#aphagias

[feelingravityspull]

if only!

[chalkrevelations]

Review guide under here, so I can cross things off as I go. Certification exam coming up soon. This is what I’m going to be doing for the next month or so. Meanwhile, queue is in charge.

disease progression and imminent death

assessment and staging scale

FAST

**FAST staging: 1. (normal adult) no difficulties; 2. (normal older adult - mild memory loss) word finding, location of objects; 3. (early dementia) decreased job function evident, decr. organizational capacity, difficult travel to new locations; 4. (mild dementia) decr. ability at complex tasks, handling finances; 5. (moderate dementia - diff with serial subtraction; date/year/home address) assistance in proper clothing choice; 6a. (moderately severe dementia - diff with names of family/friends, delusions/hallucinations/obsessions, increased anxiety, poss violent; daytime sleep/night wakefulness) assistance in dressing; 6b. assistance bathing more freq.; 6c. assistance toileting more freq.; 6d. urinary incont. more freq.; 6e. bowel incont. more freq.; 7a. (severe dementia - incontinent x2, lose speech & ability to walk; bedridden -> sepsis, pna) limited speaking ability (half dozen words in av. day/interview); 7b. single intelligible word in av. day/interview); 7c. lost amb. ability; 7d. needs assistance to sit up (i.e., arms on chairs); 7e. lost ability to smile

Karnofsky

PPS

local coverage determination

disease-specific guidelines

SSx of imminent death - usually in clusters rather than individual SSx

weeks to months

loss of appetite (early sign) -> weight loss, cachexia (family distress: signifies decline, inability to nourish as a sign of care. educate that force feeding -> vomiting and aspiration). artificial nutrition if consistent with GOC, but educate that it does little good and may increase distressing symptoms. consider decrease if patient has in place but vomiting, aspiration, edema, CHF, pulmonary edema, other SSx fluid overload

cachexia incl. muscle wasting, anorexia, fatigue, weakness, as well as weight loss

unintentional weight loss = or >5% body weight

BMI < 20 (pt <65yo) OR <22 (pt >65yo)

<10% total body fat

increased cytokine levels (-> muscle tissue breakdown/catabolism)

albumin level <35 g/L

enourage oral fluid intake for as long as possible; team to work with family to determine if supplemental hydration. NOT USUALLY NECESSARY in terminal phase, although in some cases hypodermoclysis may ease delirium, opioid toxicity, agitation, dehydration

days to weeks

possible psychological and spiritual distress - depression, anxiety, grief, isolation in final weeks (highest levels of anxiety - COPD likely d/t dyspnea). Hopelessness, general dissatisfaction with life, overall sense of suffering in advanced dz.

increasing weakenss and dependence on caregivers

dysphagia/aphagia - if unable to take PO, consult with prescriber to d/c unnecessary meds; to promote comfort, KEEP pain meds, anxiolytics, antiemetics, anticholinergics, antipyretics (alteranate routes)

asthenia -> bedbound + incontinence, malnutrition -> risk for skin breakdown. SKIN CARE, frequent repositioning. Kennedy ulcers in final days, despite skin care (sacral, pear- or butterfly-shaped)

focus care on SYMPTOM MGMT and comfort as pt declines.

hours to days

educate family on saying goodbye/resolving conflicts, creating mementos (recording pt’s voice, hand casts, photos, etc), finalizing funeral arrangements, gathering loved ones who want to be present at TOD, normal changes in pt condition (decr. appetite, incr. somnolence, cyanosis, etc.) and that they don’t cause pain/distress for pt

aggressive and prompt symptom mgmt to alleviate distress - determine if change in meds/routines is root cause.

Some SSx may not be distressing for pt (ex. some terminal agitation) but impacts safety - address via activity as tol., thx environmen, music thx, meds (haloperidol, chlorpromazine, risperidone, lorazepam)

some distressing for family but not pt - terminal secretions (death rattle). educate family, reposition pt., suction oropharynx (NOT deep suction). if dyspnea or pt distress, anticholinergics (hyoscamine SQ, atropine SL, glycopyrrolate SL, scopolamine SQ/topical

SSx: confusion and vision of loves ones who’ve passed away; terminal agitation -> incr somnolence -> unresponsiveness; respiration changes (aphea, Cheyne-Stokes, agonal breathing, terminal secretions); temporal wasting; dehydration; pain; cyanosis (lips, extremities), cooling of extremities; HTN -> hypotension; peripheral edema; mottling; incontinence -> oliguria -> anuria. increasing asthenia and somnolence -> coma OR mutliple symptoms w/ terminal agitation period prior to coma.

pts withdraw and lose verbal ability, but THOUGHT REMAINS INTACT - caregivers should continue to talk, provide soothing sounds (music) throughout dying process

educate caregivers on nonverbal signs of pain/discomfort (often r/t tumor pressure, GI distress, frailty, siffness, immobility, bladder distention (FLACC scale)

FINAL HOURS: profound weakness/fatigue, guant/pale, withdrawal from others/reduced awareness, glassy/cloudy eyes, unable to take PO, oliguria-anuria, agonal respirations/apnea, tachycardia, unresponsive

adhere to advance care plan, avoid unnecessary interventions incl. VSx monitoring, treat FEVER, d/c unneeded routine meds

educate family re: pre-death “rally” - sudden reawakening/awareness of surroundings, coherent conversation, increased appetite -> semicomatose within hours (family distress, false hope)

if esophageal varices - prep family for poss. terminal hemorrhage (not usually painful for pt but visually distressing), provide support, focused attn during. poss. pt sedation if awake and alert. hemostatic dressings in chronic bleeding. dark towels.

inteventions: agitation (benzos, music, massage, dim lights, cool env.); dehydration (freq. oral care, ice chips as tolerated, hypodermoclysis/protoclysis if GOC consistent); dry mouth (oral care, lip balm, ice chips and oral swab as tolerated, artificial saliva); dyspnea (trx cause if poss., opioids, reposition for comfort, fan for moving air/cool env.); edema (elevate extremities as tolerated, diuretics, decrease/discontinue artificial nutrition/hydration of fluid overload SSx); fever (acetominophen PR, fan, light clothing, cool compress to head); incontinence (change promptly, skin care after each incident, reposition freq to protect skin); pain (PO meds until not tolerated -> SQ, PR; adjuvant meds PRN, reposition, distraction, massaage, heat/cold); terminal secretions (reposition, anticholinergics, oral suction); decubitus ulcers (skin care, wound care, topical lidocaine)

afterdeath care

assessment/document: general appearance, absence of heart/lung sounds on auscultation (1 full minute), lack of pupillary response to light, absence of response to verbal/tactile stimuli, TOD, who was notified of death, what time family/caregiver notified hospice agency (for home care patients), to who body released (morgue, funeral director, etc.)

postmortem care with attention to cultural/religious preferences; invite family to participate if they desire; emotional support for family with assurance team will provide bereavement support up to 1yr

prep death certificate as req. by state law, notify primary care provider

FEDERAL LAW - if death in hospital, primary decision maker must be approached re: organ donation

DISEASE SPECIFIC

end-stage cancer

neuro disorders

           neurologic

           neurovascular (w/ cva, coma admission criteria)

cardiac disorders

pulmonary disorders

renal disorders

hepatic disorders

infx (esp. viral hepatitis), autoimmune dz, genetic predisposition to liver dz, cx, chroncia ETOH, fatty liver -> liver damage

risk factors: ETOH abuse, exposure to blood/body fluids (parenteral drug abuse, tattoos, blood transf. prior to 1982), hepatotoxic chemical exp., diabetes/obesity (Hep C #1, alc. cirrhosis #2)

irreversible dz processes -> chronic lliver failure (CLF) ->ESLD. erratic trajectory with increasingly frequent, severe exacerbations of symptoms. sudden death r/t complications.

ascites, hepatic encephalopathy, anorexia/cachexia, portal hypertension, poor immunity, n/v, lyte imbalance, pruritis, malaise, esoophageal varices, pain, muscle/extremities wasting d/t malnutrition

assessment: symptoms (pain, n/v, altered bowel, rectal bleeding, dysphagia, abd. distention, pruritis), jaundice of sclera and skin, rash, petichiae, open areas from scratching, nonhealing wounds, temporal wasting & sunken eyes d/t malnutrition; abd inspection/ausc/percussion/palpation (boardlike w/ generalized peritonitis; rebound tenderness with local inflamm)

Model of End-Stage Liver Dz (MELD) - INR, bilirubin, creatinine levels. (score 10-19 = 92% 6-month mortality)

Child-Turcotte-Pugh (CTP) - total bilirubin, albumin, INR, degrees of encephalopathy & ascites (Class A = 95% 12-month mortality)

ascites indicates 50% 2-year mortality (6-month median survival rate when refractory)

liver failure -> renal failure (hepatorenal syndrome); HRS type 1 -> 4-week survival rate; type 2 -> 6-month survival rate

DISCUSS PALLIATION EARLY

HOSPICE CRITERIA:

symptoms (ascites, hepatic encephalopathy, HRS, varices) are refractory to intervention

PT > 5 seconds over control OR INR > 1.5

serum albumin <2.5 gm/dL, plus one or more:

ascites, refractory or pt noncompliant

spont. bacterial peritonitis

HRS, elevated creatinine and BUN, oliguria (<400 mL/d), urine Na concentation <10mEq/L, chirrhosis and ascites

hepatic encephalopathy, refractory or pt noncompliant

recurrent variceal bleeding despite thx

SUPPORTING documentation: progressive malnutrition, muscle wasting, continued active alcoholism (>80g ETOH/d), hepatocellular carcinoma, Hep B (HBsAg) positive

dementia/neurocognitive disorders

NCDS - decline from previous function, distinct from congenital

risk factors - age (60yo, 85yo), genetic predisposition, female, poor diet/obesity/diabetes, depression, education level, multiple comorbidities

memory changes, poor recognition, word searching, decr. executive function, poor attention span, behavior/mood changes, altered perception, decreased function re: ADLs

APA diagnostic criteria (dementia): significant decline from previous level in multiple domains (complex attention, executive function, learning and memory, language, perceptual/motor, social cognition) based on concern from knowledgeable informant or clinician or documented by testing/assessment + interferes with ADL independence + not just delirium + not better explained by another mental disorder

Alzheimer’s - slow progression (6-8 years) with exacerbations of underlying illnesses; short term memory loss, decreased attn, word searching

vascular - stepwise decline; onset gen. corresponding to TIA/CVA/cerebral infarct; variability of symptoms: aphasia, motor deficits, impaired executive function/recall/problem solving

Lewy body - progressive symptoms: neurocognitive changes, movement disorders, hallucinations, parkinsonian movements, falls, delusions, sleep disturbance

frontotemporal - (umbrella - nerve cell damage) variable progression; aphasia, obstinacy, apathy, motor disturbances, disinhibition, decr. facial recognition, emotional distancing

