symptom management mgmt - extended ver… · kennedy terminal ulcer •sudden onset ... •drugs...
TRANSCRIPT
![Page 1: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/1.jpg)
Symptom Management
Mady Stovall RN, MSN, ANP-BC
![Page 2: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/2.jpg)
Acknowledgments
• Materials for this series has been adapted from the following sources:
– Core Curriculum for the Licensed Practical/Vocational Hospice and Palliative Nurse; Second Edition (2010) Tami Borneman, editor
– The End-of-Life Nursing Education Consortium (ELNEC) Project is a national end-of-life educational program administered by City of Hope (COH) and the American Association of Colleges of Nursing (AACN) designed to enhance palliative care in nursing. The ELNEC Project was originally funded by a grant from The Robert Wood Johnson Foundation with additional support from funding organizations (Aetna Foundation, Archstone Foundation, California HealthCare Foundation, Cambia Health Foundation, Milbank Foundation, National Cancer Institute, Oncology Nursing Foundation, Open Society Institute and US Department of Veterans Affairs). Further information about the ELNEC Project can be found at www.aacn.nche.edu/ELNEC. Copyright City of Hope and American Association of Colleges of Nursing, 2006; Revised 2013.
– Copyright for the TNEEL curriculum and teaching materials is held by Diana J. Wilkie and the Investigators and Staff Members of the TNEEL Project at the University of Washington School of Nursing. The copyright holders grant to all TNEEL users the permission to use, modify, or duplicate program materials for educational purposes. Participants may use or modify curriculum materials with appropriate citation, and duplicate all materials, including those originally copyrighted by others who have granted permission for duplication to the TNEEL project as long as the use is for educational purposes. This permission from the TNEEL team and other copyright holders extends to all persons who have been provided TNEEL materials by Dr. Wilkie, one of the TNEEL Investigators, or a TNEEL staff member.
![Page 3: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/3.jpg)
Module Objectives At the completion of this module participants will be able to:
1. Describe the principles of symptom management
2. Identify common symptoms associated with life-limiting and life-threatening illnesses.
3. Identify potential causes of symptoms.
4. Describe assessment of symptoms.
5. Describe interventions that can prevent or diminish symptoms.
6. Participate in individual and family education
![Page 4: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/4.jpg)
Essential Elements
• Ongoing assessment & evaluation
• Requires interdisciplinary teamwork
• Reimbursement
– Affordable options
• Research needed
ELN
EC
Core
Curr
iculu
m
Coyne, 2007; Coyne et al., 2010
![Page 5: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/5.jpg)
Palliative vs. Curative
J Palliat Medicine 2012; 15(1): 106-14
![Page 6: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/6.jpg)
LVN Role in Symptom Mgmt
• Use the nursing process
–Assessment, Diagnosis, Planning, Intervention, Evaluation
• Multidimensional care, emphasizing QOL as defined by pt/family, w/ respect for, support & education of pt/family
![Page 7: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/7.jpg)
LVN Role in Symptom Mgmt
• Understanding expectations, goals of treatment, & end-of-life goals
• Facilitate palliative &/or EOL care by maximizing pt comfort to potentially enable a time of growth, reconciliation, peace, joy, & hope
![Page 8: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/8.jpg)
Symptoms by Systems
1. Skin & Mucous Membranes
2. Respiratory Symptoms
3. Cardiovascular
4. Gastrointestinal
5. Genitourinary
6. Musculoskeletal
7. Neurologic Symptoms
– Mental Status
![Page 9: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/9.jpg)
Structure of this lecture
• Common symptom
– Definition
– Causes
– Observation & reporting
– Nursing interventions
![Page 10: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/10.jpg)
Symptoms & Suffering
• Symptoms create suffering & distress
• Psychosocial intervention is key to complement pharmacologic strategies
• Need for interdisciplinary care
ELN
EC
Core
Curr
iculu
m
![Page 11: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/11.jpg)
Sxn Mgmt in Older Adults
• May have several symptoms w/ multiple co-morbidities
• Majority of hospice diagnoses are non-cancer related, associated w/ heavy symptom burden (Ritchie, 2011)
– Heart failure
– COPD
– Dementia
– Other
• Social isolation
ELN
EC
Core
Curr
iculu
m
![Page 12: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/12.jpg)
Section 1: Skin & Mucous Membranes
![Page 13: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/13.jpg)
Integumentary Symptoms
• Alteration in Skin & Mucous Membranes
– Disruption in the integrity of the skin or oral mucous membrane
• Associated Nursing diagnosis
– Impaired skin integrity
– Pain
– Body image disturbance
– Knowledge deficit
![Page 14: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/14.jpg)
Impaired Skin - Causes • Pressure ulcers
• Skin pressure blood flow & cell death
• Shearing forces
• Friction
• Moisture
• Obesity
• Malnutrition
• Immobility
• Circulatory impairment – DM, PVD, CA
• Fistulas
• Tumor Necrosis
![Page 15: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/15.jpg)
Skin Assessment • Inspect
– Wound location
• Grade any pressure ulcers (Stage I-IV)
• Size, length, width, depth, undermining
• Drainage?
• Tissue type (i.e., granular or eschar)
• Surrounding skin?
– Pain?
– Potential for complications
– Odors?
– Nutritional status?
