Linda K. Connelly, ARNP, MSN M. Catherine Hough, PhD, RN Updated: C. Cummings RN, EdD University of North Florida Colle

1. SYMPTOM MANAGEMENT Linda K. Connelly, ARNP, MSN M. Catherine Hough, PhD, RN Updated: C. Cummings RN, EdD University of North Florida College of Health School of Nursing

2. DEFINITIONS • SYMPTOM: a subjective experience reflecting changes in the biopsychosocial functioning, sensations, or cognition of an individual • SIGN: any abnormality indicative of disease that is detectable by the individual or others

3. MANAGEMENT DEFINITION: • Act of managing • Control • Judicious use of means to accomplish an end • WHY manage a symptom? • According to The Institute for John Hopkins Nursing ineffective management of unpleasant symptoms such as pain, nausea, fatigue, dyspnea and depression contribute to longer inpatient hospital stays, slower recovery from illness, loss of productivity, lower quality of life and increased cost of care. • The reason to manage symptom… make pt as comfortable as possible in order to have pt improve & decrease length of stay

4. MORE DEFINITIONS Symptoms are “perceived indicators of change in normal functioning as experienced by patients…………they are the red flags of threats to health.” HEGYYWARY, 1993 “Symptoms can occur alone or in isolation from one another, but, more often, multiple symptoms are experienced simultaneously.” Lenz, et al, 1997

5. THEORY OF UNPLEASANT SYMPTOMS

6. THEORY OF UNPLEASANT SYMPTOMS

7. THEORY OF UNPLEASANT SYMPTOMS • Distress is one of the four dimensions of a symptoms and reflects the degree to which the person is bothered by the symptom. • The other three dimensions of a symptom are quality, timing, and intensity. • Timing is also duration

8. Symptom Management Model (Dodd et al., 2001)

9. DYSPNEA • Sensation of difficulty or uncomfortable breathing • Usually reported as shortness of breath • Severity varies greatly but is often unrelated to the severity of the underlying cause • Most people normally experience this when they overexert themselves

10. The impact on a persons life Develops slowly and the the patients adapts to his limitations • fatigue, problems concentrating, loss of appetite and difficulties sleeping. • feeling of loss, helplessness that can lead to depression, anger and social isolation • may cause anxiety making the emotional problems worse. • feeling of suffocation and thought that death is close • (not an asthmatic person… maybe COPD, maybe adjust by only walking up 3 stairs at a time)… pt must learn to adapt to best handle their symptom! Know that the symptom is real for that person. Can the person on O2 go to the mall w/out running out?

11. DYSPNEA Four major causes • Chronic obstructive pulmonary disease (COPD) • Heart diseases (cong heart failure) • Neurological diseases (guillianbarre, spinal cord injury) • Cancer (spec lung cancer)

12. Assessment of Dyspnea • Detailed history (past med hx, how long, surgery in hx • Physical examination • Chest X-Ray • PFT (pulmonary function test in resp dept & look at how well exhalation & inspiration is, xenon gas)

13. AssessmentDevelopment of dyspnea • When did it start? was it years, months, weeks or hours ago • How has it developed? : steady progression, attacks, acute exacerbations (walking or cat hair or pollen) • How does it feel ? (compressing • Do you experience more than one sort of shortness of breath? (some may be brought on by cough or feels tight like asmatic,)

14. AssessmentHow does it affect daily activities? • Are you able to ------- without becoming breathless? • ...climb a hill or stairs (how many).... • ...walk on the flat... • ...walk more than 100 meters... • ...walk indoors.... • …on mild exertion (such as undressing)... • Are you breathless at rest? How many pillows do you sleep on, do you sleep in a chair?

