dyspnea, perhaps by stimulation of trigeminal nerve pathway Positioning patient to facilitate chest expansion - head of bed elevated with feet flat or down, upper body supported with pillows Cooling of the body Conservation of patient energy; facilitation of patient rest, offer calm environment Consider having patient lean forward while sitting and supporting their upper arms on table - effective with patients with emphysema Pursed lip breathing - slows respiratory rate, increases intra-airway pressures, thus decreasing small airway collapse during periods of increased dyspnea - useful in COPD Complementary therapies: imagery, massage, breathing exercises, therapeutic touch, music, aromatherapy Consider cultural context of fatigue management interventions, example American Indians/Alaskan Natives may report “the air is heavy” Asian/Pacific Islanders may believe dyspnea is caused by too much “yin” and may self treat with warm/hot foods and wear warm clothing African American may report “difficultly in catching breath” Hispanic feels something is very wrong if oxygen is needed
- Dyspnea 1 - Patient and family education Instruct family on non-pharmacological interventions, including diaphragmatic breathing and pursed-lip breathing techniques Minimize aggravating factors specific to patient Instruct on signs/symptoms of impending exacerbations and how to manage Problem solving techniques to prevent panic Conservation of energy techniques Prioritization of activities Use of fans to cool environment Methods to maximize usefulness of medications, such as use of spacers or pre-medicating before exertion Avoid activities where arms are not supported as leads to increased breathlessness Do not leave patients in distress alone Monitor self care activities and need for additional assistance Patient Teaching Sheet Managing Shortness of Breath
- Noisy Respirations Definition - also known as noisy respiration, congestion DO NOT use terms “death rattle” Refers to noisy, moist breathing; usually in last hours of life Per one study, median time from onset of noisy respirations to death was 8-23 hours Very disconcerting to family members as sounds as though patient drowning in own secretions If patient alert, fearful that they may suffocate Prevalence Occurs in 56% of patients in last hours prior to death Increased incidence of respiratory congestion in patients with primary lung cancer, or cerebral metastasis
- Noisy Respirations - Causes Produced when turbulent air passes over pooled secretions or through relaxed muscles in the oropharynx or bronchi Mechanisms of noisy respirations include Excessive secretion of respiratory mucus Abnormal mucus secretions inhibiting normal clearance Dysfunction of the cilia Inability to swallow Decreased cough reflex due to weakness and fatigue Supine recumbent position Factors that may contribute to respiratory congestion Infection or inflammation Pulmonary embolism producing infarction and fluid leakage from damaged cells Pulmonary edema or CHF Dysphagia, odynophagia Research does not support the idea that dehydration will decrease the incidence of noisy respirations
- Noisy Respirations - Assessment Focused history and physical exam to determine underlying or contributing causes that may be potentially treatable If onset is sudden and associated with shortness of breath and chest pain, may be pulmonary embolism or myocardial infarction Findings consistent with fluid overload or CHF may warrant trial of diuretics Presence of pneumonia may necessitate antibiotic therapy Interventions based on patient goals, desires and prognosis
- Noisy Respirations - Treatment - Pharmacological Treatment should focus on underlying disorder Anticholinergics are primary mode of treatment Hyoscine hydrobromide (Scopolamine ) Inhibits muscarinic receptors and causes anticholinergic actions such as decreased peristalsis, gastrointestinal secretions, sedation, urinary retention, and dilatation of the bronchial smooth muscle Administered subcutaneously, intermittent or continuous infusion or transdermally Glycopyrrolate (Robinul ) or hyoscine hydrobromide patch (Scopolamine ) If patch fails, hyoscyamine (Levsin ) 0.125-0.25 mg every 6 hours PO/SL PRN Atropine Sulfate Has less CNS depression, delirium and restlessness and more bronchodilator effect than hyoscine hydrobromide Increased risk of tachycardia in doses > 1.0 mg Atropine 1-2 mg IM / SC or inhalation
- Noisy Respirations - Non-pharmacological interventions Repositioning of patient Suctioning not recommended as is uncomfortable and can lead to agitation and distress Suctioning only used if easily reached in oropharynx and medications alone not effective
- Noisy Respirations - Patient and family teaching This symptom can be very distressing to family Explain process and reason for secretion build up Use term “respiratory congestion” instead of “death rattle” Include this symptom in teaching family about signs of approaching death
- References 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. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC) . Washington, DC: Association of Colleges of Nursing, 2009.