PT/OT/ST to maintain function & speech/swallow ALAP; advance care planning, GOC, long-term management (LTC facility?) EARLY

cholinesterase inhibitors (donepazil) to impr. cholinergic transmission in early stages; NMDA receptor agonists (memantine) later stages (impr. memory, enhance reasoning, maintain physical function - can be used together

late stage - interdisciplinary team - serious motor impairment ->safety issues, dysphagia/incontinence/immobility -> skin integrity infection -> agitation, delirium/depression/lethargy, pain, SOB, limb contractures

terminal phase - per advance directive and GOC, d/c interventions if questionable benefit

CRITERIA FOR HOSPICE ADMISSION

FAST** Stage 7 or beyond PLUS one or more of

aspiration pna

septicemia

pyelonephritis

multiple S3/S4 pressure injuries

recurrent fever

other significant condition suggesting limited prognosis

hx shows inability to maintain sufficient fluid/calorie intake in past 6 months (10% weight loss, albumin <2.5gm/dL)

**FAST staging: 1. (normal adult) no difficulties; 2. (normal older adult - mild memory loss) word finding, location of objects; 3. (early dementia) decreased job function evident, decr. organizational capacity, difficult travel to new locations; 4. (mild dementia) decr. ability at complex tasks, handling finances; 5. (moderate dementia - diff with serial subtraction; date/year/home address) assistance in proper clothing choice; 6a. (moderately severe dementia - diff with names of family/friends, delusions/hallucinations/obsessions, increased anxiety, poss violent; daytime sleep/night wakefulness) assistance in dressing; 6b. assistance bathing more freq.; 6c. assistance toileting more freq.; 6d. urinary incont. more freq.; 6e. bowel incont. more freq.; 7a. (severe dementia - incontinent x2, lose speech & ability to walk; bedridden -> sepsis, pna) limited speaking ability (half dozen words in av. day/interview); 7b. single intelligible word in av. day/interview); 7c. lost amb. ability; 7d. needs assistance to sit up (i.e., arms on chairs); 7e. lost ability to smile

endocrine disorders (most common)

thyroid dz

hypo (high TSH) - weight gain, jaundice, hoarsenes, decreased sbp/increased dbp, pericardial effusion, bradycardia, edema, fatigue, myalgia/arthralgia, blurred vision, impaired hearing, increased perspiration, fever/sore throat, depression/emotional lability, cold intolerance, paresthesia, constipation; myxedema crisis/coma - LEVOTHYROXINE 1-2 mg/kg/d.

hyper  (low TSH, high T4/T3) - Grave’s disease comorbid 60-80%. nervousness, irritability, tremor, muscle weakness, bruit over thyroid, hyperactivity, heat intolerance, hair loss, palmer erythema; thyroid toxicosis/thyroid storm (antithyroid meds, inorganic iodine, bile acid sequestrants, beta-blockers, glucocorticoids) - antithyroid meds (methimazole, propylthiouracil), beta-blockers for andrenergic symptoms. radioactive idodine thx/thyroidectomy.

diabetes

DM2 risk factors: age, htn, hypercholesterolemia, weight/obesity, smoking, inactivity, hyperglycemia;

increased risk of stroke, cardiac events; retinopathy, neuropathy

maintain AIC <5.7% or fasting plasma glucose <100 mg/dL

prioritize comfort/quality of life (when to d/c BG monitoring; EDUCATION of pt, family re: d/c)

immunologic disorders (w/ hiv admission criteria)

PAIN MANAGEMENT

assessment

chronic pain/chronic pain syndromes

low back pain - recurrent, refractory, impaired mobility, debilitation

myofascial pain syndrome (MPS) r/t muscle, fascia, tendon injury - myositis, fibrositis, myofibrositis, myalgia,

neuropathic

peripheral - diabetic neuropathy, nutritional deficiency, HIV, carcinoma - activity, allodynia

central - spinal cord trauma, tumors, vascular lesions, MS, Parkinson’s, postherpetic neuralgia, phantom limb, reflex sympathetic dystropy (CRPS)

CRPS - neuropathic, allodynia (diaphoresis, vascular changes, asthenia, disuse (PT, nerve blocks)

chronic postoperative pain (CRPS) - phantom limb, chronic donor site, postthoracotomy pain syndrome, joint arthroplasty (acute + chronic -> multimodal trx)

reticular - compression of neck/spine nerve roots (sciatica, injury, herniated disk, foraminal stenosis, inflammation) - sharp, stabbing, radiating

cancer - neuropathy, parasthesia, r/t tumor growth, trx, comorbidities - frequent assessment for rapid changes, short- + long-acting

PQRST

palliative & precipitating factors (what makes it better or worse)

quality (what does it feel like)

radiation (is it in one area or does it travel) (somatic gen. well-localized, visceral gen. poorly localized, neuropathic gen. radiates)

severity (can you rate it for me)

timing (better or worse at certain times, when did it start, how long does it last)

nonverbal: FLACC, Wong-Baker FACES, Faces Pian Scale Revised (FPS-R) (children 1-7), PAINAD

impacts

physical - quality, severity + related symptoms (nausea, sleep disturbance, depression, anxiety, immobility,

psychological - anxiety, depression, hopelessness; quality of life, incl. planning activities around pain/meds (Patient Health Questionnaire (PHQ-9, depression); GAD (GAD-10) screenings)

social - isolation, social consequences of reporting pain

spiritual - FICA Spiritual History (spiritual distress)

SUD - gen. more severe pain experience, poss. require higher med dose

40% comorbid mental/emotional/behavioral disorder

serious illness as trigger for substance abuse

AUDIT-C, Opioid Risk Tool

interventions

nociceptive pain (somatic or visceral) (sharp and localized)

visceral (gnawing, ache) - multimodal mgmt; metasteses, pancreatic tumors/pancreatitis, biliary or SBO/colon obstruction

neuropathic - multimodal mgmt, incl. nonopioids, gabapentinoids, antidepressants, SNRIs, anticonvulsants, Na-channel blocking antiarrhytmics. (opiods as second/third-line; methadone; high doses for effective trx)

WHO pain ladder

Step 1 - nonopioids with or without adjuvants

Step 2 - opioids with or without adjuvants, nonopioids

Step 3 - opioids for mod-severe pain (long-acting + short-acting) + adjuvants

non-opioids

acetaminophen (PO, PR, IV)

NSAIDS (selective vs. nonselective COX-2 inhibitors)

opiods

SEs

constipation (gastric motility) - bowel regimen (laxative + stool softener)

n/v (gastric motility, CTZ & opioid receptor stimulation)

entiemetics to antagonize specific receptors:

haloperidol - D(2)

promethazine - H(1)

naloxone - DOR

ondansetron, tropisetron, dolasetron, granisetron - 5-HT(3)

scopalamine - ACh

aprepitant - NK-1

dronabinol - DCB(1)

pruritis (partic. MORPHINE) (histimine release; effects on mu-opioid, dopamine, serotonin receptors) - rotation, reduction, antihistimines (xerostoma, confusion, blurred vision in geriatric pt - TOPICALS instead)

sedation (difficulty clearing incl. geriatric, renal dysfunction) ->

respiratory depression (opioid naive, sleep apnea, geriatric, drug-drug interactions, obesity, cardiac/respiratory disorders, functional/psych status, comorbidities) - naloxone, education

opioid-induced neurotoxicity (accumulated opioid metabolites)

partic MORPHINE then HYDROMORPHONE (kidney excretion, i.e., risks in geriatric and renal dysfunction)

fentanyl, sufentanil

do not use meperidine in palliative/hospice d/t seizure risk

myoclonus - first, most common sign

reverse mechanism, therefore -> reduce/rotate

clonazepam, midazolam, benzos, baclofen, dantrolene

overdose - often drug-drug interaction (opoids + benzos)

confusion/delirium, n/v, pinpoint, lethargy, cyanosis, respiratory distress/failure

naloxone (IN, SL, IV, IM)

CONVERSIONS

oral to parenteral - 3:1

long-acting dose - (actual TDD incl. PRNs / 2) Q12H

oral rescue dose (breakthrough pain) - 10-20% TDD Q1-2H PRN

parenteral rescue dose - 50-100% hourly rate Q15 min PRN

drug-to-drug*

adjuvants (NSAIDs, COX-2 inhibitors, muscle relaxants, psychotropics, antidepressants, antiepileptics, anxiolytics, sedatives, amphetamines, antiarrhythmics, Ca-channel blockers, ketamine, lidocaine, capsaicin, tramadol, etc.)

non-pharmacologial

evaluation

SYMPTOM MANAGEMENT

neuro

cardiovascular

terminal cardiac diagnosis -> deteriorating status; multiorgan system failure

coagulation problems inabilty to clot or regulate clot formation d/t tumor invasion, trx SE, thrombocytpenia, nutritional deficiency, anticoag use, coag abnormalities -> bleeding disorders/internal bleeding SSx epistaxis, hemoptysis, hematemesis, melena, hematochezia, hematuria, vaginal bleeding, sings of incr ICP

bleeding/hemorrhage - if nonacute, stop bleeding (packing, compression dressing, topical hemostatic, position to decr bloodflow, astringints) and alleviate pt’s anxiety. educte pt and family for risks for bleeding (partic in liver dz). Catastrophic hemorrhage - stem further bleed IF CONSISTENT WITH GOC. Radiation thx, palliative TACE, endoscopy, vitamin K, vasopressin, antifibrinolytics, otreotide (for varices), platelet transfusion, FFP. possibly palliative sedation. Dark-colored towels to reduce visual impact for pt and caregivers.

thrombi/dvt - risk d/t immobility, orthopedic trauma, circulatory problems - use TED hose/SCDs prophylatically. DVT SSx: edema, pain, localized warmth, venous distention, localized tenderness to palpation. Dx via venogram (”gold standard” but invasive), venous doppler to detect blood flow (evaluate/compare both extremities). Trx: hepairin, low molecular weight heparin (LMWH), unfractioned heparin, fondaparinux. NO enoxoparin (Lovenox) (a LMWH) in acute renal failure.

pulmonary embolism - d/t thrombus formation, often DVT migrattion to pulmonary artery. Risks: genetic predisp., recent surgery, hx DVT/PE, immobility, hospitalization, cx, age, HF, stroke, acute respiratory failure, IBD. may be initially asymptomatic/vague symptoms. Unexplained chest pain in 97% of confirmed PE. other SSx: anxiety, diaphoresis, cought, syncope, hemoptysis, hypoxemia, hypotension, pleuritic rub.  -> pressure increase in R ventricle -> tacycardia, crackles, fever, prounounced S2 (with closure of pulmonic and aortic valves), S3 (d/t fluid overload), possible S4 gallop (d/t thickned ventricular walls 2ndry to HTN or aortic stenosis).

