management of selected non pain II

Question 1

preparing for the last hours of life

Answer 1

• time course unpredictable
• any setting that permits privacy, intimacy
• anticipate need for medications, equipment, supplies
• regularly review the plan of care

Question 2

Common signs and symptoms of imminent death (1-3 months)

Answer 2

• withdrawal from the world
• turning inward
• less communication with the world
• increased reflection
• decreased nutritional intake

Question 3

Common signs and symptoms of imminent death (1-2 weeks)

Answer 3

• altered states of consciousness
• dreams/visions/conversing w seen/unseen
• maybe restless/agitated/wanting up/down
• may want to remove clothing
• maybe quiet/resting deeply
• eyes appear unfocused/dreamy
• sleeping/waking hours prolonged
• not eating/maybe drinking
• then may request an occasional meal

Question 4

common signs and symptoms of imminent death (days to hours)

Answer 4

• maybe surge in energy
• breathing grows shallower in chest
• maybe apnea (up to 60 seconds)
• gurgling (throat)
• eyes maybe teary or dry/shinny
• eyes may remain open/not blink
• skin grows dusky/blotchy
• little observable response to outside environment

Question 5

physiological changes during the dying process

Answer 5

• increasing weakness, fatigue
• decreasing appetite/fluid intake
• decrease blood perfusion
• neurological dysfunction
• pain
• loss of ability to close eyes

Question 6

ICHABOD syndrome

Answer 6

• I = immobility
• C = confusion and coma
• H = homeostatic failure
• A = anorexia
• B = breathing changes
• O = oral intake decreased/observation
• D = dyspnea/detachment

Question 7

weakness/fatigue

Answer 7

• decreased ability to move
• joint position fatigue
• increased risk of pressure ulcers
• increased need for care
• -> activities of daily living
• -> turning, movement, massage

Question 8

decreased appetite/food intake

Answer 8

• fears: giving in, starvation
• reminders:
• -> food may be nauseating, anorexia may be protective, risk of aspiration, clenched teeth express desires, control
• help family find alternative ways to care

Question 9

Body shutting down vs starvation

Answer 9

• BODY SHUTTING DOWN (dehydration)
• -> loss of body fluids/electrolyte changes
• -> decreased blood flow/oxygen to GI tract
• -> absence of hunger sensation
• STARVATION
• -> lack of nutrition
• -> physiological homeostasis
• -> hunger

Question 10

Locus of sensation

Answer 10

• Thirst and taste are in mouth (keeps lips and mucous membranes; taste has a lot to do with smell)
• Hunger is in stomach (note impact of altered O2 and blood flow)

Question 11

Decreasing fluid intake

Answer 11

• oral rehydrating fluids
• Fears: dehydration, thirst
• Remind families, caregivers
• -> dehydration does not cause distress
• -> dehydration may be protective
• Parenteral fluids may be harmful
• -> fluid overload, breathlessness, cough, secretions
• Mucosa/conjunctiva care (keep them moist)

Question 12

decreasing blood perfusion

Answer 12

• tachycardia (try to keep up), hypotension (blood pressure can’t be maintained)
• peripheral cooling, cyanosis
• mottling of skin (lacing pattern)
• diminished urine output (not good blood flow to kidneys)
• parenteral fluids will not reverse

Question 13

Neurological dysfunction

Answer 13

• decreasing level of consciousness
• communication with the unconscious patient
• terminal delirium
• changes in respiration
• loss of ability to swallow, sphincter control

Question 14

Two roads to death

Answer 14

• Normal = sleep > lethargic > obtunded > semicomatose > comatose > death
• DIFFICULT = restless > confused > tremulous > hallucinations > mumbling delirium > myoclonic jerks > seizures > semicomatose > comatose > death

Question 15

decraesing level of consciousness

Answer 15

• the usual road to death
• progression
• eyelash reflex

Question 16

Communication with unconscious patient

Answer 16

• distressing to family
• awareness > ability to respond
• assume patient hears everything
• create familiar environment
• include in conversations (assure of presence, safety)
• give permission to die
• touch (some want it others don’t)

Question 17

Terminal delirium

Answer 17

• the difficult road to death
• medical management (benzodiazepines, neuroleptics)
• Seizures
• Family needs support, education (more help after death)

Question 18

Changes in respiration

Answer 18

• altered breathing patterns
• diminished tidal volume
• apnea (up to 60 seconds)
• cheyne-stokes respiration
• accessory muscle use
• last reflex breaths (gasping)
• FEARS: suffocation
• MANAGEMENT: family support, oxygen may prolong dying process, breathlessness

Question 19

loss of ability to swallow

Answer 19

• loss of gag reflex
• build up of saliva, secretions
• -> scopolamine to dry secretions
• -> postural drainage
• -> positioning
• -> suctioning is rarely indicated

Question 20

loss of sphincter control

Answer 20

• incontinence of urine, stool
• family needs knowledge, support
• cleaning, skin care
• urinary catheters
• absorbent pads, surfaces

Question 21

pain in the last hours of life

Answer 21

• Fear of increased pain
• assessment of the unconscious patient
• -> persistent vs fleeting expression
• -> grimace or physiologic signs
• -> incident vs rest pain
• -> distinction from terminal delirium
• management when renal clearance decreased
• -> stop routine dosing, infusions
• -> breakthrough dosing as needed (prn)
• -> least invasive route of administration

Question 22

loss of ability to close eyes

Answer 22

• loss of retro-orbital fat pad
• insufficient eyelid length
• conjunctival exposure
• -> increased risk of dryness, pain
• -> maintain moisture

Question 23

medications

Answer 23

• limit to essential medications
• choose the least invasive route of administration
• -> buccal mucosal or oral first, then consider rectal
• -> subcutaneous, intravenous rarely
• -> intramuscular almost never

Question 24

Dying in institutions

Answer 24

• home like environment
• continuity of care plans
• avoid abrupt changes of setting
• consider a specialized unit

Question 25

Laying out the body

Answer 25

lay the body out with the arms across the chest and the jaw closed before rigamortus sets in