![Page 16: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/16.jpg)
Malignant Wounds
• AKA: Fungating tumors, tumor necrosis, ulcerative malignant wounds
• Adds to the physical and emotional burden of pt/caregiver
• Adds to low self-esteem – Odor, pain, bleeding, unsightly
• May add to isolation
• Painful
• Costly
Seaman & Bates-Jensen, 2010
![Page 17: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/17.jpg)
Kennedy Terminal Ulcer
• Sudden onset – “That ulcer was not there when I started my shift”
• Usually starts on the sacrum
– Shaped as a pear, butterfly, horseshoe
– Red, yellow, black, or purple in color
– Generally has irregular borders
– Progresses quickly
![Page 18: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/18.jpg)
Treatment of Wounds
• Frequent position changes
– Turn at least q 2 hours
– Utilize pressure relief & pressure reduction support surfaces
• Seek consultation
– Dietary
– Wound/enterostomal nurse PRN
– Consult AHRQ guidelines
Seaman & Bates-Jensen, 2010
![Page 19: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/19.jpg)
Diabetic foot infection progression over 10 days
![Page 20: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/20.jpg)
Treatment of Wounds
• Provide analgesia in advance
• Wound cleaning
• Dressings
– Select the appropriate type
• Moist wound bed
• Dry surrounding skin
• Exudate control
• Caregiver time
• PREVENTION is key
Seaman & Bates-Jensen, 2010
![Page 21: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/21.jpg)
Dilemma: Wounds in Pts 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
![Page 22: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/22.jpg)
Alterations in Skin
• Pruritus – Uncomfortable itching of the skin
• Dry, flaky skin
• Wet, macerated skin
• Contact dermatitis
• Infestations (scabies, lice, fleas)
• Drugs (abx, MSO4, phenothiazines)
• Systemic disease
• Fungal infections
![Page 23: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/23.jpg)
Itch Man Scale
Itch Man Scale to rate itching intensity in children
Designed by Blakeney and Marvin 2000
Shriners Hospital for Children
![Page 24: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/24.jpg)
Assessment - Pruritus
• Hx of itching
– When, how long, where, what is tolerable?
• Examination
– Rashes or lesions?
– Abrasions?
– Overall skin integrity?
• Review of medication use/orders
![Page 25: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/25.jpg)
Pruritus: Nursing Interventions
• Non-pharmacologic
– Avoid irritants
• Alcohol containing agents
• Tight or heavy clothing
• Frequent bathing w/ harsh soaps & hot water
– Cool starch baths
– Avoid heat – keep room cool
– Apply lubricating ointments or creams to skin to avoid excessive drying
– Avoid alcohol, foods/drinks w/ caffeine, theophylline
![Page 26: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/26.jpg)
Pruritus: Nursing Interventions
• Pharmacologic
– Antihistamines
• Hydroxyzine & Diphenhydramine
– Ondansetron & Cholestryamine may be used in cholestatic, uremic, & opioid-induced pruritus
– Topical corticosteroids
– Antifungals for itching r/t Candida
– TENS units may be helpful
![Page 27: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/27.jpg)
Impaired Mucous Membranes
• Dry mouth
– Candidiasis, Meds, RT/Chemo,
– Dehydration, Mucositis, Mouth breathing,
– Metabolic issues
• Candidiasis
– RT, Chemo, Mucositis
– HSV, Meds
![Page 28: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/28.jpg)
Oral Mucositis
World Health Organization (WHO) Grading
![Page 29: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/29.jpg)
Candidiasis – aka THRUSH
![Page 30: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/30.jpg)
Assess – Alt Mucous Membrane
• Pt history
• Review medications
• Examination
– Dry cracked lips
– Sores/white patches on buccal membranes, oropharynx, tongue
– Bleeding lips, gums, tongue
• Pt current oral hygiene regimen?
• Pt/family knowledge of causes/mgmt
![Page 31: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/31.jpg)
Candida, HSV, Mucositis, Stomatitis Interventions
• ATC oral care at least every 2 hours w/ moistened oral swabs
• 1:4 hydrogen peroxide & water rinse for mucous or hard debris in mouth
• Candida
– Nystatin swish & spit
– Fluconazole tablets or suspension
![Page 32: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/32.jpg)
Oral Interventions continued
• Avoid overly hot or spicy food
• Possible medications &/or cocktails
– Topical morphine
– Viscous lidocaine
– Sucralfate slurry
– Miracle Mouthwash
• MOM, diphenhydramine, viscous lidocaine
![Page 33: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/33.jpg)
Xerostomia
• Stimulate saliva or utilize substitutes
– Peppermint water
– Gums, mints, hard candy
– Ice chips or frequent sips of water
• Review meds & alter regimen PRN
![Page 34: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/34.jpg)
Xerostomia
![Page 35: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/35.jpg)
Xerostomia
• Treat dehydration
– Offer fluids frequently
– Humidification
– Spray bottle close to pt
– Oral swabs (AVOID lemon-glycerin)
![Page 36: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/36.jpg)
Symptoms by Systems
1. Skin & Mucous Membranes
2. Respiratory Symptoms
3. Cardiovascular
4. Gastrointestinal
5. Genitourinary
6. Musculoskeletal
7. Neurologic Symptoms
– Mental Status
✔
![Page 37: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/37.jpg)
Section 2: Respiratory Symptoms
![Page 38: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/38.jpg)
Respiratory Symptoms
• Dyspnea
– A subjective sensation of shortness of breath
– “Air hunger”
• Cough
– A natural defense of the body to prevent entry of foreign material into the respiratory tract
![Page 39: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/39.jpg)
Causes of Dyspnea
• Major pulmonary causes
– Obstructive or Restrictive
– Vascular
– Interstitial or Alveolar diseases
• Major cardiac causes
– Myocardial, Valvular, Arrhythmias, Restrictive
ELN
EC
Core
Curr
iculu
m
![Page 40: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/40.jpg)
Causes of Dyspnea
• Major neuromuscular causes
– AML, muscular dystrophies, phrenic nerve palsy, poliomyelitis
• Other potential causes
– GI, Anemia, Pain, Obesity, Fatigue
ELN
EC
Core
Curr
iculu
m
![Page 41: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/41.jpg)
Assessment of Dyspnea
• Use subjective report
– Fever? Productive/nonproductive cough? SOB? Infections? Exertional dyspnea? Medication use AND response to meds? Chemical exposures? Tobacco use? Hemoptysis? Weight loss? Pain? Prior thrombosis? Nocturnal dyspnea? Hx of NM disease? Hx of anxiety/depression/trauma/abuse?
ELN
EC
Core
Curr
iculu
m
Wahls, S. (2012). Causes and evaluation of chronic dyspnea.
