The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 3: Assessment of Physical SymptomsA treatment plan for the distress associated with the symptom should beestablished. Some treatments may palliate the symptom by direct impact onthe distress caused by the symptom. The treatment of pain with analgesics isan obvious example. Another example is the treatment of sweats and chillsassociated with fever (see Table 3-2) with antipyretics such as acetaminophenor a non-steroidal anti-inflammatory medication and physical methods ofcooling (including fanning, bathing, etc). Similarly, in a case of exhaustion andfatigue caused by anemia and exacerbated by depression it may be appropriateto consider a plan for counseling, support, assistance with daily activities, andother interventions to minimize the impact of fatigue (see Table 3-1).• Monitoring plan A plan for monitoring the impact of symptom managementover time is a crucial aspect of symptom assessment. Reassessment should betimely and practical. If a symptom is very severe or distressing, monitoringmay need to be undertaken within the hour; if a symptom is less severe, adifferent schedule should be set up. A monitoring plan should be appropriatefor the patient’s abilities. For example, if a patient cannot attend the hospitalfor a follow-up visit, a telephone call or home visit by a clinician may be a goodmethod for monitoring. At times it can be most helpful to use a tool orinstrument to facilitate effective monitoring and improve team communicationin the health care setting; see following section, Symptom AssessmentMethodology and Instruments.26 picasCHALLENGING CLINICAL SITUATIONS AND SPECIAL POPULATIONSCognitive Impairment in Advanced DiseaseCognitive impairment may occur in advanced disease and in the imminently dying. In suchsituations, detailed symptom assessment may be difficult. Nonetheless, while giving attentivecare at the bedside a provider can generally ascertain whether a patient is distressed and canthen consider interventions that may be helpful in alleviating distress. Monitoring behaviors,including, for example, facial or physical movement, can be crucial in this process.A recent small study of 14 patients with cancer pain and severe cognitive failure found thatduring episodes of agitated cognitive failure, pain intensity as assessed by a nurse was significantlyhigher than the patient’s assessment had been before and after the episode. 35 After completerecovery, none of the patients studied recalled having had any discomfort during the episode.These data are difficult to interpret, but do highlight some important issues relevant toassessment. The authors of the study suggest that patients who recover from a severe episode ofdelirium may have no memory of the experience, including the pain, and that medical and nursingstaff are likely to overestimate the discomfort of patients with this condition. Although thismay be true, another interpretation might be that patients with delirium may be acutely sensitiveto many irritations including pain, noise and other factors, and therefore are at risk forcompounded distress in the presence of both delirium and one of these irritants. It is apparentthat if symptoms are to be controlled, clinicians must assess patients thoroughly to define eachproblem. When more than one problem is present (in this instance delirium and pain), eachproblem may warrant treatment in order to minimize distress; in this example, specific treatmentsmay be needed for both pain and delirium.56U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau