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Module 7 > End Of Life In The Critical Care Setting > Flashcards

End Of Life In The Critical Care Setting Flashcards

1
Q

What is still important at the end of life?

A

Human touch

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2
Q

If a pt comes in with delirium .. what do we assess?

A

Assess for cause ( can be reversible)
Assess for pain, constipation , urinary retention

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3
Q

If pt can’t talk how can we assess for pain?

A

Vitals
Facial expression
Restlessness
Moving , fidgeting

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4
Q

Psychological signs of EOL

A

Delirium
Anxiety & fear
Life review
Visions- air picking
Withdrawal
Waiting for approval
Saying good bye

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5
Q

Cardiovascular and respiratory signs of EOL

A

Tachy then Brady , irregular
Dyspnea
Weak pulse
Decrease BP
Delayed absorption of drugs
Cheyne strokes
Terminal secretions, gurgling
Cold feet ( lack of pulses in pedal about 3 days before death & radial sometimes day before)

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6
Q

If a pt is full code and they stop breathing - what do we do?

A

CPR, ventilation

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7
Q

Which drug route of administration especially have delayed absorption

A

IM or SUB Q

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8
Q

Most pt do have a peripheral line or picc .. what do we do if they dont have it?

A

Use a butterfly and place in the subq .. and put in morphine if needed for pain but Becareful because they have delayed absorption

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9
Q

Cheyne stokes

A

Stop breathing for a minute then take a deep breath

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10
Q

Interventions for terminal secretions , gurgling

A

Don’t sunction
Opt for anticholinergic- Benadryl ( if they can take oral ) , Claritin ,

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11
Q

Drugs given for terminal secretions or gurgling

A

Anticholinergics such as Benadryl (diphenhydramine), zertec , Claritin

Diphenhydramine can be given PO if they take it or IV
IM too but be careful with absorption

Sit them up and turn them on their side

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12
Q

What intervention can we do if a pt is in the middle of a Cheyne stoke to see if they are gone or just need to be stimulataed?

A

Sternal rub

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13
Q

Last thing to go as far as sensory

A

Hearing

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14
Q

Sensory issues as far as site

A

Blurred vision, blink reflex absent , eyelids stay half open

Can put something easy over eyes to close them
Teach the family this can happen

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15
Q

Other sensory issues in EOL

A

Taste and smell -decreased
Touch -decreased

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16
Q

Even though touch is decreased what do we encourage

A

Human touch

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17
Q

Pain in EOL

A

Facial grimacing
Restless, tense
Attempts to sit up
Pulls at lines
Muscle rigidity or tension
Moaning
Crying , sobbing

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18
Q

In EOL the skin is cold , clammy and mottling.. what causes this

A

Perfusion issues

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19
Q

In the musculoskeletal system in EOL care the pt has a loss of ability to move. If the pt is stable what can we do?

A

ROM

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20
Q

What causes myoclonus

A

Build up of opioids due to lack of body metabolizing them.. watch for twitches when pt has morphine.. may indicate need to change medication

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21
Q

Gastrointestinal changes in EOL

A

Hypoactive /absent BS
Distention
Constipation
N&V ( if eating)
Bowel incontinence

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22
Q

Genitourinary changes in EOL

A

Oliguria
Anuria
Incontinence

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23
Q

Pulses in EOL

A

Weaker typically in bottom
So get Doppler to hear pulses and assess if feet are cold..

3 days before death no pulses in foot and typically one day before death no radial pulses but that depends on

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24
Q

Brain death

A

No function to the brain due to stroke, trauma, herniation or sudden cardiac arrest

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25
Q

What does the brain stem control

A

Breathing
Body tempt
Digestion
Alertness
Sleeping
Swallowing

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26
Q

When they determine brain death.. what day is that considered ?

A

The day of death

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27
Q

So when a trauma occurs that leads to brain death .. what happens

A

Leads to increase ICP causing brain herniation , effecting the brain stem

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28
Q

Criteria for brain death

A

GCS -<8 (coma or unresponsive)
A sense of brain stem reflexes
Apnea

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29
Q

The brain stem reflexes that are absent is brain death

A

No cortisol brain function
Pupillary responses absent (noreaction)
Gag reflex absent

30
Q

Apnea in brain death

A

Can be slow and shallow but can’t sustain life on its own
Increase Paco2 and decrease paO2

31
Q

Process of assessing apnea for brain death

A

Pt is on a ventilator
Pre oxygenate For 30 min
Get them in normal level ( paco2 &pao2)
Shut off ventilator
Take ABG
If paco2 is up and o2 is down they are considered apnic

32
Q

Criteria prior to brain death diagnosis

A

Normothermic 98.6-100.5(cool them down or warm them up)
SBP WNL (above 90)
Free from sedation or paralytic
Metabolic issues excluded as a factor