American Family Physician, 86(2), 173-180.
Dudgeon, 2010.
![Page 42: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/42.jpg)
Assessment of Dyspnea
• Clinical assessment
– Physical exam
• Fever? Crackles, Clubbing? Wheezing? Barrel chest? Breath sounds decreased or not symmetric? Accessory muscle use? Lower extremity swelling? JVD? Irregular rate/rhythm? Decreased heart sounds? Frequent sighing?
– Up to 66% pts may achieve diagnosis based on clinical presentation alone
• Diagnostic tests
Dudgeon, 2010.
ELN
EC
Core
Curr
iculu
m
Wahls, S. (2012). Causes and evaluation of chronic dyspnea.
American Family Physician, 86(2), 173-180.
![Page 43: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/43.jpg)
Assessment of Dyspnea
• May lead to identification of a treatable condition
– Pleural effusion
– Pneumothorax
– Anemia
– Pulmonary Embolism
– Heart failure
– Pneumonia
ELN
EC
Core
Curr
iculu
m
![Page 44: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/44.jpg)
Treatment of Dyspnea
• Treating symptoms or underlying cause
• Pharmacologic treatments
– Opioids
– Non-opioids
Clemens & Klaschik, 2007;
Dudgeon, 2010
ELN
EC
Core
Curr
iculu
m
Papaver Somniferum Poppy
![Page 45: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/45.jpg)
Dyspnea + Cough Medication Interventions
• Opioids
– PO, SL, SQ, IV, Nebulized
• Promotes bronchodilation
• Start low (i.e., 5 mg po q2hr PRN) for naïve pts & pts w/ CO2 retention
• High dose steroids • For obstructive or inflammatory causes
• Antibiotics
• Anxiolytics
• Sedation at end of life may be necessary
![Page 46: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/46.jpg)
Non-productive Cough Medication Interventions
• Non-opioid or opioid antitussives
– Dextromethorphan
– Benzonatate
• Inhaled anesthetic
– Nebulized lidocaine for 10 min q2-6 hrs
– NPO for 1 hr post-inhaled anesthetic due to risk of aspiration
![Page 47: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/47.jpg)
Managing Dyspnea
• Non-pharmacologic
– Oxygen if appropriate
– Counseling
• Relaxation, Model calm reassurance, Guided imagery, Therapeutic touch
– Pursed lip breathing
– Energy conservation
– Fans +/- Humidity
– Elevation
– Other
• Palliative thoracentesis or paracentesis
ELN
EC
Core
Curr
iculu
m
![Page 48: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/48.jpg)
Symptoms by Systems
1. Skin & Mucous Membranes
2. Respiratory
3. Cardiovascular Symptoms
4. Gastrointestinal
5. Genitourinary
6. Musculoskeletal
7. Neurologic Symptoms
– Mental Status
✔ ✔
![Page 49: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/49.jpg)
Cardiovascular Symptoms
• Hematologic Symptoms
• Edema
![Page 50: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/50.jpg)
Hematologic Symptoms
• Hemorrhage
– Excessive bleeding
• Clotting
– Systemic response to disease or medication that initiates coagulation cascade causing clotting
![Page 51: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/51.jpg)
Hematologic Symptoms
• Cytopenias
– Reduction in bone marrow blood cell components, which can precipitate a systemic response
• Neutropenia – Low white blood cells
• Thrombocytopenia – Low platelets
• Anemia – Low red blood cells
• Pancytopenia – Reduction in all cells
![Page 52: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/52.jpg)
Hematologic Symptoms
• Clotting issues
– DVT
– Pulmonary embolism
– Immune issues
– Prosthetic heart valve
– Medication induced
– Disease induced
– Treatment related
• Chemo
• RT
![Page 53: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/53.jpg)
Hematologic Symptoms
• Bleeding/clotting/production issues
– Medication induced
– Disease induced
• Immunologic processes
– DIC
– Erosion of vessels due to tumor
– Treatment related
• Chemo
• RT
![Page 54: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/54.jpg)
Hematologic Assessment
• Medical history
• Review current meds, food, herbal interactions with treatment
• DVT
– Recent surgery? Immobility? Vascular access devices?
• PE
– Chest pain? Dyspnea?
![Page 55: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/55.jpg)
Hematologic Assessment
• Review CBC results
– Low platelet count
• Petechiae? Epistaxis? Gum bleeding? Sputum? Emesis? Urine or stool? Vaginal bleeding? Ecchymosis? Joint pain? Change in mental status?
![Page 56: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/56.jpg)
DVT/PE interventions
• Anticoagulant therapy
• Monitor other or new medications
• Anti-embolic stockings
• Treat dyspnea
• Treat pain
![Page 57: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/57.jpg)
Low PLT interventions
• If palliative care
– Bleeding precautions
– Transfusion of platelets if necessary
• If Hospice
– Bleeding precautions
– Treat bleeding with compression
– Other potential comfort measures
![Page 58: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/58.jpg)
Neutropenic interventions
• Significant efforts to reduce risk of infection to patient
– Avoid crowds
– Isolation precautions
– Wash/peal/cook foods
– HANDWASHING
– Avoid visitors with known infections
![Page 59: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/59.jpg)
Anemia interventions
• Transfusion if necessary
• Energy conservation measures
• Medication interventions if necessary
![Page 60: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/60.jpg)
Edema
• Presence of excessive fluid in the intercellular tissues especially in the subcutaneous tissues
![Page 61: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/61.jpg)
Causes of Edema
• Protein deficiency
• Obstruction of venous return
• Renal failure
• Lymphedema
• Ascites of liver failure
![Page 62: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/62.jpg)
Assessing Edema
• Review medical history
• Cause of edema will direct plan
• Any new or changing edema?
• Extremity edema? Pitting? Perfusion? Temperature? Weeping of fluid?
• Ascites?