15. AssessmentAttack of dyspnea • Do you get attacks of breathlessness where you are also frightened? • when do you experience them? • how do they develop? • how do you cope with them? • It is important to try to find out if the patient experience fear because of the dyspnea or it is the anxiety that causes the patient to hyperventilate and thus become dyspneic. • (usually there is more fear w/ a pt who has newer onset of symptoms)

16. Assessmentother considerations • Provoking factors • What makes it worse? Better? • Treatments already tried: medication (Inhaler), physical therapy (to get strength back), oxygen… • (often not a lot that can be done w/ many of these symptoms… we can’t fix lungs on COPD patient… we just work on managing the symptoms… pain, anxiety

17. SPECIAL CONSIDERATIONS WITH DYSPNEA • Loosen clothing • Support with pillows • Administer Oxygen • Position • High Fowler’s • Forward leaning REMEMBER: Treat underlying cause

18. Nursing Diagnosis • Dyspnea • NANDA: • Airway clearance, ineffective (first two are much more common) • Breathing pattern, ineffective • Suffocation, inability to sustain spontaneous (not as much) • NIC • Respiratory management • Ventilation assistance (cpap or oxygenation)

19. Pharmacologic therapy Opioids: • patients with moderate to severe dyspnea • work by slowing down the rate of respiration, thus allowing the patient to breath more efficiently. (morphine decreases pain & vasodialates some… codeine is also good) Anxiolytics such as lorazepam (Ativan) or xanyx (something to relax them • Many patients have attacks of dyspnea that lead to a state of panic • Bronchodilators and oxygen

20. COUGH • Important protective mechanism (to get rid of junk in lungs & keep stuff from entering lungs, we don’t want to totally take away cough as it does good stuff) • Symptom • Body’s way of removing foreign material or mucous from the lungs and throat

21. COUGH as a SYMPTOM • Acute – lasting less than three weeks • Chronic – lasting three to eight weeks or longer • NOTE: they are not mutually exclusive • Non-productive – noisy forceful expulsion of air from the lungs that doesn’t yield sputum • Productive – sudden, forceful, noisy expulsion of air from the lungs that contains sputum or blood (or both)

22. CAUSES OF COUGH • A mechanism to clear the airways from sputum or other agents in the lungs or trachea. • the sputum is too thick and dry • there is a continuous production of sputum • A stimulation of the cough reflex producing a dry cough • the cough may cause an irritation of the airways further stimulating the cough (w/in all bronchial tubes, very receptive allergic response… stimulation to contract, close off & push things out. Diaphragm is strong muscle that will push things out. Post nasal drip can be bad early in the morning, as well as cystic fibrosis or COPD… lung secretions dropping into the lung all night long.. This is one reason we turn them every 2 hours & keep head of bed up to at least 30 degrees) • the cause of the cough may not be obvious. • If person has ARDS (acute resp distress syndrome… fluid in lungs… turn to left side, compresses heart… shifts fluid from lungs onto heart which further compresses heart & drops heart rate… don’t turn on left side for this)

23. Causes due to cancer: • involvement of the major airways • pleural effusions • primary lung cancer or lung metastasis • mediastinal involvement • pericardial effusion • tracheoesophagealfistula (hole between trachea & esophagus, most often causes by pt having both intubation & NG tube in… they rub together & cause irritation… fistula) • radiation therapy of the lungs and major airways. (causes scar tissue on lungs)

24. Cause unrelated to cancer (cough): • asthma, COPD, infections • postnasal drip • pulmonary embolism • Aspiration (common with stroke pts because they can’t swallow well… neurologic damage… need to check if they can swallow well before giving food…, keep head of bed up & chin down)… get food or fluid in lungs… you get pneumonia • congestive heart faliure • gastroeosophagealreflux (GERD) • hepatic absess

25. INITIAL ASSESSMENT OF COUGH • Patient’s History – Including recent illness, surgery or trauma • Character of Cough • Chest X-Ray • Medications (ACE inhibitors) • Smoker • Recent exposure to fumes or chemicals • Allergies • PHYSICAL EXAMINATION: • General appearance • Vital signs • Respirations depth & rhythm • Check nose & mouth • Check neck • Trachea deviation (late stage… maybe mass) • Distended neck veins • Enlarged lymph nodes • Chest evaluation • Examination of abdomen

26. NURSING DIAGNOSIS • COUGH –effective/ineffective • Ineffective airway clearance r/t • Decreased energy • Fatigue • Increased age • These are for SOB & cough

27. COMPLICATIONS OF COUGH • Perception that something is wrong • Exhaustion • Feeling self-conscious • Insomnia • Life-style change • Musculoskeletal pain • Hoarseness • Excessive perception • Urinary incontinence

