Pain is complex, so there are many treatment options -- medications, therapies, and mind-body techniques.

Learn the benefits and risks of each, including addiction. What Are the Treatments for Chronic Pain? The treatments for chronic pain are as diverse as the causes. From over-the-counter and prescription drugs to mind/body techniques to acupuncture, if one approach doesn't work, another one might. But when it comes to treating chronic pain, no single technique is guaranteed to produce complete pain relief. Relief may be found by using a combination of treatment options. Drug Therapy: Nonprescription and Prescription Milder forms of pain may be relieved by over-the-counter medications such as Tylenol (acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and Aleve. Both acetaminophen and NSAIDs relieve pain caused by muscle aches and stiffness, but only NSAIDs can also reduce inflammation (swelling and irritation). Topical pain relievers are also available, such as creams, lotions, or sprays that are applied to the skin in order to relieve pain from sore muscles and arthritis. If over-the-counter drugs do not provide relief, your doctor may prescribe stronger medications, such as muscle relaxants, anti-anxiety drugs (such as Valium),antidepressants (like Cymbalta for musculoskeletal pain), prescription NSAIDs such as Celebrex, or a short course of stronger painkillers (such as Codeine, Fentanyl, Percocet, or Vicodin). A limited number of steroid injections at the site of a joint problem can reduce swelling and inflammation. In April 2005, the FDA asked that Celebrex carry new warnings about the potential risk of heart attacks and strokes as well as potential stomach ulcer bleeding risks. At the same time the FDA asked that over-the-counter anti-inflammatory drugs -- except for aspirin - revise their labels to include information about potential heart and stomach ulcer bleeding risks. Patient-controlled analgesia (PCA) is another method of pain control. By pushing a button on a computerized pump, the patient is able to self administer a premeasured dose of pain medicine. The pump is connected to a small tube that allows medicine to be injected intravenously (into a vein), subcutaneously (just under the skin), or into the spinal area. This is often used in the hospital to treat pain. Sometimes, a group of nerves that causes pain to a specific organ or body region can be blocked with local medication. The injection of this nerve-numbing substance is called a nerve block. Although many kinds of nerve blocks exist, this treatment cannot always be used. Often blocks are not possible, are too dangerous, or are not the best treatment for the problem. You doctor can advise you as to whether this treatment is appropriate for you. Trigger Point Injections Trigger point injection is a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. During this procedure, a health care professional, using a small needle, injects a local anesthetic that sometimes includes a steroid into a trigger point. With the injection, the trigger point is made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief.

Trigger point injection is used to treat muscle pain in the arms, legs, lower back, and neck. In addition, this approach has been used to treat fibromyalgia, tension headaches, and myofascial pain syndrome (chronic pain involving tissue that surrounds muscle) that does not respond to other treatment. Surgical Implants When standard medicines and physical therapy fail to offer adequate pain relief, you may be a candidate for a surgical implant to help you control pain. There are two main types of implants to control pain: Intrathecal Drug Delivery. Also called infusion pain pumps or spinal drug delivery systems. The surgeon makes a pocket under the skin that's large enough to hold a medicine pump. The pump is usually about one inch thick and three inches wide. The surgeon also inserts a catheter, which carries pain medicine from the pump to the intrathecal space around the spinal cord. The implants deliver medicines directly to the spinal cord, where pain signals travel. For this reason, intrathecal drug delivery can provide significant pain control with a fraction of the dose that would be required with pills. In addition, the system can cause fewer side effects than oral medications because less medicine is required to control pain. Spinal Cord Stimulation Implants. In spinal cord stimulation, low-level electrical signals are transmitted to the spinal cord or to specific nerves to block pain signals from reaching the brain. In this procedure, a device that delivers the electrical signals is surgically implanted in the body. A remote control is used by the patient to turn the current off and on or to adjust the intensity of the signals. Most people describe the feelings from the simulator as being pleasant and tingling. Two kinds of spinal cord stimulation systems are available. The unit that is more commonly used is fully implanted and has a pulse generator and a non-rechargeable battery. The other system includes an antenna, transmitter, and a receiver that relies upon radio frequency. The latter system's antenna and transmitter are carried outside the body, while the receiver is implanted inside the body. TENS Transcutaneous electrical nerve stimulation therapy, more commonly referred to as TENS, uses electrical stimulation to diminish pain. During the procedure, low-voltage electrical current is delivered through electrodes that are placed on the skin near the source of pain. The electricity from the electrodes stimulates the nerves in an affected area and sends signals to the brain that "scramble" normal pain signals.TENS is not painful and may be effective therapy to mask pain such as diabetic neuropathy. However, TENS for chronic low back pain is not effective and cannot be recommended, the American Academy of Neurology (AAN) now says. Bioelectric Therapy Bioelectric therapy relieves pain by blocking pain messages to the brain. Bioelectric therapy also prompts the body to produce chemicals called endorphins that decrease or eliminate painful sensations by blocking the message of pain from being delivered to the brain. Bioelectric therapy can be used to treat many chronic and acute conditions causing pain, such as back pain, muscle pain, headaches and migraines, arthritis, TMJ disorder, diabetic neuropathy, and scleroderma. Bioelectric therapy is effective in providing temporary pain control, but it should be used as part of a total pain management program. When used along with conventional pain-relieving medications, bioelectric treatment may allow pain sufferers to reduce their dose of some pain relievers by up to 50%.

Physical Therapy Physical therapy helps to relieve pain by using special techniques that improve movement and function impaired by an injury or disability. Along with employing stretching and pain-relieving techniques, a physical therapist may use, among other things, TENS to aid treatment. Exercise Although resting for short periods can alleviate pain, too much rest may actually increase pain and put you at greater risk of injury when you again attempt movement. Research has shown that regular exercise can diminish pain in the long term by improving muscle tone, strength, and flexibility. Exercise may also cause a release of endorphins, the body's natural painkillers. Some exercises are easier for certain chronic pain sufferers to perform than others; try swimming, biking, walking, rowing, and yoga. Psychological Treatment When you are in pain, you may have feelings of anger, sadness, hopelessness, and/or despair. Pain can alter your personality, disrupt your sleep, and interfere with your work and relationships. In turn, depression and anxiety, lack of sleep, and feelings of stress can all make pain worse. Psychological treatment provides safe, nondrug methods that can treat your pain directly by reducing high levels of physiological stress that often aggravate pain. Psychological treatment also helps improve the indirect consequences of pain by helping you learn how to cope with the many problems associated with pain. A large part of psychological treatment for pain is education, helping patients acquire skills to manage a very difficult problem. Alternative Therapies In the past decade, strong evidence has accumulated regarding the benefits of mind-body therapies, acupuncture, and some nutritional supplements for treating pain. Other alternative therapies such as massage, chiropractic therapies, therapeutic touch, certain herbal therapies, and dietary approaches have the potential to alleviate pain in some people. However, the evidence supporting these therapies is less concrete. Mind-Body Therapies Mind-body therapies are treatments that are meant to help the mind's ability to affect the functions and symptoms of the body. Mind-body therapies use various approaches including relaxation techniques, meditation, guided imagery, biofeedback, and hypnosis. Relaxation techniques can help alleviate discomfort related to chronic pain. Visualization may be another worthwhile pain-controlling technique. Try the following exercise: Close your eyes and try to call up a visual image of the pain, giving it shape, color, size, motion. Now try slowly altering this image, replacing it with a more harmonious, pleasing -- and smaller -- image. Another approach is to keep a diary of your pain episodes and the causative and corrective factors surrounding them. Review your diary regularly to explore avenues of possible change. Strive to view pain as part of life, not all of it. Electromyographic (EMG) biofeedback may alert you to the ways in which muscle tension is contributing to your pain and help you learn to control it. Hypnotherapy and self-hypnosis may help you block or transform pain through refocusing techniques. One self-hypnosis strategy, known as glove anesthesia, involves putting yourself in a trance, placing a hand over the painful area, imagining that the hand is

relaxed, heavy, and numb, and envisioning these sensations as replacing other, painful feelings in the affected area. Relaxation techniques such as meditation or yoga have been shown to reduce stress-related pain when they are practiced regularly. The gentle stretching of yoga is particularly good for strengthening muscles without putting additional strain on the body. Acupuncture Acupuncture is thought to decrease pain by increasing the release of endorphins, chemicals that block pain. Many acu-points are near nerves. When stimulated, these nerves cause a dull ache or feeling of fullness in the muscle. The stimulated muscle sends a message to the central nervous system (the brain and spinal cord), causing the release of endorphins that block the message of pain from being delivered to the brain. Acupuncture may be useful as an accompanying treatment for many pain-related conditions, including headache, low back pain, menstrual cramps, carpal tunnel syndrome, tennis elbow, fibromyalgia, osteoarthritis (especially of the knee), and myofascial pain. Acupuncture also may be an acceptable alternative to or may be included as part of a comprehensive pain management program. Chiropractic Treatment and Massage Chiropractic treatment is the most common nonsurgical treatment for back pain. Improvements of people undergoing chiropractic manipulations were noted in some trials. However, the treatment's effectiveness in treating chronic back and neck pain has not been supported by compelling evidence from the majority of clinical trials. Further studies are currently assessing the effectiveness of chiropractic care for pain management. Massage is being increasingly used by people suffering from pain, mostly to manage chronic back and neck problems. Massage can reduce stress and relieve tension by enhancing blood flow. This treatment also can reduce the presence of substances that may generate and sustain pain. Available data suggest that massage therapy, like chiropractic manipulations, holds considerable promise for managing back pain. However, it is not possible to draw final conclusions regarding the effectiveness of massage to treat pain because of the shortcomings of available studies. Therapeutic Touch and Reiki Healing Therapeutic touch and reiki healing are thought to help activate the self-healing processes of an individual and therefore reduce pain. Although these so called "energy-based" techniques do not require actual physical contact, they do involve close physical proximity between practitioner and patient. In the past few years, several reviews evaluated published studies on the efficacy of these healing approaches to ease pain and anxiety and improve health. Although beneficial effects with no significant adverse side effects were reported in several studies, the limitations of some of these studies make it difficult to draw definitive conclusions. Further studies are needed before the evidence-based recommendation for using these approaches for pain treatment can be made. Nutritional Supplements There is solid evidence indicating that glucosamine sulfate and chondroitin sulfate relieve pain due to knee osteoarthritis. These natural compounds were found to decrease pain and increase mobility of the knee and were well tolerated and safe.

