Clinical Review for the Hospice and Palliative Nurse · Clinical Review for the Hospice and...

Clinical Review for the

Hospice and Palliative Nurse Presented By:

Laura Scherer RN, BSN, CHPN

Symptom Management

Part 1 GI Management

1

Objectives

1. Part 1 will define gastrointestinal symptoms present at

the end of life.

2. Identify possible etiologies of symptoms at the end of

life.

3. Assess for the physical and psychosocial aspects of the

symptoms that are common at the end of life.

2

Objectives

4. Describe pharmacological and nonpharmacological

interventions for common symptoms that can be included

in the plan of care at the end of life.

5. Describe the patient and family instructions needed for

patients and families at the end of life.

3

Domains of

Quality Palliative Care

Clinical Practice Guidelines of Quality Palliative Care

Domain 2: Physical Aspects of Care

Guideline 2.1 Pain, other symptoms, and side

effects are managed based upon the best available

evidence, with attention to disease-specific pain

and symptom, which is skillfully and systematically

applied.

4

Anorexia and Cachexia

Anorexia

loss of appetite resulting in the inability to eat

Cachexia

physical wasting and malnutrition usually associated with

chronic disease

5

Anorexia and Cachexia

Prevalence

Commonly found in patients with advanced

disease

80% of cancer patients

6

Anorexia/Cachexia

Causes

Disease Related

Infections

Delayed gastric emptying

Metabolic alterations

Pain

7

Anorexia/Cachexia

Causes

Treatment Related

Medications

Chemotherapy

Radiation

8

Anorexia/Cachexia

Causes

Psychological and/or spiritual distress

Often overlooked

Depression may exhibit somatic symptoms

9

Anorexia/Cachexia

Assessment

Patient reports

Muscle wasting

Weight loss

Lab values

Intake patterns

10

Anorexia/Cachexia

Pharmacological Interventions

Megestrol acetate (Megace®)

Metoclopramide (Reglan®)

Dexamethasone (Decadron®)

Dronabinol (Marinol®)

11

Anorexia/Cachexia

Non-pharmacological Interventions

Treat underlying symptoms

Emotional support

Nutritional support

12

Anorexia/Cachexia

Non-pharmacological Interventions

Enteral and parenteral nutrition

13

Anorexia/Cachexia

Patient & Family Education

Support patient’s wishes

Discuss intake during dying process

Explore meaning of food

Address emotional needs

Redirect caring

14

Anorexia/Cachexia

References

1. Kemp C. Anorexia and cachexia, In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006:169-176.

2. Bednash G, Ferrell BR. End-of-life nursing education consortium (ELNEC). Washington, DC: Association of Colleges of Nursing; 2009.

3. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003.

15

Dehydration

Normal physiologic process at the end of life

Decreased desire for fluids

Symptoms vary

16

Causes of

Dehydration

Loss of normal body water

Isotonic dehydration

Eunatremic dehydration

Hypotonic dehydration

17

Assessment for

Dehydration

Mental status changes

Confusion, restlessness

Intake and output

Elderly may have decrease perception of thirst

Urine output reduced

18

Assessment for

Dehydration

Weight loss

Reduced skin turgor

Skin and mouth assessment

Postural hypotension

Lab values

Increased hematocrit

Serum sodium

19

Treatment of

Dehydration

Ethical considerations

Benefits vs. burdens

Review expected course of illness

Artificial hydration

Misperceptions

20

Treatment of

Dehydration

Use least invasive approach possible

Oral

Provide appropriate mouth care

Proctoclysis

21

Treatment of

Dehydration

NG/GT

NG uncomfortable

Hypodermoclysis

Subcutaneous fluid administration

IV

22

Treatment of

Dehydration

IV

Monitor for over hydration

23

Dehydration

Patient & Family Education

Oral/enteral/parenteral fluids

Instruct more than one person

Allow ample time for instruction and return

demonstration

24

Dehydration

Patient & Family Education

Review benefits/burdens of artificial nutrition &

dehydration

Address emotional needs

Assist in redirecting ways of caring

25

Dehydration

References

1. Emanuel L. von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association; 2003.

2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC). Washington, DC: Association of Colleges of Nursing; 2009.

3. Kedziera P, Coyle N. Hydration, thirst, and nutrition. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press; 2006: 239-248.

4. Kazanowski M. Symptom management in palliative care. In: Matzo, ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the End of Life. New York, NY: Springer; 2006: 319-344.

