Module 3: Symptom Management
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1 ELNEC- Public Hospitals End-of-Life Nursing Education Consortium Palliative Care For Public Hospitals Module 3: Symptom Management Course Handouts & Post Test To download presentation handouts, click on the attachment icon Presenter discloses no financial relationships with a commercial entity producing healthcare-related products and/or services. Conflict of interest disclosure and resolution statement is on file with HEN. This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice. Objectives Identify common symptoms associated with end-of-life processes for patients across the life span. Identify potential causes of symptoms at the end of life. Describe assessment of symptoms at the end of life. Describe interventions that can prevent or diminish symptoms at the end of life.
2 Section I: Introduction Essential elements of symptom management Suffering Common symptoms Essential Elements of Symptom Management Ongoing assessment and evaluation Interdisciplinary Reimbursement concerns Informed by evidence Symptoms and Suffering Symptoms create suffering and distress Psychosocial intervention is key to complement pharmacologic strategies Interdisciplinary care NCP, 2009
3 Respiratory Dyspnea Gastrointestinal Common Symptoms Anorexia/Cachexia Constipation Diarrhea Nausea/Vomiting General/Systemic Fatigue Psychological Depression Anxiety Post-Traumatic Stress Disorder (PTSD) Skin Wounds
4 Section II: Respiratory Dyspnea Distressing shortness of breath Associated diseases Dudgeon, 2010 Causes of Dyspnea Major pulmonary causes Major cardiac causes Major neuromuscular causes Other causes Assessment of Dyspnea Use subjective reports Clinical assessment Physical exam Diagnostic tests
5 Treatment of Dyspnea Treat symptoms and/or underlying cause Pharmacologic treatments Opioids Bronchodilators Diuretics Other Clemens & Kaschik, 2007; Dudgeon, 2010 Oxygen Counseling Treatment of Dyspnea: Nonpharmacologic Pursed lip breathing Energy conservation Fans, HOB elevated Other
6 Section III: GI Symptoms Anorexia and cachexia Constipation Diarrhea Nausea/vomiting Anorexia and Cachexia ANOREXIA Loss of appetite, usually with decreased intake CACHEXIA Lack of nutrition and wasting Wholihan & Kemp, 2010 Causes of Anorexia and Cachexia Disease related Psychological Treatment related
7 Assessment of Anorexia and Cachexia Physical findings Impact on function and QOL Calorie counts/daily weights Lab test Skin breakdown Coyne, 2007; Wholihan & Kemp, 2010 Treatment of Anorexia and Cachexia Dietary consultation Odor control Medication Artificial nutrition & hydration Counseling Infrequent passage of stool Constipation Frequent symptom in palliative care PREVENTION IS KEY!
8 Causes of Constipation Disease related Obstruction Hypercalcemia Neurologic Inactivity Treatment related Opioids Other medications Assessment of Constipation Bowel history Abdominal assessment Rectal assessment Medication review Treatment of Constipation Medications Dietary/fluids Other approaches
9 Diarrhea Frequent passage of loose, nonformed stool Effects Fatigue Caregiver burden Skin breakdown Causes of Diarrhea Malabsorption Disease Related CAUSES Concurrent Diseases Treatment Related Psychological Assessment of Diarrhea Bowel history Medication review Infectious processes
10 Treatment of Diarrhea Treat underlying cause Dietary modifications Hydration Pharmacologic agents Nausea and/or Vomiting Common in advanced disease Assess etiology Acute, anticipatory or delayed? Causes physical and psychological distress Causes of Nausea and Vomiting Physiological GI Metabolic CNS Psychological Disease related Treatment related Other
11 Assessment of Nausea and Vomiting Physical exam History Lab values Pharmacologic Treatment of Nausea and Vomiting Anticholinergics Antihistamines Steroids Prokinetic agents Other Non-Drug Treatment of Nausea and Vomiting Distraction and/or relaxation Dietary Small/slow feedings Invasive therapies
12 Section IV: General/Other Symptoms Fatigue Skin (wounds) Fatigue Subjective Multidimensional experience of exhaustion Commonly associated with many diseases Impacts all dimensions of QOL Disease related Causes of Fatigue Psychological Treatment related
13 Assessment of Fatigue Subjective Objective Laboratory data Treatment of Fatigue Pharmacologic Nonpharmacologic Rest Energy conservation Involve PT/OT prn Wounds Patients at risk Prevention is key
14 Assessment of Wounds Characteristics Pain Psychosocial Caregivers Treatment of Wounds Wound cleaning Dressings Provide analgesia Seek consultation Evaluation is on-going