Other dietary supplements, such as fish oils, also show some evidence of benefit, although more research is needed. Herbal Remedies It has been difficult to draw conclusions about the effectiveness of herbs. If you decide to use herbal preparations to better manage your pain, it is of critical importance to share this information with your doctor. Some herbs may interact with drugs you are receiving for pain or other conditions and may harm your health. Dietary Approaches to Treating Pain Some people believe that changing dietary fat intake and/or eating plant foods that contain antiinflammatory agents can help ease pain by limiting inflammation. A mostly raw vegetarian diet was found helpful for some people with fibromyalgia, but this study was not methodologically strong. One study of women with premenstrual symptoms suggested that a low-fat vegetarian diet was associated with decreased pain intensity and duration. Weight loss achieved by a combination of dietary changes and increased physical activity has been shown to be helpful for people suffering from osteoarthritis. Still, further research is needed to determine the effectiveness of dietary modifications as a pain treatment. Things to Consider Alternative therapies are not always benign. As mentioned, some herbal therapies can interact with other medications you may be taking. Always talk to your doctor before trying an alternative approach and be sure to tell all your doctors what alternative treatments you are using. Other Options: Pain Clinics Many people suffering from chronic pain are able to gain some measure of control over it by trying many of the above treatments on their own. But for some, no matter what treatment approach they try, they still suffer from debilitating pain. For them, pain clinics -- special care centers devoted exclusively to dealing with intractable pain -- may be the answer. Some pain clinics are associated with hospitals and others are private; in either case, both inpatient and outpatient treatment are usually available. Pain clinics generally employ a multidisciplinary approach, involving physicians, psychologists, and physical therapists. The patient as well should take an active role in his or her own treatment. The aim in many cases is not only to alleviate pain but also to teach the chronic sufferer how to come to terms with pain and function in spite of it. Various studies have shown as much as 50% improvement in pain reduction for chronic pain sufferers after visiting a pain clinic, and most people learn to cope better and can resume normal activities. Over-the-Counter Pain Relievers Over-the-counter (OTC) pain relievers include: Acetaminophen (Tylenol, Aspirin-Free Excedrin) Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen -- Motrin andAdvil -- or naproxen -Aleve and Naprosyn

Both acetaminophen and NSAIDs reduce fever and relieve pain caused by muscle aches and stiffness, but only NSAIDs can also reduce inflammation (swelling and irritation). Acetaminophen and NSAIDs also work differently. NSAIDs relieve pain by reducing the production of prostaglandins, which are hormonelike substances thatcause pain. Acetaminophen works on the parts of the brain that receive the "pain messages." NSAIDs are also available in a prescription strength that can be prescribed by your physician.
Recommended Related to Pain Management
Propofol: Expert Q&A Propofol is a strong anesthetic that's used for surgery, some medical exams, and for sedation for people on ventilators -never as a sleep aid. It's given by IV and should only be administered by a medical professional trained in its use. It takes effect in a matter of seconds. "It is very fast-acting and works by slowing brain wave activities, says John F. Dombrowski, MD, an anesthesiologist/pain specialist at the Washington Pain Center in Washington, D.C. Dombrowski, who is a board member of... Read the Propofol: Expert Q&A article > >

Topical pain relievers are also available without a doctor's prescription. These products include creams, lotions, or sprays that are applied to the skin in order to relieve pain from sore muscles and arthritis. Some examples of topical pain relievers include Aspercreme, Ben-Gay, Icy Hot, and Capzasin-P. Prescription Pain Relievers Prescription pain relievers include: Corticosteroids Opioids Antidepressants Anticonvulsants (anti-seizure medications) What Are Corticosteroids? Prescription corticosteroids provide relief for inflamed areas of the body by easing swelling, redness, itching and allergic reactions. Corticosteroids can be used to treatallergies, asthma and arthritis. When used to control pain, they are generally given in the form of pills or injections. Examples include: prednisone (Deltasone), prednisolone (Hydeltrasol), and methylprednisolone (Solu-Medrol). Prescription corticosteroids are strong medicines and may have serious side effects, including: Weight gain Upset stomach Headache Mood changes Trouble sleeping Weakened immune system Thinning of the bones To minimize these potential side effects, corticosteroids are prescribed in the lowest dose possible for as short of a length of time as needed to relieve the pain. What Are Opioids? Opioids are narcotic pain medications that contain natural, synthetic or semi-synthetic opiates. Opioids are often used for acute pain, such as short-term pain after surgery. Some examples of opioids include:

Morphine Fentanyl Oxycodone Codeine Opioids are effective for severe pain and do not cause bleeding in the stomach or other parts of the body as can some other types of pain relievers. It is rare for people to become addicted to opioids if the drugs are used to treat pain for a short period of time. Side effects of opioids may include:

Drowsiness Nausea Constipation Itching Breathing problems Addiction Antidepressants are drugs that can treat pain and/or emotional conditions by adjusting levels of neurotransmitters (natural chemicals) in the brain. These medications can increase the availability of the body's signals for well-being and relaxation, enabling pain control for people with chronic pain conditions that do not completely respond to usual treatments. Chronic pain conditions treated by low-dose antidepressants include some types ofheadaches (like migraines) and menstrual pain. Some antidepressant medications include:

Selective serotonin reuptake inhibitors (SSRIs) such as citalopram (Celexa),fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) Tricyclic antidepressants such as amitriptyline (Elavil), desipramine (Norpramin),doxepin (Sinequan), imipramine (Tofranil), and nortriptyline (Pamelor) Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine(Effexor) and duloxetine (Cymbalta)

These drugs require a steady dose of the medicine buildup in the body over a period of time to work. The doses needed to treat pain are often lower than those needed to treat depression. In general, antidepressants have fewer long-term side effects than frequent, ongoing use of other pain medicines. Generally, SSRIs and SNRIs have fewer side effects than tricyclic antidepressants. The most common side effects with antidepressants include: Blurry vision Constipation Difficulty urinating Dry mouth Fatigue Nausea Headache What Are Anticonvulsants?

Anticonvulsants are drugs typically used to treat seizure disorders. Some of these medications are shown to be effective in treating pain as well. The exact way in which these medicines control pain is unclear but it is thought that they minimize the effects of nerves that cause pain. Some examples include carbamazepine(Tegretol), gabapentin (Neurontin), and pregabalin (Lyrica). In general, anticonvulsants are well tolerated. The most common side effects include: Drowsiness Dizziness Fatigue Nausea Other Pain Treatments Another means of topical pain relief comes in the form of a lidocaine (Lidoderm) patch, which is a prescription medication. If your pain is not relieved by the usual treatments, your doctor may refer you to a pain management specialist. Doctors who specialize in pain management may try other treatments such as certain types of physical therapy or other kinds of medicine. They may also recommend TENS, a procedure that uses patches placed on the skin to send signals that stop pain. Patient-controlled analgesia (PCA) is a method of pain control that allows the patient to control the amount of pain medication administered. This is often used in the hospital to treat pain. By pushing a button on a computerized pump, the patient receives a pre-measured dose of pain medicine. The pump is connected to a small tube that allows medicine to be injected intravenously (into a vein), subcutaneously (just under the skin), or into the spinal area.

