NAPNAP Position Statement on the Acute Care Pediatric Nurse Practitioner

The acute care pediatric nurse practitioner (ACPNP) is a professional, who provides cost-effective, evidence-based
quality care for acutely, critically, and chronically ill infants, children, adolescents, and young adults in a variety of
settings. For many decades pediatric nurse practitioners (PNPs) in acute and critical care settings have been
responsible for the management of patients with illnesses characterized by impending or existing organ system
instability and failure. More recently the recognition of the unique competencies and the important contributions of
the ACPNP to continuity of care have contributed to the role's expansion (Kline, Reider, Rodriguez, & Van Roeyen,
2007; Jackson et al., 2001; Clinton & Sperhac, 2005).
The ACPNP meets the specialized physiologic and psychological needs of infants, children, adolescents, and young
adults with complex acute, critical, and chronic health conditions. The focus of care includes complex monitoring
and ongoing management of intensive therapies in a variety of settings, including but not limited to inpatient and
outpatient hospital settings, emergency departments, and home care settings. Specialty areas of practice are varied
and continue to emerge. Collaboration with an interdisciplinary team is essential for optimal patient care.
The ACPNP is an experienced nurse, masters or doctorally prepared, with education in acute care that includes
didactic and mentored clinical experiences in pediatric acute, critical, and chronic care settings. The ACPNP may
possess additional educational preparation to perform standardized procedures. Acute care PNP programs adhere to
curricular standards set by the Commission on Collegiate Nursing Education (CCNE) and the National Organization
of Nurse Practitioner Faculties (NONPF).
In 2004, the National Association of Pediatric Nurse Practitioners (NAPNAP) expanded its PNP Scope of Practice to
reflect the role of the PNP in providing care to infants, children, adolescents, and young adults who are acutely,
critically, and chronically ill. Specific components of the ACPNP role vary depending on the practice setting, the
patient population, and the type of employment arrangement (Percy & Sperhac, 2007). The scope of practice of an
ACPNP includes providing direct patient care management in a variety of settings. ACPNP practice includes
independent and interdependent decision-making and direct accountability for clinical judgment. Components of
management include, but are not limited to, performance of in-depth histories, physical examinations, interpretation
of diagnostic studies, prescribing/ordering medications and therapies, and developing and evaluating therapeutic
management plans (NAPNAP, 2008).
The ACPNP also performs a full complement of functions integral to the role including research activities,
interdisciplinary education, consultation, advocacy, and support of systems within the work environment (Kline et
al., 2007; Verger, Marcoux, Madden, Bojko, & Barnsteiner, 2005). Gaining practice privileges is a requirement for
an ACPNP as set forth by The Joint Commission. The process for becoming credentialed and obtaining practice
privileges is based on institutional policy and the state nurse practice act (NAPNAP, 2010).
NAPNAP advocates for:
1. ACPNP scope of practice that includes direct patient care responsibilities, education, leadership, and research.
2. Continued development of educational standards to prepare the ACPNP for practice.
3. Comprehensive ACPNP programs that focus on the management of complex health issues in acutely, critically,
and chronically ill infants, children, adolescents, and young adults and incorporates well-child growth and
development as well as basic health promotion and disease prevention.
4. Certification of the ACPNP in keeping with national accreditation standards for nurse practitioners (PNCB, 2010).
5. Ongoing evaluation of the impact and value of the ACPNP role for quality improvement using outcome measures.
In addition to providing direct evidence-based patient care to infants/children/adolescents/young adults with life-
threatening illnesses and organ dysfunction or failure, the ACPNP negotiates healthcare delivery systems, monitors
and ensures the quality of health care practice, provides family-centered care, and demonstrates cultural competency.
NAPNAP is an organization whose mission is promoting optimal health for children through leadership, practice,
advocacy, education, and research.

