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Palliative Care Final Exam Powerpoints

Terms in this set (113)

signs of impending death
-pulselessness of radial artery
-respirations with mandibular movement
-decreased urine output
-cheyne-stokes breathing
-death rattle
-cool extremities
-mottling
-relaxed muscles
-agonal breathing (gasping, labored breathing)
-vital sign changes (decreased bp, increased but weakened hr, decreased O2, increased temp)
care of the actively dying patient
-symptom management
-positioning
-bathing and hygiene
-checking VS
-education
considerations for ICDs near end of life
pt may chose to have defibrillator deactivated at end of life, this may be accomplished with a magnet and is noninvasive
what are the 5 signs of death?
1) unresponsiveness
2) apnea
3) absence of palpable pulses
4) unresponsive pupils
5) absence of heart sounds
an RN may pronounce death when what conditions are met?
1) death is expected
2) pt had DNR/DNI orders
3) all 5 signs of death are present
4) pronouncement of death is in accordance with policy
who can complete a death certificate?
physician, physician's assistant, or advanced practice nurse
-RN cannot complete the death certificate!
role of the nurse in post-mortem care
Prepare patient for family viewing
Arrange transportation of patient to morgue/funeral home
Determine disposition of belongings
Comfort/support family & friends
Ensure privacy
care of the body post-mortem
-remove all tubes unless there will be organ donation or pt will go to medical examiners
-identify items to remain with the pt (rings, etc.) and remove personal items to be given to family
-bathe pt, brush hair, apply fresh linens and gown
-position pt (eyes and jaw closed, arms outside sheets, etc.)
-remove excess supplies from room
-dim lights and cool air
considerations involving organ/tissue donation
-hospitals are required to contact organ procurement organizations when a pt dies or is near death
-if ruled in for donation follow procedures for organ/tissue preservation
why might an autopsy be performed?
-Curiosity about cause of death
-Advance scientific knowledge re: disease process
-Suspicious circumstances surrounding death
post-mortem documentation
-Date and time of patient's death
-Name of healthcare provider who pronounced death
-If resuscitation was attempted: indicate start/stop time & refer to code sheet
-Indicate whether death is being referred to medical examiner
-Indicate whether an autopsy is being performed
-All postmortem care given (including whether medical equipment was removed or left in place)
-list of all belongings and valuables and who accepted them
-disposition of body
-names of those present at time of death or notified of death
care, support, education provided to family
define bereavement
state of having lost a significant other
define loss
generic term indicating absence of a current or future possession or relationship
Meaning of loss is determined by the person who sustained the loss
define grief
emotional response to loss
define mourning
encompasses death rituals engaged in by the bereaved
types of grief
Anticipatory Grief: grief of impending loss
Uncomplicated/normal grief
Complicated grief: continues over a long period of time, lasts longer than a year, and interferes with normal functioning
Disenfranchised grief: grief that is not socially recognized, such as for a miscarriage
Unresolved grief
types of complicated grief
chronic grief
delayed grief
exaggerated grief
masked grief
Kubler-Ross stages of grief
1) Denial: conscious or unconscious refusal to accept or believe the situation
2) Anger: strong feelings of resentment or blame that are expressed as rage toward family, deceased loved one, health-care system, God, or other external forces
3) Bargaining: trying to strike an agreement with God or fate to postpone situation in return for a change in behavior
4) Depression: deep sadness about the situation
5) Acceptance: a sense of peace & calm about situation
common bereavement practices
Friendly visiting
Provision of meals
Informal support by previously bereaved
Lay support groups
Participation in cultural and religious rituals
A friendly listener
Involvement in a cause-related group
Exercise
Joining a new group
role of the nurse in bereavement
-normalize the grief process
-supporting disclosure
-make referrals for complicated grief
-assist with identifying coping strategies and counseling interventions
issues for survivors of disease/illness
Disease recurrence
Surveillance for related disorders (e.g. second cancers for cancer survivors)
Monitoring for other long-term and late effects of disease & its treatment
Psychosocial well-being
Fiscal well-being
Fertility & parenthood
sexuality is defined by...
Genitalia
Hormones
Attitudes
Feelings
Learned behaviors
Culture
barriers to sexual intimacy can include...
