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NUR360 > Dehydration, Palliative Care and Pain Management > Flashcards

Dehydration, Palliative Care and Pain Management Flashcards

1
Q

Dehydration

A

A “loss or removal of fluid” from the body and occurs when fluid intake fails to fully replace fluid losses, fluid or electrolyte imbalance

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2
Q

Risk Factors for Dehydration in Older Adults

A

a. gender
b. cognitive impairment
c. malnutrition
d. functional (decreased mobility, reduced swallowing)
e. environmental (access, warm temperature)
f. medications (laxatives, diuretics)
g. pain
h. social (lack of attention to drink preferences)
i. institutional factors (untrained staff)

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3
Q

Age related Factors for Dehydration in Older Adults

A

a. kidney function - decline
b. reduced thirst response
c. reduced body water content (41L/70kg > 35L/50kg)
d. fear of incontinence
e. reduced lean mass

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4
Q

Significance of Dehydration

A

Causes
- fever, vomiting, diarrhea

Effects
- hypovolemia, electrolyte balance disruption

Consequences

  • hypovolemic shock
  • delirium
  • severe dehydration
  • falls&raquo_space; fractures
  • death
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5
Q

Reasons for Inadequate Fluid Intake

A

Can drink: lack of access, dementia

Can’t drink: NPO, dysphagia

Won’t drink: fear of incontinence or poisoning

End of life: part of palliative care
- reduce edema, incontinence and lung mucous secretion

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6
Q

Health Consequences of Dehydration

A
  • heart disease
  • confusion
  • constipation
  • kidney failure
  • poor wound healing
  • infections
  • seizures
  • drug toxicity
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7
Q

Constipation

A

Infrequent/hard to pass bowel movement, fewer than 3 defecations per week

Most commonly caused by dehydration

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8
Q

Signs and Symptoms of Dehydration

A

a. Missed some drinks between meals
b. Expressed fatigue
c. Blood labs showing high sodium or glucose

traditional signs should not be relied on (fluid intake, urine colour, dry mouth)

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9
Q

Severity of Dehydration

A

Mild: headache, fatigue, weakness, dizziness, leg cramps, lethargy
- exhaustion and mood changes

Moderate: sticky or dry mouth, decreased skin elasticity, pallor

Severe: fever, confusion (delirium), kidney failure, UTI, low BP, convulsions, severe cramping

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10
Q

Interventions for Dehydration

A

Drinking water (but does not replace electrolytes)

IV fluids
a. 0.9% NaCl, isotonic (raise blood volume)
b. RL for acidosis
KCl for alkalosis
(correct pH imbalances)
c. d5w (protein-sparing, glucose drip)

Prevention!! - identify risk

a. Dehydration Risk Appraisal Checklist
b. drink in AM, throughout the day, half your fluid intake, full glass with meds

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11
Q

Take Away: H2O

A 
H = identify those at High risk
2 = causes: inadequate fluid intake and excessive fluid loss
O = offer fluids
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12
Q

Myths about Palliative Care

A
  • only for those who are recognized as approaching end of life in days to weeks
  • cause increase in anxiety and depression
  • a passive approach that involves limited assessment and intervention
  • can only be delivered on a palliative are unit or hospice setting
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13
Q

Palliative Care

A

An approach to care that aims to relieve suffering and improve the quality of living and dying in those diagnosed with life threatening and life limiting illness

  • in does not hasten death
  • avoid inappropriate treatment or suffering
  • applicable to all ages
  • should be provided by the doctors that have been following the patient: GP, specialist, etc.
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14
Q

The Approach of Palliative Care

A

a. quality of life
b. symptom management
c. preserving dignity
d. advanced care planning and treatment decisions
e. exploring wishes, values and personhood
f. discussing and preparing for end of life
g. ethical and moral problem solving
h. assessing and managing grief
i. care for the caregiver

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15
Q

Geriatric Palliative Care

A

Integrates the complementary specialities to provide comprehensive are for older patients entering the later stage of their lives and their families

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16
Q

Advanced Care Plannning (ACP)

A

a. reflecting on and communicating about one’s values and wishes for future health and personal care
b. identifying person who can make decisions regarding one’s health if one lacks the capacity to make decisions

It is NOT: a single convo, a code discussion, or set in stone!

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17
Q

Establishing Goals of Care (setting priorities)

A

Ongoing discussion that should occur when individuals are well enough to articulate their wishes

“What would be important to you if you had an advanced incurable illness?”

“What goals do you have for the time you have left?”

