Symptom Management in the Non-Verbal Patient at the End of Life Laura Carmon, ANP-BC

Transcription

1 Symptom Management in the Non-Verbal Patient at the End of Life Laura Carmon, ANP-BC 2017 NPSS Asheville, NC

2 Objectives The learner will recognize non-verbal signs and symptoms commonly seen at the EOL. The learner will identify symptom management modalities in treating patients at the end of life. NCNA 2017 NPSS

3 Non-Verbal Communication is the greatest form of communication

4 None of This

5 Approach to symptom management Recognition of the distress at the EOL Not all patients are able to voice their complaints; therefore ASSESSMENT skills are a MUST:

6 Common Symptoms at the EOL Dyspnea Pain Anxiety/Agitation Delirium Terminal Secretions Constipation

7 Dyspnea Nonverbal Signs Use of accessory muscles Stridor Tri-pod position Pursed lip breathing Tachypnea Restlessness

8 Dyspnea Pharmacologic Treatment Opioids are first-line morphine, dilaudid, fentanyl Duo-nebs Anxiolytics such as Ativan Corticosteroids (for underlying inflammatory processes) Supportive Interventions Supplemental Oxygen Fan Cool wash cloth Pet Therapy Relaxation, imagery, music

9 Pain Nonverbal signs Facial grimace or furrowed brow Moaning Guarding, holding, or splinting specified area of pain Restlessness Tachycardia Expiratory grunting Facial flushing Fatigue or excessive sleepiness

10 Pain Pharmacologic Treatments Opioids morphine, dilaudid, fentanyl NSAIDS ibuprofen, naproxens Neuro-modulators (Neurontin, Lyrica) Corticosteroids decadron Muscle Relaxants Supportive Interventions Warm compresses Massage Repositioning Pet Therapy Relaxation, imagery, music Topical Anesthetic (Lidoderm patch)

11 Anxiety/Agitation Nonverbal signs Restlessness Impulsivity Pulling at clothes, lines, sheets, etc. Moaning or calling out Insomnia

12 Anxiety/Agitation Pharmacologic Treatments Treat underlying cause (pain, dyspnea, constipation) Supportive Interventions Reduce stimulation (monitor alarms, loud noise, multiple tubes/lines) Antipsychotics haldol Anxiolytics SSRI Calm environment Do they need to void? Rule out and/or address urinary retention Distraction, entertainment with activity apron

13 Delirium Confusion Delusions Agitation Hallucinations Disorientation

14 Delirium Pharmacologic Treatments Anti-Psychotics haloperidol-(preferred) resperidone Ativan Supportive Interventions Reduce light and sounds Music therapy Remove Unnecessary IVs, restraints Provide consistent nursing care

15 Terminal Secretions Audible inspiratory and expiratory upper airway secretions Drowning sounds Gurgling sounds Congestion Death Rattle

16 Terminal Secretions Pharmacologic Treatments Anticholinergics: Scopolamine Robinul Atropine Diuretics (Lasix, Bumex) Supportive Interventions Suctioning(avoid frequent suctioning) Positioning Reduce fluid intake Reassure family members the patient is not suffocating

17 Constipation Facial Grimace Holding /guarding the abdomen Urinary Retention

18 Constipation Pharmacologic Treatments Increase fiber(psyllum)-impaction Agents to increase water content: Glycerin Suppository Lactulose Sorbitol Agents to increase GI motility Senna Biscodyl Prune Juice Assess for urinary retention Supportive Interventions High Fiber Diet Increase Water Content as tolerated

19 Summary The patient is the best bedside monitor. Effective symptom management at end of life is POSSIBLE and DESIRABLE. Symptom management at end of life involves the skillful use of SENSES and clinical principles.

20 Patient Scenario Ms K.J. is a 28 yo with metastatic cervical cancer to the liver and spine in the palliative care unit on a morphine infusion. She has become extremely restless and agitated over the last couple of days. She has not had a bowel movement in 6 days despite her very poor PO intake. What would be on your list of differential dx?? What is your management plan???

21 Is it constipation? Is it pain? Is it agitation? Is it urinary retention?

22 So How do we manage this patients symptoms???

23 Questions

24 This is How the Awesome Vidant Team does IT!

25 References A Guide to Symptom Management in Palliative Care Version 5:1 (2014). Yorkshire Cancer Network & North East Yorkshire & Humber Clinical Alliance. Center to Advance Palliative Care (2015). Comprehensive pain assessment. Available at: Accessed March 1, Ross, D. and Alexander, C;, Management of Common symptoms in terminally Ill Patients. Am Fam Physician, 2012 Sep 15:64(6).

26 None of This