Transcript available now - Grand Strand Advanced Practice Nurse Association

GSAPNA
Lecture at the Beach
September 19, 2015
M. Jane Griffith, RN, MSN, GNP-BC, ACHPN
(Caroline Duquette, DNP, APRN, CHPN, contributing author)
• Define common palliative care symptoms in a variety
of disease conditions/illnesses.
• Define components of symptom assessment.
• Develop symptom management plan of care
including pharmacologic and non-pharmacologic
interventions.
AD is a 65 year old white male presenting to
the acute care facility with SOB, generalized
weakness and rapid atrial fibrillation.
Treated with TEE-guided cardioversion to normal
sinus rhythm.
Started on amiodarone 200mg 3 times a day.
“I just feel tired”.
• Coronary Artery Disease: s/p CABG, s/p PTCA
• Ischemic Cardiomyopathy; EF 20%, congestive heart failure,
mitral regurgitation
• End-stage renal disease with hemodialysis, left upper
extremity fistula
• Hypertension
• Hyperlipidemia
• Lupus anticoagulant
• Antiphospholipid antibody syndrome with DVT
• Gastroparesis, constipation
• Renal osteodystrophy
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Obstructive sleep apnea
Tobacco dependence
Weight loss
Hypothyroidism
Depression
Sacral pressure ulcer
Cholecystitis
Pneumonia
Pleural effusions
DJD of lumbar spine, chronic pain, opioid dependence
Peripheral neuropathy
Aspirin 81mg daily
Amiodarone 200mg 3
times a day
• Levothyroxine 50mcg
daily
• Promethazine 25mg
as needed
• Atorvastatin 40mg
daily
• Senna as needed
Carvedilol 12.5mg twice a
day
• Megestrol
400mg/10ml 10ml
daily
Warfarin as directed
• Lidocaine transdermal
daily
Dalivit 800mg daily
• Nicotine patch
• Neprhrocap 1 capsule
daily
Venlafaxine ER 75mg
daily
• Omeprazole 20mg
twice daily
• Sensipar 90mg daily
Morphine ER 30mg BID
• Oxycodone 5mg prn
• Calcium acetate daily
Pertinent Positives:
• Chronic low back pain
• Insomnia/depression/anxiety
• Muscular jerks/myoclonus
• Confusion
• Nausea/Constipation/Anorexia/Abdominal Pain
• Dyspnea/Shortness of Breath/cough/pleuritic chest pain
• Fatigue/Activity Intolerance
• Weakness/Falls
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Pain is often not assessed
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Atypical presentation: confusion or agitation.
May be described as aching or discomfort
• Incidence: 25-45% elders living in community; 45-85% elders
in long term care (American Geriatrics Society 2009).
• Fear of addiction, side effects (e.g. constipation), or loss of
control.
• Etiology: osteoarthritis, cancer, diabetic neuropathy, herpes
zoster, and osteoporosis.
• “Start low and go slow” (American Geriatrics Society, 2009).
• Achieving good pain management: complicated by co-morbid
disease and increased risk of adverse drug reaction
• Pain is whatever the patient says it is whenever
they experience it (McCaffery).
• Pain is an unpleasant sensory and emotional
experience, associated with actual or potential
tissue damage (IASP).
Nociceptive pain syndromes : stimulation of the primary
afferent nociceptive neurons; indicates tissue damage.
Somatic pain – Cutaneous, bone, musculoskeletal tissues.
Well localized.
• Examples: Bone pain, postsurgical incisional pain, pain
from inflammation, obstruction or stretching of organs .
Visceral pain – Activation of pain or autoimmune fibers,
infiltration, compression, distention, or stretching of thoracic
or abdominal viscera. Poorly localized.
• Example: cirrhotic pain.
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Neuropathic pain syndromes : Dysfunction of the nervous
system. Burning, shooting, electrical, or vise like pain.
Examples: diabetic peripheral neuropathy, post herpetic
neuralgia, post- surgical pain syndromes (e.g. mastectomy,
thoracotomy, etc.) and sciatic pain.
• Acute: sudden, recent onset pain.
– Examples: abdominal pain from cholecystitis, kidney
stone, back pain due to a very recent injury.
• Chronic: present longer than 3 months.
– Examples: rib/chest pain from lung cancer, bone pain from
cancer, back pain and shoulder pain from past injuries
• Acute on Chronic pain: acute pain process overlayed on a
chronic pain
– Examples: chronic pain due to bone mets, develops
pathologic fracture; chronic arthritis pain, develops acute
pain from herpes zoster.
• Self-report is the gold standard and is best way to elicit
pain report.
• Family can corroborate pain and medication use.
• For patients who are unable to give self-report
• Assume pain is present if you suspect there is reason for
pain.
• Observe behavioral characteristics.
• Discuss with proxy and seek input for professional care
givers.
• Use appropriate scales consistently by each team member.
• Cultural consideration
• Location(s): indicate site(s) of pain.
• Intensity: numerical scale 0-10 scale, color scale light colors
to red, descriptive scale “no pain” to “worst pain imaginable.”
• Quality: Description: dull, sharp, achy, pounding, pressure,
electrical, shooting, pulsating.
• Pattern: Intermittent pain versus constant or both.
• Aggravating/alleviating factors - What makes the pain better?
What makes it worse? Provides information regarding the
etiology of the pain, as well as potential treatments. Example:
if massage makes the pain better, it is probably of
musculoskeletal origin, rather than neuropathic.
• Emotional state/suffering/ total pain: Evaluating the emotion
behind the pain. Sign of the reality of the disease? Is the
patient depressed and/or anxious?
• Meaning of the pain: can profoundly affect pain perception at
the end of life: ie, punishment. Reframing may help, resulting
in improved comfort.
• Functional assessment: ability to perform self-care: getting up
and down to toilet; dress; groom and bathe self.
• Psychosocial: effect on social, emotional, spiritual and
psychological domains.
Observation/Inspection :
• Ability to ambulate into exam area, ability to sit and stand
• Non-verbal cues: withdrawal, fatigue, grimaces, moans, and irritability.
• Inspect and examine sites of pain: trauma, skin breakdown, changes in bony
structures, etc.
Palpation: Palpate for tenderness. Range of motion. Is there allodynia? Does the pain
follow a dermatone?
Auscultation
• Abnormal breath sounds : crackles, rhonchi, decreased breath sounds
(pneumonia)
• Bowel sounds: hyperactive bowel sounds (bowel obstruction).
Percussion: fluid accumulation or gas (obstruction, ascites).
Neurological exam : evaluate sensory and/or motor loss, as well as changes in
reflexes, coordination.
• How will the course of therapy change by the findings of this test?
Is this the best use of the patient’s resources ?
• Labs- hypercalcemia as a cause of delirium.
• Radiology - X-ray or CT scan may differentiate between pain due to
ascites (potentially relieved with a paracentesis) or pain due to
obstruction (relieved by venting gastrostomy tube, or avoiding
enteral intake of fluid and food).
• Advanced studies- bone scan, PET scan, EMG (may be useful if
suspecting nerve entrapment or systemic neurological disease),
MRI, swallowing studies, testosterone and progesterone levels
(chronic opioid use).
• The Three Step Approach:
– Give The Right Drug
– Give The Right Dose
– Give At Right Time
– This approach is 80-90% effective and the most
inexpensive.
• Acetaminophen
– Mechanism of Action – Analgesic, Antipyretic
– Adverse effects- Possible liver dysfunction in routine
doses > 2000 mg/day in patients with normal liver; >
3000 mg/day acutely.
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
Examples: Aspirin, ibuprofen, naproxen, selective
cyclooxygenase-2 inhibitors (celecoxib)
– Blocks cyclooxygenase which inhibit prostaglandins;
periostium of the bone and in the uterus.
– Anti-inflammatory, analgesic and antipyretic.
• Ceiling effect. Increasing the dose beyond a certain point will
not increase analgesia; will only increase the risk of adverse
effects.
• Gastric toxicity through local and systemic effects.
• Platelet aggregation is inhibited; risk of bleeding.
• Renal dysfunction, especially in dehydration.
• Risks of adverse effect increase with concurrent use of NSAIDs
and corticosteroids.
• NSAIDs now linked to increase in deaths due to cardiac and
cerebrovascular effects.
• Codeine; morphine; hydrocodone;
hydromorphone; fentanyl; methadone;
oxycodone; oxymorphone.
– Mechanism of action: opioid agonist. Block the
release of neurotransmitters that are involved in the
processing of pain.
– Adverse effects of opioids: Respiratory depression,
sedation, constipation, nausea, sweating, pruritus,
urinary retention, hormonal changes.
– Opioid rotation/equianalgesic tables.
Medication
PO
IV
Morphine
30 mg
10 mg
Oxycodone
20 mg
X
Hydromorphone
7.5 mg
1.5 mg
Oral 24-hour morphine equivalent
(mg/day)
Fentanyl transdermal
(mcg/hr)
60 -134
25
135-224
50
225-314
75
315-404
100
405-494
125
495-584
150
585-674
175
675-764
200
765-854
225
855-944
250
945-1034
275
1035-1124
300
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History of sleep apnea or sleep disorder diagnosis
Morbid obesity
Snoring
Patients over the age of 65
Patients who are opioid naïve
Postoperative patients, especially if surgery included the upper abdomen
or thorax
Lengthy anesthesia requirements during surgery
Patients on benzodiazepines or other sedating drugs
Patients who are active smokers
Pre-existing pulmonary or cardiac diseases or major organ failure
Patients requiring significantly high doses of opiates
Methadone:
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appears to act as an antagonist in the N-methyl-D-aspartate (NMDA)
receptor, in addition to opioid receptor binding
• useful in neuropathic pain syndromes, inexpensive.
• Long half life (8-59 hours): can be an advantage but also a disadvantage ,
ie difficulty to titrate.
• QTc effects - increases the corrected QT (QTc)
• numerous drug interactions: increased methadone levels in varying
degrees via P450 3A4 inhibition.
• Methadone should be utilized by clinicians with adequate knowledge
and experience due to increased potential risks.
Tramadol: Binds to mu opioid receptors and weakly inhibits
norepinephrine/serotonin reuptake producing analgesia.
Tapentadol: Binds to mu opioid receptors and inhibits norepinephrine
reuptake.
Tricyclic Antidepressants:
nortriptyline, desipramine, imipramine, amitriptyline
• Action - appears to be related to inhibition of norepinephrine
and serotonin reuptake (neuropathic pain).
• Adverse effects: Dry mouth, constipation, dizziness, blurred
vision, drowsiness; QT prolongation
• Relative contraindications: cardiac arrhythmias, conduction
abnormalities, narrow-angle glaucoma, and clinically
significant prostatic hyperplasia.
Atypical antidepressants:
Venlafaxine and duloxetine for chronic neuropathic pain;
Milnacipran for fibromylagia.
• Action - Blocks serotonin and norepinephrine reuptake.
• Adverse effects – Fatigue, constipation, dry mouth, dizziness,
risk of suicide
Anticonvulsants: Gabapentin and pregabalin.
Action –blocks calcium channels, modulates excitatory
neurotransmitter release.
• Pregabalin has 90% bioavailability regardless of dose
• Gabapentin bioavailability diminishes to 35% when
administering higher doses.
– Adverse effects – sedation, confusion, edema (rare)
– The analgesic doses of gabapentin ranges from 900-3600
mg/day. Older adults 100 mg a day and see how they
tolerate it.
Anticonvulsants:
•Carbamazepine: Older anticonvulsant for neuropathic pain.
– Action - blocks sodium channels blocking conduction of
pain through sensory neurons
– Significant adverse effects: liver dysfunction and
aplastic anemia; monitor blood chemistries (specifically
liver function tests) and hematology profiles
• Newer anticonvulsant agents: lamotrigine, levetiracetam ,
oxcarbazepine. Unique adverse effect profiles to be
considered when prescribing.
• Cannabinoids: THC (tetrahydrocannabinal), an active derivative of
marijuana, ex: Dronabinol.
• Corticosteroids -neuropathic pain, bone pain, headache secondary to
raised intracranial pressure, pain secondary to organ capsule distension,
pain due to obstruction of a hollow viscus, and pain secondary to
lymphedema.
– Glucocorticoids reduce pain by inhibiting prostaglandin synthesis,
which leads to inflammation.
– Dexamethasone commonly used- less mineralocorticoid effects and
long half-life.
• Lidoderm: local anesthetic affect
• Capsacian: desensitizes cutaneous nociceptive neurons.
• Muscle relaxers: cyclobenzaprine, tizanadine, baclofen, carisoprodol
Interventions/Procedures: Blocks, Epidural, Intrathecal
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IDT:
– Social work: support of pain issues and assistance with coverage of
medications/treatments
– Chaplaincy – spiritual distress of pain and assessing suffering
– PT/OT: to improve function, obtain needed equipment and safety.
– Psychological support/counseling: improving coping strategies.
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Cognitive Behavior Therapy (CBT)
Relaxation
Guided imagery
Distraction
Cognitive reframing
Support groups
• Rehabilitation therapies – physical medicine and rehab
evaluation; occupational therapy/physical therapy
• Physical measures: producing relaxation and relieving pain:
heat/cold; Massage
• Meditation practices
• Pastoral counseling/prayer
• Complementary therapies
– Little data regarding the efficacy of complementary
therapies (e.g., herbals, magnets, others) in relieving pain.
Some culturally based.
– Encourage patients to report the use of any
complementary therapies to avoid interactions with other
pharmacologic agents
• Cutaneous electrostimulation
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Distressing shortness of breath; frequently called
breathlessness. Frightening experience.
Occurrence: 50% of the general outpatient cancer
population and as many as 70% of advanced cancer
patients
Respiratory rate and oxygenation status do not always
correlate with the symptom of breathlessness.
The amount of dyspnea present may not be related to
the extent of the disease.
Often overlooked and not assessed
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Pulmonary: Tumor infiltration; aspiration; pleural &/or cardiac effusion;
SVC syndrome; pneumonia; PE; COPD; thick secretions due to infection
or dehydration; bronchospasm.
Cardiac: CHF; pulmonary edema; pulmonary hypertension; severe
anemia; CAD; fluid overload.
Neurological: CVD; ALS; MS; muscular dystrophy; myasthenia gravis;
dementia; trauma.
End-stage renal disease
Metastatic cancer
Metabolic disorder e.g. alkalosis
Obesity
Anxiety
Spiritual issues e.g. feelings of guilt and issues of trust
Subjective report of the patient is the only reliable indicator.
• Dyspnea Rating Scale: 0 = no breathlessness; 10 = the worst
0
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10
Physical Exam:
• Observation – Presentation/Appearance: Wheelchair, with
oxygen, ability to talk in complete sentences, pain with
inspiration, use of accessory muscles.
• Auscultation - Breath sounds for respiratory rate and depth,
crackles, wheezes, rhonchi.
• Percussion – Dullness in lungs, evidence of mass or fluid.
• Palpation - Elevated jugular pressure, bilateral crackles, pain
with respiratory movement, diaphragmatic excursion.
Consider goals of care, the benefits and burdens of
the test itself, and whether the results or outcome
would change the care plan or overall care.
• Laboratory studies: CBC, H&H, CMP,
electrolytes, BNP, ABG
• Oxygen saturation
• PFTs
• CXR: Infection, effusion, atelectasis
• CT/MRI: Lung disease, cardiac issues, rule out
pulmonary embolism
Oxygen therapy: Consider trial of oxygen therapy.
Saturation < 88% unless on hospice. May have limited
benefit if not hypoxemic.
Severe COPD & chronic hypoxia: use of long-term O2,
>15 hours/day, improves quality of life and increases
survival (goal SaO2 >90%).
• High Flow Oxygen
• BiPAP (Bi-level positive air pressure)
• CPAP (continuous positive airway pressure)
• Ventilator as a time limited trial: goals of care.
