MEDSURG 2500 FINAL
communication techniques with the pt
- check for understanding of their diagnosis - ask for clarifications and allow the pt to explain - ask about values, preferences, and concerns - assess pt coping and support system - ask important questions to fam members when the pt is unable to participate in conversation
what are s/s of a pt at end of life
- clusters of s/s - pain (MOST FEARED) - delirium/agitation - dyspnea - weakness, fatigue - constipation - N/V - poor secretion control - nutritional probs - mottling - resp changes - decreasing LOC
how to manage parent's fears
- fear of pain they may experience - extra support can be used - feelings conflicted on what's the right choice for treatment
nursing interventions for the stages of grief
- grieving is not a linear process - each person copes in their own way, there's no right way to cope
palliative care also includes what methods of pain control?
- moderate sedation if pt is in the ICU - holistic care (same as hospice) - may use with other treatments that are cure oriented
pain assessment scales
- simple descriptive pain intensity scale - 0-10 numeric scale - visual analogs scale VAS
end of life assesssment
- talk about death, how they feel - spirituality of the pt and fam - cultural beliefs, rituals
what do both hospice and palliative care have in common
-they use the world health organization ladder to determine pain control options - holistic care
world health organization ladder
1st- mild pain (1-3) 2nd- mod pain (4-6) 3rd- severe pain (7-10)
FLACC pain scale
F: Faces. L: Legs. A: Activity. C: Cry C: Consolability used when pt can communicate their pain
During unplanned, spontaneous moments, dying clients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations?
Communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact.
determine if their child is going to be
DNR or full code; one of the most difficult decisions for a family to make.
A client has been using NSAIDs daily over an extended period. Which of the following effects should the nurse carefully monitor for in this client?
GI bleeding
Which of the following nursing interventions is appropriate with regard to pain control in the dying client?
Give pain medications on a routine schedule.
PCA pump is more effective at pain management vs IM due to
IM taking longer to be effective and it has a greater risk of toxicity. A PCA is more consistent, minimizes toxicity, and consistently helps pain management
Which is a sign of approaching death?
Irregular breathing patterns
A medical nurse is providing end-of-life care for a client with metastatic bone cancer. The nurse notes that the client has been receiving oral analgesics for pain with adequate effect, but is now having difficulty swallowing the medication. What should the nurse do?
Request the analgesics be prescribed by an alternative route.
if a pt is unable to swallow what is a similar route that works well
SL
The nurse is admitting a 52-year-old father of four into hospice care. The client has a diagnosis of Parkinson disease, which is progressing rapidly. The client has made clear his preference to receive care at home. What intervention should the nurse prioritize in the plan of care?
Supporting the client's and family's values and choices
comfort
defined by the individual and requires that they are satisfied in the physical, psycho, social, spiritual, and environmental domains
stages of grief
denial, anger, bargaining, depression, acceptance
complicated or prolonged grief
intense response after loss where profound emotions persist >1yr Ex widow who stops caring for herself after the death of her husband and sobs at the mention of his name a yr later
minimize parents anxiety bu
involving parents and other family members in ALL aspects of the child's care. this will decreased anxiety
tx for anxiety with EOL
lorazepam, valium
caring for dying children includes
managing parent's fears of death and dying question of precedence the grieving period support role for the nurse
behavioral pain scale BPS
measures facial expression, upper limb movements, compliance with mech ventilation - ranges from 3 (no pain)- 12 (max pain)
Which intervention is appropriate for a nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
obtaining baseline VS before administering the 1st dose
admin a stool softener or laxative when taking an
opioid; hydrocodone or oxycodone
STEP THREE: severe pain 7-10 tx
opioids: morphine, hydromorphone extended release (long lasting) PCA pump continue adjuvant meds, nonpharm methods may need to increase dose due to tolerance
what s/s of EOL is most feared
pain
morphine is the global standard for cancer
pain; used in hospice as there is no ceiling affect with morphine (can continue to increase the dose)
hospice is a type of what
palliative care
differences in palliative and hospice care
palliative= broader; preventative care aimed to cure including surgeries hospice= relieving pain and suffering, provided with disease remitting treatment (life ending illness)
bereavement
period of time where mourning for the loss takes place
what happens when a healthcare professional and parents don't share the same view about which is in the best interests for the child or young person?
