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