• Consider sleep study
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Opioids: Start low and go slow
Steroids: prednisone, dexamethasone
Bronchodilators/anticholinergics: Duo-Nebs
Role of benzodiazepines controversial. Should not be
considered as a first line treatment.
Diuretics: to reduce fluid overload
Pressors: dopamine, dobutamine, and milrinone
Epoprostenol: primary pulmonary hypertension and
hypertension associated with scleroderma
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Antibiotics
Influenza/pneumonia vaccines
Blood transfusions may be of benefit if goal of transfusion
outweighs burden. Erythropoietin.
Thoracentesis/paracentesis/PleurX catheter
Stent tube placement to open an occluded airway
Endobronchial laser therapy
Radiation therapy to shrink tumor
Hemodialysis or CVVH
Left Ventricular Access Device (LVAD) as bridge to
transplant or destination therapy.
• Counseling: cognitive-behavioral therapy, interpersonal and
complementary strategies for both patient and family.
• Pursed lip breathing: slows respiratory rate and decreases
small airway collapse.
• Energy conservation techniques: save energy, reduce fatigue,
allow the patient to maintain control of lifestyle changes.
• Fans, open windows and air conditioners: circulate air.
Compressed air via nasal cannula may be useful
• Elevation of the head of the bed, high fowlers position:
reduce choking sensations and promotes expansion of the
lungs.
• Placing the patient’s arms on pillows: promote air exchange.
• Education of patient/family: reduces anxiety.
• Music: relaxation and distraction, reduces dyspnea.
• Calm room environment.
• Cold air directed against the cheek may reduce the
perception of breathlessness
• Prayer: promote comfort and relaxation.
• Acupuncture may help although the studies
inconconclusive.
• A subjective perception and/or experience of extreme
tiredness/exhaustion related to disease, emotional
state and/or treatment.
• Multidimensional
• Not easily relieved by rest
• Profound impact on quality of life including physical,
psychological, social and spiritual well-being.
• Cultural influences
• Reduced capacity to carry out expected or required
daily activities.
Cancer related fatigue is reported in as many as 60% to 90% of patients.
• Anemia
• Cytokine production: anorexia-cachexia syndrome as well as fatigue
• Metabolic/Endocrine: hypothyroidism, DM (Hyper/Hypoglycemia) or
electrolyte imbalances (low Na, low K, low Mg, hypercalcemia)
• Malnutrition
• Infection
• Fever
• Pain
• Organ failure (heart/lungs/kidneys/liver)
• Adverse environment (heat or cold extremes)
• CNS injury: disruption of the electrical pathway within the nervous system
• Hypoxia
• Psychological: Depression.
• Deconditioning: Immobility resulting from disease process,
medical intervention, or psychological response: decrease
ADLs.
• Treatment related: Inadequate rest, unrelieved symptoms,
medications, psychological and spiritual distress.
• Treatment effects: drug therapy, radiation, and surgery.
• Med effect: anti-emetics, hypnotics, anxiolytics,
antihistamines, analgesics (trial of 25% dose reduction)
• Unrelieved symptoms: diarrhea, constipation, vomiting and
pain.
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Subjective
Impact on ADLs and IADLs
Medication review
Sleep pattern
Associated symptoms, ie
depression/anxiety/ability to concentrate
• Fatigue Rating Scale: 0 = no fatigue; 10= no
energy at all:
0 1 2 3 4 5 6 7 8 9 10
• Observation
• Vital signs
• Physical Assessment including cardiac,
respiratory, GI and neurological exam
• Diagnostics:
– Labs: CBC, H&H, electrolytes,
albumin/prealbumin, LFTs, TSH
– Pulse oximetry
– Electrocardiogram
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Pharmacologic
Stimulants: methylphenidate, modafinil
Steroids: dexamethasone
Antidepressants
Interventions
Based on Goals of Care
Consider transfusions if indicated
Consider feeding tube (ie, ALS, H/N cancer)
• Energy conservation: frequent rest periods and use of energy
conservation techniques and tools.
• 1-2 priority activities a day; family assistance
• Home health devices: BSC, wheelchair, and/or walker.
• Personal care to assist with ADLs and IADLs.
• Physical and occupational therapy
• Conditioning from exercise program may decrease the
severity of fatigue.
• Nausea: subjective sensation
• Vomiting: neuromuscular reflex, stimulation of
vomiting center.
• Anticipatory, acute, delayed
• Common in advanced disease (nausea up to
70% of terminally ill, vomiting up to 30%),
particularly in cancer, renal and hepatic
disease.
GI: Stimulation of vagal and sympathetic pathways
(visceral response)
• gastric irritation & stasis
• constipation
• intestinal obstruction
• pancreatitis
• ascites
• liver failure
• intractable cough
• effects of radiation.
Metabolic causes: Stimulation of chemoreceptor trigger zone
• Hypercalcemia
• Uremia
• Infection
• Drugs
CNS causes:
• Raised ICP
• Pain
• Infection
Vestibular disturbances:
• Motion sickness
• Toxic action of certain drugs (ASA, opiates)
• Frequency, duration, triggers, contributing
factors (constipation, uncontrolled pain,
infection, anxiety), relationship to food intake
• Medication review
• Volume and content of emesis, presence of
blood
• Past history of N/V and effectiveness of
treatment
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Physical Exam
Vital signs, weight.
