INNOVATIVE APPROACHES TO ATRAUMATIC CANCER CARE :INNOVATIVE APPROACHES TO ATRAUMATIC CANCER CARE Donna L. Wong, PhD, RN,
PNP, CPN, FAAN
DEFINITION OF ATRAUMATIC CARE :2 D Wong, DEFINITION OF ATRAUMATIC CARE Atraumatic care is the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminates or minimizes the psychologic and physical distress experienced by patients and their families in the health care system (Wong, 1989).
SOURCES OF PATIENT AND FAMILY STRESSORS :3 D Wong, SOURCES OF PATIENT AND FAMILY STRESSORS
PHYSICAL STRESSORS :4 D Wong, PHYSICAL STRESSORS Pain and discomfort (injections, venipunctures, intubation, suctioning, dressing changes, rectal exam, other invasive procedure, disease, treatments)
Immobility (use of restraints, fatigue, imposed bedrest)
Sleep deprivation
Inability to eat or drink
Changes in elimination habits
PSYCHOLOGIC STRESSORS :5 D Wong, PSYCHOLOGIC STRESSORS Separation from family
Lack of privacy
Inability to communicate (if intubated)
Inadequate knowledge and understanding of situation
Severity of illness
Change in patient’s appearance, behavior
ENVIRONMENTAL STRESSORS :6 D Wong, ENVIRONMENTAL STRESSORS Unfamiliar surroundings (crowding)
Unfamiliar sounds (equipment noise, such as monitors, telephone, suctioning, computer printout; human sounds, such as talking, laughing, crying, coughing, moaning, retching, walking)
Unfamiliar people (health care professionals, patients, visitors) Cont’d
ENVIRONMENTAL STRESSORS :7 D Wong, ENVIRONMENTAL STRESSORS Unfamiliar and unpleasant smells (alcohol, adhesive remover, body odors, food)
Constant lights and noise
Activity related to other patients
Sense of urgency or lack of urgency/concern among staff; unkind comments
PRINCIPLES OF ATRAUMATIC CARE :8 D Wong, PRINCIPLES OF ATRAUMATIC CARE 1. PREVENT OR MINIMIZE PATIENT/FAMILY SEPARATION
2. PROMOTE SENSE OF CONTROL AND HOPE
3. PREVENT OR MINIMIZE PHYSICAL STRESSORS
PREVENT OR MINIMIZE PHYSICAL STRESSORS :9 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Multiple punctures - use intermittent infusion device with saline, coordinate care, have “2-try only” policy; consider central venous access device EARLY. Avoid or reduce intrusive/painful procedures
PREVENT OR MINIMIZE PHYSICAL STRESSORS :10 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Painful injections - use smallest gauge needle; automatic lancet devices (One Touch), slow infusion, EMLA, buffered lidocaine, iontophoresis (Numby Stuff), vapocoolants (ethyl chloride or Fluori-Methane spray); know amount of blood needed for tests; have lab save blood for future tests. Avoid or reduce intrusive/painful procedures Cont’d
Buffered Lidocaine :Buffered Lidocaine Onset of local anesthetic (LA) neural blockage occurs when drug (lidocaine) enters nerve axoplasm and attaches itself within sodium channel of nerve.
To reach nerve, drug must traverse perineural sheath and nerve membrane.
These structures are readily permeable to drug in its nonionized (noncharged) form and nonpermeable to ionized form. Cont’d
Buffered Lidocaine :Buffered Lidocaine Cont’d Adding sodium bicarbonate (1mEq/ml) to 10 parts lidocaine (1% or 2% with or without epinephrine) reduces or eliminates stinging sensation.
Buffered solution is stable for 7 days unrefrigerated or 14 days refrigerated
Buffered Lidocaine :Buffered Lidocaine For drug solubility and stability, pH is acidic, with epinephrine (E) containing solutions commonly being most acidic.
pH < 7increases fraction of ionized lidocaine.
pH > 7 by buffering increases fraction of nonionized lidocaine.
