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GSAPNA Lecture at the Beach September 19, 2015 M. Jane Griffith, RN, MSN, GNP-BC, ACHPN (Caroline Duquette, DNP, APRN, CHPN, contributing author) – PowerPoint PPT presentation

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Symptom Management in Chronic Illness
  • Lecture at the Beach
  • September 19, 2015
  • M. Jane Griffith, RN, MSN, GNP-BC, ACHPN
  • (Caroline Duquette, DNP, APRN, CHPN, contributing

Symptom Management in Chronic Illness Objectives
  • Define common palliative care symptoms in a
    variety of disease conditions/illnesses.
  • Define components of symptom assessment.
  • Develop symptom management plan of care including
    pharmacologic and non-pharmacologic

Case Study
  • AD is a 65 year old white male presenting to
  • the acute care facility with SOB, generalized
  • weakness and rapid atrial fibrillation.
  • Treated with TEE-guided cardioversion to normal
    sinus rhythm.
  • Started on amiodarone 200mg 3 times a day.
  • I just feel tired.

Case study Past Med Hx
  • Coronary Artery Disease s/p CABG, s/p PTCA
  • Ischemic Cardiomyopathy EF 20, congestive
    heart failure, mitral regurgitation
  • End-stage renal disease with hemodialysis, left
    upper extremity fistula
  • Hypertension
  • Hyperlipidemia
  • Lupus anticoagulant
  • Antiphospholipid antibody syndrome with DVT
  • Gastroparesis, constipation
  • Renal osteodystrophy

Past Medical History
  • Obstructive sleep apnea
  • Tobacco dependence
  • Weight loss
  • Hypothyroidism
  • Depression
  • Sacral pressure ulcer
  • Cholecystitis
  • Pneumonia
  • Pleural effusions
  • DJD of lumbar spine, chronic pain, opioid
  • Peripheral neuropathy

Medication List
  • Aspirin 81mg daily
  • Amiodarone 200mg 3 times a day
  • Carvedilol 12.5mg twice a day
  • Warfarin as directed
  • Dalivit 800mg daily
  • Venlafaxine ER 75mg daily
  • Morphine ER 30mg BID
  • Levothyroxine 50mcg daily
  • Atorvastatin 40mg daily
  • Megestrol 400mg/10ml 10ml daily

Review of Systems
  • Pertinent Positives
  • Chronic low back pain
  • Insomnia/depression/anxiety
  • Muscular jerks/myoclonus
  • Confusion
  • Nausea/Constipation/Anorexia/Abdominal Pain
  • Dyspnea/Shortness of Breath/cough/pleuritic chest
  • Fatigue/Activity Intolerance
  • Weakness/Falls

Pain Overview
  • Pain is often not assessed
  • Atypical presentation confusion or agitation.
  • May be described as aching or discomfort
  • Incidence 25-45 elders living in community
    45-85 elders in long term care (American
    Geriatrics Society 2009).
  • Fear of addiction, side effects (e.g.
    constipation), or loss of control.
  • Etiology osteoarthritis, cancer, diabetic
    neuropathy, herpes zoster, and osteoporosis.
  • Start low and go slow (American Geriatrics
    Society, 2009).
  • Achieving good pain management complicated by
    co-morbid disease and increased risk of adverse
    drug reaction 

Pain OverviewDefinitions
  • Pain is whatever the patient says it is whenever
    they experience it (McCaffery).
  • Pain is an unpleasant sensory and emotional
    experience, associated with actual or potential
    tissue damage (IASP).

Types of Pain
  • Nociceptive pain syndromes stimulation of the
    primary afferent nociceptive neurons indicates
    tissue damage.
  • Somatic pain Cutaneous, bone, musculoskeletal
    tissues. Well localized.
  • Examples Bone pain, postsurgical incisional
    pain, pain from inflammation, obstruction or
    stretching of organs .
  • Visceral pain Activation of pain or autoimmune
    fibers, infiltration, compression, distention, or
    stretching of thoracic or abdominal viscera.
    Poorly localized.
  • Example cirrhotic pain.

Types of Pain
  • Neuropathic pain syndromes Dysfunction of the
    nervous system. Burning, shooting, electrical,
    or vise like pain.
  • Examples diabetic peripheral neuropathy, post
    herpetic neuralgia, post- surgical pain syndromes
    (e.g. mastectomy, thoracotomy, etc.) and sciatic

Pain History Acute vs Chronic
  • Acute sudden, recent onset pain.
  • Examples abdominal pain from cholecystitis,
    kidney stone, back pain due to a very recent
  • Chronic present longer than 3 months.
  • Examples rib/chest pain from lung cancer, bone
    pain from cancer, back pain and shoulder pain
    from past injuries
  • Acute on Chronic pain acute pain process
    overlayed on a chronic pain
  • Examples chronic pain due to bone mets, develops
    pathologic fracture chronic arthritis pain,
    develops acute pain from herpes zoster.
  • .

Pain Assessment
  • Self-report is the gold standard and is best way
    to elicit pain report.
  • Family can corroborate pain and medication use.
  • For patients who are unable to give self-report
  • Assume pain is present if you suspect there is
    reason for pain.
  • Observe behavioral characteristics.
  • Discuss with proxy and seek input for
    professional care givers.
  • Use appropriate scales consistently by each team
  • Cultural consideration

Pain Assessment
  • Location(s) indicate site(s) of pain.
  • Intensity numerical scale 0-10 scale, color
    scale light colors to red, descriptive scale no
    pain to worst pain imaginable.
  • Quality Description dull, sharp, achy,
    pounding, pressure, electrical, shooting,
  • Pattern Intermittent pain versus constant or
  • Aggravating/alleviating factors - What makes the
    pain better? What makes it worse? Provides
    information regarding the etiology of the pain,
    as well as potential treatments. Example if
    massage makes the pain better, it is probably of
    musculoskeletal origin, rather than neuropathic.