Visionary Leadership for Psychiatric-Mental Health Nurses Around the World

INTERNATIONALSOCIETYOFPSYCHIATRIC-MENTALHEALTHNURSES
Position Paper, October 2000
Assessment and Identification Management of
Alcohol Withdrawal Syndrome (AWS) in the Acute Care Setting
Background
Alcoholism is a chronic, neurobiological disorder that leads to a variety of healthcare problems often
leading to acute care hospitalization. It is not surprising that alcohol withdrawal syndrome (AWS), is a
common occurrence in acute care patients. AWS is a potentially life threatening condition, often coupled
with co-morbidities that can adversely affect the outcome of treatment. The focus of this position paper is
to address the acute care patient who is at risk for or has developed AWS. Therefore, the
recommendations are directed to the patient with alcohol withdrawal. However, many acute care patients
are suffering from polysubstance abuse and a strong denial system (patient and family) which often
produces either a complex or unexpected withdrawal syndrome presentation. Those patients require
immediate referral to addiction or psychiatric nurse/physician specialists in the medical center due to the
complex nature of their addiction and possible withdrawal state. The goals of this ISPN position
statement are to: promote nursing and medical care that is evidence-based, promote an environment that
addresses early identification and aggressive treatment of AWS that is effective and safe, and decrease the
use of automatic chemical or mechanical restraints in the treatment of patients with AWS.
Impact of Substance Abuse on Global and National Health
Alcoholism and alcohol abuse produce significant threats to health worldwide. It has been ranked as the
fourth leading cause of disability and healthcare burden in a global report (Murray & Lopez, 1996). In the
United States, alcoholism has a high lifetime prevalence rate of ten percent. (NIDA & NIAAA, 1998). At
least 15.4 million adults have alcohol-related problems (Miller, Gold, & Smith, 1997). Alcohol-related
costs adversely impact on the United States healthcare system and society at large. This healthcare
problem impacts on patients and affects many individuals while creating enormous social, physical, and
psychological problems. The Ninth Special Report to Congress indicates increasing costs, estimated at
$166.5 billion per year in direct and indirect healthcare and social costs (Ninth Report, 1997).
Alcohol has been identified as a factor in fifty percent of all motor vehicle crashes, burns, interpersonal
violence including homicides and increased crime (Rivara et al., 1993; NIAAA 1998; Ninth Special
Report, 1997). More years are lost to alcohol-related causes than to heart disease; a rate that is second
only to cancer (Miller, Gold, & Smith, 1997). Alcohol abuse is a serious problem for elderly adults
affecting as many as 17% (Blow, 1998;Caracci & Miller, 1991). Until recently, problem drinking in the
elderly has been ignored and minimized by both healthcare professionals and the general public. The
treatment of persons with coexisting mental and substance abuse disorders is a subject of growing
importance, which may involve 40 to 50% of the persons with a psychiatric diagnosis (Miller, Gold, &
Smith, 1997).
ISPN Position Paper, October 2000: AWS in the Acute Care Setting, p. 2
ISPN 1211 Locust St. Philadelphia PA 19107
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Healthcare providers encounter patients with alcohol related problems in all healthcare settings; however,
the patients' alcohol abuse is often not recognized, diagnosed or treated. Society's ambivalent views about
alcohol and other drug use may be reflected in the attitudes of many healthcare providers, including
nurses, who fail to accurately identify substance abuse problems, or harshly judge those patients (CASA,
2000). Nurses are in key positions to identify alcohol problems in patients and to facilitate their
access to appropriate and effective treatment. When substance abuse testing and assessment, especially
alcohol related, become routine, acute care settings can expect: improved patient management and followup,
increased patient and family satisfaction and improved nursing morale. (Rostenberg, 1995).
Symptoms of Acute Alcohol Withdrawal Syndrome
Alcohol withdrawal in the acute care patient is complex, underdiagnosed, and often under or mistreated
by utilizing monopharmacotherapy. Alcohol withdrawal can begin from 6 to 24 hours following cessation
of drinking or if a significant reduction in the usual alcohol consumption occurs (Giannis, 2000: Myrick
& Anton, 2000). Alcohol withdrawal delirium is typically experienced by the third day, and up to the
fifth day of abstinence. DePetrillo and McDonough (1999a) identify three symptom clusters that differ
physiologically, and the preferred treatment agents for each cluster. The three clusters provide a model
for pharmacologic intervention based on symptom presentation. Refer to Appendix 1Summary of Signs
and Symptoms by AWS Type.
Most patients develop sensory hypersensitivity. Alcohol-related seizures are often associated with head
trauma(s), history of seizures, and electrolyte instability (untreated hypomagnesaemia, hypokalemia,
hyponatremia, and hypoglycemia. Electrolyte instability can produce a medical/psychiatric emergency.
Symptoms are generally more severe and complex with women, older age, poor general health, poor
nutritional status, amounts of alcohol consumed regularly, and a long duration of alcohol dependency
(DePetrillo et al., 1999b; Sache, 2000). It is essential and medically appropriate to screen, assess, and
identify patients with alcohol-related problems so that the necessary and appropriate medical and nursing
care is instituted in a timely manner. Refer to Appendix 1 Summary of Signs and Symptoms by AWS
Type.
Pharmacologic Management of AWS
ISPN believes that the major goal of pharmacologic treatment for AWS is to decrease mortality and
morbidity,since AWS can be life threatening. It is acknowledged that alcohol withdrawal severity varies
significantly, and the medications and amounts needed to effectively manage symptoms also vary
significantly from patient to patient and among patient-related episodes of AWS. Refer to Appendix 1
Summary of Signs and Symptoms by AWS Type for symptom focused pharmacologic interventions.
Management of Medical and Psychiatric Illness
Chronic alcohol consumption is associated with a number of medical complications that must be
addressed during the acute care stay. Also, chronic alcohol consumption may exacerbate pre-existing
psychiatric-mental health illnesses. The behavioral, depletion of neurotransmitters and social problems
associated with chronic alcohol consumption may lead to the secondary development of a psychiatric
illness, such as anxiety and/or depression and an increased rate of suicide. Alcohol related complications
are described in Appendix 2: Medical Conditions Related to Alcohol Abuse.
ISPN Position Paper, October 2000: AWS in the Acute Care Setting, p. 3
ISPN 1211 Locust St. Philadelphia PA 19107
800.826.2950 215.545.8107 (f) ispn@rmpinc.com (e) www.ispn-psych .org
Recommendations
The quality and efficacy and outcomes of acute care services and treatment are
inhibited and compromised if patients' alcohol patterns and histories are not
known to the healthcare team planning and providing acute care services.
Therefore ISPN recommends that the following measures be instituted:
All healthcare providers should become knowledgeable about AWS symptom identification,
utilization of routine screening methods, AWS assessment/quantification tools, specific
pharmacologic intervention, and identification and utilization of acute care resources to facilitate
