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Managing Symptoms at Home

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Title: Managing Symptoms at Home


1
Managing Symptoms at Home
  • Debra LaFrankie RN, OCN
  • Program Nurse
  • Center for Neuro-oncology
  • Dana-Farber Cancer Institute

2
Patients with Brain Tumors may experience a
variety of symptoms at home. The goal of this
presentation will be to review the most common,
and to guide the caregiver in home management.
3
Appetite Changes
  • Decreased appetite is usually of concern
  • Smells may affect desire to eat, consider serving
    cold foods. Reduce cooking odors as possible
  • Snack foods or small frequent meals may stimulate
    the appetite
  • Use distraction (watching t.v., talk, invite
    company)
  • May consider an appetite enhancer (Marinol,
    Megace, etc.).

4
Weight Loss
  • Likely caused by the bodys changes in
    absorption.
  • Fat Intolerance (low belly pain, gas, bloating,
    diarrhea) may note an oily slick in the water
    after a BM This calls for a low fat diet.
  • Lactose Intolerance (bloating, painful gas,
    diarrhea, cramps) Eliminate dairy products.
    Substitute soy or rice based products. Lact-Aid
    can help.
  • Malabsorption (cramps and diarrhea soon after
    eating) Talk with your Doctor or Nutritionist.

5
Muscle Wasting
  • May occur when the body uses its own muscle for
    protein.
  • Increase protein in diet eggs, meat, soy,
    beans, rice, macaroni and cheese, etc.
  • Instant breakfast mixes work well, and are less
    expensive.
  • Non-fat dry mild powder can be added to scrambled
    eggs, baked goods, etc.
  • Nutritional bars or supplements may help.

6
Low Blood Counts May result from chemotherapy
  • Low Platelet Count
  • Platelets are particles in the blood that help
    to form clots so we dont bleed to death if we
    are injured.
  • A low platelet count means that you are
    vulnerable to excess bleeding if you are bruised
    or cut

7
What to do
  • Keep the living area safe to prevent falls and
    injuries (install handrails for tub, remove throw
    rugs, etc.)
  • Check all bruises, apply ice and direct pressure
    if necessary.
  • Check mouth, skin, and whites of eyes for signs
    of bleeding
  • Shave with electric razor
  • Observe for blood in urine or stool (may appear
    as black/tarry stool).
  • Clean mouth/teeth with foam toothette or gauze
    (not a toothbrush)

8
  • Check menstrual flow (monthly period). Notify
    your doctor if unusually heavy.
  • Avoid injections into the muscle.
  • Apply pressure for 15 full minutes if skin breaks
    or bruising.
  • Check daily for spontaneous bruising, especially
    legs and feet.
  • Use stool softeners to avoid straining for bowel
    movements.
  • Report immediately any change in mental status
    (sleepiness, speech or coordination problems,
    severe headaches, etc.)
  • Avoid aspirin or ibuprofen products.

9
Low Blood Counts
  • Low White Blood Cell Count
  • May increase risk of infection.
  • Good handwashing is the best first line
    defense.
  • Call your doctor is Temp gt100.5, or sign of
    infection (cough, discomfort or frequency of
    urination, etc.)

10
Nausea Feeling sick to your stomach can be
caused by medication and/or radiation.
  • What to do
  • Eat bland food such as dry toast or crackers.
  • Eat small, frequent meals and snack at bedtime.
  • Eat only foods you like that smell pleasant.
  • Eat food cold or at room temperature so it has
    less smell /taste.
  • Sip liquids and eat food slowly.
  • Report nausea to MD and take medication as
    prescribed.
  • Rest for at least one hour after each meal.
  • Relax, take deep breaths, distract with music,
    t.v., etc.
  • Dont force foods or liquids while nauseated.

11
Vomiting Throwing up can be caused by
medication and/or radiation.
  • What to Do
  • Take liquids in the form of ice chips or frozen
    juice chips that can be munched slowly.
  • If in bed, sit upright or lie on your side to
    vomit to avoid inhalation.
  • Resume foods gradually start with clear
    liquids, crackers, dry toast, ginger ale, jello,
    etc. Avoid fats.
  • Request medication in suppository form.
  • Clean out mouth soon after vomiting.

