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Chapter 8: Management of Other Symptoms

Learning objectives for this chapter

By the end of this chapter, we would like you:

- To list the types of gastrointestinal symptoms which are commonly seen in palliative care settings, and to describe their causes and their effective management.

- To define anxiety, depression and delirium in the context of palliative care, and to describe their causes and their effective management.

- To explain the types of fatigue and weakness seen in palliative care settings, and to describe their causes and their effective management.

- To list the types of skin problems which are commonly seen in palliative care settings, and to describe their causes and their effective management.

Management of gastrointestinal symptoms in the palliative care setting

People receiving palliative care can experience a range of significant gastrointestinal symptoms. These may be related directly to the person's condition, or to associated medications. These symptoms and their management are described in detail following:

  • Nausea and vomiting: these can be disabling. Up to 70% of palliative care patients experience nausea and / or vomiting; typically associated with chemotherapeutic and other medications, patients with organ failure, patients with disruption to the vestibular centre in the brain, patients with HIV/AIDS, and patients experiencing high levels of anxiety.

Pharmacological interventions are particularly effective in managing and relieving nausea and / or vomiting:

Anti-emetic Medication

Use

Haloperidol

For nausea and vomiting induced by opioids and other chemicals, and when anxiety aggravates gastrointestinal symptoms.

Metoclopramide

For nausea and vomiting caused by gastric stasis, ileus and chemotherapy; use with caution in patients with cardiac problems.

Phenothiazines (e.g. chlorpromazine)

For nausea and vomiting caused by intestinal obstruction, peritoneal irritation, vestibular problems, raised intracranial pressure, and where causes are unknown.

Scopolamine

For nausea and vomiting caused by intestinal obstruction, peritoneal irritation and raised intracranial pressure.

5-HT3 receptor antagonists

For nausea and vomiting caused by chemotherapy, radiation and post-operatively; is often combined with dexamethasone.

Antihistamines

For use in nausea and vomiting caused by intestinal obstruction, peritoneal irritation, vestibular problems and raised intracranial pressure; may have a mild sedative effect.

Non-pharmacological and complementary therapies may be used. These include self-care strategies such as dietary changes and environmental changes. Maintaining a diary can help patients be proactive in managing their symptoms.

  • Dysphagia: common in patients with head and neck cancer, and conditions affecting muscular function. Increases risk of aspiration and other problems such as choking. Management depends on the individual. A nasogastric tube or percutaneous endoscopic gastronomy (PEG) may be used. Involvement of allied health professionals is recommended.
  • Constipation: often due to bowel obstruction, adverse medication side-effects, hypercalcaemia, dehydration or inadequate dietary intake. Prevention necessitates managing these factors. However, if it does occur, oral aperients are usually very effective. Various oral aperients may be used.
  • Diarrhoea: may result from a hypermotile gastrointestinal system, a secondary complication of problems such as bowel obstruction or gastrointestinal infection, or medication side-effects. Pharmacological interventions, including antidiarrhoeals, are often effective. Management also involves nutrition interventions. Managing dehydration and electrolyte imbalances is also important.
  • Xerostomia (dry mouth): due to a reduction in salivary production, often because of radiotherapy, oral surgery, gland obstruction, medication side-effects and / or neurological problems. Xerostomia is usually managed by addressing the cause, where possible. Maintaining frequent oral hygiene, humidifying air, and using peppermint water, sugarless gum or mild citric acids, can also be effective.

Management of anxiety, depression and delirium in the palliative care setting

A variety of complex psychiatric and neurological problems can present. Occasionally, these are a result of disease processes; more often, they develop due to difficult social and emotional situations.

The management of anxiety, depression and delirium are described below:

  • Anxiety: feelings of distress or tension, disproportionate to the situation or without a clear cause. Anxiety may also be triggered by poorly-managed pain, endocrine disorders, cardiovascular and respiratory conditions (particularly those resulting in hypoxia), and / or neurological conditions. It results in a variety of physical, affective, behavioural and cognitive responses.

