Pallative Care + Obesity

What is pallative care

Care or treatment focusing on reducing the severity of symtoms

Pallative care can be used across all care plans extending into end of life care

Does a pt need to stop curative treatment to be on pallative care?

No

What is hospice care?

Type of care that begins once curvative care stops

What is needed from the physician to stop hospice care?

Physician certification for life expectancy that is 6 months or less

What are the benefits of palliative care?

Improves quality of life during illness

Decrease costs of health care

Alleviates the burden of care with supportive services

What is the time availability of services for people on hospice care?

available 24/7

Who provides hospice care?

Medical team

• Professional medical team mebers

• Hospice nurses

• Respice volunteers

What does hospice care provide?

Pain control

Pt comfort

Symptoms managment spiritual assessment, assessment and managment of family needs

Where does hospice care take place at?

Home, SNF, hospice facility, hospital

Who makes the decision in hospice care?

Patient does not the care team

What are the admission criteria for hospice care?

Pt desire the needed services

Pt must be eligible needs 6 months

What is the definition of end of life

Final phase of a Pt illness when death is imminent

At the end of life what are osme Pt goals?

Provide comfort and supportive care

Help improve quality of remaining life

Help ensure a dignified death

How long is typically end of life care

weeks to days to hrs

What are some physical manifestations at the end of life?

Decreased Metabolism

Body slowly start slowing down until all function ends

Respiratory ceases first

Heart starts beating within a few minutes

What occurs during end of life in terms of the respiratory system?

Irregular breathing that gradually slows

Cheyne Stokes respiration

Inability to cough or clear secretion

What is the special type of respiration that happens at EOL?

Cheyne- Stokes Respiration

• regular cycles of increasing and decreasing breathing depth followed by a temporary stop in breathing

What type of respiratory noises would a person at EOL make?

Grunting, Gurling, Noisy congested breathing

Death rattle

What happens to a persons sensory system (hearing + touching) at end of life?

Decreased sensation

Decreased preception of pain and touch

Hearing is the last sense to disapper

What is the last sense to disappear?

Hearing

What happens to a persons taste, smell and sight at end of life?

Blurring of vision

Blink reflex absent

Pt appears to stare

Eyelids remain half- open

Decrease sense of taste and smell

What happens to a persons integumentary system at EOL?

Mottling on hands, feet,arms, and legs

Coly, Clammy Skin

Cyanosis of nose, nail beds, and knees

Appearance of waxlike skin when near death

Hard regulating temp at EOL

How does a persons skin appear at EOL?

Waxlike

What are the changes in the urinary system at EOL?

Gradual decrease in urinary output

Incontinence of urine

Unable to urinate

What the changes in the GI system at EOL?

Slowing of GI tract and possible cessation

Constipation due decrease mobility and opoid use

Keep on BM schedule if they are on meds

Accumulation of gas distention and nausea

Are Pt at EOL usually hungry?

No they lose thier hungry senses meaning they don’t feel hungry

So this means don’t force food onto them

What happens to a Pts musculoskeletal system at EOL?

Gradual loss of ability to move

Trouble maintaing body posture and alignment

Loss of Facial muscle tone

• Sagging of jaw

• Difficulty speaking

• Loss of gag reflex

• Difficulty swallowing

What does loss of facial muscle tone look like for EOL Pts?

Mouth is open from sagging of jaw

Can’t speak

No PO stuff

Trouble sitting up

What happens to the Cardiovascular system at EOL?

HR increases at first then eventually decreases and dimishes

Irregular rhythem

Decreased BP

What in the cardiovascular system causes SQ and IM injections to be less effective and have delayed absorption

Vasoconsriction occurs shunting blood from the skin and skeletal muscle

What is a transdermal medication for EOL?

Fentanyl Patches

What is a sublingual medication for EOL?

Roxanol (Morphine Sulfate)

What is the medication to stop the death rattle

Atropine anticholinergic

What is the medication for Anxiety or insomnia?

Ativan (Lorazepam)

What routes of medication is prefered for EOL pts

Topical or IV, avoid IM

Why should you keep/offer meeds around the lock instead of prn

PRN meds will make the provider only use the med when pain occurs

around the clock allows for consistent pain managment

Do Pts during EOL have a fear of dyspnea and have a sensation of air hunger?

Yes

What are some therapies for Pts at EOL for dyspnea?

Opioids

Bronchodilators

Oxygen

When Pts are at EOL waht do they fear

Pain

Shortness of breath

Loneliness and abondonment

Meaninglessness

What is the best way to manage Pts at EOL fear non pharmacolocailly?

Relaxation and coping strategies

How do you provide psychosocial care for fear of loneliness and abandonment?

Presence of people this allows for support, comfort and sense of security

For a EOL Pt how often would you want to assess them

Depends on their stability

at least q 8hrs in the inpatient setting

More if their status changues

What happens during active dying

Decreased/stopped Urine output

Weak pulse, low BP

agonal breathing

Moddling of feet and hands

How should nursing care change once Pt is in their last hrs of life?

Limit to comfort measures

Provide emotioinal support

When does death occur?

When all vital organs and body systems cease to function

Irreversible cessation of CV, RSP, and Neuro function

After death what should the nurse do for the family so they can see their passed loved one?

Closed Pt eyes

Replace dentures

Wash and position body

What is an advance directive

Written docuemnts for a Pt to dictate their care in the event they can’t anymore

Is the nurse required to called the OPO after a Pt passes

Yes

WOuld be called one legay in Socal

What is Bereavement?

