N470: palliative care (exam 4)

Goals of palliative care (7)

• Provide relief from pain and other physical symptoms

• Maximize quality of life

• Provide psychosocial and spiritual care

• Help patients and their families determine goals of care

• Neither hasten nor postpone death; recognize dying as a natural process

• Provide support to the family and the caregivers during the patient's illness and in bereavement

• Recognize and respect the cultural values and beliefs of the patient and the family

members of the palliative care team

1) nurses

2) pharmacists

3) nutritionists

4) doctors

5) social workers

6) case managers

7) spiritual advisors

elements of palliative care (8)

- Structure and Process

- Physical

- Psychological

- Social

- Spiritual - Religious

- Cultural

- End of Life

- Ethical - Legal

Holistic assessment elements (structure and process) (6)

•Presenting illness

•Comorbidities

•Level of function

•Coping

•Support system

•Care goals

Physical elements of palliative care

- symptom management

- investigational (onset, quality, severity of symptoms)

- reassessment of effectiveness of interventions

- must also account for cultural, spiritual, emotional aspect of symptoms

Assessment of psychologic factors of illness

•Anxiety

•Depression

•Delirium

•PTSD

•Substance Abuse

social assessment has which priorities?

conducted with patient goals and preferences as priority

Environmental and Social Factors which influence palliative care (3)

•Support System

•Housing/Transportation/Food

•Insurance

FICA

- What is your faith or belief

- Is it important in your life? How does it influence your life?

- Are you part of a spiritual or religious community

- Ask how the healthcare team can support their practice

cultural elements of palliative care (4)

- cultural values and traditions

- views on health and illness

- family caregiving roles

- decision making

Coping with illness in the terminal phase

•Provide comfort

•Improve quality of life

•Dignified death

•Caregiver support

ability of a patient to make healthcare decisions

capacity

Capacity of a patient is defined by what capabilities? (4)

1.Understands information

2.Can weigh risks/benefits and alternatives (including no treatment)

3.Can communicate clearly with medical providers

4.Has logic in decision making

elements of Advanced Directives

- Durable Power of Attorney for Healthcare

- Physician Orders for Life Sustaining Treatment

- living will

- DNR/AND

- organ donation

5 Wishes - Advance Care Planning

•The person I want to make decisions for me when I cannot

•Medical treatment I do or do not want

•How comfortable I want to be

•How I want people to treat me

•What I want my loved ones to know

A protective and therapeutic intervention; positively correlated with quality of life

Hope

period of time after death when grief and mourning occurs

Bereavement

reaction to the death of a loved one

Grief

Kubler Ross stages of grief

1.Denial

2.Anger

3.Bargaining

4.Depression

5.Acceptance

Usually the most distressing symptom of death

SOB

How is SOB assessed?

- self report, ask the patient

- RDOS for patients unable to self report

respiratory symptoms in palliative care (5)

•Increased RR

•Secretions/gurgling

•Use of accessory muscles

•Wheezing

•Crackles

Etiology of respiratory s/s in palliative care

•Cardiac

•Pulmonary

•Oncologic - tumor burden

•Trauma

•Underlying cause cannot always be reversed

what to educate the family on r/t respiratory s/s in palliative care

symptom may not be indicative of distress at EOL

how is respiratory symptom relief demonstrated?

by improvement in self report - not a specific O2 saturation or RR

pharm treatment for respiratory s/s in palliative care (7)

•Oxygen (palliative - not EOL)

•Steroids - prednisone/solumedrol

•Antibiotics (palliative)

•Albuterol/Ipratropium

•Glycopyrrolate

•Benzodiazepines

•Opioids - Morphine (EOL only)

non-pharm treatment for respiratory s/s in palliative care (4)

•Increase HOB

•Fan for passive air

•Pursed lip breathing

•Provide education- EOL respiratory symptoms may not be indicative of air hunger

categories of delirium

hyperactive, hypoactive, mixed

s/s of delirium in palliative care (5)

•Agitation

•Impaired cognition

•Altered attention span

•Altered perceptions

•Hallucinations

etiology of delirium in palliative care (10)

•Liver/renal failure

•Hypoxia, infection

•Electrolyte derangements

•Dehydration

•Constipation

•Urinary retention

•Brain metastases

•Medication side effects

•Immobility

•Restraints

treatment for palliative care delirium (7)

•Correct underlying cause if possible

•Reorient gently

•Promote sleep/wake cycle

•Soft Music

•Turn off alarms/calm environment

•Haldol (PO/IM/IV), Seroquel, Risperidone

•Support family as symptoms can be distressing

What are some GI symptoms in palliative care?

