10/4/2017. Rationale symptom management. Satisfactory. NCCN Palliative Care Guidelines. Respiratory Symptoms. Dyspnea: Overview and Incidence
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1 Rationale symptom management Core Curriculum MODULE 3 PART II: SYMPTOM MANAGEMENT CARLA JOLLEY MN, ARNP, AOCN, ACHPN WHIDBEYHEALTH PALLIATIVE CARE Just because we can..doesn t mean we need to.. Assessment and interventions need to be addressed in the context of disease trajectory symptom distress/suffering benefits and burdens goals of care resources both financial and caregiver NCCN Palliative Care Guidelines Years Years to months Months to weeks Weeks to days National Comprehensive Cancer Network Satisfactory Adequate symptom control Reduction of patient/family distress Acceptable sense of control Relief of caregiver burden Strengthen relationships Optimized quality of life Personal growth and enhanced meaning Respiratory Symptoms Dyspnea Cough (at a glance) Dyspnea: Overview and Incidence Subjective experience Most reported symptom Promotes disability, poor quality of life, and suffering Balkstra, 2015; Dudgeon,
2 Causes of Dyspnea Major pulmonary causes Major cardiac causes Major neuromuscular causes Other causes Assessment of Dyspnea Use subjective report Clinical assessment Physical exam Diagnostic tests Patient experience Underlying cause Dudgeon, 2015 Directions Partner with one or two others We will review scenarios together one at a time with a break in between to confer Consider the questions and the place Joe is in his trajectory for each scenario Use the table with matrix to mark proposed interventions in appropriate columns Treatment of Dyspnea Treating symptoms or underlying cause Pharmacologic treatments Opioids Nonopioids Dudgeon, 2015; Quill et al., 2014 Treatment of Dyspnea (cont.) Nonpharmacologic Non-invasive ventilatory support (oxygen, positive pressure ventilation) if hypoxic Counseling Pursed lip breathing Energy conservation Fans, elevation Positioning Other Symptom at a Glance: Cough Overview Causes Management Treatment of underlying causes Suppressant Dudgeon, 2015 Dudgeon,
3 GI Symptoms Anorexia/cachexia Nausea/vomiting Xerostomia (at a glance) Anorexia and Cachexia Anorexia: loss of appetite, usually with decreased intake Cachexia: lack of nutrition and wasting, result of metabolic abnormalities, etiology rarely reversible Wholihan, 2015 Causes of Anorexia and Cachexia Primary cause: under investigation Disease-related Psychological Treatment-related Assessment of Anorexia and Cachexia Physical findings Impact on function and QOL Calorie counts/daily weights Lab tests Skin breakdown Wholihan, 2015 Wholihan, 2015 Treatment of Anorexia and Cachexia Dietary consultation Medications Parenteral/enteral nutrition Odor control Counseling Nausea and Vomiting Common in advanced disease Assessment of etiology is important Acute, anticipatory, or delayed Wholihan, 2015 Chow et al., 2015; Tipton,
4 Causes of Nausea and Vomiting Physiological (GI, metabolic, CNS) Psychological Disease-related Treatment-related Other Assessment of Nausea and Vomiting Physical exam History Lab values Dehydration Pharmacologic Treatment of Nausea and Vomiting Anticholinergics Antihistamines Steroids Prokinetic agents Non-Drug Treatment of Nausea and Vomiting Distraction/relaxation Dietary Small/slow feeding Invasive therapies Other 4
5 Symptom At a Glance: Xerostomia Dry mouth Difficulty in mastication, swallowing, and speech Can be caused by medications, radiation, and systemic diseases Psychosocial Issues Anxiety Post-Traumatic Stress Disorder (PTSD) Delirium/agitation/confusion Blush & Larsen, 2015 Anxiety Subjective feeling of apprehension Feelings of distress or tension from known or unknown stimuli Categories of mild, moderate, severe Causes of Anxiety Physiological changes Medications and substances Pre-existing anxiety pre-diagnosis Uncertainty Two types of anxiety disorders: general anxiety disorder and post traumatic stress disorder (PTSD) Pasacreta et al., 2015 Assessment of Anxiety Physical symptoms Cognitive symptoms Questions for assessment Pharmacologic Interventions for Anxiety Benzodiazepines Clonazepam Lorazepam Antidepressants SSRIs SNRIs Neuroleptics haloperidol, olanzapine APA,
6 Non-pharmacologic Interventions for Anxiety Empathetic listening Assurance and support Concrete information/warning Relaxation/imagery 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 Implications for EOL PTSD and End-of-Life Care Illness/death can be a PTSD activator Challenges social ties Delirium or flashbacks? Medication GOAL: Reduce PTSD symptoms and create an emotionally safe environment Delirium/Agitation/Confusion Delirium - Acute change in cognition/awareness Agitation or withdrawal - Accompanies delirium Confusion - Disorientation, inappropriate behavior, hallucinations Grassman, 2015 Heidrich & English, 2015 Delirium/Agitation/Confusion: Causes Medications Infection Hypoxemia Bladder distention Unrelieved pain Other Delirium/Agitation/Confusion: Assessment Physical exam History Spiritual distress Other symptoms Heidrich & English,
7 Delirium/Agitation/Confusion: Treatment Maintain Safety Pharmacologic Neuroleptics Monitor for side effects, withdrawal Eliminate non-essential/contributing medications Reorientation Relaxation/distraction Hydration Wounds Loss of skin integrity Pressure ulcers Malignant wounds Kennedy Terminal Ulcers Assessment of Wounds Local Wound Care Issues: HOPES Characteristics Pain Psychosocial Caregivers Hemorrhage or bleeding: Consider dressing with calcium alginate for minor bleeding Odor: Apply topical metronidazole or use activated charcoal dressings Pain: Select dressings with atraumatic and nonadherent interfaces Exudate: moisture is contraindicated in nonhealable wounds, consider foams, alginates, and superabsorbent products based on diaper technology Superficial bacterial burden: use topical antimicrobial agents for superficial wound infection and systemic for deep and surrounding wound infection Treatment of Wounds Frequent position changes Wound cleaning Dressings Provide analgesia Seek consultation Prevention is key Dilemma: Assessing/Treating Wounds in Patients with Life-Limiting Illness Assess underlying cause What are the goals of care? Is it realistic that the wound will heal? Prevent further pressure ulcers/wounds Manage pain and odor Pressure ulcer may indicate organ failure Seaman & Bates-Jensen,
8 One Final Reminder: Be Aware of Symptoms of Urgent Syndromes Superior vena cava obstructions Pleural effusion Pericardial effusion Hemoptysis Spinal cord compression Hypercalcemia Conclusion Multiple symptoms are common Coordination of care with the interdisciplinary team Use drug and nondrug treatment Patient/family teaching and support Bobb,
4/10/2018. Rationale symptom management. NCCN Palliative Care Guidelines. Satisfactory. Respiratory Symptoms. Dyspnea: Overview and Incidence
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