26

Nausea and Vomiting

Nausea

Subjectively perceived

Unpleasant sensation experienced in the back of the

throat and epigastrium, which may or may not result

in vomiting

Vomiting

expelling of stomach contents through the mouth

27

Nausea and Vomiting

Prevalence

Common in patients with advanced disease

70% of patients experience nausea

30% of patients experience vomiting

Patients under 65 and women

Stomach, breast and gynecological cancer

AIDS

28

Causes of

Nausea and Vomiting

Physiological Causes

Gastrointestinal

Metabolic

Central nervous system

Psychological

Emotional

Disease related

Treatment related

29

Nausea and Vomiting

Associated with

Opioid therapy

Uremia

Hypercalcemia

Constipation

Bowel obstruction

30

Assessment

of Nausea and Vomiting

History of disease

Effectiveness of prior treatments

Precipitating factors

Self-reporting tools

Physical

Diagnostic testing

31

Nausea and Vomiting

7 Steps for Antiemetics

1. Identify cause

2. Identify pathway of cause

3. Identify neurotransmitter receptor

4. Select potent antagonist for that receptor

5. Select a route

6. Titrate dose & administer ATC

7. If symptoms continue, additional

treatment

32

Nausea and Vomiting

Antiemetics

Butyrophenones

Indication: opioid-induced nausea, chemical and

mechanical nausea

Medications

Haloperidol (Haldol)

Droperidol (Inapsine)

33

Nausea and Vomiting

Antiemetics

Protokinetic agents

Indication: gastric stasis, ileus

Medications

Metoclopramide (Reglan)

Domperidone (Motilium)

34

Nausea and Vomiting

Antiemetics

Cannabinoids

Indication: second-line antiemetic

Medication

Dronabinol (Marinol)

35

Nausea and Vomiting

Antiemetics

Phenothiazines

Indications: general nausea and vomiting, not as

highly recommended for routine use in palliative care

Medications

Prochlorperazine (Compazine)

Thiethylperazine (Torecan)

Trimethobenzamide (Tigan)

36

Nausea and Vomiting

Antiemetics

Antihistamines

Indications: intestinal obstruction, peritoneal

irritation, increased intracranial pressure,

vestibular causes

Anticholinergics

Indication: motion sickness, intractable

vomiting, or small bowel obstruction

37

Nausea and Vomiting

Antiemetics

Steroids

Appear to exert antiemetic effect as a result of

antiprostaglandin activity

Most effective in combination with other agents

Benzodiazepines

Indication: effective for nausea and vomiting as well

as anxiety

38

Nausea and Vomiting

Antiemetics

5-HT3 receptor antagonists

Indicated for post-operative nausea and vomiting and

chemotherapy

ABHR

Compounded antiemetics

39

Nausea and Vomiting

Antiemetics

Octreotide (Sandostatin®)

Indications: nausea and vomiting associated with

intestinal obstruction

DimenhyDRINATE (Dramamine®)

Indications: nausea, vomiting, dizziness, motion

sickness

40

Non-pharmacological

Treatment of Nausea and Vomiting

Oral care

Cool damp cloth

Decrease noxious stimuli

Loose-fitting clothes

Fresh air or fan

41

Non-pharmacological

Treatment of Nausea and Vomiting

Behavioral complementary therapies

Interventions individually based

Cultural considerations

42

Nausea and Vomiting

Patient and Family Education

Assessment of nausea and vomiting

Problem solving

Family’s role

Instruct when to call healthcare provider

43

Nausea and Vomiting

References

1. Berry PH, ed. Core Curriculum for the Generalist Hospice and

Palliative Nurse. 2nd ed. Dubuque, IA: Kendal/Hunt; 2005.

2. King C. Nausea and vomiting. In: Ferrell BR, Coyle N, eds. Textbook of

Palliative Nursing. 2nd ed. New York, NY: Oxford University Press;

2006: 177-194.

3. Bednash G, Ferrell BR. End-of-life nursing education consortium

(ELNEC - Geriatric). Washington, DC: Association of Colleges of

Nursing; 20072005.

4. Kazanowski M. Symptom management in palliative care. In: Matzo

ML, Sherman DW, eds. Palliative Care Nursing: Quality Care to the

End of Life. New York, NY: Springer; 2006: 319-3442001:327-361.

