Transcript Clinical Review for the Hospice and Palliative Nurse

Clinical Review for the
Hospice and Palliative Nurse
Symptom Management
1
Objectives
1.
Define common symptoms present at the end of life.
2.
Identify possible etiologies of symptoms at the end of
life.
3.
Assess for the physical and psychosocial aspects of the
symptoms that are common at the end of life.
2
Objectives
4.
Describe pharmacological and nonpharmacological
interventions for common symptoms that can be included
in the plan of care at the end of life.
5.
Describe the patient and family instructions needed for
patients and families at the end of life.
3
Domains of
Quality Palliative Care
Clinical Practice Guidelines of Quality Palliative Care
 Domain 2: Physical Aspects of Care.
 Guideline 2.1 Pain, other symptoms, and side
effects are managed based upon the best available
evidence, with attention to disease-specific pain
and symptom, which is skillfully and systematically
applied.
4
Anorexia and Cachexia
Anorexia
 loss of appetite resulting in the inability to eat
Cachexia
 physical wasting and malnutrition usually associated with
chronic disease
5
Anorexia and Cachexia
Prevalence
 Commonly found in patients with advanced
disease

80% of cancer patients
6
Anorexia/Cachexia
Causes
Disease Related




Infections
Delayed gastric emptying
Metabolic alterations
Pain
7
Anorexia/Cachexia
Causes
Treatment Related



Medications
Chemotherapy
Radiation
8
Anorexia/Cachexia
Causes
Psychological and/or spiritual distress


Often overlooked
Depression may exhibit somatic symptoms
9
Anorexia/Cachexia
Assessment
 Patient reports
 Muscle wasting
 Weight loss
 Lab values
 Intake patterns
10
Anorexia/Cachexia
Pharmacological Interventions
 Megestrol acetate (Megace®)
 Metoclopramide (Reglan®)
 Dexamethasone (Decadron®)
 Dronabinol (Marinol®)
11
Anorexia/Cachexia
Non-pharmacological Interventions
 Treat underlying symptoms
 Emotional support
 Nutritional support
12
Anorexia/Cachexia
Non-pharmacological Interventions
 Enteral and parenteral nutrition
13
Anorexia/Cachexia
Patient and Family Education
 Support patient’s wishes
 Discuss intake during dying process
 Explore meaning of food
 Address emotional needs
 Redirect caring
14
Anorexia/Cachexia
References
1. Kemp C. Anorexia and cachexia, In: Ferrell BR, Coyle N, eds.
Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford
University Press; 2006:169-176.
2. Bednash G, Ferrell BR. End-of-life nursing education consortium
(ELNEC). Washington, DC: Association of Colleges of Nursing;
2009.
3. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on
End of Life Care (EPEC) Curriculum. Washington, DC: American
Medical Association; 2003.
15
Dehydration
 Normal physiologic process at the end of life
 Decreased desire for fluids
 Symptoms vary
16
Causes of
Dehydration
 Loss of normal body water
 Isotonic dehydration
 Eunatremic dehydration
 Hypotonic dehydration
17
Assessment for
Dehydration
 Mental status changes
 Confusion, restlessness
 Intake and output
 Elderly may have decrease perception of thirst
 Urine output reduced
18
Assessment for
Dehydration
 Weight loss
 Reduced skin turgor
 Skin and mouth assessment
 Postural hypotension
 Lab values
 Increased hematocrit
 Serum sodium
19
Treatment of
Dehydration
 Ethical considerations

Benefits vs. burdens
 Review expected course of illness
 Artificial hydration
 Misperceptions
20
Treatment of
Dehydration
Use least invasive approach possible
 Oral

Provide appropriate mouth care
 Proctoclysis
21
Treatment of
Dehydration
 NG/GT

NG uncomfortable
 Hypodermoclysis

Subcutaneous fluid administration
 IV
22
Treatment of
Dehydration
 IV

Monitor for over hydration
23
Dehydration
Patient and Family Education
 Oral/enteral/parenteral fluids
 Instruct more than one person
 Allow ample time for instruction and return
demonstration
24
Dehydration
Patient and Family Education
 Review benefits/burdens of artificial nutrition and
dehydration
 Address emotional needs
 Assist in redirecting ways of caring
25
Dehydration
References
1.
2.
3.
4.
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). Washington, DC: Association of
Colleges of Nursing; 2009.
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.
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.
26
Nausea and Vomiting
 Nausea