- n/v

- constipation

etiology of palliative care n/v (5)

•Liver failure/uremia

•GERD

•Vestibular Disease

•Medications (chemotherapy, antibiotics, steroids, NSAIDS)

•Radiation therapy

Where is the vomiting center? processes external input (sight, smell) and internal input (stretch of GI tract for example) to activate physical action of vomiting

medulla

Chemoreceptor trigger zone (CTZ) in brainstem responds to ___________ stimuli (drugs, toxins) and ____________ – transmits signals to vomiting center

Chemoreceptor trigger zone (CTZ) in brainstem responds to chemical stimuli (drugs, toxins) and motion – transmits signals to vomiting center

potential triggers for n/v to assess for (6)

•Movement

•Meals

•Smells

•Reflux

•Constipation

•Medications

treatments for palliative care n/v

•Prevention if possible

•IV Fluids for hydration (not EOL)

•Anticipatory nausea - benzodiazepines

•Antiemetics - Ondansetron, Prochlorperazine, Phenergan

•Metoclopramide - treat decreased motility

•Steroids - chemotherapy induced nausea

•Nonpharmacologic - aromatherapy, acupuncture, healing touch/Reiki

etiology of palliative care constipation (4)

disease, medications, psychologic factors, nutrition/dehydration

medications that may cause palliative care constipation (5)

Chemotherapy, opioids, antihistamines, BP meds, antidepressants

disease that may cause palliative care constipation (7)

Cancer, IBD, Parkinsons, ESRD, DMII, spinal cord injury, stroke

assessment for palliative care constipation (5)

•Flatus, bloating, cramping

•Oozing stool in presence of constipation

•Pain or straining at defecation

•Abdominal pain

•Anorexia

pharm treatments for palliative care constipation (5)

•Bulk-forming laxatives (psyllium)

•Stimulant laxatives (senna, bisacodyl)

•Lubricants (mineral oil).

•Saline Laxatives (magnesium citrate, sodium phosphate)

•Osmotic Laxatives (lactulose)

non-pharm treatments for palliative care constipation (5)

•Acupuncture

•Massage

•Positioning (Left side)

•Increase mobility

•Dietary changes (avoid dairy - add caffeine, prune juice, fiber)

causes for palliative care psychosocial s/s (4)

•Uncontrolled symptoms

• Medications (steroids)

•Lack of control

•Social/family dynamics

palliative care psychosocial s/s (5)

- anxiety

- Depression

- Fear

- Anger

- Social Isolation

management of palliative care psychosocial s/s (7)

- control physical s/s

- encourage, support, teach

- relaxation- breathing, music, imagery

- allow patient and family to control what they can

- create safe environment

- do not take outbursts personally

- meds- antidepressants, anxiolytics

an unpleasant sensory and emotional experience associated with actual or potential tissue damage; subjective report where patient experience is the most valid assessment tool

pain

conversion of noxious stimuli (tissue damage) into action potential - release of chemical mediators - nociceptors (nerve endings) activated - pain

transduction

Increased susceptibility of nociceptor activation; inflammation and release of chemical mediators lower nociceptor threshold; maybe begin to respond to signals which earlier would not have activated a response (light touch); these signals are then sent to CNS

Peripheral sensitization

increased sensitivity and excitability of neurons in the central nervous system; unrelieved acute pain can lead to chronic pain from this phenomenon

Central sensitization

Dimensions of pain (5)

Physiologic

Affective

Cognitive

Behavioral

Sociocultural

Emotional response to pain

affect

Observable reactions (grimacing, irritability, coping) to pain

behavior

Beliefs, attitude, memories which influence pain experience

cognitive

Genetic, anatomic, physical determinants of pain

physiologic

Age , gender influence response to pain management; Cultural influence on pain experience; Family/caregiver influence on pain

Sociocultural

Multifaceted Model of Pain

nociception

pain

behaviors

suffering

Processing of stimulus resulting from damage to tissue or potential damage to tissue

nociception

perception of discomfort following nociceptive fiber sending signal to neural pathway

pain

physical reaction to the conscious perception of pain; how pain is expressed and controlled

behaviors

individualized response connected to the personal meaning of pain

suffering

Pain arising from skin, mucous membranes, subcutaneous tissue; Tends to be well localized (sunburn)

superficial pain

Pain arising from muscles, fasciae, bones, tendons; can be localized, diffuse, or radiating

deep pain

Pain arising from visceral organs, such as the GI tract and bladder; can be localized, diffuse, often radiates to cutaneous site

visceral pain

Non-salicylates for nociceptive pain (1)

Acetaminophen (Tylenol)

Nonsteroidal Anti-inflammatory Drugs (NSAIDS) for nociceptive pain (4)

