Unit 5
Pharmacologic Interventions for Delirium? Non-Pharmacologic Interventions for Delirium?
Antipsychotic medications, such as haloperidol Provide a safe, quiet, and comforting environment. Familiar voices or the gentle touch of a hand can be comforting
I'm Sorry vs. I Wish
Avoid using I'm sorry. Use I wish instead. I wish shows empathy.
Bereavement Support
Bereavement support is an essential component of palliative care and continues as a service to family members after the patient has died. If the patient died in hospice care, bereavement support is provided to the family for 12 months following the death, and longer if needed.
Opioid most common adverse effect? Most people have to what along side of Opioids?
Constipation. Stool softeners or laxatives
s/s of imminent death (active dying)?
Decreased Urine Output Cold and Mottled Extremities Vital Sign and Breathing Changes Delirium and Confusion Restlessness
Dyspnea s/s?
Elevated jugular pressure Bilateral crackles Respiratory rate and depth Use of accessory muscles Pain with respiratory movement Functional status Pursed lip breathing Cyanosis Inability to speak
How to encourage conversation with the family?
First, set the right atmosphere. Get comfortable and relay to the family member that you want to spend some time with them. Remember non-verbal communication! Sit down on "eye-to-eye" level, lean forward, and make uninterrupted eye contact if culturally relevant. Be sure to silence pagers and/or cell phones. Identify if the family wants to talk. Is it a good time to talk or is there even a need to talk?
Neuropathic pain
Generally due to damage to the nervous system
Majority of Hospice is taken place where?
In the home
Adjuvant therapy is?
Is antidepressants, generally used for the treatment of neuropathic pain.
Acute pain last
Lasts less than 1-3 months
The _________ of annual U.S. healthcare spending goes toward on chronic illnesses.
Majority
Antidepressants and anticonvulsants most beneficial for?
Neuropathic pain
Randall describes his pain as a burning pain in his lower extremities. What type of pain does this describe?
Neuropathic pain
NSAIDs is? Most common side effect?
Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, ibuprofen, and naproxen. GI stuff, Renal dysfunction GI bleeding Bleeding
When does disease-modifying treatment stop with Palliative? When does disease-modifying treatment stop with Hospice?
One of the biggest distinctions is that patients can continue to receive disease-modifying treatment along with palliative care. When a patient enrolls in hospice care, the patient is no longer able to receive disease-modifying treatment. For patients who do not choose hospice for end-of-life care, palliative care can continue through the end of life and family bereavement processes.
Acetaminophen is? Most common side effect?
(Tylenol) non-opioid? Liver dysfunction
Acknowledging emotions that they may be expressing, example? Legitimizing the normalcy of the reaction, example?
-"I see this is very upsetting to you." After listening to what the patient and family has said, simply acknowledging how difficult this must be is important. -"Anyone receiving this news would be upset." Let them know that their response is normal and that anyone hearing this would be angry, upset, sad, etc.
How to "Attentive Listening" or communicate effectively?
-Be silent! -Using comments like "Tell me more about that..." -Repeating 2-3 words from their last sentence, "... you were shocked by the diagnosis" -Reflecting, "So you mean that ..." or, "If I understand what you are saying, you are feeling ..." -Do not change the subject -Try not to give advice if possible unless asked -Encourage reminiscing
Complicated Grief -
-Complicated grief affects 2-3% of the world's population. -After the death of a romantic partner and estimates are much higher for parents losing a child -Complicated grief is also higher in women age 60 or older
Disenfranchised Grief -
-Disenfranchised grief is defined as any loss that is not validated or recognized. Society may not want to acknowledge the grief and does not know how to deal with the loss. Those affected by this type of grief do not feel the freedom to openly acknowledge their grief. Those at risk include: Partners of HIV/AIDS patients Ex-spouses/partners Fiancées Friends, lovers, mistresses, co-workers Children experiencing the death of a stepparent Women (and husbands/partners) who have experienced a terminated pregnancy or a stillbirth
How to do a pain assessment
-Identify the etiology of pain. (Pain can be classified as acute or chronic) -Identify the location of pain. Ask the patient to point to it if necessary. -Assess the intensity of the pain. 0-10
Mindful presence
-Knowing and being comfortable with oneself -Knowing the other person -Connection -Affirmation and valuing -Acknowledgement of vulnerability -Skill in attentive listening -Utilization of intuition -Empathy and a willingness to be vulnerable -Being in the moment -Serenity and silence
Normal Grief-
-Physical including feeling symptoms similar to the loved one, having difficulty sleeping, and an increased or decreased interest in food -Emotional including experiencing periods of sadness -Cognitive including being forgetful (e.g., losing keys or phone) and having difficulty concentrating Behavioral including needing to go to the cemetery to "be with" the deceased -Active grieving can take years. No one "gets over" the loss, but the relationship with the deceased changes. There is a reconnection with the world of the living.
Dyspnea may be relieved by
A cool fan blowing on the patient.
Acute Grief -
Acute grief begins after the death of a loved one and includes separation response and response to stress. During this period of acute grief, the bereaved persons may be confused and/or uncertain about their identity or social role. They may disengage from usual activities and may experience disbelief and shock that their loved one is gone
Palliative team includes
An interprofessional team, usually comprised of physicians and nurses, including advanced practice and registered nurses, with access to social work and spiritual care services in order to address patient and family needs across the four domains of quality of life (physical, psychological, social, and spiritual).
