Symptom Management Flashcards
Principles complaints about end of life:
- Not recognising that people are dying and not responding to their needs
- Poor symptom control
- Inadequate out of hours service
- Poor care planning
- Poor communication
Common symptoms in advanced illness:
- Pain **
- Fatigues (asthenia) **
- Dysphea **
- Anorexia/cachexia
- Drowsiness or insomnia
- Confusion
- Peripheral edema
- Skin Ulcers
- Anxiety/Depression
- Nausea and vomiting
- Constipation and diarrhea
Symptoms are under-reported (only 1/3 od symptoms experienced were self-reported). Somes facts about it:
- Pt may be reluctant to discuss worsening of pain/symptoms due to its implications
- Education and discussions are keys.
- Discussion regarding expected course of illness/expected symptoms may reduce patient’s fear over significance of symptoms and make it easier for them to discuss any worsening with their physicians.
- Knowledge that these symptoms do no have to be endured and can be alleviated may encourage them to seek attention and improve Quality of Life.
CARES tool for the management of symptoms addresses the priority need of:
Comfort Airway Restlessness/Delirium Emotional and spiritual support Self-care
In a patient with renal failure in end of life, what should we consider?
- Consider fentanyl (also consider it if there is small seizure/tremors–>myoclonus)
- Opiods stay in the system longer with renal failure. Dosage is usually smaller.
- Morphine in renal failure can cause Opioid Neurotoxicity (hyperalgia, myoclonus, delirium, convulsion).
The focus of care for dying patient is comfort. All unecessary procedure/text/activities should be evaluated. What should we consider in obtening an order to priorizing the patient needs?
-Stop/modify vital signs
-Stop oral rx if unable to swallow
-Clarify IV option: stop or reduce
-Stop or reduce tube feedings (In end of life, nutrition and hydratation have not be proved to prolong life or improve pt wellbeing)
-Turn off monitors and alarms
-Stop or decrease lans per physician and family preference.
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The focus of care for dying patient is comfort. What can we provideas comfort measures without an orders?
- Turn and position pt only for confort
- Modify bathing or stop per family request
- Consider re-enforcing dressings only.
- Provide frequent oral care
- Provide oral suctioning if family requests.
- Provide temperature comfort measures such as a cool wash cloth and ice packs.
- Explain mottling and cyanosis as part of the dying process and not from being cold.
Pain management: Four Step Process:
- Assessment of all types of pain being experienced
- Weigh the benefit/burden of each tx offered
- Manage each pain with individualized, etiology-specific interventions
- Continuous reassessment of tx goals (Pain level/goal, functional goal, sleep, mood, social interactions, tolerability and managemetn of side effects)
Pain assessment in palliative context:
- May not verbally communicate pain. Unconscious patients still experience pain.
- Physical signs: Grimacing, furrowed brows, resslesness, moaning, tears.
- If the patient is not achieving adequate pain control, the dose could be increased by 25% to 50%.
Breakthrough doses for breakthrough pain:
-The dose should be proportionate to the total daily opioid dose. Generally the same molecule as the regular opioid: 10% of the total daily opioid dose given q1hr. PRN.
Hydratation can help improve symptom control like delirium, opioid induced neurotoxicity, and nausea. It should be considered when:
- The patient is NOT close to dying **and not able to hydrate orally.
- THe patient goal is to extend life and hydratation will helps (if the patient is NOT close to die)
Hydratation Should not be considered when?
- Pt close to death (termina phase)
- Pt has severe edema or ascites
- Pt prone to pulmonary edema
- If greatly burdensome without potential equal benefit.
Management approach to dyspnea: Educate the pt/family about
- Experience may not equal perception
- Etiologies
- Changes in respiratory patterns may not equal dysnea
- Drugs will remove perception of dyspnea but may not alter respiratory pattern.
Simple interventions in managing dyspnea:
Calm reassurance, sitting up/semi-reclined, open window, fan, be sensitive to sense of isolation, relaxation therapy, avoid exacerbation activities or irritants.
Oxygen or air? Guidelines:
- Supplemental oxygen is recommended for hypoxic patients who are experiencing dyspnea
- It is NOT recommended for dyspneic patients who are NOT hypoxic.
- For non-hypoxic patients, a fan or humidified air (via nasal prongs) may be tried, depending on the availability and pt preference.
- If the fan or humidified air is not effective or not tolerated, a trial of humidified oxygen administered via nasal prongs may be considered.
