(PowerPoint)
Dying Persons Bill of Rights: (*see box at top of page P&P 468)
DNR (P&P 328): order to withhold treatment instead of deliver treatment; written not verbal.
Advanced Directives (P&P 328): 2 kinds - living wills and durable powers of attorney for health care; both based on values of informed consent, client autonomy over end-of-life decisions, truth telling, and control over the dying process; witnessed by non-involved parties; some states do not recognize witnessing by relatives valid
Organ Donations (P&P 329): "donation of all or part of a human body to take effect upon or after death"; written; 18 years of age or older.
Euthanasia/Assisted Suicide (P&P 330): allowed only in Oregon (Washington?); elsewhere, feeding/hydration withdrawn to hasten death; high pain medication to "prevent pain" that may subsequently cause death.
(End-of-life Lecture 11/6)
- Dying person’s bill of rights
- DNR (do not resucitate)
- Advanded directives (witnessed by non-involved parties; some states do not recognize witnessing by relatives)
- Living will/Durable Power of Attorney
- Organ donations
- Euthanasia/assisted suicide
Pt and their families have the right to decide what outcome they want to have as it pertains to their end of life care. It should be based on the Pt wishes and should include: if they want to donate organs, advanced directives, and resuscitation. All states have natural death acts which tells the physicians exactly what treatment is or isn’t desired. A person may write his or her wishes w/o special forms. Verbal directives may be given to physicians that are specific instructions that pertains to how the pt would like to proceed with their care. This must be witnessed by 2 people
2. Discuss therapeutic communication when caring for the dying patient.
(P&P 473)
Establishing a caring, trusting relationship with the client and family through the use of therapeutic communication forms the basis for palliative care interventions. A grieving client may experience anger, for example, and become hostile with family members or caregivers. Some clients become demanding and accusing. Remain supportive by letting clients and family members know that feelings such as anger are normal by saying, for example, "You are understandably upset right now. I just want you to know I am here to talk with you if you want." Invite clients to reveal the emotions and concerns of greatest importance to them, and acknowledge their feelings and concerns in a non-judgmental manner.
If a client chooses not to share feelings or concerns, express a willingness to be available at any time. Some clients will not discuss emotions for personal or cultural reasons, and other clients hesitate to express their emotions for fear that others will abandon them. If you are reassuring and respectful of the client's privacy, a therapeutic relationship will likely develop. Sometimes clients need to begin resolving their grief privately before they will discuss their loss with others, especially strangers.
Avoid communication barriers such as denying the client's grief, providing false reassurance, or avoiding discussion of sensitive issues. When you sense that a client wants to talk about something, make time right then, if at all possible. Above all, remember that a client's emotions are not something you can "fix." Instead, view emotional expression as a necessary part of the client's adjustment to significant life changes and development of effective coping skills. help family members access other professional resources. Spiritual care providers, for example, help clients and family members discuss difficult issues related to personal meanings and values, death, and loss.
Face client when speaking to them
Eye-to-eye contact
Holding hands, use of therapeutic touch is acceptable if the pt is comfortable with that, doesn’t have to be verbal, can be nonverbal communication, could be as simple as companionship and just listening to the dying pt. Empathy and active listening are important. Silence is also therapeutic, allowing the pt time to gather thoughts, and listening to silence sends a message of acceptance and comfort.
3. Discuss the types of grief and grief responses.
(P&P 463)
Normal (uncomplicated) grief: feelings of acceptance, disbelief, yearning, anger, and depression.
Complicated grief: the grieving person has a prolonged or difficult time moving forward after a loss; may experience a chronic and disruptive yearning for the deceased and are likely to have trouble accepting the death and trusting others, feel excessively bitter, or are uneasy about the future; may feel emotionally numb; usually associated with conflicted relationships with the deceased, prior or multiple losses or stressors, mental health issues, or lack of social support; loss associated with homicide, suicide, sudden accidents, or the loss of a child usually fall into this category; symptoms and disturbances last at least 6 months after loss and they interrupt every dimension of the person's life.
