Lecture # 405:
Basic Daily Skills: Medications

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

Managing Pain
Uncontrolled pain is a terror for every seriously ill person. Pain comes in an endless variety of forms and with many different causes:

• Visceral pain is common with diseases or medications that interrupt normal digestion and excretion.
• Local pain is due to direct damage to soft tissue following surgery or a fall.
• Pains in joints, bones, and muscles can result from clotting disorders, disuse, and atrophy while bedridden or during a high fever.
• Headaches are caused by diseases such as tumors, drugs and steroid therapy.
• Nerve pain comes from radiation therapy or surgery, or as a result of and infections such as shingles or damage to the nerve from a lifesaving medication.

All of these can come from any number of sinister combinations and vary in intensity over the course of a day. Each person has a different threshold for pain. Other factors such as anxiety, lack of sleep, nausea and vomiting, constipation, and diarrhea can increase pain.

Meditate Word By Word On These Verses:
Luke 9:1-2.

Some people believe that tolerating pain is courageous or that suffering is somehow a test of spiritual faith; in fact, unremitting pain only leaves an ill person weaker and sicker and hastens death in some cases. Pain medicine can be one of the weapons for fighting disease and maintaining vitality. With cancer pain, a mild tranquilizer in the morning and a sleeping pill at night can help. Along with these medications, a low dose of morphine and anti-nausea agents can keep a person fairly comfortable.

Question 1: What is your philosophy of treating pain? What spiritual significance does pain have, if any?

Fundamentals of Pain Management
Notice the pattern of the pain. Sometimes people have more pain at night when they are trying to fall asleep or maybe they have more pain in the morning when they first waken. Stress and fatigue increase pain. Give the pain medication a little early before the pain gets severe and you will need less medicine and have less suffering.

Don't wait until someone is complaining of pain to medicate. Pain prevention requires lower doses than does attempting to alleviate pain after it has reached the threshold of the person's tolerance. Instead of increasing the does of the medication, try administering it more often. If the doctor has ordered 20 milligrams of morphine every four hours, but your patient is hurting after two hours, try giving 10 milligrams of morphine every 2 hours.

Question 2: Why is it important to give pain medication before the pain is intolerable to the patient?

Try a different route of giving the medication. Suppositories and shots work faster than oral medications. Skin patches deliver a continuous dose of medication. Raise the dosage level of the drug if you think that it is necessary.

Suppositories are designed to melt quickly at body temperature. Be sure to keep them refrigerated until time to give them. You need a sterile glove to grip the medication and avoid germs in the rectal canal. With the person lying on his left side (this side is preferable), bring his knee up to about 90 degrees and insert the suppository into the rectum. Push the suppository into the rectum with the tip of your finger. The anus is about 2.5 centimeters deep and you will feel when the suppository enters into the wider space of the rectum. Sometimes, the suppository slips out, so be sure to check your patient about 5 minutes after giving it to be sure that it is still in place.

Concentrate on restoring control over the situation than alleviating pain altogether. If we can just take the biting edge of pain from a sick person, he is better able to tolerate a moderate level of pain with fewer drugs. Using various methods of helping the person to rest - backrubs, positioning, warm drinks - assist in combating feelings of desperation and impotence.

Anticipate constipation especially if you are giving narcotics. These drugs slow down the digestive system. Give a mild laxative if they are constipated. Encourage them to drink plenty of fliuds and move about as much as possible.

3. What environmental factors make pain worse?
(Only one of the following answers is correct.)
loud noises, television programs, traffic noise.
lack of sufficient faith.
an uncomfortable bed.

Types of Pain Medication

1. Nonprescription pain relievers are Aspirin, Acetaminophen, and nonsteroidal anti-inflammatory drugs such as Advil and Motrin.
2. Mild Narcotics are prescription drugs such as Codeine and Percocet/Percodan.
3. If the pain increases and remains severe, an opioid such as Morephine and Dilaudid is added. Narcotics are the mainstay of pain management, but their effect is increased by adding complementary drugs to alleviate nausea and tension as well as increasing the effect of the narcotic. The complementary drugs include antidepressants, sedative, and antiemetics. As usual, pay attention to the doctor's instructions and read the inserts of the medication package. Many patients will be given a prescription such as Tagamet to prevent ulcers.

Digestive Complications
Sick people have many reasons for not eating. For those expected to die soon, we help them eat whatever they want. If they are not hungry or thirsty, we don't pressure them because one of the ways the body naturally shuts down is to refuse fuel.