successful referral to the appropriate level of addiction treatment.
All healthcare providers should conduct routine screening for substance use in their practice and
identify patients at risk for abuse and dependency.
All nurses function as advocates to insure their patients receive appropriate screening and expedient
treatment for AWS in conjunction with appropriate referrals to maintain the patients functional and
cognitive status.
Screening for Alcohol Abuse or Dependence
All patients should be screened by their healthcare providers at the point of entry into the healthcare
system. They should be asked about alcohol use, and the presence of any alcohol-related problems.
All acute care patients should be screened using reliable and easy to use screening tool that can be
implemented in any acute and emergency care environment. The CAGE questionnaire, with its four
questions, is an example of such a tool (Ewing, 1984; Beresford, 1990)), refer to Appendix 3 for
information on the CAGE questionnaire.
All acute care patients who are at high risk, (particularly trauma patients), or any patient who scores
two positive answers on the CAGE screening tool should have blood alcohol concentration (BAC)
determinations as well as urine toxicology screens performed on admission.
Assessment and Quantification of Alcohol Withdrawal Syndrome (AWS)
All acute care patients with either a positive CAGE or BAC should be assessed for the possibility of
developing Alcohol Withdrawal Syndrome (AWS).
Assessment should be done using an evidence-based clinically focused assessment tool such as the
AWS Type Indicator (DePetrillo & McDonough, 1999).
All patients with any of the following: positive blood alcohol concentrations (BAC), positive urine
toxicology screens, and positive CAGE scores- receive further assessment for proper diagnosis and
prompt intervention for substance abuse/dependency. Consultation and referral to psychiatric
consultaition liaison nurse, addiction consultation nurse or other experts available within healthcare
system for evaluation will aid in diagnosis of coexisting (co morbid) psychiatric disorders.
Pharmacologic Management of AWS
The determination of medication and dosage administered is based on the identification and
quantification of AWS symptomatology demonstrated on the AWS Type Indicator or other objective
quantification tool.
ISPN Position Paper, October 2000: AWS in the Acute Care Setting, p. 4
ISPN 1211 Locust St. Philadelphia PA 19107
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Specific treatment is instituted immediately following patient assessment with an objective
quantification tool. Particular attention should be focused on managing signs and symptoms related
to increasing circulating levels of epinephrine, since the conditions related to hyperadrenergic state
are most commonly associated with AWS mortality and morbidity.
Treatment of patients with AWS should be based on individualized and dynamic
psychopharmacologic interventions, so patients receive the appropriate medications in the correct
dosages and combinations to effectively treat their AWS symptomatology.
Individualized and dynamic treatment requires that each symptom cluster is assessed and quantified,
and then treatment is instituted with the appropriate medication for each symptom cluster where there
are symptoms present.
ISPN does not support fixed dosing medication regimens: a fixed, standardized dose for all patients
cannot effectively or adequately treat AWS. (Mayo-Smith, 1997).
ISPN does not support PRN dosing without any mean of quantifying symptoms; it is an equally
inadequate method of detoxification (Mayo-Smith, 1997).
ISPN does not recommend or support the use of ethyl alcohol (oral or intravenous) in the treatment of
AWS because of the lack of controlled studies regarding its effectiveness (evidence is only anecdotal
reports and case studies). Additionally, there is well-documented evidence of adverse effects of ethyl
alcohol as a pharmacologic agent (Mayo-Smith, 1997).
ISPN does not recommend the use of automatic restraints (chemical or mechanical) for agitated
behavior due to AWS without first attempting environmental manipulation, calming techniques and
pharmacotherapy. (ISPN Position Statement, 2000)
Management of Medical and Psychiatric Illness
Alcohol associated medical and psychiatric problems must be identified, and treated appropriately
and concurrently.
The patient must be taught to understand the link between chronic alcohol consumption and the
medical illnesses or complications present including effects on psychosocialial functioning (job loss,
DUI, interpersonal violence-especially domestic violence, impact on children- one in four children
are raised in families where alcoholism or alcohol abuse is present).
The patient must be advised to seek treatment for alcohol dependence as a necessary strategy in the
treatment of any medical illnesses or complications present that can be linked to alcohol consumption.
Healthcare providers, especially nurses in acute care settings, should request consultation with
psychiatric/addiction colleagues to determine the presence of any coexisting psychiatric illness and
the appropriate treatment. (The identification of psychiatric symptomatology may not be clearly
established if the patient develops alcohol withdrawal delirium, but can be detected after the delirium
has resolved or through collateral interviews).
Healthcare providers need to consider additional consultations to enhance the patient's general well
being, functional status and cognitive functioning in conjunction with AWS treatment. Examples of
ISPN Position Paper, October 2000: AWS in the Acute Care Setting, p. 5
ISPN 1211 Locust St. Philadelphia PA 19107
800.826.2950 215.545.8107 (f) ispn@rmpinc.com (e) www.ispn-psych .org
additional consultations are nutritional, physical therapy and occupational therapy. It is important to
identify any deficits that may interfere with further addiction treatment
Referral for Addiction Focused Treatment
All acute care patients who have been treated for AWS need a focused addiction and readiness to
change assessment (Prochaska et al., 1992) to assist patients, family and treatment providers in
determining the level and focus of addiction and possible psychiatric treatment. Acute care alcohol
detoxification only is incomplete and ineffective treatment for alcohol dependence.
Recovery focused treatment should also be individualized and may include community based mutual
help groups, low intensity outpatient treatment programs, high intensity outpatient treatment
programs, family or relationship therapy, individual therapy with a cognitive/behavioral focus, and/or
residential treatment.
All patients should be offered and receive an individualized referral for addiction treatment and all
options available to the patient should be discussed completely with the patient prior to their acute
care discharge.
Family members (including children), or significant others should be provided with community based
referrals to address the impact of alcoholism on them.
Summary
The early identification and clinically focused assessment of AWS in conjunction with individualized and
dynamic treatment results in increased patient comfort, decreased cost, decreased adverse consequences
related to the detoxification process, decreased percentage of patients leaving against medical advice
(AMA) and decreased the restraint incidences and length of time spent in restraints. Patient, family and
nursing satisfaction and with safety are all positively impacted with this approach to a potentially life
threatening syndrome.
Developed for ISPN by the ISPCLN AWS Task Force: Lynette Jack PhD. RN (Chairperson); Peggy Dulaney MSN,
