Review guide under here, so I can cross things off as I go. Certification exam coming up soon. This is what I’m going to be doing for the next month or so. Meanwhile, queue is in charge.
disease progression and imminent death
assessment and staging scale
**FAST staging: 1. (normal adult) no difficulties; 2. (normal older adult - mild memory loss) word finding, location of objects; 3. (early dementia) decreased job function evident, decr. organizational capacity, difficult travel to new locations; 4. (mild dementia) decr. ability at complex tasks, handling finances; 5. (moderate dementia - diff with serial subtraction; date/year/home address) assistance in proper clothing choice; 6a. (moderately severe dementia - diff with names of family/friends, delusions/hallucinations/obsessions, increased anxiety, poss violent; daytime sleep/night wakefulness) assistance in dressing; 6b. assistance bathing more freq.; 6c. assistance toileting more freq.; 6d. urinary incont. more freq.; 6e. bowel incont. more freq.; 7a. (severe dementia - incontinent x2, lose speech & ability to walk; bedridden -> sepsis, pna) limited speaking ability (half dozen words in av. day/interview); 7b. single intelligible word in av. day/interview); 7c. lost amb. ability; 7d. needs assistance to sit up (i.e., arms on chairs); 7e. lost ability to smile
local coverage determination
disease-specific guidelines
SSx of imminent death - usually in clusters rather than individual SSx
loss of appetite (early sign) -> weight loss, cachexia (family distress: signifies decline, inability to nourish as a sign of care. educate that force feeding -> vomiting and aspiration). artificial nutrition if consistent with GOC, but educate that it does little good and may increase distressing symptoms. consider decrease if patient has in place but vomiting, aspiration, edema, CHF, pulmonary edema, other SSx fluid overload
cachexia incl. muscle wasting, anorexia, fatigue, weakness, as well as weight loss
unintentional weight loss = or >5% body weight
BMI < 20 (pt <65yo) OR <22 (pt >65yo)
increased cytokine levels (-> muscle tissue breakdown/catabolism)
enourage oral fluid intake for as long as possible; team to work with family to determine if supplemental hydration. NOT USUALLY NECESSARY in terminal phase, although in some cases hypodermoclysis may ease delirium, opioid toxicity, agitation, dehydration
possible psychological and spiritual distress - depression, anxiety, grief, isolation in final weeks (highest levels of anxiety - COPD likely d/t dyspnea). Hopelessness, general dissatisfaction with life, overall sense of suffering in advanced dz.
increasing weakenss and dependence on caregivers
dysphagia/aphagia - if unable to take PO, consult with prescriber to d/c unnecessary meds; to promote comfort, KEEP pain meds, anxiolytics, antiemetics, anticholinergics, antipyretics (alteranate routes)
asthenia -> bedbound + incontinence, malnutrition -> risk for skin breakdown. SKIN CARE, frequent repositioning. Kennedy ulcers in final days, despite skin care (sacral, pear- or butterfly-shaped)
focus care on SYMPTOM MGMT and comfort as pt declines.
educate family on saying goodbye/resolving conflicts, creating mementos (recording pt’s voice, hand casts, photos, etc), finalizing funeral arrangements, gathering loved ones who want to be present at TOD, normal changes in pt condition (decr. appetite, incr. somnolence, cyanosis, etc.) and that they don’t cause pain/distress for pt
aggressive and prompt symptom mgmt to alleviate distress - determine if change in meds/routines is root cause.
Some SSx may not be distressing for pt (ex. some terminal agitation) but impacts safety - address via activity as tol., thx environmen, music thx, meds (haloperidol, chlorpromazine, risperidone, lorazepam)
some distressing for family but not pt - terminal secretions (death rattle). educate family, reposition pt., suction oropharynx (NOT deep suction). if dyspnea or pt distress, anticholinergics (hyoscamine SQ, atropine SL, glycopyrrolate SL, scopolamine SQ/topical
SSx: confusion and vision of loves ones who’ve passed away; terminal agitation -> incr somnolence -> unresponsiveness; respiration changes (aphea, Cheyne-Stokes, agonal breathing, terminal secretions); temporal wasting; dehydration; pain; cyanosis (lips, extremities), cooling of extremities; HTN -> hypotension; peripheral edema; mottling; incontinence -> oliguria -> anuria. increasing asthenia and somnolence -> coma OR mutliple symptoms w/ terminal agitation period prior to coma.
pts withdraw and lose verbal ability, but THOUGHT REMAINS INTACT - caregivers should continue to talk, provide soothing sounds (music) throughout dying process
educate caregivers on nonverbal signs of pain/discomfort (often r/t tumor pressure, GI distress, frailty, siffness, immobility, bladder distention (FLACC scale)
FINAL HOURS: profound weakness/fatigue, guant/pale, withdrawal from others/reduced awareness, glassy/cloudy eyes, unable to take PO, oliguria-anuria, agonal respirations/apnea, tachycardia, unresponsive
adhere to advance care plan, avoid unnecessary interventions incl. VSx monitoring, treat FEVER, d/c unneeded routine meds
educate family re: pre-death “rally” - sudden reawakening/awareness of surroundings, coherent conversation, increased appetite -> semicomatose within hours (family distress, false hope)
if esophageal varices - prep family for poss. terminal hemorrhage (not usually painful for pt but visually distressing), provide support, focused attn during. poss. pt sedation if awake and alert. hemostatic dressings in chronic bleeding. dark towels.
inteventions: agitation (benzos, music, massage, dim lights, cool env.); dehydration (freq. oral care, ice chips as tolerated, hypodermoclysis/protoclysis if GOC consistent); dry mouth (oral care, lip balm, ice chips and oral swab as tolerated, artificial saliva); dyspnea (trx cause if poss., opioids, reposition for comfort, fan for moving air/cool env.); edema (elevate extremities as tolerated, diuretics, decrease/discontinue artificial nutrition/hydration of fluid overload SSx); fever (acetominophen PR, fan, light clothing, cool compress to head); incontinence (change promptly, skin care after each incident, reposition freq to protect skin); pain (PO meds until not tolerated -> SQ, PR; adjuvant meds PRN, reposition, distraction, massaage, heat/cold); terminal secretions (reposition, anticholinergics, oral suction); decubitus ulcers (skin care, wound care, topical lidocaine)
assessment/document: general appearance, absence of heart/lung sounds on auscultation (1 full minute), lack of pupillary response to light, absence of response to verbal/tactile stimuli, TOD, who was notified of death, what time family/caregiver notified hospice agency (for home care patients), to who body released (morgue, funeral director, etc.)
