ADULT & ELDER III FINAL EXAM REVIEW GASTROINTESTINAL ALTERATIONS [8 Questions] § Acute Pancreatitis o Acute inflammation that usually resolves (reversible if caught in time) o Early activation of excessive pancreatic enzymes o Etiology • Alcoholism • Gallstones • Abdominal trauma • Operative trauma • Drug use • Infection • Unknown o Signs/symptoms: • Sudden onset of severe epigastric pain, after a large meal or alcohol use • Pain can radiate to back & left shoulder • Jaundiceàif biliary obstruction • Malaise • Restlessness • Lung involvement, respiratory distress • Decreased urine output • Decreased bowel sounds, ascites (can back up into lungs) • Abdominal tenderness with guarding o Management: • ABCs • Pain (opioids) • Decrease pancreatic secretions (it’s breaking down the pancreas!) • Decrease stimulation of the pancreas & allow it to rest • NPO & NG suctioning o Removes irritants & decreases pancreatic secretions o Reduces vomiting & gastric distention • Control Fluid & Electrolyte Imbalances o Maintain adequate circulating blood volume, volume expanders, check urine output (strict I & O)à want at least 30 ml/hr o When no longer NPOà progressive diet (increase carbs, decreased fat, increased protein) • Prevent infectionà antibiotics § Chronic Pancreatitis o Usually from ETOH o Destroyed enough cells & tissues to loss function of pancreas o Irreversible, progressive o Serious loss of exocrine & endocrine pancreatic function as well as deterioration of pancreatic structure • Decreased enzyme production = malabsorption of fats & proteins o Signs/symptoms: • Constant dull epigastric pain • Steatorrhea • Severe weight lossà may look malnourished • Onset of symptoms of DM • History of: Ø Biliary disease Ø Chronic ETOH Ø Physical trauma Ø PUD Ø Medications o Diagnostic tests: • Increased serum amylase (25-85) • Increased serum lipase (10-160) o For lipase and amylase both with be 2/3 x greater in chronic, but 5/6 x greater in acute • Increased Trypsin (most diagnostic of acute) • Increased serum bilirubin (biliary obstruction) • Increased liver enzymes • Increased WBCs • Increased serum glucose
Decreased calcium Decreased magnesium o Ca+ & Mg+ actually bind with stuff in stomach, makes “soap”, steatorrheaàto stop this address pancreatitis • Acute pancreatitis is based on history of abdominal pain, risk factors, PE, & diagnostic findings • Abdominal ultrasound = diagnose cause of pancreatitis • Contrast-induced CT scan = MOST RELIABLE (best visualization of pancreas) • Abdominal & chest x-rays to differentiate pancreatitis from other disorders (r/o cardiac/gallbladder issues) & to detect pleural effusion o Management: • PRIORITIES Ø Pain (opioid/non-opioid) Ø Nutrition Ø Other problems to worry aboutàinfection & respiratory • Oral pancreatic enzyme replacement therapy Ø Capsule is bestàenzymes enclosed Ø Take with applesauce & wash down with water (prevents breakdown of lips) Ø DO NOT MIX WITH ALKALINE THINGS! v Milk v Ice cream Ø TAKE WITH ALL SNACK OR MEALS (any intake) Cholelithiasis o Most common biliary disorder o Gallstones o Stones made up of calcium, blood, & cholesterol Cholecystitis o Inflammation of gallbladder with cholelithiasis o Stones lodged in neck or cystic duct o Can be acute (remove stones) or chronic (remove gallbladder) o Risk factors: • 4 F’s Ø Female Ø Forty Ø Fat Ø Fertile • Aging • Race/ethnicity (fair skin) • Family history • DM • Prolonged TPN o Clinical manifestations: • Indigestion to severe abdominal pain • Initial symptoms Ø Pain in RUQ Ø Pain may radiate to right shoulder & scapula Ø Biliary colic Ø Biliary obstruction • Pain may be acute with diaphoresis, N/V, clay-colored stools • Attacks occur 3-6 hours after a heavy or high-fat meal or when lying down Ø Is it GERD, ulcer, gallbladder, pancreas issue...important to know onset & where pain is • Leukocytosis (possible infection) • Fever (possible infection) • Jaundice (build up of bilirubin) • Total obstruction (symptoms related to bile obstruction) Ø Steatorrhea Ø Pruritis (bile salts sit on skin) Ø Dark amber urine Ø Jaundice Ø Clay colored stools Ø Fever • •
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Symptoms of chronic cholecystitis Ø Fat intolerance Ø Dyspepsia Ø Heartburn Ø Flatulence Complications: • Abscessàstones can irritate & cause bleeding • Pancreatitis • Gallbladder rupture (if lodged in neck) Diagnostic tests: • Oral cholecystography (through ducts) • Ultrasound (show us stones or thickening of gallbladder wall • Hepatobiliary (HIDA) scan Ø Can have clots or false +/• Endoscopic retrograde cholangiopancreatography (ERCP) Ø Stents Ø Pull out stones • Percutaneous transhepatic cholangiography (PTC) Ø Not done as often Ø Local anesthetic, sedation, invasive • Increased bilirubin due to obstruction Management: • Medications Ø Analgesicàopioids (ie: Morphine & Dilaudid) Ø Antibiotics Ø Antiemetics • NPO until symptoms subside • Gastric decompression (NGT) • Weight reduction diet • Avoidance of fatty foods & fried foods (exacerbates symptoms or creates stones) • Laparoscopic Cholecystectomy (GOLD STANDARD) Ø Gallbladder removed through several small cuts Ø Usually resolves in ~ 1 week Ø Removed below umbilicus Ø Can have diarrhea & be on special diet after surgery • Traditional Cholecystectomy Ø Removal of gall bladder through a high abdominal incision • Cholecystectomy Ø Open gallbladder to remove stones, bile, or pus • T-Tube Ø Inserted into duct & connected to drainage Ø Ensures patency of duct until edema has subsided Ø Allows excess bile to drain while small intestine is receiving continuous flow of bile Ø Connect to drainage bag by gravity (drainage bag below gallbladder) Ø After surgery contents may be bloody, then yellow, green v Monitor drainage (color, consistency) v Monitor bag placement v Protect skin around it Ø Drains ~ 400 ml/day v REPORT if > 1,000 ml/day or sudden increase Ø Semi-fowler’s Ø Drainage will decrease as fluid begins to drain in duodenum Ø Never irrigate, aspirate, or clamp w/o HCP!!! •
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NUTRITION [7 Questions] § Malnutrition (geriatric syndrome) = faulty or inadequate nutritional status, undernourishment characterized by insufficient dietary intake, poor appetite, muscle wasting & weight loss § 40-60% of hospitalized adults are malnourished § 40-85% of nursing home residents are malnourished § 20-60% of home care patients are malnourished § Risk factors: o Dietary o Economicàproblem getting food o Psychological o Physiological factors o Frailty § Obesity o Demographics: • 1/3 of U.S. adults are obese • Highest among middle-aged adults (40-59 years old) § Nutrition-Related Changes Associated with Aging: o Decreased basal metabolic rate o Decreased taste (hypogeusia) & smell (hyposmia) § Can affect what they choose to eat § Many increase salt intake to improve taste…suggest other methods of seasoning o Decreased production of gastric acids (achlorhydria) o Diminished thirst sensation o May just not want to drink because they don’t want to have to keep getting up to go to the bathroom o Important to ask why they don’t want to drink o Decreased bone density & lean body mass o Decreased saliva production (xerostomia) o Increased cholecystokinin • Stimulates gall bladder to release bile, which leads to early satiety Ø Feeling full much faster w/o eating as much = limited intake § Dietary Reference Intakes (DRIS) for Older Adults: o Energy (calories) • Based on gender, age, BMI & activity level o Vitamin D • Over 70 = 600 IU/day • Sources: Ø Liver Ø Fortified milk Ø Fish liver oils o Calcium • Over 50 = 1,200 mg/day • Sources: Ø Milk Ø Yogurt Ø Sardines (with bones) o Vitamin B12 (cyanocobalamin)à risk for pernicious anemia • Sources: Ø Meat Ø Fish Ø Poultry Ø Dairy Ø Eggs Ø Fortified almond milk/cereal (for vegans) o Vitamin B6 (pyridoxine) • 1.5 mg/day (women) • 1.7 mg/day (men) • Sources: Ø Fortified cereals Ø Beans Ø Poultry Ø Fish Ø Some vegetables/fruits (dark leafy greens, papayas, oranges, & cantaloupe) o Want ½ food to be vegetables/fruit, ¼ meat, & ¼ whole grains (helps with constipation)…also plenty of fluids!
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Physical Examination: o Nutritional data • Height/weight/BMI • VS • Condition of tongue & lips o Beefy red? o Indicative of hydration status • Skin turgor, texture, & color o Palloràanemia o Jaundiceàproblems with gallbladder, liver, or pancreas • Functional abilities (ADLs/IADLs) • Overall appearance o Moon face, buffalo hump = Cushing’s, steroid use o Anthropometrical measurements • BMI • Waist to Hip Ratio Ø Should be ~ < 0.85 (women) & ~ < 0.95 (men) Ø If 1…concerned with obesity • Body Fat % Ø Females have a HIGHER % body fat than men • Girth (abdominal measurement) Assessment: o % Weight Changes (clinically significant) • > 5% x 1 month • > 7.5% x 3 months • > 10% x 6 months • Increased weight could be from HF or sometimes bad coping o BMI • < 19 = Underweight • 19-24.9 = Normal • 25-29.9 = Overweight • 30-35 = Class 1 Obese • 35-40 = Class 2 Obese • > 40 = Class 3 Obese • *BMI below 22 in older adults is predictive of malnutrition/mortality Biochemical Measurements: o CBC • H & Hàpossible anemia o Total lymphocyte count • Decreased WBCsàincreased risk for infectionàimportant to get vaccines o Thyroid level • Deals with metabolism o CMP • BMP plus albumin, BUN, creatinine, ALT/AST, and glucose o LFTs o Urinalysis • Elevated glucose? o Cholesterol o Hemoglobin o Visceral proteins • Albumin Ø < 3.5 g/dl = concerned • Pre-albumin Ø 19.5-35 mg/dl • Transferrin Ø 204-360 mg/dl Ø Could indicate iron deficiency anemia
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Screening: o Must be screened within 24 hours of admission • Mini Nutrition Assessment Ø Looks at intake, weight loss, mobility, disorders (mental or physical) & measurements Ø Higher the score = BETTER • Dietary Intake Assessment (24 hour recall, not always used) • Anthropometry (body measurements) Management: o Referral to dietician, pharmacist, or dentist o Improve intake: • Small, frequent meals/snacks • Make food appetizing/meal atmosphere • Ensure assistance available (if necessary) • Analgesicsàrinses can numb the mouth • Anti-emeticsàaddress nausea • Oxygenàchewing can prevent effective oxygenation (ie: COPD) • Conducive environment for mealàmake it a social event Ø If eating in room…first ask WHY • Alleviate dry mouth Ø Avoid caffeine, alcohol, tobacco, & foods that are spicy or acidic Ø Mouth/oral care o Specialized nutrition: • High calorie, nutrient dense (ie: Boost or Ensure)àusually prescribed by a registered dietitian, but also MD can write a script • Disease specialized • Can be cost prohibitive $$$ • Enteral Nutrition Ø Into GI tract (ie: NG tube, PEG tube, J tube, or EG tube) Ø “Tube feeding”/Artificial Nutrition Ø Swallowing issue Ø Temporary condition or critically ill Ø Will probably need to see a speech therapist to assess swallowing • Parenteral Nutrition Ø When GI tract NOT FUNCTIONING Ø Intravascular Ø Central Venous Line (ie: PICC line or central line) Ø Potential complications: v Infection/sepsis/death v Fluid imbalance v Electrolyte imbalance Special Considerations: o Dysphagiaàwhat exercises/treatment can we do to help with swallowing? o NPO ordersàmay even need NG tube to low suction o Dementiaàmay not realize eating/drinking, if they ay they are hungry = give them food
URINARY INCONTINENCE [5 Questions] § Involuntary loss of urine § NOT a normal part of aging § Transient or “”new onset” o Causes: “DIAPERS” • Delirium • Infection (ie: UTI, especially in women) • Atrophic Urethritis (issue with urethra that leads to inflammation & scarring = improper functioning • Pharmaceuticals (ie: Loop diuretics) • Psychologic • Excess Urine Output • Restricted Mobility • Stool Impaction (ie: constipation) o Address underlying cause/concern § Chronic o Stress Incontinence • Weakened external sphincter/pelvic floor • Increased intra-abdominal pressureàpush through weakened pelvic floor & sphincter, which causes leakage • Small urine loss during sneezing, laughing, or exercise • Most common in women < 60 OR men after prostate surgery o Urge Incontinence • Destrusor instability • Internal sphincter weakness (right where bladder goes into urethra) • Overactive bladder • Loss of large amount of urine • Most common in older adults (mainly men) o Overflow Incontinence • Bladder muscles overextended & have poor tone • Overflow of retained urine • “Dribbling” or constant losses of small amount of urine (nowhere to put it in the bladder anymore) • Most common in those with DM, men with enlarged prostates, & those on ACE inhibitors or anti-cholinergics o Functional Incontinence • Physical or psychological factors (ie: dementia) impair ability to get to the toilet Ø Older adults unable to transfer from wheelchair to toilet Ø Those with walking aids take too long to get to the bathroom (void on floor) • Common in frail elderly, nursing home residents, & those with dementia o Mixed = combination of a few types § Management: o History • How does it impact their quality of life??? o Physical assessment • • • •
