how do we relieve uraemic symptoms? · 2018. 10. 24. · neuromuscular symptoms muscle soreness...
TRANSCRIPT
![Page 1: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/1.jpg)
Queensland University of Technology
CRICOS No. 00213J
How do we relieve uraemic symptoms?
Prof Ann Bonner PhD RNSchool of Nursing, Queensland University of Technology
Email: [email protected]
![Page 2: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/2.jpg)
a university for the worldrealR
[What’s] always been a big thing for me is the doctor’s check-up. Oh yeah, all your bloods are good, your fluids, you’re doing wonderful, you’re taking your tablets, all that, so you must be really feeling well,
and you go “No, I feel like crap”.
One thing that doctors should say is it doesn’t matter what it says on the paper work—it’s easiest just to say how do you feel? How are things going with you? Bugger all the bloods; bugger all what fluid and that but how do you feel in yourself? And that’s when you get down to how a person is going.
~Patient 5
![Page 3: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/3.jpg)
a university for the worldrealR
What are symptoms?
• Symptoms may or may not be related specifically to a medical problem and may have a strong psychosocial element
• Signs are objective, observable, and mostly measurable
• Symptoms are not observable
– perceived and verified only by the person experiencing the event
– cannot be observed, perceived, or verified by other persons
![Page 4: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/4.jpg)
a university for the worldrealR
• Symptom experience - the patient’s perception and response to symptom occurrence
• Symptom occurrence
– Frequency (the number of times the event occurs within a given time frame)
– Duration (the persistence or continuance of the prevailing subjective happening)
– Severity (the amount and degree of discomfort) with which the symptom occurs
• Symptom distress - the degree or amount of physical and mental upset, anguish, or suffering experienced from the specific symptom
![Page 5: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/5.jpg)
a university for the worldrealR
♂
CKD: Symptoms and Signs
![Page 6: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/6.jpg)
a university for the worldrealR
Comparison of Symptom Burden
adapted from Murtagh et al 2010 and Teunissen et al 2007
![Page 7: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/7.jpg)
a university for the worldrealR
Why are symptoms important?
• Largely overlooked in routine renal care – focus on numbers (blood results, BP, etc) → “objectivity”
• Patient-reported → “subjectivity”
• Frequently identified by nurses
• Can be assessed (measured)
Patient-reported outcome measures (PROMs)
![Page 8: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/8.jpg)
a university for the worldrealR
CKD Symptom Burden
Almutary, H., Bonner, A., & Douglas, C. (2013).
Symptom burden in chronic kidney disease: A review
of recent literature. Journal of Renal Care, 39(3):140-
150.
• Most prevalent symptoms – fatigue, feeling drowsy, pain & pruritus
• Symptoms studied in isolation
• Focus - on a single dimension
• Missed severity and frequency
• Limited to the dialysis population
• Paucity of studies in CKD stage 4 & 5
• PROM – Dialysis Symptom Index
![Page 9: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/9.jpg)
a university for the worldrealR
How does symptom burden differ in people with advanced CKD who are non-dialysis or
currently receiving dialysis?