If we care for someone who is expected to live, we don't strictly enforce rigid diets if it means that our patient eats too little. An example is given of a man who loved fried foods. He had cardiac surgery and was placed on a low salt, low cholesterol, and low fat diet. This was a highly restrictive diet for a connoisseur of fried foods. He decided this diet was making him sick and insisted on eggs and bacon for breakfast and hamburgers for dinner. He died much later of cancer and not of heart disease.

The biological process of fighting a disease and tolerating treatment demands expenditure of energy comparable to that of an athlete. However, if the person is not fed, his body wastes away to thinness and decreased muscle mass. Many patients become shockingly weak, anemic, and vulnerable to secondary infections.

Question 4: Why is exercise important for the person who has trouble eating?

The caregiver's task is to provide the person with nutrition and hydration they can tolerate. There are limits to this general rule though. Those with diabetes, heart failure, and impaired kidney function need to adhere to the diets their doctors give them.

Stimulating Appetite

• Prepare favorite foods. A grandmother from Russia living in New York ate all the Russian foods her granddaughter could find from the restaurants in Brighton Beach. It helped her recover from surgery.
• Serve small portions, perhaps 5 times daily.
• Give the sick person enough time to eat.
• Pudding, yogurt, and fruit are good snacks.
• Deep breathing or exercise before meals increases digestion.
• When cooking foods, make some extra and freeze it so that there will be some for later.

Complications that Interfere with Eating
Altered taste may result from x-ray therapy, chemotherapy, or other medications. There may be a bitter or metallic taste in the mouth. You can do these things:

• Rinse his mouth with a solution of warm water and soda or brush the teeth.
• Try serving food at room temperature so that the taste is less intense.
• Vinegar, lemon juice, pickles help to mask the metallic taste in the mouth from radiotherapy treatment.
• Choose foods that smell good to the patient.

Question 5: Why is food important to the person recovering from illness?
(Select the best answer.)
It makes the person feel more positive about life.
Fighting an illness takes as much energy as participating in athletics.
Good food is important to everyone.

Dry Mouth
Certain medications, breathing oxygen, breathing through the mouth, and general dehydration contribute to dry mouth. It makes eating anything painful. You can do these things:

• Stimulate salivation by sucking on sour candies or chewing gum.
• Moisten food with sauces, salad dressing, yogurt, soup. Dip bread in milk, soup, or olive oil.
• Sip water between bites of food.
• Minimize alcohol, caffeine, and smoking, which dry out the mouth.
• Keep lips moisturized with lip balm.

Question 6: Why is "caramel" candy helpful for the person who has a dry mouth?

Sore Mouth or Throat
The throat and esophagus can become extremely sore as a result of local infections or radiotherapy. Severe acid reflux from the stomach can also irritate the lining of the esophagus making swallowing difficult. You can do this:

• Use the soda-water solution for a rinse. Do not use commercial mouthwashes; they are too harsh.
• Avoid salty, spicy, or acidic foods. Serve bland foods - soups, mashed potatoes, even baby foods.
• Hot foods burn the inflamed tissues of the mouth.
• Coarse textured foods such as crackers and raw vegetables irritate the mucus membrane. Try cooked cereals with plenty of butter or milk, scrambled eggs, macaroni, mashed bananas, etc.
• Keep dentures clean and take them out if the person's gums are sore.

Question 7: How can you moisten foods so that swallowing becomes easier?

If there are physical impairments so that eating is a challenge ie: stroke, sclerosis, or Parkinson's disease, try using a cup with handles on it (the type used for small children) If the person has memory loss, confusion, or intellectual impairment, he may forget to eat or lose interest in eating if something distracts him. Others may not remember eating, having just eaten. You can do this:

• Turn off the TV or radio during meals.
• Keep only the necessary utensils on the table.
• Store food out of sight between meals for the person who forgets that he just ate.
• Pour liquids into cups, filling them only half full.
• Let the person eat with his hands if that is easier for him.
• A wide, low bowl is good for serving solid foods.
• Use straws to drink fluids.
• Ignore declining table manners - be prepared for spills and don't over-react when they occur.

Question 8: How do you decrease distraction for a person when it is time to eat?

Indigestion and Nausea
Causes of these two problems are antibiotic medications, reduced motility of the GI tract due to illness or immobility, obstruction of the digestive tract, gallbladder disease, kidney disease, AIDS, and many other problems. A sick stomach is one of the most debilitating aspects of illness. It can be a feeling of mild indigestion to severe dyspepsia that makes a person double over in pain. Whatever the cause, there are some things we can do to help the person with an upset stomach.