Talking about sex
Culture & sexual identity
Sexual anatomy functioning
Sexual health care & safer sex
Challenges to sexual health
Body image
Masturbation & fantasy
Positive sexuality
Intimacy & relationships
Spirituality
components of human sexuality
Talking about sex
Culture & sexual identity
Sexual anatomy functioning
Sexual health care & safer sex
Challenges to sexual health
Body image
Masturbation & fantasy
Positive sexuality
Intimacy & relationships
Spirituality
barriers to nurses discussing sexuality with pts
Time
Lack of adequate training
Assuming sexuality is only about intercourse
Assuming older patients and those without a partner are not interested in sexuality
Assuming treatments are not available
Personal discomfort
what is dyspareunia?
difficult or painful intercourse
factors that contribute to dyspareunia
diabetes; hormonal imbalances; vaginal, cervical, or rectal disorders,; antihistamine, alcohol, tranquilizer, or illicit drug use; and cosmetic or chemical irritants to genitals
ExPLISSIT model
communication tool for addressing sexuality/sexual health

Permission giving (P)
Limited Information (LI)
Specific Suggestions (SS)
Intensive Therapy (IT)
nursing interventions for sexuality concerns
-Symptom management (Fatigue, Dyspnea, Depression)
-Review medications & consider changes if appropriate (Antidepressants, Opioids)
-Creative solutions to body image concerns (ostomy)
-treatment of sexual dysfunction
-validation and normalizing
Sex tips involving ostomies
-sex will not injure the stoma
-no sex in or around the stoma (no anal sex)
-odor tablets
-empty pouch beforehand
-secure all fasteners and adhesives
-low profile pouches and pouch covers
Maslow's Hierarchy of self-care
breathing
nutrition
physical exercise
exercise for the mind
human community
exercise for the spirit
types of suffering
Physical
Psychological
Social
Spiritual distress
types of palliative sedation
Terminal Sedation
Total Sedation
Sedation for Intractable Symptoms
Sedation for Distress in Imminently Dying
define palliative sedation
Lowering of patient consciousness using medications for the express purpose of limiting patient awareness of suffering that is intractable and intolerable
-consciousness is decreased just enough to reduce symptoms
define terminal wean
mechanical ventilation is withdrawn and client is not expected to survive
define terminal extubation
removal of client's endotracheal tube
___% of hospital deaths occur in the ICU
22%
principle of double effect
1. The intended end (relief of distressing symptoms) is a good one;
2. The bad effect (death) is foreseen but not intended;
3. The bad effect is not a means of bringing about the good effect (death is not what relieves distress); and
4.The good effect outweighs the bad effect (in dying person, risk of hastening death for benefit of comfort)
symptoms requiring palliative sedation
**Pain
Agitation/restlessness
Nausea and vomiting
**Dyspnea
**Delirium
Anguish
Remorse
Hopelessness
Loss of Meaning
meds used for palliative sedation
Benzodiazepines (Midazolam)
Ativan
Neuroleptics (Haldol, Thorazine)
Chlorpromazine
Barbiturates (Phenobarbital)
Anesthetics (Propofol)
meds used for terminal weaning
opiates (morphine)
benzos
Richmond Agitation Sedation Scale (RASS)
Combative
Very agitated
Agitated
Restless
Alert and calm
Drowsy
Light sedation
Moderate sedation
Unarousable
the 4 factors that must be present in order to receive palliative sedation
-terminal diagnosis
-severe symptoms
-DNR order
-death in imminent
physical care for pt under palliative sedation
Nurses administer the medications
Suctioning- rarely used for increased secretions;
Scopolamine Patch.
Blink reflex is affected (artificial tears)
Bowel and bladder management
Skin care
Allow family to do as much care as they would like.
describe the Karen Ann Quinlan case
Mixed Valium and alcohol
Found unconscious
Persistent Vegetative State
Court permitted d/c of ventilator
describe the Nancy Cruzan case
Car skidded off icy road
Nancy submerged in water
Resuscitated on site
Persistent Vegetative State
Husband requested feeding tube be d/c'ed
Family requested feeding tube to left in place
Missouri Supreme Court
US Supreme Court
describe the Terry Schiavo case
Suffered cerebral hypoxia following cardiac arrest secondary to bulimia.