Pain Assessment
  • Emotional state/suffering/ total pain Evaluating
    the emotion behind the pain. Sign of the reality
    of the disease? Is the patient depressed and/or
  • Meaning of the pain can profoundly affect pain
    perception at the end of life ie, punishment.
    Reframing may help, resulting in improved
  • Functional assessment ability to perform
    self-care getting up and down to toilet dress
    groom and bathe self.
  • Psychosocial effect on social, emotional,
    spiritual and psychological domains.

Pain Physical Exam
  • Observation/Inspection
  • Ability to ambulate into exam area, ability to
    sit and stand
  • Non-verbal cues withdrawal, fatigue, grimaces,
    moans, and irritability. 
  • Inspect and examine sites of pain trauma, skin
    breakdown, changes in bony structures, etc.
  • Palpation Palpate for tenderness. Range of
    motion. Is there allodynia? Does the pain follow
    a dermatone?
  • Auscultation
  • Abnormal breath sounds crackles, rhonchi,
    decreased breath sounds (pneumonia)
  • Bowel sounds hyperactive bowel sounds (bowel
  • Percussion fluid accumulation or gas
    (obstruction, ascites).
  • Neurological exam evaluate sensory and/or motor
    loss, as well as changes in reflexes,

Pain Diagnostics
  • How will the course of therapy change by the
    findings of this test? Is this the best use of
    the patients resources ?
  • Labs- hypercalcemia as a cause of delirium.
  • Radiology - X-ray or CT scan may differentiate
    between pain due to ascites (potentially relieved
    with a paracentesis) or pain due to obstruction
    (relieved by venting gastrostomy tube, or
    avoiding enteral intake of fluid and food).
  • Advanced studies- bone scan, PET scan, EMG (may
    be useful if suspecting nerve entrapment or
    systemic neurological disease), MRI, swallowing
    studies, testosterone and progesterone levels
    (chronic opioid use).  

Pain Management The Philosophy
  • The Three Step Approach
  • Give The Right Drug
  • Give The Right Dose
  • Give At Right Time
  • This approach is 80-90 effective and the most

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Pharmacologic Pain ManagementNon opioids
  • Acetaminophen
  • Mechanism of Action Analgesic, Antipyretic
  • Adverse effects- Possible liver dysfunction in
    routine doses gt 2000 mg/day in patients with
    normal liver gt 3000 mg/day acutely.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    Examples Aspirin, ibuprofen, naproxen, selective
    cyclooxygenase-2 inhibitors (celecoxib)
  • Blocks cyclooxygenase which inhibit
    prostaglandins periostium of the bone and in the
  • Anti-inflammatory, analgesic and antipyretic.

NSAID Adverse Effects
  • Ceiling effect. Increasing the dose beyond a
    certain point will not increase analgesia will
    only increase the risk of adverse effects.
  • Gastric toxicity through local and systemic
  • Platelet aggregation is inhibited risk of
  • Renal dysfunction, especially in dehydration.
  • Risks of adverse effect increase with concurrent
    use of NSAIDs and corticosteroids.
  • NSAIDs now linked to increase in deaths due to
    cardiac and cerebrovascular effects.

Opioid Pain Management
  • Codeine morphine hydrocodone hydromorphone
    fentanyl methadone oxycodone oxymorphone.
  • Mechanism of action opioid agonist. Block the
    release of neurotransmitters that are involved in
    the processing of pain.
  • Adverse effects of opioids Respiratory
    depression, sedation, constipation, nausea,
    sweating, pruritus, urinary retention, hormonal
  • Opioid rotation/equianalgesic tables.

Equianalgesic Opioid Chart
Medication PO IV
Morphine 30 mg 10 mg
Oxycodone 20 mg X
Hydromorphone 7.5 mg 1.5 mg
Conversion Chart of Oral Morphine to Transdermal
Oral 24-hour morphine equivalent (mg/day) Fentanyl transdermal (mcg/hr)
60 -134 25
135-224 50
225-314 75
315-404 100
405-494 125
495-584 150
585-674 175
675-764 200
765-854 225
855-944 250
945-1034 275
1035-1124 300
Opioid Pain ManagementRisk Factors
  • History of sleep apnea or sleep disorder
  • Morbid obesity
  • Snoring
  • Patients over the age of 65
  • Patients who are opioid naïve
  • Postoperative patients, especially if surgery
    included the upper abdomen or thorax
  • Lengthy anesthesia requirements during surgery
  • Patients on benzodiazepines or other sedating
  • Patients who are active smokers
  • Pre-existing pulmonary or cardiac diseases or
    major organ failure
  • Patients requiring significantly high doses of

Pharmacologic Pain Management
  • Methadone
  • appears to act as an antagonist in the
    N-methyl-D-aspartate (NMDA) receptor, in addition
    to opioid receptor binding
  • useful in neuropathic pain syndromes,
  • Long half life (8-59 hours) can be an advantage
    but also a disadvantage , ie difficulty to
  • QTc effects - increases the corrected QT (QTc)
  • numerous drug interactions increased methadone
    levels in varying degrees via P450 3A4
  • Methadone should be utilized by clinicians with
    adequate knowledge and experience due to
    increased potential risks.
  • Tramadol Binds to mu opioid receptors and
    weakly inhibits norepinephrine/serotonin
    reuptake producing analgesia.
  • Tapentadol Binds to mu opioid receptors and
    inhibits norepinephrine reuptake.

Pain Management Adjuvants
  • Tricyclic Antidepressants
  • nortriptyline, desipramine, imipramine,
  • Action - appears to be related to inhibition of
    norepinephrine and serotonin reuptake
    (neuropathic pain).
  • Adverse effects Dry mouth, constipation,
    dizziness, blurred vision, drowsiness QT
  • Relative contraindications cardiac arrhythmias,
    conduction abnormalities, narrow-angle glaucoma,
    and clinically significant prostatic hyperplasia.