Physical Symptoms

Affective Symptoms

  • Tachycardia, tachypnoea.
  • Diaphoresis, tremors.
  • Light-headedness.
  • Nervous or restless behaviours (e.g. picking, pacing, frequent movement, etc.).

Behavioural Symptoms

Cognitive Symptoms

  • Avoidance of situations.
  • Compulsions.
  • Edginess, worry, panic.
  • Thoughts of self-injury, etc.

Management typically involves pharmacological interventions - anti-anxiolytics. Nurses can help patients acknowledge their fears, learn and make decisions about their management options, and maintain autonomy. Avoidance of caffeine, maintaining healthy activity / rest cycles, stress management techniques and psychotherapy can also be useful.

  • Depression: prolonged, unrelieved melancholy, often accompanied by physical symptoms. Predisposing factor include previous psychiatric illness, a family history of psychiatric illness, distressing symptoms such as pain, delirium, fatigue, poor social support, and advanced illness. Management focuses on the use of antidepressant medications. Non-pharmacological interventions such as psychotherapy, music, pet therapy, and group activities can also be helpful.
  • Delirium: an acute disturbance of consciousness affecting a person's cognition, arousal and attention, and often causing confusion and / or agitation. Very common in the last weeks of life in particular; up to 90% of all terminally ill patients experience some degree of delirium.

Delirium often occurs progressively, beginning with non-specific symptoms, and developing into outbursts of anger, agitation, restlessness and psychosis. Patients are alternately hypoactive and hyperactive. Management is complex. Causes, where identified, should be eliminated or reduced. Various medications, including neuroleptics, benzodiazepines, and anaesthetics, may be used. Activity pacing and maintaining healthy activity / rest cycles can also be useful.

Management of fatigue and weakness in the palliative care setting

Fatigue is very common for people receiving palliative care. It is particularly common in conditions such as cancer and chronic pain, but may occur in patients with any terminal illness. Like pain, fatigue is highly subjective.

Healthy people regularly experience some degree of fatigue; however, these people usually recover from fatigue after a period of rest. Patients receiving palliative care may not readily recover from fatigue; furthermore, this fatigue has a more significant severity, duration and impact.

Fatigue may be classified into one of three different types:

  • Acute (physiologic) fatigue: generally occurs in healthy individuals, and is linked to a single cause. Acute fatigue has a rapid onset and a short duration; it is alleviated by rest, healthy diet, gentle exercise and stress management, etc.
  • Chronic fatigue: pathological fatigue which lasts longer than 6 months and has no known physiologic purpose. It is not relieved by any of the strategies listed above. If accompanied by cognitive dysfunction and psychological problems, it may indicate chronic fatigue syndrome.
  • Secondary fatigue: occurs when the body's reserves of energy become depleted due to chronic disease. Secondary fatigue occurs following many treatments for cancer. It is also often associated with severe weakness, malnutrition, anaemia and cachexia.

In the palliative care setting, the goal of fatigue management is to relieve the fatigue to the greatest extent possible, thus improving quality of life. However, fatigue can rarely be completely relieved; therefore, nurses must assist patients to learn to cope with their fatigue. This may involve:

  • Teaching energy conservation strategies.
  • Keeping a daily journal, to identify factors associated with energy depletion and restoration.
  • Gentle exercise, within the patient's capacity and tolerance. The involvement of allied health professionals is recommended.
  • Managing nutrition. Frequent, small meals of high-glycaemic index foods can provide a regular, steady supply of energy. A patient with fatigue should be assessed for nutritional deficiencies, particularly for iron, folate and Vitamin B12.

There are also a variety of medications which may be prescribed to a patient experiencing fatigue. However, fatigue is often underpinned by the use of medications; therefore, be cautious when administrating additional medications.

Management of skin problems in the palliative care setting

Patients receiving palliative care may experience one or more of a number of common skin problems:

  • Pressure ulcers: caused by unrelieved pressure on a body part, resulting in progressive tissue ischaemia and necrosis. They typically appear over bony prominences. They are staged according to size, depth and level of tissue involvement.

