Microsoft word - pall care prl 7-31-11.doc

PALLIATIVE CAREk
PAIN (P-A-I-N) (Mnemonic for evaluation)
For End of life
P hysical
(Issues and Orders to cover)
1) Discuss & clarify with patient &/o family &/o DPOA-HC I interpersonal/social problems
N on-acceptance/spiritual distress
b) advance directives (hospitalizations?, antibiotics?) P hysical
c) anticipated sx=s of dying & plan of management 2) Involve & assure staff=s comfort with plan and orders (Pain)- (make sure of diagnosis (when you can)
3) Document discussions and write orders. Mech/Inflammatory vs. neuropathic vs. bone)
4) give AGGRESSIVE COMFORT (mnemonic)
a) A NOREX-IA/ A GGITATION
E vacuation problems
X erostomia
O ral candidiasis I atrogenic (radiation/chemo)
R eactive depression A cid (gastritis/PUD)
*Acetaminophen) scheduled dose and add PRN narcotics (write p.o. or p.r.) c) Appetite stimulants: (megestrol, remeron, trazadone) **dexamethasone: 4-10 mg per day ~Opiates po/pr* sc/iv size liquid
A GGITATION (Terminal Delirium)
morphine 5-7.5mg q 4h*. 1-2mg q 1/2hr 15mg 10,20,100mg/5ml -Haldol 0.5 mg po/sl/sc q 30 min prn delirium 15mg q 12 h* --- 15,30,60,100,200 mg ---- -lorazepam 0.5 mg po/sl/sc q 30 min prn delirium 10 mg q 12 h.* --- 10, 20, 40,80,160 mg ---- G ASTROINTESTINAL
12 mcg/h. q 3 d* ---12, 25,50,75,100mcg/h -CONSTIPATION(with opiates always start;)
* (these are starting doses-titrate to pain control and tolerance) (NO UPPER LIMITS)
-NAUSEA: Compazine or Haldol or
Tramadol (Ultram) 25mg q 6 hr* 25-100 mg q. 6 hr 50, 100 mg G ENITOURINARY
***************************************************
Antidepressants dose p.o. size
-BLADDER:-discuss incontinence management
Bupropion 37.5 mg q d to 100 mg SR q d. max 300 mg SR 100 & 150 mg SR Venlafexine (Effexor) 37.5mg (XR) bid; max 225 mg/d 37.5,75,150 mg R ESPIRATORY
duloxetine 20 mg start, max 60 mg q d. 20, 30, 60 mg -DYSPNEA AB-R-E-A-T-H A-I-R@ (for correctable causes)
Anticonvulsant
B ronchospasm
100 mg q.d.B400 mg t.i.d. 100 & 300 mg I nterpersonal issues
pregabalin 50 mg po t id, max dose 100 mg tid 25,50,75,100 mg E ffusions
Abdominal pain (colicky) (r/o urinary retention or impaction)
A irway obstruction
Phenergan 25 mg q 6hr,oxybutinin 5-10 mg t.i.d., T hick secretions
H emoglobin (low?)
If Bowel obstruction Y M.S. + anticholinergics, if severe Y Octreotide (For unresponsive dyspnea,ºgive immediate release opiates)
A nxiety (pain) (counsel, reassurance, family, friends, pastor)
E MOTIONAL SUPPORT
( choose med based on additional benefits ( hydroxyzine for secretions) S PIRITUAL SUPPORT
Medication po im/iv size liquid
S ECRETIONS If cough strong º moisten
hydroxyzine 10-50mg q 4h 10-50 mg q 4h 10 & 25 mg 10&25mg/5ml. If cough weak º dry-up (with anticholinergics) -for Death Rattle: atropine qtts, glycopyrolate, TD scopalamine
0.5-2 mg t.i.d. 0.5-2 mg q 4h 0.5 & 1 mg (If unable p.o.)º(sublingual: Dissolve lorazepam in water, give buccally q 1 hr.) NFLAMATION (FEVER)
-acetaminophen &/or ASA scheduled dose (is best) or PRN, I nterpersonal/spiritual-->counseling, family,friends,pastors
V OLUME (review with family, dehydration has no pain)
N on-acceptance--------------> A @ A
E MPATHY (secure your own emotional support)
For more explanation see Web site: geriatrics.unmc.edu visit GERI Pearls
k Adapted form APrimer of Palliative Care@ Porter Storey MD

Source: http://www.unmc.edu/media/intmed/geriatrics/reynolds/pearlcards/palliativecare/PallCarePrl.pdf