symptom management module 3. palliative management of: nausea and vomiting dyspnoea oral health...

Symptom management Module 3

Palliative Management Of: Nausea And Vomiting Dyspnoea Oral Health Anxiety Delirium Fatigue Seizures Terminal bleeding Pain Constipation

Nausea and vomiting Tiredness, trouble concentrating, slow wound healing, weight loss, and loss of appetite. interferes with your patients ability to take care of themselves. Causes Chemotherapy & Radiation therapy, cancer medications bowel slow down or blockage (obstruction) inner ear problems an imbalance of minerals and salts (electrolytes) in the blood infections anxiety the expectation of vomiting due to earlier experiences (anticipatory vomiting) other diseases or illnesses

Managing Nausea and vomiting Regular, small amounts of diet and fluids at the time of day when you the patient is best able to eat. (Many people find that breakfast time is best). Medication Alternative therapies Guided imagery -mentally block the nausea and vomiting. Music therapy Acupressure (http://www.acupressure.com/articles/Applying_pressure_ to_acupressure_points.htm )

Managing decreased intake Things you can do: Encourage favorite foods and drinks Offer drinks or sips often at least every two hours Clean the mouth often a pleasant tasting mouth may make food taste better Help family members and friends understand why eating and drinking may cause the patient to be uncomfortable- find other ways besides food and drink to show the patient they care. For example, offer the patient a massage or look through a picture album together Support the patients decision not to eat or drink Encourage the patient to rest before and after a meal Check dentures fit comfortably Make mealtime a quiet and pleasant time candles, flowers, soft music and good conversation all help Offer small meals and use smaller dishes If nausea is a problem, serve small portions of salty (not sweet), dry foods and clear liquids

Oral health affects and affected by other conditions It is important to offer or provide regular mouth care. Lips should be kept moist with an appropriate emollient. Dentures should be checked for comfort and cleaned well every night. Report any concerns or changes to the team.

Shortness of breath (dyspnoea) An uncomfortable awareness of breathing Patients may describe the feeling as not enough air or suffocating. Management Position-sitting upright, chest stretched Oxygen or concentrator Fan therapy Reduce anxiety and activity Open space/open windows or doors Restrict visitors

Anxiety -A feeling or deep sense that things are not right Symptoms Fear Worrying Sleeplessness Confusion Rapid breathing Tension Shaking Inability to relax or get comfortable Sweating Problems paying attention or concentrating Feelings that may be causing the anxiety worrying about money Concerns about the illness or fear of dying Problems with relationships with family or friends Spiritual concerns Signs and symptoms that the anxiety is getting worse

Managing anxiety Treat physical problems such as pain that can cause anxiety Do relaxing activities Keep things calm Limit visitors Play soothing music Massage arm, back, hand or foot Communicate concerns

Spirituality needs 1.Encourage story telling Life Review 2.Touch 3.Music 4.Reading poetry, meditations, prayers 5.Pictures 6.Ritual 7.Conversation 8.Writing letters to family/friends 9.Recording feelings

Fatigue What is fatigue? Tiredness, exhaustion or lack of energy A condition which impacts the ability to perform any activity Seen frequently in hospice and palliative care patients A complicated symptom which can have many causes Sometimes comes with depressed feelings What are the signs that a patient is fatigued? Unable to perform the normal activities for that patient every person is different in their normal activity level, just too tired Not participating in the normal routine Lack of appetite do not have the energy to eat Sleepiness Not talking Depressed You should report any of the behaviours listed above

Managing Fatigue The team will work with the patient and family to find the causes for the fatigue and discuss treatments. Plan, schedule and prioritize activities at optimal times of the day Assess and document which time of the day seems to be his/her best time Eliminate or postpone activities that are not his/her priority Assist with position changes - do not encourage staying in bed Use sunlight/light source to cue his/her body to feel energized Try activities that restore energy Assist with daily activities such as eating, moving or bathing, plan activities ahead of time Encourage him/her to rest as needed Establish and continue a regular bedtime and awakening Avoid interrupted sleep time to get continuous hours of sleep Plan rest times or naps during the day during late morning and mid afternoon Avoid sleeping later in the day, which could interrupt night time sleep Increase food intake Try nutritious, high protein, nutrient dense food -Small frequent meals -Add protein supplements to foods or drinks Frequent mouth care (before and after meals)

Constipation Constipation -defined as the difficult or incomplete evacuation of hard infrequent stools (e.g. twice or less per week) or stool less frequently than is usual for the individual. too small too hard too infrequent too difficult to expel unable to be expelled completely.