- Fatigue 1-4 - Description A complex phenomenon, extreme tiredness, lack of energy, weariness Criteria for identifying fatigue 1 Subjective perception Alteration in neuromuscular and metabolic processes Decrease in physical performance Decrease in motivation Deterioration in mental and physical activities
- Fatigue - Prevalence 1 Reported in 78-96% of cancer patients Reported in 51% of patients in international palliative care centers Reported in 43-70% of HIV patients Reported in 75-90% of multiple sclerosis (MS) patients Exists in all gradations of rheumatoid arthritis: everyday, constant throughout the week, affected ADL’s Reported in 41% of patients with coronary artery disease prior to death Reported in 77% of patients for 6 months to 3 years prior to acute MI Reported in >50% of patients with AIDS - the more advanced the disease, the greater the fatigue level Reported in 50% of school-aged children receiving chemotherapy
- Fatigue - Causes 1 Theories Accumulation Theory: fatigue related to the abnormal accumulation of muscle metabolites, such a lactate, that interfere with normal cellular activity Depletion Theory: muscular activity is impaired when the supply of substances such as carbohydrate, fat, adenosine, triphosphate and protein is not available to the muscle. Anemia, a deficiency of red blood cells or lack of hemoglobin that leads to a reduction in oxygen-carrying capacity of the blood, is most common example of this theory Central Nervous System Control: central control of fatigue is placed in the balance between two opposing systems: the reticular activating system and the inhibitory system, which is believed to involve the reticular formation, the cerebral cortex, and the brain stem Predisposing factors in developing fatigue 1 Personal factors: age, marital status, menopausal status, psychosocial factors, culture/ethnicity, income/insurance, physical living situation, spiritual factors Disease-related factors: anemia, stage of disease and presence of metastasis, pain, sleep pattern/interruptions, permanent change in energy, continency, cachexia, dyspnea, electrolyte imbalance, infection, malnutrition, pain, Treatment-related factors: medication side effects (nausea and vomiting, diarrhea, weight loss/gain, taste changes), permanent physiologic consequences (altered energy or sleep patterns) Care factors: number/cohesiveness of caregivers, commitment of doctor/nurse (involvement and availability)
- Fatigue - Assessment 1,2 Subjective Data Ask the patient; Are you feeling weak?, How long does your fatigue last?, What makes it better/worst?, Are you anxious/depressed?, How does the fatigue affect your daily /social activities? Consider use of fatigue-measuring scales (Multidimensional Assessment of Fatigue, Symptom Distress Scale, Fatigue Scale) Consider 0 (no fatigue) to 10 (extreme fatigue) scale - quick assessment tool Physical cause of symptom based on patient report (nerve damage, dehydration, malnourishment) Severity/intensity: does the fatigue interfere with activities of daily living Duration: how long does the fatigue last? Hours, days, weeks? Exacerbation factors: What makes the fatigue worse (activities, other symptoms, environment)? Alleviating factors: What relieves fatigue (rest, sleep, eating)? Level of activity: how has it changed; observe patient performing activities Affect: what is patient’s mood (anxious, depressed, flat)? Objective Data Medications: do any of your medications make the fatigue better or worse (such as analgesics or anxiolytics)? Test muscle strength, symmetry, and endurance of upper and lower extremities to determine if neurological changes are present Vital signs: Abnormal vitals to explain fatigue (fever, low BP, weak pulse) Laboratory results oxygenation status, hemoglobin, complete blood count and differential, thyroid function
- Fatigue - Treatment - Pharmacological interventions 2,3 Steroids: dexamethasone 2-20 mg PO daily Once daily dosing due to relatively long half life / Dose in morning for activating effect / Effect may wane after 4 to 6 weeks Lack of mineral corticoid adverse effects Associated with feelings of well being and increased energy Adverse effects: usually not a factor for patients at end of life and no need to taper if dose remains effective Methylphenidate (Ritalin ) 5-10 mg PO every morning and 5 mg at lunch, elderly may need dose adjusted downward Extended release formulations allow for once daily Stimulates CNS and respiratory centers, Increases appetite and energy levels Counteracts opioid somnolence, improves mood / Increase patient activity level Enhances effects of pain medication Improves cognition Adverse effects: tremulousness, anorexia, tachycardia, insomnia