Use 1:10 ratio of lidocaine and sodium bicarbonate and 30 g needle for injection. Cont’d
Comparison of needle gauge :Comparison of needle gauge Cont’d
Equipment for BL :Equipment for BL Cont’d
Intradermal injection for BL :Intradermal injection for BL
SURVEY OF USE OF BL FOR IVs SUMMARY OF 8-YR SURVEY :SURVEY OF USE OF BL FOR IVs SUMMARY OF 8-YR SURVEY N = 89 completed surveys from 7 nursing units in 900-bed tertiary hospital.
Total # of IVs with BL = 241,120.
Reported complication rate: 37 (0.0065%).
- 36 obscured vein.
- 1 patient complained of lidocaine burning.
- 0 adverse reactions requiring medical intervention were reported.
PREVENT OR MINIMIZE PHYSICAL STRESSORS :11 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Intramuscular injections - EMLA for 2.5 hr.; ventrogluteal (hip, not buttock) site.
Arterial blood gases - obtain baseline oximetry; use local anesthetic.
Urethral catheterization - insert Xylocaine 2% jelly into urethra before inserting catheter (Gray, 1996). Avoid or reduce intrusive/painful procedures
PREVENT OR MINIMIZE PHYSICAL STRESSORS :11 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Avoid IM for pain control. Continuous subq route can be used for “IV” route. Leave needle in as long as functional.
Intramuscular injections - EMLA for 2.5 hr.; use ventrogluteal (hip, not buttock) site. Avoid or reduce intrusive/painful procedures Cont’d
Ventrogluteal site :12 D Wong, Ventrogluteal site
PREVENT OR MINIMIZE PHYSICAL STRESSORS :13 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Shivering / rigors – adverse effect of amphotericin B and some biologic response modifiers (interferon) that produce pyrogenic activity; wrap extremities with towels (Holtzclaw, 1992; 1990). Avoid or reduce other kinds of physical distress Cont’d
Pyrogenic Response :Pyrogenic Response Hypothalamic “set point”
increased When skin and core temperatures
are sensed as cooler
than “set point” Compensatory shivering and
vasoconstriction occur Wrapping dominant skin receptors
protects sensors from heat loss
PREVENT OR MINIMIZE PHYSICAL STRESSORS :14 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Sleeplessness - organize care to provide 120 minute sleep cycles.
Smells - eliminate when possible, i.e., uncover food tray cover outside of room, do not make popcorn or wear perfume, eliminate body/mouth odor. Avoid or reduce other kinds of physical distress
PREVENT OR MINIMIZE PHYSICAL STRESSORS :15 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS NPO - (American Society of Anesthesiology, 1999).
Allow clear liquids 2 hrs and milk/light meal 6 hrs before surgery or conscious sedation. Avoid or reduce other kinds of physical distress
PREVENT OR MINIMIZE PHYSICAL STRESSORS :15 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Avoid or reduce other kinds of physical distress Anorexia/cachexia -Megestrol (Megace)
320 mg/day; 80mg q 4 X day
Available in 20 and 40 mg tablets
Megace (#240 of 40 mg) $338*
Megestrol generic $102* *Albertson Pharmacy, 81 &Yale.
PREVENT OR MINIMIZE PHYSICAL STRESSORS :16 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Nausea/vomiting – consider antiemetic gels (apply half of gel on each wrist for faster absorption).
Available from Apothecary Shoppe, 918-665-2003 or 800-610-2003. Avoid or reduce other kinds of physical distress
PREVENT OR MINIMIZE PHYSICAL STRESSORS :17 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Skin trauma - avoid tape; use skin barriers; hydro gel electrodes; promote moist wound healing; assess frequently to prevent injury. Avoid or reduce other kinds of physical distress Cont’d
PREVENT OR MINIMIZE PHYSICAL STRESSORS :18 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Consider two products: Revive (aloe vera, pramoxine (analgesic), allantoin (promotes epithelialization), retinol, beta carotene, riboflavin, niacin, pantothenic acid, alpha-tocopherol, propylene glycol, pH balanced) and Derma-Life Skin Care Formula (without pramoxine).
