Symptoms and Management Flashcards
: A patient you see regularly shares a lot of information with you. The
nurse asks you about the patient’s subjective response to receiving a new
medication in order to help the patient adjust to it.
You are most likely to tell the nurse:
A. The patient says her pain score has increased from a 2 to 5 after the dose
B. The patient seems to need to go to the bathroom more after the dose
C. The patient worries that the new medication means she is sicker
D. The patient worries that her cat needs to have her home to brush her
C
A patient you see regularly shares a lot of information with you. Which of the
following information would you share first with the nurse?
A. The patient says her pain score has increased from a 2 to 5 after the dose of a
new medication.
B. The patient seems to need to go to the bathroom more after the dose of a new
medication.
C. The patient worries that the dose of a new medication means she is sicker than
she had been.
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D. The patient worries that she needs to get home because her cat needs to be
brushed or will get ill.
A
: A patient has a fear of needles. She has to have injections weekly for
her chemo treatment. The MOST effective treatment option is:
A. Exposure therapy
B. Cognitive behavioral therapy
C. Anti-anxiety medication
D. Psychodynamic psychotherapy
A. Exposure therapy, which is a subset of CBT treatment, in which the client is
gradually exposed to more intense fear-inducing stimuli over a period of time, is
the most effective of the treatments listed.
x
x
What are the signs of distress?
Talking about suicide or wanting it to be all over now
seeking methods to hasten death
talk about hopeless or helplessness
talk about being burden to loved ones
talk about unbearable pain/suffering
past suicide attempts
triggering events in addition to terminal illness
history ineffective coping strategies (as reported by Pt)
x
x
x
x
x
x
x
x
What advice for families around terminal lucidity (rally)?
Prepare them for possibility of rally
follow the lead of the dying person for odd meals or visit by someone in particular
listen carefully and respond to their needs for conversation/silence, life review, goodbyes
after lively interaction/persons energy may be gone
regardless of how alert encourage support by sitting at bedside and holding hand/stroking arm
How to prepare families for what to expect at TOD?
breathing may stop before the heart
pupils completely dilate
muscles completely relax (bowel/bladder)
face relaxes, looks peaceful, rush of air may be released
should be no rush to declare death
at EOL what are some reasons the medical setting can be trauma or re-traumatizing?
power differential
invasiveness of some treatments
Characteristics of psychosocial distress?
recent notification of terminal illness
current/future financial worries or crises
social and/or family isolation/withdrawal
no or potential for no adequate shelter
cultural discord
needs of minor children and/or compromised adults
SI
history of depression/ DSM dx
substance abuse/misuse
non pharma/medical intervention strategies to help alleviate pain (complementary)
CBT and hypnosis based CBT
Distraction
Education about symptoms
relaxation
guided imagery
Diaries/journals
massage
Reiki
Music
use of virtual reality technology
You are employed as a licensed social worker for hospice and also have a license as a massage therapist. May you provide massage to your hospice patients?
If you are paid to provide social work services you may not provide massage services (NASW)
Non pharma medical interventions for pain treatment (all that apply)
A.. TENS
B. Equine therapy
C. Radiation and Surgical interventions
D. OT and PT
E. Intraspinal analgesia
F. Acupuncture
All but B
Clinical depression can be mistaken for
a. hyperactive delirium
b. dementia
c. hypoactive delirium
C
Roberta is a 54-year-old with end-stage lung cancer whose condition has declined significantly
over the past week, with increased difficulty swallowing. She has recently stopped eating and
drinking, and her husband is worried she is “starving to death” and wonders if tube feedings
should be started. Roberta previously completed an Advanced Directive that stated she did not
want to be kept alive by artificial means and that stated she wanted to stay in her home to die.
What information may be helpful for Roberta’s husband in this stage of her disease progression?
a. She may be receiving too much morphine.
b. Dehydration increases comfort during the dying process.
c. Intravenous fluids would be more appropriate.
d. She should be admitted to the hospital.