- Fatigue - Treatment - Pharmacological interventions 2,3 Selective Serotonin Reuptake Inhibitors (SSRI) – inhibits serotonin reuptake Paroxetine (Paxil ) / Fluoxetine (Prozac ) / Inhibit serotonin reuptake Reduces depressive symptoms associated with fatigue / Can improve sleep Primary choice for treatment of depression in cancer patients Some SSRIs have long half-lives and should be used cautiously in the terminally ill May take weeks to feel effects - use may be limited by patient prognosis or goals of treatment Start with a low dose for frail older adults Tricyclic antidepressants Amitriptyline (Elavil ) / Nortriptyline (Pamelor ) Block reuptake of various neurotransmitters at the neuronal membrane Can improve sleep Caution in elderly because of hypotension, sedation, cardio conduction defects Monitor blood levels Epoetin (Epogen ) [erythropoietin] doses varies Increases hemoglobin with effects on energy, activity and overall quality of life while decreasing transfusion requirements
- Fatigue - Non-pharmacological interventions 1,4 Consider fatigue management within context of extent of disease, other symptoms (pain, nausea, diarrhea, etc), whether palliative treatment is still in process, age, developmental stage and emotional status Consider cultural context of fatigue management interventions American Indian/Alaskan Natives tire to maintain high level of activity despite poor health and fatigue Asian/Pacific Islanders may believe fatigue is caused by too much “yin” and may self treat with ginseng herb, to bring relief Active exercise May help to decrease perception of fatigue / Maintain consistent exercise regime Take frequent rest periods / Use energy conversation techniques Attention-restoring interventions May enhance attention capacity and decrease fatigue Patient selects and engages in favorite activity for 30 minutes three times per week Activities may include spending time in natural environment, participating in favorite hobbies, writing, fishing, music, gardening Selected activities based on ability to participate within context of disease progression Reduces boredom and under-stimulation Preparatory education Opportunities to educate patient and family about disease-associated changes: progression, procedures, treatment, medication side effects, scheduling Opportunity to address patient and family questions Reinforce previous education regarding factors that may affect patient fatigue level Psychosocial techniques Psychosocial support and individualized counseling may have fatigue-reducing effects Encourage patient and family to participate in disease-specific support groups
- Fatigue - Patient and family education 1 Explain complex nature of fatigue; Encourage family to be accepting of patient’s new energy pace; Encourage patient/family to communicate with healthcare providers Conserve energy - plan, schedule, prioritize activities; Determine where energy is best spent; Listen to the body - rest as needed Arrange room so items in reach, provide places for patient to rest/sit Encourage activities to restore energy; eliminate or postpone activities that are not priority to patient; utilize optimal times of day; prepare patient for all planned activities of daily living (eating, moving, bath); establish or continue regular bedtime and awakening Obtain as long a sleep sequence as possible - plan uninterrupted time; Rest periods/naps during the day, as needed, not to interrupt normal nighttime sleeping patterns Use light source to cue the body into a consistent deep rhythm Recommend nutritious, high-protein, nutrient-dense food; suggest more small, frequent meals; use protein supplements to augment diet; maintain hydration, 8-10 glasses of water per day as tolerated, unless medically contraindicated Instruct that corticosteroids may stimulate appetite Control contributing symptoms (nausea/vomiting, pain, depression, diarrhea, dehydration) Decrease risk of falls, use assistive equipment, remove obstacles, encourage frequent rests Patient Teaching Sheet Managing Fatigue
- References Anderson PR, Dean G. Fatigue . In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing . 2nd ed. New York, NY: Oxford, 2006:155-168. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC) . Washington, DC: Association of Colleges of Nursing, 2009. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum . Washington, DC: American Medical Association, 2003. 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.