Bladder distention (palpate right above suprapubic) Bladder scans (look for residual volume in bladder, may need straight catheter) Bowel sounds (obstructions can lead to new onset urinary incontinence) Pelvic & rectal exams (DRE) by provider (look at muscle control, or feel for impaction)
Surgery § Used to elevate urethral position and/or bladder neck § Artificially open & close urethra o Prevent complications such as skin breakdown or UTIs o Psychosocial support o Continence clinics Diagnostic tests: o Labs • UrinalysisàUTIs? • Prostate-specific antigenàprostate issues o Imaging (rare)àdone when having significant issues • Voiding cystourethrogram (stress incontinence) o
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Fill bladder with dye During imaging (continuous)àhave cough or sneezing to see if leakage or have void & stop to see if able to without leakage
Other urodynamic studies Ø Ø Ø
-oscopy Bladder pressure Flowmetry
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Treatment: o Lifestyle modifications • Smoking cessation • Weight reductionàextra pressure on bladder • Bowel managementàprevent constipation of impaction • Caffeine reduction • Alcohol reduction • Avoid other “bladder irritants” (ie: carbonated beverages, high-spicy foods, artificial sweeteners, citrus fruits/juices, and dairy) • Appropriate fluid intake o Scheduled Voiding Regimens • Timed voidingàgood for stress incontinence or for men after prostate surgery • Prompted voidingàask if they have been to bathroom, good for those with dementia • Bladder trainingàincreasing length of time b/w voiding once pelvic floor muscles get stronger o Pelvic floor muscle strengthening • Kegel’sàcontraction & hold, have stop flow of urine • Biofeedback • Electrical stimulation o Anti-incontinence devices • Pessariesàinside vagina & pushed down on internal sphincter & prevents leakage, when going to bathroom it needs to be released • Condom cathetersàissue is hard to keep in place • External clamps • Urethral plugs o Supportive devices • Elevated toilet seats • Gait training • Modified clothing • Absorbent pads or undergarments • Bedside commode o Medications • Anticholinergics (urge incontinence-overactive bladder) o Ie: oxybutynin (Ditropan) • Topical estrogen (for women with stress incontinence)
ORAL HEALTH [5 Questions] § Poor oral hygiene associated with increased incidence of pneumonia § Many medications cause dry mouth, which increases risk of dental caries § Diabetic glucose control is worse in the presence of periodontal disease & periodontal disease is worse in diabetics with poor glycemic control § Poor oral health is a common cause of weight loss & failure to thrive § Common age-related changes: o Gingival recession • Need for proper flossing & brushing • This in itself won’t lead to tooth loss, but will lead to periodontal disease (which can lead to tooth loss) o Worn incisal edges & yellowing § Prevention of Oral Disease: o Patient steps: • Good oral hygiene Ø Brush at least 2x/day with soft toothbrush Ø Focus on area where tooth meets gum Ø Electric toothbrush for best resultsàbreaks up plaque better & it does the “work” for those who can’t Ø Floss regularly • Keep dentures clean • Avoid sugary snack & drinks • Avoid alcohol & tobacco • Use fluoride toothpaste o Provider steps: • Encourage regular dental visits • Assist patients in accessing care • Minimize medications with oral effects (ie: Dilantin, steroids) • Consider high content fluoride toothpastes for patients at high caries riskàbut keep in mind NOT GOOD FOR DENTURES! • Assistive devices & guidance should be considered for patients & caregivers…many patients have problem maintaining their own oral hygiene (especially stroke, arthritis, & dementia) § Denture Care: o Overnight saliva decreases & bacterial count increases • This can lead to denture stomatitis, redness, & irritation of the palatal tissue Ø Can also occur from bad denture hygiene because plaque & calculus collects on dentures just like natural teethà increased risk for infection o Should be removed at night o Brush with liquid hand soap, dishwashing liquid, or denture cleaning paste • AVOID regular toothpasteàmay damage finish o Soaked overnight in a cup of water or denture cleaner § Gingivitis: o Etiology: • Plaque buildup • Changes in hormone levels • Oral foreign bodies • Gum inflammation (but no destruction of periodontal ligament or bone) o Symptoms: • Tenderness • Erythema • Bleeding gums o Treatment: • Good oral hygiene • Routine dental visits § Periodontitis o Chronic plaque exposure = leads to inflammation, which leads to destruction of periodontal ligament o Loss of supporting bone o Tooth loosening & loss o Treatment: • Good oral hygiene • Routine dental visits • Tobacco cessation & POT • Dental referral for deep root scaling • Oral antibiotics • Topical solutions (ie: chlorhexadine)
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Xerostomia o Dry mouth due to decreased salivary flow o Common in elderly o Medications are typical cause • Anti-psychotics • Anti-cholinergics • Anti-histamines • Diuretics • Pain medications • Muscle relaxants • “BEERS” criteria o Common in patients who have rheumatic disease, Sjorgen’s syndrome, & after radiation therapy o Saliva most important protection against caries • Increases risk for caries & periodontal disease o Avoid irritants such as alcohol, caffeine, & smoking o Avoid sugary candies/drinks o Encourage sips of water, especially during eating o Sugarless gum/mints o Saliva substitutes (ie: Biotene) o Salivary stimulants (ie: pilocarpine) o Prevent caries & periodontal disease • Meticulous oral hygiene • Increased strength topical fluorides Oral-Systemic Linkages: o Nutrition • Decreased intake can lead to malnutritionàlow H & H, weight loss, low BMI, low albumin o Diabetes o Osteoporosis • Poor calcium, vitamin D, jaw is BONE, lose teeth = less intake o Aspiration pneumonia o Vascular disease • Poor perfusion = decreased oral health o Dementia
CANCER CARE [5 Questions] § Common cancers in the U.S. o Bladder Cancer o Breast Cancer o Colon and Rectal Cancer o Endometrial Cancer o Kidney Cancer o Leukemia o Lung Cancer o Melanoma o Non-Hodgkin Lymphoma o Pancreatic Cancer o Prostate Cancer o Thyroid Cancer § Consequences of Cancer: o Reduced immune and blood-producing function • RBCs, WBCs, & platelets v Increased risk for infection v Anemia (pale, tired, cold, severe SOB, tachycardic) o Altered GI structure and function • Small bowel obstruction, constipation o Motor and sensory deficits • Gait abnormalities = increased risk for falls • Decreased functioning (ADLs/IADLs)àhygiene (may already be at risk for infection), nutrition, incontinence o Decreased respiratory function • Atelectasis & pneumonia § Treatment: o Surgery (oldest form of treatment) o Radiation • Destroys cancer cells with minimal damaging effects of surrounding normal cells • Side effects: Ø Vary according to site Ø Local skin changes and hair loss v Likely permanent depending on total absorbed dose Ø Altered taste sensations v Sores in mouth Ø Fatigue related to increased energy demands v May have anemia as a response Ø Inflammatory responses that cause tissue fibrosis and scarring v Anytime we destroy cells we will have an inflammatory response v Can have internal scarring as well, possible adhesions in bowel • Nursing care: Ø Teach accurate objective facts to help patient cope Ø Do not remove markings Ø Administer skin care Ø Use lotions to protect skin according to department policy Ø Avoid direct skin exposure to sunlight Ø Care for xerostomia v Biotene (increase saliva production) v Meticulous oral care v SHOULD NOT USE: anything containing alcohol, hard toothbrushes, sugary candy, glycerin swabs or lemony stuff Ø Bone exposure to radiation more vulnerable to fracture o Teletherapy • External o Brachytherapy • In the body, in tissue or body cavity) • Limit time, clutter care (get as much done at one time) • Rotate staff • Badge on scrubs can notify us if we are getting too much exposure to the radiation • People can only visit for short periods of timeàmay need to address their isolation • If want to clean themselves avoid rubbing off the “X” o Chemotherapy • Treatment of cancer with chemical agents
Major role in cancer therapy Cures and increases survival time Some selectivity (for cancer cells, but can affect other cells) Normal cells most affected — skin, hair, intestinal tissues, spermatocytes, blood-forming cells Ø GI tractà irritate GI tract & increase motilityà N/V, diarrhea Ø Increased risk for infection & bleeding • PPE must be used when administering oral or IV chemotherapy! Ø Gown Ø Gloves Ø Prevent it from getting anywhere on you! • Extravasationà PREVENTION IS KEY! Ø Leaking into the tissue • Nursing care: Ø Infection risk v Low WBC v Neutropeniaàneutropenic precautions (mask) Ø Chemotherapy-induced nausea and vomiting (CINV) Ø Mucositis v Mouth sores Ø Alopecia v Temporary or permanent (usually not permanent, but hair may grow back differently Ø Changes in cognitive function v Especially in older adults v Worried about safety Ø Peripheral neuropathy v Numbness, tingling in extremities v Chemotherapy can affect perfusion Antiemetic Therapy: o Drug combinations are individualized for best effect • Ondansetron (Zofran) • Granisetron (Kytril) • Granisetron transdermal (Sancuso) • Dolasetron (Anzemet) • Palonosetron (Aloxi) • Be careful with patches o Rotate sight o Be careful around others (exposure) o Clean & dry skin before putting patch on o Only 1 patch should be on the body at one time Hormonal Manipulation: o Some hormones make hormone-sensitive tumors grow more rapidly o Some tumors require specific hormones to divide; decreasing the hormone amounts to hormone-sensitive tumors can slow cancer growth rate Oncologic Emergencies: o Sepsis • Antibiotic therapy • Possible fluid resuscitation o Disseminated intravascular coagulation (DIC) • Petechiae • Risk for bleedingàusing up clotting factors • Still need to anti-coagulate them, but giving them factors to clot o Collaborative management: • Prevention (best measure) • IV antibiotic therapy • Anticoagulants • Cryoprecipitated clotting factors (treat it like giving blood) o V/S • • • •
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SIADH: o Most commonly found in carcinoma of the lung o Water is reabsorbed to excess by kidneys; put into system circulation o Not peeing enough o Collaborative care: • Patient safety • Restore normal fluid balance Ø Possible fluid restriction Ø Monitor electrolytes Ø Monitor urine output Ø Monitor weight Ø Can have edemaàrisk for skin breakdown • Supportive care Spinal Cord Compression: o Manifestations depend on where the spinal cord in compressed o Possible lower extremity weakness o Respiratory difficulty o Collaborative management: • Early recognition and treatment • Palliative • High-dose corticosteroidsàreduce inflammation, which could further exacerbate compression • High-dose radiation • Surgeryàneurosurgeon to remove it • External back or neck braces to reduce pressure in spinal cord Hypercalcemia: o Occurs most often with bone metastasis o Fatigue, loss of appetite, nausea and vomiting, constipation, polyuria, severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, ECG changes o Collaborative management: • Oral hydrationàdiluting Ca+ & increasing urine output to remove it as well • Normal saline IV • Drug therapy • Dialysisàif damage to kidneys • ECG changesàshortens QT intervalàVfib (lethal/cardiac arrest) Superior Vena Cava Syndrome: o Superior vena cava compressed or obstructed by tumor growth § If blood backs up early sign is arm edema § Later stagesàfacial edema o Can lead to painful, life-threatening emergency o Potential compression of the trachea o Signs: • Facial edema • JVD • Stokes’ sign • Edema of arms and hands § Dyspnea not getting blood back to heart = bad oxygenation = difficulty breathing = tachycardic • Erythema • Epistaxis o Collaborative management: • High-dose radiation therapy • May need to de-bulk • Metal stent in vena cava Ø Larger stent (temporary or permanent) v Anticoagulants
