C C E E N N L L E E End-of-Life Nursing Education Consortium International Curriculum Symptom Management Symptom Management

E E N N E E C C L L International Curriculum Essential Elements of Symptom Management Ongoing assessment and evaluation Requires interdisciplinary teamwork Financial concerns (affordable options) Research is needed Coyne et al., 2010 Ongoing assessment and evaluation Requires interdisciplinary teamwork Financial concerns (affordable options) Research is needed Coyne et al.,

E E N N E E C C L L International Curriculum Symptoms and Suffering Symptoms create suffering and distress Need for interdisciplinary care Determine clinical intervention –Benefit (s) –Burden (s) –Risk (s) Symptoms create suffering and distress Need for interdisciplinary care Determine clinical intervention –Benefit (s) –Burden (s) –Risk (s) 3

E E N N E E C C L L International Curriculum Common Symptoms Respiratory –Dyspnea, cough GI –Anorexia/cachexia, constipation, diarrhea, nausea/vomiting Psychological –Depression, anxiety, delirium/agitation/confusion General/Systemic –Fatigue/weakness –Seizures –Fevers –Malaria Respiratory –Dyspnea, cough GI –Anorexia/cachexia, constipation, diarrhea, nausea/vomiting Psychological –Depression, anxiety, delirium/agitation/confusion General/Systemic –Fatigue/weakness –Seizures –Fevers –Malaria 4

E E N N E E C C L L International Curriculum Dyspnea Distressing shortness of breath Associated diseases Dudgeon, 2010 Distressing shortness of breath Associated diseases Dudgeon,

E E N N E E C C L L International Curriculum Causes of Dyspnea Major pulmonary causes Major cardiac causes Major neuromuscular causes Other causes Major pulmonary causes Major cardiac causes Major neuromuscular causes Other causes 6

E E N N E E C C L L International Curriculum Assessment of Dyspnea Use subjective report Clinical assessment –Physical exam –Diagnostic tests Dudgeon, 2010 Use subjective report Clinical assessment –Physical exam –Diagnostic tests Dudgeon,

E E N N E E C C L L International Curriculum Treatment of Dyspnea Treating symptoms or underlying cause Pharmacologic treatments –Opioids –Bronchodilators –Diuretics –Other Dudgeon, 2010; Jacobs, 2003 Treating symptoms or underlying cause Pharmacologic treatments –Opioids –Bronchodilators –Diuretics –Other Dudgeon, 2010; Jacobs,

E E N N E E C C L L International Curriculum Treatment of Dyspnea Nonpharmacologic –Oxygen –Counseling –Pursed lip breathing –Energy conservation –Fans, elevation –Other Dudgeon, 2010; Kravits & Berenson, 2010 Nonpharmacologic –Oxygen –Counseling –Pursed lip breathing –Energy conservation –Fans, elevation –Other Dudgeon, 2010; Kravits & Berenson,

E E N N E E C C L L International Curriculum Cough Common symptom in advanced disease Causes pain, fatigue, insomnia Dudgeon, 2010 Common symptom in advanced disease Causes pain, fatigue, insomnia Dudgeon,

E E N N E E C C L L International Curriculum Causes of Cough Assess underlying cause (e.g. infection, sinusitis, reflux) Assess type of cough Assess associated symptoms Diagnostic tests may be needed Dudgeon, 2010 Assess underlying cause (e.g. infection, sinusitis, reflux) Assess type of cough Assess associated symptoms Diagnostic tests may be needed Dudgeon,

E E N N E E C C L L International Curriculum Pharmacologic Interventions for Cough Suppressants/expectorants Antibiotics Steroids Anticholinergics Suppressants/expectorants Antibiotics Steroids Anticholinergics 12

E E N N E E C C L L International Curriculum Non-Pharmacologic Interventions for Cough Chest PT Humidifier Positioning Chest PT Humidifier Positioning 13

E E N N E E C C L L International Curriculum Anorexia and Cachexia Anorexia - loss of appetite, usually with decreased intake Cachexia - lack of nutrition and wasting Wholihan & Kemp, 2010 Anorexia - loss of appetite, usually with decreased intake Cachexia - lack of nutrition and wasting Wholihan & Kemp,