28. CHRONIC COUGH

29. Treatment for Cough • Identify the cause • If underlying disease TX the disease • Patient education • Antitussives • Expectorants • Antihistamines • Decongestants • Tincture of time (suck it up) • (bring sputum up, maybe decongestant to stop the mucus, nebulized saline …netti pots) • Humidifier or dehumidifier • Nebulized saline • Pulmonary rehabilitation • Relaxation exercises

30. Case Study • Mrs. Carter is a 56 year old female who was seen five days ago in the clinic by the nurse practitioner for her cough. Her cough has lasted about 2 weeks and 6 days at the time of her visit. She calls in today still complaining of a cough and now a feeling of “shortness of breath”. Mrs. Carter if 5’6’ and weighs 187lbs. Mrs. Carter denies any nausea and vomiting, she periodically feels “warm” and flushed , but is afebrile. Her past medical history: she has no know allergies; she smokes 1 pack of cigarettes/day for 10 years. Her present medicine include a medicine for her hypertension and Tylenol PRN for her arthritis pain. Mrs. Carter reports that she had not had a good night’s sleep for the past week. She lives with her husband who is also a smoker. She also has a new cat. She asks what should she do? • What other information do you want from Mrs. Carter? • What do you tell her? Patient education?

31. Nausea & Vomiting • Nausea is the uncomfortable feeling of needing to vomit • Wavelike symptom, associated with pallor, flushing, tachycardia, diaphoresis • The patient feels sick and does not want to eat, has less energy and may lose weight. • Vomiting or emesis occurs when the contents of the stomach are propelled out through the mouth, induced by contractions of the abdominal muscles and diaphragm. • Vomiting often occurs in connection with nausea. The cause and the treatment is the same, but vomiting can also occur as the only symptom Both nausea and vomiting are protective mechanisms against toxins (may be assoc w/ tachcardia, flushing, diaphoresis may be related to cholergenic track… Often chemo will cause vomiting w/out nausea

32. Mechanisms of N & V • Activation of neurons in the medulla oblongata, called the vomiting center • Activated by the cerebral cortex r/t: • anticipation, fear, memory • signals from sense organs sights, smells, pain • vestibular apparatus in inner ear with motion sickness • Chemotherapeutic agents stimulate enterochromaffin cells in the GI tract to release serotonin, activates the vagal afferent pathway and triggers the vomiting center (won’t ask questions about entero cells on test)

33. Mechanisms of N & V • Activated by stimuli that effect the chemoreceptor trigger zone: CTZ, on the surface of the brain and is outside of the blood-brain barrier (may see CTZ again) chemo always goes to hair, GI & ? Cells… read about this!!) • Triggered by signals from the stomach, small intestine or emetogenic compounds, like ipecac, opiods (big side effect of morphine & dilaudid) • Neurotransmitters identify substances as harmful and relay impulses to the vomiting center (activated charcoal will do this) • Neurotransmitters are: serotonin, dopamine, acetylcholine, histamine and substance P (released by opiods & pain receptors) • Antiemetics work to block these neurotransmitters

34. Major causes of N & V

35. Factors influencing N & V

36. Assessment Distinguish between the 3 main causes: • Local: Is the nausea localized in the abdomen? (neurologic, toxic problem… medication, is it CNS, affected by movement) • Toxic: Is the nausea systemic – does the thought of food provoke nausea? • CNS: does the nausea become worse when the patient moves? – is the nausea provoked by specific situations?

37. AssessmentHow severe is the nausea ? • How much does it interfere with the patient's life? (if it from motion sickness, give them something for that) • How often does the patient vomit? (if it is continuous, give them something to stop it/prevent deyhdration) • How much food and fluids is the patient able to keep down? (most imp is to see how affecting electrolytes & hydration)

38. AssessmentWhat is the patient vomiting? • Phlegm • Digested food (the stomach has had time to work) • Undigested food (vomiting just after meals or the stomach is not functioning) • Strong yellow fluid (gastric acid) • Blood-tinged or coffee-grounds appearance (the patient is bleeding from stomach or esophagus) • Green: bile (liver, gall bladder, pancreas) • Fecal: (smells and looks like feces) – indicating bowel obstruction and that the patient needs to be assessed immediately.