RN , CS (Division Director-ISPCLN); Lenore Kurlowicz Ph,D, RN, CS; Susan Krupnick MSN, RN, CARN, CS; Susan
McCabe EdD, RN, CS; Leslie Nield-Anderson PhD, RN, Karen Ragaisis, MSN, APRN, CARN, CS. Reviewed by
Diane Snow, PhD, RN, CARN, CS, President, International Nurses Society on Addictions and Dr. Paolo DePetrillo
ISPN 2000
ISPN Position Paper, October 2000: AWS in the Acute Care Setting, p. 6
ISPN 1211 Locust St. Philadelphia PA 19107
800.826.2950 215.545.8107 (f) ispn@rmpinc.com (e) www.ispn-psych .org
References
Beresford, T.P., Blow, K.C., Hill, e., et al. (1990). Clinical Practice: Comparison of CAGE questionnaire and computer
assisted laboratory profiles in screening for covert alcoholism. Lancet. 336, 482-485.
Blow, F. (1998). Substance abuse among older adults. Rockville, MD: Substance Abuse and Mental Health Services
Administration, Center for Substance Abuse Treatment, Treatment Improvement Protocol #26.
Caracci, G. & Miller, N. (1991). Epidemiology and diagnosis of alcoholism in the elderly-a review. International
Journal of Geriatric Psychiatry, 6, 511-515.
CASA (2000). Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse.
The National Center on Addiction and Substance Abuse. Columbia University, New York, NY.
DePetrillo, P. & McDonough, M. (1999a). Alcohol withdrawal treatment manual. Glen Echo, MD: Focused Treatment
Systems.
DePetrillo, P., White, K.V., Ming, L., Hommer, D., & Goldman, D. (199b). Effects of Alcohol Use and Gender on the
Dynamics of EKG Time-Series Data. Alcoholism: Clinical and Experimental Research. 23,4(745-750.
Ewing, J. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association, 252,
1905-1907.
Giannis A. (2000). An approach to drug abuse, intoxication, and withdrawal. American Family Physician. American
Academy of Family Physicians (www.aafp.org, 5/1/00).
International Society of Psychiatric-Mental Health Nurses (2000). A Position Statement: On the Use of Restraint and
Seclusion. Philadelphia, PA: ISPN.
Mayo-Smith, M. (1997). Pharmacological Management of Alcohol Withdrawal: A Meta-Analysis and Evidence Based
Practice Guideline. Journal of the American Medical Association. 278(2), 144-151.
Miller, N., Gold, M., & Smith, D. (1997). Manual of Therapeutics for Addictions. New York: Wiley-Liss.
Murray, J.L., & Lopez, A.D. (1996). The Global Burden of Disease: A Comprehensive Assessment of Mortality and
Disability from Diseases, Injuries, and Risk factors in 1990 and Projected to 2020. Harvard School Public Health,
Harvard Press: Cambridge, MA .
Myrick, H. & Anton, R.F. (2000). Clinical management of alcohol withdrawal. CNS Spectrums. 5(2), 22-32.
National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA). (1998).
The economic costs of alcohol and drug abuse in the United States, 1992. Bethesdea, MD: National Institutes of
Health.
Ninth Report to the U.S.Congress on alcohol and health. (1997). Chapter 1: Epidemiology of alcohol use and alcoholrelated
consequences. Washington,D.C.: Public Health Services.
Prochaska, J.O., DiClemente, C.C.,& Norcross, J.C. (1992). In search of how people change: applications to
addictive behaviors. American Psychologist. 47(9), 1102-1114.
Rivara, F.P., Jurkovich, G.J., Gurney, J.G., Seguin, D., et al. (1993). The magnitude of acute and chronic alcohol
abuse in trauma patients. Archives of Surgery. 128:907-913.
Rostenberg, P. (1995). Alcohol and other drug screening of hospitalized trauma patients. Rockville, MD: Substance
Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Treatment Improvement
Protocol #16.
Sache, D. (2000). Delirium Tremens. American Journal of Nursing, 100, (5), 41-42.
ISPN Position Paper, October 2000: AWS in the Acute Care Setting, p. 7
ISPN 1211 Locust St. Philadelphia PA 19107
800.826.2950 215.545.8107 (f) ispn@rmpinc.com (e) www.ispn-psych .org
Appendix 1: Summary of Signs and Symptoms By The AWS Type
AWS TYPE TYPE A
(CNS Excitation)
TYPE B
(Adrenergic
Hyperactivity)
TYPE C
(AWS Delirium)
Physiologic Basis for
Symptom Manifestation
Deficiency in GABA
activity, with effect on
serotonin,
norepinephrine and
dopamine along with an
overactivity of certain
subtypes of NMDA
receptors.
Increase in CNS
epinephrine and an
increase in circulating
levels of epinephrine
Postulated that the
glutamate-related
NMDA receptor
hypersensitivity plays a
role in AWS delirium
Signs and Symptoms Uneasiness, sense of
foreboding,
apprehension, motor
hyperactivity, enhanced
sensitivity and reaction
to abrupt sensory
stimuli, mood lability,
dysphoria, anxiety,
insomnia
Chills, diaphoresis,
fever, hypermetabolic
state, hypertension,
muscle tremors,
mydriasis, nausea and
vomiting, palpitations,
piloerection, tachycardia
Attentional deficit,
disorientation, hyperalertness,
impairment of
short-term memory,
impaired reasoning,
psychomotor agitation,
visual and auditory,
tactile hallucinations
Recommended
Pharmacotherapy
(listed based on level of
effectiveness- highly
effective to some effect)
Benzodiazepines
(lorazepam-Ativan,
diazepam-Valium,
chlordiazepoxide-
Librium)
Carbamazepine
(Tegretol)
Valproic Acid
(Depakote)
Clonidine (Catapres)
Clonidine (Catapres)
Beta Blockers
(propranolol-Inderal,
atenolol-Tenormin,
labetalol, Normodyne)
Valproic Acid
(Depakote)
Carbamazepine
(Tegretol)
Benzodiazepines
Neuroleptics
(haloperidol-Haldol,
risperidone-Risperdal,
fluphenazine, Stelazine,
droperidol-Inapsine)
Adapted and used with permission from DePetrillo, P. & McDonough, M. (1999). Alcohol Withdrawal Treatment
Manual. Glen Echo, MD: Focused Treatment Systems.
Resource: For additional information and discussions with an addictionologist studying AWS use
http://www.sagetalk.com
ISPN Position Paper, October 2000: AWS in the Acute Care Setting, p. 8
ISPN 1211 Locust St. Philadelphia PA 19107
800.826.2950 215.545.8107 (f) ispn@rmpinc.com (e) www.ispn-psych .org
Appendix 2: Medical Conditions Related to Alcohol Abuse
Cardiovascular
alcoholic cardiomyopathy
increased systolic and pulse pressure
tissue damage, weakened heart muscle, and heart failure
Gastrointestinal
abdominal distention, pain, belching, and hematemesis
acute and chronic pancreatitis
alcoholic hepatitis leading to cirrhosis
cancer of the esophagus, liver, or pancreas
esophageal varicies, hemorrhoids, and ascites
gastritis, colitis, and enteritis
gastric or duodenal ulcers
gastrointestinal malabsorption
hepatorenal syndrome
swollen, enlarged fatty liver
Genitourinary
hypogonadism, hypoandrogenization, hyperestrogenization in men
increased urinary excretion of potassium and magnesium (results in hypomagnesemia, hypokalemia)
infertility, decreased menstruation
prostate gland enlargement, leading to prostatitis and interference
with urination
prostate cancer
sexual dysfunction: decreased libido, sexual performance decreased,
impotency
Metabolic
hypoglycemia, hyperlipidemia, hyperuricemia
ketoacidosis
osteoporosis
Hematologic
abnormal red blood cells, white blood cells, and platelets
anemia and increased risk of infection
bleeding tendencies, increased bruising, and decreased clotting time
mineral and vitamin deficiencies (folate, iron, phosphate, thiamine)
Neurologic
Wernicke-Korsakoff syndrome, Marchiafava-Bignami disease, cerebellar degeneration
peripheral neuropathy, polyneuropathy
seizures
sleep disturbances
stroke (increased risk of hemorrhagic stroke)
Respiratory
cancer of the oropharynx
impaired diffusion, chronic obstructive pulmonary disease, infection, and tuberculosis
respiratory depression causing decreased respiratory rate and cough reflex and increased susceptibility to
infection and trauma
Trauma related
burns, smoke inhalation injuries
injuries from motor vehicle crashes and falls
ISPN Position Paper, October 2000: AWS in the Acute Care Setting, p. 9
ISPN 1211 Locust St. Philadelphia PA 19107
800.826.2950 215.545.8107 (f) ispn@rmpinc.com (e) www.ispn-psych .org