Auscultation of bowel sounds
Possible rectal exam (impaction)
Ear exam: infection
Oral exam: thrush
Diagnostics
Renal and liver function tests
Electrolytes, calcium, serum drug levels
Radiologic: Abdominal radiograph &/or head CT or MRI
Directed by presumed cause
• Anticholinergics: hyoscyamine, scopolamine: motion
sickness, intractable N&V, SBO
• Antihistamines: cyclizine, meclizine: intestinal
obstruction, raised ICP, peritoneal irritation, vestibular
causes
• Steroids: dexamethasone- cytotoxic induced N&V
• Prokinetic agents: metaclopramide-gastric stasis or ileus
• Benzodiazepines: lorazepam- anxiety related N&V
• 5 HT3 receptor antagonists: ondansetron-post op N&V
and chemo related emesis (QTc prolongation)
• Octeotride: bowel obstruction: inhibits peristalsis and
intestinal secretions
• Neurokinin-1 receptor antagonists: aprepitant- inhibit post
op and post chemo N&V
• Butyrophenones: haloperidol and droperidol-opioid
induced nausea, chemical and mechanical nausea
• Phenothiazines: prochlorperazine, dopamine antagonist.
• Cannabinoids: dronabinol, medical marijuana
 Hypercalcemia: bisphosphonates, diuretics, calcitonin, and
hydration
 Opioid induced N&V
• Opioid naïve: schedule anti-emetic for 1st 72 hrs
• Alter dose, schedule or consider opioid rotation
•NG tube or PEG for venting
•Hydration
•TPN: limited role in pall care; benefit/burden
•Surgical options (ie SBO)
Based on Goals of Care
• Anticipatory nausea: distraction/relaxation techniques,
acupuncture, acupressure, music therapy and hypnosis
• Dietary
– Small, frequent meals; keep prepared snacks nearby
– Use of family/friends to cook; avoid smells and stress of
food preparation.
– Serve meals at room temperature with clear fluids; avoid
strong smells.
– Restrict fluids with meals.
– Bland, cold or room-temperature food.
– Eat slowly, avoiding large, high bulk meals.
– Avoid sweet, salty, fatty, and spicy foods.
– Ginger, chamomile tea
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• Positioning
– Positioned to avoid aspiration.
– Do not lie flat for 2 h after eating.
• Personal Care
– Oral care after each episode of emesis
– Wear loose-fitting clothes.
• Topical
– Application of a cool damp cloth to the forehead, neck, and wrists
– Use of wrist pressure bands (Sea Bands®) to minimize nausea and
vomiting.
– Acupuncture
• Environment
– Decrease noxious stimuli like odors and pain.
– Have fresh air with a fan or open window.
– Limit sounds, sights, and smells that precipitate nausea and vomiting.
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Definition: less than 3 stools per week or altered
characteristics such as hard, painful, stools
accompanied by abdominal distention, nausea,
vomiting, loss of appetite, and other symptoms.
• 10% of the general population,
• May be as high as 50 to 78% in the ill adult.
• Intestinal obstruction, partial or complete, tumor in or compressing
bowel. Mesothelioma, ovarian, and gastrointestinal cancers.
• Electrolyte imbalances: hypercalcemia and hypokalemia
• Spinal cord injuries (i.e. compression or transection) slow
transmission of food via the intestines.
• Endocrine conditions: diabetes, hypothyroidism
• Other: colitis, diverticulitis, or chronic neurological states
• Surgical adhesions: scarring.
• Dehydration: stool consistency; dry, hard stools.
• Inactivity, weakness, loss of privacy: effect daily bowel habits.
• Pain
• Depression
• Decreased abdominal muscle tone
Medication profile review: many medications can contribute to
severe constipation, especially when patients are on
combination therapies.
• Vitamins and minerals – Calcium supplement, iron
• Chemotherapeutic agents - Taxanes, vinca alkaloids.
• Antidepressants – Tricyclics, SNRIs
• Pain and adjuvant pain medications – Opioids, NSAIDS,
Anticonvulsants
• Antiemetics - 5HT3 antagonists, phenothiazines
• Anti-diarrheal agents
• Cardiac medications - Diuretics, antihypertensives
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Stool: Frequency, consistency, volume, usual bowel pattern,
date of last BM
Associated symptoms: pain, bloating, flatulence, bleeding,
N&V
Recent oral intake and level of activity
Medications: prescription, OTC, dietary supplements
Past history of constipation and effective treatment
strategies (laxatives, suppositories, enemas)
Functional status: ability to toilet, environmental issues
related to toileting
Psychosocial or cognitive factors: depression, anxiety,
general mood disturbances
Physical Exam
• Inspection: bloating, distention
• Auscultation: bowel sounds (hyperactive, hypoactive or
absent)
• Palpation: assesses for distention, firmness and tenderness
• Percussion: fluid, mass
• Rectal assessment: hemorrhoids, ulceration or rectal fissure;
pain infection, fecal leakage and/or impaired rectal tone.
Caution in neutrapenic patient.
Diagnostics: consider goals of care
– Abdominal x-ray to rule out bowel obstruction
– Electrolytes BUN, calcium and potassium
– Thyroid function tests
Maintenance often requires a prophylactic stool softener and
stimulant. A minimum goal for a bowel movement is at least
every 72 hours, regardless of intake.