33
Q

Why is it important for pt to be off sedation or paralytic before brain death diagnosis

A

To make sure that they really are comatose on their own and without drugs

34
Q

Why is it important to rule out metabolic issues like DKA before a brain death diagnosis

A

Someone with DKA can be comatose as well so we should make sure they dont need insulin or something

35
Q

Test to determine brain stem function

A

Vestibulo ocular reflex
Oculocephalic reflex

36
Q

Vestibulo-ocular reflex

A

They shoot water into the ear and the eyes move to the side of the water injection - which shows present. Or positive reflex

Absent reflex - eyes stay fixed midline

37
Q

Oculocephalic reflex

A

Doll eyes
Head rotates one way eyes rotate the opposite ( positive , normal )

Absent- eyes stay fixed and midline

38
Q

Vestibulo-ocular reflex
And Oculocephalic reflex is done by who

A

A physician

39
Q

What must be cleared before test to determine brain stem function

A

C -spine

40
Q

Who can donate organs ?

A

Living relative
Living unrelated
Deceased unrelated - most common

41
Q

Organs that can be donated

A

Heart , lungs, kidneys, pancreas, liver, intestines .

42
Q

What is important to keep in mind when you have a pt on a ventilator who is an organ donor

A

They remain full code.. so we do CPR and must stay on ventilator until surgery..
maintain hemodynamics
Normothermic

43
Q

How can we assist with tissue perfusion for a pt on life gift

A

Fluid and vasopressor

44
Q

Tissues that can be donated

A

Corneas, skin, heart valves, bone, blood vessels, connective tissue

45
Q

Important to remember for tissue donation

A

Can be donated after cardiac death
Does not need to be on ventilator

46
Q

Factors that play a part organ and tissue donation

A

Geography ( organ)
Body size
Blood type
Medical urgency
Transplant team evaluate the med history of the donor

47
Q

What factors do NOT play part in tissue and organ donation?

A

Race, gender, or financial status

48
Q

Test used to assess organ function

A

Check kidney function
Type and cross match
Leparcopic (lungs)
Check tissue perfusion

49
Q

Opiates

A

Help with pain and comfort in EOL

50
Q

Antipsychotic used

A

Haldol ( haloperidol)
Used if pt is restless

51
Q

Antimetic used in EOL

A

Ondansetron

52
Q

Antipyretic used in EOL

A

Acetaminophen

53
Q

Why are benzo used in EOL

A

For anxiety

54
Q

When is blood transfusion d/c

A

During the withdrawal of life sustaining treatments

55
Q

Respiratory devices d/c in withdrawing life sustaining treatments

A

Ventilator
CPAP
Bipap

56
Q

How do you stop the shock with a implanted defib

A

Place a magnet over it

57
Q

Nutrition d/c when withdrawing life sustaining treatments

A

Enteral and tpn

58
Q

Why is CRRT and telemetry removed when withdrawing life sustaining treatments

A

It removes waste and potassium making it life sustaining

Telemetry - may want to shock if pt goes into a fib or vtach

59
Q

WOC

A

Withdraw of care

60
Q

What is imporant to document as well

A

Notes
Summary of day
Pt and family understanding
Pt level of comfort
Meds
Life sustaining treatment withdrawn of scare
Time of pt death

61
Q

Example of notes about med admin and pain level of pt

A

Pt was restless and fidgety , had a grimace on there face so i went ahead and medicated them..

62
Q

Example of documenting with drawn of care in notes

A

Pt taken off ventilator at 11:05 PM
Pt had 5 minutes of slow and shallow breathing
Time of pt death( you can’t pronounce death w/o proper training)

  • paint a picture of it
63
Q

Advance directive

A

Your voice when you can’t talk
Allows someone your wishes if you can not talk or speak for yourself

64
Q

Allow natural death (AND)

A

Palliative team coming in and withdrawing care and allowing the pt to die naturally

Can be on comfort measures like pain meds
But wont be on any large dose of profofol

65
Q

Do not resuscitate

A

Can still do anything except if they go into cardiac or respiratory arrest ( so no vent or cpr)

No advance life saving efforts

66
Q

Euthanasia

A

Physician assisted suicide
Nurse code of ethics prevents us from causing death to pt

67
Q

ED is not out pt t or f

A

False

68
Q

If someone comes in through ED and does not have out of hospital DNR presented what happens

A

They will perform CPR

69
Q

In the community what happens if pt does not present DNR

A

Have to perform CPR

70
Q

Ethical issues

A

Principles violated
No family present
Pt cannot communicate words
Families want to continue futile care

Module 7 (24 decks)

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