Nausea is an uneasiness of the stomach that often comes before vomiting. Vomiting is the forcible voluntary or involuntary emptying ("throwing up") of stomach contents through the mouth. Call a doctor about nausea and vomiting: If the nausea lasts for more than a few days or if there is a possibility of being pregnant. If home treatment is not working, dehydration is present, or a known injury has occurred (such as head injury or infection) that may be causing the vomiting. Adults should consult a doctor if vomiting occurs for more than one day, diarrhea and vomiting last more than 24 hours, or there are signs of moderate dehydration. Take an infant or child under six years to the doctor if vomiting lasts more than a few hours, diarrhea is present, signs of dehydration occur, there is a fever higher than 100 degrees Fahrenheit, or if the child hasn't urinated for six hours. Take a child over age six years to the doctor if vomiting lasts one day, diarrhea combined with vomiting lasts for more than 24 hours, there are signs of dehydration, there is a fever higher than 102 degrees or the child hasn't urinated for six hours. You should seek immediate medical care if any of the following situations occur with vomiting: There is blood in the vomit (bright red or "coffee grounds" in appearance) Severe headache or stiff neck

Lethargy, confusion, or a decreased alertness Severe abdominal pain Fever over 101 degrees Diarrhea Rapid breathing or pulse How Is Vomiting Treated? Treatment for vomiting (regardless of age or cause) includes:

Drinking gradually larger amounts of clear liquids. Avoiding solid food until the vomiting episode has passed. Temporarily discontinuing all oral medications (which can irritate the stomach and make vomiting worse). But, do not discontinue any medication before checking with your doctor first. If vomiting and diarrhea last more than 24 hours, an oral rehydrating solution such as Pedialyte should be used to prevent and treat dehydration. Pregnant women experiencing morning sickness can eat some crackers before getting out of bed or eat a high protein snack before going to bed (lean meat or cheese). Vomiting associated with cancer treatments can often be treated with another type of drug therapy. There are also prescription and nonprescription drugs that can be used to control vomiting associated with pregnancy, motion sickness, and some forms of dizziness. However, consult with a doctor before using these treatments. How Can I Prevent Nausea? There are several ways to try and prevent nausea from developing:

Eat small meals throughout the day instead of three large meals. Eat slowly. Avoid hard-to-digest foods. Consume foods that are cold or room temperature if you nauseated by the smell of hot or warm foods. Rest after eating with your head elevated about 12 inches above your feet. Drink liquids between meals instead of during meals and drink at least six to eight 8-ounce glasses of water a day to prevent dehydration (unless fluid restricted for another medical condition). Try to eat when you feel less nauseated. How Do I Prevent Vomiting Once I Feel Nauseated? When you begin to feel nauseated, you may be able to prevent vomiting by:

Drinking small amounts of clear, sweetened liquids such as soda or fruit juices (except orange and grapefruit juices because these are too acidic). Resting either in a sitting position or in a propped lying position. Activity may worsen nausea and may lead to vomiting. To prevent nausea and vomiting in children:

To treat motion sickness in a car, seat your child so he or she faces the front windshield (watching fast movement out the side windows can make the nausea worse). Also, reading or playing video games in the car could cause motion sickness.

Don't let kids eat and play at the same time.

http://www.webmd.com/digestive-disorders/digestive-diseases-nausea-vomiting?page=3

Cachexia is weight loss and deterioration in physical condition.

General measures
Hypercaloric feeding has repeatedly been shown as ineffective in increasing lean mass. However, it may confer other benefits on the patients. It may cause weight gain but this is due to deposition of fat.[10] The metabolic adaptations, notably the increase in the rate of protein catabolism, limit the ability of hypercaloric feeding to reverse the depletion of lean mass. In one study, parenteral nutritional support improved operative morbidity and mortality in cancer patients[11] but it has not been seen to improve response to chemotherapy or radiation therapy. The National Institute for Health and Clinical Excellence (NICE) recommends oral, enteral or parenteral support (according to need and swallowing ability) for adults when:[12] BMI is <18.5 kg/m3. There has been >10% of total body weight lost in the preceding 3-6 months. BMI is <20 and there has been 5% weight loss in the preceding 3-6 months. The EPCRC guidelines recommend that the enteral route should be used in certain patient groups (eg, to reverse weight loss). However, in refractory cachexia (patients with advanced cancer in whom a reversal of weight loss seems unlikely), normal eating should be encouraged in order to avoid stress-related eating disorders.

Pharmacological measures

Insulin: insulin resistance is observed in cachexia. The possibility of utilising the insulin signalling system is currently being explored.[13] Growth hormone, testosterone, oxandrolone and megestrol acetate have all been used with beneficial effect and the use of the orexigenic (= appetite-stimulating) peptide ghrelin is being explored.[14] Anti-inflammatory agents such as indomethacin may be beneficial in patients with high CRP levels. The benefits of anti-inflammatory agents may be more apparent in non-malignant conditions and convey little benefit in patients with refractory cachexia. Steroids - eg, methylprednisolone - may be used in refractory cachexia for short periods (eg, two weeks). There may be a role for antioxidants in combating oxidative stress.[15] Because of metabolic derangements seen in cancer cachexia, effective nutritional treatment regimens will probably require manipulation of host intermediary metabolism in addition to feeding: omega-3 fatty acids (eg, eicosapentaenoic acid) have been studied for their ability to reduce cytokine release but their benefits are not clearly established.

Vitamin and mineral supplementation may be required in some cases.

Treatments Treatment approaches to date have been fairly disappointing, and even with adequate calorie intake, it is difficult to reverse the process of cachexia. The aim of treatment is to stimulate "anabolic processes" (that is, muscle building) while inhibiting "catabolic processes" (the actions that result in the breakdown of muscle). Treatment may include: Diet -- Contrary to what may seem obvious, replacing and supplementing calories in the diet has not made a big difference in the syndrome of cachexia. That said, it's very important to make sure that people coping with cancer (and similar conditions that cause cachexia) have a healthy diet. One important point to keep in mind is that if someone has not been eating much for a period of time, intake should be increased gradually. If calories are pushed too rapidly, a side effect called "overfeeding syndrome" may occur. When eating is not possible (or is limited) orally, a feeding tube may be recommended.

Nutritional supplements -- It's ideal if nutrients can be obtained through food, but we know that's not always the case. Fish oil has been evaluated for its ability to treat cachexia with some studies (but not all) suggesting it may be helpful. In one study, adding a powder supplement of eicosapentaenoic acid (EPA), one of the main three omega-3 fatty acids that people get in their diets by eating fish, improved the levels of inflammatory markers that go along with cachexia. Supplements of EPA were also linked with shorter hospital stays and fewer infections and complications. Exercise -- It may seem counterinituitive, but increasing activity (if possible) may help. An obvious benefit of exercise is increased appetite, but endurance training may go beyond eating habits to help slow the decline in muscle mass seen with cachexia. Medications -- Several medications and supplements that have been tried for cachexia with limited success include: Megace (megestrol) Thalidomide Zyloprim (allopurinol) Celebrex (celecoxib) L-Carnitine Medroxyprogesterone Testosterone Medical marijuana and Marinol

The Future of Cachexia Treatment Several medications are currently in clinical trials that show promise in helping people cope with the symptoms of cachexia. A few of these are now in phase 3 trials -- experimental studies that evaluate a drug or procedure that has already been deemed relatively safe and effective. For now, and given the fact that cachexia often begins long before it is obvious on physical exam, it's important to address this complication in people with conditions such as lung cancer as soon as possible after a diagnosis.

http://lungcancer.about.com/od/effectsoflungcancer/a/Cachexia.htm
Fatigue is a feeling of tiredness or exhaustion or a need to rest because of lack of energy or strength. Fatigue may result from overwork, poor sleep, worry, boredom, or lack of exercise. It is a symptom that may be caused by illness, medicine, or medical treatment such as chemotherapy. Anxiety or depression can also cause fatigue.

What are the treatment options for fatigue?

The successful treatment of fatigue requires finding the underlying causes and treating them. Below are some examples:

Anemia or low iron without anemia - iron supplements. Scientists from the University of Lausanne, Switzerland, found that iron supplementation reduced fatigue symptoms in women with low iron but who were not anemic by nearly 50%.

Sleep apnea - specific medications and medical devices. A medical team from the University of California, San Diego found that patients with obstructive sleep apnea had much more vigor and reduced fatigue symptoms after CPAP (continuous positive airway pressure) therapy

Blood sugar - medications to regulate blood sugar levels

Underactive thyroid - targeted drugs

Antibiotics - infections

Obesity - a diet and exercise regime CBT and GET - research carried out by a team at the Medical Research Council and the UK government found that CBT (cognitive behavioral therapy) and GET (graded exercise therapy) are the most effective way of treating patients with ME (Myalgic Encephalomyelitis) or CFS (Chronic Fatigue Syndrome). Retirement reduces fatigue - a team from Stockholm University, Sweden, reported in theBMJ

(British Medical Journal) that the risk of fatigue and depression is reduced after retirement, while the chances of developing other illnesses and conditions, such as diabetes, heart disease and respiratory disease remain the same. Multiple Sclerosis - patients responded well to mindfulness medication training for their fatigue and depression symptoms. Dr. Paul Grossman, Department of Psychosomatic Medicine, in the Division of Internal Medicine at the University of Basel Hospital, Switzerland, found that compared to those on standard medical care, the patients who learned mindfulness medication had fewer and less severe fatigue symptoms.

Yoga has been shown in various studies to help alleviate the symptoms of fatigue

Yoga - cancer survivors who completed a four-week yoga program which covered postures, meditation, breathing, and some other techniques reported significant improvements in fatigue symptoms as well as sleep quality. The researchers, from the University of Rochester Medical Center in New York, said that patients reported taking less sleep medications and improved quality of life. Ginseng - a two-month course of high-dose American ginseng (Panax quinquefolius) reduced fatigue symptoms in cancer patients significantly more effectively than a placebo, Mayo Clinic doctors reported. What you can do yourself to overcome persistent fatigue Sleep

Try to go to bed and wake up at the same time each day Set your bedroom's temperature at a comfortable level. It must neither be too cold nor too hot Do not have your last meal of the day too close to your bedtime - not less than 90 minutes or two hours before you go to bed As bedtime approaches, physically and mentally slow down. Have a warm bath and listen to some soothing music. Clear your mind of stressful and worrying thoughts. Many patients have found keeping a diary helps. Eating and drinking habits

If you eat three regular meals each day, eat at the same time each day, and follow a wellbalanced diet, your overall health will improve and so will your sleep patterns. If you are underweight, add more calories to your diet, but make sure it is a healthy one. if you are overweight/obese, follow a well-balanced diet and aim for a healthy body weight. Do not crash-diet. Your sleep may be affected. Drink alcoholic and caffeinated beverages in moderation, or not at all. Scientists from Hull York Medical School, England, found that patients with Chronic Fatigue Syndrome who ate dark chocolate - i.e. high cocoa content and no milk chocolate - had considerably reduced symptoms of fatigue. They emphasized that patients should only consume moderate amounts of chocolate. Physical activity Remember that fatigue-physical inactivity-fatigue vicious cycle. If you are unfit you are more likely to feel tired. Break that cycle. It is important that any physical activity drive is done properly and gradually. Either talk to your doctor, ask an expert at a reputable gym, or see a sports scientists. Regular exercisers sleep better and suffer much less from fatigue than other people. If none of these steps help you, see your doctor. Donating blood - in 2010, the International Blood Bank association urged all its members toadvise people with chronic fatigue syndrome not to donate blood and blood components, because of the risk of passing on the virus that is thought to cause the condition, even though there is no clear link for such a risk.

http://www.medicalnewstoday.com/articles/248002.php

Depression is the most common psychiatric disorder. It is a disabling condition that adversely affects a person's family, work or school life, sleeping and eating habits, and general health. In the United States, the incidence of depression has increased every year in the past century, and now one out of six people will experience a depressive episode. Depression is typically characterized by low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities.