Terminal secretions, the"death rattle," Pharmacological intervention? Non-pharmacological intervention?
Anticholinergics First reposition the patient - this alone often assists gravity in dealing with secretions. Keep head of bed elevated. Suctioning is generally not recommended, as it can increase agitation and distress in the patient.
Pharm treatment for dyspnea?
Opioids. For most patients who are breathless and anxious, the team will start treatment with opioids.
Palliative Care
Optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitating patient autonomy, access to information, and choice. It is all about living with a serious illness, while receiving treatment for that illness. Not curing the disease. Non acute disease.
When can Palliative be offered? When can Hospice be offered
Palliative care can be offered at any time in the disease trajectory, and, in fact, should be part of care at the time of a serious diagnosis. In contrast, hospice care is regulated by CMS and is limited to care that occurs only in the last six months of life.
Palliative can occur where? Hospice can occur where?
Palliative care can occur in any clinical setting, whereas hospice is usually delivered wherever the patient calls "home."
How are Palliative care services paid for?
Palliative care services in the United States, on the other hand, are paid by philanthropy, fee-for service methods, or from direct hospital support. Practitioners working in palliative care may bill Medicare, as well as other payers, for the care they provide, but reimbursement is low, as most services are nonprocedural.
Addiction -
People who misuse substances take medications for purposes other than their intended use. For example, using an opioid to treat anxiety.
Substance Abuse -
People who misuse substances take medications for purposes other than their intended use. For example, using an opioid to treat anxiety.
Substance Misuse -
People who misuse substances take medications for purposes other than their intended use. For example, using an opioid to treat anxiety.
Chronic pain last
Persists for longer than 3-6 months
Physiological Dependence -
Physiological dependence is also a state of adaptation. It is manifested by a withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist, like naloxone. Symptoms of withdrawal include fatigue, aches, sweating, nausea, vomiting, depression, and hallucinations.
The nurses role in Palliative team
Presence, they use strong listening skills and allows the patient to direct the conversation. Assessing patients' physical, psychological, social, and spiritual well-being, managing issues related to these domains of quality of life, and coordinating care within the team. The nurse's role is to assess how patients are doing in each domain, plan interventions with the team to address symptoms and concerns in each domain, coordinate care, and evaluate intervention outcomes.
The Palliative team focuses on
The team focuses on learning what the patient and family know and understand about the illness, identifying the patient's wishes, and helping the patient understand how treatment may be helping or hindering their wishes, so that patient and family goals drive the decision-making process around treatment.
Feedback
This type of pain includes somatic and visceral pain. Somatic pain is an aching, throbbing pain, such as arthritis. Visceral pain is a squeezing, cramping pain, such as abdominal pain. Patients describe this type of pain as burning, tingling, electrical, or shooting. Examples include diabetic neuropathy or post-herpetic neuropathy related to shingles.
Tolerance -
Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug's effects over time. In the clinical setting, tolerance is not a significant problem. However, misunderstandings regarding tolerance can lead to delays in treatment or withholding adequate doses of opioids.
Nociceptive pain
Usually related to damage to bones, soft tissues, or internal organs. Lenora describes her pain as an aching and cramping pain in her lower abdomen.
Cultural humility requires
acknowledge how your own biases and values may interfere with patient and family values so that you may put those aside.
The majority of messages we send
are non-verbal.
When patients are experiencing total pain, it's important for you to assess the patient's
emotional state for depression, fear, anxiety, or hopelessness.
Palliative care focuses on
focuses on the whole person, as well as on the person's family. Quality of life
Chronic grief
is an intense reaction that may include nightmares, delinquent behaviors, phobias (abnormal fears), and thoughts of suicide.
Delayed grief
is an intense reaction that may include nightmares, delinquent behaviors, phobias (abnormal fears), and thoughts of suicide.
Exaggerated grief
is an intense reaction that may include nightmares, delinquent behaviors, phobias (abnormal fears), and thoughts of suicide.
Masked grief
occurs when the survivor is not aware that behaviors that interfere with normal functioning are a result of the loss (e.g., cancels lunch with friends, so they can go to the cemetery every day to see their loved one's grave).
At the end of the conversation, make sure you end with an
open-ended question to allow the patient to continue the conversation. For example, "What else have you heard from the team about how you are doing?"
Once a patient receives Hospice what do they have to do financially?
patients sign off their Medicare Part A (hospital payment) once they choose to receive hospice care rather than disease-modifying treatments, and enroll in the MHB with direct care provided by a Medicare-certified hospice agency.
The simplest and most successful way to do a cultural assessment is to
pull up a chair and ask the patient and family to tell you a little something about their life, before the illness. Then ask 1) What has been important to you and your family? 2) What gives your life meaning?
When conflict occurs, you should
take a step back. Identify your own emotions and try to describe them, not display them. Check that the conflict is not about "YOU" about your "getting your own way."
Hospice Care
terminally ill (i.e., those with a prognosis of six months or less), It is a team approach to providing care to people with life-threatening illnesses or injuries. The median length of hospice service is 17.4 days. It supports the patient and the surviving family through the dying and bereavement processes. It provides comprehensive medical and supportive services across home, residential facilities, and hospitals. It is based on the idea that dying is a part of the normal life cycle.
