Dehydration, Palliative Care and Pain Management Flashcards
(40 cards)
Dehydration
A “loss or removal of fluid” from the body and occurs when fluid intake fails to fully replace fluid losses, fluid or electrolyte imbalance
Risk Factors for Dehydration in Older Adults
a. gender
b. cognitive impairment
c. malnutrition
d. functional (decreased mobility, reduced swallowing)
e. environmental (access, warm temperature)
f. medications (laxatives, diuretics)
g. pain
h. social (lack of attention to drink preferences)
i. institutional factors (untrained staff)
Age related Factors for Dehydration in Older Adults
a. kidney function - decline
b. reduced thirst response
c. reduced body water content (41L/70kg > 35L/50kg)
d. fear of incontinence
e. reduced lean mass
Significance of Dehydration
Causes
- fever, vomiting, diarrhea
Effects
- hypovolemia, electrolyte balance disruption
Consequences
- hypovolemic shock
- delirium
- severe dehydration
- falls»_space; fractures
- death
Reasons for Inadequate Fluid Intake
Can drink: lack of access, dementia
Can’t drink: NPO, dysphagia
Won’t drink: fear of incontinence or poisoning
End of life: part of palliative care
- reduce edema, incontinence and lung mucous secretion
Health Consequences of Dehydration
- heart disease
- confusion
- constipation
- kidney failure
- poor wound healing
- infections
- seizures
- drug toxicity
Constipation
Infrequent/hard to pass bowel movement, fewer than 3 defecations per week
Most commonly caused by dehydration
Signs and Symptoms of Dehydration
a. Missed some drinks between meals
b. Expressed fatigue
c. Blood labs showing high sodium or glucose
traditional signs should not be relied on (fluid intake, urine colour, dry mouth)
Severity of Dehydration
Mild: headache, fatigue, weakness, dizziness, leg cramps, lethargy
- exhaustion and mood changes
Moderate: sticky or dry mouth, decreased skin elasticity, pallor
Severe: fever, confusion (delirium), kidney failure, UTI, low BP, convulsions, severe cramping
Interventions for Dehydration
Drinking water (but does not replace electrolytes)
IV fluids a. 0.9% NaCl, isotonic (raise blood volume) b. RL for acidosis KCl for alkalosis (correct pH imbalances) c. d5w (protein-sparing, glucose drip)
Prevention!! - identify risk
a. Dehydration Risk Appraisal Checklist
b. drink in AM, throughout the day, half your fluid intake, full glass with meds
Take Away: H2O
H = identify those at High risk 2 = causes: inadequate fluid intake and excessive fluid loss O = offer fluids
Myths about Palliative Care
- only for those who are recognized as approaching end of life in days to weeks
- cause increase in anxiety and depression
- a passive approach that involves limited assessment and intervention
- can only be delivered on a palliative are unit or hospice setting
Palliative Care
An approach to care that aims to relieve suffering and improve the quality of living and dying in those diagnosed with life threatening and life limiting illness
- in does not hasten death
- avoid inappropriate treatment or suffering
- applicable to all ages
- should be provided by the doctors that have been following the patient: GP, specialist, etc.
The Approach of Palliative Care
a. quality of life
b. symptom management
c. preserving dignity
d. advanced care planning and treatment decisions
e. exploring wishes, values and personhood
f. discussing and preparing for end of life
g. ethical and moral problem solving
h. assessing and managing grief
i. care for the caregiver
Geriatric Palliative Care
Integrates the complementary specialities to provide comprehensive are for older patients entering the later stage of their lives and their families
Advanced Care Plannning (ACP)
a. reflecting on and communicating about one’s values and wishes for future health and personal care
b. identifying person who can make decisions regarding one’s health if one lacks the capacity to make decisions
It is NOT: a single convo, a code discussion, or set in stone!
Establishing Goals of Care (setting priorities)
Ongoing discussion that should occur when individuals are well enough to articulate their wishes
“What would be important to you if you had an advanced incurable illness?”
“What goals do you have for the time you have left?”
POA
SDM
Power of Attorney
Substitute Decision Maker
DNR
CMO
AND
EDITH
Do Not Resuscitate
Comfort Measures Only
Allow Natural Death (proposed alternative to DNR)
Expected Death in the Home
SMK
FTC
Symptom Management Kit
Failure to Cope
Diagnosis and Prognosis
Prognosis depends on diagnoses and existing comorbidities
Prognostication is not an exact science, time frames are given in ranges (3-6 months)
Palliative Performance Scale
PPS 70% - significant disease (palliative care introduced)
PPS 50% - mainly sitting or lying
PPS 30% - bed bound, steep decline
PPS 10% - imminent death
Gold Standard Framework
Assists in the early identification of patients who would benefit from a palliative approach to care
Provides guidance on prognostication
- surprise question
- general indicators of decline (deterioration, decrease response to tx)
- specific clinical indicators (COPD, frailty, dementia)
Illness Trajectories
a. Cancer trajectory
high function for most duration and steep decline before death
b. Organ System Failure
constant dip and rise, each recovery is weaker, risk of sudden death
c. Frailty/dementia
extremely slow and long
