LifeCare Palliative Care Symptom Management Guidelines
Agitation, anxiety, delirium and depression management:
Nursing interventions:
 Reduce sensory stimulation
 Restore/re-orient routines
 Use client/patient/resident’s adaptive
devices (glasses, hearing aids, etc.)
 Calm fears for agitation and anxiety
 Educate the client/patient/resident and
family about the use of guided imagery
CDs and relaxation techniques
 Consult spiritual care
Medical interventions:
 Alprazolam (Xanax) 0.25-0.5mg TID PO
PRN for anxiety
 Citalopram (Celexa) 10mg to 40 mg daily
PO for depression or anxiety
 Haloperidol (Haldol) 0.5 mg
PO/IV/subcutaneous, titrate up to 5 mg
every hour a daily requirement is
established and then administer in 2-3
divided doses daily PRN for agitation,
anxiety, physical aggression with the
potential to cause harm and/or
hallucinations or delusions that are
causing the client/patient/resident
distress. Maximum daily dose is 30 mg/24
hours. Evaluate after each dose.
 Mirtazapine (Remeron) 7.5-15 mg daily PO
for depression
 Sertraline (Zoloft) 25-200mg daily PO for
depression or anxiety
 Refer to Social Services
 Refer to Behavioral Health
Anorexia/cachexia management:
Nursing interventions:
 Education with client and family including:
o Exploration of the meaning of
feeding
o Types of appealing food and drinks
o Use of small portions on small
plates
o Artificial hydration/nutrition
considerations
o Minimizing odors that suppress
appetite
o Use of essential oils that stimulate
appetite
 Consult dietary
Medical interventions:
 Dexamethasone (Decadron)2-6 mg PO
daily maximum dose 6 mg/24hours.
 Metoclopramide (Reglan) 10-20 mg PO 30
minutes before meals and HS
Medical interventions:
 Docusate sodium 100-400 mg PO BID,
maximum dose 800mg/24hours
 Senna 1-4 tabs PO BID
 Docusate/senna 1-4 tablets PO BID
 Magnesium hydroxide (MOM) 30 ml PO
daily PRN
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Nursing interventions:
 Educate family and client including:
o Increasing fluids and high fiber
foods
o Encouraging more activity
o Ensuring privacy for bowel
movements
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Constipation management/Bowel care

Ensure orders have been obtained for
constipation/bowel care if opioids are
prescribed.

Polyethylene Glycol (Miralax) 17 grams PO
daily mixed in 8 oz of liquid PRN
Cough Management
Nursing interventions:
 Elevate head of bed to 30°
 Add room humidifier
Medical interventions:
 Benzonatate (tessalon) 200mg PO TID PRN
 Guaifenesin & dextromethorphan
(Robitussin DM) 5 ml PO every 2 hours
PRN
 Guaifenesin with codeine 5 ml PO every 2
hours PRN
Diarrhea management
Medical interventions:
 Loperamide (Imodium) 4 mg initially then
2 mg after each loose BM to a maximum
of 16 mg/24 hours
Dry eyes/nose management
Nursing interventions:
 Add humidification to room
Medical interventions:
 Artificial tears 1-2gtts each eye PRN
 Eye lubricant (artificial tears) ¼ to ½ inch in
lower lid BID PRN
 Saline nasal spray in each nostril PRN
Dyspnea management
Nursing interventions:
 Semi-fowlers positioning as comfortable
for client
 Add a fan to room
 Open a window
 Oxygen at 2 liters via nasal canula PRN,
may titrate up for comfort, using caution
with clients with COPD
 Pulse oximetery if it will result in a change
in treatment or therapy plan
Medical interventions:
 Albuterol 2.5mg/3ml by nebulizer every 4
hours
 Albuterol/ipratropium (Duoneb) in 3 ml by
nebulizer every 4 hours
 Alprazolam 0.25-0.5mg TID PO PRN
 Furosemide 5-40 mg PO every hour PRN
for dyspnea and rales
 Morphine 2.5 mg PO/SL every hour PRN,
evaluate after each dose
 Morphine 0.5 mg IV every 15 minutes PRN
 Oxycodone 2.5-10 mg PO/SL every hour
PRN, evaluate after every dose

Fatigue Management
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Medical interventions
 Prednisone 7.5-10mg PO daily

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Nursing interventions
 Educate client and family including:
o Promote adaptation and
prioritization of activities
o Encourage mild exercise and
activity
o Schedule rest periods
Fever Management
Nursing interventions:
 Tepid sponge baths
 Cool clothes to groin, armpits and
forehead
 Minimal covers
Medical interventions:
 Acetaminophen 650mg every 6 hours
PO/rectally PRN
 Acetaminophen 1000 mg every 4 hours
PO/Rectally PRN. Not to exceed 4 gm/24
hours.
 Ibuprofen 400-800mg every 4 hours PO
PRN. Not to exceed 3200mg/24 hours
 May alternate ibuprofen dose with
acetaminophen 650 mg every 4 hours PRN
Hiccup Management
Nursing interventions:
 Educate family and client on nonpharmacological interventions, such as:
o Soft palate massage
o Holding ice water in the
oropharynx
o Swallow 2 teaspoons of sugar
o Swallow dry bread
o Tongue traction enough to trigger
gag reflex
Medical interventions:
 Chlorpromazine 25-50 mg PO every 6
hours PRN
 Baclofen 5 mg PO every 8 hours PRN,
reduce dose for clients with renal
dysfunction
Nausea & Vomiting Management
Nursing interventions:
 Educate client and family
o Avoidance of smells that trigger
nausea
o Incorporate relaxation techniques
o Use of essential oils such as ginger
Medical interventions:
 Dexamethasone 1-20 mg PO daily, may be
given in divided doses, reevaluate in 7
days
 Prochlorperazine 25 mg suppository
rectally every 12 hours PRN
 Haloperidol 2 mg PO/SQ/IV BID PRN
 Lorazepam 0.5 – 1.5 mg PO every 4 hours
 Metoclopramide (Reglan) 10-20 mg PO/IV
QID 30 minutes before meals and at hs
Medical interventions:
 Artificial saliva every hour PRN
 Topical viscous lidocaine 2% 5 ml every 4
hours PO PRN, swish and spit
 Miracle mouth wash (equal parts viscous
lidocaine 2%, disphenhydramine 12.5
mg/2ml, and antacid 200/200/20 mg/5ml)
5 ml every hour PRN, swish and spit or
swish and swallow
Candid treatment:
 Nystatin (100 000units/ml) 5 ml swish and
swallow QID x 7 days, then reevaluate
 Fluconazole 200 mg PO initially then 100
mg PO for 7 days, then reevaluate
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Nursing interventions:
 Educate family and client including:
o Use of a soft toothbrush or
toothette
o How to clean dentures
o Food preparation: lukewarm,
nothing too hot/cold, mildly
spiced, soft foods
o Lip balm as needed to keep lips
moist
o Salt solution, 1 tsp salt in 1 c H2O,
15-30 ml. Swish and spit 4 times
daily as needed
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Oral Care Management
Pain Management
Neuropathic pain:
 Amitriptyline10-25 mg daily PO HS PRN
(avoid use in elderly clients)
 Gabapentin 100 mg PO daily at HS, titrate
up to 300mg BID , then 300mg TID
 Gabapentin ( for elderly population) 100
mg PO daily at HS, titrate up to 100mg BID
then 100mg TID
 Pregabalin 50 mg PO TID, evaluate in 7
days (decrease dose for clients with renal
dysfunction)
 Transdermal lidocaine patch (1-3 patches),
apply for 12 hours then remove for 12
hours
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Medical interventions:
Mild pain:
 Acetaminophen 1000 mg every 6 hours PO
PRN
 Acetaminophen 650 mg every 4 hours PO
PRN, not to exceed 4 gm /24 hours
 Ibuprofen 400-800 mg PO every 4 hours
PRN, not to exceed 3200 gm/24 hours
 Naproxen 250 mg PO BID PRN
 Tramadol 25-100 mg PO QID PRN (reduce
dose in clients with renal dysfunction; not
to exceed 400 mg/24 hours)
 Hydrocodone/APAP 5/500mg 1-2 tabs PO
every 4 hours PRN
 Oxycodone/APAP 5/500mg 1-2 tabs PO
every 4 hours PRN
Malignant Bone Pain:
 Ibuprofen 400-800mg PO QID
 Naproxen 250 mg PO BID
 Dexamethasone 3-12 mg PO TID
Opioid medication for moderate to severe pain
 Hydromorphone (Dilaudid) 2 mg PO every
1 hour PRN
 Hydromorphone 0.1 mg IV every 15
minutes PRN
 Morphine 0.5 mg IV every 15 minutes PRN
 Morphine 10 mg PO every hour PRN
 Morphine SR (MS Contin)15 mg PO every
12 hours
 Oxycodone IR 5-10 mg every hour PRN
 Oxycodone SR 10 mg PO every 12 hours
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Nursing interventions
 Educate client and family of nonpharmacological interventions including:
o Guided imagery CDs
o Essential oils such as Pam Away,
ginger
o Diversional techniques
o Massage
o Social work referral PRN to teach
relaxation techniques
Secretion Management
Medical interventions:
 Atropine 1% ophthalmic solution 1-4gtts
every 2 hours PRN
 Scopolamine 1.5 mg transdermal patch
behind ear, change every 72 hours PRN.
May increase to 3 patches changed every
72 hours PRN
Seizure Management
Nursing intervention:
 Educate family
o Not to put anything in mouth of
client, especially fingers
o How to place client in a recovery
position.
Medical interventions:
 Lorazepam 2-4mg IV/SQ PRN, may repeat
in 15 minute intervals if seizure continues,
maximum 8 mg/ 12 hours
 Diazepam 5-10 mg IV/Buccal/IM every 15
minutes to a maximum of 30 mg PRN
 Diazepam 0.2 mg/kg rectally for seizures,
may repeat one time in 4 hours PRN,
maximum of one course of treatment
every 5 days.
Medical interventions:
For wound pain:
 Hydromorphone 2-4mg PO every hour
PRN
 Morphine 1 mg in 1 gram hydrogel applied
to cover wound surface daily
To control odor:
 Metronidazole 500 mg PO TID x 7 days,
reassess
 Metronidazole 500mg crushed and
sprinkled into wound daily x 7 days.
Reassess
 Silver sulfadiazine cream 1% applied to
wound surface daily, assess in 7 days
For Pruritus:
 Hydroxyzine 10-25 mg PO every 6 hours
PRN
 Doxepin 10-25 mg PO daily HS, use for 7
day and evaluate
 Paroxetine 10-20 mg PO daily
 Diphenhydramine 25 mg every 4 hours PO
PRN
 Hydrocortisone 1% cream or lotion applied
TID PRN
 Triamcinolone 0.1% cream topically TID
PRN
Pressure ulcers and malignant wounds:
 Cleanse wound with NS or non-cytotoxic
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Nursing interventions:
 Do a Braden skin risk assessment, if
warranted start safety protocol
 Over the counter moisturizing lotion as
needed for dry skin and discomfort of itch
 Peppermint oil for odor, on bed linen or in
room, not on ulcer
 Kitty litter, coffee grounds or activated
charcoal placed in dish under bed to
absorb odor
 Lavender oil mixed in carrier oil apply to
skin for itch
 Use of pressure reducing mattress, where
available
 Heel protection
 Evaluate chairs, wheelchairs, etc., for
appropriate pressure relieving surfaces
 Educate family and client including:
o Causes and risks for pressure areas
o Mobilization
o Minimizing friction and sheer
o Moisture control on skin
o Nutrition and hydration
o Techniques for odor control
o Wound cleansing and irrigation
 Administer PRN pain med ½ hour prior to
dressing change
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Skin and Wound Management




