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Flashcards in management of selected non pain II Deck (25):
1

preparing for the last hours of life

- time course unpredictable
- any setting that permits privacy, intimacy
- anticipate need for medications, equipment, supplies
- regularly review the plan of care

2

Common signs and symptoms of imminent death (1-3 months)

- withdrawal from the world
- turning inward
- less communication with the world
- increased reflection
- decreased nutritional intake

3

Common signs and symptoms of imminent death (1-2 weeks)

- altered states of consciousness
- dreams/visions/conversing w seen/unseen
- maybe restless/agitated/wanting up/down
- may want to remove clothing
- maybe quiet/resting deeply
- eyes appear unfocused/dreamy
- sleeping/waking hours prolonged
- not eating/maybe drinking
- then may request an occasional meal

4

common signs and symptoms of imminent death (days to hours)

- maybe surge in energy
- breathing grows shallower in chest
- maybe apnea (up to 60 seconds)
- gurgling (throat)
- eyes maybe teary or dry/shinny
- eyes may remain open/not blink
- skin grows dusky/blotchy
- little observable response to outside environment

5

physiological changes during the dying process

- increasing weakness, fatigue
- decreasing appetite/fluid intake
- decrease blood perfusion
- neurological dysfunction
- pain
- loss of ability to close eyes

6

ICHABOD syndrome

- I = immobility
- C = confusion and coma
- H = homeostatic failure
- A = anorexia
- B = breathing changes
- O = oral intake decreased/observation
- D = dyspnea/detachment

7

weakness/fatigue

- decreased ability to move
- joint position fatigue
- increased risk of pressure ulcers
- increased need for care
--> activities of daily living
--> turning, movement, massage

8

decreased appetite/food intake

- fears: giving in, starvation
- reminders:
--> food may be nauseating, anorexia may be protective, risk of aspiration, clenched teeth express desires, control
- help family find alternative ways to care

9

Body shutting down vs starvation

- BODY SHUTTING DOWN (dehydration)
--> loss of body fluids/electrolyte changes
--> decreased blood flow/oxygen to GI tract
--> absence of hunger sensation
- STARVATION
--> lack of nutrition
--> physiological homeostasis
--> hunger

10

Locus of sensation

- Thirst and taste are in mouth (keeps lips and mucous membranes; taste has a lot to do with smell)
- Hunger is in stomach (note impact of altered O2 and blood flow)

11

Decreasing fluid intake

- oral rehydrating fluids
- Fears: dehydration, thirst
- Remind families, caregivers
--> dehydration does not cause distress
--> dehydration may be protective
- Parenteral fluids may be harmful
--> fluid overload, breathlessness, cough, secretions
- Mucosa/conjunctiva care (keep them moist)

12

decreasing blood perfusion

- tachycardia (try to keep up), hypotension (blood pressure can't be maintained)
- peripheral cooling, cyanosis
- mottling of skin (lacing pattern)
- diminished urine output (not good blood flow to kidneys)
- parenteral fluids will not reverse

13

Neurological dysfunction

- decreasing level of consciousness
- communication with the unconscious patient
- terminal delirium
- changes in respiration
- loss of ability to swallow, sphincter control

14

Two roads to death

- Normal = sleep > lethargic > obtunded > semicomatose > comatose > death

- DIFFICULT = restless > confused > tremulous > hallucinations > mumbling delirium > myoclonic jerks > seizures > semicomatose > comatose > death

15

decraesing level of consciousness

- the usual road to death
- progression
- eyelash reflex

16

Communication with unconscious patient

- distressing to family
- awareness > ability to respond
- assume patient hears everything
- create familiar environment
- include in conversations (assure of presence, safety)
- give permission to die
- touch (some want it others don't)

17

Terminal delirium

- the difficult road to death
- medical management (benzodiazepines, neuroleptics)
- Seizures
- Family needs support, education (more help after death)

18

Changes in respiration

- altered breathing patterns
- diminished tidal volume
- apnea (up to 60 seconds)
- cheyne-stokes respiration
- accessory muscle use
- last reflex breaths (gasping)
- FEARS: suffocation
- MANAGEMENT: family support, oxygen may prolong dying process, breathlessness

19

loss of ability to swallow

- loss of gag reflex
- build up of saliva, secretions
--> scopolamine to dry secretions
--> postural drainage
--> positioning
--> suctioning is rarely indicated

20

loss of sphincter control

- incontinence of urine, stool
- family needs knowledge, support
- cleaning, skin care
- urinary catheters
- absorbent pads, surfaces

21

pain in the last hours of life

- Fear of increased pain
- assessment of the unconscious patient
--> persistent vs fleeting expression
--> grimace or physiologic signs
--> incident vs rest pain
--> distinction from terminal delirium
- management when renal clearance decreased
--> stop routine dosing, infusions
--> breakthrough dosing as needed (prn)
--> least invasive route of administration

22

loss of ability to close eyes

- loss of retro-orbital fat pad
- insufficient eyelid length
- conjunctival exposure
--> increased risk of dryness, pain
--> maintain moisture

23

medications

- limit to essential medications
- choose the least invasive route of administration
--> buccal mucosal or oral first, then consider rectal
--> subcutaneous, intravenous rarely
--> intramuscular almost never

24

Dying in institutions

- home like environment
- continuity of care plans
- avoid abrupt changes of setting
- consider a specialized unit

25

Laying out the body

lay the body out with the arms across the chest and the jaw closed before rigamortus sets in