. b - It would most likely be helpful for Roberta’s husband to know that dehydration actually increases comfort during the dying process. As the patient progresses through this stage, various body systems typically begin to decrease normal functioning, including the renal and cardiac systems. Diminished eating and drinking is part of the body’s normal adaptation to these changes, which prevents fluid overload. Artificial addition of fluids is typically not recommended in this situation, since fluid overload may occur, leading to increased respiratory distress and patient discomfort
Katherine is a 64-year-old with end-stage ovarian cancer who has been experiencing increasing
weakness and been bedbound for the past two weeks. Recently, she has not been eating or
drinking much, and has been sleeping more. On today’s visit, you notice that the scant amount
of urine in her drainage bag is very dark. Her husband is concerned about her condition. What
would be the most appropriate action?
a. Change the catheter
b. Encourage fluids
c. Educate the husband about the dying process
d. Flush the catheter
- c - Educating the husband about the dying process would be the most appropriate action. Families should be educated about the signs and symptoms of imminent death so they will know what to expect and how to prepare. Decreased urine output with concentrated urine is very common findings during the dying process as the renal system begins to fail.
What is a primary concern when a patient who is in the dying process begins to have difficulty
swallowing?
a. Aspiration
b. Symptom management
c. Family education
d. All of the above
. d - All of the options noted are primary concerns when the dying patient begins to have difficulty swallowing, which is a common occurrence. Aspiration prevention is certainly a concern, as well as transitioning the patient from oral medications that have been in use for symptom management to an appropriate route. Liquid medications may still be acceptable alternatives, since they are typically concentrated and administered in very low volumes, and many can be absorbed through the buccal mucosa. Anything in pill form should not be administered at this point. Other options include topical administration as well as subcutaneous, intravenous and intraosseous infusions. Families should be educated regarding swallowing limitations to prevent harm to the patient from well-meaning actions.
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x
which of the following is NOT a common breathing pattern when a patient is actively dying?
a. Kussmaul respirations
b. Cheyne-Stokes breathing
c. Apnea
d. Agonal breathing
a - Kussmaul respirations, a form of hyperventilation which is typically associated with
metabolic acidosis, is not a common breathing pattern when a patient is actively dying.
Cheyne-Stokes breathing, which is an irregular pattern of breathing which may progress to
periods of apnea is very common. Apnea, with progressively longer periods without
breathing, is common as death approaches
Which of the following statements is true regarding pain management for the patient who is in
the dying process?
a. Pain usually increases.
b. Pain medication must be increased.
c. Pain medication may need to be decreased.
d. There is usually no pain
. c - As organ systems fail during the dying process, pain medication may need to be decreased, depending on the patient’s status. The inability to efficiently clear medications through the hepatic and renal systems may create an accumulation of medication, which can be monitored by assessing for side effects such as increased somnolence or myoclonus. Generally, if the patient is showing no indications of toxicity, the pain medications should typically be left at the same dosage that the patient has been receiving prior to entering the dying process. Route of administration needs to be adjusted as appropriate.
Margaret is a 90-year-old patient with end-stage breast cancer with bone metastasis who has
entered the dying process and is no longer responsive. Margaret had been experiencing
increased pain over the past few weeks, prior to entering the dying process, which required
adjustments to her pain management regimen. Now that Margaret is unresponsive, what will be
the most accurate indicator of her pain?
a. A pain assessment scale using numbers
b. A pain assessment scale using faces
c. Behavioral changes
d. The caregiver’s assessment
. c - Behavioral changes are the most reliable indicators of pain in the patient who is no longer able to respond. It must be noted that the dying patient may have many reasons for restlessness, including urinary retention, constipation and the early stages of delirium. Once other underlying causes have been ruled out and/or addressed, behavioral changes should be attributed to pain and treated appropriately.
Richard is an 80-year-old with a diagnosis of Parkinson’s disease who has shown signs and
symptoms of imminent death over the past 12 hours. Two of his daughters, who are nurses,
want to provide nursing care for him in his final hours, and have declined the offer of continuous
care nursing. When you enter the home for your visit, you find that they have moved the
patient’s mattress to the floor, since he has been confused and restless, and tries constantly get
out of bed, though he is too weak to stand. They have been administering medications as
ordered, and the patient has a urinary catheter to straight drain. What may be most helpful in
this patient’s care?
a. Bedrails
b. Soft restraints
c. A holistic approach
d. Continuous care nursing
. c - Patients who are in the dying process typically do not maintain mental clarity until time of death due to a number of factors. Mentation changes can occur on a wide scale, from mild anxiety to severe delirium, and identifying a single underlying cause is often difficult. Ruling out possible causes and treating them accordingly is the first priority, but overall, a holistic approach must be taken, and may include trial and error to determine what interventions are most helpful. Such interventions may include medication therapy, reduction of environmental stimuli, and the use of alternative approaches such as Reiki therapy, aroma therapy and music therapy
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Steve is a 49-year-old husband and father of 2 young boys with a diagnosis of end-stage colon
cancer with metastasis to the liver. His wife called, upset, requesting a visit because he has new
onset back pain, and is having trouble walking. What do you suspect may be happening with
Steve?
