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NURS 3510 - Supportive and Palliative Care > Week 11 > Flashcards

Week 11 Flashcards

1
Q

describe the relationship between palliative care & end of life care

A
  • end of life care is a piece/part of palliative care

- end of life care does not = pall care

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2
Q

what are some normal physiological changes that indicate that death is near (8)

A
  • progressive weakness
  • fatigue
  • cardiac and circulatory changes
  • resp changes
  • integumentary changes
  • food & fluid changes
  • elimination changes
  • LOC changes
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3
Q

what LOC changes occur near end of life (4)

A
  • pts may sleep more soundly , become less and less noticable
  • may moan or jerk in sleep
  • pts may irrationally talk about doors, windows, and maps (considered a near death awareness)
  • may experience deliirum or paranoia
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4
Q

what 3 cardiac & circulatory changes occur near the end of life (3)

A
  • decreased blood perfusion
  • decreased cerebral perfusion
  • decreased cardiac output and intravascular volume
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5
Q

what is a clinical manifestation of decreased blood perfusion near the end of life

A
  • skin may become mottled
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6
Q

what are interventions for decreased blood perfusion near end of life (4)

A
  • skin care
  • regular repositioning
  • lotion to skin
  • soft pillows for support
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7
Q

what are some clinical manifestations of decreased cerebral perfusion near end of life (7)

A
  • decreased LOC
  • terminal delirium
  • drowsiness
  • disorientation
  • may moan or jerk in their sleep
  • pts may sleep more deeply, become less and less arousable
  • pts may talk irrationally about doors, windows, maps (considered a near death awareness)
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8
Q

what is terminal delirium characterized by (6)

A
  • confusion
  • agitation/restlessness
  • visions
  • may be frightening, comforting, or neither (just “there)
  • may be like a “burst of energy” in pts who have been quiet or unresponsive
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9
Q

what is included in nursing interventions for terminal delirium (4)

A
  • assess for possible causes (ex. urinary retention, pain)
  • acknowledgement if experience is comforting
  • sedation if experience is frightening or threatening
  • maintain dignity despite confusion
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10
Q

what is an example of a med used for sedation if terminal delirium is frightening to the pt

A
  • benzos ex. midaxolam –> orally or bucally
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11
Q

families often mistake terminal delirium as..

A
  • behavior for pain –> pain meds generally not effective
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12
Q

what are nursing interventions for decreased cerebral perfusion near the end of life (2)

A
  • orient pt gently if tolerated and not upsetting
  • state “i dont see what your seeing. are you comfortable?” if they describe seeing people in the room who have died before them (kinda contradicting between the readings?)
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13
Q

describe family care r/t terminal delirium near end of life

A
  • prepare the family

- assure the family that it is normal

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14
Q

what are clinical manifestations of decrease in CO and intravascular volume in near the end of life (3)

A
  • tachycardia
  • hypotension
  • peripheral cooling
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15
Q

what are nursing interventions for decrease in CO and intravascular volume near end of life (2)

A
  • minimize exertion

- space out activities

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16
Q

what respiratory changes may occur near end of life (3)

A
  • retention of secretions in the pharynx and upper resp tract
  • dyspnea
  • changes to breathing patterns
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17
Q

what are clinical manifestations of retention of secretions near the end of life (3)

A
  • noisy respirations
  • congestion or gurgling noises
  • usually no cough or weak cough
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18
Q

what are nursing interventions for retention of secretions near end of life (7)

A
  • HOB 45 degrees
  • place on side
  • meds
  • frequent repositioning
  • restrict fluids
  • if pt is receiving IV hydration and the respirations are becoming noisy, discuss w the family about DC the fluids
  • mouth spray to keep mouth moist
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19
Q

what meds can be used as an intervention for retention of secretions near end of life (2)

A
  • scopolamine (anticholinergics dry secretions)
  • glycopyrolate
  • NO lasix
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20
Q

why is suctioning not recommended for the accumulation of secretions near end of life (2)

A
  • it often cannot reach the secretions
  • causes distress to the pt

maybe yonker suction if secretions are accumulating in the mouth

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21
Q

what is a clinical manifestation of dyspnea near the end of life

A
  • SOB
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22
Q

what are nursing interventions for dyspnea at end of life (3)

A
  • O2 2-3 L may help some (but not all) pts
  • fan directed towards pt
  • opioids
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23
Q

what should you educate the family on regarding breathing changes near end of life

