T1: Palliative & EOL Care Flashcards
palliative care
Care or treatment focusing on reducing the severity of symptoms
hospice care
LESS THAN 6 MONTHS TO LIVE, comfort care
Indication for Palliative
diagnosis of a life-limiting illness
death occurs when
all vital organs/body systems cease to function
irreversible cessation of cardiovascular, respiratory, and BRAIN FUNCTION
what can help determine brain death
EEG or Neuro Assessment
goals of end of life
-Provide comfort and supportive care during dying process
-Improve quality of remaining life
-Help ensure a dignified death
-Provide emotional support to family
end of life
as the period of time during which an individual copes with declining health from a terminal illness or from the frailties associated with advanced age even if death is not clearly imminent.
at end of life, metabolism is
decreased
end of life physical manifestations: respiratory system
-Irregular breathing that gradually slows
-Cheyne-Stokes respiration
-Inability to cough or clear secretions
(Grunting, gurgling, or noisy congested breathing (“death rattle”)
death rattle
Noisy, wet-sounding respirations, or terminal secretions, are caused by mouth breathing and accumulation of mucus in the airways.
Cheyne-Stokes respiration
a pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing.
end of life physical manifestations: heating and touch
-Hearing is usually last sense to disappear
-Decreased sensation
-Decreased perception of pain and touch
end of life physical manifestations: taste, smell, sight
-Blurring of vision
-Blink reflex absent
-Patient appears to stare
-Eyelids remain half-open
-Decreased sense of taste and smell
end of life physical manifestations: integumentary system
-Mottling on hands, feet, arms, and legs
-Cold, clammy skin
-Cyanosis of nose, nail beds, knees
-“Waxlike” skin when very near death
end of life physical manifestations: urinary system
-Gradual decrease in urinary output
-Incontinent of urine
-Unable to urinate
end of life physical manifestations: GI system
-Slowing of digestive tract
-Accumulation of gas
-Distention and nausea
-Loss of sphincter control
-Bowel movement may occur before imminent death or at the time of death
end of life physical manifestations: musculoskeletal
-Gradual loss of ability to move
-Trouble holding body posture and alignment
-Loss of facial muscle tone
-Sagging of jaw
-Difficulty speaking
-Loss of gag reflex
-Swallowing can become more difficult
end of life physical manifestations: cardiovascular system
-Increased heart rate
-Decreased BP
-Later slowing and weakening of pulse
uIrregular rhythm
-Delayed absorption of IM or SQ drugs
Psychosocial Manifestations at End of Life
-Anxiety and fear
-Life review
-Peacefulness
-Saying goodbyes
-Withdrawal
spiritual needs
The patient’s and family’s preferences related to spiritual guidance or pastoral care services should be assessed, and appropriate referrals made.
Kubler-Ross stages of grief
denial, anger, bargaining, depression, acceptance
Decisional capacity refers to
the ability to consent or refuse care
Organ and Tissue Donation
Any body part or the entire body may be donated
-Decided by a person before death
-With family permission after death
full code
refers to use of complete and total heroic measures including CPR, drugs, and mechanical ventilation
Chemical code
involves use of drugs without CPR
DNR
indicates comfort measures only without interference of technology.
AND - Allow Natural Death
Also referred to as “comfort measures only” status.
Comfort measures include pain control and symptom management (usually O2 and meds given)
if an advance directive is not indicated for a client, what type of code are they?
full code
nurses often do not provide time of death in the hospital setting, but when they do, what is required
TWO NURSES will pronounce them, listen to heart beat for a full minute and then doc will sign certificate
The principle of DOUBLE EFFECT
*refers to a principle that regards it morally permissible to give a medication that has the potential for harm if it is given with the intent of relieving pain and suffering and not intended to hasten death.