Anxiety Anxiety is a normal reaction to stress, and it can serve as a prompt to deal with difficult situations. However, when anxiety becomes excessive, it may fall under the classification of an

anxiety disorder. Almost one out of four people experience an anxiety disorder during their lifetime. Anxiety disorders are characterized by emotional, physical, and behavioral symptoms that create an unpleasant feeling that is typically described as uneasiness, fear, or worry. The worry is frequently accompanied by physical symptoms, especially fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, and hot flashes.

What are the conventional treatments for depression and anxiety?

Just as no two people are affected the exact same way by depression and anxiety, there is no "one size fits all" treatment. What works for one person might not work for another. The best way to treat depression or anxiety is to become as informed as possible about the treatment options, and then tailor them to meet your needs. Psychotherapy There are many types of therapy available. Three of the more common methods used in depression include cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy. Often, a blended approach is used. Some types of therapy teach you practical techniques to reframe negative thinking and employ behavioral skills in combating depression and anxiety. Therapy can also help you understand why you feel a certain way, what your triggers are, and what you can do to stay healthy. Interpersonal and cognitive/behavioral therapies are two of the short-term psychotherapies that research has shown to be helpful for some forms of depression. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate the depression. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving that are often associated with depression and troublesome feelings.This type of therapy helps limit distorted thinking by looking at worries more realistically. Psychodynamic therapies are sometimes used to treat depression. They focus on resolving the patient's internal psychological conflicts that are typically thought to be rooted in childhood. Long-term psychodynamic therapies are particularly important if there seems to be a lifelong history and pattern of inadequate ways of coping (maladaptive coping mechanisms) in negative or self-injurious behavior. Medications for Depression Selective serotonin reuptake inhibitors (SSRIs) are medications that increase the amount of the neurochemical serotonin in the brain. Brain serotonin levels are often low in depression, and as their name implies, the SSRIs work by blocking the reuptake of serotonin in the brain so it stays around. SSRIs have fewer side effects than many of the older generation antidepressants, such as the tricyclic antidepressants (TCAs) and monoamine

oxidase inhibitors (MAOIs). Therefore, SSRIs are often the first-line treatment for depression. Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), and escitalopram (Lexapro). Dual-action antidepressants. Some of the newer antidepressant drugs appear to have particularly robust effects on both the norepinephrine and serotonin systems and are called "dual-action." These drugs seem to be very promising, especially for the more severe and chronic cases of depression. Venlafaxine (Effexor) and duloxetine (Cymbalta) are two of these dual-action compounds. Atypical antidepressants are so named because they work in a variety of ways. Examples of atypical antidepressants include nefazodone (Serzone), trazodone (Desyrel), and bupropion (Wellbutrin). Mood stabilizers and anticonvulsants include Lithium (Eskalith, Lithobid), valproate (Depakene, Depakote), carbamazepine (Epitol, Tegretol), neurontin (Gabapentin), and lamictal (Lamotrigine). They have been used to treat bipolar depression. Tricyclic antidepressants (TCAs) were developed in the 1950s and 1960s to treat depression. They work mainly by increasing the level of norepinephrine in the brain. TCAs are safe and generally well-tolerated when properly prescribed. However, if taken in excess, TCAs can cause life-threatening heart-rhythm disturbances. Examples of tricyclic antidepressants are amitriptyline and desipramine. Monoamine oxidase inhibitors (MAOIs) are the earliest developed antidepressants. MAOIs can interact with over-the-counter cold and cough medications to cause dangerously high blood pressure. Because of these potentially serious drug and food interactions, MAOIs are usually only prescribed after other treatment options have failed. Medications for Anxiety Medicines used to treat anxiety disorder may be especially helpful for people whose anxiety is interfering with daily functioning. The medications most often used to treat anxiety are:

Benzodiazepines. These medications are sometimes referred to as "tranquilizers," because they leave you feeling calm and relaxed. Common benzodiazepines include Xanax, Librium, Valium, and Ativan. Antidepressants, such as Paxil and Effexor. Dependency on anti-anxiety medications is a potential complication of treatment. Other side effects of medications include sleepiness and sexual problems. Electroconvulsive Therapy (ECT) In ECT, an electric current is passed through the brain to produce controlled convulsions (seizures). ECT is useful for certain patients, particularly for those who cannot take or have not responded to a number of antidepressants, have severe depression, and/or are at a high risk for suicide. In many people, ECT relieves depression within one to two weeks after beginning treatments. After ECT, some patients will continue to have maintenance ECT, while others will return to antidepressant medications. In recent years, the technique of ECT has been much improved.

What lifestyle changes are recommended for depression and anxiety?

Lifestyle changes are simple but powerful tools in treating depression. Sometimes they might be all you need. Even if you need other treatment as well, lifestyle changes go a long way toward helping lift depression. Lifestyle changes that can treat depression include: Exercise Numerous well-designed studies have found exercise to be as effective as prescription antidepressants or psychotherapy, which are roughly equivalent to each other in their success rates for treating depression. The bulk of studies evaluating the impact of exercise on anxiety have found an improvement in symptoms with increased physical activity. Exercise stimulates the body to produce serotonin and endorphins, which are chemicals in the brain (neurotransmitters) that alleviate depression. But that only partially explains the positive impacts of exercise on depression. Participating in an exercise program can increase self-esteem, self-confidence, and sense of empowerment, as well as improve social connection and enhance relationships. All of these things have a positive impact on a depressed individual. Diet A number of studies have shown that a diet high in simple sugars or in caffeine (750 mg daily) is related to increased rates of major depression. In one small study, eliminating refined sugars and caffeine results in improved symptoms of depression within one week. Long-term use of caffeine has been linked with anxiety as well. Longer term studies in this area are needed, but minimizing refined sugars and caffeine is currently an easy and logical recommendation. Alcohol Depressed populations also have more problems with alcohol use. People suffering from depression should stop drinking alcohol. If alcohol abuse underlies the depression, it is critical that it be addressed directly. Sleep Poor sleep has a strong effect on mood. Make getting the amount of sleep you need a priority. Social Support Strong social networks reduce isolation, a key risk factor for depression. Keep in regular contact with friends and family, or consider joining a class or group. Volunteering is a wonderful way to get social support and help others while also helping yourself. Stress Reduction Make changes in your life to help manage and reduce stress. Too much stress exacerbates depression and puts you at risk for future depression.

What are some integrative therapies and healing practices to consider for depression?

A 2001 large survey study of people in the U.S. who considered themselves anxious or depressed found that more people used integrative therapies than conventional therapies. In fact, 53.6 percent of respondents suffering from severe depression reported using complementary and alternative medicine for treatment in the 12 months prior to the survey published in the American Journal of Psychiatry. While people with depression perceive integrative therapies to be as effective as conventional medicine, the existing research literature does not necessarily confirm the effectiveness of integrative interventions. There is a significant lack of large, methodologically rigorous studies on integrative therapies for depression. However, that is not decreasing their popular usage. Part of the reason people might be attracted to integrative care for depression or anxiety is the holistic perspective found in most integrative approaches. This perspective takes into account the complex nature of depressive disorders and the numerous reasons why people experience them. Mind-Body Practices While there have not been many well-designed studies looking at relaxation training, meditation,hypnosis or imagery in the treatment of depression, these practices have been an important part of traditional healing approaches for millennia (e.g. Ayurvedic, Chinese, Tibetan). In addition, hypnosis is used by conventional psychotherapists. Early studies in yoga, breathwork, stress reduction, and relaxation therapy are promising, but require further investigation. But given that it costs little to learn these practices and there is little risk, they are worth pursuing. Therapists often recognize the importance of simply doing something and creating a sense of control over some aspect of life, and these practices can provide that. Music Therapy Music therapy involves actively listening to or performing music to promote health and healing. In an early, small study with an older population and depression, music therapy produced a significant positive impact. More and larger studies are needed before recommendations are clear, but given the low cost and risks, this may be a helpful approach for those individuals who have interest in this area. Botanical Medicines The uniqueness of each person's biochemical processes is only just beginning to be appreciated. The evolving field of Functional Medicine attempts to take into account both the genetic information and the unique differences that occur in each person's metabolism, including their extra need for certain nutrients. Current recommendations, as follows, come from a generalized understanding of human brain chemistry, without these individual considerations. Typical doses for each botanical are indicated below. However, you should talk with your healthcare provider before adding botanicals to your health regimen and ask about the right dosage for you.