postmortem care with attention to cultural/religious preferences; invite family to participate if they desire; emotional support for family with assurance team will provide bereavement support up to 1yr
prep death certificate as req. by state law, notify primary care provider
FEDERAL LAW - if death in hospital, primary decision maker must be approached re: organ donation
neurovascular (w/ cva, coma admission criteria)
infx (esp. viral hepatitis), autoimmune dz, genetic predisposition to liver dz, cx, chroncia ETOH, fatty liver -> liver damage
risk factors: ETOH abuse, exposure to blood/body fluids (parenteral drug abuse, tattoos, blood transf. prior to 1982), hepatotoxic chemical exp., diabetes/obesity (Hep C #1, alc. cirrhosis #2)
irreversible dz processes -> chronic lliver failure (CLF) ->ESLD. erratic trajectory with increasingly frequent, severe exacerbations of symptoms. sudden death r/t complications.
ascites, hepatic encephalopathy, anorexia/cachexia, portal hypertension, poor immunity, n/v, lyte imbalance, pruritis, malaise, esoophageal varices, pain, muscle/extremities wasting d/t malnutrition
assessment: symptoms (pain, n/v, altered bowel, rectal bleeding, dysphagia, abd. distention, pruritis), jaundice of sclera and skin, rash, petichiae, open areas from scratching, nonhealing wounds, temporal wasting & sunken eyes d/t malnutrition; abd inspection/ausc/percussion/palpation (boardlike w/ generalized peritonitis; rebound tenderness with local inflamm)
Model of End-Stage Liver Dz (MELD) - INR, bilirubin, creatinine levels. (score 10-19 = 92% 6-month mortality)
Child-Turcotte-Pugh (CTP) - total bilirubin, albumin, INR, degrees of encephalopathy & ascites (Class A = 95% 12-month mortality)
ascites indicates 50% 2-year mortality (6-month median survival rate when refractory)
liver failure -> renal failure (hepatorenal syndrome); HRS type 1 -> 4-week survival rate; type 2 -> 6-month survival rate
symptoms (ascites, hepatic encephalopathy, HRS, varices) are refractory to intervention
PT > 5 seconds over control OR INR > 1.5
serum albumin <2.5 gm/dL, plus one or more:
ascites, refractory or pt noncompliant
spont. bacterial peritonitis
HRS, elevated creatinine and BUN, oliguria (<400 mL/d), urine Na concentation <10mEq/L, chirrhosis and ascites
hepatic encephalopathy, refractory or pt noncompliant
recurrent variceal bleeding despite thx
SUPPORTING documentation: progressive malnutrition, muscle wasting, continued active alcoholism (>80g ETOH/d), hepatocellular carcinoma, Hep B (HBsAg) positive
dementia/neurocognitive disorders
NCDS - decline from previous function, distinct from congenital
risk factors - age (60yo, 85yo), genetic predisposition, female, poor diet/obesity/diabetes, depression, education level, multiple comorbidities
memory changes, poor recognition, word searching, decr. executive function, poor attention span, behavior/mood changes, altered perception, decreased function re: ADLs
APA diagnostic criteria (dementia): significant decline from previous level in multiple domains (complex attention, executive function, learning and memory, language, perceptual/motor, social cognition) based on concern from knowledgeable informant or clinician or documented by testing/assessment + interferes with ADL independence + not just delirium + not better explained by another mental disorder
Alzheimer’s - slow progression (6-8 years) with exacerbations of underlying illnesses; short term memory loss, decreased attn, word searching
vascular - stepwise decline; onset gen. corresponding to TIA/CVA/cerebral infarct; variability of symptoms: aphasia, motor deficits, impaired executive function/recall/problem solving
Lewy body - progressive symptoms: neurocognitive changes, movement disorders, hallucinations, parkinsonian movements, falls, delusions, sleep disturbance
frontotemporal - (umbrella - nerve cell damage) variable progression; aphasia, obstinacy, apathy, motor disturbances, disinhibition, decr. facial recognition, emotional distancing
PT/OT/ST to maintain function & speech/swallow ALAP; advance care planning, GOC, long-term management (LTC facility?) EARLY
cholinesterase inhibitors (donepazil) to impr. cholinergic transmission in early stages; NMDA receptor agonists (memantine) later stages (impr. memory, enhance reasoning, maintain physical function - can be used together
late stage - interdisciplinary team - serious motor impairment ->safety issues, dysphagia/incontinence/immobility -> skin integrity infection -> agitation, delirium/depression/lethargy, pain, SOB, limb contractures
terminal phase - per advance directive and GOC, d/c interventions if questionable benefit
CRITERIA FOR HOSPICE ADMISSION
FAST** Stage 7 or beyond PLUS one or more of
multiple S3/S4 pressure injuries
other significant condition suggesting limited prognosis
hx shows inability to maintain sufficient fluid/calorie intake in past 6 months (10% weight loss, albumin <2.5gm/dL)
**FAST staging: 1. (normal adult) no difficulties; 2. (normal older adult - mild memory loss) word finding, location of objects; 3. (early dementia) decreased job function evident, decr. organizational capacity, difficult travel to new locations; 4. (mild dementia) decr. ability at complex tasks, handling finances; 5. (moderate dementia - diff with serial subtraction; date/year/home address) assistance in proper clothing choice; 6a. (moderately severe dementia - diff with names of family/friends, delusions/hallucinations/obsessions, increased anxiety, poss violent; daytime sleep/night wakefulness) assistance in dressing; 6b. assistance bathing more freq.; 6c. assistance toileting more freq.; 6d. urinary incont. more freq.; 6e. bowel incont. more freq.; 7a. (severe dementia - incontinent x2, lose speech & ability to walk; bedridden -> sepsis, pna) limited speaking ability (half dozen words in av. day/interview); 7b. single intelligible word in av. day/interview); 7c. lost amb. ability; 7d. needs assistance to sit up (i.e., arms on chairs); 7e. lost ability to smile
endocrine disorders (most common)
hypo (high TSH) - weight gain, jaundice, hoarsenes, decreased sbp/increased dbp, pericardial effusion, bradycardia, edema, fatigue, myalgia/arthralgia, blurred vision, impaired hearing, increased perspiration, fever/sore throat, depression/emotional lability, cold intolerance, paresthesia, constipation; myxedema crisis/coma - LEVOTHYROXINE 1-2 mg/kg/d.
hyper (low TSH, high T4/T3) - Grave’s disease comorbid 60-80%. nervousness, irritability, tremor, muscle weakness, bruit over thyroid, hyperactivity, heat intolerance, hair loss, palmer erythema; thyroid toxicosis/thyroid storm (antithyroid meds, inorganic iodine, bile acid sequestrants, beta-blockers, glucocorticoids) - antithyroid meds (methimazole, propylthiouracil), beta-blockers for andrenergic symptoms. radioactive idodine thx/thyroidectomy.
