All About Nursing · Hospice & Palliative Care

Reading and Sharing My Notes (3)

  • Risk factors for complicated grief include a history of mental illness, substance abuse, previous loss, and sudden unexpected death. Medicare pays for bereavement counseling for up to 1 year after the patient’s death. Additional grief counseling would then be through a local support group. Studies have shown that men are less likely than women to openly express emotions or openly cry. This is felt to be a reflection of social norms for males having to show strength, and crying being perceived as a sign of weakness. Men often prefer to grieve alone or in private.
  • Portal hypertension often occurs in the presence of cirrhosis. Increased intrahepatic vascular resistance, and increased blood flow through the portal venous system, leads to the development of portosystemic collateral veins. With medium to large veins in the esophagus, the patient has up to a 30% chance of bleeding out within 2 years.
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All About Nursing · Hospice & Palliative Care

Reading and Sharing My Notes (2)

  • Hospice eligibility for dementia requires stage 7C or below according to the FAST scale (this means the patient is unable to ambulate without assistance, unable to dress or bathe without assistance, has urinary and fecal incontinence, and cognitive function has declined to the point where the patient can speak fewer than 6 words), as well as one or more qualifiers such as aspiration pneumonia. A decline in memory has to be substantiated by a demonstration of cognitive ability, such as verbal articulation. Inappropriate behavior such as hitting or acting out, does not neccessarily mean the patient has less than 6 months to live, nor do repeated UTIs.
  • Brain atrophy is part of normal aging, but the rate of atrophy is accelerated in individuals with Alzheimer’s disease. Studies have found patients with Alzheimer’s disease can have 3 to 4 % brain loss in a year, whereas loss of brain tissue secondary to atrophy with normal aging was < 1% a year.
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All About Nursing · Hospice & Palliative Care

Reading and Sharing My Notes (1)

  • Refractory or intractable symptoms are those that cannot be managed, even with agressive treatment. Often, for symptoms that multiple approaches have been used to manage symptoms and have failed, may require transferring the patient to an inpatient hospice facility.
  • Pain management in cancer patients is an important goal of care. Pain presents differently depending on the type of cancer. Usually, as the disease progresses, the patient increases, requiring more opioid management, as well as rotations to different opioids. Tumors can compress or stretch various organs, invade bone, or press on nerves. All of these require a different approach for pain management and should be investigated if the patient has a diagnosis of cancer.
  • Signs of pain in the cognitively impaired is demonstrated by facial expressions such as frowning or grimacing, vocalizations such as moaning, body movements such as guarding or rocking, changes in interpersonal interactions such as resisting care, becoming aggressive or withdrawn, and changes in activity patterns such as appetite or sleep changes. The combination of symptoms is more suggestive of pain, than depression or anxiety.
  • The PAINAD scale is used in advanced dementia by rating breathing, negative vocalization, facial expression, body language, and consolability.
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COVID-19 (Reading & Sharing)

Figure is Ultrastructural morphology of SARS-Co V-2

Pathophysiology of COVID-19 Infection:

SARS-CoV-2 is a single-stranded RNA virus that belongs to the Orthocoronavirinae subfamily. It consists of 16 nonstructural proteins and 4 structural components: spike glycoprotein (S), envelope protein, membrane glycoprotein, and nucleocapsid phosphoprotein (N). However, the viral types can differ across infections at different times and at least 116 mutations have been identified. The S proteins are chritical for binding to the host cell surface receptors, whereas the N proteins are essential for viral survival and expansion.

SARS-CoV-2 is transmitted through exposure to respiratory droplets from a person with COVID-19 that are inhaled or deposited on the host’s mucous membranes. Respiratory droplets may be airbone or can land on surfaces and objects, which when exposed to a host cell with the entry receptor ACE2 (angiotensin-converting enzyme 2) in the presence of TMPRSS2 (transmembrane protease serine 2) interacting with its spike protein to gain entry. Upon binding to the ACE2 receptor, the SARS-CoV-2 spike protein is activated through proteolytic cleavage by TMPRSS2, inserted into the cell membrane, and fuses the viral and cellular membranes so that transfer of the viral RNA into the host cell cytoplasm can occur, followed by viral replication. In addition to varying entry routes into host cells, questions remain regarding how SARS-CoV-2 gains access into the central nervous system (CNS), referred to as neurotropism or the ability to infect nerve tissue. The nasal-olfactory nerve route, blood-nervous stem barrier breakdown, blood-nerve barrier or blood-cerebrospinal fluid barrier permeability, lymphatic drainage system of the brain, retrograde transmission from the enteric, lung, or kidney nerve routes, or macrophage/ monocyte cargo routes have all been suggested pathways by which the SARS-CoV-2 virus reaches the CNS.

For now, general precautions (masks, social distancing, and frequent handwashing) remain in place to control the virus, as COVID-19 vaccinations are taking place worldwide. Testing for COVID-19 infection remains a critcal component of the COVID-19 detection and surveillance efforts.

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All About Nursing · Hospice & Palliative Care · Nursing Continue Education

Delirium in Dementia (Reading & Sharing)

Delirium is defined as an acute change in attention and cognition with the hallmark pattern of waxing and waning behaviors. Anyboy with a preexisting functional or cognitive impairment is at higher risk for develiping delirium, and the diagnosis of delirium in persons with dementia is commonly missed by clinicians because the presentations are mistakenly perceived as being part of the chronic day-to-day confusion of dementia or attributed to behaviors labeled as sundowning. Dementia increases the risk for delirium, and “sundowning” syndrome is frequently associated solely with dementia.

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