Pain Management Adjuvants
  • Atypical antidepressants
  • Venlafaxine and duloxetine for chronic
    neuropathic pain Milnacipran for fibromylagia.
  • Action - Blocks serotonin and norepinephrine
  • Adverse effects Fatigue, constipation, dry
    mouth, dizziness, risk of suicide

Pain Medications Adjuvants
  • Anticonvulsants Gabapentin and pregabalin.
  • Action blocks calcium channels, modulates
    excitatory neurotransmitter release.
  • Pregabalin has 90 bioavailability regardless of
  • Gabapentin bioavailability diminishes to 35 when
    administering higher doses.
  • Adverse effects sedation, confusion, edema
  • The analgesic doses of gabapentin ranges from
    900-3600 mg/day. Older adults 100 mg a day and
    see how they tolerate it.

Pain Management Adjuvants
  • Anticonvulsants
  • Carbamazepine Older anticonvulsant for
    neuropathic pain.
  • Action - blocks sodium channels blocking
    conduction of pain through sensory neurons
  • Significant adverse effects liver dysfunction
    and aplastic anemia monitor blood chemistries
    (specifically liver function tests) and
    hematology profiles
  • Newer anticonvulsant agents lamotrigine,
    levetiracetam , oxcarbazepine. Unique adverse
    effect profiles to be considered when

Pain Management Adjuvants
  • Cannabinoids THC (tetrahydrocannabinal), an
    active derivative of marijuana, ex Dronabinol.
  • Corticosteroids -neuropathic pain, bone pain,
    headache secondary to raised intracranial
    pressure, pain secondary to organ capsule
    distension, pain due to obstruction of a hollow
    viscus, and pain secondary to lymphedema.
  • Glucocorticoids reduce pain by inhibiting
    prostaglandin synthesis, which leads to
  • Dexamethasone commonly used- less
    mineralocorticoid effects and long half-life.
  • Lidoderm local anesthetic affect
  • Capsacian desensitizes cutaneous nociceptive
  • Muscle relaxers cyclobenzaprine, tizanadine,
    baclofen, carisoprodol
  • Interventions/Procedures Blocks, Epidural,

Non-Pharmacologic Management
  • IDT
  • Social work support of pain issues and
    assistance with coverage of medications/treatments
  • Chaplaincy spiritual distress of pain and
    assessing suffering
  • PT/OT to improve function, obtain needed
    equipment and safety.
  • Psychological support/counseling improving
    coping strategies.
  • Cognitive Behavior Therapy (CBT)
  • Relaxation
  • Guided imagery
  • Distraction
  • Cognitive reframing
  • Support groups 

Non-Pharmacologic Management
  • Rehabilitation therapies physical medicine and
    rehab evaluation occupational therapy/physical
  • Physical measures producing relaxation and
    relieving pain heat/cold Massage
  • Meditation practices
  • Pastoral counseling/prayer
  • Complementary therapies
  • Little data regarding the efficacy of
    complementary therapies (e.g., herbals, magnets,
    others) in relieving pain. Some culturally
  • Encourage patients to report the use of any
    complementary therapies to avoid interactions
    with other pharmacologic agents  
  • Cutaneous electrostimulation

  • Distressing shortness of breath frequently
    called breathlessness. Frightening experience.
  • Occurrence 50 of the general outpatient cancer
    population and as many as 70 of advanced cancer
  • Respiratory rate and oxygenation status do not
    always correlate with the symptom of
  • The amount of dyspnea present may not be related
    to the extent of the disease.
  • Often overlooked and not assessed

DyspneaCommon Causes
  • Pulmonary Tumor infiltration aspiration
    pleural /or cardiac effusion SVC syndrome
    pneumonia PE COPD thick secretions due to
    infection or dehydration bronchospasm.
  • Cardiac CHF pulmonary edema pulmonary
    hypertension severe anemia CAD fluid overload.
  • Neurological CVD ALS MS muscular dystrophy
    myasthenia gravis dementia trauma.
  • End-stage renal disease
  • Metastatic cancer
  • Metabolic disorder e.g. alkalosis
  • Obesity
  • Anxiety
  • Spiritual issues e.g. feelings of guilt and
    issues of trust

  • Subjective report of the patient is the only
    reliable indicator.
  • Dyspnea Rating Scale 0 no breathlessness 10
    the worst
  • 0 1 2 3 4 5 6 7 8
    9 10
  • Physical Exam
  • Observation Presentation/Appearance
    Wheelchair, with oxygen, ability to talk in
    complete sentences, pain with inspiration, use of
    accessory muscles.
  • Auscultation - Breath sounds for respiratory rate
    and depth, crackles, wheezes, rhonchi.
  • Percussion Dullness in lungs, evidence of mass
    or fluid.
  • Palpation - Elevated jugular pressure, bilateral
    crackles, pain with respiratory movement,
    diaphragmatic excursion.