E E N N E E C C L L International Curriculum Causes of Anorexia and Cachexia Disease related Psychological Treatment related Fearon et al., 2010; Wholihan & Kemp, 2010 Disease related Psychological Treatment related Fearon et al., 2010; Wholihan & Kemp,

E E N N E E C C L L International Curriculum Assessment of Anorexia and Cachexia Physical findings Impact on function and quality of life Calorie counts/daily weights Lab tests Skin breakdown Wholihan & Kemp, 2010 Physical findings Impact on function and quality of life Calorie counts/daily weights Lab tests Skin breakdown Wholihan & Kemp,

E E N N E E C C L L International Curriculum Treatment of Anorexia and Cachexia Dietary consultation Medications Parenteral/enteral nutrition Odor control Counseling Earthman, 2002; MacDonald, 2003; Wholihan & Kemp, 2010 Dietary consultation Medications Parenteral/enteral nutrition Odor control Counseling Earthman, 2002; MacDonald, 2003; Wholihan & Kemp,

E E N N E E C C L L International Curriculum Constipation Infrequent passage of stool Frequent symptom in palliative care Prevention is key Infrequent passage of stool Frequent symptom in palliative care Prevention is key 18

E E N N E E C C L L International Curriculum Causes of Constipation Disease related (e.g. obstruction, hypercalcemia, neurologic, inactivity) Treatment related (e.g. opioids, other meds) Disease related (e.g. obstruction, hypercalcemia, neurologic, inactivity) Treatment related (e.g. opioids, other meds) 19

E E N N E E C C L L International Curriculum Assessment of Constipation Bowel history Abdominal assessment Rectal assessment Medication review Economou, 2010 Bowel history Abdominal assessment Rectal assessment Medication review Economou,

E E N N E E C C L L International Curriculum Treatment of Constipation Medications Dietary/fluids Other approaches Economou, 2010 Medications Dietary/fluids Other approaches Economou,

E E N N E E C C L L International Curriculum Diarrhea Frequent passage of loose, nonformed stool Effects (e.g. fatigue, caregiver burden, skin breakdown) Frequent passage of loose, nonformed stool Effects (e.g. fatigue, caregiver burden, skin breakdown) 22

E E N N E E C C L L International Curriculum Causes of Diarrhea Disease related Malabsorption Concurrent diseases Psychological Treatment related Disease related Malabsorption Concurrent diseases Psychological Treatment related 23

E E N N E E C C L L International Curriculum Assessment of Diarrhea Bowel history Medication review Infectious processes Bowel history Medication review Infectious processes 24

E E N N E E C C L L International Curriculum Treatment of Diarrhea Treat underlying cause Dietary modifications Hydration Pharmacologic agents Treat underlying cause Dietary modifications Hydration Pharmacologic agents 25

E E N N E E C C L L International Curriculum Nausea and Vomiting Common in advanced disease Assessment of etiology is important Acute, anticipatory or delayed Mannix, 2010 Common in advanced disease Assessment of etiology is important Acute, anticipatory or delayed Mannix,

E E N N E E C C L L International Curriculum Causes of Nausea and Vomiting Physiological (gastrointestinal, metabolic, central nervous system) Psychological Disease related Treatment related Other Physiological (gastrointestinal, metabolic, central nervous system) Psychological Disease related Treatment related Other 27

E E N N E E C C L L International Curriculum Assessment of Nausea and Vomiting Physical exam History Lab values Physical exam History Lab values 28

E E N N E E C C L L International Curriculum Pharmacologic Treatment of Nausea and Vomiting Anticholinergics Antihistamines Steroids Prokinetic agents Other Anticholinergics Antihistamines Steroids Prokinetic agents Other 29

E E N N E E C C L L International Curriculum Non-Drug Treatment of Nausea and Vomiting Distraction/relaxation Dietary Small/slow feeding Invasive therapies Distraction/relaxation Dietary Small/slow feeding Invasive therapies 30

