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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 10: Common Physical Symptoms
    Specific Symptoms

     
    Breathlessness (Dyspnea)
    Nausea and Vomiting
    Constipation
    Diarrhea
    Anorexia/Cachexia
    Fatigue/Weakness
    Fluid Balance/Edema Skin
    Odors
    Insomnia

    Fluid Balance/Edema

    Case Example

    OF is a 78-year-old mathematician with alcoholic cirrhosis of the liver with ascites and dependent edema. He complains of "tight legs and abdomen". Blood pressure is 110/50 mm Hg and his wife notes he isn’t urinating very much.

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    Definition/Description

    • Frequently associated with advanced illness
    • Focus in this section is on management of patients with advanced disease
    • This does not cover the management of edema when the causes are easily identifiable and reversible
    • Difficult cases may merit interdisciplinary evaluation

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    Causes

    • Hypoalbuminemia leads to reduced oncotic pressure, decreased intravascular volume (with relative hemoconcentration), and increased fluids in interstitial spaces (edema)
      • In the face of hypoalbuminemia and consequent diminished oncotic pressure, patients will be unable to maintain their usual intravascular physiology

      • Decreased intravascular volume stimulates antidiuretic hormone secretion and increases free-water retention

      • This, in turn, leads to a relative hyponatremia as water exceeds salt retention

      • in patients with hypoalbuminemia, a small amount of peripheral edema is indicative of "closer to normal" intravascular volumes, in contrast to the significantly decreased volumes that will be present when hypoalbuminemia is not accompanied by peripheral edema

      • It is normal for some patients to develop relative hypotension, tachycardia, and reduced urine output

      • No amount of intravenous fluid and salt will return the intravascular volume to normal

        • Attempts to do so will create or exacerbate edema, resulting in swollen limbs, skin breakdown, ascites, pleural effusions, and pulmonary edema

        • Similarly, exogenous albumin infusions are ineffective and expensive and may make edema worse because of extravasation of denatured albumin into the soft tissues


        • These ineffective approaches will, if pursued, lead to markedly worsened physical symptoms due to edema that become more difficult to manage

        • Patients with clinical edema are not dehydrated
          • they have excess quantities of total body fluid and salt
          • With time, they may be able to reabsorb them, though not as efficiently as normal

        • Venous or lymphatic obstruction may contribute

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    Management

    • Limit or avoid IV fluids
    • Urine output will be low
      • urine output of 300–500 ml/day or less is normal and adequate in this setting
    • Drink some fluids with salt
      • Supplemental fluid (particularly parenteral) should be avoided

      • Patients should be encouraged to eat and drink as they usually do

      • Treat symptoms that prevent oral intake

      • Debilitated patients may only be drinking free water (such as in tap water, tea, coffee, juices, sodas that have no sodium chloride)

      • Encourage them to drink some salt-containing fluids (soups, club soda, sport drinks, red vegetable juices) to help them maintain their electrolyte balance
    • Fragile skin
      • Use other interdisciplinary team members to assess and manage it with appropriate supports and protection

      • Selected patients with limb edema may benefit from appropriate wrapping with compression bandages
    • Careful attention to mucous membranes (mouth, lips, eyes, nose, etc) can prevent sense of dryness that hypoalbuminemia and intravascular hypovolemia may bring (see Module 12: Last Hours of Living)

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    Comments on Last Hours of Living

    • As with nutrition, almost everyone ceases oral intake as they approach the last hours of their lives
    • Patients, family members, and caregivers often find these changes distressing, and need a lot of support
    • See:
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