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Bulk forming –fiber medications
Osmotics – sorbitol, lactulose, polyethylene glycol 3350
Stimulants – senna
Surfactants – docusate
Opioid-Receptor Antagonist (methylnaltrexone, lubiprostone)
Lubricant-mineral oil
Suppositories, enemas
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Dietary and fluid interventions
Gentle activity
Massage
Dietary
OTC products and herbal medicines: mulberry,
flax, and rhubarb have laxative properties
• Mood disorder with psychological symptoms:
– Low mood, inability to think or make decisions
– Somatic symptoms: altered sleep, fatigue, slowed
movements, decreased energy
– Altered mood, affect, and personality
– Includes situational depression caused by a serious life
threatening illness (American Psychiatric Association,
2013)
• Symptoms last 2 weeks or longer and associated with
loss of interest or pleasure in nearly all activities
• Depression occurs in about 22% to 77% of the terminally ill
population
• Depression in palliative care is related to many diseases and
causes:
– Uncontrolled pain and/or other symptoms (i.e.
constipation, anorexia, and sleep disturbances) may
exacerbate depression
– Neurological
– Hyper or hypothyroidism
– Infectious diseases – HIV/AIDS
– Cancer – pancreatic, head and neck, and lung
– Cardiopulmonary disease
– Trauma – head injuries
• Antibacterial and antifungals
• Antihypertensive and cardiac medications
• Anticancer medications (interferon, bleomycin,
and vincristine are common culprits)
• Antiretroviral medications
• Anticonvulsants
• Benzodiazepines
• Steroids
• Hormonal therapies
• Current diagnosis and prognosis –
– Chronic deteriorating medical illness with perceived
poor health
– recent diagnosis of a life-threatening illness
– recent conflict or a loss of significant relationship.
• Current status of symptom management.
• Previous psychiatric history/treatment including
previous depression, family history with
depression, substance abuse, past suicide
attempts.
• Social support.
• Suicide - A history of depression, suicide attempts, or
substance abuse.
• Cancer patients at highest risk for suicide include those
with diagnoses of oral, pharyngeal, or lung cancers.
• Other predictors include male gender, over the age of
45, living alone, lacking a support system.
• Other risk factors: Uncontrolled pain, presence of
multiple deficits, including inability to walk, loss of
bowel and bladder control, amputation, inability to eat
or swallow, sensory loss, and exhaustion.
• Are you depressed? Have you felt down or blue in
the last month?
• How have your spirits been lately?
• How would you describe your mood today?
• How are you sleeping lately?
• What is your energy level?
• What do you see in your future?
• What is the biggest problem you're facing?
• Can you concentrate as well as you usually could?
Questions for suicide risk
• Do you ever think that life is not worth living?
• Do you find yourself wishing you would die more
quickly?
• Have you thought about killing yourself?
• Have you discussed this with anyone?
• Are you thinking of that now?
• How have you thought you would do this? Do you
have a plan?
• Physical Examination
– Observation – overall appearance
– Inspection
– Lung, cardiac and neuro examination
• Diagnostics: Laboratory studies to rule out etiologies:
–CBC: anemia or infection
–Electrolyte imbalances
–TSH for thyroid abnormalities
–LFTs for liver impairment
• Electroencephalography (EEG)
• Radiology, including CT scan of brain
Antidepressants
• SSRIs: fluoxetine, paroxetine, sertraline,
citalopram.
• SNRIs: venlafaxine, mirtazapine, duloxetine.
Duloxetine: good for pain and depression.
Mirtazapine: insomnia, anorexia, and depression.
• Bupropion: inhibits neuronal uptake of
norepinephrine and dopamine.
• Tricyclics: amitriptyline, nortriptyline; treat nerve
pain, depression, and sleep issues.
• Psychostimulants: methylphenidate or
dextroamphetamine; rapid onset and short
duration of side effects.
• Steroids: dexamethasone and prednisone may
offer euphoria for a short term benefit;
improved overall sense of well-being.
• Ketamine: rapid anti-depressant response and
may offer a benefit to certain patients.
• Interdisciplinary collaboration between social work,
chaplaincy, and mental health professionals.
• Psychotherapy, along with medications
• Electroconvulsive therapy may be considered for
patients with suicidal or psychotic features.
• Grief counseling: assist patients and families to deal
with past, present, and future losses.
• Psychiatric counseling: for those experiencing
significant inability to cope with the experience of their
medical illness.
• Cognitive behavioral techniques: assist the patient to
re-frame negative thoughts into positive thoughts
• Cultural affects: symptom presentation and responses to
depression.
• Latino and Mediterranean cultures: may complain of
"nerves" and headaches
• Chinese or other Asian cultures: "imbalance"
• Promote and facilitate autonomy and control; participate in
own care; reduce feelings of helplessness.
• Reminiscence and life review: life accomplishments; closure
and resolution of life events for the patient and family.
• Maximize symptom management.
• Assist the patient to draw on previous sources of strength,
such as faith and other belief systems.
Feelings of distress and/or tension with or without a known
stimulus:
• An acute, severe wave of intense anxiety with cognitive,
physiologic, and behavioral components.
• A low-grade persistent distress consisting of restlessness or
being on edge, difficulty in concentrating, irritability, muscle
tension, and altered sleep that interferes with psychosocial
functioning.
• Anxiety Disorder due to Another Medical Condition: Related
to the pathophysiologic consequences of a medical condition;
not explained by a mental disorder; affects the social,
occupational and general functioning of the patient.