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Tumor Lysis Syndrome: o Large numbers of tumor cells destroyed rapidly, results in intracellular contents being released into bloodstream faster than the body can eliminate them • Too much potassium may come out of these ruptured cells (hyperkalemia)àworried about dysrhythmias • A lot of purines & acids in bodyàincreased uric acid buildup which can damage kidneys (ARF) & may need dialysis o Most common in blood related cancers o Collaborative management: § Prevention • More to prevent ARF not so much the actually tumor lysis • Proactively prevent the complications that can arise § Hydration (oral or IV) • Flush uric acid through kidneys (3 ml/day) § Drug therapy • Lasix (gets rid of K+) • Prophylactic calcium FRAILTY & HAZARDS OF HOSPITALIZATION [5 Questions] § Healthy People 2020àincrease proportion of older adults with one or more chronic health conditions who report confidence in managing their conditions § Frailty: o Dependence in 1 or more ADLs o Three or more comorbid conditions o One or more geriatric syndromes (delirium, incontinence, falls, pressure ulcers, gait disturbance) o The frail, older adult displays 3 or more of the following: • Unplanned weight lossànot getting adequate nutrition • Weakness • Poor endurance and energy • Slownessàcan be cognitively as well • Low activity • Geriatric syndromeàdelirium, incontinence, falls, pressure ulcers § Cascade Iatrogenesis: o Initial medical intervention triggers a series of complicating events o Cascade of decline o May be irreversible o Risk factors • Older • More functional impairment • Higher acuity on admission o Iatrogenic cascades have been found to occur most frequently among the oldest, most functionally impaired patients and those with a higher severity of illness on admission o Nurses must recognize their critical role in preventing iatrogenic complicationsàthe nursing staff’s ability to recognize subtle changes and to proactively intervene to keep older patients safe while hospitalized is critical o ACE units (specifically for older adults)àto prevent cascade from occurring § Dysfunctional Syndrome:
NEUROLOGIC ALTERATIONS [5 Questions] STROKE § Early detection is important! o Faceàdrooping o Armàpronator drift on contralateral side (lift arms & if one drops) o Speech o Time § Risk factors: o Modifiable • High BP • Smoking • DM • Heart disease • PAD • Poor diet • High cholesterol • Physical inactivity • Atrial fibrillationàstasis of blood in left atrium, can clot & lead to clot in brain • Periodontal diseaseàpoor dental hygiene o Non-modifiable • Age • Gender (females) • Family history • Race (African Americans) • Prior TIA/Stroke o Other • Geographic location (stress, culture, race/ethnicity, rural vs. urban setting) • Alcohol abuse • Drug abuse • Socioeconomic status (access to care/appropriate medications) o Hemorrhagic Stroke • Uncontrolled HTN • Ruptured aneurysm (usually bilateral) o Drugs (ie: cocaine, meth) • Arteriovenous malformation (AVM) o Blood vessels are tangled o Diverts blood from arteries to the veins § Types: o Ischemic stroke • Caused by embolism, infarction & thrombosis • Atrial fibrillation most frequent cause o Hemorrhagic stroke • Bleeding into the parenchyma • May be followed by clots • Caused by HTN, ruptured cerebral aneurysm or AVM • Blood sitting on brain tissue can lead to inflammation= swelling • Increase blood volume in the brain • Brain, blood, and CSF…if there is an increase in 1 of these= increased ICP o Warning signs • Sudden numbness/weakness of face, arm or leg (especially 1 side) • Sudden confusion, trouble speaking or understanding • Sudden trouble seeing in one or both eyes • Sudden trouble walking, dizziness, loss of balance or coordinationàcould have messed up vestibular apparatus in the ear • Severe headache with no known causeàusually hemorrhagic o TIA • “Mini-Stroke” • Warning sign of impending stroke • Neurological deficits lasting LESS than 24 hours
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NIH Stroke Scaleàperson should be certified to administer this 7 Ds of Stroke Care 1. Detection 2. Dispatch (call 911, get them assessed, in right away) 3. Delivery (get them where they need to go) 4. Door 5. Data (determine type of stroke… determines what medications are used) 6. Decision 7. Drug administration § Broca= expressive aphasia § Wernicke= receptive aphasia Nursing assessment (Stroke) § Common mistakes o Failure to adequately stimulate patient for best response o Inadequate history of PT baseline o Failure to check blood glucoseàcan mimic signs of stroke Diagnostic tests (Stroke) § CT Scan/MRI o Hemorrhagicàblood seen o Ischemicàdarker areas than brain tissue will show up Nursing management (Stroke) § Endovascular intervention § Drugs o Recombinant tissue plasminogen activators (rtPA)àstrong clot buster • Only for ischemic strokes • Give within 3 hours of incident • Contraindications: Ø Trauma/blow to head in last 3 months Ø Surgery, especially abdomen Ø Hemorrhagic stroke Ø > 80 years old Ø Caution in those with anticoagulants Ø Uncontrolled HTN Ø Low blood sugar o Anticoagulation (Aspirin)àworry about GI bleeds, ulcerations o Anti-hypertensivesàmore long term, don’t want to decrease BP too much because they may need that to actually perfuse the brain o Steroidsàto reduce edema o Anti-epileptic drugs (AED)àhypermetabolic o Anti-anxiety § Ischemic= need to open up that blood vessels § Angiography to clear out clot if can’t give rtPA, balloon, etc. Ø Risk of breaking off clot & causing stroke § Range of motion is important § Positioning: prevent foot drop, reduce tendency toward external rotation of hip & knee flexion deformity § Slings & splints for effected extremitiesàprevent subluxation of shoulder § Hand/legs splintsàto prevent contractures § OT/PT § Rehab ASAPàmost gains in first 3 months
Nursing priorities (Stroke) § ABCs! § LOC (Glasgow Coma Scale) o Eye Opening • Spontaneous (4) • To voice (3) • To pain (2) • None (1) o Best Verbal • Oriented (5) • Confused (4) • Inappropriate words (3) • Incomprehensible words (2) • None (1) o Best Motor • Obeys commands (6) • Localizes pain (5) • Withdraws to pain (4) • Flexion to pain/Decorticate (3)àcerebral hemisphere dysfunction • Extension to pain/Decerebrate (2)àbrainstem dysfunction • None (1) o Lowest = 3 o Highest = 15 § ICP o Early indicators • Change in LOC • Papilledema • Slurring of speech • Delay in response • Vomiting o Late indicators • Further decrease in LOC • Cushing’s triad 1. Increasing SBP with widening pulse pressure 2. Bradycardia 3. Altered respirations • Pupil changes • Altered respiratory patterns • Posturing § Abnormal pupil responses o Nonreactive midpositionàdamage to midbrain o Nonreactive pinpointàpons lesion or opiate drug overdose o Small but reactiveàbilateral injury to thalamus or hypothalamus; metabolic coma o Unilateral nonreactive and dilatedàcompression of occulomotor nerve (CN-III) • Ipsilateral to lesion o Bilateral dilation and nonreactiveàsevere anoxia or ischemia (certain drugs can cause: atropine, epinephrine § Altered cerebral tissue perfusion o Cardiac monitoring o BP monitoring o Glucose monitoring o Oxygen o HOB 30 degreesàhelps with pressure inside brain o Maintain fluid & electrolyte balance • Sodium is main electrolyte we worry about • Protein pulls wateràhigh blood volume expands vascular component • Hypertonic saline to pull water off the brain or Mannitol (but wouldn’t give if low blood volume) o Avoid procedures that increase oxygen demand (ie: suctioning) § Emotionally liable o Cry easily o Support family o Could happen from where stroke happens in the brain o Behavioral changesàfrontal
PARKINSON’S DISEASE § Resting tremor § Bradykinesiaàslowness of movement § Rigidityà cogwheeling § Postural instabilityàleaning forward, disturbed balance § Loss of flexibility § Aching § Fatigue § Sleep disturbances § Drooling, sweating, weight loss § Orthostatic hypotension § Depression, dementia, psychosis, personality changes § Micrograhpia (very small handwriting) § Good way to diagnose PDàif dopamine makes symptoms better § Risk factors o Age o Family history & genetics o Race/ethnicity (Caucasian) o Gender (male) o Declining estrogen levels o Agricultural work o Head trauma § Preventive measures? o Smoking o Alcohol o High cholesterol o High caffeine intake (GUYS WE’RE GOOD! J) § Types o Idiopathic PD • No identified cause • Insidious onset o Acquired “Parkinsonism” • Caused by infection, drug toxicity (ie: Haldol), or trauma Diagnostic tests (PD) § Medical history & clinical featuresàno disease specific biological marker § Positon Emission Tomography (PET) or Single-photon Emission Computed Tomography (SPECT) with dopaminergic radioligands § Rule out secondary causes Treatment (PD) § Levadopa o Most effective, but less effective over time o Long term use= high risk of dyskinesias (involuntary movement/spasm) § Dopamine agonists o Less effective o Less likely to cause dyskinesias o Frequently causes troubling side effects § COMT inhibitors, Dopamine Releaser, MAO-B Inhibitor § Dopamine does not cross the blood brain barrier SEIZURE § Clusters of nerve cells in the brain signal abnormally, which may briefly alter LOC, movement, or actions § Two or more unprovoked (primary) seizures § Provoked (secondary) seizures o Brain tumor o Metabolic disorder o Acute alcohol withdrawal o Electrolyte disturbance o High fever o Stoke o Head injury o Substance abuse o Heart Disease o Treat underlying cause & give anti-seizure medications
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Generalized Seizures o Tonic-clonic aka Grand malàfall to floor, jerking, shaking o Absence o Myoclonic o Atonicàcollapse to floor, complete loss of muscle tone, may have helmet on, worry about falls & head injuries § Partial Seizures o Simple • Remain conscious • May have an aura • May spread • May be sensory • Can be muscle related o Complex • Loss of consciousness (eyes still may be open) • Syncope • Safety risk, may do something they aren’t aware of Nursing interventions (Seizures) § Padded bed rails § Place on side to prevent aspiration § Stay with patient § Monitor for status epilepticus o Prolonged seizure (> 5 minutes) or keep seizing over 30 minutes o Medical emergency! o Notify HCP o Will burn up all sugar in the brain o Lorazepam (Ativan) o Have suction equipment available o Monitor vitals o Provide oxygen Seizure documentation § When seizure started § Body part 1st involved § Changes in pupil size or eye deviation? § Changes in LOC? § Presence of apnea, cyanosis, salivation? § Incontinence? § Movement/progression of motor activity? § Tongue or lip biting? § When seizure ended *Medical management (Seizures) § For all types of seizures o Divalproex (Depakote) • All seizures • Therapeutic range: 50-100 mcg/ml • Side effects: Hair loss, tremor, increased liver enzymes, bruising, & N/V o Valproic acid (Depakene) • All seizures • Therapeutic range: 50-125 (total), 6-22 (free) • Side effects: Hair loss, tremor, increased liver enzymes, bruising, & N/V o Phenytonin (Dilantin) • All types of seizures EXCEPT absence, myoclonic, & absence • For status epilepticus • Therapeutic range: 10-20 mcg/ml, 1-2 mcg/ml (Free) • Low= seizures • High= toxicity • Side effects: Gingival hyperplasia o Worry about toxicity o Must taper off o Can have GI issues & exacerbate depression
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For partial & general tonic-clonic seizures o Carbamezapine (Tegretol) • Partial or generalized tonic-clonic seizures • Therapeutic range: 4-12 mg/L • Side effects: H/A, dizziness, diplopia, blurred vision, N/V, & leukopenia o Phenobarbital (Barbita) • Generalized tonic-clonic seizures or partial seizures • Therapeutic range: 10-40 mg/L • Side effects: Sedation, overdose can be fatal, monitor for drowsiness, sleep disturbances, cognitive impairment, & depression o Primidone (Mysoline) • Partial seizures, tonic-clonic seizures • Therapeutic range: 5-10 mg/L • Side effects: Monitor for vertigo & lethargy HEAD INJURY § Traumatic Brain Injuryà#1 cause of death in those < 40 years old § Causes: o MVCs o Falls (older adults) o Firearms o Assaults o Sports-related o Recreational accidents § Primary Head Injury (what actually happened) o Contusions, hematomas, shearing injuries, diffuse white matter injuries, & lacerations to the brain § Secondary Head Injury (happened as a result of the primary ie: inflammation) o Contributes to further brain injury o Exacerbation from hypoxia, hypercapnia, systemic HTN, intracranial HTN, ischemia, age, previous medical history o Hypertonic salineàprevents secondary injury, monitor sodium & serum osmolarity § Mechanism of Injury o Acceleration/Deceleration • Acceleration Ø Stationary brain is suddenly & rapidly moved in 1 direction along linear path Ø Brain doesn’t move as fast, hits front of head • Deceleration Ø Brain stops rapidly in the cranial vault, as skull ceases movement, the brain continues to move until hits skull Ø Head stop, brain keeps moving • Coup-contrecoup Ø Acceleration & deceleration Ø Coupàaffects cerebral tissue directly under point of impact Ø Countrecoupàoccurs in a line directly opposite the point of impact o Rotational • Force impacting head transfers energy to brain in a non-linear fashion • Shearing forces exerted throughout brain • Brain itself may twist o Penetrating • Foreign object invades the brain • Most common is gun shot wounds § Skull Fractures o Linear skull fractures • Minor traumatic injury • Diagnosed by CT scan • Not life-threateningàheals overtime without intervention o Depressed skull fractures • May be visible & palpable • May tear meninges of brain & extend into brain tissue • Surgical repair of fracture & meninges • May have to evacuate hematoma • Pain & neurological assessment q1h