  • Consider goals of care, the benefits and burdens
    of the test itself, and whether the results or
    outcome would change the care plan or overall
  • Laboratory studies CBC, HH, CMP, electrolytes,
    BNP, ABG
  • Oxygen saturation
  • PFTs
  • CXR Infection, effusion, atelectasis
  • CT/MRI Lung disease, cardiac issues, rule out
    pulmonary embolism

  • Oxygen therapy Consider trial of oxygen therapy.
    Saturation lt 88 unless on hospice. May have
    limited benefit if not hypoxemic.
  • Severe COPD chronic hypoxia use of long-term
    O2, gt15 hours/day, improves quality of life and
    increases survival (goal SaO2 gt90).
  • High Flow Oxygen
  • BiPAP (Bi-level positive air pressure)
  • CPAP (continuous positive airway pressure)
  • Ventilator as a time limited trial goals of
  • Consider sleep study

DyspneaPharmacologic Management
  • Opioids Start low and go slow
  • Steroids prednisone, dexamethasone
  • Bronchodilators/anticholinergics Duo-Nebs
  • Role of benzodiazepines controversial. Should
    not be considered as a first line treatment.
  • Diuretics to reduce fluid overload
  • Pressors dopamine, dobutamine, and milrinone
  • Epoprostenol primary pulmonary hypertension and
    hypertension associated with scleroderma

  • Antibiotics
  • Influenza/pneumonia vaccines
  • Blood transfusions may be of benefit if goal of
    transfusion outweighs burden. Erythropoietin.
  • Thoracentesis/paracentesis/PleurX catheter
  • Stent tube placement to open an occluded airway
  • Endobronchial laser therapy
  • Radiation therapy to shrink tumor
  • Hemodialysis or CVVH
  • Left Ventricular Access Device (LVAD) as bridge
    to transplant or destination therapy.

DyspneaNonpharmacologic Interventions
  • Counseling cognitive-behavioral therapy,
    interpersonal and complementary strategies for
    both patient and family.
  • Pursed lip breathing slows respiratory rate and
    decreases small airway collapse.
  • Energy conservation techniques save energy,
    reduce fatigue, allow the patient to maintain
    control of lifestyle changes.
  • Fans, open windows and air conditioners
    circulate air. Compressed air via nasal cannula
    may be useful

DyspneaNon-pharmacologic Interventions
  • Elevation of the head of the bed, high fowlers
    position reduce choking sensations and promotes
    expansion of the lungs.
  • Placing the patients arms on pillows promote
    air exchange.
  • Education of patient/family reduces anxiety.
  • Music relaxation and distraction, reduces
  • Calm room environment.
  • Cold air directed against the cheek may reduce
    the perception of breathlessness
  • Prayer promote comfort and relaxation.
  • Acupuncture may help although the studies

  • A subjective perception and/or experience of
    extreme tiredness/exhaustion related to disease,
    emotional state and/or treatment.
  • Multidimensional
  • Not easily relieved by rest
  • Profound impact on quality of life including
    physical, psychological, social and spiritual
  • Cultural influences
  • Reduced capacity to carry out expected or
    required daily activities.

  • Cancer related fatigue is reported in as many as
    60 to 90 of patients.
  • Anemia
  • Cytokine production anorexia-cachexia syndrome
    as well as fatigue
  • Metabolic/Endocrine  hypothyroidism, DM
    (Hyper/Hypoglycemia) or electrolyte imbalances
    (low Na, low K, low Mg, hypercalcemia)
  • Malnutrition
  • Infection
  • Fever
  • Pain
  • Organ failure (heart/lungs/kidneys/liver)
  • Adverse environment (heat or cold extremes)
  • CNS injury disruption of the electrical pathway
    within the nervous system
  • Hypoxia

FATIGUE Etiologies
  • Psychological Depression.
  • Deconditioning Immobility resulting from disease
    process, medical intervention, or psychological
    response decrease ADLs.
  • Treatment related Inadequate rest, unrelieved
    symptoms, medications, psychological and
    spiritual distress.
  • Treatment effects drug therapy, radiation, and
  • Med effect anti-emetics, hypnotics, anxiolytics,
    antihistamines, analgesics (trial of 25 dose
  • Unrelieved symptoms diarrhea, constipation,
    vomiting and pain.

  • Subjective
  • Impact on ADLs and IADLs
  • Medication review
  • Sleep pattern
  • Associated symptoms, ie depression/anxiety/ability
    to concentrate
  • Fatigue Rating Scale 0 no fatigue 10 no
    energy at all 
  • 0 1 2 3 4 5 6 7
    8 9 10

  • Observation
  • Vital signs
  • Physical Assessment including cardiac,
    respiratory, GI and neurological exam
  • Diagnostics
  • Labs CBC, HH, electrolytes, albumin/prealbumin,
    LFTs, TSH
  • Pulse oximetry
  • Electrocardiogram

  • Pharmacologic
  • Stimulants methylphenidate, modafinil
  • Steroids dexamethasone
  • Antidepressants
  • Interventions
  • Based on Goals of Care
  • Consider transfusions if indicated
  • Consider feeding tube (ie, ALS, H/N cancer)

FATIGUE Non-Pharmacologic Interventions
  • Energy conservation frequent rest periods and
    use of energy conservation techniques and tools.
  • 1-2 priority activities a day family assistance
  • Home health devices BSC, wheelchair, and/or
  • Personal care to assist with ADLs and IADLs.
  • Physical and occupational therapy
  • Conditioning from exercise program may decrease
    the severity of fatigue.

  • Nausea subjective sensation
  • Vomiting neuromuscular reflex, stimulation of
    vomiting center.
  • Anticipatory, acute, delayed
  • Common in advanced disease (nausea up to 70 of
    terminally ill, vomiting up to 30), particularly
    in cancer, renal and hepatic disease.

Nausea and VomitingPathophysiology
  • GI Stimulation of vagal and sympathetic pathways
    (visceral response)
  • gastric irritation stasis
  • constipation
  • intestinal obstruction
  • pancreatitis
  • ascites
  • liver failure
  • intractable cough
  • effects of radiation.

