Section V: General/Other Symptoms Fatigue (at a glance) Wound Seizures Sleep disturbances (at a glance) Lymphedema (at a glance) Urgent Syndromes

Symptoms at a Glance: Fatigue Subjective, multidimensional experience of exhaustion

Wounds Loss of skin integrity Pressure injuries (ulcers) Malignant wounds Kennedy Terminal Ulcers

Assessment of Wounds Characteristics Pain Psychosocial Caregivers

Treatment of Wounds Frequent position changes Wound cleaning Dressings Provide analgesia Seek consultation Prevention is key Seaman & Bates-Jensen, 2015

Dilemma: Assessing/Treating Wounds in Patients with Life-Limiting Illness Assess underlying cause What are the goals of care? Is it realistic that the wound will heal? Prevent further pressure injuries/ulcers/wounds Manage pain and odor Pressure ulcer may indicate organ failure When orchestrating care for a patient with life-limiting illness who has a wound/wounds, it is important to Assess the underlying cause. Is this a wound from a previous injury, amputation, diabetes complication, arterial insufficiency, etc? Is the wound caused because of lack of attention in turning a patient and/or the inability of the caregiver to provide this service? What are the goals of care? Is this a patient who will likely die in the next few hours/days? If so, is taking the patient to the surgical suite to do a skin graft a good option? Is it realistic that the wound will heal? Prevent further pressure ulcers/wounds (special mattresses, cushions in wheelchairs, etc) Manage pain It is not uncommon to see pressure ulcers occur 2-3 weeks before death. This has been seen as an indicator of failure of the skin, the bodies largest organ. Some suggest that these ulcers may be unavoidable in this population. “Contrary to many health care practitioner’s beliefs, once a pressure ulcer develops, healing is possible, with reports of wound healing in persons receiving palliative care ranging from 44% for those with cancer diagnoses to 78% for those with non-cancer diagnoses. Thus, the emphasis on palliative wound care does not negate the potential for would closure and healing even in those at the end of life” (Bates-Jensen, 2010, p 359).

Seizures Definition Causes Infections Trauma HIV Tumors Medications Metabolic imbalances

Assessment for Seizures Manifestations Aura Mental status changes Sensory changes Physical exam Labs

Treatment for Seizures Limit trauma Anticonvulsant treatments Phenytoin Phenobarbital Lorazepam, diazepam Levetiracetam

Symptom at a Glance: Sleep Disturbance Affects quality of life for both the patient and caregiver Assessment Management

Symptom at a Glance: Lymphedema Chronic, progressive swelling due to failure of lymph drainage Patients at risk Side effects Assessment Management Fu & Lasinski, 2015

One Final Reminder: Be Aware of Symptoms of Urgent Syndromes Superior vena cava obstructions Pleural effusion Pericardial effusion Hemoptysis Spinal cord compression Hypercalcemia Bobb, 2015

Case Study on Assessment and Management of Symptoms: MARGARET—Part V Margaret spent 3 weeks at a long-term care facility after leaving the hospital Depressed Agrees to go to an in-patient hospice After 3 weeks at the LTC facility, Margaret decided to go to the local in-patient hospice in her community. Despite her aphasia, an ombudsman from the LTC assessed her ability to make a decision about DNR. It was determined that Margaret was of sound mind (though unable to speak, she was able to write down her thoughts) and she signed a DNR. (JUDY, we could also state that she had some neuropsychological deficits and a power of attorney was chosen for her and not go the route that she made the decision to go to hospice, along with the ombudsman…….Thoughts?) She refused to do PT and OT at the LTC and just decided she wanted to be left alone “to die.” A hospice nurse visited Margaret at the LTC facility and explained the care that she would receive at the in-patient hospice. The next morning she was transferred from LTC to hospice. While at the hospice, she received daily visits from a psychologist and chaplain. Though she was unable to speak, she appeared to appreciate their presence. Margaret refused any other visitors. She wanted to be left alone. She received good pro-active pain management for the pressure ulcer, despite the fact that she could not verbalize her pain. Two weeks later, Margaret died peacefully at the hospice. Stop and Consider: Nurses have opportunities to care for patients who may be difficult and non-compliant. Many patients may die without making peace with unresolved conflicts. Many patients may be “loners” and they choose to die alone. For some, their medical condition prevents them from saying what they may want to say. Note: Stroke is the #3 leading cause of death in the US. Many of these patients would benefit greatly from palliative care, depending on the severity of the stroke. Think about these patients receiving a palliative care consult. Remember, palliative care is not just for patients with cancer. With obesity being at an all-time high in the US, along with it comes many life-limiting illnesses (e.g. CHF, diabetes, hypertension, etc). Nurses must be aware of this epidemic and include these patients in palliative care consults, when appropriate.

Conclusion Multiple symptoms are common Coordination of care with the interdisciplinary team Use drug and nondrug treatment Patient/family teaching and support