• SVC Syndrome
![Page 63: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/63.jpg)
Interventions for Edema
• Cause will direct interventions
• Symptomatic relief – Peripheral edema
• Compression stockings
• Diuretics
• Meticulous skin care
• ROM to promote venous return
• Limb elevation above the heart
![Page 64: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/64.jpg)
Interventions for Edema
• Cause will direct interventions
• Symptomatic relief – Ascites
• Spironolactone
• Paracentesis
– Lymphedema
• Usually not responsive to diuretics
• May not resolve despite elevation or compression stockings
• Manual drainage therapies may promote improved QOL in pts not actively dying
![Page 65: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/65.jpg)
Symptoms by Systems
1. Skin & Mucous Membranes
2. Respiratory
3. Cardiovascular
4. Gastrointestinal Symptoms
5. Genitourinary
6. Musculoskeletal
7. Neurologic Symptoms
– Mental Status
✔ ✔
✔
![Page 66: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/66.jpg)
GI Symptoms
• Nausea & Vomiting
• Dysphagia
• Hiccups
• Anorexia & Cachexia
• Bowel Incontinence
• Bowel Obstruction
• Constipation
• Diarrhea
![Page 67: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/67.jpg)
Nausea & Vomiting
• Nausea
– A subjectively perceived, stomach discomfort ranging from stomach awareness to the conscious recognition of the need to vomit
• Vomiting
– The expelling of stomach contents through the mouth
![Page 68: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/68.jpg)
SOME Causes of N/V • Physiological
– Fluid & electrolyte imbalances
– GI disorders
• Psychological
• Disease related
– Neurologic disorders
– Renal failure
– Chemical
• Treatment related
• Other
![Page 69: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/69.jpg)
Assessment of N/V • History
– Timing & Duration
• Acute – Delayed – Anticipatory
– Aggravating or alleviating factors
– Volume & appearance of vomitus
• Physical Examination
– Oral infection? Abdominal pain, cramping, distention, bowel sounds? Neuro?
• Lab values
• Dehydration
![Page 70: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/70.jpg)
Pharmacologic Tx of N/V
• Anticholinergics
– Primarily for vestibular or ICP etiologies
– May help reduce anxiety too
• scopolamine patch, hydroxyzine
• Antihistamines
– Primarily for visceral, vestibular, pharyngeal, or ICP causes
– Also may help in anxiety
• meclizine, dimenhydrinate
![Page 71: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/71.jpg)
Pharmacologic Tx of N/V
• Prokinetic agent
– For delayed gastric emptying
• metoclopramide
• Butyrophenones
– Opioid-induced nausea
• haloperidol or droperidol
• Steroids
– For a variety of causes of N/V
– Should be a short-term intervention
• dexamethasone, methylprednisolone
![Page 72: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/72.jpg)
Pharmacologic Tx of N/V
• 5-HT3 antagonists
– Helpful post-chemotherapy, radiation, post-operatively, or for a variety of disease conditions
• ondansetron, granisetron
• Substance-P inhibitor
– Helpful in delayed N/V only
• aprepitant
![Page 73: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/73.jpg)
Non-pharmacologic Tx of N/V
• Dietary modifications
– Bland food that pt enjoys
– Cool or room temp foods
– Small frequent meals
– Avoid fatty, greasy, spicy or very sweet foods
– Slow feeding
![Page 74: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/74.jpg)
Non-pharmacologic Tx of N/V
• Complimentary therapies
– Acupressure
– Ginger, Lavender
– Fans
– Cool room
– Relaxation techniques
![Page 75: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/75.jpg)
Dysphagia
• Dysphagia
– A subjective awareness of difficulty in swallowing
• Odynophagia
– Is a report of painful swallowing
![Page 76: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/76.jpg)
Phases of Swallowing
![Page 77: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/77.jpg)
Dysphagia • Possible causes
– Obstructive
• Cancers, other benign strictures of esophageal ring, compression of vessels or mediastinal nodes
– Motor
• NM, esophageal stasis, AML, Parkinson’s MS, dementia
– Systemic
• Scleroderma, inflammation, infections
– General deconditioning
• Fatigue, medications
![Page 78: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/78.jpg)
Assessing Dysphagia
• The cause directs the intervention plan
• History
– Oral care habits?
• Current nutritional status
– What are the current goals of care?
– What are the pt/family expectations?
• If accompanied by anorexia, evaluate for disease progression
– Discuss with team
![Page 79: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/79.jpg)
Odynophagia • Possible causes
– Inflammatory process
• Infection
– Dry mucous membranes
• Chemo, RT, anticholinergic or other meds
– Corrosive esophagitis
– Bronchoesophageal fistula with reports of “coughing after ingesting fluids”
![Page 80: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/80.jpg)
Assessing Odynophagia
• The cause directs the intervention plan
• History
– Onset, duration
– I&O
– Chemo, RT, DM AIDS
– Medications
• Physical
– Assess oral cavity
• Look at tongue, gingiva, mucosa, lips, saliva
• Lesions or patches?
![Page 81: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/81.jpg)
Swallowing Interventions
• Treat the underlying cause – Infection, mucositis, medications, etc.
– Consider steroids if obstruction
• Speech therapy consultation
– Swallow study
• Alter nutritional offerings as appropriate
• Artificial feeding may need to be considered
– Consider disease trajectory
![Page 82: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/82.jpg)
Hiccoughs
• An involuntary contraction of the diaphragm, followed by rapid closure of the glottis
![Page 83: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/83.jpg)
Anorexia & Cachexia
• Anorexia – Loss of appetite or inability to
take in nutrition
• Cachexia – Weight loss & wasting due to
inadequate intake of nutrition
![Page 84: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/84.jpg)
Anorexia Causes
• GI causes
– Constipation, N/V, Altered Mucous Membranes, Impaired gastric emptying, Change in food taste/smells
• Altered mental status
• Medications
– Opioids, antibiotics
• Fatigue
• RT/Chemo
• Pain
![Page 85: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/85.jpg)
Cachexia Causes
• nutritional losses r/t anorexia
• nutritional losses assoc. w/
– Bleeding
– Diarrhea
– Malabsorption
• Metabolic disorders
– Abnormal protein metabolism
– Abnormal carbohydrate metabolism
– Abnormal lipid metabolism
– Fluid & electrolyte imbalance
![Page 86: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/86.jpg)
Assessing Anorexia/Cachexia
• History
– Appetite
– Associated symptoms
– Pt food likes/dislikes
– Family impressions
– Medications
– Bowel habits
![Page 87: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/87.jpg)
Assessing Anorexia/Cachexia
• Physical examination
– Oral exam
– Abdominal exam
• Stool frequency & consistency
• Impaction?