Subjectively perceived
Unpleasant sensation experienced in the back of the
throat and epigastrium, which may or may not result
in vomiting
 Vomiting

expelling of stomach contents through the mouth
27
Nausea and Vomiting
Prevalence
Common in patients with advanced disease





70% of patients experience nausea
30% of patients experience vomiting
Patients under 65 and women
Stomach, breast and gynecological cancer
AIDS
28
Causes of
Nausea and Vomiting
 Physiological Causes



Gastrointestinal
Metabolic
Central nervous system
 Psychological

Emotional
 Disease related
 Treatment related
29
Nausea and Vomiting
 Associated with





Opioid therapy
Uremia
Hypercalcemia
Constipation
Bowel obstruction
30
Assessment
of Nausea and Vomiting
 History of disease
 Effectiveness of prior treatments
 Precipitating factors
 Self-reporting tools
 Physical
 Diagnostic testing
31
Nausea and Vomiting
7 Steps for Antiemetics
1.
2.
3.
4.
5.
6.
7.
Identify cause
Identify pathway of cause
Identify neurotransmitter receptor
Select potent antagonist for that receptor
Select a route
Titrate dose and administer ATC
If symptoms continue, additional
treatment
32
Nausea and Vomiting
Antiemetics
Butyrophenones

Indication: opioid-induced nausea, chemical and
mechanical nausea
 Medications


Haloperidol (Haldol)
Droperidol (Inapsine)
33
Nausea and Vomiting
Antiemetics
Protokinetic agents

Indication: gastric stasis, ileus
 Medications
 Metoclopramide (Reglan)

Domperidone (Motilium)
34
Nausea and Vomiting
Antiemetics
Cannabinoids

Indication: second-line antiemetic
 Medication
 Dronabinol (Marinol)
35
Nausea and Vomiting
Antiemetics
Phenothiazines

Indications: general nausea and vomiting, not as
highly recommended for routine use in palliative care
 Medications
 Prochlorperazine (Compazine)
 Thiethylperazine (Torecan)
 Trimethobenzamide (Tigan)
36
Nausea and Vomiting
Antiemetics
 Antihistamines
 Indications: intestinal obstruction, peritoneal
irritation, increased intracranial pressure,
vestibular causes
 Anticholinergics

Indication: motion sickness, intractable
vomiting, or small bowel obstruction
37
Nausea and Vomiting
Antiemetics
 Steroids
 Appear to exert antiemetic effect as a result of
antiprostaglandin activity
 Most effective in combination with other agents
 Benzodiazepines
 Indication: effective for nausea and vomiting as well
as anxiety
38
Nausea and Vomiting
Antiemetics
 5-HT3 receptor antagonists
 Indicated for post-operative nausea and vomiting and
chemotherapy
 ABHR

Compounded antiemetics
39
Nausea and Vomiting
Antiemetics
 Octreotide (Sandostatin®)

Indications: nausea and vomiting associated with
intestinal obstruction
 DimenhyDRINATE (Dramamine®)

Indications: nausea, vomiting, dizziness, motion
sickness
40
Non-pharmacological
Treatment of Nausea and Vomiting
 Oral care
 Cool damp cloth
 Decrease noxious stimuli
 Loose-fitting clothes
 Fresh air or fan
41
Non-pharmacological
Treatment of Nausea and Vomiting
 Behavioral complementary therapies
 Interventions individually based