Anticipatory grief: the unconscious process of disengaging or "letting go" before the actual loss or death occurs, especially in situations of prolonged or predicted loss - usually a benefit; sometimes the stress and strain of a terminal illness, including ruptures in spousal intimacy, separation anxiety, security threats, and the traumatic helplessness of watching a loved one die, outweigh the supposed benefits of anticipatory grieving; forewarning may be a buffer for some, it may increase stress for others, posing a sort of emotional roller coaster of highs and lows.
Disenfranchised grief: known as marginal or unsupported grief because their relationship to the deceased person is not socially sanctioned, cannot be openly acknowledged or publicly shared, or seems of lesser significance; examples include the death of a very old person, an ex-spouse, a gay partner, or even a loved pet.
(End-of-life Lecture 11/6)
**Unresolved Dysfunctional Grief**
absent: taotally absent as if dath never occurred
inhibited: lasting inhibitions of many manifestations of normal grief
delayed: postpones
conflicted: frequently exaggerated or distorted
anger and extreme guilt
can be prolonged; assoc w/previously dependent or ambivalent relationship w/the deceased
chronic: cont. exhibits intense grief
fails to draw natural conclusion
often assoc. w/intense yearning and dependence fastered by mourner’s insecurities
also evident after the loss of an irreplaceable relationship
unanticipated: occusrs affter a sudden unanticipated loss
so disruptive that recovery is usually complicated
adaptive capabilities seriously assaulted
suffer extreme feelings of bewilderment, anxiety, self-reproach, depression which renders them unable to function
difficulty in accepting loss
abbreviated: often mistaken for unresolved grief
short lived byt normal form
may occur because of immediate replacement or insufficient attachement of the lost person
sometimes can occur after a gnificant amount of anticipatory grief was completed before death.
Pathologic grief- which is an intense grief that lasts more than a year the grieved person becomes bogged down in the grieving process.
Conflicted grief- when the bereaved person has not resolved abivalent feelings towards the deceased.
Absent grief when the bereaved person appears to be coping and carrying on as if nothing ever happened.
Dysfunctional/Complicated grief- is grief that is delayed or exaggerated may be identified as dysfunctional. Dysfunctional grieving may relate to a real loss or a perceived loss, it may occur when grief is not resolved from a prior experience. Has a difficult time moving forward after a loss. Can feel bitter or numb, more commonly associated with sudden loss.
Anticapatory grief- is the unconscious feeling of letting go before the actual loss or death occurs, especially in situations where the loss was expected.
Adaptive grief- it is helpful or assists the person in accepting the reality of death. THIS IS A HEALTHY RESPONSE.
Normal uncomplicated grief- when people are in the process of grieving a loss this is a normal and healthy response to grief it’s the most common reaction to death
4. Discuss the concerns of the dying patient.
(PowerPoint)
-Must arrange a variety of affairs
-Cope with loss of loved ones and self
-See to future medical needs
-Plan for the future
-Anticipate future pain and discomfort and face possible loss of various forms of sensory, motor, or cognitive abilities
-Cope effectively with loss of self and identity and deal with the death encounter
-Decide whether to attempt to slow down or speed up the dying process
-Must deal with numerous psychosocial problems:
loss of control
suffering
types of death
living-dying interval
acute/chronic crisis phase
dying as a gradual process
(End-of-life Lecture 11/6)
♣ must arrange a variety of affairs
♣ coping w/loss of loved ones and self
♣ see to furute medical needs
♣ plan for the future
♣ anticipate future pain and discomfort and face possible loss of various forms of sensory, motor, or cognitive abilites
♣ cope effectively w/loss of self and identity and deal w/the death encounter
♣ decide whether to attempt to slow down or speed up the dying process
♣ must deal w/numerous psychosocial problems:
• loss of control
• suffering
• types of death
• living-dying interval
• acute/chronice crisis phase
• dying as a gradual process
Fearing the unknown, what is going to happen to their loved ones once they have died. Making sure that all the loose ends are tied before they die, and having their final affairs in order. Spiritual concerns, where am I going after I die. Fear of pain is it going to hurt, fear of loneliness and abandonment they don’t want to be alone. Fear of meaninglessness what accomplishments have they made, and what have they done with their lives, the fear that all of that will be forgotten