![Page 10: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/10.jpg)
a university for the worldrealR
Palliative care
Outcome Scale-
Symptoms – renal
(POS-S)
Chronic Kidney Disease
Symptom Burden Index
No. of
symptoms
17 + 3 free fields 32 + 3 free fields
Ideal
population
CKD stage 5 (RSC) - only CKD stage 4 & 5
Prevalence
Distress (0-4) (0-10)
Severity × (0-10)
Frequency × (0-10)
Benefits Simple
Quick
Easy to use
Clinical application
Comprehensive
Multidimensional
Clinical & research
applications
Different CKD populations
Limitations Tested only in RSC
Limited dimension Long
![Page 11: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/11.jpg)
a university for the worldrealR
Research
Aims1. Examine symptom burden in advanced CKD (stages 4 and 5)
2. Compare the symptom experience between those receiving dialysis or those who are non-dialysis
• Design: Cross-sectional
• Setting: 3 renal units
• Inclusion criteria• Adults (≥18 years)
• Diagnosed with CKD (eGFR <30 mls/min/m2)
• Cognitively capable to consent
![Page 12: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/12.jpg)
a university for the worldrealR
Sample n = 436
107
(24.5 %)
329
(75.5 %)
Non-dialysis Dialysis
Results
Stage 4 (69)
Stage 5 (38)
HD (287)
PD (42)
![Page 13: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/13.jpg)
a university for the worldrealR
Symptom dimensions and CKD
** p < 0.001
CKD
Mean (SD)
Prevalence Distress Severity Frequency
Stage 4 6.6 ± 5.45 20.35 ± 18.2 19.98 ± 19.4 25.24 ± 21.53
Stage 5 7.16 ± 5.7 23.06 ± 24.36 22.09 ± 24.43 27.46 ± 26.66
HD 15.16 ± 7.77** 72.24 ± 55.9** 70.39 ± 55.3** 73.5 ± 53.6**
PD 9.76 ± 4.26 41.18 ± 24.76 34.1 ± 20.77 34.18 ± 19.78
![Page 14: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/14.jpg)
a university for the worldrealR
Symptom Prevalence (%)
51.1
30.4
40.6
27.5
52.6
42.147.4
39.5
83.3
71.466.6
57.1
95.2
5054.8 52.4
0
10
20
30
40
50
60
70
80
90
100
Feeling tired or lack
of energy
Bone or joint pain Pruritus Decreased appetite
Stage 4 Stage 5 HD PD
![Page 15: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/15.jpg)
a university for the worldrealR
4.263.9
2.132.38
2.57
4.35
3.38
21.75
2.78
6.1 6.025.75
5.46 5.61
6.95
4.3
5.29
4.33
3.48
0
1
2
3
4
5
6
7
8
Feeling tired or
lack of energy
Bone or joint pain Feeling irritable Decreased
interest in sex
Pruritus
Stage 4 Stage 5 HD PD
Symptom Distress (mean, max = 10)
![Page 16: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/16.jpg)
a university for the worldrealR
Symptom Severity (mean, max = 10)
4.63
3.67
4.34
3.48
2.6
4
4.54.25
2.692.94
6.946.61
6.03 5.855.48
4
5
6.55
3.152.82
0
1
2
3
4
5
6
7
8
Decreased
interest in sex
Difficulty to
becoming
sexually aroused
Feeling tired or
lack of energy
Bone or joint
pain
Pruritus
Stage 4 Stage 5 HD PD
![Page 17: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/17.jpg)
a university for the worldrealR
Symptom Frequency (mean, max = 10)
0
1
2
3
4
5
6
7
8
Decreased
interest in
sex
Difficulty to
becoming
sexually
aroused
Feeling
tired or lack
of energy
Bone or
joint pain
Pruritus Trouble
falling
asleep
Worrying Depression Feeling
nervous
Stage 4 Stage 5 HD PD
![Page 18: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/18.jpg)
a university for the worldrealR
![Page 19: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/19.jpg)
a university for the worldrealR
Patients seldom present with a single symptom—which may perhaps explain
why treating one symptom may not necessarily improve health-related quality
of life
![Page 20: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/20.jpg)
Queensland University of Technology
CRICOS No. 00213J
Symptom Clusters
![Page 21: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/21.jpg)
a university for the worldrealR
Symptom Cluster
• Two or more symptoms that occur together, are stable and relatively independent of other clusters
• Symptoms in a cluster may or may not share the same aetiology (Kim et al., 2005)
![Page 22: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/22.jpg)
a university for the worldrealR
Why are symptom clusters important?
