แนวทางการดูแลผู้ป่วยระยะสุดท้าย 2557
DESCRIPTION
แนวทางการดูแลผู้ป่วยระยะสุดท้าย 2557TRANSCRIPT
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8-11 10-29 80,780 29.2
2
20 2557
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1 1
2
2 3
1 4 2 8
3
12 4 14 5 16 6 18 7 20
8 21 24
1 26 2 27 3 18 4 32 5 32
Risk Fall Assess Form
Bradens Score Q 9Q
8Q MMSE
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Edmonton Symptom Assessment Scale (ESAS) Log
()
1 62 30
25 29
30
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468.3 2548 759.8 2555 8 12.6 2510 43.8 2540 98.5 2555 25.3 2548 31.7 2555 0.8 2547 1.6 2553 10 (2542 - 2552) 11
(102,330 113,548 ) ( ,2555; Cancer control, knowledgeinto action World Health Organization,2007)
8-11 10-29 ( ,2553) (Hospice)
(Caregiver) (Hospice)
(Palliativecare) WHO
()
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(Bereavement Care) (European Association for Palliative Care, WHO)
(Quality of Life care Unit) 8
1 2 3 4 5 6 7 8
5 1 2 3 4 5
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1
(Staff)
1. /2. 3. 4.5. 6. /7. /8.
1. 2. (Communication skills)
(Nurse)1. ()2.
(Communication skills)3. 2 4.
3 5. 3 6.
4
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5
1. morphine 2.
1. 2. ()
1.
2.
3. 4.
1. 2.
3.
/
1.
2. 3. 4.
5.
6.
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1
1. 2. 3. 4.
5.
6. 7.
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/1. ()2. 3.
4. (Walker)5. 6. 7.
1.
/ 2. 3.
4. (
Healing environment)5.
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8
2
(Pain)
(1) (non invasive) (by mouth) (by the clock)
codeine tramadol (around the clock) (breakthrough pain)
1
(by the ladder)
1 non opioids2 weak opioids non opioids3 strong opiods non opioids
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3 1. :
1.1
(Body chart)
1.2 1.3 1.4 1.5 1.6
2.
2.1 2.2 Palliative radiotherapy
2.3 (massage) (acupressure) (acupuncture) (heat) (cold) (TranscutaneousElectrical NerveStimulation:TENS) ( touch) (therapeutic touch)
3. (1 )
(Dyspnea)
1. : (Visual Analogue Scale :VAS)
2. :
(hematocrit) (hemoglobin) Pericardial effusion, Pleural effusion, Superior vena cavasyndrome, Pneumonia
3. :
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3.1 Opioids, Benzodiazepines, Phenothiazines, Beta2-Agonist stimulators , Methylxanthines , Steroid , Oxygen therapy Dyspnoea in Palliative Care www.patient.co.uk
3.2 (pursed-lip) diaphragmatic
(Fatigue)
1.
:
2. :
3. : Steroid Erythopoctive Anti-depressive
(Constipation) Opioid
Surfactant Docusate Osmotic Lactulose,magnesium hydroxide Lubricant Mineral oil Stimulants Bisacodyl, senna
(Nausea and Vomiting)
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:-domperidone, prochlorperazine , metoclopramide ,
ondamsetron, granisetron , haloperidol
(Skin and pressure sore)
(BardenScore) 2
/ /
(Complementary and alternative medicine) / , (massage therapy), (acupuncture),(Aroma therapy) , (Music therapy) , ( Humor therapy) , ( imagery) , (distraction) , (Yoga) , (Pet-therapy) , , (Hydro therapy), (prayer) , (Hypnotictherapy) , (Biofeedback) , (Relaxingtraining) , (Self help group) , (Educative and Supportive) ,(Art therapy), (Thai-traditional medicine),( Herbal medicine)
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3
(Psychological)1. (
/ (Spiritual)
2. 2Q , 9Q 8Q () (cognition) MMSE-T ()
3. : Five stage reaction Kubler-Ross (1969)
1.(Shock & Denial)
2. (Anger)
3.(Bargaining)
/
4.(Depression)
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13
5.