5. Mannix K. Gastrointestinal symptoms. In: Doyle D, Hanks GWC,

MacDonald N, eds. Oxford Textbook of Palliative Medicine. 3rd New

York, NY: Oxford University Press: 2005:1998464-468: 489-499.

44

Bowel Obstruction

Prevalence

Related to site of disease

Tumors of splenic flexure obstruct 49% of the time

Rectum or rectosigmoid obstruct 6% of the time

45

Bowel Obstruction

Occlusion of the lumen or absence of the normal

propulsion

Intralumen obstruction

Extramural obstruction

Mechanical obstruction

Metabolic disorders

Medications

46

Assessment of

Bowel Obstruction

Assess within palliative care goals

Bowel history

Pain

Palpate abdomen

Rectal exam

Location of obstruction

47

Treatment of

Bowel Obstruction

Prevention

Principles

Goal of treatment is prevention whenever possible

Verify cause of obstruction: tumor vs. fecal

impaction

If stool, goal is to move the stool down through the

intestinal tract

Avoid stimulant laxatives - usually increase

discomfort and may cause intestinal wall rupture

48

Treatment

Bowel Obstruction

Pharmacolologic

Octreotide (Sandostatin®)

Scopolamine

Opioids

Antiemetics

49

Treatment of

Bowel Obstruction

Pharmacolologic

Corticosteroids

Antispasmodic

Laxative / Antidiarrheal

50

Treatment of

Bowel Obstruction

Surgical

Considered within context of established palliative care

goals

51

Treatment of

Bowel Obstruction

Non-pharmacological

Avoid hot drinks

Avoid big meals

Consider NG

52

Bowel Obstruction

Patient & Family Education

Review causes

Discuss treatment options

Educate to prevent

Instruct when to call healthcare provider

Review medications

Review dietary recommendations

53

Bowel Obstruction

References

1. Economou DC. Bowel management: constipation,

diarrhea, obstruction, and ascites. In: Ferrell BR, Coyle

N, eds. Textbook of Palliative Nursing. 2nd ed. New

York, NY: Oxford University Press; 2006: 219-238.

2. Kazanowski M. Symptom management in palliative

care. In: Matzo ML, Sherman DW, eds. Palliative Care

Nursing: Quality Care to the End of Life. New York,

NY: Springer; 2006:319-344.

3. Emanuel L. von Gunten C, Ferris F. The Education for

Physicians on End of Life Care (EPEC) Curriculum.

Washington, DC: American Medical Association; 2003

54

Constipation

Infrequent passage of stool

Increases with age

Frequent with illness and at the end of life

Results from some medications

Opioids!

55

Constipation

Prevalence

10% of general population

Increases with age

Effects more than 50% of patients in a palliative care

unit or in hospice

Frequently seen symptom at the end of life

Undertreated by nurses and doctors

Can be very embarrassing for some patients

Prevention is the key!

56

Causes of

Constipation

Disease Related

Cancer

Diabetes

Hypercalcemia

Medication Related

Other

Dehydration

Inactivity

Depression

57

Assessment for

Constipation

Bowel history

Abdominal assessment

Rectal Assessment

58

Assessment for

Constipation

Physical assessment

Diagnostic tests

Medication review

Prescription

Over the counter

Herbals

59

Pharmacological

Treatment of Constipation

Laxatives

Lubricant laxatives - lubricate the stool surface & soften

the stool leading to easier bowel movement

Surfactant/detergent laxatives

Reduce surface tension, increase absorption of fluids and

fats into stool which soften it can increase peristalsis

60

Pharmacological

Treatment of Constipation

Combination medications

Osmotic laxatives

non-absorbable sugars that exert an osmotic effect in

primarily the small intestine

Osmotic suppositories

Glycerine suppositories: Soften stool by osmosis and act

as lubricant

61

Pharmacological

Treatment of Constipation

Laxatives

Saline laxatives - increase gastric, pancreatic, & small

intestinal secretions, & motor activity throughout the

intestine

62

Pharmacological

Treatment of Constipation

Bowel stimulants

Bowel stimulants - Work directly to irritate bowel &

stimulate peristalsis;

Use with caution when liver disease present

63

Pharmacological

Treatment of Constipation

Bulk Laxatives

Provide bulk to the intestines to increase mass -

stimulates bowel to move

64

Pharmacological

Treatment of Constipation

Enemas

Soften stool by increasing water content

65

Opioid Induced

Constipation

Opioid Induced Constipation

Opioids

bind to mu–opioid receptors in the central nervous system – provide analgesia

also bind to peripheral mu–opioid receptors in the gastrointestinal tract, inhibiting bowel function – opioid induced constipation (OIC).

