Archive | October 2011

Edmonton Symptom Assessment System (ESAS)

Edmonton Symptom Assessment System:
(revised version) (ESAS-R)
Please circle the number that best describes how you feel NOW:

No Pain 0  1  2  3  4  5  6  7  8  9  10 Worst Possible Pain

No Tiredness (Tiredness = lack of energy) 0  1  2  3  4  5  6  7  8  9  10 Worst Possible Tiredness

No Drowsiness (Drowsiness = feeling sleepy) 0  1  2  3  4  5  6  7  8  9  10 Worst Possible Drowsiness

No Nausea  0  1  2  3  4  5  6  7  8  9  10 Worst Possible Nausea

No Lack of Appetite
Worst Possible
Lack of Appetite

No Shortness of Breath 0  1  2  3  4  5  6  7  8  9  10 Worst Possible Shortness of Breath

No Depression
(Depression = feeling sad)
0  1  2  3  4  5  6  7  8  9  10 Worst Possible Depression

No Anxiety(Anxiety = feeling nervous)
    0  1  2  3  4  5  6  7  8  9  10 Worst Possible Anxiety

Best Wellbeing
(Wellbeing = how you feel overall)
   0  1  2  3  4  5  6  7  8  9  10 Worst Possible Wellbeing
No __________

Other Problem (for example constipation)
0  1  2  3  4  5  6  7  8 9 10

Pancoast Tumor

Pancoast tumors are tumors that form at the extreme apex of either the right or left lung in the superior sulcus (a shallow furrow on the surface of the lung). Pancoast tumors are a subset of lung cancers that invade the top of the chest wall. Because of their location in the apex of the lung, they invade adjoining tissue.

They principally involve the chest wall structures rather than the underlying lung tissue.

They typically invade the following structures:

  • lymphatic system
  • lower brachial plexus root  (network of nerves that is formed chiefly by the lower 4 cervicalvertebrae nerves and the first thoracic nerve of the chest)
  • Intercostal nerves
  • Stellate ganglion (a mass of nerve tissue containing nerve cells that form an enlargement on a nerve or on 2 or more nerves at their point of junction or separation)
  • Sympathetic chain (either of the pair of ganglionated lengthwise cords of the sympathetic nervous system that are situated on each side of the spinal column)
  • Adjacent ribs
  • Vertebrae
Symptoms: “Pancoast syndrome”
  1.  Shoulder pain
  2. Pain along the medial aspects of the arm and hand
Pancoast tumors tend to spread to the tissue surrounding them in the early stage.
As nerves are affected, the hand, arm, and forearm may weaken, atrophy (degenerate or shrink from disuse), or develop paresthesia (a sensation of pricking, tingling, or creeping on the skin).
As nerves of the face are affected, Horner (sign) syndrome is characterized by drooping eyelids (ptosis), absence of sweating (anhidrosis), sinking of the eyeball (enophthamos), and excessive smallness or contraction of the pupil of the eye.
10-25% of persons with Pancoast tumor may develop spinal cord compression and paraplegia  when the tumor extends into the intervertebral foramina.

Corneal Erosion

Recurrent breakdown of the corneal epithelium, typically caused by a previous corneal abrasion or by map-dot-fingerprint dystrophy. Symptoms include blurred vision, foreign body sensation and eye pain or discomfort.

 

Lynch Syndrome or hereditary nonpolyposis colorectal cancer (HNPCC)

Lynch syndrome, often called hereditary nonpolyposis colorectal cancer (HNPCC), is a type of inherited cancer of the digestive tract, particularly the colon (large intestine) and rectum. People with Lynch syndrome have an increased risk of cancers of the stomach, small intestine, liver, gallbladder ducts, upper urinary tract, brain, skin, and prostate. Women with this disorder also have a high risk of cancer of the endometrium (lining of the uterus) and ovaries. Even though the disorder was originally described as not involving noncancerous (benign) growths (polyps) in the colon, people with Lynch syndrome may occasionally have colon polyps. In individuals with this disorder, colon polyps occur at an earlier age than in the general population. Although the polyps do not occur in greater numbers than in the general population, they are more likely to become cancerous.