- Pressure Ulcers 1-6 Definition 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 1,2
- Pressure Ulcers Prevalence 1,2 Reported in up to 17% of hospitalized patients 70% of pressure sores in hospitalized patients occurring within 2 weeks Ischemic episode leading to pressure ulcer in hospitalized patient often occur in emergency department or operating room Incidence much higher in cancer patients due to associated risks, conditions that impair wound healing Associated with adverse outcomes such as osteomyelitis, septicemia, pain, increased or additional hospitalizations, increased costs 95% of skin ulcers develop in these areas: sacral/coccygeal area, greater trochanter, ischial tuberosity, heel, lateral malleolus
- Pressure Ulcers - Causes 1-3 Intrinsic factors Immobility Cognitive deficient Chronic illness, for example, diabetes mellitus Poor nutrition Use of steroids Aging Extrinsic factors Pressure Friction Moisture Sharing
- Pressure Ulcers - Causes 1-3 Pressure ulcer represents localized tissue death Consequence of impaired vascular and lymphatic system of skin and deep tissue High pressure on prominent bony areas such as occiput, sacrum, heels, ischial tuberosities, trochanter cause ischemia and hypoxia to the area; Less available tissue for compression in these bony prominences cause them to be at greater risk for pressure ulcers Impaired nutritional status and weight loss of palliative care patient increases risk Pressure over time occludes blood and lymphatic circulation leading to insufficient tissue nutrition, oxygenation and subsequent build up of waste products due to ischemia Subcutaneous fat, muscle & tissue are much more susceptible to effects of ischemia than skin surface - indicates that damage to deeper structures may be greater than is visible or significantly worse than external skin problem might indicate Pressure ulcer development may occur with low pressure over long period of time; Tissue appears to tolerate higher cyclic pressure better than constant pressure Pressures will differ in various body positions: high pressure areas in the supine position - occiput, sacrum, heels; sitting - ischial tuberosities; side-lying - trochanters; Tissue that has been compressed for long period of time may continue to suffer ischemic damage even after relief In healthy individual, initial skin breakdown can occur in 6-12 hours In debilitated individual, can occur in less than 2 hours
- Pressure Ulcers - Clinical assessment 1,4 Goals for care (curative vs. palliative) Expectations about wound progression Psychosocial, cultural, economic history Presence of medical co-morbidities (diabetes, vascular disease, immunosuppression) Previous wound treatments Physical assessment Focus on areas that impact wound healing Assess peripheral perfusion (quality of pulses, warmth, capillary refill, presence of hair), and effects of disease on wound perfusion Monitor tissue integrity Mobility of patient Nutrition status Risk factors for infection Assess for signs of infection: redness, drainage, status of surrounding skin, purulent drainage, foul odor, fever, chills) Pain Use pain intensity scale Assess pain before, during and after procedures / Assess pain during periods when no procedure occurring Lab and diagnostic testing Serum albumin (normal > 3.5 mg/dl) Arterial blood gases (for perfusion) Hemoglobin and hematocrit (for perfusion) Blood glucose levels (look for fasting of less 140 mg/dl) Glycosylated hemoglobin (less than 7%) National Pressure Ulcer Advisory Panel Staging Criteria Wound severity 1 www.npuap.org/pr2.htm
- Pressure Ulcer Staging Criteria Stage I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding tissue Area may be painful, firm, soft, warmer or cooler as compared to adjacent skin The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact o open/ruptured serum-filled blister Presents as a shiny or dry shallow ulcer without slough or bruising. Bruising indicates suspected deep tissue injury Not skin tears, tape burns, perineal dermitis, maceration, or excoriation Stage III Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include tunneling and undermining The depth varies by anatomical location Stage IV Full-tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed Until slough and/or eschar is removed to expose the base of the wound, the true depth, and stage cannot be determined Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed
- Pressure Ulcers - Assessment Wound status Evaluate the wound at least weekly to monitor progress or deterioration of the pressure sore to determine treatment plan effectiveness Consider use of comprehensive assessment tool Pressure Ulcer Scale for Healing (PUSH) Surface area measurements, exudate amount, surface appearance May be helpful in predicting healing outcome Pressure Sore Status Tool (PSST) Developed to standardize the description of pressure ulcers Can help with the communication better clinicians in the evaluation of therapeutic interventions Evaluates 15 wound characteristics; location, shape, size, (length x width), depth, edges, undermining, necrotic tissue type, necrotic tissue amount, surrounding tissue color, peripheral tissue edema, peripheral tissue induration, granulation tissue, epithelialization