5. Discuss the interventions needed to assist the patients to die with dignity.
(P&P 475)
-Includes a person's positive self-regard, an ability to invest in and gain strength from one's own meaning in life, feeling valued by others, and how one is treated by caregivers; nurses promote this by respecting him or her as a whole person with feelings, accomplishments, and passions independent of the illness experience.
-Giving importance to the things that a client cares about validates the person, at the same time strengthening communication among the client, family members, and the nurse.
-Spending time with clients as they share their life experiences, particularly what has been meaningful, helps you know the client better and facilitates the development of individualized interventions.
-Show respect for older clients by calling them by surnames and titles and by obtaining their permission to include others in private conversations.
-Attend to the client's physical appearance - cleanliness, absence of body odors, attractive clothing. When caring for a client's bodily functions, show patience and respect, especially after the client becomes dependent.
-Allow clients to make decisions, such as how and when to administer personal hygiene, tests, or therapies, their purpose, and anticipated effects. Provide privacy during nursing care procedures, and be sensitive to when the client and family need time alone together.
(End-of-life Lecture 11/6)
Keep pt comfortable
If possible meaning if the Pt is AoX3 let the Pt make their own decisions about their health care, talking to them about their treatments asking for permission before initiating care. Promote the Pt sense of dignity and self-esteem by respecting the person as a whole respecting the person’s feelings, accomplishments, independent from the illness experience. Valuing things that the Pt finds important validates the Pt and helps build better communication.
6. Explain the purpose of Hospice care.
(P&P 478)
Hospice care is a philosophy and a model for the care of terminally ill clients and their families. Hospice is not a place, but rather a client- and family-centered approach to care. It gives priority to manage the client's pain and other symptoms, comfort, quality of life, and attention to physical, psychological, social, and spiritual needs and resources. Hospice services are available in home, hospital, extended care, or nursing home settings.
*see list of "hospice care focuses" at bottom of page 478
(End-of-life Lecture 11/6)
Usually reserved for those living 6 months or less
The purpose of hospice is to provide palliative care to the dying p, compassion, concern and support of the dying pt. Hospice is geared to the trtmnt and management of the persons symptoms rather than trying to cure them. Focuses on caring interventions, such as pain relief or decrease in pain, decrease in symptoms of the disease and psychosocial support, so that they pt is able to live as fully as possible during the EOL transition. This is usually for a pt that has less than 6mo of life left.
7. Discuss the concepts of pain and pain management.
(P&P Ch43)
-McCaffery's definition of pain: "Pain is whatever the experiencing person says it is, existing whenever he says it does."
-pain is categorized by duration (acute or chronic) or by pathologic condition (e.g., cancer or neuropathic).
-factors that influence pain include:
social (attention, previous experience, family & social support) spiritual (punishment, lesson)
psychological (anxiety, coping style)
physiological (age, fatigue, genes, neurological function)
cultural influences (the meaning of pain based on ethnicity)
-Effective pain management improves quality of life, reduces physical discomfort, promotes earlier mobilization and return to work, results in fewer hospital/clinic visits, and shortens hospital stays, thus reducing health care costs.