Nausea and VomitingPathophysiology/Etiology
  • Metabolic causes Stimulation of chemoreceptor
    trigger zone
  • Hypercalcemia
  • Uremia
  • Infection
  • Drugs
  • CNS causes
  • Raised ICP
  • Pain
  • Infection
  • Vestibular disturbances
  • Motion sickness
  • Toxic action of certain drugs (ASA, opiates)

Nausea and VomitingAssessment
  • Frequency, duration, triggers, contributing
    factors (constipation, uncontrolled pain,
    infection, anxiety), relationship to food intake
  • Medication review
  • Volume and content of emesis, presence of blood
  • Past history of N/V and effectiveness of

Nausea and VomitingAssessment
  • Physical Exam
  • Vital signs, weight.
  • Auscultation of bowel sounds
  • Possible rectal exam (impaction)
  • Ear exam infection
  • Oral exam thrush
  • Diagnostics
  • Renal and liver function tests
  • Electrolytes, calcium, serum drug levels
  • Radiologic Abdominal radiograph /or head CT or

Nausea VomitingPharmacologic Management
  • Directed by presumed cause
  • Anticholinergics hyoscyamine, scopolamine
    motion sickness, intractable NV, SBO
  • Antihistamines cyclizine, meclizine intestinal
    obstruction, raised ICP, peritoneal irritation,
    vestibular causes
  • Steroids dexamethasone- cytotoxic induced NV
  • Prokinetic agents metaclopramide-gastric stasis
    or ileus
  • Benzodiazepines lorazepam- anxiety related NV
  • 5 HT3 receptor antagonists ondansetron-post op
    NV and chemo related emesis (QTc prolongation)

Nausea and Vomiting Pharmacologic
  • Octeotride bowel obstruction inhibits
    peristalsis and intestinal secretions
  • Neurokinin-1 receptor antagonists aprepitant-
    inhibit post op and post chemo NV
  • Butyrophenones haloperidol and droperidol-opioid
    induced nausea, chemical and mechanical nausea
  • Phenothiazines prochlorperazine, dopamine
  • Cannabinoids dronabinol, medical marijuana

Nausea and Vomiting
  • Hypercalcemia bisphosphonates, diuretics,
    calcitonin, and hydration
  • Opioid induced NV
  • Opioid naïve schedule anti-emetic for 1st 72 hrs
  • Alter dose, schedule or consider opioid rotation
  • NG tube or PEG for venting
  • Hydration
  • TPN limited role in pall care benefit/burden
  • Surgical options (ie SBO)
  • Based on Goals of Care

Nausea and VomitingNon-Pharmacologic Management
  • Anticipatory nausea distraction/relaxation
    techniques, acupuncture, acupressure, music
    therapy and hypnosis
  • Dietary
  • Small, frequent meals keep prepared snacks
  • Use of family/friends to cook avoid smells and
    stress of food preparation.
  • Serve meals at room temperature with clear
    fluids avoid strong smells.
  • Restrict fluids with meals.
  • Bland, cold or room-temperature food.
  • Eat slowly, avoiding large, high bulk meals.
  • Avoid sweet, salty, fatty, and spicy foods.
  • Ginger, chamomile tea

Nausea and VomitingNon-Pharmacologic
  • Positioning
  • Positioned to avoid aspiration.
  • Do not lie flat for 2 h after eating.
  • Personal Care
  • Oral care after each episode of emesis
  • Wear loose-fitting clothes.
  • Topical
  • Application of a cool damp cloth to the forehead,
    neck, and wrists
  • Use of wrist pressure bands (Sea Bands) to
    minimize nausea and vomiting.
  • Acupuncture
  • Environment
  • Decrease noxious stimuli like odors and pain.
  • Have fresh air with a fan or open window.
  • Limit sounds, sights, and smells that precipitate
    nausea and vomiting.

  • Definition less than 3 stools per week or
    altered characteristics such as hard, painful,
    stools accompanied by abdominal distention,
    nausea, vomiting, loss of appetite, and other
  • 10 of the general population,
  • May be as high as 50 to 78 in the ill adult.

  • Intestinal obstruction, partial or complete,
    tumor in or compressing bowel. Mesothelioma,
    ovarian, and gastrointestinal cancers.
  • Electrolyte imbalances hypercalcemia and
  • Spinal cord injuries (i.e. compression or
    transection) slow transmission of food via the
  • Endocrine conditions diabetes, hypothyroidism
  • Other colitis, diverticulitis, or chronic
    neurological states
  • Surgical adhesions scarring.
  • Dehydration stool consistency dry, hard
  • Inactivity, weakness, loss of privacy effect
    daily bowel habits.
  • Pain
  • Depression
  • Decreased abdominal muscle tone

  • Medication profile review many medications can
    contribute to severe constipation, especially
    when patients are on combination therapies.
  • Vitamins and minerals Calcium supplement, iron
  • Chemotherapeutic agents - Taxanes, vinca
  • Antidepressants Tricyclics, SNRIs
  • Pain and adjuvant pain medications Opioids,
    NSAIDS, Anticonvulsants
  • Antiemetics - 5HT3 antagonists, phenothiazines
  • Anti-diarrheal agents
  • Cardiac medications - Diuretics,

  • Stool Frequency, consistency, volume, usual
    bowel pattern, date of last BM
  • Associated symptoms pain, bloating, flatulence,
    bleeding, NV
  • Recent oral intake and level of activity
  • Medications prescription, OTC, dietary
  • Past history of constipation and effective
    treatment strategies (laxatives, suppositories,
  • Functional status ability to toilet,
    environmental issues related to toileting
  • Psychosocial or cognitive factors depression,
    anxiety, general mood disturbances

  • Physical Exam
  • Inspection bloating, distention
  • Auscultation bowel sounds (hyperactive,
    hypoactive or absent)
  • Palpation assesses for distention, firmness and
  • Percussion fluid, mass
  • Rectal assessment hemorrhoids, ulceration or
    rectal fissure pain infection, fecal leakage
    and/or impaired rectal tone. Caution in
    neutrapenic patient.
  • Diagnostics consider goals of care
  • Abdominal x-ray to rule out bowel obstruction
  • Electrolytes BUN, calcium and potassium
  • Thyroid function tests

