pbl lobs Flashcards
(133 cards)
clinical abnormalities of refeeding syndrome
hypomagnesiaemia, hypophosphataemia, hypokalaemia, and abnormal fluid balance
what are the higher risks of refeeding syndrome:
lower BMI than 18.5
higher BMI than 18.5
chemotherapy
little nutritional intake for more than 10 days
unintentional weight loss more than 10% in 3-6 months
high risk:
BMI lower than 16, unintentional weight loss 15% in 3-6 months, little nutritional intake more than 10 days.
low risk:
BMI lower than 18.5, unintentional weight loss 10% in 3-6 months, little nutritional intake in more than 5 days, alcohol abuse, chemotherapy, insulin, diuretics
What is the management for refeeding syndrome
if the patient has not been eating for more 5 ore more days, aim to re-feed at no more than 50% of daily requirements for the first two days
What layers do you cut through during a tracheostomy
skin, subcutaneous fat, platysma muscle, thyroid, trachea
What is the location of a emergency cricothyroidotomy
cricothyroid membrane
What is the location of a tracheostomy
1-2cm inferior to the cricoid cartilage, between the 1st and 2nd tracheal ring
What are the indications for a tracheostomy
cannot intubate or ventilate, laryngeal cancer or upper airway obstruction, pulmonary lung disease.
What are the precautions for a tracheostomy
generally suctioning of secretions in the airway, humid airway and maybe a damp gauze in the hole
two differences between cricothyroidotomy and a tracheostomy
1) one is in the cricothyroid membrane and other between the 1-2nd ring. 2) tracheostomy needs general/full anaesthesia
What are the clinical features of upper airway obstruction
dysphagia, marked rep distress, inspiratory stridor, voice change, reduced breath sounds and tachycardia
complications of tracheostomy
infection, collapsed lung, blocked tracheostomy tube
what is a stridor
an high pitched inspiratory stridor suggestive of a tracheal or main bronchi obstruction
presentation of oral cancer
recurrent mouth ulcers that do not heal, lumps in the neck or mouth that do not go away, dysphagia, unintentional weight loss,
what is the needle and fluid is inserted into the neck for in a tracheostomy
needle is inserted into the space, apply negative pressure on the syringe and if air is found you are in a trachea
risk factors for laryngeal carcinoma
smoking tobacco, drinking above the alcohol limit, unhealthy diet with low fruits and vegetables, exposure to asbestos and coal dust and stong family history
Describe the social and historical developments that
have brought about changes in the meanings
associated with death and dying in contemporary
society
In many of the more traditional societies that continue
to exist around the world, the social processes
associated with dying and death remain culturally‘well
scripted’.
This generally involves a distinct set of funeral rites
and mourning customs which serve to facilitate
the‘social death’ of a person following their ‘biological
death’.
However, in modern high-income societies, this
intimate link between the biological and social death
of individuals has over time become more tenuous.
In the past, death typically came suddenly, resulting
from traumatic injuries or acute infectious disease.
However, with rising standards of living in the UK, with
improvements in public health infrastructures, and
more effective biomedical therapies, people began to
enjoy longer lives.
As a consequence, the meanings and practices
associated with many traditional death rites in the UK
gradually lost much of their power.
Death now typically comes after the prolonged
deterioration associated with chronic diseases in latter
life.
This epidemiological shift has reversed the
traditional sequence: now social death typically
precedes biological death.
The “work” of separating the dying from society
within hospitals and nursing homes, now routinely
occurs well before an individual’s definitive
biological death.
Without what anthropologist’s term the ‘sheltering
canopy’ of cultural customs associated with death
and dying, the individual and their family can find it
difficult to achieve a satisfactory separation before
and after biological death.
In such circumstances the lack of a cultural
script for dying, results in what has been
termed ‘disorderly deaths’, that is made all the
more painful because they typically occur in our
temples of hope - the modern hospital
(Joralemon:2002).Since the pre-modern period, much more rigid corporeal
boundaries now exist, both symbolic and actual, between
the dead and the living.
This in part reflects the decline in the importance of the
sacred within modern secular societies, where death is
generally perceived as separated from life.
It also reflects the decline in personal exposure to death
and dying associated with the ‘epidemiological transition’
(death occurring predominantly in later life and from chronic
disease).
This decline in the culture of mourning in modern societies
has had important personal and social consequences for
the process of grieving for the death of a loved one.
Describe the social and organisational processes that
are associated with the ‘medicalisation of death’
construct.
One of the major outcomes of this process of medicalisation
is termed iatrogenesis.
‘Clinical iatrogenesis’ refers to the potentially detrimental
consequences of medical interventions, but the process of
iatrogenesis goes beyond clinical interventions, and
involves the broader social and cultural spheres of life.
The latter process is termed ‘cultural iatrogenesis’, and
refers to the way in which biomedical accounts serve to
undermine people’s ability to manage their own health, as
well as their autonomy in coping with pain, suffering, and
death. Leading to an ever greater reliance on medical
intervention to solve these issues.