! - Constipation Facts Regular Bowel movements does not necessarily mean that a patient is not constipated. Whenever a Palliative Patient presents with diarrhoea it is a good idea for you to suspect faecal impaction with overflow. Even patients with little or no oral intake need to have regular bowel movements.

What are the Symptoms of Constipation? Confusion- delirium anxiety restlessness abdominal bloating or pain loss of appetite nausea urine retention and incontinence urge to defecate but inability to do so - suggests hard stool or rectal obstruction overflow diarrhea - occurs when liquid faeces leaks around a hard blockage or when unaware of stool passage

Causes Decreased mobility Poor dietary or liquid intake Medications (iron, opioids, anti-emetics) Weakness Dehydration Confusion Discomfort with unfamiliar toilet facilities. Directly related to malignancy haemorrhoids

Management of Constipation It is so much easier to avoid constipation in the first place than it is to treat it once it happens. Your patient might need your help to create a bowel routine aimed at the prevention of constipation. If a patient does develop constipation, interventions are aimed at: Identifying and treating underlying causes. Using a laxative and supportive regime to maintain soft, regular stool Overall be aggressive toward resolving constipation unless imminent death is apparent.

Other management strategies Fluid and Food Intake Encourage generous fluid intake with diet as tolerated Mobilization Encourage mobilisation and exercise as tolerated. Ensure pain/symptom control is maximised Toileting- 1. Sit upright when toileting if possible. 2. Enhance comfort by using raised toilet seat 3. Consider local anaesthetic creams or ointments. 4. Provide privacy and time 5. Time toileting events 30-60 minutes following ingestion of a meal, especially morning or lunchtime

Seizures Seeing someone have a seizure can be a frightening experience. Try to remain calm. Signs and Symptoms The person having a seizure may have some or none of these signs: Muscle jerking / Twitching (convulsion) Stiffening of the body Unable to awaken for a period of time Loss of bladder control Blurred vision Inability to speak / Difficulty talking Eyes rolling back Sudden confusion or memory loss Recurring movements chewing, lip smacking, clapping Blank staring or blinking

Managing Seizures Safety is the first concern. Stay with the patient and call for help. Keep the person free from injury remove any objects that the person may fall on or bump into Turn the person on his/her side if vomiting occurs, or when the seizure ends It is important not to restrain the person. Do not attempt to place any objects in the mouth. Do not feed him/her until he/she is fully awake/alert If possible, gently support the head by placing a pillow under the head

Confusion, agitation & Delirium Delirium is one of the most frequent and serious complication -acute onset and fluctuating course Supportive treatment Explanation of delirium, communication with relatives. Calm, quite environment Clear and simple communication Reorientation Glasses, hearing aids, dentures Good light Visible clock Uninterrupted sleep

Characteristics Abrupt onset Disorientation, fluctuation of symptoms Hypoactive or hyperactive (restlessness, agitation, aggression) or mixed Changes in sleeping patterns Incoherent, rambling speech Fluctuating emotions Activity that is disorganized and without purpose

The Management Of Irreversible Delirium In The Imminently Dying

24 Agitated EOL Delirium Is A Medical Emergency Imagine in the last few hours of life being: agitated, combative, striking out at caregivers paranoid, saying hurtful things to family children / grandchildren afraid to visit Loss of self / personhood / dignity Lifelong difficult memories for family No chance for a do-over if poorly managed An overarching goal of care becomes the effective, consistent sedation of the patient until the condition's natural course unfolds, and the patient dies as expected from the underlying condition i.e. the goal is to ensure that the patient does not waken again before dying

25 Supporting Families At minimum, effective sedation changes the beside dynamics from one in which people are afraid to visit and there is no meaningful interaction to one in which people can talk, read, sing, play favourite music, pray, tell stories, touch. Health care team has a role in facilitating meaningful visits family/friends may not know the right things to do Individuals may want time alone but be reluctant to ask others (friends/family) to leave the room. The health care team can suggest that this might be something that the family can explore with each other

26 Supporting Families Hearing is a resilient sense, as evidenced by its potential to endure into the early phase of general anesthesia If not true hearing, the comforting/settling effect of the awareness of the presence of family can be remarkable The approach is that some nature of hearing/awareness/spiritual connection is maintained this therefore must be considered when speaking about the patient in his/her presence. The question of can they still hear us? arises frequently of course its not possible to know this, however:

Terminal bleeding clotting disorders, tumors that erode (or wear away) blood vessels, and ulcers. Patients who have had previous bleeding are at increased risk. Anticipate bleeding and plan in place to respond should bleeding occur. The primary goal is patient comfort and lessening patient and family anxiety and fear. Signs and Symptoms of bleeding? Previous bleeding from any site of the body including gums Blood-tinged coughing or vomiting Blood in urine or stool Nose bleeds Skin with excessive bruising or many pinpoint sized red areas on the skin What to Report to the RN Any change in frequency or quantity of the above stated signs or symptoms Keep air humidified Keep dark colored towels or blankets and waterproof underpads on hand in the event that bleeding occurs Do relaxing activities Keep things calm Limit visitors Play soothing music

Pain management Pain is not exclusively physiological but also includes spiritual, emotional and psychosocial dimensions. The goal of pain management is to provide maximum pain relief with minimal side effects. A wide variety of factors including inaccurate information, myths, rumors. fear and cultural issues contribute to inadequate pain management. Since pain is identified and reported primarily through patient self- reporting, difficulty in communicating increases the patients risk for under-treatment.

A fundamental Human Right (WHO) Seniors are among the biggest group that suffers from inadequate pain control. The elderly tend to minimize the expression of pain. They may also have underlying depression or dementia, which may affect their ability to communicate pain effectively. They may have impaired kidney or liver function that affect the absorption and metabolism of pain medications.

Describing pain only in terms of its intensity is like describing music only in terms of its loudness von Baeyer CL; Pain Research and Management 11(3) 2006; p.157-162

PAIN HISTORY How to report Description: severity, quality, location, frequency, aggravating & alleviating factors Previous history Context: social, cultural, emotional, spiritual factors Interventions: what has been tried?

Non-Pharmacological Pain Management Distraction Aromatherapy Meditation/relaxation Guided imagery Therapeutic massage or reflexology Music therapy Art Therapy Pet therapy

Common myths -True or False? 1. Too much pain medication too frequently constitutes substance abuse, causes addiction, will result in respiratory depression or will hasten death; 2. Pain should be treated, not prevented; 3. People in pain always report their pain to their health care provider; 4. People in pain demonstrate or show that they have pain - pain can be seen in the patients behavior; 5. The level of pain is often exaggerated by the patient; 6. Generally a patient cannot be relieved of all pain; 7. Some pain is good so that the patients symptoms are not masked 8. It is expected that the elderly, especially the frail elderly, always have some pain.

TOLERANCE A normal physiological phenomenon in which increasing doses are required to produce the same effect Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

PHYSICAL DEPENDENCE A normal physiological phenomenon in which a withdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3

Opioid Side Effects Constipation need proactive laxative use Nausea/vomiting Urinary retention Itch/rash Dry mouth Respiratory depression uncommon when titrated in response to symptom Drug interactions Neurotoxicity (OIN): delirium, myoclonus seizures Any of the above should be reported to the RN

Constipation risk There's an old saying: "The hand that writes the opioid order also writes the laxative order". In other words, a patient should be started on a laxative regime AT THE SAME TIME that an opioid is started.

Subcutaneous Medication Administration Infusions Unable to take medications orally. Subcutaneous is frequently referred to as SubQ. The SubQ insertion site may be on the abdomen, chest wall, upper outer thigh, or the upper outer arm Care of SQ sites Avoid sudden twisting or turning of the body area where the site is located to avoid stretching the tubing During SQ administration or infusion, slight redness or swelling at the site is common but should decrease soon after the infusion is complete and should disappear within 2-4 hours Check the site whenever you are caring for the patient. If you notice leaking, pain, redness, bruising, burning, or swelling at the site, report it to the nurse If the site becomes painful or redness and swelling persist for several hours, report it to the nurse

Oh, how to place a value on the things that cannot be measured? (Jones, 2009) What is it worth, when you receive a look that says I feel your pain? What is it worth, when a hand reaches out to you in comfort? What is it worth, to sit together in silence and know that even without words, you have been heard? And what is the cost, if these things had never occurred? Oh, how to place a value on the things that cannot be measured?

symptom management module 3. palliative management of: nausea and vomiting dyspnoea oral health...

Documents

worse slide

managing nausea

vomiting tiredness

blood infections anxiety

regular mouth care

physical problems

money concerns

soft music