lab testing is not definitive. rule out differential dx w/ d-dimer, ESR, leukocyte level, dehydrogenase, BNP, troponin. rule out differential dx with chest XR. spiral CT with contrast can more accurately confirm - if non-contrast d/t allergy, renal impairment then ventilaion/perfusion (V/Q) scanning. Gold standard dx - confirmation via pulmonary angiogram (expensive and invasive)

trx: stabilize. invasive measures only if consistent with GOC (mechanical vent, intubation) - improve ventilation. BIPAP noninvasive may also improve.

pharm (IV resuscitation, vascular stabilization) - vasopressors (norepinephrine, dopamine, epinephrine), anticoags (LMWH, unfractioned heparin, fondaparinux, warfarin, rivaroxaban). in initial phase, intiate parenteral heparin, LMWH, rivaroxaban, fondaparinux - > transitioned to oral or other agent. IF NOT CONSISTENT WITH GOC: alleviate dyspnea and anxiety, incl. sedation if sever distress and symptomatic. Family education, d/t suddenness, poor prognosis

DIC - thrombi -> infarction in multiple vessels/organs -> organ damage + internal bleeding d/t platelet depletion; risks: sepsis, inflamm dz, cx, liver dz, trauma, aneurysms, vascular disorder. ssx initially subtle; bruising purpura, petechiae, hematemesis, hematuria, hematochezia, hemothorax. trx: replace blood and blood products, correct metabolic shifts. anticoags (may need cautery, cryoablation to control bleeding), synthetic protease inhibitors (block serine proteases, incl. thrombin), antifibrinolytics, IF ORGAN FAIULRE, natural protease inhibitors, but avoid antifibrinolytics

angina d/t increased cardiac O2 demand d/t activity, cardiac vessel onbstruction, MI. stable vs. unstable. ssx: sudden chest pain, tightness, heaviness, squeezing, pain radiating to jaw/arms/back, SOB, fatigue, nausea (2-3 symptoms together - atypical angina). trx: rule out MI or occlusion, treat symptomatically - discontinue precipitating activities, nitroglyc SL/PO/TD/IV/lingual spray. Possible invasive (angioplasty, stent, CABG) if benefits outweigh risks

edema

lower extremities d/t ES organ failure (partic (R) heart/liver/kidney), med SE, superior vena cava syndrome (SVCS), vascular insufficiency, hypoalbuminemia, fluid overload. pitting vs. non-pitting. incr weight -> discomfort, decr mobility. trx: elevation, compression. diuretics may NOT be useful, particularly if refractory. interventions implemented slowly to prevent incr. cardiac symptoms.

lymphedema d/t obstruction/removal of lymph nodes (r/t cx surgeries, other trx) -> lymph accumulation -> fibrosis, sclerosis -> permanent edema. pre-fibrosis, trx with elevation, compression. diuretics generally NOT useful. SKIN CARE. manual lymphatic drainage by trained massage or PT (promoting mobility, ROM, QOL)

syncope temp. loss of consciousness d/t low blood flow to brain (hypotension, r/t (ES) cardiac dz/afib, dehydration, fluid shifts, postural changes (orthostatic)). SAFETY - educate pt and family on changing position slowly, assistance for transfers, sit/lie down at warning SSx: nausea, diaphoresis, lightheaded. Recurrent -> anxiety, somatization, panic -> fluoxetine. Testing (EKG, lab studies for lyte imbalance/dehydration, tilt table to test) for cause if GOC consistent. Pacemaker may relieve fatigue, dyspnea, syncope.

SVCS obstruction of SVS/nearby lymph nodes/vessels (usually d/tprimary tumor or mets from lung cx/breast cx/lymphoma) -> SSx obstructed drainage from hed/neck/UEs (facial swelling, JVD, distention of chest veins, UE edema, ruddy complexion; over 2-week period - cough, dyspnea, hoarseness, blurred vision, syncope, HA, confusion, obtundation). Confirm dx via chest XR, CT, MRA. trx via chemo/radiation, steriods, diuretic, thrombolytics, stent/bypass. RAISE HOB 45-90 degrees to promote drainage. prognosis (age over 50, extent of malignancy, hx smoking, steroid use) fair to poor, <6mo to 2yr -> team discussion GOC re: interventions

respiratory

gi

constipation (abd distention, nasea/indigestion, <3BM/wk, difficult to pass/straining, feeling of incomplete emptying)

d/t slowed gi mobility, increased intestinal water absorption, obstruction, meds (incl. antidiarrheals, opioids), immobility, low fiber, dehydration

ausculate, palpate, skin turgor, hx (diet, mobiliyt, usual patter, associated issues, typical consistency)

high fiber diet, 2-3L fluids/day, exercise as tolerated, laxatives (increase if opiod increases)

bulk forming (absorb water, increase mass, stimulate peristalsis - psyllium (Metamucil), 5-7g daily start OR methylcellulose (Citrucel) 4-7g daily startt; 12-72H to onset. Use prophylactically, DO NOT use with ileus or impaction; req. 300-500ml fluid each dose (prevent impact.)

lubricant (also prevents reabsorption of water) - glycerin suppository 1PR qd OR mineral oil 30-60mL PO qd; 6-8H to onset (suppository 15-30 min)

opioid antagonists (block opioid receptors in bowel) methylnaltrexone (Relistor) for chroninc NON-cx pain 450mg PO qAM or 12mg SQ qAM (dose weight-based for adv. illness), OR naloxegol (Movantik) 12.5-15mg PO qd; 30-60min onset; d/c all maintenance laxatives prior to use, ensure close proximity to br

osmotic (pull water in and increase peristalsis) - lactulose (10g/15mL) @ 15-30mL qd to MAX 60mL/d in devided doses (24-48H onset), OR polyethylene glycol (Miralax) (48-96H onset) 17-34 g/d (dissolve 1cap in 8oz liquid /day up to 8 doses per day; poss bloating, flatulence

surfectant/detergent (draw water into colon) - docusate sodium (Colace) (whatever - this is useless) 100mg qd-BID (1-3 d onset) OR mineral oil 14-15mL qd (onset PO 6-8H, PR 2-15min); BITTER liquid, mix with juice or milk

bowel stimulants (stimulate submucosal nerve plexus -> incr. peristalsis) bisacodyl (Dulcolax PO) - 5mg qd start up to 30mg qd (6-10H onset), Dulcolax suppository (10mg PR qd) (,1H onset), OR senna (senokot) 15mg qd start to max 70-100mg qd (6-12H onset) - AVOID with ileus, obstruction, monitor for lyte/fluid imbalance, may develop tolerance. SE cramping, n/v with senna.

fecal impaction - bisacodyl or glycerin suppository, 2% lidocaine gel with disimpaction (avoid if possible perf or bleeding)

diarrhea (passed too quickly for water absorption) - abd pain, cramp, lethargy/weakness, n/v, distention, anorexia, incr thirst - dehydration, nutrient/lyte imbalance

d/c laxatives, assess for impaction, ID any ssx infx, replace fluids/lytes, provide skin care for incontinence. antidiarrheals cautiously with fever

opiods/opiod derivatives (ex. diphenoxylate/atropine (Lomotil)) 1-2 tabs PO BID-QID PRN

nonopiod (ex loperamide (Immodium)) 4mg PO 1x at ssx onset, then 2mg after each loose stool. (GERI SE - anticholinergic effects - prefer Lomotil)

antacids, adsorbents (bismuth salicylate - also antiinflamm and antibx) for n/d/indigestion; 2 262mg tabs QH PRN up to 16 tabs/24H

bulk-forming/fiber agents (absorb excess water) - ex. psyllium 1-2 tsp mixed with liquid up to TID

incontinence (muscle weakness/atrophy, neuro dz, severe diarr) - ID and remove (if poss) the cause; track associated ssx (weight loss, fever, R bleeding, steatorrhea)

env changes - BSC, clear path and proper lighting, remove physical restraints

skin care, with barrier cream/ointment

ascites (portal hypertension, hypoalbuminemia; malignancy, HF -> abd fluid collection) - indicate ES dz

discomfort, altered body image, decr mobility, dyspnea (diaphr. pressure), umbilical hernia, cellulitis, bacterial peritonitis

restrict NA 2g/d, fluid restriction, spironolactone (50-400mg qd), furosemide (20-130mg qd), paracentesis (if >4L, IV albumin), TIPS (potential hepatic encephalopathy)

repeated paracentesis -> indwelling abd cath

maintain trx consistent with GOC

hiccups (benign minutes to 2 d, persistent 2 d to 1mo, intractable longer than 1mo) -> indigestion, bloating, pain, abd distention, insomnia, fatigue. Quality of life

nonpharm - hold breath, breath into paper bag, compress diaphr., ice in mouth, induce cough/sneeze, pressure on nose, swallow sugar, eat lemon wedge with bitters, eat soft bread, touch palate with cotton swab, ocular compression, carotid massage, CBT (???), repositin, faseting, NG tube, acupuncture, induce emesis, disrupt phrenic nerve action (ablation last resort d/t pulmonary function risk)

pharm - simethicone 15-30mL PO q4H for distention; baclofen 5-10mg PO q6-12H up to 15-37mg qd OR midazolam 5-10mg PO q4H for muscle spasms; gabapentin 300-600mg PO TID for anticonvulsant; amitryptyline 10-50 mg PO OR sertraline 50-150mg PO QIS for CNS effects; haloperidol 2-10mg PO/IV/SQ q4-12H to block dopamine and alpha-andrenergic receptors

n/v (increased salivation, loss of appetite, diaphoresis) ASSESS N/V SEPARATELY

 cerebral cortex (fear, anxiety, stress, memories, sensory stimulation)

pressure receptors (increased ICP)

chemoreceptor trigger zone (central neural pathway) (opioids, serotonin, dopamine, histamine, acetylcholine, antibx, NSAIDS, electrolyte disturbance, inhln agents)

glossopharyngeal/trigeminal (stimulate GP nerve - surgery, tumor growth, etc.)

vestibular (middle ear surgery, motion, vertigo)

 GI (infx, cytotoxic meds, GI irritants, constipation, obstr., decr. motility)

-> stim vom center in medulla oblongata ->emesis

ANTICHOLINERGICS (hycoscine (scop) 1.5mg patch, 0.5-3 patch TD Q72H OR 0.6-1mg SQ/IV Q6-8H - spec. if d/t motion or obstruction. geri - anticholinergic SEs) (atropine opthm 1%, 1-2 drops SL Q8H PRN) (hyoscyamine 0.4-0.6mg SQ Q4H PRN)

ANTIHISTIMINES  (diphenhydramine 25-50 PO/SC/IV Q6H PRN (blocks H1 receptors in vom center, CTZ, vestibular nuclei). GERI - risk for extrapyramidal SEs) (cyclizine 50mg PO Q4-6H PRN to max 200mg/day - rec. for incr. ICP, motion sickness pharyngeal stimulation, mechanical BO)

BENZOS (lorazepam 0.5-2mg PO/SQ/IV Q8-12H - use with another agent unless caused by anxiety)