12
Call the Doctor
  • If you think some vomited material was inhaled.
  • If a person vomits more than three times an hour,
    or for three hours.
  • If there is blood or coffee grounds in vomit.
  • If the person cant drink more than 4 cups of
    fluid in a day or hasnt eaten food for two days.
  • If the person cant take their medicine.
  • If the person feels very weak/dizzy.

13
Fever A body temperature of more than 100.5
degrees F orally, that lasts for 1 or more days.
  • Signs/Symptoms
  • Shaking chills, feeling cold.
  • Increased skin temperatures.
  • Complains of feeling warm.
  • Skin rash or reddening.
  • Feeling tired, very inactive.
  • Headache or body aches.
  • Confusion or delirium.

14
What to Do
  • Cover with a blanket if chilly.
  • Cover only with a sheet if hot.
  • Drink lots of liquids (juices, soda, popsicle,
    soups, etc.)
  • Rest
  • Take acetaminophen or other medicine recommended
    by your MD for fever.
  • Apply cool compress to head and back of neck if
    hot.
  • Take and record temperature every 4 hours (do not
    take for 1 minute after food/drink).
  • Do NOT use ice baths or alcohol rubs

15
Call the Doctor
  • When a fever is new and wont come down or stay
    down.
  • If a fever lasts for more than 24 hours or wont
    stay down with treatment.
  • If the person is delirious.

16
Dehydration Not enough water/fluids in the body.
  • What to Do
  • Drink fluids (soda, water, ice chips, juices,
    Popsicles, sports drinks, Jello, soups, etc.
  • Fill a small cooler with ice and keep drinks
    close at hand.
  • Apply lotion to skin frequently.
  • Encourage foods, such as fruit, that contain
    fluids.
  • Keep the mouth clean.
  • Attempt to get rid of the cause of dehydration.

17
Dehydration
  • Signs/Symptoms
  • Thirst
  • Dry mouth, unable to swallow dry foods,
    difficulty talking, swollen, cracked, dry tongue
  • Dizziness, weakness, fatigue
  • Fever
  • Dry skin that tents when pinched.
  • Weight loss
  • Sunken eyeballs
  • No urine/small amounts of dark urine
  • Confusion/delirium/hallucinations
  • Call the Doctor
  • If vomiting, diarrhea or fever lasts for more
    than 24 hours.
  • If urine is either very dark in color and of
    small amounts, or if there is no urine for 12
    hours.
  • If dizzy or faint when standing up.
  • If there is confusion, delirium or
    hallucinations.
  • If the fever wont come down, and stays over 101.

18
Sleep Problems A change in the usual sleeping
habits trouble getting to sleep or staying
asleep.
  • What to Do
  • Allow the person to sleep as much as they feel
    like, but when awake, encourage exercise at least
    once daily.
  • Drink warm, non-caffeine drinks before sleep
    avoid caffeine (coffee, cola, tea, chocolate)
    late in the day.
  • Make sure that the environment is quiet for
    sleep.
  • Take sleeping medications as directed at a
    regular time each night.
  • Have someone rub the persons back or feet.
  • Make sure bedding is clean and wrinkle-free.
  • Encourage a light meal before bedtime.
  • Have them take a warm bath at bedtime.
  • Call the Doctor
  • If pain is keeping the person awake.
  • If the person feels confused at night
  • If the person cannot sleep at all during the
    night.

19
Seizures Uncontrolled movement of muscles,
also known as convulsions or fits. Caused by
abnormal electrical discharges in the brain. They
usually last less than five minutes and are
followed by a period of unconsciousness or
confusion.
20
Seizures
  • Signs/Symptoms
  • Eyes stare blankly or roll back.
  • Body jerks and spasms, especially arms and legs.
  • May lose control of bowels and bladder.
  • May ooze saliva blood from the mouth.
  • Call the Doctor
  • When the seizure is over and the person is
    comfortable.
  • Call 911 if this is the persons first seizure,
    or if occurring repeatedly. Stay with the person.