• Provide better method of assessment as it can assist with anticipating other symptoms within the cluster
• Assist in prioritising assessment and management by targeting the clusters that strongly predict patients’ outcomes
• To facilitate development of effective intervention strategies
• Improve patient outcomes (e.g. health-related quality of life)
![Page 23: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/23.jpg)
a university for the worldrealR
Evidence of Symptom Clusters
• The majority of studies have explored symptom clusters in oncology
• Research suggests that symptom clusters independently predict
– functional status
– quality of life
– mortality rate
![Page 24: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/24.jpg)
a university for the worldrealR
![Page 25: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/25.jpg)
a university for the worldrealR
Cluster Core Symptoms
Fluid volume symptoms Cough
Shortness of breath
Chest pain
Light headedness or dizziness
Difficulty concentrating
Neuromuscular symptoms Muscle soreness
Numbness or tingling in feet
Sexual symptoms Decreased interest in sex
Difficulty becoming sexually aroused
Psychological symptoms Feeling anxious
Worrying
Feeling sad
Depression
Feeling nervous
Gastrointestinal symptoms Vomiting
Nausea
Pattern and structural cut-off > 0.50
![Page 26: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/26.jpg)
a university for the worldrealR
A
1. Fluid volume symptom cluster
2. Neuromuscular symptom cluster
3. Gastrointestinal symptom cluster
4. Sexual symptom cluster
5. Psychological symptom cluster
B
Fatigue
1
5
4 3
2
Restless legs
Sleep disturbance
1
CKD Symptom Clusters
Almutary et al. J Adv Nurs, 2016;72(10):2389-2400.
![Page 27: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/27.jpg)
Queensland University of Technology
CRICOS No. 00213J
Symptom Theory
![Page 28: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/28.jpg)
a university for the worldrealR
Theory of Unpleasant Symptoms
Lenz, E. R., et a.. (1997). The
middle-range Theory of
Unpleasant Symptoms: an
update. Advances in Nursing
Science, 19(3), 14-27.
![Page 29: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/29.jpg)
a university for the worldrealR
Theory of Unpleasant Symptoms - CKD
Almutary et al. 2017. Towards a symptom cluster model in chronic
kidney disease: A structural equation approach. J Adv Nurs
DOI 10.1111/jan.13303
![Page 30: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/30.jpg)
a university for the worldrealR
Almutary H, Douglas C, Bonner A. Journal of Advanced Nursing, 2017;73:2450-2461.
![Page 31: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/31.jpg)
a university for the worldrealR
Are symptoms multidimensional? YES
Are there differences in symptom burden between CKD stage and treatment modality? YES
Do symptoms cluster (occur) together? YES
Are there consequences of symptom burden? YES
![Page 32: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/32.jpg)
a university for the worldrealR
ANZDATA Registry 40th Report (2018)
![Page 33: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/33.jpg)
a university for the worldrealR
Integrating Palliative Care into Teams
• Compelling evidence for early integration of PC into usual cancer, heart failure and respiratory care:– Better symptom control and HRQoL
– Less anxiety and depression
– Greater prognostic awareness
– Less futile care
– Less caregiver distress
– Equal or better survival
– Modulates expected escalation of health service use
1. Temel et al. NEJM, 2010;363:733-742
2. Bakitas et al. J Oncol Prac, 2017;13(9):557-566
3. Brannstrom et al. Euro J Heart Fail, 2014;16:1142-1151
4. Higginson et al. Lancet Resp Med, 2014;2:979-987
5. Gunjur Lancet Oncol, 2015;16(7): e321
![Page 34: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/34.jpg)
Queensland University of Technology
CRICOS No. 00213J
Conservative Care or is it Supportive Care?
And who should receive it?