Open/Compound skull fractures • Depressed skull fracture with scalp laceration • Risk for infection (skin is broken, bone is protruding) • Surgical repair & debridement of wound • Pain management, antibiotics o Basilar skull fractures • Fracture of 1 of the bones that make up base of skull • Periorbital ecchymosis (raccoon eyes) • Mastoid ecchymosis (Battle’s sign)àblood behind ears • Facial nerve paralysis • Otorrheaàleakage of CSF from ear • Rhinorrheaàleakage of CSF from nose • Dextrostix or Tes-Tape Strip Ø See if glucose is present Ø Halo/ring signàblood moves to center & yellow ring encircles blood if CSF present • Medical management Ø Allow CSF to drain & dura close on its own Ø Surgery if not healed in 1-2 weeks • Nursing management Ø Neurological & pain assessment Ø Monitor for infectionàif leaking CSF, gives access for something to work its way up Ø Change dressings with aseptic technique Ø Cotton to absorb CSF leak/raise HOB to decrease CSF pressure (help to drain) Epidural Hematoma o Between dura mater & skull from high impact to temporal areas of brain o 90% associated with linear fracture o Classic presentation: • Brief loss of consciousness • Followed by AOx3 • Loss of consciousness again o Surgical evacuation of hematomaàget rid of blood o Nonreactive & dilated pupil on side of injury= EMERGENCY Subdural Hematoma o Between dura & arachnoid layers o Typically venous injury o Types: • Acute SDH Ø < 48 hours from injury Ø Often associated with sudden deceleration injuries (ie: MVCs) Ø Manifestations o Drowsiness o H/A o Confusion o Slowed thinking o Agitation • Sub-acute SDH Ø 48 hours to 2 weeks from injury Ø Rare & harder to detect, education important Ø Neurological deterioration does not occur for days/weeks • Chronic SDH Ø > 2 weeks from injury Ø Usually from low impact injury Ø Manifestations o H/A o Lethargy o Projectile vomiting o Seizures o Pupil changes o Hemiparesis Ø Subdural drain placement Ø Surgical evacuation of hematoma Ø Monitor LOC Ø Pain management o
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Subarachnoid Hematoma o Between arachnoid layer of meninges & the brain o Common in severe brain injuries (ie: aneurysm) o Nuchal rigidity & headache o Placement of an intraventricular catheter & monitor ICP o Look at quantity & color of CSFàmay have blood in it § Intracerebral Hematoma o On brain itself o Hemorrhagic stroke o Accumulation of blood in the brain parenchyma o From uncontrolled HTN, ruptured aneurysm, or trauma o Manifestations • H/A • Decreasing LOC • Dilation of one pupil • Hemiplegia o Medical management • Manage ICP (Normal: 7-15 mmHg) • Elevate HOB • Hypertonic saline, Mannitol, protein • Manage oxygen • Manage carbon dioxide in blood § Complications of Closed Head Injury o Diabetes Insipidus (DI) • > 200 cc/hr., losing too much urine • Pressure on pituitary gland & loss of ADH secretion • Dilute urine • Increased serum sodium • Treatment Ø Vasopressinàantidiuretic to decrease urine output Ø If improving…will have decreased urine output & increased specific gravity o SIADH • Excess secretion of ADH • Oliguria • Concentrated urine • Decreased serum sodium • Increased ICP • Treatment Ø Fluid restriction o Cerebral Salt Wasting (CSW) • State of hypovolemia with low sodium & urine osmolality • Often mistaken for SIADH • SIADH is too much fluid, CSW is low fluid • Treatment Ø Sodium replacement o Herniation • Brain pushes through foramen magnum o Seizures • Irritation in brainàanti-seizure medications NORMAL PRESSURE HYDROCEPHALUS (NPH) § Accumulation of CSF, causing ventricles of brain to enlarge § Stretches the nerve tissue of the brain causing gait disturbance, dementia or forgetfulness, & urinary incontinence § Diagnostic tests o CT or MRI o Clinical assessment § Treatment o Shunt o PT to regain lost function
RESPIRATORY ALTERATIONS [5 Questions] § Decrease in # of alveoli as we age § Alteration in shape of alveoliàincreases AP diameter § Decreased elastic recoil due to stiffening of elastin & collagen connective tissue § Chest wall stiffness § Arteriosclerosis § Loss of muscle tone § Increase in thoracic rigidity § Change to spine (ie: kyphosis)àcompresses thoracic cage, can’t expand to breathe as well § Factors that lead to lung problems: o Age o Exposure to pollutants o Cigarette smokingà4-5 years of not smoking will bring lungs back to almost normal o Comorbidities ASTHMA: § Reversible airflow obstruction & wheezing § Want to consider older adults change in sensitivity of beta-adrenergic receptors o Bronchoconstriction/dilation o Beta 2 receptor agonists may not be beneficial § More common in women § Type 1 hypersensitivity reaction o IgE triggers histamine release from mast cells § Onset in early life (often childhood) § Symptoms may vary day to day § Symptoms may worsen at night/early morning § Family history of asthma § Allergy, rhinitis and/or eczema also present § Clinical manifestations: o Audible wheezeàinitially on expiration…if getting worse will hear on inspiration o Increased RR o Increased coughàif getting worse sputum would come up (white/thick)…possibly blood if coughing hard enough o Use of accessory musclesàto produce more space for oxygen or to expel air o Retractionsàtrying to breathe air in…making negative space o “Barrel chest” from air trapping o Long breathing cycleàquick intake, but long to get air out o Cyanosis o Hypoxemia § Diagnostic tests o ABGs • Decreased O2 • Decreased CO2 level early & increase lateràpoor gas exchange • pH: 7.35-7.45 • CO2: 35-45 • HCO3: 22-26 • O2: 80-100 • Respiratory Acidosis: elevated pCO2 due to ventilation depression • Respiratory Alkalosis: depression of pCO2 due to alveolar hyperventilation • Metabolic Acidosis: depression of HCO3 or an increase in non-carbonic acids • Metabolic Alkalosis: elevated HCO3 due to excessive loss of metabolic acids o Allergic asthma will have elevated serum eosinophil count & IgE levels o Sputum with eosinophils & mucus plugs with shed epithelial cellsàfrom coughing o Pulmonary Function Tests • Forced vital capacity (FVC) • Forced expiratory volume in the first second (FEV1) • Peak expiratory flow rate (PEFR) § Management o Patient education important! o Peak flow meter should be used twice a day daily o Want to rinse mouth after steroidsà prone to thrush
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Treatment o Anti-inflammatory agents: • Corticosteroids • Leukotriene antagonists • Immunodulators o Rescue • Short-acting beta 2 agonists Ø Salbutamol • Anti-cholinergic Ø Atrovent o Preventive • Inhaled corticosteroids Ø Fluticasone • Long-acting beta 2 agonists (LABA)àgive first…this will open up airway so steroids are more effective Ø Salmeterol • Leukotriene receptor antagonist (LTRA) Ø Singulair (pill) o Other • Theophylline Ø Less effective & less well tolerated than long acting bronchodilators Ø Can reduces exacerbations • Cromolyn • Omalimuzab • Stabilize mast cells, which stop release of histamines o Administration • Metered dose inhaler (MDI) • Dry powder inhaler (DPI) • Autohaleràgoes in with breath o Exercise (ie: swimming) & activityàpromotes ventilation & perfusion o Oxygen therapy Status Asthmaticus o Severe, life-threatening, acute episode of airway obstruction o If not reversed patient may develop pneumothorax and cardiac or respiratory arrest o Clinical manifestations (that asthma attack worsening) • Cyanosis • Inspiratory wheezing • Altered LOC • Use of accessory muscles • Check ABGs or O2 saturation o Treatment • IV fluids • Potent systemic bronchodilator • Steroids • Epinephrine • Oxygen Bronchospasm & dyspnea Tissue damage is not reversible & increases in severity…eventually respiratory failure Leading cause of morbidity & mortality worldwide Associated with significant economic burden Onset in mid-life Symptoms slowly progress Long smoking history Risk factors: o Cigarette smoking • Smoking cessation! Ø ASK Ø ADVISE Ø ASSESS Ø ASSIST Ø ARRANGE
Alpha 1 antitrypsin (AAT) deficiency • Helps breakdown enzymes around alveoli • If not working they will breakdown alveoli = emphysema at younger age with no PMH of smoking o Air pollution o Gender o Age o Respiratory infections o Socioeconomic status o Asthma/bronchial hyperreactivity o Chronic bronchitis Emphysema o Loss of lung elasticity o Hyperinflation of the lung o Dyspnea o Increased RR o Decreased expiratory phase = can’t get as much air in = decreased expiratory even more…and so on o Air trappingàdue to loss of elastic recoil in alveolar walls, overstretching, & enlargement of the alveoli into bullae, & collapse of small airways (bronchioles) o Clinical manifestations • “Pink Puffer” • Pursed lip breathingàexhale slowly, help expand to get air out that’s “deep down” • Dyspnea • Hyperessonance on chest percussionàdue to air trapping • Orthopnea • Barrel chest • Prolonged expiratory time • Speaks in short, jerky sentences • Anxious • Use of accessory muscles • Thin appearance • Tripod positioning Chronic Bronchitis o Inflammation of the bronchi & bronchioles caused by chronic exposure to irritants, especially tobacco smoke o Inflammation, vasodilation, congestion, mucosal edema, & bronchospasm o Affects only the airways NOT the alveoli o Production of large amount of thick mucus o Hard to get rid of air on way out due to blockage o Clinical manifestations • “Blue Bloater” • Cyanotic • Recurrent cough & sputum production • Hypoxia • Hypercapnea • Respiratory acidosis • Increased hemoglobin (secondary polycythemia) • Increased RR • Dyspnea or exertion • Increased incidence in heavy cigarette smokers • Digital clubbing • Cardiac enlargement • Use of accessory muscles • Leads to right-sided heart failure Complications o Hypoxemia o Acidosis o Respiratory infections o Lung cancer o Diabetes o Osteoporosis o Cardiac failure, especially cor pulmonale (hypertrophy/right-sided heart failure) • Air trapping = taking up more space = more resistance = more pressure = R ventricle working harder to pump blood o
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Cardiac dysrhythmias • Hypertrophy of heartàincreases distance electrical conduction has to travel o Ventilation failure (not getting air in/out) o Oxygenation failure (not getting O2 to blood) o Or Combination o Anxiety & depression Diagnostic tests o Dyspnea assessment tool o ABGs o Sputum samples (culture & sensitivity, infection?) o CBC (hemoglobin/hematocrit) o Serum electrolyte levels (dilutional hyponatremia) o Serum AAT levels (Alpha 1 Antitrypsin deficiency?) o Chest x-ray o Pulmonary function test o Spirometry: required to establish diagnosis • Should be performed after administration of dose of short-acting inhaled bronchodilator to minimize variability • FEV1/FVC < 0.70 confirms airflow limitation • 2 or more incidences that FEV1 < 50% OR 1 + hospitalizations for COPD exacerbations = HIGH RISK Treatment o Pulmonary rehab • Incentive spirometer 10x/hour • Chest physiotherapy • Hydrationàif not fluid overloaded • Exercise o Beta-adrenergic agents o Cholinergic antagonists o Methyxanthines o Corticosteroids o Mucolyticsàto get mucus out o Want to stop Robitussin or any other cough suppressants…stop cough, which will prevent them from removing secretions o Lung transplantationàfor end-stage • Large midline incision or a transverse anterior thoracotomy Management o Ineffective breathing • Breathing techniques • Positioning to help alleviate dyspnea or drainage • Energy conservationànot doing too much at one time Ø Encourage patient to pace activities Ø Do not rush through morning activities Ø Gradually increase activities o Ineffective airway clearance • Possible suctioning • Controlled coughing • Chest physiotherapy with postural drainage • Hydration via beverage & humidifier • Flutter-valve mucus clearance devices • Tracheostomy o Risk for imbalance nutrition • Often in a hyper-metabolic stateàneed more calories • Prevent protein-calorie malnutrition through dietary consultation • Monitor weight, skin condition, & serum pre-albumin levels • Dyspnea management • Food selection to prevent weight loss o Prevent anxietyàthis can worsen symptoms o Risk for pneumonia & other respiratory infections • Avoid large crowds • Pneumonia vaccine • Yearly influenza vaccine o