Cultural considerations
42
Nausea and Vomiting
Patient and Family Education
 Assessment of nausea and vomiting
 Problem solving
 Family’s role
 Instruct when to call healthcare provider
43
Nausea and Vomiting
References
1. Berry PH, ed. Core Curriculum for the Generalist Hospice and
Palliative Nurse. 2nd ed. Dubuque, IA: Kendal/Hunt; 2005.
2. King C. Nausea and vomiting. In: Ferrell BR, Coyle N, eds. Textbook of
Palliative Nursing. 2nd ed. New York, NY: Oxford University Press;
2006: 177-194.
3. Bednash G, Ferrell BR. End-of-life nursing education consortium
(ELNEC - Geriatric). Washington, DC: Association of Colleges of
Nursing; 20072005.
4. Kazanowski M. Symptom management in palliative care. In: Matzo
ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the
End of Life. New York, NY: Springer; 2006: 319-3442001:327-361.
5. Mannix K. Gastrointestinal symptoms. In: Doyle D, Hanks GWC,
MacDonald N, eds. Oxford Textbook of Palliative Medicine. 3rd New
York, NY: Oxford University Press: 2005:1998464-468: 489-499.
44
Bowel Obstruction
Prevalence
 Related to site of disease
 Tumors of splenic flexure obstruct 49% of the time
 Rectum or rectosigmoid obstruct 6% of the time
45
Bowel Obstruction
 Occlusion of the lumen or absence of the normal
propulsion
 Intralumen obstruction
 Extramural obstruction
 Mechanical obstruction
 Metabolic disorders
 Medications
46
Assessment of
Bowel Obstruction
 Assess within palliative care goals
 Bowel history
 Pain
 Palpate abdomen
 Rectal exam
 Location of obstruction
47
Treatment of
Bowel Obstruction
Prevention
 Principles




Goal of treatment is prevention whenever possible
Verify cause of obstruction: tumor vs. fecal
impaction
If stool, goal is to move the stool down through the
intestinal tract
Avoid stimulant laxatives – usually increase
discomfort and may cause intestinal wall rupture
48
Treatment
Bowel Obstruction
 Pharmacolologic
 Octreotide (Sandostatin®)
 Scopolamine
 Opioids
 Antiemetics
49
Treatment of
Bowel Obstruction
 Pharmacolologic
 Corticosteroids
 Antispasmodic
 Laxative / Antidiarrheal
50
Treatment of
Bowel Obstruction
 Surgical
 Considered within context of established palliative
care goals
51
Treatment of
Bowel Obstruction
 Non-pharmacological



Avoid hot drinks
Avoid big meals
Consider NG
52
Bowel Obstruction
Patient and Family Education
 Review causes
 Discuss treatment options
 Educate to prevent
 Instruct when to call healthcare provider
 Review medications
 Review dietary recommendations
53
Bowel Obstruction
References
1. Economou DC. Bowel management: constipation,
diarrhea, obstruction, and ascites. In: Ferrell BR, Coyle
N, eds. Textbook of Palliative Nursing. 2nd ed. New
York, NY: Oxford University Press; 2006: 219-238.
2. Kazanowski M. Symptom management in palliative
care. In: Matzo ML, Sherman DW, eds. Palliative Care
Nursing: Quality Care to the End of Life. New York,
NY: Springer; 2006:319-344.
3. Emanuel L. von Gunten C, Ferris F. The Education for
Physicians on End of Life Care (EPEC) Curriculum.
Washington, DC: American Medical Association; 2003
54
Constipation
 Infrequent passage of stool
 Increases with age
 Frequent with illness and at the end of life
 Results from some medications

Opioids!
55
Constipation
Prevalence
 10% of general population
 Increases with age
 Effects more than 50% of patients in a palliative care




unit or in hospice
Frequently seen symptom at the end of life
Undertreated by nurses and doctors
Can be very embarrassing for some patients
Prevention is the key!
56
Causes of
Constipation
 Disease Related



Cancer
Diabetes
Hypercalcemia
 Medication Related
 Other



Dehydration
Inactivity
Depression
57
Assessment for
Constipation
 Bowel history
 Abdominal assessment
 Rectal assessment
58
Assessment for
Constipation
 Physical assessment
 Diagnostic tests
 Medication review



Prescription
Over the counter
Herbals
59
Pharmacological
Treatment of Constipation
Laxatives
 Lubricant laxatives - lubricate the stool surface and soften
the stool leading to easier bowel movement
Surfactant/detergent laxatives
 Reduce surface tension, increase absorption of fluids and
fats into stool which soften it can increase peristalsis
60
Pharmacological
Treatment of Constipation
 Combination medications
 Osmotic laxatives
 Non-absorbable sugars that exert an osmotic effect
in primarily the small intestine
 Osmotic suppositories