Related critical constructs such as ‘over-treatment’ and
‘heroic medicine’ also reflect this position that the
institutional focus on clinical intervention and treatment has,
until the recent past, too often blinded the medical
profession to attending to the needs of the dying patient.
That is, dying has too often been confused with illness
within the hospital environment.
Hospitals seen as the institutional expression of the
modern desire to remove evidence of sickness and
death away from the public gaze (Mellor and
Shilling:1993).
Bauman (1992) has argued that the nosologies
(classification of diseases i.e ICD-10) of biomedicine,
have inadvertently reduced death to nothing more than
a series of pathological anatomical and physiological
processes.
This perspective sees the biomedical model as
inadvertently generating the illusion that death can
somehow be controlled.
Outline the meaning of the concept of the ‘good death’.
(1) Awareness of Dying: A personal and social process
of greater openness about the prognosis of an illness
where it known that there is a high probability of death.
(2) Personal preparations and social adjustments: An
enablement of the settling of‘emotional accounts’.
(3) Public preparations: sorting out wills, putting practical
affairs in order.
(4) The relinquishing, where appropriate of formal work
roles. Too often it is automatically assumed that dying
individuals are beyond the age of retirement. This is
not the case with AIDS and forms of CHD and Cancer.
(5) A Good death involves formal and informal farewells.
However, because a ‘Good Death’ involves the
gradual withdrawal from an individual’s social roles
and responsibilities, it requires the involvement of
other’s, family, friends, as well as appropriate
professional support.
In doing so, it shifts death and dying from the
private to the collective sphere, thereby promoting
the social role of death in all our lives
However, because a ‘Good Death’ involves the
gradual withdrawal from an individual’s social roles
and responsibilities, it requires the involvement of
other’s, family, friends, as well as appropriate
professional support.
In doing so, it shifts death and dying from the
private to the collective sphere, thereby promoting
the social role of death in all our lives.
Outline the distinction that is drawn between ‘social’
and biological’ death.
In many ways, the origins of what was to become the
ideology of the ‘good death’ go back to the1960s and
the beginning of what became known as the ‘hospice
movement’.
It was charitable organisations that first established
hospices as institutions for effective end of life care,
outside of the organisation of the NHS.
Hospices sought to give more autonomy to the dying.
This involved proactive symptom management, and
attention to the religious, social and psychological
needs of the dying to achieve the normative goal of
accepting impending death.
The hospice movement sought to ‘de-medicalise’ the
dying process and challenge the practices of clinical
professionals which frequently led to the isolation of
the dying patient within hospital.
Whereas, hospice care was once on the periphery of health
care practice in the UK, it now constitutes part of a the much
wider shift in attitudes towards death and dying (discussed
above).
The success of hospices led directly to the development of the
palliative care medicine specialism, and an associated shift in
professional practice.
Professional attitudes have changed, with much greater
emphasis now placed on the emotional and psychological
dimensions of the experience of dying.
The ‘medicalisation’ of death approach has become much less
pervasive in health care systems (Timmermans:2005).
To the extent that the debate about the rights of individuals to
‘Assisted dying’ (voluntary active euthanasia and physician-
assisted death) has now opened up across European health
care systems
define CPR
This is an emergency procedure for people
in cardio-respiratory arrest.in cardio-respiratory arrest.
define DNACPR
Do Not Attempt Cardio Pulmonary
Resuscitation document states
resuscitation should not be attempted if a person suffers cardio-respiratory arrest..
It is not legally binding if only a DNACPR document is
present
An advance refusal of treatment (a legally binding advance decision) can give DNACPR legal grounding
Outline the need for a DNACPR
CPR is unlikely to be successful (“futility”)
The patient is mentally competent and does not want
to be resuscitated
Patient lacks capacity but has a legally valid advance
directive stating that they do not want CPR
Resuscitation is not in the best interests of the patient because the quantity and/or quality of life of the
patient following CPR is likely to be short/poor
DNACPR & Competent Patients
It has long been recognised that competent adultsIt has long been recognised that competent adults
have the legal & ethical right to refuse treatment.have the legal & ethical right to refuse treatment.
This right includes theThis right includes the right to refuse life savingright to refuse life saving
treatment.treatment. Thus competent adult patients have theThus competent adult patients have the
legal & moral right to refuse CPR and demand alegal & moral right to refuse CPR and demand a
DNACPR order.DNACPR order.
This right to refuse consent to treatment is vital toThis right to refuse consent to treatment is vital to
protect patientsprotect patients autonomyautonomy..
DNACPR & Incompetent patients
Where patients are incompetent, physicians must
Where patients are incompetent, physicians must
decide whether to issue a DNACPR order on the
decide whether to issue a DNACPR order on the
basis ofbasis of best interestsbest interests - MCA (2005)- MCA (2005)
Questions:Questions:
Can it ever be in a patient’s best interests not toCan it ever be in a patient’s best interests not to
be resuscitated?be resuscitated?
Is this the same as saying that it is in theIs this the same as saying that it is in the
patient’s best interests to die?patient’s best interests to die?