CANNABINOIDS (dronabinol 5-10mg PO Q3-6H, nabilone 1-2mg PO BID - CHEMO, if other trx ineffective)

CORTICOSTEROIDS (dexamethasone 4mg PO Q6H WITH FOOD - prophylactically during chemo/radiation; may help reduce BO)

DOPAMINE RECEPTOR AGONISTS 0-20mg PO/SQ/IV Q6H OR 25mg PR (partic for opoiod-induced nausea) - blocks dopamine in CTZ. sedating effect - may be beneficial for imminent patients)

OCTREOTID (100-400mcg SQ Q8H) - BO

PROKINETICS (metoclopromide 10-20mg PO/SQ/IV Q4-6H up to 40mg - CHEMO n/v) - for gastric stasis, admin prior to meals; reduce dose geri, renal dz. NOT in BO, perf, or immediately postoperative

SELECTIVE 5-HT3 RECEPTOR AGONISTS (ondansetron 4-8mg PO/SQ/IV Q8H on Day 1 chemo; 16-24mg PO 1x OR 8-16mg IV 1x (max dose 16mg)) - specif. prophyl. chemo/radiation n/v (PREMED)

SUBSTANCE P AGONISTS (NKI receptor agonists) (aprepitant 125mg PO 1x Day 1 chemo, then 80mg PO Qmorning on Day 2-3. PREMED 1H prior on Day 1, with a corticosteroid (dex) and a 5-HT3 agonist (Zofran)) - used with ondansetron prophyl. chemo/radiation n/v

nonpharm: hydration, small meals/fulll liquid, withhold routine meds if poss, complementary thx (aromatherapy, meditation, relaxation), reposition, CBT, intervention for tumor growth (surgery, stent, NGT, decompression)

(malignent) bowel obstruction (d/t intraabdominal cx) (-> sepsis, perf, necrosis) (n/v undigested food, poss fecal matter in advanced MBO; hyperactive bowel sounds/borborygmi; pain/distention with large intestince) - prognosis 30-90 days

palliative mgmt for n/v, pain, colic, possible parenteral fluid fo comfort, NGT for distention. FREQ oral care, ice chips for dry mouth

palliative pharm: opioids, anticholinergics, corticosteroids (metoclopramide 10mg Q 6-8H nausea 1st line; octreotide 50-100mcg SQ/IV Q8-12H antisecretory, but high cost, SE (n/d, pain, constipation))

gu

infx, cx, ES dz, iatrogenic

bladder spasms - stabbing/cramping, colicky suprapubicpain d/t detrusor muscle acting agaisnt partial/fully blocked bladder outlet (by tumor, blood clot, stent, cath (too large, kinked, blocked)). urgency or leakage poss. smaller cath, balloon inflated to appropriate size, drink sufficient fluids, avoid caffeine/alcohol/other irritants, anticholinergics (with care in geri pt); botulinum toxin A injection into detrusor to decr. urgency sensation

incontinence - transient in delirium, UTI, immobility, sever constipation; med SE; diminished contraction of detrusor. review meds for SE incontinence, sedation (reduced sensitivity to fullness); timing (only at night, stress (sneeze, etc.), continual?. Skin care; review incontinence aids with caregiver for bedbound patient. SSX of UTI - > sample and UA. Poss indwelling cath (UTI risk))

retention - d/t UTI, mechanical obstruction (partic in BPH, colon/pelvice cx), neuro issues, meds (anticholinergics, antihisitmines, antidepressents, antihypertensives, anit-Parkinsons, antipsychotics, sympathomimetics, opoids (partic. with anticholinergics). REVIEW MEDS and d/c if possible. Indwelling cath if bladder firmness on palpation, bladder scan >300mL or PVR 200-300mL (including after straight cath)

msk

immobiility, pain, debility, mestatses, ESdz

impaired mobility + complications - incr. risk of skin breakdown, physical deconditioning, activity intolerance, pathological frx. assess skin condition and ulceration risk factors with reliable tool (Braden Scale***). combined with sensory loss, incontinence, poor nutrition -> incr risk of pressure ulcers. Risk of skin shear of friction abrasion when pt repositioned by others. PRIORITY PREVENTION - encourage active participatoin in repositioning using rails/trapeze bar; freq reposition for immobile pt; pillow, cushions, antipressure devices/mattresses. Nutritional assessment for deficiencies, weight loss, cachexia (direct correlation b/t pressure ulcer risk and nutritional deficiency (low protein, albumin); consider supplements if appropriate

deconditioning/activity intolerance - d/t prolonged immobility, med SE, anemia, dz progression -> fatigue, weakness, decr. stamina -> incr falls risk, decr ADLs and QOL. weakness, dyspnea with exertion, fatigue with activity. preserve stamina in nonambulatory pt through passive/active ROM as tolerated. prevent falls - proper lighting, assistance with transfers and ambulation, necessary objects (glasses, telephone, call bell) within reach

pathological fractures d/t dz (most common osteoporosis; bone mets). femur most common site, 75% of which at proximal end. Also tibia, humerus, ribs, spine. SSx - localized pain/swelling, numbness; if femur, affected leg uually shorter and externally rotated. -> surgical stabilization (w/ or w/out joint replacement) common; contraindicated if widespread meets or life expectancy <6mo. Determine risks and educated on proper positioning, safety. pain mgmt and joint stabilization. team should collab with pt/famlly for plan of care to promote QOL, consistent with GOC.

integumentary and mucous membrane

meds, dz progression, poor nutrition/hydration,

xerostomia (radiothx head/neck, Sjogren’s, depression/anxiety/stress, malnutrition) dry mouth + hyposalivation. assoc: thrush, poor dentition, dry mucous membranes -> ability to eat/talk/wear dentures, incr. risk halitosis/caries/thrush/taste change. remove reversible causes (incl. meds if poss.), proper hydration, freq oral hydration, sugar-free gum/candy

pharm: pilocarpine 5mg TID, cevimeline 30mg TID (SE: d/n/v, sweating); sialagogue - oral topical

pruritis chronic in renal/liver dz, hypo/hyperthyroidism, anemia, malginancies, HIV; med SE (partic. opioids) -> disrupt ADL/sleep patterns. assess using Woods lamp if poss; parasites, bacterial/fungal infx, lesions. trx any underlying cause; also topical ointments, barrier creams, soakes (calamine, menthol, oatmeal bath, antihist. cream, steroids, capsaicin). Geri use of systemic thx (antihist) with caution (anticholinergic SE)

wounds (pressure ulcers, tumor extrusions, nonhealing wounds) - pressure and anoxia -> tissue damage in as little as 20-40 minutes.

frequent reposition - if bedbound, every 2-4H on pressure-reducing surface away from ulcer site; premed 20-30 min if pain; flexibility if actively dying or comfortable in only one position

adequate nutrition/hydration incl PO, SQ, IV dydration if appropriate, nutritional supplements. Provide as appropriate with GOC and prognosis

wound care based on staging, GOC, prognosis. NPWT to remove excess drainage/necrotic tissue/infx if large. Debridement of necrotic tissue: mechnical (wound irrigation/hydrotherapy, enzymatic via topical agents with dressing change Qday); biosurgical (medical maggots); autolytic (moisture-retaining dressing changed Q3-5 days, causing self-destruction of necrotic tissue)

S1 nonblanchable erythema, localized, usually over bony prominence. skin intact, red/purple/blue

S2 partial thickness loss of epidermis, some dermis. shallow open ulcer/superficial erosion, pink-red wound bed, no slough

S3 full thickness loss of skin, necrosis of SQ tissue, SQ fat poss. visible, but tendon/muscle/bone NOT exposed. Poss. undermining/tunneling, slough, necrotic tissue

S4 full thickness loss of skin including epidermis, dermis, SQ tissue; poss. muscle/bone/tendon exposure, slough, undermining/tunneling

(suspect) deep tissue injury - localized discoloration (purple/maroon), non-blanching, epidermis intact, feels boggy

unstageable - full thickness tissue loss covered by eschar or extensive necrotic tissue (tan, yellow-green, brown) (must be cleared before true depth can be determined)

OTHER DATA: length/width/depth (mm), description of edges, presence/description/amount of undermining/necrotic tissue/exudate/granulation tissue and epithelialization, condition of surrounding tissue

increased infx risk - debridement and wound care. high-risk wounds: silver-release topical dressings, medical-grade honey dressings, thin film dressings, hydrocolloid for S2-3, faom for exudative S2 pressure ulcers, hydrogel for nonexudative/necrotic, calcium alginates to absorb exudate

control odors - QOL. metronidazole gel (0.77-1.0%) Qday x 1wk to reduce microbe growth. dessings with activated charcoal. if not expected to heal, povidone iodine.

manage pain with systemic analgeisic, low-dose morphine

psychosocial/emotional/spiritual

anger/hostility r/t illness, lack of control, dependency, family/caregiver response to illness - interdisciplinary team (partic. social workier, chaplain) to help pt/family proces and express in safe manner. provide reassurance feeling is common AND usually related to abother emotion (fear, depression, grief)

depression (persistent low mood, anhedonia >2wks + accompanied by at least four of: sleep disruption, weight loss/appetite change, psychomotor retardation/agitation, fatigue/energy loss, worthlessness/excessive guilt, decr. ability to think/concentrate, recurrent thoughts of death/suicidal ideation). uncertainty of dz trajectory, possibility of death. FREQ with anxiety, so assess for both. Therapeutic listening, team collaboration with pt to develop plan: relaxation techniques, meditation, CBT.