21
Focal Seizure Fully conscious no special
actions needed.
22
Partial Complex Seizure Awake, perhaps in a
vague state. May be partially aware of
surroundings. May be amnesic about the event.
Keep surroundings safe. Do not restrain.
23
Seizures Grand Mal/Generalized
  • What to Do
  • Stay calm and note the time seizures start.
  • If the person falls to the floor, put a cushion
    under their head.
  • Note what types of movement/body parts are
    involved.
  • Move objects out of the way loosen clothing.
  • As soon as the jerking stops, turn the person on
    their side so mouth secretions drain onto the
    ground.
  • Reassure them that they are okay and tell them
    that they have had a seizure.
  • Make them comfortable and let them sleep.
  • Do Not
  • Leave the person during the seizure, not even to
    call the doctor.
  • Restrain their movement or forcibly turn the
    neck.
  • Try to open their mouth or put anything in it,
    even if they are biting their tongue.
  • Move the person unless they are near a dangerous
    object (glass, radiator, stairs, etc.).
  • Put your hands/fingers in or near the mouth.
  • Give them anything to eat/drink until they are
    fully awake.

24
Seizures Commonly used Medications
  • Phenytoin (Dilantin)
  • Carbamazepine (Tegretol)
  • Valproic acid (Depakene)
  • Levetiracetam (Keppra)
  • Gabapentin (Neurontin)
  • Lamotrigine (Lamictal)
  • Topiramate (Topamax)
  • Phenobarbital (Luminal/Solfoton)
  • Common side effects include blurred vision,
    ataxia (loss of balance when standing/walking),
    lethargy, and nystagmus (jerking of the eyes
    horizontally).
  • Call the Doctor if the patient develops a rash,
    or difficulty walking.
  • The Doctor may prescribe lorazepam (Ativan)
    which may be used under the tongue, to help
    stop/limit seizure activity.

25
Seizures
  • Driving
  • In the initial period following diagnosis and
    before/after surgery, most patients will take
    anti-seizure medications.
  • Most states have mandatory driving restrictions.
    It is important for patients to check with their
    states DMV to understand the restrictions.
  • Driver Rehabilitation programs, which are not
    part of DMV, offer a closed course driving
    evaluation with a trained instructor, to assess
    reaction time, and other necessary driving skills.

26
Fatigue Feeling tired, usually unrelieved by
sleep or rest. It can be caused by the tumor,
radiation therapy, medications, anemia, or
depression.
27
Fatigue
  • What to Do
  • Believe them.
  • Plan rest periods to conserve energy for
    important activities.
  • Evaluate and treat for depression if necessary
  • Schedule necessary activities for high energy
    times of day, and with rest in between.
  • Get enough sleep/rest.
  • Exercise every day.
  • Do Not
  • Force the person to do more than they can manage.
  • Signs/Symptoms
  • Person says that they have no energy.
  • Person sleeps more.
  • Seems sad or blue.
  • Wants to do less than usual.
  • Has less interest in personal appearance and
    grooming.
  • Call the Doctor
  • If they cant get out of bed for 24 hours.
  • If confusion occurs.
  • If the fatigue continues to worsen.

28
Swelling Edema build up of fluid in the
tissues.
  • What to Do
  • When sitting in a chair, keep feet elevated.
  • Rest in bed with swollen part elevated above the
    heart level.
  • Have them eat as well as they can, especially
    foods high in protein.
  • Take medications as directed.
  • Ask the doctor if they should modify their diet.

29
Swelling
  • Signs/Symptoms
  • Feet/lower legs get larger when sitting or
    walking.
  • Rings feel too tight on fingers.
  • Hands feel tight when making a fist.
  • Abdomen looks distended or blown up.
  • Trouble breathing, especially when lying down.
  • Call the Doctor
  • If they cant eat for a day or more.
  • If they have not made any urine, or very little
    urine for a day or more.
  • If you press your fingers into the swollen area
    and the mark stays.
  • If the swelling spreads up or legs.
  • If belly appears puffy or blown up.