-Pain management can include:
nonpharmacological:
relaxation & guided imagery
distraction
cutaneous stimulation (TENS), massage
herbals
reducing pain perception
pharmacological:
analgesics (nonopioids, opioids, adjuvants/coanalgesics)
PCA
perineural infusion
topical analgesics
local/regional anesthetics
invasive interventions (injections, spinal cord stimulators, deep brain stimulation)
(Pain management Lecture 11/13)
Affective: emotions, suffering
Behavioral: behavioral responses
Cognitive: beliefs, attitudes, evaluation, goals
Sensory: pain perception
Physiologic: transmission of nociceptive stimuli
**PAIN MANAGEMENT:**
♣ Medications (opioid, non-opioid, co-analgesic or adjuvant)
There are two parts of pain Physical and emotional. The physical part of pain is the sensation which is the unpleasant felling due to stimuli. The other part is the suffering which is the emotional part of the pain. Pain is multidimensional there is the affective, behavioral, cognitive, sensory, physiologic. Pain management refers to helping the pt control their pain not necessarily the absolute reduction of pain. It is unrealistic to expect total pain relief especially if it’s chronic pain, so the reasonable expectation is finding out what is an acceptable pain level for the pt.
8. Discuss ethical considerations for the terminal patient. (from lecture on Ethical and Legal Issues of Dying)
Dying Person’s Bill of Rights
DNR
Advanced Directives
Witnessed by non-involved parties
Some states do not recognize witnessing by relatives valid
Living Will/Durable Power of Attorney
Organ Donations
Euthanasia/Assisted Suicide
You want to make sure that you keep the Pt comfortable, you want to improve the quality of the pt remaining life, you need to know in advance what the pt wishes are about being resuscitated and conversations regarding EOL care needs to include the pt not just the pt family. Early communication about EOL care should be initiated early when the client is still able to make decisions regarding their care and treatment what their wishes are and how to carry them out. Who they want present, what they want to be kept private who they want to administer their last rites, assessing the pt spiritual needs. You want to educate the Pt about
9. Discuss the nursing interventions for the patient receiving chemotherapy or radiation treatment. (from cancer lecture)
Remember speedy nursing encounters and visitor restriction!
INFORM CLIENT BEFORE:
The need to visit the place where they will receive therapy in advance
They need to lie very still on the table while irradiation occurs
They will have a tattoo applied to mark the place – DO NOT REMOVE
They will be alone in the room during therapy, but a technologist will be available via intercom
FOR IMPLANTABLE OR OTHER RADIATION:
Need to avoid contact with others—children should not sit on their laps.
Flush toilet 2-3 times after voiding so all radiation passes
All linens need to be handled according to facility policies for the specific treatment
Drainage from site of radioactive colloid injection – considered radioactive, MUST be reported to MD immediately
Dressings with radioactive seepage, MUST be removed with long handled forceps
MUST NEVER BE TOUCHED WITH UNPROTECTED HANDS
Shielding is REQUIRED
FOR BONE MARROW:
Nursing implications will be needed to deal with nausea, vomiting, GI tract inflammation, taste changes, anorexia, mucositis, stomatitis, esophagitis, intestinal damage, and diarrhea. Pt is also at a risk for infection so all interventions related to that risk diagnosis need to be followed.
(Cancer Lecture 11/6)
Moisturizing lotion
Turning if bedridden
Encourage ambulation
Fluids
Cough and deep breathe
I.S
Rest/activity periods
Food like/disliked
Admin. Antiemetics as ordered
Protective/reverse isolation
Avoid crowded places (no daycare)
No fresh flowers
No animals
Palliative interventions are key such as helping to reduce irritation to skin during radiation. Applying creams and ointments that are nonirritating to the skin in the areas that the pt is receiving radiation treatment, gently cleansing the skin, and making sure that it is dry, dusting with cornstarch may reduce itching, for areas that are oozing, rinse the area with saline solution and expose that area to air to allow it to dry, use no adhesive absorbent dressing to remove drainage, giving pt education about what to avoid while being treated such as wearing loose fitting clothes, taking off bra’s and girdles during treatment, not wearing harsh fabrics like wools and corduroys and avoiding direct sunlight, giving the pt antiemetics prior the procedure, and as a regimen of care to prevent nausea and vomiting helps to counteract the affects of chemotherapy and radiation treatment. Giving the Pt frequent oral care since may pt that receive chemotherapy experience dry mouth due to decreased salivary production. Maintaining a comfortable environment for the pt while they are receiving treatment has a therapeutic affect. Pt should receive small, frequent, soft, nonirritating and high protein and caloric meals to help prevent nausea and vomiting which will help the pt maintain their weight and energy. Encourage ambulation, cough and deep breathing exercises, incentive spirometer use, eat foods they like, resting during periods of activities, and doing things in small increments.