DM2 risk factors: age, htn, hypercholesterolemia, weight/obesity, smoking, inactivity, hyperglycemia;
increased risk of stroke, cardiac events; retinopathy, neuropathy
maintain AIC <5.7% or fasting plasma glucose <100 mg/dL
prioritize comfort/quality of life (when to d/c BG monitoring; EDUCATION of pt, family re: d/c)
immunologic disorders (w/ hiv admission criteria)
chronic pain/chronic pain syndromes
low back pain - recurrent, refractory, impaired mobility, debilitation
myofascial pain syndrome (MPS) r/t muscle, fascia, tendon injury - myositis, fibrositis, myofibrositis, myalgia,
peripheral - diabetic neuropathy, nutritional deficiency, HIV, carcinoma - activity, allodynia
central - spinal cord trauma, tumors, vascular lesions, MS, Parkinson’s, postherpetic neuralgia, phantom limb, reflex sympathetic dystropy (CRPS)
CRPS - neuropathic, allodynia (diaphoresis, vascular changes, asthenia, disuse (PT, nerve blocks)
chronic postoperative pain (CRPS) - phantom limb, chronic donor site, postthoracotomy pain syndrome, joint arthroplasty (acute + chronic -> multimodal trx)
reticular - compression of neck/spine nerve roots (sciatica, injury, herniated disk, foraminal stenosis, inflammation) - sharp, stabbing, radiating
cancer - neuropathy, parasthesia, r/t tumor growth, trx, comorbidities - frequent assessment for rapid changes, short- + long-acting
palliative & precipitating factors (what makes it better or worse)
quality (what does it feel like)
radiation (is it in one area or does it travel) (somatic gen. well-localized, visceral gen. poorly localized, neuropathic gen. radiates)
severity (can you rate it for me)
timing (better or worse at certain times, when did it start, how long does it last)
nonverbal: FLACC, Wong-Baker FACES, Faces Pian Scale Revised (FPS-R) (children 1-7), PAINAD
physical - quality, severity + related symptoms (nausea, sleep disturbance, depression, anxiety, immobility,
psychological - anxiety, depression, hopelessness; quality of life, incl. planning activities around pain/meds (Patient Health Questionnaire (PHQ-9, depression); GAD (GAD-10) screenings)
social - isolation, social consequences of reporting pain
spiritual - FICA Spiritual History (spiritual distress)
SUD - gen. more severe pain experience, poss. require higher med dose
40% comorbid mental/emotional/behavioral disorder
serious illness as trigger for substance abuse
AUDIT-C, Opioid Risk Tool
nociceptive pain (somatic or visceral) (sharp and localized)
visceral (gnawing, ache) - multimodal mgmt; metasteses, pancreatic tumors/pancreatitis, biliary or SBO/colon obstruction
neuropathic - multimodal mgmt, incl. nonopioids, gabapentinoids, antidepressants, SNRIs, anticonvulsants, Na-channel blocking antiarrhytmics. (opiods as second/third-line; methadone; high doses for effective trx)
Step 1 - nonopioids with or without adjuvants
Step 2 - opioids with or without adjuvants, nonopioids
Step 3 - opioids for mod-severe pain (long-acting + short-acting) + adjuvants
acetaminophen (PO, PR, IV)
NSAIDS (selective vs. nonselective COX-2 inhibitors)
constipation (gastric motility) - bowel regimen (laxative + stool softener)
n/v (gastric motility, CTZ & opioid receptor stimulation)
entiemetics to antagonize specific receptors:
ondansetron, tropisetron, dolasetron, granisetron - 5-HT(3)
pruritis (partic. MORPHINE) (histimine release; effects on mu-opioid, dopamine, serotonin receptors) - rotation, reduction, antihistimines (xerostoma, confusion, blurred vision in geriatric pt - TOPICALS instead)
sedation (difficulty clearing incl. geriatric, renal dysfunction) ->
respiratory depression (opioid naive, sleep apnea, geriatric, drug-drug interactions, obesity, cardiac/respiratory disorders, functional/psych status, comorbidities) - naloxone, education
opioid-induced neurotoxicity (accumulated opioid metabolites)
partic MORPHINE then HYDROMORPHONE (kidney excretion, i.e., risks in geriatric and renal dysfunction)
do not use meperidine in palliative/hospice d/t seizure risk
myoclonus - first, most common sign
reverse mechanism, therefore -> reduce/rotate
clonazepam, midazolam, benzos, baclofen, dantrolene
overdose - often drug-drug interaction (opoids + benzos)
confusion/delirium, n/v, pinpoint, lethargy, cyanosis, respiratory distress/failure
naloxone (IN, SL, IV, IM)
long-acting dose - (actual TDD incl. PRNs / 2) Q12H
oral rescue dose (breakthrough pain) - 10-20% TDD Q1-2H PRN
parenteral rescue dose - 50-100% hourly rate Q15 min PRN
adjuvants (NSAIDs, COX-2 inhibitors, muscle relaxants, psychotropics, antidepressants, antiepileptics, anxiolytics, sedatives, amphetamines, antiarrhythmics, Ca-channel blockers, ketamine, lidocaine, capsaicin, tramadol, etc.)
terminal cardiac diagnosis -> deteriorating status; multiorgan system failure
coagulation problems inabilty to clot or regulate clot formation d/t tumor invasion, trx SE, thrombocytpenia, nutritional deficiency, anticoag use, coag abnormalities -> bleeding disorders/internal bleeding SSx epistaxis, hemoptysis, hematemesis, melena, hematochezia, hematuria, vaginal bleeding, sings of incr ICP
bleeding/hemorrhage - if nonacute, stop bleeding (packing, compression dressing, topical hemostatic, position to decr bloodflow, astringints) and alleviate pt’s anxiety. educte pt and family for risks for bleeding (partic in liver dz). Catastrophic hemorrhage - stem further bleed IF CONSISTENT WITH GOC. Radiation thx, palliative TACE, endoscopy, vitamin K, vasopressin, antifibrinolytics, otreotide (for varices), platelet transfusion, FFP. possibly palliative sedation. Dark-colored towels to reduce visual impact for pt and caregivers.