a. Start of the dying process
b. Spinal cord compression
c. Poor medication compliance
d. Early delirium
. b - Steve is most likely experiencing spinal cord compression, which is an oncologic emergency. Pressure on the cord caused by tumor invasion or cord ischemia creates neurological symptoms which may quickly progress to complete paralysis. Localized back pain may be the only symptom prior to paralysis occurring, or may be accompanied by motor deficits such as hypotonicity and hyperreflexia as well as sensory deficits such as paresthesia, bowel and bladder incontinence and urinary retention. This condition requires emergency treatment in accordance with patient/family goals and the patient’s condition. Diagnosis and treatment options include high dose corticosteroids, MRI or CT scan, radiation and surgical consult for decompression and stabilization
Which of the following most accurately describes the disease course for the patient in the
terminal phase status-post cerebral vascular accident (CVA)?
a. Multiple exacerbations over months to years
b. Slow deterioration
c. Acute, non-reversible episode
d. All of the above
d - All of the above choices describe the disease course of the terminal phase for the patient who has suffered a cerebral vascular accident (CVA) and meets hospice criteria for care. Neurological conditions, along with cardiovascular, renal and respiratory conditions, are non-cancer diagnoses commonly seen in the hospice population. The progression of disease for these conditions is unpredictable and may involve many exacerbations over months to years. Most patients with these conditions die due to failure of one or multiple organs as a result of progressive debility
Of the following, what is the most predictable indicator of end of life in the patient with
amyotrophic lateral sclerosis (ALS)?
a. Weakness of sphincters and extraocular muscles
b. Choking spells
c. Involvement of respiratory muscles
d. Fasciculations and impaired speech
d - All of the above choices describe the disease course of the terminal phase for the patient who has suffered a cerebral vascular accident (CVA) and meets hospice criteria for care. Neurological conditions, along with cardiovascular, renal and respiratory conditions, are non-cancer diagnoses commonly seen in the hospice population. The progression of disease for these conditions is unpredictable and may involve many exacerbations over months to years. Most patients with these conditions die due to failure of one or multiple organs as a result of progressive debility
Dialysis-dependent patients with chronic renal failure who have decided to discontinue dialysis
typically manifest signs and symptoms of uremia. Of the following, which are signs and
symptoms associated with uremia in this patient population?
a. Hypotension
b. Hypokalemia
c. Muscle cramps
d. Hyponatremia
c - Muscles cramps are included in a variety of symptoms that occur in a uremic state. Additional symptoms include skeletal deformity, twitching, severe pruritus, CHF and coronary insufficiency and hypertension. Encephalopathy may occur as the patient’s condition worsens and death approaches.
End-stage liver disease creates hepatic failure from a number of etiologies. One of the
indications of advanced liver disease is ascites. Of the following, which is a major risk of ascites?
a. Hepatic encephalopathy
b. Esophageal varices
c. Respiratory compromise
d. Liver capsule pain
c - Respiratory compromise, spontaneous bacterial peritonitis and hepatorenal syndrome (HRS) are major risks of ascites. In its most virulent form (type I) there is an inexorable worsening of TOP
Certain comorbid illnesses are predictors of poor outcomes in the patient with advanced HIV
disease. Of the following, which is NOT one of them?
a. Liver decompensation
b. Metastatic neoplasms
c. Treatable infections
d. Progressive encephalopathy
c - Opportunistic infections are common in this patient population, but if they respond to treatment, they are not a predictor of poor outcomes. Other options noted are included as predictors of poor outcomes, in addition to lymphomas unresponsive to treatment, substance abuse and opportunistic infections which are not responsive to treatment
Many hospice patients have the comorbidity of diabetes mellitus, either type I or type II. Often,
this is a major contributor to the development of the patient’s terminal diagnosis. Therefore, it
is important for hospice nurses to be aware of the variety of complications that may arise from
diabetes. Of the following, which is a symptom of the diabetic complication of autonomic
neuropathy?