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LUNG CANCER: § Leading cause of cancer deaths § Poor long-term survival because of late-stage diagnosis § Bronchogenic carcinomas § Staged to assess size & extent of disease § Warning signs o Hoarseness o Change in respiratory pattern o Persistent cough o Blood in sputum o Chest pain/tightness o Shoulder pain o Recurrent pneumonias o Dyspnea o Wheezing o Weight loss o Possible JVD & edema in upper extremities § Management o Can be curative (if caught early) to increase survival time, and/or palliative o Chemotherapy o Targeted therapy (to de-bulk, then do in & remove it) o Radiation therapy (to de-bulk, then do in & remove it) o Photodynamic therapy o Wedge resection o Lobectomy o Pneumonectomy o Postoperative care • Chest tube placement (except for pneumonectomy) Ø Sterile technique Ø Place drainage system below level of patient Ø Look for kinks Ø Tidaling Ø Vaseline dressing • Pain management • Respiratory management (mechanical ventilation) § Interventionsàto maintain quality of life, ADLs, IADLs o Oxygen therapy o Drug therapy o Radiation therapy o Thoracentesis (remove fluid from pleural space) o Pleurodesis (injection to “close off” pleural space so fluid can’t get it) o Dyspnea management o Pain management o Hospice care (~6 months) SLEEP APNEA: § Breathing disruption during sleep that lasts at least 10 seconds & occurs a minimum of 5 times an hour § Results in upper airway obstruction by the soft palate or tongue § Risk factors o Obesity o Large uvulaàsometimes they will laser off the uvula o Short neck o Smoking o Enlarged tonsils/adenoids o Oropharyngeal edema • Can be from ACE inhibitorsàstop drug § Clinical manifestations o Heavy snoring o Excessive daytime sleepiness o Inability to concentrate o Irritability o Headaches o Personality changes
MECHANICAL VENTILATION: § Modes of ventilation o BiPAP • 2 levels of positive airway pressure via nasal or oral mask, nasal pillow, or mouthpiece • Higher level of pressure during inspiration augments spontaneous breathsàkeep soft palate & tongue away from back of throat • Lower level of pressure during exhalation o CPAP • Delivers a set positive airway pressure continuously during each cycle of inhalation & exhalation • Keeps alveoli open during inhalation & prevent collapse during exhalation o Assist-control (A/C) • Set tidal volume & rate (how fast they will breathe, but can initiate breaths) • All breaths (assisted or controlled) are delivered with the same set pressure/flow rate • Used in initiating mechanical ventilation and/or when patient at high risk for respiratory arrest • If start breathing on own, probably not the best because they can be overventilated o Synchronized intermittent mandatory ventilation (SIMV) • Preset tidal volume & rate • Allows spontaneous breaths • Starting to “wean” patient off ventilator • Breaths synchronized with patient’s effort o Pressure support (PS) • Positive pressure to augment inspiratory effort • Patient controls RR, flow rate, & tidal volume • Used for weaning off or in combination with other modes • Can have with A/C or SIMV (as an extra boost) • All breaths on own, but assists with breathing in • “Last step” § Reasons for Ventilation o Improve gas exchange & decrease work of breathing o Doesn’t cure anything o Support patient until natural breathing can resume § Ventilator Settings o RRàwhen weaning off, will set lower so they breathe on their own o Tidal volume o Oxygen concentration o Flow rateàhow fast in o Positive end-expiratory pressure (PEEP)àto keep alveolar open & prevent lungs from collapsing o Pressure supportàextra push when they breathe in § Ventilator Alarms o High pressure • Secretions or mucus plug • Coughing, gagging, biting tube • Obstruction • Asynchrony (“fighting the ventilator”)àmay need to sedate, or it may indicate they are ready to be weaned off • Airway displaced or movedàwant to auscultate • Pulmonary complications (ie: bronchospasm, pneumothorax, pneumonia) o Low pressure • Leak in circuit • Cuff leak • Loss of spontaneous breathing or decreased respiratory effort • If patient can talk to you with ET tubeàLEAK § Complications o Cardiac problems • May need to address fluid overload, electrolytes) o Lung problems (ie: barotrauma) o GI & nutritional issues (ie: ulcersàmay need Nexium) o Infections o Ventilator dependence
MUSCOLOSKELETAL ALTERATIONS [5 Questions] OSETOPOROSIS: § Chronic metabolic disease in which bone loss causes decreased density & possible fractures § Osteoblasts put stuff into bone, osteoclast take stuff out…more osteoclastic activity than osteoblastic activity § Primary o Most common in postmenopausal women & men in 60-70 (especially those thin & frail) o Bone mineral density (BMD) decreases rapidly post-menopausal § Secondary o From an associated medical condition • Hyperparathyroidismàpulling Ca+ out of bone = bone weaker • Long-term drug therapy • Long-term immobility (may have MS or Parkinson’s) • Chronic drug use (ie: corticosteroids, heparin, anticonvulsants) § Regional o When limb is immobilized (ie: related to fracture) o Can build bone back up usually, but we worry about age § Risk factors: o Older age o Family history o Low body weight/thin build o Chronic low calcium & vitamin D intakeàactivate Ca+ to move around body to get into bone o Estrogen/androgen deficiencyàaffects bone density o Early menopause o Smokingàaffects bone density o High alcohol intake (1 drink for women, 2 for men) o Lack of physical exercise/immobility o White, thin women are likely to develop osteoporosis at an earlier age § Health Promotion/Illness Prevention!!! o Teaching should start with young women who begin to lose bone density after 30 years of age o Focus of osteoporosis prevention is to decrease modifiable risk factors o Ensure adequate nutrition • Vitamin D • Calcium • Make sure not getting too frailàkeep good BMI o Avoid sedentary lifestyle o Continue program of weight-bearing exercises § Physical assessment: o “Dowager’s hump”àdue to bone density loss, kyphosis o Loss of height o Complains of back painàif spine is losing a lot of bone density, affect cartilage, possible compression of nerves o Fallophobiaàmay be sedentary due to fear of falling § Diagnostic tests: o No definitive lab tests o Serum calcium, vitamin D, & phosphorus to rule out secondary osteoporosis & other metabolic bone diseases o Dual X-ray Absorptiometry* • To measure bone mineral density • Look at hip and spine • T Score Ø More commonly used Ø To help determine risk of fracture (fragility fracture) v Might just be walking & fracture a hip Ø < -2.5 = osteoporosis v Times # by 10 to get % of bone loss (ie: -2.5 x 10 = 25% loss of bone density compared to that of a 30-year-old female) Ø -1 to -2.5 = osteopenia v Want to start treating in this stage to prevent osteoporosis Ø < -1.5 & has risk factors = should start some kind of treatment Ø < -2 should start treatment right away even without risk factors Ø Compares score to that of a normal 30-year-old female • Z Score Ø This compares the patient to someone of the same relative age & gender Ø Not really used in diagnostic testing
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Interventions: o Nutritional therapy • Calcium & vitamin D • Protein, magnesium, vitamin K, & other minerals o Lifestyle changes • Muscle strengthening & weight-bearing exercises • Water aerobics are good too • Walking for 30 minutes 3-5 times/week • Avoid smoking o Drug therapy • Calcium & vitamin D (Os-Cal, Citracal) Ø 1-1.5 grams in divided doses Ø Vitamin D is in units • Estrogen Agonist/Antagonist (Raloxifine) Ø Hormone therapy Ø Normal for post-menopausal therapyàgreat risk for DVTs, especially if also smoking Ø Watch for DVT & monitor LFTs • Bisphosphonates [Alendronate (Fosamax), Risedronate (Actonel), Ibandronate (Boniva)] Ø Can affect lower esophageal sphicter Ø Side effect: Esophagitis Ø Take on empty stomach first thing in morning with full glass of water & stay upright/sitting for 30 minutes-1 hr. • Other agents Ø Parathyroid hormone Ø Calcitonin Ø Fortero (Pen)àsubQ daily v Possibly helps increase bone density, but definitely helps with further loss v Lots of education! v Rotate site (deltoid, abdomen, thigh) v Clean site v Proper disposal OSTEOARTHRITIS: § Most common type of arthritis § Joint pain & loss of function characterized by deterioration & loss of cartilage in the joints § Development of osteophytes § Less we use it, less mobility & function § Most common in hips, knees, & ankles § Bone hypertrophyàbony outgrowths § Bone rubbing against bone = pain & inflammation § Primary o Triggered by aging or genetics o Weight-bearing joints mostly affected (ie: knees) § Secondary o Results from other musculoskeletal conditions such as rheumatoid arthritis (can lead to osteoarthritis), congenital anomalies, joint sepsis, obesity, smoking, & other metabolic conditions (ie: diabetes) § Clinical manifestations: o Chronic joint pain & stiffness o Pain may be present at rest (getting worse) o Interruption of sleep patterns o Tenderness on palpation/ROM o Enlarged joint o Heberden’s (DISTAL) & Bouchard’s nodes (PROXIMAL) o Joint effusion o Atrophy o Loss of function § Diagnostic tests: o Elevated ESR (Normal: 0-22 men/ 0-29 women) o Elevated C-reactive protein (Normal: < 1)àlot of inflammation throughout body • The more joints affected, the higher the ESR & CRP will be o Better diagnostic tests: • X-rayàchanges in bone structure, bone spurs, hypertrophy • MRIàwhat’s going on in joint, joint space, & blood flow to area • CT
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Nursing management: o Manage pain o Get them moving o Address secondary causes o Analgesics • Tylenol is the drug of choice* (keep under 4g/day to prevent overdose) Ø Remember that other drugs may have Tylenol in them • Lidoderm 5%àpatch Ø Follow instructions on how long to have it on Ø Don’t use bare hands/be careful applying it Ø Change location (don’t want to wear skin out) • NSAIDsàworry about GI problems o Other • Cortisone injectionsàinto joint space to decrease inflammation • Hyaluronate injectionsàsimilar to a compound in our joint spaces, help lubricate & move properly • Muscle relaxantsàhelpful especially with back spasms o Rest & positioning • Positioning depends on wear the pain is o Weight control o Hot or cold application • Heat may decrease muscle tension • Hot shower/baths • Cold to reduce swelling/inflammation • Depends on the patient & what works for them o Complementary/alternative therapies • Worry about drug interactions! • Chondroitin & glucosamine (for osteoarthritis), & turmeric (strong anti-inflammatory) • Acupuncture • Massage therapy • TENS (Transcutaneous electric nerve stimulation)àget blood flowing & muscle moving o No therapy will halt progression o Current therapy directed at relief of pain & minimizing functional disabilityàaddress ADLs, IADLs, pain, & mobility o Agents for pain relief • Topical agents • Systemic oral agents (acetaminophen, NSAIDs) • Intra-articular agents Ø Corticosteroids for synovial inflammation Ø Hyaluronic acid Surgical management: o Total Joint Arthroplasty (most commonàhip or knee replacement) • Pre-Op Ø Teaching what to expect post-op Ø Medications (insulin , BP meds, Coumadin, Lovenox, aspirin, etc.) Ø Pain management • Operative • Post-Op Ø Prevention of discoloration Ø Make sure placement stays Ø Prevention of infection v Prophylactic antibiotics Ø Thromboembolic complications Ø Assess for bleeding Ø Management of anemia
HIP FRACTURE: § Most common injury in older adults § High mortality rate § Especially concerned with femoral neck fractureàcould lead to avascular necrosis of the femoral head § Clinical manifestations: o Injured leg shortened o Externally rotated o Extreme pain prevents movement § Treatment: o Immobilize immediately to prevent further damage o Buck’s traction may be used before surgery • Little boot around lower leg (traction & weight) • Make sure weight is NOT on floor • DO NOT turn side to side • Trapeze can be used to help the patient move (sit upright more) • No pins • Assess skin • Look at circulation • May need to reposition o Surgery is treatment of choice • Open Reduction Internal Fixation (ORIF) Ø Femoral neck fracture repairs = pins Ø Intertrochanteric fracture repairs = bidirectional o Surgical procedure depends on • Type of injury • Condition of the person • Preexisting orthopedic conditions o With acute or chronic diseases the risk of surgery may be too greatàmedical management may be preferred § Nursing management: o ABCs! o Pain assessment o Skin assessment o Body alignmentàabduction pillow o Ambulation • Provide analgesic before first time out of bed o Education to return home o Monitor for complications • Dislocation of the device • Avascular necrosis • Infection • Delayed healing • PEàfrom DVT or fracture surgery, fat embolism or something else from rupturing the tissue, etc. • DVTàdue to immobility • Compartment Syndrome Ø Due to lack of perfusion Ø Reduced circulation in an area due to edema Ø Pain, pressure, paralysis, parathesia, pallor, pulselessness (use Doppler) Ø Notify HCP! • Poor alignmentàdislocation of the prosthesis • Infection • Skin alterations • Hazards of immobility *Side note: For NCLEX questions, pain is considered psychosocial, BUT chest pain is ABCs!