10. Discuss the relevant assessment data needed for the terminal patient on pain medication.
Look for nonverbal signs of pain, ask about possible side effects as they may be worse than pain. Pain medication is often under administered to the terminally ill, so be aware of that.
Pain control is important regardless if the Pt has a terminal illness or an acute illness. Assess what their pain level is, and what is an acceptable pain level to the Pt. Assess their pain level frequently, communicate and collaborate with others regarding the plan of care and how to keep the Pt at their acceptable level of pain. Initiate adequate pain relief measures. Assess the Pt response to analgesics and other no pharmacologic interventions at least 30-60 min after administering. Assessment must include level of sedation.
11. Differentiate between the assessment needed for the patient in acute and chronic pain.
(from pain lecture)
Acute Pain Assessment:
Direct interview (OPQRST)
Observation
Diagnostic studies
Physical examination
Chronic Pain Assessment:
How has the pain affected his/her ADL’s
Ensure informed consent for pain management.
Assess pain and evaluate response to pain management interventions using a standard pain management scale based on patient self-report
Acute: (multidimensional)
♣ Direct interview
♣ Observation
♣ Diagnostic studies
♣ Physical examination
Chronic: How has the pain affected his/her ADL’s
You want to know if the person is having acute pain vs. chronic pain, so that you will know how to treat the pain. Acute pain should be aggressively treated. The goal is pain reduction and pain free if possible. You want to find out where the pain is coming from. Acute pain is usually brief with rapid onset and duration, high intensity and frequency. Chronic pain is gradual or can be sudden the duration lasts longer than 6mo, you want to know how this pain affects the person in their day to day life, what aggravates the pain and what makes it better. How is the person’s social life affected and does the pain make them withdraw from others, does it make them feel depressed, cause fatigue and activity intolerance. Assess pain according to daily activities, direct interview, observation of the Pt, diagnostic studies, and physical examination.
12. Describe the different types of pain.
(from wikipedia)
Acute Pain- pain that comes on quickly, can be severe, but lasts a relatively short period of time
Chronic Pain- pain that persists longer than the temporal course of natural healing, associated with a particular type of injury or disease process
Referred Pain- pain perceived at a site adjacent to or at a distance from the site of an injury's origin
Breakthrough Pain- pain that comes on suddenly for short periods of time and is not alleviated by the patients' normal pain suppression management.
Phantom Pain- perceptions that an individual experiences relating to a limb or an organ that is not physically part of the body.
Acute and chronic, cancer pain which is pain at he tumor site or distant to the site. Nociceptive pain is the stimulation of the afferent nerves which transmitts pain signals, it is caused by damage to the somatic or musculoskeletal tissues, visceral pain which is internal organ pain. Neuropathic pain is pain that is caused by damaged nerves which causes pain. Idiopathic pain which is pain that has an absence of an identifiable cause. Pain can be affective-emotions and suffering. Physiologic-transmission of nociceptive stimuli. Sensory-pain perception. Cognitive-pain beliefs and attitudes. Behavioral-behavioral responses.
14. Discuss the education needed for the patient on opioid medication.
(from pain lecture)
Explain that risk for addiction is low, tell the patient what the side effects to look out for are, other than that educate them on general things relating to pain meds, like how to operate a PCA, dose, interval, and route, and the pain management plan.