• Bowel sounds
– S/S metabolic disorders
• Hypoglycemia, hypernatremia, hypokalemia, dehydration, hypercalcemia
– Pt/Family knowledge
![Page 88: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/88.jpg)
Treating Anorexia/Cachexia
• Dietary consultation
• Medications
• Parenteral/enteral nutrition
• Odor control
• Counseling
Earthman et al., 2002; MacDonald, 2003;
Wholihan & Kemp, 2010
![Page 89: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/89.jpg)
• Dietician referral – Nutritional supplements as appropriate
• Encourage small frequent meals
• Avoid strong odors
• Offer foods pt prefers
• Give permission to eat less
• Treat underlying cause – Manage N/V
Anorexia/Cachexia Interventions
![Page 90: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/90.jpg)
• Enteral feedings – GI function must be adequate
– Major decision if EOL
• Parenteral nutrition – Only if indicated
– Very rare at EOL
Anorexia/Cachexia Interventions
![Page 91: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/91.jpg)
Anorexia/Cachexia Interventions
• Pharmacologic interventions – Metoclopramide
– Dexamethasone
– Megestrol acetate
– Dronabinol
– Alcohol
– Vitamins
![Page 92: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/92.jpg)
Bowel Incontinence
• The inability to control bowel movements
![Page 93: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/93.jpg)
Possible causes of Bowel Incontinence
• Obstruction
• Diarrhea
• Sphincter damage
• Sensory or motor dysfunction
• Changes to sphincter tone
• Dementia
• Impaired mobility
![Page 94: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/94.jpg)
Assessing Bowel Incontinence
• History
– Urgency? Awareness? Frequency?
– Loose or formed?
– Impaction?
• Physical examination
– Mobility?
– Neurologic & sensory function?
– Skin integrity
![Page 95: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/95.jpg)
Interventions: Bowel Incont.
• Bowel regimen review/implementation
• Consider constipating medication
• Disimpact PRN
• Modify diet if needed/tolerated
• Maintain skin integrity
• Utilize incontinence products
• Alter environment
– Place close to toileting facilities
– Place on toilet after eating
![Page 96: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/96.jpg)
Constipation
• Difficulty in passing stools or an incomplete or infrequent passage of hard stools
![Page 97: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/97.jpg)
Causes of Constipation
• Obstruction
• Medications
– Opioids, TCA, 5-HT3 antagonists, antacids, diuretics, iron, VCR, HTN-meds, anticonvulsants, NSAIDs, anticholinergics or drugs with these effects
• Metabolic disorder
– calcium, potassium, hypothyroidism
![Page 98: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/98.jpg)
Causes of Constipation
• Diseases
– Colitis, diverticular disease
• Dietary problems
– Low fiber intake, inadequate fluid intake, dehydration
• Neurologic impairment
– Confusion, depression, sedation
![Page 99: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/99.jpg)
Causes of Constipation
• Weakness, inactivity, immobility
• Pain
• Changes in environment
– Decreased privacy
– Unfamiliar facilities
– Reluctant to ask for help
• Embarrassment
• Loss of independence
• Do not want to be a burden
![Page 100: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/100.jpg)
Assessment of Constipation
• History taking from pt/family/staff
– Bowel history
• Last 2-3 BMs
• Amount, color, consistency
• Straining or pain during defecation
• Current bowel regimen, if any
– Fluid & food intake
– N/V
– Flatus?
• Medication review
![Page 101: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/101.jpg)
Assessment of Constipation
• Physical examination
– Abdominal assessment
• Distention, tenderness, fullness or bloating, bowel sounds, palpable masses
– Digital rectal exam
• Hemorrhoids, rectal fissures, obstruction
– Mobility assessment
![Page 102: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/102.jpg)
Constipation Interventions
• Prevention is key!
• Rule out impaction/obstruction
– Pre-medicate +/- pain/anxiety med
• Non-pharmacologic interventions
– Increase fluid intake
– Encourage high-fiber foods
– Increase activity
– ASK what has been effective in the past
– Comfort measures if pain
• Warm sitz baths
![Page 103: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/103.jpg)
Constipation Med Interventions
• Stool softeners
• Stimulant laxatives
– Senna, biscodyl
• Osmotic laxatives
– Lactulose, sorbitol
• Escalate to suppository or enema
– Glycerin, biscodyl suppository
– Sodisum bisphosphonate enema
• Consider changing meds that may be causing the consipation
![Page 104: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/104.jpg)
Bowel Obstruction
• Occlusion of the lumen of the intestine, delaying or preventing the normal passage of feces
![Page 105: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/105.jpg)
Causes of Bowel Obstruction
• External compression of bowel
• Internal compression
• Ischemic or inflammatory process
• Fecal blockage
• Metabolic disorder
• Medications
• Often combination of causes
![Page 106: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/106.jpg)
Assessment - Obstruction
• History – Predisposing factors
• Cancer? Pancreatitis?
– Habits
– Medication use
– Pain
• Location? Duration? Frequency? Cramping? Aggravating/alleviating factors?