Glycerin suppositories – soften stool by osmosis and act
as lubricant
61
Pharmacological
Treatment of Constipation
 Laxatives
 Saline laxatives – increase gastric, pancreatic, and
small intestinal secretions, and motor activity
throughout the intestine
62
Pharmacological
Treatment of Constipation
 Bowel stimulants
 Bowel stimulants – work directly to irritate bowel and
stimulate peristalsis
 Use with caution when liver disease present
63
Pharmacological
Treatment of Constipation
 Bulk Laxatives
 Provide bulk to the intestines to increase mass –
stimulates bowel to move
64
Pharmacological
Treatment of Constipation
 Enemas
 Soften stool by increasing water content
65
Opioid Induced
Constipation
Opioid Induced Constipation
 Opioids


Bind to mu–opioid receptors in the central nervous
system – provide analgesia
Also bind to peripheral mu–opioid receptors in the
gastrointestinal tract, inhibiting bowel function –
opioid induced constipation (OIC).
 Pharmacologic / non-pharmacologic treatment
 Oral erythromycin
 Metoclopramide
66
Pharmacological
Treatment of Constipation
Methylnaltraxone / (Relistor®)
 Inhibits opioid induced decreased gastrointestinal
motility and delay in gastrointestinal transit time
 Does not affect opioid analgesic effect
 Subcutaneous route / dose according to weight
 Decrease dose with renal impairment
 50% of patients had a bowel movement within 30
minutes to 4 hours of the first injection
67
Non-pharmacological
Treatment of Constipation
 Prevention
 Manage side effects of pain medication
 Encourage fluid and fiber intake
 Encourage activities
 Intervene only if causing distress
 Cultural considerations
68
Constipation
Patient and Family Education
 Monitor bowel patterns
 Encourage fluid intake
 Encourage dietary intake
 Encourage activity
 Instruct when to call healthcare provider
69
Constipation
References
1. Economou DC. Bowel management: Constipation, diarrhea,
obstruction, and ascites. In: Ferrell BR, Coyle N, eds. Textbook of
Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006: 219-238.
2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium
(ELNEC ). Washington, DC: Association of Colleges of Nursing,
2009.
3. Sykes N. Constipation and diarrhea. In: Doyle D, Hanks G,
MacDonald N, eds. Oxford Textbook of Palliative Medicine. New
York, NY: Oxford, 2005: 483-490.
70
Constipation
References
4. McMillan S, Williams F. Validity and reliability of the constipation
assessment scale. Cancer Nursing 1989;12:183-188.
5. Emanuel L, von Gunten C, Ferris F. The education for Physicians on
End of Life Care (EPEC) Curriculum. Washington, DC: American
Medical Association, 2003.
6. Kazanowski M. Symptom management in palliative care. In: Matzo
ML, Sherman D W, eds. Palliative care nursing: Quality care to the
end of life. New York, NY: Springer, 2006: 319-344.
71
Diarrhea
 Frequent passing of loose, non-formed stool
 More severe in HIV-infected patients and bone
marrow transplant patients
72
Diarrhea
Prevalence
 Considered a main symptom in 7-10% of hospice patients
 Especially prevalent in the HIV patient
 43% of bone marrow transplant patients develop diarrhea
related to radiation
 Occurs in 10% of cancer patients
73
Causes of
Diarrhea
 Disease related
 Psychologically related
 Treatment related
74
Assessment of
Diarrhea
 Bowel history





Assess frequency and nature of diarrhea in last 2 weeks
Complaints of pain or abdominal cramping
Rapid onset may indicate fecal impaction with overflow
Colonic diarrhea: watery stools in large amounts
Malabsorption: foul smelling, fatty, pale stools
 Diet history
 Treatment history
 Medication review
75
Assessment of
Diarrhea
 Physical assessment



Abdominal assessment
Examine stools for signs of bleeding
Evaluate for signs of dehydration
76
Pharmacological
Treatment for Diarrhea
 Opioids
 Suppress forward peristalsis and increase sphincter tone
 Loperamide (Imodium®)
 Bulk forming agents
 Promote absorption of liquid / increase thickness of stool
 Psyllium (Metamucil®)
 Antibiotics
 Steroids
 Somatostatins
 Slows transit time by decreasing secretions
 Octreotide (Sandostatin)
77
Non-pharmacological
Treatment for Diarrhea
Dietary management
 Initiate a clear liquid diet
 Eat small, frequent, bland meals
 BRAT diet
 Low residue diet
 Increase fluids in diet
 Consider homeopathic remedies
78
Non-pharmacological
Treatment for Diarrhea
 Psychosocial interventions