Opiod analgesics should be used to treat moderate to severe pain. Pt should be advised that opiods cause sedation, respiratory depression, constipation, nausea, vomiting, itching, urinary retention, cyclones and altered mental processes. Educate the Pt that the appropriate use of opiods for pain rarely leads to addiction.
15. Discuss the nursing diagnoses relevant to grief.
( Ch. 30 Potter)
* Compromised family coping
* Ineffective denial
* Fear
* Grieving
* Complicated grieving
* Risk for complicated grieving
* Spiritual distress
* Anxiety
Potter#470
Death anxiety, caregiver role strain, compromised family coping, readiness for enhanced comfort, disturbed personal identity, ineffective denial, fear, grieving, complicated grieving, risk for complicated grieving, hopelessness, risk for loneliness, spiritual distress, readiness for enhanced spiritual well being
16. Discuss goals/outcomes for patients in chronic pain.
Describe experience in order to treat, identify goal for therapy and
resources for self management, prevent pain whenever possible, will
require only oral analgesics for pain, reports pain is less then 3 on
a 1-10 scale after the use of PCA. Decrease pain to tolerable level
according to patient’s tolerance. NEVER USE: PAIN WILL BE GONE BY…!
(Pain management study guide)
When managing clients’ pain, your goals of care should promote the
client’s optimal function. Determine, along with the client, what the
pain has prevented the client from doing. Then decide on a mutually
acceptable level of pain that allows return of function. An indication
of a plan’s success is dertermined through attainment of goals and
outcomes. For example, in the case of the goal of “ the client will
achieve a satisfactory level of pain relief within 24 hours. The
following are possible outcomes: reports that pain is a 3 or less on a
scale of 0-10. Identifies factors that intensify pain, uses pain
relief measures safely, level of discomfort will not interfere with
ADL activities.(CH. 43 Potter pg.1067)
Goals: Patient will obtain tolerable level of pain before discharge.
Client will actively participate in ADLs. Outcomes: pain control;
client willl report pain at stated goal or below, client uses PCA
device properly. Pain disruptive effects; sleep 5-6 hours without
interruption form pain, will complete own hygiene with minimal
assistance, will walk the hallway with husband every 4 hours for 15
minutes. Medication response; will report having a normal bowel
movement every other day. Will not experience unmanageable opioid side
effects. (CH. 43 potter pg. 1069)
- control pain to possible extent
-focus on enhancing function and quality of life
Decrease pain, ability to administer self-care, ability to do ADL’s, return to doing day to day activities. Pt will achieve satisfactory level of pain relief within 24 hours. Use pain relief interventions safely. To prevent pain as much as possible.
17. Discuss the safety precaution education needed for patients receiving chemotherapy.
Chemotherapy induced side effects are the result of the destruction
of normal cells. Chemotheraupeutic agents cannot distinguish between
normal cells and cnacer cells. (CH. 16 Lewis pg. 291)
Integumentary effects of chemo/radiation: skin changes, alopecia(hair
loss)
Respriratory: pneumonytis
Cardiac: carditis, myocarditis
GI: anorexia, nausea, vomiting (most important) diarrhea,
constipation, indigestion, stomatitis, mucositis, esophagitis
GU: hemmorhagic cystitis (from meds), sterility, nephrotoxicity
Hematologic: pandolopenia (anemia, leudemia, thrombocytopenia)
Phsycosocial: anxiety, depression. (Lecture11/12/2008)
Lewis pp#294-296
- Treatment regime
-supportive care options ( eg. Antiemetic, antidiarrahea)
-what to expect during the course of treatment is important to help decrease fear and anxiety, encourage adherence, and guide at home self-management.
- Common side effects and symptoms ( see table 16-15 Lewis pp295-296)
18. Discuss the use of the pain diary in pain management.
GOOD FOR CHRONIC PAIN!! Help the nurse and patient identify pain
patterns and causative factors. Frequency and total dosages of
medication, including breakthrough pain. ( Pain lecture)
- help the nurse and patient identify pain patterns and causative factors
-it is good for chronic pain
- it includes frequency and total dosages of medication, including breakthrough pain
Pain diary’s are good for people who have chronic pain. Helps the nurse and the Pt identify pain patterns and causative factors. Should include the frequency and total dosages of medication, including break-through pain.