E E N N E E C C L L International Curriculum Fatigue Subjective, multidimensional experience of exhaustion Commonly associated with many diseases Impacts all dimensions of quality of life Anderson et al., 2010; Ferrell et al., 1996 Subjective, multidimensional experience of exhaustion Commonly associated with many diseases Impacts all dimensions of quality of life Anderson et al., 2010; Ferrell et al.,

E E N N E E C C L L International Curriculum Causes of Fatigue Disease related Psychological Treatment related Disease related Psychological Treatment related 32

E E N N E E C C L L International Curriculum Assessment of Fatigue Subjective Objective Laboratory data Subjective Objective Laboratory data 33

E E N N E E C C L L International Curriculum Treatment of Fatigue Pharmacologic Nonpharmacologic (rest, energy conservation, involve physical therapy/occupational therapy) Anderson et al., 2010 Pharmacologic Nonpharmacologic (rest, energy conservation, involve physical therapy/occupational therapy) Anderson et al.,

E E N N E E C C L L International Curriculum Depression Ranges from sadness to suicidal Often unrecognized and undertreated Distinguish normal vs. abnormal Should not be dismissed Pasacreta et al., 2010 Ranges from sadness to suicidal Often unrecognized and undertreated Distinguish normal vs. abnormal Should not be dismissed Pasacreta et al.,

E E N N E E C C L L International Curriculum Causes of Depression Disease related Psychological Medication related Treatment related Disease related Psychological Medication related Treatment related 36

E E N N E E C C L L International Curriculum Assessment of Depression Situational factors/symptoms Previous psychiatric history Other factors (e.g. lack of support system, pain) Pasacreta et al., 2010 Situational factors/symptoms Previous psychiatric history Other factors (e.g. lack of support system, pain) Pasacreta et al.,

E E N N E E C C L L International Curriculum Example Questions for Depression Assessment How have your spirits been lately? What do you see in your future? What is the biggest problem you are facing? Pasacreta et al., 2010 How have your spirits been lately? What do you see in your future? What is the biggest problem you are facing? Pasacreta et al.,

E E N N E E C C L L International Curriculum Suicide Assessment Do you think life isn’t worth living? Have you thought about how you would kill yourself? Do you think life isn’t worth living? Have you thought about how you would kill yourself? 39

E E N N E E C C L L International Curriculum Pharmacologic Interventions for Depression Antidepressants Stimulants Non-benzodiazepines Steroids Antidepressants Stimulants Non-benzodiazepines Steroids 40

E E N N E E C C L L International Curriculum Non-Pharmacologic Interventions for Depression Promote autonomy Grief counseling Draw on strengths Use cognitive strategies Promote autonomy Grief counseling Draw on strengths Use cognitive strategies 41

E E N N E E C C L L International Curriculum Anxiety Subjective feeling of apprehension Often without specific cause Categories of mild, moderate, severe Subjective feeling of apprehension Often without specific cause Categories of mild, moderate, severe 42

E E N N E E C C L L International Curriculum Causes of Anxiety Medications and substances Uncertainty Pasacreta et al., 2010 Medications and substances Uncertainty Pasacreta et al.,

E E N N E E C C L L International Curriculum Assessment of Anxiety Physical symptoms Cognitive symptoms Questions for assessment APA, 2000 Physical symptoms Cognitive symptoms Questions for assessment APA,

E E N N E E C C L L International Curriculum Pharmacologic Interventions for Anxiety Antidepressants Benzodiazepines/anticonvulsants Neuroleptics Non-benzodiazepines Antidepressants Benzodiazepines/anticonvulsants Neuroleptics Non-benzodiazepines 45

E E N N E E C C L L International Curriculum Non-pharmacologic Interventions for Anxiety Empathetic listening Assurance and support Concrete information/warning Relaxation/imagery Empathetic listening Assurance and support Concrete information/warning Relaxation/imagery 46