thrombi/dvt - risk d/t immobility, orthopedic trauma, circulatory problems - use TED hose/SCDs prophylatically. DVT SSx: edema, pain, localized warmth, venous distention, localized tenderness to palpation. Dx via venogram (”gold standard” but invasive), venous doppler to detect blood flow (evaluate/compare both extremities). Trx: hepairin, low molecular weight heparin (LMWH), unfractioned heparin, fondaparinux. NO enoxoparin (Lovenox) (a LMWH) in acute renal failure.
pulmonary embolism - d/t thrombus formation, often DVT migrattion to pulmonary artery. Risks: genetic predisp., recent surgery, hx DVT/PE, immobility, hospitalization, cx, age, HF, stroke, acute respiratory failure, IBD. may be initially asymptomatic/vague symptoms. Unexplained chest pain in 97% of confirmed PE. other SSx: anxiety, diaphoresis, cought, syncope, hemoptysis, hypoxemia, hypotension, pleuritic rub. -> pressure increase in R ventricle -> tacycardia, crackles, fever, prounounced S2 (with closure of pulmonic and aortic valves), S3 (d/t fluid overload), possible S4 gallop (d/t thickned ventricular walls 2ndry to HTN or aortic stenosis).
lab testing is not definitive. rule out differential dx w/ d-dimer, ESR, leukocyte level, dehydrogenase, BNP, troponin. rule out differential dx with chest XR. spiral CT with contrast can more accurately confirm - if non-contrast d/t allergy, renal impairment then ventilaion/perfusion (V/Q) scanning. Gold standard dx - confirmation via pulmonary angiogram (expensive and invasive)
trx: stabilize. invasive measures only if consistent with GOC (mechanical vent, intubation) - improve ventilation. BIPAP noninvasive may also improve.
pharm (IV resuscitation, vascular stabilization) - vasopressors (norepinephrine, dopamine, epinephrine), anticoags (LMWH, unfractioned heparin, fondaparinux, warfarin, rivaroxaban). in initial phase, intiate parenteral heparin, LMWH, rivaroxaban, fondaparinux - > transitioned to oral or other agent. IF NOT CONSISTENT WITH GOC: alleviate dyspnea and anxiety, incl. sedation if sever distress and symptomatic. Family education, d/t suddenness, poor prognosis
DIC - thrombi -> infarction in multiple vessels/organs -> organ damage + internal bleeding d/t platelet depletion; risks: sepsis, inflamm dz, cx, liver dz, trauma, aneurysms, vascular disorder. ssx initially subtle; bruising purpura, petechiae, hematemesis, hematuria, hematochezia, hemothorax. trx: replace blood and blood products, correct metabolic shifts. anticoags (may need cautery, cryoablation to control bleeding), synthetic protease inhibitors (block serine proteases, incl. thrombin), antifibrinolytics, IF ORGAN FAIULRE, natural protease inhibitors, but avoid antifibrinolytics
angina d/t increased cardiac O2 demand d/t activity, cardiac vessel onbstruction, MI. stable vs. unstable. ssx: sudden chest pain, tightness, heaviness, squeezing, pain radiating to jaw/arms/back, SOB, fatigue, nausea (2-3 symptoms together - atypical angina). trx: rule out MI or occlusion, treat symptomatically - discontinue precipitating activities, nitroglyc SL/PO/TD/IV/lingual spray. Possible invasive (angioplasty, stent, CABG) if benefits outweigh risks
lower extremities d/t ES organ failure (partic (R) heart/liver/kidney), med SE, superior vena cava syndrome (SVCS), vascular insufficiency, hypoalbuminemia, fluid overload. pitting vs. non-pitting. incr weight -> discomfort, decr mobility. trx: elevation, compression. diuretics may NOT be useful, particularly if refractory. interventions implemented slowly to prevent incr. cardiac symptoms.
lymphedema d/t obstruction/removal of lymph nodes (r/t cx surgeries, other trx) -> lymph accumulation -> fibrosis, sclerosis -> permanent edema. pre-fibrosis, trx with elevation, compression. diuretics generally NOT useful. SKIN CARE. manual lymphatic drainage by trained massage or PT (promoting mobility, ROM, QOL)
syncope temp. loss of consciousness d/t low blood flow to brain (hypotension, r/t (ES) cardiac dz/afib, dehydration, fluid shifts, postural changes (orthostatic)). SAFETY - educate pt and family on changing position slowly, assistance for transfers, sit/lie down at warning SSx: nausea, diaphoresis, lightheaded. Recurrent -> anxiety, somatization, panic -> fluoxetine. Testing (EKG, lab studies for lyte imbalance/dehydration, tilt table to test) for cause if GOC consistent. Pacemaker may relieve fatigue, dyspnea, syncope.
SVCS obstruction of SVS/nearby lymph nodes/vessels (usually d/tprimary tumor or mets from lung cx/breast cx/lymphoma) -> SSx obstructed drainage from hed/neck/UEs (facial swelling, JVD, distention of chest veins, UE edema, ruddy complexion; over 2-week period - cough, dyspnea, hoarseness, blurred vision, syncope, HA, confusion, obtundation). Confirm dx via chest XR, CT, MRA. trx via chemo/radiation, steriods, diuretic, thrombolytics, stent/bypass. RAISE HOB 45-90 degrees to promote drainage. prognosis (age over 50, extent of malignancy, hx smoking, steroid use) fair to poor, <6mo to 2yr -> team discussion GOC re: interventions
constipation (abd distention, nasea/indigestion, <3BM/wk, difficult to pass/straining, feeling of incomplete emptying)
d/t slowed gi mobility, increased intestinal water absorption, obstruction, meds (incl. antidiarrheals, opioids), immobility, low fiber, dehydration
ausculate, palpate, skin turgor, hx (diet, mobiliyt, usual patter, associated issues, typical consistency)
high fiber diet, 2-3L fluids/day, exercise as tolerated, laxatives (increase if opiod increases)
bulk forming (absorb water, increase mass, stimulate peristalsis - psyllium (Metamucil), 5-7g daily start OR methylcellulose (Citrucel) 4-7g daily startt; 12-72H to onset. Use prophylactically, DO NOT use with ileus or impaction; req. 300-500ml fluid each dose (prevent impact.)