a. Recurrent infections
b. Postural hypotension
c. Multi-organ failure
d. Peripheral vascular disease
. b - Postural hypotension is included in the various symptoms associated with autonomic neuropathy associated with diabetes. Other symptoms include persistent tachycardia, neurogenic bladder, incontinence of urine or feces and diabetic nephropathy. Other complications of diabetes mellitus include diabetic retinopathy, peripheral vascular and coronary artery disease, impaired gastrointestinal motility, diabetic neuropathy, recurrent infections, impaired wound healing and multi-organ failure
Although much progress has been made in the treatment of HIV, what remains a major concern
regarding this disease?
a. Viral mutations
b. Limited prognosis
c. Lack of screening
d. None of the above
. a - The most concerning, complex factor regarding HIV is its continued ability to mutate in addition to the crossing of socioeconomic, cultural, political and geographic borders. 48. d - All of the above along with micronutrients, surveillance of symptoms and prophylactic treatment are all important factors for health promotion in the HIV population.
Which of the following are important factors in the health promotion of palliative care patients
with HIV?
a. Diet
b. Exercise
c. Stress management
d. All of the above.
. a - The most concerning, complex factor regarding HIV is its continued ability to mutate in addition to the crossing of socioeconomic, cultural, political and geographic borders. 48. d - All of the above along with micronutrients, surveillance of symptoms and prophylactic treatment are all important factors for health promotion in the HIV population.
Frank is a 74-year-old hospice patient who was diagnosed with non-Hodgkin’s lymphoma 8 years ago
and underwent treatment with subsequent remission. The lymphoma recurred 1 year ago and has
been unresponsive to chemotherapy and surgical intervention. He has been hospitalized, in a
rehabilitation facility or nursing home for the past 8 months, with decreasing mental and physical
capacity along with significant weight loss and dependence for all activities of daily living. He has now
been at home with hospice care for the past 4 days and has been primarily unresponsive the majority
of that time but appears comfortable.
50. Which of the following symptoms would be indicative of imminent death in Frank?
a. Increased urinary output
b. Increased intake
c. Increased activity
d. Increased heart rate
d - As death becomes more imminent, the heart rate can double, but with decreased contraction due to decreased blood pressure and overall fluid volume as a result of dehydration. Urine output, intake and activity would remain decreased as signs of imminent death, not increased
Of the following, which statement is most accurate in terms of the pain experience?
a. 40-50% of patients have severe pain.
b. 70-90% of patients with advanced disease experience pain.
c. Pain scores (on a 0-10 scale) ≥ “8” greatly impact quality of life.
d. It is estimated that 45-50% of all patients could be pain free
b - Pain is experienced by 70-90% of patients with advanced disease. Of these patients, 40-50% experience moderate pain, and 25-30% have severe pain. Pain scores (on a 0-10 scale) ≥ “4” greatly impact quality of life. It is estimated that 85-90% of patients could be pain free, and 98-99% could have their pain controlled, using the knowledge and methodologies available today
Which of the following most accurately describes “breakthrough” pain?
a. Associated with pathological fractures
b. Refers to a new psychological or spiritual insight
c. Can occur as end-of-dose failure
d. An aspect of opioid pseudo-addiction
C
If Roberta becomes unable to communicate verbally, what will be the most important aspect of
her pain assessment?
a. Family/caregiver input
b. Her pain level prior to losing ability to verbalize
c. Change in behavior
d. Her vital signs
c - Change in behavior is the gold standard in assessing pain in the individual who is cognitively impaired or unable to communicate verbally. A furrowed brow is an excellent indication that the patient is uncomfortable and can be used as an indication of the effectiveness of the pain management regimen. Family and caregiver input is also a critical component
What are the three etiologies of cancer pain syndromes?
a. Direct tumor involvement, cancer therapy and non-cancer pain
b. Neuropathic pain, visceral pain and bone pain
c. Hollow organ pain, peripheral neuropathy and somatic pain
d. Phantom limb pain, ischemic pain and sensory neuron pain
a - The three etiologies of cancer pain syndromes are pain associated with direct tumor involvement, pain associated with cancer therapy and pain unrelated to cancer or cancer therapy. Many patients have pre-existing pain which occurs in other sites and may not be related the patient’s cancer diagnosis.