A
  • pts who are actively dying do not experience distress due to breathing changes
  • these breathing changes are a normal part of the dying process as the brain’s “breathing center” slows down
  • can become very rapid
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24
Q

what are 3 common breathing patterns near end of life

A
  • cheynes-stokes respirations
  • ataxic respirations
  • agonal breath
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25
Q

describe cheyne-stokes respiration

A
  • rhythmic waxing and waning of the depth of respiration
  • breathes deeply for short time, and then breathes very slightly or stops breathing all together
  • repetitive pattern
  • periods of rapid breathing interspersed w periods of very slow breathing or breathing that stops for short periods of time (apnea)
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26
Q

describe ataxic respiration

A
  • complete irregularity
  • irregular pauses
  • increasing apnea
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27
Q

what is agonal breathing

A
  • pt starts to gasps
  • sign that final breath is near
  • shallow pursing of the lips, like that of a fish out of water
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28
Q

what integumentary changes may occur near end of life (2)

A
  • decreased blood perfusion

- ulcers r/t bedbound and decreased nutritional status

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29
Q

what is a clinical manifestation of decreased blood perfusion near end of life

A
  • skin may become blue or mottled

- extremities will feel cool (but pt will not feel cold)

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30
Q

where is skin mottling often seen first

A
  • feet
  • hands
  • knees
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31
Q

what are nursing interventions for decreased blood perfusion near end of life (4)

A
  • skin regular
  • regular repositioning
  • lotion to skin
  • soft pillows for support
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32
Q

what are clinical manifestations of ulcers near end of life (2)

A
  • red spots to bony prominences are first signs of stage 1 ulcer
  • open sores may develop
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33
Q

what are nursing interventions for ulcers near end of life

A
  • relieve pressure over bony prominences or other areas of breakdown w turning and positioning q2h if tolerated
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34
Q

if turning causes pain, what should you do

A
  • time it to peak effect of analgesics
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35
Q

what food & fluid changes occur near end of life (2)

A
  • decreased interested in food & fluid

- swallowing difficulties

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36
Q

what are clinical manifestations of decreased interest in food and fluid near end of life (2)

A
  • weight loss

- dehydration

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37
Q

what are nursing interventions for decreased interest in food & fluids near end of life (2)

A
  • do not force fluid or foods into mouth

- provide excellent mouth care

38
Q

it has been shown that artificial hydration can… (6)

A
  • increase pt discomfort in last days of life
  • cause SOB
  • coughing
  • breathing difficulties
  • fluid overload
  • edema
39
Q

what are clinical manifestations of swallowing difficulties near end of life (3)

A
  • food pocketed in cheeks or mouth
  • choking w eating
  • coughing after eating
40
Q

what are nursing interventions for swallowing difficultiies near end of life (2)

A
  • soft foods & thickened fluids as tolerated

- stop feeding pt if choking or pocketing food

41
Q

what elimination changes occur near end of life (2)

A
  • decreased urinary output d/t decreased BP & kidneys begin to shut down
  • incontinence of urine and stool d/t loss of sphincter control
42
Q

what clinical manifestations of decreased urinary output & near end of life

A
  • decreased urine output

- concentrated urine

43
Q

what are nursing interventions for decreased urinary output and incontinence near end of life (3)

A
  • keep pt clean & dry
  • determine if full bladder: palpate, bladder scan, pain, agitation
  • indwelling foley cath if retaining urine (assess carefully d/t its association w UTIs)
44
Q

what are 2 other signs of nearing end of life

A
  • inability to close eyes

- moaning, grimacing, involuntary jerks, “picking” behavior (picking at objects floating in air)

45
Q

why does the inability to close the eyes occur near end of life

A
  • tissue wasting around the eye and eyelid
46
Q

what is a nursing intervention for the inability to close the eyes near end of life

A
  • use lubricating eye drops as needed
47
Q

what causes the moaning, grimacing, jerking, and “picking” behaviors near end of life

A
  • changes in CNS
48
Q

what is a nursing intervention for the moaning, grimacing, jerking, and “picking” behaviors near end of life

A
  • prepare the family and assure them that these symptoms do not indicate that the pt is uncomfortable
49
Q

describe our approach to care near end of life (7)

A
  • anticipate changes
  • talk to the family about changes we expect to see as the illness progresses –> ask if convo should occur in pt room or hallway
  • aggressive symptom mngmt
  • keep careful watch for changes
  • proactive communication
  • comfort!
  • intentional support for family
50
Q

describe care of the family near end of life (10)

A
  • communication (what we might see or are seeing)
  • teach family what they can do and expect
  • involve them in care (if desired) –> ex. mouth care
  • respect need to “not be there”
  • support those unable to be there (ex. hold phone to pts ear)
  • whole person care –> physial, emotional, cultural/spiritual
  • consider things like, are there comfortable chairs, kleenex, water in the room
  • encourage family to tell stories about the pt, sing, pray, play pts fav music, hand massage, etc.
  • encourage parting words
  • offer spiritual services
  • let family know if pt talked about them
51
Q

describe pain near the end of life

A
  • does not increase as a pt nears death –> behaves persistently throughout the illness experience –> may actually decrease
  • may be overtreated as nurses mistake grimacing and moaning (neurological symptom of dying) for pain
52
Q

describe palliative sedation in relation to end of life

A

may be required for symptoms such as:

  • pain
  • anxiety
  • restlessness/agitations
  • total suffering
  • should be a last resort
53
Q

describe conditions requiring sedation near end of life

A
  • conditions requiring sedation do not improve near end of life
  • removing sedation to allow clarity in their final moments does not work out
54
Q

what routine procedures are discontinued at the end of life (4)

A
  • daily labs
  • VS assessment
  • routine weights
  • any procedure that does not promote comfort
55
Q

what is an example phrase used to simplify the changes associated w dying to family r/t breathing changes

A

“his breathing is changing. he may stop for a few seconds and then start again. this is normal, and its not uncomfortable for him”

56
Q

what is an example phrase used to simplify the changes associated w dying to family r/t symptoms associated w decreased cerebral perfusion

A

” often pts see people from their past. this does not mean that he is “out of his head”. we don’t know why it happens, but it seems to provide great comfort for the pt”

57
Q

what is an example phrase used to simplify the changes associated w dying to family r/t decreased CO near end of life

A

” its not unusual to see the BP drop or the heart speed up. this is part of the body slowing down. It is not uncomfortable for the pt”

58
Q

describe nursing interventions/responsibilities regarding difficult choices as death nears

A
  • make sure the substitute decision makers are framing their choices based on what the pt would want if they could choose for themselves
  • gently emphasize that the underlying illness is not survivable –> comfort should be priority (we are not wanting to extend final days but may those final days as peaceful as possible)
59
Q

describe pt’s energy near end of life

A
  • progressive health conditions deplete energy reserves
  • pts may have massive crashes close to death –> no energy to communicate, eat, drink, remain awake
  • treatments (ex. chemo) may withdraw more energy than a person has , leading to a signif decline = why procedures often halted when end of life is suspected
60
Q

describe med admin near end of life

A
  • med intake may be challenging –> PO meds may be replaced w subcut injections, sublingual sprays, rectal suppositories, topical patches etc.
  • non-essential meds should be DC –> only meds which remain should be those used to manage symptoms
61
Q

describe how to understand how long someone has left

A
  • typically patterns of decline indicate imminence of death
    ex. if pt is gradually declining every month, then they typically have months to live. if signif changes every day, then may only have hours or days left
62
Q

describe bedside care near end of life r/t the family (3)

A
  • encourage family to behave as they normally do, this would likely please the pt
  • hearing is often the last thing to go
  • sometimes it seems as if an unresponsive patient needs to hear a specific thing from a family member to let go, encourage discussions which promote finanilty
63
Q

describe reflexes near the end of life

A
  • several reflexes may be noticed at the end of life = primitive reflexes
64
Q

what 2 primitive reflexes may occur at the end of life

A
  • grasp reflex

- sucking reflex

65
Q

what is the grasp reflex r/t end of life

A
  • when an unconscious patient may seem to hold one to a family’s hand harder when they are trying to leave
66
Q

what is the sucking reflex r/t end of life

A
  • pts may clamp onto objects placed in their mouth (ex. toothettes), particularly when those objects are being withdrawn
67
Q

describe visits from acquitances near end of life

A
  • should be encouraged to stay brief as they can overwhelm the pt
68
Q

describe final physical changes near end of life (4)

A
  • mottling
  • HR beats more quickly, but not as strongly (pulse rapid & difficult to palpate)
  • bowel and bladder slow (constipation common, oliguria progressing to anuria)
  • breathing changes
69
Q

describe what final breathing changes may occur at end of life (6)

A
  • may look labored
  • rapid, shallow resps common
  • increasing periods of apnea
  • accessory muscles in the necks and shoulders used more heavily
  • breathing becomes louder
  • build up of secretions results in rattling or gurgling sound
70
Q

describe resp assessment near end of life

A
  • rely on if the pt appears comfortable rather than resp assessments
71
Q

what is an unexpected rally

A
  • a sudden period of alertness near death which is unpredictable
72
Q

what is an example of an intro to a conversation w the family regarding changes that occur near the end of life

A
  • “this must be difficult for you to see. these are natural changes at the end of life as the body is trying to slow down”
  • “we are starting to see some changes. would you like to hear what some of them mean. would your relative want to hear this too?”
  • keep in mind the pt can hear you*
73
Q

what is an example of a family concern r/t mottling? how can we explain it to them?

A
  • mottling = pt is cold

- explanation: body and circulation slowing down

74
Q

what is an example of a family concern r/t breathing changes? how can we explain it to them?