HIP REPLACEMENT SURGERY: § Precautions o DO NOT stand or sit for long periods o DO NOT flex hips more than 90 degrees o Abduction pillow o Avoid internal rotation § Prevention of complications o Continuous Passive Movement (CPM) • Give pain medication before o Assess for neurovascular compromise o Manage pain o Progression of activityàup & moving post-op day 2 o Promotion of self-careàOT ELDER ABUSE [4 Questions] § Elder mistreatment = intentional actions that cause harm or create serious risk of harm to a vulnerable elder by a caregiver or other person § Types of Elder Mistreatment: o Physical o Sexual o Emotional/psychological o Financial/exploitation o Caregiver neglect (intentional or non-intentional) o Abandonment o Self-neglect o OR a combination § Theories of Elder Mistreatment: o Situational Theory • From caregiver strain/stress o Psychopathology Theory • Due to perpetrator’s OWN psychological issues o Exchange Theory • Related to victim-perpetrator long term relationship & dependency o Social Learning Theory • How abuse was learned o Political Economy Theory • Focuses on challenges faced by older adults in society § Dementia & Elder Mistreatment: o ~47% of older adults with dementia are victims of some type of elder mistreatment o Can occur in LTC settings by caregivers of patients with dementia of multiple chronic conditions o Problem is older adults with dementia are not often able to provide a detailed history (difficult to report abuse if can’t remember it) o There is a lack of objective assessment & policies of elder mistreatment screening & management o Risk factors: • Functional impairment • Dependency on others • Cognitive impairment • History of childhood trauma or abuse, substance abuse, depression, or other mental health disorders • Social isolation • Lack of support system • Low socioeconomic status § Perpetrator Characteristics: o Usually a family member (80-90%) o Long history of conflict with victim o Living with victim for an extended period of time o Caregiver strain/stress o Recent financial stress or job loss o History of substance abuse, gambling (not often seen), depression, or mental health disorder o Dependency of victim o Lack of support system o Social isolation o Poor housing o Low socioeconomic status
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Elder Mistreatment Screening o Elder Assessment Instrument (EAI) • Used in inpatient & outpatient • Relies of objective assessment by physician Ø General appearance Ø Evidence of dehydration Ø Physical & psychological indicators o Hwalek-Sengstock Elder Abuse Screening Test (HS-EAST) • Self-report • If positive screen…comprehensive history & physical assessment should be done Caregiver Strain Screening o Modified Caregiver Strain Index Assessment (what to look for): o To assess for actual OR potential risk o Interview older adult & caregiver separate o Look at overall appearance & hygiene o Clothing & footwear appropriate? Clean? o Overall hydration & nutritional status o Skin appearance o Physical abuse • Bruises (look at stages of healing, signs of grabbing) • Injury • Burns • Lacerations • Fractures • Repeated falls • Suspected sexual abuse • Repeated ED visits • Exhibiting anxiety behavior, especially towards perpetrator o Psychological abuse • Anxiety • Agitation • Dementia • Depression • Delirium • Change in usual behavior • Mood • Affect • Willingness to communicate • Report from older adult victim about verbal or psychological mistreatment o Neglect • Poor hygiene • Inappropriate clothing/footwear • Dehydration and/or malnutrition • Change in usual bowel habits • Decreased function • Contractures • Change in medication adherence • Pressure ulcers • Repeated falls • Urine odor • Basic needs not being met • Report from older victim o Financial abuse/Exploitation • Misuse of older adult’s assets • Change in ability to pay usual bills, afford medications, pay for life essentials • Older adult report someone demanding money, threatening in exchange for money, caregiving in exchange for money • Phone solicitation • Older adult victim report of “missing money”, unexplained loss of social security checks or pension funds
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Abandonment • Left at home alone for long periods of time • Left home unsafely • Caregiver withdrawal • Report from older adult victim
SEXUAL HEALTH [4 Questions] § Older adults are frisky & risky § 73% of adults 57-64 report being sexually active…53% for 65-74 § 47% use drugs/alcohol before intercourse § Males more sexually active as a whole § STIs/STDs o 5% HPV/Genital warts o 5% Gonorrhea o 3% Hepatitis o 3% Herpes o 1% Syphilis o 1% HIV/AIDS § Use of protection among single/datingà 12% (men) & 32% (women) § Older Adults & STI Risk: o Lack knowledge about STIs & how to prevent transmission o Inconsistent condom use o Multiple partners o Widowed/divorced individuals begin dating again & especially lack knowledge about STIs & prevention o Women who no longer worry about pregnancy may not use condoms o Use of condoms needs an erect penis… o Availability of ED medications may facilitate older men who may not otherwise be capable § Common STIs: o Syphilis • Malaise • Low-grade fever • H/A • Muscular aches & pains • Sore throat • Generalized rash o Chlamydia • Vaginal & urethral discharge • Dysuria • Pelvic pain • Irregular bleeding o Gonorrhea • May be asymptomatic • Usually presents with symptoms 3-10 days after contact with an infected person • Anal manifestations may include itching, inflammation, rectal bleeding, diarrhea, & painful defecation • Assess mouth for reddened throat, ulcerated lips, tender gingivae, & blisters in throat • Menàdysuria, profuse yellowish-green penile discharge or scant, clear fluid • Womenàyellow/green vaginal discharge, profuse, odorous, urinary frequency, dysuria • Common sites of infection = cervix & urethra • If systemic…may experience fever, chills, skin lesions on distal extremities, & joint pain o Genital herpes • May start as small blisters that eventually break open & produce raw, painful sores that scab & heal over in a few weeks • May be accompanied by flu-like symptoms (fever, swollen lymph nodes) o HPV/Genital warts • In most cases it goes away on its own • Can have genital warts or develop cervical cancer • Small bumps (small or large, raised or flat) o Candida infections (yeast infection) § Itchiness & irritation § Odor
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Sexual Health Assessment: o Done every visit o Many HCP don’t ask about sexual activity or test them for HIV o Past history of STIs? o Part OBGYN surgeries, circumcision? o Menstrual history o Sexual history • Sexual orientation • Type/frequency of sexual activity • # of partners o Contraceptive history o Preventive healthcare practices • Pap smear • Regular STD/HIV screenings o Assessment: • Oropharyngeal • Abdominal • Genital/pelvic • Anorectal • Little information related to HIV screening in LTC setting • CDC says ALL patients should be educated, screened, & tested if at risk o Routine testing up to age 64 o Test over 64 if risk factors PRESENT o Labs: • Urinalysis • Hematology • Cervical, urethral, oral, and/or rectal specimens • Lesion samples for microbiology & virology HIV & Older Adults: o Those 50+ account for 35% of people living with HIV (2010)…42% with AIDS o HIV was the 10th leading cause of death among men & women ages 50-54 o ¼ of all new HIV infections are those 50+ o Heterosexual (risks) • Multiple partners • Lack of condom use • IV drug use • Lack knowledge about HIV transmission & own HIV status o Fear o Don’t think they are at risk o Gay, bisexual (risks) • Increase in anal sex w/o condom • Increased risk of other STIs • Increased alcohol & illegal drug use • This leads to homophobia, discrimination, & stigmaàprevents them from getting proper treatment or adequate screenings
COGNITIVE IMPAIRMENT & THE 3Ds [4 Questions] § Changes in an Aging Brain o Some parts of brain shrink (prefrontal cortex & hippocampus) § Changes in neurotransmitters & brain’s blood vessels o Decreased dopamine= Parkinson’s o Actylcholine= dementia o Not managing high BP or DM= vascular dementia § Damage from free radicals & inflammation increases § Memory loss is NOT a normal part of the aging process § Age is the biggest risk factor for dementia/Alzheimer’s § Mild cognitive impairment o Prior to dementia (prodromal stage) o Independent with ADLs, but some decline in performance o This combined with depression can increase chance for developing Alzheimer’s DEMENTIA § Changes in mental ability severe enough to interfere with ADLs § Memory loss & cognitive decline § Not curable…will lead to death eventually § DSM V: Decline in memory and one of the following o Expressive or receptive aphasia o Unable to identify objects in hand o Difficulty with motor activities o Inability to think abstractly, make sound judgments, and plan & carry out complex tasks § Warning signs of Alzheimer’s o Poor judgment/decision making o Inability to manage a budget o Losing track of the date or season o Difficulty having conversation o Misplacing things and being unable to retrace steps to find them § Risk factors o Age o Family history (if someone has early onset) o Genetics (some people that can’t get rid of proteins that make the plaques & tangles are at increased risk) o Head trauma, DM, depression o Higher education, greater social networks…living longer § Behavioral symptoms o Psychomotor agitationàwandering, not being able to sit still o Psychosisàhallucinations, delusions o Aggressionàverbal or physical o Apathyànot wanting to do anything all of a sudden o Depression o Sleepàdaytime sleepiness, sundowning, want to keep them awake during the day § *Stages of Alzheimer’s o Early • Mild cognitive decline • Noticeable deficits in demanding job situations o Mild • Deficits with complicated tasks • Moderate cognitive decline • Denial & withdrawal from challenging situations • Poor attention • Apathy • Depression • Word finding difficulty o Moderate • Deficits with choosing proper attire • Moderate severe cognitive decline • Disorientation • Increasing memory loss • Insomnia • Wandering • Speech difficulty • Restlessness
Moderately Severe • Deficits with ADLs • Severe cognitive declineàtotal dependence o Severe • Declined speech ability • Loss of ability to walk, sit up, smile, hold head up • No verbal or self abilities • Agnosiaàcan’t identify things in hand • Apraxiaàunable to move tongue to speak • Aggression • Agitation • Incontinence • Poor ADL function • Gait disturbance Nursing management (Dementia) § Psychomotor agitation o Manage surroundings o Address underlying issueàcan also have acute things that can lead to delirium on top of dementia o Safety! § Psychosis o Evaluate medications o Optimize sensory deficits (especially in hospital) § Aggression o Cognitive therapiesàsedatives used as last resort o Effective communication techniques § Apathy o Activity therapy (things they enjoy) § Depression o Therapy, behavioral interventions (CBT), medications if indicated § Sleep o Daytime activities to re-align wake cycles § *Acetylcholinesterae inhibitors o Prevents breakdown of acetylcholine o Want to titrate & slowly increase to avoid side effects (N/V, diarrhea, abdominal pain, jaundice, decreased HR, dizziness, & headache o Ex: donezepil hydrochloride, rivastigmine tartrate, galantamine hydrobromide, & tacrine hydrochloride § *Memantine o NMDA receptor blockeràworks by blocking excess activity of a substance in the brain called glutamate, which may reduce the symptoms associated with Alzheimer disease o Side effects (dizziness, constipation, & headache) § *Pharmacological therapy for problematic behaviors o Haloperidol (Typical antipsychotic)àfor psychotic symptoms • Too much can lead to EPS (TD, shuffling gait) o Atypical antipsychotic medications (Respiridone, olanzapine, quetiapine, & zisprasidone • Less EPS= better option o Benzodiaepinesàto manage agitation & aggression • Ex: Versaid, Konopin, Ativan • Slows progression but does not treat • Risk for falls! o
DELIRIUM § Disturbance in attention § Disturbance develops over a short period of time § Can’t really focus § Impaired and fluctuating, changes in orientation § Speech is incoherent § Reversible if cause is treated § Causes: o Drug therapy (anticholinergics & psychoactive drugs) o Electrolyte imbalances (Na+, K+, and Mg+) o Pain o UTIàcatheters should be out by 48 hours after surgery o Fecal impaction or severe diarrhea o Surgery (anesthesiaàdo full pre-op cognitive assessment to asses for delirium or risk for o Metabolic problems (ie: hypoglycemia) o Neurologic disorders (ie: tumors) o Circulatory, renal, & pulmonary disorders o Nutritional deficiencies (vitamin B) o Hypoxia o Relocation o Major loss Assessment (Delirium) § Confusion Assessment Method (CAM) o Acute onset & fluctuating o Inattention o AND disorganized thinking OR altered LOC Nursing management (Delirium) § Provide orientation § Provide appropriate sensory stimulation § Facilitate sleep § Foster familiarity (have stuff from home) § Maximize mobility & avoid restraints (should be up 2 days after surgery) § Communicate clearly, provide explanations, short, simple, direct § Reassure & educate § Minimize invasive interventions (ie: blood draws)àcan increase agitation § Consider psychotropic medications as last resort for agitation DEPRESSION § Most common mental disorder § Symptoms o Depressed mood o Suicidal thoughts • Suicideàhigh mortality • White men ages 75-85 years at greatest risk • There is direct relationship between depression, suicide, & alcoholism • Often miss it because of aging or another disorder we think they may have o Psychotic symptoms § Geriatric Depression Scale o < 5= fine o 5-10= assess o > 10= most likely depressed § PHQ-2
Nursing management (Depression) § Pharmacologic o SSRIs • Function: block reuptake of serotonin & enhances transmission • Side effects o Dry mouth o Blurred vision o Insomnia, nervousness o Sexual dysfunction o Nausea, anorexia, & diarrhea o Headache o GI issues/bleeding o SNRIs (serotonin & norepinephrine reuptake inhibitors) • Antidepressant • Help relieve depression symptoms (irritability & sadness) • Side effects o Nausea o Dry mouth o Dizziness o Excessive sweating o Agitation or anxiety o Constipation o Insomnia o ED or other sexual problems o Headache o Loss of appetite o TCA-related medications • Ease depression by affecting naturally occurring chemical messengers (neurotransmitters), which are used to communicate between brain cells • Side effects o Dry mouth o Blurred vision o Constipation o Urinary retention o Drowsiness o Increased appetiteàweight gain o Orthostatic hypotension o Increased sweating o Disorientation or confusion o Tremor o Increased HR o ED § Group/individual psychotherapy o Cognitive behavioral therapies (CBT) § Electroconvulsive therapy Nursing interventions (Depression) § Safety precautions for suicide risk as per institution § Remove/control etiologic agents § Monitor/promote nutrition, elimination, sleep/rest patterns, physical comfort (pain control) § Enhance physical function § Enhance family/social/spiritual support § Maximize autonomy/personal control/self-efficacy § Remove catheters after surgery § Education about medications
