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geriatrics 2 > managing non-pain symptoms > Flashcards

managing non-pain symptoms Flashcards

1
Q

Non pain symptom management

A
  • choose treatment strategies that support the patients goals of care (age, function status, overall needs, rate of change of disease, life expectancy)
  • identify the cause whenever possible and treat the CAUSE of the symptom
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2
Q

goals of clinical symptom assessment

A
  • elicit the most distressing symptoms for the patient and family
  • determine underlying pathophysiology, cause, and contributing factors for each symptom
  • screen for common distressing symptoms
  • review current and past treatments, their effectiveness and side effects
  • document assessment and plan
  • reassess at regular intervals
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3
Q

Dyspnea

A
  • Discomfort in breathing
  • aka: breathlessness, shortness of breath, work of breathing
  • subjective sensation (physical, psychological, social and spiritual)
  • occurs in broad range of diseases (cancer, COPD, AIDS, CHF, ALS, dementia)
  • tends to worsen as death approaches
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4
Q

Dyspnea assessment

A
  • self-report is GOLD standard
  • RR, sings of increased WOB, oxygen saturation and other tests DO NOT CORRELATE with patient report of dyspnea
  • hx/PE - clarify causes of dyspnea
  • Rx dependent upon prognosis, goals of care risks and benefits of tests/interventions
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5
Q

Causes of dyspnea

A
  • BREATH AIR
  • B = bronchospams
  • R = Rales
  • E = Effusion
  • A = airway obstruction
  • T = Thick secretions
  • H = hemoglobin low
  • A = anxiety
  • I = interpersonal issues
  • R = religious concerns
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6
Q

tx for dyspnea

A
  • oxygen (may be no more beneficial than air; caution if CO2 retention)
  • Opioids (first line, small doses)
  • anxiolytics (treat anxiety, not dyspnea)
  • general measures
  • alternative, complimentary (acupressure, acupuncture, meditation, massage)
  • Non-invasive ventilator support
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7
Q

describe general measures to tx dyspnea

A
  • reduce exertion/energy expenditure
  • reposition the patient (upright or compromised lung down)
  • provide skin care for the buttocks
  • improve air circulation (draft/fan, adjust humidity, avoid strong odors, fumes etc)
  • address anxiety and provide reassurance
  • consider rehabilitative strategies (breathing retraining - prolong experiation)
  • discuss any patient, family, or staff concerns about using opioids to relieve dyspnea
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8
Q

Dysphagia

A
  • difficulty swallowing
  • discern whether neurologic or non-neurologic (solids progressing to liquids is obstruction; simultaneous solids and liquid is neurological)
  • Conservative management can ameliorate dysphagia for a majority of patients (emphasize good oral hygiene, etc)
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9
Q

what are some conditions that result in dysphagia

A
  • dentures fit poorly
  • poor dental hygiene
  • taste disorder
  • weakness or neuromuscular problems
  • stress and tension
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10
Q

Anorexia-cachexia

A
  • multi-faceted cascade of events leading to loss of appetite for food, usually resulting in cachexia
  • often superimposed on the anorexia of the aging process
  • Hx and PE (seek to identify reversible causes)
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11
Q

what are reversibel causes of anorexia

A
  • ANOREXIA
  • A = aches and pains
  • N = nausea and gastrointestinal dysfunction
  • O = oral candidiasis
  • R = reactive depression
  • E = evacuation problems (constipation, retention)
  • X = xerstomia (dry mouth)
  • I = Iatrogenic (radiation, chemo, drugs)
  • A = Acid related problems (gastritis, peptic ulcers)
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12
Q

Tx for anorexia

A
  • appetite stimulants
  • artificial nutrition and hydration
  • -> enteral feeding (tube); parenteral feeding (TPN)
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13
Q

artificial nutrition and hydration (anorexia)

A
  • ANH does not improve healing of decubitus ulcers
  • ANH often shortens, not lengthens survival
  • perioperative mortality/PEG placement 6-24%
  • infection, thrombosis, aspiration
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14
Q

Nausea and vomiting

A
  • in seriously and terminally in patients, N/V are common symptoms in
  • N/V cause significant distress
  • can usually be controlled in 90% of patients
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15
Q

describe the various origins of nausea and vomiting

A
  • intracrnail pressure, anxiety and memories (CEREBRAL CORTEX)
  • Motion sickness, vestivular disease (VESTIBULAR APPARATUS)
  • uremia, hypercalcemia, drugs (CHEMORECEPTOR TRIGGER ZONE)
  • Gastric irritation, intestinal distension, gag reflex (GI TRACT)
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16
Q

Neasua and vomiting tx

A
  • Select antiemetic agent on the basis of: likely cause, pathway mediating the symptoms, NT involved
  • General measures
  • -> small and frequent meals
  • -> frequent small sips of fluid
  • -> avoid strong odors or unpleasant tastes
  • -> address nonphysical factors
17
Q

malignant bowel obstruction

A
  • up to 50% of patients with ovarian and GI cancers have malignant bowel obstruction
  • patients diagnosed with malignant bowel obstruction have median survival of 3 months
  • HIGH SYMPTOM BURDEN (N/V, colic and abdominal pain)
18
Q

Tx of maligant bowel obstruction

A
  • management dependent upon functional status, goals of care, expected survival
  • tx options
  • -> surgical-limited evidence of benefit QoL and EoL
  • -> endoscopic techniques: stents
  • -> medical management: mainstay of Rx
19
Q

Delirium

A
  • ACUTE ONSET
  • Fluctuating course
  • altered level of consciousness (hyperactive or hypoactive or both)
  • cognitive impairments
  • -> altered orientation
  • -> altered organization of thoughts
  • -> altered perceptions (delusions, hallucinations)
  • -> emotional labiality
  • -> reversal of sleep wake cycle
  • -> memory impairment
20
Q

delirium assessment and treatment

A
  • Hx and PE - identify potential reversible causes
  • treat underlying cause
  • use low dose non-sedating antipsychotic
  • actively dying, non-ambulatory patients may benefit from sedating antipsychotic
  • AVOID BENZODIAZEPINES (NEVER use without an antipsychotic)
21
Q

describe preventative measures of delirium

A
  • prevent dehydration
  • remove unnecessary catheters/IVs, restraints
  • decrease environmental stimuli
  • reduced light and sound at night; minimal interventions
  • hearing and visual assessment
  • reorientation and cognitive stimulation
  • inducement of sleep with music or massage
22
Q

KEY POINTS

A
  • most patients receiving palliative care have multiple symptoms
  • screening assessment is key to identifying the symptom constellations
  • detailed History and comprehensive PE are needed to determine most probably cause
  • tx strategies should be determined by patients goals of care and directed at treating the underlying cause whenever possible

geriatrics 2 (13 decks)

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