Statistics indicate that 30-97% of patients with AIDS experience pain. Of this, what percentage is
estimated to be directly related to HIV infection?
a. 40%
b. 20%
c. 70%
d. 50%
d - It is estimated that 50% of the pain that patients with AIDS experience is directly related to HIV infection, and 30% is related to therapy. HIV pain is usually classified similarly to cancer pain syndromes in that there is pain directly related to the virus, pain related to the treatment, and non-related pain. Nearly one half of pain in HIV/AIDS is neuropathic pain, which spares no part of the nervous system. Pain may result from direct viral infections, infection with secondary pathogens, or be a side effect of drug therapy (neurotoxic). Central or peripheral manifestations and, particularly, painful peripheral neuropathies, generally follow the stage of HIV. Knowledge about the stage of the disease is imperative in the diagnosis of painful conditions as they vary by stage
Of the following, which type of pain is common in patients with multiple sclerosis (MS)?
a. Ischemic pain
b. Bone pain
c. Neurological pain
d. Visceral pain
c - Neurological pain is common in patients with multiple sclerosis (MS). Examples include paroxysmal trigeminal neuralgia, optic neuritis, periorbital pain and extremity pain. Musculoskeletal pain is also common, and presents as extremity pain and low back pain. Pain is experienced in 55-82% of individuals with MS.
When is pain most often experienced after a stroke?
a. Several weeks
b. Several days
c. Several months
d. Several years
. c - The medical literature estimate of the prevalence of chronic post-stroke pain ranges from 32- 42% at four to six months and 11-21% at twelve to sixteen months after a stroke. Shoulder pain alone has been found to affect up to 72% of post-stroke survivors. If one were to include other causes of post-stroke pain, this number could be significantly higher. It is usually accompanied by decreased temperature sensation, may be deep or superficial, and can be severe. Allodynia (painful response to a normally innocuous stimulus) and hyperalgesia (increased response to a painful stimulus) are often present. Mechanical shoulder pain is another common post-stroke pain syndrome, though it is unrelated to the cerebral injury.
Hilda is an 89-year-old patient with a diagnosis of Alzheimer’s disease. Recently, she fell, and
fractured her left hip. She underwent surgery for a hip replacement. When you visit her in the
hospital, she is noted to be having a great deal of post-operative pain, for which she is receiving
prn dosing of pain medication. Of the following, what type of pain most accurately describes
Hilda’s situation?
a. Chronic pain
b. Acute pain
c. Visceral pain
d. Refractory pain
. b - Hilda is having acute pain, which usually has a clear cause, is reversible and has observable signs. In contrast, the cause for chronic pain is often not clear. Chronic pain can create decreased social interaction, depression and insomnia. There may not be any observable or behavioral signs of chronic pain.
Ron is a 66-year-old patient with a diagnosis of colon cancer with liver metastasis. When
reporting his pain, he describes it as a “cramping” pain in his abdomen, which often “aches”.
What type of pain is Ron experiencing?
a. Somatic pain
b. Referred pain
c. Neuropathic pain
d. Visceral pain
d - Ron is experiencing visceral pain, which is often difficult to localize, and may be described as “cramping”, with a sensation of aching and pressure. This type of pain can be controlled with conventional analgesics, antispasmodics, and possibly antineoplastic agents, depending upon the situation.
What type of physical pain responds well to anti-depressant medications as a primary or
adjuvant analgesic?
a. Visceral pain
b. Nociceptive pain
c. Neuropathic pain
d. Bone pain
. c - Neuropathic pain responds well to anti-depressants, anticonvulsants and corticosteroids as either primary or adjuvant analgesics. This type of pain is described as sharp, burning and shooting. Examples include spinal nerve compression, invasion of nerves by tumors, post-herpetic neuralgia and post-stroke pain syndromes
What is a common site of referred pain for the patient who has gallbladder or liver disease?
a. Left shoulder
b. Right arm
c. Right shoulder
d. Sacrum
. c - A patient with gallbladder or liver disease may have referred pain to the right shoulder or back. Referred pain is a phenomenon in which pain is experienced distant from the site of origin. Pain from tumors in the pancreas, lower esophagus, stomach or retroperitoneal area may be referred to the back
Rebecca is a 49-year-old with end stage lung cancer who has been on morphine sulfate for pain
for one week. She has quickly developed a tolerance for the side effects of opioids, except one.
