Rural Palliative Care Networking Group Meeting May 6, 2014 Alexandria, Minnesota Agenda Welcome and Introductions Educational Session Symptom Management at End-of-Life Part III Presented by Laura Scherer, RN, Director, Unity Family Home Care and Hospice Round-robin discussion Wrap-up and next steps Clinical Review for the Hospice and Palliative Nurse Symptom Management Dyspnea, Nosy Respiration, Fatigue, & Pressure Ulcer 3 1
Objectives 1. Define dyspnea, noisy respiration, fatigue, and pressure ulcers present at the end of life. 2. Identify possible etiologies of dyspnea, noisy respiration, fatigue, and pressure ulcers at the end of life. 3. Assess for the physical and psychosocial aspects of dyspnea, noisy respiration, fatigue, and pressure ulcers that are common at the end of life. 4 Objectives 4. Describe pharmacological and nonpharmacological interventions for dyspnea, noisy respiration, fatigue, and pressure ulcers 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. 5 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. 6 2
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 7 Causes of Dyspnea Related to primary or secondary diagnosis Related to treatment Pulmonary congestion Bronchoconstriction Anemia Hyperventilation 8 Assessment of Dyspnea Acknowledge the subjective report Not tachypnea Functional Status Past history of related factors Diagnostic tests 9 3
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 10 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 11 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 12 4
Non-pharmacological Treatment of Dyspnea Fans, circulate air Positioning Conserve energy Rest Pursed lip breathing Prayer Complementary therapies 13 Dyspnea Patient & Family Education Instruct breathing techniques Minimize aggravation Prevent panic Conserve energy Use of fans Don t leave patient in distress alone 14 Noisy Respirations Noisy, moist breathing Median time - 23 hrs before death May be very disturbing to family members 15 5
Noisy Respirations Causes Turbulent air passes over pooled secretions or through relaxed muscles of oropharynx 16 Assessment of Noisy Respirations Onset Contributing causes Pulmonary embolism Fluid overload or CHF 17 Pharmacological Treatment of Noisy Respirations Treat underlying disorder Anticholinergics Hyoscine hydrobromide (Scopolamine ) Atropine 18 6
Non-pharmacological Treatment of Noisy Respirations Repositioning 19 Noisy Respirations Patient & Family Education More distressing to family than patient - reassure Explain process Teach as a sign of impending death 20 Dyspnea & Noisy Respirations References 1. 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. 2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC - Geriatric). Washington, DC: Association of Colleges of Nursing, 2007. 21 7
Fatigue A complex phenomenon, extreme tiredness, lack of energy, weariness Subjective perception 22 Fatigue Prevalence Reported in 78-96% of cancer patients 51% of patients in international palliative care centers 50% of school-aged children receiving chemotherapy Effects Activities of Daily Living 23 Causes of Fatigue Accumulation Theory Depletion Theory Central Nervous System Control Predisposing factors 24 8
Assessment of Fatigue Subjective Data Location, severity, intensity and duration Aggravating & alleviating factors Objective Strength Vital signs Lab values Oxygenation status, CBC and Diff, Hgb 25 Pharmacological Treatment of Fatigue Steroids Methylphenidate (Ritalin ) stimulates CNS and respiratory center increases appetite and energy levels, improves mood, reduces sedation 26 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 27 9
Non-pharmacological Treatment of Fatigue Active exercise Attention-restoring interventions Preparatory education Psychosocial support 28 Fatigue Patient & Family Education Explain nature of fatigue Plan, schedule & prioritize activities Rest Instruct on nutrition Control contributing symptoms 29 Fatigue References 1. Anderson PR, Dean G. Fatigue. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006:155-168. 2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC - Geriatric). Washington, DC: Association of Colleges of Nursing, 2007. 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. 4. 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. 30 10
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 31 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 32 Causes of Pressure Ulcers Intrinsic factors Extrinsic factors 33 11
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 34 Assessment of Pressure Ulcers Clinical Physical Lab values National Pressure Ulcer Advisory Panel Staging Criteria www.npuap.org 35 Assessment for Pressure Ulcers Pressure Ulcer Staging Criteria Stage l Stage ll Stage lll Stage lv Unstageable 36 12
Assessment for Pressure Ulcers Wound Status Pressure Ulcer Scale for Healing (PUSH) Pressure Sore Status Tool (PSST) 37 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 38 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 39 13
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 40 Assessment for Pressure Ulcers Wound Characteristics Edema will impede healing of pressure ulcer Granulation & Epithelialization markers of wound health 41 Treatment of Pressure Ulcers Nutritional support Maintain nutritional status 42 14
Treatment of Pressure Ulcers Management of tissue load Pressure reduction surfaces Alternating airflow mattresses 43 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 44 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 45 15
Patient & Family Education for Pressure Ulcers Teach prevention and early signs Repositioning Protecting bony prominences Keep heels off bed surface Skin care Nutrition Mobility 46 Patient & Family Education for Pressure Ulcers Nutrition Supplements Protein Fluids Dietitian Mobility Review importance of pressure ulcer prevention by maximizing activity and/or mobility 47 Pressure Ulcers References 1. 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. 2. 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. 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. 48 16
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 49 Review Questions? All information presented over the three part training is directly from HPNA Review Course for Nurses. Patient/family education, quick information, TIPS sheets can be found for FREE at www.hpna.org HPNA memberships offer many free CEU s, Hospice and Palliative Care Journal, and much more 50 Round-Robin Discussion 17
Wrap-Up and Next Steps Next meeting Thursday, September 18, 2014, 10 am noon Lakeland Home Care & Lakeland Hospice hosting 805 E. Channing Ave. Fergus Falls, MN 56537 Educational Session: Measurement Strategies for Rural Palliative Care Programs Presented by Karla Weng and Laura Grangaard, Stratis Health and Palliative Care Programs Questions? Janelle Shearer, MA, RN, BSN 952-853-8553 or 877-787-2847 jshearer@stratishealth.org www.stratishealth.org Stratis Health is a nonprofit organization based in Minnesota that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities. This effort is sponsored by UCare and supported by Stratis Health. 18