![Page 35: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/35.jpg)
a university for the worldrealR
Kidney* (or Renal) Supportive Care
For all CKD/ESKD patients (focus on frailty regardless of its cause and CKD stage)
• Includes people CKD stage 4 ESKD on dialysis and/or failing transplant
• Similar holistic person-centred care Shared decision making in a safe (‘ethos’) environment Coaching and support patient/family in self-discovery; dealing
with unfinished business in life Advance Care Planning Social and family support, etc… Emphasis on symptom-burden reduction and health-related
quality of life Planned withdrawal from dialysis
• Emphasis on symptom-burden reduction and health-related quality of life
• Planned withdrawal from dialysis
![Page 36: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/36.jpg)
Queensland University of Technology
CRICOS No. 00213J
INTEGRATING RENAL
AND
PALLIATIVE CARE
![Page 37: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/37.jpg)
a university for the worldrealR
Metro North Hospital and Health Service
Kidney Health Service 9 sites
2 x hospitals 2 x satellite dialysis units Home training (PD & HD) 4 x Community outpatient clinics
Performed 1st dialysis in Australia (1955)
>3,000 CKD stages 3-5 2 Nurse Practitioners Nurse-led CKD model of care
Size = 4,157 km2
![Page 38: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/38.jpg)
a university for the worldrealR
Kidney Health Service
Palliative & Supportive Care Service
Kidney Supportive Care Program
Symptom management
Support for dialysis decision-making
Psychosocial support
Planning for end-of-life
![Page 39: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/39.jpg)
Queensland University of Technology
CRICOS No. 00213J
Renal carePalliative
care
Kidney
supportive care
Patient choices Symptom management
PURPOSE
![Page 40: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/40.jpg)
a university for the worldrealR
Integrated KSCp
Clinical Nurse
Consultant
Palliative Care
Physician
Adv Trainee (Nephrology)
Social Worker
Renal Pharmacist
Patient
(& Carer)
![Page 41: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/41.jpg)
a university for the worldrealR
Dialysis
General nephrology service
![Page 42: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/42.jpg)
a university for the worldrealR
KSCp model of care
![Page 43: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/43.jpg)
a university for the worldrealR
Symptom Management Strategies
![Page 44: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/44.jpg)
a university for the worldrealR
Fatigue
• Debilitating and difficult to manage
Management:
– Optimise Hb 110-120 g/L
– Encourage simple activity
– Strategies to conserve energy
– Assess for depression
![Page 45: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/45.jpg)
a university for the worldrealR
Itch
• Mechanism unclear (dry skin, immune dysfunction, stimulation of C fibres)
Management:– 15 minute bath every day
– Moisturiser use
– Evening primrose oil (100-200mg bd)
– Gabapentin
– Thalidomide
– Naltrexone, antihistamines, ondansetron
![Page 46: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/46.jpg)
a university for the worldrealR
Restless legs syndrome
• Urge to move limbs when at rest
• Worst at night
Management:
– Clonazepam
– Pramipexole (dopamine agonist)
– Gabapentin
![Page 47: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/47.jpg)
a university for the worldrealR
Dyspnoea
• Common at end-of-life
• Can rapidly progress and cause severe distress
Management:– Non-pharmacological (calm reassurance, fan, open
window, sitting upright)
– Pharmacological (oxygen, opioids, sedatives, antisecretoryagents)
![Page 48: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/48.jpg)
a university for the worldrealR
Pain
• Chronic, non-malignant origin (e.g. osteoarthritis, peripheral neuropathy, cramps)
Management:
– Step 1: paracetamol 1g qid
– Step 2: tramadol 50-100mg bd
– Step 3: oxycodone, hydromorphone, fentanyl
![Page 49: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/49.jpg)
a university for the worldrealR
Nausea
• Mechanisms include uraemia, dehydration, gastroparesis, medications
Management:
– Haloperidol
![Page 50: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/50.jpg)
a university for the worldrealR
Diarrhoea
• Can be related to medications or autonomic nervous system
Management:
– Decrease caffeine
– Rationalise medications
– Bulking agents (metamucil)
– Anticholinergics (not codeine)
![Page 51: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/51.jpg)
a university for the worldrealR
Depression
• Present in ~25-30% of patients on HD
• Linked to poor quality of life
Management:
– Social work/psychology/psychiatry
– SSRIs, tricyclic antidepressants, SNRIs
![Page 52: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/52.jpg)
a university for the worldrealR
Sexual dysfunction
• ED, decreased libido, decreased fertility
• Often poorly recognised
Management:
– Sildenafil for ED
– Oral zinc (?)
![Page 53: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/53.jpg)
a university for the worldrealR
Questions
![Page 54: How do we relieve uraemic symptoms? · 2018. 10. 24. · Neuromuscular symptoms Muscle soreness Numbness or tingling in feet Sexual symptoms Decreased interest in sex Difficulty becoming](https://reader033.vdocuments.us/reader033/viewer/2022051901/5fef8dd0a777dd6e871dc2ba/html5/thumbnails/54.jpg)
a university for the worldrealR
All the patients of the Kidney Support Care program who participated in the research
Carol Douglas
Katrina Kramer Bernie Taylor
Isle Berquier
Louise Purtell
Helen Healy
Carla Scuderi
Ann Bonner Wendy Hoy
Marcin Sowa