ConstipationPharmacologic Management
  • Maintenance often requires a prophylactic stool
    softener and stimulant. A minimum goal for a
    bowel movement is at least every 72 hours,
    regardless of intake.
  • Bulk forming fiber medications
  • Osmotics sorbitol, lactulose, polyethylene
    glycol 3350
  • Stimulants senna
  • Surfactants docusate
  • Opioid-Receptor Antagonist (methylnaltrexone,
  • Lubricant-mineral oil
  • Suppositories, enemas

ConstipationNon-Pharmacologic Interventions
  • Dietary and fluid interventions
  • Gentle activity
  • Massage
  • Dietary
  • OTC products and herbal medicines mulberry,
    flax, and rhubarb have laxative properties

  • Mood disorder with psychological symptoms
  • Low mood, inability to think or make decisions
  • Somatic symptoms altered sleep, fatigue, slowed
    movements, decreased energy
  • Altered mood, affect, and personality
  • Includes situational depression caused by a
    serious life threatening illness (American
    Psychiatric Association, 2013)
  • Symptoms last 2 weeks or longer and associated
    with loss of interest or pleasure in nearly all

  • Depression occurs in about 22 to 77 of the
    terminally ill population
  • Depression in palliative care is related to many
    diseases and causes
  • Uncontrolled pain and/or other symptoms (i.e.
    constipation, anorexia, and sleep disturbances)
    may exacerbate depression
  • Neurological
  • Hyper or hypothyroidism
  • Infectious diseases HIV/AIDS
  • Cancer pancreatic, head and neck, and lung
  • Cardiopulmonary disease
  • Trauma head injuries

DEPRESSIONMedication Profile Review
  • Antibacterial and antifungals
  • Antihypertensive and cardiac medications
  • Anticancer medications (interferon, bleomycin,
    and vincristine are common culprits)
  • Antiretroviral medications
  • Anticonvulsants
  • Benzodiazepines
  • Steroids
  • Hormonal therapies

  • Current diagnosis and prognosis
  • Chronic deteriorating medical illness with
    perceived poor health
  • recent diagnosis of a life-threatening illness
  • recent conflict or a loss of significant
  • Current status of symptom management.
  • Previous psychiatric history/treatment including
    previous depression, family history with
    depression, substance abuse, past suicide
  • Social support.

  • Suicide - A history of depression, suicide
    attempts, or substance abuse.
  • Cancer patients at highest risk for suicide
    include those with diagnoses of oral, pharyngeal,
    or lung cancers.
  • Other predictors include male gender, over the
    age of 45, living alone, lacking a support
  • Other risk factors Uncontrolled pain, presence
    of multiple deficits, including inability to
    walk, loss of bowel and bladder control,
    amputation, inability to eat or swallow, sensory
    loss, and exhaustion.

  • Are you depressed? Have you felt down or blue in
    the last month?
  • How have your spirits been lately?
  • How would you describe your mood today?
  • How are you sleeping lately?
  • What is your energy level?
  • What do you see in your future?
  • What is the biggest problem you're facing?
  • Can you concentrate as well as you usually could?

  • Questions for suicide risk
  • Do you ever think that life is not worth living?
  • Do you find yourself wishing you would die more
  • Have you thought about killing yourself?
  • Have you discussed this with anyone?
  • Are you thinking of that now?
  • How have you thought you would do this? Do you
    have a plan?

  • Physical Examination
  • Observation overall appearance
  • Inspection
  • Lung, cardiac and neuro examination
  • Diagnostics Laboratory studies to rule out
  • CBC anemia or infection
  • Electrolyte imbalances
  • TSH for thyroid abnormalities
  • LFTs for liver impairment
  • Electroencephalography (EEG)
  • Radiology, including CT scan of brain

DEPRESSIONPharmacologic Management
  • Antidepressants
  • SSRIs fluoxetine, paroxetine, sertraline,
  • SNRIs venlafaxine, mirtazapine, duloxetine.
    Duloxetine good for pain and depression.
    Mirtazapine insomnia, anorexia, and depression.
  • Bupropion inhibits neuronal uptake of
    norepinephrine and dopamine.
  • Tricyclics amitriptyline, nortriptyline treat
    nerve pain, depression, and sleep issues.

DEPRESSIONPharmacologic Management
  • Psychostimulants methylphenidate or
    dextroamphetamine rapid onset and short duration
    of side effects.
  • Steroids dexamethasone and prednisone may offer
    euphoria for a short term benefit improved
    overall sense of well-being.
  • Ketamine rapid anti-depressant response and may
    offer a benefit to certain patients.

DEPRESSION Non-pharmacologic Interventions
  • Interdisciplinary collaboration between social
    work, chaplaincy, and mental health
  • Psychotherapy, along with medications
  • Electroconvulsive therapy may be considered for
    patients with suicidal or psychotic features.
  • Grief counseling assist patients and families to
    deal with past, present, and future losses.
  • Psychiatric counseling for those experiencing
    significant inability to cope with the experience
    of their medical illness.
  • Cognitive behavioral techniques assist the
    patient to re-frame negative thoughts into
    positive thoughts

DEPRESSION Non-Pharmacologic Interventions
  • Cultural affects symptom presentation and
    responses to depression.
  • Latino and Mediterranean cultures may complain
    of "nerves" and headaches
  • Chinese or other Asian cultures "imbalance"
  • Promote and facilitate autonomy and control
    participate in own care reduce feelings of
  • Reminiscence and life review life
    accomplishments closure and resolution of life
    events for the patient and family.
  • Maximize symptom management.
  • Assist the patient to draw on previous sources of
    strength, such as faith and other belief systems.