Pressure ulcers are a completely preventable condition. Incidence can be reduced through:

  • Regular bathing in warm (not hot) water, using only mild soaps.
  • Using gentle moisturisers to treat dry skin.
  • Avoiding low-humidity environments.
  • Proactively managing incontinence.
  • Regular turning and repositioning (at least every 2 hours).
  • Use of positioning devices, including pillows.
  • Using lifting devices.
  • Assisting a patient to do range-of-motion exercises.

If a pressure ulcer develops, it must be proactively managed. Management of the acute pain is also important; this may be achieved using pharmacological interventions, as well as pressure-relieving devices.

  • Skin tears: these are acute wounds which occur when a patient's fragile skin 'tears' when shearing pressures are applied. They usually occur on the upper extremities. Skin tears can be prevented using a variety of techniques:
  • The use of soaps which help to maintain the skin's natural pH.
  • Patting the patient's skin dry.
  • Proper positioning, turning, lifting and transferring techniques.
  • Encouraging the patient to wear long sleeves.
  • Padding bed rails, wheelchair arms and leg supports, etc.
  • Using non-adherent tapes and dressings on frail skin.
  • Using gauze around drains, catheters, etc.

If a skin tear occurs, healing should be promoted, where possible. The wound should be protected using non-adherent tapes and dressings; an arrow should be placed on the dressing to indicate the direction of the skin tear, and to minimise further skin injury when the dressing is removed. Pain relief is important.

  • Ostomy-related skin injury: the skin around an ostomy site can break down. Ostomy-related skin injury can be prevented by techniques to maintain peristomal skin integrity. If an ostomy-related skin injury does occur, it should be managed using standard skin-care strategies.
  • Fistulas: abnormal openings in the tissue between two organs, or between an organ and the skin. Fistulas can be very difficult to prevent and manage. Often, complex pouching and drainage systems are used. Promoting the comfort of the patient, both in terms of pain relief and exudate, is a key consideration.
  • Malignant wounds: wounds can occur when cancerous cells infiltrate and erode through the skin. They are common in patients with primary cancers of the breast, head and neck and genital region; however, they may occur as a primary cancer. Around 5% of patients with metastatic cancer will develop a malignant skin wound.

There are five key strategies in the management of malignant wounds:

  1. Controlling the growth of the cancer - using typical therapies, depending on the cancer type.
  1. Controlling malodour - malignant wounds are typically necrotic, fungating and very malodorous. Occlusive dressings and charcoal pads can control the odour associated with the wounds. Consider antibiotic therapy and de-sloughing the wound. Using air-freshening and aromatherapy products may also be beneficial.
  1. Controlling pain - pain may be controlled through a combination of pharmacological and non-pharmacological interventions.
  1. Controlling exudate - highly-absorbent dressings and pads can help occlude the wound, where possible. Heavily-exudating wounds may require negative pressure wound drainage systems and / or radiotherapy. Protection of the surrounding skin to prevent the wound spreading is important.
  1. Controlling bleeding - malignant wounds often bleed easily and significantly. Padded dressings which allow application of pressure, and haemostatic dressings, are important considerations. Specialised gauzes and radiotherapy may be considered for wounds which bleed heavily. If cancer infiltrates a major vessel, a patient may haemorrhage rapidly and uncontrollably, causing their sudden death.
  • Other skin injuries, including incontinence-related skin injury: these are common skin injuries which, although originating from different causes, typically result in regional skin maceration. These should be managed using standard skin-care strategies. Controlling bleeding in friable areas of the wound, odour management and the management of exudate are particularly important.

Skin problems can have significant psychological impacts on patients. Patients may be fearful of or repulsed by their wounds. Psychological support strategies are key considerations.

Conclusion

Management of symptoms associated with the condition for which a patient is receiving palliative care is an essential consideration. In previous chapters, you studied in detail the management of two of the most common symptoms which occur in the palliative care setting - dyspnoea and pain. In this chapter, you have studied the types, causes and management of other common problems in the palliative care setting - including gastrointestinal symptoms, anxiety / depression / delirium, fatigue / weakness and skin problems. In completing this chapter, you are now further equipped with the skills and knowledge necessary to provide high-quality palliative care.


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