Provide support to patient and family
Recognize negative effects of diarrhea on
quality of life
 Sitz baths
 Cultural Considerations

Many cultures modest – may prevent reporting
79
Diarrhea
Patient and Family Education
 Respect level of comfort during discussions
 Monitor frequency and consistency
 Instruct when to contact healthcare provider
 Provide skin care
80
Diarrhea
References
1. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium
(ELNEC - Geriatric). Washington, DC: Association of Colleges of
Nursing, 2007.
2. Economou DC. Bowel management: Constipation, diarrhea,
obstruction, and ascites. In: Ferrell BR, Coyle N, eds. Textbook of
palliative nursing. 2nd ed. New York, NY: Oxford, 2006: 219-238.
3. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on
End of Life Care (EPEC) Curriculum. Washington, DC: American
Medical Association, 2003.
81
Anxiety
 Feeling of deep sense of unease without an
identifiable cause
 Prevalence – varies
82
Causes of Anxiety
 Poorly controlled pain
 Altered physiologic states
 Medications
 Withdrawal from alcohol/medications
 Medical conditions
 Physiological/emotional/spiritual distress
83
Assessment of
Anxiety
 Physical symptoms
 Cognitive symptoms
 Pain
 Bowel/bladder
 Familiarity with environment
 Interview questions
 Explore psychological and emotional dimensions
84
Pharmacological
Treatment of Anxiety
 Antidepressants

Blocks serotonin reuptake
 Benzodiazepines

Acts on limbic-thalmic-hypothalmic area of the
CNS producing anxiolytic, sedative, hypnotic,
skeletal muscle relaxation
 Neuroleptics

Blocks dopamine reuptake
85
Non-pharmacological
Treatment of Anxiety
 Coping skills
 Reassurance and support
 Manage stress and decrease stimulation
 Symptom management
 Complementary therapies
 Counseling
86
Anxiety
Patient and Family Education
 Review causes
 Monitor for signs and symptoms
 Avoid stimulation
 Patient safety
 Discuss unresolved issues
87
Anxiety
References
1. Kazanowski M. Symptom management in palliative care. In: Matzo ML,
Sherman D W, eds. Palliative care nursing: Quality Care to the End of
Life. New York, NY: Springer, 2006: 319-344.
2. Pasacreta JV, Minarik PA, Nield-Anderson L. Anxiety and depression.
In: Ferrell B R, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed.
New York, NY: Oxford, 2006: 375-399.
3. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium
(ELNEC – Geriatric ). Washington, DC: Association of Colleges of
Nursing, 2007.
4. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative
care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of
Palliative Medicine. New York, NY: Oxford, 2003.
5. Berry PH, ed. Core Curriculum for the Hospice and Palliative Nurse
2nd ed. Dubuque, IA:Kendal/Hunt; 2005.
88
Delirium/Agitation
 Delirium – a global, potentially reversible
change in cognition and consciousness that is
relatively acute in onset

Common in patient near death (approx 88%)
 Agitation – excessive restlessness accompanied
by increased mental and physical activity
89
Delirium/Agitation
Prevalence
 Almost half of patients experience
delirium/agitation in last 48 hours
 Experienced by 77-85% of terminally ill cancer
patients
90
Causes of
Delirium/Agitation
 Infection
 Malignancies – tumor burden and secretions
 Renal or hepatic failure
 Metabolic abnormalities (low/hi Na, low K, hi Ca,





low/hi glucose, hypothyroid, renal/liver failure)
Hypoxemia
Sensory deprivation
Medications
Fecal impaction / urinary retention
Vitamin deficiencies
91
Assessment of
Delirium/Agitation
 Distinguish from other related symptoms
 Physical assessment
 History
 Spiritual distress
 Consider medical etiologies
92
Assessment of
Delirium/Agitation
Established tools
 Mini-Mental Status Examination (MMSE)
www.chcr.brown.edu/MMSE.pdf
 Memorial Delirium Assessment Scale (MDAS)
www.painconsortium.gov
 Delirium Rating Scale (DRS)
93
Assessment of
Delirium/Agitation
Established tools


