Week 8 Flashcards
what is a palliative care emergency?
- acute change in condition resulting in decreased QOL, comfort, and risk to life
- includes pain and emotional sufferring
- sudden and severe exacerbation in symptoms that negatively impact QOL and can lead to death
- kind of like a code, but diff goal (make comfortable)
what are 3 examples of paliative care emergencies
- spinal cord compression
- exsanguination
- dyspnea crisis
what are imp considerations for palliative care emergencies (3)
- consider context
- focus not on what can be done, but what is the appropriate treatment for the particular pt in the particular situation
- each situation is unique
what factors must be taken into consideration in the mngmt of palliative care emergencies (4)
- prognosis (days, months, years to live?)
- wishes (what is imp to them, ACP)
- impact of the condition on the whole person & QOL
- considerations regarding the outcomes of the treatment (risk vs benefits)
what is the nurses role r/t palliative care emergencies (6)
- anticipate pall care emergencies
- identify risk factors
- identify baseline and assess condition and deviations from baseline
- collaborate w IPC team
- manage symptoms and provide support (not only physical)
- educate
how is spinal cord compression considered a palliative care emergency
- can cause paralysis and permanent damage
what is spinal cord compression
- occurs when a spinal cord tumour or metastatic tumour grows in the spine & detsroys the bony vertebral body that surrounds the cord, or wraps around thw spinal cord and its nerve roots
what are risk factors for SCC (6)
- breast cancer
- lung cancer
- prostate cancer
- renal cancer
- multiple myeloma
- lymphoma
cancers that tend to metastasize
why is SCC an emergency?
- if it is not promptly assessed, recognized, and treated it can result in permanent paralysis = signif impact on QOL
what are signs of SCC (4)
- back pain ***
- motor weakness (heavy, weak legs)
- sensory disturbances (numbness)
- autonomic dysfunction
describe back pain r/t SCC (3)
- occurs in majority of pts w SCC
- local or radicular pain
- may experience band like pressure radiating from back to front
what causes back pain d/t SCC to worsen (4)
- straight leg raises
- when lying down
- at night
- when intrathoracic pressure is increased (ex. coughing)
what are signs of autonomic dysfunction (2)
- loss of bladder control (incont or retention)
- loss of bowel control (incont. or constipation)
what should be included in assessment of SCC (4)
- pain assessment
- neuro assessment (reflex, motor strength, sensation)
- assess GU (incont or retention)
- assess BM
what should be included in GU assessment for SCC (4)
- last void
- how much voided
- bladder scan
- palpate
what should be included in BM assessment for SCC (3)
- LBM
- change from normal?
- incont?
what is the gold standard for diagnostic investigation of SCC
- MRI
what is included in a neuro assessment r/t spinal cord compression (3)
- sensations
- motor
- reflexes
what should be included in pain assessment of SCC (5)
- OPQRSTU
- social pain
- spiritual pain
- emotional pain
- what makes physical pain worse (ex. straight leg raises, lying down)
what does the U in OPQRSTU stand for
- what impact does it have on yiu
- what is your understanding
what are the goals of SCC management (4)
varies by person, may be:
- improved pain
- improved QOL
- improved independence
- improve survival
what is imp to consider for an appropriately guided treatment of SCC (2)
- understand pt’s goals
- understand clinical scenario
what med is used for treatment of SCC
- dexamethasone , usually high dose
what effect does dexamethasone have on SCC (4)
- reduces inflammatyion
- reduces swelling
- relieves pain
- helps preserve/improve function
what should you monitor for w a pt on dexamethasone (7)
steroid related s/e:
- hyperglycemia
- impaired wound healing
- immunosuppression = risk of infection
- sleep disturbances
- mood changes
- GI irritation
- fluid retention
what else is included in mngmt of SCC (7)
- neurosurgery for spinal decompression and stabilization
- radiation for pain
- pain mngmt
- bowel mngmt
- bladder mngmt
- DVT prophylaxis
- rehab (OT, PT)
why is bowel mngmt imp for SCC mngmt
- opioids (for pain) + spinal cord dysfunction + inability to mobilize = risk of constipation
what interventions can help w bowel mngmt for SCC (2)
- bowel schedule
- assess for and treat constipation
what interventions can help manage the bladder w SCC
- retention = cath
- incont = keep clean & dry
nursing care for SCC includes (4)
- skin care (turns, keep clean & dry, imp d/t immbolity, incont.)