39. AssessmentWhat other symptoms? • Irregular bowel movements: • Constipation may be an (additional) factor • Heartburn, a feeling of hunger, pain in the epigastrium: • Too much gastric acid (dyspepsia) may be an (additional) factor • Headaches, disturbances of vision or neurological abnormalities: • The cause may be raised intracranial pressure. (often subdural bleed slowly progresses… find them dead 5 days after the head injury)

40. Nausea: NOC Outcomes Comfort level, hydration, nausea and vomiting severity, nutritional status, food and fluid intake, nutrient intake • Client will • Report relief from nausea • Explain methods to decrease nausea

41. Nausea: NIC Interventions Distraction, medication administration, progressive muscle relaxation, simple guided imagery, therapeutic touch • Apply a cold washcloth to forehead • Assess for fluid and electrolyte imbalances • Provide frequent oral care

42. Main anti-emetic drugs • Serotonin receptors: (works on the brain… works sooner than the dopamine • Dopamine receptors: • (longer wait than the serotonin meds… works on GI tract) • Some pts do better on one meds than on another • Ondansetron (Zofran) used a lot for chemo • Ganisetron (kytril) • Dolasetron (anzemet) • (act on the vomiting chemo sites in the brain • Promethazine (Phenergan) (very irritating to veins, mix w/ saline, can make pt very sleepy) • Chlorpromazine (thorazine) often given for hiccups post-op • Prochlorperazine (Compazine) • Supposatories work better if not already vomiting

43. Main Antiemetics • Dopamine receptors: • Histaminic receptors: • Muscarinic cholinergic receptors: • Droperidol (Inapsine) used in PACU some, has had some controversary • Haloperidol (Haldol) (antipsychotic) • Metoclopramide (Reglan) (increases peristalsis in GI tract… we will see this again!!, clears out GI tract • Dimenhydrainate (Dramamine) motion sickness • Meclizine (Antivert) • Scopolamine (cholergenic receptors… patches

44. Other medications for antiemesis • Glucocorticoids: • Cannabinoids(central sympathmimetic action): • Benzodiazipines (Limbic system inhibition): • Dexamethasone (Decadron) • Methylprednisolone (solu-medrol) (can be used for pts w/ brain injuries… takes swelling down) • Dronabinol (Marinol) (stop nausea & increases appetite) • Lorazepam (Ativan) (affect emotional state, calm you down)

45. Types of nausea and vomiting • Post-operative nausea and vomiting (PONV) • Opioid-induced nausea and vomiting (morphine related) • Chemotherapy- and radiotherapy-induced (CINV or (RINV) • Nausea and vomiting in early pregnancy • Motion sickness and vestibular disorders

46. Drug treatment of nausea and vomiting

47. Home care • Family centered approach • Teach about regimen • Develop full medication profile • Assess for drug interactions • Take antiemetics whenever nausea begins or before you anticipate stimuli occurring, such as prior to chemotherapy and motion • Discuss alternatives, such as music, TENS, acupuncture or acupressure, aromatherapy, herbs (ginger)

48. What is pain? • Pain is whatever the person experiencing it says it is, existing whenever the person says it does. (Lewis, Heitkemper & Dirksen, 2004, p. 132) • Pain is the body’s response to illness: it is the first thing many people associate with illness and what they fear most. (Frank, 1991, p. 29)

49. Pain type • Acute pain occurs suddenly usually in association with known trauma. signs of acute pain: sweating, pallor, perhaps nausea. (can also cause diaphoresis, nausea…) • Subacute pain develops over several days, often increasing in intensity with a pattern of progessive pain symptomatology. Typical cancer pain. (may or may not increase w/ intensity) • Episodic pain occurs over shorter periods of time at regular or irregular intervals. Arthritic pain that comes and goes is an example.

50. Chronic pain • Pain that has persisted for more than 3 months. • There is an adaptation of the autonomic system and there may not be any objective signs. • Characterised by significant changes in the person's personality, lifestyle and functional ability. • Importance to acute and subacute pain before becomes a more complex chronic pain state. • Chronic pain will change your whole way of life… life can become centered around the pain