E E N N E E C C L L International Curriculum Delirium/Agitation/ Confusion Delirium - Acute change in cognition/awareness Agitation - accompanies delirium Confusion - disorientation, inappropriate behavior, hallucinations Heidrich & English, 2010 Delirium - Acute change in cognition/awareness Agitation - accompanies delirium Confusion - disorientation, inappropriate behavior, hallucinations Heidrich & English,

E E N N E E C C L L International Curriculum Causes Infection Medications Hypoxemia Bladder distention Infection Medications Hypoxemia Bladder distention Examples: 48

E E N N E E C C L L International Curriculum Assessment Physical exam History Spiritual distress Other symptoms Heidrich & English, 2010 Physical exam History Spiritual distress Other symptoms Heidrich & English,

E E N N E E C C L L International Curriculum Treatment Pharmacologic Evaluate medications Reorientation Relaxation/distraction Hydration Pharmacologic Evaluate medications Reorientation Relaxation/distraction Hydration 50

E E N N E E C C L L International Curriculum Wounds Patients at risk Prevention as key Patients at risk Prevention as key 51

E E N N E E C C L L International Curriculum Assessment of Wounds Characteristics Pain Psychosocial Caregivers Characteristics Pain Psychosocial Caregivers 52

E E N N E E C C L L International Curriculum Treatment of Wounds Wound cleaning Dressings Provide analgesia Seek consultation Wound cleaning Dressings Provide analgesia Seek consultation 53

E E N N E E C C L L International Curriculum Seizures Definition Causes –Infections –Trauma –HIV –Tumors –Medications –Metabolic imbalances Definition Causes –Infections –Trauma –HIV –Tumors –Medications –Metabolic imbalances 54

E E N N E E C C L L International Curriculum Assessment for Seizures Manifestations –Aura –Mental status changes –Sensory changes Physical exam Labs Manifestations –Aura –Mental status changes –Sensory changes Physical exam Labs 55

E E N N E E C C L L International Curriculum Treatment for Seizures Limit trauma Anticonvulsant treatments –Phenytoin –Phenobarbital –Lorazepam, diazepam Limit trauma Anticonvulsant treatments –Phenytoin –Phenobarbital –Lorazepam, diazepam 56

E E N N E E C C L L International Curriculum Fevers Definition Causes –Infection –Tissue injury –Altered thermoregulation Definition Causes –Infection –Tissue injury –Altered thermoregulation 57

E E N N E E C C L L International Curriculum Assessment/Treatment of Fevers Clinical –Flushing –Malaise/fatigue Rigors/shaking Treatment –Antibiotics –Antipyretics –Cooling measures Clinical –Flushing –Malaise/fatigue Rigors/shaking Treatment –Antibiotics –Antipyretics –Cooling measures 58

E E N N E E C C L L International Curriculum Malaria High morbidity/mortality Caused by a parasite Use of prompt and effective treatment WHO, 2010 High morbidity/mortality Caused by a parasite Use of prompt and effective treatment WHO,

E E N N E E C C L L International Curriculum Symptoms/Treatment of Malaria Fever Chills Headache Nausea/vomiting Fever Chills Headache Nausea/vomiting 60

E E N N E E C C L L International Curriculum Key Roles Patient advocacy Assessment Pharmacologic treatments Non-pharmacologic treatments Patient/family teaching Patient advocacy Assessment Pharmacologic treatments Non-pharmacologic treatments Patient/family teaching 61

E E N N E E C C L L International Curriculum Conclusion Multiple symptoms common Coordination of care with physicians and others Use drug and nondrug treatment Patient/family teaching and support Multiple symptoms common Coordination of care with physicians and others Use drug and nondrug treatment Patient/family teaching and support 62

E E N N E E C C L L International Curriculum A Nurse's Touch 63

E E N N E E C C L L International Curriculum Give the answers to the following questions please 1.List the respiratory symptoms that occur in palliative care patients? 2.What Non-pharmacologic Interventions for Anxiety do you know? 3.What are the causes of Delirium? 1.List the respiratory symptoms that occur in palliative care patients? 2.What Non-pharmacologic Interventions for Anxiety do you know? 3.What are the causes of Delirium?