Tuesday, December 13, 2011

Symptom management in hospice

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SYMPTOM MANAGEMENT IN HOSPICE


I. Pain an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of tissue damage.


A. Acute and Chronic Pain


1. Acute severe and lasts a short time.


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- indicates body tissue injury


- generally disappears when injury is healed





. Chronic Pain ranges from mild to severe and is persistent.


- usually presents in varying degrees for long periods of time.


B. Three Types of Pain


1. Visceral involves body organs.


- caused by tissue damage to an organ.


- usually pain cannot be pinpointed.


- described as sharp, spasm, cramping


- aches all the time.


. Somatic bone, incisional, and musculo-skeletal pains.


- usually pain is in a specific area.


- described as tender, deep, aching.


- worse when I move.


. Neuropathic caused by injury to the structures of the peripheral and


central nervous system.


- often associated with sensory changes.


- described as shooting, stabbing, burning, numbness.





C. Pain Assessment must include


1. Location


. Quality


. Intensity


4. Onset


5. Duration


6. Alleviation Factors


7. Aggravating Factors


8. History of Present Illness


. Frequency (constant, intermittent, transient)


10. Radiation


11. Meaning of Pain to Patient


1. What Co-Morbid Conditions are present?


1. Previous Pain History


14. Medication Review


15. Impact on Quality of Life


- ADLS


- Moods


- Relationship with Others


- Enjoyment of Life


D. Essential Steps in Pain Management


1. Understand the Barriers.


. ASSESS and CONTINUALLY REASSESS.


. Treat


- use appropriate meds


- titrate to desired effect


- anticipate side-effects


- prescribe breakthrough meds


- use ATC dosing (Avoid prn)


- consider the use of adjuvant medications


4. Believe the patients report of pain.


5. Dont forget non-pharmacologic modalities for pain control.


6. Use a multi-disciplinary approach.


7. Keep it simple


8. Modify pathologic processes if possible.


. Consult specialist when needed.


10. Immobilize when necessary.


11. TRY AND KEEP ON TRYING


E. World Health Organization Analgesic Ladder


1. Step 1(mild pain)


- 1 to on pain scale


- may be atc or prn


- use non-opioids (tylenol, aspirin, trilisate, ibuprofen, celebrex, etc.)


- may add a weak opioid if needed (codeine, hydrocodone)


. Step (moderate to severe pain)


- 4 to 6 on pain scale


- must be ATC


- weak opioids (oxycodone, oxycontin, duragesic patch)


- need breakthrough medication with oxycontin and duragesic patch


. Step (severe pain)


- 7 to 10 on pain scale


- must be ATC


- strong opioids (morphine, dilaudid, duragesic patch, methadone)


F. Adjuvant Meds- drugs used for other clinical problems that may provide pain relief in


specific situations.





1. Include NSAIDS, anti-depressants, anti-convulsants, corticosteroids


G. Non-Pharmacologic Pain Management


1. Positioning for comfort


. Support affected area


. Use of heat and cold


4. PT/ OT/Dietary consults


5. Assistive devices


6. Visualization, self-hypnosis, relaxation techniques


7. Music therapy, pet therapy


8. Massage


. Humor, meditation


10. TENS, biofeedback


11. Acupressure, acupuncture


1. Aromatherapy, therapeutic touch


1. EDUCATE PATIENT AND FAMILY ABOUT TREATMENT OPTIONS,


MEDICATIONS AND ANTICIPATED EFFECTS


H. Opioids to Avoid


1. Darvocet toxic metabolites, poor effectiveness


. Demerol toxic metabolites, short duration of action, effective only IV and IM


. Mixed agonist-antagonist (e.g. talwin)


I. Opioid Side Effects


1. Constipation


. Nausea and vomiting


. Sedation


4. Confusion/delirium


5. Respiratory depression


J. Final Thoughts


1. PRN dosing is only appropriate for true episodic pain and breakthrough medication


. There is no ceiling dose on most opioids. Titrate analgesics to achieve optimal


pain control with minimal side effects.


. Goal is an alert, pain free patient.


II. Dyspnea uncomfortable awareness of breathing. Unpleasant sensation of shortness


of breath.