Genetics:

Autosomal dominant inheritance.

Variations in the MLH1, MSH2, MSH6, and PMS2 genes increase the risk of developing Lynch syndrome. All of these genes are involved in the repair of mistakes made when DNA is copied (DNA replication) in preparation for cell division. Mutations in any of these genes prevent the proper repair of DNA replication mistakes. As the abnormal cells continue to divide, the accumulated mistakes can lead to uncontrolled cell growth and possibly cancer. Although mutations in these genes predispose individuals to cancer, not all people who carry these mutations develop cancerous tumors.

Source: http://ghr.nlm.nih.gov/condition/lynch-syndrome

Nonpharmacologic Management of Dyspnea

Oxygen

The administration of oxygen either on an as needed or continuous basis has been shown to improve exercise tolerance, neuropsychological performance and not surprisingly, survival in patients with chronic end stage disease (Ferrell & Coyle, 2010, p. 308).

Positional changes

sitting upright, reclining semi-Fowler’s or leaning forward and supporting the torso on an overbed table can be highly effective at easing breathing (Ferrell & Coyle, 2010, p. 308). If a patient is not mobilizing well and spending much of their time in a chair or in bed, positioning strongly influences their level of comfort. Positions that alleviate abdominal compression or open the chest cavity quickly ease breathing (Downing and Wainwright, 2006, p. 370). Positional changes are effective by acting to increase the length-tension state of the diaphragm, increasing its oxygen intake efficiency (Ferrell & Coyle, 2010, p. 308). Supportive aids such as pillows or mechanical bed elevations of the knees or behind the back can also help further open air ways and ease of respiration.

Pursed lipped breathing.

This can be performed anywhere, at any time, and is easily taught to patients. Purse-lipped breathing is effective through slowing the respiratory rate down while simultaneously increasing the airway pressure. This dual action maintains the smaller air passages, facilitating greater oxygen delivery during times of severe dyspnea (Ferrell & Coyle, 2010, p. 309).

cold air directed against a cheek from an open window breeze or that of a fan.

It has been observed that the flow of cold air across the nose or cheek slows ventilation and relieves the sensation of breathlessness. Cold-air triggered ventilation changes exert their effect through stimulation of the trigeminal nerve pathway by a combination of the thermal and motion stimuli (Ferrell & Coyle, 2010, p. 308). A cool breeze directed towards the patient’s face may also lessen their sensation of breathlessness through physiologic stimulation of the fifth cranial triggering a central inhibitory effect of the sensed dyspnea (Indelicato, 2006, p. 6).

A cool breeze can be very effective in decreasing anxiety, so can the patients environment. A cool, humidified room may trigger some of the same dyspnea-sensation relieving neural pathways as the cool breeze. Very dry air is an exacerbating factor for any respiratory condition, and the addition of a humidifier to the patient’s environment can quickly eliminate this (Downing and Wainwright, 2006, p. 370).

Ensuring the patient’s social environment is not exacerbating their sensation of breathlessness is foundational. Interpersonal tensions and even positive interactions such as high excitement can negatively impact an individual’s breathlessness. Nurses may make psychosocially calming suggestions to decrease stressful interactions limiting the number of visitors at any given time.

Acupuncture:

It has been found to significantly reduce both moderate and severe dyspnea for patients suffering from end stage COPD and cancer-related breathlessness.

Relaxation techniques, music therapy, therapeutic or healing touch, and guided imagery were also reported as extremely beneficial in supporting a patient with breathlessness (Ferrell & Coyle, 2010, p. 308 and Indelicato, 2006, p. 6). The complimentary therapies listed above, not only decrease breathlessness, but also act to relieve or lessen the degree of anxiety associated with a severe acute episode of breathlessness. When the experienced breathlessness is predominantly triggered or exacerbated by emotional angst, relaxation techniques, a quiet atmosphere and a calming presence may relieve dyspnea far more quickly and effectively that pharmacologic means. Studies have shown that combinations of counselling, breathing re-training, relaxation and teaching of coping and adaptive strategies provide significant improvement in dyspnea symptom management over control groups who did not receive such therapies

References:

Downing, G. M., & Wainwright, W. (2006). Medical care of the dying. (4th ed.). Victoria, BC: Victoria Hospice Society, Learning Center for Palliative Care.