Celecoxib

Ibuprofen

Ketorolac

Naproxen

Opioids for nociceptive pain (7)

Morphine

Fentanyl

Oxycodone

Oxycontin

Hydromorphone

Methadone

Tramadol

Abnormal processing of sensory input

Neuropathic Pain

neuropathic pain caused by a primary lesion or CNS problems;

Ex: MS or post stroke

central

neuropathic pain caused by direct damage to the nerve - patient experiences pain at the site of the nerves;

Ex: Diabetic neuropathy

peripheral

neuropathic pain results from loss of or alteration in afferent nerve;

Ex: Phantom Limb pain

Deafferentation

med classes for neuropathic pain (6)

Local Anesthetics

Antidepressants

Anticonvulsants

Cannabinoids

Corticosteroids

GABA receptor agonist

Local Anesthetics for neuropathic pain (3)

Lidocaine

Bupivacaine

Capsaicin

Antidepressants for neuropathic pain (4)

Tricyclics

- Nortriptyline

- Amitriptyline

SNRIs

- Duloxetine

- Venlafaxine

Anticonvulsants for neuropathic pain (2)

Gabapentin

Pregabalin

cannabinoids for neuropathic pain (1)

marinol

Corticosteroids for neuropathic pain (1)

Dexamethasone

GABA receptor agonist for neuropathic pain (1)

Baclofen - works well for pain r/t increased muscle spasticity

non-pharm interventions for neuropathic pain (10)

acupuncture

heat/cold therapy

exercise

massage

reiki

deep breathing

relaxation/imagery

hypnosis

music therapy

distraction

associated symptoms of pain

aggravating or alleviating factors, influence on anxiety, depression, fatigue, sleep

assessment techniques that can be limited by communicative ability of patient; beneficial in determining effectiveness of interventions

Unidimensional

assessment techniques that measure multiple aspects of the pain experience; not often used in high acuity setting

Multidimensional

Reliable indicator of pain in nonverbal high-acuity patients; Can be used with intubated or non-intubated patients; Does not measure intensity; Score of 3 or higher is indicative of pain

Critical Care Pain Observation Scale (CPOT)

decrease in effectiveness or diminished side effects for the same dose that has previously been effective or had caused side effects

Tolerance

physiologic response to ongoing exposure to drugs; Results in symptoms of withdrawal if drug is abruptly stopped or dose reduced; Must taper dose if patient no longer experiencing pain after long term use

Physical Dependence

neurologic and biologic dependence; Impaired control of drug use; Compulsive use despite harm to self or others; Use of drug for purpose other than pain relief

Addiction

behaviors which mimic addiction which are resulting from inadequate pain management

Pseudoaddiction

safety monitoring parameters for palliative care (4)

•RASS

•Respiratory Rate

•ETCO2

•POSS (Pasero Opioid Induced Sedation Scale (POSS))

palliative care vs hospice care

Palliative Care

•Can pursue curative treatment

•Considered consulting service with insurance

•May be provided by primary team

Both

•Symptom relief

•Holistic framework

•Focus on quality of life

•Caregiver support

Hospice

•Terminal condition life expectancy < 6 months

•No longer seeking curative treatment

•Covered by Medicare/Medicaid/Private Insurance

concept that medical intervention may continue to have an effect but there is no benefit to the patient

Medical Futility

Termination of life sustaining interventions; Ethical rationale of reduction in patient suffering when prognosis is poor and it aligns with patient preferences

Withdrawal of Care

Nurse's role in withdrawal of care

- acknowledge feelings (anger, fear, sadness, helplessness) and provide support

- documentation of conversations with patient and/or family and rationale for decision

- assess patient and family spiritual, cultural, religious preferences

- create environment for comfort

- anticipate and manage symptoms as treatments are discontinued

EOL cardiac symptoms (3)

Decreased/irregular HR

Weak pulses

Hypotension

EOL pulmonary symptoms (5)

Altered respiratory pattern

Cheyenne Stokes

Accessory muscle use

Increased secretions

Death rattle

EOL GI symptoms (2)

Dehydration

Incontinence may indicate imminent death

EOL sensory symptoms (3)

Blink reflex absent

Decreased sensation

Hearing last to disappear

EOL integumentary symptoms (3)

Mottling hands/legs/coccyx

Peripheral cyanosis

Skin breakdown on pressure areas

EOL musculoskeletal symptoms (3)

Loss of mobility/Fatigue

Difficulty swallowing

Loss of gag reflex

EOL GU symptoms (3)

Gradual decline in urine output

Incontinence

Retention

EOL neurologic symptoms (3)

Decreased LOC

Hallucinations

Agitation/Restlessness