– N/V
![Page 107: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/107.jpg)
Assessment - Obstruction
• Physical examination – Distention
– Bowel sounds
– Constipation or inability to pass flatus
– Diarrhea
– Fever +/- chills
![Page 108: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/108.jpg)
Interventions - Obstruction
• Disimpact PRN
• Surgery may be needed
• Medication for pain
• STOP stimulant laxatives
• Treat N/V
• NG tube for gastric decompression PRN
• Increase oral fluids, if tolerated
![Page 109: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/109.jpg)
Diarrhea
• The frequent passage of loose, unformed, liquid stool
![Page 110: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/110.jpg)
Possible Causes - Diarrhea
• Laxative overuse
• Side effect of other med
• RT +/- chemo
• Food intolerance
• Tube feedings
• Malnutrition
• Fecal impaction
• Partial obstruction
![Page 111: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/111.jpg)
Possible Causes - Diarrhea
• Surgical procedures
– Gastrectomy, ileal resection, colectomy
• Infection
– Especially in the immune compromised
• Malignancies
• GI disorders
– Crohn’s disease, IBD, diverticulitis, ulcerative colitis, pancreatic insufficiency
• Chronic disorders
– DM & hyperthyroidism
![Page 112: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/112.jpg)
Assessment of Diarrhea
• History
– Stool appearance? Frequency? Recent chemo/RT? Medication use?
• Physical examination
– Abdominal assessment
– Nature & consistency of stool
– S/S dehydration
– Skin integrity
![Page 113: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/113.jpg)
Treatment of Diarrhea
• Increase fluid intake
• Clear liquids + light carbs advance as tolerated small frequent meals
• Disimpact PRN
• Discontinue laxatives
• Maintain skin integrity
![Page 114: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/114.jpg)
Treatment of Diarrhea
• Antidiarrheals
– Loperamide
– Diphenoxylate + atropine
– Opioids if pt not already taking
• Pancreatic insufficiency
– Pancreatic enzymes with meals
– Add loperamide to slow peristalsis
![Page 115: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/115.jpg)
Symptoms by Systems
1. Skin & Mucous Membranes
2. Respiratory
3. Cardiovascular
4. Gastrointestinal
5. Genitourinary Symptoms
6. Musculoskeletal
7. Neurologic Symptoms
– Mental Status
✔ ✔
✔
✔
![Page 116: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/116.jpg)
GU Symptoms
• Bladder Spasm
• Urinary Retention
• Urinary Incontinence
![Page 117: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/117.jpg)
Bladder Spasms
• Intermittent, painful contractions of the detrusor muscle, leading to suprapubic pain & urgency
![Page 118: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/118.jpg)
Bladder Spasms - Causes
• Indwelling catheter +/- issues associate with catheter
• UTI
• Tumor
• RT or chemo cystitis
• Urethral obstruction
• Neurologic disorders – Stroke, spinal cord lesions, MS
![Page 119: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/119.jpg)
Bladder Spasms - Assessing
• Medical causes – Bladder or prostate CA history
– Neurologic disorder
– Recent RT or chemo
• S/S UTI
• Indwelling catheter function
• Hematuria
• Food & fluid intake
• Fecal impaction?
![Page 120: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/120.jpg)
Bladder Spasms - Interventions
• Underlying cause with guide treatment
• Indwelling catheter
– Reassess the need for a Foley
– Change to appropriate size
– Partially deflate balloon
– Gently irrigate with sterile NS
– May need continuous irrigation if R/T clots
![Page 121: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/121.jpg)
Bladder Spasms - Interventions
• UTI
– Antibiotics
– Reassess need for Foley
– Change catheter if catheterized
– Increase oral fluid intake if possible
• Non-pharmacologic measures
– Assist to void frequently (q2-4 hrs)
– Sit or stand to void
– Teach relaxation
– Disimpact PRN
![Page 122: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/122.jpg)
Bladder Spasms - Interventions
• Medication interventions
– Antispasmodic drugs
• oxybutynin
– NSAIDs
– Hycoscyamine
– B&O suppositories (belladonna & opium)
![Page 123: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/123.jpg)
Urinary Incontinence
• The inability to control urination
![Page 124: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/124.jpg)
Urinary Incontinence
• May be caused by: – Urge incontinence
– Stress incontinence
– Overflow incontinence
– Functional incontinence
• Metabolic disturbance – Hypercalcemia
• Fistula
![Page 125: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/125.jpg)
Urinary Incontinence
• Atonic bladder – No awareness of full bladder or urge
• Diabetic neuropathy
• Spinal cord lesion or compression
• Neurologic dysfuntion
• Medications – Diuretics
– Sedatives
– Anticholinergics
– Antiparkinsonism meds
![Page 126: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/126.jpg)
Assessing Urinary Retention or Incontinence
• History
– Meds? Length & character of symptoms? Recent treatments for cancer?
– Night-time urination? Frequency? Leakage? Distention? Discomfort? Urgency? Amount of void? Impaction? Mobility? ADL ability? Cognitive level? Depression?
![Page 127: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/127.jpg)
Assessing Urinary Retention or Incontinence
• Physical examination
– Bladder distention? Perineal swelling? Impaction?
– Basic neuro-exam including sensory & motor deficits
– Signs of hypercalcemia
– Skin assessment
– Functional assessment
• Ability to dress/undress self
• Aphasia or dysphasia
![Page 128: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/128.jpg)
Interventions- Retention/Incont
• Review meds
• Establish regular voiding schedule
• Alter environment
– Move closer to toilet
– Utilize Bedside Commode, urinal or bedpan
– Assure modesty
– Maintain dignity
• Decrease fluids in the evening/night
• Utilize incontinence supplies
![Page 129: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/129.jpg)
Interventions- Retention/Incont
• Urge incontinence
– Oxybutynin or tolterodine
– Treat UTI & give urinary analgesics
• Stress incontinence
– Teach pelvic floor muscle exercises
– Voiding schedule
– Pessary or penile clamp
– Anticholinergics at bedtime
![Page 130: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/130.jpg)
Interventions- Retention/Incont
• Functional incontinence
– Depends on the cause
– May require indwelling catheter
• Incontinence r/t fistulas
– Establish voiding schedules, catheterization, & urinary diversion (if not
EOL)
![Page 131: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/131.jpg)
Symptoms by Systems
1. Skin & Mucous Membranes
2. Respiratory
3. Cardiovascular
4. Gastrointestinal
5. Genitourinary
6. Musculoskeletal Symptoms
7. Neurologic Symptoms
– Mental Status
✔ ✔
✔
✔
✔
![Page 132: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/132.jpg)
MS Symptoms
• Extrapyramidal Symptoms
• Myoclonus
• Impaired Mobility / Weakness
![Page 133: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/133.jpg)
Extrapyramidal Symptoms
• Involuntary movements, hyperkinetic (akathisia) or hypokinetic (dystonia); tardive dyskinesia is a late-effect, which may not respond to reversal therapies
![Page 134: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/134.jpg)
EPS - Akathisia
• A movement disorder characterized by a feeling of inner restlessness & a compelling need to be in constant motion, as well as by actions such as
– Rocking while standing or sitting
– Lifting the feet as if marching on the spot
– Crossing/uncrossing the legs while sitting
![Page 135: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/135.jpg)
EPS - Dystonia
• A disorder characterized by involuntary muscle contractions that cause slow repetitive movements or abnormal postures.