Of the following, which one would that be?
a. Respiratory depression
b. Sedation
c. Constipation
d. Nausea
. c - Tolerance develops quickly for the side effects of opioids, with the exception of constipation. The patient’s body will never adjust to this side effect, and therefore the patient must remain on an appropriate bowel regimen that typically consists of a stool softener and cathartic for the duration of opioid therapy. Additional orders are usually in place to adjust the bowel regimen to effect according to specific guidelines
Of the following, which medication does not have a dosage ceiling and can be titrated to effect?
a. Codeine
b. Morphine
c. Hydrocodone
d. Nalbuphine
. b - Morphine is a pure opioid agonist and does not have a dosage ceiling, therefore, it can be titrated to effect. Though there is no dosage ceiling, side effects, such as constipation, will become more severe at higher doses, so adjustments to the bowel regimen must be made as the opioid dosage is increased. In addition, morphine also has the active metabolites morphine 6-glucuronide (M6G) and morphine 3-glucuronide (M3G) which may be retained more by the elderly and those with decreased renal function. Increased M3G levels can produce myoclonus, and increased M6G levels can cause sedation.
When using transdermal delivery systems for patients who are cachectic, which of the following
is an appropriate consideration?
a. They may need lower doses than a person of normal weight.
b. They may need higher doses than a person of normal weight.
c. This is not an appropriate delivery system for cachectic patients.
d. None of the above
b - Studies have indicated that cachectic patients have lower blood levels of the medication being delivered through a transdermal system due to decreased subcutaneous tissue available for absorption. Therefore, such patients may need higher doses than the person of normal weight. In addition, these patients may also experience more erratic absorption of the drug.
Of the following, which tricyclic antidepressant is NOT the preferred choice for use in treating
neuropathic pain?
a. Amitriptyline
b. Nortriptyline
c. Desipramine
d. All of the above
. a - Of the tricyclic antidepressants, amitriptyline is not the preferred choice for use for treating neuropathic pain, due to increased side effects from anticholinergic actions. These include dry mouth, constipation, mentation changes and cardiac changes.
Of the following, what are the most common side effects that the patient should be monitored
for when using tricyclic antidepressants?
a. Sedation, orthostatic hypotension, urinary retention
b. Sedation, tremors, urinary frequency
c. Sedation, cardiac impairment, increased bleeding
d. Sedation, respiratory depression, gastropathy
. a - The most common side effects of tricyclic antidepressants are sedation, orthostatic hypotension, urinary retention and cardiovascular impairment. Dosage should be adjusted according to the patient’s wishes if side effects become burdensome
Of the following, what other class of medications can be used as an adjuvant to treat
neuropathic pain?
a. Serotonin selective reuptake inhibitors (SSRIs)
b. Serotonin-norepinephrine reuptake inhibitors
c. Anticonvulsants
d. Both b and c
d - Both anticonvulsants and serotonin-norepinephrine reuptake inhibitors are additional classes of medications that can be used as adjuvant medications to treat neuropathic pain.
Margaret is a newly admitted 65-year-old with a diagnosis of stage IV breast cancer with metastasis to
the lungs and brain. She has been confused, agitated, is very sensitive to touch and her pain is not
well-controlled with her current pain management regimen which includes transdermal fentanyl. The
hospice medical director would like to convert her to oral morphine and states he may reduce her
dose of the new medication by 25%
Of the following, what non-pharmacologic interventions would be most appropriate to add to
Margaret’s pain regimen at this time?
a. Music therapy
b. Physical therapy
c. Massage therapy
d. Counseling
a - Since, at this time, Margaret is confused, agitated and sensitive to touch, the best nonpharmacologic option to add to her regimen would be music therapy. All other options either include physical touching or the ability to function cognitively at a higher level. Once Margaret’s basic need for adequate pain management is met, these options may be appropriate
When you explain the new dosing schedule to Margaret’s husband, he states that he never gives
her a rescue dose when she is due for her long-acting dose at the same time, even if she is in a
lot of pain. He states that he’s afraid he’ll “kill” her with an overdose. Of the following, what
would be the most appropriate response?
a. His fears are warranted and he’s wise to be careful
b. He can hold the long-acting dose when he gives the rescue dose
c. The long-acting dose is released over an extended period
d. Consult with the social worker to help him with his fears
. c - The most appropriate response would be to provide Margaret’s husband with education about how the long-acting agent and short-acting agent work differently to provide optimal pain relief for Margaret. Since the opioid in the long-acting agent is released over an extended period of time, giving Margaret her rescue dose at the same time will not “overdose” her, and will provide optimal pain relief quickly. The long-acting agent provides a consistent blood level of opioid for pain relief, and the short-acting agent provides needed intermittent treatment that is quickly available for Margaret’s pain if it worsens.