• Generalized Anxiety Disorder, phobia, Panic Disorder
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Poorly managed pain and symptoms
Cancer related conditions – Hormone producing tumors
Cardiovascular – Angina, CHF, past history of MIs
Endocrine disorders – Diabetes, thyroid dysfunction, Cushing Syndrome,
Carcinoid
Immune disorders - AIDS, infections
Pulmonary – Asthma, COPD, PNA pulmonary edema, dyspnea, PE
Metabolic - Anemia, hyperkalemia, hyponatremia
Neurological - Encephalopathy, brain lesion
Psychosocial:
– Coping with uncertain future and prognosis and mortality
– Lack of control - Multiple changes: health, lifestyle, employment, finances
– Dealing with difficult/exhausting treatment regimens/side-effects
– Dependency on others; Confronting family conflicts
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Stimulants
Corticosteroids
Analgesics
Thyroid replacement hormones
Neuroleptics
Digitalis
Antihypertensives
Antihistamines
Antiparkisonian medications
Anticholinergics
Abrupt cessation/withdrawal of medications such as alcohol,
analgesics, benzodiazepines, antipsychotics, and nicotine
• Paradoxical reactions from medications
• Assessment of chronic apprehension, worry, inability to relax,
difficulty concentrating, difficulty falling and staying asleep.
• Physical symptoms: sweating, tachycardia, restlessness,
agitation, trembling, chest pain, hyperventilation, tension.
• Cognitive symptoms: sadness, fear, anger, difficulty
concentrating, confusion, and loss of control.
• Recurrent and persistent thoughts, ideas, or impulses, the
fear of "going crazy", and the fear of dying. Treatment
depends on the etiology and severity of symptoms.
Questions for anxiety assessment
• Have you experienced any anxiety 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 going crazy, 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?
Physical examination
• Observation – VS, tachycardia, shortness of breath,
sighing, diaphoresis, rapid speech, tense posture
• Inspection – Dilated pupils, tremors
• Palpation - Gastrointestinal distress
• Cardiac, respiratory, neuro assessment
Diagnostics: To rule out other conditions:
• CBC
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Electrolytes
Thyroid function test
Pulmonary function test if indicated
CT Scan-for suspected PE
Benzodiazepines are the first-line drugs
• Lorazepam, midazolam and alprazolam have short half-lives Diazepam
and clonazepam have longer half-lives.
• Cautious use in older adults: may cause cognitive dysfunction and ataxia.
Antidepressant: used for primary anxiety disorders
– May take 2-6 weeks to take full effect and relieve anxiety.
– Sertraline, citalopram, and escitalopram have fewer drug-to-drug
interactions.
– Mirtazapine: use with related insomnia, anorexia, and weight loss;
beneficial side effects of sedation and increased appetite.
– Consider tricyclic antidepressants (amitriptyline, nortriptyline, and
desipramine) with patients who have anxiety, chronic pain, and
diarrhea. Caution in patients with conduction abnormalities.
Antipsychotics: anxiety associated with delirium
• Haloperidol:
• Most frequently used in the medical setting
• Inexpensive and accessible
• Monitor for side effects: restlessness, increased anxiety, EPS
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Olanzapine:
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More expensive
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Monitor QTc changes, particularly if on methadone.
• Risperidone/quetiapine
• Hypnotics for sleep: zolpidem and antihistamines.
• Psychiatric counseling: Stress management programs,
exercise programs, music, art and expressive therapies for
patient and family
• Cognitive behavioral therapy (CBT) for reframing
• Behavioral techniques: guided imagery techniques
• Psychotherapy: promote coping clarifying of fears and
identifying and building on existing coping strategies.
• Spiritual counseling
• Integrative therapies: acupuncture, massage, Reiki,
aromatherapy, therapeutic touch are helpful.
• Encourage these interventions for families as well to avoid
the spread of anxiety from patient to family.
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Acknowledge patient’s fears
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Written materials to promote education. Be consistent in answering
repetitive questions
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Provide concrete information to eliminate fear of the unknown
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Provide warning and counseling for stressful events
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Write prescriptions for anxiety reducing measures: medication,
distraction, &/or exercise
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Promote dietary modifications: decreasing caffeine and alcohol intake,
food diary
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For older adults: environmental manipulation, may enable confidence in
living situations. Consider PT/OT.
• Difficulty falling asleep or maintaining sleep; interrupted sleep
• Ineffective or inconsistent sleep contributing to poor
cognition, mood, and overall functioning with potential for
accidents
• Causes/contributing factors:
– Cardiac disease
– Respiratory failure
– Obesity
– Pulmonary conditions
– Acute/chronic pain
– Psychiatric disorders: dysthymia, depression, anxiety, psychiatric Dx
– Medications: stimulants, steroids, albuterol
– OTC substances: alcohol, nicotine and caffeine
– Delirium
– Uncontrolled symptoms
History: onset, pattern and duration of sleep; transient,
intermittent or persistent.
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How often do you have trouble sleeping, how long has the problem persisted?
How often do you take naps?
When do you go to bed and get up during the week and weekends?
How long does it take you to fall asleep, how often do you wake up at night, and
how long does it take to fall back asleep?
Do you snore loudly and frequently, or wake up gasping or feeling out of breath?
How refreshed do you feel when you wake up, and how tired do you feel during
the day?
How often do you doze off or have trouble staying awake during routine tasks
especially driving?