– Movements may be painful
– May have a tremor or other neurologic features
– May affect only one muscle, groups of muscles, or muscles throughout the body
![Page 136: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/136.jpg)
Causes of EPS
• Iatrogenic drug-induced – Neuroleptics
– Phenothiazines
– Butyrophenones
– Clozapine
– Metoclopramide
– Opioids
• Parkinson’s disease
• Cerebral lesions
![Page 137: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/137.jpg)
Assessing EPS
• Medical history
• Medication review
• Safety assessment – ADLs, Ambulation
• Anxiety of pt/family
![Page 138: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/138.jpg)
Myoclonus
• Twitching or brief spasm of a muscle or muscle group
![Page 139: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/139.jpg)
Causes of Myoclonus
• High dose opioid therapy
• Metabolic derangement – uremia
• Inflammatory or degenerative CNS diseases – End-stage Alzheimer’s disease
– Creutzfeldt-Jakob
– Encephalitis
• Hypercalcemia due to bone mets
![Page 140: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/140.jpg)
Assessing Myoclonus
• Onset, duration & impact on functional status
• Sleep/rest interruption
• Anxiety of pt/family
• Pt/family disease understanding
• Safety
• Potential causes – Change medications if possible
![Page 141: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/141.jpg)
Myoclonus - Interventions
• The cause will direct the intervention
• Non-pharmacologic interventions
– Local heat
– Massage
– Relaxation
– EDUCATION
![Page 142: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/142.jpg)
Myoclonus - Interventions
• Muscle relaxants may benefit
– Diazepam
– Baclofen
– Cyclobenzaprine
– Quinine sulfate if bedtime cramps only
• Treat hypercalcemia if appropriate
– Pamidronate or zoledronic
– Supplement hydration
• Treat symptoms
– Clonanzepam
– Valproic acid
![Page 143: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/143.jpg)
Impaired Mobility
• A loss or abnormality of function due to physiological, anatomical, psychological or fatigue factors
![Page 144: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/144.jpg)
Weakness
• A subjective term to indicate a lack of strength as compared to what the patient feels is normal
![Page 145: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/145.jpg)
Symptoms by Systems
1. Skin & Mucous Membranes
2. Respiratory
3. Cardiovascular
4. Gastrointestinal
5. Genitourinary
6. Musculoskeletal Symptoms
7. Neurologic Symptoms
✔ ✔
✔
✔
✔ ✔
![Page 146: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/146.jpg)
Neurologic Symptoms
• Altered Mental Status
• Aphasia
• Seizures
• Paresthesia & Neuropathy
• Fatigue
![Page 147: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/147.jpg)
Altered Mental Status
• Confusion
• Delirium
• Terminal Restlessness
• Agitation
![Page 148: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/148.jpg)
Altered Mental Status
• Confusion – Clouding of consciousness,
memory impairment
– Change in cognition, impaired perceptions, & emotional disturbances
– May be accompanied by LOC, disorientation & misperceptions
![Page 149: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/149.jpg)
Altered Mental Status
• Delirium – Exaggerated emotions or
memories w/ aggression, paranoia or displays of terror
– Disturbance of consciousness w/ reduced ability to focus
– Disturbance develops over a short period of time & tends to fluctuate over the course of the day
![Page 150: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/150.jpg)
Altered Mental Status
• Terminal Restlessness – Excessive restlessness, mental
& physical activity
– Frequent, non-purposeful motor activity, inability to concentrate or relax, disturbances in sleep/rest patterns, potential for progression to agitation
![Page 151: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/151.jpg)
Altered Mental Status
• Agitation – Accompanies delirium *
– Clouding of consciousness, memory impairment
– Change in cognition, impaired perceptions, & emotional disturbances
– May be accompanied by LOC, disorientation & misperceptions
* Heidrich & English, 2010
![Page 152: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/152.jpg)
Some Causes for AMS
• Infection
– UTI, respiratory, septicemia
• Medications
– Opioids, phenothiazines, benzodiazepines, anticholinergics, beta-blockers, diuretics, dopaminergics, steroids, atropine, phenytoin, H2-antagonists, digoxin toxicity
• Hypoxemia
• Bladder or bowel distention
![Page 153: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/153.jpg)
Some Causes for AMS
• Unrelieved pain, discomfort or other sxn
• Cardiac or respiratory failure
• Brain cancer
• Nicotine, alcohol or drug withdrawal
• Extreme, uncontrolled anxiety
• Metabolic disturbances
– Calcium, glucose, sodium, urea nitrogen
![Page 154: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/154.jpg)
Assessment of AMS
• Physical exam
• History
• Spiritual distress
• Other symptoms
Heidrich & English, 2010
![Page 155: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/155.jpg)
Treatment
• Pharmacologic
• Evaluate medications
• Reorientation
• Relaxation/distraction
• Hydration
![Page 156: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/156.jpg)
![Page 157: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/157.jpg)
Aphasia
• Absence of impairment of ability to communicate through speech, writing or signs
![Page 158: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/158.jpg)
Aphasia
• Causes
• Observation & reporting
• Nursing interventions
![Page 159: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/159.jpg)
Seizures
• Large numbers of neurons discharging abnormally
– Focal / Partial
• Involving specific regions of the brain with symptoms reflecting the location of the disturbance
– Primary / Generalized
• Involving large parts of the brain
![Page 160: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/160.jpg)
Seizures
• Definition
• Causes
– Infections
– Trauma
– HIV
– Tumors
– Medications
– Metabolic imbalances
![Page 161: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/161.jpg)
Assessing Seizures
• Manifestations
– Aura
– Mental status changes
– Sensory changes
• Physical exam
• Labs
![Page 162: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/162.jpg)
Partial Seizures
Behavior changes
Speech interruptions
Motor expressions
Somatosensory auras
Motor/Sensory expressions Kim et al., 2004.