lubricant (also prevents reabsorption of water) - glycerin suppository 1PR qd OR mineral oil 30-60mL PO qd; 6-8H to onset (suppository 15-30 min)
opioid antagonists (block opioid receptors in bowel) methylnaltrexone (Relistor) for chroninc NON-cx pain 450mg PO qAM or 12mg SQ qAM (dose weight-based for adv. illness), OR naloxegol (Movantik) 12.5-15mg PO qd; 30-60min onset; d/c all maintenance laxatives prior to use, ensure close proximity to br
osmotic (pull water in and increase peristalsis) - lactulose (10g/15mL) @ 15-30mL qd to MAX 60mL/d in devided doses (24-48H onset), OR polyethylene glycol (Miralax) (48-96H onset) 17-34 g/d (dissolve 1cap in 8oz liquid /day up to 8 doses per day; poss bloating, flatulence
surfectant/detergent (draw water into colon) - docusate sodium (Colace) (whatever - this is useless) 100mg qd-BID (1-3 d onset) OR mineral oil 14-15mL qd (onset PO 6-8H, PR 2-15min); BITTER liquid, mix with juice or milk
bowel stimulants (stimulate submucosal nerve plexus -> incr. peristalsis) bisacodyl (Dulcolax PO) - 5mg qd start up to 30mg qd (6-10H onset), Dulcolax suppository (10mg PR qd) (,1H onset), OR senna (senokot) 15mg qd start to max 70-100mg qd (6-12H onset) - AVOID with ileus, obstruction, monitor for lyte/fluid imbalance, may develop tolerance. SE cramping, n/v with senna.
fecal impaction - bisacodyl or glycerin suppository, 2% lidocaine gel with disimpaction (avoid if possible perf or bleeding)
diarrhea (passed too quickly for water absorption) - abd pain, cramp, lethargy/weakness, n/v, distention, anorexia, incr thirst - dehydration, nutrient/lyte imbalance
d/c laxatives, assess for impaction, ID any ssx infx, replace fluids/lytes, provide skin care for incontinence. antidiarrheals cautiously with fever
opiods/opiod derivatives (ex. diphenoxylate/atropine (Lomotil)) 1-2 tabs PO BID-QID PRN
nonopiod (ex loperamide (Immodium)) 4mg PO 1x at ssx onset, then 2mg after each loose stool. (GERI SE - anticholinergic effects - prefer Lomotil)
antacids, adsorbents (bismuth salicylate - also antiinflamm and antibx) for n/d/indigestion; 2 262mg tabs QH PRN up to 16 tabs/24H
bulk-forming/fiber agents (absorb excess water) - ex. psyllium 1-2 tsp mixed with liquid up to TID
incontinence (muscle weakness/atrophy, neuro dz, severe diarr) - ID and remove (if poss) the cause; track associated ssx (weight loss, fever, R bleeding, steatorrhea)
env changes - BSC, clear path and proper lighting, remove physical restraints
skin care, with barrier cream/ointment
ascites (portal hypertension, hypoalbuminemia; malignancy, HF -> abd fluid collection) - indicate ES dz
discomfort, altered body image, decr mobility, dyspnea (diaphr. pressure), umbilical hernia, cellulitis, bacterial peritonitis
restrict NA 2g/d, fluid restriction, spironolactone (50-400mg qd), furosemide (20-130mg qd), paracentesis (if >4L, IV albumin), TIPS (potential hepatic encephalopathy)
repeated paracentesis -> indwelling abd cath
maintain trx consistent with GOC
hiccups (benign minutes to 2 d, persistent 2 d to 1mo, intractable longer than 1mo) -> indigestion, bloating, pain, abd distention, insomnia, fatigue. Quality of life
nonpharm - hold breath, breath into paper bag, compress diaphr., ice in mouth, induce cough/sneeze, pressure on nose, swallow sugar, eat lemon wedge with bitters, eat soft bread, touch palate with cotton swab, ocular compression, carotid massage, CBT (???), repositin, faseting, NG tube, acupuncture, induce emesis, disrupt phrenic nerve action (ablation last resort d/t pulmonary function risk)
pharm - simethicone 15-30mL PO q4H for distention; baclofen 5-10mg PO q6-12H up to 15-37mg qd OR midazolam 5-10mg PO q4H for muscle spasms; gabapentin 300-600mg PO TID for anticonvulsant; amitryptyline 10-50 mg PO OR sertraline 50-150mg PO QIS for CNS effects; haloperidol 2-10mg PO/IV/SQ q4-12H to block dopamine and alpha-andrenergic receptors
n/v (increased salivation, loss of appetite, diaphoresis) ASSESS N/V SEPARATELY
cerebral cortex (fear, anxiety, stress, memories, sensory stimulation)
pressure receptors (increased ICP)
chemoreceptor trigger zone (central neural pathway) (opioids, serotonin, dopamine, histamine, acetylcholine, antibx, NSAIDS, electrolyte disturbance, inhln agents)
glossopharyngeal/trigeminal (stimulate GP nerve - surgery, tumor growth, etc.)