- Pressure Ulcers - Wound characteristics Edges or margins Characteristics of distinctness, degree of attachment to the wound base, color, thickness Assess through visual inspection and palpation Assess wound edges Edges indistinct, diffuse, normal tissue blends with wound tissue; indicates edges not attached to wound base - wound with some depth of tissue involvement Edges even with the skin surface and wound base indicate edges attached to base of wound - wound is flat with no appreciable depth Crater or bowl shape indicates a wound with edges not attached to wound base - wound with depth Undermining and tunneling Loss of tissue underneath an intact skin surface Undermining involves a greater percentage of the wound margins with more shallow length than tunneling Undermining usually involves subcutaneous tissue If undermining present, will usually have more aerobic and anaerobic bacteria than wounds without undermining Degree and amount of undermining is good indicator of amount of tissue necrosis Can measure undermining using probe cotton-tipped applicator or pre-formed measuring device to assess extent of undermining Can also use ultrasound to assess tissue impairment due to undermining
- Pressure Ulcers - Wound characteristics Necrotic tissue type and amount Assess for necrotic tissue color, consistency, adherence, and amount present in the wound indicate the degree of severity or involvement Color: variations as necrosis worsens; white gray nonviable tissue to yellow slough & black eschar Consistency: cohesiveness of debris (thin vs. thick, stringy, clumpy) Adherence: adhesiveness of the debris (slough or eschar) to the wound bed and the ease of separation of the two; tissue adheres more to wound bed as necrosis worsens Eschar signifies deeper tissue damage - May be black, gray or brown in color Adherent to wound base but may be lifting from edges of wound if eschar soft or soggy Hard, crusty eschar will be strongly attached to base and edges of wound Amount present: necrotic tissue acts as bacterial growth medium and physical obstacle to epidermal resurfacing, wound contraction, and granulation Greater the amount of necrotic tissue, longer healing time needed Use measuring device to assess amount of necrosis present to determine percentage of wound that is necrotic Exudate type and amount 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 In pressure ulcers, excess exudate is response to inflammatory process or infection - normally serous or serosanguineous Infected wound: exudates thickened, purulent, moderate to large amounts, with foul smells characteristic of infecting organism Assess for type and amount of exudates Assess characteristics of exudates: color, consistency, adherence, distribution in the wound, odor Amount of exudates will vary based on size of wound Remove dressing/cleanse wound with normal saline before assessing exudate Assess wound dressing for amount of exudates based on type of dressing, length of time dressing worn, wound etiology Types and amounts of exudates will vary depending on stage of wound Characteristics of exudates may indicate infection/wound degradation: copious, seropurulent, purulent
- Pressure Ulcers - Wound characteristics Surrounding tissue conditions Assess surrounding tissue for color, induration, edema May be first warning of potential further damage Color: assess tissue from within 4 cm of wound edge Dark-skinned persons show colors as bright red, dark red (deepening of normal pigmentation) - new skin may be pink and never darken as it heals Blanching: differentiates new epithelium from tissues that are erythematous Press firmly on skin with finger, lift finger, look for blanching or sudden whitening of skin followed by prompt return of normal color to the area Non-blanchable erythema indicates more severe tissue damage Induration : an abnormal firmness of tissues with margins is a sign of impending damage to tissue Assess tissues within 4 cm of wound Palpate where induration begins and ends by gently pinching the tissue; compare to soft spongy feel of healthy tissue Inability to pinch tissue associated with induration
- Pressure Ulcers - Wound characteristics Edema: will impede healing of pressure ulcer Assess within 4 cm of wound Non-pitting edema: shiny and taut (glistening) Pitting edema: press firmly into tissue and wait 5 seconds – tissue will fail to return to previous position upon release: indentation present Measure extent of edema beyond wound edges Granulation tissue and epithelialization - markers of wound health Granulation tissue: growth of small blood vessels and connective tissue into the wound cavity Healthy granulation: bright, beefy red; shiny; granular with a velvety appearance; looks bumpy; may bleed easily Unhealthy granulation: due to poor vascular supply, is pale pink or blanched to a dull, dusky red Often first layer of granulation will be pink and develop to beefy red Assess the percentage of the wound that has been filled with granulation tissue Epithelialization: epidermal resurfacing and regeneration occurs from lateral migration at the wound edges and the base of the hair follicles as the epithelial cells proliferate and resurface the wound Occurs throughout the wound bed in partial thickness wounds Occurs from the wound edges in full-thickness wounds Appears as pink or red skin Assess by evaluating the amount of the wound that is surrounded by new tissue and the distance new tissue extends into the wound base