A
  • apnea = SOB, struggling to breath
  • resp congestion = choking
  • explanation: does not distress the pt, pt has inability to clear their throat = buildup of harmless fluids, not choking, simply a natural thing that occurs and is not distressing to ptof their ability to breathe
75
Q

what is an example of a family concern r/t decreased oral intake ? what is an explanation for this?

A
  • concern = starving?

- explanation = normal for them to have decreased interest in food and fluid

76
Q

describe head to toe assessment near end of life (10)

A
  • introduce yourself
  • gauge where pt is and if comfortable
  • assess response to verbal stimuli, light touch, NO painful stimuli
  • assess for signs of pain or discomfort
  • check respirations: rate, depth, regular, apnea, congestion, time periods of apnea if present
  • check radial pulse: weak and thready? (indication of slowing down)
  • assess feet and lower limbs for mottling
  • check urinary output
  • assess brief
  • explain what you are doing
77
Q

describe VS near end of life (4)

A
  • count resps and that’s it
  • may be done if it is indicated in their goals of care
  • VS not good indicator of if a pt is dying and will not change the outcome
  • comfort care = no vitals
78
Q

describe how to respond to “are they in pain” questioned by the family

A
  • pain does not increase at end of life
79
Q

describe how to respond to the questions “can they hear us” by the family

A
  • yes they can hear you

- they can hear their fav music

80
Q

describe how to respond to the question “what should i do” by the family (2)

A
  • emphasize that even if they cant be in the room, there is a spiritual connection
  • involve them in care : hold hand, put on lotion, mouth care
81
Q

describe how to respond to the question “ should i stay here?” by the family

A
  • what would you like to do/what are you able to do?
  • “can you tell me a little more about why you are asking that question?”
  • i can’t make the promise that the pt won’t change or pass away while you are gone
  • is there a way i can make things more comfortable for your stay?
  • say you support their decision
82
Q

describe how to respond to the question “how much time is left?” by the family

A
  • we can never say for certain
  • “i cant give you an exact timeframe, however theses are the signs I am seeing that tell me death is near”
  • assure that this is a very common question
83
Q

describe how to respond when a family member says “I think her breathing has stopped”

A
  • use therapeutic touch and empathy

- “i am so sorry. i am going to check to see if they have died”

84
Q

describe the nurse’s role in pronouncing death

A
  • check the facility policy and procedure regarding the nurse’s role in pronouncing death
  • often, when death is expected the nurse may pronounce death (if ACP is M or R)
85
Q

when is death proncounced? (3)

A

after:

  • no respirations for one minute
  • no apical pulse for one minute (auscultate for one min)
  • pupils fixed and dilated
86
Q

describe how to pronounce death (6)

A
  • explain to family what you are doing and when you are doing it
  • don’t check vitals
  • don’t do a painful stimulus check
  • note time of death but dont say it out loud
  • assess breathing, apical pulse for 1 minute
  • assess pupillary response
87
Q

what is an example of what to say when proncouncing death

A

“i am so sorry to tell you this, but they have died”

  • make sure you say died, not passed or moved on
88
Q

describe care to the family after death (5)

A
  • allow emotional reactions
  • provide time and space to say final goodbyes –> privacy and peaceful deathbed
  • consider cultural and spiritual needs
  • be available
  • answer any questions
89
Q

what should you do if the family was not there when the pt passed and they are on their way over (8)

A
  • arrange room
  • straighten limbs
  • put down side rails
  • HOB down
  • provide mouth care
  • provide peri care
  • give them time w the pt
  • tell them they will come check on them
90
Q

describe care of the body after death (13)

A
  • treat the body with respect and dignity
  • bathe and put a clean gown on the body
  • remove dessings and tubes
  • place pt in body alignment w extremities straight
  • place dentures in mouth
  • comb pt’s hair
  • check for jewelry: return belongings and valuables to family (chart)
  • shroud as per policy
  • gentle transfer to morgue stretcher
  • can talk to body, detailing what you are doing
  • can open window if want to let the spirit out
  • remove catheter, subcut lines, etc.
  • if dressing if holding a lot of exudate, dont remove it
91
Q

describe nursing considerations when shrouding (2)

A
  • remember that shroud can leave marks
  • make sure the shroud is loose on the face –> can deform face if it is too tight and make it hard to present pt in open casket
92
Q

describe how to notify the family over the phone of a pt’s death (9)

A
  • confirm who you are speaking with
  • identify self
  • inquire where the person is and whether they are alone
  • ask what they know abt the pt’s condition
  • notify over phone if death was expected, if not expected ask to come to hospital (but depending what they are asking you may tell them over the phone)
  • “im afraid i have some bad news”
  • allow space for an emotional response
  • give clear instructions as to where to go and whom to contact when arriving at the hospital
  • end with an empathetic statement

NURS 3510 - Supportive and Palliative Care (11 decks)

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