Persistent Vegetative State
Husband requested feeding tube be d/c'ed
Parents requested feeding tube be left in
Began 11 year dispute about who should be surrogate decision-maker and whether life-prolonging interventions (feeding tube) should be withdrawn for purpose of allowing Terry to die
what did "Terri's law" do?
it was an executive order to reinsert Terry Schiavo's feeding tube
what is patient assisted death?
Intent is to produce death to relieve suffering.
"The means to end a patient's life is provided to the patient (ie. a lethal dose of medication) with knowledge of patient's intention"
what is euthanasia?
Someone other than patient commits an action with the intent to end patient's life
can be voluntary or involuntary
define "mercy killing"
act of putting to death someone suffering from a painful and prolonged illness or injury
___% of pts with cancer have nausea/vomiting
40-70%
where is the vomiting center located?
medulla oblongata
which places send signals to the vomiting center?
GI tract
pressure receptors
CTZ
cerebral cortex
vestibular apparatus
common causes of N/V
biochemical/drug induced
gastric stasis
GI obstruction/irritation
Increased ICP
vestibular
psychological
A VOMIT mnemonic
Anticipatory/Anxiety
Vestibular
Obstructive
Metabolic/Medication
Infection/Inflammation
Toxins/Tumor
assessment of N/V
Acuity
Frequency
Associated signs and symptoms
Eating pattern
Bowel pattern
Past medical history
Scales:
-Visual Analog Scale (VAS)
-Morrow Assessment of Nausea and Vomiting (MANE)
-Rhodes Index of Nausea and Vomiting Form 2 (INV-2)
-Functional Living Index Emesis (FLIE)
Non-pharmacological interventions for N/V
Cool cloth
Decrease stimuli
Fan
Relaxation
Distraction
Acupuncture or acupressure
Maintain good oral hygiene
Cut out intolerant foods.
Restrict intake when gastric distension is a factor.
Start with sips, ice chips or popsicles, after nausea settled; gradually increase from fluids to semi-solid to full
food. If nausea recurs, step back until nausea resolves.
Avoid spicy, fatty and salty foods, or ones with strong odors.
Avoid mixing liquids and solids.
Use small frequent, bland meals when hungry.
Drinking cool, fizzy drinks.
Avoid lying flat after eating.
classes of antiemetics
Prokinetic agents
Dopamine receptor antagonists
Antihistamine agents
Selective 5HT3 receptor antagonists
Corticosteroids
Anticholinergic agents
Octreotide
Cannabinoids
Substance P antagonists (NK1 receptor antagonists)
common N/V meds
Lorazepam, 0.5 to 1 mg every 6 hours PRN
Prochlorperazine, 10 mg every 4 to 6 hours PRN
Haloperidol, 0.5 to 1 mg every 4 to 6 PRN
Scopolamine, 1 to 3 patches every 3 days
Promethazine, 12.5 to 25 mg every 4 to 6 hours PRN
Metoclopramide, 10 mg three to four times daily before meals
ABHR (Ativan, Benadryl, Haldol, Reglan) gel, 1 mL every 4 to 6 hours as needed, or suppository, 1 PR every 4 to 6 hours PRN
What meds are in ABHR used to treat N/V?
ativan
benedryl
haldol
reglan
anorexia
The reduction or loss of desire to eat
Weight lost can be replaced with increased intake or nutritional supplements
Weigh loss of starvation involve loss of fat
cachexia
Complex syndrome involves, anorexia along with significant weight loss, loss of muscle tissue and adipose tissue, generalized weakness
Increased protein catabolism and inflammatory response
anorexia and cachexia are common in...