Confusion Assessment Method (CAM)
www.hartfordign.org/publications/trythis/issue13.pdf
Neecham Confusion Scale (NCS)
www.unc.edu/courses/2005fall/nurs/213/001/neuropsychiatric
/neecham.html
94
Treatment of
Delirium/Agitation
 Correct underlying cause
 Consider symptomatic and supportive therapies
 At end of life, causes may not be reversible and
medications are indicated
95
Treatment of
Delirium/Agitation
Pharmacological interventions
 Neuroleptics

Blocks dopamine uptake; metabolized by the liver

Haloperidol (Haldol)
 Severe agiation
96
Treatment of
Delirium/Agitation
 Benzodiapines

Midazolam (Versed)
 Anxiolytics

Lorazepam (Ativan)
 Atypical Antidepressants – blocks dopamine
uptake selectively, but with less anticholingeric
effects

Risperidone
97
Non-pharmacological
Treatment of Delirium/Agitation
 Encourage presence of family
 Avoid excessive stimulation
 Reorient if indicated
 Familiar people and items
 Acknowledge visions
 Complementary therapies
98
Delirium/Agitation
Patient and Family Education
 Reassure patient and family
 Review symbolic language
 Review medications
 Sensory stimulation if indicated
 Instruct how to reorient
99
Delirium/Agitation
References
1.
2.
3.
4.
5.
6.
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.
100
Delirium/Agitation
Additional References
Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium
(ELNEC). Washington, DC: Association of Colleges of Nursing, 2009.
101
Depression
 Intense and often prolonged feelings of sadness,
hopelessness and despair
102
Depression
Prevalence
 25–77% terminally ill population
 22% of nursing home residents
 Often not recognized at end-of-life
103
Causes of Depression
 Medical conditions

Pain
 Treatment-related factors

Medications
 Psychological factors

Financial issues
104
Assessment of Depression
 Symptoms associated with medically ill




Enduring sad mood
Hopelessness
Fatigue
Diminished ability to make decisions
105
Assessment of Depression
 Risk factors




Medical co morbidity
Male > age 45
Stressful life events
Uncontrolled pain
106
Assessment of Depression
 Screening tools
 Mini-Mental Status Examination (MMSE)
 Beck Depression Inventory
 Geriatric Depression Scale
 Cultural influences
 Cultures may judge severity of depressive symptoms
differently
 Symptoms should not be dismissed because it is seen as a
characteristic of a particular culture


Chinese may use the term ‘imbalance’
Latino/Mediterrean may say ‘nerves’, ‘headaches’
107
Assessment of Depression
 Ask questions regarding



Mood
Behavior
Cognition
 Suicide assessment risk factors



Psychiatric disorder
Depression
Alcohol abuse
108
Treatment of Depression
 Optimal
 Pharmacological
 Non-pharmacological
 Interpersonal interventions
 Complementary
109
Pharmacological
Treatment of Depression
 Antidepressants


Blocks serotonin, (5HT) reuptake
SSRIs
 Considered as first line treatment
 For debilitated patients start at 1/3 dose
110
Pharmacological
Treatment of Depression
 Tricyclics



Blocks reuptake of various neurotransmitters at the
neuronal membrane
Improves sleep
Effective on 70% of patients treated
111
Pharmacological
Treatment of Depression
 Stimulants




Stimulates CNS and respiratory centers
Increases appetite and energy levels
Improves mood
Reduces sedation
112
Pharmacological
Treatment of Depression
 Other


Steroids
 Improves appetite
 Elevates mood
Non-benzodiazepines
 Useful in patients wit mixed anxiety/depressive
symptoms
113
Non-pharmacological
Treatment of Depression
 Counseling

Reinforce goals and interventions of care plan established by
interdisciplinary team
 Behavioral interventions


Provide directed / structured activities
Focus on goal attainment / prepare for future adaptive coping
114
Non-pharmacological
Treatment of Depression
 Cognitive interventions

Assist patient to reframe negative thoughts into positive
thoughts
 Interpersonal interventions


Build rapport with frequent, short visits
Mobilize family and social support systems
 Complementary therapies