B-Vitamins are necessary for the production and regulation of neurotransmitters connected to depression. B-vitamin deficiency has been linked with mood disorders, including depression

and anxiety. Elderly patients are at particular risk of B12 deficiency; and women on oral contraception or estrogen replacement are at increased risk of B6 deficiency. Thus, although long-term prospective studies have not been completed, it seems beneficial to take Vitamin B complex, with 100 mg each of the major B vitamins. Folic acid is low in one-third of depressed adults. Depression is also the most common symptom of folate deficiency. If there is a deficiency, some depression medications (i.e. SSRIs) are not as effective. Take 0.8-1 mg daily of folic acid. Omega-3 fatty acid deficiency, or an imbalance with omega-6, correlates with an increased rate of both anxiety and depression. Dosage range has not yet been clearly established, but studies have shown improvement in depressive symptoms with as little as 1 gram, or as much as 6 grams a day. Begin with 1 gram a day of fish oil, and go up to 6 grams a day if desired. Flaxseed oil, or ground flaxseed meal, (2 tbsp daily) is a vegetarian alternative. St. John's wort is a plant that impacts several neurochemical pathways in the brain and has been shown in numerous studies of mild to moderate depression to be as effective as conventional antidepressants. Take 900 mg daily in three divided doses, using a product standardized to a minimum of 2-5 percent hyperforin or 0.3 percent hypericin. There are potential side effects to this botanical, although the side effect rate is lower than that of prescription drugs. There are also potential herb/drug interactions, especially with blood thinners. St. John's wort should not be used in combination with SSRIs, and may interfere with oral contraceptives. S-Adenosylmethionine (SAMe) is a naturally occurring chemical substance intimately involved in the production, regulation, and action of many brain neurotransmitters. Multiple studies have found SAMe to be a safe and effective natural antidepressant that starts working faster than pharmaceutical antidepressants. An initial dose is 1,600 mg per day, divided into two doses; however, because of gastrointestinal side effects, it should be started at 200 mg twice daily and gradually increased. It is best to use this with the guidance of a professional, especially if combined with an antidepressant. It should not be used in bipolar disorders, like manic depression. Kava at 50 to 70 mg three times a day (standardized to either a 30 or 50 percent kava lactone concentration) has been found to help with anxiety disorder in seven small clinical trials, but has not yet been confirmed by a larger prospective study. Valerian is another botanical that has been used in Europe as a calmative agent and tranquilizer, especially for sleep disturbances. It has been tried in several small studies on anxiety, in combination with either passionflower or St. John's wort, with promising results. It may be tried clinically, if Kava has failed after six weeks, at doses of 150 to 300 mg in the monring and 300 to 600 mg in the evening for at least a six-week trial. Naturopathic Medicine Naturopathy includes diet, exercise, natural botanicals and supplements, mind/body practice, hydrotherapy, and other tools. For those preferring natural approaches, treatment with a naturopath can certainly be partnered with psychotherapy of some kind. Traditional Chinese Medicine Traditional Chinese Medicine practitioners work with an individual to optimize their nutrition, activity, and internal energetic balance, using herbs, acupuncture, movement practices (Qi Gongand Tai Chi), massage (Tui Na), and other techniques. Acupuncture for mild to moderate depression has been found to be promising in early studies, although larger prospective studies have not been completed.

Homeopathy Homeopathy is another systemic approach used by some individuals in combination with psychotherapy.
Delirium is defined as a transient, usually reversible, cause of cerebral dysfunction and manifests clinically with a wide range of neuropsychiatric abnormalities. It can occur at any age, but it occurs more commonly in patients who are elderly and have compromised mental statu

Treatments and drugs

By Mayo Clinic staff The first goal of treatment for delirium is to address any underlying causes or triggers by stopping use of a particular medication, for example, or treating an infection. Treatment then focuses on creating the best environment for healing the body and calming the brain. Supportive care Supportive care aims to prevent complications by protecting the airway, providing fluids and nutrition, assisting with movement, treating pain, addressing incontinence and keeping people with delirium oriented to their surroundings. A number of simple, nondrug approaches may be of some help: Clocks and calendars to help a person stay oriented A calm, comfortable environment that includes familiar objects from home Regular verbal reminders of current location and what's happening Involvement of family members Avoidance of change in surroundings and caregivers Uninterrupted periods of sleep at night, with low levels of noise and minimal light Open blinds during the day to promote daytime alertness and a regular sleep-wake cycle Avoidance of physical restraints and bladder tubes Adequate nutrition and fluid Use of adequate light, music, massage and relaxation techniques to ease agitation Opportunities to get out of bed, walk and perform self-care activities Provision of eyeglasses, hearing aids and other adaptive equipment as needed

Medications Talk with the doctor about avoiding or minimizing the use of drugs that may trigger delirium. However, certain drug treatment may calm a person who misinterprets the environment in a way that leads to severe paranoia, fear or hallucinations, and when severe agitation or confusion: Prevents the performance of a necessary medical exam or treatment Endangers the person or threatens the safety of others Doesn't lessen with nondrug treatments

Coping and support

By Mayo Clinic staff If you're a relative or caregiver of someone at risk of or recovering from delirium, you can take steps to improve the person's health, prevent a recurrence and help manage responsibilities. Promote good sleep habits To promote good sleep habits: Keep inside lighting appropriate for the time of day Encourage exercise and activity during the day Offer warm, soothing, noncaffeinated beverages before bedtime Promote calmness and orientation To help the person remain calm and well oriented: Provide a clock and calendar and refer to them regularly throughout the day Communicate simply about any change in activity, such as time for lunch or time for bed Keep familiar and favorite objects around, but avoid a cluttered environment Approach the person calmly Identify yourself or other people regularly Avoid arguments Keep noise levels and other distractions to a minimum Help the person keep a regular daytime schedule

Maintain and provide eyeglasses and hearing aids Prevent complicating problems Help prevent medical problems by:

Giving the person his or her medication on a regular schedule Providing plenty of fluids and a healthy diet Encouraging regular exercise and activity Caring for the caregiver If you're providing regular care for a person with or at risk of delirium, consider support groups, educational materials or other resources offered by the person's health care provider, nonprofit organizations, community health services and government agencies. Examples of organizations that may provide helpful information include the National Family Caregivers Association and the National Institute on Aging.

Prevention
By Mayo Clinic staff The most successful approach to preventing delirium is to target risk factors that might trigger an episode. Hospital environments present a special challenge frequent room changes, invasive procedures, loud noises, poor lighting and lack of natural light can worsen confusion. Evidence indicates that these strategies help prevent or reduce the severity of delirium in hospitalized people: Provide adequate fluids Provide stimulating activities and familiar objects Encourage the use of eyeglasses and hearing aids, if applicable Use simple and regular communication about people, current place and time Provide mobility and range-of-motion exercises Reduce noise and avoid sleep interruptions Provide appropriate pain management and offer nondrug treatment for sleep problems or anxiety

 Constipation occurs when bowel movements become difficult or less frequent. The normal length of time between bowel movements ranges widely from person to person. Some people have bowel movements three times a day; others, only one or two times a week. Going longer than three days without a bowel movement is too long. After three days, the stool or feces become harder and more difficult to pass. There are several things you can do to prevent constipation. Among them: Eat a well-balanced diet with plenty of fiber. Good sources of fiber are fruits, vegetables, legumes, and whole-grain bread and cereal (especially bran). Fiber and water help the colon pass stool. Drink 1 1/2 to 2 quarts of water and other fluids a day (unless fluid restricted for another medical condition). Liquids that contain caffeine, such as coffee and soft drinks, seem to have a dehydrating effect and may need to be avoided until your bowel habits return to normal. Some people may need to avoid milk, as dairy products may be constipating for them. Exercise regularly. Move your bowels when you feel the urge. What Should I Do If I Am Constipated? If you are constipated, try the following: Drink two to four extra glasses of water a day (unless fluid restricted). Try warm liquids, especially in the morning. Add fruits and vegetables to your diet. Eat prunes and/or bran cereal. If needed, use a very mild stool softener or laxative (such as Peri-Colace or Milk of Magnesia). Do not use laxatives for more than two weeks without calling your doctor, as laxative overuse can aggravate your symptoms. Warning About Constipation Call your doctor if: Constipation is a new problem for you You have blood in your stool You are losing weight even though you are not dieting You have severe pain with bowel movements Your constipation has lasted more than two weeks

Home remedies and OTC medications to treat constipation

Comment on thisRead 1 CommentShare Your Story

Dietary fiber (bulk-forming laxatives)

The best way of adding fiber to the diet is increasing the quantity of fruits and vegetables that are eaten. This means a minimum of five servings of fruits or vegetables every day. For many people, however, the amount of fruits and vegetables that are necessary may be inconveniently

large or may not provide adequate relief from constipation. In this case, fiber supplements can be useful. Fiber is defined as material made by plants that is not digested by the human gastrointestinal tract. Fiber is one of the mainstays in the treatment of constipation. Many types of fiber within the intestine bind to water and keep the water within the intestine. The fiber adds bulk (volume) to the stool and the water softens the stool. There are different sources of fiber and the type of fiber varies from source to source. Types of fiber can be categorized in several ways, for example, by their source. The most common sources of fiber include:

fruits and vegetables, wheat or oat bran, psyllium seed (for example, Metamucil, Konsyl), synthetic methyl cellulose (for example, Citrucel), and polycarbophil (for example, Equilactin, Konsyl Fiber).