How is this affecting your family?
Physical examination
• Observation – Age, vital signs
• Inspection – Any sites of pain
• Cardiac, Respiratory, Neurological exam
Diagnostics
• Usually not necessary unless ruling out another
issue(s)
• EEG
• Sleep clinic, if appropriate
Pharmacologic:
• Pain medication adjustment for optimal pain management
• Sleep medications: non-benzodiazepines, trazodone, zolpidem
• Antidepressants
Non-Pharmacologic
• Sleep evaluation; Adjust sleep hygiene
• Cognitive behavioral therapy (CBT)
• Relaxation therapy (i.e. guided meditation, yoga)
• Psychotherapy to discuss worries and concerns with mental health
specialist, and/or chaplain
• Environmental setting; calm setting at bed time
• Use of rituals, such as a warm bath or shower
• Massage; Aromatherapy; Acupuncture
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Chronic low back pain/peripheral neuropathy
Muscular jerks/Myoclonus/Confusion
Nausea/Constipation/Anorexia/Abdominal Pain
Dyspnea/Shortness of Breath/cough/pleuritic chest pain
Depression/anxiety/Insomnia
Fatigue/Activity Intolerance
Weakness/Falls
Nociceptive and Neuropathic components
Is morphine ER a good choice?
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Toxicity due to impaired renal function: myoclonus/confusion.
M3G metabolite: neuroexcitatory/lacks analgesic properties
M6G metabolite: adverse effects/toxicity
Other options: Fentanyl and methadone, limited doses of
short acting hydromorphone.
Neuropathic : methadone (NMDA antagonist), adjuvants:
gabapentin, pregabalin; venlafaxine, duloxetine.
TCA: not a good choice due to arrhythmia and fatigue.
Non-pharmacologic:
– Nociceptive: heat/cold compresses (skin integrity),
repositioning, distraction(music, relaxation)
– Neuropathic: Soothing lotions (Sarna), optimize blood sugars.
Nausea/Constipation/Anorexia/Abdominal Pain
Multifactorial: CHF, CKD, med effect, hypothyroidism,
constipation, cholecystitis, depression
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Gastroparesis: trial metaclopramide, d/c promethazine
Constipation: Senna or polyethylene glycol or lactulose
Discontinue megestrol (high risk for thrombosis)
Small, frequent meals.
Antibiotics for choleycistitis
Consider haloperidol
Dyspnea/Shortness of Breath/cough/pleuritic chest pain
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CHF: Diuretic, beta blocker, opioid (no ace-I due to renal failure), O2, fan
Obstructive Sleep Apnea: CPAP
Anemia: erythropoeitin, blood transfusions if indicated
CKD: dialysis dependent
Tobacco Use Disorder: encourage smoking cessation, con’t nicotine patch
Thyroid Disorder: check TSH (amiodorone effect)
Amiodarone : risk for Pulmonary Fibrosis: CT scan
Pleural Effusion: diuretics, thoracentesis, PleurX catheter, pleurodesis
Pneumonia: CAP v. HAP v. Asp PNA: O2, Antibiotic
Hypoalbuminemia: treat GI symptoms.
PE: Supratherapeutic INR: Vitamin K, hold Coumadin, medication/food
interactions
Depression/Anxiety/Insomnia
Multifactorial: multiple co-morbidities/med effect/psychosocial
• Venlafaxine ER: titrate to 150mg daily dose: improve mood
and effective dose for pain management; duloxetine
• Or consider changing to mirtazepine: + effect on mood,
insomnia, nausea and appetite.
• Consider low dose benzo: lorazepam 0.25 to 0.5mg BID to TID
prn (caution with hx sleep apnea).
• Above may improve insomnia or consider low dose zolpidem.
• Non-pharmacologic: counseling/psychosocial support, sleep
hygiene.
Fatigue/Activity Intolerance/Weakness/Falls
Multifactorial: disease burden/med effect
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PT/OT
Regular exercise routine if able
Adequate nutritional intake
Methylphenidate/modafinil not recommended due
to his history of PSVT and rapid a fib, and may also
worsen anxiety.
Goals of Care
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Importance of Goals of Care discussion
Benefits/Burdens of interventions
Advanced Care planning: Living Will, MPOA, code
status.
Palliative care or hospice referral
Visual Analogue Scale: Can be used for any symptom
ORT: Opioid Risk Assessment Tool: http://www.opioidrisk.com/node/1203
Edmonton Symptom Assessment Scale
http://www.palliative.org/newpc/professionals/tools/esas.html
The St . George’s Respiratory Questionnaire:
http://www.fda.gov/ohrms/dockets/ac/03/briefing/3976B1_01_LGlaxo-Appendices.pdf
Baseline and Transition Dyspnea Index:
http://ekstern.infonet.regionsyddanmark.dk/files/Formularer/Upload/
2013/06/BDI.pdf
Geriatric Depression Scale
http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf
PHQ 9: Patient Health Questionnaire
http://www.integration.samhsa.gov/images/res/PHQ%20%20Questions.pdf
Generalized Anxiety Disorder Scale http://carybehavioralhealth.com/wpcontent/uploads/2011/06/Generalized-Anxiety-Scale.pdf
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Insomnia Severity Index: https://www.myhealth.va.gov/mhvportalweb/anonymous.portal?_nfpb=true&_pageLabel=healthyLiving&c
ontentPage=healthy_living/sleep_insomnia_index.htm