Transcript Hospice Education for Care Aides

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
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Support the patient’s 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
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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?
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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
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Toileting-
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Sit upright when toileting if possible.
Enhance comfort by using raised toilet seat
Consider local anaesthetic creams or ointments.
Provide privacy and time
Time toileting events 30-60 minutes following ingestion of a meal, especially
morning or lunchtime
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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
Agitated EOL Delirium Is A
Medical Emergency
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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
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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
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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
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Supporting Families
The question of “can they still hear us?” arises frequently… of
course it’s not possible to know this, however:
 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.
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Terminal bleeding
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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?
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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
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Any change in frequency or quantity of the above stated signs or symptoms
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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 patient’s 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 patient’s 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 patient’s 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?