19. Discuss titration in pain management.
Analgesic titration is dose adjustment based on assessment of the
adequacy of analgesic effect versus the side effects produced. There
is wide variability in the amount of analgesic needed to manage pain,
and titration is an important strategy in addressing this variability.
An analgesic can be tritrated upward or downward, depending on the
situatin. For example, in a post op patient the dose of analgesic
generally decreases over time as the acute pain resolves,. On the
other hand, opioids for chronic, severe cancer pain may be titrated
upward many times over the course of therapy to maintain adequate pain
contro. The goal of titrationis to use th smallest dose of analgesic
that provides effective pain control with the fewest side effects.
(Ch. 10 Lewis Pg. 140)
Dose adjustment based on assessment of analgesic effect versus side
effects. Use the smallest dose to provide effective pain control with
fewest side effects. Working with patient to decide the optimal
analgesic dosae required but minimizing side effects. (pain lecture)
- dose adjustment based on assessment of analgesic effect versus side effect
-use the smallest dose to provide effective pain control with fewest side effects
-working with patient to decide the optimal analgesic dosage required but minimizing side effects
Titrated doses should be based on assessment of analgesic effects that are desired versus side effects produced. Use the smallest dose possible to provide effective pain control. When titrating the Pt has to decide the optimal analgesic dosage required while minimizing side effects. There is a wide variability in the amount of analgesic needed to manage pain, and titration is good for addressing this variability. Analgesics can be titrated upward or downward depending on the type of pain and the cause of the pain.
20. Discuss the nursing care for the patient using PCA or continuous opioid analgesia.
Clients need to understand the PCA and be able to locate and press
the button to deliver the dose. Check IV line and PCA device regularly
to ensure proper functioning. Assess to determine if your client is
opiod naïve and if so do not increase dose or shorten time interval
this may cause oversedation and respiratory depressin. Document drug
dosages, and track any waste of medications according to agency
policy. Teach patient how to use PCA before procedure so when they
awaken they know how to use it. Instruct client on lhow to use PCA and
assure they know that they control their medication. Explain how the
pump prevents overdose. No family members may operate pump. Have
client demonstrate PCA pump use. Evaluate clients pain 15-20 minutes
after use. (CH.43 Potter pg. 1076)
Potter pp#1076 & lecture note
Risk factor- Diet- acrylamide, artificial sweeteners, heterocyclic amines, contaminants; obesity, sedentary life style, genetics, fertilized drugs, diethylstilbestrol, contraceptive, HRT, environment, smoking, 2nd hand exposure to smoke, smokeless tobacco , micro-organisms.
Education
- Teach client the use of PCA before any procedure so that clients understand how to use it after awaking from sedation or anesthesia.
-instruct client the purpose of PCA, emphasizing that pt controls the medication delivery.
-explain the pump prevents the risk of overdose.
- tell family member or friends to not operate the PCA device for the pt.
-have client demonstrate use of the PCA delivery button.
-check IV line and PCA device for proper functioning
-In opioid-naïve client do not increase demand or basal dose and shorten the interval time simultaneously because this will increase the risk for over sedation and respiratory depression.
-assess pt for sign of SE such as respiratory depression, sedation, nausea, vomiting , constipation, itching, urinary retention, myoclonus, and altered mental status. Page#1074
- tell pt that if the dosage are inadequate to relieve pain, the pump can be reprogrammed and also bolus dosage can be given by the nurse if it is included in physician order.