A. Causes of Dyspnea


1. Muscle weakness


. Pneumonia


. Tumor


4. Anemia


5. Psychological distress


6. COPD, CHF


B. Medical Management of Dyspnea


1. Opioids Morphine is the best choice


- give oral or nebulized


- morphine dose is 10 to 0 mgm. q 1 � 6 hrs PO or 5-10 mgm IV


- if patient is on morphine, increase dose by 50%


. Oxygen


. Benzodiazepines Ativan is usually good


- should be short-acting


- use only if dyspnea is a manifestation of a panic attack or severe anxiety


4. For respiratory panic


- make sure someone stays with the patient


- midazolam 5-10 mgm. IM or IV slowly or


- lorazapam (ativan) 0.5- mgm. sl or IV or


- morphine 5-10 mgm. by nebulizer or IV


- nebulized morphine morphine .5 mgm with decadron mgm in .5 ml


of saline q 4 hrs. prn


5. Dyspnea due to CHF


- furosemide 0-40 mgm PO or IV, titrate as needed


- nitropatch 0.-0.4 mg/hr qd or nitrodrip titrated to effect


- oxygen


- morphine or other opioid may require IV drip


C. Supportive Care Measures for Dyspnea


1. Fans/open windows to increase air movement


. Position sitting up or leaning forward


. Behavioral treatments


- visualization


- relaxation exercises


- education


- distraction


- emotional support and reassurance


4. Pursed lip breathing


5. Humidified air for distressing cough


D. Managing Excess Secretions


1. Reposition patient on side or semiprone may reduce gurgling


. At onset of symptoms


- transderm scopolamine q 7 hrs


- hycosyamine preps(levsin drops 0.15mg q 6 hrs prn)


- robinal 1- mgm. po/sl tid


. Avoid sunctioning


- sunction only for bleeding in throat, fulminating pulmonary edema, and


tracheostomy with copious secretions


4. IV hydration and/or tube feedings may increase secretions at end of life


5. Family education and support


III. Nausea and Vomiting


A. Causes


1. Metastases


. Meningeal irritation


. Movement


4. Mental anxiety


5. Medications


6. Mucosal irritation


7. Mechanical obstruction


8. Motility dysfunction


. Metabolic


10. Microbes


11. Myocardial


B. Pharmacologic Management of Nausea and Vomiting


1. Depends on cause


- increased intracranial pressure decadron


- gastro-esophageal reflux prilosec, prevacid, zantac, pepcid, carafate


- motion sickness symptoms compazine, antivert


- bowel obstruction DBR or RDA suppositories q 6 hrs prn


- DBR decadron(4 mgm), benedryl(5 mgm), raglan(10 mgm)


- RDA raglan(50 mgm), decadron(10mgm), ativan( mgm)


- reduced gastric motility reglan


- unknown compazine, zofran, kytril, lorazapam, haldol


C. Non-Pharmacologic Interventions


1. Serve foods cold or at room temperature


. Low fat, small frequent feedings, non-gas forming foods


. Clear liquids for 4 hrs to rest GI tract


4. Companionship for meals


5. Relaxation techniques


6. Experiment with sour foods


7. Vary eating patterns


8. NPO for 1- hours after vomiting


. Bland foods


IV. Delirium


A. Acute confusional state resulting from global impairment of mental function


1. must differentiate from depression and dementia


B. Very common and under diagnosed


1. In the last weeks of life, up to 85% of patients may develop delirium


C. Symptoms of Delirium


1. Acute onset that develops over hours to days


. Fluctuating level of consciousness with reduced ability to focus, sustain, or


shift attention


. Change in cognition such as memory deficit, disorientation


D. Risk Factors for Delirium


1. Advanced Age


. Polypharmacy


. Cardiopulmonary MI, hypoxia, hypotension


4. CNS stroke, dementia


5. Infections UTI, pneumonia, sepsis


6. Electrolyte Imbalances


7. GI/GU bleeding, constipation, urinary retention


8. Sensory deprivation, over-stimulation, environmental changes


E. Non-Pharmacologic Treatment of Delirium


1. Treatment is mostly symptomatic with focus on comfort


. Improve orientation, decrease sensory overload or deprivation, and provide


reassurance


- windows, clocks, calendars


- quiet, well-lit room with familiar surroundings


- presence of family


- follow fixed daily schedules


- one to one care may be necessary


F. Pharmacologic Treatment of Delirium


1. Correct underlying metabolic or infectious processes


. Assess current medications and reduce or delete if indicated


. Medications Haldol, Ativan


G. Terminal Delirium


1. 10 to 0 % of terminally ill patients experience delirium that can only be


controlled by sedation to the point of decreased level of consciousness


. Brain Metastasis Decadron 16-6 mgm. daily


. Haldol 0.5-5 mgm. q to 1 hrs. po/iv/pr/sc


4. Thorazine 1.5 -50 mgm. q 4-1 hrs. po/iv/im


5. Add benedryl 5 mgm. tid to prevent extrapyramidal reactions + sedation


References


Doyle D, Hanks GWC, MacDonald N, ed. Oxford Textbook of Palliative Medicine.


Oxford Oxford University Press, 18.


Wrede-Seaman Linda. Symptom Management Algorithms A Handbook for Palliative Care. Intellicard Inc., 1


Waller Alexander, Caroline Nancy L. Handbook of Palliative Care in Cancer. Butterworth-Heinemann, 000.


Maxwell Terri., RN, MSN, AOCN. Symptom Management Presentation. Pennsylvania Hospice Network Conference, April , 00


Maxwell, Terri, RN, MSN, AOCN. Pain Management Presentation. Pennsylvania Hospice Network Conference, April , 00


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