vestibular (middle ear surgery, motion, vertigo)
GI (infx, cytotoxic meds, GI irritants, constipation, obstr., decr. motility)
-> stim vom center in medulla oblongata ->emesis
ANTICHOLINERGICS (hycoscine (scop) 1.5mg patch, 0.5-3 patch TD Q72H OR 0.6-1mg SQ/IV Q6-8H - spec. if d/t motion or obstruction. geri - anticholinergic SEs) (atropine opthm 1%, 1-2 drops SL Q8H PRN) (hyoscyamine 0.4-0.6mg SQ Q4H PRN)
ANTIHISTIMINES (diphenhydramine 25-50 PO/SC/IV Q6H PRN (blocks H1 receptors in vom center, CTZ, vestibular nuclei). GERI - risk for extrapyramidal SEs) (cyclizine 50mg PO Q4-6H PRN to max 200mg/day - rec. for incr. ICP, motion sickness pharyngeal stimulation, mechanical BO)
BENZOS (lorazepam 0.5-2mg PO/SQ/IV Q8-12H - use with another agent unless caused by anxiety)
CANNABINOIDS (dronabinol 5-10mg PO Q3-6H, nabilone 1-2mg PO BID - CHEMO, if other trx ineffective)
CORTICOSTEROIDS (dexamethasone 4mg PO Q6H WITH FOOD - prophylactically during chemo/radiation; may help reduce BO)
DOPAMINE RECEPTOR AGONISTS 0-20mg PO/SQ/IV Q6H OR 25mg PR (partic for opoiod-induced nausea) - blocks dopamine in CTZ. sedating effect - may be beneficial for imminent patients)
OCTREOTID (100-400mcg SQ Q8H) - BO
PROKINETICS (metoclopromide 10-20mg PO/SQ/IV Q4-6H up to 40mg - CHEMO n/v) - for gastric stasis, admin prior to meals; reduce dose geri, renal dz. NOT in BO, perf, or immediately postoperative
SELECTIVE 5-HT3 RECEPTOR AGONISTS (ondansetron 4-8mg PO/SQ/IV Q8H on Day 1 chemo; 16-24mg PO 1x OR 8-16mg IV 1x (max dose 16mg)) - specif. prophyl. chemo/radiation n/v (PREMED)
SUBSTANCE P AGONISTS (NKI receptor agonists) (aprepitant 125mg PO 1x Day 1 chemo, then 80mg PO Qmorning on Day 2-3. PREMED 1H prior on Day 1, with a corticosteroid (dex) and a 5-HT3 agonist (Zofran)) - used with ondansetron prophyl. chemo/radiation n/v
nonpharm: hydration, small meals/fulll liquid, withhold routine meds if poss, complementary thx (aromatherapy, meditation, relaxation), reposition, CBT, intervention for tumor growth (surgery, stent, NGT, decompression)
(malignent) bowel obstruction (d/t intraabdominal cx) (-> sepsis, perf, necrosis) (n/v undigested food, poss fecal matter in advanced MBO; hyperactive bowel sounds/borborygmi; pain/distention with large intestince) - prognosis 30-90 days
palliative mgmt for n/v, pain, colic, possible parenteral fluid fo comfort, NGT for distention. FREQ oral care, ice chips for dry mouth
palliative pharm: opioids, anticholinergics, corticosteroids (metoclopramide 10mg Q 6-8H nausea 1st line; octreotide 50-100mcg SQ/IV Q8-12H antisecretory, but high cost, SE (n/d, pain, constipation))
infx, cx, ES dz, iatrogenic
bladder spasms - stabbing/cramping, colicky suprapubicpain d/t detrusor muscle acting agaisnt partial/fully blocked bladder outlet (by tumor, blood clot, stent, cath (too large, kinked, blocked)). urgency or leakage poss. smaller cath, balloon inflated to appropriate size, drink sufficient fluids, avoid caffeine/alcohol/other irritants, anticholinergics (with care in geri pt); botulinum toxin A injection into detrusor to decr. urgency sensation
incontinence - transient in delirium, UTI, immobility, sever constipation; med SE; diminished contraction of detrusor. review meds for SE incontinence, sedation (reduced sensitivity to fullness); timing (only at night, stress (sneeze, etc.), continual?. Skin care; review incontinence aids with caregiver for bedbound patient. SSX of UTI - > sample and UA. Poss indwelling cath (UTI risk))
retention - d/t UTI, mechanical obstruction (partic in BPH, colon/pelvice cx), neuro issues, meds (anticholinergics, antihisitmines, antidepressents, antihypertensives, anit-Parkinsons, antipsychotics, sympathomimetics, opoids (partic. with anticholinergics). REVIEW MEDS and d/c if possible. Indwelling cath if bladder firmness on palpation, bladder scan >300mL or PVR 200-300mL (including after straight cath)
immobiility, pain, debility, mestatses, ESdz
impaired mobility + complications - incr. risk of skin breakdown, physical deconditioning, activity intolerance, pathological frx. assess skin condition and ulceration risk factors with reliable tool (Braden Scale***). combined with sensory loss, incontinence, poor nutrition -> incr risk of pressure ulcers. Risk of skin shear of friction abrasion when pt repositioned by others. PRIORITY PREVENTION - encourage active participatoin in repositioning using rails/trapeze bar; freq reposition for immobile pt; pillow, cushions, antipressure devices/mattresses. Nutritional assessment for deficiencies, weight loss, cachexia (direct correlation b/t pressure ulcer risk and nutritional deficiency (low protein, albumin); consider supplements if appropriate
deconditioning/activity intolerance - d/t prolonged immobility, med SE, anemia, dz progression -> fatigue, weakness, decr. stamina -> incr falls risk, decr ADLs and QOL. weakness, dyspnea with exertion, fatigue with activity. preserve stamina in nonambulatory pt through passive/active ROM as tolerated. prevent falls - proper lighting, assistance with transfers and ambulation, necessary objects (glasses, telephone, call bell) within reach
pathological fractures d/t dz (most common osteoporosis; bone mets). femur most common site, 75% of which at proximal end. Also tibia, humerus, ribs, spine. SSx - localized pain/swelling, numbness; if femur, affected leg uually shorter and externally rotated. -> surgical stabilization (w/ or w/out joint replacement) common; contraindicated if widespread meets or life expectancy <6mo. Determine risks and educated on proper positioning, safety. pain mgmt and joint stabilization. team should collab with pt/famlly for plan of care to promote QOL, consistent with GOC.
integumentary and mucous membrane
meds, dz progression, poor nutrition/hydration,
xerostomia (radiothx head/neck, Sjogren’s, depression/anxiety/stress, malnutrition) dry mouth + hyposalivation. assoc: thrush, poor dentition, dry mucous membranes -> ability to eat/talk/wear dentures, incr. risk halitosis/caries/thrush/taste change. remove reversible causes (incl. meds if poss.), proper hydration, freq oral hydration, sugar-free gum/candy
pharm: pilocarpine 5mg TID, cevimeline 30mg TID (SE: d/n/v, sweating); sialagogue - oral topical
pruritis chronic in renal/liver dz, hypo/hyperthyroidism, anemia, malginancies, HIV; med SE (partic. opioids) -> disrupt ADL/sleep patterns. assess using Woods lamp if poss; parasites, bacterial/fungal infx, lesions. trx any underlying cause; also topical ointments, barrier creams, soakes (calamine, menthol, oatmeal bath, antihist. cream, steroids, capsaicin). Geri use of systemic thx (antihist) with caution (anticholinergic SE)
wounds (pressure ulcers, tumor extrusions, nonhealing wounds) - pressure and anoxia -> tissue damage in as little as 20-40 minutes.