15 Section V: Mental Health Issues Most common mental health issues: Post traumatic stress disorder (PTSD) Depression/suicide Anxiety Delirium/agitation/confusion Post Traumatic Stress Disorder (PTSD) PTSD is characterized by persistent/severe reaction to a traumatic event Combat Terrorist attacks Sexual or physical assault Accidents National/natural disasters Symptom clusters Avoidance Re-experiencing the event Hyperarousal Occurs in about 30% of Veterans who were in war zones Implications for EOL VA Advisory Council, 2009 PTSD: Factors Associated with PTSD Strong emotional and/or behavioral reaction to a traumatic event Fears for their own life or another s Witnessed horrific events Felt helpless in responding to the event Research in pathophysiology of PTSD Koenigs & Grafman, 2009; Veterans Advisory Council, 2009
16 PTSD: Screening and Assessment Symptoms Reliving the trauma Avoiding reminders Persistent hyperarousal Risk Factors Diagnosis and on-going assessment should be made by a mental health professional with experience in treating PTSD PCL Periyakoil, 2009 PTSD: Treatment Psychotherapy Medications PTSD and End-of-Life Care Illness/death can be a PTSD activator Challenges social ties May affect staff-veteran relationships Delirium or flashbacks? Medication GOAL: Reduce PTSD symptoms and create an emotionally safe environment Veterans Advisory Council, 2009
17 Depression Symptoms may be on-going Often unrecognized and undertreated Early diagnosis is key Should not be dismissed 31% prevalence among Veterans Veterans Advisory Council, 2009 Causes of Depression Disease related Psychological Medication related Treatment related Symptoms Assess various symptoms that have been present for at least two weeks.
18 Assessment of Depression Situational factors and/or symptoms Previous psychiatric history Other/Risk Factors Lack of support Pain Culture Glass, et al., 2010; Pasacreta et al., 2010 Examples of Screening Measures for Depression Patient Health Questionnaire-2 (PHQ-2) Patient Health Questionnaire-9 (PHQ-9) Karlin & Fuller, 2007 Suicide Facts: Veterans and Suicide 20% of all suicides in America are Veterans 5 Veterans receiving VA health care commit suicide DAILY Suicide rates among male Veterans are ~2 times greater than men in the general population Risk factors Veterans Advisory Council, 2009
19 Suicide Assessment Warning signs Important questions to ask Interdisciplinary Care is CRITICAL! Responding to Suicide Risk Assure the patents immediate safety Refer for mental health treatment or assure that follow-up appointment is made. Inform and involve someone close to the patient. Limit access to means of suicide Increase contact and make a commitment to help the patient through the crisis. Pharmacologic Interventions for Depression Antidepressants Stimulants Nonbenzodiazepines Steroids
20 Non-Pharmacologic Interventions for Depression Promote autonomy Grief counseling Draw on strengths Use cognitive/ behavioral strategies Team effort Anxiety Subjective feelings Apprehension Tension Insecurity Uneasiness Often without specific cause Categories Mild Moderate Severe PTSD Medications Other substances Withdrawal Uncertainties Treatments Lifestyle changes Financial concerns Family conflicts Facing mortality Others Causes of Anxiety
21 Assessment of Anxiety Physical symptoms Cognitive symptoms Questions for assessment Pharmacologic Interventions for Anxiety Antidepressants Benzodiazepines/ anticonvulsants Neuroleptics Nonbenzodiazepines Non-Pharmacologic Treatments for Anxiety Listening Assurance and support Concrete information Cognitive behavior therapy
22 Delirium/Agitation/Confusion Delirium Acute change in cognition/awareness Agitation Accompanies delirium Confusion Disorientation Inappropriate behavior Hallucinations PTSD Causes Infection Medications Hypoxemia Bladder distention Constipation Unrelieved pain Rapid withdrawal of certain meds and ETOH PTSD Other Heidrich & English, 2010; Lawlor & Bruera, 2002 Assessment Physical exam History Spiritual distress Other symptoms
23 Pharmacologic Evaluate medication Reorientation Relaxation Distraction Hydration Treatment Key Nursing Roles in Symptom Management Patient advocate Assessment Pharmacologic treatments Non-pharmacologic treatments Patient/family teaching Invaluable member of interdisciplinary team Conclusion Multiple symptoms common Coordination of care with physicians and other team members Use drug and nondrug treatments Patient/family teaching and support
24 Course Handouts & Post Test Thank you for viewing this course on the Hospice Education Network The Course evaluation and post test are available from your course catalog page To achieve credit for this course, close the video portion when completed and click on Start Test
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