wound cleanser
For low to moderate amounts of exudates
in stage 2-3 ulcers:
o Hydrocolloid dressing; change
every 2-5 days
o Foam dressing, change every 3-5
days
For copious exudates:
o Alginate (avoid in bleeding
wounds). Apply topically within
wound borders, change every 2-4
days
o Ostomy appliance to contain
drainage from fungating wounds
To prevent bleeding:
o Use non adherent absorbing
dressings
o Moisten dressings with NS before
removal
To manage active bleeding:
o Apply gauze saturated with 1:1000
solution of epinephrine
o Apply firm pressure to wound
Sleep Disturbance/Insomnia Management
Nursing interventions:
 Educate client and family including:
o Good sleep environment
o Relaxation therapies
o Avoidance of stimulants such as
caffeine
o Use of essential oils such as Peace
& Calm or lavender
Medical interventions:
 Alprazolam 0.25 to 0.5mg may repeat dose
in 1-2 hours
 Temazepam 15 mg PO at HS PRN may
repeat x 1 dose
 Trazodone 25-100 mg PO HS PRN, may
repeat x 1 dose
 Zolpidem 5-10 mg PO HS PRN
Urinary Incontinence and/or Retention Management
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Medical interventions:
 Oxybutynin 2.5mg PO2-4 times daily PRN
for bladder spasms
 Straight/indwelling catheter PRN
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Nursing interventions:
 Bladder scan PRN to confirm retention
 Rectal exam to rule out fecal impaction