• Try to keep a little food in the stomach at all times to buffer stomach acids and digestive juices. Small, frequent meals are much easier to keep in the stomach and digest.
• Serve cool foods - hot foods increase nausea.
• Experiment with medications for nausea that you can get at the pharmacy.
• Use antiemetic drugs such as Compazine. Give medication before your patient begins to lose weight and sleep. Get the drug in a suppository form if he is vomiting frequently.
• Drinking herbal tea with honey or ginger root can often settle an upset stomach.
• Reduce external stimulation - lower the amount of light in the room, turn down the volume of the TV, don't bump the bed!
• Don't let your patient lie down immediately after a meal. Encourage them to sit up or take a walk.
• Sometimes, cool air helps to alleviate nausea: opening windows can help.

If vomiting occurs, have the person take deep breaths. Clean up the area as soon as possible. Rinse the mouth and/or brush teeth.

9. It is important to keep food in the stomach of a person with indigestion:
(Only one of the following answers is correct.)
to keep digestive juices from irritating the stomach.
to keep him well fed.
to make sure he is happy.

Difficulty Swallowing
Causes include mechanical difficulties seen as a result of stroke, Parkinson's disease, traumatic brain injury, and ammyotrophic lateral sclerosis. Some people simply forget to swallow. These are people who have dementia, Alzheimer's disease, and AIDS. Surgical removal of the tongue due to tumor and radiation therapy present real loss of function of the body as well as difficulty eating.

With this problem, the caregiver has two major concerns. One is that the person will not be able to eat enough to stay adequately nourished and aspiration or inhaling food into the lungs causing pneumonia. You can do this:

• Feed the person while he is sitting up
• Encourage him to sit up for 30 minutes after eating.
• Before swallowing, have him take a deep breath and exhale after each bite. This way, the windpipe is cleared.
• Encourage him to keep his head in normal position. Throwing back the head increases the possibility of diverting liquid or food into the windpipe.
• If liquids are well tolerated, alternate sips with bits of food. Again, sipping from a straw may make liquids easier to swallow.
• You may need to add thickener to liquids such as cornstarch or kisel. Pureed foods may also be better tolerated.
• Very hot or very cold foods can cause a spasm of the esophagus. We need to avoid them.

Constipation and Gas
Causes include dehydration, low fiber diet, immobility, narcotic pain relievers and many other medications, bowel obstructions, and neuromuscular diseases such as Parkinson's disease.

One does not have to be sick to be constipated. It is a particularly dangerous problem with the seriously ill person and older people. It is uncomfortable and can lead to other problems that can be life threatening. These are fecal impactions, perforated intestines, and peritonitis or inflammation of the membrane that lines the abdominal cavity.

Part of our task is to help so that our clients never get constipated. Because this entails using a bedpan or chair commode, it is hard to do. However, he will have an even worse time if we do not help him. We can do this to help our client:

• Encourage him to drink fluids. In people whose kidneys are functioning, urination comes at about 5-6 times per day. If it does not, they are not drinking enough fluids. This means they need to drink1.5 liters of water per day.
• Our clients need to maintain physical activity if they can tolerate it. If our clients are in bed, we need to turn them frequently and have them take deep breaths.
• The client needs to eat high fiber foods such as cereals, vegetables, and fruits.
• If constipation persists, check with the doctor to see if you can give laxatives such as suppositories.
• Try not to give an enema frequently since it weakens the bowel muscle tone and disrupts the internal chemistry of the bowel.
• Establish a daily routine for the client. For example, those with neurological damage may be given an oral laxative in the evening before bed, OR a suppository when he gets up in the morning, OR a hot drink following breakfast and then into the toilet. It also helps to know the client's own bowel habits. Does he go in the evening or the morning? His body also has a rhythm that we need to work with and he will feel more comfortable.

Question 10: What does fiber do to help the intestine?

Fecal Impaction
When constipation persists for several days, the dehydrated stool becomes hard and sticks to the inside wall of the colon. There is more stool and gas behind it that cannot escape and the result is abdominal pain, bloating, nausea, and vomiting. There may be episodes of explosive diarrhea and gas as the backed-up stool and gas escape past the hard stool under great pressure.

The danger of impacted stool means that the person cannot eat and digest food. He is unable to absorb water in the intestines. The bowel wall becomes ulcerated and pressure on the colon can cause perforation in the bowel wall. Sometimes, impactions can be relieved with a combination of increased oral fluids, physical activity, and stool softeners. Enemas can help as well - oil retention and tap water types. When all else fails, the stool is removed manually. This is excruciating and dangerous. It should be done only by experienced healthcare personnel.

Question 11: Why are fecal impactions dangerous for older people?