prioritize parent decisions in care
hospice uses
pt MUST have terminal diagnosis end of life care, home care, bereavement care to family
opioid risks
resp depression addiction tolerance of dose- may need to increase change in LOC slows GI tract
death rattle is caused by
secretions
disenfranchised grief
the grieving person feels that society doesn't acknowledge or support a person's right to grieve ex: mistress, homosexual partner, colleagues
A feeding tube doesn't need to be placed for EOL as
they aren't utilizing these calories; teach family this
goal of hospice
to allow pt to be able to die at home, if the pt chooses, in comfort with their family
When a client who has been taking opioids becomes less sensitive to the drug's analgesic properties, that client is said to have developed a(n)
tolerance
unresolved grief
traumatic or unexpected losses Ex: death of a child, suicide, disaster-related death
tx for pain at EOL
tylenol, lortab/percocet, morphine, fentanyl, dilaudid routes: PO, SL, rectal, transdermal patches, PCA
visual analogs scale for pain (FACES)
usually used for children
Which of the following assessment tools will be most effective when assessing for pain in a four-year-old client?
a FACES scale
hospice
a coordinated program of interdisciplinary care and services for terminally ill pts and their families
medicare hospice benefit
a medicare entitlement that provides comprehensive, interdisciplinary palliative care and services for eligible beneficiaries who have a terminal illness and life expectancy of less than 6 mons
palliative care
a pt and family centered approach that attends to the physical, functional, psychological, spiritual, and existential aspects of a serious illness
to minimize fear that the child will die alone by remaining
with the child when a family member is not in the room
both hospice and palliative care use what to determine the steps of pain treatment
world health organization ladder of pain control
STEP ONE: mild pain 1-3 tx
acetaminophen NSAIDS adjuvant meds: tricyclic antidepressants, muscle relaxants nonpharm methods
get a reassignment if you aren't comfortable doing what as a nurse
administering meds that help them pass away
some facilities refer to DNR as
allowing a natural death-- is a more acceptable option for families facing the decision to withhold resuscitation
Families may want to specify a certain extent of resuscitation that they feel more comfortable with for example
allowing supplemental O2 but not providing chest compressions
admin what for N/V
antiemetics
A transmucosal pain management is used
at the beginning of the administration of a transdermal patch d/t it taking time to be effective; and can be used at the tail end of the transdermal patch for the pain that begins there
tx for excessive secretions with EOL
atropine drops, hyoscyamine, scopolamine
to support as a nurse
be present, hearing, listening to the parents
tx for dyspnea EOL
bronchodilators, diuretics O2 , lorazepam and morphine in combo
illness that progress over time and are terminal (hospice care)
cancer, COPD, HF
involve children in their own
care; according to the extent that they are able to
involve parents in all aspects of their
children's care
synergism
clusters of s/s of EOL have this effect
STEP TWO: moderate pain 4-6 tx
combo opioids: hydrocodone and acetaminophen, oxycodone and acetaminophen, continued adjuvant meds
hospice is care minded NOT
cure minded; care team helps fam and pt accept dying as a normal part of life
other s/s of death
cyanosis/mottled skin loss of bowel and bladder control change in muscle control restless decreased urine outpt decreased temp
critical care pain observation tool
CPOT; used in critical care units who cannot self report their pain whether they are intubated or not.
parents may feel they are giving up on their child to allow withholding
CPR
anticipatory grief
grief experienced prior to a loss Ex: grief at diagnosis at loss of "normal" life; preparing for the loss of a limb for amputation
tx for delirium EOL
haloperidol
hospice also includes what methods of pain control?
holistic care: - spiritual care - singing with pt - music - holding hands
NO treatments or attempt for curing a pts dx is made with what kind of care
hospice
goal of palliative care
improve the quality of life to both patient andfamily in comfort-focused approaches to care inconjunction with cure-focused treatment.
uncomplicated grief
Range of emotions experienced after a loss moving toward adjustment; brief periods of relapse common Examples: Missing a deceased grandparent during holidays
teach parents that CPR may be
inappropriate and lead to more suffering than if death were allowed to occur naturally. When palliative care is chosen, the focus on the child's care is changing but the child and family are not being abandoned.
give the pt what they want to
eat
A hospice nurse is well aware of how difficult it is to deal with others' pain on a daily basis. This nurse should put healthy practices into place to guard against what outcome?
emotional exhaustion
tx for constipation EOL
enema, suppository