frequent reposition - if bedbound, every 2-4H on pressure-reducing surface away from ulcer site; premed 20-30 min if pain; flexibility if actively dying or comfortable in only one position
adequate nutrition/hydration incl PO, SQ, IV dydration if appropriate, nutritional supplements. Provide as appropriate with GOC and prognosis
wound care based on staging, GOC, prognosis. NPWT to remove excess drainage/necrotic tissue/infx if large. Debridement of necrotic tissue: mechnical (wound irrigation/hydrotherapy, enzymatic via topical agents with dressing change Qday); biosurgical (medical maggots); autolytic (moisture-retaining dressing changed Q3-5 days, causing self-destruction of necrotic tissue)
S1 nonblanchable erythema, localized, usually over bony prominence. skin intact, red/purple/blue
S2 partial thickness loss of epidermis, some dermis. shallow open ulcer/superficial erosion, pink-red wound bed, no slough
S3 full thickness loss of skin, necrosis of SQ tissue, SQ fat poss. visible, but tendon/muscle/bone NOT exposed. Poss. undermining/tunneling, slough, necrotic tissue
S4 full thickness loss of skin including epidermis, dermis, SQ tissue; poss. muscle/bone/tendon exposure, slough, undermining/tunneling
(suspect) deep tissue injury - localized discoloration (purple/maroon), non-blanching, epidermis intact, feels boggy
unstageable - full thickness tissue loss covered by eschar or extensive necrotic tissue (tan, yellow-green, brown) (must be cleared before true depth can be determined)
OTHER DATA: length/width/depth (mm), description of edges, presence/description/amount of undermining/necrotic tissue/exudate/granulation tissue and epithelialization, condition of surrounding tissue
increased infx risk - debridement and wound care. high-risk wounds: silver-release topical dressings, medical-grade honey dressings, thin film dressings, hydrocolloid for S2-3, faom for exudative S2 pressure ulcers, hydrogel for nonexudative/necrotic, calcium alginates to absorb exudate
control odors - QOL. metronidazole gel (0.77-1.0%) Qday x 1wk to reduce microbe growth. dessings with activated charcoal. if not expected to heal, povidone iodine.
manage pain with systemic analgeisic, low-dose morphine
psychosocial/emotional/spiritual
anger/hostility r/t illness, lack of control, dependency, family/caregiver response to illness - interdisciplinary team (partic. social workier, chaplain) to help pt/family proces and express in safe manner. provide reassurance feeling is common AND usually related to abother emotion (fear, depression, grief)
depression (persistent low mood, anhedonia >2wks + accompanied by at least four of: sleep disruption, weight loss/appetite change, psychomotor retardation/agitation, fatigue/energy loss, worthlessness/excessive guilt, decr. ability to think/concentrate, recurrent thoughts of death/suicidal ideation). uncertainty of dz trajectory, possibility of death. FREQ with anxiety, so assess for both. Therapeutic listening, team collaboration with pt to develop plan: relaxation techniques, meditation, CBT.
SSRI (citalopram 20-60mg/day, escitalopram 10-20mg/day, paroxetine 20-50mg/day, fluoxetine 20-60mg/day, fluvoxamine 50-100mg BID, sertraline 50-200mg/day) - may take sveral weeks for effect.
methylphenidate (Ritalin) if life expectency <2weeks
denial shields pt from consequences of illness until psychologically ready to cope - challenging may increase distress. Active listening, therapeutic silence, reflection, calm reassurance team is available for support as needed.
fear -> tachycardia, tachypnea, shaking, insomnia, diaphoresis, stomach upset, nightmares (response to real threat vs. anxiety response to perceived as well as real threat). Distraction, deep breathing, meditation, massage, CBT, focused support by team social worker/chaplain
grief -> intrusive thoughts, regrent, inability to think clearly, dulled/heightened emotions, nausea, fatigue, myalgia. Therapeutic listening, empathetic support, reassurance experience is normal. team social worker/chaplain factilitate life review, teach CBT techniques, provide spiritual support/guidance
loss of hope/meaning as hope for recovery fails. GOC convo with team to help pt focus shift from hope of recovery to comfort, preserved function, preserved dignity, other comforts. team facilitates life review, which may ID source of meaning.
guilt r/t regret for actions taken or failed to take. personal responsibility for illness, leaving family. -> existential suffering. Encourage pt to explore and express, also to work with team.
nearing death awareness (NDA) about 50% of terminal pts experience, usually coherent, comforting. Generally brings preace, may involved communicating with deceased loved ones, preparing for change, seeing the afterlife, knowing death is near. Culturally bound and varies by pt. Center on differentiating from negative delirium/hallucinations, validate perceptions.
sleep disturbances (insomnia, unusual patterns, daytime fatuge) - review and address dz progression, socioec factors, pain, meds, psych issues; promote restful sleep via sleep hygiene, allowing undisturbed rest, avoiding stimulants. nonpharm: relaxation techniques, massage, aromatherapy, music
suicidal ideation - warning signs: bebavior changes, withdrawing from friends/activities, giving away possessions, talking about suicide, incr. use of drugs/alcohol
Key assessment questions: Are you considering harming yourself? Do you have a plan to harm yourself? if either, considered at risk, take steps to ensure safety
intimacy/relationship issues incl. caregiver stress vs. dependency issues, loss of sexual relationship d/t illness. Discuss openly, normalize experience, reassure, encourage counseling
d/t dz progression, organ failure, med SE
anorexia/cachexia (anorexia/cachexia syndrome (ACS)) - cx, HF, COPD, HIV, renal dz - sign of advanced dz (POOR prognosis, even with intervention) - metabolic & neurohormonal changes, systemic inflamm, catabolism
oral nutritional suppl., ease diet restrictions, small/freq meals; enteral/parenteral supplementation NOT generally beneficial end-stage, before trial consider potential benefit, life expectencey, functional status (Karnofsky >50, medical issues manageable, caregiver available and pt able to have follow-up lab monitoriing
pharm - megestrol acetate, glucocorticoids, cannabinoids increase appetite/weight but uncertain effect on QoL. with depression, mirtazapine (Remeron) 15mg QHS, methylphenidate 2.5-10mg PO at 0800 and 1200
mid-arm circumference to assess malnutrition over time - weight loss and muscle wasting
dehydration r/t anorexia, med SE, n/v, BO, dysphagia, cognitive impairment (mucous membranes, skin turgor, bowel function - diarr; constip., impact.). may exacerbate delirium, confusion, agit,, myoclonus - NOT usually responsive to fluid replacement. SE artificial hydration - nausea, fluid overload, dyspnea, ascites, edema. is patient acutely ill/expected to recover some function or actively dying? PT AND FAMILY DISTRESS - educate.
oral or enteral fluid replacement; parenteral nutrtion through CVC or other long-term access. SQ fluids (hypodermoclysis) -absorption rate comparable to IV admin. (rarely use protoclysis, PR admin fluids to GI tract).