Period of death after a loved one

Grief and mourning is expected

What is Grief?

A normal reaction that occurs to real loss or to anticipatory loss

What are the psychologic responses that grief brings

Anger

Guiilt

Anxiety/Despair

Saddness and depression

What are the physiological responses that grief brings

Sleeping issues

Appetite changes

Physical problems

illness

What are the five stages of grief acording to Kubler-Ross

Denial

Anger

Bargaining

Depression

Acceptance

What is anticipatory grief?

Grieving before person actaually dies

What is adaptive grief?

Normal grief that happens as a person adjust to life without the person they lost

Positive

What is prolonged grief

Grief that occurs for greater than 6 months

Complicated, prolonged and intense griefing

What is spirituality?

Beliefs, values, practices that relate to the search for existential meaning and purpose

Does spirituality include a belief in a higher power, or relgiion

No and Yes

Does not necessarily equate to religion

What race has largest numbers of obesity

Black and Hispanic

Does lower income and less education risk factor for obestity

Yes

What is primary obesity

Excess body fat caused by excess calories required for bodys metabolic demands

What is secondary obesity?

Weight gain due to chromosomal and congenital anomailes

Metabolic problems

CNS lesions and disorders

drugs

What does Leptin do?

Suppresses appetite

Increases fat metabolism

What does Ghrelin do?

Regulates appetite by inhubiting leptin

Plays a part in compulsive eating

Why is obesity bad

Increases Fat Mass

Production of increased adipokines

• Leads to insulin resistance, dyslipidemia

• hypertension

• Distrupts immune factors

If someone is obese and has an apple shaped body what is it called

Android Obesity

Where is the fat located at for android obesity?

Abdominal area

What body system is at risk for android obesity?

Cardiovascular

Increased LDL

Decreased HDL

High Triglycerides

What is a Pear shaped body for obesity called?

Gynecoid obesity

Where is the fat located for Gynecoid obesity?

Upper legs

Is obesity a significant risk factor for CV disease and stroke

Yes

IS obesity a significant risk factor for DM type 2

Yes makes drug treatment less effective

Causes insulin resistance

glucose intolerance

Hyperinsulinemia

What are GI and Hepatic complications caused by obesity?

GERD: Gastroesophageal reflex disease

Gallstones

Nonalcoholic steatohepatitis

What conditions for respiratory and sleep issues does obestity a risk factor for?

Sleep Apnea: Snoring

Obesity Hypoventilation syndrome

Why does obesity put one at risk for osteoarthritis?

Excess weight places stress on weight bearing joints (knees and hips)

Causes cartilage deterioration

Does obesity cause cancer

Yes

What psychosocial problems come from obesity?

Stimatization

Low self esteem

social isolation

depression

discrimination in employment education and healthcare

When assessing a Pt for obesity what should be done first

Determine if out of control factors are contributing to obesity

Be sensitive + Nonjudgmentao

How to lose weight?

Reduce caloric intake compared to expenditure

Eat Healthy: Fruits and vegetables

Eat protein

Exercies

Can you use drug therapy. alone for weihgt loss

No you must have other factors such as diet, excerise, behavior modification

What is the only treatment with successful and lasting impact for those with extreme obesity?

Bariatric Surgery

What BMI is required to be qualified for bariatric surgery

BMI > 40 kg

BMI > 35 with other significant comorbidites

• hypertention DM 2, Heart failure, sleep apneia

Before Bariatric Surgery what Pts must be screened for

Psychological, physical, behavioral conditions that could cause poor surgical outcomes

Illness that won’t be improved with surgery

What are the three types of bariatric surgery?

Restrictive

Malabsorptive

Combination (restrictive + Malabsorptive)

What is an is issosoijsijo?

Restrictive Surgery: Limits stomach size with inflatable Band around fundus of the stomach

Band can be adjusted to meet Pt needs as weight is lost

It reversible

What is a sleeve Gastrectomy?

Procedure where 75% of the stomach is removed

Non reversible

Stomach function is preserved

removed part of the stomach that make Ghrelin

What type of surgery is Roux-en-Y surgical procedure (RYGB) for bariatric surgery?

Combination of Restrictive and Malabsorptive surgery

Why is Roux-en-Y surgical procedure a gold standard?

Low complication rates

Excellent Pt tolerance

Is effective because food bypasses 90% of the stomach, duodenum, and small segment of jejunum

Explain the Dumping syndrome complication from RYGB?

Occurs when gastric content empty to quickly into the small intestine causin water to be pulled in rapidly

What is the best way to avoid dumping syndrome?

Avoiding sugary foods

20, 20 , 20

20 bites

Smaller bites

Count 20 between quotes

take bites smaller than a quarter

What is the time frame for early dumping syndrome?

Occurs 15-30 minutes

What are the signs of early dumping syndrome?

Nausea, Vomitting, Diarreha, dizziness

What is the cause of late dump syndrome

Sudden large amount of carb intake causes massive overload of insulin

Insulin with no glucose causes hypoglycemia S/S

When does late dumping syndrome occur in time fram

1-3 hrs

What are the S/S of a late dumping syndrome?

Signs of hypoglycemia

Sweating, Weakness

Before a baraitric Pt goes into surgery what is important to put on them

SED

What sized tools woudl be needed for a bariatric pt

larger bed, larger blood pressure cuff, larger gown

Would should bariatric pt practice ough deep breathing turning and position and spiritimer and cpap uised

Excess tissue causes issues breathing

Should bariatric patients get longer IV

Yes

After bariatric pts get their operation what shoudl you stabilize

Airway

Managage pain