- Pressure Ulcers - Treatment 1,4 Agency for Health Care Policy and Research established algorithms for treatment of pressure ulcers (AHCPR guidelines of 1994) Nutritional support Studies link development of pressure ulcers with malnutrition Nutritional support during treatment of pressure ulcers includes assessment of following Prevention of malnutrition may prevent further breakdown of pressure ulcer, but is not always possible in palliative care patient – particularly at the end of life Nutritional assessment includes Albumin > 3.5 Total lymphocyte count (TLC) > 1800 Patient eating or weight > 80% of ideal with adequate dietary intake Recent weight change - loss of > 10% of ideal If no to the above, consider Physical and psychosocial barriers to intake Consider gut function with periodic reassessment If gut function adequate, consider nutritional supplements and assistance and assess dietary intake If dietary intake still inadequate, consider tube feedings, reassess If dietary intake still inadequate, assess if patient candidate for TPN vs. comfort measures only
- Pressure Ulcers - Treatment 1,4 Management of tissue load Management in palliative care patient is to ease suffering and discomfort from wound. Consider alternating airflow mattress when assessing for use of pressure reduction devices. Monitor ulcer & progress to supportive surfaces if patient bottoms out or ulcer not healing properly Appropriate patient positioning must be considered when using any of following surfaces For management of tissue loads with support surfaces, consider AHCPR recommendations No special surface needed No multiple large and no truncal Stage III or IV ulcers, Ability to keep patient off ulcer Patient not at risk for additional ulcers Static devices (foam overlays, cushions, water mattress) No multiple, large truncal Stage III or IV ulcers No moisture problem Multiple turning devices available Unable to keep ulcer off surface Patient at risk for additional ulcers Dynamic overlays or mattress (alternating air mattress) No multiple, large truncal Stage III or IV ulcers Skin moisture problem present Multiple turning devices not available Unable to keep ulcer off surface Patient at risk for additional ulcers Consider if static device not effective or ulcer is not healing properly Low-air-loss bed Use for patients with multiple, large, truncal Stage III or IV ulcers Consider if previously tried dynamic overlay or mattress not effective or ulcer is not healing properly Air-fluidized bed Use for patients with multiple, large, truncal Stage III or IV ulcers Consider if low air loss bed not effective or ulcer is not healing properly
- Pressure Ulcers - Treatment 1,4 Debridement 1 Debridement of necrotic tissue necessary for wound healing Necrotic tissue impedes healing and provides bacterial growth medium In palliative care, debridement still important for decreasing odor Sharp debridement: presence of advancing cellulites, sepsis or large and adherent amounts of necrotic tissue Mechanical debridement Wet to dry dressings: least recommended in palliative care due to time involvement and potential pain Hydrotherapy: whirlpool may be helpful for wounds with large amounts of necrotic debris adherent to healthy tissue and allows for easier sharp debridement Wound irrigation: most favorable for wound healing Enzymatic debridement: application of topical agent containing an enzyme that destroys necrotic tissue; useful if sharp debridement not possible, home setting, long term care setting or other palliative care settings; usually changed daily Autolytic debridement: use of moisture-retentive dressings to cover the wound & allow necrotic tissue to self-digest from enzymes normally found in wound fluid or exudate; may be used in conjunction with wound irrigation or periodic sharp debridement; dressing changed every 2-4 days Bacterial colonization and infection 1 Most open pressure ulcers often colonized by bacteria Clinical infection can usually be prevented with adequate debridement and irrigation Routine swab cultures not recommended as they may reflect wound surface bacterial contamination and not organism Needle aspiration or tissue biopsy recommended for diagnosing wound infection Consider surface swab: cleanse wound with normal saline to remove debris; swab a 1 cm square area of wound bed for 5 seconds until tissue fluid appears on swab; send directly to lab Consider 2 week trial of topical antibiotics (silver sulfadiazine or triple antibiotic) if wound appears clean but healing not progressing; reduces surface bacteria that may impede healing Avoid topical antiseptics in clean pressure ulcers: providone iodine, iodophor, sodium hypochlorite, hydrogen peroxide, acetic acid as they harm healing tissue in clean wound; 2 week trial course may be considered in necrotic, debris-filled wounds and reevaluate