USING ULTRASOUND (US) TO CONFIRM PROPER

ENDOTRACHEAL TUBE (ETT) POSITION IN AN ACUTE CARE
SETTING
Rahul Khosla, * and Cara R. Kistler, MD

Veterans Affairs Medical Center, Washington, DC

PURPOSE: Visualization of the vocal cords, end-tidal capnography, auscultation of bilateral chest and
epigastrium are the standard methods to confirm proper ETT placement, immediately post-intubation, in our
medical intensive care unit (MICU). A chest radiograph is also done to confirm ETT position. The goal of this
study was to determine the accuracy of US to confirm proper ETT placement, defined as, in the trachea with
bilateral lung ventilation, indicating an ETT position above the carina.

METHODS: This was a prospective study. Eligible patients were 18 years or older, admitted to the MICU, that
required endotracheal intubation due to their underlying clinical condition. Endotracheal intubation was
performed by an anesthesiologist, intensivist or a critical care fellow under supervision. An immediate pre and
post intubation US examination was performed by an intensivist who was blinded to the result of the standard
confirmatory methods of ETT placement. A post-intubation chest radiograph was done in all the patients.

RESULTS: As per the standard methods of confirmation of ETT placement, 19/20 patients had a properly
placed ETT. US examination was able to confirm correct placement in all 19 cases. 1 patient, confirmed to have
a properly placed ETT by standard methods had a right main stem intubation, as seen on a post-intubation chest
radiograph. US examination was able to detect a right main stem intubation in this patient. The sensitivity of US
in identifying correct ETT placement was 100%, specificity 100%, diagnostic accuracy 100%, false positive rate
0% and a false negative rate of 0%.

CONCLUSION: This study demonstrates that US imaging is an accurate method to confirm proper ETT
placement in an acute care setting.

CLINICAL IMPLICATIONS: US is a rapid, readily available, and a noninvasive technique that can be used
as an additional tool to immediately confirm proper ETT placement in an acute care setting.

DISCLOSURE: Rahul Khosla, No Financial Disclosure Information; No Product/Research Disclosure

Information

Day in the Life of a CNA in the Acute Care Setting

In a CNA job, a certified nursing assistant will start an eight hour shift at 7 am, 3 pm, or 11 pm. The twelve
hour assistant usually starts at 6am or 7am for day shirts, and 6pm or 7pm for the night shift.  The
responsibilities for each shift may differ, but most tasks are the same regardless of the shift you work.

 CNA Jobs
 Nursing Schools
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The Responsibilities of an Acute Care CNA

Certified Nursing Assistant (CNA) Acute Care

The day shift assistants start by receiving an assignment and report on the patients in their care.  In some
institutions, the report is CNA to CNA, but in other facilities, the CNAs may sit in on the overall nursing report.

When reporting is completed, the first responsibility usually involves taking the vital signs on the assigned
patients and assisting clients with breakfast. Both of these responsibilities involve direct patient contact and
documentation. The vital signs need to be recorded, regardless of the practice of your institution. Some facilities
allow the CNA to document directly in the chart or in the computer chart, and some just want it written on a
flow sheet for the nurse to transcribe. The intake and output sheet for a patient can be taped to the bathroom
door, the patient room, or in the chart. This is where the assistant will record what the patient drank for
breakfast and how much the patient ate.

In the acute care setting, linens are changed every day. The CNA is responsible for assisting the patient with a
bath, shaving, oral care, and changing the bed. Any assistance needed to use the bathroom or bedpan,
ambulating, or being taken in a wheelchair for x-rays during the course of the shift falls to the CNA.
 Nurses give the medications, treatments, and conduct full assessments. Nurses may also assist the CNA with
turning and positioning patients or transferring the patient to a chair.

Other CNA Job Responsibilities

Other tasks the certified nursing assistant is responsible for during the course of the day in an acute care setting
are as follows:

 Answering the patient call lights

 Providing each patient with fresh ice water and glasses
 Delivering freshly washed clothes and towels if needed
 Assisting the nurses with errands or bringing equipment
 Picking up dirty eating trays when breakfast or lunch is finished
 May be asked to feed patients who are not able to feed themselves
 May be asked to collect urine or stool samples from a collection pan when the patient voids or stools
 May be asked to change diapers of pediatric patients or incontinent adult patients
 May need to change linen more than once if a patient has vomited, bled, or soiled the linens throughout
the shift

The shift for a certified nursing assistant goes quickly, and the activities are centered on patient care and
assisting the nurses during the shift. CNAs do not answer the phone, take physician orders, or do patient
treatments or dressing changes. Their role is non-technical, yet hands on. It is one of the most important parts of
direct patient care in the overall hospital stay. Most CNAs find providing direct patient care can also be the
most satisfying part of the job.

You might also like:

 Become a CNA: A CNA Education Is a Springboard into Other Nursing Careers
 Become a CNA: Career Advantages to Starting Out as a CNA
 Become a CNA: A Day in the Home Health Care Setting
 Become a CNA: A Check List of Characteristics and Skills Needed to be a CNA
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What does a cna do in an acute care setting?

I am going to be starting a position as a cna in an acute care hospital and was wondering what the duties usually involve.
The program where I did my training only involved long term care settings. I have been a caregiver for an elderly woman,
but I know that it will be different in the hospital setting. Are there any CNA's out there that work in acute care that can
kind of give me a "day in the life" kind of advice?

Ans: bed baths, changing bed, transfers, transport, walking people, bed pans Very similar to SNF

Full Article Title: Skin failure in the acute care setting.(Preparing for Certification)(Report)
Article Excerpt
Skin is the largest organ of the human body and, like other organs, it can fail, especially in the geriatric
population. The aging process results in a loss of fatty tissue, collagen, and skin elasticity, as well as a decrease
in vascularity and sweat gland function (Langemo & Brown, 2006).

The acutely ill older adult is at even greater risk of skin failure as the body fights to provide more circulation to
the diseased system. The elder with multiple co-morbid conditions is at increased risk for skin breakdown.
Decreased mobility and malnutrition can lead to loss of fat and muscle mass. Nutrition and hydration are
essential in the plan of care for older adult patients, as well as good hygiene and frequent turning and
positioning to alleviate and redistribute the areas of pressure (Langemo & Brown, 2006).

A patient's skin integrity must be assessed and documented accurately on admission. Beginning in 2008, the
Centers for Medicare & Medicaid Services (CMS), no longer reimburses hospitals for "never events or serious
and costly errors in the provision of health care services that should never happen" (CMS, 2006).

Nutrition is a key consideration when treating the patient with pressure ulcers because of its direct correlation
with healing. A sound nutritional assessment on admission is vital, with a focus on adequate protein intake and
overall optimal nutrition for each patient. Other helpful interventions might include provision of small frequent
meals and/or use of nutritional supplements (Baranoski & Ayello, 2004).

Stage That Wound

Clear, concise documentation of skin integrity is a must. Documentation of any existing skin condition should
include size, location, and description of the wound or ulcer, stage of the ulcer, and a description of any
drainage or odor that may be exiting the wound. For additional information on staging, see the Academy of
Medical-Surgical Nursing's Core Curriculum for Medical-Surgical Nursing (Brozenec & Russell, 2004).

1. Jeannine Cooper, age 92, is admitted with altered mental status and to rule out sepsis. While performing the
initial admission assessment, the nurse notices that Ms. Cooper has an area of breakdown in her sacral area as
well as a round purple area on the left heel. It is most important that the nurse initially:

a. Calls Adult Protective Services to report suspicion of neglect in the patient's home setting.

b. Calls the doctor to report the findings and ask for an order to consult the wound care nurse for staging.

c. Ensures the nursing assistant turns and repositions the patient every 1-2 hours and applies barrier cream to the
patient's sacral area.

d. Documents clearly on the admission assessment the alterations in skin integrity noting size, location, and
stage of any injured area as well as performs a sound nutritional assessment.