-when making transition from PCA to oral drugs , pt should receive increasing doses of oral drug as the PCA analgesic is tapered . Lewis pp#142
-encourage dietary roughage, fluids, and exercise to prevent constipation
PCA is used to administer opiod analgesics when the Pt decides its needed. It’s used to manage acute pain, post op pain and cancer pain. The Pt needs to understand how to use the PCA device, and how to titrate the drug to achieve good pain relief. Encourage the Pt to administer the dose before the pain reaches a level greater than Pt desired intensity level and educate the Pt that they cannot OD from using a PCA.
21. Discuss nursing diagnoses relevant for patients with terminal disease.
* Anxiety
*chronic sorrow
* complicated grieving
* compromised family coping
* disturbed thought process
* fear
* grieving
* hoplessness
* impaired religiosity
* impaired social interaction
* impaired verbal communication
* ineffective coping
* ineffective dnial
* insmnia
* interrupted family processes
* readiness for enhanced spiritual well being
* risk for complicated grieving
* RF lonliness, spiritual distress, prone health behavior
* social isolation
* spiritual distress ( ch11 Lewis pg. 158)
Lewis page#158 table 11.5 and 11.6
22. Discuss risk factors for cancer and the education needed.
DIET: acrylamide source= overcooked vegetables. artificial sweeteners
cyclamates, saccharine, stevia no link with aspartame at this time.
Heterocyclic amines form in meat cooked at high temps, BBQ.
Contaminants :pesticides, and herbicides. WEIGHT AND PHYSICAL
ACTIVITY: energy balance obesity, sedentary lifestyle, diet. GENETICS:
BRCA1 and 2 breast cancer genes help identify those at risk, 30-40% of
women with the gene develop breast cancer, 8-30% of women with the
gene develop ovarian cancer, 16-25% of men with the gene develop
prostate cancer. PSA: measure in levels, should be less than 4,
prostate specific antigen, higher levels=higher level of active
disease. DRUGS-HORMONAL: Diethylstilbestrol (DES) increased risk of
cervical dysplasia, incompetent cervix. Fertility drugs varies with
combinations used. Contraceptives earler intercourse, later firest
births. Hrt (hormone replacement therapy)may encourage breast cancer
growth. ENVIRONMENT: sun, randon exposure, x-rays, cell phones,
electromagnetic field exposure: powerlines, microwaves, TV and
computers. Agricultural exposure, round up. Asbestos, benzene, cancer
clusters, formaldehyde. IRRITANTS: smoking, 2nd hand smoke, smokeless
tobacco, oral pharyngeal concers, gastric cancers. MICROORGANISMS:
Epstein barr virus. HPV, simian virus 40.
Change in bowel or bladder, lesion that does not heal, unusual
bleeding or discharge, thickening or lump in breast or elsewhere,
indigestion or difficulty swallowing, obious changes in wart or mole,
nagging cough or persistent hoarseness. CAUTION! Reducing cancer risk
encourage patient to consume these foods: fruits and vegetables,
especially those rich in vit C or carotene, cruciferous veggies
(cabbage, broccoli, Brussels sprout), whole grains. Encourage patient
to limit these foods: excessive meat, especially when smoked, salted,
charbroiled,or cooked at high temp. Excessive fat, excessive calories,
alcohol. ( Cancer lecture)
- to reduce or avoid cigarette smoking and sun exposure
-To eat a balanced diet that includes vegetables and fresh fruits, whole grains, adequate amount of fiber, and reduced amount of fat and preservatives, including smoked and salt-cured meats containing high nitrite concentration.
-participate in a regular exercise regime
-obtain adequate, consistent period of rest.
-have a health examination on a regular base
- eliminate , reduce or change the perceptions of stressors and enhance the ability to effectively cope wutg stressor.
-Know seven warning signs of cancer, see lecture note (CAUTION)
- learn and practice recommended cancer screening test on a timely basis
-learn and practice self- examination
-seek immediate medical care if you notice a change in what is normal for you and if cancer is suspected.
Dosage and Calculations
23. Can you calculate:
a) Infusion time
b) Flow rate
1) gtt/min
2) mL/hr
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