30
Sweating Heavy perspiration, sometimes
occurring at night, and is not brought on by
external temperature changes.
31
Sweating
  • What to Do
  • Take fever reducing medications (acetominophen)
    at bedtime.
  • Change wet clothing as quickly as possible.
  • Keep bed linens clean and dry.
  • Dress in two layers of light, cotton clothing-the
    outer layer will draw wetness away from the skin.
  • Bathe daily to avoid skin irritation.
  • Keep rooms at a comfortable temperature.
  • Drink lots of liquids.
  • Call the Doctor
  • If the person has a fever greater than 100.5 for
    more than 24 hours.
  • If they become dehydrated from frequent soaking
    sweats.
  • Signs/Symptoms
  • Feeling wet or damp during the night.
  • Waking up to find sheets wet.
  • Fever, followed by heavy sweating as the
    temperature falls.
  • Chills
  • Drenching sweats when there is no sign of
    fever/infection.

32
Itching Unpleasant sensation of the skin that
causes a person to want to scratch or rub the
skin often caused by radiation treatment.
33
Itching
  • What to Do
  • Use only mild soaps for washing.
  • Use skin creams with a water-soluble base 2-3
    times a day, especially after bathing (ie.
    Aquaphor, A D, Eucerin, Radiacare).
  • Add baking soda or bath oil to bath water.
  • Use warm water instead of hot water for washing.
  • Use baking soda instead of a deodorant.
  • Apply cool, moist packs to the skin.
  • Keep room cool/well ventilated.
  • Keep nails clean and cut short.
  • Try rubbing, pressure, vibration instead of
    scratching.
  • Wear loose clothing made of soft fabric.
  • Change bed linens daily.
  • Use mild laundry soaps rinse laundry well.
  • Drink plenty of fluids and rest
  • Take medication for itching as ordered by your
    doctor.

34
Itching
  • Signs/Symptoms
  • Dry, red, rough, flaky skin.
  • Rash or skin sores.
  • Yellow color to skin.
  • Scratch marks
  • Scratching without thinking about it.
  • Do Not
  • Use adhesive tape or bandages
  • Use scented or alcohol based skin products.
  • Use harsh soaps or detergents
  • Drink alcohol or caffeine
  • Call the Doctor
  • If itching does not stop after two or more days.
  • If skin appears yellowish or urine turns the
    color of tea.
  • If the rash worsens after cream or ointment is
    applied.
  • If pus pockets develop on the skin.
  • If they become anxious, restless, or cannot sleep
    due to the itching.
  • If they develops hives
  • this may indicate a serious, allergic reaction
    call the doctor immediately.

35
Sore Mouth Can be caused by little cuts or
ulcers in the mouth, as well as gum disease or an
oral yeast infection.
36
Sore Mouth
  • What to Do
  • Check mouth often using a flashlight and padded
    tongue blade or spoon. If they have dentures,
    remove them.
  • Use good mouth care 30 minutes after meals and
    every 4 hours while awake.
  • Brush teeth using a soft bristled toothbrush
    (soak in hot water to soften)
  • Rinse toothbrush well store in cool, dry place.
  • Use non-abrasive toothpaste or baking soda
    solution.

37
Sore Mouth
  • Rinse mouth frequently during the day (swish,
    gargle, and spit out) with one of the following
  • 1 tsp. Baking soda 2 cups of water
  • ½ tsp of salt, 1 tsp baking soda 1 qt water.
  • Equal parts hydrogen peroxide and water. Use
    right after mixing, hold in mouth x 1 ½ minutes,
    spit, and then rinse with plain water.

38
Sore Mouth
  • What to Do
  • Keep lips moist with lip balm.
  • Have regular dental checkups.
  • Drink lots of fluids
  • Use numbing medication as directed.
  • Modify diet use chilled, soft, bland foods
    fluids, eat small, frequent meals of bland,
    non-spicy foods.
  • Avoid citrus fruits, carbonated drinks, hard or
    coarse food, alcohol and tobacco
  • Call the Doctor/Dentist
  • If gums bleed
  • If redness or shininess in the mouth lasts for
    more than 48 hours.
  • When the person first notices any sore or cut in
    the mouth.
  • If they are eating less.
  • If their temperature is above normal.
  • If white patches appear on the tongue or sides of
    the mouth.
  • Do Not
  • Use lemon/glycerin swabs