- Pressure Ulcers - Treatment 1,4 Wound cleansing 1 Removes necrotic tissue, excess exudate and metabolic waste from wound bed to promote healing Decreases potential for wound infection Wounds should be cleansed initially at each dressing change Normal saline is preferred cleansing solution: physiological and will not harm healthy tissue Avoid skin cleansers and antimicrobial agents as they destroy healthy tissue and are toxic to fibroblast cells Wound irrigation pressure: 4-15 pounds per square inch (greater pressure may force bacteria into wound) using 35 ml syringe with a 19 gauge angio-catheter Ulcer care: dressing 1 Goal of dressing is to provide an environment that keeps the wound bed tissue moist and the surrounding intact skin dry Moist dressings support greater healing progress than dry; minimize odor, absorb exudate and minimize dressing change discomfort Moisture-retentive wound dressings are most appropriate for pressure ulcers; optimal for palliative care as changed every 2-4 days Thin film dressings have no absorptive capacity Hydrocolloids, hydrogels, foam dressings usually have minimal to moderate exudate absorption Calcium alginates, alginate collagen dressings and exudate absorbing beads, flakes, pastes, or powders absorb large amounts of drainage Minimal drainage: consider hydrocolloids, hydrogels, thin film dressings, foam dressings Moderate draining wounds: consider hydrocolloids, foam dressings, hydrogel sheet dressings, or combination such as foam island in center covered with thin film dressing Large draining wounds: consider calcium alginates, alginate collagen combinations or specific beads, pastes, or powders designed to handle large amounts of drainage Wounds with odor: consider dressings formulated with charcoal Wounds with undermining: loosely fill pockets with dressing to prevent abscess formation by preventing premature wound closure; consider calcium alginates, impregnated hydrogel gauze strips, wound cavity fillers Wounds of sacrum:protect from urine/stool; consider newer hydrocolloid products that can be shaped to stay in place Monitor dressing to determine appropriate treatment or necessary changes, i.e., monitoring amount of exudate & switching dressings as exudate decreases & healing continues
- Pressure Ulcers - Patient and Family Education 1,5 Prevention Teach appropriate responses to early signs / Include reasons for all actions during instruction Educate patient and family regarding methods of preventing skin breakdown Instruct & observe caregiver in turning/positioning of patient & implementation of regular turning schedule Reposition patient at least every 2 hours Instruct & observe caregiver in prompt management of incontinence by cleaning/drying skin surfaces Instruct family to examine skin, especially over bony prominences, for signs of skin breakdown Avoid massage over bony prominences keep body and room temperature warm to maintain perfusion keep bony prominences from direct surface contact - use pillows/foam wedges elevate heels off surface of bed using pillows under calfs lift patient using devices to prevent friction/shearing on skin, use surface covers to reduce pressure (i.e., alternating airflow mattress) - Avoid donut-type seating devices use lubricants/lotions (without alcohol) to prevent drying of skin Review use of powders for moist areas (under breast, groin, abdominal folds) minimize use of products that hold moisture against body such as chux or adult incontinence products monitor nail length to avoid scratching / ensure patients clothing fit properly - avoid tight fitting apparel maintain head of bed in lowest possible position while maintaining patient comfort and maximizing breathing Discuss benefits/burdens of catheterization if unable to control moisture TIPS Sheets TIPS for Skin Care
- Pressure Ulcers - Patient and Family Education 1,5 Nutrition Address nutritional needs of patient within context of palliative care goals Calories: 30-35 kg/day Supplements: several protein shakes per day Grams of protein: 1.25-1.5 g/kg/day Fluids: normal 2000-3000 ml/day Urine output: > 20ml/hour, light straw color, no odor Maintain disease-specific diet as necessary (CHF, renal, DM) Consider use of multivitamins Consider dietician consult Mobility Review activity/mobility status with patient and family Review importance of pressure ulcer prevention by maximizing activity and/or mobility Address need to maintain some degree of activity even if patient bed bound Instruct patient to move or shift weight every 15 minutes Consider physical therapy consult for active & passive range of motion exercises
- References 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. 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. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum . Washington, DC: American Medical Association, 2003. 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. Wrede-Seaman L. Symptom management algorithms: A handbook for palliative care . Yakima, WA: Intellicard, 1999. National Pressure Ulcer Advisory Panel Staging Criteria, 2007. Available at. www.npuap.org/pr2.htm Accessed October 21, 2009.