(Acceptance)
1 5
5 ( , , ,2551)
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4
(Social assessment) 1. :
2. :
3. :
4. :
5. : (Family / Relatives)
(Friends) (Work / School Associates) (ProfessionalCaregivers) (Neighbors)
6. :
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1.
2. 3.
4.
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5
( ) ( , 2555)
1. EQ 2. 3.
1.
2. 1 (spiritual screening)
3.
4. (2004)///
5.
5.1 -
5.2 24
5.3 Family meeting/
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17
5.4
(Narayanasamy, 2004)
- - --
- -- - -
-
-
- - -
- -
--/
--
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6
1. 1.1 ( ) ( ) ( ) 1.2
1.3 (
)1.4 1.5
( ) ( )
( ) ( )( ) ( ) ( ) ( )( ).
1.2.
3.
( )
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19
()
4. ()
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20
7
2 7
1. :
2. :
3. :
4. : 5. :
6. :
7. :
( )
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8
1. (Biomedical ethics) : 4
1.1(Beneficence)1.2 (Nonmaleficence)1.3 (Autonomy)1.4 (Justice)
2. (Patients Bill of right) : - ( 10 )
3. (Informed Consent) :
3.1 3.2 3.3 ()
- :
- - ( Informed
Consent) ()
4. (Advance Directives):
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---- Delirium , Dementia , Coma -
Advance directives
4.1 Living will:
...2550 12
Living will pain medication
4.2 Durable power of attorney (DPA) for health care :
4.3 Conversation :
Advance Directives
4.4 Written directives :
()
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23
4
) )
) )
(mercy killing)
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24
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(The Association for Childrens Palliative Care and British Royal College ofPediatricians and Child Health)
.
.
.
.
() (concept)
concept
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26
-
() (concept)
- magical thinking
-
(causality) (irreversibility) (finality) (universality)
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3
Counseling
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End of Life (no CPR, oxygen)
End of Life
dyspnea, , no CPR
privacy
autopsy tissue donation
Bereavement Care
(pain assessment) (pain management)
(qualitative assessment)
(quantitative assessment)
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(pain intensity)
(Composite pain
measures)
(Behavioral
measures)
(Self-report)
PIPP CHEOPS VAS
NIPS FLACC Wong-Baker Faces Scale
CRIES OPS FPS-R
NRS
PIPP = Premature Infant Pain Profile, NIPS = Neonatal Infant Pain Profile, CHEOPS =
Childrens Hospital of Eastern Ontario Pain Scale, FLACC = Face Legs Activity Cry
Consolability, VAS = Visual Analog Scale, FPS-R = Faces Pain Scale-Revised, NRS = Numeric
Rating Scale, OPS = Objective Pain Scale
self-report(gold standard)
(pain diary)
()
.
/ /
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(pharmacological management) (non-pharmacological management)
.
.
2
Non - opioids Acetylsalicylic acid (ASA),
Paracetamol, Ibuprofen,
Indomethacin, Naproxen, Diclofenac
Opioids
Codeine, Tramadol
Opioids Morphine, Methadone,Hydromorphone, Pethidine,
Buprenorphine,Fentanyl (transdermal)
Opioid antagonist Naloxone
Antidepressants Amitryptyline, Imipramine
Anticonvulsants Carbamarzepine, Valproic acid
Corticosteroids Prednisolone, Dexamethasone
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. prn(rescue dose) breakthrough pain 4
. )(
4.
pethidine toxic metabolite
1. opioid
2.
3. opioid - withdrawalsymptom %
.
Supportive therapy: family centered care,
Cognitive therapy: distraction, imagery, hypnosis, music
Behavioral therapy:
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Physical therapy: / aromatherapy, transcutaneous electrical nerve stimulation (TENS)
4
5
palliative care
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1.
2.
3.
4.
5.
6.
7.
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Spiritual support
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... .....
Last wish
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Last wish
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Last birthday
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Home care
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Healing Environment
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Complementary and Alternative medicine
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Volunteer
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1.
. 2555.. , .2. . 2556. . .
3. . 2556. Palliative care. 1. ,.
4. .. 2550..2., .
5. , , . 2551.
.
,
.
6. . . :; 2547.
7. . . : , , , . . : ; 2552. 239-257.
