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Flashcards in managing non-pain symptoms Deck (22):
1

Non pain symptom management

- choose treatment strategies that support the patients goals of care (age, function status, overall needs, rate of change of disease, life expectancy)
- identify the cause whenever possible and treat the CAUSE of the symptom

2

goals of clinical symptom assessment

- elicit the most distressing symptoms for the patient and family
- determine underlying pathophysiology, cause, and contributing factors for each symptom
- screen for common distressing symptoms
- review current and past treatments, their effectiveness and side effects
- document assessment and plan
- reassess at regular intervals

3

Dyspnea

- Discomfort in breathing
- aka: breathlessness, shortness of breath, work of breathing
- subjective sensation (physical, psychological, social and spiritual)
- occurs in broad range of diseases (cancer, COPD, AIDS, CHF, ALS, dementia)
- tends to worsen as death approaches

4

Dyspnea assessment

- self-report is GOLD standard
- RR, sings of increased WOB, oxygen saturation and other tests DO NOT CORRELATE with patient report of dyspnea
- hx/PE - clarify causes of dyspnea
- Rx dependent upon prognosis, goals of care risks and benefits of tests/interventions

5

Causes of dyspnea

- BREATH AIR
- B = bronchospams
- R = Rales
- E = Effusion
- A = airway obstruction
- T = Thick secretions
- H = hemoglobin low
- A = anxiety
- I = interpersonal issues
- R = religious concerns

6

tx for dyspnea

- oxygen (may be no more beneficial than air; caution if CO2 retention)
- Opioids (first line, small doses)
- anxiolytics (treat anxiety, not dyspnea)
- general measures
- alternative, complimentary (acupressure, acupuncture, meditation, massage)
- Non-invasive ventilator support

7

describe general measures to tx dyspnea

- reduce exertion/energy expenditure
- reposition the patient (upright or compromised lung down)
- provide skin care for the buttocks
- improve air circulation (draft/fan, adjust humidity, avoid strong odors, fumes etc)
- address anxiety and provide reassurance
- consider rehabilitative strategies (breathing retraining - prolong experiation)
- discuss any patient, family, or staff concerns about using opioids to relieve dyspnea

8

Dysphagia

- difficulty swallowing
- discern whether neurologic or non-neurologic (solids progressing to liquids is obstruction; simultaneous solids and liquid is neurological)
- Conservative management can ameliorate dysphagia for a majority of patients (emphasize good oral hygiene, etc)

9

what are some conditions that result in dysphagia

- dentures fit poorly
- poor dental hygiene
- taste disorder
- weakness or neuromuscular problems
- stress and tension

10

Anorexia-cachexia

- multi-faceted cascade of events leading to loss of appetite for food, usually resulting in cachexia
- often superimposed on the anorexia of the aging process
- Hx and PE (seek to identify reversible causes)

11

what are reversibel causes of anorexia

- ANOREXIA
- A = aches and pains
- N = nausea and gastrointestinal dysfunction
- O = oral candidiasis
- R = reactive depression
- E = evacuation problems (constipation, retention)
- X = xerstomia (dry mouth)
- I = Iatrogenic (radiation, chemo, drugs)
- A = Acid related problems (gastritis, peptic ulcers)

12

Tx for anorexia

- appetite stimulants
- artificial nutrition and hydration
--> enteral feeding (tube); parenteral feeding (TPN)

13

artificial nutrition and hydration (anorexia)

- ANH does not improve healing of decubitus ulcers
- ANH often shortens, not lengthens survival
- perioperative mortality/PEG placement 6-24%
- infection, thrombosis, aspiration

14

Nausea and vomiting

- in seriously and terminally in patients, N/V are common symptoms in
- N/V cause significant distress
- can usually be controlled in 90% of patients

15

describe the various origins of nausea and vomiting

- intracrnail pressure, anxiety and memories (CEREBRAL CORTEX)
- Motion sickness, vestivular disease (VESTIBULAR APPARATUS)
- uremia, hypercalcemia, drugs (CHEMORECEPTOR TRIGGER ZONE)
- Gastric irritation, intestinal distension, gag reflex (GI TRACT)

16

Neasua and vomiting tx

- Select antiemetic agent on the basis of: likely cause, pathway mediating the symptoms, NT involved
- General measures
--> small and frequent meals
--> frequent small sips of fluid
--> avoid strong odors or unpleasant tastes
--> address nonphysical factors

17

malignant bowel obstruction

- up to 50% of patients with ovarian and GI cancers have malignant bowel obstruction
- patients diagnosed with malignant bowel obstruction have median survival of 3 months
- HIGH SYMPTOM BURDEN (N/V, colic and abdominal pain)

18

Tx of maligant bowel obstruction

- management dependent upon functional status, goals of care, expected survival
- tx options
--> surgical-limited evidence of benefit QoL and EoL
--> endoscopic techniques: stents
--> medical management: mainstay of Rx

19

Delirium

- ACUTE ONSET
- Fluctuating course
- altered level of consciousness (hyperactive or hypoactive or both)
- cognitive impairments
--> altered orientation
--> altered organization of thoughts
--> altered perceptions (delusions, hallucinations)
--> emotional labiality
--> reversal of sleep wake cycle
--> memory impairment

20

delirium assessment and treatment

- Hx and PE - identify potential reversible causes
- treat underlying cause
- use low dose non-sedating antipsychotic
- actively dying, non-ambulatory patients may benefit from sedating antipsychotic
- AVOID BENZODIAZEPINES (NEVER use without an antipsychotic)

21

describe preventative measures of delirium

- prevent dehydration
- remove unnecessary catheters/IVs, restraints
- decrease environmental stimuli
- reduced light and sound at night; minimal interventions
- hearing and visual assessment
- reorientation and cognitive stimulation
- inducement of sleep with music or massage

22

KEY POINTS

- most patients receiving palliative care have multiple symptoms
- screening assessment is key to identifying the symptom constellations
- detailed History and comprehensive PE are needed to determine most probably cause
- tx strategies should be determined by patients goals of care and directed at treating the underlying cause whenever possible