  • Feelings of distress and/or tension with or
    without a known stimulus
  • An acute, severe wave of intense anxiety with
    cognitive, physiologic, and behavioral
  • A low-grade persistent distress consisting of
    restlessness or being on edge, difficulty in
    concentrating, irritability, muscle tension, and
    altered sleep that interferes with psychosocial
  • Anxiety Disorder due to Another Medical
    Condition Related to the pathophysiologic
    consequences of a medical condition not
    explained by a mental disorder affects the
    social, occupational and general functioning of
    the patient.
  • Generalized Anxiety Disorder, phobia, Panic

  • Poorly managed pain and symptoms
  • Cancer related conditions Hormone producing
  • Cardiovascular Angina, CHF, past history of MIs
  • Endocrine disorders Diabetes, thyroid
    dysfunction, Cushing Syndrome, Carcinoid
  • Immune disorders - AIDS, infections
  • Pulmonary Asthma, COPD, PNA pulmonary edema,
    dyspnea, PE
  • Metabolic - Anemia, hyperkalemia, hyponatremia
  • Neurological - Encephalopathy, brain lesion
  • Psychosocial
  • Coping with uncertain future and prognosis and
  • Lack of control - Multiple changes health,
    lifestyle, employment, finances
  • Dealing with difficult/exhausting treatment
  • Dependency on others Confronting family

ANXIETYMedication Effects
  • Stimulants
  • Corticosteroids
  • Analgesics
  • Thyroid replacement hormones
  • Neuroleptics
  • Digitalis
  • Antihypertensives
  • Antihistamines
  • Antiparkisonian medications
  • Anticholinergics
  • Abrupt cessation/withdrawal of medications such
    as alcohol, analgesics, benzodiazepines,
    antipsychotics, and nicotine
  • Paradoxical reactions from medications

  • Assessment of chronic apprehension, worry,
    inability to relax, difficulty concentrating,
    difficulty falling and staying asleep.
  • Physical symptoms sweating, tachycardia,
    restlessness, agitation, trembling, chest pain,
    hyperventilation, tension.
  • Cognitive symptoms sadness, fear, anger,
    difficulty concentrating, confusion, and loss of
  • Recurrent and persistent thoughts, ideas, or
    impulses, the fear of "going crazy", and the fear
    of dying. Treatment depends on the etiology and
    severity of symptoms.

  • Questions for anxiety assessment
  • Have you experienced any anxiety symptoms since
    your diagnosis or treatment? When do they occur
    and how long do they last?
  • Do you feel nervous, shaky, or jittery?
  • Have you had a sudden onset of feeling you might
    be going crazy, losing control, or dying?
  • Do you worry about when your pain will return and
    how bad it will get? Do you worry if you'll be
    able to get your next dose of medication on

  • Physical examination
  • Observation VS, tachycardia, shortness of
    breath, sighing, diaphoresis, rapid speech, tense
  • Inspection Dilated pupils, tremors
  • Palpation - Gastrointestinal distress
  • Cardiac, respiratory, neuro assessment
  • Diagnostics To rule out other conditions
  • CBC
  • Electrolytes
  • Thyroid function test
  • Pulmonary function test if indicated
  • CT Scan-for suspected PE

ANXIETYPharmacologic Management
  • Benzodiazepines are the first-line drugs
  • Lorazepam, midazolam and alprazolam have short
    half-lives Diazepam and clonazepam have longer
  • Cautious use in older adults may cause
    cognitive dysfunction and ataxia.
  • Antidepressant used for primary anxiety
  • May take 2-6 weeks to take full effect and
    relieve anxiety.
  • Sertraline, citalopram, and escitalopram have
    fewer drug-to-drug interactions.
  • Mirtazapine use with related insomnia, anorexia,
    and weight loss beneficial side effects of
    sedation and increased appetite.
  • Consider tricyclic antidepressants
    (amitriptyline, nortriptyline, and desipramine)
    with patients who have anxiety, chronic pain, and
    diarrhea. Caution in patients with conduction

ANXIETYPharmacologic Management
  • Antipsychotics anxiety associated with delirium
  • Haloperidol
  • Most frequently used in the medical setting
  • Inexpensive and accessible
  • Monitor for side effects restlessness,
    increased anxiety, EPS
  • Olanzapine
  • More expensive
  • Monitor QTc changes, particularly if on
  • Risperidone/quetiapine
  • Hypnotics for sleep zolpidem and antihistamines.

AnxietyNon-Pharmacologic Interventions
  • Psychiatric counseling Stress management
    programs, exercise programs, music, art and
    expressive therapies for patient and family
  • Cognitive behavioral therapy (CBT) for reframing
  • Behavioral techniques guided imagery techniques
  • Psychotherapy promote coping clarifying of fears
    and identifying and building on existing coping
  • Spiritual counseling
  • Integrative therapies acupuncture, massage,
    Reiki, aromatherapy, therapeutic touch are
  • Encourage these interventions for families as
    well to avoid the spread of anxiety from patient
    to family.

ANXIETYNon-Pharmacologic Interventions
  • Acknowledge patients fears
  • Written materials to promote education. Be
    consistent in answering repetitive questions
  • Provide concrete information to eliminate fear of
    the unknown
  • Provide warning and counseling for stressful
  • Write prescriptions for anxiety reducing
    measures medication, distraction, /or exercise
  • Promote dietary modifications decreasing
    caffeine and alcohol intake, food diary
  • For older adults environmental manipulation, may
    enable confidence in living situations. Consider

  • Difficulty falling asleep or maintaining sleep
    interrupted sleep
  • Ineffective or inconsistent sleep contributing to
    poor cognition, mood, and overall functioning
    with potential for accidents
  • Causes/contributing factors
  • Cardiac disease
  • Respiratory failure
  • Obesity
  • Pulmonary conditions
  • Acute/chronic pain
  • Psychiatric disorders dysthymia, depression,
    anxiety, psychiatric Dx
  • Medications stimulants, steroids, albuterol
  • OTC substances alcohol, nicotine and caffeine
  • Delirium
  • Uncontrolled symptoms

  • History onset, pattern and duration of sleep
    transient, intermittent or persistent.
  • How often do you have trouble sleeping, how long
    has the problem persisted?
  • How often do you take naps?
  • When do you go to bed and get up during the week
    and weekends?
  • How long does it take you to fall asleep, how
    often do you wake up at night, and how long does
    it take to fall back asleep?
  • Do you snore loudly and frequently, or wake up
    gasping or feeling out of breath?
  • How refreshed do you feel when you wake up, and
    how tired do you feel during the day?
  • How often do you doze off or have trouble staying
    awake during routine tasks especially driving?
  • How is this affecting your family?