Olfactory auras Chen, 2003.
Visual hallucinations, visual illusions,
blindness/field defect, dizziness Lee et al., 2005.
Temporal Occipital
Parietal Frontal
![Page 163: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/163.jpg)
Seizures
• Triggers
– CNS Neoplasms
– Metabolic Disturbances
– Cerebral infarct or hemorrhage
– Infections
– Treatments
– Sleep Deprivation
– Weaning steroids
• Observation & reporting
![Page 164: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/164.jpg)
Managing Seizures
• Create a safe environment
• Anticonvulsant treatments
– Levetiracetam
– Phenytoin
– Phenobarbital (preferred at EOL)
– Crisis relief
• Benzodiazepines (Lorazepam, diazepam)
![Page 165: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/165.jpg)
Paresthesia & Neuropathy
• Paresthesia
– A sensation of numbness, prickling or tingling
– Heightened sensitivity
• Neuropathy
– Any disease of the nerves
– May include sensory loss, muscle weakness and atrophy & DTR
![Page 166: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/166.jpg)
Paresthesia & Neuropathy
• Causes
• Observation & reporting
• Nursing interventions
![Page 167: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/167.jpg)
Paresthesia & Neuropathy
• Causes
• Observation & reporting
• Nursing interventions
![Page 168: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/168.jpg)
Fatigue
• A subjective sense of exhaustion with decreased motivation, ability to do activities, and a decreased capacity for physical or mental activity
![Page 169: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/169.jpg)
Lethargy
• Advanced fatigue
• Abnormal drowsiness or stupor
![Page 170: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/170.jpg)
Cluster of Fatigue Symptoms
• Causes
• Observation & reporting
• Nursing interventions
![Page 171: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/171.jpg)
Symptom Management
-----------
Wrap up
![Page 172: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/172.jpg)
Photo by Bastienne Schmidt and Philippe Cheng
![Page 173: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/173.jpg)
Psychosocial Issues
• Delirium/agitation/confusion
• Depression
• Anxiety
• PTSD
![Page 174: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/174.jpg)
Depression
• Ranges from sadness to suicidal
• Often unrecognized and undertreated
• Occurs in 25-77% of terminally ill
• Distinguish normal vs. abnormal
• Should not be dismissed
Pasacreta et al., 2010
![Page 175: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/175.jpg)
Causes of Depression
• Disease related
• Psychological
• Medication related
• Treatment related
![Page 176: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/176.jpg)
Assessment of Depression
• Situational factors/symptoms
• Previous psychiatric history
• Other factors
– Lack of support system
– Pain
Pasacreta et al., 2010
![Page 177: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/177.jpg)
Suicide
• Risk factors for suicide
• Suicide plan?
• Asking an important question
• Interdisciplinary care
![Page 178: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/178.jpg)
![Page 179: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/179.jpg)
Nonpharmacologic Interventions
• Promote autonomy
• Grief counseling
• Draw on strengths
• Use cognitive strategies
![Page 180: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/180.jpg)
Anxiety
• Subjective feeling of apprehension
• Often without specific cause
• Categories of mild, moderate, severe
![Page 181: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/181.jpg)
Causes of Anxiety
• Medications and substances
• Medical complications
• Uncertainty
Pasacreta et al., 2010
![Page 182: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/182.jpg)
Assessing Anxiety
• Physical symptoms
• Cognitive symptoms
• Questions for assessment
APA, 1994
![Page 183: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/183.jpg)
Anxiety
![Page 184: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/184.jpg)
Pharmacologic Interventions
• Antidepressants
• Benzodiazepines/anticonvulsants
• Neuroleptics
• Non-benzodiazepines
![Page 185: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/185.jpg)
Nonpharmacologic Interventions
• Empathetic listening
• Assurance and support
• Concrete information/warning
• Relaxation/imagery
![Page 186: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/186.jpg)
PTSD
• PTSD is characterized by persistent/severe reaction to a traumatic event
– Combat
– Terrorist attacks
– Sexual or physical assault
– Accidents
– National/natural disasters
![Page 187: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/187.jpg)
PTSD
• Symptom clusters
– Avoidance
– Re-experiencing the event
– Hyperarousal
• Occurs in about 30% of Veterans who were in war zones
• Implications for EOL
VA Advisory Council, 2009
![Page 188: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/188.jpg)
PTSD & EOL Care
• Illness/death can be a PTSD activator
• Challenges social ties
• May affect staff-Veteran relationships
• Delirium or flashbacks?
• Medication
• GOAL
– Reduce PTSD symptoms & create an emotionally safe environment
Veterans Advisory Council, 2009
![Page 189: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/189.jpg)
![Page 190: Symptom Management Mgmt - Extended Ver… · Kennedy Terminal Ulcer •Sudden onset ... •Drugs (abx, MSO 4, phenothiazines) •Systemic disease •Fungal infections . Itch Man Scale](https://reader036.vdocuments.mx/reader036/viewer/2022071022/5fd72f5b2efa51783212d14f/html5/thumbnails/190.jpg)
Conclusion
• Multiple symptoms are common
• Coordination of care with the interdisciplinary team
• Use drug and nondrug treatment
• Patient/family teaching and support