8.. 2551..
9.
. 2556..1., .
10.. 2552..
11.. 2552..
12.. 2556.. 1 1. .,.
13.
American Academy of Pediatrics, Committee on Bioethics 1999-2000. Guidelines
on forgoing life-sustaining medical treatment. Pediatrics. 2000; 106(2): 3517.14.American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and
Family Health. The pediatrician and childhood bereavement. Pediatrics 2000;
105: 445-7.
15.Brown MR, Sourkes B. Pediatric palliative care. In: Shaw RJ, Demaso DR editors.
Textbook of pediatric psychosomatic medicine. Arlington: American psychiatric
publishing; 2010. 245-57.
16.
Complementary,Alternative, or Integrative Health: Whats In a Name?
Available6/3/2014 from:http://www.nccam.nih.gov
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17.Cunningham T. MCCN Psychosocial assessment guidelines version 2: March 2010.
1-5.
18.Goldman A, Frager G, Pomietto M. Pain and palliative care. In: Schechter N, Berde
CB, Yaster M, ed. Pain in Infants, children, and adolescents 2nd
ed. Philadelphia:
Lippincott Williams&Wilkins; 2003: 539 562.
19.Grgoire M, Frager G. Ensuring pain relief for children at the end of life. Pain Res
Manage 2006; 11 (3): 163 171.
20.Himelstein BP, Hilden JM, Boldt AM, Weissman D. Pediatric Palliative Care. N Engl J
Med 2004; 350: 1752-62.
21.Hution N, Levetown M, Frager G. The hospice and palliative medicine approach to
caring for pediatric patients. Glenview: American academy of hospice and palliative
medicine, 2008.22.Kuber-Ross E. On death and dying. New York: Scribner; 1969.
23.Lewis M, Schonfeld D. Dying and Death in Childhood and Adolescence. In: Lewis
M, ed. Child and Adolescent Psychiatry. Philadelphia: Lippincott Williams & Wilkins;
2002: 1239-45.
24.Narayanasamy A. The puzzle of spirituality for nursing. A guide to practical
assessment. Br J Nurs. 2004; 13(19): 1140-1144.
25.Vachon ML, Kristjanson L, Higginson I. Psychosocial process and issues in palliative
care: the patient, the family, and the outcome of care. J Pain Symptom Manage.
1995; 10(2): 142-50.
26.World Health Organization. Cancer pain relieve and palliative care in children.
Geneva: World Health Organization, 1998.
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( Palliative Performance Scale version 2 ) (PPS v2)
PPS v2
100%
90%
80%
70%
60%
/
50% /
40%
+/-
30%
+/-
20%
+/-
10%
()
+/-
0% - - - -
+/-
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()
1.
2.
3.
4.
5.
6.
7.
8.//
9.
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Edmonton Symptom Assessment Scale (ESAS)Log
-.. ..
HN.DX.
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Prn 1
2.. 2
3.. 3
scale
10
9
8
7
6
5
4
3
2
1
0
Pain Prn
sedation score
respirations
signature
site
characterize
time
s=
sedation score =2+RR10/min
sedation 0=
3=
..................................................................... HNDXMetastasis....
......................
1= 2=
.....................
....................
(cont.)
pain 1.....................................................................
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(Risk Fall Assess Form)
Name............................................................................... Age........................HNWARD
Risk Factor ScaleScore Patient score
Morse Fall Risk Score Date.. Date.. Date.. Date.. Date.. Date..
History of FallYes 25
No 0
Secondary Diagnosis
Yes 15
No 0
Ambulatory Aid
Furniture 30
Crutches/Cane/Walker 15
None/ Bed rest/ Wheel chair/ Nurse 0
IV/Injection plug Yes 20
No 0
Gait / Transferring Impaired 20
Weak 10
Normal / Bed rest / Immobile 0
Mental Status Forgets / Limitations 15
Oriented to Own Ability 0
Morse Fall Score Date. Date. Date. Date. Date. Date.
45
25 44
0 - 24
Morse Fall Risk
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Bradens Score
Name. Age HN..Ward
Score ........................ ............
4 3 2
1
4 3 2
1
4/ 3/ 2 1
4Feed /> 3Feed / 2NPO/
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2Q
NameAgeHN..Ward...............