39
Dry Mouth Not enough saliva in the mouth can
be caused by mouth breathing, dehydration or the
side effect of some medication and radiation.
40
Dry Mouth
  • What to Do
  • Drink plenty of fluids
  • Drink fluids with meals to moisten food and help
    swallowing.
  • Take high calorie diet supplements between meals.
  • Use ice chips, hard candies and sugarless gum to
    stimulate saliva production.
  • Add liquids to solid foods (i.e. gravy, melted
    butter, yogurt, mayonnaise, etc)
  • Keep lips moist (if on oxygen, avoid petroleum
    jelly/Vaseline)
  • Use good mouth care.
  • Avoid spicy, hot, or acidic foods.
  • Avoid food that requires a lot of chewing (tough
    meats, raw vegetables, chewy candy)
  • Use artificial saliva.

41
Dry Mouth
  • Signs/Symptoms
  • Dried, flaky, whitish-colored saliva in and
    around the mouth.
  • Thick, mucous-like saliva that stays attached to
    the lips when the person opens their mouth.
  • Mouth is always open to breathe.
  • Call the Doctor
  • If the mouth remains dry for more than 3 days.
  • If dry, cracked lips or sores develop.
  • If there is trouble breathing.

42
Blood in Stool Can be caused by straining very
hard, irritation in the bowel, ulcers,
hemorrhoids, sores in the anal area, low platelet
count or possible tumor.
43
Blood in Stool
  • What to Do
  • Assess the amount of blood being passed.
  • Wash area well with warm, soapy water, rinse
    well, pat dry.
  • Sitting in a tub of warm water may help
    hemorrhoids.
  • Signs/Symptoms
  • Blood on toilet paper.
  • Blood on underwear, sheets, underpants.
  • Streaks of blood in feces.
  • Bright red blood from rectum.

44
Blood in Stool
  • Do Not
  • Strain to move bowels.
  • Try to push hemorrhoids back in the rectum.
  • Use enemas, laxatives or rectal suppositories.
  • Use a rectal thermometer.
  • Call the Doctor
  • Call 911 if severe distress.
  • If you notice blood on toilet paper two or more
    times.
  • If you notice blood streaks in stool.
  • If you notice bright red blood from the rectum.
  • If you notice dark red or black, tarry stools.

45
Constipation Infrequent or difficult passage of
feces or stool. This can cause pain/discomfort.
Can be caused by Temodar, lack of activity, poor
food and fluid intake, general weakness, pain
medications, muscle relaxants and voluntary
holding of feces.
46
Constipation
  • What to Do
  • Increase high fiber foods (bran, wheat germ, raw
    fruits/vegetables, juices, etc).
  • Increase fluid intake. Fresh juices or warm/hot
    fluids in the morning are helpful.
  • Use laxatives/stool softeners as directed.
  • Do Not
  • Do not use extreme force or straining to move
    bowels.
  • Do not use over-the-counter laxatives unless
    approved by doctor.
  • Do not eat foods that cause constipation
    chocolate, cheese, eggs, bananas, rice and apples.

47
Constipation
  • Signs/Symptoms
  • Small, hard bowel movements.
  • Seepage of soft stool resembling diarrhea.
  • Stomach ache/cramps.
  • Excess gas/belching.
  • Belly appears blown-up/puffy.
  • No regular bowel movement within 3 days.
  • Nausea/vomiting.
  • Feeling of fullness/discomfort.
  • Call the Doctor
  • If there has been no regular BM within 3 days.
  • If you notice blood in or around the anal area or
    stool.
  • If you cannot move your bowels within 1 or 2 days
    of taking laxatives.
  • If you have persistent cramps or vomiting.

48
Hiccoughs occur when the diaphragm suddenly
contracts between normal breaths.
  • What to Do
  • Breathe slowly and deeply into a paper bag for
    ten breaths at a time.
  • Drink water slowly
  • Hold a mouthful of sugar in the mouth and then
    swallow.
  • Do Not
  • Ignore the hiccoughs
  • Force the person to eat it may cause vomiting.
  • Call the Doctor
  • if hiccoughs last for more than a day.
  • If they have difficulty breathing
  • If their stomach seems puffy or blown-up.

49
Shortness of Breath Difficulty breathing, not
enough oxygen is delivered to the body, either
lungs cannot breathe in enough air or they cannot
get enough oxygen to the bloodstream.
50
Shortness of Breath
  • What to Do
  • Remain calm
  • Sit person upright in chair, or raise head with
    pillows
  • Give medications prescribed for problem breathing
    (inhalers, oxygen, etc.)
  • If in distress, check pulse and respiratory rate,
    and temperature.
  • Instruct to inhale through nose, exhale through
    pursed lips
  • If spitting up mucous, note amount, color and if
    there is an odor (normal is clear or white and
    foamy).
  • Do Not
  • Lie flat.
  • Signs/Symptoms
  • Shortness of breath or trouble breathing
  • Chest pain
  • Breathing is fast.
  • Pulse rate increases
  • Skin looks pale or bluish
  • Skin feels cold and clammy
  • Nostrils flare when inhaling
  • May have wheezing
  • Call the Doctor
  • Call 911 if severe distress
  • If difficulty breathing and chest pain
  • If thick green, yellow and/or bloody sputum
  • If skin pale/bluish or cold and clammy
  • If fever occurs
  • If nostrils flare during breathing, or if
    wheezing.

51
Pain Management
  • The Patients report of pain is the most reliable
    information.
  • Assessing pain is the key to management
  • 0-10 scale
  • How much relief did medication bring (what is the
    number now?)
  • How long did relief last?

52
Pain Management
  • Routes of Administration of medication
  • Preferred pain medication administration is by
    mouth
  • Injections
  • Pain patch
  • Sublingual (under the tongue)

53
Pain Management
  • Keep expectations realistic (pain may be
    controlled, but not always eliminated).
  • Side Effects
  • Opiates (narcotics) may cause constipation, or
    sedation.
  • Stool softeners will help to reduce constipation.

54
Headaches
  • Headaches may have been the heralding symptom for
    a patient with a brain tumor.
  • Post-operative headache after surgery is common,
    but usually subside after a short time.
  • Notify the Doctor is the patient develops new
    headaches, as this may be a sign of increased
    intracranial pressure.
  • Sometimes, depression may bring on headaches.
  • Rarely, may experience a constant low grade
    headache or painful headaches.
  • Pain medications or alternate therapies, such as
    acupuncture may be helpful.

55
Focal Deficits
  • Focal deficits arise depending on the location of
    the brain that has been damaged.
  • Common Focal Deficits
  • Vision loss (may be partial) may result from
    changes in the eye, occipital lobe and any
    connections between those areas.
  • An appointment should be made with an
    Ophthalmologist or Optometrist.
  • Hearing loss
  • Motor difficulties
  • Speech impairment
  • Sensory impairment
  • Consultation with a Physical Therapist,
    Occupational Therapist, or Speech Therapist may
    be helpful to reduce the risk of injury, and to
    promote optimal independent activity.

56
Thromboembolic Disease Blood Clots
  • About 1/3 of patients with malignant gliomas
    develop clinically apparent thromboembolic
    disease during the course of their illness.
  • Patients at high risk are those with loss of
    mobility or who are confined to bed, someone with
    one-sided weakness, or when someone is on
    chemotherapy.
  • Most commonly, blood clots occur in the legs or
    in the arms. Rarely, clots may occur in the
    lungs.

57
Thromboembolic Disease
  • Symptoms
  • Tenderness or pain in the calf, behind the knee,
    or in the thigh.
  • Swelling in one leg or arm, particularly in the
    one that is weakest.
  • Pain in the leg when it is squeezed.
  • Pain in the leg when the foot is moved toward the
    face.
  • Blood clotting in the lung is characterized by
    difficulty breathing or chest pain.
  • The Doctor should notified immediately if a clot
    is suspected.
  • An ultrasound or CT scan may be performed to
    diagnose the clot
  • Patients may be treated with anticoagulant
    therapy (heparin, warfarin). Blood levels may be
    monitored to make sure that the blood dose not
    lose its ability to clot, which may lead to
    hemorrhage.
  • Filters may be placed in the vein to reduce the
    risk of blood clots moving toward the lungs or
    brain.

58
Do not hesitate to contact your Doctor or Nurse
if symptoms or concerns arise.
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