18
Q

POA

SDM

A

Power of Attorney

Substitute Decision Maker

19
Q

DNR
CMO
AND
EDITH

A

Do Not Resuscitate
Comfort Measures Only
Allow Natural Death (proposed alternative to DNR)
Expected Death in the Home

20
Q

SMK

FTC

A

Symptom Management Kit

Failure to Cope

21
Q

Diagnosis and Prognosis

A

Prognosis depends on diagnoses and existing comorbidities

Prognostication is not an exact science, time frames are given in ranges (3-6 months)

22
Q

Palliative Performance Scale

A

PPS 70% - significant disease (palliative care introduced)

PPS 50% - mainly sitting or lying

PPS 30% - bed bound, steep decline

PPS 10% - imminent death

23
Q

Gold Standard Framework

A

Assists in the early identification of patients who would benefit from a palliative approach to care

Provides guidance on prognostication

  • surprise question
  • general indicators of decline (deterioration, decrease response to tx)
  • specific clinical indicators (COPD, frailty, dementia)
24
Q

Illness Trajectories

A

a. Cancer trajectory
high function for most duration and steep decline before death

b. Organ System Failure
constant dip and rise, each recovery is weaker, risk of sudden death

c. Frailty/dementia
extremely slow and long

25
Q

The Importance of Dignity

A

Quality of being worthy of honour and respect, mitigates suffering at the end of life

Undermining of dignity is associated with: depression, anxiety, hopelessness, desire for death, lower quality of life, feeling of being a burden

26
Q

Edmonton Symptom Assessment System - Revised (ESAS-R)

A

Symptom assessment tool used in palliative care

  • best done via self-report
  • can be used to follow efficacy of intervention

Assesses the following symptoms on scale of 0-10:

tiredness, drowsiness
nausea, loss of appetite
depression, anxiety
dyspnea, pain
overall wellbeing, other
27
Q

Facts about Symptom Management in Palliative Care

A

a. same meds used to treat pain/anxiety is used to treat dyspnea (i.e. hydromorphone)
b. use of meds that are often discouraged for use (not worried about long term effects)
c. non-pharmaco interventions can be helpful and should overlap meds
d. off-label use is common

28
Q

Pain

A

an unpleasant sensory and emotional experience that is subjectively defined

  • multidimensional, shaped by physical and psychological factors
  • can be influenced by emotional trauma
29
Q

Types of Pain

A
  • direct vs indirect
  • nociceptive, neuropathic, central, sympathetic
  • acute vs chronic
30
Q

Assessment of Pain

A

a. interview and review of systems
b. in-depth pain and medical history
c. pain assessment tools
d. physical exam
e. diagnostics

31
Q

Pain Assessment Tools

A

a. Brief Pain Inventory
b. Short-form McGill Pain Questionnaire
c. Visual Analogue Scale
d. Numeric Rating Scale
e. Faces Pain Scale (revised)

pain diaries - ongoing self-report

32
Q

Geriatric Considerations about Pain

A

Cognitive impairment

  • self-report is not useful in severe cases
  • all clients with or without dementia should be asked about pain
  • small behavioural changes may indicate pain

Pain is not a normal part of aging

33
Q

Barriers to Pain Assessment in the Elderly

RNAO

A
  • less frequent reports of pain
  • choosing to suffer in silence
  • perception of pain by others
  • fear of losing self-control
  • fear of addiction
  • inability or difficulty swallowing pills
34
Q

Under-treatment of pain

A

Common in patients with cognitive impairment

Consequences:
- depression, impaired sleep, functional disturbances, decreased QOL

35
Q

Non-verbal signs of pain

A
  • grimacing, wincing
  • moaning
  • rigidity, arching
  • restlessness, shaking
  • pushing, responsive behaviours
  • mood changes

*interpret in its content

36
Q

PAINAD Tool

A

Used for cognitively impair individual
scored out of 10 (0-1-2)

a. breathing independent of vocalization (occasional laboured, prolonged hyperventilate)
b. negative vocalization
c. facial expression (frown, grimace)
d. body language (fidget, rigid)
e. consolability (distracted, unconsolable)

37
Q

Pain Management

A

Non-pharmacological (always include)

  • mindfulness meditation
  • massage
  • physical therapy and exercise

Pharmacological

  • dictated by types of pain: cancer vs non-cancer, acute vs chronic
  • anticipate and prepare for side effects
  • end-of-life pain management is often more aggressive

Holistic

  • physical
  • social
  • spiritual
  • psychological
38
Q

Equianalgesic

A
  • calculation of an equivalent dose between different analgesics
  • equivalent amounts of meds in a similar drug class that also take into account route of administration
39
Q

Pain Medication Considerations

A
  • drug coverage
  • medication management
  • side effects
  • DDI
  • renal or hepatic function
  • tolerance
40
Q

Side Effects

A

Opiods

  • constipation
  • nausea/vomiting
  • respiratory depression
  • pruritis
  • delirium

NSAIDs

  • GI symptoms
  • risk of bleeding

Acetaminophen

  • risk of hepatic dysfunction
  • safe: <3g/day

NUR360 (13 decks)

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