SSRI (citalopram 20-60mg/day, escitalopram 10-20mg/day, paroxetine 20-50mg/day, fluoxetine 20-60mg/day, fluvoxamine 50-100mg BID, sertraline 50-200mg/day) - may take sveral weeks for effect.

methylphenidate (Ritalin) if life expectency <2weeks

denial shields pt from consequences of illness until psychologically ready to cope - challenging may increase distress. Active listening, therapeutic silence, reflection, calm reassurance team is available for support as needed.

fear -> tachycardia, tachypnea, shaking, insomnia, diaphoresis, stomach upset, nightmares (response to real threat vs. anxiety response to perceived as well as real threat). Distraction, deep breathing, meditation, massage, CBT, focused support by team social worker/chaplain

grief -> intrusive thoughts, regrent, inability to think clearly, dulled/heightened emotions, nausea, fatigue, myalgia. Therapeutic listening, empathetic support, reassurance experience is normal. team social worker/chaplain factilitate life review, teach CBT techniques, provide spiritual support/guidance

loss of hope/meaning as hope for recovery fails. GOC convo with team to help pt focus shift from hope of recovery to comfort, preserved function, preserved dignity, other comforts. team facilitates life review, which may ID source of meaning.

guilt r/t regret for actions taken or failed to take. personal responsibility for illness, leaving family. -> existential suffering. Encourage pt to explore and express, also to work with team.

nearing death awareness (NDA) about 50% of terminal pts experience, usually coherent, comforting. Generally brings preace, may involved communicating with deceased loved ones, preparing for change, seeing the afterlife, knowing death is near. Culturally bound and varies by pt. Center on differentiating from negative delirium/hallucinations, validate perceptions.

sleep disturbances (insomnia, unusual patterns, daytime fatuge) - review and address dz progression, socioec factors, pain, meds, psych issues; promote restful sleep via sleep hygiene, allowing undisturbed rest, avoiding stimulants. nonpharm: relaxation techniques, massage, aromatherapy, music

suicidal ideation - warning signs: bebavior changes, withdrawing from friends/activities, giving away possessions, talking about suicide, incr. use of drugs/alcohol

Key assessment questions: Are you considering harming yourself? Do you have a plan to harm yourself? if either, considered at risk, take steps to ensure safety

intimacy/relationship issues incl. caregiver stress vs. dependency issues, loss of sexual relationship d/t illness. Discuss openly, normalize experience, reassure, encourage counseling

nutritional/metabolic

d/t dz progression, organ failure, med SE

anorexia/cachexia (anorexia/cachexia syndrome (ACS)) - cx, HF, COPD, HIV, renal dz - sign of advanced dz (POOR prognosis, even with intervention) - metabolic & neurohormonal changes, systemic inflamm, catabolism

oral nutritional suppl., ease diet restrictions, small/freq meals; enteral/parenteral supplementation NOT generally beneficial end-stage, before trial consider potential benefit, life expectencey, functional status (Karnofsky >50, medical issues manageable, caregiver available and pt able to have follow-up lab monitoriing

pharm - megestrol acetate, glucocorticoids, cannabinoids increase appetite/weight but uncertain effect on QoL. with depression, mirtazapine (Remeron) 15mg QHS, methylphenidate 2.5-10mg PO at 0800 and 1200

mid-arm circumference to assess malnutrition over time - weight loss and muscle wasting

dehydration r/t anorexia, med SE, n/v, BO, dysphagia, cognitive impairment (mucous membranes, skin turgor, bowel function - diarr; constip., impact.). may exacerbate delirium, confusion, agit,, myoclonus - NOT usually responsive to fluid replacement. SE artificial hydration - nausea, fluid overload, dyspnea, ascites, edema. is patient acutely ill/expected to recover some function or actively dying? PT AND FAMILY DISTRESS - educate.

oral or enteral fluid replacement; parenteral nutrtion through CVC or other long-term access. SQ fluids (hypodermoclysis) -absorption rate comparable to IV admin. (rarely use protoclysis, PR admin fluids to GI tract).

fatigue (subjective, some objective effects) r/t cx, HF, COPD, renal dz, HIV/AIDS, MS, etc.; poss. secondary to insomnia, distressing SSx, dz process, med SE, psych/spiritual distress

nonpharm - exercise as tolerated, pain and sx mgmt, counseling, medication, relaxation, music thx, sleep hygiene, avoid sleep disruption

pharm - benzo or antidepressent to enhance sleep. if not related to sleep quantity/quality, psychostimulants (methylphenidate, modafinil); corticosteroids; megestrol

hypercalcemia (serum Ca >14mg/dL -> urgent intervention) (metastatic cx as bone deteriorates and released Ca; hyperparathyroidism, lithium thx, Addison’s, Paget’s, vitminan A or aluminum toxicity) -> n/v, anorexia, wekness, constipation, thirst, AMS.

intervention for comfort even in advanced dz

bisphosphanates (pamidronate, zoledronate), calcitonin admin, IV hydration, bone reabsorption agents (gallium nitrate, plicamycin), dialysis

hypo/hyperglcemia d/t uncontrolled DM, sepsis, organ failure, cortisol imbalance, altered intake

monitoroing and mgmt may not be feasible in terminal illness d/t PO inability; ASSESS necessity of fingersticks, dietary control at EoL, EDUCATE pt and family on change to normal routine, REVIEW GoC

hypo <70mg/dL -> diaphoresis, dizziness, pallor, tachycardia, weakness, anxiety, tremors, nausea, hunger. <50mg/dl -> irritability, blurry/double vision, confusion, HA, slurred speech. <40mg/dL -> severe reactions incl. coma, seazure, death

15g carb, 15 minutes BG check, repeat PRN until >70mg/dL

glucagon 1mg IV/SQ (5i minutes to effect)

D50 IV/SQ (immediate)

corticosteriods for dual effect if dyspnea, pain, inflamm

hyper = fasting >116mg/dL OR postprandial >200mg/dL - overtreatment or non-compliance with treatment plan, DM, acute ilness, stroke, sepsis, MI, pancreatitis, meds (glucocorticoids, high-dose thiazides, dobutamine, atypical antipsychotics, cocaine) -> polyuria, polydipsia, polyphagia, glucosuria, weakness, fatigue, weight loss, blurred vision, poor wound healing, incr. infx risk, diabetic ketoacidosis (usually in DM1)

lifestyle modification

pharm: metformin up to 2250mg/day; sulfonylureas (glipizide, glyburide, glimepiride); metglitinides (matelinide, repaglinide); glucosidase inhibitors (acarbose, miglitol); thiazolidinediones (pioglitazone, rosiglitazone); dipeptidyl peptidase 4 (DPP-4) inhibitors (sitagliptin phosphate); amylin agonists (pramlintide); insulin

immune/lymphatic

d/t dz progression, organ failure, med SE

fever (T 101.3F/38.5C x1 OR 100.4F/38C x3 1H apart); d/t infx, immunological disorders, metabolic imbalance; antipyretics PO, PR + poss. antibx for symptom control. possible central fever (high T, skin cool) near death - antipyretics for comfort.

myelosuppression (anemia, neutropenia, thrombocytopenia) - dt decr. bone marrow activity (cx trx, end-stage dz)

anemia (Hgb <8.0 g/dL) - heart dz, pulmonary dz, kidney dz, inflammatory processes r/t chronic dz (age/weight-> higher risk). RBC transfusion (threshold 9.0 g/d/L in advanced dz), erythropoiesis-stimulating agents (epoitin-alpha, darbepoetin) although NOT wiht advanced cx (stimulation of tumor growth)

neutropenia (ANC <1,000/mm3) - bone marrow suppression, cx trx, infx med SE, autoimmune disorder; risk for febrile neutropenia (T 100.4F/38.3C longer than 1H + ANC < 500/mm3 with expectation to decrease). ASSUME with fever while on chemo until proven otherwise. if confirmed: broad-spectrum antibx, possible hospitalization for IV thx.

thromobocytopenia (<20,000/mm3 OR clinically significant active bleeding) - cx, aplastic anemia, med SE, autoimmune disorder, chronic ETOH; purpura + petichiae. if hemorrhage - rad thx, endoscopy, vitamin K, vasopressin, octreotride (for varices), antifibrinolytics, platelets or FFP, palliative TACE. (dark towels to reduce visual impact for pt and caregivers)

lymphedema - lymph accumulation -> fibrosis or sclerosis -> permanent edema. skin care, elevation and compression if no fibrosis yet, manual drainage (PT, MT). (diuretics not usually effective)

mental status changes

altered LOC (CNS dysfunction, med SEs, metabolic imbalance, infx, anxiety, psych issues)

confusion - Confusion Assessment Method (CAM) to detect delirium

delirium - inpt geriatric, postop, advanced illness (infx (UTI), renal failure, hepatic failure, CNS disorders, vascular disorders, pain) - acute onset, fluctuating symptoms, perceptual changes, sleep-wake cycle altered, delusions, hallucinations, paranoia, hyperactivity/lethargy; haloperidol (1mg), risperidone (1mg)

terminal delirium/terminal agitation - symptoms not reversible in >50% of patients - haloperidol 2-4mg PO/SC/IV Q30minutes up to 20mg/24hr, olanzapine 2.5-5mg SL HS-BID plus PRN Q4hr

patient/family care/education/advocacy

goals of care

psychosocial/spiritual/cultural

grief & loss

caregiver ed/support/advocacy

practice issues

coordination and collaboration

scope and standards of practice

* opioid drug-to-drug conversions (equianalgesic - PO and TD)

morphine  30mg

hydocodone   30mg

codeine   200mg

tramadol 100mg

oxycodone   20mg

oxymorphone, methadone 10mg

fentanyl TD   12.5mcg/H ##

hydromorphone   7.5mg

levorphanol 4mg

calculate current 24H dose (TDD including PRNs)

convert using equianalgesic

calculate new dose

reduce by 50% to account for cross-tolerance (can be titrated PRN) (DO NOT REDUCE FOR TD FENTANYL)

## morphine to fentanyl patch - each 2 mg PO morphine approximately equivalent to 1 mcg/hr fentanyl patch (e.g., morphine 100 mg/day → 50 mcg/hr patch applied q3days) (approx 2mg : 1mcg/H) Note: using this formula, 25 mcg/hr of transdermal fentanyl is roughly equivalent to 50 mg oral morphine/24 hours. This dose may be excessive when used in the opioid naïve or the elderly.

MORE CONSERVATIVELY: FDA prescribing information for transdermal fentanyl: 135-224 mg of morphine per 24 hours = 50 mcg/hr patch. Note: this range of morphine is very broad which may result in significant under-dosing.

IV morphine : IV hydromorphone = 5:1

IV morphine : fentanyl patch = 4mg/hr : 100 McG patch (approx.)

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Ribs (1/1)

summary: “Hi, um. Sorry, I hope I have the right number. Is this Will Solace? Shit, sorry, you can’t answer me, this is a voicemail. Um. You modeled for my life drawing class, and I was wondering if you could model for me privately? Wait, shit, that sounds creepy, hold on. Start over. My name is Nico di Angelo and I’d like to hire you as a model so I can complete my final portfolio for my class. The one you modeled for. Um. Please call me back if you’re interested. Thanks.”

word count: 2925

read on ao3

“Hi, um. Sorry, I hope I have the right number. Is this Will Solace? Shit, sorry, you can’t answer me, this is a voicemail. Um. You modeled for my life drawing class, and I was wondering if you could model for me privately? Wait, shit, that sounds creepy, hold on. Start over. My name is Nico di Angelo and I’d like to hire you as a model so I can complete my final portfolio for my class. The one you modeled for. Um. Please call me back if you’re interested. Thanks.”

Nico and Will had communicated everything through text. Time and place - Nico’s apartment was closer for Will than the school’s studios, and they would work around Will’s busy schedule - Will’s rate was discussed, and they set up a time for their first meeting. They didn’t speak in person before then, and Nico didn’t want to make a terrible first - technically second or maybe even third - impression by letting Will think he was a slob before they’d even properly met, which meant that Nico had been furiously cleaning his apartment for a while before the time Will was supposed to show up.

Nico would never admit it, but there was a reason he’d asked Will over any of the other models that had sat for his class. He’d met Will once, so briefly that there was no way Will would remember it, but Will had complimented something of Nico’s that had been on display in the studio. There had been a sparkle in Will’s eyes when he saw Nico’s painting, and Nico had wanted to recreate that same look in as many medias as he could manage.