fatigue (subjective, some objective effects) r/t cx, HF, COPD, renal dz, HIV/AIDS, MS, etc.; poss. secondary to insomnia, distressing SSx, dz process, med SE, psych/spiritual distress
nonpharm - exercise as tolerated, pain and sx mgmt, counseling, medication, relaxation, music thx, sleep hygiene, avoid sleep disruption
pharm - benzo or antidepressent to enhance sleep. if not related to sleep quantity/quality, psychostimulants (methylphenidate, modafinil); corticosteroids; megestrol
hypercalcemia (serum Ca >14mg/dL -> urgent intervention) (metastatic cx as bone deteriorates and released Ca; hyperparathyroidism, lithium thx, Addison’s, Paget’s, vitminan A or aluminum toxicity) -> n/v, anorexia, wekness, constipation, thirst, AMS.
intervention for comfort even in advanced dz
bisphosphanates (pamidronate, zoledronate), calcitonin admin, IV hydration, bone reabsorption agents (gallium nitrate, plicamycin), dialysis
hypo/hyperglcemia d/t uncontrolled DM, sepsis, organ failure, cortisol imbalance, altered intake
monitoroing and mgmt may not be feasible in terminal illness d/t PO inability; ASSESS necessity of fingersticks, dietary control at EoL, EDUCATE pt and family on change to normal routine, REVIEW GoC
hypo <70mg/dL -> diaphoresis, dizziness, pallor, tachycardia, weakness, anxiety, tremors, nausea, hunger. <50mg/dl -> irritability, blurry/double vision, confusion, HA, slurred speech. <40mg/dL -> severe reactions incl. coma, seazure, death
15g carb, 15 minutes BG check, repeat PRN until >70mg/dL
glucagon 1mg IV/SQ (5i minutes to effect)
corticosteriods for dual effect if dyspnea, pain, inflamm
hyper = fasting >116mg/dL OR postprandial >200mg/dL - overtreatment or non-compliance with treatment plan, DM, acute ilness, stroke, sepsis, MI, pancreatitis, meds (glucocorticoids, high-dose thiazides, dobutamine, atypical antipsychotics, cocaine) -> polyuria, polydipsia, polyphagia, glucosuria, weakness, fatigue, weight loss, blurred vision, poor wound healing, incr. infx risk, diabetic ketoacidosis (usually in DM1)
pharm: metformin up to 2250mg/day; sulfonylureas (glipizide, glyburide, glimepiride); metglitinides (matelinide, repaglinide); glucosidase inhibitors (acarbose, miglitol); thiazolidinediones (pioglitazone, rosiglitazone); dipeptidyl peptidase 4 (DPP-4) inhibitors (sitagliptin phosphate); amylin agonists (pramlintide); insulin
d/t dz progression, organ failure, med SE
fever (T 101.3F/38.5C x1 OR 100.4F/38C x3 1H apart); d/t infx, immunological disorders, metabolic imbalance; antipyretics PO, PR + poss. antibx for symptom control. possible central fever (high T, skin cool) near death - antipyretics for comfort.
myelosuppression (anemia, neutropenia, thrombocytopenia) - dt decr. bone marrow activity (cx trx, end-stage dz)
anemia (Hgb <8.0 g/dL) - heart dz, pulmonary dz, kidney dz, inflammatory processes r/t chronic dz (age/weight-> higher risk). RBC transfusion (threshold 9.0 g/d/L in advanced dz), erythropoiesis-stimulating agents (epoitin-alpha, darbepoetin) although NOT wiht advanced cx (stimulation of tumor growth)
neutropenia (ANC <1,000/mm3) - bone marrow suppression, cx trx, infx med SE, autoimmune disorder; risk for febrile neutropenia (T 100.4F/38.3C longer than 1H + ANC < 500/mm3 with expectation to decrease). ASSUME with fever while on chemo until proven otherwise. if confirmed: broad-spectrum antibx, possible hospitalization for IV thx.
thromobocytopenia (<20,000/mm3 OR clinically significant active bleeding) - cx, aplastic anemia, med SE, autoimmune disorder, chronic ETOH; purpura + petichiae. if hemorrhage - rad thx, endoscopy, vitamin K, vasopressin, octreotride (for varices), antifibrinolytics, platelets or FFP, palliative TACE. (dark towels to reduce visual impact for pt and caregivers)
lymphedema - lymph accumulation -> fibrosis or sclerosis -> permanent edema. skin care, elevation and compression if no fibrosis yet, manual drainage (PT, MT). (diuretics not usually effective)
altered LOC (CNS dysfunction, med SEs, metabolic imbalance, infx, anxiety, psych issues)
confusion - Confusion Assessment Method (CAM) to detect delirium
delirium - inpt geriatric, postop, advanced illness (infx (UTI), renal failure, hepatic failure, CNS disorders, vascular disorders, pain) - acute onset, fluctuating symptoms, perceptual changes, sleep-wake cycle altered, delusions, hallucinations, paranoia, hyperactivity/lethargy; haloperidol (1mg), risperidone (1mg)
terminal delirium/terminal agitation - symptoms not reversible in >50% of patients - haloperidol 2-4mg PO/SC/IV Q30minutes up to 20mg/24hr, olanzapine 2.5-5mg SL HS-BID plus PRN Q4hr
patient/family care/education/advocacy
psychosocial/spiritual/cultural
caregiver ed/support/advocacy
coordination and collaboration
scope and standards of practice
* opioid drug-to-drug conversions (equianalgesic - PO and TD)
oxymorphone, methadone 10mg
calculate current 24H dose (TDD including PRNs)
convert using equianalgesic
reduce by 50% to account for cross-tolerance (can be titrated PRN) (DO NOT REDUCE FOR TD FENTANYL)
## morphine to fentanyl patch - each 2 mg PO morphine approximately equivalent to 1 mcg/hr fentanyl patch (e.g., morphine 100 mg/day → 50 mcg/hr patch applied q3days) (approx 2mg : 1mcg/H) Note: using this formula, 25 mcg/hr of transdermal fentanyl is roughly equivalent to 50 mg oral morphine/24 hours. This dose may be excessive when used in the opioid naïve or the elderly.
MORE CONSERVATIVELY: FDA prescribing information for transdermal fentanyl: 135-224 mg of morphine per 24 hours = 50 mcg/hr patch. Note: this range of morphine is very broad which may result in significant under-dosing.
IV morphine : IV hydromorphone = 5:1
IV morphine : fentanyl patch = 4mg/hr : 100 McG patch (approx.)