-give more medication for pain for example, TO RELIEVE PAIN AND SUFFERING even if you know It will slow breathing ect.
principle of beneficence
means that care is provided to benefit
assessment: if patient is alert
-Brief review of body systems to detect signs and symptoms
-Assess for discomfort, pain, nausea, or dyspnea
-Assess coping abilities of patient and family
In the last hours of life
-Limit to comfort measures
-More peaceful for patient and family
-Pain level, respiratory status concerns should be addressed
-Transition your efforts to emotional and comfort support for patient and family as death approaches
Psychosocial Care: Anxiety and Depression management
-Pharm and Non-pharm interventions
-Encouragement, support, and education
Psychosocial Care Hopelessness, Powerlessness, and Fear management
-Encourage realistic hope within the limits of the situation
-Decision making about care can foster a sense of control and autonomy
Four specific fears
1.Pain
2.Shortness of breath
3.Loneliness and abandonment
4.Meaninglessness
Respiratory distress and dyspnea are common near the EOL, so…
Anxiety-reducing agents (e.g., anxiolytics) may help produce relaxation.
nursing interventions for Fear of Loneliness and Abandonment
Holding hands, touching, and listening
Anorexia, Nausea, and Vomiting
Assess the patient for nausea or vomiting and possible contributing causes
* Provide antiemetics before meals if ordered
* frequent meals with small portions of favorite foods
* Offer culturally appropriate foods
* frequent mouth care, especially after vomiting
* Ensure uninterrupted mealtimes
* If ordered, give drugs to increase appetite
* Teach family that appetite naturally decreases at end of life and hunger is rare
* Do not force the patient to eat
EOL constipation causes
Immobility, opioid medication use, depression, lack of fiber in the diet, and dehydration
EOL constipation nursing management
- Assess for and remove fecal impactions
- Encourage movement and physical activities as tolerated
- Encourage fiber in the diet if appropriate
- Encourage fluids if appropriate
- Assess for confusion, agitation, restlessness, and pain, which may be signs of constipation
- Use suppositories, stool softeners, laxatives, or enemas if ordered
Candidiasis
White, cottage cheese-like oral plaques
* Fungal overgrowth in the mouth due to chemotherapy and/or immunosuppression
Candidiasis nursing management
- If ordered, give oral antifungal nystatin
- Clean dentures and other dental appliances to prevent reinfection
- Provide oral hygiene and use soft toothbrush
Dehydration nursing management
- oral care to provide for comfort and hydration of mucous membranes
- Encourage consumption of ice chips and sips of fluids
- Use moist cloths and swabs for unconscious patients to avoid aspiration
- Apply lubricant to the lips and oral mucous membranes as needed
- Do not force the patient to drink
- Teach family that thirst is rare in the last days of life
- Reassure family that cessation of food and fluid intake is a natural part of the process of dying
Delirium nursing mamagement
- room that is quiet, well lit, and familiar to reduce the effects of delirium
- Reorient the dying person to person, place, and time with each encounter
- Stay physically close to frightened patient Reassure in a calm, soft voice with touch and slow strokes of the skin
- Provide family with emotional support and encouragement in their efforts to cope with the behaviors associated with delirium
Dysphagia nursing management
- Identify the least invasive alternative routes of administering drugs needed for symptom management
- Suction orally as needed
- Modify diet as tolerated/desired
- Hand feed small meals
- Elevate the head for meals and at least 30 minutes after
- Discuss risk for aspiration
Dyspnea nursing management
- Elevate the head and/or position patient on side to improve chest expansion
- Use a fan or air conditioner to help movement of cool air
- Teach and encourage the use of pursed-lip breathing
- Give supplemental oxygen as ordered
- Suction PRN to remove accumulation of mucus from the airways. Suction cautiously in the terminal phase
- Give an expectorant as ordered
Myoclonus
- Mild to severe jerking or twitching sometimes associated with use of high dose of opioids
- Patient may have involuntary twitching of extremities
myoclonus nursing intervention
- Changes in opioid medication may decrease myoclonus, discuss with HCP
pain nursing intervention
intervention
* Assess pain thoroughly and regularly to determine the quality, intensity, location, and contributing and alleviating factors
* Minimize irritants, such as skin irritations from wetness, heat or cold, pressure
* Give medications around the clock, in a timely manner, and on a regular basis to provide constant relief rather than waiting until the pain is unbearable and then trying to relieve it
* Provide complementary and alternative therapies, such as guided imagery, massage, and relaxation techniques as needed
Skin Breakdown nursing management
- Implement protocols to prevent skin breakdown by controlling drainage and odor and keeping the skin and any wound areas clean
- nursing management to prevent skin irritations and breakdown from urinary and bowel incontinence
- Use blankets to cover for warmth. Never apply heat
Postmortem Care
-Close patient’s eyes
-Replace dentures
-Wash and position body
*Remove tubes and dressings if appropriate.
*Straighten the body, leaving the pillow to support the head and prevent pooling of blood and discoloration of the face.