Guided imagery
Art and music therapy
115
Non-pharmacological
Treatment of Depression
Specific Behavioral Strategies
 Negotiate structured schedule
 Realistic goals
 Positively reinforce
116
Depression
Patient and Family Education
 Review signs and symptoms
 Instruct on prevalence
 Review medications
 Review non-pharmacological interventions
 Provide private opportunity to talk
117
Depression
References
1.
2.
3.
4.
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.
118
Dyspnea
 Difficult or distressing shortness of breath
 Prevalence



Experienced in 50-70% of dying patients
Marker for terminal phase of life
Varies according to disease
 Higher in pulmonary patients
119
Causes of Dyspnea
 Related to primary or secondary diagnosis
 Related to treatment
 Pulmonary congestion
 Bronchoconstriction
 Anemia
 Hyperventilation
120
Assessment of Dyspnea
 Acknowledge the subjective report
 Not tachypnea
 Functional status
 Past history of related factors
 Diagnostic tests
121
Pharmacological
Treatment of Dyspnea
 Opioids


Reduce respiratory drive
Reduce oxygenation consumption
 Bemzodiazepines

Lorazepam
 Conflicting reports of efficacy for dyspnea –
should not be first line treatment
122
Pharmacological
Treatment of Dyspnea
 Diuretics

Used in patients with signs of fluid volume excess
 Bronchodilators
 Relax smooth muscles of respiratory tract
 Corticosteroids
 Appears to decrease inflammation
123
Pharmacological
Treatment of Dyspnea
 Antibiotics
 Useful if dyspnea secondary to infection
 Anticoagulants
 Prevents clot formation which may prevent future
incidence of pulmonary emboli
 Oxygen therapy
124
Non-pharmacological
Treatment of Dyspnea
 Fans, circulate air
 Positioning
 Conserve energy
 Rest
 Pursed lip breathing
 Prayer
 Complementary therapies
125
Dyspnea
Patient and Family Education
 Instruct breathing techniques
 Minimize aggravation
 Prevent panic
 Conserve energy
 Use of fans
 Don’t leave patient in distress alone
126
Noisy Respirations
 Noisy, moist breathing
 Median time – 23 hrs before death
 May be very disturbing to family members
127
Noisy Respirations
Causes
 Turbulent air passes over pooled secretions or
through relaxed muscles of oropharynx
128
Assessment of
Noisy Respirations
 Onset
 Contributing causes
 Pulmonary embolism
 Fluid overload or CHF
129
Pharmacological
Treatment of Noisy Respirations
 Treat underlying disorder
 Anticholinergics
 Hyoscine hydrobromide (Scopolamine®)
 Atropine
130
Non-pharmacological
Treatment of Noisy Respirations
 Repositioning
131
Noisy Respirations
Patient and Family Education
 More distressing to family than patient – reassure
 Explain process
 Teach as a sign of impending death
132
Dyspnea and Noisy Respirations
References
1.
2.
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 - Geriatric). Washington, DC:
Association of Colleges of Nursing, 2007.
133
Fatigue
 A complex phenomenon, extreme tiredness, lack of
energy, weariness
 Subjective perception
134
Fatigue
Prevalence
 Reported in



78-96% of cancer patients
51% of patients in international palliative care centers
50% of school-aged children receiving chemotherapy
 Affects activities of daily living
135
Causes of Fatigue
 Accumulation Theory
 Depletion Theory
 Central nervous system control
 Predisposing factors
136
Assessment of Fatigue
 Subjective Data
Location, severity, intensity and duration
 Aggravating and alleviating factors
 Objective
 Strength
 Vital signs
 Lab values
 Oxygenation status,
 CBC and Diff, Hgb

137
Pharmacological
Treatment of Fatigue
 Steroids
 Methylphenidate (Ritalin®)


Stimulates CNS and respiratory center
Increases appetite and energy levels, improves
mood, reduces sedation
138
Pharmacological
Treatment of Fatigue
Antidepressants


Reduces depressive symptoms associated with fatigue
Can improve sleep
SSRIs

Inhibits serotonin reuptake
Tricyclics

Monitor blood levels
Epoetin (Epogen®)