2. Glenda Jones, age 65, is admitted for exacerbation of chronic bronchitis. While performing the shift
assessment, the nurse notices patches of erythema on the right side of the patient's.

Palliative Care in the Acute Care Setting

Background

Palliative care has been defined by the World Health Organization (WHO) as "the active total care of patients whose
disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and
spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their
families."
Another way to look at palliative care is the concept of a "good death," free of avoidable pain and suffering for the patient
and the patient's family. At first glance, this definition would seem to have little to do with acute care delivered in a setting
such as the emergency department. In fact, while up to 60% of patients die at home in the United States, reportedly as
few as 35% of patients want to die at home. Consequently, many patients who are terminally ill present to emergency
departments. They may do so when death is imminent, for treatment of an acute illness superimposed on their existing
disease, or for symptom control, especially of pain. This article focuses on symptom control.

For more information, see Medscape's Palliative Care Resource Center.

Symptoms and Pathophysiology

Pain is the single most prevalent symptom for patients receiving palliative care. The pathophysiology varies with the
anatomic location of pain and the underlying disease process. In a large study of patients with cancer who were in
palliative care, approximately 55% of pain was somatic in origin, with the remainder nearly equally divided between
visceral and neuropathic causes.1 

For example, patients with advanced cancer may have headache due to increased intracranial pressure from tumor
masses or from inflammation. Bone pain is the most common source of cancer pain and may occur with either
osteoblastic or osteolytic activity. Bone pain can originate directly from bone (direct invasion with microfracture, distortion
of the periosteum) or from nerve root compression or muscle spasm in the lesion area. Major pathologic fractures may
occur at the site of primary or metastatic tumor. Abdominal pain in patients with cancer may be due to solid organ masses
causing capsular distension. Ascites or tumor mass may lead to uncomfortable abdominal distention and constipation is
common. Chest pain is most often due to tumor invasion of bone or other pain sensitive structures. The pathophysiology
of pain in patients who do not have cancer and are in palliative care is a function of the specific nature and anatomic
location of the underlying disease process.

Shortness of breath in patients in palliative care is especially common with lung cancer or advanced congestive heart
failure. Sixty-five percent of patients with lung cancer and nearly all patients with heart failure experience dyspnea.

In patients with lung cancer, underlying chronic obstructive pulmonary disease (COPD), which may cause dyspnea, is
often present. More specific causes include pleural effusion, pericardial effusion or tamponade,superior vena cava
syndrome, pulmonary embolism, and pneumonia. Besides disease progression, patients with heart failure may also have
pleural effusion and pericardial effusion or tamponade. Each of these may cause increased dyspnea. Severe anemia is
another etiology of dyspnea, but chronic anemia may be very well tolerated in this population.

Gastrointestinal symptoms are also common in the palliative care population. Anorexia, nausea, and vomiting are
common symptoms at the end of life, occurring in 62% of terminally ill cancer patients. Nausea and vomiting also occur
frequently in other terminal illnesses such as congestive heart failure, end-stage renal disease, and AIDS.

The most frequently cited etiologies in patients with cancer are chemical abnormalities (eg, metabolic, drugs, infection) in
33%, impaired gastric emptying in 44%, and visceral causes (eg, bowel obstruction, GI bleed, enteritis, constipation) in
31%. A study of 40 patients on a palliative care unit identified 59 reversible etiologies for GI symptoms, with medications
(51%) and constipation (19%) presenting most commonly. 2 Hypercalcemia is a cause of constipation that is common in
patients with cancer. Dry mouth is a bothersome symptom that may often be medication related.

Anxiety and depression are the most common psychological symptoms in patients with terminal illnesses.

Frequency

Because of the fragmented nature of health care in the United States, measuring the number of patients in palliative care
is difficult. A current estimate of patients receiving the Medicare benefit for hospice and palliative care is more than
500,000. Another estimate is that, in 2000, approximately 20% of patients dying in the United States received hospice
care. 
In the United Kingdom, in 2005-2006, approximately 65,000 new patients enrolled in palliative care programs. According
to one estimate, approximately 70% of deaths in the developed world are preceded by a condition for which death is
predictable in the foreseeable future.

Morbidity and Mortality

Cancer is the most common diagnosis among patients in palliative care. The traditional eligibility criterion for hospice care
in the United States includes an estimated lifespan of 6 months or less; this reflects the predominance of patients with
cancer who are in palliative care. However, lifespan may be easier to determine for cancer than for certain other terminal
diseases such as COPD, congestive heart failure (CHF), severe dementia, and stroke. Many patients request only
palliative care early in the course of a fatal, incurable disease. These patients may survive for years rather than 6 months
or less.

Race and Ethnicity

A 2006 study of the California population found that views on a patient's right to die varied significantly by ethnicity, with
whites much more willing to allow a loved one to die than any other ethnic group including African Americans, Asians, and
Latinos.3 Once a patient or family requests palliation only, medical care does not differ by ethnicity. Differences may also
exist in the ways that cultural groups express pain, and clinicians should consider this.

An article by Smith et al provides a comprehensive discussion regarding cultural issues that clinicians should be aware of
while caring for terminally ill patients of Latino heritage. Included are various recommendations on how to effectively utilize
interpreters and universal strategies for patient health communication. 4

History

Patients in palliative care already carry a diagnosis of terminal illness. The focus of the encounter is therefore different
than for other patients in acute care settings. New symptoms that may indicate a new disease process should be sought
when appropriate. Often though, the focus of the visit is explicitly for relief of long-standing symptoms that are progressive
or poorly controlled. Consulting the patient's medical history and treating physicians, when available, is often valuable in
learning the details of prior symptoms, diagnostic tests, and treatments.

With the exception of pain, there is poor concordance between symptom questionnaires as completed by the patient and
the physician history as recorded in the medical record.5 It is therefore often appropriate to ask specifically about other
symptoms such as anorexia, incontinence, gastrointestinal symptoms, respiratory symptoms, or level of functioning, in
order to best identify the patient's needs.

Physical

Physical examination for patients in palliative care should be based on knowledge of preexisting diseases and presenting
symptoms. As with the history, the primary goal is to determine if a new, acute condition needing further evaluation and
management is present or to verify that a preexisting condition needing further symptomatic treatment is responsible for
the presenting complaints.