cancer, AIDS, COPD, HF, end stage renal disease
mechanisms and effects of ACS
*loss of appetite --> tissue wasting, nausea, loss of pleasure at meals
*reduced motor activity and decreased muscle synthesis --> muscle wasting, exhaustion, weakness
*decreased immune response --> increased risk of infection
*decreased response to therapy --> earlier demise and complication from illness
primary anorexia/cachexia syndrome
chronic illness disrupts homeostatic function of the CNS leading to metabolic changes
-Systemic inflammatory response = cytokine production
-Glucose intolerance, insulin resistance
-Increased lipolysis
-Increased skeletal muscle catabolism
-Negative nitrogen balance
secondary anorexia/cachexia syndrome
exogenous factors
-Physical symptoms
-Treatment side effects
-Psychological or spiritual distress
-Oral health
assessment of ACS
Anorexia and/or early satiety
Weakness and fatigue present
Mental status decline, depression
Weight
Triceps skin fold thickness decrease
Midarm muscle circumference decreased
Serum albumin
nutritional support for ACS
Early in disease
Ascertain meaning for patient and family
Culturally appropriate food and customs
Smalls meals on patient's schedule, according to preferences
Offering different tastes, textures, liquids
Consult with nutritionist
Enteral and parental nutrition: generally not recommend
Assist patient and family in understanding nutritional needs and limitations.
meds for ACS
progestational agents (megace)
costicosteroids (dexamethasone)
cannabinoids (dronabinol)
metaclopramide
approach to treatment of ACS
Early and on going determination of goals of care
Optimal treatment of underlying disease according to goals of care
Prevention, recognition and prompt treatment of exogenous causes
Guidance from nutritional specialists
Appropriate pharmacological interventions
Resistance exercise as appropriate
Compassionate counseling to patient, family
define spirituality
A way of being and experiencing that comes about through awareness of a transcendental dimension.
Characterized by certain identifiable values in regard to self, others, nature, life, and whatever one considers to be the Ultimate.
That which gives one purpose, meaning and hope and provides a vital connection
tasks of spiritual integration
Coming to terms with limits
Enhanced sense of self
Defining purpose, meaning and hope
Belonging
Putting the pieces together
symptoms of grief in young children
Nervousness
Uncontrollable rages
Frequent sickness
Accident proneness
Antisocial behavior
Rebellious behavior
Hyperactivity
Nightmares
Depression
Compulsive behavior
Memories fading in and out
Excessive anger
Excessive dependency on remaining parent
Recurring dreams...wish-filling, denial, disguised
symptoms of grief in older children
Difficulty in concentrating
Forgetfulness
Poor schoolwork
Insomnia or sleeping too much
Reclusiveness or social withdrawal
Antisocial behavior
Resentment of authority
Overdependence, regression
Resistance to discipline
Talk of or attempted suicide
Nightmares, symbolic dreams
Frequent sickness
Accident proneness
Overeating or under eating
Truancy
Experimentation with alcohol/drugs
Depression
Secretiveness
Sexual promiscuity
Staying away or running away from home
Compulsive behavior
4 phases of bereavement
1) shock and numbness- most intense in first 2 weeks
2) searching and yearning- week 2 to 4th month
3) disorientation- month 5-9
4) recognition/resolution- month 18-24
define delirium
Disturbance in attention & awareness
Disturbance develops over a short period of time & tends to fluctuate in severity during course of day
Disturbance in cognition
Disturbances not explained by another preexisting, established, or evolving neurocognitive disorder & do not occur in context of a severely reduced level of arousal, such as coma
three subtypes of delirium
Hyperactive: e.g. climbing out of bed, pulling out IV, picking at air, incoherent speech
Hypoactive: e.g. quiet, very sleepy, hard to arouse, mumbling speech
Mixed
assessment tools for delirium
Confusion Assessment Method (CAM)
Delirium Rating Scale (DRS)
Memorial Delirium Assessment Scale (MDAS)
4 features of delirium
1) acute onset of mental status changes or fluctuating course
2) inattention
3) disorganized thinking
4) altered level of consciousness
common causes of delirium
Constipation
Hypovolemia
Hypoglycemia
Infection
Medications
Bladder catheter or outlet obstruction
Oxygen Deficiency
Pain
prevention of delirium
Maintaining sleep/wake patterns
Frequent orientation
Mobilizing patient
Engaging in mentally stimulating activities
Maintaining consistent/familiar caregivers
Ensuring use of eyeglasses & hearing aids
Monitoring fluid & food intake
Monitoring bowel function
Avoid urinary catheters, intravenous lines, and use of restraints when possible
management of delirium
Workup to identify underlying cause (CBC, BUN & creatinine, Liver function, Thyroid function, Rule out infectious process-urine culture, chest X-ray, Nutritional imbalance-B12, folate levels, Brain imaging)
Avoid restraints
Provide safe, quiet, comforting environment
Debrief patient after episode
Note: at EOL, avoid invasive testing. Search for common causes only.
