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![Staging and treatment planning
Appropriate radiologic staging must be performed
before therapy, usually including computed tomographic
(CT) imaging. Fluorodeoxyglucose-positron emission
tomography (FDG-PET) adds to CT in select
malignancies. Brain imaging with magnetic resonance
imaging ([MRI] preferable) or CT with intravenous
contrast should be considered in advanced melanoma
and lung and kidney cancer. See tumor type discussion
for further details.
Complete surgical staging provides more accurate
extent of the disease than clinical staging and is
possible only in patients with resectable disease when
surgery is performed with an intent to cure.
Tumor grade is an assessment by the pathologist of the
tumor's similarity to the cell of origin and the
proliferation rate, usually low, moderate, or high grade.](https://image.slidesharecdn.com/terminalillnesscare-141101144931-conversion-gate02/85/Terminal-illness-care-21-320.jpg)
![SUGGESTED QUESTIONS FOR THE CLINICAL
INTERVIEW WITH PATIENTS FACING THE END OF
LIFE
Tell me the story of your illness. [the
patient's perspective]
Tell me how you first found out about your
illness. [hearing bad news]
What is your understanding now about the
illness? [patient's understanding or
explanatory model]
What do you want to be told about your
illness? [shared decision making and
information preferences]
How has the illness affected you?
[patient's coping]](https://image.slidesharecdn.com/terminalillnesscare-141101144931-conversion-gate02/85/Terminal-illness-care-181-320.jpg)
![SUGGESTED QUESTIONS FOR THE
CLINICAL INTERVIEW WITH PATIENTS
FACING THE END OF LIFE
How has your family (or close friends) been
affected? [family's coping] What have you
discussed with them?
How have you been helped? [supports]
Have there been other tough times you have
had to face? [previous coping]
Do you have a religious or spiritual practice or
set of beliefs?
Have you been thinking about dying?
[addressing death and dying] What kinds of
thoughts have you had? What worries?](https://image.slidesharecdn.com/terminalillnesscare-141101144931-conversion-gate02/85/Terminal-illness-care-182-320.jpg)
Uploaded byMohammad Asif
Terminal illness care
The document discusses the leading causes of death worldwide due to illnesses like heart disease, malignant neoplasms, and cerebrovascular disease. It then covers various risk factors for cancer and heart disease, including smoking and diet. The rest of the document details cancer treatment methods such as staging and surgery, as well as principles of chemotherapy, radiation therapy, hormonal therapy, immunotherapy, and molecularly targeted agents. It provides examples of cancers that may be cured through chemotherapy alone or in combination with other treatments.
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Terminal illness care
- 2. Ten Leading Causesof Death in world due to Severe illnesses
- 3. HEART DISEASE MALIGNA NT NEOPLASM CEREBROVASCULAR DISEASE CHORIC LOWER RESP. DISEASE ACCIDENTS ALZHEIMER’S DISEASE DIABETES MELLITUS INFLUENZA AND PNEUMONIA NEPHRITIS,NEPRITIC SYNDROME,NEPHROSIS SEPTICEMIA
- 4.
- 5. Cancer Patient accordingto geographic
- 7.
- 8. Cancer vs heartdisease
- 9. Risk factor Smoking Tobacco smoking is a strong, modifiable risk factor for cardiovascular disease, pulmonary disease, and cancer. Smokers have an approximately 1 in 3 lifetime risk of dying prematurely from a tobacco-related cancer or cardiovascular or pulmonary disease. Tobacco use causes more deaths from cardiovascular disease than from cancer. Lung cancer and cancers of the larynx, oropharynx, esophagus, kidney, bladder, pancreas, and stomach are all tobacco-related.
- 10. Diet Modification diets high in fat are associated with increased risk for cancers of the breast, colon, prostate, and endometrium. These cancers have their highest incidence and mortalities in western cultures, where fat comprises an average of one-third of the total calories consumed
- 11.
- 14. Screening Recommendations forAsymptomatic Normal-Risk Subjects
- 18.
- 20. TREATMENT Stagingand treatment planning Cancer stage is an assessment of the extent of tumor spread and treatment is based on staging. Most malignancies are staged by the tumor, lymph node, and metastasis (TNM) system from stages I to IV. The T classification is based on the size and extent of local invasion. The N classification describes the extent of lymph node involvement, and the M classification is based on the presence or absence of distant metastasis.
- 21. Staging and treatmentplanning Appropriate radiologic staging must be performed before therapy, usually including computed tomographic (CT) imaging. Fluorodeoxyglucose-positron emission tomography (FDG-PET) adds to CT in select malignancies. Brain imaging with magnetic resonance imaging ([MRI] preferable) or CT with intravenous contrast should be considered in advanced melanoma and lung and kidney cancer. See tumor type discussion for further details. Complete surgical staging provides more accurate extent of the disease than clinical staging and is possible only in patients with resectable disease when surgery is performed with an intent to cure. Tumor grade is an assessment by the pathologist of the tumor's similarity to the cell of origin and the proliferation rate, usually low, moderate, or high grade.
- 22. Principles of radiation Curative intent radiotherapy is used in several settings. Neoadjuvant: Preoperative therapy intended to reduce both the extent of surgery and the risk of local relapse. Adjuvant: Postoperative intended to reduce the risk of local relapse. Definitive: High dose with curative intent, usually not followed by surgery. Concurrent chemo radiation: Chemotherapy with definitive radiation significantly increases toxicity but increases efficacy in some settings.
- 23. Palliative radiotherapy isused in lower dosing to reduce symptoms, including bony pain, obstruction (esophageal, bronchial), bleeding (GI, gynecologic, bronchial, cutaneous), and neurologic symptoms (brain metastasis)
- 24. Principles of chemotherapy Traditional, cytotoxic chemotherapy targets all dividing cells and has broad toxicities. Chemotherapy is typically given in 2-, 3-, or 4-week “cycles.” In most regimens, intravenous treatment is given on the first day of the cycle, with no further treatment until the next cycle. In other regimens, treatments are weekly for 2 or 3 weeks, with 1 week off prior to the next cycle. Curative intent chemotherapy includes neoadjuvant, adjuvant, and chemoradiation protocols in solid tumors. Chemotherapy alone is curative in many lymphomas, leukemias, and germ cell tumors (GST). Palliative chemotherapy is used in advanced solid tumors and hematologic malignancies, with a focus on prolonging survival without overly affecting quality of life. Should only be used in patients with a good performance status.
- 25. Chemotherapy on variousdisease
- 26. Surgical Management Goals of therapy, cure versus palliation, must guide any surgical intervention. Surgical resection is often performed only when there is a possibility of cure, though palliative surgery is performed to relieve discomfort (mastectomy for local control in a patient with metastatic disease) in some malignancies. Complete lymph node staging provides useful information for postoperative treatment planning (adjuvant therapy). Surgical resection of isolated metastatic sites in select patients can improve survival. Examples include solitary brain metastases, pulmonary metastases from colorectal cancer or sarcomas, and
- 27. Hormonal Therapy Endocrine or hormonal therapy for cancer, the earliest form of systemic therapy, is almost entirely limited to breast cancer and prostate cancer . Many premenopausal breast cancers are thought to be under the influence of estrogens, and hormonal deprivation (ablation) may produce long-term responses in properly selected patients (those with estrogen and/or progesterone receptor positivity who have predominantly soft tissue or bone disease).
- 29. Aromatase Inhibitors Patients who have experienced a prolonged objective response or stable disease with hormonal therapy may be candidates for second, third-, or fourth-line hormonal therapy. Recently, aromatase inhibitors (e.g., anastrazole, letrozole, exemestane), which decrease the conversion of metabolites in fat and muscle into estrogen, have been found to be more effective than tamoxifen as first-line therapy in both the adjuvant and metastatic settings
- 30. Corticosteroids Thecorticosteroids, typically prednisone or dexamethasone, are widely used in the treatment of hematologic and oncologic cancers. In Hodgkin's disease , the non-Hodgkin's lymphomas , and multiple myeloma ,corticosteroids have antitumor activity.
- 31. Immunotherapy Two cancersthat are characterized by often unpredictable clinical behavior, melanoma and renal cell carcinoma , are treated with interferon or interleukin-2 or both , Dramatic responses are uncommon, and immunotherapy is only a minor component of cancer therapy.
- 32. Molecularly Targeted Agents Targeted agents are drugs directed at a specific molecular point, such as a protein tyrosine kinase, or at the presence of a specific antigen on a tumor cell. Tyrosine kinase inhibitors include imatinib and erlotinib. The current best example of the success of tyrosine kinase inhibitor therapy is the dramatic response of chronic myelogenous leukemia (CML ) to imatinib (Gleevec). Imatinib also has activity against gastrointestinal stromal cell tumors.
- 34. Bone Marrow/Stem Cell Transplantation Because the major dose-limiting toxicity of most chemotherapeutic agents is myelosuppression, approaches have been developed to harvest the pluripotent stem cells found in bone marrow, peripheral blood, or, less often, cord blood before marrow-damaging chemotherapy, so that the stem cells can be reinfused later . This technique is most effective for acute leukemias , relapsed lymphomas, and germ cell tumors.
- 35. CANCER OF UNKNOWN PRIMARY ORIGIN The first signs or symptoms of cancer are frequently the result of metastases to visceral or nodal sites. In most such patients, routine clinical evaluation with a comprehensive history, physical examination, complete blood cell count, screening chemistries, and directed radiologic evaluation of specific symptoms or signs identifies the primary tumor. Patients who have no primary tumor located after this routine clinical evaluation are defined as having cancer of unknown primary site. Further clinical and pathologic evaluation will identify the primary site in only a few patients, and approximately 80% will never have a primary site identified during their subsequent clinical course.
- 36. The initialclinical and pathologic evaluation should focus on identifying a primary site when possible and on identifying patients for whom specific treatment is indicated. In most patients with cancer of unknown primary site, the diagnosis of advanced cancer is strongly suspected after the initial history and physical examination.
- 37. Biopsy Thediagnosis of metastatic cancer should be confirmed by biopsy of the most accessible metastatic lesion. Fine-needle aspiration may or may not provide sufficient material for optimal histologic examination and special pathologic procedures. If tissue is inadequate, a larger biopsy sample should be obtained so all necessary stains and procedures can be performed.
- 38. RECOMMENDED EVALUATION FOLLOWINGINITIAL LIGHT MICROSCOPIC DIAGNOSIS
- 40. SPECIFIC PATIENT SUBSETS AND RECOMMENDED TREATMENT
- 42. Curability of Cancerswith Chemotherapy A. Advanced Cancers With Possible Cure Acute lymphoid and acute myeloid leukemia (pediatric/adult) Hodgkin's disease (pediatric/adult) Lymphomas—certain types (pediatric/adult) Germ cell neoplasms Embryonal carcinoma Teratocarcinoma
- 43. . Advanced CancersWith Possible Cure Choriocarcinoma Gestational trophoblastic neoplasia Pediatric neoplasms Wilms' tumor Embryonal rhabdomyosarcoma Ewing's sarcoma Peripheral neuroepithelioma Neuroblastoma Small cell lung carcinoma Ovarian carcinoma
- 44. Advanced Cancers PossiblyCured by Chemotherapy and Radiation Squamous carcinoma (head and neck) Squamous carcinoma (anus) Breast carcinoma Carcinoma of the uterine cervix Non-small cell lung carcinoma (stage III) Small cell lung carcinoma
- 45. Cancers Possibly CuredWith Chemotherapy as Adjuvant to Surgery Breast carcinoma Colorectal carcinomaa Osteogenic sarcoma Soft tissue sarcoma
- 46. Cancers Possibly Curedwith "High-Dose" Chemotherapy With Stem Cell Support Relapsed leukemias, lymphoid and myeloid Relapsed lymphomas, Hodgkin's and non- Hodgkin's Chronic myeloid leukemia Multiple myeloma
- 47. Cancers Responsive WithUseful Palliation, But Not Cure, by Chemotherapy Bladder carcinoma Chronic myeloid leukemia Hairy cell leukemia Chronic lymphocytic leukemia Lymphoma—certain types Multiple myeloma Gastric carcinoma Cervix carcinoma Endometrial carcinoma Soft tissue sarcoma •Head and neck cancer •Adrenocortical carcinoma •Islet-cell neoplasms •Breast carcinoma •Colorectal carcinoma •Renal carcinoma
- 48. Tumor Poorly Responsivein Advanced Stages to Chemotherapy Pancreatic carcinoma Biliary-tract neoplasms Thyroid carcinoma Carcinoma of the vulva Non-small cell lung carcinoma Prostate carcinoma Melanoma Hepatocellular carcinoma Salivary gland cancer
- 51.
- 52. OVERVIEW • Septicshock is the most common cause of mortality in the intensive care unit. It is the 10th leading cause of death overall. • Despite aggressive treatment mortality ranges from 15% in patients with sepsis to 40-60% in patients with septic shock.
- 53. Reference Diseases Incidence in US (cases per 100,000) AIDS1 17 Colon and rectal cancer2 48 Breast cancer2 112 Congestive heart failure3 ~196 Severe sepsis4 ~300 Number of deaths in US each year Acute myocardial infarction5 218,000 Severe sepsis4 215,000 1Centers for Disease Control and Prevention. 2000. Incidence rate for 1999. 2American Cancer Society. 2001. Incidence rate for 1993-1997. 4Angus DC et al. 2001. Crit Care Med 29:1303-1310. 5National Center for Health Statistics. 2001.
- 55. SIRS Sepis Severesepsis-SIRS Septic shock MODS
- 56. SIRS (Systemic InflammatoryResponse Syndrome) is a systemic inflammatory response to non specific insults Clinically?! 1. hyperthermia >38°C or hypothermia <36°C 2. • tachycardia >90 bpm 3. • tachypnoea >20 r.p.m. or PaCO2 <4.3 kPa 4. • neutrophilia >12 × 10–9 l–1 or neutropenia <4 000 SIRS is either due to Infection or others (major burn-major traume-pancreatitis –hypovolemic shock)
- 57. Sepis •The systemicinflammatory response to infection. Clinically?! • Known or suspected infection, plus • >2 SIRS Criteria. Severe sepsis-SIRS •Severe sepsis resulting in at least one organ failure Clinically?! •Sepsis plus >1 organ dysfunction.
- 58. Septic shock •Sepsisinduced shock with hypotension despite adequate resuscitation along with the presence of perfusion abnormalities which may include, but are not limited to lactic acidosis, oliguria, or an acute alteration in mental status. MODS (multiple organ dysfunction syndrome) The presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention.
- 59. SIRS systemic inflammatory response syndrome SEPSIS SIRS with a presumed or confirmed infectious process •Severe sepsis Sepsis with ≥1 sign of organ failure Septic shock SIRS + Infection + Organ Failure + Refractory Hypotension
- 62. Caustive organisms •Gram –ve the commonest • Staphylococcus • Candida Sources of infection • Endogenus source 1. Causes ofPeritonitis 2. Perforated viscous 3. Gangrenous bowel 4. Genitourinary infection • Exogenus source Infected CVP Predisposing factors • Old age • DM • Corticosteroid therpy • Malignancy • Major operation
- 64. It isnot precisely understood, but it involves a complex interaction between the pathogen and the host's immune system. Physiological response to localized infection: o Influx of activated PMN leukocytes & monocytes release of inflammatory mediators o Local vasodilatation & increased endothelial permeability o Activation of the coagulation cascade. The same occurs in septic shock but at a systemic level. Diffuse endothelial disruption Increased vascular permeability Vasodilatation Thrombosis of end organ capillaries
- 66. Infection Inflammatory Mediators Endothelial Dysfunction Vasodilation Hypotension Microvascular Plugging Vasoconstriction Edema Maldistribution of Microvascular Blood Flow Ischemia Cell Death Organ Dysfunction
- 67. Pathogenesis of SIRS/MODSin surgical patients Preoperative Illness Trauma or Operation Tissue Injury Inadequate Resuscitation optimal oxygen delivery and support Recovery Excessive Inflammatory Response SIRS/MODS
- 68. Lungs Kidneys CVS CNS PNS Acute Organ Dysfunction Coagulation GI Liver Endocrine Skeletal Muscle Adult Respiratory Distress Syndrome18% Acute Tubular Necrosis 50% Shock Metabolic encephalopathy Critical Illness Polyneuropathy Disseminated Intravascular Coagulopathy 38% Gastroparesis and ileus Cholestasis Adrenal insufficiency Rhabdomyolysis
- 69. Identifying Acute OrganDysfunction as a Marker of Severe Sepsis Tachycardia Hypotensio n CVP PAOP Altered Consciousness Confusion Psychosis Tachypnea PaO2 <70 mm Hg SaO2 <90% PaO2/FiO2 300 Jaundice Enzymes Albumin PT Oliguria Anuria Creatinine Platelets PT/APTT Protein C D-dimer
- 71. • You mustsuspect sepsis in patient with predisposing factors,dont wait for septic shock • The diagnosis of sepsis requires the taking of an EXCELLENT history, physical examination, appropriate laboratory tests, and a close follow-up of hemodynamic status • Early recognition is live saving in such rapid overwhelming situation
- 72. Hyperdynamic- Warm- Early Septic Shock Restlness & confusion Vitals 1. Temperature fever more than 38 chills 2. Mild decrease ABP 3. Tachycardia 4. Tachypnea Skin warm ,dry ,flushed High cardiac output Hypodynamic- Cold- Late Septic Shock Semicomatosed Vitals 1. Temperature decreased 2. Tachycardia 3. Tachypnea 4. SBP<90mmHg Oliguria & low COP Multiorgan failure start at this stage
- 74. Work-up… Laboratorystudies o CBC o Coagulation studies o Blood & urine cultures Imaging studies o Chest radiography o Abdominal radiography o Others according to the suspected cause.
- 75. • Glucose controlis important in the management of sepsis, with hyperglycemia associated with higher mortality • LFTs and bilirubin, alkaline phosphatase, and lipase levels are important in evaluating multiorgan dysfunction or a potential source (eg, biliary disease, pancreatitis, hepatitis). • Serum lactate …It is the best serum marker for tissue perfusion. Lactate levels >2.5 mmol/L are associated with an increase in mortality.
- 77. Septic Shock & MODS Septic • Control Infection Source Shock • Optimize Organ Perfusion (Resuscitation) MODS • Support Dysfunctional Systems & Monitoring
- 78. Shock • OptimizeOrgan Perfusion (Resuscitation) 1)Circulatory support I. Fluid replacment to achieve cvp 10-12 cm H2o II. Packed RBCS if low HCT III. Drugs Inotropes & vassopressor 2)Respiratory support 3)Renal support haemodyalisis in ARF 4)TTT of DIC fresh frozen plazma
- 79. EGDT is a3-step protocol aimed at optimizing tissue perfusion
- 81. Septic • ControlInfection Source Eliminate surgical causes?! Huge abscess Peritonitis gangernous bowel Antibiotic therapy Parentral ,compined ,broad spetrum.
- 82. • Antibiotics shouldbe administered within the first hour of recognition of septic shock, and delays in antibiotic administration have been associated with increased mortality. • Selection of particular antibiotic agents is empirically based on an assessment of the patient's underlying host defenses, the potential source of infection, and the most likely responsible organisms. • One regimen for septic shock of unknown cause is ogentamicin or tobramycin 5.1 mg/kg IV once/day o3rd generation cephalosporin “cefotaxime 2 g q 6 to 8 h or ceftriaxone 2 g once/day” oor if pseudomonas is suspected ceftazidime 2 g IV q 8 h”
- 83. MODS • SupportDysfunctional Systems & Monitoring •Renal replacement therapies (dialysis). •Cardiovascular support (pressors, inotropes). •Mechanical ventilation. •Blood Transfusion for hematologic dysfunction.
- 84. Recent guidline isthat steroids should be administered only in patients with septic shock whose hypotension is poorly responsive to fluid resuscitation and vasopressor therapy. NEVER resuscitate with glucose 5%
- 86. Sudden Cardiac Death Risk factors & Managements
- 87. Risk Factors forSCD Old aged Male Has PMHx of Coronory Artery Diseases High total cholesterol level Arterial hypertonia (Hypertrophy of Left Ventricle) Diet factors Has active physical lifestyle Smoking Tachycardia / Variable heart rhythm Prolonged Q-T segment
- 88. Stages of SCD Prodromal Period Acute Cardiac Symptoms Disturbances in blood circulation Biological Death
- 89. Evidence of clinicaldeath Main Features • Asystolic • Absent of pulsation at major vessels (Carotid artery) Additional Features • Dilated pupils • Areflexia ( Absent Corneal Reflex and Pupil reflex towards light ) • Skin paleness (pallor)
- 90. 1. SPrCimDar yMeavnalaugateiomn eofn ptatient’s condition 2. Basic Life Support (CPR) 3. Advanced measures to maintain life support & full resuscitation of patient 4. Treatment during post- resuscitation period 5. Long- term treatment
- 91. Criteria of adequate 1C. RPeRt u rning of pulse on major vessels, synchronous with compression on chest. 2. Present of pupil reflex 3. Pink condition of patient
- 92. Algorithm of managementof ventricular tachycardia 1. 3 - multiple defibrillator (200 J, 300 J, 360 J) (if not effective) 2. Continue resuscitation method, tracheal intubation, prepare lines for IV (If not effective) 3. Introduce Adrenaline IV 1 mg bolus (if not effective) 4. Second defibrillator (360 J) (if not effective) 5. Antiarrhythmic Drugs Amiodarone ( 300mg IV) Lidocaine (2.0 -1.5 mg/kg IV) Magnesium Sulfate (1.0-2.0 g IV)
- 93. Antiarrhythmic Drugs 1.It is to stabilize patient’s condition 2. If patient’s condition is still unstable, continue with defibrillator 3. All Anti-arrhythmic drugs have pro-arrhythmic effects. 4. Do not use more than 1 anti-arrhythmic drug
- 94. Atropine in SuddenCardiac Death Indications 1. Asystolic 2. Heart arrest or bradyarrythmia 1st bolus dose 0.6 - 1.0 mg If atropine is not effective, change to adrenaline or euphiline.
- 96.
- 97. What is Alzheimer’sDisease (AD)? Of all the diseases to be diagnosed with, Alzheimer’s strikes the most fear into people’s hearts. It is progressive and debilitating. It will rob you of: The ability to communicate Think clearly Function Awareness of yourself and environment All controls including the ability to dress yourself, eat or keep up on personal hygiene. Memories of your family and loved ones. Will eventually lead to death.
- 98. 60-80% cases ofdementia fall under Alzheimer’s Disease In AD Patients: The areas that control memory & thinking are affected first. Plaques form when protein pieces called beta-amyloid clump together. These are dense and mostly insoluble. Neurofibrillary tangles are aggregates of the protein tau which has accumulated inside the cells. Where tangles form the transport system falls apart and disintegrates. Nutrients and essential supplies can’t move through cells and they die. This process spreads throughout the brain. Deficient in an important neurotransmitter, acetylcholine, which is involved in memory function and Clusters of plaques and dying nerve cells in a person with AD
- 99. Healthy Brain (L)AD Brain (R) The bottom image shows the two brains together to see the difference in size.
- 100. Diagnosing AD Diagnosis is not a simple process and includes: Brain Scans Cognitive Assessments Laboratory Tests On average, patients with AD live 7-10 years after initial diagnosis. The disease can last as long as 20 years. 4.5 million Americans have AD. Affects women more than men: 2/3 of those diagnosed are women.
- 101. Signs & Symptoms Depression can be a symptom and may begin occurring up to 3 years prior to diagnosis of AD. Most people put this off as not a big deal when it could mean a great difference in outcome if examined. Memory Loss Behavioral Issues not normal to the patient. Confusion about time and place. Trouble finding appropriate words or loss of speech. Poor judgment. Changes in mood and personality, such as suspicion.
- 102. Types of Alzheimer’s Early Onset Alzheimer’s Diagnosed before the age of 65. Rare Late Onset Alzheimer’s Occurs after the age of 65. Most common Familial Alzheimer’s Entirely inherited Extremely rare
- 103. Cures Thereare no known cures for Alzheimer’s. There are many studies underway with some promising results in slowing the disease down. Memantine has shown encouraging results among those in advanced stages of AD. Melatonin has also shown some promise but needs further study. Antioxidants are extremely important. Exercise for the body & brain at any stage. A blue dye, methylene blue (MTC), slowed progression by 81%. It causes tau filaments to dissolve.
- 104. Prevention Thegeneral consensus is that prevention is the key in dealing with AD. Exercise regularly both body and mind. Maintain a normal healthy body weight. Enjoy leisure activities. Stay connected and social. Practice stress reduction techniques. Consume a diet rich in antioxidants. Avoid trans fat and saturated fat. Eat a diet that is 75% raw. Avoid toxins as much as possible in your food and environment.
- 105.
- 106. CEREBROVASCULAR DISORDERS refersto any functional abnormality of the central nervous system that occurs when the normal blood supply to the brain is disrupted.
- 107. STROKE a suddenneurological event which results in the new onset of neurological symptoms.
- 108.
- 110. ISCHE MIC STROK E “BRAIN
- 122. MOTOR LOSS -disturbanceof voluntary motor control on the side of the body opposite the location of the stroke lesion •Hemiplegia •Hemiparesis
- 123. COMMUNICATION LOSS •Dysarthria •Apraxia •Agnosia •Dysphasia or Aphasia
- 124. PERCEPTUAL DISTURBANCES •HomonymousHemianopsia •Disturbance in Visual-Spatial Relations - Unilateral Neglect •Loss of Peripheral Vision •Night Blindness •Diplopia •Horner’s Syndrome
- 125. SENSORY LOSS •SlightImpairment of Touch •Loss of Proprioception •Difficulty in interpreting visual, tactile, and auditory stimuli
- 126. COGNITIVE IMPAIRMENT & PSYCHOLOGICAL EFFECTS Memory Loss Poor Comprehension Limited Attention Span Forgetfulness Lack of Motivation Depression Emotional Lability Hostility Frustration Resentment Lack of Cooperation
- 127. ASSESSMENT & DIAGNOSTICS •Patient History •Complete Physical and Neurologic Examination •Initial Assessment: Airway Patency, Cardiovascular Status, Gross Neurologic Losses •Stroke Time Course Classification
- 128. STROKE TIME COURSE CLASSIFICATION Stage 1: Transient Ischemic Attack Stage 2: Reversible Ischemic Neurologic Deficits Stage 3: Stroke in Evolution Stage 4: Completed Stroke
- 129. DIAGNOSTIC TESTS •CTScan •12-Lead ECG •Carotid ultrasound •Cerebral Angiography •Transcranial Doppler Flow Studies •Transthoracic or Transesophageal Echocardiography •MRI of the brain and/or neck •Xenon CT •Single Photon Emission CT
- 134. MEDICAL MANAGEMENT 1.Treatment of TIA from atrial fibrillation or suspected embolic or thrombotic causes 2. Thrombolytic Therapy for Ischemic Stroke 3. Therapy for Patients with Ischemic Stroke NOT Receiving Thrombolytic Therapy 4. Managing Potential Complications
- 135. NURSING MANAGEMENT •ImprovingMobility and Preventing Joint Deformities •Managing Sensory-Perceptual Difficulties •Attaining Bowel and Bladder Control •Improving Thought Processes •Improving Communication •Maintaining Skin Integrity •Improving Family Coping •Helping the Patient Cope with Sexual Dysfunction
- 136. SURGICAL MANAGEMENT CAROTIDENDARTERECTOMY - Main surgical procedure for the management of TIAs and small stroke - Indicated for patients with symptoms of TIA or mild stroke found to be due to carotid stenosis - Complications: stroke, cranial nerve injuries, infection, hematoma at the incision site, carotid artery disruption
- 138. HEMMORH AGIC STROKE CEREBRAL ANEURYSM SUBARACHNOID HEMORRHAGE
- 143. Elements of Communicating Bad News the P-SPIKES Approach
- 144. Acronym Steps Aimof the Interaction P Preparation Mentally prepare for the interaction with the patient and/or family. S Setting of the interaction Ensure the appropriate setting for a serious and potentially emotionally charged discussion. P Patient's perception and preparation Begin the discussion by establishing the baseline and whether the patient and family can grasp the information. Ease tension by having the patient and family contribute. I Invitation and information needs Discover what information needs the patient and/or family have and what limits they want regarding the bad information. K Knowledge of the condition Provide the bad news or other information to the patient and/or family sensitively. E Empathy and exploration Identify the cause of the emotions—e.g., poor prognosis. Empathize with the patient and/or family's feelings. Explore by asking open-ended questions. S Summary and planning Delineate for the patient and the family the next steps, including additional tests or
- 145. Common Physical and Psychological Symptoms of Terminally Ill Patients
- 147.
- 148. What is PalliativeCare? Medical care that focuses on alleviating the intensity of symptoms of disease. Palliative care focuses on reducing the prominence and severity of symptoms.
- 149. What is PalliativeCare? The World Health Organization describes palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual."
- 150. WHO Definition ofPalliative Care Palliative care: provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten or postpone death; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible until death;
- 151. WHO Definition ofPalliative Care (cont.) offers a support system to help the family cope during the patients illness and in their own bereavement; uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated; will enhance quality of life, and may also positively influence the course of illness; is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.
- 152. What is thegoal of Palliative Care? The goal is to improve the quality of life for individuals who are suffering from severe diseases. Palliative care offers a diverse array of assistance and care to the patient.
- 153. The History ofPalliative Care Started as a hospice movement in the 19th century, religious orders created hospices that provided care for the sick and dying in London and Ireland. In recent years, Palliative care has become a large movement, affecting much of the population. Began as a volunteer-led movement in the United states and has developed into a vital part of the health care system.
- 154. Palliative vs. HospiceCare Division made between these two terms in the United States Hospice is a “type” of palliative care for those who are at the end of their lives.
- 155. Palliative vs. HospiceCare Palliative care can be provided from the time of diagnosis. Palliative care can be given simultaneously with curative treatment. Both services have foundations in the same philosophy of reducing the severity of the symptoms of a sickness or old age. Other countries do not make such a distinction
- 156. Who receives PalliativeCare? Individuals struggling with various diseases Individuals with chronic diseases such as cancer, cardiac disease, kidney failure, Alzheimer's, HIV/AIDS,etc
- 157. Cancer and PalliativeCare It is generally estimated that roughly 7.2 to 7.5 million people worldwide die from cancer each year. More than 70% of all cancer deaths occur in developing countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent. More than 40% of all cancers can be prevented. Others can be detected early, treated and cured. Even with late-stage cancer, the suffering of patients can be relieved with good palliative care.
- 158. Palliative Care andCancer Care Palliative care is given throughout a patient’s experience with cancer. Care can begin at diagnosis and continue through treatment, follow-up care, and the end of life.
- 159. Palliative Care andCancer "Everyone has a right to be treated, and die, with dignity. The relief of pain - physical, emotional, spiritual and social - is a human right," said Dr Catherine Camus, WHO Assistant Director- General for Noncommunicable Diseases and Mental Health. "Palliative care is an urgent need worldwide for people living with advanced stages of cancer, particularly in developing countries, where a high proportion of people with cancer are diagnosed when treatment is no longer effective."
- 160. “Cancer Control: KnowledgeInto Action” Excerpts from the WHO guide for Palliative Care: “Palliative care is an urgent humanitarian need worldwide for people with cancer and other chronic fatal diseases. Palliative care is particularly needed in places where a high proportion of patients present in advanced stages and there is little chance of cure.”
- 161. Who Provides PalliativeCare? Usually provided by a team of individuals Interdisciplinary group of professionals Team includes experts in multiple fields: Doctors Nurses social workers massage therapists Pharmacists Nutritionists
- 162. Volunteers Patient and Family Physicians Spiritual Counselors Social Workers Pharmacists Nurses Therapists Home Health Aides
- 163. Kübler-Ross model TheKübler-Ross model, or the five stages of grief, is a series of emotional stages experienced when faced with impending death or death of someone.
- 164. KUBLER ROSS -REACTION TO TERMINAL ILLNESS
- 165. KUBLER ROSS -REACTION TO TERMINAL ILLNESS Denial
- 166. KUBLER ROSS -REACTION TO TERMINAL ILLNESS No I am not
- 167. KUBLER ROSS -REACTION TO TERMINAL ILLNESS Denial Anger
- 168. KUBLER ROSS -REACTION TO TERMINAL ILLNESS Denial Why me?
- 169. KUBLER ROSS -REACTION TO TERMINAL ILLNESS Denial Anger Bargaining
- 170. KUBLER ROSS -REACTION TO TERMINAL ILLNESS Denial Anger Make deals
- 171. KUBLER ROSS -REACTION TO TERMINAL ILLNESS Denial Anger Bargaining Depression
- 172. KUBLER ROSS -REACTION TO TERMINAL ILLNESS Denial Anger Bargaining Sense of lose
- 173. KUBLER ROSS -REACTION TO TERMINAL ILLNESS Denial Anger Bargaining Depression Acceptance
- 174. KUBLER ROSS -REACTION TO TERMINAL ILLNESS Denial Anger Bargaining Depression Make peace with death
- 175. KUBLER ROSS -REACTION TO TERMINAL ILLNESS Denial Anger Bargaining Depression Acceptance
- 176. Children grieving indivorce Denial Children feel the need to believe that their parents will get back together, or will change their mind about the divorce. Example: “Mom and Dad will stay together.” Anger Children feel the need to blame someone for their sadness and loss. Example: “I hate Mom for leaving us.”
- 177. Children grieving indivorce Bargaining In this stage, children feel as if they have some say in the situation if they bring a bargain to the table. This helps them keep focused on the positive that the situation might change, and less focused on the negative, the sadness they’ll experience after the divorce. Example: “If I do all of my chores maybe Mom won’t leave Dad.”
- 178. Children grieving indivorce Depression This involves the child experiencing sadness when they know there is nothing else to be done, and they realize they cannot stop the divorce. The parents need to let the child experience this process of grieving because if they do not, it only shows their inability to cope with the situation. Example: “I’m sorry that I cannot fix this situation for you.” Acceptance
- 179. Children grieving indivorce Acceptance This does not necessarily mean that the child will be completely happy again. The acceptance is just moving past the depression and starting to accept the divorce. The sooner the parents start to move on from the situation, the sooner the children can begin to accept the reality of it
- 180. Approaches to PalliativeCare Not a “one size fits all approach” Care is tailored to help the specific needs of the patient Since palliative care is utilized to help with various diseases, the care provided must fit the symptoms.
- 181. SUGGESTED QUESTIONS FORTHE CLINICAL INTERVIEW WITH PATIENTS FACING THE END OF LIFE Tell me the story of your illness. [the patient's perspective] Tell me how you first found out about your illness. [hearing bad news] What is your understanding now about the illness? [patient's understanding or explanatory model] What do you want to be told about your illness? [shared decision making and information preferences] How has the illness affected you? [patient's coping]
- 182. SUGGESTED QUESTIONS FORTHE CLINICAL INTERVIEW WITH PATIENTS FACING THE END OF LIFE How has your family (or close friends) been affected? [family's coping] What have you discussed with them? How have you been helped? [supports] Have there been other tough times you have had to face? [previous coping] Do you have a religious or spiritual practice or set of beliefs? Have you been thinking about dying? [addressing death and dying] What kinds of thoughts have you had? What worries?
- 183. FEW NURSING INTERVENTIONS Pain – limit unnecessary painful procedures sedation and giving pre-emptive analgesia prior to a procedure (e.g., including sucrose for procedures in neonates) Address coincident depression, anxiety, sense of fear or lack of control. Consider guided imagery, relaxation, hypnosis, art/pet/play therapy, acupuncture/acupressure, biofeedback, massage, heat/cold, yoga, transcutaneous electric nerve stimulation, distraction.
- 184. Dyspnoea or airhunger- Suction secretions if present positioning, comfortable loose clothing, fan to provide cool, blowing air. Limit volume of IV fluids, consider diuretics if fluid overload/ pulmonary oedema present. Behavioural strategies including breathing exercises, guided imagery, relaxation, music
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- 186. Fatigue – Sleep hygiene Gentle exercise Address potentially contributing factors (e.g., anaemia, depression, side effects of medications)
- 187. Nausea/vomiting – Consider dietary modifications (bland, soft, adjust timing/ volume of foods or feeds) Aromatherapy: peppermint, lavender; acupuncture/ Constipation - Increase fibres in diet, encourage fluids
- 188. Oral lesions/dysphagia – Oral hygiene and appropriate liquid, solid and oral medication formulation (texture, taste, fluidity). Treat infections, complications (mucositis, pharyngitis, dental abscess, esophagitis).Orophayngeal motility study and speech (feeding team) consultation
- 189. Anorexia– Managetreatable lesions causing oral pain, dysphagia, and anorexia. Support caloric intake during phase of illness when anorexia is reversible. Acknowledge that anorexia is intrinsic to the dying process and may not be reversible. Prevent/treat coexisting constipation
- 190. Pruritus – Moisturize skin, Try specialized anti-itch lotions, Apply cold packs, Counter stimulation, distraction, and relaxation.
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- 192. Diarrhoea – Evaluate/treat if obstipation, Assess and treat infection, Dietary modification. Depression – Psychotherapy, behavioural techniques
- 193. Anxiety – Psychotherapy (individual and family), behavioural techniques Agitation/terminal restlessness – Evaluate for organic or drug causes, Educate family, Orient and reassure child; provide calm.
- 194. Medications for theManagement of Delirium
- 195. NURSING CARE Answeringthe question Helping the parents Helping the dying child
- 196. ORGAN DONATION Benefit another human being irreversible cessation of neurologic function of the brain discuss the topic with family Healthy child who dies unexpectedly, children with cancer, chronic disease etc should be considered for organ donation
- 197. PATIENTS' PERSPECTIVE ON A “GOOD DEATH” Control pain and other symptoms Avoid inappropriate prolongation of dying when life is no longer enjoyable Relieve burden on the family Achieve a sense of control Strengthen relationships with loved ones
- 198. Common and uncommo n clinical courses in the last days of terminally ill patients
- 199. GRIEF AND BEREAVEMENT Grief is the emotional response to that loss. Bereavement is the acknowledgment of the objective fact that one has experienced a death.
- 200. BEREAVEMENT Theword 'bereavement' comes from the ancient German for 'seize by violence'. Today the word 'bereavement' is used to describe the period of grief and mourning we go through after someone close to us dies. Bereavement is about trying to accept what happened, learning to adjust to life without that person
- 201. STAGES OF BEREAVEMENT Ways to mourn and express the loss Accepting the loss Experiencing pain that comes with grief Trying to adjust without that person Finding new place to put emotional energy
- 202. The importance ofmourning Mourning allows to say goodbye. Seeing the body, watching the burial, or scattering the ashes is a way of affirming what has happened. Sometimes we need to see evidence that a person really has died before we can truly enter into the grieving process.
- 203. COUNSELLING DEFINITION Counsellingis a definitively structured permissive relationship which allows the client to gain an understanding of himself to a degree which enables him to take new positive steps in the light of his new orientation. - ROGES
- 204. Characteristics 2 individual Self realization Realistic goals Attitude & action
- 205. Bereavement counselling -tohelp people cope more effectively with the death of their patient or a loved one. Specifically, bereavement counselling can: offer an understanding of the mourning process explore areas that could potentially prevent you from moving on help resolve areas of conflict still remaining help you to adjust to a new sense of self address possible issues of depression or suicidal thoughts
- 206. CONCLUSION Knowledge abouthospitalization, terminally ill child and the nursing management help nurses to provide the adequate and quality care, to support the family and child and to help her by self satisfaction. Even though time heals the wound, an adequate support accelerates the process.
- 207. What does PalliativeCare Provide to the Patient? Helps patients gain the strength and peace of mind to carry on with daily life Aid the ability to tolerate medical treatments Helps patients to better understand their choices for care
- 208. What Does PalliativeCare Provide for the Patient’s Family? Helps families understand the choices available for care Improves everyday life of patient; reducing the concern of loved ones Allows for valuable support system Image courtesy of mdanderson.org
- 209. Approaches to PalliativeCare A palliative care team delivers many forms of help to a patient suffering from a severe illness, including : Close communication with doctors Expert management of pain and other symptoms Help navigating the healthcare system Guidance with difficult and complex treatment choices Emotional and spiritual support for the patient and their family
- 210. Palliative Care IsEffective Successful palliative care teams require nurturing individuals who are willing to collaborate with one another. Researchers have studied the positive effects palliative care has on patients. Recent studies show that patients who receive palliative care report improvement in: Pain and other distressing symptoms, such as nausea or shortness of breath Communication with their doctors and family members Emotional and psychological state
- 211. Where to findPalliative Care? In most cases, palliative care is provided in the hospital. The process begins when doctors refer individuals to the palliative care team. In the hospital, palliative care is provided by a team of experts.
- 212. Settings for PalliativeCare Outpatient practice Hospital Inpatient Unit based Consultation Team Home care Nursing Home Hospice
- 213. Cost of PalliativeCare Most insurance plans cover all or part of the palliative care treatment given in hospitals. Medicare and Medicaid also typically cover palliative care.
- 214. WPRO Palliative CareSystems