Causes

The most common reason to enter palliative care is advanced cancer. According to the Centers for Disease Control and
Prevention, in the United States, the most common primary sites as causes of cancer death are (in order) lung, colon-
rectal, breast, and pancreas.6 Other diseases commonly leading to palliative care are HIV/AIDS, congestive heart failure,
chronic obstructive pulmonary disease, renal failure, liver failure, dementia, and stroke.

Laboratory Studies
Laboratory studies are dictated by the suspicion of a specific acute disease that would require treatment if discovered.
Many patients may have a high pretest probability of disease yet not require testing. For example, it would often be of little
benefit to confirm an elevated serum creatinine level in a patient in palliative care who has end-stage renal disease and
presents with an unrelated complaint such as a minor soft tissue infection.

Imaging Studies

As with laboratory studies, imaging studies should be reserved for the identification of conditions that will change
treatment when present. For example, merely documenting known findings such as a lung mass in a patient with lung
cancer who has symptoms unrelated to the chest is unnecessary. Conversely, a patient with a cough and a fever may
warrant a chest radiograph provided that he or she would wish antibiotic treatment for pneumonia, if discovered.

Procedures

Common procedures in patients in palliative care include intravenous or subcutaneous clysis fluids for
dehydration,thoracentesis for symptomatic pleural effusion, paracentesis for symptomatic ascites, and placement of a
urinary catheter for hygienic purposes or to ameliorate obstruction. One study reported on a collaboration of emergency
physicians and palliative care specialists in performing sonographically guided paracentesis at home. 7 

Nasogastric (NG) tubes may be used temporarily to supplement oral intake. However, they are uncomfortable and
significantly increase the risk of aspiration. When patients desire artificial nutrition, arrangements for a semipermanent
type of feeding tube, such as a percutaneous endoscopic gastrotomy (PEG) tube, may be considered. An NG tube can be
an acceptable short-term bridge to a longer-term solution. A Foley catheter may be used as a short-term replacement for
an extruded or blocked gastrotomy tube needing replacement.

Emergency Department Care - Pain Management

Care for patients in a palliative acute care setting is primarily concerned with symptom relief. At times, specific treatment
aimed at an acute condition is appropriate. For these situations, other sections of this text or other references should be
consulted. This section focuses on treatment strategies for pain, the most common symptom in patients receiving
palliative care. Pain is the most common symptom of patients with cancer who are in palliative care and seeking acute
care. Other patients in palliative care may also experience continuous or intermittent pain, and the principles of treatment
are the same. The WHO has disseminated a 3-step "stepladder" outlining an approach to treating pain in patients with
cancer. While not specifically formulated for other types of patients in palliative care, the scheme is clearly applicable.
According to the WHO8 :

 If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and
acetaminophen); then, as necessary, mild opioids (codeine); then strong opioids (such as morphine), until the
patient is free of pain. To calm fears and anxiety, additional drugs – "adjuvants" – should be used. To maintain
freedom from pain, drugs should be given "by the clock", rather than "on demand." This three-step approach of
administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. Surgical
intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.

The stepladder approach has been questioned but is generally considered to be a valuable tool in guiding treatment of
chronic cancer pain. The basic principle of reserving opioids for pain that cannot be successfully treated with nonopioids,
and continuing nonopioid treatments when possible, is important for both patients with cancer and patients without cancer
who are in palliative care settings. For a description of the ladder, see WHO's pain relief ladder.

The time course of pain may be continuous, intermittent, or breakthrough pain. In one study, 48% of patients with cancer
had continuous pain, with 75% experiencing breakthrough pain at some time. The other 52% experienced intermittent
pain.1 Inadequately treated continuous pain is also common with studies reporting frequent deviation from evidence-based
guidelines for treatment. A specific type of inadequately treated chronic pain is known as end-of-dose pain. Each type
requires a somewhat different therapeutic approach and, therefore, being able to differentiate them is important.
Patients in palliative care may present with chronic pain to an acute care setting early in the course of their disease. In
that situation, as suggested by the WHO ladder, nonopioids or mild opioids are the most appropriate symptomatic
pharmacological treatment. The initial treatment of pain that requires opioids should be with short-acting/rapid-onset
preparations. More commonly, patients present with inadequately controlled chronic pain and are already receiving
narcotic pain medication. In that circumstance, end-of-dose pain needs to be differentiated from breakthrough pain.

Breakthrough pain is described as an acute pain exacerbation in the setting of chronic pain. A specific precipitating event,
such as coughing in a patient with rib metastases, may occur, or it may occur with no identifiable precipitant.
Breakthrough pain is best treated with a short-acting narcotic as a "rescue" medication. End-of-dose pain is diagnosed by
the characteristic time course. It occurs fairly predictably prior to the next scheduled dose of analgesic. End-of-dose pain
is treated by increasing the dosing frequency or switching to a longer-acting narcotic.

When pain relief from a long-acting opioid is inadequate, the primary approach is to increase the dose. Opioids have no
ceiling effect and, therefore, no specific maximum dose, whatever amount the patient is receiving. The correct dose is the
dose needed to relieve pain. Fear of addiction or respiratory depression is not appropriate in this setting. At times, rather
than simply increasing the dose, switching from one opioid preparation to another is reasonable. Side effects may differ
with different preparations, and cross-tolerance is incomplete. When switching, begin the new drug at 50% (or more) of
the published equianalgesic dose. Less than this dose will almost certainly be inadequate.

Opioid side effects can be anticipated and treated prophylactically. Nausea and vomiting are common in the first few days
after initiating treatment. An antiemetic such as metoclopramide or a serotonin antagonist is often effective and should be
prescribed for the first week or so of narcotic treatment.

In certain circumstances, specific types of pain may be targeted with relatively specific therapies. The mechanism of
specific pain relief varies and, in some cases, is not well understood. Some pharmacological examples of specific pain
treatments are listed below.

Table. Medications and Indications

Open table in new window

Drug Class Indication

Corticosteroids Increased intracranial pressure Nerve compression

Cyclic antidepressants, anticonvulsants Neuropathies

Nonsteroidal anti-inflammatory drugs Bone pain, soft tissue pain

Bisphosphonates Bone pain

In addition to pharmacologic treatment of pain, nonpharmacologic treatments are available. Radiation, radiofrequency
ablation, or surgery may be used to treat a tumor in a specific area causing pain. Physical modalities such as splinting or
the application of heat or cold may be used. Cold application with ice packs, gel packs, and coolant sprays reduces nerve
conduction, muscle spasm, inflammation, and edema. Ice massage, in which skin overlying tender tissue is rubbed with a
block of ice, produces analgesia after several minutes. No controlled studies of cold-induced analgesia for treatment of
cancer pain have been completed. Cold should be avoided in ischemic and irradiated tissues.