Polycarbophil often is combined with calcium (for example, Fibercon). However, in some studies, the calcium-containing polycarbophil was not as effective as the polycarbophil without calcium. A lesser known source of fiber is an extract of malt (for example, Maltsupex); however, this extract may soften stools in ways other than increasing fiber. Increased gas (flatulence) is a common side effect of high-fiber diets. The gas occurs because the bacteria normally present within the colon are capable of digesting fiber to a small extent. The bacteria produce gas as a byproduct of their digestion of fiber. All fibers, no matter what their source, can cause flatulence. However, since bacteria vary in their ability to digest the various types of fiber, the different sources of fiber may produce different amounts of gas. To complicate the situation, the ability of bacteria to digest one type of fiber can vary from individual to individual. This variability makes the selection of the best type of fiber for each person (for example, a fiber that improves the quality of the stool without causing flatulence) more difficult. Thus, finding the proper fiber for an individual becomes a matter of trial and error.

The different sources of fiber should be tried one by one. The fiber should be started at a low dose and increased every one to two weeks until either the desired effect on the stool is achieved or troublesome flatulence interferes. (Fiber does not work overnight.) If flatulence occurs, the dose of fiber can be reduced for a few weeks and the higher dose can then be tried again. (It generally is said that the amount of gas that is produced by fiber decreases when the fiber is ingested for a prolonged period of time; however, this has never been studied.) If flatulence remains a problem and prevents the dose of fiber from being raised to a level that affects the stool satisfactorily, it is time to move on to a different source of fiber. When increasing amounts of fiber are used, it is recommended that greater amounts of water be consumed (for example, a full glass with each dose). In theory, the water prevents "hardening" of the fiber and blockage (obstruction) of the intestine. This seems like simple and reasonable advice. However, ingesting larger amounts of water has never been shown to have a beneficial effect on constipation, with or without the addition of fiber. (There is already a lot of water in the intestine and extra water that is digested is absorbed and excreted in the urine.) It is reasonable to drink enough fluids to prevent dehydration because with dehydration there may be reduced intestinal water. Because of concern about obstruction, persons with narrowings (strictures) or adhesions (scar tissue from previous surgery) of their intestines should not use fiber unless it has been discussed with their physician. Some fiber laxatives contain sugar, and patients with diabetes may need to select sugar-free products.

Lubricant laxatives
Lubricant laxatives contain mineral oil as either the plain oil or an emulsion (combination with water) of the oil. The oil stays within the intestine, coats the particles of stool, and presumably prevents the removal of water from the stool. This retention of water in the stool results in softer stool. Mineral oil generally is used only for the short-term treatment of constipation since its long-term use has several potential disadvantages. The oil can absorb fat-soluble vitamins from the intestine and, if used for prolonged periods, may lead to deficiencies of these vitamins. This is of particular concern in pregnancy during which an adequate supply of vitamins is important for the fetus. In the very young or very elderly in whom the swallowing mechanism is not strong or is impaired by strokes, small amounts of the swallowed oil may enter the lungs and cause a type ofpneumonia called lipid pneumonia. Mineral oil also may decrease the absorption of some drugs such as warfarin (Coumadin) and oral contraceptives, thereby decreasing their effectiveness. Despite these potential disadvantages, mineral oil can be effective when short-term treatment is necessary.

Emollient laxatives (stool softeners)

Emollient laxatives are generally known as stool softeners. They contain a compound called docusate (for example, Colace). Docusate is a wetting agent that improves the ability of water within the colon to penetrate and mix with stool. This increased water within the stool softens the stool. Although studies have not shown docusate to be consistently effective in relieving constipation. Stool softeners often are used in the long-term treatment of constipation. It may take a week or more for docusate to be effective. The dose should be increased after one to two weeks if no effect is seen. Although docusate generally is safe, it may increase the absorption of mineral oil and some medications from the intestine. Absorbed mineral oil collects in tissues of the body, for example, the lymph nodes and the liver, where it causes inflammation. It is not clear if this inflammation has any important consequences, but it generally is felt that prolonged absorption of mineral oil should not be allowed. The use of emollient laxatives is not recommended together with mineral oil or with certain prescription medications. Emollient laxatives are commonly used when there is a need to soften the stool temporarily and make defecation easier (for example, after surgery, childbirth, or heart attacks). They are also used for individuals withhemorrhoids or anal fissures.

Hyperosmolar laxatives
Hyperosmolar laxatives are undigestible, unabsorbable compounds that remain within the colon and retain the water that already is in the colon. The result is softening of the stool. The most common hyperosmolar laxatives are lactulose (for example, Kristalose), sorbitol, and polyethylene glycol (for example, MiraLax). and are available by prescription only. These laxatives are safe for long-term use and are associated with few side effects. Hyperosmolar laxatives may be digested by colonic bacteria and turned into gas, which may result in unwanted abdominal bloating and flatulence. This effect is dose-related and less with polyethylene glycol. Therefore, gas can be reduced by reducing the dose of the laxative. In some cases, the gas will decrease over time.

Saline laxatives
Saline laxatives contain non-absorbable ions such as magnesium, sulfate, phosphate, and citrate [for example, magnesium citrate (Citroma), magnesium hydroxide, sodium phosphate). These ions remain in the colon and cause water to be drawn into the colon. Again, the effect is softening of the stool. Magnesium also may have mild stimulatory effects on the colonic muscles. The magnesium in magnesium-containing laxatives is partially absorbed from the intestine and into the body. Magnesium is eliminated from the body by the kidneys. Therefore, individuals with impaired

kidney function may develop toxic levels of magnesium from chronic (long duration) use of magnesium-containing laxatives. Saline laxatives act within a few hours. In general, potent saline laxatives should not be used on a regular basis. If major diarrhea develops with the use of saline laxatives and the lost fluid is not replaced by the consumption of liquids, dehydration may result. For constipation, the most frequently-used and mildest of the saline laxatives is milk of magnesia. Epsom Salt is a more potent saline laxative that contains magnesium sulfate.

Stimulant laxatives
Stimulant laxatives cause the muscles of the small intestine and colon to propel their contents more rapidly. They also increase the amount of water in the stool, either by reducing the absorption of the water in the colon or by causing active secretion of water in the small intestine. The most commonly-used stimulant laxatives contain cascara (castor oil), senna (for example, Ex-Lax, Senokot), and aloe. Stimulant laxatives are very effective, but they can cause severe diarrhea with resulting dehydration and loss of electrolytes (especially potassium). They also are more likely than other types of laxatives to cause intestinal cramping. There is concern that chronic use of stimulant laxatives may damage the colon and worsen constipation, as previously discussed. Bisacodyl (for example, Dulcolax, Correctol) is a stimulant laxative that affects the nerves of the colon which, in turn, stimulate the muscles of the colon to propel its contents. Prunes also contain a mild colonic stimulant.

Enemas
There are many different types of enemas. By distending the rectum, all enemas (even the simplest type, the tap water enema) stimulate the colon to contract and eliminate stool. Other types of enemas have additional mechanisms of action. For example, saline enemas cause water to be drawn into the colon. Phosphate enemas (for example, Fleet phosphosoda) stimulate the muscles of the colon. Mineral oil enemas lubricate and soften hard stool. Emollient enemas (for example, Colace Microenema) contain agents that soften the stool. Enemas are particularly useful when there is impaction, which is hardening of stool in the rectum. In order to be effective, the instructions that come with the enema must be followed. This requires full application of the enema, appropriate positioning after the enema is instilled, and retention of the enema until cramps are felt. Defecation usually occurs between a few minutes and one hour after the enema is inserted. Enemas are meant for occasional rather than regular use. The frequent use of enemas can cause disturbances of the fluids and electrolytes in the body. This is especially true of tap water

enemas. Soapsuds enemas are not recommended because they can seriously damage the rectum.

Suppositories
As is the case with enemas, different types of suppositories have different mechanisms of action. There are stimulant suppositories containing bisacodyl (for example, Dulcolax). Glycerin suppositories are believed to have their effect by irritating the rectum. The insertion of the finger into the rectum when the suppository is placed may itself stimulate a bowel movement.

Combination products
There are many products that combine different laxatives. For example, there are oral products that combine senna and psyllium (Perdiem), senna and docusate (Senokot-S), and senna and glycerin (Fletcher's Castoria). One product even combines three laxatives, senna-like casanthranol, docusate, and glycerin (Sof-lax Overnight). These products may be convenient and effective, but they also contain stimulant laxatives. Therefore, there is concern about permanent colonic damage with the use of these products, and they probably should not be used for long-term treatment unless non-stimulant treatment fails.
Urinary incontinence the loss of bladder control is a common and often embarrassing problem. The severity of urinary incontinence ranges from occasionally leaking urine when you cough or sneeze to having an urge to urinate that's so sudden and strong you don't get to a toilet in time. Behavioral techniques Behavioral techniques and lifestyle changes work well for certain types of urinary incontinence. They may be the only treatment you need. Bladder training. Your doctor may recommend bladder training alone or in combination with other therapies to control urge and other types of incontinence. Bladder training involves learning to delay urination after you get the urge to go. You may start by trying to hold off for 10 minutes every time you feel an urge to urinate. The goal is to lengthen the time between trips to the toilet until you're urinating every two to four hours. Bladder training may also involve double voiding urinating, then waiting a few minutes and trying again. This exercise can help you learn to empty your bladder more completely to avoid overflow incontinence. In addition, bladder training may involve learning to control urges to urinate. When you feel the urge to urinate, you're instructed to relax breathe slowly and deeply or to distract yourself with an activity.