Available from Derma-Life Corp, 800-658-9341. Avoid or reduce other kinds of physical distress
PREVENT OR MINIMIZE PHYSICAL STRESSORS :18 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Avoid or reduce other kinds of physical distress TOTAL BLOCK
Complete sun block for UVB/UVA
Mixture of 8 forms of highly reflective, micronized particles plus three organic ultraviolet absorbers
Protective ingredients (antioxidants and trace elements) counteract free-radical damage and increase protection against UV and acute oxidation damage Cont’d
PREVENT OR MINIMIZE PHYSICAL STRESSORS :18 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Avoid or reduce other kinds of physical distress TOTAL BLOCK SPF 60 FOUNDATION
Protective liquid make-up to cover up hyper-pigmented skin
Comes with light and dark control packets to custom match skin tone
TOTAL BLOCK CLEAR SPF 65
Formulation dries invisible on the skin Cont’d
PREVENT OR MINIMIZE PHYSICAL STRESSORS :18 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS TOTAL BLOCK recommended for:
Skin Cancer Protection
Post Laser Surgery
Drug Photosensitivity
Lupus Photosensitivity
Facial Trauma
Post Radiation Therapy
Post Transplant Chemotherapy
Rosacea
Camouflage Make-up
PREVENT OR MINIMIZE PHYSICAL STRESSORS :19 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Mouth ulcers – Tetracaine 1% suckers (80 mg); tetracaine 1% lozenge (10 mg); tetracaine 0.025% popsicle (4 mg); tetracaine 0.5% spray (5mg/spray).
DO NOT EXCEED 4mg/kg/day.
Available from compounding pharmacist. Avoid or reduce other kinds of physical distress
PREVENT OR MINIMIZE PHYSICAL STRESSORS :19 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Mouth ulcers – Peridex, PerioGard (chlorhexidine gluconate 0.12%)
- Effective antiplaque and antigingivitis oral rinse agent
- Medicinal taste, potential to stain teeth Avoid or reduce other kinds of physical distress
PREVENT OR MINIMIZE PHYSICAL STRESSORS :19 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Mouth ulcers –Capsaicin
- Active ingredient in red chili peppers
- Depletes and prevents reaccumulation of of substance P, a neurotransmitter
- Produces burning sensation before analgesia occurs
- Apply with gloved hand or applicator Avoid or reduce other kinds of physical distress
PREVENT OR MINIMIZE PHYSICAL STRESSORS :20 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Selected Pain Control Issues Consider financial cost of analgesics and benefit of methadone (“poor man’s morphine”).
Encourage price comparison among pharmacies for EACH drug. Cont’d
Analgesic price comparison :Analgesic price comparison
Analgesic price comparison :Analgesic price comparison
Methadone :Methadone Mu-opioid agonist similar to MS
20 mg equianalgesic to 30 mg MS po
Initial dosing 10-25% of equianalgesic dose or 1:10
Initial doses q4-6 hours PRN
Variable long-half life (12-190 hrs) can lead to drug accumulation and toxicity
Extend duration to 6-8 hours
Negative association with “drug addicts” Cont’d
Methadone (Dolophine) :Methadone (Dolophine) Available in following oral dosages:
5 or 10 mg/5 ml solution
10mg/ml concentrated solution
5, 10, 40 mg. tablets
Also available for IM, IV, subq, rectal, sublingual, and spinal routes Cont’d
PREVENT OR MINIMIZE PHYSICAL STRESSORS :21 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Selected Pain Control Issues To divide a patch in half, e.g., Duragesic or Clonidine, remove only half the protective covering and apply for the appropriate duration; for next dose, remove the other half of covering and reapply. DO NOT CUT PATCHES. Cont’d
Conversion of IV Fentanyl to Duragesic patch :Conversion of IV Fentanyl to Duragesic patch Apply patch and maintain IV dose.
After 6 hr decrease IV dose by 50%.
After 12 hr discontinue IV fentanyl.