Increases hemoglobin with effects on energy
139
Non-pharmacological
Treatment of Fatigue
 Active exercise
 Attention-restoring interventions
 Preparatory education
 Psychosocial support
140
Fatigue
Patient and Family Education
 Explain nature of fatigue
 Plan, schedule and prioritize activities
 Rest
 Instruct on nutrition
 Control contributing symptoms
141
Fatigue
References
1.
2.
3.
4.
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 - Geriatric). Washington, DC:
Association of Colleges of Nursing, 2007.
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.
142
Pressure Ulcers

A Pressure ulcer is a localized injury to the
skin and/or underlying tissue usually over a
bony prominence as a s result of pressure, or
pressure in combination with shear and/or
friction.
143
Pressure Ulcers
Prevalence
 Reported in up to 17% of hospitalized patients
 70% of pressure sores in hospitalized occur within 2
weeks
 Incidence higher with conditions that impair wound
healing
144
Causes of Pressure Ulcers
 Intrinsic factors
 Extrinsic factors
145
Causes of Pressure Ulcers
 Impaired vascular and lymphatic system of skin
and deep tissue
 Impaired nutritional status and weight loss
increases risk
 Compressed tissue may continue to suffer
ischemic damage even after relief
146
Assessment of Pressure Ulcers
 Clinical
 Physical
 Lab values
 National Pressure Ulcer Advisory Panel Staging
Criteria

www.npuap.org
147
Assessment for Pressure Ulcers
 Pressure Ulcer Staging Criteria





Stage l
Stage ll
Stage lll
Stage lV
Unstageable
148
Assessment for Pressure Ulcers
 Wound Status
 Pressure Ulcer Scale for Healing (PUSH)
 Pressure Sore Status Tool (PSST)
149
Assessment for Pressure Ulcers
Wound Characteristics
 Edges / margins

Assess through visual inspection and palpation
 Undermining and tunneling
 Loss of tissue underneath an intact skin surface
150
Assessment for Pressure Ulcers
Wound Characteristics
 Necrotic tissue

Indicate the degree of severity or involvement
 Exudate
 Assists in assessment of potential infection, evaluation
of therapy, and monitoring of healing
 Healthy wound will have some degree of moisture as
part of healing
151
Assessment for Pressure Ulcers
Wound Characteristics
 Surrounding tissue conditions


Assess surrounding tissue for color, induration, edema
May be first warning of potential further damage
 Induration
 Abnormal firmness of tissues with margins is a sign of
impending damage to tissue
 Assess tissues within 4 cm of wound
152
Assessment for Pressure Ulcers
Wound Characteristics
 Edema

Will impede healing of pressure ulcer
 Granulation and Epithelialization
 Markers of wound health
153
Treatment of Pressure Ulcers
 Nutritional support

Maintain nutritional status
154
Treatment of Pressure Ulcers
 Management of tissue load


Pressure reduction surfaces
Alternating airflow mattresses
155
Treatment of Pressure Ulcers
 Debridement
 Necrotic tissue impedes healing and provides bacterial
growth medium
 Important for decreasing odor
 Bacterial colonization and infection
 Most open pressure ulcers often colonized by bacteria
156
Treatment of Pressure Ulcers
 Wound cleansing
 Decreases potential for wound infection
 Dressings
 Goal of dressing is to provide an environment that keeps
the wound bed tissue moist and the surrounding intact
skin dry
157
Patient and Family Education
for Pressure Ulcers
 Teach prevention and early signs
 Repositioning
 Protecting bony prominences
 Keep heels off bed surface
 Skin care
 Nutrition
 Mobility
158
Patient and Family Education for
Pressure Ulcers
 Nutrition
 Supplements
 Protein
 Fluids
 Dietitian
 Mobility
 Review importance of pressure ulcer prevention by
maximizing activity and/or mobility
159
Pressure Ulcers
References
1.
2.
3.
Bates-Jensen BM. Skin disorders: pressure ulcersassessment 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.
160
Pressure Ulcers
References
4..
Agency for Health Care Policy and Research (AHCPR). Treatment
of pressure ulcers. Clinical practice guideline number 15.
Rockville, MD: Public Health Services, U.S. Department of Health
and Human Services, 1994
5. Wrede-Seaman L. Symptom management algorithms: A handbook
for palliative care. Yakima, WA: Intellicard, 1999
6. National Pressure Ulcer Advisory Panel Staging Criteria, 2007.
Available at www.npuap.org/pr2.htm. Accessed October 21, 2009
161