VASCULAR ALTERATIONS [4 Questions] § Cardiovascular diseases are highest among African-Americans § Higher in men, until age 45 then women are § Uncontrolled BP increase the risk of co-morbidities o 20 mmHg (systolic)/10 mmHg (diastolic) increase in BP doubles the risk for CVD HYPERTENSION § Want BP < 120/ < 80 § Prehypertension: 120-139/80-89 § Hypertension 1: 140-159/90-99 § Hypertension 2: > or equal to 160/ > or equal to 100 § Diagnose by “worse” # (systolic or diastolic) § Need 2 separate visits to diagnose! § BP influenced by cardiac output & peripheral vascular resistance o CO=HR x SV o Peripheral vascular resistance • Autonomic Nervous System Activityàdiameter of those arteries, fight or flight= blood vessels dilate • Renin Angiotensin Aldosterone System o Renin released when kidneys not perfused or damage to arteries o ReninàAngiotensin 1àLungsàAngiotensin 2àconstricts blood vessels & releases aldosterone (bad because it increases HTN)àretain sodium & water § Risk factors: o Essential/Primary HTN • Family history • African-American • Hyperlipidemia • Smoking • > 60 years old or post menopausal • Excessive sodium & caffeine intake • Overweight/obese • Sedentary lifestyle • Excessive alcohol intake • Reduced intake of potassium, calcium, or magnesium • Stress o Secondary HTN • Renal disease • Primary aldosteronism • Phenochromocytoma • Cushing’s Syndrome • Brain Tumors • Pregnancy • Medicationsàestrogen, glucocorticoids, mineralcorticoids, sympathomimetics § Hypertension treatment goals o Patients 60+ = 150/90 o Patients with DM or CKD = 140/90 § Treatment o ACE • Stops conversion of angiotensin 1 to angiotensin 2 o ARB • Blocks angiotensin 2 from binding to special areas on the blood vessels (receptors) o Both of these increase potassium so want to avoid more potassium, unless losing excess fluid or diuresis o Look out for angioedema, get up slowly (orthostatic hypotension) o Aliskirenàanyone with ACE or ARB should not be on this direct renin inhibitor if have DM or kidney problems PAD § Thickening & degeneration of arteries with narrow lumens & fatty deposits § Leading cause is atherosclerosis § Risk factors o Hyperlipidemia o Smoking o HTN o DM o Obesity o Family history o Advanced age
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Location o Femoral-popitealàNon-diabetics o Below the knees, more distal, closer to ankleàDiabetics Manifestations: o Intermittent claudicationàpain with activity, usually calf (ischemic muscle ache precipitated by exercise & relieved with rest) o Decreased or absent pulses o Loss of hair on legs, toes, & feet o Ulceration or gangrene of toes & feet o Nails thickened, brittle o Skin • Color: dependent rubor (when below level of heart), pallor on elevation (no more gravity, not enough blood flow to get it there) • Texture: thin & shiny, dry • Temperature: cool Stages 1. Asymptomatic 2. Claudication 3. Rest pain 4. Necrosis, gangrene, ulcers Complications: o Atrophy of skin o Delayed healing o Wound infection o Tissue necrosis o Arterial ulcers o Non-healing ulcers may lead to amputation if blood flow not restored NEVER COMPRESS ARTERIAL! *Ankle-Brachial Index (ABI) o 1.0 = Normal o 0.95- = Mild/moderate insufficiency o < 0.5 = Ischemic rest pain o 0.25 or less = Severe ischemia or tissue loss o If brachial much higher than ankle…worry about perfusion! o Over age 50…should have this checked EVERY visit Collaborative Care o Assess risk factors: smoking, HTN, & DM o Protect the extremity from trauma o Nutritionàoptimal weight, saturated fats, sodium, cholesterol o Walking is best exercise o Foot care Drug Therapy o Antiplatelet agents • Plavix (Clopidogrel) Ø Inhibits platelet activation Ø Decrease risk of stroke or MI Ø More effective than ASA • Trental (Pentoxifylline) Ø Reduces blood viscosity Ø Improves supply of oxygenated blood • ASA Ø Not always tolerated due to GI effects • Pletal (Cilostazol) Ø Inhibits platelet aggregation Ø Increases vasodilation Ø Increase in pain free walking Ø Side effects: H/A & diarrheaàcaution in PT with heart failure
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Surgical Therapy o PTCA • Usually femoral o Arterial Bypass Surgery • Take vein from arm & put it down in leg to bypass (keep in mind vein isn’t as strong) • Bypass carries blood around the lesion • Worry about bleeding • Assess pulses • Notify HCP if problem with rest pain or absent pulses persist • Avoid bending, sitting for long periods of time • Check BP • Look out for signs/symptoms of infection • Check ABIàwant close to 1 o Endarterectomy • Open artery & remove obstructive plaque with a patch graft o Amputation • If ALL arteries are affected • Complications: o Tissue perfusion o Hemorrhage o Infection o Phantom limb pain o Body image Incompetent valves of deep veins, venous obstruction Usually caused by HTN Perfusing the extremities, but blood not coming back up & edema occurs Pulses still present Edema occurs because RBCs infiltrate surrounding tissues o Skin thick, hard, & contracted o Brown leathery skin o Hyperpigmentationàenzymes break down RBCs o Stasis dermatitisàcellulitis, infection Ulcers develop above the ankle Gravity will keep blood from getting back to heart…want to ELEVATE! Collaborative care o Elevate extremity o Compression o Moist dressing o Observe for infection o Good nutrition ABI less than 0.9 suggest PAD Can have bothàusually patients with long-standing HTN Feature Arterial Ulcers § Claudication after walking 1-2 blocks History § Rest pain § Pain at ulcer site Ulcer location/ § End of toes appearance § Between toes § Deep § Ulcer with even edges § Little granulation tissue
Other assessment findings
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Cool NO pulses Hair loss Pallor with elevation Dependent rubor Possible neurological deficits
Venous Ulcers § Chronic non-healing ulcer § No claudication or rest pain § Ankle/leg swelling
Diabetic Ulcers § Diabetes § Peripheral neuropathy § No claudication
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Ankle Brown pigmentation Ulcer bed pink Uneven edges Granulation tissue present
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Ankle discoloration & edema No neurological deficits Pulses present Scarring (ulcers that have healed)
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Plantar foot Pressure points on feet Deep Pale Even edges Little granulation tissue Pulses present Cool or warm foot Painless
HOSPITAL ACQUIRED INFECTIONS [3 Questions] § Normal flora = characteristic bacteria of a body location; often competes with other microorganisms to prevent infections § Colonization = microorganism present in tissue but not yet causing symptomatic disease § Surveillance = tracking and reporting of infections § Endogenous infection = from patient flora § Exogenous infection = from outside the patient, often health care workers’ hands (we gave it to them)àpreventable § HAIs are acquired in inpatient setting, not present at admission § Portal of Entry Sites: o Respiratory tractàventilator associated pneumonia/pneumonia o GI tractà C. diff o Genitourinary tractàUTI (CAUTI) o Skin/mucus membranesàthrush, yeast infection o Bloodstream § Mode of Transmission: o Contact (direct or indirect) o Droplet (ie: influenza) o Airborne (ie: TB) o Vector-borne (ie: deer ticks = Lyme disease) o Contaminated food/water o Portal of exit § Common HAIs o UTIàCAUTI (most common) o Surgical site infection o Lung (pneumoniaàventilator or aspiration) o Bloodstream (often central-line associated aka CLABSI) • Change every 3 days § Infection control: o Takes 72 hours for someone to spike a feverà before that they probably came in with something o Hand hygiene o Proper hand washing o PPE o Adequate staffing • A nurse with more patients has a greater risk for giving their patients infections • Poor staffing = poor outcomes o Sterilization = killing ALL microorganisms o Disinfection = eliminating or reducing harmful microorganisms from inanimate objects and surfaces o Patient placement (cohorting)à”same” patients together, optimal is private o Patient transportation § Standard Precautions: o Respiratory hygiene/cough etiquette (RH/CE) • Patient, staff, and visitor education • Posted signs • Hand hygiene • Cover nose/mouth with tissue o Safe infection practices o Airborne Precautions • Negative airflow rooms required to prevent spread of microbes • HEPA filter • N95 mask • For TB, measles, chickenpox (varicellaàshingles, herpes zoster) Ø Pregnant nurses wouldn’t take care of these patients o Droplet Precautions • Protect from droplets that may travel 3 feet but are not suspended for long periods • For influenza, mumps, pertussis, meningitis • Mask within 2-3 feet of patient o Contact Precautions • For known or suspected infections transmitted by direct contact or contact with items in environment • For MRSA, pediculosis, scabies, RSV (can be droplet too), C. difficile
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MRSA: o Vancomycin (most common in hospital) o Linezoid o Community-associated MRSA • Healthy non-hospitalized people infected • Health teaching = best way to decrease incidence Ø Perform frequent hand hygiene, including use of hand sanitizers Ø Avoid close contact with people with infectious wounds Ø Avoid large crowds Ø Avoid contaminated surfaces Ø Use good overall hygiene Vancomycin-Resistant Enterococcus (VRE): o Normal bacteria that live in intestinal tract, important for digestion o Can cause infection outside GI tract • Womenàurinary tract = UTI o Can live on almost any surface o If at home (education) • Hand hygiene…especially after bathroom • Not sharing things (maybe private bathroom) Multidrug-resistant tuberculosis Gonorrhea Vancomycin-intermediate Staphylococcus aureus (VISA) Vancomycin-resistant S. aureus (VRSA) Inadequate Therapy: o Noncompliance o Legal sanctions compelling a patient to complete treatment • TB o Septicemia o Septic shock Management: o History o Physical assessment & clinical manifestations • Surgical site may have redness & purulent drainage o Psychosocial assessment o Labs • Culture & antibiotic sensitivity • CBC • Imagine
SENSORY ALTERATIONS [2 Questions] VISION: § Age-related changes o External changesàsagging of lower lid (curling in or out), often “cosmetic”, loss of fat, sunken eyelids o Internal changesàlacrimal glands don’t work as well (dry eyes), increased intraocular pressure, glaucoma o Visual acuityàpresbyopia, safety/quality of life o Light sensitivityàdriving at night difficulty; pupil doesn’t dilate or constrict as rapidly o Arcus senilis • Grayish ring • NOT damage related or “mean” anything § Vision alterations o Refractive errors: • Emmetropia (normal vision) • Myopia (nearsightedness) Ø Distant objects can’t come into focus Ø Blurry Ø Squinting • Hyperopia (farsightedness) Ø Harder to see up close (bigger issue) Ø Close objects can’t come into focus (eye strain & ocular fatigue) • Astigmatism Ø Blurred or distorted vision due to irregular shape of cornea Ø Headaches & ocular fatigue • Presbyopia Ø Crystalline lens of eye loses flexibilityàdifficulty focusing on close objects Ø Is a natural part of the aging process Ø Blurred near vision Ø Eye fatigue Ø Headaches with close work (eye strains) Ø Hold items at an arm’s length o Glaucoma: • Increased IOPàcauses separation in the back of the eye • Progressive or functional damage to eye • IOP regulated by formation & elimination of aqueous humor • *Peripheral vision loss • Leading cause of blindness in African Americans • Types: Ø Primary Open Angle Glaucoma o *NONEMERGENT o Insidious o Outflow problemàdecreased aqueous outflow, which leads to increased IOP o Increased IOP leads to slow optic degeneration, which leads to slow, deteriorating vision loss o Signs/symptoms: • “Tunnel vision” • Mild eye discomfort • Impairment of peripheral vision BEFORE central vision • Bumping into things • Increased IOP >21 (Normal: 10-21 mmHg) Ø Acute Closed Angle Glaucoma o Sudden build up of ICP (complete blockage of filtering angle)àfluid producing too much or not draining properly o *EMERGENCY o If untreated it can lead to blindness o Signs/symptoms: • Halos and/or rainbows • Pain in & around the eye (due to increased IOP) • N/V • Ocular redness • Blurry or cloud vision
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Diagnostic tests o Confrontation test (to test peripheral vision) o Tonometry (to test ICP) o Measure peripheral & central vision loss • Central acuity may remain 20/20 with severe peripheral loss Ø Nursing management o PREVENT BLINDNESS • Early detection • Lifelong treatment/monitoring o Keep IOP low to prevent optic nerve damage o Open angle glaucoma • Initial treatment: Drugs -Decrease aqueous humor production v Beta adrenergic blockers v Alpha adrenergic v Cholinergic agents v Carbonic anhydrase inhibitors -Decrease IOP by increasing aqueous humor outflow v Prostaglandin agonist • Secondary: Surgical interventions to decrease IOP Cataracts: § Progressive opacity or clouding of the lens § Size, site, and density vary among individuals (can be different in person’s two eyes § Risk factors: o Increased age o Eye trauma o Smoking o Exposure to the sun & UVB rays o Alcohol use o Long-term corticosteroid use o Diabetes o Caucasian o Hyperlipidemia § Signs/symptoms: o Blurry vision (becomes darker over time) o Glare o Halos around objects o Double vision o Difficulty sensing contrasting colors o Poor night vision § Nursing management o Surgery is treatment of choice (outpatient, lens replacement) o If both eyes have cataracts…will do one at a time o Macular degeneration: § Degeneration of the fovea, the central portion of the retinal macula § Risk factors: o Older adults o Smoking o Obesity o Caucasian o Family history o Females (because they live longer than men) § Sign/symptoms o CLASSIC SYMPTOM: Scotoma (blind spots) o Dryàslow, degenerative, blurry central vision o Wetàneovascular exudates (straight lines appear crooked) § Types: o Dry (atrophic) • Drusen deposition • Fatty deposits in macula o Wet (exudative) • Chorodial neovascularization • Blood vessels in the eye are affected • More severe • Occurs quicker