Provide PCA boluses of IV fentanyl equivalent to 50 to 100% of the final hourly infusion rate for first 25 hr of patch. From Oncology Times, June 2001, p. 36.
Ketoralac (Toradol) :Ketoralac (Toradol) Only parenteral NSAID; same side effects as other NSAIDS.
Multiple dosing: <65 yr, 30 mg IM or IV q 6 hr; >65 yr, 15 mg IM or IV q 6 hr.
Oral dose only to follow IM/IV dose: <65 yr, 20 mg initial dose, then 10 mg q 4-6 hr; >65 yr, 10 mg initial and subsequent doses q 4-6 hr. Cont’d
Ketoralac (Toradol) :Ketoralac (Toradol) If inadequate analgesia, do not escalate doses (ceiling effect); use opioids to supplement.
Must use only for 5 days because of increased risk of side effects, especially renal failure.
PREVENT OR MINIMIZE PHYSICAL STRESSORS :22 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Selected Pain Control Issues Consider topical compounded preparations:
Ketotripazepine Plus organogel (ketoprofen, lidocaine, amitriptyline, carbamazapine) (nerve pain).
Cytoketocaine organogel (ketoprofen, lidocaine, cyclobenzaprine) (musculoskeletal pain).
Available from compounding pharmacist. Cont’d
PREVENT OR MINIMIZE PHYSICAL STRESSORS :23 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Selected Pain Control Issues Other analgesics with human data to support topical use: aspirin, capsaicin, clonidine, desipramine, gabapentin, guanethidine, ketamine, NSAIDS, local anesthetics. Cont’d
PREVENT OR MINIMIZE PHYSICAL STRESSORS :24 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Selected Pain Control Issues Other topical agents with varying levels of support from experimental research: baclofen, dextromethorphan, glucosamine, guaifenesin, mexiletine.
Dextromethorphan capsules (DexAlone, 30 mg) are available from DexGen, 866-438-7339.
PREVENT OR MINIMIZE PHYSICAL STRESSORS :24 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Selected Pain Control Issues Breakthrough cancer pain
Transitory episodes or flares of moderate to severe pain occurring in conjunction with chronic, persistent pain that is otherwise controlled
End-of-dose pain BTCP that occurs just prior to the next scheduled dose of a long-acting analgesic. For example, a patient receiving long-acting morphine every 12 hours at 8 a.m. and 8 p.m. may report severe pain occurring consistently at about 7 a.m. and 7 p.m. Cont’d
PREVENT OR MINIMIZE PHYSICAL STRESSORS :24 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Selected Pain Control Issues Characteristics of BTCP
Sudden or gradual onset
Mean duration of 30 minutes (range: 1 minute to several hours)
Often precipitated by action such as coughing or movement
Often extreme, immobilizing the patient and causing severe distress
Often significantly undertreated Cont’d
PREVENT OR MINIMIZE PHYSICAL STRESSORS :24 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Selected Pain Control Issues Treatment Regimens for BTCP
Oral IR morphine
100% of q 4 h dose prn
50% of q 4 h dose q 2 h
5-15 % of total daily dose q 2 h prn
Oral transmucosal fentanyl citrate (Actiq)
Individually titrated beginning at 200 g
PREVENT OR MINIMIZE PHYSICAL STRESSORS :25 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Selected Pain Control Issues Pain Relief Electro Membrane (PREM) – high technology membrane electron reservoir in a dressing that when placed in contact with the skin, releases the stored electrons which then interfere with pain transmission. Cont’d
PREVENT OR MINIMIZE PHYSICAL STRESSORS :26 D Wong, PREVENT OR MINIMIZE PHYSICAL STRESSORS Selected Pain Control Issues Cancer is a contraindication to the use of PREM, but has been used for intractable pain in terminally ill patients.
Available from Helio Medical Supplies, 606 Charcot Ave., San Jose, CA 95131; 888-PAIN TEM (888-724-6836).
www.mosby.com/WOW :www.mosby.com/WOW
Slide 54 :27 D Wong, www.mosby.com/WOW
Slide 55 :27 D Wong, www.mosby.com/WOW