Since hospice care involves the patient and family, what additional interventions may be helpful
for Margaret’s husband as he deals with the challenges of changes in her condition?
a. Ask the hospice medical director to prescribe an anti-anxiety agent for him
b. Collaboration with the hospice chaplain and social worker
c. Offer to have the hospice massage therapist give him a massage
d. Ask the hospice physical therapist to provide treatment for his back pain
b - Collaboration with the interdisciplinary team is a critical aspect of hospice care. Involving the hospice chaplain and social worker is an excellent means of providing support for the entire patient/family unit. Unfortunately, nurses may sometimes focus too much on pharmacologic/physical interventions, and/or tend to function too independently. Hospice care is a wonderful collaborative effort, in which all team members play an equally vital role in meeting the physical, psychosocial and spiritual needs of the patient and family unit
After meeting with the hospice counselor, Rachel states that she is ready to try a few
alternatives to pain medicine to try to decrease her pain. She says the counselor mentioned
reiki, aromatherapy, music therapy and massage therapy. She states she is still not used to
interacting with so many people and does not want to feel invaded. In light of her feelings,
which of the following would be the most appropriate non-pharmacologic options for Rachel?
a. Massage and music therapy
b. Reiki therapy and massage
c. Aromatherapy and massage
d. Reiki and aroma therapy
d - Since Rachel does not like much stimulation, non-touch therapies would likely be most appropriate for Rachel at this point. Reiki (a non-touch energy therapy) and aromatherapy would be excellent options according to Rachel’s wishes.
Nausea is also a common side-effect of opioid use. If Rachel experiences this, what education
can you provide that may be helpful for her?
a. Opioid-induced nausea never goes away
b. Opioid-induced nausea is very difficult to treat
c. Opioid-induced nausea usually resolves after about a month
d. Opioid-induced nausea usually resolves after about a week
. d - It would be helpful to educate Rachel regarding the fact that opioid-induced nausea usually resolves after about a week of starting the medication. With a diagnosis of pancreatic cancer, Rachel may have more than one etiology for her nausea, therefore, it will be important to try to determine causative factors in order to provide appropriate treatment
If Rachel continues to have nausea, of the following, what interventions would be appropriate?
a. Bland foods, identify etiology
b. Serve foods warm, administer metoclopramide
c. Warm environment, administer scopolamine patch
d. Decrease meal frequency, administer dexamethasone
a - Nausea can be due to a variety of factors in this patient population, therefore, if it’s possible to determine etiology, this will guide pharmacologic intervention to the appropriate agent. Diet modifications, such as eating bland foods, small frequent meals and avoiding greasy or fatty foods may be helpful. Additionally, serving foods at room temperature or cold may help decrease the odor of food preparation, which can add to nausea. If opioid-induced nausea doesn’t resolve, treatment with butyrophenones (ie, haloperidol or droperidol) may be helpful
David is a 45-year-old patient with liver cancer who belongs to a religious order that does not believe
in using any type of medications for any reason. Therefore, he states he will not accept medication for
his pain, no matter how bad it gets.
123. Of the following, what is the most appropriate response?
a. Ask the hospice chaplain to help change his mind
b. Support his decision and provide alternative therapies
c. Provide educational materials about pharmacologic interventions for pain
d. Ask his family to intervene
b - Providing alternative therapies and supporting David’s decision is the appropriate response. This honors his value system, and provides him with non-judgmental support of his decision. The role of the hospice professional is to provide options and optimize care and comfort in the context of the patient’s right to self-determination.
Emily is a 79-year-old with ovarian cancer who was started on morphine two days ago for the first
time. When you call to check on her, she reports excessive generalized itching. Upon visiting, you find
her restless with a flat red rash over her upper chest and abdomen.
125. What do you suspect is happening with Emily?
a. Side effect of morphine
b. Allergic reaction to morphine
c. Dermatitis from environmental factors
d. Food allergy
. b - Emily is most likely having an allergic reaction to morphine, since it was recently started, and she had not had it previously. Although itching is a common side effect of opioids, a new rash should cause suspicion for an allergic reaction and be treated accordingly
