Palliative Care Order Set - Stratis Health

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Palliative Care Annotations Committee on Evidence-Based Practice/May 6, 2008 Reduce dose in patients with renal dysfunction Pregabalin: 50 mg twice daily. Adjust dose upwards for comfort. Evaluate in 7 days Reduce dose in patients with renal dysfunction Bone Pain Ibuprofen 400-800 mg every 4 hours as needed (maximum dose 3,200 mg/day) Naproxen 250 mg twice daily as needed (maximum dose 1,500 mg/day) Dexamethasone 3-12 mg 2 or 3 times daily 18. Secretion Management Identify cause, when possible. Respiratory infections and postnasal drainage from chronic sinusitis may increase sputum production, while medications and poor hydration may increase the thickness of secretions. Poorly controlled pain may prevent the patient from coughing effectively; be sure patient's pain is optimally managed. Approaches to managing secretions can include the following strategies: Orders • Improve clearance. Patients who can cough effectively may benefit from measures to thin or mobilize secretions. Techniques include: - Hydration/humidification - Expectorants - Positioning - Chest physiotherapy - Suctioning – oral, not deep (Bickel, 2004 [R]) • Decrease quantity. This can be particularly helpful for patients who cannot clear secretions. Anticholinergic agents are the most commonly used, but side effects can be troublesome and may include dry mouth, urinary retention, confusion/sedation and mucus plugging. • For thick secretions - Guaifenesin 200 mg (200-400 mg) (Guaifenesin 100 mg/5 mL liquid) every 4 hours or 600- 1,200 mg extended release tablet every 1 to 2 hours, as needed for thick secretions • For excessive secretions - Atropine 1% ophthalmic drops, 1 to 4 drops sublingual every 2 hours as needed - Hyoscyamine (Levsin®) 0.125 to 0.25 mg sublingual every 6 hours as needed - Scopolamine (Transderm-scop®) 1.5 mg transdermal patch, apply every 72 hours. May increase number of patches to three as needed. Apply behind ears. - Glycopyrolate (Robinul®) 1 to 2 mg by mouth or sublingual every 8 hours as needed (Bickel, 2004 [R]; Hsin, 2006 [R]) www.icsi.org Institute for Clinical Systems Improvement 31
Palliative Care Annotations Committee on Evidence-Based Practice/May 6, 2008 19. Seizure Management The goal of the acute management of seizures is to stop the seizure activity. Diazepam and lorazepam are drugs that are utilized for the acute control of seizures. Once the acute seizures are under control, then evaluation and further anticonvulsants may be initiated based on the seizure type. Orders Lorazepam 2 to 4 mg IV. Repeat in 15 minutes if necessary Diazepam 5-10 mg IV or IM every 10-15 minutes up to total of 30 mg Diazepam 0.2 mg/kg rectally. May repeat in 4 to 12 hours if necessary (Cereghino, 2002 [B]; Collins, 2001 [R]; Pellock, 2004 [R]) 20. Skin and Wound Care Management Pressure Ulcers Pressure ulcers may occur despite optimal care in a patient whose immunological and nutritional status is compromised. Overall goals of care will influence specific treatment approaches. In some patients, complete healing of pressure ulcers is an achievable outcome. Control of pain, drainage and odor are essential in all patients. Emphasize prevention, when possible. Assess risk with a validated tool such as the Braden Scale. Address nutrition within the overall goals of care. Evaluate beds, chairs and other furniture the patient will use regularly, and provide appropriate pressure-relieving surfaces where needed (Nixon, 2006 [A]). Frequently changing the patient's position will relieve pressure on the skin, but must be balanced against possible discomfort such movement may cause. Good perineal care to manage incontinence of urine and stool is critical. Indwelling urethral catheters and rectal tubes may reduce skin irritation from moisture and fecal material, particularly if open areas are already present. Because skin integrity can be compromised within hours, caregivers must monitor the patient frequently (McDonald, 2006 [M]). The use of doughnut-shaped cushions or devices is contraindicated for both pressure reduction and relief. Do not massage pressure points; this further compromises circulation to the ischemic area. In all cases, the clinician must accurately describe the wound, using accepted staging criteria, as these characteristics will define the best wound care regimen. The wound stage is not revised as a wound heals, although a worsening wound is reclassified. Pressure ulcer staging Stage 1: non-blanchable erythema, epidermis intact Stage 2: partial thickness loss of epidermis or dermis Stage 3: full thickness skin loss, into subcutaneous tissue, but not involving fascia Stage 4: full thickness skin loss, involving fascia, muscle, bone, other supporting structures (Oxford Textbook of Palliative Care Medicine, 2004 [R]) A wound whose base is completely covered by exudate or necrotic tissue is unstageable until the material is removed. Pressure sores on the heels that are covered with dry eschar are unstageable. Institute for Clinical Systems Improvement www.icsi.org 32
Page 1 and 2: I CSI Health Care Order Set: Pallia
Page 3 and 4: Palliative Care Committee on Eviden
Page 5 and 6: Palliative Care Foreword Committee
Page 7 and 8: Palliative Care Order Set Committee
Page 17 and 18: Annotations Palliative Care Committ
Page 19 and 20: Palliative Care Annotations Committ
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Page 39 and 40: Institute for Clinical Systems Impr
Page 41 and 42: Brief Description of Evidence Gradi
Page 43 and 44: Palliative Care References Committe
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Page 47 and 48: Priority Aims and Suggested Measure
Page 49: Resources Available Palliative Care

Palliative Care Order Set - Stratis Health

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