Nurb End of life symptom management Flashcards
i. Assessment and evaluation
ii. Interdisciplinary teamwork
iii. Economics: costs, and what going to do, is there a purpose, reimbursement
iv. Indications of diagnostic tests
v. Research
a. EOF
Essential elements of symptom management
b. Priority symptoms
c. : suffering and distress, psychosocial intervention is key to complement pharmacologic strategies
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Symptoms and suffering
– may cause significant distress to pt and family, determine the cause, comfort care
-Pt symptomatic: see what they can do to alleviate when dying , monitors turn down or away
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II. Common Symptoms
– distressing shortness of breath, associated disease, mostly subjective
- Causes: Pulmonary- COPD, Cardiac- CHF, Neuromuscular -ALS
- Assessment
a. Subjective report of patient- what every they say it is/ decrease o2 sat, increased resp rate
b. Impact on function and quality of life
c. Clinical assessment
a. Respiratory Symptoms
i. Dyspnea
- pre-medicate for extabation
a. : opioid, Bronchodilators, diuretics
b. : oxygen= even if o2 sat is high make feel better, counseling, pursed lip breathing, energy conservation, fans, elevation
- give morphine to ease pain
a. Respiratory Symptoms dyspnea treatment A. Pharmacologic B. Non-pharmacologic Terminal dyspnea
- annoying, interferes with sleep=fatigue, worse N/V, common symptom in advanced disease
1. assess underlying cause- choice of test up to fam and pt
2. A.suppressants=dem in name, antibiotics, steroid, anticholinergic
B. : humidifier, chest pt, positioning
Cough
- Causes:
- Treatment
a. Pharmacologic
b. Non-pharmacologic:
- loss of appetite, usually with decreased intake
- lack of nutrition and wasting, extreme symptom, just skin and bones Ex: refugee
b. GI Symptoms
i. Anorexia
ii. Cachexia
Assessment
a. Physical findings
b. Impact on function and quality of life
c. Impact on self/family
d. Calorie counts/daily weights- will we do anything about it cost benefit
e. Laboratory tests
f. Skin breakdown
Gi symptoms
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a. Dietary consult/dietary interventions- what they want, let them eat but don’t make them
b. Medications
c. Paraenteral or enteral nutrition
d. Problem odors control
e. Counseling
GI symptoms EOF
3. Treatment
- Causes- Disease related, Treatment related
- Assessment
a. Bowel history- important
b. Abdominal assessment- check for bowl obstruction
c. Rectal assessment
d. Medication review
iii. Constipation
- Medications: try oral route first, then try rectal Laxatives and enemia
iii. Bowel obstruction in eof- so many variables how are they doing over all are they actively dying, or just terminally ill, do they want anything done
iv. Dietary and fluid interventions- encourage fluids as able, more fiber, if able increase activity
v. Additional approached- symptom management
vi. Complementary approaches - min goal is to have a bowel movement every 72 hours
treatment constipation
– frequent passage of loose non formed stool
- Effects fatigue caregiver burden, skin breakdown
- work with them there to help them, have done it before, reassure
1. Causes: Disease related, Psychological, Treatment related, concurrent disease, malabsorption
iv. Diarrhea
a. Bowel history
b. Medication review
c. Evaluate for infectious process
diarrhea
2. Assessment
a. etiology as appropriate- underlying cause, decrease amount of fiber, adequate hydration=electrolytes, can consider IV fluid =is it considered for what care they want to
b. Dietary modification (increase bulk, decreased gas-producing foods)
c. Medications
d. Hydration
diarrhea
treament
– 70 percent, common in advanced disease, etiology
1. Causes: Physiological (GI, metabolic, CNS), Psychological (burden) , Disease related, Treatment related
v. Nausea/vomiting
a. Clinical/physical
b. History
c. Laboratory values
n/v assessment
= ____patch behind ear good for pt that can’t take things po
, _____ vestibular cause(vertigo),
Steroids= thc help to alleviate nausea,
-food not sitting there
- Treatment
a. Pharmacological
Nv
anticholinergics Scopolomine
antihistamine= Benadryl
Prokinetic agents= Reglan
b. - distraction/relaxation, dietary, small/slow feeding, invasive therapies
c. Invasive therapies
treatment nv
Non-pharmacological
i. subjective, multidimensional experience of exhaustion, commonly associated with many diseases, impacts all dimension of QOL
1. - Disease related, Psychological, Treatment related
2. –Subjective, Objective, Laboratory data
3. - Pharmacological, Non-pharmacologic
fatigue
cause
assessment
treatment
- no assumed to be a normal occurrence in eof, ranges from sadness to suicidal, often unrecognized and undertreated, occurs in 25-77% of terminally ill
-distinguish normal- normal loss process vs abnormal- true clinical
-helplessness and hopelessness is seen a lot not considered
normal
1. Causes : Disease related, Psychological, Treatment related
ii. Depression
- symptoms and treat aggressively
a. Situational factors and symptoms
b. Previous psychiatric history/treatment
c. Presence of risk factors- lack of support system, pain
- Assessment
depression
how have your spirits been lately? What do you see in your future?=see event in family life hoping to be there for, What is the biggest problem you are facing?
d. Questions for depression assessment:
are they considering because symptoms are not managed=alleviate physical pain/ Do you think life isn’t worth living? Have you thought about how you would kill yourself?
e. Suicide assessment:
take 2-4 weeks to work, will it work for them will they live that long / - counciling
- Treatment
a. Pharmacological:
Antidepressants, Benzodiazepines
b. Non-pharmacologic
depression
- subjective symptom, what are their fears, concerns, issues they are having
1. Causes- not specific
iii. Anxiety
a. Symptoms- what are you experience since dx or tx/ shaky, nervous, jittery
b. Questions for assessment
assessment anxiety
a. - benzodiazepines , neuroleptic, antidepressants, nonbenzo
b. counseling, physiological symptoms, assurance and support, concrete information, relaxation
anxiety
pharmacological
nonpharmacologic
- acute change in cognition and awareness could be electrolyte balance, actively dying don’t fix
iv. Delirium
- accompanies delirium but not always, Ativan suppository
agitation
- disorientation, inappropriate behavior, hallucination
confusion
- fluid and electrolyte, volume induced, more side effects because kidneys not working well build up, hypoxemia, bladder distention
assessment: list to the family= notice change
pharmacological- Haldol, hospital= provide sitters or family to watch
cause
delirium agitation confusion
deal with symptomatically, how are we going to treat
-not normal symptoms
wounds, seizures
: pt advocate, family and patient goals, assessment skills very important= pharmacological and non-pharmalogical, teaching of the symptoms, us interdisciplinary team, Symptom management challenges
symptom management
Key nursing roles