When Will finally knocked on the door, Nico had to shout, “Just a second!” while he struggled to hide things away in a closet before he could rush over to open the door.

“Um. Hi,” Nico said.

Will smiled brightly down at him. “Oh! You’re Nico! I remember you now, hi!”

“Hi,” Nico said again, and moved out of the doorway. “Um. Please, come in.”

Will walked past him and set his backpack down on the couch, pulling off his jacket as well. “So, what are we doing today? You said you wanted to work in different medias, right? And you probably need specific poses or something? How do you want me?”

Nico was almost frozen. “Um, however you want is good. I was going to stick with charcoal today, and probably leave ink and paints for another time. I’ll need one standing, one halfway - like, sitting or crouching or something - and one full down.”

Will tugged his shirt over his head and tucked his thumbs in the waistband of his sweatpants before he caught Nico staring at him. “Sorry, um, I just figured if you’re going to see me naked then there’s no harm in just, uh… You know?”

“Right, of course,” Nico said, and his gaze dropped to the ground. “You...do that. I’ve got a space heater around here somewhere, so I’ll go find that. Just, uh, get comfortable.”

Nico kept his eyes on the ground as he went to his bedroom, finding the space heater where he’d shoved it under the bed about a week ago to get it out of his way.

“Hey, I’ve got some reading to do for class, is it cool if I’m holding something while we’re doing this?” Will called from the living room, and Nico bumped his head on his bed frame as he tried to get out from underneath it.

“Yeah, that’s fine,” he shouted, and got to his feet to drag the space heater out of the room. He brought it out to the living room as he said, “I really don’t care what you do, as long as you don’t move. You could take a nap if you wanted to, and I’d just draw you while you’re sleeping.”

He nearly dropped the space heater when he spun around to face Will. “Wait, no! That sounded weird, I’m not trying to be creepy, I promise.”

Will chuckled. “I believe you, don’t worry about it.”

Nico allowed himself to relax, though that was the same moment he noticed that Will was completely naked. Nico’s heart skipped a beat as his eyes fell back to the floor, and he said, “Do you want to start?”

“Oh, right,” Will said, and Nico watched his bare feet pad across the wood floors for a moment, like he was scouting a place to pose. “Anywhere?”

Nico nodded.

He waited until Will had stopped moving to set up the space heater, and dragged over his easel and a chair. When Nico took a seat, he finally looked up to see the pose Will had taken.

He was sort of standing in front of the window, one foot propped up on the windowsill while the other was planted on the ground to keep his balance. His back was straight against the wall and his textbook was sat in his lap, and Nico was so thankful that he wouldn’t be getting such an eyeful as long as the textbook stayed where it was.

“Are you going to be able to hold that for an hour?” Nico asked, already itching to start drawing the smooth lines of Will’s shoulders and legs and the sharp point of his hip that seemed to be staring right at Nico.

“It’ll be fine,” Will told him. “My neck might start to get stiff, but I’ll be fine. Are you starting yet?”

“Uh, yeah. Let me know if you need a break or some water or if you get too cold,” Nico told him, and started to draw.

Nico tended to get lost in his work when he was as focused as he was, and he almost forgot he was sketching out a real person and not a statue when Will’s face started to twitch.

“Will?” Nico said, and Will flinched.

“Sorry, can I move my hand?” Will asked.

“Oh, sure, but try not to move anything else,” Nico told him.

Will reached up with the hand closest to the window and scratched at his nose. “Ugh, finally. My nose has been itching for like, an hour.”

“Wait, an hour?” Nico repeated. “How long have we been sitting here?”

Will shrugged his shoulder just slightly. “I dunno, long enough for me to get a headstart on next week’s readings.”

Nico leaned over and checked his phone, seeing that more than an hour and a half had passed since they’d started. “Oh, shit. I’m sorry, I didn’t mean to keep you here so long. Do you think you could hold on for just ten more minutes? I’ve done everything but your face and hair, but I can try to be quick.”

“Yeah, I can do ten minutes,” Will replied. “But not much longer than that, I have somewhere I have to be.”

Nico nodded and went back to work, drawing Will’s face in great detail but only sketching out the basic shape of his hair - he could fix that up later on his own time.

“Alright, I think we’re done for today,” Nico said finally, and Will didn’t hesitate to stand up stretch his arms up over his head. Nico ducked his head behind his easel so that he could only see Will from the waist up.

“Can I see?” Will asked, already walking closer and leaning over Nico’s shoulder to take a look. “Oh, wow.”

Nico didn’t see what Will was so impressed by, since the sparkle he could see in Will’s eyes was already more beautiful than an emotionless drawing.

“That’s amazing,” Will told him. “You really are good at this, you know? I remember seeing something of yours in the studio once, it was the coolest thing I’ve ever seen.”

Nico felt himself flush from the proximity - when they turned their heads to look at each other, their noses almost brushed. Plus, Will was still completely naked.

“Anyway, I should probably get going,” Will said, finally moving away, toward the couch where he’d left his backpack. He took out a pair of boxers and pulled those on before dressing in clothes different than the ones he’d been wearing when he arrived.

Nico tried to occupy himself with cleaning up so that he wasn’t simply staring at Will while he dressed, but eventually Will asked him, “How do I look?”

He didn’t understand how it was possible for someone to look better wearing so many layers of clothes than when they were naked, but somehow Will made it happen. He’d put on jeans and a t-shirt and a flannel and a jacket, despite the fact that it really wasn’t all that cold outside.

Nico realized after a moment that he hadn’t answered, so he nodded his head. “Uh, good. You-- That’s not what you were wearing earlier.”

“Yeah, no,” Will said, slipping his hands into his pockets. “My sister set me up on a date with some guy tonight. She thinks I’ll like him, but I’m not a fan of setups.” He shrugged. “I like to meet the guy myself, you know?”

“Yeah, I get it,” Nico said, and Will picked up his backpack. “Well, uh, good luck?”

“Thanks,” Will said with a smile. “Let me know when you want me to come over again, okay?”

Will was slouching in a chair, one arm relaxed on his lap and the over holding up his head, his feet flat on the floor. His body was facing Nico but his head was turned away slightly, and his eyes were starting to droop shut.

“Will?” Nico said when the model had started tipping forward.

“Sorry,” Will said, and righted himself. “I was up all last night studying for a practical I had earlier. I don’t think I did very well.”

“Practical?” Nico prompted, partially because he was genuinely curious but also because he figured that if he kept Will talking, then he wouldn’t fall asleep.

“I had to diagnose a patient based on the symptoms my classmates pretended to have, but I think I confused aphagia and aplasia, and I made a mistake when I was giving somebody else symptoms and messed them up, and--” He sighed. “It’s been a long couple of days.”

Nico didn’t respond to that, so he chose not to. He checked the time and saw that they’d been going for about half an hour, and Nico had inked out Will’s basic form. He could easily spend another half out just on Will’s face and hands, and figured that if Will moved now, he could easily recreate the pose.

“Do you want to take a second to stretch?” Nico asked. “We can take a break, if you think you can get back to that position.”

Will shook his head just slightly. “Nah, I think I’ll be fine.” While keeping his head pointed in one direction, he glanced at Nico out of the corner of his eye and let his lips twitch up in a tiny smile. “You could try talking to me, then maybe I won’t start falling asleep again.”

Nico felt himself starting to blush so he tried to hide behind his easel. “It’s hard for me to keep up a conversation when I’m trying to concentrate.”

“Okay, then ask me something and hopefully it’ll be a good enough question that I can talk about it for a little while,” Will suggested.

Nico hummed. “Alright. Um. How was your date?”

Will seemed surprised by the question, but maintained his pose. “My date?”

“You don’t have to answer if you don’t want to,” Nico said quickly. “I shouldn’t have asked something so personal, sorry.”

“No, no! It’s fine, really,” Will said. “It was...fine. We had dinner at a mediocre place, and he was--” Will huffed and rolled his eyes. “He was so boring, and kind of an asshole, too. He only talked about himself and pretended not to notice when the waitress dropped off the check. Like, I wasn’t the one that ordered two beers and a dessert for himself, which was probably a third of the check on its own.”

“He was just in it for the free meal, then?” Nico asked, and realized that he was studying Will’s sour expression more than he was sketching it out.

“I guess so, yeah,” Will sighed.

“Asshole,” Nico agreed.

Will went on complaining about his date, and Nico seemed to hum in all the right places because it kept Will talking. Soon enough, Nico was able to finish inking all of the lines, and told Will that he could move.

Immediately, he stretched his arms over his head and groaned. “Damn, the complaining felt good but my back feels like shit. I’ve been hunched over tables for days with all this studying and I think it’s finally catching up to me. Maybe sitting like that for so long was a mistake.”

“Hey, don’t blame me, I offered you a stretch break,” Nico reminded him.

“Yeah, I know,” Will said, and slowly got to his feet. “Can I see?”

“Sure,” Nico replied, and angled his easel so that Will could come around and see it. “I’m done with all the inking, and I’m going to use watercolors to finish it up, but that’s something I can do on my own time.”

“You’ll have to show me the next time I’m here,” Will said. “It looks amazing already, but I’m sure it’ll be even better when you’re done with it.”

Nico scratched the back of his neck uncomfortably. “An artist’s only as good as his model.”

Will was stretched out on Nico’s couch, legs propped up on one arm, his head against the other. His head was turned toward Nico for the first time during one of these sessions, so he was able to watch Nico as he worked.

“How’d you get into all this?” Will asked suddenly, breaking the silence around them. “Drawing and painting and everything.”

Nico shrugged. “Something to do. I moved around a lot as a kid, and art was the only thing that was really constant. What about you? You want to be a doctor, right?”

“That’s the dream,” Will said. “I like helping people, it seemed like the way to do it.”

“Maybe someday if you get your own practice or whatever, then I can paint something for you to hang in your waiting room,” Nico told him, not even realizing that he was saying it out loud.

“I would love that,” Will said sincerely, and when Nico looked up, he noticed that same sparkle that would appear whenever Will saw a piece of Nico’s art that he really liked.

“Don’t move,” Nico whispered, like saying the words too loudly might startle the look off Will’s face.

“Don’t move what?” Will asked.

“Your face,” Nico said, working quick so that he didn’t lose this chance. “You-- It’s… It’s a good face, just don’t move it.”

“A good face, huh?” Will repeated, expression softening and making the sparkle in his eyes shine brighter.

Nico brushed his hair away from his eyes, smearing paint across his forehead unknowingly. Will looked like he was holding back laughter.

“What?” Nico asked.

“Please just hurry before I laugh and ruin this,” Will told him.

“Right, okay,” Nico said, and got back to work.

He wasn’t exactly happy with the finished product, but any more touch ups might have ruined it completely, so Nico set down his brushes.