( )
1. 2
2. 2
2
2
9Q
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9Q
NameAgeHN..Ward...............
( )
2
(7 )
1.
2.
3.
4. 5.
6.
7.
8.
9.
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- 7-12
- 13-18
- >19
: > 7 8Q
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8Q
NameAgeHN..Ward...............
( )
1. 1
2. 1
3. 1
(..)
4.1
5. 1
6. 1
7. 1
8.
- 1-8
- 9-16
- >17
Admit
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MMSE Thai 2002*Mini Mental State Examination : Thai version (MMSE Thai 2002)
1. Orientation for time ( 5 ) (1 ) ()1.1 ..1.2 ..1.3 ..1.4 ..1.5 ..2. Orientation for place ( 5 ) ()(1 2.1 2.1.1 ...... ..2.1.2 ..2.1.3 - ..2.1.4 ..2.1.5 ..2.2 2.2.1 ..2.2.2 /// ..
2.2.3 / ..2.2.4 ..2.2.5 ..3. Registration ( 3 )
3 (, ....) () (,....)
3 * ( 1 1 )
..*2 ..
4. Attention/Calculation ( 5 ) ()(,....) ?4.1 4.2
4.1 100 7 () 51,2,3 4.2
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4.2 () (, ....) (, ....) ----
(,....)
5. Recall ( 3 )
3 ( 1 1 ) ..
2 ..
6. Naming ( 2 )6.1
..6.2
..7. Repetition (1 )
(1 )() () (,)()
..8. Verbal command ( 3 )
()(, ....)............(,,)-4
(,,) ..9. Written command (1 )
(, ....) (, ....) ...
10. Writing (1 )(, ....) 1 ...............................
..11. Visuoconstruction (1 )
() ..
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-(-) < 14 23(4,9,10)- < 17 30- < 22 30
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..............................................................
(-)...
...
..
..
.
.
( 1 )
...(I.C.U )
......................................................................................................................... ....................................
................................................................................................. ............................................................
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( )
( - ) .... ()
................................................................................................................................................................................................................................................................................
(
)
-..................................................................................................................................................................................................................................................................................................................................................................... -....................................................................................................................................................................................................................................................................................................
-.........................................................................................................................................................................................
................................................................................................................................................
-..................................................................................................................................................................................................................
................................................................................................ ..................................................
( )
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-....
.
HN..
//..............................................
/
(2)
(1)
0
1.
2.3. 4..
5.Morphine
.......................................................................................................................................... ....................................
.................................................................................................. ............................................................................
............................................................................................................................. .................................................
.................................................................................................. ............................................................................
............................................................................................................................. .................................................
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- ................................................................................ HN ..
Admit /................................................ ....................................................
-........................................................... .................................................... .....................
............................................................ ................................................................
/
...............................................
...................................................
(2)
(1)
(0)
(2)
(1)
(0)
1. ( )2. 3. Retained
foleys cath. / on urostomy
On Colostomy4. ...........................
5. / 6. 7. ....................................................8.
9. 10. 11. Duragesic
12. 13. /
/
/
/
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1
(Pain assessment form for Palliative Care)
-...................................................................... ................ Palliative care case No. ....................................
HN. AN ward
..................................................................................................................
Brief Hx, Physical exam and investigation
Diagnosis
Pain assessment
Location
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2
Quality (characteristics, onset, duration etc.)...........................................
Nociceptive somatic visceral Neuropathic
Pain score: present........ pain at rest ..... worst pain...acceptable pain ..
Aggravating factor .
Relieving factor ..
Other symptoms .
Previous treatment
.
..
..
Plan
..
............................................... ..........................................
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1
(palliative care case file)
............................................................ .......................... ................... .............
HN ............................................
(primary diagnosis)
(date of diagnosis) .................................................
-............................................................... ...........
..............
........................................................................................................................................................
...............................................................................................................................................................................
................................................. ..................................................................
Case coordinator 1.
2.
/
Pain team
Spiritual team
PalliativecarecaseNo._____/__
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2
Admission
Admission date Discharge date summary
Result
Cure expire
PalliativecarecaseNo._____/__