Ferrel, B. R., & Coyle, N. (Eds.). (2010). Oxford textbook of palliative nursing (3rded.). New York: Oxford University Press.

Indelicato, R., A. (2006). Palliative care and the management of dyspnea: Nonpharmacologic interventions in the management of dyspnea. Advanced Practice Nursing eJournal. 6 (4) 1-7. Retrieved October 5, 2011 from http://www.medscape.com/viewarticle/551364_6.

Pain Assessment at End of Life

Overview

  1. Pain is prevalent in palliative care, but the majority of patients have good pain management with available treatment options
  2. An awareness of barriers to adequate pain management is essential for the healthcare proider as it allows the nurse to assess for and plan interventions for potential obstacles which may arisis in delivering good pain managment and overall paitnet care. Strong patient advocacy is essential for a palliative care nurse.
  3. A combination of thorough history and physical exam guides the pharmacologic and nonpharmacologic interventions
  4. Pharmacologic therapies: nonopioids, opioids, coanalgesics, chemotherapeutic agents and other intervention techniques
  5. Intractable pain and symptoms, although not common, must be treated aggressively. In some cases, palliative sedation may be warranted.

Pain is one of the most common and most feared symptoms at the end of life. However, this fear is largely unwarranted as the majority of patients can obtain relief. Nurses play a pivotol role in assessment and providing pain management.
1/3rd of patients receiving active cancer treatment and 2/3rds of those with advanced malignancies experience pain.
Understanding barriers to pain management will help better educate patient, family and professionals involved to ensure that effective pain management is achieved.
It is important to note that unrelieved pain hastens death by increasing the physicological stress, has the potential to diminish immune response, decreases mobility which tends towards complications such as pneumonia and thromboembolisims. It also increases respiratory effort and myocardial oxygen requirements.
Unrelieved pain can also crush the spirit resulting in “spiritual death” as the individual’s quality of life is significantly impaired.
Pharmacologic Managment
Non opioid analgesics
Acetaminophen is one of the safest analgesics for long term managment of mild pain.
  • It can also be supplemented  in the management of more intense pain syndomes.
  • It should be considered an adjunct in any chronic pain regime.
  • It has limited anti-inflammatory capabilities.
  • It should be used in low doses or avoided in cases of renal insufficiency or liver failure, and in individuals with significant alcohol abuse.
Nonsteroidal antiinflammatories are effective analgesics in their limitation of prostaglandin synthesis, inhibiting the inflammatory cascade.
“Classic” NSAIDs such as asprin or ibuprophen are relatively nonselective in their inhibitory effects on the enzymes that convert arachidonic acid to prosteglandins, resulting GI ulceration, renal dysfunction and imparied platelet aggregation is common.
The addition of NSAIDs to opioid analagesic therapy allows for a reduced opioid dose to be used when sedation, confusion and dizziness has become bothersome.
Like acetomenophen, decreased renal or hepatic function contraindicated NSAID use.
Platelet dysfunctioin or other potential bellding disorders contraindicate the use of non-selective NSAIDs.
Proton pump inhibitors can be given to prevent GI bleeding.

Pain assessment in the nonverbal or cognitively impaired

Hierarchy of pain assessment techniques

  1. Obtain self-report if possible
  2. search for potential causes of pain or other pathologies that could cause pain
  3. observe patient behaviors that are indicative of pain
  4. obtain surrogate reporting from family/parents/caregivers of pain and behavioral activity and changes
  5. Attempt an analgesic trial to assess a reduction in possible pain behaviors

Ferrel, B. R., & Coyle, N. (Eds.). (2010). Oxford textbook of palliative nursing (3rd ed.). New York: Oxford University Press.