“Okay,” Nico said with a sigh, and Will hated how disappointed he looked.

He jumped up off the couch and went to look over Nico’s shoulder, eyes landing on the most lifelike painting he’d ever seen. It was like Nico had caught him mid-laugh, eyes shining, and Will gasped at the sight. “Wow,” he whispered. “That’s… I know I always say your stuff is amazing, but… This is really…”

“It’s not perfect, though,” Nico said. “Some of the shadows are uneven, and your eyes aren’t the same shape, and--”

“No, they’re just right,” Will told him, leaning in and pointing at the painting’s eyes. “My one eye squints like that whenever I smile, so you got it perfect.”

Nico huffed. “I doubt my instructor will see it that way.”

Will stepped back and went over to the chair where he’d stacked his clothes, pulling on his underwear once he found it. “I’ll tell you what,” he said while tugging his shirt on over his head. “When you get a perfect score on your portfolio, we’ll go out for drinks to celebrate.” He put on his pants while Nico stood up and started cleaning up his supplies.

“And what happens when I don’t get a perfect score?” Nico asked.

Will moved to stand in front of him, stuffing his hands in his pockets. “I’ll buy you dinner.”

Nico looked up in surprise. “You don’t have to do that.”

“But I want to,” Will replied. “I’ve...really enjoyed spending time with you, and I don’t want that to end just because you’re finished with your assignments. I like you, Nico.”

“You’re...serious?”

Will rolled his eyes and smiled. “Of course I’m serious. “You’re funny, and nice, and you’re cute when you’re concentrating and when you’re nervous and...all the time, really. So I want to go out with you, like, on a date. So, Nico, will you--”

Nico pressed forward and kissed him, brushing his fingers across Will’s cheeks. When he pulled back, he saw paint streaked on Will’s face and the brightest of sparkles in his eyes as he smiled down at Nico.

thanks for reading!!

buy me a coffee | more (solangelo) auctober stuff

[sugasweetsubs]

You Never Walk Alone [BTS Apocalypse AU]

Members | Taehyung & Jungkook

Words | 1.4K

Warnings | violence, language

Summary | Taehyung doesn't mean to be a hero, but sometimes the approaching end of the human race doesn't leave you much of a choice.

Disclaimer: This is the DRAFT EDITION of this story. It has been sitting in my drafts for almost two years, it isn’t finished and I don’t know if it ever will be, but I wanted to share. It is mostly unedited. Feedback is welcome!

Prologue | Part One | Part Two | Part Three | ?

Prologue: Sometimes People Die

Coughing--the first sign.

They say it started on a plane--a standard flight from New York to Paris that left JFK International Airport at 8:00 a.m. sharp. If the stories are to be believed, at some point during those eight hours and thirty-seven minutes a passenger came down with a cough that then spread throughout the entire aircraft. Due to recent international health scares, the flight was quarantined upon arrival and the one hundred and fifty-seven passengers and crew members were kept under careful medical observation for what was meant to be a ninety-six hour period.

Subconjunctival hemorrhaging--bleeding underneath the lining of the eye.

Fifteen hours before the quarantined passengers were set to be discharged, a new symptom appeared. As startling as bright red blood covering every part of the eye except the iris may appear, subconjunctival hemorrhaging on its own is harmless and clears up on its own. Normally, the condition would be written off as a result of the intense coughing fits that the passengers had suffered from since the flight; however, the sudden onset of the bleeding in every single patient worried the medical staff. The quarantine was extended by one week.

Aphagia--the inability or refusal to swallow.

Less than twenty-four hours after the last of the patients showed signs of hemorrhaging in their eyes, many of them also began to display a disinterest in eating their rationed meals. Thought to be a result of the sudden stress and isolation, the affected patients were kept under closer observation, but otherwise nothing more was done. Throughout that same day, the remainder of the plane’s occupants started to refuse their meals as well. By the time the extended quarantine period was meant to end, every last affected patient was receiving an intravenous rehydration treatment and being tube fed. The quarantine duration was extended indefinitely. An unknown disease outbreak was confirmed.

Death--the permanent cessation of vital bodily functions.

From there, the progression of the disease was rapid. The inability to eat left the patients weak and listless, blood began to leak from their tear ducts, they started to cough blood, they wheezed with every breath, and their skin broke out in patches of bruises that ranged in color from dusty gray to deep violet. Not long after the bruising reached its peak, the patients showed drastic, aggressive personality changes: they snapped at their nurses, threw anything they could get their hands on, and yelled nonsense for hours at a time. Some patients grew violent with the staff and were placed in bed restraints.

In addition to these external symptoms, the patients were also a mess internally: organs were failing, fevers raged, and their blood pressures sank to dangerous levels. Despite doing their best to treat each symptom as it appeared, the doctors were unable to find an effective treatment for this disease without a name.

On the thirtieth day of the quarantine, the first of the patients died. Over the course of the next thirty-six hours, the rest of the infected passed. News outlets went wild, headlines shouted questions like "157 Die in Quarantine, Beginning of an Epidemic?" and public fear spread like wildfire. The United States and French governments were quick to soothe the public with pretty words and smudged statistics that appeared tremendously comforting to the untrained eye; for the next few weeks this method was effective as no other cases of the mysterious disease had been reported. People moved on to more pressing matters, as people do. The governments covered up the news that was even more startling than the deaths of one hundred and fifty-seven people, as governments do.

Reanimation--a restoration to life or consciousness.

When humans die of unknown causes, it is natural for some questions to be raised. Most people don't like not knowing. So when one hundred and fifty-seven people died of a disease no one had ever seen before, doctors and scientists from around the world wanted to take a crack at solving the mystery.

A small number of families agreed to donate the bodies of their loved ones to science. Those donated bodies were transported to top medical research labs across the world to be used in diagnostic and cure research.

It was during this research that the final symptom of the disease made itself known.

The first documented case was in a lab in Australia. The researcher in charge of collecting tissue samples for further analysis left the subject's body unattended for approximately twenty minutes while running files to a different research team one floor up. Upon returning to the autopsy room, the researcher discovered that the subject's body was no longer lying on the examination table. At the time, it was believed that another researcher had taken the body for a CT scan without proper notice; however, it was later discovered that neither research team knew the location of the subject's body. Facility security conducted a sweep of the building, but there was no sign of the subject.

Until they reached the basement.

The figure that huddled in a dimly lit corner of the facility's basement was dressed in a standard medical gown and was thought to be an escaped patient from the hospital next door. The security team approached the figure--meaning to detain the patient and return them to the hospital--but as the team came closer the patient stood and began to back into a different hallway. It was then, when the patient stepped into full lighting, that a member of the security team claimed to recognize the patient.

The supposedly dead research subject.

Ignoring the ridiculous claims of their teammate, the remainder of the security team moved to detain the patient. This movement was met with hostility from the patient, who attacked one of the security guards so viciously that the team resorted to lethal force.

Later, blood testing confirmed suspicions. The patient in the basement was indeed the research subject come back to temporary life.

Over the span of a week, every single lab studying one of the bodies reported situations eerily similar to the Australian lab's. Some were more prepared than others. Not every location was lucky enough to escape fatalities.

It is unknown what happened to the bodies not sent to research locations, but by then the world was more preoccupied with the increasingly common outbreaks of the still unnamed disease. The public panicked as the news of a 'real life zombie virus' spread with every new case of the sickness and with every new example of the dead coming back to...not quite life.

Viral Hemorrhagic Fever Z. In the eight months it took scientists to decide on a name for the deadly virus, over a million people had been killed by the disease and the number continued to grow with every passing day. The staggering infection rate and 100% chance of mortality of the airborne virus created immense paranoia all over the world: governments shut down borders, mandatory curfews took effect in nearly every city across the world, and scientists jumped immediately into intensifying the research for a cure.

The violent tendencies of patients in the late stages of "Z Fever" led to any confirmed cases of infection being detained and held in specially designated compounds where they were to either become experimental subjects for cure research or be terminated. After their initial deaths, patients were considered to be beyond saving and it became standard practice to burn their bodies before they were able to reach the 'reawakening stage' of the disease.

One year and ten months passed with nearly sixteen million deaths before a vaccine was created.

A cure was still considered to be years away, but that same research led to the invention of a vaccine that reduced the infectiousness of the disease. No longer airborne--spread only through contact with an infected person's blood or saliva--the rate of infection was cut in half.

Eight years later, the world's population has fallen to a mere 2.1 billion. While a cure is thought to only be a few months away by even the most conservative estimates, the surviving human population is struggling to hold out for salvation when the world's remaining cities are overrun with the infected and resources have hit critical lows.

Notes: I really liked where this story was going and I’ve been searching for the best time to post it. I wanted to wait until it was complete, but after two years I said f*** it and decided to post on a whim. Feedback is welcome!! I’ll be updated every two days until I run out of pre-written content and after that it’s a mystery. I’m very busy these days, but I miss writing TT

If you want more of this universe check out the video ‘trailer’ I made for it here and a semi-related video edit here

masterlist

[unabashedlystupendousbeliever]