Heating has long been used to relieve muscle, bone, and joint pain. The analgesic effect of heat is due in part to
increased blood flow and also decreasing joint stiffness. Heat also induces mental relaxation and relieves stress. Hot
packs, heating pads, or hot baths improve cutaneous blood flow and relax muscles and ligaments.

Psychological treatment may play a long-term role. In the ED, recognition of the role of anxiety and depression may lead
to referral to a mental health provider or to pharmacologic treatment with anxiolytics or antidepressants. Both anxiety and
depression can decrease pain thresholds and increase opioid requirements. Anxiolytics can be an extremely important
adjunct in achieving pain control acutely, and anxiolytics or antidepressants may play a bigger role in the management of
chronic pain.

There are also interventional techniques that are effective for relief of pain. Neurolytic blocks of the sympathetic axis may
be used to relieve visceral pain in the abdominal or thoracic cavity. Implantable devices, such as epidural or intrathecal
catheters, are beneficial for patients on high-dose opioids when side effects are debilitating. These devices provide
analgesia that targets the selected regions, dependent on the catheter tip location. These devices allow significant
reduction in the amount of opioids required. Some authors consider interventional techniques as a "fourth step" on the
WHO ladder.9

Emergency Department Care - Dyspnea

Patients with end-stage lung disease or congestive heart failure are invariably dyspneic, and 75% of all dying patients
experience dyspnea. This may represent a progression of their disease or a complicating illness. In cases of disease
progression, when the patient desires no further treatments for the primary condition, palliation is
appropriate. Patients may already be using supplemental oxygen, and the oxygen concentration may be increased or
oxygen therapy begun.

Increased dyspnea is often associated with anxiety, and a positive feedback loop may exist in which difficulty breathing
leads to anxiety that causes an increased respiratory rate and oxygen demand leading to even more severe dyspnea. In
this situation, medications are appropriate. Concerns about respiratory depressant effects are not well founded and
should not be a concern.

Benzodiazepines are often effective. For patients not already taking opioids, low-dose opioids may relieve dyspnea. For
example, codeine, 30 mg orally every 4 hours may provide relief of mild dyspnea. For those already using opioids, the
dose may be increased.

When the evaluation reveals a potentially treatable cause of dyspnea, such as pneumonia, pneumothorax, pleural
effusion, or superior vena cava syndrome, the ratio of the risk and discomfort of diagnostic and therapeutic interventions
needs to be considered in light of the patients projected lifespan and probability of the therapy being successful.

Emergency Department Care - Gastrointestinal Symptoms

Up to 50% of patients who receive morphine and derivatives develop significant constipation. This is due to narcotic-
induced suppression of intestinal motility. A rectal examination should be performed to determine if fecal disimpaction is
needed. Enemas and stimulant cathartics that promote intestinal motility are a logical treatment.

A comparative study of the efficacy of lactulose and senna was conducted in patients with terminal cancer. Both laxatives
were found to be equally effective in treating narcotic-induced constipation, but senna was recommended because of its
lower cost.10 Stool softening agents may also help prevent narcotic-induced constipation. Bulk-forming laxatives are not
appropriate in opioid-induced constipation. They allow the colon to stretch but do not stimulate peristalsis. The use of
these agents may result in bowel "pseudo obstruction."

A relatively new agent, methylnaltrexone bromide (Relistor), is an opioid antagonist indicated for opioid-induced
constipation. Relistor is a peripherally acting agent and is able to reverse the undesired peripheral affects of opiates, like
constipation, without diminishing the analgesic nature of the drug class. In two clinical trials reported on the package
insert, Relistor was shown to reverse opioid-induced constipation in 48-62% of patients within 4 hours. 11 Relistor is
administered as a subcutaneous injection and is dosed in a weight-based fashion. It is typically used every other day if
needed.  

Regardless of the etiology, up to 90% of patients with terminal illness report constipation. Treatment is similar to opioid-
induced constipation. Bowel obstruction may present as constipation but will have additional signs or symptoms such as
vomiting, abdominal pain or distension, or peritoneal signs that point toward the diagnosis. If there is doubt, plain
abdominal films usually help differentiate simple constipation from obstruction. More sophisticated imaging, such as CT
scanning, should be used rarely in this population.

Hypercalcemia occurs in 10-20% of patients with lung cancer and is also common in breast cancer and myeloma. The
most common symptom is constipation. Many patients may elect not to treat hypercalcemia in the setting of terminal
illness. In that case, symptomatic treatment with laxatives and enemas may be helpful.

Nausea and vomiting are common in patients with cancer, congestive heart failure, end-stage renal disease, and AIDS.
This may be a reflexive response to bowel distention from constipation, the most common reversible cause. The second
most commonly identified reversible cause of nausea and vomiting is medications. Narcotics often cause nausea and
vomiting when treatment is initiated. Tolerance usually develops during the first week of treatment. An antiemetic such as
metoclopramide or a serotonin antagonist may be effective. Another narcotic may be substituted. If another medication is
suspected, it should be discontinued with substitution as needed. When no specific etiology is identified, an antiemetic
should be used.

Anorexia is a common end-of-life phenomenon. No specific treatment for this exists.

Emergency Department Care - Psychological Symptoms

Depressive symptoms are common at the end of life. While many people believe that depression is "normal" among dying
patients, it is not a necessary element of terminal illness and may be treatable. Major depression needs to be
differentiated from the expected anger, sadness, and anxiety associated with a serious illness. The degree and
persistence of symptoms are a key to considering major depression, which is estimated to occur in fewer than 25% of
patients with terminal illness. An open-ended question such as "how much of the time do you feel depressed?" may be the
best screening tool. A previous history of depression or a family history increases the likelihood of developing depression
in response to a serious illness.

As with other cases of depression, selective serotonin reuptake inhibitors are the mainstay of treatment. Low doses may
be started in the acute care setting with upward titration as needed. Therapeutic effects may be delayed for weeks, so
these are appropriate when a patient has a prognosis of at least a few months. Some authors have advocated use of
stimulants for patients with a very short-term prognosis. 12,13 They may be effective within a day or two and may be
particularly helpful in patients who have severe fatigue as part of their symptom complex. Dextroamphetamine and
methylphenidate are amphetamine stimulants that have been used. Pemoline is a nonamphetamine stimulant that has
also been used in this context.

Anxiety is common in patients in palliative care. It is often a component of a depressive syndrome and, in that case,
treatment of depression usually results in improvement. Anxiety may also be a primary psychiatric disorder or represent
an exaggerated response to the stress and worry associated with a terminal illness. Anxiety disorders may increase the
requirements of opioids in acute and chronic pain management, and anxiolytics should be considered as an adjunct in
these patients. Benzodiazepines or neuroleptics are reasonable options for the pharmacologic treatment of anxiety.