  • Physical examination
  • Observation Age, vital signs
  • Inspection Any sites of pain
  • Cardiac, Respiratory, Neurological exam
  • Diagnostics
  • Usually not necessary unless ruling out another
  • EEG
  • Sleep clinic, if appropriate

  • Pharmacologic
  • Pain medication adjustment for optimal pain
  • Sleep medications non-benzodiazepines,
    trazodone, zolpidem
  • Antidepressants
  • Non-Pharmacologic
  • Sleep evaluation Adjust sleep hygiene
  • Cognitive behavioral therapy (CBT)
  • Relaxation therapy (i.e. guided meditation, yoga)
  • Psychotherapy to discuss worries and concerns
    with mental health specialist, and/or chaplain
  • Environmental setting calm setting at bed time
  • Use of rituals, such as a warm bath or shower
  • Massage Aromatherapy Acupuncture

Symptom Management in Chronic IllnessCase Study
  • Chronic low back pain/peripheral neuropathy
  • Muscular jerks/Myoclonus/Confusion
  • Nausea/Constipation/Anorexia/Abdominal Pain
  • Dyspnea/Shortness of Breath/cough/pleuritic chest
  • Depression/anxiety/Insomnia
  • Fatigue/Activity Intolerance
  • Weakness/Falls

Case Study Pain Management
  • Nociceptive and Neuropathic components
  • Is morphine ER a good choice?
  • Toxicity due to impaired renal function
  • M3G metabolite neuroexcitatory/lacks analgesic
  • M6G metabolite adverse effects/toxicity
  • Other options Fentanyl and methadone, limited
    doses of short acting hydromorphone.
  • Neuropathic methadone (NMDA antagonist),
    adjuvants gabapentin, pregabalin venlafaxine,
  • TCA not a good choice due to arrhythmia and
  • Non-pharmacologic
  • Nociceptive heat/cold compresses (skin
    integrity), repositioning, distraction(music,
  • Neuropathic Soothing lotions (Sarna), optimize
    blood sugars.

Case Study Symptom Management
  • Nausea/Constipation/Anorexia/Abdominal Pain
  • Multifactorial CHF, CKD, med effect,
    hypothyroidism, constipation, cholecystitis,
  • Gastroparesis trial metaclopramide, d/c
  • Constipation Senna or polyethylene glycol or
  • Discontinue megestrol (high risk for thrombosis)
  • Small, frequent meals.
  • Antibiotics for choleycistitis
  • Consider haloperidol

Case Study Symptom Management
  • Dyspnea/Shortness of Breath/cough/pleuritic chest
  • CHF Diuretic, beta blocker, opioid (no ace-I
    due to renal failure), O2, fan
  • Obstructive Sleep Apnea CPAP
  • Anemia erythropoeitin, blood transfusions if
  • CKD dialysis dependent
  • Tobacco Use Disorder encourage smoking
    cessation, cont nicotine patch
  • Thyroid Disorder check TSH (amiodorone effect)
  • Amiodarone risk for Pulmonary Fibrosis CT scan
  • Pleural Effusion diuretics, thoracentesis,
    PleurX catheter, pleurodesis
  • Pneumonia CAP v. HAP v. Asp PNA O2, Antibiotic
  • Hypoalbuminemia treat GI symptoms.
  • PE Supratherapeutic INR Vitamin K, hold
    Coumadin, medication/food interactions

Case Study Symptom Management
  • Depression/Anxiety/Insomnia
  • Multifactorial multiple co-morbidities/med
  • Venlafaxine ER titrate to 150mg daily dose
    improve mood and effective dose for pain
    management duloxetine
  • Or consider changing to mirtazepine effect on
    mood, insomnia, nausea and appetite.
  • Consider low dose benzo lorazepam 0.25 to 0.5mg
    BID to TID prn (caution with hx sleep apnea).
  • Above may improve insomnia or consider low dose
  • Non-pharmacologic counseling/psychosocial
    support, sleep hygiene.

Case Study Symptom Management
  • Fatigue/Activity Intolerance/Weakness/Falls
  • Multifactorial disease burden/med effect
  • PT/OT
  • Regular exercise routine if able
  • Adequate nutritional intake
  • Methylphenidate/modafinil not recommended due to
    his history of PSVT and rapid a fib, and may also
    worsen anxiety.

Case Study Symptom Management
  • Goals of Care
  • Importance of Goals of Care discussion
  • Benefits/Burdens of interventions
  • Advanced Care planning Living Will, MPOA, code
  • Palliative care or hospice referral

Symptom Management Evaluation Tools
  • Visual Analogue Scale Can be used for any

Symptom Management Evaluation Tools
  • ORT Opioid Risk Assessment Tool
  • Edmonton Symptom Assessment Scale
  • http//
  • The St . Georges Respiratory Questionnaire
  • Baseline and Transition Dyspnea Index
  • http//

Symptom Management Evaluation Tools
  • Geriatric Depression Scale
  • http//
  • PHQ 9 Patient Health Questionnaire
  • http//
  • Generalized Anxiety Disorder Scale
  • Insomnia Severity Index https//

ELNEC-APRN End-of-Life Nursing Education