1. What does the Classification of Pain include? 2. What steps of Pain Assessment do you know? 3. What special scales for Pain Assessment are used for children? Which non-opioid analgesics are used at the end of life? 4. Give a list of side-effects of opioids. 5. Which alternative methods of pain management do you know? 1. How to do the ESAS-r and who should do the ESAS-r? 2. Describe the management of the Dyspnea. 3. Compare, please, two psychological symptoms: depression and delirium. Which condition of a patient needs the first nurse care? 4. List and describe the Common symptoms related to malaria 5. Give the answers to the Discussion questions of Case Study #1 and #2 (presented in the Methodological instruction). Case Study #1 Mr. Hayes: Cough/Diarrhea/Agitation Mr. Hayes is a 53-year-old with widely metastatic colon cancer, which has spread throughout his abdomen. He arrives on your unit with a chief complaint of intractable nausea and vomiting for 24 hours and diarrhea (1000 cc emesis and 400 cc diarrhea in the past 24 hours). He describes that he is barely capable of managing any activities of daily living. Mr. Hayes has been found to have a non-resectable partial small bowel obstruction. The patient asks, ″How much longer do I have?″ and ″Can we speed this up?″ “I don’t want my children (ages 11 & 13) to see me like this.” The patient admits to feeling down but denies any ideas of suicide. He is clearly anxious about becoming a burden to his family and wonders how his children see him. His 13 year-old daughter confides in you that she is “afraid” her daddy is going to die. He is a devoutly religious man and mentions to the night shift staff that he is certain his symptoms and suffering are a punishment for his having a divorce ten years ago. He says to the staff that he just wants to be left alone and does not want anyone to bother him tonight. Discussion Questions: 1. What additional assessment should be done? 2. Is additional suicide assessment indicated? 3. How might various disciplines contribute to his care? 4. How would you answer the daughter who says she is afraid her “Daddy is going to die?” 5. What community resources are available to assist Mr. Hayes and his children? 6. What role might his religion play in his illness? Case Study #2 Mr. J: Constipation/Depression/Confusion Mr. J. is an active 71-year old gentleman whose wife calls you to tell you about his symptoms, which include increase in lethargy, constipation and questionable altered mental status. The patient is known to have widely metastatic prostate cancer, including bone metastasis. He is a very proud and private man, she tells you, and he doesn’t always listen to what the doctor tells him. As the nurse in the medical oncology clinic, you have cared for this patient and family for several months. He has been on long-acting morphine at 60-mg every 12 hours orally with morphine sulfate immediate release tablets 10mg to be taken every 2-3 hours orally as needed for pain. His pain has been well managed on this regimen for the last month. He has been on an effective bowel regimen until the last week. You, the oncology nurse, instruct the wife to bring the patient to the clinic. Discussion Questions: Part 1: 1. Discuss the physical assessment that would be conducted on Mr. J. 2. What laboratory or radiographic studies might be ordered? Why? 3. Discuss the differential diagnosis for these complaints and how might these be managed? 4. What education would you provide to the patient/family? 5. Describe the strategies you would review develop in promoting a comprehensive plan of care for this patient. Case continued: Mr. J’s wife is concerned about his mental status. She states he has become very withdrawn and has refused to see any family or friends. He stays in bed most of the day with the curtains closed. His appetite is poor. He becomes confused and agitated at times. Mrs. J. is very concerned about his mental status. “My husband’s brother committed suicide 3 years ago and I am afraid my husband may do the same thing.” Discussion Questions: Part 2: 6. How would you assess depression in a patient who is confused? 7. What other members of the interdisciplinary team should be involved with Mr. J? 8. What community services and coping strategies would you suggest for Mrs. J? 1. Euthanasia: discuss some of the key ethical issues and legal concerns in end-of-life? 2. What does Palliative Sedation mean in nursing issues? 3. How should the nurse make the right ethical decision according to Palliative Sedation? 4. Describe Tools for Diagnosing and Mediating Cultural Misunderstandings. 5. What are the roles of Language and Cultural Needs in Palliative Care? 6. Give the answers to the Discussion questions from Case Study #4 (presented in the Methodological instruction). Case Study #4 Max: Communicating Sudden Death Max Klein is an 84-year-old retired plumber who has brought his 83-year-old wife, Mary, to the hospital complaining of chest pain. Mary′s condition declines, she experiences cardiac arrest and full resuscitation is attempted. During this time Max communicates to the social worker and chaplain that ″This just can′t be. Mary is healthy as an ox.″ He doesn′t want to notify his children who live out of town ″until she′s stable because I know they′ll get her straightened out.″ Max seems anxious but distracted and talks incessantly about how Mary′s been sick before but ″always gets better before you know it.″ After 2 hours of numerous procedures and attempts, Mary dies. Discussion Questions: 1. What are useful communication strategies while Mary is still receiving aggressive care to communicate her status? 2. How should Max be told of Mary’s death? 3. What is the role of the interdisciplinary team in communication in this case? 1. What Changes are occurring in an organism During the Dying Process? 2. Write the list of Signs That Death Has Occurred. What should a Nurse do in case of a patient′s death? 3. Give the answers to the Discussion questions from Case Study # 1 (presented in the Methodological instruction). Case Study #1 Mr. Ahmed: A Case for an Advanced Directive You are an Advanced Practice Nurse (APN) on a Palliative Care team at a local hospital. You have been seeing Mr. Ahmed for the past 4 months, since his hospitalizations have increased due to severe symptoms from cardiomyopathy. The palliative care team has been vigilant about treating his symptoms, such as angina, pedal edema, and dyspnea. Mr. Ahmed, a Muslim, is 42 years old, has a wife and 7 children (ranging from 4 years to 18 years of age). His heart continues to deteriorate and you notice a huge decline in his physical status since he was last admitted, three weeks ago. Mr. Ahmed is going in and out of consciousness and has refused to sign an advanced directive. Despite the fact that his condition is worsening by the hour, you and the other members of the Palliative Care team have repeatedly talked with both Mr. and Mrs. Ahmed about signing an Advanced Directive. Over the past 4 months, since you and the palliative care team have been seeing Mr. Ahmed, he and his wife have refused to discuss home hospice. Mrs. Ahmed states that she knows her husband is dying and requests that his bed be turned so that it faces Mecca. Discussion Questions: 1. How would you and the Palliative Care team proceed in obtaining an Advanced Directive? Is one necessary at this time? 2. What unique role does the APN have in this situation? 3. How would you meet this patient’s potential spiritual needs? 4. How would you manage dyspnea, fluid overload, anxiety, hypertension, etc. in the realm of palliative care? 5. Identify possible needs of the wife, children, other family members.