Pharmacologic / non-pharmacologic treatment

Oral erythromycin

Metoclopramide

66

Pharmacological

Treatment of Constipation

Methylnaltraxone / (Relistor®)

Inhibits opioid induced decreased gastrointestinal

motility and delay in gastrointestinal transit time

Does not affect opioid analgesic effect

Subcutaneous route / Dose according to weight

Decrease dose with renal impairment

50% of patients had a bowel movement within 30

minutes to 4 hours of the first injection

67

Non-pharmacological

Treatment of Constipation

Prevention

Manage side effects of pain medication

Encourage fluid and fiber intake

Encourage activities

Intervene only if causing distress

Cultural Considerations

68

Constipation

Patient & Family Education

Monitor bowel patterns

Encourage fluid intake

Encourage dietary intake

Encourage activity

Instruct when to call healthcare provider

69

Constipation

References

1. Economou DC. Bowel management: Constipation, diarrhea,

obstruction, and ascites. In: Ferrell BR, Coyle N, eds. Textbook of

Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006: 219-238.

2. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium

(ELNEC ). Washington, DC: Association of Colleges of Nursing,

2009.

3. Sykes N. Constipation and diarrhea. In: Doyle D, Hanks G,

MacDonald N, eds. Oxford Textbook of Palliative Medicine. New

York, NY: Oxford, 2005: 483-490.

70

Constipation

References

4. McMillan S, Williams F. Validity and reliability of the constipation

assessment scale. Cancer Nursing 1989;12:183-188.

5. Emanuel L, von Gunten C, Ferris F. The education for Physicians on

End of Life Care (EPEC) Curriculum. Washington, DC: American

Medical Association, 2003.

6. Kazanowski M. Symptom management in palliative care. In: Matzo

ML, Sherman D W, eds. Palliative care nursing: Quality care to the

end of life. New York, NY: Springer, 2006: 319-344.

71

Diarrhea

Frequent passing of loose, non-formed stool

More severe in HIV-infected patients and bone

marrow transplant patients

72

Diarrhea

Prevalence

Considered a main symptom in 7-10% of hospice patients

Especially prevalent in the HIV patient

43% of bone marrow transplant patients develop diarrhea

related to radiation

Occurs in 10% of cancer patients

73

Causes of

Diarrhea

Disease related

Psychologically related

Treatment related

74

Assessment of

Diarrhea

Bowel history

Assess frequency and nature of diarrhea in last 2 weeks

Complaints of pain or abdominal cramping

Rapid onset may indicate fecal impaction with overflow

Colonic diarrhea: watery stools in large amounts

Malabsorption: foul smelling, fatty, pale stools

Diet history

Treatment history

Medication review

75

Assessment of

Diarrhea

Physical assessment

Abdominal assessment

Examine stools for signs of bleeding

Evaluate for signs of dehydration

76

Pharmacological

Treatment for Diarrhea

Opioids

Suppress forward peristalsis and increase sphincter tone

Loperamide (Imodium®)

Bulk forming agents

Promote absorption of liquid / increase thickness of stool

Psyllium (Metamucil®

Antibiotics

Steroids

Somatostatins

Slows transit time by decreasing secretions

Octreotide (Sandostatin) 77

Non-pharmacological

Treatment for Diarrhea

Dietary management

Initiate a clear liquid diet

Eat small, frequent, bland meals

BRAT diet

Low residue diet

Increase fluids in diet

Consider homeopathic remedies

78

Non-pharmacological

Treatment for Diarrhea

Psychosocial interventions

Provide support to patient and family

Recognize negative effects of diarrhea on quality of life

Sitz baths

Cultural Considerations

Many cultures modest – may prevent reporting

79

Diarrhea

Patient & Family Education

Respect level of comfort during discussions

Monitor frequency and consistency

Instruct when to contact healthcare provider

Provide skin care

80

Diarrhea

References

1. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC - Geriatric). Washington, DC: Association of Colleges of Nursing, 2007.

2. Economou DC. Bowel management: Constipation, diarrhea, obstruction, and ascites. In: Ferrell BR, Coyle N, eds. Textbook of palliative nursing. 2nd ed. New York, NY: Oxford, 2006: 219-238.

3. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association, 2003.

81

Questions

82

Thank You