- monitor function
- monitoring pain
- educate and support the pt
what should you do first if a pt is experiencing signs of SCC
- emergency MRI
- report to HCP
what is a good question to use to guide your education of the pt and family on SCC
- tell me what your understanding is of what’s happening
what are malignant wounds (3)
- a break in the epidermal integrity caused by infiltration of malignant cells
- cancer infiltrating skin, afferent blood & lymph vessles
- cancerous, open lesion in skin
- may look like a cavity or be nodular
what are malignant wounds also called (4)
- fungating tumours
- tumour necrosis
- ulcerative malignant wounds
- fungating malignant wounds
what do malignant wounds result in (6)
- ulceration
- exudate that would appear anytime during day or night
- leakage
- unpleasant odour
- pain
- bleeding
where do malignant wounds often occur (6)
- breast
- head
- neck
- genitalia
- groin
- back
+ other areas
what is the life expectancy of a pt with a malignant wound
- 6-12 months
malignant wounds do not heal
what should be included in assessment of malignant wounds (4)
- history
- pain (all four domains)
- pruritis (d/t stretching of skin)
- wound assessment
what should be included in assessment of history r/t malignant wounds
- where
- when did it occur
- has anything been used to try to treat it? did it work or not?
describe the impact of malignant wounds on all 4 domains (14)
may experience
- changes w body image
- embarressment
- depression
- fear
- anxiety
- shame
- denial
- guilt
- difficulty utilizing resources
- changes in social activities
- loss of feminitity, attractiveness, sexuality
- partners avoid touching or talking about wound
- isolation
what impact has the embarressment some pts feel regarding malignant wounds have
- restricted social behavior
- embarressed to show to doctors = prolonged diagnosis
what was most distressing r/t malignant wounds in the reading
- odor mngmt –> compared to rotting mear or mold
describe the exudate of malignant wounds
- very copious
- required clothing changes constantly and dressing changes q4h
what is included in mngmt of malignant wounds (4)
manage:
- exudate
- odour
- bleeding
- physical pain
focused on mngmt, not treatment
who may be consulted to assist w management of malignant wounds
- wound care specialist
- consult to palliative care team
what is included in mngmt of physical pain r/t malignant wounds
- pharmacological (opioids, non-opioids, adjuvants)
- non pharm
what is included in mngmt of odour associated w malignant wounds (6)
- wound cleansing
- charcoal dressing (absorb exudate, trap odour)
- topical flagyl
- systemic anitbiotics that may be used to irrigate
- room ventilation & circulation
- kitty litter under bed
why is odour significant w malignant wounds
- d/t necrotic tissue & bacterial growth
what is included in mngmt of bleeding r/t malignant wounds (5)
- nonadherent dressings
- hemostatic agents
- minimize unnecessary dressing changes
- gentle wound care
- moist wound bed
what is an example of a hemostatic agent for malifnant wounds
- silver nitrate
what is included in nursing mngmt of exudate r/t malignant wounds (2)
- many types of dressings
- change PRN and based on amt
what is included in mngmt for pruritis r/t malignant wounds (2)
- promote hydration
- moisturization of periwound
what should nurses do when caring for a pt with a malignant wound (7)
- active listening
- “normalize the experience”
- get to know the person
- consult wound care specialist
- brainstorm ways to manage
- validation
- affirmation
what should nurses NOT do when caring for a pt with a malignant wound (3)
- say “its not that bad”
- comment or make faces r/t odour
- provide false reassurance
what is exsanguination
- acute catastrophic bleed where the pt is likely to die in a short amt of time
what are common contributors to exsanguination (4)
- liver failure (r/t varices, impact on plts and vit K)
- thrombocytopenia
- DIC
- certain cancers
what plt count is considered thrombocytopenia
plts <150
what certain cancers are common contributors to exsanguination (3)
- tumours arising from head & neck cancers (esp if close to blood vessels)
- lung cancer
- gynecological cancer
describe what is included in plan of care for exsanguination (5)
- identify those at risk
- prep pts, families, and staff in advance
- educate
- develop a plan of care for those at risk
- mngmt depends on ACP status and amt/type of bleed
what interventions are included for exsanguination (8)
for rapid blood loss and ACP C:
- stay with the person
- have dark towels supplied in the room (mask amt of blood, reduce fear & anxiety)
- assist pt in comfy position (ex. coughing up blood = sit up)
- hold pt’s hand and therapeutic touch
- apply pressure to site of bleeding
- suction oropharyngeal airway w Yankauer suction
- cover suction canister w towel
- meds (if time)
what meds may be given for exsanguination
- benzo (ex. midazolam) –> sedative
- opiods
if know pt at risk, have the meds ordered and ready to go on MAR (crisis meds)