Abasia, Abdominal Compartment Syndrome, Abdominal Discomfort, Abdominal Distension, Abdominal Pain, Abdominal Pain Lower, Abdominal Pain Upper, Abdominal Strangulated Hernia, Abdominal Symptom, Abnormal Behaviour, Abnormal Chest Sound, Abnormal Dreams, Abnormal Sleep-Related Event, Abortion Incomplete, Abortion Induced, Abortion Missed, Abortion Spontaneous, Abscess, Accident, Accidental Death, Accidental Drug Intake By Child, Accidental Exposure, Accidental Overdose, Acetonaemia, Acidosis, Acne, Activated Partial Thromboplastin Time Prolonged, Activities of Daily Living Impaired, Acute Abdomen, Acute Coronary Syndrome, Acute Hepatic Failure, Acute Myocardial Infarction, Acute Prerenal Failure, Acute Psychosis, Acute Pulmonary Oedema, Acute Respiratory Distress Syndrome, Acute Respiratory Failure, Acute Sinusitis, Acute Tonsillitis, Adenoma Benign, Adverse Drug Reaction, Adverse Event, Affect Lability, Affective Disorder, Ageusia, Aggression, Agitation, Agitation Neonatal, Agonal Rhythm, Agranulocytosis, Akathisia, Akinesia, Alanine Aminotransferase Decreased, Alanine Aminotransferase Increased, Albuminuria, Alcohol Interaction, Alcohol Poisoning, Alcohol Problem, Alcohol Use, Alcohol Withdrawal Syndrome, Alcoholism, Alopecia, Amblyopia, Amenorrhoea, Ammonia Increased, Amnesia, Anaemia, Anaemia Macrocytic, Anaemia Megaloblastic, Anal Candidiasis, Anal Infection, Analgesic Drug Level Increased, Anaphylactic Reaction, Anaphylactic Shock, Aneurysm, Anger, Angina Pectoris, Angina Unstable, Angioneurotic Oedema, Angiopathy, Angle Closure Glaucoma, Anhedonia, Anion Gap Abnormal, Ankle Fracture, Ano-Rectal Stenosis, Anorexia, Anorgasmia, Anosmia, Anoxic Encephalopathy, Anticholinergic Syndrome, Anticoagulation Drug Level Below Therapeutic, Anticonvulsant Drug Level Below Therapeutic, Anticonvulsant Drug Level Decreased, Anticonvulsant Drug Level Increased, Antidepressant Drug Level Above Therapeutic, Antidepressant Drug Level Increased, Anti-Hbc Antibody Positive, Antinuclear Antibody Positive, Antipsychotic Drug Level Above Therapeutic, Antipsychotic Drug Level Increased, Anuria, Anxiety, Anxiety Disorder, Aorta Hypoplasia, Aortic Arteriosclerosis, Aortic Disorder, Aortic Rupture, Apallic Syndrome, Apathy, Apgar Score Low, Aphagia, Aphasia, Aphonia, Aphthous Stomatitis, Aplastic Anaemia, Apnoea, Appendicectomy, Appendicitis Perforated, Apraxia, Aptyalism, Arachnoid Cyst, Arrhythmia, Arterial Thrombosis, Arteriosclerosis, Arteriosclerosis Coronary Artery, Arteriovenous Fistula (Acquired), Arthralgia, Arthritis, Arthritis Bacterial, Arthropod Bite, Ascites, Aseptic Necrosis Bone, Asocial Behaviour, Aspartate Aminotransferase Increased, Aspiration, Asterixis, Asthenia, Asthma, Ataxia, Atelectasis, Atherosclerosis, Atonic Urinary Bladder, Atrial Fibrillation, Atrial Flutter, Atrioventricular Block, Atrioventricular Block Complete, Atrioventricular Block First Degree, Atrioventricular Block Second Degree, Atrophie Blanche, Atrophy, Attention-Seeking Behaviour, Aura, Auricular Swelling, Autism, Autoimmune Disorder, Autoimmune Hepatitis, Autoimmune Thyroiditis, Autonomic Nervous System Imbalance, Azoospermia, Azotaemia, Back Injury, Back Pain, Bacteraemia, Bacteria Sputum Identified, Bacteria Urine Identified, Bacterial Infection, Balance Disorder, Benign Intracranial Hypertension, Beta Haemolytic Streptococcal Infection, Bile Duct Cancer, Bile Duct Obstruction, Bile Duct Stenosis, Bile Duct Stone, Biliary Neoplasm, Biliary Tract Disorder, Bilirubin Conjugated Increased, Biopsy Liver Abnormal, Bipolar Disorder, Bipolar I Disorder, Bipolar II Disorder, Bite, Bladder Dilatation, Bladder Disorder, Bladder Obstruction, Bladder Pain, Bladder Prolapse, Bleeding Time Prolonged, Blepharospasm, Blindness, Blindness Transient, Blindness Unilateral, Blister, Blood Albumin Decreased, Blood Alcohol Increased, Blood Alkaline Phosphatase Increased, Blood Amylase Increased, Blood Bilirubin Increased, Blood Bilirubin Unconjugated Increased, Blood Chloride Decreased, Blood Chloride Increased, Blood Cholesterol Increased, Blood Count Abnormal, Blood Creatine Increased, Blood Creatine Phosphokinase Increased, Blood Creatinine Increased, Blood Culture Positive, Blood Disorder, Blood Electrolytes Abnormal, Blood Electrolytes Decreased, Blood Ethanol Increased, Blood Glucose Abnormal, Blood Glucose Decreased, Blood Glucose Fluctuation, Blood Glucose Increased, Blood Lactate Dehydrogenase Increased, Blood Magnesium Increased, Blood Osmolarity Decreased, Blood PH Decreased, Blood Phosphorus Increased, Blood Potassium Decreased, Blood Potassium Increased, Blood Pressure Abnormal, Blood Pressure Decreased, Blood Pressure Fluctuation, Blood Pressure Immeasurable, Blood Pressure Inadequately Controlled, Blood Pressure Increased, Blood Pressure Orthostatic, Blood Pressure Orthostatic Decreased, Blood Pressure Systolic Decreased, Blood Pressure Systolic Increased, Blood Proinsulin Increased, Blood Prolactin Increased, Blood Sodium Decreased, Blood Sodium Increased, Blood Test Abnormal, Blood Triglycerides Abnormal, Blood Triglycerides Increased, Blood Urea Decreased, Blood Urea Increased, Blood Urea Nitrogen/Creatinine Ratio Decreased, Blood Urine, Blood Urine Present, Bloody Discharge, Body Temperature Decreased, Body Temperature Increased, Bone Density Decreased, Bone Disorder, Bone Marrow Depression, Bone Marrow Disorder, Bone Marrow Failure, Bone Neoplasm Malignant, Bone Pain, Bradycardia, Bradycardia Neonatal, Bradykinesia, Bradyphrenia, Bradypnoea, Brain Abscess, Brain Damage, Brain Death, Brain Neoplasm, Brain Oedema, Brain Scan Abnormal, Brain Stem Syndrome, Breast Cancer, Breast Cancer Female, Breast Cancer In Situ, Breast Discomfort, Breast Pain, Breast Swelling, Brief Psychotic Disorder With Postpartum Onset, Bronchial Infection, Bronchiectasis, Bronchitis, Bronchitis Acute, Bronchopneumonia, Bronchospasm, Bruxism, Bulimia Nervosa, Bundle Branch Block, Bundle Branch Block Bilateral, Bundle Branch Block Left, Bundle Branch Block Right, Burning Sensation, Bursitis, Caesarean Section, Calcinosis, Campylobacter Infection, Candidiasis, Carbon Monoxide Poisoning, Cardiac Arrest, Cardiac Death, Cardiac Discomfort, Cardiac Disorder, Cardiac Failure, Cardiac Failure Acute, Cardiac Failure Congestive, Cardiac Fibrillation, Cardiac Flutter, Cardiac Hypertrophy, Cardiac Malposition, Cardiac Murmur, Cardiac Pacemaker Insertion, Cardiac Valve Disease, Cardioactive Drug Level Decreased, Cardiogenic Shock, Cardiomegaly, Cardiomyopathy, Cardiopulmonary Failure, Cardio-Respiratory Arrest, Cardiotoxicity, Cardiovascular Disorder, Cardioversion, Carotid Artery Occlusion, Carotid Artery Stenosis, Carpal Tunnel Syndrome, Cataplexy, Cataract, Cataract Subcapsular, Catatonia, Catheter Related Infection, Cellulitis, Central Venous Pressure Decreased, Cerebellar Haemorrhage, Cerebellar Infarction, Cerebral Arteriosclerosis, Cerebral Artery Occlusion, Cerebral Artery Stenosis, Cerebral Atrophy, Cerebral Disorder, Cerebral Haemorrhage, Cerebral Infarction, Cerebral Ischaemia, Cerebral Thrombosis, Cerebrovascular Accident, Cerebrovascular Disorder, Cervical Vertebral Fracture, Cervix Carcinoma, Cheilitis, Chest Discomfort, Chest Pain, Chest X-Ray Abnormal, Cheyne-Stokes Respiration, Chills, Choking, Choking Sensation, Cholecystitis, Cholelithiasis, Cholelithotomy, Cholestasis, Chondromalacia, Chorea, Chorioamnionitis, Chromatopsia, Chromaturia, Chronic Myeloid Leukaemia, Chronic Obstructive Pulmonary Disease, ;.......................................................................

There it is on the bottom. Chronic Obstructive Pulmonary Disease, What I’ve had for almost 3 years after a cold withdrawing from “antipsychotics.”

The reason I feel like I have no energy and can’t breathe and  sound like Marianne Faithful from a constantly inflamed throat.

https://www.futurity.org/lungs-copd-inflammation-1752872-2/  I wonder if I’ll live long enough to take these drugs they’re deveolping to stop the high white blood cell counts that’s causing my body to destroy my lungs. How do I get on a trial...

[fiylno]

Video games have been taking my time lol

Experiment I did a while ago, inspired by nier soundtrack, I love the way they compose, so I tried my shot in harmonic minor.

Its completely unbalanced, minimal mixing, just piano, and as you can hear the one I have is pretty garbo.

[tipterimlerisozlugu]

Aphagia Nedir? Türkçe Ne Demek? https://ift.tt/34pZZ1a

[anhedonically]

To crave aphagia

[neurogenpapers]

The tyrosine kinase receptor Tyro3 enhances lifespan and neuropeptide Y (Npy) neuron survival in the mouse anorexia (anx) mutation.

PubMed: Related Articles The tyrosine kinase receptor Tyro3 enhances lifespan and neuropeptide Y (Npy) neuron survival in the mouse anorexia (anx) mutation. Dis Model Mech. 2017 Jan 12;: Authors: Kim DY, Yu J, Mui RK, Niibori R, Taufique HB, Aslam R, Semple JW, Cordes SP Abstract Severe appetite and weight loss define the eating disorder anorexia nervosa, and can also accompany the progression of some neurodegenerative disorders, such as amyotrophic lateral scelerosis (ALS). While acute loss of hypothalamic neurons that produce appetite-stimulating neuropeptide Y (Npy) and agouti related peptide (AgRP) in adult mice or in mice homozygous for the anorexia (anx) mutation causes aphagia, our understanding of the factors that help maintain appetite regulatory circuitry is limited. Here we identify a mutation that converts an arginine to a tryptophan (R7W) in the Tyrosine receptor kinase 3 (Tyro3) gene, which resides within the anx critical interval, as contributing to the severity of anx phenotypes. Our observation that, like Tyro3-/- mice, anx/anx mice exhibit abnormal secondary platelet aggregation suggested that the R7W-Tyro3 variant might have functional consequences. Tyro3 is expressed in the hypothalamus and other brain regions affected by the anx mutation, and its mRNA localization appeared abnormal in anx/anx brains by postnatal day 19 (P19). The presence of wild type Tyro3 transgenes, but not an R7W-Tyro 3 transgene, doubled the weight and lifespans of anx/anx mice and near normal numbers of hypothalamic Npy-expressing neurons were present in Tyro3-transgenic anx/anx mice at P19. While no differences in R7W-Tyro3 signal sequence function or protein localization were discernible in vitro, distribution of R7W-Tyro3 protein differed from that of Tyro3 protein in the cerebellum of transgenic wild type mice. Thus, R7W-Tyro3 protein localization deficits are only detectable in vivo. Further analyses revealed that the R7W-Tyro3 variant is present in a few other mouse strains, and hence is not the causative anx mutation, but rather an anx modifier. Our work shows that Tyro3 has prosurvival roles in the appetite regulatory circuitry and may also provide useful insights towards the development of interventions targeting detrimental weight loss. PMID: 28093506 [PubMed - as supplied by publisher] http://dlvr.it/N8PFlf