meds to treat delirium
rarely used in hypoactive delirium
Antipsychotics for severe agitation (Haloperidol, Chlorpromazine, Olanzapine, Risperidone, Quetiapine)
May add benzodiazepine (e.g. Lorazepam) if not effective
common coping mechanisms
Taking action
Finding favorable characteristic in the situation
Denial
most common psychiatric complications of terminal disease/dying
Delirium
Depression
Suicidal ideation
Severe anxiety
define anxiety
Vague, subjective feeling of apprehension, tension, insecurity, and uneasiness, usually without a known, specific cause identifiable by the individual
stages of anxiety
mild
moderate
severe
panic
which symptoms of anxiety could be misinterpreted to be part of a medical disorder or a med side effect?
Palpitations
Panic
Restlessness
Chest pain
Irritability
Jitteriness
Headache
Anorexia
Apprehension
symptoms of an anxiety disorder
Chronic apprehension, worry, inability to relax not related to illness or treatment
Difficulty concentrating
Irritability or outbursts of anger
Difficulty falling asleep or staying asleep not explained by illness or treatment
Exaggerated startle response
Perspiring for no apparent reason
Chest pain or tightness in chest
Fear of places, events, certain activities
Unrealistic fear of dying
Fear of "going crazy"
Recurrent & persistent ideas, thoughts, or impulses
Repetitive behaviors to prevent discomfort
define depression
Spectrum of human emotions & behaviors ranging from expected, transient, and non-clinical sadness following upsetting life events to clinically relevant extremes of suicidality and major depressive disorder
depressive syndromes vs. depressive symptoms
Depressive syndromes: symptoms that comprise a discrete psychiatric disorder (e.g. major depression, dysthymia, organic affective disorder)

Depressive symptoms: varying degrees of depressed feelings not necessarily associated with psychiatric illness
depression can lead to...
Decrease immune response
Decrease survival time
Impair ability to adhere to treatment
Impair quality of life
risk factors for depression
Prior episodes of depression
Family history of depression
Prior suicide attempts
Female gender
Age under 40 years
Postpartum period
Lack of social support
Stressful life events
Personal history of sexual abuse
Current substance abuse
symptoms of depression
Enduring depressed or sad mood, tearful
Marked disinterest or lack of pleasure in social activities, family, and friends not explained by pain or fatigue
Feelings of worthlessness & hopelessness
Excessive enduring guilt that illness is a punishment
Significant weight loss or gain not explained by dieting, illness, or treatments
Hopelessness about the future
Enduring fatigue
Increase or decrease in sleep not explained by illness or treatment
Recurring thoughts of death or suicidal thoughts or acts
Diminished ability to think and make decisions
anxiety and depression scales
Beck Depression Inventory
Center for Epidemiological Studies of Depression Scale
Geriatric Depression Scale
Hospital Anxiety and Depression Scale
Zung Self-Rating Depression Scale
Zung Self-Rating Anxiety Scale
PhQ9
signs of possible suicidal ideation
Isolated or withdrawn behavior
Death wishes
Death themes in art, writing, play conversation
Joking about suicide
Asking questions about death (e.g. "How many of these pills would it take to kill someone?)