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Nursing management o Vision acuity tests o Amsler grid: broken or distorted line or missing area o Dilated eye examsàDrusen o Laser surgery for wet AMD • Cauterizes the leaky blood vessels • May be once a month o Antioxidant supplements • Vitamin C, Vitamin E, beta-carotene, zinc (plus copper that helps prevent anemia when using high-dose zinc) o Diabetic retinopathy: § Damaged or abnormal blood vessels within the retina o Leakage of proteins, etc. causing inflammation § Leading cause of blindness § Often no symptoms until advanced stages § Signs/symptoms o Gradual vision loss o Generalized blurring o Areas of focal vision loss § Can be prevented o Eye exams annually § Treatment o Laser therapy, vitrectomy • Get rid of “sacs” outside the blood vessels that are affecting the microvasculature o Manage HTN, hyperlipidemia, and hyperglycemia o Blindness: § Central vision acuity of 20/200 or worse in corrected eye and/or visual field no greater than 20 degrees in widest diameter § Chronis disease increases risk for visual impairment (DM & HTN) o Cataracts o Glaucoma o Diabetic retinopathy o Macular degeneration o May cause disorientation or confusion § Psychosocial impact o Risk for falls o Self care o Affects quality of life Nursing interventions (Vision) § Safety! § Assistive devicesàmagnifiers, text to speech software, talking clocks § Health promotionàsunglasses, hand washing (especially with eye drops…infection), smoking cessation, antioxidant rich foods, control of BP/glucose/cholesterol § Medications § Encourage adults > 40 to have annual eye exam with IOP measurement § Non-surgical corrections o Corrective lenses § Keratorefractive surgery o Laser or knife to correct curvature of cornea o Myopia most commonly corrected § Lasik o Laser removes internal layers of cornea § Intraocular Lens Implantation o Surgical implantation of an intraocular lens o Small plastic lens o Correction for aphakia (absence of lens) at time of cataract extraction
Nursing management (after surgery) § Prevent injury! § Assess for use of anticoagulants § Decrease anxiety § Shampoo/scrub around eyes § Administer pre-anesthetic medications o Mydratic eye dropsàdilates pupil • Give first…you can’t dilate the pupil after you paralyze it o Cycloplegic eye dropsàparalysis o Topical anesthesia § Eye patch or eye shield § HOB 30-45 degrees or lay on unaffected side to decrease IOP § Corticosteroid drops decrease inflammatory response § Analgesics as ordered (post-op vomiting or constipation can increase IOP) § Check for surgical complications o Sudden sharp eye painàEMERGENCY if new onset o Hemorrhage o Corneal edema § Avoid activities that can increase IOP (sneezing, vomiting, straining) HEARING: § Hearing loss o Can lead to social withdrawal, isolation, depression, & paranoia o Age-related changes • Cerumen o Changes consistency as we age o Contact HCP o OTC wax softener or baby oil • Presbycusis o Age-related hearing loss o Can be sensorineural, conductive, or combination of both o Permanent o Affects both ears equally o Loss of high-pitched sounds o More common & severe in men o Worsens with age Nursing interventions (Hearing Aides) § Keep dry § Clean ear mold with mild soap and water § Clean debris from hole § Turn off battery/remove battery when not in use § Check & replace battery frequently § Have extra batteries available § Store in safe place § Avoid dropping § Avoid temperature extremes § Adjust volume § Avoid oil based products
PRESSURE ULCERS AND WOUND CARE [2 Questions] § Wound Types: o Acute • Surgical • Trauma o Chronic • Vascular ulcers • Pressure ulcers • Diabetic foot ulcers § Pressure Ulcer Staging: o Stage 1ànon-blanchable redness, skin intact o Stage 2àblisters, partial thickness o Stage 3àfull thickness, subcutaneous fat may be visible o Stage 4àfull thickness, bone, tendon or muscle exposed, slough or eschar present o Unstageableàfull thickness, depth unknown, completed obscured by slough and/or eschar o Deep Tissue Injuryàpurple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear o Location: • Where is it anatomically located? o Measurements: • Length x width x depth • Greatest length (head to toe) • Greatest width (side to side) • Depthàuse cotton tipped applicator, note/mark depth & hold against ruler o Wound Characteristics: • Describe by % of type of tissue • Granulation Ø Red Ø Cobblestone appearance Ø Filing-in appearance • Necrotic Ø Slough o Eschar • Undermining Ø Separation of tissue from the surface under the edge of the wound Ø Describe by clock face • Tunneling o Wound Drainage & Odor: • Exudate Ø Scant, light, moderate, heavy, copious Ø Clear Ø Sanguineous (red, thin, watery) Ø Serosanguineous (thin, watery, clear-pink) Ø Purulent (sign of infection, green/yellow) • Odor Ø Most wounds have an odor Ø Clean well prior to assessing odor o Periwound • Protection is important! • Assess color, texture, temperature, & skin integrity o Infection • All wounds are contaminated, but not necessarily infected • Contamination on wound surface • Colonization • Infection invades soft tissueàleads to systemic response • Look for inflammation, pus, increased/different exudate, fever, pain, & delirium • Sterile technique during dressing changes § Other factors that contribute to wound healing o Nutrition/hydration (especially protein) o Circulation (pressure relief, oxygenation, no smoking) o Edema o Glucose control o Delayed wound healingàadvanced age, type-2 diabetes, smoking, etc.
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Nursing management: o Prevention! • Minimize friction, sheer, & pressure • Incontinence • Nutrition • Education o Relieve pain • Use appropriate pain scale • Try to alleviate pressure where the pressure ulcer is • Administer pain before debridement or dressing change • Encourage communication when uncomfortable o Proper positioning • Turn & reposition (regardless of support surface) • Avoid positioning on bony prominences with existing non-blanchable erythema • Don’t keep on bedpan too long • 30 degree titled side-lying position • Moving and shifting in chair • Do not use donut-shaped devices • Should not use these devices to elevate heels: Ø Synthetics sheepskin pads Ø Cutout, ring, or donut-type devices Ø IV fluid bags Ø Water-filled gloves Ø Use specialized cushioned boots o Proper nutrition • Assess ability to swallow • Ask patient food preferences • Ensure a high protein diet (supplements like Ensure or Boost) • Education of patient and family/caregiver • Hydration • Consult with registered dietitian • 30-35 kcalories/kg body weight with 1.25-1.5 grams protein/kg of body weight • Consider enteral or parenteral nutrition when oral intake is inadequate • Older adults we really want BMI above 21 even though normal is 18.5-25…older adults are very frail o Relieve pressure • Support surfaces o Enhanced pressure redistribution, shear reduction, & microclimate control such as air-loss or air fluidized mattress for those with Stage 3, 4, or unstageable pressure ulcers o Foam mattressesàstage 1 or 2 o Fill in dead space if wound is deep o Protect skin from incontinence o Protect periwound skin o DO NOT USE WET to DRY Dressings o Clean wound with saline or “wound cleaner” o Debridement • Wound will not heal with presence of necrotic tissue • Necrotic tissue increases bioburden • Firm, dry, stable eschar should not be debrided from heels • Autolytic, enzymatic, sharp, & biological Dressing Selection: o Manage drainage while maintaining a moist wound healing environment o Dressing Types: 1) Firms 2) Hydrogel • Doesn’t have a lot of drainage, but has lots of granulation tissue that you want to protect while healing 3) Hydrocolloids • Shallow stage 3, non-infected, most common 4) Alginates • Heavy exudate 5) Foams • Lots of exudate, stage 2/shallow stage 3
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6) Gauze • Pressure ulcers that have been cleaned/debrided 7) Silicone • To prevent periwound tissue injury when area is fragile 8) Silver-Impregnanted • Very infected…silver helps kill 9) Honey-Impregnanted • Stage2/3…promote wound healing 10) Cadexomer Iodine • Those that have lots of exudate • Be careful…relates to thyroid • A lot of people are allergic to iodine • Be cautious in those with impaired renal function 11) Collagen Matrix • Stage 3 or 4 to help heal Specialty Dressings • Antimicrobial dressings Vacuum-assisted wound treatments (NWPT) o No recommended in: § Inadequately debrided § Necrotic, or malignant wounds § Where vital organs are exposed § Wounds with no exudate § Individuals with untreated coagulopathy, osteomyelitis or local/systemic clinical infection § Actively bleeding wounds § Wounds in close proximity to major blood vessels Hyperbaric oxygen treatment
ADVANCED CARE PLANNING [2 Questions] § Barriers to Quality EOL Care: o Limited evidence base o Fear & discomfort about death o Lack of experience with death o Death denying culture o Uncertainty about communication § Advanced Directives o An order to let the provider know what they want ahead of time in case a decision needs to be made o Progressive, ongoing discussion o Patient status & wishes often change with time o Should be about values, not documents o Durable Power of Attorney (Health Care Proxy) • A person who can speak for you when you cannot speak for yourself o Living Will • DNR (Do Not Resuscitate) • DNI (Do Not Intubate) • AND (Allow Natural Death) • DNH (Do Not Hospitalize) • Can decide about other things we may not think about such as artificial hydration & nutrition, dialysis, antibiotics, re-hospitalization, etc. § MOLST (Medical Orders for Life Sustaining Treatment) § FIVE WISHES (person you want to speak for you, who you want around you, etc.) § Where people want to die, differs from where people actually do die o 50% Hospitals o 25% Nursing Homes o 25% Home § Communication Skills: o Assessment first o Open-ended questions o Reflecting/Validating o Therapeutic use of silence § Moral Uncertainty (just doesn’t feel right) o Uncertain if a problem exists, unsure about its nature, & unclear which values conflict
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Moral Dilemma (discomfort feeling that can be identified) o 2 or more ethical principles clash Moral distress (we can identify, but feel like we can’t do anything about it) o Emotion resulting from inability to act upon the right course of action Our values may not match the patient’s & that’s okay! Autonomy: the right to make your own choices Beneficence: doing good Nonmaleficence: do no harm Veracity: truthfulness Confidentiality Fidelity: doing what you promised the patient Justice: equality across all boundaries CAPACITY COMPETENCY Task specific Global Clinical determination Legal determination Waxes & wanes Global Patient must understand: 1. Nature of intervention 2. Risk/benefits 3. Alternatives Anytime you think patient doesn’t understandàknow their capacity Ethics Committees o Advisory services designed to assist patients, families, & health professional in identifying, analyzing, & resolving ethical dilemmas o Interdisciplinary o Confidential o In most institutions anyone can call an ethics consultation Euthanasiaàillegal everywhere, patient is “killed” Assisted Suicideàhelp patient to kill themselves, legal in 5 states o Nurses should promote comfort & relieve suffering even if death hastened o Withholding/withdrawing can be ethically acceptable o Nurses should seek to understand request for assisted suicide o Nurses should create environment where patient can feel comfortable expressing their thoughts o Get help for pain & symptom management Many patients have an issue of control: fear of pain, uncontrolled symptoms, loss of dignity, being a burden Palliative Care o Focus on Quality of Life o Pain & symptom management (throughout treatment) o Aligning goals with treatment o Interdisciplinary team o Given at any point in illness along with active treatment o Almost anyone with a chronic illness can benefit from palliative care o It works...when people feel better they do more for themselves Hospice Care o Medicare benefit o Care provided in the last 6 months of life Care of an Actively Dying Patient: o Change in Rhythm of Care • More intensive care o Change in Goals of Care o Shift in Focus of Care • More about quality of life • Focus on existing or new symptoms • Initiation of new measures for comfort • Discontinuing non-essential treatment • Family needs may become more pronounced o Change in priorities • Life prolonging treatments • Vital signs • Diagnostic tests • Fluid & nutrition • Medications (re-evaluate) • Increased focus on family!
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Nursing response • Validate • Normalize • Intervene Signs of Pending Death • Cold, mottled, clammy skinàbody shunting blood from extremities to brain & heart • Cyanosis • Changes in breathing pattern (Cheyne-Stokes) Ø Periods of rapid respirations followed by apnea Ø Oxygen Ø Opioids Ø Fan Ø Family education Ø Morphine (for respiratory distress or dyspnea) • Decreased LOC • “Death Rattle” Ø Noisy secretionsàsaliva on voice box, sounds worse than it feels Ø Raise HOB Ø Positioning Ø No deep suction Ø Anticholinergic Ø Glycopyrrolateàto dry up secretions • Agitation Ø Address causes (ie: pain, urine retention) Ø Palliative sedation Ø Anti-psychotics (Haldol or Ativan) • Some may die with eyes openàloss of subcutaneous fat or blink reflex Ø Eye drops to prevent dryness • Decreased PO intake Ø Oral care at end of life is essential! Ø Avoid IVs/hydrationà3rd spacing can occur where fluid in vessels leak into tissue = increased secretions, increased incontinence, edema, etc.-->substitute with other “caring” habits (ie: do hair, massage, oral care) Emotional-Spiritual Symptoms • Withdrawal Ø Some family members experience loss of intimacyàtell them its okay to touch them Ø We believe hearing is the last to go…encourage family to speak to the patient even if he/she cannot respond • Letting go: Restlessness • Visions • Saying Goodbye Cultural Competence Ø Self-reflection…how do you view this issue? Ø Identify & integrate knowledge of most common cultural groups in your practice Cultural Humility Ø Commitment to self-reflection & self-critique Ø Developing mutually beneficial, respectful partnerships Ø Is there anything about your culture/religion that would help me take care of the patient? The Death Vigil • Family presence • Common fears Ø Being alone with patient Ø Time of death: how do you know death has occurred Ø Missing the moment When Death Occurs… • Cessation of integrated tissue & organ function manifested by lack of heartbeat, absence of respirations, or irreversible brain dysfunction • No pulse • No respirations • Fixed & dilated pupils • Relaxation of muscles & sphincters • Eyes may remain open, jaw may drop