Scheduled toilet trips. This means timed urination going to the toilet according to the clock rather than waiting for the need to go. Following this technique, you go to the toilet on a routine, planned basis usually every two to four hours.

Fluid and diet management. In some cases, you can simply modify your daily habits to regain control of your bladder. You may need to cut back on or avoid alcohol, caffeine or acidic foods. Reducing liquid consumption, losing weight or increasing physical activity are other lifestyle changes that can eliminate the problem. Physical therapy

Pelvic floor muscle exercises. These exercises strengthen your urinary sphincter and pelvic floor muscles the muscles that help control urination. Your doctor may recommend that you do these exercises frequently. They are especially effective for stress incontinence, but may also help urge incontinence. To do pelvic floor muscle exercises (Kegel exercises), imagine that you're trying to stop your urine flow. Squeeze the muscles you would use to stop urinating and hold for a count of three and repeat. With Kegel exercises, it can be difficult to know whether you're contracting the right muscles and in the right manner. In general, if you sense a pulling-up feeling when you squeeze, you're using the right muscles. Men may feel their penises pull in slightly toward their bodies. To double-check that you're contracting the right muscles, try the exercises in front of a mirror. Your abdominal, buttock or leg muscles shouldn't tighten if you're isolating the muscles of the pelvic floor. If you're still not sure whether you're contracting the right muscles, ask your doctor for help. Your doctor may suggest you work with a physical therapist or try biofeedback techniques to help you identify and contract the right muscles. Your doctor may also suggest vaginal cones, which are weights that help women strengthen the pelvic floor.

Electrical stimulation. In this procedure, electrodes are temporarily inserted into your rectum or vagina to stimulate and strengthen pelvic floor muscles. Gentle electrical stimulation can be effective for stress incontinence and urge incontinence, but it takes several months and multiple treatments to work. Medications Often, medications are used in conjunction with behavioral techniques. Drugs commonly used to treat incontinence include:

Anticholinergics. These prescription medications calm an overactive bladder, so they may be helpful for urge incontinence. Several drugs fall under this category, including oxybutynin (Ditropan), tolterodine (Detrol), darifenacin (Enablex), fesoterodine (Toviaz), solifenacin (Vesicare) and trospium (Sanctura). Possible side effects of these medications include dry mouth, constipation, blurred vision and flushing.

Topical estrogen. Applying low-dose, topical estrogen in the form of a vaginal cream, ring or patch may help tone and rejuvenate tissues in the urethra and vaginal areas. This may reduce some of the symptoms of incontinence.

Imipramine. Imipramine (Tofranil) is a tricyclic antidepressant that may be used to treat mixed urge and stress incontinence.

Duloxetine. The antidepressant medication duloxetine (Cymbalta) is sometimes used to treat stress incontinence. Medical devices Several medical devices are available to help treat incontinence. They're designed specifically for women and include:

Urethral insert. This small tampon-like disposable device inserted into the urethra acts as a plug to prevent leakage. It's usually used to prevent incontinence during a specific activity, but it may be worn throughout the day. Urethral inserts aren't meant to be worn 24 hours a day. They are available by prescription and may work best for women who have predictable incontinence during certain activities, such as playing tennis. The device is inserted before the activity and removed before urination.

Pessary (PES-uh-re). Your doctor may prescribe a pessary a stiff ring that you insert into your vagina and wear all day. The device helps hold up your bladder, which lies near the vagina, to prevent urine leakage. You need to regularly remove the device to clean it. You may benefit from a pessary if you have incontinence due to a dropped (prolapsed) bladder or uterus. Interventional therapies

Bulking material injections. Bulking agents are materials, such as carbon-coated zirconium beads (Durasphere), calcium hydroxylapatite (Coaptite) or polydimethylsiloxane (Macroplastique), that are injected into tissue surrounding the urethra. This helps keep the urethra closed and reduce urine leakage. The procedure usually done in a doctor's office requires minimal anesthesia and takes about five minutes. The downside is that repeat injections are usually needed.

Botulinum toxin type A. Injections of onabotulinumtoxinA (Botox) into the bladder muscle may benefit people who have an overactive bladder. Researchers have found this to be a promising therapy, but the

Food and Drug Administration (FDA) has not yet approved this drug for incontinence. These injections may cause urinary retention that's severe enough to require self-catheterization. In addition, repeat injections are needed every six to nine months. Nerve stimulators. Sacral nerve stimulators can help control your bladder function. The device,which resembles a pacemaker, is implanted under the skin in your buttock. A wire from the device is connected to a sacral nerve an important nerve in bladder control that runs from your lower spinal cord to your bladder. Through the wire, the device emits painless electrical pulses that stimulate the nerve and help control the bladder. Another device, the tibial nerve stimulator, is approved for treating overactive bladder symptoms. Instead of directly stimulating the sacral nerve, this device uses an electrode placed underneath the skin to deliver electrical pulses to the tibial nerve in the ankle. These pulses then travel along the tibial nerve to the sacral nerve, where they help control overactive bladder symptoms. Surgery If other treatments aren't working, several surgical procedures have been developed to fix problems that cause urinary incontinence. Some of the commonly used procedures include: Sling procedures. A sling procedure uses strips of your body's tissue, synthetic material or mesh to create a pelvic sling or hammock around your bladder neck and urethra. The sling helps keep the urethra closed, especially when you cough or sneeze. There are many types of slings, including tension-free, adjustable and conventional. Bladder neck suspension. This procedure is designed to provide support to your urethra and bladder neck an area of thickened muscle where the bladder connects to the urethra. It involves an abdominal incision, so it's done using general or spinal anesthesia. Artificial urinary sphincter. This small device is particularly helpful for men who have weakened urinary sphincters from treatment of prostate cancer or an enlarged prostate gland. Shaped like a doughnut, the device is implanted around the neck of your bladder. The fluid-filled ring keeps your urinary sphincter shut tight until you're ready to urinate. To urinate, you press a valve implanted under your skin that causes the ring to deflate and allows urine from your bladder to flow. Absorbent pads and catheters If medical treatments can't completely eliminate your incontinence or you need help until a treatment starts to take effect you can try products that help ease the discomfort and inconvenience of leaking urine.

Pads and protective garments. Various absorbent pads are available to help you manage urine loss. Most products are no more bulky than normal underwear, and you can wear them easily under everyday clothing. Men who have problems with dribbles of urine can use a drip collector a small pocket of absorbent padding that's worn over the penis and held in place by closefitting underwear. Men and women can wear adult diapers, pads or panty liners, which can be purchased at drugstores, supermarkets and medical supply stores.

Catheter. If you're incontinent because your bladder doesn't empty properly, your doctor may recommend that you learn to insert a soft tube (catheter) into your urethra several times a day to drain your bladder (self-intermittent catheterization). This should give you more control of your leakage, especially if you have overflow incontinence. You'll be instructed on how to clean these catheters for safe reuse.

Dyspnea (/dspni/ disp-NEE-; also dyspnoea; Latin: dyspnoea; Greek: , dspnoia), shortness of breath (SOB), or air [1] [2][3] hunger, is the subjective symptom of breathlessness.

How can dyspnea be treated?

Treatment of dyspnea is usually directed toward the treatment of the underlying disease. For example, if fluid is collecting in the lung, the fluid may need to be drained to lessen the dyspnea. Chemotherapy or radiation therapy may shrink a tumor to lessen the dyspnea. If dyspnea is being caused by an infection, antibiotics may be needed. Your doctor may treat dyspnea with medication. The type of medication will depend to some extent on the cause. Here are some options for that:

Bronchodilators open a patient's airways and decrease their dyspnea. Steroids help reduce swelling in the lungs that may be causing the shortness of breath. Anti-anxiety drugs can help break the cycle of panic that can lead to more breathing difficulties. Pain medications can make breathing easier.

Your doctor might also prescribe oxygen to help with your breathing. Ask your health care team about breathing and relaxation techniques you can try on your own.

What can a patient do to manage dyspnea?

Relaxation exercises, meditation, breathing techniques, conservation of energy, and limitations of activity may be helpful in dealing with dyspnea. These techniques may also control your anxiety level, an important part of treating dyspnea.

It might also be helpful to change the way you sit or sleep. Patients with dyspnea may find it helpful to try sitting upright in a chair, leaning forward slightly, and resting their forearms on the arms of the chair or their knees to help their lungs to expand. Sleeping with several pillows or in a recliner can also help. Here are two types of breathing exercises to help manage dyspnea. Always talk with your doctor or nurse before trying these techniques. It can also be helpful to talk to a respiratory or physical therapist for hints on how to manage dyspnea:

Diaphragmatic breathing (also called abdominal breathing). To do this type of breathing, you must first find your diaphragm. Here's how: Place your fingers just below your breastbone and breathe in. The muscle that moves is the diaphragm. You may find it useful to lie flat on your back and place a book on your abdomen so you can watch your breathing pattern as the book rises and falls. Your goal is to make the book rise and fall with each breath.

Pursed-lip breathing. To do this type of breathing, keep the lips pressed together tightly, except for the very center. Take normal breaths. Breathe in through the nose. Then take twice as long to breathe out through the center of your mouth.