Comments about giving up
Statements that indicate hopelessness or helplessness
interventions for suicidal ideation
Identification
Provision of safety & supervision
Initiation of psychiatric evaluation
Hospitalization if person has an immediate, lethal, and precise plan
Palliation of pain & other symptoms
suicidal ideation documentation
Patient's behavior & verbatim statements
Suicide assessment
Time & date provider was notified
meds for anxiety
Benzodiazepines
-Lorazepam (Ativan & others)
-Alprazolam (Xanax)
-Diazepam (Valium & others)
-Clonazepam (Klonopin)
Antidepressants (cyclic antidepressants, SSRIs/SNRIs)
-Fluoxetine (Prozac)
-Sertraline (Zoloft)
-Escitalopram (Lexapro)
-Duloxetine (Cymbalta)
-Venlafaxine (Effexor)
Neuroleptics
-Haloperidol (Haldol)
interventions for mild-moderate anxiety
Provide concrete objective information
Ensure stressful event warning
Increase opportunities for control
Increase patient & family participation in care activities
Acknowledge fears
Explore past and/or present perceptions of an event
Manage symptoms
Encourage hope
interventions for moderate-severe anxiety
Use presence of support person as "emotional anchor"
Support expression of feelings, doubts, and fears
Explore past and/or present perceptions of an event
Provide accurate information for realistic restructuring of fearful ideas
Teach anxiety-reduction strategies, such as focusing, breathing, relaxation, and imagery techniques
Use massage, touch, and physical exercise
Manage symptoms
Use antianxiety medications
Delay procedures to promote patient control & readiness
Consult psychiatric experts
interventions for panic level anxiety
Stay with the patient
Maintain calm environment & reduce stimulation
Use antianxiety medications and monitor carefully
Manage symptoms
Use focusing and breathing techniques
Use demonstration in addition to verbal direction
Repeat realistic reassurances
Communicate with repetition and simplicity
Consult psychiatric experts
meds for depression
Selective serotonin reuptake inhibitors (SSRIs)
-Sertraline (Zoloft)
-Paroxetine (Paxil)
-Citalopram (Celexa)
-Escitalopram (Lexapro)
Serotonin/norepinephrine reuptake inhibitors (SNRIs)
-Venlafaxine (Effexor)
-Duloxetine (Cymbalta)
Tricyclic antidepressants
-Amitriptyline (Elavil)
-Desipramine (norpamin)
-Nortriptyline (Avnetyl, Pamelor)
Psychostimulants
-Dextroamphetamine (Dexedrine)
-Methylphenidate
-Provigil (Modafinal)
Dopamine reuptake blocking compounds
-Bupropion (Wellbutrin, Zyban)
cognitive interventions for depression
clarify misconceptions/modify faulty assumptions
Examples:
Help individual identify & test negative automatic thoughts
Review & reinforce patient's strengths
Set realistic, achievable goals
Teach thought interruption to halt negative thoughts
Avoid denying the patient's sadness or depressed feelings
Avoid chastising the patient for feeling sad
interpersonal interventions for depression
Focus on improved self-esteem, development of effective social skills, & dealing with interpersonal/relationship difficulties
Examples:
Give consistent attention, even when patient is uncommunicative, to show that the patient is worthwhile
Direct comments & questions to the patient rather than to significant others
Encourage patient to maintain open communication & share feelings with significant others
Avoid medical jargon, advice giving, sharing personal experiences, or making value judgments
behavioral interventions for depression
Avoid reinforcement of dependent or negative behaviors
Instead: provide contingency relationship between positive reinforcement and independent behavior/positive interactions with environment
Examples:
Provide directed activities
Develop structured daily activity schedules
Focus on self-care functional areas: e.g. breathing, eating, drinking, elimination patterns, personal hygiene behavior, rest and activity patterns, patterns of solitude/social interactions
alternative/complementary therapies for depression
Guided imagery & visualization
Music therapy
Art therapy for creative self-expression
Humor/laughter
Aerobic exercise
Aromatherapy
Massage
Phototherapy (exposure to bright, wide-spectrum light)
benefits and burdens of mechanical ventilation
benefits: Support breathing, treat acute respiratory failure, COPD exacerbation

burdens: Discomfort, invasive, limits mobility
interventions for mechanical ventilation withdrawal
premedication for anticipated distress (opioids)
weaning (gradual reduction of O2 and ventilation, extubation or use of t-tube)
considerations for extubation
After ventilation withdrawal place a tracheostomy mask with humidified air or low flow O2
Removal of endotracheal tube for patient comfort and aesthetics
Prepare for distressing noises
Consider medication with dexamethasone for airway edema
Continue O2 via nasal cannula as needed and patient preference
considerations for dialysis
Avoid volume overload
Utilize medication not metabolized by kidneys
Discontinue all non symptoms management medications to reduce risk of toxicities
Involve a pharmacist
Anticipate common symptoms and have appropriate medications available
Prepare patient and family for what to expect
common symptoms in EOL and treatments
-pain (methadone and fentanyl)
-delirium (haloperidol, benzos)
-dyspnea (anticholinergics, opioids, O2)
-nausea (haloperidol)
-itching (benzos, benadryl, lanolin creams)
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