Information for Families and Carers

This page contains information and links that might be useful to carers and families.

Helpful Reading
Care for the Caregiver(s) Bethlehem Health Care Melbourne Many people faced with a terminal illness prefer to stay in their own home surrounded by those with whom they share a special relationship; but, nursing and supporting an ill relative or friend can be difficult and demanding and may seem a daunting task, especially if the caregiver(s) have no prior experience with chronic illness and the dying process. A patients illness can affect the entire family; especially when the illness is relentlessly progressive and causes changes in the patterns of life for all the family. Although caring for the patient at home is rewarding, it may also be strenuous; physically and emotionally draining. It is important that you, the caregiver, take care of yourself to keep physically and emotionally able to help the patient. During the illness, the patient at times may be angry or act strangely towards the caregivers; those people the patient knows will continue to love and care for them despite their bad moods. Such behaviour is usually a reflection of the mixed feelings and emotions that the patient is experiencing, the loss of independence, change of role and feelings of why did this happen to me? Many caregivers, naturally, feel hurt or angry when this behaviour is directed towards them, particularly when they are feeling

emotionally fragile. If the patient is not directly angry or hostile, try t o discuss your feelings with him or her. Sometimes the patient is not aware s/he is behaving differently. You can share your feelings, fears and frustrations with members of the palliative care team who are there to help the entire family cope with this difficult experience. Plan time for yourself to get out of the house. Other family members or friends may be able to help, or a volunteer can be organised through the palliative care program. Having time out allows things to be put into perspective, as 24-hour caring can be overwhelming at times. Try to get at least six hours sleep each night, and have a rest during the day when the patient is sleeping. If they do not sleep for long periods overnight, perhaps family or friends could assist with a roster system to enable you to get adequate sleep. Community services may be appropriate; this can be discussed with your palliative care nurse. Setting priorities helps. Time spent on regular responsibilities, such as housework and shopping could be lessened, or perhaps given over to other family members, or a volunteer from the palliative care team. Proper nutrition helps to maximise energy. Although the patient may not be eating it is important that you continue to eat regular and nutritious meals. Share your feelings with family, friends or someone outside the family, such as the palliative care team. It is normal for you to have a mixed range of emotions and feelings at this time, and to feel concerned about continuing to cope. Talking this over often helps to clarify feelings and identify problems and to share your load. Resolutions can be planned together. Relaxation techniques and/or medication may be useful in helping you to relieve tension and allow you to continue your role as caregiver in a calm and relaxed manner. Respite care allows you to have a rest and time to yourself and can be very helpful in renewing you physically and mentally to continue caring for the patient at home. Many patients feel positive about a short-term stay in a hospital or palliative care inpatient facility (formerly called a hospice) during which they can be reassessed and reviewed by the medical staff. Because the entire family has usually become involved when one member is ill, sharing this experience makes it easier. Each member of the family is unique and will deal with the patient in his or her own way, contributing as they can. Not all families can be open and share their feelings. It can be helpful for family members to talk with someone outside the family with whom they feel comfortable, such as the nurse, doctors, social worker, pastoral care worker or a counselor. They can help family members explore any issues, listen and support each other. Children, as part of the family, need to be involved and can be encouraged to spend time with the patient and help with the daily care. Sharing the experience helps to lessen their fears and assist them through the grieving process. Death may have different meanings to children, depending on their stage of development and past experiences. Answer questions honestly and in a way they can understand.

Spiritual Care
The journey to find meaning and purpose in life may be described as our spiritual dimension. For some people, faith and their religion is a source of strength and comfort during this time. For others, the spiritual dimension may involve a less formal search for peace and comfort. Individuals have differing beliefs and needs. These are respected by those who are caring for them. The church community, minister or pastoral care worker from the palliative care team can visit to support the family.

Volunteers
Many palliative care services have volunteers who are selected and trained to work with people who are dying and their families. They can provide additional support by staying with the patient so the caregiver(s) can get out of the house and have a break, or by assisting with chores such as shopping. They can also be there to provide companionship and an open ear to listen to your fears and frustrations. an outsider may also bring comfort and friendship to the patient who may choose to unload to a person who is not as close as family members. Read more about volunteers here.

Social Workers
Social workers are available through most palliative care services to provide advice and support concerning financial matters, identifying community resources available and to liaise where appropriate for the patient or family. They can also provide counseling to deal with the many changes that occur, and the issues that arise, in the family as a result of an illness.

Friends
Some of your friends, as well as friends of the patient, will want to provide support and assistance. Others may find this time more difficult, feel awkward and disappear out of your lives during this time. When friends offer help, accept it and give them direction as to how they can be most useful, such as doing the shopping or preparing a meal. Spending time with the patient, sharing past experiences and common fond memories can be enjoyable for all. Although friends want to continue to visit, this can be tiring for you as a host, and for the patient. Making visiting times, limiting the number of visitors and leaving some space for the family will help alleviate this.

Shared Experiences

Management of Palliative Wound Care

Wound treatment at the end of life must include advanced clinical knowledge, skills, and technology. Nenna[22] states that "the goals of palliation are stabilization of existing wounds, prevention of new wounds if possible and symptom management to improve patient comfort, well-being and quality of life." She also concludes that "there are no definitive wound protocols for treating dying patient's wounds, only guidelines." The management of symptoms in palliative wound care is critical. It has been suggested that local wound care for malignant wounds must address several key concerns that include hemorrhage, odor, pain, exudate, and superficial infection.[27] Table 5 presents an adaptation of interventions suggested for wound symptoms. Palm and Altman[28] suggest the use of a variety of strategies to treat hemorrhage, which range from pressure and temperature variations (that may result in vasoconstriction) to silver nitrate (readily available, inexpensive, sticks or 10%

solution). Afrin is a vasoconstrictor available over the counter, is off label, and when sprayed directly onto the wound bed, helps to control mild to moderate bleeding.[29] Epinephrine 1:1000 solution is another topical vasoconstrictor, sprayed onto the wound followed by application of epi-soaked gauze to wound base for several minutes. Gentle cleansing with warmed normal saline can be effective in managing bleeding in wounds.[30] Odor management is another critical aspect of quality palliative wound care. Alexander[18,19,30,31]reported that "of all the symptoms associated with malignant wounds, the offensive smell is often described as the one causing most distress to patients, their caregivers and families." Metronidazole has been suggested to be the treatment of choice. It is available to be used topically as a gel or cream or gauze can be soaked with intravenous metronidazole solution to use as a compress. Tablets can be ground into a powder and sprinkled onto the wound bed. [27] However, research is lacking in the evidence regarding topical or systemic use of metronidazole.[31] Other odor-reducing treatments that are suggested in the literature but also lack evidence are silver dressings, iodine, activated charcoal, debridement, honey, and others.[18,27,3035] Several studies have reported that pain was the most significant consequence of having a pressure ulcer and affected every aspect of patient's' lives. [3,27,36] Three types of pain have been described.[37]Noncyclic acute wound pain occurs in a single or infrequent single episode such as during sharp debridement. Cyclic acute wound pain occurs more regularly when the wound is manipulated, and chronic wound pain is persistent and occurs without external stimulation. Pain management begins with the selection of the dressing. Comfort is enhanced when dressings are selected that need to be changed less frequently. Nonadherent dressings cause less pain because they do not damage the tissues when removed. Pain can also be managed using systemic analgesics or topical anesthetics and analgesics such as 2% lidocaine gel applied to the wound bed.[37] Morphine gel has been shown to be beneficial and efficacious, with good outcomes for not only cutaneous ulcers but also esophageal and mucosal damage due to chemo radiotherapy.[38] However, there are not enough high-quality studies to recommend the topical route over the systemic route.[36]

Management of wound exudate is essential for patient confidence and comfort and can also contribute to decreased odor. Increased exudate may lead to maceration of the periwound skin and pain.[39]Dressing selection is critically important to control wound exudate. Unfortunately, many of modern dressing products are designed to provide moisture to enhance healing, and this may not be therapeutic for many malignant and palliative wounds that are increasingly moist.
At the University of Phoenix College of Health Sciences and Nursing, we have the cure for the common curriculum. Our coursework focuses on key critical-thinking and leadership skills.

Learn how we are putting nurses to work

Information from Industry

Many wounds are dressed in layers. The primary layer is nonadherent and conforming. The primary dressing should be nonadherent and conforming to vent excess moisture to the secondary dressing. The secondary layer should be highly absorbent, conformable, and as aesthetically pleasing as possible. Hydrocolloid dressings may be useful in wounds with low exudate. Alginate and foam dressings have been found to be highly absorbent and useful as a primary dressing for a wound with moderate to large amounts of exudate. In addition, there are some super-absorbent products based on diaper technology that can be helpful. [40] Bacteria thrive on wound exudate and moist devitalized tissue, which can cause wound odor.[37] Infected wounds can show signs of malodor, exudate, and pain. Many products that are recommended to reduce odor also reduce bacteria levels. Debridement is suggested because eschar or slough material provides growth media for bacteria.[27] Topical antimicrobial products are available for superficial wound infections, but no one product is found to be indicated or suitable for all patients. Silver delivery products lack randomized controlled trial evidence but are one of the most popular topical agents. Other antimicrobial agents that are found in current literature include gentamicin sulfate cream/ointment, metronidazole cream/gel, mupirocin 2% cream/ointment, and polymyxin B sulphate.

http://www.nursingcenter.com/lnc/CEArticle?an=00129334-20100900000009&Journal_ID=54015&Issue_ID=1055450